How Do you Talk with Doctors?

There was a recent post on the FeeDR Pediatric Dysphagia Facebook from a therapist who detailed the frustration that occurred while  accompanying one of her clients to an appointment with her pediatrician. She explained that the doctor seemed underwhelmed and not overly concerned with the infant’s feeding and reflux issues and suggested only a referral to GI that was several months out.  However, with the therapist’s help in advocating for the family and child, the physician agreed to constipation and reflux management as well as providing referrals for further evaluation. I applaud this therapist for having the gumption to go to the appointment and advocate the way she did. But why do we have to do that? And what happens when we don’t have the time or ability to attend appointments with our patients?

I have spent most of my career working in pediatric hospitals and have daily interactions with various pediatric medical specialists. I have heard on many occasions about the lack of training physicians receive in medical school regarding feeding skills and nutrition. I’m proud to report that the community pediatric residents at UNC spend time with us in the feeding clinic. However, this is not the norm. I think I am safe in saying that most primary care specialists are guided by the weight and growth of the child. I have seen children who are failing to thrive get a referral to a specialist but if a child is gaining weight, even if they are vomiting, grazing, or eating frequently to meet calorie needs, they may not get referred. Sometimes caregivers are even told not to worry or the child will grow out of the problem all the while they are going to extraordinary lengths to feed their child.

My advice to therapists working with feeding clients is to consider yourself part of the medical team. You may well be the part of the team that knows the child’s feeding issues and parental concerns the best. Remember, most physicians do not watch the child eat or observe a meal time.

Feeding problems are often best served by multiple professionals working together to address the many factors that contribute to the feeding problem. Reach out to the pediatrician or primary care providers to collaborate on the child’s care. If you can’t attend an appointment then call the physician or send a brief summary with concerns and recommendations. Just like in the initial example, a physician may listen to another professional differently than a caregiver. The truth is-  having a professional advocate can make a significant difference in the intervention the child gets.

When talking with the medical provider, be brief but clear. I recommend illustrating what your concerns are and specific techniques that have been tried and for how long. When suggesting recommendations, be respectful. Sometimes I will say  something like this, “Could we trial a month of increasing bowel movements to determine if intake is better? what would you recommend for treating reflux?” or “ Could we try slowing down tube feedings to determine if the child is more comfortable and the gagging decreases?”.  Have a thick skin, if the physician is busy or doesn’t seem to agree, you are still doing your job of advocating for your client. Your job will be easier if the child feels better and has their underlying issues addressed.

          Know the research. Physicians like evidence based medicine. We don’t always have research for what we do but I recommend knowing the research that is out there. It helps to give credibility when asking for medical interventions.

          Inservice your local pediatricians. This is a great way to provide education to your referral sources as well as to build your reputation as a feeding therapist. Many pediatricians meet monthly and often have guest speakers come in. Typically, these types of inservice are brief and should cover things such as signs and symptoms of feeding and dysphagia issues, when to refer a child, and guidelines for intervention. Our feeding team is planning on presenting this Fall at grand rounds at one our affiliate hospitals to reach local pediatricians and then at UNC in early 2017. I will keep you posted on that!

In summary:

1. The feeding therapist IS part of the team.
2. Make contact and collaborate with the primary care provider.
3. Advocate for your client. Attend an appointment, call or send a brief summary with concerns and suggested interventions.
4. Know the research.
5. Offer to provide an inservice or plan to inservice local pediatrician groups.