Effective and efficient communication with adolescent patients is an essential skill that pediatric physicians must develop in order to become truly successful in the field. Specifically for young male athletes, injury concealment has implications for both short- and long-term health outcomes. This is one of the reasons why being able to converse with our patients is paramount to providing the best possible care.
The potential for young male athletes to conceal injury symptoms is high for a number of reasons such as perceived masculinity, competitiveness and others. Therefore, it is imperative for health practitioners to understand the core psychosocial constructs predictive of injury concealment among young male athletes in an attempt to promote wellness and longevity.
A team of researchers from the University of Central Florida’s Behavioral Health Research Group and Men’s Health Initiative, Inc., conducted a cross-sectional study aiming to identify variables associated with injury concealment among adolescent male athletes. Results indicated that those athletes with significantly higher masculinity scores and “fear of losing a performance role” scores were more likely to conceal injuries. Further, individuals with low potential to conceal an injury were significantly more likely to participate in non-team sports.
The study implicates peer pressure, perceived masculinity, participation in team sports and other external influences as factors associated with injury concealment among young male athletes. This study is important as it initiates a larger conversation on how we can better understand injury concealing behaviors among young athletes. We suggest that an improvement in patient-provider communication serve as the first step. Without a thorough understanding of why a young male athlete may be withholding injury symptoms, which foundationally stems from an effective and efficient conversation with a primary healthcare provider, proper diagnosis and treatment methods may be rendered ineffective. By a physician simply being aware that these psychosocial factors may be present among young athletes, they can better adjust their approach to obtaining information or even speak and educate the athlete on these subconscious thoughts that may be putting their future state of health in jeopardy. Current research at the Edward Via College of Osteopathic Medicine – Carolinas is aimed at designing an intervention to improve the reporting of sports injuries, specifically concussions, among adolescent athletes by targeting psychosocial aspects in an attempt to improve athlete longevity.
My first patient funeral was for a two-month-old baby boy. He had a severe congenital heart defect that would be fatal if it went untreated, and the surgery required to fix it was also very risky. His parents opted for the surgery, and after a long attempt at recovery post-operatively, he passed peacefully in his mother’s and father’s arms. The funeral was beautiful and full of life. The focus wasn’t on death or grief, but instead on how much joy he had brought to everyone around him. The pastor said something that I will never forget: “Most 80-year-olds I’ve seen don’t have half this many people at their funerals. It seems this little one touched more lives than most of us can ever hope to… and maybe that was his purpose.” It was a deeply moving service made all the more meaningful by the many home videos that the family shared. I won’t soon forget this little boy or the privilege of getting to meet him during his short life.
I am a fourth-year medical student at ATSU-KCOM & I recently matched into my top-choice Pediatric residency program. My Pediatric Intensive Care Unit rotation (PICU) showed me more heartache in one month than all of my other rotations combined.
Another very memorable patient that I helped to take care of in the PICU was a young girl who had been the victim of a near-drowning incident. She wasn’t even a toddler yet. She was brought to our unit intubated and on a ventilator. Her MRI didn’t show much hope. The background story is too horrible to divulge in detail, but it involved a terrible accident that threatened to ruin this family. After four days in the hospital and showing no signs of clinical improvement, her family made the difficult decision to withdraw care. The attending taught me how to do a brain death examination - something very important but heartbreaking to learn; I never thought I would be learning it on a baby. The exam involves looking into the patient’s eyes. I will never, ever forget how beautiful this baby’s eyes were. Perhaps the most difficult moment for me was pulling her breathing tube out and handing her fragile tiny body to her parents to hold one last time. We were left standing outside the room, watching the heart monitor to assess her precise moment of death and listening to her parents say their goodbyes to their baby. It was by far one of the most painful days I’ve ever had. A small comfort was that the attending and nurses were all crying with me. It’s nice to know that we never “get used to it” and situations like these never become easy.
I asked my attending how he ever gets through cases like these. He told me, “There’s a good way and bad way to do these tough exams. The way to make it through is to make this terrible situation a little easier on the family by doing it the good way. That way, you helped at least a little bit. You may not know it, but they’ll always be grateful for that.” What great advice.
The month wasn’t all heartache and death, though! There was a small chapel on the PICU floor and I made it a habit to visit it daily, a sort of personal “debriefing” session. I realized on this rotation that, yes, the losses are the MOST devastating of any rotation I’ve been on, but the wins, the good stories, and the kids-who-get-to-go-home stories are the MOST rewarding I’ve ever seen.
I told my attendings that I was pursuing pediatrics as a specialty, so they gave me as much exposure to different fields as possible. I saw a bilateral Morgagni diaphragmatic hernia repair & a total repair of Tetralogy of Fallot. The surgical fields on these babies were the size of the top of a soup can! The surgeons were so delicate in their work. It was incredible to see what medical technology and the skilled hands of a surgeon can do. It was even more amazing to see the babies wake up and both go home less than one week later!
PICU is fast-paced, hands-on, and incredibly interesting. I saw a one-year-old code on the floor and saw the physicians bring him back to life in front of me and go home the next day. I saw an 8-month old code on the operating table and the anesthesiologist temporarily stopped her heart with medications to allow her to recover. I saw medical diagnoses on this rotation that I’ll probably never see again in my career. Medically and intellectually, it was the most interesting rotation I have ever been on.
Now that I have matched to my AOA pediatric residency, I could easily see myself doing Pediatric ICU. I love that the Pediatric Intensivist doctors have to think on their feet, get to do small procedures, and get to put their energy into handling a few high-intensity cases at a time.
All in all, this rotation stretched me beyond my capacity in more ways than one. I was challenged emotionally, intellectually, spiritually, and physically. I feel honored that I got to see so many interesting patients and blessed that I got to know their families and be a part of their intense ICU stays. My attendings were awesome and taught me a great deal about what it means both educationally and career-wise to be a Pediatric Intensivist. I am so excited to start my Pediatric residency program in July and care for kiddos myself! In the words of a character from the show “Grey’s Anatomy”: “These are the tiny humans. These are children. They believe in magic. They play pretend. There is fairy dust in their IV bags. They hope, and they cross their fingers, and they make wishes, and that makes them more resilient than adults. They recover faster, survive worse. They believe.”
Rhythm Gandhi, OMS-III KCU
The thought of children being removed from their home is sad, but the reality of child neglect by parents is even worse. It wasn’t until my inpatient pediatric rotation that I realized the importance of a physician’s medical judgment for Department of Children and Families Services’ (DCFS) cases.
A 10-year-old female presented to the pediatric clinic with an eczema exacerbation. My attending had been involved in this patient’s case for years. The patient was diagnosed with asthma, allergies and eczema, all of which were severe. On physical exam, the patient had dry, scaly patches of skin with many excoriations all over her body. This little girl came from a lower income family with eight children. Apparently, she had many exacerbations, which were due to noncompliance from her parents. They failed to provide their daughter with the medication and care she needed. Soon after, a DCFS report was filed and the patient was admitted to the hospital in order to get away from the allergens in her home that were triggering her atopic disease.
As we admitted the patient, the parents approached the attending and me. They were furious that their daughter was being taken away from her home. The attending calmly responded, “DCFS only consults me for my medical opinion. I tell them the patient’s conditions and I give my medical opinion on what is best for the patient. I do not decide who gets pulled away from their family, I simply state what I feel is best for the patient medically.”
It was that moment that I realized, even though it is awful for children to be pulled away from their home, sometimes it is the best thing for their health and future. This is something I want to remember when I have to make difficult decisions for my patients in the future.
There are many issues facing healthcare today. There are some challenges that are universal across all medical specialty fields, such as the mounting debt of new graduates, the increase in patient flow and the increased expectations placed on physicians. An advisor I had in my undergraduate studies once told me after I expressed my interest in pediatrics, “There will always be parents who, when their child is sick, will take them to the doctor even at the expense of their own health.” Often times the cynicism of today’s world distracts us from this truth. However, there is an increasing threat to that parent’s ability to have their child seen in a timely fashion by the provider they need most. While the shortage that plagues primary care is not as pronounced in pediatrics as in other areas, when the child requires a specialist, it is a whole different story. Deeper to this issue is the atmosphere in which those deciding their future profession are influenced.
We begin our journey in medical school. As students we are required to start making decisions that poise our career path in medicine during our 3rd year of school. Many times at this juncture we have not had all of our core rotations, and yet with less than 6 months of clinical exposure we are expected to decide on the specialty that we will practice for the rest of our careers. If we cannot get those coveted audition and sub-internship rotations locked down early we often miss out, meaning we can’t acquire the letters of recommendation we need or interviews at the programs we want to attend.
|CURRENT SALARY NUMBERS PER SPECIALTY|
|Pediatric Endocrinology||$ 157,394.00|
|Medical Genetics||$ 158,597.00|
|Pediatric Infectious Disease||$ 163,658.00|
|Pediatric Nephrology||$ 183,730.00|
|Pediatric Gastroenterology||$ 196,708.00|
|Pediatric Rheumatology||$ 200,027.00|
|Infectious Disease||$ 205,570.00|
|Pediatric Pulmonology||$ 218,106.00|
|Internal Medicine||$ 223,175.00|
|Family Medicine||$ 227,541.00|
|Occupational Medicine||$ 229,450.00|
|Preventive Medicine||$ 270,888.00|
|Pediatric Emergency Medicine||$ 273,683.00|
|Physical Medicine/Rehab||$ 278,282.00|
|Nuclear Medicine||$ 290,639.00|
|Allergy and Immunology||$ 296,705.00|
|Pediatric Cardiology||$ 303,917.00|
|Obstetrics & Gynecology||$ 315,295.00|
|Emergency Medicine||$ 320,419.00|
|Colon and Rectal Surgery||$ 343,277.00|
|General Surgery||$ 360,933.00|
|Otolaryngology (ENT)||$ 369,790.00|
|Plastic Surgery||$ 407,709.00|
|Radiation Oncology||$ 418,228.00|
|Vascular Surgery||$ 428,944.00|
|Thoracic Surgery||$ 471,137.00|
|Orthopaedic Surgery||$ 535,668.00|
|(Salary information: http://www.theatlantic.com/health/
Indecisiveness is not an option. The system is designed to take someone who spent two years focusing on books and boards, then gives them a few moments in a clinical world to decide what path to follow for the next 40+ years. As we begin to make this choice we look to those around us for support and direction; the attending we respect, the colleagues that have seen how we perform, the friends that know us best. We begin to form an idea; when that idea is pediatrics we casually ask, “Do you think I would like peds?” Now the flogging begins.
I recently watched a classmate go through this process, the immediate response from colleges and attendings alike was so profoundly negative that my classmate began to doubt himself. It took three months for my classmate to encounter a single non-pediatrician physician that supported their decision. The culture of medicine is often so preoccupied with the paycheck that the first response is about how little you will make after all of the schooling. Idealistically the response is, “it’s not about the money, it is about the people.” At some point you have to ask if so many feel this strongly against pediatrics, are they really that wrong in their thinking.
The average medical student last year graduated with over $200,000 in debt and the number is climbing. The salary for the next 3 years of residency is just over $50,000 per year. Meanwhile that debt continues to compound interest at an ever-alarming rate. Depending on the repayment method and willingness to live on Ramen the average $200,000 in debt ends up easily totaling $340,000-$500,000 in repayment. This is without loan forgiveness, but keep in mind we are looking at this as students, not knowing where we are going to be working in 5-10 years or what options will be available. The fear of handling the debt is all we see at this stage of the game: we have no income, and our monthly statements are increasingly in the red.
We begin to worry and look at what the future holds. A quick online search about potential income begins to put weight behind the naysayers of our potential pediatric career. In a 2015 study of the average income of 48 specialties, 11 were pediatric (general and subspecialties). Eight of the lowest paying 10 were pediatric specialties, General Pediatrics weighing in at $206,961/yr with seven of those 10 subspecialties paying less than General Pediatrics (See Table). As a reward for your extra three to five years in fellow you take a pay cut. Adding insult to injury each adult medicine counterpart annual income was substantially higher in every subspecialty ($40,000 - $183,000). If we truly wanted to pursue a subspecialty we realize during our time in fellowship we will unlikely be able to cut into that ever-present debt. We begin to ask ourselves, “Can I afford to become a pediatrician?”
With the barrage of obstacles facing anyone brave enough to speak up and say, “Pediatrics is what I want to do,” it is no wonder that there is a shortage of pediatric subspecialists. General Pediatrics, on the other hand, has still been able to sway residents its way, preventing the shortage seen among pediatric subspecialties. Why would you add years to the decades you have already spent in school if you are only going to move your career backward by pursuing a subspecialty?
Looking to the future, the need for those subspecialists is only growing and the demand for general pediatric care continues to increase. The addition of more than 32 million insured Americans, under recent healthcare reform has brought with it many children. There was a three-fold increase in patients who visited a pediatric subspecialist from 1980-2000 and it continues to increase as we see the diabetes and obesity epidemic take hold in the pediatric population. The demand for physicians is far outpacing the current supply trends. There is an average wait time between five weeks and three months, depending on the subspecialty and location. This has directly lead to 52.2% of Children’s Hospitals reporting a reduction in the level of services provided due to a lack of staffing. It is not uncommon for hospitals around the country to hold vacancies for more than a year hoping for a subspecialist. The next time you meet a child that needs a subspecialist, try and tell them to flip a coin: heads you get the care you need; tails “better luck next time.” That is the state of our current system, and until the attitude of the healthcare community begins to change, it is likely a problem not too soon remedied.
The first three years of medical school are our most impressionable: this is the time during which we must choose our futures. This is a time when students need the support and guidance required to make such a decision. While I cannot expect to change the financial state of the system overnight, one thing each of us can influence very easily is how we interact with our colleagues and colleagues-to-be. I can imagine most of you truly believe that children are our future; those of us in school are still children ourselves when it comes to the practice of medicine.
Reach out to a student, become a mentor, share your story, and let us know how you overcame the adversity. You have to show us not only that it can be done, but that we can make it as well and that all of the sacrifice is worth it. When everyone is telling us that going into pediatrics is a huge mistake, we need someone in our corner. Then once we are there in residency, don’t allow us to lose sight of that goal. If someone shows an interest in fulfilling a need in an underserved subspecialty, push us. I say this not only for my classmates, but for my future children. I want to know that they won’t have to flip a coin and hope for the best. With your help, how can I not afford to become a pediatrician?
By Stephanie Prudencio, OMS-I, Liberty University College of Osteopathic Medicine
Stephanie Prudencio, OMS-I
“Why don’t we read it out loud?” my classmate suggested.
She had a good point. The articles we were assigned to read on neuromuscular disorders were dense. At a quick glance, the names of the antibodies, receptors and signaling pathways could arguably pass as a foreign language. Talking through the articles together could help us solidify the concepts. So I began to read.
I blazed through the background information, read the paragraph discussing etiology, and then reached the epidemiological section. “Should I just skip this part?” I asked, figuring there were more testable points to discuss than demographics and percentages. “No,” she replied, “I like reading about epidemiology. It reminds me of the people we will take care of someday.”
Stunned by her answer, I paused for a moment in thought. “I can’t believe I never looked at it that way.” As we finished up our studying, I learned a lesson far greater than the pathophysiology of myasthenia gravis. I was reminded that someday I will be treating people. Having knowledge of whether a disease primarily affects males or females, kids or elderly, or Hispanics or African Americans, is not only helpful to answering a question on an examination. As a physician, I will not simply be providing healthcare for my patients. I will care for mothers, sons, students, and employees. They will bring life to these statistics.
As a first year medical student, this can be a difficult idea to stay grounded in. I encounter more PowerPoints than patients. My mind is constantly consumed by facts accumulated for the next exam or practical. But I was once again reminded of the “care” in healthcare when I got the opportunity to attend a seminar presentation given by D. Holmes Morton, MD.
Dr. Morton is a pediatrician practicing at The Clinic for Special Children in Lancaster County, Pennsylvania. In addition to running a successful practice in an area well known for its small founder population and rare genetic diseases, he has traveled the world giving presentations to leading professionals in his field. A Harvard graduate and expert in biochemistry, Dr. Morton can easily recite the details of any metabolic pathway in the human body. As he began his talk, I sat in the lecture hall thinking to myself, “I can barely remember the steps in the Krebs cycle.” It was easy to feel as if I could not relate to his accomplishments. However, the remainder of his presentation revealed something that I will take with me as I go through my medical studies.
It was clear that the Amish and Mennonite children that Dr. Morton spent many years treating in Lancaster County held a special place in his heart. In addition to discussing the genetics of maple syrup urine disease and other common disorders in this population, he told many stories about the children he treated. Though he had undoubtedly given this presentation numerous times, he recounted these stories much like a musician who never tires performing the same song over and over again, or a child eagerly listening to his favorite bedtime story. These children were more than just an interesting demographic reserved within the lines of the epidemiology section in a genetics journal. They were family.
The following quote from Dr. Morton, which can be found on the clinic’s website, summarizes what I envision “care” in healthcare to be: “Special children are not just interesting medical problems, subjects of grants and research. Nor should they be called burdens to their families and communities. They are children who need our help, and if we allow them to, they will teach us compassion. They are children who need our help, and if we allow them to, they will teach us love. If we come to know these children as we should, they will make us better scientists, better physicians and thoughtful people.”
As we progress through medical school and beyond, may we recall what the medical profession is all about. Together with our knowledge of science, let us strive to provide not only healthcare, but care, for our future patients. While we may not have the means to practice medicine quite yet, each day presents an opportunity to practice the art of caring. Echoing the words of Dr. Morton, let us expand our studies to those that teach us compassion and love.
For more information about The Clinic for Special Children and the work of Dr. Morton, visit https://clinicforspecialchildren.org/
Photo credit: Patient Care Technician