As most of you know, my career started as a nurse in the Obstetrical Intensive Care Unit, and then I worked for a smidge in the Neonatal Intensive Care Unit. I liked the challenge of those high acuity specialty areas, and if we're catching babies too, it's even more fun!
It was the need to protect my clients that really blazed a trail for me through my career. Initially, I was frustrated with how women who wanted to #breastfeed were treated, realizing it wasn't just me who suffered in my own personal experience. This motivated me to get training as a lactation consultant, but I didn't just pack my kids up in my car, with my mother, and drive across country to take a five-day-workshop earning a certification as a Breastfeeding Counselor and Educator. I didn't even stop at becoming a Board Certified Lactation Consultant (IBCLC); I earned a bachelor's degree in Lactation Consulting and wrote graduate level curriculums, led breastfeeding coalitions, and wrote letters to our legislative leaders to improve laws to protect breastfeeding couples. I was all in and wanted to get all the knowledge, and be the very best advocate I could be.
This still wasn't enough though, women were still be overpowered, violated, and traumatized so I went to graduate school to earn my #midwifery certification so I could be their advocate throughout their childbearing experience. I wanted to offer them authentic care, without gag orders from physicians or propaganda from sales representatives, administrators, and even public health. Becoming a Nurse-Midwife was a dream for me. I created all my own educational programs, wrote all my own practice guidelines because I wanted to thoroughly understand the research and all the little caveats of why each decision might be wise or risky, and I dedicated myself to raising the standards, again, because I realized my bad experience wasn't just personal bad luck; it was more the norm in maternal and child health than I had ever imagined. I sat at the tables, rubbed the shoulders, and earned my doctorate via efforts to improve outcomes of homebirth and birth center families.
Midwifery was the dream job for me, for many, many years, but it is also a really, really hard one, an exhausting labor of love... sometimes even a bit toxic, like a co-dependent relationship. I was feeling a bit battered and bruised. I needed more balance in my life, so I returned for my family nurse practitioner certificate so I could continue to care for the women in my practice, leaning into functional and integrative medicine a bit more, but also their families. I also wanted to sleep, but these really were the prevailing motivations for me - balance and peace - at least at first.
When I got into clinical practice, in the primary clinic I would be learning, I became a bit more aware of the realities of conventional medicine beyond my own experiences as a client. My career had thus far been in the hospital or in the community, but outside of my own clinic which I managed for ten years, I had not really witnessed the assembly-line type care that occurs in direct primary care. It was a challenge connecting, educating, and truly listening to clients in what averages to about 6-minutes per visit. Certainly some connections were made and those were precious.
Having had a large midwifery practice, I knew well the traumas that occur in medicine, the over powering we do in healthcare with our authoritarian, even dictator-type approach, and I also know that when the assembly line is passing you by nurses have to be efficient and just get people moving. There isn't a lot of time for conversations or even consent. Trust me and just let me do my job, right? But I've also seen loads of mistakes and recognize that I just don't have all the answers. I am not always going to be right, so this authoritarian approach humbles you real fast; that is if right and wrong is what motivates you as a clinician, and not just holding the power.
My heart for pediatrics though came in recognizing that kids are often an after thought. These visits in primary care, within conventional medicine, are largely about immunizations. There will be some kids with asthma, some with ADHD, some skin stuff, but mostly, kids are brought in for their scheduled immunizations or sports physicals. Strep, the flu, COVID, and ear infections are also common, but ultimately, they are in and out pretty quickly. We print sheets with information no one reads just to cover our bums, and that's it. Teaching, connecting, and building a relationship with your young client was not really talked about in training, although my preceptor was clear to remind me on several occasions, we don't have time for that - get in and get out!
Experienced allowed me to manage a little bit of efficiency while also creating a few connections, so the day my faculty visited my clinical site to observe my progress, she quietly observed as I cared for a child I had seen several times. He was a young adolescent being treated for ADHD and in prior visits he and his mother had shared more vulnerable life circumstances which caused this young man to feel he was his mother's protector, giving him nightmares. We had bonded, and they had both felt safe enough to be quite vulnerable, but today, with my professor over my shoulder, they were much more reserved.
I had asked this young man if he would jump up on the #exam table and let me check him out before we conclude our visit. He was there for a refill on his prescription and I had just previously conducted a pretty thorough physical exam, so I was just covering my bases with a limited physical exam. As usual, I made conversation during my assessment, offered some teaching points, and asked him if he would feel comfortable lifting his shirt and letting me listen to his belly as I worked head-to-toe. He agreed and I completed my exam; however, afterwards I was asked to join my faculty in a separate office so we could talk about her observations.
She shared that she felt I was quite comfortable working with clients, as if I had done this many times before. She felt my connection was easy and she appreciated my ability to gather data and offer education simultaneously, but she explained that it was inappropriate of me to ask his permission to listen to his belly. She said he is just a child and I needed to move forward with the exam and that asking would slow my efficiency.
I explained that my comfort came from more than ten years in clinical practice as a #clinician and more than twenty years working with birthing families, and my desire to ask his consent was intentional and maybe the most important thing I could teach my pediatric clientele, that they are their own agency. They have the power to say no, even to their #doctor. They alone determine if they feel safe and if they would like to welcome someone into their private space. My role is to teach children how to honor themselves, and her response was, "Well, what if he said no!?"
I responded quite confidently that, "I would have honored his request." If it takes me a visit to gain his trust and teach him that I will respect his boundaries and in that, he learns that honoring himself is perfectly appropriate, then I have won as a clinician. I can certainly bring him back for another visit to gather the physical exam, and of course, in this scenario, I had just obtained a full physical exam three months prior so honoring his wishes offered far more benefit than risk. My faculty member truly could not wrap her head around my approach and I recognized that the pressure in conventional medicine to get it all done, as fast as possible, and to not miss any of those points that create liability has really caused the clinician to dissociate a bit from their client, and sit back in a task-oriented mindset. I was so grateful to have had the opportunity to work in private practice.
Creating Safe Space for Your Client
This past week I visited a young client of mine, a little guy I got to catch when he was born, and his parents shared concern that he was snoring, waking from his sleep, and having trouble eating some of his food. When I examined him, his little tonsils were nearly touching each other. He wasn't sore and he had just had a negative rapid strep test, so I wanted to double check that and rule out potential for a false negative so we could avoid unnecessary surgery.
I asked him if I could get a swab of the back of his throat for a culture that would look for germs. He was very hesitant and asked if I could go in his ears instead. This would have been so handy, if the ears could connect me to his throat, and when I explained this to him, gently, he listened and understood.
I could see he wanted to open his mouth for me and let me get the culture, but his prior experience had him really concerned. Mom knew she may need to use her voice to get his compliance, so when he started to whimper, she explained how important this testing was. He looked at me and said, "Will you please go slow?"
I looked at him and said, "This is really hard. Take a few deep breaths and I will wait for you. When you open your mouth, I will very gently swab your throat and we will be all done." He agreed, although wasn't super eager. He trusted me though and took a deep breath, clinched his eyes tight, and then opened his mouth so I could swab. We did it!
There was no holding him down, no screaming, no trauma. He made the decisions and he drew the boundaries. The great fear that we can never do our job unless we bully through with children has been largely unfounded in my career. Certainly when performing circumcisions without anesthesia, immunizations in those very early years, and even on occasion when caring for a wound or when suturing, a collaborative effort needs to happen to maintain the utmost safety for the child, but this shouldn't be the overriding approach to carrying for the pediatric clientele.
Certainly there are super uncomfortable moments, but these are much more necessary in the emergency room than in primary care. Building a relationship with your practitioner is vital so they don't avoid you until they absolutely have to come in with a problem. Many of you probably recognize your own anxiety about visiting the doctor or the dentist. Imagine having had the opportunity to talk about health and wellness, even happiness, throughout your life and building a relationship with them. Maybe they even became one of your trusted confidants so when you were struggling as a teen, you didn't hesitate to text your primary care provider and tell them you wanted to hurt yourself or maybe you were hoping to discuss something you were afraid to share with your parent. Yes, these moments have absolutely been part of my experience and I am so very grateful for having had the time to build safe connections.
Investing Time to Dig Below the Initial Concern
Did you know that The Accreditation Committee for Graduate Medical Education only requires one month of adolescent medicine training from a board-certified adolescent medicine specialist for all pediatric residency programs? The importance of addressing the physical and mental health of adolescents has become more evident with rising suicide rates, self-harm, even increasing diagnoses of neurodiversity. Unmet health needs during adolescence and into adulthood predict not only poor health outcomes as adults, but also lower quality of life in adulthood (Alderman & Breuner, 2019).
Adolescents are the perfect example of why my desire to build a trusting relationship with my younger clientele is so important. They are gradually developing their autonomy and getting closer to when they will be making their own decisions. However, they are often faced with situations that they aren't well prepared, and many are likely to be involved in risk-taking behaviors, such as the use of alcohol, tobacco, vaping, and others drugs as well as engaging in unprotected sex. The truth is that most healthcare visits by adolescents to their primary care providers are to seek treatment for conditions or injuries that could have been prevented if screened for and addressed at an earlier visit, yet there is no time to address these topics in conventional medicine, and even if there was, these topics are hard and uncomfortable, so often avoided unless the client brings them up but building relationships and creating safe space offers me more opportunity.
Although some risk-taking behavior is normal and expected in the adolescent years, engaging in some risky behaviors can really pose risk, even into their adult years. The majority of mortality and morbidity during adolescents, which can be prevented, is attributed to unintentional injuries, #suicide, and #homicide. Approximately 72% of deaths among adolescents are attributable to injuries from motor vehicle crashes, other unintentional and intentional injuries, injuries caused by firearms, injuries influenced by use of alcohol and illicit substances, homicide, or suicide. These causes of death surpass deaths from cancer, HIV, and heart disease (Alderman & Breuner, 2019).
Beyond Our One-on-One Consultations
Even extending visits an additional 54 minutes over the average primary care visit, there is still so much to discuss! What I've done is create an extensive forum for connection and education. Every single age group is discussed, what to expect in growth and development, but not just how many words should they be able to speak or can they ride their bicycle; we explore emotional regulation. We discuss behavior based on their brain maturity. Many times we just expect too much of our children or we aren't helping them identify and regulate their emotions because it seems so easy for us now, or maybe we aren't sure how to articulate this stuff. Maybe we aren't good at regulating our own emotions.
We discuss wellness screenings, the benefits and risks, and we think way outside the box on this stuff. We explore the controversies, we challenge our thinking, we consider opposing views without threat or judgment. We explore nearly 200 acute and chronic conditions both in the private forum and in live, virtual talks. We hike together, do yoga together, and create nature art together. We even craft first aide kits from botanical medicine and learn how to manage bumps and bruises, upset bellies and runny noses at home.
If you'd like a primary care practitioner that is a bit more Dr. Quinn, than Dr. Modern but balances the most current understanding of today's science with the art of ancient wisdom, connect! We'd love to add new Lexington families to our growing practice.
References
Alderman, E. M. & Breuner, C. C. (2019). Unique needs of the adolescent. Pediatrics, 144(6). doi: https://doi.org/10.1542/peds.2019.3150