Early one morning not long ago, Dr. Boots and his partner, Dr. J.J., visited 13-year-old Alicia George in her hospital room at the Johns Hopkins Children's Center.
Alicia had been in a car accident three days earlier, and just before the visit her neck brace was removed and she was taken off her intravenous medications.
"Have they tested your eyes today?" Boots asked Alicia gently.
She said they did. "Well, let me give you the Standard Eye Test anyway." He pulled a card out of his lab coat pocket. The card had two letters on it: a capital I and a small I. "What's this?" Boots asked, as he pointed to the capital. Alicia giggled and answered, "An I." He pointed to the lowercase letter, "What's this?" he asked. Another giggle and another, "An I."
"Your I's are fine," Boots said with a grin.
Dr. Boots and Dr. J.J. don't have medical degrees. Like most doctors they wear white lab coats -- but they also wear red noses, colorful hats and clown makeup. Their specialty is comedy. They are clown doctors. Their only procedure is to make people laugh.
Also known as Bill Boots and John Dodge, they are part of Clown Care, a national outreach program of the nonprofit Big Apple Circus, based in New York. The program was started in 1986 by Big Apple's co-founder, Michael Christensen. More than 90 clown doctors perform at 17 pediatric centers nationwide.
Clown Care has been at Hopkins for three years. The five clown doctors there work in pairs and perform clown rounds three times a week in most of the units. Their tools include bubbles, magic tricks, musical instruments and, most of all, improvisational skills, Boots said. There is also a five-member team at Children's National Medical Center in Washington, and members of both teams perform rounds at both hospitals.
"We don't go in a room with a pre-determined routine," Boots said. "The kids and the environment are what drive us." By performing "red nose transplants," "kitty cat scans" and "chocolate milk transfusions" the clowns ease anxiety and help children through procedures that could be frightening.
"We can be more helpless and more needy than any of the children we visit," said Christensen, who started the program after his brother's death from pancreatic cancer. "They have to help us. We reverse the roles where the doctors are idiots and the kids are helpful."
"We empower the child," said Boots, sitting quietly in the doctors' on-call room that the clowns use for a dressing room. "We always knock and wait for an invitation to come in. They can say no. They are in a situation where they can't make many decisions."
Doctors and staff appreciate having the clowns as part of the team. "They come in and it's a timeout from all the difficulties kids are having," said Dr. Will Savage, a pediatric hematologist. "... It gives them some time not to be sick and just to be a regular person. The only thing clowns represent is fun. It's important to have somebody like that to rely on.
"It's very well known that people have better outcomes when they have hope, are happier and feel supported," Savage added.
The clowns are called in for clown consults to help children through scary procedures.
Dr. Marichi Capino, a certified child life specialist who works on the School Age Medical Surgical Unit, told of a 7-year-old burn patient named Donavin Bunn. "He was in an airplane splint with his arms outstretched. Every day he needed a dressing change, which was very painful. When he was getting the gauze removed we needed him to blow the pain away."
That's where the clowns stepped in.
"The wind would come from Donavin and [the clowns] would be slammed in the door. That would make him blow harder."
After a two-month stay in the hospital Donavin came back to visit. His face lights up when he sees the clowns.
Sometimes clowns are called when other techniques aren't working.
"We have kids that have had neck or cranial surgery. We need them to turn their head, but they're afraid," Capino said. "We try relaxation techniques and working with dolls. But they're still afraid. ... The clowns go from one side of the room to the other. The patient must turn her head to watch them. It's effortless, she's not thinking about it. It's all done in the universal language of play."
The clown doctors are never pushy. They are professional performers who are trained in hospital procedures and are always aware that they are in a sensitive situation, Boots said.
Before every round, the clowns check in with the child-life specialist.
"If a child can't eat before surgery, we won't discuss food," Dodge said.
"If he's had abdominal surgery we might not go for the big belly laugh," Christensen said.
But in the end it's all about the joy, such as what occurs when the clown doctors visit 9-year-old Rolando Paniagua.
"If we came back in 30 minutes, would you remember our names?" Dr. J.J. asked, standing at Rolando's bedside.
"Yes," Rolando said with a big smile.
"How about 60 minutes -- would you remember who we are?" Dr. J.J. asked.
"Yes, Dr. Boots and Dr. J.J.," Rolando said, his laugh getting stronger.
"Knock, knock," Dr. J.J. said.
"Who's there?" Rolando replied.
"He doesn't know who we are," Dr. J.J. said. Rolando and his mother, Rocio Roca, shared a laugh.
"They make me forget about being sick," said Rolando.