As a doctor, I receive endless interest from seeing how other physicians’ offices function. It’s highly educational, and last week I got to satisfy my curiosity one more time. This time the visit to the doctor was for my daughter, a 6-year-old, who had experienced a couple of migraines in sequence about a month ago. These migraines were apparently severe enough to cause her to vomit. Given that this was our beautiful little girl, my wife and I didn’t mess around, so we had her referred to Dr Neurologist (obviously not his real name).

My daughter is an incredibly talkative, outgoing, and energetic person, and was very excited about her “brain doctor” appointment. I, on the other hand, wasn’t terribly excited for the obvious reason that although she seemed ok (I had done a neurological examination on her myself), there is always that apprehension that the doctor would pick up something bad.

Arriving at the office, I was particularly unimpressed by the bland waiting room and professional – but aloof – office staff. It didn't help that there was a television running neurology education information on a loop. Normally, I’m happy to see this – patient education is highly important – except it gave my daughter about six million extra questions to ask.

My daughter’s pretty observant, so this was an opportunity for a blessedly short conversation since we didn’t have to wait very long to be taken back. (This was a real plus!)

I was again perturbed when we were brought back to the doctor’s office where, in a formal and somewhat old-fashioned way, we sat across from Dr Neurologist at his large wooden desk. He said hello and shook my hand but didn’t engage my daughter. There was no small talk to establish a relationship or make her feel comfortable. When I have a pediatric patient, I like to establish a rapport as much as possible both with the parents and the child. Why not treat them like the people they are? Kids are remarkably fun to work with if you give them a chance. That wasn’t going to happen with my daughter’s neurologist.

Getting right down to business, he started asking me questions, again not speaking with my daughter. The funny thing was that my daughter wasn’t having any of that. She blithely spoke to the doctor telling him about the headaches from her perspective, expecting him to listen to her. Imagine that: a patient actually telling a doctor their own history? Go figure. It’s as if she were actually a human being with her own story to tell. Sadly, the neurologist would not listen to her and repeatedly asked me for clarification. Of course, since she’s the center of the universe (she lights up every room she enters with her ebullient personality), she just steamed ahead with her story, while I filled in the details.

One of the reasons the neurologist wasn’t paying attention to my daughter – besides not respecting her personhood – was his involvement with his electronic medical record system. He was dictating his notes as we went, which, although making for an accurate record, it created a disjointed and anti-social encounter. It was also a little disconcerting to listen to everything I said being quietly repeated back to me. Clearly, the neurologist was more concerned with completing his notes than having an authentic patient encounter. In fact, more than once, he asked my daughter to wait to tell her story while he dictated the pieces.

At the completion of this oh-so-personal history, he brought us into an examination room and performed a reasonable neurological examination. During the exam, he stated out loud his findings and their significance. For me as a podiatrist, this was interesting and educational, but for a nonmedical patient, the heavy use of jargon reinforced the impersonal nature of the encounter.

My daughter had a normal neurological examination. Dr Neurologist then went into his obviously customary authoritarian mode to dictate his treatment plan. He wanted to order some blood work and an MRI of the brain with and without contrast. It was at this point that I stopped him and asked about the recent medical concerns regarding the potential deposition of gadolinium contrast in the brain and its uncertain long-term effects. If you’re interested in knowing more about this read Practice Perfect 587 on this very subject. He brushed this off quickly, clearly not noticing that I’m a medical professional and even more clearly, not realizing that an MRI of the brain with intravenous contrast would be both a highly negative experience for my daughter, and also virtually impossible for her to sit still long enough to obtain quality images.

We left the neurologist’s office with my 6-year-old happy that she wouldn’t receive a shot (that’s all she really cared about in the end) and me unhappy with the overall low quality of the encounter.

For those of you interested, my wife and I chose not to do the brain MRI. A quick review of Up-To-Date on the topic of headaches in children revealed, “Most patients with a history of migraine headaches and no signs or symptoms of neurologic dysfunction or increased intracranial pressure do not need neuroimaging”.¹ This was the general consensus of not less than seven medical societies. Why put my daughter through the trauma of the MRI (IV placement, small space, loud banging, and the need to sit absolutely still for more than an hour) for no medically legitimate reason?

As a teacher of medical professionals at different levels, if given the chance to provide constructive feedback to my daughter’s neurologist, I would tell him the following things he could do to improve his practice (and why we will not be returning to him):

Luckily, my daughter’s situation was nothing to worry about other than keeping an eye on her and watching for recurrent migraines. Our day ended with a stop at a local gourmet cupcake shop where we were greeted by a very friendly person who was oh so happy to sell us delicious chocolate cupcakes that my daughter and I ate with gusto.

A wonderful chocolate smile shone back at me despite an unsatisfying appointment. Dr Neurologist could have learned something from watching how this cupcake shop worked. It ended with me as my daughter’s hero, but it could have been him. A little sweetness in his office would have gone a long way.