By Susan Slowinski, MD
Pediatricians, family doctors, nurse practitioners, and physician assistants all provide primary care to children. Many other professionals touch a child’s life as well. Daycare and early learning providers, teachers, and counselors spend more hours with an individual child than his or her primary care clinician.
Yet, pediatricians are in a unique position to enjoy the long view. We watch children grow. We see the dependent infant become the strong-willed toddler, the observant preschooler, the questioning teen. We have the chance to teach children, to the best of their ability, how to take care of themselves.
For pediatricians, the doctor-patient relationship usually begins with the parents. I encourage expectant parents, newcomers to the area, guardians, and prospective adoptive parents to schedule a “Meet and Greet” visit at the medical practice they are considering. The visit is free. We each can discuss our expectations.
I watch personalities emerge. I think newborns are fascinating people. They are already developing their individual quirks and characteristics. They do not use spoken language. Yet, they express their needs so clearly!
The infant becomes a toddler. I have to work harder to accomplish my goals while still giving the child a sense of comfort and control. I do as much of the physical exam as possible with the infant on the parent’s lap, trying to be gentle and predictable.
Everyone in a pediatric office must learn to work with reluctant children. Before I examine a child’s ears, I shine the otoscope light on his or her finger. I ask them to extend a few fingers, or even toes, for my light. This simple routine (usually) helps me earn their cooperation for the ear exam.
Even the best delivery of health care involves discomfort at times. For immunizations, we plan with parents on the best way to comfort the child. We use colorful Band-Aids as a reward and as a way of saying “All done!”
Discussing medical concerns with a young child is an adventure. Some are real chatterboxes: they launch in to the story of a sister’s stitches. “That happened three years ago”, the parent interrupts. Then, the child may roll up pant legs and sleeves to give me a tour of scrapes and bruises, both new and well-healed.
In contrast to the chatterboxes, some children decline to speak. I may say, “I understand you came today because your tummy hurts.” The child then buries his head into his mother’s lap. “Do you want me to ask you or would it be better if your mommy tells me?” The child looks at his mother, “You tell her.” The mother responds, “How can I tell her what your tummy feels like?” We reach a compromise. The child whispers to the mother. The mother repeats the words to me. The child boldly corrects the mother. I confirm with the child. Eventually, I learn the “history of the present illness.”
In early adolescence, the doctor-patient relationship enters a new phase when I introduce the concept of confidentiality. I like to be clear with adults and children about changing expectations.
“When you were little you could not talk. I had to ask the person who brought you to the office to help me understand what was going on. Today your parent (or grandparent or guardian – I indicate the person who accompanied the child) figured out that you needed an appointment, made the appointment, provided the transportation, and is one of the most important people in your life. When kids get to be your age, you may be ready to have time alone with me. When you are ready, either today or another time, we will take time to talk just the two of us.”
I define confidentiality for the young person. This helps round out the concept of the doctor patient relationship. I mention some concerns that kids might hesitate to discuss with their parents. An example might be a concern for a friend who is starting to smoke. I promise to help them discuss their concerns or to problem solve, upon request. I promise not to talk to parents, teachers, the principal without permission.
I discuss the legal boundaries of confidentiality. “If I think you are really going to hurt yourself or someone else, or if somebody is really hurting you, then the law says I must do something about it.” For many young people their relationship with their primary care clinician is their introduction to conducting a confidential relationship as an adult.
My relationship with the parents or guardians continues. They are the most important people in the child’s life. The teen years are often when the parents have the most concerns. Many parents confirm that a good relationship with their child’s pediatrician helps them navigate turbulent times.
Sometime during the late teens or early twenties, the young adult leaves the pediatrician for an adult provider. It is my hope that after our years together, this person knows what it is like to feel known, welcomed, and respected at every medical visit. I hope he or she will have the persistence and confidence necessary to stay as healthy as possible and to try to regain health when ill.
Susan Slowinski, MD is a board certified pediatrician at Cornerstone Pediatrics in Bellows Falls, VT.