In the world of television and movies, the ‘Fourth Wall’ is the invisible barrier between the audience and the action. When you look at the set you typically see three physical walls and then there is the view through the camera lens that lets the audience peer into the lives of the characters, but rarely do actor and audience ever interact (unless you are Zack Morris).
I have started thinking a lot about the Fourth Wall the past couple of weeks. Most of my time at work is spent at Methodist, but because of some of my administrative duties I spend some time at Riley. Having been around Riley for 7+ years now, I have taken care of, come across and walked past numerous children and their families. But I haven’t really thought about what any of these interactions really mean.
While I would like to think that I am a great doctor and an even better father/husband, I am not perfect. (I am just as shocked as you are!) Some of my biggest mistakes and problems have come when these two roles meet. One of the worst ones I made was the first time that Hannah had a fever. She was 5 or 6 months old and Susie was nervous about her elevated temperature, which was only about 100 degrees Fahrenheit. When she wanted to share her concerns with me and have me help her problem solve what to do next, I said “You know, that’s not a real fever.”
While I was trying to be helpful and supportive (Yay! Our daughter is not that sick! Isn’t it great?), to my wife it came across as flip and uncaring. To her, this was her one and only child and she was sick! Something horrible was going to happen because fevers are bad. Her life experience was much different than mine. My medical education and experience had and still has built up a wall between us that can’t be easily broken down. I have learned my lession since then (although I still sometimes slip and say that something isn’t a true fever or isn’t “that bad”). Luckily, I have never had any slip ups of that magnitude with a patient or a family, but many times the Fourth Wall separates doctor and patient as well.
In the early days of medicine, this wall was encouraged, even celebrated. “Don’t get attached to the patient, that would blind your decision-making and bias you”, said conventional wisdom. Over time, this wall has been chipped away at and connections to the patient and family are encouraged. The old way is seen as cold and unfeeling. The patient isn’t “boy with diabetes” or “girl with pneumonia” anymore, it’s Jimmy or Sally. Which overall is a very good thing.
I can see why (and I agree with) this transition occurred. It sets the patient and the patient’s family up for a much better experience and it fosters a better relationship between doctor and patient. That is not to say that there were no redeeming qualities of the older, separated way. I think to stay sane, especially when working with children, you have to hide behind the Wall to some degree. Otherwise you will start seeing your own son, daughter, brother, sister, niece or nephew in that bed and it will be much harder to come to work everyday.
To that end I have come across more people than usual lately who all state that they “could never work at Riley” because of all the sick children. To which I usually respond that it isn’t that bad because most of the kids are pretty healthy and recover just fine. Which is definitely part of what always helps me get through. The part that I don’t talk about very much is that I hide behind the Wall, especially when I am not the room with the patients. They are a list of patients to get through, a problem to solve, a note to write.
In the room is a different story. I almost always comment on what the child is watching on TV or cartoon characters that they have in their bed or on their clothes. I ask about school, to name the people in the room or what their favorite food is. To me the big key is to do both, you need to compartmentalize and also relate to the patient. I think that I do a pretty good job of that but I can always do better.
What has struck me lately, and what has inspired this post, is thinking about the parents. When I was a resident, I would think about how the case affect the parents some of the time, usually when I could tell that the parents were frustrated or when the child was deathly ill or when they just received a very serious diagnosis. Once I graduated from residency, most of those situations were well behind me. As a general pediatrician, I don’t make a lot of devastating diagnoses or take care of patients that are dying (thankfully!) Occasionally I would have a frustrated or scared parent and I would make sure to sit down and work with them to reassure them and related to them as best I could.
But what struck me a few weeks ago was all of the parents I would ignore outside of Riley. At any given moment there are families walking outside of the hospital. Maybe they are going to/from their car. Maybe they are grabbing a smoke. A lot of times they are out calling someone on a cellphone. Rarely, if ever, were they a family member of one of my patients. So I would invariably just keep walking by, lost in my own thoughts on the way to the next meeting or appointment on the calendar. But one day, for no particular reason, after seeing a parent calling someone and talking frantically into a cellphone to a friend or family member that I couldn’t see, I tried to put myself in that person’s shoes.
I thought about how scared they probably were and how every minute probably felt like 10 hours. About how much that person’s world had probably been turned upside down today by their child getting admitted to the hospital. They woke up today and everything was fine, but by nighttime they had a sick child in the hospital. They were probably feeling just like my wife did that first time (or most any time) one of our children has a fever. Their child was sick and everything was crashing down around them. Odds were that their child did not have a fatal disease, rare genetic disorder or newly diagnosed chronic illness. More than likely, the child was in for something straightforward that would need only a short stay in the hospital and then they would be good as new. But that would be of little solace to the family right now, because they had a sick child and they were scared to death.
It made me wonder about all the times I told families,” it’s just pneumonia” or “it’s just a urine infection”. “They’ll only have to stay in the hospital for a week”, “a PICC line is just a long IV”, “your new baby is going to have to stay in the NICU for just a little bit”. I always tried to say it in a reassuring way so that they would know that their child was going to be fine. But maybe they didn’t see it that way. Maybe they were still scared to death. Maybe it made the family think that I didn’t really care about their child because I was minimizing things. I don’t remember anyone ever mentioning anything, but maybe they were just putting on a brave front for the doctor so they didn’t look weak or stupid. Maybe they didn’t want to express their true fears because they didn’t think I would understand.
In the end, medical school and residency changes you. There is no way that something with such concentrated and prolonged learning and such intense and formative experiences can leave you unchanged. There is no way from preventing the Wall from being built up. In some ways this is good and in some ways it makes our job more difficult. There are definitely times when we need to hide behind the Wall to protect ourselves from harm, but we need to be able to get out from behind the Wall, lest we become jaded and cynical. Like most things in life, a balance needs to be struck. Luckily for me, I work with children and they are just easy to get down with and have some fun. Especially for a guy who can name every Disney Princess and fairy in Pixie Hollow and is proud of it.