The Trust of the Young

In a multi-specialty seminar group that I attended some years ago, various specialists were asked who they considered their most challenging group of patients.

“Diabetics with rapidly progressive eye disease”, said the ophthalmologist.

“Cosmetic surgery patients ‘of a certain age’”, the plastic surgeon pronounced.

“Patients with head and neck carcinoma”, responded the otolaryngologist.

Without a moment’s hesitation, when the group leader pointed at me, a family practitioner, I answered,

“Children.”

Everyone laughed, including me. But consider:

In caring for children, you never see the same patient twice, because they grow. No patient possesses a more finely-honed hogwash detector than a child; thus demanding of their doctor a carefully tactful, yet scrupulous honesty. In my years of doctoring, I do not think there is any category of patient who evokes in their caretakers more wary caution, joy, protectiveness, or heart-stopping fear, than the care of children.

And what other group of patients, when displeased, frightened, or disliking your counsel, is more likely to kick you in the stomach with their surprisingly hard little shoes? No patient asks more pointed, and often personal, questions than a child.

“Dr. Lyons, what is wrong with your hair today? It looks silly.”

 No one makes more telling observations of their perceived quality of care.

“You are mean! I hate you!”

No patient is more alert to the possibility of pain.

“Are you going to give me a shot?’

This most important question is asked most visits, by most children. Even the pre-verbal manage to convey their anxiety about the prospect of this procedure. I make it an iron-clad rule to establish first thing in a child’s visit that “there will be no shot”, if and only if, I can promise this with certainty. This usually provides enough relief that the diminutive patient can relax and tell me their history.

Children are remarkably good at telling their own history, if given the chance, which I always do in non-emergent situations. I direct my first question to the child,

“Hi, Stella! What’s up?”,

to see if they wish to answer or defer to Mommy/Daddy.

Their replies often stick with me for years, or forever:

“I just petted him, but he bitted me!”

This pronouncement, uttered in an indignant tone of injured disbelief was from Mack, a tearful 4-year-old, cradling a forearm with several puncture wounds.

In another memorable encounter:

“Well, her toof fell out, and I was playing with it, and then-POW!- it was in my ear!”

This time I had two patients: 5-year-old twin girls. The one with the missing tooth was outraged that she might be robbed of her tooth-fairy fee.  The second was embarrassed and anxious that she was suddenly the focus of so much alarmed parental attention.

Sara, the first, needed only sympathetic counselling. The second, Minna, required a minor procedure, as on otoscopy one could clearly see the missing, tiny, pearly incisor, wedged into her left ear canal.

One of my favorite moments of any well-exam or sick visit with a mildly-ill child who can still enjoy his/her surroundings, comes after I listen to the heart and lungs.  I offer to put my stethoscope on my patient’s ears, and its bell on their chest so they can hear their own heartbeat.

Nothing is more enjoyable to me than seeing wide-eyed surprise at the offer, then the serious, and sometimes apprehensive look as I help them fit the unfamiliar stethoscope tips into miniature, petal-soft ears.

I place the bell over the heart’s apex. There is always a moment of intent, internal introspection on the small face. Then, invariably, a huge grin appears; the child’s expression blooms like a flower.

“What does it sound like?’’ I always ask.

The varied answers:

“Boom…boom.”

“A drum.”

“Like mommy.”

And my favorite: “It sounds like a ‘molcano’!” (volcano)

Sometimes I must gently pry sticky fingers off my stethoscope to regain custody.

Childhood emergencies, in my experience, are among the most frightening medical encounters to parents and providers. The innate fear of the serious injury, illness or death of a child is ensconced deep in our psyche, and childhood emergencies evoke this, not only in family doctors but also, I am assured by my colleagues, in the most seasoned pediatric specialists.

I will never forget the day I just happened to be at the computer of the waiting room reception desk during the midday lunch break. The waiting room was empty of patients and the receptionist and I were in the middle of a hasty confab about who could be squeezed in to be seen that afternoon. The office was quiet.  I heard a tiny squeak of stridor (a harsh creaky respiratory sound) and looked up to see 8-year-old Franklin stumbling into the waiting room ashen and wheezing. His father, just behind him, only got as far as:

“There was some peanut butter in…”

before we had snatched Franklin up and hastily administered epinephrine.  At the same time, our receptionist was alerting 911 by phone. Peanut allergies are deadly, and well beyond the scope of office treatment. Franklin lived, but it was close, and he required care in the pediatric ICU. All we could hope to do was buy a few minutes with the Epi-Pen, until he could receive desperately needed hospital care.

No one in the office could shake the feeling of dread and fear until we learned that Franklin was stable and doing well in the ICU. I couldn’t relax even after he was well and discharged, now knowing that my patient would forever need to negotiate a world where a tiny, ubiquitous legume was as Kryptonite to this little Superman. I imagined how his parents must feel, having to incorporate the knowledge of their child’s permanent vulnerability into the already formidable responsibilities of parenthood.

We, our providers and office staff, partnered in planning Franklin’s future care, his and his family’s education regarding his allergy, his referral to the allergist.  We helped alert and prepare the principal, teachers, and nurse at his school. We were happy to hear of Franklin’s enrollment in a new treatment study at the University. The bond forged with this family, through our fear, pain, and concern for this child included our whole office. This, in my view, is what makes a family practice.

It is not uncommon for a sick child to ask,

“Am I gonna’ die?”

Children pick up parental (and physician!) anxiety very quickly, even if it’s disguised in an attempt to keep the child calm. It is always wonderful when one can assure them,

“No, you will be fine.”

In my career, I have been fortunate enough to have seen very few deaths in childhood. My hat goes off to those stalwart souls who are nurses, doctors, physician assistants and nurse practitioners in those fields where the death of children is common, like pediatric oncology. These folks are worthy of our utmost respect, as their task is so important, and so hard to imagine bearing.

I am 60 now, and so, “really old”, according to a neighbor’s child, whose swollen lymph node I was asked to assess. In almost 30 years of doctoring, one of the skills I am proudest to have learned, is to listen to children with the same attention that I listen to adults. After all, they are people too, and deserve to have their thoughts heard and considered, their emotions taken as authentic and important, and their bodies and personal boundaries treated with the same respect as those of adults.

Children change, grow, and their care subtly alters year by year, requiring mental adjustment by their parents and their doctors, in order to provide quality care and support. Seemingly in an instant, the children I cared for became adolescents, then adults. I cried quietly in the breakroom the day a baby I delivered brought me her baby to take care of, and I don’t care who thinks I’m soppy because of it.

Many of my most challenging patients have been children, and I have liked them and liked being their doctor. Often, they liked me back, and our good rapport aided their growth. When I consider the whole of my formal career, now completed via retirement, I make a confession. There is nothing I take more pride in, no award or accolade received that I treasure more, than the incredible boon, hard-earned, of the trust of the young.

Paula Lyons, MD

7/14/2020