I am not a pediatrician. Don’t get me wrong, I have nothing against pediatricians. Some of my best friends are pediatricians. I love kids and I do fine on pediatric rotations. But by week two of the pediatric rehabilitation elective at Children’s Hospital of Oakland, I missed the straightforwardness of a surgical elective, when someone would hand me a retractor and tell me to hold still. The extensive conversations about our pediatric patients – what they felt, why they felt it, and how they expressed their suffering – at first seemed irrelevant to the pressing medical issues at hand. But as I began to contribute knowledge of my own patients to these conversations, I grew to embrace this explicit discussion of my patients’ emotional needs as essential to their recovery, and found myself applying this awareness to adults.
Children’s Hospital of Oakland (CHO) is a community hospital, a level one pediatric trauma center, a research center, and an old hospital (1914 is old in West Coast time). Patients can be strikingly privileged or excruciatingly impoverished, coming from San Francisco Bay Area, the central valley, and the far northern reaches of the state. I had been considering applying in physical medicine and rehabilitation, and this rotation was intended to expand my experience in said field. But my “secondary gain,” as physicians call it, was significant. By landing a rotation at CHO, I had a relatively lighter rotation during the crunch of residency applications. I was in an area I love – with hiking trails, cultural events, friends and family nearby. The pediatric aspect of the rehab rotation was a perk, as I enjoy working with children and benefitted from more experience with a pediatric population. I was unprepared, however, for the intense level of empathy working in a pediatric hospital requires. Children express their pain and grief in different ways, and unlike adults, they do not censor their emotions. I began to recognize that in order to manage and treat a child’s illness, pediatricians must frankly address these emotional needs.
My lack of a pediatric mindset was most obvious at sign-out, when I would discuss our short list of very stable patients with the night float resident. The residents were usually familiar with our service, either from previous night floats or from when the kids were on more acute services. But when describing these kids to a new resident, I invariably bumped up against our different approaches to medical management. The conversation would go something like this:
Me: “Okay, this is an eleven year old boy, four weeks out from a traumatic spinal injury, now quadriplegic. He–“
Resident: “Oh that is so sad!”
Me: “It is. He–“
Resident: “How did it happen?”
Me: (Succinct description of immigration issues, drug-related violence, and terrible luck)
Resident: (exclamations of pity)
Me: “He’s been stable for the past two weeks on our service. Now he’s throwing tantrums and refusing to swallow his meds.”
I was focused on what could be fixed, not the sad story behind it. I was either going to re-experience my pity for this boy’s terrible fate, or focus on the issue at hand – that he was acting like a sassy eleven year-old, and it was getting in the way of his medical management.
To be fair, these were medically stable kids who had undergone either a great physical trauma or had a recent change to the management of their congenital/near congenital condition. The children were admitted to the inpatient rehabilitation service for a minimum of six weeks, where they participated in intensive physical, speech, cognitive, language, and occupational therapies, which I got to observe. I could track day by day as their bodies healed and changed, as new medications took effect, and as they responded to therapies. I got to know their evolving neurological exams. The change in a patellar reflex or sentence structure had enormous significance regarding the efficacy of our treatments. I also got to know their personalities – the boy who bit and scratched when feeling helpless, the girl with wholly unrealistic expectations about her future. I also struggled with how their behavior as children influenced their medical management and therapy sessions.
By definition, every child admitted to the hospital has a sad story. On the rehab floor, the tragedy is prolonged. These patients are going to be disabled for a long time, but through these interventions their futures were improving immensely. One girl was regaining function in a single muscle group, allowing her to control a motorized wheelchair. Another boy went from minimally interactive to playing a complex clapping game with me. The mechanism of these improvements was physiological, enabled by the intensive therapies the kids were undergoing.
The pediatric residents with whom I was working reacted first to the tragedy of a sick child, then addressed the medical management of that child. My focus was usually first medical, then personal. So when a child refused to take his meds, these pediatricians could acknowledge that he was trying to exert control over his helplessness and frustration. They could respect his youth and personality, but would ultimately prioritize his safety by giving his meds through his gastric feeding tube.
I was drawn to the specialty of physical medicine and rehab because it prioritizes the social and functional as much as the physical and physiological. This philosophy of holistic care is more obvious in the pediatric setting. We must negotiate a child’s raw, uncensored responses to stress and pain to elicit participation and compliance. When my adult patients behave emotionally and irrationally, I remember these children’s uninhibited reactions and how acknowledgement of these reactions allowed us to better care for them. I attempt to give these adults space and permission to express their suffering. This act of compassion establishes trust in me as a provider, and forms an invaluable human connection in a time of need.
*Some details have been changed to protect patient confidentiality.