Biding One's Tongue

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.

pdnews@elsevier.com

I glanced at the chief complaint scribbled on the top of the billing sheet before I entered the exam room. I usually ignore these little “heads-ups” from the receptionists because they often bear little if any resemblance to the parent's real concern or the patient's problem.

In this case, I was hoping the “?development” was one of those red herrings.

The patient I was about to see was a 16-month-old whom I had examined at least nine times since his birth, and I couldn't recall receiving bad vibes on any of those previous health maintenance visits.

So, I took a deep breath and gave my nose the habitual rub before entering a patient encounter, and opened the door carefully because one can never tell where a toddler might be motoring. Fortunately, the history spilled out quickly.

It turns out that a friend of a sister-in-law of the child's day-care provider is a recently trained occupational therapist. She had paid a social call at the day-care center one day the previous week and after a 20-minute informal observation, had shared her concerns about this young man's development.

Apparently, she was troubled by how he rose from sitting to standing and by the fact that he was totally uninterested in television. The day-care provider felt obligated to share these unsolicited observations with the parents and voila, we have an office visit.

I re-asked a handful of questions from the previous two well-child visits as I watched this little rascal cavort around the room. I then took him for a run down the hall and examined him.

Luckily, the parents were already skeptical about the off-the-cuff appraisal they had received secondhand. They readily accepted my qualified reassurances, including, “I don't know whether he is going to graduate first in his class, but I don't have any worries about your son's development.”

The scenario could have been much different. At any one moment, there are three or four infants and toddlers with soft signs of developmental delay circulating in my subconscious. I haven't shared my concerns with their parents because I know that within 12 months, the tincture of time will have coaxed 90% of these little outliers back under the safe umbrella of the bell-shaped curve.

Of course, once or twice a year it will become obvious that things haven't moved along as well as I had hoped, and I must begin the careful process of sharing my concerns with the parents.

I'm sure that people who equate early intervention with motherhood and apple pie will feel that by keeping my worries to myself for a few months, I have done irreparable harm to these patients and their families.

Trust me, I would much prefer to cleanse my mind of all those private worries I harbor about my patients. But, it is just part of being a physician. One can minimize some of these worries by ordering unnecessary but reassuring lab work and CT scans. But when the worry is about something as nebulous as a subtle developmental delay, the lab and the imaging department can't bail me out. Only time will tell, and I choose to keep my tongue clenched firmly between my teeth while I wait.

To do otherwise can open a can of worms that has parental angst written all over it. When I finally say, “Mrs. James, I'm just a teeny bit concerned because your baby is just a little bit floppy,” I had better be ready for several long discussions about what this can mean and have a plan of how we are going to move forward with evaluations and therapy.

If I'm lucky, the parents will say, “We're glad you mentioned that because we were just beginning to wonder about his development ourselves.”

Timing is everything.