Postscript: The last well visit

July 1, 2007

Eventually pediatricians must say goodbye to our patients.

If you're a matured pediatrician you regularly encounter what I call "The Last Well Visit." This often occurs when adolescents, who became your patients as newborns, have grown to high school seniors. Graduation is time for them to transfer their medical care to an internist or family physician. The "last" well-child exam of these long-term patients is a special event for me. It underscores what it means to be a pediatrician, and brings closure to our important role in the patient's extended family.

Our care for these long-term patients began with them in the nursery. We discussed feeding, burping, cord care, and jaundice with nervous parents. There was the first set of immunizations, the first ear infection, and the first case of gastroenteritis. We were there to calm, help, and advise. We monitored growth and development, praised parents when they and their children did well, and provided a welcome ear for concerns.

A few patients had uneventful, almost boring childhoods. But for most, there were lots of bumps and bruises that required pediatric intervention. If there was a speech delay, we arranged a hearing test and a consult to a speech pathologist. If headaches developed, we ordered an MRI. In the middle of the night when the patient was up with abdominal pain, we investigated the possibility of appendicitis. There were often school and behavior issues, mild acne, menstrual cramps, a broken finger, and many other issues. Each time we made a small, or sometimes major, contribution to their well being.

Even though I've had thousands of patients, I remember my long-term patients and their families the best. Without reviewing a single chart, I can often recall the names of all siblings, and their hobbies and interests.

When the last well visit finally comes, we talk about jobs, education, future plans, as well as future health care needs. At the end of the visit, thanks are exchanged between pediatrician and patient and parent. I thank them as well, for allowing me to participate in the upbringing of their child. We end the visit with a handshake, and sometimes a hug. The rest of the day, my pace is somewhat slowed.

After that last well visit, I may see the patient a few more times for injuries, or respiratory infections before they depart from the practice. But there never is that same meaningful dialogue we shared during the last well visit. After the departure, I sometimes learn about these patients through parents and younger siblings. I am always eager to hear how they are progressing through jobs, college, or life.

And sometimes, although not too often, a once-departed patient shows up to my office. They have a spouse and a new baby of their own, for its first well visit. And we start the whole process over again. ...