A tired but beaming mom greeted me as I entered the room. In her lap was a content appearing, slightly chubby, cherubic faced baby.

“This is Caleb … isn’t he beautiful” mom gushed. “He is named after his dad …” but then added in a softer voice, “but I’m not sure how much he plans to be involved.” Mom’s smile waned for a moment but quickly came back. “Looking forward to coming here often,” she said as she gave me a tight bear hug that literally took my breath away.

Mom ended up being prophetic on both accounts. Dad Caleb indeed ended up falling away while our Caleb would soon become one of our most frequent clinic visitors. At first, it was for the routine visits of the first few years of life. Mom, as many of our parents, was haunted by the demons of mental health problems (anxiety in her case), poor housing, smoking (“helps my anxiety” said mom) and poverty. This, in part, with time led to an ever increasing proportion of Caleb’s visits focusing on asthma, obesity and behavioral concerns. These visits were partly medical in nature but mostly social, with lots of discussions and hand holding, focusing on mom’s anxiety, her anxieties about Caleb, her need to quit smoking, and trying to find help for her economic situation.

Caleb developed mild persistent asthma and struggles with behavior in school, and despite almost monthly visits, these issues improved only some and slowly at that. At age 7, Caleb and his mom moved back home to a rural town so as to live with her father, Caleb’s beloved grandfather. Despite the nearly 90 mile commute, mom continued to bring Caleb to us for his medical care. With a more stable financial situation and home, and feeling overwhelmingly loved by his grandfather, Caleb started to do better at his local school.

However, his asthma worsened significantly, leading to two admissions for exacerbations back at our hospital. This, in part, may have been caused by the grandfather being a chain smoker. Unfortunately, the grandfather passed away the second year that Caleb and his mom were there, leaving mom and Caleb alone again. This led mom to move from town to town working jobs as they came up. Caleb moved from school to school (6+ times over a four year period) each in a new county (I am still amazed how many counties are jammed into the southeastern portion of our state!) and each school requesting intensive counseling for a now hostile and grieving Caleb.

During this time our clinic social worker and I spent hours reaching out and working with local county mental health groups setting up help for Caleb. Consistently these underfunded, overworked, county counselors did an amazing job of keeping Caleb as stable as possible. While not a role model student Caleb still moved along in school and life.
One day a few years ago Caleb and his mom came to the clinic and announced that they have moved back to Columbus, with mom marrying a man from our area. At first, Caleb was quite hesitant about the new addition to the family, but with time got very close to him. The asthma was better controlled, in part since stepdad implemented a no smoking in the home rule and helped Caleb with his daily medication administration.

Still, Caleb still had asthma flares at least yearly. Behavior was the big change. With each passing visit, Caleb seemed happier and more focused. Due to his bevy of issues in the earlier school years, he was still behind in school, but improving and definitely improved with his hostility. Most importantly, Caleb just seemed more mature each visit, and more and more loving to his family, now including two little sisters.

As I recently prepared for Caleb’s annual health check, I started to think about what value we at our clinic provided for Caleb and his family. While his asthma and school performance had improved, it was a slow process with plenty of bumps on the road. Plus, he was still not a “success” based on most of the performance markers out there and which may be used as we transition more and more to a value based medical reimbursement world. I felt that there was no one visit or even series of visits that led to a quantifiable improvement. It took time and it was due to his devoted mom, his sisters, his deceased grandfather that loved him dearly, the stepfather, the amazing rural county teachers/social workers/counselors that are so much underappreciated, our social workers, our staff and our residents that have worked with this family over the years.

In retrospect, it was a slow life course impacted by many folks, including our clinic, that led to his current state. I continued to think about this as the intern came out and presented. The formal presentation soon deteriorated, leading to gushings about how neat mom and Caleb. I smiled knowingly as I entered the room. There was Caleb, still with a content appearance, still chubby and holding his two cherubic looking sisters on his lap.

“Can I get them some stickers?” Caleb asked, and the sisters laughed in anticipation. After my reply, he bounded with them out of the room. Now alone with mom, she started by saying “Caleb has come a long way, hasn’t he … I am so proud of him.”

Then she provided the answer to my questions (this is a teaching clinic after all, and moms are our best teachers): “Doc, I just wanted to thank you for always being there for us and for never stopping believing in Caleb and me … it means everything.”

I then got one of her patented pulmonary function test inducing bear hugs, and she stepped into the hallway joining Caleb and his two sisters, each holding one of his hands, while laughing and pointing out the myriad of stickers that he placed on their jackets. This was indeed the answer I was looking for.

Alexander Rakowsky is a pediatrician.

Image credit: Shutterstock.com