Ysabel, my daughter, is three years old, and my son, Dylan, turned three months yesterday. With each passing day, sleepless night, running nose or milestone, I am more amazed at how much I now appreciate what parents mean when they say, “If only my child came with a guidebook or manual.” The mystery of children, I find, is only enhanced when you place them in a medical office. Sure, the stickers at the end of the visit seem to make sense to all involved. And yes, I think all can agree that swabbing in search of evidence of strep throat is a jarring experience at any age. Beyond that, though, I remain in awe of the pediatrician (and family doctor who fills that role). That awe is coupled with an acknowledgement that, in medical school, I morphed into someone who did not want to be a pediatrician; a decision that I realized was probably for the best.
I have long recognized that being an effective pediatrician requires an exhaustive (and exhausting) set of skills normally identified in a magician, a therapist and a physician.
The magician must make fire with her penlight and allow the otoscope to be extinguished when, in a blow-out-the-birthday-candles manner, a child exhales carbon dioxide and spit in a robust burst. She must use the slide-of-hand common in magic to allow a proper inspection of a child…or, if all else fails, wave the toy-du-jour in the air as a distraction. She must employ tricks that are, as they say, trade secrets.
The therapist must listen to parents not just in terms of understanding her patient, but must listen, sometimes, just for the sake of listening. Parents, I have noticed during my brief time in the pediatric zone, have lots to talk about when someone is willing to listen. Captive (adult) audiences may be hard to come by when a parent is struggling to balance life with children. Of course, even those parents who are no happier to be in the germ-infested pediatrician’s office than if it was them on the receiving end of the immunization smorgasbord of the day, seem to have a lot to say and ask. This part, I get. In the case of caring parents, concerns over the most minor issues get elevated to Level Orange on the Homeland Security Advisory System. A loved child is precious, and because that manual of care does not exist (Did Dr. Spock really know what he was talking about?), parental anxiety is understandable…but no, you’re child still does not need an antibiotic for every viral illness! And yes, I’m quite sure that it is not an issue if your child cannot recite the Gettysburg address by 18 months of life.
The physician role in the multiple-personality disorder that is required to be a pediatrician is by far the scariest. Sure, if your tricks fail, the kid cries for a few minutes. He’ll get over the cold stethoscope and the sting of the MMR vaccine. If the therapist just does not have the patience to listen to how the family pet did in the Westminster Kennel Club dog show, there will always be the next “well visit” in 3 months or the next “sick visit” next week to hear about it. But, if the physician fails, the ramifications are beyond – for me, as a parent – comprehension. It is my understanding that, for the most part, pediatricians treat healthy children. Certainly, these doctors see a plethora of ear aches, tummy aches, sore throats and rashes. And while these maladies may seem traumatic to both child and parent, most childhood issues seen by the pediatrician are resolved with rest, a confident dose of reassurance and maybe a dropper full of ibuprofen. The physician under the cloak of the pediatrician’s multi-colored robe (hey, colors make kids happy, right?) is the ultimate gatekeeper. If she fails to detect papilledema, a cardiac murmur or (in this day) the early signs of autism, the results can be catastrophic. Sure, all doctors carry similar responsibilities and risks. And, I do not think that one could argue rationally or philosophically that a child’s life has more value than an adult life. But, doesn’t it sometimes or in some way feel that way? I would have to argue yes.
Said another way, the emergency room doctors expect the worst, and look for it. A good pediatrician has to avoid being lulled into a sense of bad-things-don’t-happen-to kids. They can treat weeks or even months of bumps and bruises, coughs and runny noses, and pooping and peeing issues. They have to be even more vigilant in looking for the terrible brain tumor or childhood disease. If they miss it, no one else catches it until it is often too late.
It was with these feelings and fears shadowing me that I had to respond to my attending physician’s question in the spring: “Follow-up on 83-year old hypertensive in Room 8 or do a seven-year-old physical in Room 9?” Having had my share of hypertension for the day (I can always tell when I reach that point when my own systolic pressure hits a certain abnormal threshold!), I ventured onto the proverbial thin ice and opted to meet Courtney. I had seen her in the hallway staring intently to decipher Snellen’s secret code of “E-C, D, E, F, L, N, P, T, Z.” She had skipped to the designated viewing position (“one shoelace dangerously untied,” said the parent in my evolving brain). I stood amazed at her enthusiasm. I cannot remember the last time that I skipped or even had reason or temptation to do so. With her vision test charted by the nurse as OD 20/25 OS 20/30, Courtney excitedly ventured toward the bathroom with a plastic cup in hand. Moments later, and still prior to my introduction, she returned carrying the prized cup of pee as though it was a truly valuable possession.
Hesitant to enter, I perused Courtney’s chart (again!). She seemed like a medically unremarkably kid, who had survived to the age of seven with only a few bumps and bruises. When I knocked, I heard a triumphant “hello” squeak over a more adult voice. Both mother and daughter welcomed me into the room and into their lives.
Almost immediately, I found myself distracted by Courtney’s face, which was sprinkled with adorable freckles, her smile, which highlighted that the tooth-fairy had recently paid her family a visit, and the careful way that she repeatedly brushed her hair behind each of ears in preparation to speak to me. She was fun, and immediately made me feel at ease (strange how that works!). Her responses and stories were delivered machine-gun style, with her words peppering me with no interruption. I did not have to wonder about lung capacity based on her ability to string 52 words together without ever inhaling. After an extensive history, which was both entertaining and informative, I set out to practice my clinical skills. Head and scalp cleared, I moved to an inspection of her eyes. I can only assume that someone was filming me for “Americas Funniest Videos” when I repeatedly tried to have Courtney follow my finger without moving her head. With each attempt, she giggled with the infectious force of influenza. Ultimately, this task could only be accomplished with me holding her chin in place.
Courtney proved to be a great audience, and for that I was grateful. She laughed when I looked in her ear and asked her about the dog I saw in there. While looking into her left pupil, she became very focused when I commented that I could see that she had a very smart brain. (It was unsettling to hear her confidently say, in further response, that “I’m going to be a scientist” when I’m still trying to figure out what I’m going to be when I grow up.) Her lungs were the clearest, healthiest and, in some ways, the most beautiful sounds that ever filled the earpieces of my stethoscope.
During the exam, she continued to question me like a trained patient-instructor. I think I passed.
In the end, Courtney’s physical examination was normal and I reported that and my historical findings to her pediatrician in the hallway. Back in the room, her doctor repeated her heart and lung examinations, declared in her good health – based largely and in a very scary way on my presentation, signed a camp physical form and chatted briefly before bringing the session to a close. I put my hand out to Courtney for a high-five and instead she repeated one of the cerebellar exams; this time trying to keep my fingers from spreading apart. I explained the confusion and she laughed, commenting with great confidence, “Why didn’t you just say, ‘High five?’” At that moment, I felt like telling her the truth: I was not really that comfortable with physical examinations, pediatrics or anything related to medicine. I felt like telling her that I was spending most of my time at that point just trying to get the physician part down pat and that the magic of my doctor-child interaction would have to wait. I felt like admitting to her that I’ll be leaving behind the waiting room littered with saliva-coated toys and dog-eared books (how many times is it possible to “Pat the Bunny?!?!”), the injections to unsuspecting kids, and the symphony of coughs and screams to people like my friend, Dr. Lu Lu Waterhouse. She’s a kid at heart; she gets it, and she’ll be a great magician.