ART OF MEDICINE

To steal from Yogi Berra, ninety percent of pediatric medicine is “art,” the other half is “science.”  As a pediatrician, my day is spent talking with parents, children, and adolescents.  Despite eight years of post-graduate training, much of what I talk about is not found in any text.  It can not be proven scientifically.  It cannot be taught.  It is experiential.  John Voket, editor of the Bee, challenged me with a topic, which I felt pertained more to “the art of medicine,” rather than “the science of medicine;” the latter actually being easier to discuss.  To my surprise, on CNN, there was an article regarding how and when to question your pediatrician’s advice (Elizabeth Cohen, March 13, 2008 Health editorial).  In this column, I plan to take a slightly broader view and demonstrate that you need not be well-educated to be a good parent.  Being a pediatrician has not helped me be a better parent.  Being a parent has helped me be a better pediatrician.

The following are issues which I discuss on a regular basis.  As I talk with parents, I learn from them--which, in turn, helps me in talking with other parents.  The knowledge which is acquired is dynamic and its value varies from family to family.  How do you deal with teenagers who show a genuine lack of respect for their parents?  How do you modify a child’s bad behavior?  Is there any scientific evidence to support my recommendations on childhood sleep, eating habits, and potty-training?  John Voket originally wanted this column to be a discussion on talking with your child about other children’s special needs.  That, too, is not discussed anywhere in medical literature.  As a disclaimer, the following represent my opinions and are not supported by any scientific research.

Teenagers are hormonal, by definition.  They are more influenced by their peers than they are by their parents and family.  When a teenager is acting out in a manner that is disrespectful, the last thing a parent should do is to force their own agenda onto the adolescent.  This simply leads to everyone butting heads.  A teenager will tell me that his mother won’t let him go out with his friends to a party because she thinks there will be alcohol served.  The mother says she doesn’t trust him to drive responsibly.  A lack of mutual disrespect and distrust develops which cannot be ameliorated unless one person “gives in.”  While I do not have teenagers, I am fully aware that giving in is not an option for most teens.  A parent, however, can “give in” in a manner that is controlled.  I often will broker a contract between the parent and the patient.  If the teen sees the parent’s angst (often crying) and her willingness to “budge” on a very specific issue, then the adolescent will be given an opportunity to prove himself, which can often reverse the trend towards disrespect.  Teenagers don’t enjoy seeing their parents cry and generally prefer to make them proud.  Of course the lines of communication need to be kept open in order for this to continue.  I often recommend that families have dinners together regularly and, at the very least, remain available to the child without the threat of reprisal.

Behavior modification is another difficult topic.  It’s easy to say and sounds good.  “Reward good behavior and punish or ignore bad behavior.”  Again, easy to say and sounds good.  It’s putting it into practice that is difficult.  Teachers and parents need to identify two or three specific behaviors which need to be addressed.  Every other behavior needs to be ignored or, at the very least, put on hold.   I often see a child’s “Daily Behavior Chart” for school and it invariably has one section devoted to “staying on task.”  What does this mean to an 8-year old?  What does this mean to a 38-year old?  Behaviors need to be specific and concrete; e.g. raising your hand before speaking, or putting your pencil down when instructed.  Once these tendencies are developed they can be generalized into more productive and less disruptive behaviors.  Additionally, it is very difficult, especially as a parent, to acknowledge when children are doing the right thing when that is what’s “expected.”  Most parents can’t recall a time when they have actually said, “Johnny, you are doing a nice job sitting quietly and eating all your peas.”  Yet, I have said the exact opposite 12,372 times:  “Sit down, stop fooling around, and eat your (damn) peas!”  Which action (eating vs. not eating) gets the most attention?

How do you talk to your children about another child’s special needs?  How do you answer your child when he asks “Why can’t Christopher see?” or “Why does Michael talk funny?” or “If Thomas is my age, why does he act like a 3 year-old?”  Explaining blindness, cerebral palsy, and mental retardation to a young child is difficult but needs to be addressed honestly, openly, and very concretely.  As the child matures, they can better appreciate the more abstract and intricate details.  “Thomas is your age.  He may learn more slowly, but he will learn.  You may be shorter and grow more slowly, but you will grow.”  Difficult to discuss?  Yes.  Scientific?  No.

While there are some basic principles with regard to infant sleep, toddler’s eating habits, and potty-training, what works in some families is simply doomed to fail in others;  which is why there are so many in-laws, grandparents, and friends offering advice  However, what worked for them may not work for you.  And, what worked for your pediatrician may not work.  It is my job as a pediatrician to teach some basic principles and allow the parent to adapt them and develop their own approach.  The most basic principle I confer to parents is that “a toddler/infant can control only three things:  sleeping, eating, and toileting.”  If you, as a parent, try to enforce limits or allow these issues to become battles, the child will win and you will lose.  No parent has ever forced a toddler to eat brussell sprouts.  No parent has ever convinced a toddler that sitting in their own stool is uncomfortable or socially unacceptable.  No parent has ever taught a child that she is tired and needs to sleep.  How a parent uses this principle in guiding their child will vary from family to family and may require more specific strategies.  However, there is no one singular answer. 

While you should trust your pediatrician when she tells you that your child has strep throat and needs to be treated with an antibiotic or that your child needs to wear a helmet when riding her bike, you need to understand that these are issues based on science and research.  Keep in mind, however, that many of your concerns, as your child grows, may not have scientific answers.  The most we can do, as pediatricians, is to provide you with our own brand of knowledge and experience which may lead you to your own answer.  That is the true “art” of medicine.