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Looking ahead to a new season
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The calendar correctly identifies the season as spring, but here in Vermont, the snow is still flying, thank you very much. Despite the vagaries of the weather, it is clearly springtime in practice. Always an odd combination of persistent and recurrent leftover winter viral illnesses, school-related problems and the joys of newborns — practice remains frenzied. Despite the pace, as the axis of the Earth is increasing its tilt toward the sun, I feel the sun’s increased warmth and seeming promise of both new beginnings and re-energizing of old loves.
Perhaps it is because of my previous columns’ emphasis on the future, with the requisite attention to the current and upcoming challenges and frustrations, that I so look forward to the new season. Undoubtedly, the alternating presence in my office over the past several weeks of both a first-year and a fourth-year medical student from the University of Vermont has also added a layer to my understanding of life cycles and deepened my sensitivity to and forced reflections on the truly privileged position we, as pediatricians and physicians, hold in practice. When you can participate in the beauty of a healthy first baby to a new family, or help a family cope with the challenges of a sick child, it allows another very rewarding month in practice.
Sandwiched between seasonal epidemic bronchiolitis, influenza, streptococcal pharyngitis and gastroenteritis and the school spring vacation lies the vast (seemingly, some days more than others) numbers of patients with recurrent and/or prolonged respiratory illness often complicated by acute otitis media, sinusitis (which I hope in my next quarter-century of practice I decipher how to define) and pneumonia. Perhaps our newer vaccines for pneumococcus and rotavirus will more obviously begin to affect practice at the office level, but in the meantime, we certainly remain busy.
Clearly, influenza vaccination can affect our daily schedule and lessen post-infectious complications (as has varicella vaccination), but the year-to-year variation in influenza disease prevalence and severity make it often difficult to appreciate. None of these vaccines have led to the transformational change in practice that Haemophilus influenzae type b vaccination has in my career, or of measles-mumps-rubella and polio vaccines in an earlier generation of pediatrics.
The art of pediatrics
The art of practice, I believe, is most critical when applied to these patients and their families as they deal with the burden of frequent illness. We likely set the tone for our relationships with families at the first newborn visit, and re-enforce it during the subsequent well visits. Our art is certainly challenged at the time of severe illness, premature birth, chronic debilitating or fatal illness, and the diagnosis of a developmental disorder. But we are more commonly called upon to assist those facing several weeks to months of recurrent illness.
Data are nice. The recent publication of the likely definitive studies on the effectiveness of antibiotics for AOM in early childhood has been a welcome addition to practice. However, we pediatricians in the office setting are still left to manage the chronic recurrent episodes of AOM, and rightfully so. Every patient and each family bring to the discussion multifaceted concerns. Antibiotic choices, seasonality and natural history of infections, timing of otolaryngology referral, environmental and allergic challenges, including parental smoking, immune status, parental stress and missed days of work, among many others — all contribute to a far-reaching discussion in the office setting.
Effective management relies on the strength of relationship with families embedded in our system of continuity of care. Trust, in us by our patients and in our patients and their families by us, and our dedication to excellence in care are critically important in the success of our efforts. The sum total of which I try to explain to students, such as the two I mentioned above as they face their medical careers, one just beginning medical school and the other just recently matched to a pediatric residency.
I use the patient with otitis metaphorically with students — perhaps to counterbalance the message they often get, which is that office-based pediatrics is 50% ear infections and the other half writing prescriptions for amoxicillin. If you cannot explain the art of medicine and the rewards of practice as you describe the intricacies of managing OM, you are likely not happy in practice.
Renewed sense of joy
I find that teaching in the office setting with first- and fourth-year medical students, and even third-year residents, is a terrific opportunity to validate the intellectual challenge and the compassion that brought the student/resident to medicine in the first place. To engage them in the discussion of the pathophysiology of disease and the art of medicine at the bedside equivalent in office practice is to me ideal. It is also deeply rewarding to me personally, as I both give back to pediatrics and reinvigorate my own sense of profession.
Pediatric practice may not be as pleasant each day as a visit to Lake Wobegon. However, when given an opportunity to pause and contemplate — I cannot see anything else I would rather do than practice pediatrics. Having students and residents in the office allows such time to reflect, something I also find happens with prenatal visits. Spring brings a renewed sense of joy, and not just because the sun rises on my way to the hospital and still is high in the sky when I leave the office in the evening. Helping patients and families navigate the byways of illness and well-being is a privilege.
William T. Gerson, MD is clinical professor of pediatrics at the University of Vermont College and a member of the Infectious Diseases in Children Editorial Board.
Disclosure: Dr. Gerson reports no relevant financial disclosures.