By Dr. Joseph Chiaramonte
(Note: Dr. Joseph Chiaramonte is a board-certified pediatric allergist, now retired, who is not related to Dr. Larry Chiaramonte, although he trained with him.)
Clinical judgment is the immeasurable quality a doctor develops after the book learning in medical school. Think of how you learned about parenting. You can read all the books, but you don’t truly appreciate what it entails until you are a parent. You develop an emotional connection to a child very quickly, and try to remember what you read as problems arise on very short notice, balancing that book learning with what your emotions tell you. You learn experience, and the next time, you make decisions about what is best for the overall welfare of that child based on the accumulated knowledge. That to me is similar to clinical judgment.
Clinical judgment has always been to me the attribute that separates the men from the boys and the women from the girls. I was told in medical school that, “There are many doctors but few physicians.” Clinical judgment is what gives the doctor the quality of being a physician.
I would now like to relate a few common scenarios that parents can keep in mind in advocating for their children that may indicate the need for a referral to a pediatric allergist/immunologist. In each example, you should be alert to the fact that a simple diagnosis or label may point to a deeper problem with the immune system that may be lost in the hurry-up environment of general pediatric practice.
First case: You have an infant or young child who was diagnosed with a common respiratory ailment called “Bronchiolitis”. After the episode has improved the child is left with persistent breathing problems including bronchial wheezing. This may be a sign of developing asthma, which needs a referral to the specialist for the appropriate work-up and treatment.
Second case: Your child seems to get repeated ear infections and the primary care provider eventually says the child has “fluid in his/her ears”. This is a problem that maybe caused by malfunctioning of the Eustachian tube and allergy is a major contributor. Once again referral is indicated for proper evaluation and treatment.
Third case: Your child seems to have trouble in gym and wheezes when running, called exercise-induced asthma. This again needs evaluation by the specialist that should include complete pulmonary function testing.
Fourth case: Persistent skin rash that causes severe itching and no matter how many creams or ointments the primary care provider gives the rash stays and gets progressively worse. This is probably “Atopic Dermatitis” (eczema) and needs again the expertise of the specialist. In all my years of practice this is one of the most frustrating ailments to treat and I have always found that dust mites played a role in the etiology.
Fifth case: Here I would like to discuss asthma and the fact that in my opinion all asthmatics should be under the care of the specialist. In practice I always found that primary care providers underestimate and under treat the problem. Leading to this under treatment is the classification of asthma into mild, moderate and severe. The mild category often leads to bad outcomes for a variety of reasons, among them: doctors don’t treat aggressively enough to control inflammation along with current symptoms, and patients (and their parents) are lax about taking medication because it’s “only” mild. In all my years of practice I have found more children with mild asthma in the ER than the severe cases. Here again, these patients should be followed by the specialist with a proper treatment plan and appropriate pulmonary function testing.
If these scenarios ring any bells, I hope you will raise the issue of specialist referral as parent and health care proxy for the care of your child. In my opinion the welfare of all children is a primary goal.
Dr. Joseph Chiaramonte went to medical school at the University of Padua, Italy from 1960 to 1965, then trained in pediatrics at Brooklyn-Cumberland medical center, Brookdale Hospital Medical Center, where he was chief resident. After two years in the United states Air Force practicing general Pediatrics, he did a fellowship at the Long Island College Hospital in the program chaired by our own Dr. Larry. He then entered private practice and served as director of out-patient services of Good Samaritan Hospital in West Islip NY, where he was for a time director of Pediatrics, and director of the allergy-immunology clinical center and associate director of the Cystic Fibrosis Center.