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The art of pediatrics: Connecting through observation

On my first day of inpatient rounds during intern year, I was taken aback when the attending stated, “Let’s stop outside the room and just spend a few moments watching the child and mom.” I started my residency on my community rotation site in Chester, PA, where several of the Philadelphia training programs at that time were sending residents. It was a nice introduction to pediatrics with a smaller inpatient ward, a small academic clinic, and a busy enough ER for us to see and get comfortable with sicker children more quickly. Dr. Baker, quite possibly my favorite attending of all time, was the lead physician and, while an amazing teacher of the science of pediatrics, was also a believer that to understand children, you had to watch them in their interactions. “Just use these moments to connect with this family…” or “You’ll appreciate the patients more if you spend some downtime with them” were commonly stated to us and something that I have honestly tried to do in my 30+ years in this field.

However, it gets more difficult each year with our field of primary care pediatrics consistently losing the reimbursements battle (and another Medicaid cut upcoming), necessitating seeing more patients per shift. All at a time when our patients are more complex, with so many issues needing to be addressed at each visit ranging from mental health concerns to complex social needs. The issues in our field are daunting, and the fact that pediatrics is now ranked third among all medical specialties for burnout (let that sink in for a few moments) reflects this vividly. As the president of the AAP (American Academy of Pediatrics) recently stated, it is getting more difficult to recruit and maintain primary care pediatricians. Changes are needed and quickly, and our AAP leadership, among others, is working diligently to move these along. But the reality remains that for most primary care pediatricians, the days are very busy, allowing little time to just stop for a few moments to bond with our patients and families.

But stop we must. What makes medicine unique is that it is not just a science but an art form, and to truly appreciate the art of “humanness,” you need to stop (like at a museum) to just watch and appreciate. The memorable events that I discuss with my wife when I get home are not how many notes I got done early or how many labs I reviewed, but recalling that little toddler that tried talking with me or the parents that literally blushed with sheer delight seeing their little one doing some new skill or something similar.

It boils down to, what is a child? It is beyond the developmental tests that we do, or the growth curves or the exam, or the final diagnoses given. All of these shed some light on what the child is but are akin to looking at the Grand Canyon through a window. Children are so much more, complex beings with huge potentials who live in a world of loves and fears and of support and stress. I am always amazed when I see a patient for many years and watch their significant changes yet deep inside still being themselves. It is a privilege to see what becomes of them but more importantly what they become. Ultimately, we deal with immortal beings who are all children of our Creator, and that in and of itself should be awe-inspiring.

I recently saw a little guy in clinic with a head cold. The dad had been one of our patients for years, and I saw how he developed from a shy middle schooler (when I first met him) to a deep thinking yet quite funny, and just cool teenager, to now a college grad and a new parent. The nurses smiled at the baby (our group in clinic is so much better at taking those brief seconds to bond than I am, and I love watching their joy when doing this) making funny noises and the little guy responding in turn. Dad, though worried, was enjoying this whole scene with a loving look on his face. Human bonding at its best. I watched for those brief moments before quickly diagnosing a mild URI and discussed the expected course and when to worry. Dad and I shared a handshake, but more than that: it was a sharing of commonality, of both caring for that child, of trusting one another, of having the honor of sharing another life in ours.

As they left, I wondered what would become of this little guy. What will he be doing in 20 years, and will he one day be a legacy father in our clinic? It was a short, brief moment of loving this job and one that I hope that all of us in medicine get to appreciate at least once a day.

Alexander Rakowsky is a pediatrician.

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