The First Stone

by Douglas Krohn

When I graduated from my residency training, licensing boards considered me qualified to practice only one discipline of medicine: primary care pediatrics. I found this ironic, since so-called general pediatrics was the one specialty in which I possessed no real qualification. Had you asked me back then to attend to the blood pressure fluctuations of a kidney transplant recipient, or the deceptive potassium levels of a child in diabetic ketoacidosis, I would’ve said, “No problem –when do I start?” But put me face-to-face with a kid whose edematous ear canal throbbed from too much swimming, or tasked with the retrieval of splinters from the foot of a toddler who’d run around on his family’s old wooden deck, I wouldn’t have known what to do. I cowered at the sight of an earring backing that wouldn’t unscrew, struggled with the notion that a stuffy nose was considered a medical condition, and flailed at the deer tick stapled behind some kid’s ear. Everybody, it seemed, wanted me to either pull something out or shrink something that was swollen, and I just couldn’t do it. No one had ever taught me how. In my first years of practice, with certification to tend exclusively to the conditions my residency directors deemed too unimportant to teach, I longed for the simpler days of my medical training, when all I had to do was resuscitate an asphyxiated baby; or load an intractably seizing child with phenytoin; or squeeze a unit of blood, with my own hands, into a boy who was exsanguinating, post-operatively, following the removal of his tonsils. It was just so much easier back then.

But that was not the view of national boards and academies, who more or less took the unstated position that if a trainee could handle the tough and ostensibly important stuff—the pneumonia in children with HIV, the renal flares of an adolescent girl with lupus, the excruciating swelling in the fingers of a toddler with sickle cell anemia—then the easy things should explain themselves. That we all know a mechanical engineer who can build his own combustion engine but can’t boil an egg made no dent in this false belief. If it weren’t for my one afternoon a week in a primary care pediatric clinic in the northern Bronx—tucked in between rusty auto body shops, rising in a green glass facade above car dealer service centers whose showrooms were miles away, and just a short drive from the Bruckner overpass, which cast its shadow over commercial vessels in wet dock, themselves corroded by the salty air that came off of some polluted inlet of the Long Island Sound—I would have started my days in official practice knowing almost nothing that was of any use to my patients. After all, they didn’t need someone who could manage a ventilator. What they wanted was someone who could stop the bedwetting.

The office was situated along a stretch of the Hutchinson River Parkway, where you get as dramatic a view of a full moon as you do over the Grand Canal in Venice—better even, particularly if you’re driving northbound. In a patch of the Bronx that availed itself to little more than industry and highway offramps, this was perhaps the most redeeming feature of the clinic’s location. The force of the sublime was never more apparent than on the evening of December 22, 1999, when the winter solstice converged with a full moon at lunar perigee—the closest point at which the moon orbits about the earth, coinciding with a day in which the earth is closest to the sun, and the moon has managed to fully escape our shadow. The monolithic satellite reflected so much of a dark winter’s sunlight that the rush hour traffic could have turned off its collective headlights and still stayed in their lanes. The moon sat like a mammoth boulder on the shoulder of the southbound Hutch, a meteor that touched down gently on our earth yet threatened to roll us over, and this scared me. I felt as if I were physically drawn to a power that threatened my life. It was the most beautiful phenomenon I’d ever witnessed. I drove home that evening—along a stretch of parkway that reached for the city’s northern suburbs and the naked trees of Connecticut—bathed in white light, silently worshiping a prehistoric stone. I was moonstruck, I realized, finally comprehending the Natural emotion of a word I had forever heard in ignorance. Had my hands not been on the steering wheel, I would have opened my arms wide to the moon, as if inviting its rough-surface beauty to hurtle into my embrace, to crush me and everyone else on the planet, in a last happy moment. Fittingly, I will have to wait another hundred years for a second crack at this experience.

The physicians at this office, buried within the city’s decaying infrastructure, were remarkable: expert preceptors, wise mentors, reputable role models. They were as transformational as the rest of the city was transactional, their skills in attending to the bread-and-butter problems of everyday people equaled only by the pediatric attendings in the emergency department (nota bene: patients are clever, and their dreaded utilization of hospital emergency rooms for quotidian maladies does not reflect a lack of sophistication, but rather a well-honed knowledge of the precise locations where doctors are properly trained to care for them). This outpost in the urban hinterlands hosted the few teaching faculty who instructed us in things we would actually be eligible to practice upon completion of training: They taught us how to address parents whose children toddled with bowed legs, and provided us with the normative parameters of childhood limb contours — which, not surprisingly, are normally as bowed as a river’s bend. Like urban wilderness medics they taught us how to identify poison ivy by its leaf patterns, as well as its oak and sumac brethren, and armed us with its remedies. They assigned us reading on the engineering principles of various diaper designs (contrasting, for example, the water-absorbent traits of polyacrylate gels with the moisture-transmitting wicking of cotton), and lectured us on the rashes that accompany them—providing the clinical pearls revealed by eruptions that spare the skin folds, and those that dwell within them. They put their hands on our backs as we fielded complaints of colic and gas, teething and tantrums, feeding refusal and formula intolerance; flattened heads, flattened affects—and, of course, constipation.

Looking back, the problem with my primary care preparedness was not with how we were trained, but how little: one afternoon a week, rarely seeing the same patient twice, inundated with social issues whose resolution we’d never be around to realize. At one point I met with my residency director and asked if I could just practice the entirety of my residency in this one office, a haven in the tangle of outer borough parkways, and avoid the madness of a hospital ward and its diminishing marginal returns. The director shot it down without pausing to even think about it, not so much as stopping to wonder why I would even ask such a question, and seemed surprised by the naivete in simply requesting the accommodation. It was a hard no.

One of the many talented physicians in this office left after my internship year. I worked with him infrequently, though I remember him almost as well as I remember everyone else. He struck me as different, dwelling within a sphere distinct from that of the other doctors—something less academic, perhaps closer to the workaday orbit I recall a pediatrician circling during my own childhood. Even his name, in an office filled with Andy’s and Pete’s and Karen’s and Gail’s, was unique. His parents had named him Emmett. He had a close-cropped beard that followed the contour of his jawline, and plastic-rim glasses that sat atop a prominent nose, jutting out like a flat-topped rock formation. I remember him as being not quite young, though that may be because he was a little older then than I am now, and I would like to consider myself young. He wore ties with short-sleeved button-down shirts—kind of like my chemist father, forever socializing in a laboratory with other nerds—and I’ve chosen to remember at least one of Emmett’s ties stained with egg yolk, just like my dad’s would’ve been, though that memory is probably embellished. As observed then, his responsibilities appeared to be less didactic than that of the other doctors, and he seemed to perform much more heavy lifting—he saw patients all day long, one after the other, working through incredible volume in a job that offered no productivity incentive. His efforts were all the more impressive because he appeared to do this with a third-year medical student often in tow, all the while imparting pearls of clinical wisdom with a calm and deliberate voice. And, like everybody else in this office, he endeavored to take care of it all: throats with capillaries broken into red doughnuts by streptococci, and bellies plagued with the feverish cramping of enterovirus, skin desiccated by excessive bathing, and mouths eroded by aphthous ulcers, adolescent boys with twisted ankles, unwed mothers with tortuous paths at their feet. He worked devotedly, without any glamorous title or departmental appointment. And, despite all this good work, I viewed him as more of a curiosity than a role model, as he was doing something that we saw no other general pediatrician do: He cared for patients with mental illness.

This was astonishing to me, for the proper care of patients with behavioral health issues should have fallen exclusively to those physicians who had received extensive residency and fellowship training in such disciplines—at least this was the collective opinion of the pediatric house staff. After all, we ourselves were not being adequately prepared for such clinical aspirations in our own training. That Emmett offered mental health care because no other doctor in the neighborhood was offering this service to the community we served (poor children in the Bronx, far removed from the private psychiatric offices of Manhattan) was lost on me. So I snickered at him, behind his back, sometimes joined by others, nice and compassionate and hard-working as he was, for rolling his sleeves up and providing healthcare in a field in which I thought he had no formal training. Had I ever taken the time to ask him about this aspect of his practice, I would have learned that he had, in fact, supplemented his pediatric residency with post-graduate training in child psychiatry, shortly after I was born—something I would discover two decades later through Google, in my own fact-checking of this essay, and a point which illuminated the considerable lengths this man was willing to go to actuate his compassion.

In any case, with every prescription he wrote for a psychoactive medication, with every stimulant he prescribed for impulsivity, I viewed him as something of a quack—precisely because he was willing to do something for his patients that I would not—and I promised myself that I would never offer my patients counsel in a specialty in which I had not been explicitly certified. With this as my attitude, and with no meaningful training outside of one afternoon a week in a primary care office and several dozen extremely useful nights in an urban emergency room (in which the depressed and the anxious and the abused and the psychotic were kept quietly in a room of their own until the psychiatry resident arrived and dealt with the matter), I went off into private primary care practice, under-qualified, and with no formal preceptor to supervise me in the outside world.

* * *

I find myself one April afternoon sitting at somebody else’s desk, moved there temporarily because of the strains of the worst pandemic in a century. Many of my group’s clinical sites, including the one I had called home for 16 years, have been temporarily shuddered. Half our staff has been furloughed. My patient volume is down by three-quarters. Many of the visits I conduct occur over a video feed, with a technology to which I am just beginning to grow accustomed. The majority of my visits on this day revolve around mood and self-management and a distorted perception of threat. I see a teenager who is having panic attacks, and I review techniques of cognitive-behavior therapy, meditation and mindfulness—even though I have training in none of these methods, and it is a full month before I would finally break down and enroll in an online certification class taught by psychologists in Boston. I follow up on a child whom I had started on amphetamines for ADHD, reviewing his organizational approach to schoolwork with his mother—even though the extent of my training in this type of behavioral health care was a two-hour seminar taught over dinner by the head of the pediatric unit at the local psychiatric hospital. Then I see, for the second time in four days, a depressed and anxious adolescent who is dependent on weed and electronically combusted nicotine. After speaking to his therapist for 30 enlightening minutes, I’ve decided to start him on a selective serotonin reuptake inhibitor — even though my formal training in this space was limited to a different seminar taught over a different dinner by the same aforementioned child psychiatrist. Finally I close the day with a medication follow-up on a teenager with emotional dysregulation and disruptive school behavior, all of which I have addressed (successfully so far) with stimulant therapy—even though my expertise in this case extends no further than having read the consult notes on this child from all the multiple unsuccessful attempts by neurologists and psychiatrists and behavioral-developmental pediatricians over the last decade, and culling from those documents the one therapy that had worked somewhat in the past but was not adhered to.

And I finish up my notes on these patients in the electronic health record, and I create a bill for each encounter, and I make sure my powder-blue surgical mask fits snugly across the bridge of my nose before I make my way downstairs to my car and reflect on the day. In doing so, a flash of light from the past overwhelms my eyes, and a flushing heat rises in my face as I realize the terrain I tread upon is a quicksand of my own making. Looking in the rear-view mirror of my car at my heavy lower eyelids, wrinkled by time, careful not to dent the Jeep behind me as I inch my car backwards, I realize that the inevitable has occurred:

I have become Emmett.

Douglas Krohn is a primary care physician and a Clinical Assistant Professor of Pediatrics at New York Medical College. His fiction and non-fiction have appeared in Intima, Crossroads, The Westchester Review and other journals.