Wash your hands!
so you don’t get
Wash your hands!
so you don’t get
Here’s a rundown of reasons to love pediatrics:
Reason Number 1: Pediatrics is about prevention.
Reason Number 2: Tickling toddler toes.
Reason Number 3: Making a connection with patient & parent
Reason Number 4: Shopping my brain for tailored advice for patients.
Reason Number 5: New Stuff
Reason Number 6: Being anti-pain
Reason Number 7: Medicine in the age of the internet.
Reason Number 8: Cultural diversity in my practice.
Reason Number 9: Research and information gathering.
Reason Number 10: Toys.
Reason Number 11: Loyal adolescent male patients.
Reason Number 12: Twins.
Reason Number 13: My partners.
Reason Number 14: Books for patients and parents
Reason Number 15: Books 2: Books for doctors by doctors
Reason Number 16: A-Ha! Moments
Reason Number 17: Kid’s Hair
Reason Number 18: Pediatrics is a specialty
Reason Number 19: Making a specialty within pediatrics
Reason Number 20: Concierge medicine @ home
Reason Number 21: Foreign bodies
Reason Number 22: Tricks of the trade
Reason Number 23: My community
Reason Number 24: New Parents
Reason Number 25: Follow-up Phone Calls
Reason Number 26: Intuition
Reason Number 27: Patience
Reason Number 28: Rashes
Reason Number 29: Life out of the office
Reason Number 30: Spouse support
Reason Number 30: Spouse Support
The saying goes that it takes a village to raise a child. A physician also needs the support of a village to do the job of medicine. Running a pediatric practice is an on-the-job MBA. Medical school and residency taught me many things, but accounting, marketing, public relations, employment law, OSHA and CLIA regulations were not part of my curriculum.
My husband in the yin to my yan, the peas to my carrots, the sunrise to my sunset, and the bass to my soprano. His education was about all those things I’ve learned through experience. In his former life, he ran a “village”. Our strengths compliment each other in the business. So it was natural to ask him to run the operations/management/administrative side of my practice.
Working together is not a cakewalk. The division of responsibilities is dynamic. I’ve stepped on his toes and he’s stepped on mine, and despite our best intentions work comes home with us from time to time. Our tendency is to take shifts both at home and when the office needs our attention outside of our usual 9-5. That flexibility enables him to do pick-ups at school, errands for home and office simultaneously, and meet the washing machine repairman. Sometimes he’ll work after the kids go to bed when all is calm and quiet.
My spouse is the extrovert of the two of us which is ironic since he spends most of his day at his desk filing insurance claims, keeping me and my partners on track with CME, credentials, and scheduling, and juggling all tasks that happen behind the scenes. It’s a treat to hear him talking to patients and parents when he’s able. He’s patient, kind and positive. He gives our office a flow of happy energy even when we’re giving shots and tending to lots of sick children.
At the end of the day, I enjoy the debriefing and stories we share. Even the days when I’m irritated with him, I know he has my back, our vision for the business is similar, and how hard we both work to pull this all off.
Reason Number 28: Rashes
My new partner makes me chuckle every time she reaches for Hurwitz‘s Clinical Pediatric Dermatologytextbook or Krowchuk’s Pediatric Dermatology. With ardent effort, she tries to match reality with textbook – no small task. Since skin is the largest, most visible organ, rashes are bread and butter pediatrics, and no two are ever alike. Despite the intensity of pediatric training, outpatient dermatology training takes a backseat to other maladies. New pediatricians usually get their training on the job, and with experience become proficient in treating this common complaint.
Dermatology fascinates me for six reasons:
1. Disease is visible to the naked eye or touch – no microscope, lab test, CT scan needed
2. Parents can determine whether the malady is getting better from observation.
3. Treating skin disease also treats self-esteem in some cases. Example: acne vulgaris
4. I love the language of dermatology – molluscum, papulosquamous, acanthosis nigricans
5. Pediatric rashes can be clues to other disease
6. Each new rash is a chance to learn another variation on dermatology.
Reason Number 27: Patience
My residency director described me as zealous. I was a bit taken back when he announced this at our graduation dinner. To me the term meant militant maybe even with terrorist tendencies – Yikes! Not exactly the touchy-feely pediatrician you would take your babies and children to, huh? On introspection with the help of Miriam – Webster, I’ve come to realize the postive aspects of being zealous – ardent, eager, passionate. That impetuous side works well in emergencies and in critical care settings, and knows how to prioritize information and tasks.
Yet most of pediatrics is not emergencies, and I have had to learn the fine art of patience. Parenthood has taught me to slow down and wait, but medicine, pediatrics, and patients – despite the breakneck speed of practice – has drilled lessons of composure into me, too.
Patience is waiting for a toilet-training two year old to return from the bathroom. It is letting a parent tell his or her reason for the appointment in more than 20 seconds before interrupting. Patience is knowing that Roseola takes a big fever before declaring itself with a rash. Patience is waiting for a phone call from a subspecialist. It is coaching a reluctant patient through an ear examine, throat swab, or suture removal. Being patient is embracing flexibility and letting the day flow. Patience is gentleness. presence and listening. I hope that’s how my patients remember me.
Reason Number 21: foreign bodies
Once I had a patient who had been to several doctors over the period of two weeks. His mother complained about the odor coming from his green, drippy nose. Despite medication, the color and smell persisted. In my office I noted something white in addition to ruby nasal mucosa, and purulent snot. With a well placed tweezer, I located the white spot and pulled to reveal a sodden wad of foreign body – probably wadded up tissue, but hard to tell after a two week vacation in the nasal passages of a preschooler. Viola!
Yes, I pick noses for a living – and that activity is personally satisfying. Identify object. Locate object. Pull object out. Problem solved.
Not all objects are easily removed. Play doh melts. M & Ms melt. Beads can be a challenge. Foreign bodies in ears can be difficult, too. Sometimes, those need to be referred down the street to the ENTs who can suction them out. (There is a similar hint of glee in my ENT colleagues about foreign bodies.) Splinters can be difficult. Glass is a challenge, too.
Picking pediatric noses is anything but glamorous. Kids put objects in the darndest places including their nostrils. However, I would take a whole day of picking noses for the instant gratification it beings me.
Reason Number 19: Specialty in a specialty
At one point in my career, I wondered if I had taken a wrong turn by choosing general pediatrics. As a resident, my neonatology attending encouraged me to subspecialize – preferably in neonatology. While I really enjoyed the NICU – the rotation allowed me to do procedures, attend deliveries, care for really sick patients, and care for unusual problems – the ethical dilemas I encountered took their toll on my young interests. This attending told me I would be bored in general pediatrics taking care of runny nose after runny nose.
I have never been bored in general pediatrics. Quite the opposite. Just when I think that my practice is humdrum, a patient will arrive with a zebra – a problem seen mostly in textbooks and on board exams. My medical curiosity will smack me between the eyes as I dig in annals and journals and zebra websites. So that time I was pondering the value of general pediatrics was not from the mundane. Instead and because of the amount of information I am expected to keep in my cranium, I pondered fine tuning my specialty choice.
I applied for fellowship in a very competitive specialty, dermatology, and as no surprise to anyone but me, I was not chosen for the extra training despite a shortage of pediatric dermatologists in the area. No regrets about the experience. I am meant to be in general pediatrics.
Now with partners and the prowess of mentors, I see myself able to specialize in an informal way. Already, my nurses will say to my younger partners, “Ask Dr. MWAS about that – she likes rashes.” Fellow pediatricans in my town have marketed themselves as “specialists” in ADD or autism. I’m not ready to market myself, but I do see that I can develop a niche in my own practice. It’s nice to be able to refer to my own partners because of special interests they have in areas of pediatrics.
So I may never hang the shingle for pediatric derm at my office, but my scheduling staff steers dermatological concerns my way. And I’ll keep working on that knowledge base so that maybe one day I can trade a day of general pediatrics for pediatric dermatology.
Reason Number 18: The specialty of pediatrics
In a typical week, I refer patients to lots of different specialists – ophthalmology, cardiology, pediatric surgery and ENT to name a few. Some patients need more specialized examinations than I am trained to do, some need surgery, some need studies or lab work that is best ordered from the office of a specialist. It is easy to be lulled into a triage mentality when some visits feel like your purpose is to identify and send to the appropriate next step.
Every so often, another physician will consult me, the primary care pediatrician. At that moment, I realize pediatrics is indeed a specialty with specific knowledge and skills. Part of my job is to put together pieces of a problem, and to see them as a whole. So that the patient with juvenile rheumatoid arthritis needs an influenza vaccine when he is on medication that treats his JRA but also compromises his immune system.
In my 120 bed local hospital, my colleagues look to me and my fellow pediatricians to make recommendations about care of children that effects the entire hospital. When the call comes in at 2 AM for my opinion, my brain sometimes wants to say “duh, who doesn’t know that?” By grace and experience, I don’t blurt that out. Instead, I try to give information that is appropriate, and specialized. In return, I’m reminded that caring for children takes expertise that I have earned and should use judiciously.
Reason Number 17: Hair.
“He had more hair than you would think a single skull could hold. His hair – blue-black, thick and straight – it did not have the hard sheen of the hair of the Chinese or Japanese but had the soft look of fabric.”
About Julian Singh in E.L. Konigsburg’s The View From Saturday
“Hair is vitally personal to children. They weep vigorously when it is cut for the first time; no matter how it grows, bushy, straight, or curly, they feel they are being shorn of part of their personality.”
Charles Chaplin, My Autobiography. 1964
“And forget not that the earth delights to feel your bare feet and the winds long to play with your hair.”
Toddler curls that cascade and rebound when tugged. The brushy feel of a new summer buzz cut. Silky, inky braids. A shock of dense hair on a newborn. I love the endless variety of color, texture, and length of hair on children. I make it my professional responsibility to examine a patient’s hair during a physical, but secretly, playing with all the different strands is a marvel.
One patient in my practice is recovering from Alopecia universalis. At the onset of the diagnosis, I felt I was in mourning and panic each time she presented to my office. Her pre-diagnosis hair was lovely shoulder length blonde. It was the type of blonde that we adults strive for – bright strands intermixed with tawny like the sun knew what it was doing each time it touched her head. I referred her to three different dermatologists in hopes that one would have a new protocol for stemming the loss of this patient’s eyebrow, scalp, and even nostril hair. Despite the collective efforts of her mother, myself, and the dermatologists, my patient lost all of her hair. She has handled the course in the face of uncertain prognosis with grace and a great wig. Eight months later, small tufts are beginning to come back.
Once a mom came to my office with her preschooler, and she told me that she knew the child was sick because her hair wasn’t right. It turns out she was right, so maybe I’m on to something by examining the ringlets of infants and the swath of hair covering the eyes of the young teen. Maybe it’s not just curious fascination, but yet another clue to the inner workings of my patients.
Reason Number 16: Ah Ha! Moments. This was a piece that I intended to submit for a recent Grand Rounds, but didn’t get it finished on time.
A mother of a three year old called my office one afternoon with a rash. She described her daughter’s skin as blue bordering on purple and appearing suddenly on the arms and legs. Several thoughts went through my head as I cued Colleen, my nurse, to bring this patient in for an appointment at 2:15. Colleen assured me that the child was in no distress other than her mother’s angst.
Is this cyanosis? Was there occult congenital heart disease? Is this poisoning or methehemoglobinemia? My mind raced to make a differential. I googled cyanosis. I searched for pictures of children with acute purple extremitites.
Jennifer, my young patient, hopped onto the papered exam table with her usual vim and vigor. She didn’t appear to be in any acute distress of pain. Her mother pulled off her coat, and continued pull the layers of socks and leggings and tops.
I reached out to touch her legs. No texture. No signs of trauma or bruising. Not tender or sensitive. Just blue as a blueberry.
“No.” Her mother answered.
“Does it itch?”
“No.” mother and daughter offered.
For a full five minutes, I touched, I examined, and pondered.
“Hmm.” I mindlessly reached into the drawer of the exam table and pulled out an alcohol wipe. It could have been a throat culture had I touch that first. I was just looking for a way to solve the mystery. I ripped open the package and wiped it over Jennifer’s leg. A streak of normal skin appeared where I swiped. The pad turned more and more blue with successive swipes.
“You’re kidding me!” Jennifer’s mom gasped. “It’s just some kind of dye?”
“Yea. That’s all it is. Has she worn anything new and blue?” Jennifer’s mom couldn’t recall any exposure to blue anywhere. No blue bubble bath. No blue markers. No blue bath crayons. No new blue jeans.
“How did you know to try to wipe it off?” Colleen asked me afterward.
“I don’t know. It just felt like the right, least invasive thing to try first.”
Still trying to figure out how to ICD code that visit…