To pediatric hospitalists, the 2022 Center for Disease Control and Prevention’s report on child and adolescent mental health was more than just statistics. To us, the 10% of youth that attempted suicide in 2021 were patients in our care, and the Center for Disease Control and Prevention’s theories of the pandemic and cultural events leading to teenagers’ pervasive hopelessness were our patients’ stories.1  With mentally ill patients filling acute care floors, the critical shortage of mental health resources is our lived reality.2 

Some pediatric hospitalists and trainees have reacted negatively to being asked to care for these patients. Their suggestion is that mental health is not pediatric hospital medicine (PHM), that these patients are not our responsibility. Admittedly, I too have sulked back to my office after rounding on a panel of patients awaiting transfer to psychiatric facilities, bemoaning “I did not sign up for this.” With skyrocketing physician burnout already threatening the workforce,35  I am left wondering, if compassionate, forward-thinking physicians were finding this shift in our job description unbearable, will PHM survive?

Then 1 evening, my team debriefed a deescalation event in which, we, the physicians, had stood idly by while 4 security guards held down a wailing autistic teenager while nurses applied physical restraints. I was struck by a familiarity in my colleagues’ agonized questioning about whether there was anything we, as physicians, or our institutions could offer these children. I realized that this work, and our reactions to it, evoked vivid memories from my experiences working abroad. I offer these parallels to give perspective to profound challenge the mental health crisis presents for PHM clinicians, but to share a lesson in how we can cope.

I arrived at the Malawian hospital as a successful pediatric resident in a top-tier program prepared by years of experience in sub-Saharan Africa. However, as I toured the crowded pediatric wards, I quickly felt the added responsibility that came with being a doctor in this setting. A bold, expatriate physician pulled me toward an intubated child. Because there were no ventilators, he instructed me to bag the child so the mother could gather medications from the tuberculosis clinic. After several minutes, his oxygen saturations trended downward, followed by his heart rate. Pushed aside by the ex-pat physician, I stool by idly as he resuscitated the child, who regained circulation just as the mother returned, resuming her place at the head of the bed, valve bag in hand.

Such was how I experienced the daily work: Volume high, pathology severe, diagnoses uncertain, medications limited, processes unpredictable, interpreters sparse. I cared for children through a fog of doubt. Is my read of a chest x-ray really the final call? Is it reasonable to use the hospital’s last dose of morphine for postsplenectomy pain? And, with every glance at a mother clutching a valve bag over her unconscious child, I grappled for a way to communicate reassurance that, when the saturations inevitably began to drop, it would not be her fault Everything that had made me a doctor thus far no longer seemed to matter.

Nearing the end of my time abroad, I was stopped by a mother speaking frantic Chichewe. I exhaled upon seeing her toddler appeared well, picked up the paper scraps folded together at the corner that were her chart, and scanned to see “Digitalis,” “furosemide,” and “advanced right heart failure.” Avoiding the mother’s pleading eyes, I tried to remember everything I knew about right heart failure. Etiologies? Prognosis? Treatment? I questioned what this institution could do for her, or if I, as a physician, could offer anything at all. Overcome, I handed the chart back, mumbled that the Malawian staff would round shortly, and turned away.

I returned to the United States, like many global health workers exposed to intense stress, with the emotional exhaustion and reduced professional efficacy that define burnout.69  With each patient encounter, I grappled to understand my responsibilities as a physician and, in time, I rebuilt. I enthusiastically became a hospitalist, relishing in directly applying the knowledge and skills from my training to heal children and help families. It is this balance of accompanying families through times of sorrow, punctuated by daily, gratifying successes, that defines the work of PHM.

Then in 2020, as societal stressors grew and safety nets crumbled, the dynamics of PHM shifted. Wards filled with distressed young people and exhausted families, often suffering through psychiatric holds, their isolation and agitation intensifying in our care.10  Suddenly, in our daily work, we lacked the knowledge to confidently arrive at diagnoses or dispositions; we led deescalation events without proper training in ill-equipped facilities; we used medications we barely recognized that were temporizing at best. Even our communication was ineffective, because systems barriers and our own lack of experience made outcomes or next steps unpredictable. Everything that had made us doctors thus far no longer seemed to matter.

These parallels, supported by the work of Penwill et al on the moral distress of hospitalists caring for boarding mental health patients, demonstrate that the responsibility of caring for these children and adolescents, like working in resource deprived settings, is wearying, even traumatic at times.57,11  We bear witness to society’s neglect of young people and their invisible suffering. Even this far into the crisis, many of us are working without sufficient resources or consensus statements to guide us.11  In our scanning of these patients’ charts and deferring their care to another team of doctors, we lacked control and efficacy, leading contributors to burnout.8,12  Although negative reactions to this disrupted balance of the work of PHM are understandable, a final anecdote from my experience abroad offers a lesson in how we might move forward.

Upon returning to Malawi, I spent a day shadowing a colleague, focusing on his workflow and decisions, scrutinizing which of his successes were possible for me. After a long shift, he drove me home, breaking the heavy silence by asking how I felt.

“I don’t get it,” I stammered. “I watched 4 children die today!”

“Yes,” he admitted sighing, “and that isn’t a great day. But did you count the number of children who did not die today?”

Replaying the scenes from the day, I saw that I had not. I had not counted the kids who perked up from the blood each of us had sprinted across the hospital to retrieve. Or the infants who settled out after their loose continuous positive airway pressure prongs were attended to by dedicated nurses. Or the children cheerfully going to the stepdown unit, largely staffed by Chichewe-speaking staff, who were now able to follow treatment plans clearly delineated in the medical record booklets implemented since I’d left. Distressed children and despairing families had come, and we had helped them. And the only difference between myself and my thriving colleague was his practiced mindfulness (ie, a minute-to-minute awareness) that afforded him an appreciation of these successes.1316 

Recently, I rounded with my team on a patient with relentless depressive symptoms despite years of treatment, including inpatient stays. The encounter consisted of the resident’s pointless update: “We are still waiting on a psychiatric bed,” and the brief affirmation I give each suicidal teenager daily. She had been nearly silent throughout her stay; I startled when she called back my attention from the doorway.

“Hey,” she said flatly. “No one has ever told me that before, the thing you said about not deserving to feel this badly.” The moment hung between us before I nodded and hustled to join my team, already discussing the next patient. Though small and hidden in an otherwise busy morning, I registered this success.

These successes, unlike the bronchiolitics blowing us kisses on the way out the door, may not be obvious in the behavioral health population. Many teenagers are angry when the ambulance arrives for psychiatric transfer and parents may not be eager to go home to trial the new regimen that seems to be working in the hospital. Mostly, patients leave the way they came in. However, if we are mindful, we will see the teenager with a functioning liver after acetaminophen ingestion; the catatonic patient who ate 3 meals yesterday; a mother’s trust in the team’s treatment plan; the child whose medicine and nonpharmacological measures have kept him out of restraints long enough to qualify for transfer, where experienced psychiatrists are situated to help. Training ourselves to recall these successes emulates the practice gratitude and other related mindfulness practices, which have been shown to mitigate burnout and improve wellness,1419  is how we can keep showing up to help these children and families who, like our patients in Malawi, have nowhere else to go.

Undeniably, the mental health crisis has fundamentally changed PHM. Pediatric hospitalists, who are committed and accustomed to providing excellent, evidence-based care, are bound to falter because we take on the suffering of patients for which they are not equipped. However, through mindfulness, we can name the profound challenge before us and, furthermore, cope by appreciating each success as we continue to face this trial.14,16,17  In time, through advocacy and experience, our successes will become frequent and robust, eventually blending in with the daily work that sustains us. Then, we will see that caring for mentally ill children and adolescents is PHM.

I thank D. Brody Lipton for his reviews and edits.

Dr Dean conceptualized, designed, and wrote this manuscript in its entirety; and approved the final manuscript as submitted and agrees to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: Dr Dean has indicated she has no conflicts of interest relevant to this article to disclose.

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