Maybe Later We'll See

I could go on and on about the ways that becoming a mother made me a better doctor. It's much easier to build rapport with families when you can throw a genuine, understanding "yup, my kids do that, too!" into the conversation. It helps me to give much better, more realistic, advice, especially to parents of very young children. (How I wish I could apologize to every new mother whom I advised to just "sleep when the baby sleeps.") Not to mention the fact that I didn't need to study developmental milestones for my General Pediatrics boards.

But until recently, I felt hard-pressed to list any ways in which being a doctor has made me a better mother. It has made me a more tired mother, a more guilt-laden mother, a mother who excels at multi-tasking, though I'm not entirely certain that that's a good thing. Because of my specialty, my kids are growing up with an exorbitant emphasis on safety (Safe sleep habits! Rear-facing car seats past age 2! No riding down slides on grown-ups' laps!). This will likely make their lives slightly less exciting than they would be otherwise, and might even be a detriment to their social skills; at two and a half, Bean regularly points to people biking through our neighborhood and shouts, "Ridin' bike not wearin' helmet! Need get helmet!"

The other day, however, I witnessed an interaction that shook me and has already changed, in no small way, an aspect of my parenting. As a fellow in Hospice & Palliative Medicine, I frequently participate in family meetings and discussions surrounding goals of care. I'm there when people learn that their health or that of their loved one is declining, that the remaining time is likely measured in weeks to months; when they hear for the first time that their end-stage organ failure isn't simply a chronic condition but one that will drastically shorten their life. When they learn that they are no longer a candidate for cure-directed treatment. Oftentimes I am the one to deliver these emotional blows. Regardless, whenever I am involved, my job is to help patients and families understand their clinical conditions and the options that remain - the pros and cons, best- and worst-case scenarios. Their decisions and goals don't have to make sense to me or coincide with my own values and beliefs, but my job is to try to ensure that the choices they make are well-informed.

I recently met a man and his family who quickly became one of my favorites that I have worked with. The couple were in their seventies, with several grown children and young grandchildren living nearby. His diagnosis was one that most in the medical community would consider devastating, though he and his wife maintained an upbeat attitude and an intention to pursue any form of treatment offered, no matter how severe the side effects or how slim the likelihood of benefit.

The first steps in his treatment knocked him down hard. He suffered debilitating side effects. He began to recover bit by bit, but then, still miles away from his pre-treatment baseline, he landed in the hospital with another complication.

I began to explore with him and his wife the potential paths that lay ahead. There was always the possibility of declining aggressive treatment and focusing on comfort, though he insisted over and over again that he would keep fighting his disease. But after yet another complication, it became clear that he might not, in fact, even be a candidate for any further treatment.

They had many appropriate questions, and I tried for days to get the primary team to sit down with this couple and give them some answers about what might lay in the patient's future. When they finally did, the meeting began before I could arrive, and I entered the room to hear them discussing a plan to wait one more week and then meet to assess whether or not he might be able to tolerate further treatment. The patient and his wife pressed the physician further. "How likely do you think it is that he will be strong enough to get more treatment?" the wife asked.

"Well, we'll have to wait and see," replied the physician.

And there it was. The line that I had been using as of late to side-step Bean's requests, to put them off in the hopes that he would forget, to deny without officially saying no. As he rounds the bend from two and a half to three years old, he has become quite a skilled negotiator; a frequent refrain is, "Later, nappy time over, do good listening, watch Cars [his current favorite movie]?" He'll ask even if he's just seen it the day before. And because I feel bad denying his request - and also because I would prefer to avoid a meltdown - I use a variety of stock Mom-phrases that I hadn't even realized I relied on until he began repeating them back to me in response to requests of my own: "We'll see." "Maybe later." "Wait and see."

When I heard it from a fellow physician in such a loaded setting, I grew angry. Of course nothing is certain in medicine and our prediction skills are often poor. But when I looked at the patient before me, knowing his course and his current condition, I knew that I would be utterly shocked if he recovered to the point of being able to press onward with treatment. And the other physician - as he admitted later when we spoke outside of the room - knew it, too.

It made me think hard about the responses that I present to my own child. Yes, it's easier to give some hand-wavy answer in an attempt to move on, change the subject, dodge the thing staring you in the face. And yes, a toddler's request for more screen time is exponentially less serious than a family's request for a clinical prediction. But in both cases, I think that we as humans should show one another the respect that comes with an honest answer, no matter how uncertain, no matter how difficult to deliver and to hear.

So I have started explaining to Bean what we are waiting to see. "It depends on how much time we have after we shop for groceries and take baths," I'll say. Or, "Well, let's see if it's nice outside; if it's sunny, we should go to the park instead." He doesn't always love my answer, but he knows where things stand and what it is that we are waiting to see.

*Cross-posted at The Growth Curve (www.thegrowthc.com).*