Wednesday, August 14, 2013

Another Afternoon in the Pediatric Office

As doctors, we bring our ideals, we bring our training, and we bring ourselves.

The simplest is our ideals.  “To do good,” that’s pretty much it.  Hippocrates’ famous dictum “Do no harm,” is cautionary.  He was wise to caution, because doctors have an inherent predilection to act, to do something, which is why he says, “First, think, what’s the downside?”  “Do no harm” is more quotable, however.  But that’s translated from ancient Greek.  Before the translation, who knows, it could have been, “WTF?”

Medical professional training is less simple than our ideals, and with medical advances the technical training gets harder and harder and longer and longer.  I suspect, but it may not be true, that all the technical training has crowded out training in how to actually be a doctor.  Empathy, understanding, judgment – I’m pretty sure this has to be taught by people actually experienced in being real doctors, not just medical educators.  It has to be personal, in small groups or individually, and it’s mostly look at the way I do it. 

I admire the doctors who really tend to teaching the next generation personally.  I went to one of the best foot orthopedists in the country yesterday, and he had a young woman with him who must have been a resident – so young, oh so young! After he saw me I saw him in the hallway explaining to her, one on one.  This guy is more emeritus than I am, and here he is, passing along his art, the way he does it, the way he understands it, for no payment or recognition whatsoever.  Who knows what he was telling her?  About the foot?  Or about how other doctors – and me, the patient – got the diagnosis wrong.  If it had been my father there in the hallway, I know he would have emphasized the latter.  This guy is old school, so maybe that was what he was doing, too.

And finally, besides ideals and training, we bring ourselves.  We have our own experiences, our own understanding of life that is often hard won, and if we are good doctors, we will pass this on.

Last Monday I used this last tool, myself, and I hope I didn’t do any harm.  Two brothers ages 12 and 13 came to see me for their first visit, just for checkups.  They were brought by their stepmother; their divorced mother and father had both remarried and share custody.  The older boy is at his Mom’s in San Francisco Monday and Tuesday, then over to his Dad’s in Oakland.  The younger one goes to another school and so is at his Mom’s Monday through Friday, as I understood it.  I had a shock of recognition when I heard this, since I shared custody of my two eldest sons with my ex-wife for years and years, splitting up the weeks and having the kids travel back and forth.  I told them I was familiar with their situation and observed that it must be a hard for them.  Or, as their stepmother put it, “The Backpacks.”

In a checkup visit, I try to do some good.  I can do it with prevention – I always deal with exercise, usually with nutrition, etc.  But I bring myself to the visit, and try to figure out how they can leave the room better off than when they came in, rather than a simple “everything’s fine.”  So, since there were no obvious health issues, I persisted in asking them if the schedule was working for them, even though it’s hard.  The stepmother, a nice lady who commented on their and her Myers-Briggs typology, so she’s pretty aware, said “No, it doesn’t.  It’s really a lot of driving, but we make it work.”  Hard on her, clearly, as well as them.  But she was honest and clearly determined to overcome barriers.  One barrier being that the younger one is INT (introverted thinking) and J, so she finds it hard to make contact.

I don’t have a lot of time in these visits, so I tend to shoot things out and hope they work.  I immediately told them that I was divorced also and had shared custody of two boys, which led the stepmother to say, “Maybe you will be able to help us some, then.”  Maybe so.  I had to save time, so I just preemptively said, hoping it would help to frame the situation well, that it might be difficult going back and forth, but it’s a lot better than having to feel deserted by one or the other parent.  Maybe it helped, maybe it didn’t.  Maybe that will resonate.

Later when I was alone with the younger boy I asked him if everyone got along OK, assuring him everything was confidential, as I always do.  He said that he felt that they two boys were asked to clean up the house at his Dad and stepmother’s house, and he didn’t think it was fair, since she was the one who messed it up the most.  I asked him if he could talk about this to his Dad or stepmother and he said, not really.  Do you have anyone to talk to about it?  “My mom,” he said.

The plot thickened – I know this pattern.  So I asked him, “What does your Mom say when you tell her about it?” I asked.

He said, “She says, ‘Well, I guess you should live here with me.’”

I’m so proud that I didn’t comment directly on this.  I was hoping I could bring my best self to this visit.  So, I asked if I could try to help this situation a little.  He said yes.  I told him that it would be best if he could bring up complaints about his Dad’s house directly to them without fear of repercussions.  I went through with him how he could first say something good – maybe how he appreciates how his stepmother cooks for them – and then tag on the complaint.

“She doesn’t cook,” he said.

Right.  “Well,” I said, ”maybe you could say how much you appreciate all the driving she does back and forth?”  Yes, he thought that was valid; I don’t think he had really thought about that, about how hard his stepmother tries.

Then I asked him if I could help by bringing up the issue in a way that couldn’t be traced back to him.  He trusted me and said OK.

So when I got the three of them back in the room, I traded on our common experience to say to them that they might think about having some meetings as a family together, where they could say what was working well, and what was a problem.  The stepmother said, we just had a meeting on Friday, but that was over a problem; maybe it’s a good idea to have one where we can say good things.  I said I thought that was important.  The younger boy kind of looked at his stepmother sideways, warily, but I knew he knew that I was doing what I said I would, and had carried it out OK.

Hard to know what will happen.  Easy to conceptualize, hard to do, especially with the subterranean undermining mother.  Although I understand her.  It’s so hard not to have your kids all the time.  I was watching old videos of our family as I copy them to disk.  My kids stayed at their Mom’s Christmas Eve and early on Christmas morning, but were expected at our house at 10 AM, when their stepbrother, stepsister, and half-brother would also be there for opening presents.  How hard it had to be for their mother to say goodbye to them on Christmas morning.  And how hard it would have been for me not to see them.  I know, because as time went on I didn’t see them anymore for Christmas. 

Divorce just sucks.  I just hope that what I did with these two boys and their stepmother helped in some little way.  At least they know they are not alone, and maybe something I said helped.  Like I say, ideals are important, training sometimes helps, experience certainly helps, but bringing yourself to the visit might be the most important thing of all.

Budd Shenkin

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