Drped

I grew up somewhere between discipline and abuse.

During my internship, a boy a little over three years old came into the emergency department with abdominal pain. He was drowsy, his pupils were dilated, and he sat hunched over in a way that bothered me immediately.

He looked like a puppy that had been kicked.

His mother had stepped away to buy him a toy.

I don’t know exactly how I knew. I just did.

When I called the pediatric resident, I told him I suspected child abuse.

It turned out that I was right.

Later he asked me how I had known, and I couldn’t give him an answer.

That was when I decided to become a pediatrician.

I remember thinking that if I became a pediatrician, maybe I could become a good adult.

Everyone already knew pediatrics was not a specialty you chose to get rich. The work was hard, the financial rewards were modest, and there were much easier ways for a doctor to make a living.

That didn’t matter much to me.

I thought the work was important.

My first year of residency was exhausting. I barely left the hospital.

That winter, a 19-year-old boy with cerebral palsy died after repeated aspiration pneumonia. I had spent much of that year caring for him.

His mother had spent almost his entire life doing the same.

Nineteen years.

You might think that after that long, after so much illness, a parent would be prepared for the possibility of death.

She wasn’t.

When he died, she cried just like every other parent I had seen lose a child.

I had first heard that kind of crying during my internship.

A six-year-old boy had been brought into the emergency department after a car accident. He was already dead when he arrived.

We kept doing CPR while we waited for his family.

I knew they had arrived before anyone told me.

I heard the sound from the entrance.

It was almost animal.

I remember thinking, Can a human being really make that sound?

Later, after I had spent more time in pediatrics, I heard it again.

And again.

Parents do not get used to losing children.

A child does not become less precious because he has been sick for years.

That realization did something to me.

I started believing that every child had to be saved.

Not most of them.

Every one.

I wanted to believe that if I worked hard enough, moved fast enough, thought carefully enough, I could somehow make that happen.

For a while, that belief gave me a great deal of pride.

Then children kept dying.

Miracles happened in dramas. They didn’t happen very often in my hospital.

Every time a child died, something stayed with me.

Part of it was the parents’ grief.

Part of it was the feeling that I had failed them.

As I became more experienced, the patients I cared for became sicker and the decisions became harder.

Sometimes, after a death, the questions became legal complaints.

Then every decision was examined afterward.

Why did you do this then?

Why did you wait?

Why wasn’t another treatment tried?

Why wasn’t someone called sooner?

I knew why the parents were asking.

They had lost a child.

But sitting there while every minute of what I had done was taken apart, I sometimes felt less like the doctor who had tried to save the child and more like the person accused of killing one.

At first, I became angry.

I blamed the system.

I blamed society.

Sometimes, if I’m being truthful, I was angry with the parents too.

There were moments when I wanted to say: I was there.

I was awake.

I was running between patients.

I was making the decisions.

I was trying to save your child.

Apart from you, who wanted that child to live more than I did?

But what could I actually say to parents whose child was dead?

Arguing about fairness felt obscene.

So most of the anger stayed inside.

Over time I became anxious, sensitive and exhausted.

I started thinking of myself as a victim, and then I hated myself for thinking that way.

Eventually I decided that I wasn’t suited to work that involved saving lives.

So I left pediatrics.

I later came back.

Today I run a small pediatric practice.

The work is much less dramatic.

Most of the children I see are not critically ill. I treat ordinary illnesses, follow children as they grow, answer parents’ questions and try to deal with problems before they become serious.

There are no miracles.

A child gets sick.

I treat the child.

The child gets better and goes home.

I’ve learned to appreciate that.

What still bothers me is how many people who seemed better suited to pediatrics than I was never came back.

Pediatrics used to attract people who really loved the work.

I had a friend who would make rounds over and over because he wanted to see the kids again.

Another would spend days off buying little things and bringing them back to the ward.

Some of them seemed born to be pediatricians.

They were better than me in ability and, I thought, in character.

They left.

I came back.

People often assume that doctors leave difficult specialties because they want more money.

Money obviously matters. Everyone has to live.

But that explanation misses something.

Many of the doctors who leave are people who chose difficult, poorly rewarded work in the first place even though easier and more lucrative options were available to them.

They knew what the pay was.

They knew the hours were bad.

They went into it anyway.

So when those same people eventually leave, it is worth asking what changed.

Consider the kind of job we sometimes ask pediatricians to accept.

The hours are punishing, staffing may be thin, and on some nights a single pediatrician may carry responsibility for every child who arrives.

If something goes badly, the consequences can follow that doctor long after the shift is over.

For someone with a family and a life outside the hospital, a high salary does not automatically make that a good job.

At some point the risk, exhaustion and uncertainty become more important than the paycheck.

This is why I have trouble believing that simply producing more doctors will solve everything.

If people are leaving because the work itself has become difficult to survive, adding more people at the beginning does not necessarily fix what happens at the end.

The environment matters.

Health systems and policymakers naturally think differently from individual doctors.

A policy can help a thousand people and still produce one terrible outcome.

On paper, it may still be a successful policy.

For the doctor caring for that one patient, the arithmetic feels different.

The patient has a face.

A name.

Parents.

If that patient dies in a way you believe should not have happened, you may remember it for the rest of your life.

I think that difference explains some of the tension between doctors and the people who design medical systems.

One side sees populations.

The other keeps seeing individual patients.

Both perspectives are necessary.

But the people doing the work have to be listened to, especially when they keep saying that the work is becoming impossible.

They know which jobs nobody wants anymore.

They know which rules make people afraid to take responsibility.

They know what looks sensible on paper but works badly in a hospital at three in the morning.

That doesn’t mean doctors are always right.

It means their experience is information.

I still don’t think I was one of those people who was naturally destined for pediatrics.

Some of my colleagues loved children more easily than I did.

They were more patient.

Kinder.

Probably better doctors.

And yet I’m the one who returned.

When I was an intern, I thought becoming a pediatrician might make me a good adult.

I don’t think about it that way anymore.

Pediatrics made me angry sometimes.

It frightened me.

It exhausted me.

There were periods when I wanted nothing to do with it.

But it also taught me that being a good adult is probably not the same thing as saving everyone.

You can’t save everyone.

Maybe it is simpler than that.

You notice when someone needs help.

You do what you can.

And when what you can do is not enough, you try not to lose your humanity along with the patient.

I no longer expect miracles.

These days, if a sick child gets better before becoming seriously ill, that is enough.

If worried parents leave my clinic a little less worried, that is enough too.

It is a smaller ambition than the one I started with.

I think it may be a healthier one.

I became a pediatrician because I thought it might help me become a good adult.

Years later, after leaving and coming back, I’m still working on it.