From The Chair

February 2016


Maybe I'm the only one, but some days when I am running around the hospital I feel remarkably young and spry, while other days I feel old and worn-out. I suspect, though that I'm not the only one: that all of us live with a sense that our position on the timeline of life is a bit wobbly, shifting back and forth, oscillating between optimism and anxiety. And not just in terms of how we are doing physically or mentally, but also regarding how secure we feel about our careers, our abilities or accomplishments, and what lies ahead.

This train of thoughts and feelings got me thinking about how we in the pediatric palliative and hospice care community work not only with interdisciplinary teams, but also intergenerational teams- indeed, we ourselves may feel ourselves to be shifting at times between different generations.

I am not speaking here of all the attention paid to so-called generational differences under the heading of Gen X, Millennials, or whatever (although I should perhaps confide that I'm in the last ranks of the Baby Boomers, which- gasp - how did this happen? - means that I'm in my early 50s).

What I want to focus on instead is our personal, internal sense of where we are located vis-a-vis both our peers and also our imagined ideal self in terms of - well, all the things that mark the progress of a work-life devoted to clinical practice: our volume of clinical experience and commensurate wear-and-tear; our career potential, goals, and accomplishments; our reasons to be proud and other reasons to be disappointed; the amount of time already clocked into our career versus the time we have left on our career clock; and (I am sure) many other thoughts and feelings that pass through our minds as we pass through our lives.

Let me be concrete: When I sit in one of our interdisciplinary team meetings, I see around me a host of different disciplines, but I also see a broad generational spectrum. Focusing on the discipline of pediatric medical care, I likely see medical students just starting out (relatively speaking; they are likely more than $100,000 in educational debt, which hardly sounds like just starting out), residents and fellows (who in their early-to-mid 30's may already have young children of their own or are keen to find a life partner and start a family), junior attending physicians (who, like everyone else, are trying to figure out how to balance commitments to work life and to private life, while also toiling to develop their niche area of expertise, to make their mark, to secure their reputation and long-term job prospects), mid-career physicians (who may now be secure having achieved promotion and are either advancing forward with new leadership and other career opportunities or may be looking around wondering if they are in a rut or have plateaued), and later-career physicians (who are engaged in the mind-game of calculating how many more years they have in their career, how they should use this diminishing time, what they still want to achieve, or simply trying to hold on and not become obsolete). All of this, of course, may be entirely in my head, revealing far more about me than the people in the room, but I hazard that these thoughts and concerns are in play when intergenerational groups of preofessionals gather.

Now let me propose my not-too-novel thesis: Suppose, in the midst of team discussion, a debate emerges over the best way to care for one of the children on the service and the two debaters are at different generational points on the career spectrum- well, whatever the focus and facts of the debate might be, an extra dimension in this encounter will be the different generational preoccupations, longings, and anxieties that each party brings to the discussion. Just as is the case in all consultations that we perform, there is most often an invisible elephant in the room, perhaps quite small and well behaved, or maybe large and on the rampage, an elephant consisting of how the people view and judge themselves, judgments that in turn shape their reactions to what others say and do. These thoughts and feelings about where we stand in the social order, and in our internal vision of ourselves, do not solely arise when engaging with others from different career generations, but such engagements often do cause these interpersonal issues to arise.

What are we to do to manage this extra dimnesion? How can we make sure that we do not inadvertently stoke the generational angst of our colleague? Or even more optimistically, how can we use our generational differences to support each other in a generative manner, helping us to build ideas or plans, to empower action and commitment? This may be particularly important for our work, which so often hinges not so much on clinical knowledge but instead on clinical judgment, on making thoughtful and wise choices, the kinds of decision-making and problem-solving that can benefit so much by incorporating multiple perspectives into the process.

Our clinical practices provide guidance about dealing with unacknowledged elephants. When I am talking with a (now most often junior) colleague, I first have to detect my own triggers, how the conversation is stirring up any concerns or anxieties that I have about who I am and how others view me. Do I detect that I think my knowledge or judgment is being questioned, or that my opinion is being discounted, or that I am realizing as we talk that my initial position was overly stated or misinformed or plain wrong in some way? If so, can I not "bite the hook", that is, not immediately react to these thoughts but instead hold them as they are for a moment and think about how I want to respond? I also try to check my own internal weather-am I feeling pressured or frazzled, irritable or sad? If so, can I feel those feelings for a few moments and see whether they disconnect on their own accord from this specific conversation?

Then I might seek to expand the framework of the conversation to include these additional thoughts and feelings. I might say something like: "Is it okay if I raise a related but different topic? As we talk, I'm realizing that my mind is in two places, the first being about what we are talking about, the second having to do with reactions I'm having to our discussion." The next step is important yet often omitted: I should reflect on how I feel now. The temptation is to skip this and immediately talk about how I used to feel when I was younger; this step, which plays a role, comes next. Right now I should share how I am feeling right now. "I am intrigued by the medication you are proposing to use, but I have to admit that I've never used that before and I don't know it well and thus I feel reluctant to try it in this case." Now, if apt, I can reflect on how I used to feel when I was more junior. "I remember when I was the one proposing the latest therapy, pushing to make sure my patients got what I felt was the best evidence based care." I can also reflect on my feelings about the interaction we are having with each other: "I also want to be clear that I appreciate you pushing for what you think is best."

Then my job is to be silent, to hand the conversation back over to my colleagues, and see what happens next. Maybe that person will also reflect and share. Or not. The choice is theirs, and their is not necessarily right choice. As much as I would personally welcome their own self-reflective reply, they may just silently note what I said and return back to the topic at hand. But I have found that most of the time, there is a shift in the tone and substance of the subsequent discussion, which breaths a bit fuller and easier.

Now, people I work with might have a different view of what I do, and I don't doubt them. I can be preoccupied and gruff, and I'm sure I muff up these kinds of conversations all the time. But occasionally, I think that together with whomever I am talking we manage to address these additional elements of our intergenerational thoughts and feelings. And when we do, the ideas and solutions we devise for the patients and families we serve are improved, and-an ancillary benefit- we both walk away having advanced on our journey forward as people.

Chris Feudtner, MD, PhD, MPH, FAAP

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