You'd expect a doctor to be extra careful with your child's health, but guesswhat: Not all pediatricians are kid-friendly.

1. "I can't afford to spend time with you."
What do you think of when you think of a doctor? Most imagine a wealthy gentleman, driving a luxury car, taking Wednesdays off to play golf with his buddies. But the fact remains: Pediatricians are among the lowest-paid doctors of all.

Pediatricians in California, for instance, are paid around $24.24 per month per patient by HMOs, even though the average cost of caring for a patient and administering all the mandatory immunizations is $47 per month, according to a study by the California Medical Association. The disparity between HMO reimbursements to pediatricians and to adult internists is considerable, adds Dr. Philippa Gordon, a pediatrician in Brooklyn, N.Y. She says the typical internist receives $200 from an HMO for a basic physical exam of an adult, while a pediatrician would receive as little as $100 for performing that same service on a child.

How might a doctor compensate for that financial disparity? Says Dr. Joel Bradley, a pediatrician based in Clarksville, Tenn., "When the financial pressures are heavy, all physicians feel pressured to spend less time with a given patient." Dr. Lawrence Diller, a Walnut Creek, Calif., behavioral pediatrician — and the author of Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill — says that pediatricians who do spend a lot of time with their young patients are typically a practice's "loss leaders." He adds, "Pediatricians lose money by spending a lot of time speaking with patients. There are great economic disincentives to doing an adequate examination."

2. "My assistant does most of my work."
Most people today take their kids to the doctor and deal with everyone, it seems, but the doctor. Someone else takes your child into the examining room, asks all the questions, gives the shots and takes the vital signs. What you are experiencing is the physician-assistant phenomenon, which, in an age of medical efficiency, is booming. Physician assistants typically complete a two-year medical program, learn many of the clinical skills that are used in primary care and are an asset to many offices. Pediatricians argue that the use of assistants allows them to more efficiently use their skills and time.

This may be true, but how qualified are these assistants to actually treat a young patient's maladies? Philippa Gordon — who does not employ physician assistants — points out that they can be fine, as long as they're not getting in over their head. "You need to have clear guidelines as to when the pediatrician needs to be called in," says Gordon, ticking off abdominal pain, joint problems and newborns with fevers as examples of things you would want the physician to handle. "Limits need to be set."

3. "I make diagnoses just by looking."
When Pat and Sue Sheridan's first child was born in 1995, doctors did not think much of his jaundice. Neither did the Sheridans — until the baby, just four days old, wouldn't wake up. When Sue called the hospital, the nurse there suggested that she visit her pediatrician, who prescribed antibiotics for an ear infection and sent them on their way. When the baby seemed worse the next day, Sue took him to the hospital, where his blood was tested for the first time. "Nurses there told us it was the (worst case of jaundice) they had ever heard of," she says, adding that her son's blood should have been tested at birth to detect the extremity of the jaundice. "Now he's five years old, he can't walk and his speech is impaired." (In 1999, a jury found the doctor and hospital not liable for any of the charges. A judge, however, granted a retrial — which is now being contested by the defense — saying that he was "dumbfounded" by the original verdict, which he found totally inconsistent with the evidence.)

Like the Sheridans' doctor, pediatricians often use their eyes to make diagnoses. This is helpful when it is combined with a thorough physical examination. When it's not, it's irresponsible. Dr. Barbara Korsch, author of The Intelligent Patient's Guide to the Doctor-Patient Relationship and a professor at Childrens Hospital Los Angeles, knows it happens too often. Recalling instances in which she's examined children in front of their parents, Korsch recounts, "I've had patients' mothers say to me, 'My goodness. Our pediatrician did not give my child an examination.' You can learn a lot from observing a child, but that in itself is not enough. When it's all you do, it's dangerous."

4. "My waiting room is a breeding ground for disease."
Chuck Gerba, a professor of microbiology at the University of Arizona, is a germ hunter. One of his studies entailed finding the places where germ-filled bodily fluids were most likely to show up. Second only to restrooms were the waiting rooms of pediatricians' offices. "It makes sense when you think about why all the kids are there," he notes.

How do you make sure that your kid doesn't leave the doctor more germ-infested than when he came? Gerba offers three strategies: Tell your kids to keep their hands in their pockets. (Yeah, right.) Be sure that they stay away from the toys (which every other kid has put right into his mouth), and bring along hand wipes. Some pediatricians have found their own solutions, like seeing healthy kids in the mornings and setting aside the afternoons for sick kids. That said, Gerba is not surprised that many pediatricians' waiting rooms are rife with germs. "Pediatricians are not versed in public health and sanitation," he says. "That's why you should always wash your hands when you leave the pediatrician's office."

5. "ADHD is my favorite disease."
Dr. Lawrence Diller estimates that as of 1998, 3.75 million kids in the U.S. were being treated for attention-deficit/ hyperactivity disorder. The diagnosis is usually arrived at quickly: A parent will come in with a kid who is fidgety in class, misbehaving at home and unable to focus for very long, and the pediatrician will declare that the child has ADHD. Dr. Mary Ann Block, a pediatrician in Dallas and the author of No More Ritalin, thinks that the glut of ADHD diagnoses is a by-product of physicians' looking for quick and easy answers without searching for the root cause of the symptoms: "Laziness (on the part of the pediatricians) is one part of it," she says.

Another part is surely the doctors' financial pressures, says Lawrence Diller: "The American Academy of Pediatrics came out with guidelines for evaluating ADHD. But doctors who are willing to do it will go broke. It entailed meeting parents, speaking with a teacher, spending time talking with the child to rule out other emotional and behavioral problems. Nobody will do that on a regular basis."

6. "I am impossible to reach."
Dr. Mark Holton, a pediatrician in Bedford, Tex., used to run a nice old-fashioned practice. At the very least, he was easy to reach on the telephone, a fact that made him a bit of an anomaly among his colleagues, who received more than 200 phone calls a day from parents — many of whom were overreacting to minor problems. How do many busy pediatricians handle the volume of calls? By installing voice-mail systems that are the verbal equivalent of Victorian-era mazes: Once inside, you will have a hard time getting out. (And you'll definitely have a hard time reaching a real, live person.)

That is the kind of system that Holton found himself forced to work with when he left private practice to join a large medical group. "With some of the managed care programs" — particularly the ones in which doctors are paid flat rates regardless of how many patients they see — "you can make just as much money if you don't see patients," says Holton, who recently retired. "So they see how many patients they can chase away."

7. "The mistakes I make now may only show up later."
When a doctor makes a medical error with an adult, the consequences are often fairly immediate and easily articulated. Such is not the case with a newborn. For this reason, it can be difficult to detect critical mistakes that pediatricians make on their youngest patients. Compounding the problem, the ill effects of pediatric errors invariably tend to be longer lasting and more debilitating than those made by doctors on adults. "In terms of a lifetime of problems, the mistakes are more significant with pediatricians," says Ralph Brindley, a partner with the Seattle-based law firm Luvera, Barnett, Brindley, Beninger & Cunningham.

Brindley, who specializes in medical malpractice cases, cites a particularly horrifying situation in which a pediatrician was called in to treat a newborn who was not breathing. Deploying a fairly common procedure, the pediatrician moved to insert a tube into the baby boy's lungs. Accidentally, however, the tube was originally placed in the child's esophagus, a fact the doctor didn't notice right away. It was eventually moved to the right spot, the child was resuscitated, and everything seemed fine. That is, until the boy was three and the parents noticed that he seemed slow to develop. An MRI indicated profuse brain damage, explains Brindley, noting that the damage was the result of oxygen deprivation during those critical moments after birth. (The parents ultimately got a settlement from the pediatrician's malpractice insurance company.)

8. "My past is a closed book."
The National Practitioner Data Bank is a research source that contains the names of over 100,000 doctors who've had lawsuits filed, made settlements or had state discipline actions taken against them. Maybe your child's pediatrician is included on that list. Too bad you can't find out. At the moment, the National Data Bank is open only to medical professionals. And the American Medical Association is fighting hard to keep it that way, arguing that since most malpractice suits are settled out of court, it's seldom proved whether or not the doctor was at fault.

However, according to Arthur Levin, the executive director of the Center for Medical Consumers, the status quo is terrible for patients. "Organized medicine has forever opposed making any information available about physicians. The AMA argues that just because a physician gets sued does not mean he is a bad doctor. That's true, but it's no reason to hold it back. It's public information."

9. "I can't get inside your kid's head."
Teenagers have all kinds of reasons for being depressed and rebellious: hormones, social pressures, a need to carve out their own identities. Parents hope that their kids' doctors will be able to recognize when a sullen disposition is typical teenage stuff and when it's an indicator of something more serious, such as suicidal tendencies. Unfortunately, a lot of pediatricians are not paying attention. The trade journal Physician Assistant recently reported that in a survey of 816 pediatricians and 592 family physicians about suicide among their patients, "Overall, 328 physicians reported that one or more adolescent patients attempted suicide in the previous year, but only 158 either frequently or always screened adolescent patients for suicide risk factors."

Dr. Katherine Sundstrom, a pediatric psychiatrist in Brooklyn, N.Y., often sees kids go untreated for their psychological problems. "The big thing you get from pediatricians and parents is that it's only a phase," she says.

To parents who are concerned about their kids' emotional states, Sundstrom suggests seeking out pediatricians who are "psychologically minded." She suggests that parents align themselves with the kinds of pediatricians who "ask about how their patients are feeling, who want to know what their temperaments were like when they were infants and whether or not the child seems happy and has a lot of friends. You want somebody who looks at the context of the child's life."

10. "I shoot first and ask questions later."
Amparo Perales's son, Javier, was vaccinated, like most kids, at two and four months of age. After the second set of shots, however, he cried inconsolably, nearly round the clock, for two weeks. Despite this, the child's pediatrician went ahead with Javier's third series of shots, after which things got much worse. Javier began having repeated seizures, and a neurologist eventually spotted "an irritation on his brain." Today, at age seven, Javier is autistic and is just starting to speak. Perales, who believes that Javier's reaction to the second round of shots made it clear that he should not have received a third, received a cash settlement from a government-run vaccine-injury compensation program.

While laws in all states currently require children to receive 24 doses of vaccine against 11 highly contagious diseases such as whooping cough and polio, there are certain kids who merit a closer look, and Javier was probably one of them. Inconsolable crying for days on end "is not a common reaction, and I would not want to continue vaccinating that child," says Dr. Bill Gray, a Saratoga, Calif., physician with a medical degree from Stanford and a homeopathic practice that focuses on chronic diseases (40% of his patients are children). And the Centers for Disease Control and Prevention — whose guidelines suggest that a child who cries nonstop for three hours or more is having a "moderate to serious reaction" and should possibly "not get these vaccines or should wait" — is on his side.

Most doctors react appropriately to symptomatic problems, says Gray, but others are so gung-ho about vaccines that they tend to ignore even the most blatant ones. He cites the example of a patient he recently saw because her pediatrician gave her two rounds of hepatitis B vaccine, despite the fact that all her hair fell out after each round of shots. "If the body is not reacting well, why continue with the vaccines?" asks Gray. Even those pediatricians who feel strongly about the need for vaccinations agree that in certain cases doctors should hold off. Says Dr. Meg Fisher, a pediatrician at the Monmouth Medical Center in Long Branch, N.J., "If there are contraindications and the doctor continues administering the vaccinations, that is inappropriate medical care."