University of Toronto
Class of 2016
On the first day of my Social Paediatrics elective, I accompanied a nurse on a visit to a family shelter. I entered the single room and noticed a healthy newborn girl, sleeping peacefully in an old crib. The room consisted of a bed, a table, two chairs, a fridge, and a microwave. There was no stove, no kitchen sink. Clothes, toiletries, dishes and bottles were strewn everywhere. The floor was dirty and there was graffiti on the wall. One of the parents was present, but the other was out looking for work. It was my first time in a shelter, and I was stunned that a family with a newborn was living in such conditions.
As my elective continued, I encountered children facing a variety of challenges such as failure to thrive, mental health issues, school difficulties, and maltreatment or neglect. I kept thinking about this baby girl and about what her life might look like as an infant, a toddler, a schoolgirl, an adolescent. I am no pessimist, but we do know that adverse childhood experiences can profoundly affect one’s lifelong physical and mental health (1).
My own experiences of parenthood made these encounters all the more striking. I know first-hand how costly formula, diapers, and clothes for a fast-growing baby can be. How would this family afford these things, let alone healthy food down the road?
I thought of the mental energy it takes, as a parent, to cultivate positive feeding and sleeping behaviours without getting frustrated. I thought of all the precious moments I have spent reading, singing, or playing piano with my child and how this has contributed to her emotional and cognitive development. I also thought of how difficult it is to be fully engaged with her when I am anxious or stressed.
This girl’s caregivers were under incredible pressure to find work and housing and to make ends meet. Would they have the time or mental space needed to invest in these activities or even just to spend time talking to their daughter? Might she be at risk for language delay and academic difficulties? Would they get frustrated easily at mealtime, paving the way for feeding aversions and even malnutrition? How would the infant have space to crawl and cruise – developing both her motor skills and independence – amid all the clutter in that single room? Would the caregivers’ own troubled upbringings affect their ability to be fully attuned to her emotional cues? How would all this impact the girl’s own social and emotional development and subsequent mental health?
It is now several weeks later, and I am busy on a general paediatrics ward. I am looking after children of various ages, managing reflux, constipation, hypoglycemia, and respiratory tract infections. I keep thinking about my Social Paediatrics experience and about how it has influenced my interactions with children and their families.
First, I have learned never to make assumptions about a family’s daily routine. My eyes were opened to children living in situations I could never have imagined. Based on my own life and experiences, I once might have presumed that a child would start eating solids at a certain age, take regular meals in a high chair, and sleep at regular times in a crib. I have since realized that taking the time to ask carefully about these seemingly mundane things can often yield surprising answers and point to simple but meaningful steps that can ameliorate a child’s wellbeing or a family’s daily functioning.
Secondly, I have gained an appreciation for encouraging parents to talk, read, and sing to their child – even amid more pressing medical concerns – and how this can significantly enrich both their child’s development and the bond they share. In fact, there is evidence that for families with limited means, giving out children’s books in the clinic or hospital, in addition to being a warm gesture, can have a meaningful impact on a child’s early language development (2).
Finally, I have become aware of how crucial it is to be attentive to all the psychosocial factors that can impact the parent-child relationship. While I deal with a child’s medical issues, I try to simultaneously show genuine concern about the parents’ own mental wellbeing because of how much it can affect that of their child. In a sensitive and nonjudgmental way, I might invite parents to share their own thoughts about the evolving parent-child bond. I might ask about their comfort with their ability to sense when their baby seems hungry, anxious, or happy, and how they respond to those cues. Sometimes, to revitalize the bond, I simply comment on how special the baby is and how most important is that the parents enjoy their lovely child.
I will never know what life has in store for the little girl I saw in the shelter. But that encounter, together with my other experiences in Social Paediatrics, has given me a new appreciation for the many small things that impact a child’s wellbeing and development. I hope this awareness will make me try harder – not only for my own little one, but for all the children I care for in my future practice.
1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
2. Mendelsohn, A. L., Mogilner, L. N., Dreyer, B. P., Forman, J. A., Weinstein, S. C., Broderick, M., … & Napier, C. (2001). The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics, 107(1), 130-134.
Dr Iain J Robbé
Dear Dr Bierstone: thank you for your insightful reflections on your experiences on the Social Pediatrics elective.
Your words speak eloquently about your humanity and empathy towards your patients and their families. Also you recognise the value of the social determinants of health and the importance of seeking to reduce health inequalities of opportunity at all stages of health care.
In the CanMEDS competency framework the areas of health advocacy and collaborator are not the most glamorous but as you realise they are crucial in relation to the social influences on health.
I wish you well in your future career.
Kind regards, Iain
Dr Iain J Robbé
Clinical Medical Educationist
Dundee University, Scotland & Memorial University, Newfoundland
Thanks for sharing this experience. It highlights the importance of a broad range of learning opportunities in medical schools. There is so much to be learnt about health outside the walls of the hospital.
This kind of learning will lead to doctors who are more effective as they can understand and appreciate the challenges of their patients.
A great read and I will circulate to colleagues in Australia!