My modus operandi

If we were asked how we would want a portrait to be painted of us as a professional, it would undoubtedly be in a clinical setting and that is where I will start. My modus operandi for any encounter with infants, children, adolescents and their parents is to be a respectful, active listener. I believe in the goodness and unique power of every child I encounter, regardless of their ability. I learned these values from my parents, but also from pivotal experiences working at L’Arche Foundation with Jean Vanier. There, we – the assistants and the residents – were all equal as human beings; we just knew that some of us were blessed with abilities that called us to serve others with greater needs. Dr T Emmett Francoeur This recognition of goodness and power is even more amplified when I stand before a neonate. My life as a developmentalist enables me to recognize the splendor and awesome capacities of these little beings who at first are seen as dependent, sleepy, needy parts of a family. As we learn in psychology of how early on they can differentiate much of what is happening around them, how their endocrinological and immunological systems are being set by their environment and how there is ‘biological embedding’ via epigenetics based on the mundane, everyday, loving gestures of the parents, one does stand in wonder before them. Imparting this amazement to especially young parents is indeed a thrill for me, and hopefully a gift to the parents. This is also why, when some clinicians look at a chart in the emergency department and say, “Oh, it’s just another cold”, I always react, because I know that that little person represents a massive product of psychosocial biology. He or she is very special in his or her own singular way. Thus, a theme song, which rolls around in my head when I am performing clinical work, is Otis Redding’s ‘Respect’, sung by Aretha Franklin; music is a good way to remember vital values. It is also a good way to reach children. I find that singing little songs such as “There’s a little white duck” very mesmerizing for children as you go about the physical examination. They then associate good times with meeting a doctor. Humour also goes a long way toward the overarching goal of trying to understand everything you need to know about helping a given child. It comes at information collection in a tangential and less confrontational manner. I often enter a room, meet the child eyeball to eyeball and say, “Hang on, let me guess, your name is Bob”, knowing full well it is not. They fall into hysterics denying my claim but then often go on to talk about their problems, even at quite young ages. Children, and parents for that matter, really appreciate your zeroing in on the child when you first encounter the family; after all, they are the reason for the consultation. As we all do, I try to ask as many questions as possible of parents in a very short time, but always leave room for total silence for at least a minute, which often leads to the parent divulging some fact they may not have expressed. When the parent makes a comment about a trending public person or song, I often look at them and ask, “How young are you anyway?” Such outrageous statements often lead a parent to share information they might not have disclosed. One of the joys of working with children is their unfiltered candid observing, often commenting on your appearance. For me that almost always means my “lack of hair” so I just say back to them “Oh yeah but look at my hairy arms”. This self-deprecating humour often then elicits disinhibited divulging of important information from the child or parent. My two rules for the clinician are: 1) parents never ask a stupid question; and 2) same as the first. It helps to see yourself as a learner in the clinical situation, not the distant medical expert. A nice opening comment to a parent or a child is “Teach me about yourself” or “Teach me about your child”. The successful community or consulting paediatrician embraces the important ‘Rule of Three A’s’: availability, ability and affability (in any order you wish). The next domain of activity is administration or interpersonal activity. When my children were studying long hours in medical school, I told them that their work was indeed a necessary stepping stone because knowledge is a basic piece of the medical professional’s life. But when they arrived in the clinic or hospital setting, 90% of the angst would be interpersonal communication. Medical schools have now added interprofessional collaboration to their curricula, but I believe some elements of family systemic therapy would be just as worthy a topic. Learning how to navigate through the differing belief systems of our colleagues can be a challenging activity. If we do manage to work with kind and understanding partners, as is true in my case in the community, we should count ourselves lucky. Most of the time we are dealing with folks who have preconceived notions, and protocols, which are ingrained, entrenched ideas and are married to systems already in place. As my friend Charles Larson says, “When you try to change something in the health care system, even something as small as moving the garbage can will bring about complaints and arguments from people you have probably never met”. As an advocate, be prepared for resistance. Persist. If you have a vision for health care delivery, be primed to do your homework, not only in producing a well-informed argument, but also in finding the right like-minded collaborators. Above all, perseverance is essential; be ready to be there for the long term. In the midst of all these worries, one can never become too emotional, however. Understanding yourself and your own beliefs is important to maintain balance. The best antidote to angst is to look systematically at the challenges and to understand that, most of the time, the pushback is not a personal attack. It is also essential to distinguish between the person and the performance. No matter what outrageous behaviours are plaguing you, that perpetrator, just like your little patients, is coming from a very complicated and rich environment, which demands respect. When I am in a particularly prolonged stretch of interpersonal challenges, I often recall the scene from the movie ‘All That Jazz’ when the actor portraying Bob Fosse, the embattled and exhausted dance director, wakes in the morning, looks in the mirror, splashes water on his face, and barks “Showtime” and heads off for work. I try to match that energy and spirit. When medical students ask my opinion regarding career advice, I do suggest that, even in the paediatric context, they should consider pharmacogenomics. This may be the next big thing. Inevitably, you will make errors, be blamed or blame others for misdeeds, or have patients ask to leave your care because of misunderstandings. As I mentioned above, it is then that you need to know yourself and believe in yourself. If, in fact, you are committed to your life mission, then these incidents will pale in comparison. What also aids is the integration of mindfulness into your daily routine at work, the ability to celebrate and enjoy not only the love of your family and friends, but the special gifts of the newly blossoming crabapple tree, the warmth of the sun and even the miracle of your everyday motor movements. We are fortunate to have chosen paediatrics. We should honour that reality by actively maintaining our physical and mental health. BIOGRAPHICAL NOTE: DR T EMMETT FRANCOEUR Dr Emmett Francoeur is a community-based paediatrician in Montreal, Quebec, and is director of the Child Development Program and medical director of the Developmental Behavioural Pediatric Services of the Montreal Children’s Hospital. He is also the vice chair of the Department of Pediatrics. He is an Associate Professor of Pediatrics at McGill University and a clinical researcher in areas of memory development in children, and is interested in the developing field of child psychopharmacology. As past president of the Canadian Paediatric Society, he has been involved in the initiation and maintenance of many national programs for the benefit of Canadian children. He is also on the Directing Council of the Center of Excellence for Early Child Development. He retains the designation of Founder of Developmental Behavioral Paediatrics at the Royal College of Physicians and Surgeons of Canada. He is married to Patricia O’Connor, the Director of Nursing of the McGill University Health Centre, and is the father of 30-year-old twins, Maeve and Conall, a family medicine physician and paediatric resident, respectively. He tries to uphold the tenets of healthy active living by playing hockey, dancing and cycling as much as possible.

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