Monday, April 20, 2009

Another Day in the Life: Practice in a Time of Transition

Last week, we had news of new systems of mental health care, of cuts in the state budgets for mental health and other children's services, of CSAs building up and outreach offices closing down.  Today, I was an old-fashioned pediatrician, seeing kids and families with a variety of illnesses at the start of Massachusetts Spring vacation.  It is an interesting time;  the wave of illness that consumes us each winter breaks on the shore of spring (is that what Chaucer meant by "shores soote"?)  I saw croup today, and strep throat,  urinary tract infections and hematochezia (there's a word you don't get to use every day).  In the midst of sorting through some really interesting clinical problems, however, I still found myself wrestling with issues of mental health.  We screened, a little, with 5/5 screens negative.  A girl with poor school performance screened negative on the Y-PSC, but she is already receiving counseling (in home, actually, but not at the SED level).  A toddler boy seems a little slow of speech, an elementary school student meets criteria for anxiety disorder and needs a letter to qualify her for SPED services, brother with depression and substance abuse issues come in for follow-up (both are doing better after initiating regular exercise, and really don't want to go on SSRIs.  So I didn't start them, despite my initial plan).  My SED patients continue to lurk in the background, some getting FST, some unable to reach their therapist or their psychiatrist.  For my patients, the events of last week wash up against the reality of their complex mix of mental and physical health problems.
In the midst of all of that, I have doubts;  doubts about how to choose a treatment plan when the eidence is murky, doubts that we can build a new system in the culture of a shrinking pie, doubts that, even if we build a decent system, we can get our families to navigate it.  I think these things, and then, I get over it.  I remember that, it isn't just about me and my clinical (or political) sense of how to manage this patient or that system issue.  I work with a great group of families and professionals;  together we may actually develop something useful.
More patients tomorrow.

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