At 10:19 AM 7/4/98 -0400, wrote: >In a message dated 7/4/1998 6:12:25 AM Eastern Daylight Time, > writes: > >> What about not charging patients if they don't get better <g> ? >> >Isn't that what we do with capitation? When the patient is still sick, and >returns a few days later, we're basically seeing them for free, other than a >small copayment. Of course, to the patient it's no different, because they >only pay the copayment for the initial visit, too. > >Moshe Adler, MD Tim's comment was obviously made in jest (maybe the <g> should have been capitalized), but it does bring up an important point - the unrealistic expectation that we can always make sick kids better or that we can always predict who will get worse. The vast majority of the illnesses we see are self-limited and get better despite white we do, not because of our actions. On the other hand, sometimes things get worse because they're destined to or despite our best efforts. No matter how many times we tell families "It's a virus and will run it's course over 3-6 days", we still get calls 1-2 days later asking why the child's not better. We're not going to start a child with a URI for one day on antibiotics just because there's a small percentage chance that AOM will develop a few days later. Part of being a good clinician is deciding if and when a child should be re-checked when there's not improvement and communicating warning signs to the parents. When there is a (probable) mild bacterial illness, even the best antibiotics statistically only result in a 90-95% cure rate (and this is only 10-15% more than the 80% placebo cure rate seen in a lot of studies). Unless we're going to do typanocentesis for all AOM (or bronchoscopy and sputum samples for all pneumonia), we can only make our best guess as to when an illness is likely to be bacterial and which antibiotic will be the best choice. And although sometimes we'll be wrong, this doesn't mean we haven't done our job properly and to the best of our ability. Michael Sachs, M.D. General Pediatrician