Notes from a Medical Student:


St. Francis de Sales is credited with saying "Have patience with all things..." In my clerkship rotations so far, I've found this to be an important and indispensable piece of advice. A significant part of medicine is often spent waiting. Allowing for the tincture of time to set in often remedies the most painful of problems. Waiting for a culture, a lab value, or a patient to be ready for an interview requires the physician to have this virtue in spades. I've found this quality of character no more useful than in pediatrics.

As I walk into the exam room, I'm confronted with patient who cannot talk, cannot walk, and cannot communicate in such a way that I can understand. Despite these circumstances, nothing is wrong with this patient. She's only 9 months old. Here for a well-child check-up, I introduce myself to her translator. Mom sits the infant in her lap and I start the run of questions: bottle-fed, breast-fed, cereal, other foods, stool, diapers, babbling, stranger anxiety, etc. Mom has no questions or concerns. Everything with this little one is good. So I start the exam. I swivel on my rolling stool over to mom and spend a couple moments playing peek-a-boo. I slide the little one down, intending to listen to the heart and lungs when I'm faced with my first challenge: the Onesie. It's this little bodysuit for infants which buttons with three snaps at the bottom. At this point you can guess I have no children of my own and have virtually no experience with human beings of this length and weight. I fumble at the snaps, hoping Mom won't notice and think, "Who is this kid, think he is, examining my baby?!?" I breathe slowly, and with a little patience, it comes apart and I slide my stethoscope up underneath onto the chest. I start to listen, then look down. She's looking back up at me with a dazed look. I smile. She smiles. I get lost for a moment and then move my stethoscope. As I continue to listen to the lungs, I realize that while I was lost in her smile, I hadn't really been listening to her heart at all. I move the stethoscope back and listen again, this time with my eyes closed. I slide her down then, squeeze her belly, feel for femoral pulses, and attempt the Barlowe and Ortolani maneuver. As I squeeze and jostle her, I'm amazed with how strong this little one is as she extends her legs and pushes back on me, almost moving both me and the rolling stool that I'm sitting on. I feel the back, look in the mouth, and finally the ears. As I finish the exam, I hold the infant in my arms for few moments to get a feeling for movements and strength. I turn her on her belly in my hand and fly her towards mom; back and forth, away from mom's face and then towards her. She laughs and moves her arms, clapping her hands together, while mom's face goes from relaxed and smiling to wide eyes and puckered lips. It is in this moment, that I forget all the things I might be forgetting and suddenly this all feels a lot like simple fun. I set her down in mom's arms, thank them, and leave the room. I start worrying as the door closes, my face drops from its smile. I'm not worrying because of something I found in the history or physical exam. I'm worrying because I don't know what's normal, and without that important feature in my arsenal of medicine, learning the disease state becomes even more challenging.

Two hours later, I find myself standing outside the same exam room. As the physician whom I'm following asks if I can start, I can hear several voices, some loud, some soft, issuing forth from the room. As I enter the room, I see three children, one about 9 months sitting in mom's arms, another around 2 years of age running around the room, and finally a 5 year olds sitting in a chair giving me an interesting look. Mom looks at me and says, "Do you have any kids?" I shake my head no and smile. She smiles back, "Well this will certainly be a learning experience for you." Each of these children are here for the same complaint: cough. So, I start at the beginning, with the five year old. She sits still on her chair but clearly doesn't want to have anything to do with me. Next I move to the 2 year old, which at the beginning seems like an act of futility. I point to pictures on the wall, distract him with lights and my stethoscope, and have him hold a tongue depressor trying anything to obtain 15 straight seconds of stillness. Finally, I move to the 9 month old, who starts screaming the second I roll towards her and mom. I play peek-a-boo, move around the stethoscope on her siblings to show her there's nothing to fear, and bop the otoscope on my nose to be funny. The latter only causes her to scream more and turn her head toward mom. I try my best to listen to her lungs. She sounds clear through the screaming; at least she is definitely moving air well. Finally, I end with the ear exam. After I simply mention the exam, mom already assumes the position, holding the little one's head against her chest. I press my fingers against the head so I can move with her as she shifts her head one way and then the other. I never got near seeing the Tympanic membrane. I walk out of the room, feeling inefficient, and admit to my attending that I couldn't visualize the Tympanic membrane. Not because of earwax or discharge. I just couldn't get her to stay still enough. My attending smiles and walks in the room, within minutes, the 9 month old is laughing, and the exam is done within seconds.

Patience is really all it takes. Patience in learning the baseline of all things. Patience in learning what makes children distracted. Patience in seeing an ear infection in all of the other siblings and what settled them down after a good cry. Francis de Sales quote holds true, and as the rest of it goes, "Have patience with all things, but chiefly have patience with yourself."