The Riveting World of Well-Child Checks

11 05 2012

Outpatient pediatrics.  I promised the scoop from my point of view, and here it is.

Bottom line: I was sure I would hate it.  I’ve had outpatient clinic components of every single rotation so far, and they have almost always bored me to tears.  The only time I wasn’t miserable was when I was in a private office rather than a resident clinic—which was also the only time I was able to take a history and physical independently and come up with an assessment and plan on every single patient.  Nothing against residents, whom I like as a group in general, but they are often so busy that they can’t afford the time to teach students.  At many resident clinics, there is an attending present, but that physician generally sits in their office doing paperwork and the residents run their patients and plans by them for a second opinion.  This means no working with an attending.

I’m at another resident clinic now, for peds, but I love the way it’s structured.  Not only am I working with an attending consistently, but I’m working with the same attending 3 mornings every week.  It might sound sporadic, but this is way more continuity than I’ve ever had working in an outpatient clinic (with the exception of internal medicine outpatient).  In the afternoons, I work with a senior resident.  I don’t know what it is about the pediatric residents—maybe it’s just these residents—but they really seem to get what it means to teach medical students.  I don’t get to see every patient, but I get to see at least half of them on my own, which is infinitely better than just being a shadow (which has happened a few times, but it’s the exception rather than the rule).

My experience and competence now may very well play a hand in my increased patient care involvement in the clinic. There is a massive difference in my abilities when you compare how I was at the beginning of the year rather than now.  I’m almost a certified 4th-year student, and as such will be trusted with more clinical responsibility.  This difference became much more pronounced yesterday, when my attending preceptor in the clinic introduced me to a resident as an “almost-4th-year student.”  The comment might sound  a little stupid to you if you’re not familiar with medical education, but I took it as a compliment.

Who knows, maybe I’m just over-thinking it.

At any rate, my enjoyment of this particular clinic might boil down to something else entirely.  I’m certain the personalities of the physicians and nursing staff play a role, and my improved competence does as well.  The kids themselves spice up the experience, and I definitely can’t complain about the hours.  Perhaps there’s a simpler answer.

I just like pediatrics.  Maybe that alone makes all the difference.

I don’t think this is entirely the case, because prior to this point I universally disliked ambulatory medicine regardless of the specialty.  It’s nice to know that I am capable of liking clinics, because it means more opportunities to diversify my career as a physician.

So what goes on in peds clinic?  Easy answer: either the kid is sick or the kid is well.  If they are sick, it’s all about figuring out what’s wrong (and sending them to the ED if it’s serious) and treating them.  If they’re just a regular well kid needing a physical, there’s a set of developmental questions that evolve to fit their age, from newborns to college freshmen, as well as going over general health issues and actually doing a physical exam.  Many of my classmates find the Well-Child Checks tedious and dull, but I think they’re fun.  You basically just play with the kid and chat with the parent.  I’ve found that even the adolescents—for whom I have a low tolerance when I see them in mobs in malls or movie theaters—are entertaining and fun for me.

I even enjoy talking to the parents—for the most part.  Some of them actually are idiots to the point where I wonder how they can take care of themselves, let alone their kids, but most are either educated enough to have a clue or else they care enough about their kids to ask if they don’t know how something should be carried out.  In 2 weeks, I’ve only had 2 sets of difficult parents.  One of them, a mother who decided at that visit not to vaccinate her youngest son (she had two older boys as well), turned out not to be difficult for long, because as soon as she signed the waiver refusing care, that child was booted out of the practice.  Maybe it sounds horrible, but it’s not a hard decision to make: nobody wants a baby too young for the vaccines to catch pertussis in the waiting room from a 4-year-old whose parents chose not to vaccinate.  Herd immunity doesn’t work if there’s not enough of a herd.

The other difficult parent encounter was a woman who you could tell was poorly educated simply from the conversation.  Her 10-year-old kid had ADHD controlled on Concerta for a year, and the improvement in his grades and his behavior was undeniable.  He went from C’s and D’s to A’s and B’s, and rarely did his teachers call from school because of discipline issues.  It wasn’t enough for his mom, though, and when I asked her why she thought his medication should be increased, the response was something to this effect:

“He still behaves terrible at home.  I ask him to do his homework before he goes outside, he doesn’t want to.  He gets mouthy when I ask him to do something, he tells me ‘no’ all the time, and when he doesn’t like what I tell him he stops up to his room and slams his door. I just want his behavior under control.”  Naturally, when I ask whether he ever gets violent, threatens to kill her or himself, tries to hit her with objects, anything, she says no.

Well, duuuuuuh!  This sound like a normal kid to anyone else?  I know I acted like this as a kid—heck, I still don’t like to study or do chores, except maybe gardening and some forms of cleaning.  Can you blame the kid for trying to get out of doing chores?  So I very gently suggested that parenting a special-needs child can require a different set of parenting skills and behavior modifications, and offered her information.  When she refused and insisted that he needed more medicine, I smiled politely and said that was up to the doctor, and reverse-sauntered out of there.

When I reported this to the resident, he nodded, looking very pensive, and said “Okay, then.  Haldol it is.”

We’ll end on this note:




3 responses

31 05 2012

I don’t get the resident’s end comment – was he seriously considering prescribing haldol for the kid, or was it a joke about what to do for the mother? Poor kid.

3 06 2012

Haha, no. The comment was sarcasm, more in mockery of the mother’s desire to medicate the kid into submission, rather than just medicating to control his ADHD.

4 06 2012

That comment just made my entire evening!

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