Hopefully the painting I created in the past will start them at a different point when they see the next painter, who will add more nuance and colour.
“What is it that you were hoping for, for your young person?” I found myself asking once again in a crowded paediatric clinic, running overtime as always, inching closer to the end of a very short rope at the end of a very long day.
It is a loaded question that opens up the consultation to an unwelcome extension of a 20-minute appointment that has already gone on for 30. No matter; we’re in it now, and for once, the room’s electricity was at a level of dangerous that was survivable for all enveloped in it, so we continue.
Most of the time, the answers are geared towards the problem at hand, namely the child or adolescent’s behavioural outbursts, taciturn personality or disengagement from the life they were meant to be busy enjoying.
Sometimes we invest in a conversation about sleep initiation and melatonin, sometimes we dare to discuss the environmental effects of screens and sleep.
The subtext is rich and drips down the walls like so much congealed paint that no one is game to examine – glaring like the television in the room loaded with an MA15+ game or blaring away with smaller screens loaded with 10-second attention-thefts such that we are dying a slow death from a thousand cuts and can no longer read as a generation.
The subtext is that their ward has been shaped and moulded inadvertently into someone utterly foreign to the original, picture-perfect intent. And could we, as the paediatrician, please force them back into the factory setting, back into that child to whom they all had attached a lifetime of dreams and hopes? Hopes unrealised for themselves?
The presenting concern is that it is unbearable that the child their parents had imagined a future for is so far departed from this living, pulsing being with their slouching, grouching and often hateful diatribes, that they must be medically, developmentally unwell to be such.
Often this can be true, but more often still it is not.
But the issue remains that the fracture of the internal world of expectations of family and the realities of the living, breathing and often very personable child continues to poison the family’s dynamics and attachment.
All this at minute 40 and we still have not come close to the fracture of the child’s internal world and view of their emerging self.
Deep breaths as we remind ourselves that any step, however small, at opening the door to insight is worth it – worth every parry and opportunity in the never-ending fencing match with parents who pivot wildly from medications to blame, regret to shame; the child being discussed horrifyingly relegated to spectatorship in a discussion of their own fate.
What new bitter medication am is the child going to be made to have for their sins of trying to communicate their discontent with their lot?
So, we wrap up for the review. We discuss practicalities of small changes to medication or routine to keep parents engaged in the hopes that next time we will open the door a bit more than the sliver we managed today. Hope that we took enough paint from the wall to put some different shades of colour on their child’s psyche other than the black and white of “so will you diagnose my child or not”.
If we say stay patient, stay in the match, one brushstroke after another, one day a functioning portrait of the child enmeshed in their family’s story may emerge.
You and I can take a small hit, kid, maybe we will win the next round. A maybe spaced over six months, where another 20-minute appointment storming with static energy awaits us all.
The door closes behind the family with all remaining tenants of the clinic room’s hair and patience on end.
The next patient has waited almost an hour and the clinic admin knocks on the door to advise they are really quite angry at this point.
It’s not quite the perfect, cleanly executed clinic list we always secretly set as expectations for ourselves when the day begins. Beaten down by proxy, my student politely excuses themself to escape into the blissful and safe embrace of a tutorial. When one falls, we continue, I guess.
And what do we have to look forward to as our next patient then?
Et voila, quelle surprise, another similar list of presenting concerns, different perpetuating factors, but the same expectation that I will smear a quick diagnosis and find a medication that will “fix” the child.
This time the family comes equipped with almost an hour’s wait of hellfire stoked by previous traumatic experiences of healthcare, and the perception that waiting is rejection, on my part, of their concerns by default.
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There’s no parrying or dodging this heat sadly, and we arrive at the point of “I don’t mean to be rude but so what is the point of you, then?”
A quick pause of the scene to highlight the futility of the first half of that sentence. But we continue on despite the attempted assassination of self-worth.
After all, in a full day’s list of any community-based clinic this would hardly be the first time that sentiment was shared. And because of exactly that, in the instance where the elegance of fencing is no longer an option, only an ice-cold douse of reality was called for.
The point of me, thinking in that ice cold and succinct tone I usually reserve for newborn resuscitations, that cuts through a room with not a single raised voice, is to be your child’s doctor.
Nothing more, nothing less. I do not owe you a single thing more, than to look for medical issues and treat them. The rest I do because I also – somewhat miraculously at this stage of your performance of cause of presenting complaint – view advocacy of children’s rights as an essential component of my work with them.
If you would like to return from some version of fantasy where I somehow work for you, back to the very harsh reality of the situation that we are all in, that would be productive and preferred.
I wish I could say that that diatribe remained just a thought, but to say that would be to deny the realities of being a living, breathing human paediatrician, and choosing to remain in a perfectly painted picture of one.
Some version of that, markedly less articulate and filled with tremulous near-tears anger probably got lisped out into the real world.
So, we push on and the day unceremoniously ends after 18 patients are finally seen, with some non-attendees in the mix.
The last patient’s family threatens to not come back if there is no diagnosis provided despite being advised that complex childhood trauma is a valid one, and there are agencies able to assist other than the rosy promised garden of the NDIS.
In a moment of delirium after inhaling too many paint fumes from painting portrait after portrait of children’s psyches I almost cackled at this threat. Please don’t tempt me with a good time, I won’t be able to resist in my current weakened state.
The lights go out, and I set the alarms as I’m usually the last person leaving the clinics after registrar supervision and writing notes peppered with clues to set up the next consultation better for my future self.
The end of this day dissolves the bittersweet palette of today’s clinic. For all the aftertaste of paint thinner and micro-agressions, there is some sweet satisfaction at small steps walked in pace with some of the children and their families.
On the drive home, I reflect as always on the essential question of my vocation: “What is it that you were hoping to do with this work?”
And despite the complexities of the day-to-day and wrangling of human emotions in all its glorious colours, at the moment, it seems still quite clear to me.
The point of me is that of medical diagnoses and care, but the bigger point is to formulate. The art of formulation is to paint, starting with broad bold strokes of clinical suspicion and observed behaviours, then small flecks and dots of nuance as rapport, safety and details emerge to add depth to the emerging portrait of the child in nested in the love of their family.
A portrait of a life shared together, beautiful dreamed-of landscapes and monsters alike inclusive. Within the confines of 60 minutes for news and 20 for reviews of course.
But enmeshed within the artistry and beauty of our work in this field, is a warning. A painting, no matter how beautiful and perfect, serves as but an imitation of the family’s reality.
The purpose of such should not be lost, but work as a mirror in which the truth of reality may be seen, and more importantly acted upon.
The point of me? To speak the truth of the painting we made together painstakingly over months, if not years, of therapeutic relationship. And then to make usually therapy-based recommendations, and importantly to then let go of my attachment to my expectations.
Handing the child and family agency to make their choices with the knowledge we all now share. Nothing more, nothing less.
And if the family remains not ready for care in this reality, we would still have paved the way for when they return through that sliver of the door that will always be open in the service.
Hopefully the painting I’d created in the past will start them at a different point when they see the next painter, who will add more nuance and colour.
For those who come after, right?
Dr York Xiong Leong is a general paediatrician in Eastern Health, Melbourne, working in public inpatient and community paediatric services, and a medical educator with Monash and Deakin universities. One of the best compliments he has ever received is “Babe you barely live on this planet”.
