The patient, whose medical anxiety is such that we invariably need to repeat the blood pressure measurement at the end of the visit, looked remarkably chipper when I entered the room for his annual visit. After greeting me, he immediately disclosed the reason for his ebullient mood by saying, “The front desk told me you are not going to kick me out until after I graduate college!”

Temperamentally, pediatricians make poor bouncers. I have never successfully kicked anyone out of anywhere; I had no plans to evict this patient from my practice. When I was a resident and junior attending, I viewed pediatric care as an unchangeable 1-way ticket—the kind of flight where you could get kicked off. The experience of watching my first generation of infant patients graduate college has altered my perspective; pediatric care is actually a long and flexible journey.

In explaining his trepidation about moving to adult care, my patient observed, “No one has ever taken care of me except you—for my whole life.” Later, I was struck by the truth of this assertion. Most patients, based on the duration of care, geographic location, and physician longevity, will have more than one internist; many have only one pediatrician. The one-to-one permanence of that relationship is rare within medicine.

The patient issued his poignant rationale to stay in my practice by reminding me (though I needed no reminder) that I had been there for “all the changes.” Like a transcontinental railroad trip, the pediatric train moves through a vast and changing landscape over 20-something years.

In infancy, the railroad car is often crowded, like the hospital room at the first visit: parents and grandparents, balloons and parental hopes and dreams, overflowing luggage, literal and metaphorical. Gradually, the car clears out. Pediatricians remember the family unit before death or divorce, or after new siblings and blended families. In the last few miles of the journey, no one remains, save for the pediatrician and patient. Patients’ traveling companions—boyfriends or girlfriends, roommates, or friends—I know solely by the patients’ stories. I no longer see the parents unless I bump into them at the grocery store. Yet, like a good conductor, I still recall which seats were once occupied.

The infant is now a wholly unrecognizable adult—as if the scene outside the window has transitioned from New England’s evergreen-studded coast to the vast expanse of the Pacific shore. Along the way, we have passed through seemingly endless expanses of terrain (middle school). We have had delays—gotten stuck in stations and illness when we would have preferred a swift departure. Some patients cannot wait to jump off this slow and steady train—they depart for the jetliner of adult care as soon as they can. Most are content to stay on, comfortable in the familiarity of a constant conductor, present despite changing environments and seatmates.

Early in my career, it was hard to predict which 18-year-old, each of whom I had known only a few years, was ready for jet travel. As a result, I stood in the aisle like an impatient flight attendant waiting for their drink order, reminding them with every visit and refill request that it was time to move to adult care. With the certainty of a youthful clinician, I felt a sense of urgency about this transition—my cart was blocking the aisle, and I needed definitive closure.

These days, I see it differently. In part, because I now know these patients so well, I have an innate understanding of who will be ready to leave, and when. The more important change is internal—my own acceptance that pediatric care, the slow train that it is, requires a different mindset than the flight attendant eager to lock the door for takeoff. On this train, as anyone who has taken the local through Connecticut can tell you, there are many stops: New London, New Haven, New Britain… Understanding the diversity of options has decelerated my rushing; there is no flight to catch, just the next stop waiting.

In turn, this understanding changes my role. Now I am like the conductor who walks through the cars calling “Stamford Station in 5 minutes, next stop New York City.” I will not kick anyone off the train, but I call attention to milestones; I talk overtly with each patient about their plans for the next year—geographically, educationally, and socially. I want them to be aware of the upcoming choices and stations. By foreshadowing the coming disembarkment, I give passengers time to collect their metaphorical baggage. Often, this includes concrete plans, such as suggesting we optimize their SSRI treatment together before they hop off my train. I stroll down the wobbly aisle to alert the dozing passengers, lest someone wake up surprised to find themselves in Philadelphia.

Eventually, Friends episodes notwithstanding, everyone leaves pediatric care by their twenties. Sometimes, it is necessary when they develop medical problems outside my scope. And when you have your second baby, or you show up in a suit and tie (because the 1-year prelaw school job turned into a political career) and joke with the pediatrician about being ready to start a family, it is time to go. If you leave your phone number at the front desk in case the nurse wants to get a drink with you someday, we have reached the end of the line.

At Jewish life events like a baby naming or a bar mitzvah, the community prays that the parents will see their child study Torah, do good deeds, and walk to the wedding canopy. Our local rabbi invariably adds to the English translation of this blessing the phrase “in their own time” just before the wish to walk down the aisle. Most people hear this as a humorous acknowledgment of the implausibility of a tiny baby (or awkward 13-year-old) being married. As a pediatrician, I hear it as true clerical wisdom—a reminder that we should encourage children to reach maturity on their timeline, not ours.

At the end of such a long and eventful trip, the passenger ought not to be rushed off the train. In their own time, when they have collected their belongings and are ready to disembark, they will move on. There is plenty of time for the next leg of the journey.

2024