Paediatrics? That must be heartbreaking...

It's not unusual for people, on hearing that I work in paediatrics, to ask how I can do it. "Gosh," they say, "isn't that really upsetting?". When I mention that I have a particular interest in children with cancer, they start to look at me like I've sprouted a second head. Even medical colleagues of mine, who deal with illness, pain and sufferring on a daily basis, sometimes struggle with the idea of these things happening to children. My response, generally, is a little blase. "Oh but it's so much fun!", "I get to cuddle babies as part of my job!" or "Well the tough bits are tough, but they're so rare!". What I don't think I ever say is "Yes, it is. I love what I do but it breaks my heart".

There's a lot of talk about burnout and resilience at the moment. I find it difficult to understand what's really meant by either term, but I certainly find myself worrying that admitting things are tough is somehow suggesting that I'm not cut out for this. I know different people mean different things when they talk about being "resilient", but I have to say that a lot of the time when I read headlines saying we need to "improve resilience" amongst doctors, it feels like someone in an ivory tower is telling us to "man up". I know a lot of people say that isn't what's meant by it, but I also know that I'm not the only person who hears it that way.

Increasingly, I'm realising the need to be honest about how tough my job can be at times. I'm not complaining - I love it and I genuinely can't see myself doing anything else - but downplaying the stresses and strains does no one any favours.

There are phrases that make all paediatric trainees break out in a cold sweat. "Category 1 section, obstetric theatres" - something has happened during a delivery and they need to get the baby out now. You sprint to theatres, check the oxygen is working, get out tubes and catheters in varying sizes. Someone hands you a white, floppy, lifeless baby. You hear an anxious parent ask "why aren't they crying?" as your anaesthetic colleague tries to reassure them that sometimes babies born by Caesarian are a little bit shocked and take a while to wake up - and you know they're trying to convince themselves as much as the parents. Mostly, it's ok. You dry the baby off, position their airway, sometimes give a few breaths, and then they gasp, cry and pink up. Except the times they don't. The times they stay white. The times the heart rate doesn't improve and you start chest compressions and give adrenaline and do everything totally right and it just doesn't work. Maybe you detect a heart rate after 10, 15, 20 minutes. You start trying to explain cooling and neuroprotection and know that nothing you're saying will be taken in because up until half an hour ago, these people were having a healthy baby - a normal thing that millions of people do - only it's not quite gone to plan. Sometimes, a well meaning senior tells you to get a sense of perspective. Your day was pretty bad, but nothing compared to what those poor parents are going through...

It's not just the very sick children that can upset you. Part of our role as paediatricians is in child protection; assessing children who have been abused or neglected, usually by the very people who were meant to love and protect them. You might be treating a child for a chest infection and realise that this three year old, ill and in pain, turns not to his own mother for comfort, but to a doctor or nurse he's never met before. You might be listening to his chest when you see a hand-shaped bruise on his back. You could be just walking into the room when you realise he's malnourished and dirty. You have to act to protect this child in the best way that you can.

There are so many things that can get to you as you go about your work. Sometimes, it's seeing a parent struggling to come to terms with a horrible situation and realising that you can do nothing more than offer a hug, a listening ear and a cup of tea. Other times, it's watching a child undergo futile and sometimes painful treatment because their family aren't yet ready to accept that nothing more can be done to help them. It might be being hugged by a gorgeous little one and then finding out that Mum is actually foster Mum and she doesn't understand why no one will give him a forever home.

The point of this post is not to attract pity, sympathy or praise. I chose this career with my eyes open and it's a wonderful, rewarding, fulfilling one. But it can be difficult, and admitting that should be something that it's ok to do. Would you want your child to be cared for by someone who didn't care? If you can deal with the situations I've mentioned above (and yes, all of them have happened to me over the past couple of years) and not be saddened, I would genuinely wonder whether you were in the right career. I once described paediatrics as "the little girl, with the little curl", a reference to an old nursery rhyme...

There was a little girl 
Who had a little curl Right in the middle of her forehead; And when she was good She was very, very good, But when she was bad she was horrid. 

I still feel like it's the best way of summing the job up. When it goes well, when good things happen, it's brilliant. And when they don't go so well, it's fairly dreadful.

Paediatrics? I love it, but it breaks my heart. And that's ok.

Empathy

empathy, n.
Pronunciation:  /ˈɛmpəθɪ/
The power of projecting one's personality into (and so fully comprehending) the object of contemplation.

Definition from the Oxford English Dictionary

Following on from my recent quality improvement blog, I've been thinking a lot about patient centredness and what patient centred care really means. I stated (probably more than was strictly necessary) that I believed that so long as we aimed to provide high quality patient care, quality improvement would naturally occur. I also used a definition of quality which included the term patient centred. I think, therefore, that it is pretty important to reflect on what patient centredness actually is.

I don't actually think patient centred care is a difficult concept. It's all about providing care which focuses on the patient and what they both want and need. What is trickier is working out how to go about actually doing this.

At this point, I'd like to share a favourite video of mine. It's from the Cleveland Clinic in Ohio and, like many things I am likely to blog about, I was first shown it during my MSc teaching. It is slightly "American" in tone, so for those of you who feel you'd prefer a "British" alternative, there is a very similar version produced by Wrightington, Wigan and Leigh NHS Foundation Trust. Both videos end with a quote: "If you knew how they felt, would you treat them differently?".

I don't know who first said "Everyone you meet is fighting a battle you know nothing about. Be kind, always" - it's been attributed to so many people, from Plato to the Dalai Lama. Regardless, I think it sums up the essence of those videos nicely. It is all too easy see a patient's illness in isolation, without considering what else may be happening in someones life. If you don't at least attempt to understand an illness in the context of a patient's wider life, how can you even attempt to work out what they want and need from their healthcare interaction?

I think that really, empathy is what patient-centred care is all about. The most important person in any healthcare setting is the patient. Empathy is a crucial quality for any healthcare professional to possess. Without it, ascertaining what a patient wants and needs (and therefore providing patient centred care) becomes almost impossible.

I'll end this post with a challenge: next time you're about to get frustrated with a patient who has turned up late to an appointment or not taken their medications as directed, just stop and think about what else could be going on in their lives.