Fall 1998
Articles
Reviews
1998 Award Recipients
1997 Award Recipients
Special Presentation
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1997 Aldrich Award Acceptance
by Morris Wessel, M.D. FAAP,
New Haven, CT
Editor’s Note: It is with great pleasure that I reprint excerpts from
Dr. Wessel’s Aldrich Award acceptance speech. Dr. Wessel has been a mentor to many
pediatricians throughout his long career, and has had profound impact on everyday
pediatric practice. I have personally enjoyed a vigorous email correspondence with Dr.
Wessel in the last year. The full text of his speech was published in Pediatrics. These
remarks are edited from the original speech, with permission from Pediatrics.
Dr. Wessel recalled previous winners of the Aldrich award.
I am honored to receive this award. I first became aware of "Andy" Aldrich
in 1942 during my third year in medical school when I discovered Babies Are Human
Beings in the Yale Pediatric Library. This book set a goal as to the kind of a
pediatrician I hoped to become.
I was fortunate in 1947 to be appointed a Pediatric Fellow at the Mayo Clinic. I had
applied for this position because of my interest in the Rochester Child Health Project
which Dr. Aldrich created to serve children—and to study "What a child is doing
in the process of growing up." I recall with awe Dr. Aldrich’s extraordinary
clinical skill and his ability to present behavioral conceptualizations in language easily
understood by students and house officers.
I wish to comment briefly on a few previous Aldrich Award recipients, namely Ben
Spock, Edith Jackson, Milton Senn, Albert Solnit, Sally Provence and Anna Freud, who were
important mentors during my training. These teachers had a passion for ideas, a clarity
about what they believed and a love of communicating with students and house officers.
Their teaching is particularly relevant today when the role of the primary pediatrician
assumes greater importance than ever before.
While the contemporary notion of drive-through deliveries hadn’t
even been imagined during most of Dr. Wessel’s career, the idea of mothers staying
with their children in the hospital was equally startling to his generation.
In 1948 I was appointed a Rooming In Fellow in the Department of Pediatrics at Yale.
Rooming In, an elective lying-in arrangement for mothers and babies began at Yale in 1946
under the direction of Dr. Edith Jackson.
Fellows interviewed primiparous couples who chose the Rooming In plan. It was
surprising to me how eagerly women, and men too, shared their concerns as they anticipated
becoming parents.
I was surprised that men frequently reported morning sickness, food fads, and
abdominal discomfort during a wife’s pregnancy.
Rooming In Fellows served as pediatricians for the babies during the lying-in period,
visited homes shortly after discharge, maintained frequent phone contacts and provided
well baby care for one year.
I learned that "normal" findings of a baby’s examination, such as
contour of a baby’s head, dilated capillaries of the eyelids, and blue tinge of the
extremities often concerned parents. They were reassured as to the normality of these
findings. Mothers often remarked "How did you know I was worried about the shape of
my baby’s head, the eyelids, and the color of his hands and feet?"
House calls during the first week at home acquainted Fellows with the "baby
blues," the common tendency for new mothers to burst into tears, seemingly without
reason.
We also observed that many women in the initial weeks of parenthood experience a
transitional state during which they are almost totally preoccupied with their baby. They
often present little interest in the world about them. This phase, described as Primary
Maternal Preoccupation by Donald Winnicott, a British psychoanalyst, originally a
pediatrician, is familiar to obstetricians and pediatricians.
I learned however, that many couples wondered whether this state indicated a serious
psychological disturbance. They were relieved by my comment:
"Many women find the first weeks of motherhood exhausting. It is normal to be
preoccupied with your baby. My experience is that usually by six or eight weeks mothers do
begin to regain interest in the world about them."
I believe that my interest in the parents at this early phase of the relationship
established my concern with their experiences. It served as a solid basis for a trusting
relationship later on with the parents, as well as with children and adolescents.
As most pediatricians, I recognized that some infants are "highly
perceptive," that external and internal stimuli are perceived more intently that by
most infants. I believe that the term "highly perceptive" characterizes the
uniqueness of these infants and reduces the parents’ feelings of failure as they
struggle to comfort their babies.
The Yale Child Study Center was a major influence on Dr. Wessel’s
thinking.
The Child Study Center under Milton Senn’s creative leadership gained
international recognition as a major center for the study of behavior in the early years
of life and for the treatment of children experiencing difficulties in meeting
developmental challenges in their lives.
I was delighted in 1951 when Dr. Senn offered me a part time appointment to assume
with Dr. Albert Solnit, well trained in pediatrics and child psychiatry, and Mary Stark, a
seasoned social worker, the responsibility for teaching medical students during their
Pediatric Clinic rotation.
Two distinct memories stand out as I recall this experience. Al Solnit and Mary Stark
broadened tremendously my understanding of the meaning to parents and children of the
illness, injury or other stresses motivating the clinic visit.
Equally vivid in my memory is the eagerness with which students and house officers
integrated this comprehensive approach into their dealings with parents and children.
On many occasions the clinic served families experiencing the birth of a significant
handicapping condition or the onset of a critical illness. Mary Stark’s and Al
Solnit’s discussions sensitized me to the enormous task these parents face. As
parents mourn the loss of the healthy baby they anticipated having, they must assume care
of the child who differs greatly from their expectation. I gained tremendous admiration
for parents as they assumed nurturing roles in this difficult situation.
Dr. Wessel is quick to acknowledge what he has learned from others,
especially his patients.
A former patient now age twenty seven recalled recently that as a healthy sibling she
felt deprived when parents, and physicians too, were preoccupied with the needs of a
handicapped child. I quote with her permission:
"All those years my sister was so sick, I felt that I never had a mother, a
father, or a doctor. When I came to your office your first words were always.
"How’s your sister?"
Her memory of my greeting was correct. I am grateful of her comments that reminded me
to initiate visits in comparable situations with "How have you been?"
With a universal requirement for Developmental and Behavioral
Pediatric training, Dr. Wessel reminds us that the "new" field of behavioral
pediatrics has always been a hard sell to students.
I was troubled however when a student commented:
"I heard all that jazz in lectures. I never thought it had any relevance for what
I would be doing as a practitioner."
I was pleased upon my retirement from primary practice to receive a number of letters
from pediatricians who recalled spending a day with me during medical school and
remembered the discussions of behavioral issues. I am convinced that practicing
pediatricians have a unique opportunity to serve as mentors for students and house
officers.
Sometimes the most powerful question is the simplest.
The simple question "How have things been going with you?" encourage a
mother to discuss crises in the family.
"Well, just now when I’m so tired with my pregnancy" or "I’m
so upset that my husband is considering a new job and we may have to move again" or
"I’m worried sick about my mother who has cancer" are common responses.
Preoccupations of parents influence the manner in which they nurture a child. Toddlers
sense these changes and often react by demanding increased attention.
I also discovered that a young child who is demanding may be reacting to the absence
of a favorite staff member at day care or nursery school.
No matter how I tentatively considered the basis for a child’s behavior, I always
proceeded with an examination. It was surprising on many occasions to discover that a
healthy appearing child was suffering from an unsuspected otitis media, a foreign object
in the external ear canal, or a inguinal hernia. In rare instances, I discovered wide
spread adenopathy, an abdominal mass, hypertension or other significant findings.
Dr. Wessel had the privilege of following many patients through their
life cycle from prenatal visit to the birth of their own children. He was practicing
adolescent medicine long before the Academy extended the age range of pediatric practice
to age 21.
As children reached early adolescence, I would take an opportunity to comment to my
young patient in the presence of a parent:
"Some time in the future you may wish to change to another doctor. I can
understand your feeling. I will suggest a good doctor for you. I want you to know that
while you remain under care here, you have the right to a confidential relationship. What
we discuss will be between us. If I find you have a serious health problem, we will decide
together how to share this with your parents. Your parents also have a right to a
confidential relationship when they have concerns about you."
Having offered young patients the opportunity to leave our practice, the majority
remained under our care through adolescence and often into early adulthood. They
appreciated being considered as individuals in their own right rather than as a appendage
to their parents. Parents having developed trust in a doctor they knew so well were
pleased that my partners and I would be readily available to care for their adolescent son
or daughter and also to confer with them from time to time.
One former patient remarked, "I liked coming to you as a teenager because you
always made my mother feel better about me."
The art of grief counseling, still difficult for most physicians,
benefited greatly from Dr. Wessel’s thoughtfulness. He was a pioneer in the
children’s hospice movement. He recalls one incident with his characteristic insight,
poignancy, and humor.
Throughout my years of practice I spent one day a week in community activities. Thirty
five years ago I received a grant to serve as a physician in an inner city school.
One day—thirty years ago this month—a beloved first grade teacher suffered a
fatal heart attack in the hall. The principal requested that I meet with the children.
I shall never forget this experience. The principal introduced me saying:
"You all know Dr. Wessel. He’s going to make you feel better." He then
walked out the door! I had no idea what to do next. I finally said:
"When some we love dies, we are very sad. Some people like to cry, others like to
listen to music or talk about memories of the person who has died. Others like to draw
pictures, or just sit quietly and think about the person.
"What do you feel like doing?" The children knew what they wanted to do!
"We must go to see her. Could we go now? Please take us in your station
wagon"
I struggled to think of an appropriate response. Nothing in my training at Yale,
Babies Hospital or Mayo Clinic prepared me for this task!
Patty a seven year old with long pigtails and shining black eyes suddenly commented:
"I don’t think it would do any good if we did see Mrs. Smith. My dog was hit
by a car last week. I found him lying by the road. He was stiff and cold. When I petted
him, he didn’t know I was there. Mrs. Smith wouldn’t know either!"
Patty’s experience with the death of her dog enabled her to comprehend the
reality of being dead and to share her understanding with her classmates.
We proceeded to record on the black board a list of pleasant memories of Mrs.
Smith’s activities. We later requested the school secretary to transcribe these
comments for the teacher’s husband.
This experience stimulated me to concentrate in my practice far more than I had
previously on reaching out to families when they experienced the death of a loved one. I
commented to parents on an initial visit that I wanted to be notified when tragic
situations occurred. It soon became common for parents to seek our help in supporting a
child at tragic moments.
I learned that bereaved children and adolescents, just as adults, may experience
somatic symptoms and fear they are about to die. I respected every call from a child,
adolescent, or parent regarding symptoms. An office visit and examination usually revealed
no serious illness or a minor viral infection. This was reassuring to both generations.
I will conclude by recalling another experience. My partner Robert LaCamera and I were
sitting with the parents of an adolescent boy who had fallen off a cliff and sustained a
critical head injury. He was being maintained on life support. One EEG had revealed no
activity. We were awaiting the results of the second EEG. If this too revealed no
activity, we commented that the end of his life was upon us.
Suddenly the mother said, "I’m sitting here with my husband remembering the
day we came to see you during our pregnancy. You were there at the beginning, and now you
are here at the end. Thanks for always being available."
Dr. Wessel finally summed up his talk to an audience visibly moved by
his words.
My goal was to use my relationship to families to enhance the capacities of parents
and children to meet as effectively as possible stresses in their lives. I appreciate
sharing these memories of my pediatric practice. I feel very much a part of a timeless
continuity of values that binds pediatricians together as we care for children and
families.
I realize that managed care is upsetting to most physicians. We have a greater
challenge than ever before since the primary pediatrician’s role is enhanced. I
believe that the motivation that led us to become pediatricians will enable us to master
current challenges and provide the best possible care when parents entrust their children
to us in sickness and in health. We also have an important role as mentors for students
and house officers.
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