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Averse to being risk-averse: There is no pediatrician in me

May 13, 2011

Being keen-on geriatrics, I’m not that risk-averse. If one works with respect, keeps the patient’s goals in mind, and involves the family in the management plan, it’s very difficult to go wrong with caring for a patient in extended care (aka a nursing home). Our goal is not to save their life, or even necessarily to prolong it, but to ensure that whatever time they have left is as enjoyable and comfortable as it can be. If a nurse tells me the patient couldn’t swallow their heart medication, maybe we’ll elect to stop it rather than crush it into an awful tasting powder that ruins their morning. If a diabetic, demented octogenarian likes to hoard chocolate bars, I won’t tell the staff to take them away from her. I’ll talk with the family and suggest we let her have her chocolate bars. And maybe stop checking her blood sugars. Although geriatrics can be in some ways like pediatrics (a post for another time), the goals with dependent, elderly patients are so different than with healthy babies and kids.

Care is so much more complicated in pediatrics. Some pediatricians operate on a common-sense “if the kid looks well, they are well” basis. Some are a little more careful. Some are  – to my taste – too careful. I’ve never been good at fretting. I might worry sometimes about the results of an exam I wrote, a patient for whose care I had to make a tricky judgment call, or whether I forgot something important, but I don’t worry for long. My worries about patients are always relieved by the fact that I’ve done my best to give them clear instructions about when to return, like “If you find you are short of breath, coughing up blood, feeling progressively weak, or are otherwise worried, please come back.” The vague sense of worry is sometimes the only sign that something is wrong, and I want to give them permission to return and not feel silly about it.

Many patients (or parents of pediatric patients) try to hold off seeing the doctor because maybe their condition won’t be serious enough, or maybe they’ll be a burden. But we all feel better if I invite them to return when any red flags appear or at their discretion otherwise. I’d rather this well-looking child go home with mom and dad, live their life, and return if there is any trouble than stay in the hospital “just in case” anything happens.

Some pediatricians operate this way, but compared to family doctors, pediatricians as a group are more risk averse. Rightly so in so many ways – kids can be fragile and things can change very quickly. I have a hard time figuring out when to accept a little risk and when not to in kids. One day, the babe with bronchiolitis that I want to send home can’t go because she hasn’t been off oxygen for 24hrs according to Pediatrician A. Today, in a very similar case, I want to send home but don’t choose to because of this new rule I learned yesterday. I discussed with attending doc. Pediatrician B scoffs at this rule and continuous oximetry (oxygen saturation measurement) in principal. The kid goes home. I go home, confused.

I just don’t understand. I’ve tried to crank up my “fear of bad outcomes” dial for this rotation, thinking it will help me do my job. While it may help me think more like an anxious parent, it doesn’t seem to be a reliable way to masquerade as a pediatrician.

In fact, I’ve always felt I wasn’t quite up to snuff in the peds game. Not being a parent, it’s really hard to feel genuine while dispensing advice. It’s the hardest place for me to empathize – not that I don’t want to. I just don’t know what it’s like to be a parent. I think because I find it hard to relate that I lack the type of patience needed for dealing with the frantic families of sick kids, although I excel at this in the geriatric and palliative context.

A Cartoon Guide to Becoming a Doctor

So accurate. from A Cartoon Guide to Becoming a Doctor (without permission)

We never had babies around while growing up and so I never developed that easy comfort for handling them. I do want my older brother and his wife to have babies soon so that I have excuse to cuddle and hold and tickle and spoil some wee ones. I love playing with kids and making goofy faces at babies, even if their parents look at me like I have an intellectual and social disability. Even examining kids can be fun, as I try to make everything into a silly game (see the cartoon above). But I don’t have much passion for the pathology in peds. I can’t get excited about dehydration, bronchiolotis, asthma or conduct disorder. It’s just not as interesting to me as old adults, who have had years to collect all sorts of bizarre conditions, or who have conditions that require conflicting management and so create a puzzle simply by occurring simultaneously.

Clearly I’m no pediatrician, but my experience on this rotation will serve me well in the Family Practice clinic and in rural Emergency Rooms. And, if and when I have kids, I bet I’ll be a little more risk averse too.

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