Excellence in clinical care is the most important thing, but not the only thing

Dr Jonathan Kronick Although I must begin with a confession of the importance of family and one’s life outside of medicine, allow me to comment about some of the lessons I have learned about being a paediatrician, often the ‘hard way’, during my more than 30 years of practice. Education and learning are fundamental to the practice of paediatrics. We must find ways to keep up with the ever-growing knowledge base in paediatrics, the very real need for lifelong learning. Over the past few years, I have led seminars about learning methods for genetics trainees. I quickly got their attention by telling them about the many genetic ‘facts’ I learned early in my career which are now incorrect, truly ‘fake facts’, such as one gene → one protein. Recently, I joined our daughter when she went for a well baby visit to her twins’ community paediatrician. I was struck by how many important changes in newborn care I wasn’t aware of, yet another example of the ever-changing practice of paediatrics. Fortunately for my patients, my subspecialty practice does not include the care of healthy newborns. While paediatric metabolic genetics is now my only area of practice, I am sure that every field of medicine has an evolving knowledge base, so none of us are off the hook for lifelong learning. Our patients deserve our continuing learning so that we can best serve them and their families. We should learn from everyone around us, including colleagues, trainees, nurses, family physicians, etc. You have been to medical school, worked hard to get there and to become a paediatrician, yet you and I still have much to learn and should be eager to learn from everyone and every situation. When I was paediatric program director, a very good paediatric PGY1 refused to listen and learn from the very experienced nurses he was working with; this was not only a lost learning opportunity but also led to his dysfunctional relationship with the nursing staff, much to his detriment. Our patients and their families provide unique and essential learning opportunities which we should always take advantage of. In addition to our own learning, becoming an effective teacher/educator is not just for academic physicians, but in fact, for all physicians. Regardless of where one practices there will be others who rely on you to teach them, not the least of whom will be your patients and their families. Likewise, other health care professionals, colleagues, even hospital administrators, are potential learners and you should be their teacher. I have worked in hospital administration and learned from other administrators and I likely taught other administrators a few things. To be an effective and respected teacher, it is foundational that one must practice excellent evidence-based care in a respectful and compassionate fashion. In the absence of excellent medical and psychosocial care, one’s ability to be an effective teacher/educator is limited. The caring part of excellent paediatric care is as important as being evidence-based, up to date and technically superb. Being a fine physician and teacher, and where appropriate, researcher, will inevitably lead to becoming a role model for more junior colleagues. I am fortunate to have been a role model for the occasional trainee which has been deeply rewarding for me. For those of you in training or early in your careers, it is helpful to identify those who are role models you can emulate, or at least emulate their most admired qualities. Modelling the best attributes of those around you, like learning, is a task that we all must do throughout our professional lives. As physicians we are fortunate to have career paths that can evolve and change, often in ways that we may not have anticipated. My professional career plan was abandoned within my first year of practice and my path has been essentially unplanned since. I neither wanted nor expected to be a department chair, an administrator or a leader, yet to my surprise that’s what has happened. I was able to change my professional focus a few times, none really planned, but all have been learning experiences and, in most cases, great fun. I always continued to practice paediatrics and never agreed to give up clinical work. While planning one’s career is important, it is essential to also be flexible and ready to seize opportunities that present themselves. For those of you still in training I want to comment about choosing your career path. While none of us can know what lies ahead, I have always recommended that residents choose to do ‘what their heart tells them to do, choose to do what you love the most’. Your career choice should be influenced by not only the type of practice but also your personal life, that is family and friends. Your type of practice and where you live will be critical decisions for you and my advice is to make your decisions based on what is most likely to be the most fulfilling, satisfying and enjoyable in the long run. Advocacy on behalf of children and youth is a very important part of paediatrics. We should be advocates for children in whatever way seems best to each of us. When possible, we should advocate beyond caring for our own patients by working in some way within our communities. For me advocacy involved trying to be a good teacher to future paediatricians, assuring that their Royal College certification examination was fair and objective and by being active in the Canadian Paediatric Society. I have tried to make at least a small contribution to the improvement of paediatric care in Canada. I encourage each of you to find a way to advocate for children and youth, to do more than provide excellent care to your patients, although doing so is certainly the most important thing most of us will do in our professional work. Paediatrics is increasingly a ‘team sport’. All of us must therefore be good team members and when appropriate, team leaders. This of course requires good communication skills, being a good listener, being respectful, and being humble as well as occasionally being more tolerant than we feel like being. I have found that it is not uncommon to have to put my own feelings aside and make or support a decision that was in the best interest of the team, but one that was either controversial or not popular. In addition, all of us on occasion must work with someone we dislike, yet it is essential that we find a way to work effectively and respectfully with all. Not everyone around you will be a star or a role model, but most will have their strengths; we should be the type of person who recognizes, seeks out, finds and celebrates the strengths of those around us (colleagues, parents, learners, etc), even when we would rather not do so. In summary, being an optimist and finding the positive in others is sometimes difficult but always worthwhile. Communicating and working well with parents has been an ongoing learning experience, especially my understanding of their emotional reactions to what we may say or do. Early in my career I believed that I understood the feelings of parents and could therefore effectively empathize with the parents of ill children. Until l had children of my own, however, I had failed to appreciate the incredible depth of feelings parents have for their children. It is certainly not necessary to be a parent to be able to have a sense of a parent’s feelings, but becoming a parent helped me better understand my patients’ parents’ reactions. All of us should remember that what is ‘bad news’ to us (your child has cancer) will certainly be bad news to parents, but so will learning about ‘minor’ (to us) illnesses which often have an impact on parents that seems extreme to busy paediatricians. Likewise, the impact on parents of seeing their child in pain or suffering, even when the cause is relatively minor such as a blood draw, can often seem extreme. If we appreciate the situation as best we can from the parent’s perspective, we should be better able to more effectively support the parents. As professionals we must learn to respect and understand the intensity of parents’ feelings and reactions to the information we provide them as well as the distress of their children. It is part of our job to give information to parents in an honest yet respectful and compassionate manner. While we can rarely if ever have the same or similar experiences as the parents of our patients, we must strive to understand as best we can to effectively and compassionately support parents. We are in the business of caring not only for the child, but also for the child’s family and thus being care givers requires us to at times ignore our own feelings, or at least not let them show, so we can effectively support children and their families. Finally, but importantly, I have tried to act with integrity throughout my career. To me integrity means being honest, respectful and making decisions which are in the best interest of others to support the common good; often putting one’s own interest as a lower priority than the interest of others. The practice of paediatrics is great fun and as paediatricians we should celebrate our good luck. We are fortunate to have the privilege of caring for children and youth, who together represent less than a quarter of Canada’s population but all of its future. We all want to be the best paediatricians we can possibly be, and our patients and their families deserve no less than the best. In closing, I want to wish all of you the very best in your professional and personal lives; may they be filled with success, happiness, good health and peace. Regards, Jonathan Dr Kronick received his MD and PhD from McMaster University and did his postgraduate training at the Montreal Children’s Hospital and Toronto’s Hospital for Sick Children (HSC). Formerly he was a Professor of Pediatrics at the University of Western Ontario and Dalhousie University where he was Head of Pediatrics. Currently he is Professor of Pediatrics at the University of Toronto and practices in the HSC Division of Clinical and Metabolic Genetics. He was Program Director of Pediatrics and Pediatric Critical Care as well as Associate Dean of Post Graduate Education and Vice Dean Education at Western and Chief of Education at HSC. He has published over 50 papers and delivered many invited presentations in Canada and internationally. He led the development of Canada’s first Pediatric Academic Half Day program, the revision of the RCPSC Pediatric certification examination and chaired the RCPSC Pediatric Examination Board for 10 years. Most importantly Jonathan is the proud father of two daughters as well as four grandchildren and is particularly fortunate to have been married to Chris for almost 49 years and counting. He enjoys spending time with his family and Gracie as well as wood carving, canoeing and of course playing hockey (he has given up on being called up to the Leafs).

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