Transitional medicine: Patients
 who are just passing through

"Even though the form suggests a vision and hearing screen, she's uncooperative—typical 3-year-old. The mother's concerned because she wants to have everything ready so her daughter can start preschool when they move to Florida at the end of the month."


The medical assistant hands me the child's chart; the name is not a familiar one. "Have we seen this child before?" I ask, opening the record.


"No, she's a new patient. It looks like she's also going to need a lead test—"


"Wait—this is a brand new patient, and we're seeing her one time for a physical exam before the family relocates to Florida?"


"They lost their health insurance when the father lost his job. The mother told me that they were forced to go on state medical. I guess their previous pediatrician doesn't participate, so they transferred the records here."


"Just passing through," I muse, as I flip through the copies. This child has been followed at the same pediatric practice since birth. Every visit has been transcribed in typical EMR format—myriad data, most of it useless from a practical standpoint. Thankfully, the immunization record is complete; the girl will require no vaccines today.


I rise from my desk and step into the exam room across the hall. A lanky young man lounges by the long exam table beside a curly-haired girl who's dressed in a faded top. A slightly older girl stands nearby. A young woman rises from the sole chair and introduces herself as the girls' mother. I take a short step across the tiled floor and greet the father, then turn to the little girl.


"I understand you've come here today for a checkup so you can start school when you get to your new home. Are you excited about moving?"


The child immediately buries her face in her father's arm.


"It's okay, Danielle. Don't be shy. The doctor won't hurt you."


"Your daddy's right—nothing's going to hurt today. We're just going to look in your ears, look at your teeth, listen to your heart and feel your belly. We'll have you back in your clothes in a jiffy."


The girl turns her head slightly and regards me out of the corner of a pale blue eye.


"How old are you?" I ask.


"She's almost three," her sister pipes up. "Her birthday's next month. I'm five," she offers, "and I'm not shy at all."


"Let Danielle answer the doctor's questions," the mother says. "It's not your turn today."


The older girl drops her gaze and bites her lip.


Although I've reviewed the child's medical records, I elect to take her medical history myself. I ask the mother about the pregnancy, the birth, developmental milestones, past illnesses. There are no previous hospitalizations or surgeries. Up to this point, the little girl has enjoyed excellent health.


"Good," I say. "Now it's time to have a look at Danielle."


"Sit up, Dani," the father says. "The doctor has to examine you now."


The child throws her arms around her father's neck and buries her face deeper into his chest.


"It's all right," I tell him, "she can sit in your lap for the exam."


Quietly, I approach the little girl with otoscope in hand. "It's just a funny flashlight," I say. "We're going to look in your ears for potatoes."


"She doesn't put potatoes in her ears," her sister giggles. "That's silly!"


Danielle lets me look into one ear. "No potatoes in there," I muse. "Let's look in the other one." She readily turns her head. "None there either. Let's look at your teeth. Is there a frog in your throat?" Danielle starts to smile.


By the time I finish palpating her belly and check her femoral pulses, Danielle and I are friends.


I make my pronouncement. "Danielle looks like a healthy little girl. I don't see any problems today. She doesn't need any shots. There was a question about a lead test..."


"I know she's had one," the mother says. "I remember taking her to the lab."


I find a hemoglobin logged in the problem list. I flip back through the record to locate the date of the visit and discover the lead test result recorded there.


"I'm terribly sorry about all of this," the mother says. "I know it's been a chore for you and your staff. After my husband lost his job and we had to go on state insurance, we couldn't see her previous pediatrician any more. We asked around, and we were told that this was a good practice to go to."


"Looks like we got good advice," the husband says. "Too bad we didn't come here from the get-go."


We shake hands all round. Danielle has donned her clothes. She stands by her father's side, holding his hand. "We'll have your form ready at the front desk," I tell them.


I watch them go, this father, this mother, these two little girls—a new family I will most likely never see again. They've played by the rules, but got burned by the system. Lose your job, lose your health insurance, lose your doctor.


Fractured relationships, displaced families: like so many folks in this recession, they're just passing through. JAAPA