The first child patient at a pediatrics rotation

For the sake of patient privacy, I am going to tell this story very ambiguously and hope that the insanity of it is not missed with the lack of details.

Because most of us do clinical training with non-pediatrician tutors, we have mandatory pediatric tutorial sessions. While I had already done a little bit of lung and heart listening on some children earlier on in the year, this session was the first time I really sat down and talked to a child about his or her health.

Granted, I like kids, but as the youngest of four myself, I have not had much interaction with them. In fact, when my brother had a child I was confused (and still remain a bit stupid about it all) why the baby didn’t really do much for most of the first year and why all the developmental milestones were actually much later than I thought they were in my head (not because of something with my nephew, just because development is really quite slow). Therefore, if I had to do more than just make a little kid laugh, play peek-a-boo, or stick out my tongue, I was ill-prepared.

In groups of 5 we had two “interviewers” and 3 observers, and for lack of others’ motivation, I was one of the interviewers. We had debated whether or not to wear a white coat (most pediatricians do not) and decided to wear one mostly out of convenience (we had no where else to put our stuff while we were walking around), and not really because we had strong feelings either way about wearing them.

When we went to find our patient, he was not in his room but was instead in the activity center drawing a picture. We were incredibly cautious about approaching him in there or taking time away from his fun, but nurses and activity coordinators urged us in (nearly pushed us in), and we obliged. He was very enthusiastic, but not at all focused. At first, he barely acknowledged that we sat with him and even with his mother urging him to “listen and talk to us” from another table, he was intent on finishing his drawing. Yet, as they had told us to try to break the ice by talking about hobbies and school, we (me and the other interviewer) thought the drawing would be an easy jump-off point. Boy were we wrong, and this was what happened next:

My friend: What are you drawing … is that you?

Patient: No, its a girl.

Friend: Is it your mom?

Patient: No … IT’S YOU (pointing at my friend)..

Insert car screech veering off the path sound here.

Me: Why do you think he’s a girl (asking about my friend)?

Patient: His hair (which, might I add, isn’t at all long)

Friend: That’s not cool. The picture doesn’t even have glasses

Patient … draws glasses.

Then, the patient decided he liked messing with my friend and he drew, and drew, and drew (all the while further digging my friend into a hole he couldn’t escape from and virtually cutting off his ability to ask the patient any pertinent questions). He had a wild imagination and just died laughing at every element he added to the picture, from harmless to much more violent and disturbing. At one point he even drew a weapon causing the person in the drawing to bleed. Graphic, and hard to know how to respond. We did not know whether to laugh, to admonish, or to change the subject. Sure, we tried a lot of ”why would you draw that” and “that is not nice” responses, but our roles had definitely shifted to become more like spectators and peanut gallery members than his doctors.

As he was not in the hospital for a psychiatric reason we were not “scared” of his drawings, and lucky for our goal of talking to him about his illness … we finally caught a break. He decided to draw my friend with the same physical impairment that he was in the hospital for (insert shock that perhaps drawing therapy really does work and is not b.s. like I thought it was) and we finally had a solid jumping off point. We tried a lot of “how does the person in the picture feel with those problems” and got some answers, but really we were struggling to hear much at all about his condition. At one point he told my friend to close his eyes so that he could add to the picture and my annoyed-at-failing self responded “Sure, but only if you answer my questions while his eyes are closed.” I had finally found a way to mesh the drawing and the history taking. Fabulous. True, it did not last long, and true, with his rich fantasy world I could not tell what was real history and what was in his mind, but hey, at least he was talking. Our tutor had also suggested another method to get him to speak, which was to have my friend draw a picture for the kid, and in the meantime he would answer questions. This worked too, albeit for a short time.

Ultimately, even though I would be shocked if I could even give you much more than a two-sentence history after that conversation, there was something about the day that felt like a good challenge. Sure, it was really hard to get the kid to talk about anything at all relevant, but it was just so different than working with adults where every sentence has to be phrased a certain way to be ok or you have to act more serious and more “your age” to be respected (hard for me when I look really young and during my last visit for clinical training was asked if it was “high school day,” even though I was wearing my white coat). The challenge in this was like you couldn’t really go wrong, you just were trying to go right. It was like swinging and missing at a bunch of balls but then creatively adjusting until you finally hit one out of the park.

Jessica Gold is a medical student.

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  • Ardella Eagle

    Responding as a mother, this had me in hysterics! In placing myself as the author, I understood her confusion.

    Poor Ms. Gold is ill-equip to handle pediatrics at this stage in her life. I totally understand; at her age, I was terrified of children. I hadn’t a clue as to what to do with them. However, as one gains experience (in my case, first-hand with my own), one gains ‘techniques’. Unfortunately, residents can’t put off for later-in-life training and not everyone can return to school for a second career in medicine. No, Ms. Gold, there is no “insanity” here, just a bunch of students left with an experiment and no instructions. You were ill-prepared for the aged child, someone of diminutive age yet made cynical by illness. You and your partner ‘fell’ for every one of your patient’s guiles and only re-enforced his disdain for all things medical. In time, you’ll figure it out. In the meantime, spend some time with your sister-in-law and watch how she deals with your nephew on a really bad day. Better yet, come and watch me deal with my 13 year-old and 9 year-old girls and my 11 year-old son. There’s also trial by fire, but that’s a long term commitment.

  • http://barkingdoc.com maggie kozel, MD

    The good news is, the longer you do this, the better your batting average gets. In fact the learning curve is generally very steep. Your sense of humor will get you there even more quickly. Best of luck!

  • sharon a. wander M.D.

    This was a very confusing article, no mention of age, No mention what division in Pediatric care did they find the patient. Unsually you study the case, progress notes and know the patient’s problem so as not to bring up bad questions and not scare the child. What is the wrong questions were asked? My how training has changed to not making any sense for the patient, his medical problems etc.. This was like throwing the writer to the lions den without any concern for the patient the child.

  • Baby Daddy

    Given that this child was apparently old enough to draw fairly complicated pictures, s/he was probably old enough to sit down and answer the students’ questions in a civilized manner instead if indulging his/her every whim for what seems like a very, very long time. I’m not sure what kind of physician would have time for that kind of thing, or of what medical/diagnostic utility it is.

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