The Apprenticeship

No! Surely not. Retirement? That's for other people, not you. You are supposed to practice forever… to always be around! On hearing this news, I flash back to our earliest conversations, years ago, so pivotal in my career trajectory. Years of hospital medicine behind me, now an advanced trainee immersed in the multifaceted, murky world of developmental and behavioural paediatrics. Looking at my cases through the lens of the medical model. Agitation rising as the inadequacy of this approach was repeatedly laid bare. Problem➔ Diagnostic checklist ➔ Diagnostic Label ➔ Treatment ➔ Problem solved. It just didn't seem that simple to me. It isn't, you confirmed. You need to think differently. Hold on to your roots in physical medicine. These skills were hard won and will always be valuable. Keep them in the tool kit. But to practice well in developmental paediatrics, you will need to add a lot more tools. And with that, the shackles were released, as I knew in my heart they needed to be. A new apprenticeship had begun. Deconstructing all I thought I knew was anxiety-provoking. In making it through the clinical exams in paediatrics, I believed I'd scaled the heights. Turns out I was still in the foothills. Yet the rebuild was fascinating. Exhilarating. Ongoing! Learning to see, and help, at multiple biopsychosocial levels, with positives as well as difficulties in focus. Developing an armament of interviewing skills. The most dependable of all our instruments. Deployed with the power of human connection. A force forever out of reach of a sterile checklist or soulless AI bot. Sewing together a patchwork quilt of developmental and psychological domains, to help decode and describe a child's development, learning, emotions and behaviour. Making a habit of examining a child's ecosystem, and wondering how I might be able to influence the various components to their best advantage. Establishing a process for navigating grey zones. The ever-present uncertainty. Thereby avoiding a knee jerk default to the faux surety of diagnostic labels and prescribed fixes. A framework for multimodal intervention was constructed, as an inseparable corollary of assessment. It's all very well to fuss over what to call something. Make sure to ask the bigger question—what things may best aid my patient's development? And so for the “difficult” child, the “hyperactive” child, the “struggling” child, I began to see bigger pictures. The underlying learning and regulation challenges, the anxiety, the damaged morale, the pressure cooker of school life, the state of relationships at home. Best of all, I learned to look past problems, and allow strengths and possibilities to come into focus. I was challenged to develop a model of practice that might address these bigger pictures for each case. Not just pay lip service—to really do it. No going back once I walked through that door. Thank you for opening it. Beyond the doorway, a career-long journey to improve my ways of doing the work. Further developing a framework for case formulation that is fit for purpose in developmental paediatrics. Collating a flavoursome assortment of clinical approaches, with bite-sized elements delivered right there in the quiet confines of the consulting room. Practical, solution-focused problem solving. Guidance on the highly-recommended, the worth-a-try, the don't-waste-your-time, the avoid-at-all-costs. Facilitating reflection, for parents and children alike. Coaching on ways to build skills. To harness and enhance strengths. Empowering, through the distillation of knowledge. Consoling. Providing hope. A fascination with family dynamics was ignited during the apprenticeship, and continues to burn. Comprehending how situational factors and patterns of interaction can exacerbate or even cause a child's difficulties. How we can draw attention to these, and catalyse change where feasible. How the protective factors can be recognized, supported, enhanced. Family-centred practice? We have to walk the walk in developmental paediatrics. All the while utilizing, not abandoning, my training in physical medicine and neurological disability. Thinking broadly about physical health. Judicious use of medical treatments, where indicated, but not on demand, not as a reflex, and not as the only offering. On this learning expedition, I've been lucky to have had other outstanding role models for company. A conglomerate of skills and personalities. A unique perspective from each added to the mix. All of these additional pillars of clinical practice constructed upon the firm foundations of the apprenticeship. **** You warned there would be resistance to implementing this more expansive approach to developmental paediatrics. Systems in which we operate constantly defaulting to reductionist views of our role. Hurry up! Get through that waiting list! Inordinate value placed on simplistic responses. We just need a diagnosis! We just need medication! Not easy to maintain a broad approach in this transactional atmosphere. Timely infusions of encouragement helped to reset a course when my sense of direction wavered, especially in the early years. Acknowledge the pressures, then find a way to do it anyway, it will be worth it. It was. A framework of a multilevel diagnostic formulation and multi-modal management made sense early in the apprenticeship. The benefits became increasingly apparent in the years that followed. Stronger therapeutic relationships, more coherent and realistic explanations, a multiplier effect on intervention. It took a decade or more, however, to really feel the full power. To truly understand the unique value a paediatrician with a well-stocked developmental and behavioural toolbox can add over time. By walking alongside the families. Actually participating in the longitudinal care for neurodevelopmental conditions. Changing it up as we go, depending on stage and need. Minimizing harm, maximizing capacity. So many possible ways to help along the way! How thrilling it is to witness the slow-burning turnaround, the gathering of momentum, the emerging sense of confidence and belonging. Enormous compounding returns on incremental investments. The nuances may be invisible to KPI counting bureaucrats… but not to the families. Not to the kids. **** Mentors are such precious assets in medicine. A behind the scenes role of course. Official recognition inversely proportional to importance. With the responsibility comes the joy. Passing on something of value to a bright and talented up-and-comer. What a privilege it is! In developmental paediatrics, it all starts with validating that inner voice—the one that compels a trainee to look beyond simplistic linear algorithms. Helping an early-career colleague to see greater value in their own strengths, and how these might energize their future, and the care of those they consult. The ability to “think psychologically”. The passion for unravelling complexity. The patience to play the longer game. The drive to stick up for the underdog. Helping them to recognize the calling. It is no accident they have been drawn to this field. Confessing to one's own fallibilities helps. None of us will ever reach perfection across all aspects of developmental paediatrics. Sure has been fun, the trying to get better! The message—perfection may be unattainable, but excellence is within your grasp. As experience accumulates, we must tell the stories! Nothing crystallizes the learnings better than a broadcast from real life. Best of all, the accounts of practice highlights. Expectations exceeded, against-the-odds fightbacks, returns on investment, advice heeded, a difference made. Let us habitually shift our gaze toward the peaks of potential. For our patients, and for ourselves as specialists in the field of developmental paediatrics. We are the firestarters. As supervisors, as mentors in developmental paediatrics, we can issue an invitation to a grand traverse of biopsychosocial domains. For the next generation, for the curious and willing, a rich professional life awaits. **** Meanwhile, my own learning continues. Plenty of expertise potholes still to be filled. Strengths to be taken further. Shiny new things to try out. Just so you know—your teaching is still keenly felt. Early career mentorship may have morphed into friendship and collegiality, but it's all still there, you see. All that you have passed on, inscribed in my memory, accessible at any time of need. You have illuminated the possible, and I thank you for this wonderful gift. The author has nothing to report. The author declares no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.