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Teaching and Learning Moments

Two Days and Twenty Years

Kind, Terry MD, MPH

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doi: 10.1097/ACM.0000000000003139
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He was only 2 days old and already in my office for his first well-child check. I was pleasantly surprised and jokingly wondered if he came straight from the newborn hospital stay to our health center. Reviewing the paperwork in the chart in advance of entering the room, I saw why he had an appointment this early—he had been born at home. Admittedly, I was skeptical of the parents’ decision; it is not what families typically choose in our urban practice situated in a city with several tertiary care hospitals. I wondered to what extent they would embrace our routine medicalization of health maintenance and disease prevention. Nonetheless, I was glad they were here, embracing primary care in our fully equipped children’s health center. I headed to meet them with an open mind and welcoming stance.

Our lactation specialist was in the room when I knocked and entered. Typically I defer, letting the consultant finish, but this time she told me I should stay and look at the baby. So I proceeded with the visit, with congratulations and then data gathering. Both parents were attentive, while the 2 older siblings amused themselves, seemingly unaffected by the newest family member. The mother described her prenatal care, their planned home birth with a doula, and how smoothly everything had gone. Then she raised her concern, “He just doesn’t want to feed anymore.” Though sucking and swallowing on day one, she told me that he didn’t want to wake to feed the night before. I gathered a little more information and then examined the baby. At first, I felt my usual confidence that we could get this baby to feed if we tried again here, with my guidance and support. But this situation was different.

This beautiful baby was not alert and would not latch. I heard him softly grunting and noticed his dry tongue. I was doubly worried, both about how sick he might be and about how I was going to convince the parents—who may not be comfortable with medical intervention, given the home birth—that they should bring their newborn to our tertiary care hospital, where he might be tapped and treated. And then another worry set in. Was he sick or would he simply perk up, suck, and swallow at any moment? Was he sleepy or was he septic?

Sick versus not sick. Discerning this is a skill I first heard about long ago as a third-year medical student, then honed during my acting internship, residency, and 2 decades as an attending. This is something I now work to teach trainees and even help plan medical school curriculum for. And still, in this moment, I questioned whether I was making the right decision. Impostor syndrome reared its head. Did I make the right call or was I overdoing it, overmedicalizing, acting hastily?

Moving ahead with an abundance of caution, I explained to the parents that they needed to go to the hospital, possibly just for observation but maybe for more. I explained my worry for the baby’s well-being and said that we needed to act. They welcomed this suggestion, and, for the sake of their baby, they headed right to the emergency room across town.

Checking the baby’s status online later that day, confirmation of my decision unfolded. Yes, my colleagues at the hospital were indeed drawing labs, yes they were admitting him, and, alas, he was en route to the critical care unit, intubated. Very sick.

It turns out that my caring for predominantly healthy infants, toddlers, and children for the past 20 years in the outpatient setting helped me set apart the rare emergently sick one. The tests indicated that this baby had a metabolic condition that would have been diagnosed by a screening performed during a hospital birth. And yet, together we caught it early anyway.

Weeks later, we await his discharge from the hospital. He is not “sick” anymore, but he and his family need to know they did what was necessary, seeking attention at a critical moment, at 2 days of life. And I learned to trust both my 20 years of experience and what the 2-day old was telling me. The red flags were there—a poor suck, dry mucous membranes, and lethargy. But so was a sliver of self-doubt. I now understand that some degree of self-doubt throughout one’s career can serve a useful purpose. It makes us think critically in times where we would much prefer to think that everything is fine. It pushes us to question, weigh multiple perspectives, listen attentively, see more clearly, and make even better decisions.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

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