“Time gives it meaning.” – Laurie, White Lotus Season 3. Amid overwhelming pressure, the hardest and best thing is sometimes to stop and wait.
“Is it only just May, and also is it truly already May?” I found myself musing, head down on the clinic desk.
What a mad time already so far, with state shakeups for funding, ever-growing paediatric waitlists, and the sense of impending doom and a collapsing world order.
Hope is intangible, distant, on days like these, a plume of smoke from sweet incense and the sound of bells. The families we look after are in a constant state of flux and strife, and I feel it too, the fear of uncertainty.
Uncertainty has always plagued me like a shadow, through early life and identity, the choice to enter medicine, to stay in medicine when I saw the scale of human suffering and didn’t know what to do with it, the harrowing process of getting into and then surviving training. So much to learn and so little time.
Perfection is the standard, despite perfection not existing in medicine. Don’t miss anything, never miss anything, you’ll end up in an M&M. Visions of your colleagues or the inpatient team having a wine together on the veranda talking about your incompetence.
Paediatrics is known for admitting “soft referrals”, whether it is bronchiolitis, poor intake from simple viral illnesses, dodgy-looking febrile infants or behavioural change in the behaviourally challenged children.
Some of these are easy enough to figure out: the bronchiolitis will either fall in a heap in the next day or so or giggle off home. Some are less easy: the infant who won’t grow despite adequate feeding, with a parent who re-presents every few weeks for minor illnesses, which turns out to be a family enmeshed in violence and trying to find safe harbour on the wards.
Were all the health practitioners, daycare educators, parents and passersby inept for not picking the one thin child in the line who needed an escape route?
Who is the most reliable person to refer to when a problem is tangled, convoluted by human manufacture and has so many faces and minds of its own that it can barely function?
Whose job is it to manage the socioeconomic disadvantages that contribute so strongly to these issues?
The truth is that time remains the tincture (apart from acute conditions like septic shock, where I suppose broad spectrum antibiotics and inotropes are the tincture) by which the child’s pain is clarified, extracted and healed.
We sit and resist the inner and outer voices chanting away at us to overmedicalise. Zebras, zebras, zebras … it sometimes becomes so tempting to just fall into the hole and drift down into the stress. I’m learning that when overwhelmed by the need to throw a textbook at an amorphous problem, it’s best to pause, wait for the issue to declare itself.
But how do you get a family to share the stillness of the pause with you for long enough to make a robust assessment? Worse still, how do you get a social media-addicted society to listen to medical knowledge anymore?
Doctors are not immune to TikTok. Between the post-covid tsunami of behaviour, developmental and mental health disorders and our shared anger and disenfranchisement, the impulse to sprint across the boardwalk to safety can be overwhelming.
I wish I had a perfect piece of secret wisdom derived from ancient learned folk with centuries of truth that could save us all from this mess. But there is no perfection in medicine.
The baby you chose to discharge from clinic comes back with weight loss when the family loses their home, or the teen you entrusted with textbook drug and alcohol advice over two whole days comes back high as a kite again.
So the cycle begins anew, we fight the kneejerk reaction to quit medicine yet again, and we carry on, hoping that something will shift. In the right direction, of course.
And despite all the misfires, false starts and seemingly pointless meetings, now and then something truly pure and beautiful happens. A transgender young person finds their footing and community and so finds their voice in a transphobic family. A parent sees their child’s strengths for the first time despite their explosive behaviour. You graduate your first extreme premature infant from the service.
All we can do in paediatrics sometimes is to sit still and provide the tincture of time. Discuss the family’s concerns, re-examine and reassure when there are no pathological features of disease. Sit, look each person in the eyes, listen intently and respond meaningfully. Maybe just the one management plan will do. Celebrate the one management plan’s completion with the family and your friends after. Keep a lid on the lorazepam jar, and wait with the family for the true problems list to emerge.
If there is a diagnosis to be made, it will reveal itself in due time, and if there isn’t, the love and support from time spent in patience is therapeutic in itself.
It’s like when you’re surrounded by your best friends, and take a moment to take stock after an epoch of friendship. You note that one is not like the others, and ask yourself how did this ridiculously unlikely friendship stand the test of time?
The potency of time itself, minutes first, then hours, then days and weekends, years of quiet camaraderie through all kinds of times did this. Long silences, tram rides, drunken dinners, holidays, fights over forgotten dishwasher-loading related incidents, new lives, old loves, first deaths all rolled into one and now you have each other’s Zelles/Cashapps for weekly dinners. Not a lot of big aha moments, but a lot of chitchat, and not a single diagnosis made.
In this brave new world, forming the deep connection needed for meaningful change is a luxury. The pressure to diagnose, refer, treat and medicate in a way that meets funding requirements, amid economic pressures on each household; balancing the unseen children on long waitlists against the expedited discharge of families in your care that might just be over the line of being able to survive.
Work faster, work cheaper! Quick reviews, coffee catch-up meetings between meetings, tell me the main problem you have today while I type on my standup workstation on wheels, while all the time the child is moving further out of focus.
The smell of burning rubber permeates life, and you never meet your one quiet friend who balances the group by telling you the coconut milk is off.
When I submit my application for despair my old friends remind me of the cyclical nature of all things. Ups, downs. Yin and yang. Balance is the goal. Today we might uptitrate efficiency and discharge, but we live in hope that it buys time for our most vulnerable.
I don’t know if despite all the years of training in children’s health that I will rise to the occasion when I see the next patient, but I know I’ll try. I don’t know if any of the work we do will make meaningful changes to our society in flux, but I know we’ll all in our various rooms continue to doggedly overbook lists, pore through assessments, argue for more funding, and feel the pinch.
I don’t know if we will ever catch up on our waitlists, but I know we will keep making time stand still for the families who need it most.
I hope we can slow down to find one another, to recognise each other’s journeys for balance instead of perfection, and lament with a chaos-addled head on our desk that it’s already May.
Despite the wild ride, I’m glad to be at the table.
Dr York Xiong Leong is a general paediatrician in Eastern Health, Melbourne, working in public inpatient and community paediatric services, and a medical educator with Monash and Deakin universities. One of the best compliments he has ever received is “Babe you barely live on this planet”.
