Author: Susan R. Johnson MD, F.A.A.P.
Published: October 16th, 2004
Pediatric Residency is a three-year apprenticeship. It is supposed to be the culmination of learning and patient experiences from medical school applied to the caring and treatment of children and their families. Entering my residency, I saw myself as a kind, empathetic human being who adored children and was eager to learn how to help others. I felt especially empathetic and connected to deeper feelings toward life, since I had just undergone surgery and six months of chemotherapy for a skeletal muscle tumor, a rhabdomyosarcoma, a tumor usually occurring in children. I also felt a deep connection to this Children’s Hospital where I was now a resident. I had been a patient at this hospital when I was three years old and had a kidney removed because of a cystic tumor. I had perceived this hospital as a healing place, a place that had once saved my life. Then my residency started, and I learned very quickly that managing time and being efficient were far more valued than being empathetic or caring.
During my first year of residency, I still felt like I had a soul and was a caring human being. I was not considered a very “accomplished” first year resident because I was so inefficient and seem to place too much emphasis and time on the “unimportant” psychological aspects of the child and family, but in the eyes of my teachers, I had potential. Well, as a third-year resident, I was acknowledged as an excellent pediatrician and even won a coveted Pediatric Research award, yet my soul was lost and maybe even sold.
During my residency, I was taught to treat children based on a specific diagnosis. In my continuity clinic, pills were dispensed to children with chronic migraine headaches and potent laxatives were given to children with constipation. My Attending Physician in the continuity clinic did not believe in finding out about stressors in the life of the child or family. He considered that a waste of time. Even on the inpatient wards, I was actually forbidden during a night on call to ask any child I admitted how they liked school and what things they liked to do for fun. These questions were open-ended, and I was taught the important information came from closed-ended questions (those that were simply answered by yes, no, or an exact amount). Besides, I was told it took too much time to listen to patient’s answers to open-ended questions and time was of the essence. Even on morning rounds, very few of my attendings (my teachers) wanted to talk about the personal or psychosocial aspects of patients.
During this training, I cared for so many sick and dying children and yet I had no idea and few role models to show me how to handle all the feelings and emotions around the issues of death and dying. If a patient was newly diagnosed with leukemia and the parents were angry, I was instructed just to get the social worker (there were only three social workers for the entire children’s hospital). One time I burst into tears during rounds, when I was talking about an adolescent boy who was dying from his leukemia. I was told to go to the bathroom and wipe away my tears. It was not okay to cry. There were other patients to see and one must remain objective. A 14-year-old girl tried to commit suicide by overdosing on Tylenol. After she had stabilized, I spent a couple hours talking to her about her life, on my own time. The next morning during rounds, my ward attending told me he didn’t want to know why she made the suicide attempt that was not part of my job.
I didn’t go to any funerals during my residency though I must have known more that 20 children that had died. I can’t even remember hugging the parents of those children. I couldn’t bring myself to visit the intensive care unit when an adolescent girl that I knew for almost three years died after getting pneumonia while on chemotherapy. I started to learn to not remember the names of the children I cared for-it was too painful. Instead, like all the other residents, I kept the children’s names on index cards filled with their lab values and lists of medications, and then I could throw out the cards at the end of each six-week rotation, purging myself of all the pain. I was too sleep-deprived and deprived in general to care about anything anymore. I had been working at least 12 to 14 hour days and 36-hour-around-the-clock shifts every 3rd or 4th night for 3 years, with only 2 weeks off a year for vacation. I became sick with colds all the time. My marriage was dying. There was no time for family or friends, and I didn’t even hear my soul crying.
By the end of my third year of residency, I was considered an accomplished Pediatrician. I could manage the emergency room myself and supervise all the residents in the hospital at night, supervise the intensive care nurseries and intensive care unit, manage the inpatient wards, and go on transports to bring back sick children from other hospitals. Even my infamous continuity clinic Attending had no complaints. I was praised highly for my competency and diagnostic abilities. I even won a research award and my name was put on a plaque, but my soul had died. I now had to fill the air around me with loud music, for to be alone with only my thoughts was unbearable. I stopped singing. I had no voice to sing. I used to pride myself in being able to make eye contact with an infant or young child and get them to smile back immediately. My gift was gone. I couldn’t look at children that closely anymore, and they sure didn’t look at me. There was no more sparkle in my eyes. Yes, I had arrived. I was now part of the Pediatric Faculty (a teacher of other medical students and residents).
I was a resident 20 years ago and I wrote these thoughts down more than 8 years ago. Much of the pain from my residency experience has been transformed. My gift with children returned and I am now a mother and I remain a pediatrician with a sub-specialty in behavioral and developmental pediatrics. I also am a certified Waldorf Teacher and studied Anthroposophical medicine (the wisdom of the human being) at the Lukas Klinik in Arlesheim, Switzerland. I have attended numerous workshops focusing on complementary medicine and various sensory-motor integration therapies. I have Osteopathic and Naturopathic students rotate in my clinic as well as medical students, nursing students, educational therapists, teachers, and sensory-motor integration specialists.
I believe what is missing from medical training is the opening of the heart and acknowledgment of the Spirit. There needs to be a space to feel and express emotions. Priority needs to be given to attend a funeral or be with a family when their child has died or is dying. When one experiences loss and can share the pain of that loss in the company of fellow human beings then compassion develops. When one acknowledges the Spirit then one acknowledges the mystery of life and death. No longer does one need to feel responsible for “knowing” all the answers. It becomes possible to say "I don’t know" because there is a higher place of knowing. Death no longer is the final resting place. Death of the physical body is not to be feared because the Spirit is immortal and the soul can be healed.
I realize now that much of my residency training was based in fear, not love: the fear of doing something wrong or the fear of the patient dying because I didn’t do or know enough. This fear created egotism because the focus shifted away from the other to “me”, and only what I knew or didn’t know became important. Being in this constant state of fear took me away from the present moment, I was stuck worrying about the future or the past. Yet, it is only when one is living in the present moment and really present to others that one is in a place of love and compassion.
I now have many heroes in my life like Naomi Rachel Remen, Thich Nhat Hanh, Rudolf Steiner, The Dalai Lama, Huston Smith, Peter Kingsley, and Marshall Rosenberg to name only a few. I have learned from them and my own experiences that the most important thing we can give to another human being is our presence. It is not just our knowledge that matters but rather it is our capacity to be fully in the present moment, to be fully present to the other, and to come from a place of unconditional love and profound empathy. The ultimate healing force is to be able to listen, really listen to the other. To know that the other is as important as we are. To know that I am you, you are me and that we are, literally, all one. We are all drops of the same ocean. The patient and the physician are one. We work together as equals and fellow human beings. This is the Art of Medicine. It is the Medicine that transcends the physcial body and truly heals the soul while acknowledging and uplifting the spirit.
A voice coming out of the wilderness