The well-child visit was one of the first skills I first had to master when I started working in pediatric primary care many years ago. It didn’t take long for me, bright-eyed and fresh out of school, to memorize the standard questions: Does your child get 2–3 cups of milk a day? Eat five fruits and vegetables? Get one hour of physical activity? Do you limit screen time to less than two hours a day? Easy enough. In 20 minutes or less, I trained myself to breeze through the questions with a degree of surface-level assurance, believing that I was providing parents with the primary requirements for raising healthy kids. When I became pregnant with my first child, I assumed I had rehearsed enough to start my own parenting journey without questions. I assumed I was already equipped with the correct answers.
Then I actually had a kid … and fell flat on my face.
Today, two kids later, and with several more years of pediatric practice under my belt, I still frequently fall flat on my face. To my shock and dismay, parenting has proven persistently hard! It’s also exhausting, ever-changing, and unpredictable.
Taking my own kids to their well-child visits over the years hasn’t always been the experience I’d hoped it would be — or the interaction I needed at the time. Instead of finding support, I often left the visits feeling like I was leaving confession. Even though I knew the questions that would be asked going in, I still feared that I’d have to admit failure when answering. After all, I allowed my toddler to hold onto the pacifier longer than recommended, and there were nights when, in exhaustion, I left the screen on for longer than the recommended two hours. As a parent, I didn’t view the well-child visit as an opportunity for guidance; it felt like a platform to be judged against a rigid set of recommendations for “doing it right.”
In my practice now, after becoming a parent myself, I often reflect on my personal experience of being on the other side of the clinician-patient relationship. Recently, I had a well-child visit scheduled with an 11-year-old boy in my clinic who I knew well. I’d been seeing him for several years, and I noted the remarkable increase in his BMI before entering his exam room. When I opened the door, he was sitting on the exam table, his mom in the chair next to him. Both sets of eyes looked heavy … sadder than I remembered.
“Buenos días,” I said with a smile. “How have you been since I last saw you”?
“Not so well,” the mother replied, shaking her head, her eyes downcast with shame. My patient shadowed his mom’s response, also looking downward. The mom explained that in the past year, she’d lost her job cleaning schools. They had been living in their car and buying fast food from the nearest restaurant in the parking lot where they slept. My patient wasn’t doing well in school — in fact, he was failing every class. He was cold, exhausted, and depressed, and he was being bullied by the other kids at school. His mother sighed, and tried to say something positive. “Things will surely get better, though. He’s such a good boy.”
I paused and looked down at the well-child visit template on my clipboard. I already knew the patient’s answers to many of these standard questions without having to ask. Most of the answers would obviously be “no.” I feared that it would be out of touch to suggest that the family’s path to wellness would fall neatly into checkboxes. Furthermore, I didn’t want to give this family the message that they were in my clinic to be graded; I wanted to avoid their visit being another spotlight on their perceived failures. How could I offer guidance without judgment? Were the “healthy” answers really the same for every child in every environment?
More and more, I question whether the pediatric well-child visit might have some wiggle room. Maybe as clinicians we can do some reimagining of the time we are given to connect with patients and their families. I’ve recently altered my template to include fewer polarizing questions and more questions asking about who the child is as an individual. I encourage them to tell me how they shine. To tell me what is unique about them. What are their strengths? What are their challenges? What is working to promote their wellness right now? (Keep doing that!) What barriers are present? (There are strategies and resources available to help!) Ironically, with this open-ended template, I find that most of the standard questions are still addressed, albeit indirectly.
As a clinician, and probably more importantly, as a parent, I see a need for more acceptance of the gray areas on the bumpy journey of raising a family. The unpredictable variables that arise, big and minor, are the only truly predictable part of the ride. Pediatric well-child visits are an incredibly important space for clinicians to foster growth and offer support for families. Our message should transition from “are you doing it right?” to “what do you need to keep doing your best?” Ultimately, whether a family is living in their car or the caregiver is following the standard recommendations to a tee, I can’t say that one family is doing it right or doing it wrong. Every family I get to work with is unique. They are all doing their best, even if sometimes it looks like treading water. Maybe the best approach to walking with a family toward optimal health is asking, point blank: Where are you thriving and where do you need some help? Our combined goal is the health of the child, and we are in this together.
How do you approach wellness visits? Do you ever go off script or modify the standard template? Share your thoughts in the comments!
Kyra is a pediatric NP who trained in Denver, CO and now works in a neighborhood community clinic in the Bay Area. She loves having the opportunity to interact with families and their community as a whole. In her free time, Kyra enjoys spending time with her two kids doing anything that requires being outside in nature. Kyra is a 2021–2022 Doximity Op-Med Fellow.
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