By 6:45 a.m. last Saturday, pediatrician Diane Holmes was bent over a 2-day-old girl at Northwestern`s Prentice Women`s Hospital, making sure the bawling 7-pound infant was as healthy as she seemed. ”You`re beautiful,” she told the baby playfully. ”We need a girl. Want to come live with me?”
By the time Holmes arrived at her Lincoln Park office at 9:30 to start office hours, she had already examined six newborns-including her
partner`s-answered all of the nervous parents` questions, and seen a very sick baby at Children`s Memorial Medical Center, conferring with his anxious father. ”It`s hard when things aren`t straightforward and you can`t explain it,” she sighed.
There had been no time for breakfast, nor would there be for lunch. All day there would be a non-stop procession of patients with earaches, sore throats, rashes and infected fingernails and sinuses, as well as healthy children who needed checkups: 33 patients in all, some screaming, some smiling, some simply eager to get the visit over. And this was a light day.
”I wouldn`t do this if it weren`t fun,” said the 35-year-old Holmes, explaining that she works half time to spend the rest of her week at home with her two young sons. ”I get to talk to mothers (like me) all day long. But you can never get away from the fact that this is a big responsibility.”
This is the new face of pediatrics: women doctors who are juggling the demands of career and motherhood, just like the parents of their patients;
extended evening and weekend office hours to meet working parents` needs;
hospitalization of only the sickest children; and a decided emphasis on psycho-social issues, whether the child is 2 and struggling with temper tantrums, 10 and dealing with a divorce, or 14 and grappling with sexuality.
For all children, there is an increased emphasis on prevention, including immunizations, physical fitness and good nutrition. ”You start with a healthy baby and you want to keep it that way,” Holmes said.
On the other end of the spectrum, teenagers are now a big part of the pediatrician`s equation. Dr. Antoinette Parisi Eaton, president-elect of the American Academy of Pediatrics, based in Elk Grove Village, explains that while birth rates were high, pediatricians were swamped dealing with very young patients. But as birth rates dropped, they increasingly realized that the adolescents they had taken care of from infancy were slipping through cracks in the health care system.
Now some pediatricians specialize in adolescents and their problems. A teenager`s pregnancy is likely to be confirmed in a pediatrician`s office. So is a drug problem or homosexuality.
But the presence of adolescents in their offices is just one of the big demographic shifts pediatricians are seeing. A lot more fathers-and baby-sitters-are there too. Mothers are older and more sophisticated and they have fewer children. There are more youngsters with chronic illnesses, the result of advanced technology that saves many children at birth and from once- fatal illnesses. They need careful managing and more specialists to help handle them.
”The way I practice now is unrelated to how I practiced 25 years ago,”
observed Howard Rice, who invited Diane Holmes to join his pediatric practice six years ago. ”Pediatrics is better. There`s more we can do for our patients.”
Concerning the growing number of women pediatricians, more than half of those now in training, Rice said, ”it`s good PR” to have women in the office, noting that he has two other part-time women pediatricians working for him as well as a full-time male pediatrician. ”Since we have so many working mothers coming here, I like to say we have working mothers working here.”
Added Holmes, ”Pediatrics is one of the few specialties that allows you to work part time and still be good at what you do.” She explained that while a surgeon hones his skills every time he steps into the operating room, hers are as good whether she`s in the office 20 or 40 or 60 hours a week, as long as she keeps up with the latest advances. For her life right now, she says,
”the balance is perfect.”
It wasn`t when Rice started practicing 26 years ago. He spent a lot more time in his car, trudging from patient`s house to patient`s house, than in his office. He was out seeing patients virtually every night. The worst part, he said, was all the time wasted looking for parking spaces.
”A runny nose and a fever of 101 and you`d make a house call,” Rice recalled. ”We jumped out of bed in the middle of the night if there was a sick baby. It was not fun.”
Nor was it efficient. Patients frequently had to wait hours for something that could have been handled much earlier, Rice said. And the doctors weren`t able to do complete exams, including lab tests.
Now the patients come to Rice, Holmes and their partners, seven days a week, plus four evenings a week. Sometimes the doctors work until 10 at night seeing sick children whose parents were working all day. Often at checkups they spend more time talking about a child`s behavior or the effect of his parents` divorce or his falling grades than about his health.
”I don`t think the problems are greater, but they`re more easily talked about,” said Dr. James Downey, who has practiced pediatrics in Evanston for 25 years.
Now, Downey said, even parents` problems may come to light in a pediatrician`s examining room. He has had cases, for example, in which a child confides that he is worried that his father is drinking too much; the doctor, in turn, can refer the parent for treatment. Some parents even seek medical advice for themselves from pediatricians.
There is even a new specialty in behavioral and developmental pediatrics, requiring an additional three years of training, noted Eaton, a professor of pediatrics at Ohio State University and the mother of four, of whom three are doctors.
Rx for a `miracle baby`
At the same time, pediatric medicine has become so highly technical that there is a growing body of specialists to handle every disorder imaginable:
prematurity, heart problems, emotional disorders, growth abnormalities, neurosurgery. As many as a third of new pediatricians, Eaton said, become specialists.
It`s gotten to the point, she continued, that pediatric hospital units are like ”one big intensive care unit.” Unless children are desperately ill or need surgery, she said, they`re treated at home.
That`s why general pediatricians such as Holmes and Rice find themselves coordinating the sophisticated care needed by these sick children at home and the growing number of chronically ill children who wouldn`t have survived in the past-children like the 2-month-old ”miracle baby” Holmes saw Saturday who was born with a severe heart defect and had open heart surgery when she was just 2 days old.
Holmes has treated children with Down`s syndrome who would have been institutionalized in the past, and other children who have residual neurological or lung problems from a premature birth. There also are those with birth defects, including two with severe brain defects who ultimately died.
These are very difficult cases, Holmes said. ”The parents know the prognosis is terrible, but they love their baby and you just do what you can to keep the family sane,” she said.
Yet some complicated cases have far happier outcomes. Eaton has treated many children with phenylketonuria, a disorder of the body chemistry that results in the lack of a needed enzyme. In the past, those children were destined to become severely retarded. Now, Eaton said, a simple blood test required by law can identify those youngsters shortly after birth and, with close monitoring and a controlled diet, they can grow up to lead normal lives. ”It`s been one of the most exciting experiences of my career dealing with these PKU children,” she said, recalling one such youngster who grew up to be an honor student and an athlete.
Roles overlap
On Saturday, Holmes had none of these tough cases to deal with. It turned out to be an easy day, though she didn`t have a single break from 6:30 a.m. until almost 5 p.m.
Between patients, instead of a meal, she gulped a pastry and a pop while filling out charts and answering the phone calls the nurse has decided need her attention: the baby who might have swallowed a coin, another who has hives, the mother who needed advice about breast feeding, the 13-year-old who had just gotten her period for the first time, the parent distressed because a shoe salesman said her child`s feet were turned in.
Holmes remained resolutely cheerful, calm and encouraging throughout the long day.
In one examining room, Holmes commiserated with the sleep-deprived parents of a newborn. ”I remember that period unfondly,” she told them.
”Your baby will never be less rewarding.”
Down the hall, she joked with a toddler`s mother about the impossibility of keeping the house clean when a child pulls out everything as fast as you put it away.
As for the shoe salesman who refused to sell the child shoes because his feet turned in, she told that mother not to worry. The baby`s feet are perfectly fine. Besides, she said, he really doesn`t need to wear shoes yet.
”I don`t think there`s another career where being a mother helps you so much in your job,” Holmes said. ”My roles overlap all of the time. It`s wonderful.”
She understands why a mother of a 2-year-old couldn`t get the child`s temperature taken or how difficult it might be to get a preschooler to take her medicine. She can even laugh about the mother who woke her up at 5 a.m. to say her daughter had a dream about spiders.
”My kids have woken screaming in the middle of the night and I know the wild things that can go through your mind,” she explained. ”You just want to hear someone say, `This is normal.”`
Doctor shopping
Clearly, pediatricians say, parents are demanding a lot more from them these days. At the same time, they are seeking more basic child-rearing advice than their parents did. They obviously have read more about child development and health and don`t hesitate to challenge a pediatrician`s advice-especially if it`s advice they don`t want to hear.
Indeed, expectant parents now routinely interview several pediatricians before deciding on one, making the doctors acutely aware that they must compete for business. In Evanston, for example, Downey is convinced that the early-morning walk-in hour for sick children that their seven-doctor practice offers has attracted many new patients with working parents.
At the same time, pediatricians say they find themselves continually reassuring nervous parents who don`t have family nearby.
”We are the grandmothers,” said Dr. Richard Burnstine, who practices in Northbrook and Evanston with Downey and five other pediatricians. ”The mothers come in looking for advice that the grandmothers gave 20 years ago.” ”Their mothers are a long-distance call away and I`m not,” said Dr. Aleta Clark, who with her partner has been practicing in Chicago for 10 years. Clark frequently gets calls late at night asking questions that easily could have waited until office hours the next day, like what dose of Tylenol to give, when the directions are on the bottle, or what to do if a child has been exposed to chicken pox.
”When we had chicken pox or measles, we never went to the doctor,” said Holmes, who grew up in Livonia, N.Y., a small town near Rochester. ”We called Mrs. Sweeney (a neighbor) to say what it was. She had older kids.”
One couple told Holmes in the hospital Saturday morning that they are so dependent on her that they have decided not to move to the suburbs because she is in the city.
Eaton thinks the option for part-time practice may be one factor drawing women to pediatrics. Holmes, for one, never planned to work part time but now she can`t imagine any other arrangement. ”My kids would be fine if I worked full time, but I wouldn`t,” she said, explaining that she just wants to be with them.
She is luckier than most when it comes to child care. Her husband, Bruce, a writer who has a fledgling computer software company, works from their home, taking care of 4-year-old Christopher and 2-year-old David much of the time Holmes is gone.
Holmes acknowledges that working part time is a financial sacrifice while her husband is trying to start a business. ”But the time with the children is invaluable.”
Indeed, pediatrics has long been considered one of the lowest-paid specialties. ”You don`t become a pediatrician to get rich,” Holmes said.
”You`ve got to love kids.”
Dr. Mom
Just before 5 p.m. Saturday, Holmes was headed home to Evanston-early for her. She was pleased. No emergencies, no really sick patients in the office, thank goodness, she said. ”There are a lot of times I go home and I`m really worried about somebody,” she confided. ”The biggest fear is that we might blow it (miss something), and if we do, that can have devastating
consequences.”
Add that to an ironic worry about her own kids. ”It`s a little scarier being a parent, because of all the things I know can go wrong,” she acknowledged. ”I know about the one kid in a million who died from `just` a virus.”
As Holmes walked up to her back door, she heard her children yelling,
”Mommy! Mommy!” She grinned expectantly. But even then her work wasn`t done. Her 2-year-old had an earache that needed attending.
