The Experience
For this patient visit, I shared participation 50/50 with my preceptor. The 5-year-old female patient was accompanied by her current guardian, presenting for annual well child exam. Change in guardian care since 06/2023 with siblings (2 brothers). Current foster parent reports that patient and siblings have moved foster homes 6 times in the past 18 months. Pt has been having allergy symptoms of sneezing and runny nose for about one month. Patient tends to have dry skin despite moisturizer use. She will sometimes have itching/scratching to genital area.
Her past medical history includes lactose intolerance, specific developmental disorder of motor function, mixed receptive-expressive language disorder, adjustment disorder, allergic rhinitis, xerosis cutis, and congenital preauricular pit with history of infection. She was evaluated with ENT for possible excision vs tertiary referral. She has had a cyst in right ear that comes and goes.
On exam vital signs were within normal range, and there was a noted right preauricular pit, with no pre or postauricular swelling or discharge seen. She did not pass her Pure-tone audiometry hearing screen (MedlinePlus, n.d.), but this may be related to her age and ability to interpret instructions for screening process, more than her ability to hear. Nonpruritic skin with mild xerosis to extremities.
Her ASQ-3 developmental screen demonstrated developmental concerns for fine motor skills, which will need monitoring. Learning activities were discussed with the foster parent/guardian, and AAP Bright Futures parenting guide was provided and discussed. A TAP-TAM book "Bears on Chairs" given.
Note: TAP-TAM is the early literacy program in Kansas, and stands for, “Turn a page, touch a mind” (Kansas Chapter American Academy of Pediatrics, 2017). It is an amazing program, held in high esteem along with programs like Dolly Parton's Imagination Library (The Dollywood Foundation, n.d.).
The plan consisted of a referral made to Audiologist as follows: 5-year-old female with failed hearing screening 7/19/23, history preauricular sinus/cyst formation with abscess management by ENT in 2021. No current infectious concerns. Referral with audiology through ENT requested.
Additionally, patient was to start a daily antihistamine as instructed. She could also use saline spray in nose a few times a day to flush out allergens. Also discussed allergen reduction strategies, avoidance of strong-smelling soaps and detergents, as well as avoidance of bubble baths. Patient was to also avoid prolonged sitting in a wet swimsuit with outdoor activity. Samples of CeraVe were given for home use for routine care. Her follow up was planned for one year, for next well child exam.
Thoughts and Feelings
The nature of the exam, findings, referral, and plan - was not the lesson for me in this situation. This was a shy, submissive child that sat powerless on the exam table. She intermittently made eye contact but did not hold it for more than a second or two, before looking away or down at her feet. This child had been passed around to six different foster homes in 18 months. There was so much about this patient and her circumstances that exposed the broken systems in our country.
I thought pediatrics would be difficult, and that this rotation would be challenging for me on many levels, but I did not expect the emotions I have felt in caring for this population. My clinical rotation is at a Federally Qualified Health Center (FQHC). FQHC are usually located in rural or underserved communities and provide care and services for those most impacted by SDOH - social determinants of health (HealthCare.gov, n.d.).
Evaluation of Strengths and Challenges
This visit was not about the medicine for me. This visit triggered compassion that overwhelmed me, and sorrow that burdened me. Despite being considered the richest and most advantaged country in the world, the United States have not done enough to care for our children. We have hungry, sick, impoverished children, yet we are living in a nation of abundance. We promote birth and yet we fail to preserve the well being of those born. Jacobson (2022) has gathered many statistics that provide further insight on just how well we are caring for the children in some areas of the country...and just how well we aren't.
We have children that have been removed from their homes or removed from their parents for various reasons. And then there are the children that were cast aside by their own parents, seemingly discarded. It was not just this patient either - it seemed like this patient was the tipping point for me. I remember driving home from clinic that day and just feeling discouraged...and crying for all of the kids in "the system" who get shipped around from home to home. Actually crying... like call-your-mom-crying and overcome with emotion. Crying not because this was a new revelation, but it was conspicuous and routine in this setting.
Developing my skills to align more with practicing medicine has been very difficult. I don't have a clear boundary established where I give myself permission to treat the patient and not take on their problems as my own.
Analysis and Self Reflection
I asked my preceptor how he is able to separate his feelings, how he is able to do this - in this population - day in and day out. He said that there is no other way to do what we do everyday, but to establish and maintain boundaries in our profession. He said that we have to approach the care with compassion, but from a bird's eye view.
I appreciate that he doesn't take on the burdens of our patients. It made me think of a quote from a book I had for my BSN, by Koerner (2011), "It is the ultimate misuse of our power to take responsibility for solving problems that belong to others. Our role as witness is to create a safe space for them to sort through the issues of the day, offering understanding & interpretation along the way" (p. 138).
Action Plan
Jones (2019) said it best in her online article, "...setting boundaries doesn’t signal you don’t care or that you are selfish...Boundaries show you value a relationship enough to be thoughtful about making sure it thrives" (para. 5). My plan is to develop and maintain trusting relationships with patients, and boundaries are a great foundation for building those relationships.
I cannot risk caregiver or provider burnout, by taking on the hardships of patients and thinking it is up to me to solve their problems for them. I will not allow myself to own the issues of the patients in my care. I can only provide supportive counseling, reassurance, guidance, and empathetic listening, along with feedback and encouragement regarding solution focused changes.
References
HealthCare.gov. (n.d.). Federally qualified health center (FQHC). https://www.healthcare.gov/glossary/federally-qualified-health-center-fqhc/Links to an external site.
Jacobsen, L. A. (2022, August 9). Are the states banning abortion truly pro-child or just pro-birth?. Population Reference Bureau. https://www.prb.org/articles/are-the-states-banning-abortion-truly-pro-child-or-just-pro-birth/Links to an external site.
Jones, G. (2019, September 9). Creating healthy clinical boundaries with patients and clients. LeaderLive. https://leader.pubs.asha.org/do/10.1044/creating-healthy-clinical-boundaries-with-patients-and-clients/full/Links to an external site.
Kansas Chapter American Academy of Pediatrics. (2017, June 6). TAP-Tam: A program that Kansas should be proud of - Kansas chapter American academy of pediatrics. http://www.kansasaap.org/wordpress/tap-tam-a-program-that-kansas-should-be-proud-of/Links to an external site.
Koerner, J., & Bender, S. (2011). Chapter 5: Quantum Healing the Power of Integration. In Healing presence: The essence of nursing (2nd ed., p. 138). essay, Springer Pub. Co.
MedlinePlus. (n.d.). Hearing tests for children. MedlinePlus. https://medlineplus.gov/lab-tests/hearing-tests-for-children/Links to an external site.
The Dollywood Foundation. (n.d.). Dolly Parton’s imagination library. Dolly Parton’s Imagination Library. https://imaginationlibrary.com/Links to an external site.
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