Unbabbled Episode 8: Talking to Your Pediatrician

Talking to Your Pediatrician with Dr. Marshall Lerman

“Talk to your pediatrician.” It’s the advice parents hear frequently when they have a concern about their child. However, no one tells you how to bring up these concerns or what to look for in the pediatrician’s response. In this episode, Marshall Lerman, MD discusses tips for finding a pediatrician that fits your family and bringing up concerns with your doctor, while empowering you to become a strong advocate for your children. 
Dr. Lerman received his medical degree from The University of Texas Medical School at Houston. He completed his pediatric residency training at The University of Texas Health Science Center at San Antonio. He graduated with highest honors from The University of Texas at Austin with a Bachelor of Arts in government and a minor in business administration. He also holds a Juris Doctor degree from Georgetown University Law Center where he made law review, serving as an editor of the Georgetown Law Journal. Dr. Lerman is a licensed attorney by the State Bar of Texas and is board eligible by the American Board of Pediatrics.


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Stephanie:                        00:05                   Hello and welcome to Unbabbled, a podcast that navigates the world of special education, communication delays and learning differences. We are your hosts, Stephanie Landis and Meredith Krimmel and we're certified speech language pathologist who spend our days at The Parish School in Houston, helping children find their voices and connect with the world around them. In this episode, we speak with pediatrician Dr. Marshall Lerman. Dr Lerman received his medical degree from the University of Texas Medical School at Houston and completed his pediatric residency training at the University of Texas Health Science Center at San Antonio. He currently works at Bootin and Savrick Pediatric Associates in Houston. We sat down with Marshall to discuss a variety of topics ranging from tips on finding a pediatrician that fits your family. To ways to bring up concerns to what parents can expect when bringing up those concerns with their doctor. Throughout the episode, Marshall provides information to empower parents to be strong advocates for their children.

Stephanie:                        01:05                   Welcome. We're very excited to have Dr. Lerman here talking to us today as a pediatrician. Personally. I'm very excited to chat with you and I think it'll be great for all of our listeners. So welcome.

Marshall:                          01:15                   Thank you so much. Thank you for having me.

Stephanie:                        01:17                   All right, well I want to start off just giving everybody a little bit of a chance to get to know you. What got you into wanting to be a pediatrician? You have so many options when you're in med school.

Marshall:                          01:26                   Great question. So actually I'm a recovering lawyer who's always loved children and when I was practicing law, I did some pro bono work, free work, for children that were wards of the state of Texas in adoption proceedings and I just loved kids. Then I came over actually to where my wife worked at The Parish School and she was working with groups of 3- to 5-year-olds and they were sitting there and she said, does anybody know who this is? And they all in unison screamed, "your Daddy!" Amy is very short. She's very awesome. So anyway, I love kids and I just knew I wanted to be a pediatrician. I love working with parents and their kids.

Stephanie:                        02:03                   Fantastic. That's awesome. That's so great. So one of the things we've been talking about with so many of our other guests is when we encourage them to when they have concerns is the first step is to go and see their pediatrician. However, then we don't give them the advice of what do you then say to your pediatrician? Do you have any advice for parents on how to bring up concerns?

Marshall:                          02:25                   I think it's very important to go see your pediatrician in these instances because the pediatrician is the one who's looking at the holistic view of the kid. For parents, I would say to be honest, I mean as a parent, you know your child better than anyone else and so if you have a concern, I think it's very appropriate to be honest and straightforward on what your concern is. If you don't want your child to hear what your concern is, for instance, you can say you want to speak or let the nurse know you want to speak to the pediatrician alone before the appointment that way, and that can guide you. But I would say be very forthright. Tell the pediatrician what you're thinking. Good pediatricians are listeners. And that's what I would do.

Meredith:                         03:02                   That's great advice to speak to your pediatrician without your child in the room.

Stephanie:                        03:07                   That was actually one of my questions is, is it common to ask, because my child is getting older and you know, I never want to say anything in front of her and for her to then internalize that, so it's wonderful to know that that is an option.

Marshall:                          03:19                   That's an option. And you just let the nurse know beforehand or when the doctor comes and say, Hey, can I speak to you for a second? And we'd go into a different room and if we then want to bring it up in front of the child, I speak to their parent how they would like to do that. But yes, absolutely pediatricians would prefer that.

Meredith:                         03:33                   So when a parent brings concerns up with you as a pediatrician, what types of responses might parents hear from you? Do we get referrals out or, you know, what should we be looking for in our answers?

Marshall:                          03:45                   So I'd say every kid is is unique, but there are sort of milestones, baseline milestones that we want all kids of a certain age to meet. So the first thing I would do would be to evaluate whether those milestones are being met. Some of them are verbal, some of them are social, some of them are cognitive, some of them are gross motor. And so that would be the first thing we look at. And that should be done at every well child exam once a year. At that point I would then tell the parents, so if the parent was concerned about a speech delay, I either do or don't think it's present. I'm taking into account that there's ranges of normal and I would either say, I think at this time we should refer to something like ECI, speech therapy, occupational therapy or we monitor this and I give parents exercises to work on to watch and if need be we follow up closer

Stephanie:                        04:31                   And early childhood...

Marshall:                          04:34                   ECI is early childhood intervention, excuse me. Yes. And so early childhood intervention is great and I actually learned that through my wife. They go out either to the family's home or oftentimes they'll go into those school and they do an independent evaluation, whether it's a speech therapist, an occupational therapist, a physical therapist about whether services are needed. And if they're needed then I believe it's up to age three. They will set that up however often necessary. And then we'll monitor the progress for that.

Stephanie:                        05:02                   And that's a service that is done through the state that's free of charge to families?

Marshall:                          05:06                   Yes.

Meredith:                         05:07                   And then after three they move into their school districts, which is good for parents as well.

Marshall:                          05:11                   And uh, if a kid is in school or in a grade level, I always tell parents if they're concerned, especially about let's say learning disabilities or something like that, um, that they need to speak to the school and request that this school does their independent testing. If it's a public school, usually that's done. If it's a private school, there are methods as well to do that. Cause I think being evaluated in two environments is good.

Stephanie:                        05:32                   Are there other types of doctors that you would refer to if each parent has like global concerns?

Marshall:                          05:37                   Oh, absolutely. So, you know, pediatric neurology would be one that if a of a child is having any sort of brain or a neurologic injuries or, or difficulties, um, ENT is wonderful, especially with speech delays. I would, uh, every child who has a speech delay or pediatricians thinks so should be tested by an audiologist to make sure first hearing is not the issue. And then I'm a, I w so let me say for me, if a parent is concerned, I'm concerned. And so, you know, if a parent comes in and I say, I don't think somethings present, if a parent is still worried about it, then I think it's reasonable to either ask for a second opinion or to continue advocating for your child to see someone else within the practice and if you need to go elsewhere. But what I wanted to say is for me, if a parent is concerned, I'm concerned. So if I'm seeing global issues or I'm having concerns on a higher level than individual, whether it's speech or gross motor or other issues, then I will refer to a developmental pediatrician, who are the experts in making certain diagnoses that can get kids the help they need and the type of services that they need.

Stephanie:                        06:47                   And can you give a little bit, you touched on it a little bit, the difference between like your general pediatrician and a developmental pediatrician?

Marshall:                          06:53                   So all physicians go to medical school for four years and then do a residency. So if you're a general pediatrician, you've done three years in general pediatrics. Meaning you're getting all the basics you need to know about the holistic child. Other subspecialists such as a pediatric neurologist, for instance, studies the brain and neurons. They're still a pediatrician, but then they branch off and do an extra fellowship year, which is either two or three years to learn a specialty. So developmental pediatricians, as far as I know, do their residency and then they do a three year fellowship, which means three extra years just devoted to development. Okay. Including autism spectrum disorder, other issues, they have the training required to make specific diagnosis related to development. Yeah.

Stephanie:                        07:42                   So they're focusing on that instead of, you know, everyday rashes or fevers or other sicknesses?

Marshall:                          07:46                   Great. Yes, exactly. That is what they were doing and that's all they're doing, which makes them more skilled because they're seeing a lot of it. I always liken it to say a child breaks their arm or leg. I can certainly get an x ray, diagnose it, and I actually did urgent care. I could probably splint it, but most pediatricians will then refer to an orthopedist, meaning they are, they are trained to deal with bones. Um, there are rheumatologists are trained to deal with joints, pediatricians manage it's kind of like the quarterback managing everything. But it's very important that if your child has a need, that they are being referred to subspecialists. And as a parent, if you think that's necessary, you advocate for that.

Meredith:                         08:25                   So what kind of red flags would alert you that maybe you should refer to a developmental pediatrician?

Marshall:                          08:31                   So there are usually a constellation of symptoms. For instance, a child is behind verbally, not speaking, perhaps not making eye contact, perhaps acting out and getting very frustrated at home and in school. Perhaps they're not yet walking or crawling or a different scenario would be perhaps they were doing all these things and then they stop. It's important to remember that there are a broad ranges of normal and certain things such as walking on your toes, while not normal is not necessarily abnormal. I have flat feet. Not Everybody has. It doesn't affect me in any way, but when you get essentially walking on your toes, no eye contact, difficulty in social situations, grades suffering, very stringent. Then I start to see more of a global picture. Is this possibly something that we should refer to developmental pediatrician for to get a better view?

Stephanie:                        09:29                   You've mentioned before parents continuing to advocate for themselves. Is there certain phrases or ways parents can word things that make it seem more of a higher concern on your end? I know that for me myself, I even sometimes going into the pediatrician feel a little worried bringing concerns up. So I'm like, oh, afterwards I'm like, oh, did I, did I really express myself well enough there? Are there certain ways that we can empower ourselves?

Marshall:                          09:57                   For me, yes. So you look the pediatrician in the eyes and you say, understand me, I am very concerned about this. Okay. And when we make an assessment, if you don't agree, tell us. Yeah, I am still worried about this. I don't feel better. Okay. That to me signals, even if I think the child is doing well, mom is really worried about this. And for me that's concerning because mom knows kid best. It doesn't necessarily mean mom or dad are right medically, but it's important. And so I tend to say at that point we talked further, hey, let's come back for a specific visit for this. Let's follow up more closely. Or do you want to go for or do you want a referral? Is that what you're looking for? Meaning that's important to know. I won't feel better until I get this assessment for whatever reason. And if that's the case, a lot of times I will, I will refer because you know what, parents, your comfort level and you knowing an answer is oftentimes valuable. Yeah. If it's not going to hurt the child, I do not. My best interest in any pediatrician's best interest should be the child. Yeah, and if something is not going to hurt the child, then I'm for it and sometimes that means a referral.

Meredith:                         11:13                   It sounds like you have to be really comfortable and feel safe with your pediatrician. As a parent it's hard to bring up things about our children that maybe worry us or, so it sounds like having a pediatrician that you do feel comfortable with looking in the eye and saying, no, I don't feel better. Is is really important?

Marshall:                          11:29                   Absolutely. Pediatrician should have a very high social acuity, but you know, yes. Talking to your pediatrician and finding that comfort level and if you don't have it then you find someone else. The main thing is that if you don't feel like you are heard to again repeat that, this is my concern, this is what I am worried about. I don't feel better based on what you told me and going from there. And if you don't do that, it's tough to fully advocate for your kid. And if you feel like you're getting pushback from a pediatrician or anyone, this is your child and you are in charge and so you either seek a second opinion or you go elsewhere.

Stephanie:                        12:08                   Luckily I have a really wonderful pediatrician and I did the same thing. I brought up the concern and I was like, you know what? I'm not going to feel comfortable until I get a referral. And she was like, great, that's fantastic. Let's do that. Here's the list.

Meredith:                         12:20                   Yeah, I had a concern with my son and my pediatrician said exactly what you said, which was, I think he's fine, but if you need an occupational therapy referral, I'd be happy to do it. And I said, let's wait. Let's see. And then I actually talked to my child's teacher who sees more of the fine motor activities than I do at home, and then I felt much better, much better and much more reassured.

Marshall:                          12:41                   And what you, you, you just touched on. It's a very important, a lot of this pediatricians or medical providers want to see in two different environments, especially if it's a behavioral issue. A lot of kids will act up at home act, you know, behaviorally not what parents want to see. And then you go to school and the same thing's happening well at the same things happening there then that's concerning to a pediatrician. If it's only happening at home, it is still concerning. But that is showing me the kid's capable of not doing that. They feel comfortable enough to do it at home. Yeah. And that's a dynamic that we can work on. Yeah. But two different environments is very important.

Meredith:                         13:17                   Yeah, that makes sense. My, I was concerned because my son refused to cut or color at home. He didn't want to sit at the table, you know, all those things. And then I talked to his teacher and she said, oh, I mean it's not his favorite thing to do, but he's happy to do. And he does very well. Here's an example of his cutting. I was like, oh, okay. Well, clearly it's a work at home. Clearly it's an environmental thing. We don't cut in color at home apparently.

Marshall:                          13:38                   I think what you said is, is gathering information. Just like you talked to your pediatrician, you talked to the teacher. Yeah. And if you're not happy with what you're hearing or not getting, ask if you can observe.

Stephanie:                        13:46                   That's a great advice. Yeah, that's great. Do you have any tips for parents too, to find a pediatrician that they're comfortable with? Any sort of questions that they could ask and kind of a basis go-to?

Marshall:                          13:58                   I don't know if all, we certainly give interviews to new mothers, but we also give interviews to parents who have kids who want to switch over. So you make an appointment with the pediatrician, you meet with them. I think that's a great way to sit down and look someone in the eye and say, is this someone I feel comfortable with and you know pretty much right away. And if you happen to go to the appointment and that's not what's happening, then you know as well. As far as picking a pediatrician, certainly I like our practice a lot. With Bootin and Savrick pediatrics, one thing I love about our office, and you might see if other offices have this, we have a person in our office and employee who specifically does referrals. That is all, so any referral that's needed, it's done in the office and they either do it there or call you that day or the next day they look at your insurance and everything. We also have someone who's in charge of home health, global management as well. So if your office has those resources, that's certainly helpful. And if you're at a practice who has, um, some physicians who've been around for a long time, they build a long list of referrals.

Stephanie:                        14:54                   I like the idea of sitting down and interviewing because it's an important job. You don't want to just go to anyone. And even if you get a referral from a friend, I have some close friends that they love their pediatrician and their pediatrician goes at things one way. But for me personally, like that's not a fit for my personality. I wouldn't be a fit for that one. Yeah.

Meredith:                         15:13                   I need to find a pediatrician who matches your philosophy. Yes, absolutely. So that's different for everyone. Yep, that's true. You touched on that as a pediatrician. If it's you're, you're doing what's in the best interest of the child and if it's not going to hurt the child then that's, that's what your plan is. But what if parents come to you with concerns or philosophies that you might feel like aren't in the best interest of the child? Um, how is that handled with a family?

Marshall:                          15:41                   And so I'm very honest with my families and my parents and I will tell you, first of all, state my medical opinion and why I think my medical advice is good for the health, whether it's a physical or emotional of, of your child who's my patient. Then I will talk about shift to the parents. Why do you feel the way you feel? Cause that's important too. And then we see if there's a way to bridge that gap that's in the best interest of the child. Because me making a kid do something and the parents not wanting it is not, I want us all to be on the same page. So there's a back and forth. I think your doctor should be explaining to you why not just saying this is the way it has to be and you're wrong. You shouldn't hear that. Yeah, there's no right or wrong. There's just advocating for our kids.

Stephanie:                        16:31                   Oh yeah, that's great. So one of those things that we know many parents have strong feelings on would be vaccines or even for some parents and how they approach allergies and food allergies. Can you speak to a little bit about ways parents can specifically address those concerns with pediatricians?

Marshall:                          16:48                   Yes, that's another great question. So certainly food allergies is a, is a big topic. It's a developing field. There are specialists called allergists who are excellent, but you know there's a rising incidence of allergies to peanuts. And the reason that research is showing, I think one of the main reasons for that is that in the past we expose kids to peanuts early. A very small subset of kids had reactions, sometimes deadly. We never want that. So there was a global and you're seeing an effort to remove peanuts. Okay. And so kids are getting less exposed earlier. So for the kids that are allergic, that's wonderful. But for the kids that aren't, they're not getting exposed earlier. And then building up immunity vaccines are very similar. So vaccines are a small amount of whatever the virus is that we're trying to prevent. Not enough to make a child sick, just enough for the body to recognize it and start fighting it. So it's sort of a little exposure earlier. Right now there is a measles and mumps outbreak in America. Okay. Measles and mumps are in Texas and the immigration centers. And then there are measles outbreaks within New York, California, Detroit. So parents who are vaccinating sometimes are concerned that the other kid parents are not vaccinating their kids and therefore they're going to be exposed to that. And this is, you know, parents have a right to make decisions for their children. But just like everything else, when you're in a home, you have a right to do what you want in your home. But if you're blaring music so loud that it's hurting someone else's ears next door and making them go deaf, that's not okay. And so if you don't vaccinate your kids, and this is just a general statement and then they get something like measles and they're around other kids who aren't old enough to yet get that vaccine and they get it, well that's not safe for the other child. So this outbreak of measles is heightening our awareness of how important vaccines are in preventing diseases because measles outbreaks had not been happening since we were doing vaccinations. My advice in my practice is I strongly, strongly recommend every parent vaccinate. If parents want to be on a delayed vaccination schedule, that means they give all the vaccines but just not at the mandatory intervals. They want to spread them out and our practice will see those patients, but with the understanding that they are going to get vaccinated. One important thing I want to mention with the measles in Texas, the American associatiation of pediatrics has advised pediatricians that we can give the MMR vaccine, early measles, mumps, rubella. We can give it starting at six months if there's a known exposure for a child or if a child is going to an area where measles is, whether it's travel or not, if that happens, we give it somewhere between six months to a year and then we still give it at one and four years, like regularly.

Stephanie:                        19:40                   I think that's a really great explanation because there have been within the past few years, differing ideas on things like, I mean, more parents are pushing back on wanting delayed vaccination. It feels like there's more vaccines, but it's because we're having better immunity and wanting to have preventative care and same thing with allergies. It makes more sense that way.

Meredith:                         20:03                   Was there anything else that you think is important for parents to know in regards to pediatricians or your child's health and wellbeing?

Marshall:                          20:12                   So, good question. I think taking an active interest in your child's life is very important. Actively playing with your child's? For me right now the biggest challenge we're facing is phones, screen time, tablets, phones. Those weren't available I'm guessing to y'all and me when we were younger all the time, so we're outside playing, we're talking if we're bored, we're doing imaginative play, we're thinking of stuff to do. We may be watching TV but it's a very, it was a very slow non stimulating thing. Now children and the schools are requiring, right? You need to know how to learn to type and do all this in school, but kids that are on their phones more than two hours a day and I still think two hours is a lot. It is going to negatively impact their social development and oftentimes their physical development. We are seeing delays in social skills because children are staring at phones all day and these phones are designed based off of slot machines to activate dopamine receptors. They are addicting and it is part of life that we do it, but I want to make sure kids are still interacting, talking, playing, doing things that require verbal, eye contact, social awareness. Otherwise when you walk into a job interview one day and unless times have changed and you're sitting on your phone looking at your phone and the other person's looking at their phone and you're talking to their phones, you actually have to put down your phone, talk to someone and understand social cues and so that's the biggest challenge. I would urge parents to try to limit screen time if you can't or you choose not to, I would advise doing a TV rather than a tablet and a tablet rather than an iPhone. The bigger the less stimulation.

Stephanie:                        21:59                   I didn't know that. Thank you. All right. There's one thing that we ask every guest, so we're going to put you on the spot for this one. We asked them for their best piece of advice. It can be generally life related, it can be related to, I'm talking to pediatricians, whatever you give as your go-to elevator speech piece of advice.

Marshall:                          22:20                   Well this may be short, but it's a quote that I love and I don't know who to attribute it to, but it says, be yourself, everybody else has already been taken. And what I take from that is you, for each child, each parent, you are special. There's nobody else like you. And there's a big push we see on TV. There's a certain way to be this. No. The way you are is the best way to be and be yourself. And when you realize later in life and you start loving yourself, then you will see how other people will start loving you.

Stephanie:                        22:52                   Yeah, I like that. Yeah. Great Advice. Well thank you so much for joining us. We learned a lot.

Marshall:                          22:57                   This was a privilege. Thank you so much and thanks for all the great work you do at your school.

Meredith:                         23:02                   Thank you for listening to the Unbabbled podcast. For more information on today's episode, including links to resources mentioned, please see our episode description for more information on The Parish School, visit parishschool.org if you're not already, don't forget to subscribe to the Unbabbled podcast on your app of choice. And if you like what you're hearing, be sure to leave a rating and review. A special thank you to Stig Daniels, Amy Tanner and Amanda Arnold for all their hard work behind the scenes. Thanks again for listening.