Israeli/Canadian study: Pediatric neurosurgeons have a heart – and they cry when young patients suffer or die

The popular notion that physicians – including surgeons – tend to be hard-hearted and don’t develop emotional connections with their patients because they constantly treat new ones is erroneous, at least when it comes to neurosurgeons who specialize in children, according to Israeli and Canadian specialists in this field. 


“Every patient is like my child,” declare Prof. Shlomi Constantini and Prof. Jonathan Roth of the pediatric neurosurgery department at Dana Hospital in Tel Aviv Sourasky Medical Center; Dr. Leeat Granek at the School of Health Policy and Management at Toronto’s York University and doctoral student Shahar Shapira at the department of gender, sexuality, and women’s studies at Simon Fraser University in Burnaby, Canada. 


They have just published their emotion-filled article in the British Journal of Neurosurgery under the title “ ’Every patient is like my child’: pediatric neurosurgeons’ relational and emotional bonds with their patients and families.” 


The authors set out to explore the relational and emotional components of the surgeon-patient relationship from the perspective of practicing pediatric neurosurgeons in the field based on videoconference interviews with 26 pediatric neurosurgeons from 12 countries. They found that pediatric neurosurgeons find meaning, joy and pleasure in the relationships they form with their patients and their families, while also experiencing difficult and painful emotions when these patients cannot be cured or significantly helped. 


Their analysis touched on pediatric neurosurgeons having a relational attachment to patients; forming bonds with the parents/caregivers of these patients; dealing with patient suffering, death and complications; and communicating bad news to parents. The interviews proved that pediatric neurosurgeons develop deep and enduring bonds with their patients and their families that are an integral part of what brings meaning and joy to their work and are one of the most significant emotional challenges of their careers. 


They argued that the training of specialists in this very demanding field should include courses on the relational and emotional dimensions of their work with a specific and dedicated focus on communicating bad news.


The doctor-patient relationship is one of the most important and meaningful aspects of practicing medicine, they wrote. “This is especially true within the field of pediatric neurosurgery where young patients face significant health challenges that may involve one or more brain surgeries over their lifetimes. The patient and their caregivers are required to put their trust and their child’s life in the hands of a neurosurgeon, who, in many instances, they may have just met.”


“A situation in which one person permits another to put him/her to sleep and operate on his/her brain reflects a deep sense of trust,” said one of the surgeons who was interviewed. “Even more extreme is the situation of parents consenting for their child’s surgery, which is against any parental nature to protect their child.”


Another colleague noted: “The most sacred part of what we do is our relationship with the patient. There is deep meaning, reward and satisfaction in that relationship.” 


Unlike other surgical specialties where children may be seen for a short period of time surrounding an operation, pediatric neurosurgeons maintain long-term relationships with their patients, as children are often followed in a clinic for many years after an operation and may sometimes undergo additional surgeries over

the years, the authors declared. “In this sense, pediatric neurosurgery may be more akin to pediatric oncology where children are treated for acute disease and then followed by the same oncologist until they are 18, and in some cases, well into adulthood.”


While no published research exists on the relational and emotional components of pediatric neurosurgery, “some studies within pediatric oncology have suggested that oncologists develop meaningful, caring, long-term relationships with the patients and the families they treat. This may also be true for pediatric neurosurgeons, though this has not been documented by empirical research.”


Since the surgeon-patient relationship is critical within pediatric neurosurgery and that little is known about this topic, the British Journal of Neurosurgery study focused on exploring the relational and emotional components of this bond from the perspective of practicing pediatric neurosurgeons in the field.


One of the 26 said: “I am very emotional in my work. I let my patients touch me. Because it puts meaning into our life. …I allow myself to be influenced by cases, to be influenced by families. I’ve cried in my life, not once, because of cases – because of crazy things that you see. You see the child now and you know where it’s going. … You’ve got to … laugh with patients. To cry. I try not with patients but, yes, to cry. “ 


This quote, wrote the authors, “reveals both the beauty and the pain of being a pediatric neurosurgeon…Pediatric neurosurgeons talked at length about the deep and enduring relationships they have with their patients over the course of their lifetimes. This bond was so deep, it was often described as akin to a parental relationship. On this one, neurosurgeon remarked: ‘Those are my kids. I bond with every patient. So every patient is like my child. I think about them,’ ” 


Another neurosurgeon said: “You have a much stronger emotional connection, I think, with your patients by virtue of … if you have children of your own or by extension, your nieces or nephews, grandkids, whatever, of a certain age, I think it creates a much stronger emotional bond to their whole investment to their well-being.” 


“One of the great things is that I get to follow my patients for the long term. Surgeons in general have short-term relationships. Maybe two thirds of my patients I’ve continued to follow now for up to three-and-a-half decades,” said another. “I’ve been privileged in my own pediatric neurosurgical circle practice that I don’t lose my patients when they hit eighteen. So I’m embedded in a unit in a general hospital such that I will continue to follow children with ongoing pediatric neurosurgical problems as adults.”


The oldest surgeon in the study with 40 years of experience in the field and with thousands of operations under his belt reflected on the experience of what it might be like to give your child over to brain surgery. “It’s amazing. A kid shows up, and I’m a stranger to them. We met yesterday, but he or she needs to be in the operating room the next day or on the same day…Yet, they put their entire trust on me.” 


While the attachment to patients and their families provided meaning and joy to the work that pediatric neurosurgeons do, the challenging side of these relational bonds was being involved with patients who suffer or die as a result of surgery. “I think it’s human nature to take things a lot harder when you either can’t do right by a child, you can’t prevent harm from coming to the child or – God forbid – you actually cause the harm yourself as a surgeon. I think it creates an emotional investment that’s a lot stronger than other sub-specialties. So that’s difficult –the only worse thing than not being able to save a child is to save a child that you’ve made disabled and rendered a poor quality of life,” confessed a surgeon. 


While neurosurgeons recognized that some deaths or complications were unavoidable, watching this suffering, or being part of a surgical event that may have led to a complication during surgery could produce feelings of tremendous guilt, self-doubt, and failure, sometimes even many years after the death of the child. 


A difficult part of the job is when you don’t have the answers for the family, as with a brain-stem tumor. The doctor has to tell parents that their child will survive for only a year or so. “You will be the person to tell them, and you need to listen, to encourage them, maybe it’s the only moment that I really talk about spirituality with them,” said another interviewee. “Because I can do nothing besides.” 


Surgeons described feeling apprehension and difficulty in either having to share the bad news or fear of disappointing the family when things did not go as planned.


It is vital to give neurosurgery residents the emotional and practical skills to be able to respond to these scenarios when they come up in their own careers. “It is possible that this training might also help mitigate the high levels of burnout among neurosurgeons,” the authors suggested.


To date, only one study on communication training has been published in the field of pediatric neurosurgery – pediatric neurosurgery residents from around the globe were provided with one-day training on communicating bad news using professional actors. Feedback was collected immediately after the training and three years later to assess both the short and long-term effects of this program. 


Most participants reported satisfaction with the training sessions and were interested in further education on the topic, indicating thirst for more knowledge and practice in these skills. “It is critical that any communication skills training program for pediatric neurosurgeons incorporates both the emotional and relational dimension of the interaction and give residents practical skills and the language in how to deliver bad news,” the Israel/Canadian team concluded. 


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