What You’ll Learn

A pediatrician discusses common issues in care delivery in the urgent care setting where families do not have a long relationship with the physician, along with the trust that is needed to talk about vaccines with parents. She also offers insights to the reasons a MedTech innovation inspires her: making care more comfortable and less invasive for young patients and more efficient for clinicians. 

Interviewee: I’ve been a pediatrician for nine years, and I primarily work in a pediatric urgent care office that’s affiliated with a children’s hospital. I also spend a little time working in their emergency department, but the majority is the outpatient urgent care office setting. I’ve been doing pediatric urgent care medicine for eight years now. The majority of time I was practicing in New York, but as of the past 10 months, I’ve been out in Arizona.

VIVO: How big is your unit from a rough physician numbers perspective and also how many patients are coming through in a week or month?

Interviewee: In terms of the physician staffing, I would say physically working at the urgent care during a shift is anywhere from one or two clinicians. So it’s either a pediatrician and another pediatrician or an NP and a PA and a pediatrician. So there can be a little variable in that, but it’s either one or two clinicians. The overall practice size, because everyone who’s in the emergency department also does these urgent care shifts, I think there’s maybe a hundred, but that’s divided among two other ER departments.

Not everyone goes to the same urgent cares. So it’s a larger pool that gets divided down into subgroups. In terms of the people that actually rotate through the urgent cares that I work at, I would say maybe it’s 20 or 30 that are the regular people that rotate through.

VIVO: About how many patients are you personally seeing in a given week or month?

Interviewee: I think it’s a little variable depending on the season, being that pediatrics tend to be a little busier in the wintertime compared to the summer months. I would say in a seven to eight hour shift, right now we’re seeing probably about 25 to 30 patients. And then in the wintertime that can be anywhere from 40 to 60 patients.

VIVO: When was the last time that something new inspired you at work?

Interviewee: That’s a good question. I think it’s been a while, unfortunately. I think the last time something inspired me at work was a new device that was being introduced to our office for doing suture repairs. Rather than for doing laceration repairs, so rather than doing sutures or glue, it was a new type of device that used adhesive strips to bring the wound edges together.

And I thought it was so great, especially from a pediatric standpoint because it’s less scary, it’s more comfortable for the patients. For adults, I feel they can handle more things. Seeing that really inspired me. It made me feel that these companies are taking into account pediatric patients and making things more comfortable and less invasive for patients and also helping things be more streamlined and more time efficient for clinicians.

VIVO: Have you used it yet, the device?

Interviewee: It was actually at my previous job where we had that and I was able to use it a few times, but I don’t have it at my new place, so maybe it’s something I’ll recommend that they get.

VIVO: Did it do what you thought it was going to? The patients that you used it on, did they feel like they had a better reaction, were a little less scared maybe?

Interviewee: I do. I think it worked well for the patients and also for the parents, for them to have this very anxious, crying, screaming six-year-old who doesn’t want to get stitches. And then I said, “Well, I have this new option that we can use, and we’re going to put some stickers on your skin and come back in a week and then we take it off.”

And when we put it on and everything was sealed up, I think the parents really appreciated that it wasn’t a traumatic experience for their child and the kid was in shock that that’s all it was. I think it met the goals that it had set out to do.

VIVO: In general, how has business been over the last few years?

Interviewee: In general, I think the offices have had a steady flow of patients and I think they are getting busier. I think in the past few years, if you’re including the times of COVID, I think we definitely saw a big dip and lull during that time period. I don’t have hard numbers, but from my personal experience, I think the numbers are back or higher than they were pre-COVID. I think there definitely is a growth in the market space.

VIVO: What’s one of the most persistent challenges you have seen over the past months or years to doing your work well?

Interviewee: I think one of the most challenging issues is trying to get information. Sometimes parents don’t always know the information in terms of, “What was that most recent antibiotic you were on?” or “What medications is your child taking?” and “I don’t remember the name.” If their prescribing clinician wasn’t within our network, I have no way of accessing what their pediatrician prescribed.

It would be nice if there was one central location that we could pull all this information from in terms of their past medicines rather than being, “Mom, can you call the pharmacy and I’ll come back in 10 minutes and you can let me know what it was?” I feel that’s one roadblock because that can definitely change the management that I would be recommending based on previous management that they had.

VIVO: You previously were in a different role. Was that also emergency medicine or was that emergency pediatrics or was it a different kind of environment you were in?

Interviewee: It was all urgent care, so I was 100% urgent care there. Here I think I’m 95% urgent care, 5% emergency medicine.

VIVO: Do you feel like access to information has been different depending maybe from your previous job to this one or statewide? Are there regulations or programs in place that make it harder or easier?

Interviewee: I feel like it’s been pretty consistent. I haven’t really noticed any differences in terms of my access to information and my discussions with the patients and their families. I haven’t noticed a big disparity between medical knowledge between the two different groups of populations that I’ve worked with.

VIVO: Why did you become a pediatrician?

Interviewee: I think the main reason is because when going through all my clinical rotations, I found that the pediatric world was an overall positive environment to be working in. Thankfully, the majority of times kids tend to get better and have good outcomes and good prognosis. And aside from a clinical standpoint, kids are generally happy. They generally try to see the positive outlook.

Sometimes they’re in their own little world and we’ll talk to you about their stickers or their favorite foods, and I feel there’s not a day that goes by that I don’t smile with the kids or laugh with the parents over something. I feel it’s a very positive work environment to be in.

VIVO: Has it been what you expected since you’ve been in pediatrics from what you thought it would be?

Interviewee: I think for the most part I think it has been in terms of the type of medicine, the type of environment that I work in. I think probably the more eye-opening or probably what I didn’t expect as much is the… I’m trying to find the right word here. I don’t want to say mistrust and I don’t want to say disrespect, but I feel that there sometimes can be… You can give your recommendations and have evidence and say why, and then a parent can say, “No, I don’t want to do that.”

More of a pushback. And I feel I wasn’t expecting that as much because I would like to think that we all have the child’s best interest in mind. Having that difference in opinions over something, to me that seems very straightforward because it’s science-based was a little more eye-opening to me.

VIVO: Do you think even from residency up until now, do you think that’s been a change? Do you think it’s evolved toward mistrust?

Interviewee: I don’t know if I was that aware of it, because in residency I felt that the majority of my training was inpatient in the hospital setting where there wasn’t too much of this discussion. It was “Your kid’s in the hospital. They need antibiotics. This is what we need to do.” And I think at that point when you’re in that setting, I think maybe parents are more agreeable to following your recommendations as opposed to in the outpatient, especially in an urgent care.

I mean, they’re coming in. They’re walking in. They don’t know me. They chances have never met me before. I’m not their pediatrician. They don’t have a rapport or relationship with me. I feel they can take my recommendation and say, “I want to go talk to my pediatrician now because I know them longer.” I feel that in residency I didn’t notice it as much because of the setting I was in. Plus, I think if there was a concern, it was, “I’ll have my attending come talk to you.”

I was able to have the leader work out those issues. I think now when you’re out of training and you’re the one fielding those questions and heading on those conversations, you’ve got a different exposure to it.

VIVO: What are the most common things that come to mind that you feel like you’re getting¬† pushback from parents on?

Interviewee: Yeah. I think sometimes it can be the need for or the request for antibiotics when it’s not indicated when they have a viral infection and having to have that conversation multiple times and say, “No, it’s not indicated. This is a virus. Antibiotics don’t treat viruses.” I think that’s the most common conversation that I have. And then I think sometimes the recommendation to have further evaluation in the emergency room because I have concerns that it’s outside of my scope or there’s a concern that I have.

Sometimes parents will give a little bit of caution and say, “Well, why?” Usually with that after explaining it two or three times, then they understand. But I think some of it is the instant gratification that parents are seeking in the sense of their kid has been sick for two days. They want a quick solution.

Or they’re coming in, and even though there could be a waiting room full of people and the rooms are booked and busy before them, they want to be seen right this instant regardless of they walked in and there was already 20 people ahead of them. I feel that also adds to the customer service realm of medicine that it’s evolved into, which isn’t always a positive thing I feel.

VIVO: What wisdom have you learned from pediatrics?

Interviewee: I think that a lot of pediatrics is doing a lot of discussions and explanation and sometimes having that shared decision-making with the parents and sometimes saying… It’s really working like a team I think with the families, in the sense that I can say, “Listen, I know your kid fell and hurt their ankle earlier today, but they seem to be walking okay. I don’t see any signs of any injury. I don’t necessarily feel that we need to do an x-ray at this point, but I understand that if you say you’re not going to sleep tonight unless we do, as long as you understand that an x-ray is radiation, this is a potential risk of it, we can still do it.”

I think it’s a lot of open communication that needs to be had in pediatrics and working as a team because sometimes the patient is 99% of the time a minor, so they’re not the one able to make their decisions on their own. I think that’s one thing is definitely having a lot of patience is needed in the world of pediatrics. I think that’s probably the main focus that I’ve seen.

VIVO: What will pediatrics look like in 10 years?

Interviewee: It will be interesting. I feel that there will be, I don’t want to say a divide, but I wonder if there will be more of a population that, there are certain populations that don’t want to vaccinate their kids and then they will find pediatricians who agree with not giving those vaccines. And then you’ll have one section of pediatrics that will be doing this and then one section that would be following these guidelines. I feel we’ve started to see some of that.

Where I am now compared to being on the East Coast, I feel I see a lot more of that pattern. I wonder if there will be this somewhat of a division between those thoughts. I feel that there will always be a need for inpatient evaluations as opposed to telemedicine only because a lot of pediatric care I think is based on your physical exam that you can’t always do through a computer screen, looking through an ear or running a strep test.

I think there will always be a need for inpatient or in-person evaluations as opposed to moving towards a telemedicine focused. We’ll see what happens, I guess.

VIVO: I’ve heard the term a couple times or the idea of delayed vaccination. Is that another school of thought? What do you know about or what do you see around that?

Interviewee: I definitely have heard a little bit of it. I mean, I guess it’s another option that can be had. But being in the urgent care, we don’t administer routine vaccines, so I really haven’t had to be part of that type of conversation. Usually they’re coming in, and if they have a fever for three days and they have their vaccines, I have this kind of thought. If they’re unvaccinated, then I have this kind of thought.

It changes my thought process, which is why it’s relevant in my standpoint. I’ve had a few that I’ll say, “They’re on a delayed vaccine schedule,” but I think it’s a very gray area because even I’ll say to the parents, “What vaccines have they received or what point of the vaccine schedule are they up to?” And a lot of the times I don’t get an answer because the parents don’t know.

They’re like, “They’ve gotten some, but I don’t know which ones.” It’s hard for me to have a further insight, but I think there’s no real schedule for it. I think it’s a touch and go kind of thing.

VIVO: What is not being said in pediatrics that needs to be said?

Interviewee: I think the one thing that I feel is especially I think general pediatricians do a lot, a lot, a lot of work in terms of they have a very important job of doing these well visits and being able to identify when a kid has an issue and back to school forms and paperwork and all of that. And I think in terms of general pediatricians and I think pediatrics as a whole, I think we’re slightly devalued in the medical field in the sense of I think our compensation reflects that a lot.

Unfortunately, I’ve seen that working in an urgent care setting where I can see a job posting for urgent care, but they want someone who is family medicine trained and the salary is quite higher than what my salary would be when you think about we’re doing not the same medicine, but we all went to med school. We all went to residency. We all did this training.

I think there’s a little bit of devaluing pediatricians in terms of compensation, and I think sometimes the way people view things. Not that everyone in medicine is the same obviously, but I feel someone could be, “Oh, they’re a cardiologist,” and they’re, “Oh, they’re a pediatrician.”

It’s a very different kind of connotation to it, which I feel is disheartening because the patients that we’re taking care of are our next generation. If we don’t take care of them, who’s going to take care of our world? I think there should be more value for the field of pediatrics.

VIVO: What do you think makes pediatricians different from other specialists, other HCPs?

Interviewee I think in general, I mean, part of it is stereotype, but part of it I think is true that I think we tend to be good-natured and very nice people because you are working with kids and you definitely need to have a lot of patience working in the field and good communication skills to be able to talk to an eight-year-old and explain to them what’s going on, but then also have the same conversation and explain to the parents what’s going on.

I think you need to wear multiple hats in this role, that you have to have certain tricks up your sleeve to make a patient feel comfortable. You have to be a little versatile in how you can do things. I think definitely people tend to think the world of pediatrics is unicorns and rainbows and stickers, which a lot of my day sometimes it is, which is nice, but there are hard conversations that need to be had.

It’s not always good things that you’re talking about or good news, or there are some hard conversations to have with parents. And I think you have to be able to have the ability to switch that, that you can go into one room and say, “This is okay. You’re doing great,” and then go into the next room and say, “Hey, listen, we got these blood work results back. I’m concerned. You need to go to the ER.” I think you have to be able to be very adaptable.

Participant Profile

• Female Pediatrician
• Currently in Arizona (previously New York)
• 8 years in pediatric urgent care
• Pediatric urgent care affiliated with a children’s hospital, with some time in emergency department
• Patient volume: 25-30 patients per 7-8 hour shift (normal season); 40-60 patients per shift (winter season)
• Notable challenges: Limited access to patient medication histories across healthcare networks, increasing parental pushback against medical recommendations
• Key priorities: Improving patient experience, particularly for children requiring procedures