The practice of medicine encompasses many specialties. Some are organized around specific organ systems—nephrology, cardiology, neurology—while others fall into broader categories, including the familiar divide between adult and pediatric medicine.
Doctors-in-training often discover where they belong relatively early. My own moment of clarity came during my first week on an adult medicine rotation, when I realized that while it is one thing for a 4-year-old to vomit on you, it is something entirely different when a 40-year-old does the same. I have told that story many times.
Conversely, I have met plenty of “adult doctors” who knew just as quickly that their future patients would not be children—whether because pediatrics can feel uncomfortably similar to veterinary medicine, with many age-related developmental “species,” some of whom are nonverbal, or because their empathetic heartstrings were simply too sensitive.
All these reasons are understandable.
Ultimately, we each find our place. And once we do, physicians tend to spend the rest of their careers—mostly tongue-in-cheek, but with at least a small amount of sincerity—defending the superiority of the path we chose. I am no different.
Adults are gross, and you will never convince me otherwise. But my recent experiences as a patient have reinforced one truth I believe is difficult to dispute: adult medicine too often lacks urgency around when it comes to pain and fear.
No one wants to hurt a child, and of course no one sets out to hurt an adult. The difference is that in pediatric medicine, we proactively work to reduce—or sometimes even eliminate—the looming specters of pain and fear. We prescribe EMLA cream with instructions for parents on applying it before frequent blood draws. We involve Child Life specialists, an entire profession devoted to age-appropriate distraction, explanation, preparation, and emotional support. These efforts are not extraordinary in pediatrics; they are routine features of care. The same cannot always be said of adult medicine.
In 1980, I was a child who needed frequent, routine blood draws. At the time, options for numbing the skin before a needle stick were limited: a freeze spray that worked for only a few seconds and affected only the most superficial layer of skin, or a separate injection of lidocaine into the area. Many of you may remember that blood draws and IV starts often meant holding terrified children firmly in place to keep them from pulling away. In my case, that experience led to an admittedly ironic needle phobia.
It was significant enough that I may have traumatized my heroic nurse instructors during the “IV Start and Blood Draw” portion of medical school procedure training, as they talked me through practicing on them while I sobbed, “I’m so sorry. I really don’t want to hurt you!”
Fast-forward to pediatric residency, and I found the fortitude to pull myself together when an infant with suspected sepsis needed blood cultures and a spinal tap. But my personal fear of needles remained intact. Now, at over 50 years of age, I am not ashamed to admit that it still does. I make a point of telling my care teams about it.
Too often, however, that disclosure is not met with consideration or compassion. The most striking example occurred a few months ago, when I landed in an emergency department for the second time in 48 hours while on vacation far from home.
I was suffering from severe abdominal pain and tenderness, and my dread over the impending IV start was nearly as intense. I am a “bad stick,” with tiny veins that like to hide even under nonstressful conditions. The IV placed the day before had used my most reliable site, making it unavailable for at least a few days.
So, when the ER nurse came in and began slapping and flicking the skin at the sides of my wrists and the backs of my hands, I panicked. I told her about my fear, explained my history of difficult IV placement, and asked whether they had ultrasound-guided IV capability or a nurse in the ED who was especially skilled with difficult starts. She answered with a withering gaze and a sigh, confirmed my request, removed the tourniquet, and left the room.
An hour later, still in severe pain and now kicking myself for not simply asking for EMLA to be applied to every possible IV location, I pressed the call button. It turned out I had a new nurse, and her sign-out included the information that we were waiting for someone from vascular surgery to start my IV.
There had been no apparent effort to identify another nurse who might feel confident placing the much needed IV and drawing labs in a single attempt. As luck would have it, this nurse was willing to try. More importantly, she made me feel that she genuinely understood my fear. She reassured me that she would not try unless she felt as confident as possible that she would succeed.
That reassurance made all the difference in the world.
I know I am a huge baby when needles are involved, and I know plenty of adults do not share this fear. Still, even in medical school, I was never comfortable with the idea that adults should simply “suck it up” and tolerate discomfort—or even pain—during testing and procedures.
As time passes and I more often find myself on the patient side of the encounter, that assumption feels even more unsettling.
As physician advisors, we are frequently involved in initiatives intended to support high-quality care for the patients our hospitals serve. While I certainly do not want to return to the era of reflexively linking every reported pain score to opioids, perhaps it is time for our adult medicine colleagues to take a closer look at applying the same empathetic, patient-centered approach not only to pain but also to fear.
