The infant with acute, unexplained, excessive crying.

This study describes 56 infants who presented to the Emergency Department of The Children's Hospital of Denver during a 1-year period with an episode of excessive, prolonged crying, without fever and without a cause that was apparent to the parents. The final diagnoses included a broad array of conditions, of which 61% were considered serious. The history provided clues to the final diagnosis in 20% of cases. Physical examination revealed the final diagnosis in 41% and provided clues to the diagnosis in another 13%. Accurate diagnosis requires a thorough physical examination, which should include careful skin inspection underneath all clothing, palpation of all large bones, fluorescein staining of the cornea, eversion of eyelids, rectal examination, retinal examination, and thorough neurologic examination. "Screening" laboratory tests, except for urinalysis and urine culture, were of little help. This study indicates that for those patients in whom the physical examination is not diagnostic, the persistence of excessive crying after the initial examination predicts the presence of a serious cause. Those infants who cease crying before or during the initial assessment are unlikely to have a serious cause. Recommendations for a stepwise assessment are offered.

Pediatric locum tenens provided by an academic center.

BACKGROUND: Locum tenens, the use of a substitute physician to replace a physician who must be temporarily absent from his practice, is widely accepted in the United States. Locum tenens has not previously been described or studied in pediatric practice. OBJECTIVE: This article describes a locum tenens service for Colorado and Wyoming pediatricians provided by the Division of General Pediatrics and Pediatric Emergency Medicine at the University of Colorado School of Medicine and the Children's Hospital of Denver. An analysis and an evaluation of the program are presented, and implications are discussed. METHODS: All program data were prospectively collected and tabulated and later analyzed for the period from July 1, 1994, through June 30, 1995. A survey of all physicians using the Pediatric Locum Tenens Service was conducted within 2 months of service to evaluate the program and to refine the orientation, credentialing, and evaluation processes. RESULTS: During the year, 35 pediatricians (14% of pediatricians in Colorado and Wyoming) made 97 requests for 398 days of locum tenens coverage. Coverage was used for vacation (85%), medical education (10%), medical leave (3%), and family matters (2%). Solo and rural pediatricians used the service at a higher rate than pediatricians in group or urban practices. Eighty-six percent had never used locum tenens coverage before because of either the expense (67%) or their unwillingness to trust their practices to physicians or services with whom or with which they were unfamiliar (50%). The majority (83%) were willing to pay an amount for locum tenens equal to the net income derived from the locum tenens coverage in the practice. None indicated a willingness to pay more than that. Referrals and admissions to the Children's Hospital from the pediatricians who used the service increased by 22% during the study period compared with the preceding year, whereas referrals and admissions increased by 9% among all other Colorado and Wyoming pediatricians. All pediatricians completed surveys, and satisfaction with the locum tenens pediatricians, charges, and program administration was high. Their suggestions are described. DISCUSSION: The following topics are discussed: (1) the economics of pediatric locum tenens; (2) the use of a locum tenens service as a physician relations program by children's hospitals or academic departments of pediatrics; (3) guidelines for orientation of locum tenens pediatricians; and (4) a proposed evaluation and credentialing process for locum tenens physicians.

Reducing after-hours referrals by an after-hours call center with second-level physician triage.

OBJECTIVES: One-third of practices signing-out to The Children's Hospital Call Center in Denver, Colorado, choose to do second-level physician (SLP) triage for calls judged by the Center to require after-hours referral (AHR). We examined: 1) the effect of SLP triage on the rate of AHRs and 2) reasons for physicians' decisions. DESIGN: From January 1998 to August 1998 all calls from patients using a 5-member suburban pediatric practice judged by the Call Center to require AHR were referred to the practice's on-call physician who did SLP triage and completed a questionnaire. RESULTS: There were 955 eligible calls, 22% (N = 216) of which were initially given an urgent disposition by Call Center nurses. Physician questionnaires were completed for 97% (N = 209). Of patients initially triaged for AHR, 49% (N = 103) were subsequently given an AHR, 17% (N = 35) a next day office referral, and 34% (N = 71) home care and advice. Reasons for not urgently referring included the following: 1) medical problem didn't require urgent evaluation (95%, N = 99); 2) change in the patient's condition; (40% N = 43); 3) prior knowledge of family's ability to evaluate and care for the patient (40%, N = 43); and 4) knowledge of the patient's medical history (18%, N = 19). After SLP triage the overall urgent referral rate was 11%. CONCLUSIONS: Signing out to a Call Center decreased physicians' after-hours calls by 77% and SLP triage halved the number of urgent after-hours referrals.

After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices.

BACKGROUND: After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. OBJECTIVES: This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. METHODS: After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. RESULTS: In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. CONCLUSIONS: Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.

The role of the pediatrician in abolishing corporal punishment in schools. Committee on School Health, American Academy of Pediatrics.

Corporal punishment in school is allowed in 30 states in the United States. The American Academy of Pediatrics, together with numerous other child-advocacy groups, has reaffirmed its position that corporal punishment in schools should be prohibited by state statute in all states. This article provides background information and recommendations regarding the potential role for pediatricians in attaining this goal.

Monozygotic twin girls with congenital malformations resembling fanconi anemia.

Monozygotic (MZ) twin girls, diagnosed at birth to have Fanconi anemia (FA) on the basis of multiple anomalies and an apparently increased baseline chromosomal breakage frequency in one twin, have been followed prospectively for 13 years. They have not developed aplastic anemia or other hematologic manifestations of FA. There was no evidence for increased baseline or diepoxybutane (DEB)-induced chromosomal breakage in either twin when the studies were repeated in Denver as well as in New York. Since the cellular phenotype must be considered in establishing the diagnosis of FA, these MZ twins should not be classified as affected with FA. Using the scoring system for FA diagnosis developed by Auerbach et al. [1989], the probability coefficients of their having FA based solely on clinical findings, prior to DEB testing, were .75 and .92, respectively. When the combination of their anomalies are taken together, their FA probability coefficient is .98. Through the International FA Registry, 15 additional patients have been identified with an FA probability score of .75 or greater, but who have not developed aplastic anemia and who are DEB negative. These patients, as well as the twins described in this report, are most likely a heterogeneous group and may represent other syndromes like Holt-Oram, VATER, VACTERL and IVIC, with genetic as well as nongenetic etiologies. These cases demonstrate the importance of testing with DEB or other DNA crosslinking agent in order to discriminate between FA and other syndromes with a similar phenotype.

Computerized pediatric telephone triage and advice programs at children's hospitals: operating and financial characteristics.

OBJECTIVE: To describe the operating characteristics, financial performance, and perceived value of computerized children's hospital-based telephone triage and advice (TTA) programs. DESIGN: A written survey of all 32 children's hospital-based TTA programs in the United States that used the same proprietary pediatric TTA software product for at least 6 months. MAIN OUTCOME MEASURES: The expense, revenues, and perceived value of children's hospital-based TTA programs. RESULTS: Of 30 programs (94%) responding, 27 (90%) were eligible for the study and reported on their experience with nearly 1.3 million TTA calls over a 12-month period. Programs provided pediatric TTA services for 1560 physicians, serving an average of 82 physicians (range, 10-340 physicians) and answering 38880 calls (range, 8500-140000 calls) annually. The mean call duration was 11.3 minutes and the estimated mean total expense per call was $12.45. Of programs charging fees for TTA services, 16 (59%) used a per-call fee and 7 (26%) used a monthly service fee. All respondents indicated that fees did not cover all associated costs. Telephone triage and advice programs, when examined on a stand-alone basis, were all operating with annual deficits (mean, $447000; median, $325000; range, $74000-$1.3 million), supported by the sponsoring children's hospitals and their companion programs. Using a 3-point Likert scale, the TTA program managers rated the value of the TTA program very highly as a mechanism for marketing to physicians (2.85) and increasing physician (2.92) and patient (2.80) satisfaction. CONCLUSIONS: Children's hospital-based TTA programs operate at substantial financial deficits. Ongoing support of these programs may derive from the perception that they are a valuable mechanism for marketing and increase patient and physician satisfaction. Children's hospitals should develop strategies to ensure the long-term financial viability of TTA programs or they may have to discontinue these services.

Introduction of a recorded health information line into a pediatric practice.

OBJECTIVE: To examine the utilization, satisfaction, and parental health-seeking behavior associated with the introduction of the Parent Advice Line (PAL), a collection of 278 recorded health-related messages accessible by telephone, into a private practice. DESIGN: Booklets listing PAL topics were mailed to eligible families, and utilization data were collected for all incoming PAL calls from June to August 1996. Satisfaction and effect on health-seeking behavior were assessed using a recorded questionnaire appended to each call (n = 561) and a randomized telephone questionnaire (n = 821). SETTING: A suburban, 7-pediatrician practice in Colorado. PATIENTS: Families with children younger than 12 years seen in the practice within 2 years (N = 8365). RESULTS: Of families who reported receiving the mailed PAL booklet, 32% used PAL. Sixty percent of PAL calls were placed during office hours, 21% from 5 PM to 9 PM, and 8% after midnight; call volume was higher on weekdays than on weekend days (25 calls per day vs 10 calls per day, respectively; P<.05 by chi2 test). The 5 most commonly requested topic categories were toilet training, sexual development, discipline problems, sleep problems, and teenage behavior. Preventive care topics predominated in infants, behavioral topics in preschool children, and acute illness topics in school-aged children. Of users, 88% were satisfied or very satisfied and 98% said that they would use PAL again. Respondents to the 2 questionnaires reported that use of PAL made a call or visit to their child's physician unnecessary 58% to 69% and 61% to 70% of the time, respectively. CONCLUSIONS: The PAL was used primarily to access information about behavioral and developmental issues during office hours. Its use was associated with high rates of satisfaction and, by parental report, decreased calls or visits to a physician.

The "over-anxious" parent.

This study describes the sources of anxiety in parents who report being highly anxious at pediatric visits for minor problems, despite usual management and reassurance. During a one-year period, 44 parents (0.8% of all visits; 3% of all families) were identified as "over-anxious" in a private pediatric practice. The most common sign of anxiety in these parents was the lack of satisfaction, or lack of closure, at the end of the visit. Each parent had from one to three underlying sources of anxiety in addition to the presenting complaint. The underlying sources of concern were uncovered in a brief interview and they fell into six categories: hidden agenda (28%); vulnerable child (23%); inexperienced parents (23%); psychosocially stressed parents (14%); iatrogenic anxiety (7%); and the chronically anxious parent (4%). Reassurance alone did not relieve anxiety for these parents. However, their anxiety decreased when the physician recognized and treated their specific underlying concerns. Techniques are suggested for understanding and treating "over-anxious" parents in the practice setting.

Hyperactivity.

Overactivity and poor attention span are symptoms for which there are several possible causes. The physician's role is to assist the family and school in recognizing the specific cause of the hyperactivity, institute appropriate treatment, and document and evaluate that treatment is effective.

Common behavioral problems in infants and children.

Primary care physicians can serve as important sources of behavioral information to patients of infants, toddlers, school-aged children, and adolescents. Behavior results from a blend of biologic qualities, such as gender and temperament, and social experiences, such as attachment and family experiences. Common problems include disorders of sleep, crying, feeding and diet, discipline and sexuality, aggression and biting, toilet training, and school avoidance. Family physicians should be aware of the management of behavioral problems and provide anticipatory or responsive guidance or reference information.

Pediatric behavioral science in family practice.

Behavioral science is a well-accepted component of family practice, but official guidelines and proposed curricula have a predominantly adult focus. This paper describes a pediatric behavioral science curriculum for family practice residents that has been successfully integrated into the three-year family practice residency curriculum at the University of Colorado. Details of development and implementation are presented: the requisite knowledge base, skills, and attitudes; the core pediatric behavioral science topics and diagnoses; the family physician's role in handling each core diagnosis; guidelines for making management decisions; suggested approaches to teaching the curriculum; and a reference list for behavioral science faculty.

Bibliotherapy: an adjunct to care of patients with problems of living.

Bibliotherapy, or the selected use of reading as an adjunct to the treatment of medical and psychological problems, has a long history in the library science literature. However, the use of bibliotherapy by practicing physicians has not been significant. Many patients who see family physicians are candidates for bibliotherapy as adjunctive treatment. In the past five years numerous well-written books that address various patient problems of living have been made available. The authors surveyed a variety of health care specialists in the Denver area to develop a reading list for people with life problems. These problems have been categorized under the following headings: dealing with life crises and transitions, parents and children, parenting, coping with illness and disability, death and dying, lifestyle modification, sexuality, and coping with feelings. The resulting annotated bibliography may be used as a guide for practicing physicians who feel that appropriate reading material may be beneficial to their patients with such problems.

Adolescent health care in family practice.

This paper describes the 12,414 health care problems of 3,657 adolescent patients visiting 12 Colorado family practices (4 rural, 3 urban, and 5 residency practices) over a one-year period. All 12 practices utilize the Family Medicine Information System, a selectively automated system for storing and analyzing medical, family, and billing data. Age-sex distribution, visiting patterns, and morbidity are described for patients between 13 and 20 years of age. The 25 most frequent adolescent diagnoses account for 74 percent of visits, and 134 diagnoses account for 95 percent of pediatric visits. Significant sex differences and differences among early, middle, and late adolescent age groups are described. All diagnostic categories are explored in detail, and comparisons are made between urban, rural, and residency practices.

Stepfamilies in family practice.

Stepfamilies have several important structural features and developmental milestones that differ from the nuclear family: complex relationships, ambiguous roles and expectations for family members, wide variety of previous family experiences for the various members, changes in support group and living arrangements, unresolved grief, and lack of institutional support. These features influence physical and mental health. The family physician must be aware of how stepfamily problems are likely to present and how to assist the stepfamily members with their problems. This paper describes an approach to recognition and management of stepfamily problems, anticipatory guidance for prevention of problems, and a number of patient education resources.

Patients with delusional and bizarre thinking.

Patients with delusional or other types of bizarre thinking are often incorrectly labeled as schizophrenic. This error has significant medical and social implications to the patient. Delusional thinking has been linked with a variety of nonschizophrenic problems including the use of licit and illicit drugs, a wide variety of medical diseases, and nonschizophrenic psychiatric disturbances. A series of case studies in which the diagnosis of schizophrenia was incorrectly made elucidates the problem and helps the physician consider the alternatives.

Newborn care in family practice.

Official guidelines regarding the training of family practice residents in newborn medicine have been meager and general. Guidelines have traditionally focused on defining the requisite duration rather than the content of nursery rotations. A competency-based curriculum in newborn medicine is needed that defines requisite knowledge, skills, and attitudes; defines the appropriate role for the family physician in managing newborn problems; reflects the actual newborn experience of family physicians; is incorporated into residency training on a daily basis; and can be utilized in documenting resident competency in newborn health care. This paper describes the development, content, and daily implementation of a newborn curriculum that addresses these issues.

Pediatric training in family practice: a core curriculum.

Official residency guidelines for pediatric training of family practice residents focus on the number of months of block time on pediatric rotations and the percentage of pediatric patients in the resident's model practice. These guidelines do not ensure competence in pediatrics. Family practice residencies need a competency-based curriculum derived from actual pediatric experience in family practice. Such a curriculum should define specific knowledge, skills, and attitudes required, define the family physician's role in handling each issue or condition, be used on a daily basis, and form a basis for evaluation of residents and curriculum. This paper describes the development and implementation of such a pediatric core curriculum at the University of Colorado Family Practice Residency.

Pediatric health care in family practice.

This paper describes the 32,926 health care problems of 9,117 pediatric patients visiting 12 Colorado family practices (4 rural, 3 urban, and 5 residency practices) over a one-year period. All 12 practices utilize the Family Medicine Information System (FMIS), a selectively automated system for storing and analyzing medical, family, and billing data. Age-sex distribution, visiting patterns, and morbidity are described for patients under 18 years of age. The 25 most frequent pediatric diagnoses account for 77 percent of visits, and 121 diagnoses account for 94 percent of pediatric visits. All diagnostic categories are explored in detail, and comparisons are made among urban, rural, and residency practices.

The nurse practitioner's role in adolescent health care.

This study describes the 12,414 health care problems of 3,657 adolescent patients visiting 12 family practices over a one-year period. Age-sex distribution, visiting patterns and all categories of morbidity are described for patients between 13 and 20 years of age. Significant sex differences and differences among early, middle and late adolescents are also described. The results of this study have important implications for the training of nurse practitioners. Traditionally, nurse adolescent patients in their clinical setting to determine what conditions they learn about. This paper proposes the need for a competency-based curriculum and offers a list of topics to form the core of such a curriculum.