The following reflection was written in response to a prompt about advocating for those in vulnerable positions:

Over the past couple of weeks, pediatric inpatient work has brought me back to the familiar emotional distress I experienced earlier in my career, as an elementary school teacher immersed in the inequities that unfortunately characterize our society. Granted, these inequities exist at all ages, but they become especially heartbreaking in taking care of children. I am talking about the children who are lovable but unloved–the ones who are left to their own devices instead of being nurtured toward their potential until they are ready to fly solo. 

He was a 16-year-old boy who was functionally homeless–charming and smart, despite having been repeatedly suspended and expelled from high school for fighting and for selling marijuana on campus. He has a history of ADHD, GAD, and PTSD, which he prefers to self-medicate with CBD and THC, and a social and sexual history that are the unfortunate products of being forced to be an adult during early adolescence, all leading to his present illness. The social worker was trying every avenue to help him, but his age, school truancy, and substance use excluded him from many of the programs and resources that may have otherwise set him on a better path. My heart broke a little more every time I sat and talked with him. He was clinically improving but did not want to leave the hospital; to him it was a five-star hotel, complete with care and attention from competent adults who wanted the best for him. 

Before writing my progress note one morning, I went to listen to the nursing shift handoff. I wanted to hear firsthand how his progress had been from a nursing perspective: vital signs, medications given, ins and outs, general disposition. In giving her synopsis, a nurse who barely knew his case laughed in confusion as she read all of the acronyms in his medical and social history and the group synchronously rolled their eyes about his THC use. The presenting nurse looked to me to clarify our medication choices for him, as the others finished chuckling about his predicament. These attitudes were not surprising; I know that these children are dismissed and misjudged more often than not. But as all eyes turned to me, I felt a certain duty to respectfully set the record straight. This was my patient. I knew his story, and he was not to be blamed for his condition. It was a situation devoid of humor from every angle I could see.

I took a deep breath, and with a forgiving tone, calmly and kindly rephrased his “History of Present Illness” in a way that replaced judgement with genuine concern. Then I explained the answer to the nurses’ question regarding medication. They all nodded in understanding, and there was a moment of complete quiet before I thanked them for their work and turned to go check on the child for myself.

Now, this story is not intended to shame any member of the health care team, who I’m sure were doing their best with what they were given. The truth is that this boy reminded me of someone in my own life whom I had helped in the past. In medicine, this phenomenon, known as countertransference, occurs when a patient reminds a care provider of someone who they’ve known before. In this particular instance, the patient reminded me of someone whom I had cared for immensely and mentored intensively. Thus, I found myself feeling very protective of him, which motivated my response to the other staff members’ behavior. Countertransference can easily go the opposite way, when the patient reminds a care provider of someone of whom we are less fond. The goal is to be aware and conscious of these biases.

Additionally, I realize that working in any area of medicine for an extended period would put any of us at risk for feeling jaded at times. It is undeniably frustrating when a patient’s choices stand in the way of their health. However, patients who are noncompliant with health recommendations often have reasons for their behavior that extend beneath the visible surface. In remembering this story, I hope that I will be able to maintain a compassionate attitude, even when it isn’t the easiest path, even when I don’t completely understand the reasons for a patient’s choices, or even when the patient does not fill a special place in my heart that was created by someone I used to know.

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