It is seldom a good thing to enter an exam room and unexpectedly find everyone crying. You are rendered somewhat discombobulated as your mind is faced with several options. Part of you wants to hold them and give reassurance, even though you don’t know what has brought on the tears. Part of you wants to cry along with them. And part of you – let’s be honest here – wishes a wormhole would miraculously open up so you can slip into it and return later at a less emotional time.
So imagine my confusion and worry a few months back when one of my long-time patients was scheduled for a well-exam and I had not even said “Good morning” when her mother sobbed as she hugged me.
“It’s our last visit with you,” she explained.
“Why? Are you moving? What’s wrong?” My head was spinning.
“She’s 18 and now has to find another doctor. We don’t want that.”
Relieved, I took a deep breath, let out a small laugh, and reassured her that was not the case, and I would be there for them until she turned 21. Most likely what I said was something along the lines of, “Sorry. But you’re stuck with me for another three years.”
The visit improved greatly after that, but in reality it only delayed the inevitable. Three years from now I will have to say good-bye, and that will not be easy.
It is an aspect that is unique to my specialty. As a pediatrician, all my patients at some point are going to leave, and often many of them will be healthy and not want to go. Nor do I want to send them off. Early in my career it was not so difficult, as I had cared for most only a few years. But now the ones who are aging out have been mine from the start. Often I held them in my hands on the first day of life and seeing them depart is not sweet sorrow. It is just sorrow.
From a purely clinical standpoint, I know it is the right thing to do. I have not cared for an adult patient in over 30 years, and I am fortunate to have so many excellent family and internal medicine colleagues who will provide a seamless transition of care. Still, I am never in a hurry to make the hand-off.
I never liked the idea of 18 as a transition point. This is a time of upheaval as teens are either off to college or to the work force (or both). With all the changes, responsibilities, and independence I thought it unfair to require a new physician as well. When you come home sick on college break the last thing you need is a new, strange place to receive care. Moving out to 21 allowed my patients to have another safe, comfortable place to come home to.
For me, the rewards of caring for this age group are immeasurable. I did not deceive myself into thinking the care I provided was better than anyone else. Rather, the benefits I reaped were mainly selfish. While I find joy in all my patients at any age, every now and then it is nice to have an adult conversation with someone other than the parents. I have learned so much as I listened to them tell me about their classes, their work, their hobbies. If I am lucky, at times I can relate my own similar experiences, which I believe allows my patients to see me less as a doctor and more as a person. For them to hear I struggled with physics, calculus, or Beowulf in Middle English breaks down a lot of barriers.
So do I bend the rules? You bet I do. Sometimes it can take a while to get established with a new physician so I let them know I will be available during the transition phase. At times, one of my 21-year-olds is close to finishing college and I will hang on to them until they graduate. For many of my patients in college, I have found that upon graduation they are ready to move on.
So to my patients as they enter adulthood: Thank you. Thank you for the privilege of caring for you, it has been my pleasure. Thank you for making me a better doctor, as caring for you through college allowed me to be more versed in issues like birth control and anxiety. Thank you for teaching me about subjects I had little concept of. Thank you for realizing I am human and would not get everything right. I hope that you take some small part of me with you as you leave. I am proud of each and every one of you. Remember the words of Dr. Benjamin Spock, “Trust yourself. You know more than you think you do.”
To those former patients who now have children that I care for: I cannot adequately express what it means that you have put your trust in me. It is flattering. And humbling. Having this honor allows me to think I did some things right. I truly enjoy getting to know you again – this time as a parent and friend. What a great journey we continue on.
As it stands now, the American Academy of Pediatrics recommends transitioning patients to adult health care between 18-21. While this internal debate will persist in me, I am intrigued by recent studies that indicate the human brain does not fully finish developing until the mid to late twenties. Maybe the American Academy of Pediatrics will revise its age recommendation?
Photo: Ezzo cared for the Greene quadruplets from the time they were born until age 21, when they all towered over him. From left: Duncan, Logan, Ezzo, Terra-Marie and Joshua.