Steve Server // A critical part of pediatrics is mastering the physical exam. Kids are squirmy. They aren’t used to tolerating noxious stimuli—like instruments in ears or cold metal on skin—like adults are. Consequently, seasoned pediatricians have a box full of tricks to make for effective physical examinations for kids. Don’t rush immediately to place a stethoscope right over the heart; rather, work slowly up to it by placing the tool on the child’s knee or a parent’s hand to demonstrate that it doesn’t hurt. Let the child hold the stethoscope, listen to her own heartbeat.
As one spends time in the pediatric clinic, they discover more and more the centrality of play in anchoring the pediatrician/patient/family relationship. Play is viewed as so vital to child development that the United Nations High Commission recognized play as a fundamental human right of every child. In 2007, the American Academy of Pediatrics published a white paper representing a full-throated defense of play as central to child life:
Pediatricians can promote free play as a healthy, essential part of childhood. They should recommend that all children are afforded ample, unscheduled, independent, non-screen time to be creative, to reflect, and to decompress. They should emphasize that although parents can certainly monitor play for safety, a large proportion of play should be child driven rather than adult directed (Ginsburg).
“Children’s developmental trajectory,” the authors write, “is critically mediated by appropriate, affective relationships with loving and consistent caregivers as they relate to children through play”; parental participation in play helps “tell children that parents are fully paying attention to them and help to build enduring relationships” (Ginsburg).
This positioning of pediatricians as guardians of play is supported by about a century of research into the positive benefits of play in the life of the child. Famed developmentalist Jean Piaget wrote in his 1951 work, Play, Dreams and Imitation in Childhood, that play “provides the child with the live, dynamic, individual language indispensable for the expression of [the child’s] subjective feelings for which collective language alone is inadequate” (Piaget 166). That is, play grants a vocabulary for the child to express their inner life when their linguistic and emotional skills are not yet capable of expressing themselves. It also permits children to engage in reality-testing in a low-stakes situation: as written in the American Journal of Play, “Fantasy play gives children a sense of power and mastery that is not possible in their real world, resulting in an increased ability to regulate affect, reduce aggression, and generate positive feelings” (Homeyer 212).
Research around play has led to wonderful developments in the way that we help care for children within medicine. Child Life Professionals have a large role to play in both adult and pediatric hospitals across the country, as they “provide evidence-based, developmentally and psychologically appropriate interventions including therapeutic play, preparation for procedures, and education to reduce fear, anxiety, and pain” for children (Association of Child Life Professionals). Devices such as “Buzzy”—a bee- or ladybug-shaped vibrating cooling pack—have been developed to help children cope with pain and procedures (Buzzy). Hospitals have developed apps such as “Simply Sayin’” which assist clinicians in explaining medical procedures to children in a non-intimidating, non-jargon filled manner (Simply Sayin’). Play has become an integral part of therapeutic interactions with children—we have come a long way from the era in which parents were not permitted to stay overnight with children in their hospital rooms.
Play is most often considered the provenance of childhood, and for good reason: play is an activity that is developmentally intrinsic to childhood. It is what children tend to do in their natural state. Scholars have established definitions of play which render them highly child-specific: in 1955, cultural historian John Huizinga contended that play was unconnected to material interest and without profit motive (Huizinga 13); others have argued that play is an intrinsically motivated activity, means rather than ends oriented, free from externally imposed rules (Rubin). That is easier for children to do, when not burdened by the demands of “adapting to adult roles” as the AAP puts it (Ginsburg).
But what if the power of fantasy can be leveraged in medical care more broadly? My contention is that keeping the therapeutic value of play in mind is something that can be valuable for physicians caring for patients across the life cycle.
Indeed, much of what under-girds the benefit of narrative medicine approaches seems to be the spirit which animates play—namely, the lower-stakes exploration of an unfamiliar reality. Surgeon and surgical ethicist Gretchen Schwartze has developed a program for improving informed consent prior to surgery known as “Best Case/Worst Case”. It involves discussing surgical procedures with patients in terms of vivid narrative constructions of possible outcomes, rather than the conventional statement of risk in terms of percentages, in the hopes of assisting doctors and patients make decisions more congruent with patient values (Best Case/Worst Case). The strength of the program is that it paints vivid pictures for patients and families alike in a way which permits the mastery of an unfamiliar domain—namely, the likely outcomes of surgical intervention—in a lower stakes situation than creating active suffering for a patient after a surgery has already been performed.
A week ago, one of my classmates and I spent some time with a geriatrics patient walking her through the process of planning for end-of-life care. We had an open conversation regarding what our patient would like the end of her life to look like when the end ultimately was imminent, which transcended discussion of the medical considerations of Do Not Resuscitate/Do Not Intubate (DNR/DNI). Would she like to be at home when she died? Would she like specific prayers to be read? Would she like any particular music to be played? This was not play as defined by previous scholars—there was an immediate material interest to our conversation. But nevertheless, one could describe it as “playful,” given that we were exploring a fantasy together in the hopes of mastering a part of reality yet unfamiliar—the edge of death. Together, we walked through a future-yet-to-be to see how she might feel about it, to grant her future-self a “power and mastery” that maybe denied her at the time by virtue of her critical illness.
Overall, then, the benefits of play which have led to better conditions for children throughout the medical system may, in fact, lead to concrete benefits for older adults as well. For non-physicians, the medical world is an unfamiliar and overwhelming place, whose underlying physics are not always apparent. Playfulness may help children and adults alike to deal with this stress and make better decisions more congruent with their wishes. If we permit ourselves as providers to think of play as a fundamental human activity, then we may sow the seeds of a more productive, more empathic doctor/patient relationship.
Image: “Child on obstetrical table.” US National Library of Medicine. http://resource.nlm.nih.gov/101448886
“Best Case/Worst Case (BC/WC) SURGEON Communication Tool.” YouTube. https://youtu.be/FnS3K44sbu0.
“The Child Life Profession.” Association of Child Life Professionals. https://www.childlife.org/the-child-life-profession/.
Ginsburg, K. “The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bonds.” American Academy of Pediatrics, 2007.
Homeyer, Linda, E. “Play Therapy: Practice, Issues, and Trends” . American Journal of Play (2008) 1: 212.
Huizinga, J. Homo Ludens: A study of the play-element in culture. Boston, MA: Beacon Press, 1955.
Piaget, J. Play, Dreams and Imitation in Childhood. New York: W. W. Norton & Company, Inc, 1962.
Rubin, K. H., Fein, G. G., & Vandenberg, B. “Play.” In P. H. Mussen, & E. M. Hetherington (Eds.), Handbook of child psychology (Vol. 4, pp. 693–774). New York, NY: Wiley, 1983.
“Simply Sayin’: Medical Jargon for Kids,” Phoenix Children’s Hospital Child Life.