The first rule of pediatric hospital medicine is that having a child hospitalized does not make people happy. Hospitalization is almost never a good thing for a family and you always have to keep in mind that families can be under intense stress, even when the child’s illness is not life-threatening. Many families don’t have enough ready cash to afford to feed a parent staying with a child in the hospital or to make the drive back and forth from home. They often struggle to find a safe place for other children to stay when the parents are at the hospital. Sometimes they are in danger of losing their job due to missed work. And worse, all the sympathy in the world won’t defuse certain situations that we get into as hospitalists. How, exactly, do you make the best out of telling a parent their child is having a pseudoseizure? How about when the parent is suspected of being the problem, as with child abuse? Those are never going to be positive interactions and nobody expects them to be, but we are still human beings first and professionals second. Cut us and we’ll bleed.
Sometimes the more overtly adversarial interactions are less emotionally costly, if only because you’ve steeled yourself for it. The cases that can really get to you are what I call the “hot potatoes”. You know the type, the medically complex patient with a large psychosocial overlay complicating care. There are always multiple consulting services involved but nobody really owns the whole patient. The patient gets passed from doc to doc like a hot potato because everybody is avoiding the real issue. Sometimes that issue is pursuing aggressive interventional care in a patient with a really poor prognosis. Sometimes it’s simply that the parents have unrealistic expectations about what medicine can actually achieve. Often the parents are angry and often with good reason. Often you are angry as the doctor, because any number of people could have or should have addressed the issue, but somehow it fell to you. And, if you are addressing the issue, you are likely doing it solely out of a sense of duty or professionalism or even pity for a suffering child and it is costing you personally to deliver the bad news or to push the difficult question when you could just pass the buck instead. When you catch the hot potato, it burns.
And then, there are your mistakes. We all define mistakes differently and punish ourselves to varying degrees, but let’s not pretend we don’t make them. Medicine is full of uncertainty. You can overtreat or you can undertreat, but getting it just right is mostly fiction. It’s impossible because most of the time the “truth” in the illness is only revealed after the fact, if ever. Is it better to try early transition to oral antibiotics and risk a treatment failure or is better to expose a child to sedation, a central line and risk a complication of prolonged access? Is it better to take a chance on an unproven or potentially risky therapy or to persist in watchful waiting? We know there are no completely right answers in most cases but we are tormented by the feeling that somebody else might have done it differently….and might have been right when we were wrong.
And finally, the job is just not easy, even when you get it mostly right and when the parents and the patients are mostly happy. There is something I call “decision fatigue” that hits me after a few days of sustained high-acuity or high-volume inpatient work. Every decision comes with risk, even in the least ill of hospitalized children. Weighing the risks, weighing the evidence and weighing patient and family understanding and preference all take time and effort, sometimes an astonishing amount of time and effort. By the end of a week, I am occasionally so tired of making decisions that I can’t even choose what I want for dinner off of a restaurant menu. Even the simple questions can send me into a circular spiral of angst over evidence, risk and benefit. How many days of treatment? Further imaging? Dex or Pred? Do you want fries with that?
So, yes and no, it gets easier but it never gets easy. Doing the job can be a source of tremendous satisfaction. It’s a meaningful job and I’m glad I do it. Sometimes, it’s even fun. But it’s never, ever easy.