510 CARE OF THE CHILD WITH CANCER ing a colleague about Jim that tile obvious
appeared to me. I had worked long and
hard and well at helping Dr. Bill, and,
through him, the ward and clinic staffs
managed Jim and prepared themselves for
his death. I had neglected only one
charac-ter in the drama-myself. What I had not
realized was tilat I was using my work with
the others to avoid my own feelings about
Jim. Indeed, I realized in retrospect that I
had tried unconsciously to place myself
quite outside all of the human transactions,
in the role of observer and supervisor. It
followed that I had failed to work with my
own guilt and anger responses, the repres-sion of which led to my feelings of depres-sion.
METHODS OF APPROACHING CONFLICT
How, then, are we to resolve this core
conflict which revolves about the
simulta-neous impulses to move towards and away
from the child with cancer and his family.
One might well ask, “Can we ever really
accept death, especially in children, in the
deepest sense, and thus eliminate the im-pulse to withdraw from it?” My answer, for
the overwhelming majority of health care
workers, is “No.” Therefore, we can’t
re-solve the conflict by eliminating one of its elements. As with the disease itself, the so-lution of the core conflict lends itself to no
simple formula. We can only point out the
right road and some ways to avoid the
major potholes in it.
Our resolution must come from
con-sciously forcing ourselves to remain moving toward tile patient and his family; while
si-multaneously recognizing, expressing, and,
finally, understanding and thus coping with
the many reactions which would trigger off
our movement in the opposite direction.
This means literally and repeatedly check-ing oneself out in regard to such feelings as
fear, anger, guilt, sadness,
overprotective-ness, and overindulgence. Isn’t this
some-thing that only the clinical psychologist or psychiatrist, with his special training and
technique can do? My answer-an emphatic
“No.” The specialist in psychological
medi-cine has his consultant’s role to play in
helping us to see unconscious and,
there-fore, hidden reactions. But I feel that it is the responsibility of the pediatrician, if he is to practice truly comprehensive care with
children and their families, to assume the
leading role in bringing himself and all
other health care workers to examine, un
derstand, and effectively use their own
emotional reactions as they affect the form
and content of the care that is being
pro-vided the patient and his family.
It’s not enough, for example, to under-stand that it’s all right to be angry at a pa-tient but not to act angry at a patient, and
to understand why a health care worker
may become angry at a patient in the first
place. We don’t have each feeling once, or
even once with each patient. The feelings
occur over and over and over again, and
our seeking out and positive management
of our reactions must be as relentless and
untiring as our seeking out and positive
management of the signs and symptoms of
the disease itself. In short, our examination
of our own reactions must become as
auto-matic and exhaustive and unending as our
search for tumor cells and new drugs.
We have poured an endless stream of
time, money, and energy into the perfection
of our instruments, procedures, and drugs
in the battle against cancer. It seems to me that we owe it to ourselves and our patients and their families to do as much for the
un-derstanding and perfection of what is in
many ways the most critical “instrument” of
all in the provision of comprehensive care
to the child with cancer-our own emotions.
DISCUSSION
DR.
KENNETH
WILLIAMS: I think theproblem of staff avoidance which was
al-luded to is one of the major problems in
our hospital. For example, on routine ward
rounds, our leukemia patients are
physi-SUPPLEMENT 511
cian saying, “Well, it’s a hematology
pa-tient.” Our children and our parents tell us this directly and indirectly in many ways.
l)n. BERGMAN: I have just completed a
rotation as ward attending physician and
confess to doing just what you say.
Obvi-ously the parents and children are very
aware of the regular ward routine and were
conscious of being skipped. After becoming cognizant of this situation, I made special efforts to include all patients on rounds.
Du. HARTMANN: There are some house
staff whom we don’t know how to
ap-proach. We’re the plague; they won’t even
talk to us when they are assigned to a floor
where there are a number of children with
malignancies. We must learn some manner
in which we can help them approach the
dying child with an assured attitude. We
ourselves certainly don’t always have this.
We feel guilty, we avoid the parents, we
even tend to avoid the child terminally.
There must be some way you can help us,
perhaps by going back to the medical
stu-dent or explaining to all of us who go into pediatrics that, even though we think we’re going to cure everybody, we really don’t.
DR. ROTHENBEEG: I think part of the
an-swer is when you mentioned medical
stu-dents, because I certainly think this is
where it should begin. The teaching of
comprehensive care, by which I mean the
systematic inclusion of psychosocial
dy-namics and personality development in the
practice of medicine, should begin in
medi-cal school. Furthermore, I think that the
care of the dying patient as a separate issue from the care of the chronically ill patient who is not dying, needs to be dealt with as
a separate subject, but not exclusively by
one department. Dying children pack,
gen-erally speaking, more emotional wallop
than anybody else who dies for many
obvi-otis reasons.
As far as house officers are concerned, we have tried to anticipate what an individual
may do and begin to verbalize with him
right from the outset when he’s assigned to
the case, and not in any kind of
“half-baked” psychotherapeutic fashion. When I
say we, by the way, I mean the senior pedi-atric staff, not just child psychiatrists.
Whether it’s during the working rounds or
over a cup of coffee or wherever it
ap-propriately fits into the working day, we
begin talking about some of the
considera-tions that are inevitably going to come up
with Johnny B., who has been assigned to
this particular physician. It is obvious that
there are certain people who, for very
deeply built-in character structural reasons,
are going to have a dreadful time with any
dying patient regardless of what we do. We
have to be cautious when we face tile
ne-cessity of giving that kind of a house officer
such experience before he gets out into
practice.
DR. HARTMANN: Is this not perhaps a
de-ficiency in our medical school teaching of
pediatrics?
DR. ROTHENBERG: What do you mean? Dn. HABTMANN: The failure to attempt
to have the medical student and the young
pediatrician accept death as a fact of life.
We run away from it.
DR. ROTHENBERG: I’m not so sure it’s a
failure in our medical school teaching or
even in our early house officer teaching. In
a large way it’s the nature of the beast.
When a young “physician” isn’t even yet a
physician, he is being reinforced like a rat
in a maze to the following stimulus and
re-sponse: the stimulus is a question, “what is
this?” or “how do you explain that?” or
“what would you do about that?” and if he
fails to come up with a response, he flunks.
So it behooves him never to say “I don’t
know,” or never to intentionally face the
fact that he can’t do anything or can’t give
an answer to something. So at the point in
his career when a young house officer
hard-ly feels that he’s begun to equip himself
with any kind of tools of his trade, even for tllOse patients who aren’t dying, it’s awfully tough for him to face the kind of situation
where he doesn’t have authority and magic
to offer the patient.
DR. FRIEDMAN: Speaking as a
tra-512 CARE OF THE CHILD WITH CANCER
ditionally, departments of pediatrics have
been unwilling to accept this as a
commit-ment. I wonder how many departments
really are willing to hire pediatricians who
wish to devote their full efforts to the
psychological and social aspects of
pediat-rics. So often the department turns to the
child psychiatrist to come in, consult,
and then go away. He often is not an
inte-gral part of the pediatric department.
I’m hoping that more pediatricians will
view it as “legitimate” to be interested in
what might be termed “psychological or
be-havioral pediatrics,” from the service and
teaching points of view, and also with an
interest in research. Perhaps I should
un-derline research. So many of us have strong
feelings without supporting data. I would
certainly include my own thoughts in this
matter. Perhaps it should be tile depart-ments of pediatrics who would do research
investigation in this area and not wait for the cllild psyciliatrists necessarily to help
us, though indeed I would hope that they
would.
Dii. MCCLELLAND: I would share Dr. Friedman’s feelings of inadequacy
concern-ing dying children, but I’m not sure that the problem a pediatric house officer faces with dying children is greatly different than with
children who are retarded. The finality is
more abrupt, but it’s the same kind of
cop-ing problem of handling an ongoing,
unto-ward long-term, or short-term relationship. At Western Reserve we’ve seen the very
interesting, spontaneous development of
patterns of house officer involvement.
We’ve also been concerned with how house
officers will acquire a vertical 2- or 3-year
follow-up with patients to have some idea
of continuity of care. We’ve been strongly
committed to the idea that a house officer
follows several patients during the entire time that he’s in the program.
DR. WuLIA1 SHERMAN: I would like to
make one brief comment. Dr. Rothenberg
said in passing that we psychiatrists need to
involve ourselves at the level of work
rounds. In trying to teach liaison to
pediat-ric house staff at the University Hospital I
have found that this simple maneuver is
more effective than any other: if a
psy-chiatrist will unbend himself and appear at
7:30 in the morning once a week or so and
just walk around the ward for an hour,
throwing back and forth the issues coming
up with each child in the ward, more
mean-ingful teaching transactions take place in
that hour than in 10 hours of formal confer-ence.
Panel
Discussion
EFFECTIVELY USING THE TEAM
DR. LOREN MACKINNEY: The pluralistic
approach that Dr. Green has described
im-poses severe demands on the time,
emo-tions, and skills of the physician who is not part of a well organized single-purpose
can-cer team. Incidentally, such teams exist in
only a few medical centers at the present time. How can the consulting pediatrician in a medical center cope with the problems inilerent with caring for such a patient and
his family? What aspects of the many
prob-lems can he delegate to others? After this,
which the physician must do ilimself, he can begin to ask others to help him. As the parents come out of their initial shock and
daze and begin to take stock, it is very
helpful to have a sympathetic,
non-authori-tarian figure make a relationship with the
family and the physician. This person can
be a social worker in the hospital, the
fam-ily’s minister, a hospital chaplain, or
a friend. The physician may have to
active-ly look for such a person to serve as a
buffer and an informant. From this time on
it is important for the physician to try to
maintain good lines of communication
be-tween himself, the patient, and the
par-ents. The social worker can be of great help in reviewing with the parents what the
phy-sician has said and reinterpreting it for
