One of my favourite shows growing up was "Kids Say the Darndest Things".The forthrightness of innocent minds left us all in stitches. Children say it as it is to the level of their comprehension. The beauty of this innocence is that it carries through even when they are unwell.
Ruth was embarrassed when she walked into the consulting room. Her daughter Mabel had just broken a toy in the reception while awaiting to see the doctor. She was full of energy and curiosity, and her hands were wet from attempting to feed the fish in the tank in the reception.
Yet the night before, the family had not slept. Mabel had fevers of 40 degrees Celsius on and off, and the fever was unresponsive to paracetamol. Twice she had vomited the medication and the heaving left her weak. By morning, the fever had settled and Mabel even managed to take a few spoons of oatmeal before coming to the hospital.
Ruth felt like an imposter describing her daughter’s condition. She did not realise that children are exactly like that. When illness weighs them down, they are listless and in a low mood. They get glassy-eyed with fever or teary with pain. Immediately the discomfort settles, temporarily, they bounce back with amazing speed. One would be forgiven for thinking they had imagined the whole affair.
A great paediatrician who taught me many years ago, ingrained in me the importance of listening to the whole story. He emphasised that the history of the illness is critical to arriving at a diagnosis, even before one gets down to examining the patient. This golden gem of advice has served me well over the years. It taught me patience and I learnt to pick important clues from distressed mums and dads.
However, examining a child is a whole other skillset. While adults will lie down on the couch and cooperate without question, children require the doctor to be extremely warm, attentive and highly creative. It is said that one cannot make a good paediatrician if they genuinely do not love children. Children turn even the sternest of professors into fuzzy, warm beings.
Paediatrics was my very first clinical rotation in my fourth year of study. Our lecturers were diverse, but each had their unique bag of tricks when handling the children. It was fascinating to watch their interaction. During one of the teaching ward rounds, as the lecturer was examining a five-year-old, he asked her to cough so he could assess whether the increased pressure in the chest would make the neck veins bulge abnormally. The child looked at him blankly and calmly stated that she did not have an urge to cough. We all burst out laughing, much to the bewilderment of the girl.
One hot afternoon, we stood around a nine-year-old girl’s bed learning about meningitis. As any medical doctor would tell you, examining the central nervous system is one of the most difficult skills to acquire. The little girl was extremely cooperative, even getting out of bed and walking in a straight line. However, when it came to the past-pointing sign, she dug in her heels. The doctor asked her to alternate between touching the tip of her nose and the tip of her left index finger, which was held about foot away from her face. The good doctor even went ahead to demonstrate, but our little angel absolutely refused. When asked why she didn’t want to do it, she bluntly stated that she did not want to look as stupid as he looked. None of us had thought just how silly the action appeared because our perspective was purely medical.
Despite the moments of mirth that little children bring to the wards, the bigger lesson remains that the art of medicine is heavily dependent on social skills. A doctor can easily extract a diagnosis just by listening and doing a thorough examination on the patient. Some of the examining procedures may be unpleasant, but they must be done and the findings documented.
The wonder of being able to not only appreciate a heart murmur, but also characterise it, should not be allowed to lose its magic. The first time I listened to the chest of an infant with bronchiolitis, I was awed. The little boy sat calmly in his mother’s lap while his chest sounded like a marching band. I totally understood why he would have trouble breastfeeding. The cacophony in his chest was his airways struggling to get enough oxygen to him despite being overrun by inflammation. It is not the same as just seeing the abnormality on an X-ray film.
Unfortunately, this fine art is slowly being disregarded as we become more and more reliant on technology. Patients are less satisfied when the doctor fails to order a battery of lab tests or imaging diagnostics. The results may be objective, but their interpretation is subject to the patient’s history and examination findings.
We must not allow the robotic culture of technology to replace a good patient experience that can only be brought about by a good conversation and a skilled examination. The ideal process dictates that diagnostic tests are meant to confirm a diagnosis, not to go on a fishing expedition. Technology is here to assist us to decipher what is wrong with our patients, not to turn us into lazy technology-obsessed and antisocial caregivers!