Saturday, September 18, 2010

Adventures in Primary Pediatrics

Leave it to medical couples to have interesting children.

I have a lovely, low-key family in my practice with a three year old in for a check up. He is a quiet child, non-obstreperous, maybe even diffident, much like his charming and engaging very low-key nephrologist Dad. He has had a little trouble with constipation and is not enthusiastic about the potty, which he seems to fear. But his development is great – very verbal, draws a cross on the exam table paper with no hesitation. He thinks I’m funny (true, I am). A nice, smart little boy.

So as I was examining him with his parents seated over by the window, and his Mom, Laurie, said, “He says he doesn’t want to grow up.” Now, I haven’t heard this symptom very much, and from a three year old! But child psychology is something I enjoy. It gives me room for imagination and creativity, and it’s something many pediatricians are a little deficient in. So, a chance to engage! And with a boy who thinks I’m funny, especially when I do my Donald Duck talking.

So I said to little Grayson, “Well, that’s OK. I didn’t want to grow up, either.” A little tittering from the parents in the Peanut Gallery, but actually it’s true, I didn’t. Why grow up? It’s great being a well-loved little boy, and in my case, the #1 son, as my father used to say, recalling the Charlie Chan movies of his youth. I’ve always regarded development as a double-edged sword, and maybe little Grayson does, too.

Did Grayson feel too much pressure to “grow up” from these accomplished parents? Were they more striving and directive than I thought they were? Was being #2 son too much for him, and he was retreating from the competition? What would they be demanding of a three year old boy, after all?

So, follow the logic. What would the developmental challenge be to a three year old, this three year old? Toilet training, of course. But why would he not want to toilet train? They said he was afraid of the potty. Why would he be afraid? Projective fears (see Bettelheim)? I asked him – are you afraid that the potty will eat you up? He looked mystified at that. Well, it was a try, I thought.

But then why would he fear the potty? Which potty did they use, one on the ground (preferred) or one on the adult toilet? The sound of that toilet gurgling can be intimidating. They use the ground-based potty, and he didn’t seem to have any reaction as I talked to him about it.

Then the “Aha!” moment. He’s constipated! What does constipation mean? Pain, torture. (With Portnoy’s father, I believe that colonic health is the doorway to happiness.) So what does he hear about growing up? Big boys use the potty. I don’t want to use the potty, he thinks, it hurts! So, the intelligent solution for this verbal and intelligent three year old doctor to be, specialty yet unchosen? “I don’t want to be a big boy. I don’t want to grow up.”

A chuckle of appreciation from John in the Peanur Gallery. “Of course,” said in appreciation. I felt so good, the triumph of discovery. Of course, it should have been obvious from the start, it’s pretty basic pediatrics, and as I enjoy and congratulate myself, it’s really quite elementary. Still, I’ll let myself enjoy it.

I had a long, hard time finding pediatrics as my vocation. And I still feel humbled by the task. But you have to admit, this was pretty cool.

Now to fix that constipation.

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