I love children. I won’t claim to ‘understand’ them, but I am comfortable with them, and happy to work in their universe rather than asking them to be part of mine. I find them easy to work with. The ED nurses occasionally referred to me as the “child whisperer.” I am often asked by friends and colleagues why I did not become a pediatrician.
I knew from the beginning that I wanted to do primary care, and initially thought of pediatrics as the obvious choice. I loved my medical school pediatric rotation, and I saw as many pediatric patients as I could during my emergency room rotation. Years later, I still remember the day - and the patient - when I realized I could not become a pediatrician.
I was doing a one-year pharmacology fellowship between my 3rd and 4th years of medical school. It involved seeing patients whose physician wanted consultation from the clinical pharmacology team about some medication issue. Common concerns were drug-drug interactions, side effects, or off-label uses. I would review the chart, interview and examine the patient, formulate the problems in a detail, spend time in the library collecting information (this was before the Internet), and then present the case to my pharmacology attending. Together we would create recommendations, and I would write a note and talk to the attending and nursing staff. It was a fascinating experience. It combined basic and clinical science, and covered a broad range of medical specialties. Besides the educational value, it was also good for my ego: I was performing a real clinical service and my notes were part of cutting-edge care for complicated patients in a tertiary care center.
I loved it. I especially looked forward to consultations from the pediatrics floor. The pediatric staff was supportive and the pediatric attendings treated me well. And, of course, I enjoyed the pediatric patients themselves. Then I met Emily.
We were asked to address Emily’s drug choice and dosing of chemotherapy in the setting of mild renal malfunction, immunosuppression and recurrent fungal infections. She was 9 years old and sharp as a tack. She had penetrating big brown eyes that could look right through me. I loved her huge, ear to ear infectious smile. She was a favorite on the floor. She always apologized if she flinched or cried during a procedure or when she threw up on the floor. The pictures in her room showed that she once had had curly light brown hair but I only knew her as a charming young lady with a bald head and no eyebrows; she refused to wear the multicolored scarves her parents tried hard to convince her to use, decorating her room with them instead.
The first day I saw her went according to plan.
The second day I arrived as the breakfast trays were being put out. I was there to write my note in the chart, after which I stopped by her room to say hello and see how she was. She was sitting up in bed with a mouth partially full of pancakes. She smiled back at me and asked if she could see her morning’s laboratory results. That was an unusual question for child that age, and I asked her why.
Fixing those brown eyes on me with an intensity that did not allow me to look away, she said she needed to know if they were good or bad, because if they were bad she had to be extra nice to her parents, who were always sad, angry at the staff, and sometimes fought with the nurses or each other if the test results were not good. Every morning for her two week stay, I delivered her the day’s report before her parents arrived and listened and watched as she supported and cared for them.
As the tears came that morning (which they do again while I write this more than 40 years later) I realized that this untrained but sweet 9-year-old knew more about caring for patients and their families than I could learn in a lifetime. I knew that she would almost certainly not survive another 18 months, and I knew that she knew how ill she was. And I knew I could not select a career path that would make this a recurring theme.
I had seen similar circumstances in adults, of course, and had seen tragedy in both adults and children, but this was different. This was something I had never imagined, let alone experienced. I knew it would be uncommon even in pediatric practice, but I also knew I could not become a pediatrician.
The irony, of course, is that deciding against pediatrics did not protect me. The joy of watching and learning from patients is unavoidably linked to the pain of sharing their tragedies. If one wants the good, the bad simply cannot be avoided in medicine.