Let the Little Children Come

I’ve said it before.  I love my job.  It is intellectually stimulating, emotionally rewarding, and even spiritually healing.  I think I was born to be a pediatrician and was lucky enough to find my calling in life.

This week I had a little one, 9 years old, come in with moderate to severe pain in the left upper quadrant of her abdomen.  Her abdomen was not “board-like” and she didn’t have rebound tenderness, but still, there was something that wasn’t right about this scenario.  It didn’t fit the algorithms and paradigms in my head.  Her mother thought she was having a kidney stone. Even though kidney stones are increasingly found in children and while not impossible in this child, it just didn’t fit.  The pain was too high and anterior.  I was concerned enough to order a CT scan—something I seldom have to do as a primary care pediatrician.  She had a congenital malrotation of the intestines and a ruptured appendix up where her spleen ought to be.  I don’t rejoice in her suffering, but there is something immensely satisfying to know that you found a potentially life-threatening condition that was not otherwise suspected.  That’s what I mean when I say it’s intellectually stimulating and rewarding.

I also see Medicaid patients.  Many of my colleagues, especially here in the city of Atlanta, refuse to see kids on Medicaid.  I can barely wrap my head around this concept.  I am politically conservative and would defend the rights of my colleagues to see whoever they choose to see, but just because they have a legal right to do so doesn’t make it morally right.

I know a family, who will remain nameless, who has been going to a big name, long established, practically famous, pediatric practice, which will also remain nameless, for THREE generations.  Three generations of the same family going to the same practice!  That’s great!  I love that families trust their doctor and stay where they are comfortable.  One of the second generation families, however, decided to take in some foster kids.  Foster children by definition are wards of the state.  As wards of the state, children in the custody of Child Protective Services are automatically enrolled in Medicaid.  The state, as their guardian, provides the insurance for the children.  Also, when a child is taken into CPS custody, they must be examined by a pediatrician in the first few days.  Why in the name of all that is holy would a physician who has taken care of three generations of the same family refuse to see two foster kids for their intake evaluation and well visit?  Hell, I would have done it for free!

I have one foster mom, a single lady, who routinely takes foster children that are difficult to place.  She has a large house with several bedrooms and several beds so she is on the list to take family groups.  Yesterday, she brought in five children who had just been placed with her.  Their story is almost too tragic to write about and might even be a HIPPA violation, so suffice it to say, these children are as shell-shocked as a Vietnam Vet in a wheelchair.  Tragedy upon tragedy.  When I entered the room, the children were sitting all in a row.  A nine-year-old boy and three little sisters all sat quietly while the foster mom held the 8-month-old.  When I asked who wanted to go first the oldest girl shot her hand up in the air and was followed almost immediately by the 9yo boy, both yelling “Me. Me. Me.”  Starving for attention.

“Well, buddy.  I think its Lady’s First.” I said.

“But I’m the man and I have to show them that it’s OK.”

I almost cried.  I thought I was going to have to leave the room but managed to hold my emotions in check.  I’d never met a nine-year-old MAN, but MAN he was.  He wanted to protect his sisters.  How long has he had to protect them?  I may have told him 12 times how proud I was of him.  During the course of the visit, he helped one sister climb onto the exam table.  He fed the infant a bottle while the foster mom was talking on the phone with CPS about an important piece of the history.  A child was forced to protect.  A child was forced to provide.  Who will protect and provide for him?  A Man Indeed.

I methodically went through each child’s exam, vaccines records, problem list, social history, medical history, medication list.  During the visit with the 6-year-old girl, who was precociously verbal, the 4-year-old girl walked over and just leaned against me, literally laying her head on my arm.  The 2-year-old sat in my lap while I documented her information into her chart.  She refused to get out of my lap while I talked to the foster mom about the infant, only getting down when I told her she had to in order for me to exam the baby.  When I finished the exam of the baby, the 2-year-old wanted back in my lap.  I held her and hugged her.  My heart was breaking for these babies and their wounds.  These children wanted, needed, couldn’t live without love and attention.  Can any of us?

Let the little children come to me and do not hinder them, for the Kingdom of God belongs to such as these, Luke 18:16

Some of my colleagues refuse to care for patients on Medicaid.  Why?  I cannot come to any conclusion other than greed.  I have a friend who is fond of saying “Where there is no margin, there is no mission.”  This is true and we cannot see patients for free for there would quickly be no mission.  Medicaid, however, does pay and it pays quickly, it just pays a little less than commercial insurance plans.  Unfortunately, the physicians who refuse to see Medicaid patients over a few dollars are poorer for it.

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