Continuity Clinic, Part 1

My next patients are from one of my favorite families. The mother is in her early 20s, with three children and another on the way. Despite her youth she is fiercely maternal, round and protective. Today I see the oldest, a five-year-old girl, and her two-year-old brother; the three-year-old girl is scheduled for next week, but she’s here, too.

There are no medical concerns about the oldest child, but her mother asks me about her behavior. Since her grandmother died last summer, she’s changed. More attitude, more moodiness. The girl’s mother is worried that she is still grieving for her grandmother. What should she do?

Turns out that with the death of her grandmother, the family has moved in with the mother’s new boyfriend, and that it’s now clear that mother and father won’t be getting back together. The father is still involved, but the girl sees him less and less. The mother is frankly overwhelmed by the three children, and, although she loves babies, is terrified about adding another child to the mix. In past visits we’ve talked about enormous energy bills and evictions. I don’t ask, but wonder, how the family is supporting itself. She doesn’t work and welfare is no longer generous.

One of the reasons we go into medicine, spend four years of college grubbing for A’s, waste our youth in more school and training, is that we love to solve problems. We are fixers of people. But how can I fix this?

How do you deal with a mother who has labeled her two year old as “bad” because he likes to get into things? Even the five year old says he is a “bad boy”. The three-year-old girl is also “bad”, but she climbs into my lap and wants to use my stethoscope. She draws me a picture and is touched when I take it. Where can I even begin?

I have 15 minutes to cover these questions, explain the ever-expanding list of immunizations, examine her, do developmental screening, and counsel about safety and reading. How could I possibly begin to talk about how she might be reacting to having a new stepfather? Explain how the mother should deal with it? Counsel her on how to deal with moodiness?

So I tell her that she should try to ignore the attitude, and should focus on the priority behaviors, that she and the boyfriend should both take individual “special” time out to spend with the child, that they should “catch her being good”. I ask the social worker to meet with the child to explore the question of grief. Reading this you may get the wrong idea about my methods. You may think that when I say I told her to focus on priority behaviors, I spent time coming to an understanding of what things were important to the mother, using what I learned to tailor the advice. That I spent time demonstrating what “catching her being good” means, that I probed the intricacies of the mother-boyfriend-father relationship. You would be wrong. All of my schooling, personal growth seminars, volunteer workshops, supervision, and reading have given me the right catch phrases. But any observer could see the distance between my words and her life.

I know this, and I don’t know how to change it. And I have to get to my next patient, and this family’s ride is almost here.