Study yourself too

“A Letter to my Younger Colleagues” is a series of essays written by selected senior Canadian paediatricians, who were named as outstanding mentors by a prominent group of their younger peers. I hope you enjoy and treasure the rich pearls of wisdom that each author offers, based on a lifetime of professional practice and personal reflections. Andrew Lynk MD Assistant Editor,Paediatrics & Child Health After spending my childhood watching my father in private medical practice and completing almost 45 years in academic paediatrics, what advice can I offer? Dr Ronald Gold The first issue is time: how many hours per day, per week, will you devote to medicine? Sooner than later, you have to accept the fact that, as a doctor, you must set limits. For me, the workload involved in being a clinical clerk, intern and resident, similar to the workload of solo practice, could not be continued as a way of life. Too heavy of a workload was bad for me, bad for my family and bad for my patients. Moreover, I wanted more in my life than just medicine. There had to be time for the other parts of life. Regardless of how you choose to practice paediatrics, you will be no help to anyone if you are exhausted all the time. Indeed, the probability of making mistakes has clearly been shown to correlate with increasing fatigue. Overwork and exhaustion have an added toll: they make dealing with the emotional stresses arising from patient care much more difficult, leading to potential disaster for a happy and healthy family life. So choose carefully when you pick your career path. Think of all that you want from life, not just your life as a paediatrician. The second issue is crucial to successful patient care: learning how to talk to patients and parents. To be an effective physician, you must learn, early on, how to communicate information to patients and their parents. Medical jargon distances you from them and usually fails to teach them very much. You have to learn to translate medical information into grade 8 language if you want your patients and parents to understand you. This takes practice and commitment. It is always much easier to use jargon than to think of ways to really communicate. The third issue is learning to deal with the emotional stresses of caring for very ill and dying patients. Most often, doctors develop schizoid personalities (what Robert J Lifton, in writing about Nazi doctors, called splitting). The doctor splits her personality into a doctor persona and a nondoctor persona: the former for dealing with the medical world, the latter with everything else – and never are the two allowed to meet. This is not done consciously, although there is certainly pressure in medical school and residency to develop a personality that hides (and/or denies) emotional reactions of any kind to what goes on with patients. It's called professionalism, which is another word for blunting, denying, hiding the normal and unavoidable emotional responses to pain and suffering. I believe all doctors do this to a certain extent when they deal with seriously ill/dying patients. Another way is to drink and/or take drugs to deaden the feelings – obviously not a good solution for anyone, but a much too frequent one among doctors. These reactions by doctors to their own emotional responses to patients become particularly apparent when faced with a severely ill patient or with the death of a patient. How the doctor reacts in these situations reveals the doctor's own understanding, beliefs and emotions about dying and death. I don't think a doctor can avoid the denial responses to his/her emotions (drinking, drugs and personality splitting) until he/she learns to deal with death and dying. Dying and death have become uncommon events for most people because they no longer occur at home, but are hidden away in hospitals, old age homes, nursing homes, etc. Doctors, however, are forced to deal with dying and death unless they go into nonpatient care specialities. Unfortunately, they usually receive little or no help with the issue during their training and are usually confronted with the reality of death long before they have found any understanding or resolution of their own fears and feelings about death and dying. The death of a patient is very rarely your failure. Modern medicine, modern medical education and current medical culture often regard death of a patient as a failure. The reality is quite different. You have to accept the fact that death occurs in spite of everyone's best efforts. Part of medicine is to help people be in control of their death. Thus, self-understanding is key, not only for coping with the workload imposed by a career in medicine, but also with the emotional stress of dealing with severely ill and dying patients. Dr Ronald Gold was Head of the Division of Infectious Disease at The Hospital for Sick Children, Toronto, Ontario, and Professor of Pediatrics at the University of Toronto from 1979 to 1992. He retired in 1996. He received his AB from Harvard University (Massachusetts, USA) in 1957, his Medical Degree from Harvard Medical School in 1962 and his Masters in Public Health from the Harvard School of Public Health in 1967. He obtained his paediatric training at the Boston City Hospital, Children's Hospital Medical Center in Boston (USA) and St Mary's Hospital in London (United Kingdom). Dr Gold's research has focused primarily on the safety and immunogenicity of vaccines. He served as a member of both the National Advisory Committee on Immunization and the Infectious Disease and Immunization Committee of the Canadian Paediatric Society for many years. He was coprinciple investigator in the development of the Immunization Monitoring Program, Active [IMPACT], an active surveillance system based at 12 Canadian children's hospitals to detect severe adverse events occurring after vaccination. Since retirement, Dr Gold has been a medical consultant to sanofi pasteur Ltd, advising on its vaccine research programs, senior medical advisor to the Meningitis Research Foundation of Canada, member of the Governing Council of the Confederation of Meningitis Organizations, and member of the Ontario Provincial Subcommittee on Immunizations. His current major clinical activity is advising on immunization of his four grandchildren and explaining to them why they need yet another needle.

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