During the first year of medical school, one of the most nerve-wracking, but exciting, experiences was learning how to interview and examine patients. At that time, we mostly worked with “standardized patients” — people who are trained specifically to play the role of a scripted medical case. Although working with them seemed incredibly challenging at the time, the rules of engagement were in fact very favorable to us. Asking a question would generally bring an appropriate answer, and when it came to the examination, the “patients” would readily follow instructions.
Back then, the nightmare scenario for my first-year self would probably have gone something like this: You walk into an exam room and introduce yourself, and your patient just stares at you as if you’re speaking gibberish. You start asking the patient questions about how they’re feeling, but they don’t answer anything you ask. Eventually, you give up and move on to the physical exam. You ask your patient to lie down on the exam table, but they refuse and turn away from you. When you move towards them with your stethoscope to listen to their heart, they start screaming at you at the top of their lungs. It’s quickly becoming evident that all of your textbook skills that you have faithfully practiced during first year are no longer helpful.
Welcome to pediatrics!
Far from being made up or imagined, the above scenario is one that any student on a pediatrics rotation might face daily. Indeed, after four weeks on my outpatient pediatrics rotation, it has quickly become clear that the traditional “rules of engagement” that we learned during our first year are thrown out the window when it comes to working with kids. As any parent knows all too well, young children generally are not skilled at describing their symptoms, and they often aren’t particularly interested in making your job easier when you’re examining them.
Over time, though, with tips and tricks picked up from my preceptors, it has become easier to turn these encounters into productive visits. Rather than asking a patient about fluid intake and symptoms of dehydration, I’ve learned to instead ask a parent how many wet diapers their young child has had in the past day. Instead of asking a patient to take big, deep breaths by mouth, I’ve had to listen closely to the gasps of air that a crying baby takes in between wails. There may even be a little bit of bribery involved now and then (“Somebody’s going to get a sticker on their way out for being so good today!”). And sometimes, there’s no getting around it — you just need to move in quickly and check the ears of a squirming child while mom or dad holds them tightly.
Most of the time, pediatrics isn’t as elegant as adult medicine. There’s a little bit more detective work to be done, more inferring and reading between the lines. As a result, rarely do I leave a room with a young child feeling as though I have the “perfect” history of their illness or that a complete physical exam was done. Still, that’s OK. With a few tricks up my sleeve, working with kids is anything but that nightmare scenario that I could have once imagined.
Nathaniel Fleming is a medical student who blogs at Scope, where this article originally appeared.
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