Monday, September 26, 2022

After a gentle knock on the door, I slowly turn the knob and poke my head inside. My next patient is a toddler here for his 18-month check-up. With a startling glance, he quickly looks at me and turns away, running into his mother’s lap and crying.

While, to some, this may sound like the upsetting beginning of a bad interaction, to me it is actually a reassuring start to our visit. In just those brief seconds, I have gleaned a lot of information. The toddler displays appropriate social interaction skills with his stranger anxiety. He acknowledges his mother and relies on her as a source of support. His motor skills seem great, given how fast he ran away.

Approaching an anxious toddler is always a difficult challenge. It can be hard to get a good history while he whimpers in the background. The crying can also upset the parent. The anxiety frequently makes the examination more difficult as well–checking the ears with my otoscope can be like trying to hit a moving target. Keeping a bit of distance and avoiding direct eye contact early on with the toddler frequently helps in these encounters. Usually, with a bit of patience and gentle coaxing, we can get a few minutes of quiet in the office to discuss the family’s questions and concerns.

These subtle tips and techniques are not things taught to us in medical school. They are a part of medicine that doesn’t involve hard science and cold facts. They are the “art” of medicine.

The crying child is not an infrequent part of my day. It causes me to recall the numerous discussions my classmates and I would have back in medical school when we were all trying to figure out what we wanted to with our medical education. I knew early on that I wanted to work in pediatrics. “How do you handle all those runny noses and nervous mothers?” I would be frequently asked. “I can’t deal with all the crying; I don’t know how you do it,” was another common claim. To be honest, though, it isn’t as difficult as it may seem. Once you put yourself in the child’s position and look at things from his or her perspective, it really starts to make sense. Being approached by someone who you have only met a few minutes ago, especially when not feeling well, is upsetting. Coming to an office, where last time a few shots were given, would make me anxious too! It is with that empathy (and a few of my bad jokes), that the beginning of a successful patient-doctor relationship can begin–even if the encounter is for just a few moments of time.

Body language speaks volumes. Noticing the frown on a teenager’s face when she realizes she will miss soccer for the next week due to a sprained ankle, opens up an opportunity to express condolence and address her frustration. A rolling of a father’s eyes when telling me a history reveals his skepticism about the severity of his child’s illness. The slightly hesitant glance and subtle hand gesture by a parent as s/he sees me getting up when finishing our encounter tells me there is just one more question or concern. Picking up on these clues helps guide me in how I manage an encounter. There are visits that can be quite lighthearted and there are other times that require a more serious approach.

I, too, have had to learn my own nuances. Do I need to sit down to get on a better level with the child or should I remain standing and not disturb the 3-year-old playing with my chair? I must be clear in my tone of voice and my mannerisms so they are not misinterpreted. If I look nervous or harried, it will impact my ability to communicate effectively with the family.

Little techniques go a long way. Showing children how the otoscope feels by their ears can make them feel less anxious. Letting one know that there are no shots at the day’s visit provides reassurance. A quick compliment of a young girl’s shoes or earrings builds a level of comfort and trust that makes the visit more pleasant for everyone. These techniques extend beyond my own interaction with the child. Getting some stickers and having a few minutes to check out the fish tank in the waiting area afterwards makes the visit more satisfying. Well wishes from the medical staff display another level of care. Medicine is more than just about following guidelines based on our current best evidence. It is about using that information and applying it in a human manner. It is that challenge, to constantly hone my craft and provide excellent medical care that I strive to meet on a daily basis. A handshake, a pat on a patient’s knee, simple mutual eye contact or a sympathetic tone does wonders to help solidify an unspoken arrangement and agreement. You have come to me for help and I will do my best to provide you with care. But that is a topic for another time.

For you see, my time for this encounter is coming to an end and I have many more children to see today. I do not worry as I leave that 18-month-old’s room. He has realized the visit is over and is staring at me as I get up to leave the room. Oh, and yes, I notice his little hand waving bye at me as I head to the door.

By Dr. Joshua Menasha

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