All in a pediatrician's day All in a pediatrician's day (November 14, 2003)

By Diana Reynolds Roome

"Anyone who welcomes a new baby without complaint is crazy," says Dr. Elliot Lepler matter-of-factly to the mother who has brought her newborn into his Mountain View office for the two-week checkup.

He's talking, of course, about the three-year-old brother who (the mother reports) has expressed mixed feelings about this new addition to the family. "He loves and hates her at the same time - so you can't trust him, and you must forbid any physical aggression. But every time you go to nurse the baby, spend a few minutes with him first and say, 'When you were little, I nursed you too.' And tell him over and over again that he's your number one boy."

After examining the infant, Lepler pronounces her "terrific," asks the mother to check on a point of family medical history and informs her about the pros and cons of the Hepatitis B vaccination. While giving a routine physical, Lepler has made sure he offers a recipe for the health of the whole family, not just its newest member. In this case, he has done his part towards preventing what can potentially become a destructive force in family life: sibling rivalry run amuck.

"I key off the parent's concerns," says Lepler, who has practiced pediatrics in Mountain View for 22 years. "So much of what we do is prevention and support, and I do see a big part of my function as [providing] preventive psychiatry."

Lepler delivers this with a light touch - slipping in an affirmation or suggestion at a timely moment when it will have most impact. Like a well-administered vaccination, most people barely feel it. That's partly because Lepler is a reassuring presence, with salt-and-pepper beard, purple shirt and baseball tie, plus an undeniable cuddly-bear quality. While no snippets of advice can radically alter family dynamics, small adjustments in a parent's attitude or handling of their children can help to avert problems down the line.

When he was a resident at the Children's Hospital of LA, one of Lepler's professors told him, "If you go into pediatrics the biology is relatively limited - you have to find your satisfaction elsewhere."

Part of this satisfaction, he says, is building a long-term relationship with patients in the context of their families - from two weeks old until they become healthy, productive adults. Lepler has known some of his patients long enough to be treating their offspring. He has some 2,000 young people on his books, and with an average of 6,000 visits a year he cannot know every detail of a patient's life and history.

He sees more patients as a volunteer at the Rotacare free clinic for children without insurance. Nevertheless, in his brief interactions (generally between 10 and 20 minutes, depending on the situation) he has made an art of listening.

Lepler listens not only to pulses, lungs and the telltale sounds of croup in the throat, but also to what else is going on. This means being tuned into family interractions of all kinds.

"We have people from all over the world, with different cultures and styles. The patient population in this area is one of the most interesting in the country," says Lepler, who keeps a globe in his office and a map of the Himalayas, where he once trekked to the Base Camp of Mount Everest at 18,250 ft., and hopes to return one day. "To talk to people about their values is a wonderful education."

The five-year old boy he sees next comes in with his father, who reads carefully in Spanish from the notes the mother wrote down before she left for work. Lepler, who learned fluent Spanish while in LA, tells the father that the boy's respiratory problems and ear-ache are caused by a virus. He suggests ways to make him more comfortable, but assures him the cold will run its course. A reference to school brings up what may be a more important problem than his current illness. Once again, Lepler is able to offer some advice that may prevent the compounding of the boy's troubles when he returns to the classroom.

As he examines a small girl with a hoarse cough and fever, he has time to ask the mother what language is spoken at home. When the answer is "Malayalam," Lepler says, "Then you're from Kerala?" Beaming, the mother confirms him right. Though the child's lungs are clear of pneumonia, a two-day course of cortisone is prescribed to reduce the inflammation around the vocal cords. This is somewhat controversial but Lepler believes it's worth preventing complications from croup. He is proud to say that he has never had to admit a child to emergency with this common but potentially serious ailment.

Physicians who specialize in the disorders of childhood are mostly focused on making sure their patients stay well. A child who becomes seriously sick - a rarity, in Lepler's long years of practice - is generally handed over for care to the appropriate specialist.

A typical day involves troubleshooting usually common childhood conditions, giving checkups to young children, and making sure the vaccination schedule is up to date. Today, one of his patients is manifesting something that could potentially be more serious. A 17-year-old athlete was hit by a baseball, which broke his nose, caused concussion and a spell at the emergency room. He has also suffered recurring light-headedness during games. Lepler's first question involves diet - what did he eat before the game? As it turns out, almost nothing - plus a carbonated drink. If he eats suitably a couple of hours before games, Lepler advises, this problem should cease. Meanwhile, he refers him to an ENT specialist to set the broken nose.

Between patients, Lepler talks a little about his other interests. He is an active Democrat, president of his synagogue, and in 1999 was president of the Santa Clara County Medical Association, helping to bring recognition to the fact that the medical community is at risk in this area because new physicians cannot afford to live where they establish a practice, and often end up leaving. He is also enthusiastically involved in the continuing effort to bring major-league baseball to Santa Clara, and is working on getting a ballpark here for the Athletics.

Meanwhile, he makes notes on his computer, picks up phone messages and makes callbacks. One is to the athelete's mother, whom he phones at work to reassure and explain the need for appropriate nutrition before games. He's also making callbacks on behalf of an absent colleague (there are four physicians in his office, all part of the Camino Medical Group) as well as seeing a few of her patients. This brings the day's total patient contacts to near 30 from the 24 he originally estimated. The office recently implemented a policy of open access, so sick children can be seen at short notice and this makes a doctor's day more unpredictable. One of the ways parents can help most, he says, is to come prepared with notes so they don't forget questions, or important information about the child's symptoms.

By afternoon, Lepler has no spare moments between consultations. He has to leave in good time to give a lecture at Stanford Medical School. When the receptionist calls in to ask him if he can take one more case, he asks a question about the child's symptoms and immediately says, "I'll see her." The subject of his lecture at Stanford: What it's really like to practice medicine today.

The writer shadowed Dr. Elliot Lepler as part of Santa Clara County Medical Association's Mini-Internship Program, designed to establish ongoing and open communication between community leaders and the medical profession.

www.sccma.org
Dr. Elliot Lepler, M.D.,
515 South Drive, Suite 21,
Mountain View, CA 94040
650-934-7956