Some days everything just clicks, and I act almost like a doctor. Other days, it all falls apart. Today, for example. The next-to-last patient of the day, a four-month-old with a complaint of runny nose, cough, and ear pain. Simple, right? Except that I inexplicable got the idea that the baby was 11 months old (that’s how big it was), and presented it as such. Also I failed to detect the otitis media. And finally, I completely did not see a roaring case of diaper rash, which actually extended beyond the diaper (the mother was cradling the baby in her arms in a blanket the whole time I was looking at it, but that’s hardly an excuse) and turned out to be candidiasis. (And I gasped when the doctor opened the diaper and revealed this ugly red mess. Very very unprofessional, Alice, very very bad.) But that was not enough for me. Oh no. The last patient was a cute five-year old, complaining of cough for some 24 hours. And incidentally, mom says, she has asthma. After I asked all the “cough/runny nose/ virus vs. strep” questions. So, I completely failed to get an adequate history of her medications (yes, so, mom couldn’t tell the difference between pulmicort (daily inhaled corticosteroid, maintenance medication) and albuterol (prn rescue medicine), but the doctor managed to elicit a workable explanation from her, and I didn’t.). And then, listening to the little girl, I heard the most awful wheezing. So I went and told the preceptor, she’s wheezing very badly, but she’s not in distress, she’s very cheerful and happy. Well, he listened, and said it was upper airway congestion, and her lungs were fine at the moment. Duh, Alice, have you been doing peds for this long and can’t tell the difference between upper and lower airways? Very very stupid. So I was glad to slink out of the office. . . (Although, as I’m writing this, I’m wondering, was it really upper airway? It sure sounded very asthmatic. But you must always look at the patient, as they said about VFib, if the patient is talking and breathing, don’t shock them. If her lungs were really that bad, she should have looked at least slightly distressed. . . I didn’t know kids could make both inspiratory and expiratory wheezing with their mouths. . . But he gaver her steroids, anyhow, so she’s taken care of.)

So, those are my practical problems; now for the philosophical objections. Pediatricians are nice people. But their existence is mainly justified/necessitated by break-up of American society, to the point that even the nuclear family is splintering. Do we really need a doctor to tell mothers that babies should start eating baby foods between four and six months old? Or that they should start potty-training around two years? Or that giving in to temper tantrums is the way to perpetuate them? Do we need a doctor to explain that fever for nine hours with a runny nose does not require any particular treatment beyond over-the-counter tylenol and decongestant? Call me old-fashioned; but that sure sounds to me like what grandmothers and aunts, and even older friends with children, are for. A good 75+% of what my preceptor does on a regular basis is give advice about child-rearing; which he does very well, for a man. But he didn’t need to go to medical school to find it out. A few years spent in the company of several normal children would tell any observant person the same. Which is what grandparents are for. . . to share their experience. Although, in these days when couples usually have only one or two children, perhaps the older women really don’t have enough experience to help the younger women. . .

Vaccines, yes, I will not commit the heresy of questioning them. The health department does a very nice job of immunizing the poor kids, who get their shots, but don’t spend as much time/money getting [pointless/unnecessary] advice from the doctor. We could do that for all the kids. You don’t really need a doctor’s office to do regular immunizations.

All of these well-checks, and visits with a 48-hr history of cough/runny nose/sore throat, are really bothering me. They would be completely unnecessary, if our society had even the basic cohesiveness of mother-daughter relationships. Or even some elementary common sense, which I am beginning to believe is now extinct in the American population at large. I will admit it: once we had our shots, my mother managed to raise five children, healthy children, without once taking them near a doctor. And my father doesn’t count, because his value as a pediatric consultant consisted solely of saying, “They’re not sick, they don’t need a doctor.”

And then there’s the pediatrician-as-psychologist-and-counselor aspect. My preceptor sees ADD kids on Thursday afternoon. There was one little girl, brought in by her father and uncle. (The doctor observed later that he was hampered in conversation by smelling alcohol on their breath. I was mainly impressed at two men getting together to bring a child to the doctor’s office.) The father observed that his daughter had been having trouble in school and behaviorally ever since her mother and grandmother died in the space of two months last summer. She obviously had issues: Her hair wasn’t much brushed, and she was bouncing around the room, and ended up hugging me repeatedly, without invitation. Obviously, she needs help to deal with her grief, and she needs a woman around to take care of her and the other kids. I doubt that she needs the Adderall she got. Even by the book, she should probably have been diagnosed with an adjustment disorder or depression, not ADD.

The next patient was 16-yr old boy, who sat on the table and stared at the floor for twenty minutes while his mother complained to the doctor about his behavioral problems, how he gets angry and lashes out wildly, and she’s afraid of what will happen when he gets his driver’s license. On the good side, the doctor didn’t respond with a dosage increase. On the other hand, he sat there talking in professional, meaningless gibberish about anger management, and coping skills, and behavior modification, to the mom, hardly addressing the boy at all. I so wanted to take the boy in a room by himself, and ask him why he was angry, how he gets along with his mother, why he thinks he’s having trouble in school. This is what happens all the time with the ADD patients. By definition, they’re at least 7 years old, often older, in junior high. And the doctor just sits there discussing them with the parent, without ever asking them (in any way which would seriously invite conversation) what they think of how they’re doing in school, or at home, or what they think the problem might be. I cannot imagine the effect this must have on a child, first off to hear themselves discussed by adults they ought to be able to trust, discussed as an object, without any input into the situation. And then, to hear their behavior described as an illness. What does that teach a child, when their anger and disobedience and rebellion and impatience is treated as an illness, to be cured by the right dose of the right medicine? I would be astonished to find any of these kids developing any real power of self control as they grow older.

And finally: discipline. I grit my teeth every time he gives parents of toddlers a lecture on how corporal punishment is bad, and time-outs and “positive reinforcement” and just ignoring the kid are good. Today there was a single mom in with her two year old. She was already concerned about how the little girl manipulates her: refusing to sit down to eat meals, refusing to go to bed till midnight, insisting on her own way in everything. Just as we sat talking, the little girl grabbed for one of the rings on mom’s hand, and cried and snatched till mom gave it to her. She told me she was wondering about spanking, since when her boyfriend threatens a spanking, the little girl jumps to obey; but her own “sit in the corner” doesn’t accomplish anything, because the toddler just won’t sit there, and her little slaps on the diaper have of course no impact. So I threw caution to the winds, and told her: Dr. —- will definitely tell you that spanking is bad. But, my mother would say that spanking is a very good discipline, but you must use a stick, not your hand, and you must make it hurt, otherwise it’s meaningless. Being too honest for my own good, I then told my preceptor what I had said. I think I must tax his patience greatly. He did not say anything, just raised his eyebrows; but when he was explaining to her at length about behavior modification and positive reinforcement and “proper” methods of discipline, he kept glancing over at me, to make sure I was listening. I did recover enough discretion not to try to argue with him afterwards. (Time to study. I’ll save my speech on the importance of corporal punishment for tomorrow. . .)