Despite claims to the contrary, the practice of medicine in the 1960s was not the ‘good old days’. In my youth, we were given, and accepted without thinking, responsibility beyond our level of expertise and experience; this situation was not always in the interests of the patients. Moreover, there was little regard paid to us as individuals and, regretfully, this attitude probably spilled over into our personal lives. Thankfully, my devotion to medicine was blessed with wonderful support from my late wife, tolerated by my children and welcomed by my grandchildren.
Dr Ian Mitchell
My long career as a paediatrician has afforded the opportunity to appreciate that there are some lessons that were slow to come to me; they would have made life easier had I realized them sooner. Although the practice of paediatrics has changed and continues to change, some lessons learned remain relevant today.
First, it is vital to state that paediatrics is fun; I have never had any regret about my choice of career. To be sure, some aspects of paediatrics involve commitment and a great deal of hard work. However, this is probably true of almost any endeavour in life, whether the occupation is a trade or profession, developing one’s own business or deciding to be the best possible parent to one’s child. There remains great satisfaction in mastering difficult tasks and developing expertise in a chosen occupation or way of life. Paediatrics may even be more fun than when I entered the field, because sick children are more likely to get better with the care we can now offer, and much more is now known about how to cope with competing demands on oneself, and how to combine a career with a full family and personal life.
Second, the role of companionship with the patient cannot be understated. Susan Sontag speaks about illness as being “the night side of life”. She claims that everyone is born holding “dual citizenship, in the Kingdom of the Well and in the Kingdom of the Sick”. Sontag refers to adults, but her words are also applicable to children. I have spent my career as a companion of those who were born into the Kingdom of the Sick and remain there throughout childhood. This is a very humbling and rewarding companionship. And “companionship” is the correct descriptor of the role of paediatricians.
Third, there are lessons to be learned from things that seemed positive at the time, but in reality contained a warning to tread carefully. For example, early in my career, I saw a child with the rash of Henoch-Schonlein purpura. Confidently, I told the mother, “This rash usually lasts six weeks”. When I saw the child in review six weeks later, the mother was very impressed. My prognosis was right to the exact minute. Although I was tempted to accept the compliment of being spectacularly accurate, I knew that this was luck and learned to temper my prognostications.
Fourth, paradoxically, there are lessons to be learned from events that, at first, seem not in the slightest positive, and this included my humble background. I have never known a time that I did not want to be a doctor. Yet none of my family members were professionals; indeed, education for my parents and for my extended family generally stopped after elementary school. Physicians, therefore, belonged to a different world than I did. At medical school and in my early days in paediatrics, I was rather diffident about my background, surrounded as I was by colleagues who had come from a long line of physicians, or whose social circle included physicians and others with higher education. Yet my background taught me something they did not appear to know: the need to respect all families and to speak clearly and with empathy. Most of my colleagues, whatever their background, develop the abilities to relate to all families, but it took some longer to learn to speak clearly, without technical jargon.
Fifth, it is important to accept that paediatrics is a team effort. We in paediatrics sense our importance to the whole endeavour of the care of the sick child. It is true that we have depth of knowledge and a high level of skill. But many other health care providers are involved in children’s health care. The professional skills and talents of these paediatric health care professionals are vital to the child and their views are not inferior to those of physicians. Indeed, their insights are often much more important than ours. We may think of ourselves as central to paediatric care, but we are not alone on centre stage.
Sixth, two specific paediatric abilities are important and often underappreciated: taking a full history and being prepared.
History taking remains central even in the era of paediatric specialties, subspecialties and special interests. Like most of us, I find it easy to become immersed in a specific area of expertise. Yet it is to everyone’s benefit, and especially to the benefit of the child and family, that we retain our core knowledge and expertise in the whole child. I do not wish to be misunderstood: the development of paediatric specialization has, in my view, been a major advance and, overall, has contributed greatly to the well-being of children and families. Nevertheless, the development of specialization sometimes establishes undesirable barriers among colleagues that inhibit good patient care. Specifically, overreliance on specialized areas of knowledge is not always helpful when faced with difficult diagnostic or management problems.
I offer two examples of the essential role history taking still plays, one from my specialty practice and one from consultations in medical child abuse.
In paediatric respirology, I have a tendency, and sometimes have seen this also in my colleagues, to think that if I see a child who has, for example, shortness of breath, then I will be able to make a specific diagnosis and develop an acceptable management plan with the family. Usually this is true. When it is difficult to make a diagnosis in the early stages, then I order a number of tests. If I have not solved the problem to my and the family’s satisfaction, then I go on to order more tests, and often consult with colleagues in other specialties. This may produce a solution, but, perhaps surprisingly, not as often as I hope. When faced with a genuine major diagnostic problem, I have learned the hard way that it is better to start again. In other words, retake the history, but in much more detail. At the same time, discover as much as you can about the family medical history, how the family responds to crisis, what the family enjoys doing together and what the specific anxiety is about the child. Then proceed to more focused and precise tests to confirm the suspicion that has arisen from this detailed history.
History taking has a special role in the rare case of medical child abuse, previously called ‘Munchausen syndrome by proxy’. There, consultations and tests usually compound rather than clarify the situation. I usually become involved after the child has been seen by many paediatric specialists in an understandable response to the confusing array of symptoms. Over time, disagreement develops among different members of the team, and between the parents and medical staff. At this stage, resolution is unlikely to come from more tests. On the contrary, one must go back in time, taking the history from the beginning, exploring family’s expectations and reading every nursing note in the inpatient chart. In my experience, the nurses have rarely suspected the diagnosis. But their recorded observations expand the information available from the medical history and often provide insight into the true situation, making it possible to decide whether this is child abuse, which creates a legal duty to report to child welfare authorities, or whether another diagnosis explains the situation.
Paediatricians are usually well prepared for consultations and have skills in communicating clearly to parents. Being prepared and communicating clearly are beneficial skills when appearing in court and before the media. Paediatricians often dread such experiences, although they should not. The tasks of giving evidence in court, facing cross-examination and speaking to a journalist asking probing questions involve paediatricians’ skills of preparation and speaking clearly and coherently. In both situations, it is essential to remain cool and to use clear language, without being insultingly oversimplistic. Transcripts and quotes are permanent records of what we have said and how we handled ourselves. Paediatric skills are essential in these activities, and paediatricians should be willing to speak in court and to the media as part of advocacy for excellent child care. Whatever the nature of the consultation and however experienced we are, we must always be prepared and we must be able to communicate clearly.
It is true that ‘time flies’ and I have lived through remarkable changes in medicine. I have been looking after children for a long time. From them, I’ve learned how to rise above adversity; from their parents, I’ve learned that silence can be better than speech; and from my colleagues, I’ve learned to be patient and to be grateful for their patience with me. Paediatrics is fun. Helping children is a privilege. I have always been glad that I chose to become a paediatrician.
Acknowledgments
The author thanks Dr Roxanne Goldade for suggesting this article and Dr Juliet Guichon for helpful comments on various drafts.
BIOGRAPHICAL NOTE: DR IAN MITCHELL
Dr Ian Mitchell is currently Professor, Paediatrics, University of Calgary (Calgary, Alberta); Director, Office of Health and Medical Education Scholarship, Cumming School of Medicine (Calgary); and a paediatric respirologist in the Alberta Children’s Hospital (Calgary). Dr Mitchell graduated in medicine from the University of Edinburgh (Edinburgh, United Kingdom) in 1968, eventually settling in to paediatrics, with additional training in paediatric critical care and respirology in Edinburgh and respiratory physiology in Toronto (Ontario). He was a staff paediatrician in Scotland before moving to Calgary in 1982. Dr Mitchell has held a variety of administrative positions, both at the Alberta Children’s Hospital, including Vice-President, Medical Services; and at the University of Calgary, including Director of the Office of Medical Bioethics. He has published extensively in peer-reviewed journals, and has made many research presentations. Dr Mitchell has edited or coauthored several books.
Dr Mitchell is active in bioethics education, is a member of national bioethics committees and has received many teaching awards. He has been honoured by the Canadian Medical Association’s ethics award (2013), the University of Calgary Faculty Association’s Community Service Award, (2011) and national lifetime achievement awards in both respirology and bioethics.