Written by Jesse Hackell MD.
In pediatrics, perhaps uniquely among the fields of medicine, change is more than something which just happens. It is at the very core of growth and development.
There is no stage of life which manifests growth and development more than childhood. For pediatricians, change is a part of every visit (“her development and growth have been right on track since your last visit”) and part of every piece of guidance and advice that is given to parents.
In fact, “anticipatory guidance” is specified as a standard element of preventive care visits, at every age through the pediatric and adolescent years. We comment on how a child has changed since the last visit, and suggest the changes to be anticipated during the months before the next one.
A child who does not change from day to day, month to month, is so unusual as to be cause for concern.
I have watched the transitions of my now-adult son and daughter, living through every stage of their growth and development, from infancy and toddlerhood, through the early years of school, sports, friendships, puberty, right on through college and graduate school, into adulthood, marriage and, soon, parenthood. Living with this change on a daily basis, one can almost forget the magnitude of the changes they go through, as they seem mostly the same day to day, until, suddenly, they have woken up one morning as a totally new person.
But in practice, we see children episodically—frequently in the early years, but less so as they grow, so from one visit to the next, the changes are notable and dramatic.
I was particularly struck by this recently, when on one busy Monday, of the 12 well visits I had that day, nine were for long-time patients getting ready to start their freshman year of college.
Many of these young people had been my patients since birth—one mother reminded me that I had attended the delivery of the young woman I was about to examine, and thus had really been the “very first person to see her.” While others had become patients at somewhat later ages, none were strangers—all had been coming to our practice at least since before they entered the teen years.
I had seen them over the years for visits both well and sick; had treated their acute illnesses; had counseled them on exercise and health, safety and risk behavior; and had gotten to know them and their families, and watched the changes that are common to us all as they occurred in each of them.
The pre-college physical is a different sort of visit. Many of the kids, as I still call them, come on their own, without a parent.
But it is most different in my view for what it represents in terms of the adolescent’s burgeoning independence.
While they may have varying degrees of independence while in high school, and living at home, for those who choose to live away at college, this is often the first prolonged period of time living away from their parents, as well as the first episode of living in a peer group, and having to learn the new social skills necessary to get along, fit in and succeed in that new environment.
While most of these 18 year olds are excited about the prospects of college, it is fair to say that most are also having some trepidation about it as well. It is always a part of the visit for me to mention this ambivalence that many fear, and to let them know that it is normal and expected, as well as that it usually eases quickly upon meeting new people who are also going through the same experience.
It is also important to acknowledge the transition that occurs when young people start living independently in terms of needing to develop the skills of self-monitoring and self-control, in the absence of supervising parents.
Many will need to assume primary responsibility for managing chronic health conditions, from diabetes to asthma to ADHD, and part of this pre-college visit is concerned with making sure that they are current with their management, as well as knowing how to get help if things do not remain stable once they are away from home.
Alcohol, drugs and other risky behaviors are an inescapable part of college age, and it never hurts to remind the newly independent that they, alone, will be responsible for the choices that they make, in terms of both health-related behaviors as well as academic behaviors such as classwork and studying.
One aspect I emphasize is the benefits of having a medical home.
We have been their trusted source of care for many years, and I emphasize that we are happy to continue to provide that care for them until they graduate from college (always emphasizing that I mean on the “four-year plan.”)
For practical reasons, since many are only at home sporadically over the course of a year, it makes little sense to try to establish a relationship with a new physician in bits and pieces.
Additionally, we know their medical history, and we make it a point to see them (as we do for any of our patients) on an immediate or same-day basis for their acute problems, which is important when they may only be in town for a long weekend and cannot wait three days for the next available appointment.
It always amazes, and gratifies, me how many respond to my offer to continue to be their physician with a comment such as “I don’t ever want to go to another doctor, even after I graduate.” It just demonstrates, once again, that transitions, although ongoing and inevitable, are fluid and variable in their nature.
That is part of the beauty of change—it is going to occur, but we can all do things to help make it smoother and easier. It is what you make of it.
Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.