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New Ways to Offer Better Health Care
New Ways to Offer Better Health Care WILLIAM G. CROOK, M.D.
Readers of the pediatric journals are aware that they are exposed to few articles dealing with such mundane subjects as keeping records, taking histories, and establishing modern systems of communication in an office. True, there are periodicals whose function it is to offer such articles, but it is also true that, all too often, those of us in pediatric practice fail to take the time to write up some of our own observations that might help others to work more productively. For years I have experimented with many methods designed to improve office procedures, and I have learned of many more from other peq.iatricians. Some of the successful ones are briefly described in this article.
The Bellboy The Bellboy is a kind of miniature short-wave radio receiver that can be carried in a pocket. Its signal is a buzzing or ringing sound, activated by dialing a special telephone number. It functions when the physician is away from his office and a telephone answering service is responding to his calls. The answering service can instantly contact the physician by use of the Bellboy, and when the user hears it, he simply shuts it off and calls the answering service by telephone. The apparatus will work within a 20 to 40-mile radius, depending on local conditions, and is not affected by steel-framed buildings. Naturally the transmitter is a central one, and it must be installed and operated by the local telephone company. Once the system exists in a community, the cost of the service is nominal. More expensive two-way radio devices are also on the market and serve the same purpose where no Bellboy system has been installed.
Dictated Records Tape recorders and dictating machines have intrigued me since I first entered practice, when I tried to interest my first two associates in investing in dictating and transcribing equipment. Their response was to buy a half-dozen memo pads and some pencils that I could carry, saying that those would have to suffice. But finally in 1956, we bought some Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
989
990
WILLIAM
G.
CROOK
equipment and hired our first full-time typist. We have dictated all of our patient records ever since. It might be thought that this system is either too expensive or too troublesome to be useful, and while all physicians would agree that written records of histories, physical examinations, and general medical records are important and necessary for hospitalized patients, few believe them needed for "routine" office patients. We have found that good records of all patients possess manyadvantages. (1) Adequate records permit better medical practice. If the physician commits his thoughts to paper, he will of necessity examine his patients more carefully. More pertinent findings can be recorded more quickly when records are dictated. (2) Dictated records help in reviewing charts. Trends and patterns become clearer when everything has been written down. (3) Dictated records are a clear asset in a partnership or group practice. (4) They are an aid in remembering what has been said to a patient. (5) They save time. It is said that 10 to 15 per cent of a physician's day is taken up with paperwork, and in my opinion, the use of dictated records cuts the time of preparation in half. (6) Dictated records allow the patient to have a copy of what he has been told. This is important with respect to allergies, diabetes, and other chronic conditions. (7) They can be valuable in legal matters. (8) They will become more important as third-party payment becomes more common. If pediatricians expect to be paid for careful examinations and consultations (as are surgeons and pathologists), they will have to describe and document what they do. (9) Typewritten records are easier to read. In my own opinion, again, it is poor economy to buy a cheap recording system that, in the end, consumes more time. My preference is for a magnetic tape machine, because recordings on magnetic tape can be quickly erased in case of error. We have IBM equipment, and in this case the same tapes can be used on portable machines, so that dictation can be done while driving or walking, or in the hospital. A few minutes' dictation "on the run" each day can amount to many hours over the course of a year. I have also bought a Norelco pocket-size tape recorder, costing less than $100, that fits easily into a pocket, and I have been using it in place of a memo pad for notes that need not be transcribed. Its tiny cassettes record 10 minutes' dictation on each of two sides of the tape, and they are easy to mail, so that the pocket recorder can be used to swap taperecorded letters to friends and associates.
History Taking The classic way of taking a medical history is gradually becoming totally impractical. The increasing demands of today's busy practices require a new approach. It does not make good sense for a busy physician to use his expensive time asking a hundred or more questions of a parent or patient at every annual check-up. Questionnaires to be filled in by patients have not been an effective solution, the average patient's attitude toward more paperwork being about the same as the average physician's.
59
NEW WAYS TO OFFER BETTER HEALTH CARE
991
The Medical History Scanner System, developed and marketed by Medical Practice Systems, Inc., Bountiful, Utah, consists of about 100 plastic cards and a plastic tray with compartments labeled "Yes" and "N 0." There are three different sets of cards - one for a child aged 5 to 12, to be used by the parent; one for a teenager; and one for a parent's review of an adolescent. Statements on the cards pertain to medical history, behavior, personal relationships, and similar areas, and the cards are sorted into the trays by the patient or parent in what would otherwise be 6 to 10 minutes of wasted waiting time. Only the "yes" cards are significant; they can be recorded by means of a numerical code onto an accompanying history check sheet by the nurse or by the physician. Careful editing (by Sydney S. Gellis, M.D., M. Eugene Lahey, M.D., and the originators of the system) assures that most patients answer "yes" to relatively few questions. The scanning system helps to extract information that may be not only time-consuming to obtain by standard methods, but also may be difficult or even impossible to elicit - such as drug use, sexual problems, and other difficulties that are talked about only with great reluctance by most patients and some doctors.
Forms and Form Letters It is theoretically possible to devise some sort of a printed form to serve in practically every situation requiring the distribution of information. Physicians who attempt to do so will find sooner or later that there is a point beyond which a multiplicity of forms tends to reduce efficiency rather than increasing it. But there are a number of realistic ideas in this area that are being used in daily practice. LETTER TO PHARMACISTS. One of these is a form letter to pharmacists that outlines the physician's fundamental rules about prescriptions and refills. The example I have seen specifies that all medications are to be labeled by name unless otherwise stated and lists those prescriptions that are and are not refillable. While explaining that the practice is a busy one, the same form letter can urge pharmacists to refer any patient who telephones for medication. ADVICE FOR DETAIL MEN. Keeping on schedule is made more difficult in a busy practice by interruptions to deal with visitors who are not patients. Unknown salesmen can be routinely dismissed by the receptionist, while a physician's insurance agent or investment counselor quickly learns not to interrupt the office schedule. Still, there are the pharmaceutical representatives to be dealt with; they are excellent conversationalists and are friendly and interesting, but they can waste a great deal of time. A form letter can serve a useful purpose here. It can ask a pharmaceutical representative to condense his message to a few words or to leave only the most important written material or samples. If the physician has particular problems or, on the other hand, particular topics that he does not want to discuss, these can be identified in advance. SHORT ILLNESS FORM. Medical Practice Systems has available a short form that can be given to sick patients (or their parents) by the
1 992
WILLIAM
G.
CROOK
pediatric assistant. It consists of a list of symptoms and a series of columns headed "Today," "Yesterday," "2 Days Ago," and so forth. When prepared by the patient, the form not only indicates which of the most common symptoms are bothersome, but also how long they have persisted. A quick glance gives the pattern of illness, which can be enlarged upon if necessary. Space is provided at the bottom for brief notes on the physical examination, laboratory tests, and treatment recommended, and the form is printed on glue-backed paper so that it can be attached to the patient's chart. MONTHLY INFORMATION LETTER. To help inform their patients and reduce the number of telephone calls, one group of pediatricians that I know distributes a monthly letter with their statements. Typical subjects are current immunization recommendations, how we treat "strep throats" and why (including the importance of throat cultures), and "why no house calls." INFORMING THE REFERRING DOCTOR. Physicians who do consultation practice often will dictate a two or three page letter to the referring doctor, giving so much detail that the primary physician has trouble telling just what has been discovered and what is recommended. Of course the primary physician will need to have all the relevant information, but in addition he ought to have a short note covering the essential points: what has been found, what is recommended, and when he will see his patient again.
Group Conferences Periodic conferences with groups of parents and patients are much more effective ways of disseminating information than tedious one-toone conversations. One pediatrician who has conducted such classes for years makes use of a hospital assembly room or a school classroom, and he deals with such topics as emotional and behavioral problems, management of allergies, and problems of teenagers. Individual conferences can still be scheduled for parents needing more personal attention.
Screening Examinations in Private Practice A group of California pediatricians has had 3 years' experience in the use of a pediatric assistant to conduct health screening examinations in place of the annual physiCian examination in alternate years for children aged 6 to 12. The assistant obtains the medical history, height, weight, and blood pressure, and performs the complete eye test (using the Titmus Professional Vision Tester), audiogram, laboratory work, and immunizations. She also advises parents of any problems related to growth and weight, of immunizations that have been given, and of any difficulties that will require follow-up care. She spends about 30 to 40 minutes with each patient. The pediatrician may review the chart either before or after the patient leaves the office, depending on the findings of the assistant. The charge for this screening examination is just half of what the pediatrician would have charged; laboratory work and immunizations are billed at the usual rate.
NEW WAYS TO OFFER BETTER HEALTH CARE
993
Personnel Testing There is no way to be sure that a new office assistant will be honest, able to get along with people, conscientious, and able to do the job. Hiring the wrong person and investing time and effort in training her, only to realize later that she does not fit into your scheme of things, is something to be avoided whenever possible. My own experience has shown that a key factor is intelligence. All prospective employees at our clinic take a simple Personnel Test, available from E. F. Wonderlic and Associates, P.O. Box 7, Northfield, Illinois. The test consists of 50 questions, some with multiple-choice answers and others simple mathematical problems. Each candidate is given exactly 12 minutes to work as many of the questions or problems as she can, and the results are compared with standard norms. Interviews are still required for evaluation of a prospective employee's appearance, voice, manners, poise, and other characteristics. But this simple test helps to screen out many applicants who simply could not do the job. Possibly before long there will be a specially prepared psychological test to assist in screening such applicants from the points of view of intelligence, emotional maturity, and aptitude for medical service. It also seems likely that we will soon have programed learning applied to the training of medical office workers, using such modern devices as video tapes as well as the traditional self-testing instruments.
Computers and Telediagnosis Farther in the future will come the more widespread application of electronic data processing to medicine. It is already possible to obtain a medical history by the use of a computer which, like the doctor, can use answer to previous questions to determine what new questions to ask. Since April 1968 there has been a system of "telediagnosis" in operation between the Logan International Airport Medical Station and the Emergency Room of the Massachusetts General Hospital in Boston, which are almost 3 miles apart. A patient entering the consultation room at the medical station sees his physician on a television monitor; the doctor in turn sees the patient by television and can follow his movements about the room. One of the cameras has a close-up lens to permit detailed observations, such as examination of the eye for foreign bodies or visualization of dilated vessels at the back of the throat. With an electronic stethoscope, positioned by a nurse under the supervision of the physician, heart sounds, breath sounds, and bowel sounds can be heard. With the rapid expansion of modern methods of communication, it is not difficult to imagine the day when every home will have facilities for "two-way television." Then the time will be at hand when the pediatrician in his office can supervise a nurse-directed well-baby clinic located many miles away. As everyone knows, children like to watch television, and in the Boston experience, children have been willing and happy to talk to the televised doctor.
-
l 994
WILLIAM
G.
CROOK
Mobile Clinics These, of course, are not new; they have been operated by physicians and health departments in various areas for many years. But we ought to have more of them and make better use of them. An advance team of pediatric aides and other allied health workers, including laboratory technicians, could drive out into the country (or into the urban slum) and set up shop in an abandoned store, or a barn, or a school room. U sing modern interviewing systems and techniques, they would obtain medical histories and administer simple screening tests, such as the Goodenough Draw-A-Man Test or the Ammons test for performance capacity. Social workers could take more detailed social histories when indicated. Educational filmstrips for parents (in cartoon form for youngsters) could be shown while the initial processing of data was being completed. Then, perhaps, physicians {;ould be brought from their distant offices by helicopter or other rapid means, and every patient would get to see the doctor. Some patients would need no more than a minute or two of the physician's time, and most would take less than 5 minutes, but a few would require more time. Those requiring lengthy study would be referred to the nearest medical center.
Audiovisual Aids for Parent Instruction About a year ago, a medical communications company (Medcom) introduced a system of audiovisual instruction for use in offices or clinics. There are eight different motion pictures packaged in plastic cartridges and shown to patients on viewers that look like small teleVision sets. The drawings and charts are colorful, and the sound is quite good. I have been using this system for several months, and I have found that it helps me to instruct parents quite effectively. The only problem that prevents my wider utilization of this new tool is personnel. If I had an extra assistant or two, and about three of these viewers, I know I could do a better job of teaching parents the things they need to know.
Eye Screening Pediatricians used Snellen eye charts for years. We had one at the end of the hall, but the problem was that often someone would walk across the child's line of vision in the middle of a test. We purchased a Titmus vision tester to help us screen children's eyes more rapidly and help us make more appropriate referrals to an ophthalmologist. We have also used the Sjogren card, showing a picture of a hand. This kind of test can be given at home, which we recommend to mothers of 3-year-olds because amblyopia should be detected at the earliest possible moment. I am currently working on mimeographed sheets with E's of different sizes that can also be given to parents.
Forms to Answer Parents' Questions In 1963, I published a book entitled Answering Parents' Questions. It was a collection of more than a hundred mimeographed sheets that I use in my practice, plus references to books and pamphlets that I have
•
;
NEW WAYS TO OFFER BETTER HEALTH CARE
995
found useful. I still use th\:)se instruction sheets; they can be overdone, and they cannot replace personal interest and concern on the part of the physician. A doctor cannot answer a parent's question unless he knows what lies behind the question. He needs to avoid being misled by the apparent intellectual interest of parents to the point of overlooking their emotional interest. Further, he must remember that printed materials are no panacea but only an adjunct that may help to give patients more complete pediatric care. In our own group of five pediatricians, we have different attitudes toward mimeographed material. One partner uses these sheets about half as much as I do, two about a quarter as much, and the fifth even less. All of us give new mothers a copy of our Health Manual while she is still in the hospital. This manual contains general information about our office procedures and hours, recommendations for newborn care, and notes about immunizations. The mother is asked to bring the manual with her at the time of the 6-week check-up, and at that time, other sheets are added to it that deal with the baby's general development to the age of 6 months, feeding habits, and accident prevention. Additional sheets are added to the manual on future visits, covering the most usual questions that parents will have up to about the age of 3 years. ACKNOWLEDGMENTS
Ideas and suggestions mentioned have been drawn from a great many sources, and in some instances similar ways of improving health care are in use at more than one place. But the following physicians are responsible for these specific ideas: Glenn Austin, M.D., William Foster, M.D., and John C. Richards, M.D.: Screening examinations in private practice. Robert C. Brownlee, M.D., Claude C. Cowan, Jr., M.D., William R. DeLoache, M.D., and Harold P. Jackson, M.D. (the Christie Pediatric Group): Monthly information letter, and informing the referring doctor. Glen C. Griffin, M.D.: Medical History Scanner System, letter to pharmacists, advice for detail men, and the short illness form. Jerome Grossman, M.D.: Computers. Blackburn S. Joslin, M.D.: The Bellboy. Ramond Murphy, M.D.: Telediagnosis. (See Proceedings, Regional Meeting on the Delivery of Health Care to Children, American Academy of Pediatrics, Swampscott, Massachusetts, September 1968, p. 35.) Charles A. Tompkins, M.D.: Group conferences. 648 W. Forest A venue Jackson, Tennessee 38301
Readers of the pediatric journals are aware that they are exposed to few articles dealing with such mundane subjects as keeping records, taking histories, and establishing modern systems of communication in an office. True, there are periodicals whose function it is to offer such articles, but it is also true that, all too often, those of us in pediatric practice fail to take the time to write up some of our own observations that might help others to work more productively. For years I have experimented with many methods designed to improve office procedures, and I have learned of many more from other peq.iatricians. Some of the successful ones are briefly described in this article.
The Bellboy The Bellboy is a kind of miniature short-wave radio receiver that can be carried in a pocket. Its signal is a buzzing or ringing sound, activated by dialing a special telephone number. It functions when the physician is away from his office and a telephone answering service is responding to his calls. The answering service can instantly contact the physician by use of the Bellboy, and when the user hears it, he simply shuts it off and calls the answering service by telephone. The apparatus will work within a 20 to 40-mile radius, depending on local conditions, and is not affected by steel-framed buildings. Naturally the transmitter is a central one, and it must be installed and operated by the local telephone company. Once the system exists in a community, the cost of the service is nominal. More expensive two-way radio devices are also on the market and serve the same purpose where no Bellboy system has been installed.
Dictated Records Tape recorders and dictating machines have intrigued me since I first entered practice, when I tried to interest my first two associates in investing in dictating and transcribing equipment. Their response was to buy a half-dozen memo pads and some pencils that I could carry, saying that those would have to suffice. But finally in 1956, we bought some Pediatric Clinics of North America- Vol. 16, No.4, November, 1969
989
990
WILLIAM
G.
CROOK
equipment and hired our first full-time typist. We have dictated all of our patient records ever since. It might be thought that this system is either too expensive or too troublesome to be useful, and while all physicians would agree that written records of histories, physical examinations, and general medical records are important and necessary for hospitalized patients, few believe them needed for "routine" office patients. We have found that good records of all patients possess manyadvantages. (1) Adequate records permit better medical practice. If the physician commits his thoughts to paper, he will of necessity examine his patients more carefully. More pertinent findings can be recorded more quickly when records are dictated. (2) Dictated records help in reviewing charts. Trends and patterns become clearer when everything has been written down. (3) Dictated records are a clear asset in a partnership or group practice. (4) They are an aid in remembering what has been said to a patient. (5) They save time. It is said that 10 to 15 per cent of a physician's day is taken up with paperwork, and in my opinion, the use of dictated records cuts the time of preparation in half. (6) Dictated records allow the patient to have a copy of what he has been told. This is important with respect to allergies, diabetes, and other chronic conditions. (7) They can be valuable in legal matters. (8) They will become more important as third-party payment becomes more common. If pediatricians expect to be paid for careful examinations and consultations (as are surgeons and pathologists), they will have to describe and document what they do. (9) Typewritten records are easier to read. In my own opinion, again, it is poor economy to buy a cheap recording system that, in the end, consumes more time. My preference is for a magnetic tape machine, because recordings on magnetic tape can be quickly erased in case of error. We have IBM equipment, and in this case the same tapes can be used on portable machines, so that dictation can be done while driving or walking, or in the hospital. A few minutes' dictation "on the run" each day can amount to many hours over the course of a year. I have also bought a Norelco pocket-size tape recorder, costing less than $100, that fits easily into a pocket, and I have been using it in place of a memo pad for notes that need not be transcribed. Its tiny cassettes record 10 minutes' dictation on each of two sides of the tape, and they are easy to mail, so that the pocket recorder can be used to swap taperecorded letters to friends and associates.
History Taking The classic way of taking a medical history is gradually becoming totally impractical. The increasing demands of today's busy practices require a new approach. It does not make good sense for a busy physician to use his expensive time asking a hundred or more questions of a parent or patient at every annual check-up. Questionnaires to be filled in by patients have not been an effective solution, the average patient's attitude toward more paperwork being about the same as the average physician's.
59
NEW WAYS TO OFFER BETTER HEALTH CARE
991
The Medical History Scanner System, developed and marketed by Medical Practice Systems, Inc., Bountiful, Utah, consists of about 100 plastic cards and a plastic tray with compartments labeled "Yes" and "N 0." There are three different sets of cards - one for a child aged 5 to 12, to be used by the parent; one for a teenager; and one for a parent's review of an adolescent. Statements on the cards pertain to medical history, behavior, personal relationships, and similar areas, and the cards are sorted into the trays by the patient or parent in what would otherwise be 6 to 10 minutes of wasted waiting time. Only the "yes" cards are significant; they can be recorded by means of a numerical code onto an accompanying history check sheet by the nurse or by the physician. Careful editing (by Sydney S. Gellis, M.D., M. Eugene Lahey, M.D., and the originators of the system) assures that most patients answer "yes" to relatively few questions. The scanning system helps to extract information that may be not only time-consuming to obtain by standard methods, but also may be difficult or even impossible to elicit - such as drug use, sexual problems, and other difficulties that are talked about only with great reluctance by most patients and some doctors.
Forms and Form Letters It is theoretically possible to devise some sort of a printed form to serve in practically every situation requiring the distribution of information. Physicians who attempt to do so will find sooner or later that there is a point beyond which a multiplicity of forms tends to reduce efficiency rather than increasing it. But there are a number of realistic ideas in this area that are being used in daily practice. LETTER TO PHARMACISTS. One of these is a form letter to pharmacists that outlines the physician's fundamental rules about prescriptions and refills. The example I have seen specifies that all medications are to be labeled by name unless otherwise stated and lists those prescriptions that are and are not refillable. While explaining that the practice is a busy one, the same form letter can urge pharmacists to refer any patient who telephones for medication. ADVICE FOR DETAIL MEN. Keeping on schedule is made more difficult in a busy practice by interruptions to deal with visitors who are not patients. Unknown salesmen can be routinely dismissed by the receptionist, while a physician's insurance agent or investment counselor quickly learns not to interrupt the office schedule. Still, there are the pharmaceutical representatives to be dealt with; they are excellent conversationalists and are friendly and interesting, but they can waste a great deal of time. A form letter can serve a useful purpose here. It can ask a pharmaceutical representative to condense his message to a few words or to leave only the most important written material or samples. If the physician has particular problems or, on the other hand, particular topics that he does not want to discuss, these can be identified in advance. SHORT ILLNESS FORM. Medical Practice Systems has available a short form that can be given to sick patients (or their parents) by the
1 992
WILLIAM
G.
CROOK
pediatric assistant. It consists of a list of symptoms and a series of columns headed "Today," "Yesterday," "2 Days Ago," and so forth. When prepared by the patient, the form not only indicates which of the most common symptoms are bothersome, but also how long they have persisted. A quick glance gives the pattern of illness, which can be enlarged upon if necessary. Space is provided at the bottom for brief notes on the physical examination, laboratory tests, and treatment recommended, and the form is printed on glue-backed paper so that it can be attached to the patient's chart. MONTHLY INFORMATION LETTER. To help inform their patients and reduce the number of telephone calls, one group of pediatricians that I know distributes a monthly letter with their statements. Typical subjects are current immunization recommendations, how we treat "strep throats" and why (including the importance of throat cultures), and "why no house calls." INFORMING THE REFERRING DOCTOR. Physicians who do consultation practice often will dictate a two or three page letter to the referring doctor, giving so much detail that the primary physician has trouble telling just what has been discovered and what is recommended. Of course the primary physician will need to have all the relevant information, but in addition he ought to have a short note covering the essential points: what has been found, what is recommended, and when he will see his patient again.
Group Conferences Periodic conferences with groups of parents and patients are much more effective ways of disseminating information than tedious one-toone conversations. One pediatrician who has conducted such classes for years makes use of a hospital assembly room or a school classroom, and he deals with such topics as emotional and behavioral problems, management of allergies, and problems of teenagers. Individual conferences can still be scheduled for parents needing more personal attention.
Screening Examinations in Private Practice A group of California pediatricians has had 3 years' experience in the use of a pediatric assistant to conduct health screening examinations in place of the annual physiCian examination in alternate years for children aged 6 to 12. The assistant obtains the medical history, height, weight, and blood pressure, and performs the complete eye test (using the Titmus Professional Vision Tester), audiogram, laboratory work, and immunizations. She also advises parents of any problems related to growth and weight, of immunizations that have been given, and of any difficulties that will require follow-up care. She spends about 30 to 40 minutes with each patient. The pediatrician may review the chart either before or after the patient leaves the office, depending on the findings of the assistant. The charge for this screening examination is just half of what the pediatrician would have charged; laboratory work and immunizations are billed at the usual rate.
NEW WAYS TO OFFER BETTER HEALTH CARE
993
Personnel Testing There is no way to be sure that a new office assistant will be honest, able to get along with people, conscientious, and able to do the job. Hiring the wrong person and investing time and effort in training her, only to realize later that she does not fit into your scheme of things, is something to be avoided whenever possible. My own experience has shown that a key factor is intelligence. All prospective employees at our clinic take a simple Personnel Test, available from E. F. Wonderlic and Associates, P.O. Box 7, Northfield, Illinois. The test consists of 50 questions, some with multiple-choice answers and others simple mathematical problems. Each candidate is given exactly 12 minutes to work as many of the questions or problems as she can, and the results are compared with standard norms. Interviews are still required for evaluation of a prospective employee's appearance, voice, manners, poise, and other characteristics. But this simple test helps to screen out many applicants who simply could not do the job. Possibly before long there will be a specially prepared psychological test to assist in screening such applicants from the points of view of intelligence, emotional maturity, and aptitude for medical service. It also seems likely that we will soon have programed learning applied to the training of medical office workers, using such modern devices as video tapes as well as the traditional self-testing instruments.
Computers and Telediagnosis Farther in the future will come the more widespread application of electronic data processing to medicine. It is already possible to obtain a medical history by the use of a computer which, like the doctor, can use answer to previous questions to determine what new questions to ask. Since April 1968 there has been a system of "telediagnosis" in operation between the Logan International Airport Medical Station and the Emergency Room of the Massachusetts General Hospital in Boston, which are almost 3 miles apart. A patient entering the consultation room at the medical station sees his physician on a television monitor; the doctor in turn sees the patient by television and can follow his movements about the room. One of the cameras has a close-up lens to permit detailed observations, such as examination of the eye for foreign bodies or visualization of dilated vessels at the back of the throat. With an electronic stethoscope, positioned by a nurse under the supervision of the physician, heart sounds, breath sounds, and bowel sounds can be heard. With the rapid expansion of modern methods of communication, it is not difficult to imagine the day when every home will have facilities for "two-way television." Then the time will be at hand when the pediatrician in his office can supervise a nurse-directed well-baby clinic located many miles away. As everyone knows, children like to watch television, and in the Boston experience, children have been willing and happy to talk to the televised doctor.
-
l 994
WILLIAM
G.
CROOK
Mobile Clinics These, of course, are not new; they have been operated by physicians and health departments in various areas for many years. But we ought to have more of them and make better use of them. An advance team of pediatric aides and other allied health workers, including laboratory technicians, could drive out into the country (or into the urban slum) and set up shop in an abandoned store, or a barn, or a school room. U sing modern interviewing systems and techniques, they would obtain medical histories and administer simple screening tests, such as the Goodenough Draw-A-Man Test or the Ammons test for performance capacity. Social workers could take more detailed social histories when indicated. Educational filmstrips for parents (in cartoon form for youngsters) could be shown while the initial processing of data was being completed. Then, perhaps, physicians {;ould be brought from their distant offices by helicopter or other rapid means, and every patient would get to see the doctor. Some patients would need no more than a minute or two of the physician's time, and most would take less than 5 minutes, but a few would require more time. Those requiring lengthy study would be referred to the nearest medical center.
Audiovisual Aids for Parent Instruction About a year ago, a medical communications company (Medcom) introduced a system of audiovisual instruction for use in offices or clinics. There are eight different motion pictures packaged in plastic cartridges and shown to patients on viewers that look like small teleVision sets. The drawings and charts are colorful, and the sound is quite good. I have been using this system for several months, and I have found that it helps me to instruct parents quite effectively. The only problem that prevents my wider utilization of this new tool is personnel. If I had an extra assistant or two, and about three of these viewers, I know I could do a better job of teaching parents the things they need to know.
Eye Screening Pediatricians used Snellen eye charts for years. We had one at the end of the hall, but the problem was that often someone would walk across the child's line of vision in the middle of a test. We purchased a Titmus vision tester to help us screen children's eyes more rapidly and help us make more appropriate referrals to an ophthalmologist. We have also used the Sjogren card, showing a picture of a hand. This kind of test can be given at home, which we recommend to mothers of 3-year-olds because amblyopia should be detected at the earliest possible moment. I am currently working on mimeographed sheets with E's of different sizes that can also be given to parents.
Forms to Answer Parents' Questions In 1963, I published a book entitled Answering Parents' Questions. It was a collection of more than a hundred mimeographed sheets that I use in my practice, plus references to books and pamphlets that I have
•
;
NEW WAYS TO OFFER BETTER HEALTH CARE
995
found useful. I still use th\:)se instruction sheets; they can be overdone, and they cannot replace personal interest and concern on the part of the physician. A doctor cannot answer a parent's question unless he knows what lies behind the question. He needs to avoid being misled by the apparent intellectual interest of parents to the point of overlooking their emotional interest. Further, he must remember that printed materials are no panacea but only an adjunct that may help to give patients more complete pediatric care. In our own group of five pediatricians, we have different attitudes toward mimeographed material. One partner uses these sheets about half as much as I do, two about a quarter as much, and the fifth even less. All of us give new mothers a copy of our Health Manual while she is still in the hospital. This manual contains general information about our office procedures and hours, recommendations for newborn care, and notes about immunizations. The mother is asked to bring the manual with her at the time of the 6-week check-up, and at that time, other sheets are added to it that deal with the baby's general development to the age of 6 months, feeding habits, and accident prevention. Additional sheets are added to the manual on future visits, covering the most usual questions that parents will have up to about the age of 3 years. ACKNOWLEDGMENTS
Ideas and suggestions mentioned have been drawn from a great many sources, and in some instances similar ways of improving health care are in use at more than one place. But the following physicians are responsible for these specific ideas: Glenn Austin, M.D., William Foster, M.D., and John C. Richards, M.D.: Screening examinations in private practice. Robert C. Brownlee, M.D., Claude C. Cowan, Jr., M.D., William R. DeLoache, M.D., and Harold P. Jackson, M.D. (the Christie Pediatric Group): Monthly information letter, and informing the referring doctor. Glen C. Griffin, M.D.: Medical History Scanner System, letter to pharmacists, advice for detail men, and the short illness form. Jerome Grossman, M.D.: Computers. Blackburn S. Joslin, M.D.: The Bellboy. Ramond Murphy, M.D.: Telediagnosis. (See Proceedings, Regional Meeting on the Delivery of Health Care to Children, American Academy of Pediatrics, Swampscott, Massachusetts, September 1968, p. 35.) Charles A. Tompkins, M.D.: Group conferences. 648 W. Forest A venue Jackson, Tennessee 38301