A Good Pediatrician
by Ute Carson
MOBIUS, Vol. 5, No. 4, October 1985

The phones in Dr. Tomson's office buzz with the subdued tones of battery-operated alarm clocks. Gone are the ringing bells which once startled the receptionist into alertness. Having been put on hold, the waiting parent is alternately soothed and irritated by recorded music. "Pediatric Associates, may I help you," a friendly programmed voice asks. "No, this is Dr. Tomson's day off. Dr. Ridley will be glad to see you." "But I wanted my own pediatrician," comes the anxious reply. "Dr. Ridley doesn't know anything about Mary." "I'm sure Dr. Ridley will do his best. You'll be pleased with him." Gone are the days of the privileged encounter between one doctor and one patient. Shared workloads and on-call commitments are a must in today's pediatric world. But this can be a cause of concern for parents. Will Dr. Ridley be as good with my Mary as I know Dr. Tomson to be?

Many people shop for a pediatrician prior to the birth of their first child and newcomers to a town are likely to inquire about a good pediatrician soon after arriving. Competence is what one seeks in a surgeon but a pediatrician has to be both skillful and a nice person. Why? By the time a healthy newborn is one year old he will have already been seen by his pediatrician six or eight times. After the regular well-baby checkups come all the fevers, sore throats, earaches and childhood diseases of the next ten years about which you, the parent, will consult your pediatrician for diagnosis and support. Multiply this by two or three children in quick succession, and it becomes obvious that you will have seen quite a bit of your pediatrician by the time your last child is through elementary school. It is no wonder then that we establish a special relationship with this person with whom we periodically entrust our most precious endowments‹our children.

A pediatrician has to be of a certain ilk to satisfy the expectations of parents and to earn the trust of his young patients. Running the risk of stereotyping, I would claim that there are certain personal qualities peculiar to this medical specialty. A pediatrician has to be a patient person because communication is often carried on at preverbal levels. He has to be decisive when children's fears and parents' apprehensions stymie the carrying out of discomforting or painful treatments. More than once I have been surprised at how my kind and softspoken pediatrician was able to act forcefully when it was in the interest of my children to do so. It seems no accident that Dr. Tomson combines sensitivity and candor in his manner and behavior. And a pediatrician has to be able to hear two stories at once‹the child's story and the parents' story. To do this well, he must be both an attentive listener and a sauté observer of subtle interactions between children and parent‹quite a requirement for someone whose main function is that of diagnostician.

The waiting room is crowded. A baby moans; a little boy is carried around, his head cuddled against his mother's shoulder One mother tries to interest her child in the colorful fish darting from one end of the aquarium to the other. Parents exchange stories about pregnancy and nursing and their child's illnesses and how they like Dr. Tomson better than his younger associates. I try to interest Cecile in a book about animal families. Finally, we are called. We know the routine. The weighing and measuring, the nurse writing down a complaint or a progress report. When Dr. Tomson enters I'm prepared for his questions and have mine ready to ask. Each time Dr. Tomson examines Cecile I watch his hands. They possess the same quality as his manner‹that combination of gentleness and decisive probing. He starts with Cecile's head, feeling for the fontanelle‹next making sure that no glands are swollen under jaws and arms, pressing to feel the normal softness of the abdomen, and bending the legs to check hip flexibility. The movements of his hands suggest an intimacy between himself and the child. I try to hold off with my questions until he has completed the examination but they sometimes get asked simultaneously. We chat about things pertaining to Cecile's development and I am pleasantly surprised when instead of answering one of my questions, he queries, "Why are you asking that?" Cecile begins to fuss. I pick her up and Dr. Tomson continues the examination while I hold her to my shoulder. "Never take a baby away from its mother' he explains to his nurse. "You'll be surprised how much you can do while a mother carries her child." The atmosphere is easygoing. You feel the concern for the child and you like the person who gives this kind of attention. In no hurry he leaves the room while I put a fresh diaper and clothes on Cecile. "Now, who do I see next?" I hear Dr. Tomson ask his nurse in the hallway, and the voices fade.

I have mixed feelings when I leave. We bring quite different emotions to encounters like this. The parent is all-involved in what he tells the pediatrician and what transpires during that interaction. After the visit is over, the parent takes the experience home with him. For the parent and the child, the relationship is I personal. For the pediatrician it is professional. He may especially like a child and give to all children he attends the best personal service but still he must close the door behind this patient and move on to that one. He cannot carry over one encounter into the next. I remind myself that what for me is a single all-encompassing experience is for him one in a succession of many. He starts the day with his hospital rounds where the sight of a healthy newborn may make his morning but where all the frailty of beginning life is also brought to his attention. During his office rounds he not only sees your well baby and your child with a minor ill- ness but sickly children and abused children as well. Even the most severe or puzzling illness must not occupy him to the extent that it fogs his alertness with the next patient.

Caught up in a visit to the pediatrician where it matters a great deal how your child is treated, where you want information and expect clear answers, your judgment of a pediatrician is severe. It is difficult to step back and imagine being on the other side of the fence. Dr. Tomson's daily work contains, in addition to stress and emergencies, and high responsibility for every child, a quantum of the ordinary, the routine. There is repetition as well as frustration and even boredom at seeing yet another ear infection or a sore throat. He, too, has a private life and may have started the morning arguing with his wife while brushing his teeth. He gets tired when his public image allows him no reprieve. Sometimes he cannot live up to the expectations his professional role requires of him. There are beautiful afternoons when he would rather be golfing or sailing than attending a w infant. So I tell myself I must not expect the impossible from my pediatrician.

The time you spend with your pediatrician on routine visits allows you to build trust so that when a crisis occurs, you are confident in his ability to handle it. The time spent during these regular checkups also gives the doctor a chance to assess parents' reactions. How trustworthy is the parents' account of their child's illness? Is this parent likely to over-react? Is that a parent who postpones until the last? Had Dr. Tomson not learned to trust me as I trusted him, an episode involving a minor laceration might not have gone as smoothly as it did.

Middle children have a reputation for being accident prone. Our Claudia often lived up to that reputation to our dismay. Jumping on the living room couch, she fell backwards and cut her head on the edge of the stereo. Unable to get the bleeding stopped, we made a rush visit to Dr. Tomson's office. She was two years old at the time and Dr. Tomson instructed his nurse to restrain her in a papoose. Panic overtook Claudia as the nurse struggled to lace her in. She started to scream. "Wait a minute," I interrupted, "is that necessary?" "Yes," countered Dr. Tomson sternly. "I need her absolutely still." "No problem," I said, "I'll steady her head on my lap and sing to her." Lullabies have soothed our children from infancy. An embarrassed silence fell over us. "I can't stitch if she moves," was Dr. Tomson's reply. "She won't," I answered with that assurance only mothers in emergencies can summon. I proceeded to take Claudia's head firmly between my hands in a forceps-like position and started with one of the old familiar songs while Dr. Tomson shaved the hair from the back of her head. Claudia jerked only when he gave the injection to numb the area which would receive the sutures.

It is sometimes difficult for a parent to step back and allow a pediatrician to carry out a procedure. But a pediatrician also has to be prepared to let a parent's judgment influence his handling of a situation.

Medical treatments change as do attitudes about child-rearing. I vividly remember the time when Dr. Tomson would not allow me to nurse for the first twelve hours after delivery because it was then believed the newborn's digestive system needed time to adjust to taking nourishment by mouth. Five years later I was permitted to nurse my third child on the delivery table. Where once the authoritative, older family member was, today the pediatrician often is. Being without traditional sources of support and knowledge, we turn to him with all sorts of questions about child- rearing. Having lost confidence in our own ability to judge and assess, we expect from our pediatrician cures for our children's illnesses, advice as to whether to use prepared or home-made baby foods, support in our efforts to nurse and guidance on how to get an active child to bed at night. Even if we think of ourselves as fairly self-reliant, confident parents, we can probably recall seeking his help when we might have been able to handle the situation ourselves.

It was a weekend. My husband was out of town. Our oldest girl had come down with a fever in the morning; by noon our middle daughter started to vomit, and by nursing time at night our baby felt hot. I supplied all three with aspirin and when the eldest's temperature shot up, I sponged her down and wrapped her legs in wet towels. I settled down to my after-dinner cup of coffee. Uninvited thoughts cropped up‹the temperature is already high- . . . what if at next reading it has climbed again . . . should I call Dr. Tomson . . . I am sure it is just flu, but babies can go into convulsions with fever. . . it is the weekend and I might not get Dr. Tomson but his partner. . . I could take them all on Monday during regular office hours . . . I just need to wait it out. I went back to check on the children again. The baby and Claudia felt warm but were sleeping soundly. Caitlin tossed and turned. I took her temperature again‹up a degree. I filled the bathtub, sponged her, and renewed her wrappings. Anxiously I took her temperature again. It had not dropped. I looked at my I watch . . . already 11 p.m. . . . Dr. Tomson might still be awake . . . if I am going to call, I must do it now. So I dialed his number. I was relieved when the answering service told me he was on call.

The minute I heard his voice I knew I had gotten him up. He spoke more deliberately than usual, but was kind and understanding. He countered my apologies by assuring me that calling was the right thing to do. After listening to my account, interjecting a few questions of his own, he told me to increase the aspirin dosage and report to him in the morning, unless during the night any new symptoms appeared. It was probably the flu. As it turned out, it was just the flu. After pacing from bed to bed during the night, cleaning up vomit, carrying the baby to soothe her, all was under control by morning. Should I have known that? Yes, I thought in retrospect, we do have a very special relationship with our pediatrician. How many other people would we call out of bed in the middle of the night, in spite of our reluctance? And who, even among our closest friends, has heard us giving an account of an incident with so much hurried weariness in our voice? Who else has seen us so emotionally disheveled out of concern for our sick children?

It is for reasons such as these that my anxiety at having to deal with a substitute for my child's doctor can never fully be put to rest. Dr. Ridley will always be a stand-in, even if Dr. Tomson assures me that he has chosen the very best as his partner, acknowledging that interim care is a fact of contemporary medical practice, how then am I to accept Dr. Ridley as a substitute, however temporary? Only by keeping in mind that even my child's pediatrician has a life to lead beyond his practice can I come to terms with his sending his partner when I really want him.

We hand over to our pediatricians a great deal of power when we entrust the care of our children to them. And their professional position underpins their authority. But any good pediatrician knows that he is not infaffible. He is aware that his authority can isolate him from patients. Partners in a group practice can be a source of support and informed criticism to each other, but the best commentaries on how things are going in a practice often come from patients. Time and money problems complicate the relationship between parents and pediatrician. Frequent well- baby checkups can be experienced as burdensome even if preventive medicine is considered a keystone of pediatrics. Taking a healthy child to a doctor understandably gets short shrift from indigent parents who can't afford such a visit, even when the child is sick.

If the relationship between pediatrician and parent is based on mutual trust, arguing with your pediatrician about treatment or even locking horns over an issue like the thumb versus the pacifier may not be out of character. A parent should also feel free to bring up general concerns. A pediatrician has to be reminded when things are getting a bit too rushed or crowded in his office or when a staff member has treated a patient rudely. Merited praise and appropriate criticism should get back to the doctor from time to time.

One of our evening family routines consists of sitting down at the bedside of each child and talking briefly about the events of the day. "What was special today?" I asked Caitlin one evening. "The visit to Dr. Tomson.' good," I commented. "Do you know why?" she continued. "I have a few guesses, but tell me why," I urged. "He said something very special to me. He said, ŒYou are a beautiful girl, Caitlin.' Isn't that something very special to say to someone?" I agreed that it was and kissed her goodnight.

The dynamics of a pediatrician's office are only felt by the patients as ripples that spill out into the waiting area or seep into their encounter with nurses and office workers. A hierarchy of staff relationships prevails alongside staff relations with patients. The nurse who feels she is relegated to carrying out only the unpleasant tasks, like giving injections and sticking fingers, is not likely to be very cordial with parents or understanding with children. Staff members bring to the job the personal problems and joys of their lives and although these must always be subordinated to patient care, personal considerations inevitably affect patient encounters.

You learn a lot about your pediatrician during regular office visits. A crisis situation confirms what you already know. If your judgment of him has been accurate all along, your trust in him will deepen in a crisis. Claudia had to be hospitalized for dehydration after a long bout with the flu. It was Dr. Tomson's weekend off but since he had begun the care he chose to continue it. He remained her doctor from admission to release from the hospital. Once again, my husband was out of town. So Dc Tomson stepped in. He not only met me in the lobby of the hospital, he himself carried our weakened daughter up to the pediatric floor, putting off the admission process until later. The following day Cecile got sick too. I was at a loss as to how to manage commuting between a clinging, feverish baby at home and a little girl who needed her mother at her bedside. Dr. Tomson had a crib brought into the hospital room for Cecile without admitting her. It was Claudia's first hospitalization. Secure in the knowledge that I would stay with her and that Dr. Tomson was trustworthy, she faced the new experience unafraid. Dr. Tomson did all the right things, explaining about x-rays as we went to radiology, and did not rush me when I put her to bed.

No matter how desperately a parent wishes to take away the pain, it cannot be done. But when it starts to hurt, you can prevent panic. Through the anchoring of Claudia's IV, I concentrated foremost on reminding her that she is loved and would not be abandoned even if the experience turned nasty. And it did. How long Dr. Tomson tried to get the needle into her elusive little veins I do not remember. I know only that I had trouble concentrating on the story line of my second fairy tale. After that I switched to lullabies. Time was no longer measured by the clock but by Claudia's fierce attempt to hold on to the trust that permitted her to submit. Perspiration was pouring down Dr. Tomson's forehead. "Hold on, honey, we are almost there." And then, turning to the nurse, "Let's try this one." The nurse's attempt was also futile. Claudia began to sob, her body became rigid, and her nostrils grew pale and quivered. Soon, I knew, she would rebel, pull her arm away or kick a leg. But she held steady, crying now between attempts to suck her thumb. Dr. Tomson cupped his head in his hands. "Let's give her a break." I demanded. He moved to the other side of the bed and looked at her other hand. "Let's give her a break;' I repeated. "I heard you," he looked up at me briskly. This time he was lucky and in no time the IV was in place. As Claudia relaxed so did I. It is in the moments after such an experience that tears are difficult to control. When called upon to act, most of us can rise to the task. Only afterward do your knees get shaky. And my tears welled up when Dr. Tomson sat down at Claudia's bedside, took her hand and asked her, "Can you ever forgive me for hurting you?" To which she responded with a hardly audible but unquestionably affirmative, "uh huh?' Two days after Claudia's release from the hospital she drew Dr. Tomson a picture titled "In the Hospital Room?' The setting is realistically depicted, but above it all are a blue sky and a shining sun.

Parents who have been through such an emotional experience with their pediatrician know about the upsurge of feelings there. An attachment is formed, even if it is one-sided. But a good pediatrician cannot be good without feelings of his own. What matters is how he handles his feelings. He cannot claim each child as if he or she were his own, but he can empathize with you and your child. Attachment is not the same as dependence. To be dependent on your pediatrician would be to require his presence in your everyday life. To be attached, however, is to be bound together throughout a situation that requires both of you.

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