Wednesday, March 4, 2009

Where Have I Been? Back in the land of Primary Care

I am tremendously flattered to note that, despite it being 3 days since my last post, people are still visiting the site, which means it must still be filling a need among those who have been diligently been working to improve children's mental health services in Massachusetts.  As I mentioned on Friday, I was away at the AAP's Future of Pediatrics meeting last weekend, and returned home to a blizzard and 90 minutes of shoveling to get the car into the driveway, and then a full day of clinical practice yesterday, ending in a Providence Singers rehearsal.  Concert coming up.  Get your tickets now!

I was an interesting day in the office-  we are at that point in the winter where it seems like every child in Massachusetts has been coughing for the last 3 months, and parents can't remember which child had a fever last night and which had a fever last month.  I saw 23 patients, but only 4 of them were well child visits (read EPSDT or the kind of visit in which we screen for behavioral health).  Those kids were fine- doing well in school, participating in sports, perhaps a bit on the overweight side- and their PEDS/M-CHAT/PSC screens were all fine.  Among the children who were sick, however, were several who were having difficulty in school.  

One stands out in my mind-  a young person in middle school, who needed a note to excuse an absence of 4 days for a cough.  Now, on examination, this person had a diagnosable condition, that would be amenable to treatment with an antibiotic.  I diagnosed the condition and gave the antibiotic, with my usual pronouncement that the youth should return to school tomorrow if afebrile.  This child, however, was being investigated for truancy (hence the need for the note) and on review was noted to have been referred for counseling back in the Fall, during a health maintenance visit in which school anxiety had been discussed.  We had screened, identified a problem, made a referral- all by the book.  It would have been easy to wash our hands of the situation, by saying that the family was "non-compliant".  Would have been accurate, except that in the eyes of the family, the child was having no problem.  We had a long conversation in which I advocated for school attendance, and the parent wanted to assure the youth that there were many people who made it in the world without graduating highs school.  Very different world views-  I cited Malcolm Gladwell's book Outliers, which points out how graduating from a "good enough" college gives one a leg up on the good life that being born brilliant really does not - the parent wanted to be clear that one simply cannot give up on oneself because of failure.  I am not sure that any minds were changed in the exchange.  It is pretty clear, however, that screening alone means little without the ability follow children longitudinally and follow-up on the recommendations that one makes.

The results of the CSA bids are supposed to be announced on Friday.  It will be interesting to see who will get the contracts.

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