New pediatricians are seeing few ‘bread and butter’ cases, but an influx of mental health crises

In his first month as a pediatric intern at the University of California San Francisco, Alexander Hartman saw his first patient with an eating disorder. The same night, he saw a dozen more.

His first rotation of his first year of residency was in the general pediatrics ward, and on nights, Hartman and the other interns covered the adolescent service, seeing teens starting from puberty. One night in June 2020, there were around a dozen patients in the ward, all with eating disorders. It was double the usual caseload.

Some patients had been there for weeks, Hartman said, and were well known to the service due to their long-term eating disorders, while others were new. All of them found that the pandemic had exacerbated their stress. Hartman found himself running between the ward and the adolescents, intercepting pages. He saw one 16-year-old girl, who he was told had come to the department for treatment before, who was now refusing food, her heart rate dipping into the 30s.

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“I’m just like, I don’t know anything about treating eating disorders,” he said of his anxiety that night. “And now it’s just routine.”

The climbing rate of eating disorders diagnoses fit into a broader increase in mental health crises among youth in recent years, a trend that experts worry has been worsened by the Covid-19 pandemic.

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For physicians new to pediatrics, this has created an inverse training experience: they’re treating children with mental health concerns daily, but don’t see nearly as many of the “bread and butter” conditions that define pediatrics like the contagious, spreadable bronchiolitis or flu.

It wasn’t until nine months after he first treated teens with eating disorders that Hartman diagnosed his first ear infection. When he peered into the patient’s ear and realized that’s what it was — “that’s a bulging tympanic membrane!” — he had to look up the right amount of amoxicillin to prescribe, the dose not yet committed to memory. The attending on duty gathered all the medical students and Hartman’s co-interns to come take a look at the ear, as if it were a rarified orphan disease they may not see again.

Fewer asthma attacks and fewer kids giving each other the flu is good. But for trainees who expected to cover plenty of ground in their first year, it’s intimidating to feel so uncertain and unsteady. This summer, interns will advance to second-year, “supervising” residents, even though some have little to no experience with certain basic conditions.

When Nishant Pandya, a pediatric intern at Yale, talks to his senior residents, they tell him about how they often treated eight kids with bronchiolitis, a common respiratory infection, in just one day. Pandya said he’s seen maybe 15 cases all year.

“There’s something about doing the thing and seeing the thing and being forced into decision-making at that moment.”

Nishant Pandya, pediatric medicine intern, Yale

“You can academically read about it all you want,” he said. “But there’s something about doing the thing and seeing the thing and being forced into decision-making at that moment.”

In April, almost a year into his internship, Pandya had a patient with asthma and sleep apnea who received medication overnight to help his breathing. But as Pandya watched his loud breathing, coughing, and snoring in his sleep, he grew nervous. Was this normal, or is his asthma worsening? He didn’t have enough real-world experience to know for certain. His supervisor was taking a nap, so he asked another resident to come take a look.

“Being a supervising doctor next year for interns, I think that will just require approaching the year with continued humility,” Pandya said.

While they might still lack “bread and butter” experience, interns have gained hours of treating mental health emergencies — training that, in another year, might be far less intensive. In a 2013 survey of pediatricians, two out of every three people polled said they lacked training in how to treat mental health conditions in kids.

When Sonia Taneja, a first-year resident in Boston, interviewed for spots in pediatric residencies last year, she told interviewers she wanted a program that would have her “inundated with patients.” She was interested in pursuing a broad specialty such as emergency medicine or primary care, and expected to become an expert at treating the basics.

Instead of the usual infections, she has seen an overwhelming number of mental health crises, including kids coming in with suicidal ideation or having attempted suicide. She has seen so many of those cases in the past 10 months, that she can’t even remember her first such patient.

When kids come to the emergency room for a mental health concern like passive suicidal ideation, they can wait hours, days, or even weeks to be transferred to an inpatient facility where they can receive more appropriate care. It’s often Taneja’s job to check in with these patients daily until they’re transferred. It can be a short interaction, and she tries to gauge her mood and demeanor off of theirs. Some patients are more upbeat or talkative than others, but they’re all in a holding pattern until psychiatric care can begin.

Taneja might not have had so many conversations with kids in psychiatric distress during any other intern year, and it has left her rethinking her role in their care.

“I feel like doing something about it from a more policy, broader perspective,” she said. “Trying to be a provider for some of these patients, to me, has become less satisfying.”

Taneja isn’t the only first-year physician to feel this way. Hartman says that he’s noticed more pediatricians speaking and writing publicly about treating children since the pandemic. There’s a feeling that perhaps the younger, incoming generations of physicians will bring more change to the way that medicine approaches mental health, a sentiment that could be further spurred by their experiences treating kids during the pandemic.

“I’ve always been a little frustrated with the way the system works,” said Pandya. “I think there’s been an underinvestment in mental health and psychiatric care, especially for children.”

At Nationwide Children’s Hospital in Columbus, Ohio, the staff recognized that a growing number of children with mental health concerns was one of many changes in the pandemic they needed to adapt to. They built a two-week elective rotation for residents on pandemic response, including a short module focused on how disasters can affect children’s mental health. In that portion of the curriculum, trainees shadowed the hospital’s psychiatric crisis department.

“That was an adaptation that we realized our pediatric residents really needed,” said Maya Iyer, a physician and professor who helped to build the curriculum. She said they plan to continue offering the curriculum even after the pandemic has ended.

Pediatric interns said that the lessons they’ve learned treating patients during the pandemic are already shaping their beliefs on how to approach patients in need of mental health care.

“I’ve come home so inspired by conversations that I’ve had with some of these kids who are boarding and have so much insight as to what’s going on with them and that they need help,” Taneja said.

In the past year, Taneja said she’s honed her practice collecting medical backgrounds so that she’s not re-traumatizing a young person experiencing a mental health crisis.  She doesn’t necessarily need to know the entire emotional story of what brought them to the hospital in order to empathetically collect a medical history. She’s also learned to be cautious about over-examining children while they wait for care, which can cause unwarranted anxiety.

Like Taneja, Pandya has developed his own methods of interacting with patients as they wait for other care.

“Even if I’m not the one who can find you an inpatient facility, I can be the one who spends a couple more minutes in the room. I can swing by a couple more times,” he said. “Treating someone with an acute mental health need, that challenged my schema that I was walking into medicine with.”

But the year of caring for young people in crisis has also taken a toll on interns. “We’re seeing this explosion of symptoms really associated with mental health and we’re seeing it on every rotation,” Hartman said.

Hartman started medical school later than most, already married with a daughter, who is now six years old. One day after returning from work, he walked through the door and grabbed his daughter in a hug and began to sob. Seeing so many children, especially young girls, come to the service for eating disorders was terrifying for him as a parent. Children who have all the support a parent can offer are still vulnerable to mental health struggles and the scrutiny of society and their peers.

“If these families can’t protect their children,” he asked. “What in the world can I do?”

Source: STAT