Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seeking. "That's what primary care medicine is like," Victoria Rogers McEvoy told me. McEvoy is a tall, lean woman in her fifties with short-cropped blond hair and steady eyes. She practices general pediatrics in a town west of Boston. "It's much harder than finding the proverbial needle in a haystack, because the haystack is not moving. Each day there is a steady flow of children before your eyes. You are doing baby checks, examinations for school, making sure each child is up to date on his vaccinations. It can become routine and you stop observing closely. Then you have the endless number of kids who are irritable and have a fever, and it's almost always a virus or a throat infection. They can all blur. But then there's that one time it's a life- threatening disease."
"The blessing of pediatrics, but also its curse, is that almost all of the children who come to the office turn out to be healthy or to have a minor problem," McEvoy continued. A blessing, of course, that the kids are fine, but a curse because the continual flow of minor problems can cause you to lose concentration. With that in mind, she asks herself one key question each time she sees a child, in essence the same question doctors who work in emergency rooms ask about each patient: Does he or she have a serious problem? "Every pediatrician" should consider that as soon as the child comes into the room." And because many of the patients are infants and small children who cannot communicate what they are feeling, "your powers of observation have to be particularly acute."
Essentially the doctor gets all the information from the parents, which means she has to consider both the parents' degree of familiarity with their child and their emotional reaction to the possibility that something is wrong. This reaction can be extreme: some parents deny the existence of a serious problem; others exaggerate what is normal because of their anxiety. Parents have reported that their child was lacking in energy and not eating, information that would trigger a high level of concern in the doctor: but with one glance she would see the child playing happily on the examining table and grinning. "The story was completely exaggerated, and you knew immediately that the kid was not seriously sick." Then there was the opposite, where a mother said that her baby felt a little warm but was otherwise okay. McEvoy was stunned to see the child breathing rapidly and lying weak in her mother's arms. The child had pneumonia. McEvoy, like all pediatricians, looks for certain key features. Does the child smile, play with toys, actively walk or crawl, or is she passive, not resisting when a medical instrument is placed on her chest?
Pattern recognition in pediatrics begins with behavior. And the art of pediatrics is to further study the child while simultaneously interpreting what the parents report. This combining of data, McEvoy said, is not a skill that comes from a textbook, because it requires a level of awareness by the doctor about his own feelings towards the family. While first impressions are often right, you have to be careful and always doubt your initial response. "It's a foolish pediatrician who does not listen closely to the parents and take seriously what they are saying," McEvoy said. "But you need to filter what they say with the child's condition." I told her the story of my first child, Steven. My wife, Pam, and I had returned from living in California to the East Coast. It was the July Fourth weekend, and we stopped in Connecticut to visit her parents. Steven was then nine months old, and had been irritable and not feeling well during the cross-country flight. When we arrived at Pam's parent's house, he was restless in his crib. We took him to an older pediatrician in the town; the doctor glanced at Steve and quickly dismissed Pam's worries that he was seriously ill. "You're over-anxious, a first-time mother," the pediatrician told her. "Doctor parents are like this." By the time we arrived in Boston, Steve was grunting and drawing his legs up to his chest. We rushed him to the emergency room of the Boston Children's Hospital. He had an obstruction in his intestines and required an operation immediately. Pam and I could only conclude that despite his many years in practice, the pediatrician in Connecticut had made a hasty judgment ― that Pam was irrationally worried about her first-born child, not a reliable reporter of a meaningful change in her baby's behavior and condition.
The pediatrician in Connecticut watched the train go by, hour after hour, day after day, year after year, for decades. I asked McEvoy, who had also been in practice for decades, "How do you keep your eyelids open?"
"I prepare myself mentally before each session," she replied, just as she used to prepare herself mentally before a competitive tennis match. In 1968, when she was in college, McEvoy was ranked third in the nation in tennis, and played at Wimbledon. As an athlete, she learned to focus her mind, to anticipate the unexpected spin, and not to become overconfident despite her expertise. But beyond the skill from sports, "you simply have to control the volume," she said. "And the truth is that most pediatricians stay afloat by seeing large numbers of children each day."
Before McEvoy took her current job, she worked in a busy group practice in another Boston suburb. At the time she had four children of her own at home. She spent each day tending to dozens of patients and their parents. "But it was the night calls that were killing me," she said. She was contacted every twenty or thirty minutes, and the calls continued until the next morning. If there was serious concern based on the telephone contact, then McEvoy returned to the office and saw the child, regardless of the hour. "After doing this for a few years, I was beginning to burn out. I just couldn't stand it." McEvoy found herself becoming irritable and bitter. "I was so exhausted from this hard schedule that at times I said things to parents that were rude and sharp, and later regretted saying them," she told me. "Pediatrics was no longer fun. Most worrisome, it affected my thinking. I would immediately assume that the parent was telephoning inappropriately. I was just so exhausted."
McEvoy left that practice. In the course of a day, a full-time pediatrician may see two dozen or more children. Now she limits the number of patients she will see in. any single session, despite the pressure to schedule brief visits and maintain a high volume. Many doctors who provide primary care do this because they feel they cannot function properly otherwise. Some suffer a fall in income. Others move into administrative roles, seeing fewer patients but sustaining their income. McEvoy chose this last path. Her group is associated with Partners Healthcare and the Massachusetts General Hospital. This association largely fixed the problem of relentless night calls; the Partner group hired experienced pediatric nurses who take the phone calls at night. These nurses offer advice to the parents, but if a family insists on speaking directly to the doctor, then the doctor will be paged. "This is the only way to maintain one's sanity," McEvoy said. "And the care is much better, because the doctors are not burned out."