A double dose of vulnerability

A pediatrician's typical week includes at least one frantic visit with a weepy or sheet-white parent whose child has just fallen off a couch (or bed, changing table, counter). In this scenario, the doctor has two tasks: Examine the child and make sure there is no serious injury. And reassure the chagrined parent that these things do happen.

The situation produces a sense of vulnerability for both sides.

If one were doing a reality cartoon about the visit, the balloon over the doctor's head would read, "I think he is OK but maybe I should do a CT scan to be sure, but the data tells us we are doing unnecessary CTs and exposing children to unnecessary radiation and it is our fault medical costs are skyrocketing."

The balloon over the parent's head would read, "Oh my God, what was I thinking? The doctor thinks I am such a bad parent!"

It is unlikely the pediatrician is really sitting in judgment of the parent's parenting skills, especially if the pediatrician has children, too. But because all parents feel at times inadequate as parents, it is easy to see why many may feel that their doctor - the presumed expert on child-raising - is judging them.

Dr. Lynn Wachs notes that the long anticipatory guidance checklist that each pediatrician needs to cover in a well child visit could make a parent feel judged. Is your child brushing his teeth? Wearing a bike helmet? Watching television? The list goes on and on, and few of us could meet all the standards.

Which may be why some parents say that taking their child to the doctors can be a humbling, nerve-racking experience. It puts their child-raising skills on the line, examined under the intense exam room lights, inevitable shortcomings laid bare for all to see.

No wonder some parents show up for their kids' appointments with a case of performance anxiety.

One mother recalled how her then 2-year-old had a trio of accidents. First, he fell out of his crib. Then he decided to spray Windex in his eyes, followed by a precipitous fall down the attic stairs. By the third accident, the mother - who had been present for all three events - told her husband that unless the boy seemed injured, they should not go to the emergency room, because she was afraid hospital staffers would report the family to state social service investigators.

Worries about child abuse and neglect do sometimes put pediatricians in the role of judge. As advocates for children, it is our moral and legal duty to report suspected child abuse or neglect. This is a role that pediatricians find extremely unpleasant, but important. As such, it sometimes pits parents and pediatricians against each other.

But what parents must realize is that, short of evidence of serious abuse, a pediatrician could care less about the rough edges of everyday life that manifest in, say, dirty socks or a mother's confession that she started feeding her baby solid food two weeks before the guidelines said it was OK.

Afternoon visits to the doctor after sports and after-school play often mean bringing children straight to the office from their fields of play. When removal of socks causes a cloud of foul foot odor to fill the room, many a parent looks in horror at the dirty socks and feet and apologizes to the doctor for this lapse of hygiene. One parent told me that she makes sure her child changes clothes and looks spotless before the annual physical.

I can't speak for all pediatricians but I am happy to see dirty socks and bruises along the legs. That means that the kids are outside playing the way children should play. I tell parents that I worry when I don't see any bruises on the lower legs; often this means they are inside watching television or playing video games.

Even when there are bruises, it does not mean a presumption of abuse. One boy was brought to me for evaluation of bruises on his buttocks. The alleged "bruises" were pigmented spots called Mongolian spots, common in Asian populations and totally harmless. I was only too happy to reassure the authorities that the child was not being abused.

It would probably surprise most parents to realize that their child's doctor probably has some anxieties of his or her own.

Pediatricians are generally on the lowest end of the power, money, and influence food chain of medicine, opposite cardiac surgeons or cancer doctors. Pediatricians care for the world's least empowered and smallest citizens.

Often we are the ones feeling judged. Each encounter with a wee one is potentially a career-ending, diagnostic mishap. The 1 child in 50 who comes in with vomiting and abdominal pain but turns out not to have the same stomach virus that the 49 others have, but instead has a perforated appendix - these are the nightmares that keep us up at night.

The prenatal or meet-the-doctor visits are punctuated with questions about our competence, degrees, and experience.

Pediatricians understand how hard parenting is. We view ourselves as child advocates but also cheerleaders for the enormous work of parenting. After all, the office is not a church or temple, but a place where parents, kids, and the medical team come together to solve problems.

Dr. Victoria Rogers McEvoy is chief of pediatrics of the Mass General West Medical Group and assistant professor at Harvard Medical School.