Thursday, May 26, 2011

My failures

Two posts in one week? Don't have a heart attack. Seriously.

I've had requests in the past to blog a little about my work, so I'm sitting in a class right now, waiting for them to figure out the projector, and I've been thinking a lot this week about a couple failures I've had that I thought I'd share with you.

I love being a pediatrician. I think I'm a pretty good doctor, and most of my patients are extremely loyal to me (they hate when I'm away, or they can't get appointments with me, or they are sick and have to see someone else on a different day of the week than my regular clinic day). I also think I'm a pretty good teacher and hopefully helping to shape some other budding primary care pediatricians.

But I saw two patients recently, both of whom have been in my care for a while, and both of whom I feel like I've really failed. And it bums me out. Not sure I can or could have done anything differently. But it's hard being a primary care doc and dealing with these issues.

One is a girl who is nearly 11, so I've known her since she was 7 -- JF. Like many patients in East Harlem, she has bad asthma and is obese. For the past 4 years, I've spoken to her and her Mom (who is also obese) regularly about making changes to her diet -- namely cutting out juice and other sugary drinks, eliminating fast food, and having healthy snacks available. One of the barriers for this particular patient is that after-school she goes to Grandma's house, and Grandma always has cakes and cookies and brownies available. JF is hungry, so she indulges, and Grandma loves to see her enjoy herself. The other big problem is that she eats lunch at school, and they serve things like chicken nuggets and pizza -- not salads or grilled chicken.

So she shows up last week for a follow-up visit. Thankfully, her asthma is well controlled (she has one PICU admission since I've known her, but hasn't even been to the ER in over a year). But she actually gained weight since the last visit, when the goal for kids this age is to grow in height without gaining anything in height (yielding a lower BMI). She is over 150 lbs! When we started talking about things like juice intake again, it's like she's never heard that she shouldn't be drinking the stuff. In one ear and out the other. And her Mom just sighs and shakes her head, not realizing how serious this can be -- diabetes, heart disease, high cholesterol, not to mention the social issues. Sigh. I don't know how else to get through to them. I keep repeating the same things -- about diet, and exercise -- keep giving her the same advice, visit after visit, year after year. I'm a broken record. But I don't think it's working for her.

The other patient makes me even sadder. WR is now 3 years old, and has been my patient since he was born. Looking back through his chart this week, at the one year visit Mom asked me about some of his behaviors -- namely, his tantrums -- but I reassured her that they were normal 1 year-old behaviors and that he was developing appropriately. By 18 months, however, I noticed that he was not behaving appropriately for his age -- his social skills were lacking. I tried talking to Mom about it then to get him evaluated, but at that visit she thought he was fine and told me that what I was seeing in the office was NOT how he behaved at home, and that his language was much more developed than I was seeing, he was just being shy. So I didn't push it, but wanted them to come back sooner for a follow-up visit -- they didn't. At the 2 year visit, it was very clear to me that the child had features of the Autism Spectrum Disorders, and I encouraged the family to get him evaluated by Early Intervention immediately so he could get started in therapies. They refused to believe me. Dad has an older son with autism, and stated that WR has none of the features of the older boy so it couldn't be true. At 2 1/2 they finally agreed to get him evaluated. The people from EI came in and all of the therapists used the word "autism" or "autism spectrum" so the family got mad. I saw him last week on his 3rd birthday (when he ages out of EI and has to place into school-based therapies). They are angry about the evaluation because they still don't believe he has ASD. They don't want to accept the diagnosis and want 2nd opinions. Meanwhile, the kid has every feature of Pervasive Developmental Disorder (which is on the Autism Spectrum) you've ever seen. He has no significant speech other than "juice" to refer to all food and liquids. He makes minimal eye contact, talks/sings to himself, plays by himself, etc. I tried to convince them to just accept whatever diagnosis the therapists want to make if that means he qualifies for lots for lots of therapies, they can think whatever they want to themselves. But it's difficult. This kid should have started therapy at least 18 months ago and I feel like I failed him.

So there you go. It's frustrating to be a doctor.

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