A pediatrician reflects after a difficult conversation [PODCAST]

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“There is silence, then the words from the family flow forth. Angry, accusatory, confused, dismissive, worried, ugly, personal. The words cut deeply, and when I pick up the next chart, I feel as though I am still bleeding.”

Alexandra Seabury is a pediatrics resident.

She shares her story and discusses her KevinMD article, “Let it go: A pediatrician reflects after a difficult conversation.”

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Transcript

Kevin Pho: Welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today on the show we have Alex Seabury. She’s a pediatrics resident. Her KevinMD article is titled “Let it go: A pediatrician reflects after a difficult conversation.” Alex, welcome to the show.

Alexandra Seabury: Thank you so much for having me. I really appreciate it.

Kevin Pho: We’ll get to your article in a little bit. First off, briefly share your story and journey to where you are today.

Alexandra Seabury: Originally, when I came out of college, I thought I wanted to be a child psychologist. So I went and got my master’s in school psychology, child psychology, and in starting to practice that a little bit, I realized I wanted to be more on the medicine side. So I went to Cooper Medical School here in Camden, New Jersey, did their three-year pediatrics program, and then matriculated right into our Cooper pediatrics residency here.

Kevin Pho: Excellent. And what are the rewards of pediatrics today? What drew you to the field?

Alexandra Seabury: There’s everything about peds that I love. I love that I get to invest in our future every single day, but I love that I get to see bits of myself from when I was a teenager, when I was younger, and just getting to relive the world through their eyes, I think, keeps us young. It keeps us fresh. And I just love how resilient they are. So every single day, I just love getting to come in and see our kiddos.

Kevin Pho: And you’re a second-year pediatrics resident?

Alexandra Seabury: Yes.

Kevin Pho: And just from those last couple of years, what are some of the challenges that you see facing pediatrics going forward?

Alexandra Seabury: COVID was a huge thing for all of our kids. I think it really highlighted a lot of the things that we were feeling prior to the pandemic: not having adequate mental health resources, and how important school is to kids, and the social aspect. And so when a lot of our kids could not attend school for extended periods of time, or no longer had access to early intervention, or had limited access to their therapist or their psychiatrist, we really saw a lot of regression in a lot of kids.

And so I think now that we’re starting to come out the other side, we’re asking ourselves what changes we are going to be able to make to reintegrate all of these kids. We’re seeing now a lot of kids that hadn’t been seen in two, two and a half years, whether it be for a well visit or a very serious psychiatric concern. And so we’re really trying to bring them back into the fold and ask ourselves how we can do better.

Kevin Pho: All right. Now let’s turn to your KevinMD article. It’s titled “Let it go: A pediatrician reflects after a difficult conversation.” Now, for those who didn’t get a chance to read your story, just walk my audience through it. Share the story and why you decided to write it.

Alexandra Seabury: Sure, absolutely. It was about halfway through intern year, and in medicine, the difficult encounter is really just part of the deal. But I think this one was the one that impacted me the most because of the pain that it caused me afterward. It was a general failure-to-thrive admission that we saw in the clinic, and it was just one of those times where I felt like I had to sit down and write about it and say, “What did I do here? What happened here, really? And how could I improve in the future?”

But I really wanted to write this because I think it’s important for clinicians to put it out there that we’re people too. A lot of times, I think we get a rap that we just get to leave this stuff at work, and we really truly do not. We take this home. We see it in our own families. And I also wrote it for people who aren’t providers, to understand that as well: that the difficult encounter goes both ways, that it’s very stressful for them and very stressful for us. And so we really need to be able to come together to figure out how we can all do it better. Because in pediatrics, the real focus is the child, and often the patient can’t speak for themselves. And so it’s really among the adults to have these difficult conversations, and how can we align everything so that we’re really doing what’s best for the patient?

Kevin Pho: So take us into that difficult day, for those who didn’t get a chance to read your story.

Alexandra Seabury: We had to advise her that the child, developmentally and weight-wise, was going to have to be admitted to the hospital. And pediatrics is a little bit different than adult medicine, because with certain admissions, it’s no longer up to the parental judgment at that point. The provider can make the call that the child has to be admitted for their own safety.

Kevin Pho: So how did this child present to you that day?

Alexandra Seabury: That day, the child had not been seen since they were a newborn. I believe they were now approaching four or six months old, and they had completely fallen off the growth chart. So they were at failure-to-thrive levels and not developmentally appropriate, and all the physical signs were there. I even wrote in my piece that it was one of those encounters where, as we always learned in medical school, “sick, not sick,” this was a sick child, very ill.

And it was one of those where the parental concerns did not align with our concerns. This was a first child, and the parent really did not feel that there was a problem. And in going through the history and things, there were a lot of medical concerns for this child. And so we had decided that we had to inform the parent this was going to be a mandatory admission, and the parents took that very personally, and the response was very angry, very accusatory.

Kevin Pho: Now, were both parents in the room or just one?

Alexandra Seabury: Originally, it was just one, but because we were talking about admission, the other parent did come, and they also had an additional family member on the phone. So it was a very volatile environment, and they were very angry at me. I was able to pull my attending in, and they were very angry at that person as well. But the words just got so personal. I think that was what hurt the most, that I really felt like I was trying to come from a place of helping this child, that it was not meant to be punitive or anything like that. But when the parents did not share similar concerns, it was a very difficult conversation.

And I think the hardest part for me: I have a 15-month-old son now. He was a fairly similar age at the time, and one of the caregivers asked me if I was a mother, and I said that I was. And they said that I couldn’t possibly be a mother if this was how I felt about this child. And that stung quite a bit. So it was that kind of back and forth, trying to keep it as civil as possible but just not seeing eye to eye, and that was a difficult day, I think, for everybody.

Kevin Pho: What were some of the things that those parents said to you, or some reasons that they gave you, that they didn’t want their child to be admitted?

Alexandra Seabury: Sure. So in their minds, the child was eating appropriately, seemed appropriate, and was sleeping appropriately. They really felt that the stature of the parents was being reflected in the child. And even though we were pulling up the growth chart and showing it, to a nonmedical person that really doesn’t mean an awful lot. “Yeah, he’s a little on the thinner side, but so was I when I was a baby,” kind of stuff like that. So I think they really felt that their child was normal, and they felt that we were trying to take the child away. That was really their angle.

Kevin Pho: And then you brought the attending into the room. What happened next?

Alexandra Seabury: So the attending mirrored a lot of what I had said and reiterated a lot of it, but it just really wasn’t going anywhere. It was a stalemate, because we were trying at first to get the caregivers to bring the child over voluntarily. That would obviously be in the best interest of everyone. But once there was pure refusal, that they did not feel that the child needed to be admitted and would not present the child, then we had to go on to the next steps, which is getting child protective services and things involved to make sure that the child got the care that they needed.

Kevin Pho: All right. Tell us what happened next in the story. So the child was admitted, and then what happened after that?

Alexandra Seabury: The child had an extended hospital stay. It was found that it was most likely nutritional; that was the reason that the child was not growing. And once the child was adequately supplemented, they grew fantastically. And last I checked in with my attending, just to follow up with the child, the child was doing excellent, has come back on the growth curve, and is doing very well. So the admission did end up being the right thing for this child.

But I think that was what really struck me: even knowing that, how much this encounter really stuck with me for the next several days. And now, it’s been months, and it’s interesting, going back and reading the piece today before chatting with you, how differently I’m able to feel reading it now than I did then. I think residency is just a time of such constant growth that it was fascinating to me to revisit those moments and how I felt very acutely, and how I feel now, months and months later.

Kevin Pho: Yeah. So talk more about those feelings. Can you contrast how you feel now versus back then?

Alexandra Seabury: Sure. So at the time, this was so fresh, and as clinic progresses, once that child left to go for the admission, I just had to walk into another room in the fast-paced environment. I believe it was in the morning, kind of lunchtime, so I still had a full day of patients, and I was trying not to let that cloud anything, because these next patients don’t know what happened. They’re just expecting great care and that their child is now 100 percent of my focus. And so it was really an exercise in emotional regulation to get through that day.

And then leaving, I cried in the car on the way home. I just felt so awful in a way that I didn’t really understand, because I felt I had done the right thing, but it still felt so wrong, and it still hurt so much. And so I was battling with what parts of this I want to keep with me and what parts of this I need to put behind me in order to move on. And so that’s really when I sat down to write the piece, to say it has this residue effect, and parts of this I want to keep and parts of this I want to throw away, and right now it doesn’t feel like I have a choice in terms of what’s staying and what’s leaving.

And now I can look back, and there have been many difficult conversations since then, but I think I have now been able to say, OK, look at it more from a clinical perspective than an emotional perspective, and say, “When we have a failure-to-thrive admission, which is not particularly uncommon, how do I want to approach that differently? How can we come at this in a way that’s better for the patient? How can I phrase it in a way that’s understood better by the parents? How can we all be one team instead of more of an adversarial relationship?” And I think it’s helped in the end. It really has. This encounter, as unpleasant as it was, I think has really informed my care since then, because I’ve been able to take a lot of the emotionality out of it and really look at it for the educational experience that it turned out to be.

Kevin Pho: Now, if you had to relive this encounter all over again, what would you do differently, or what would you say differently?

Alexandra Seabury: I think I would try to come at it, like I said, more from a team perspective. And it was really hard in that case, because the parents didn’t have any concerns. But I think I would change the way I was trying to educate the parents about my concerns, because I think that we jumped right to admission. Our concerns were so great that I think I skipped some steps educationally, and really breaking it down and saying, “This is why I’m concerned, and let me show you what I would expect here,” or this or that, or what he should be doing. And I’m not sure if it would have changed the outcome, but I think that was something that I really took with me into further encounters, to say we need to start with the education, because I can’t expect them to just understand why I’m concerned. So I think that was the big thing I would change.

Kevin Pho: Now, have you or your attending had any future encounters with the parents, and do they realize that you guys did the right thing?

Alexandra Seabury: The parents actually no longer have custody of the child, and so the child is now living with a family member and has done fantastically, and follows for their well visits with the attending that came in the room with me that day. So we never really got the chance to repair that relationship. I think that would have been helpful, because it just got left the way it was left, and we never really got to circle back, even for their feedback on how we could have done better. So in that way, we haven’t had a great conclusion, but the child is doing so well.

Kevin Pho: We’re talking to Alex Seabury. She’s a pediatrics resident. Her KevinMD article is titled “Let it go: A pediatrician reflects after a difficult conversation.” Alex, what kind of wisdom or advice can you share with, say, new interns or medical students who haven’t had a lot of opportunities to have these difficult conversations? What kind of advice can you give them?

Alexandra Seabury: Sure. I think what I always try to do, especially in pediatrics, is approach every interaction with love first. Because sometimes I think we need to leave the clinical stuff at the door and always enter in to try to love every family and love every patient. And I think that if you come at it from that perspective, the knowledge and everything else will follow. I think you will always provide excellent care if you just approach it just like you would want anyone to give care to your child or your family member.

And I think patients and families can feel that. So when you’re there to understand them, and you’re really there to help them, not necessarily to doctor to them, I think that they tend to appreciate that. And that can help you to not even get to the point of a difficult encounter in the first place, because I feel like so many difficult encounters are built out of people feeling frustrated, not feeling listened to, and not feeling respected. So when you enter any encounter in that way, I feel like you can help to avoid those difficult encounters altogether.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Alexandra Seabury: I would say, at the risk of repeating myself, lead with love for your patients. Lean into what you’re doing. Get involved in what you’re doing. That’s a tip for success for me in residency: just to say yes as much as you can to every opportunity, because it flies by, and to remember that patients are human, doctors are human, everyone’s human, and everybody wants to feel good after an encounter. So just keep that in mind, when you go to the doctor or when you’re being the doctor or the clinician, that everybody here is human and deserves some grace.

Kevin Pho: Alex, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Alexandra Seabury: Absolutely. Thanks for having me.

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