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It started with a kiss
  1. Nicola Kerruish1,
  2. Lynley C Anderson2
  1. 1Department of Paediatrics and Child Health, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand
  2. 2Bioethics Centre, University of Otago, Dunedin, New Zealand
  1. Correspondence to Dr Nicola Kerruish, Department of Paediatrics and Child Health, University of Otago, Dunedin School of Medicine, Dunedin 9013, New Zealand; nikki.kerruish{at}

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A medical student attempting to carry out a procedure such as inserting a cannula within a paediatric setting faces complex issues. First, because the student lacks experience, he/she will understandably be nervous about carrying out the procedure. This is true for medical students in every clinical setting, but these feelings may be heightened in the paediatric context because the procedure may be technically more difficult and the child patient possibly unaware of the need for learning or the inexperience of the operator. Second, the student will be conscious that they are being observed by the child's parents, who while probably aware of the student's inexperience and supportive of learning goals, will also be anxious to minimise their child's distress.

Reflection on ‘difficult cases’ is a key component of a medical student's life, and this ideally continues post graduation. In this case, the student rightly suggests that the incident described may seem trivial to many, but we applaud the decision to submit the paper, as it highlights some important issues.

The student has also correctly identified that the child's distress was felt by all in the room, not least by the student themselves. The student in such a situation might understandably and appropriately wish to take action to reduce this distress. As they point out, this is part of ‘human nature’. Such qualities are also key aspects of being a competent paediatrician (or trainee), indeed the American Academy of Pediatrics lists ‘compassion/empathy’ as one of the important principles underlying professionalism in paediatrics.1

While we acknowledge that it appears that no actual harm was caused in this particular case, we argue here that the course the student took in attempting to address these multiple sources of distress was flawed. First we explain why we consider a kiss to be an inappropriate response, and then propose an alternative.

Why not a kiss?

In this case, the student instinctively moved to give the child a kiss to ‘comfort him and perhaps mend the evil impression’. But here we might pause and ask whose needs are being met by this action? Will a kiss ease the child's distress, or is it done to ease the distress felt by the student?

In one sense, a kiss is easy to understand, as being a ‘touch with the lips’. But in reality the concept is much more complex and culturally bound. Depending on culture and context, a kiss can express sentiments of love, passion, romance, sexual attraction, affection, respect, greeting and friendship, among many others. Views regarding kissing may also evolve over time and at present, kissing is not universal and seen as improper in some societies.2 This complexity means that the act of kissing may easily be misunderstood. While the student may be clear what they were trying to convey with the kiss, the assumption that the child and his parents view it in the same way may be incorrect. Consequently, while the kiss may have alleviated the student's distress, it runs the risk of not doing so for the child and family, and potentially even making matters worse. The compassion and empathy that underlie professionalism in paediatrics necessitate distinguishing between one's own distress and the child's, and responding to children and families' reactions from their point of view, rather than that of the student or clinician.1

An alternative approach

We consider first the issue of the child's distress. The importance of good management of procedural pain is now well established in paediatrics, not least because the cumulative effects of these painful experiences can result in long-term adverse psychological outcomes for both child and family. Such management generally involves a multimodal approach that combines pharmacological and non-pharmacological interventions during three distinct phases of a medical procedure: before, during and after. Many major teaching hospitals, such as the one where the student was performing this procedure, have their own policies and guidelines concerning this important issue; an excellent example is those developed at the Royal Children's Hospital in Melbourne.3 The student in this case made reasonable attempts to consider such issues, by enlisting help and support, and recognising the importance of easing the child's distress after the failed procedure. However, both the acute situation, and the student's learning and future practice, could arguably have been enhanced through more formal consideration of these practices prior to attempting cannulation.

Turning now to the distress felt by the student; such distress is not unexpected and should not be ignored. The distress may arise because the student feels responsible for the level of pain and discomfort experienced by the patient; the student may also feel that a more experienced clinician would have been successful, thereby compounding feelings of inadequacy. Students may also consider that, but for their own learning needs, the young patient would not have suffered. Causing pain in order to learn is a well-known source of discomfort for medical students. The issue becomes how students should respond to such feelings.

Clinical medical students trained in reflective activities will have avenues available to discuss these concerns. Reflection is defined as ‘a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters’.4 By writing about a difficult situation, perhaps where emotions are high, the student can think about the features that made the situation difficult, what emotions they felt, why they responded as they did, and what they might learn from the situation.

Reflective writing assists the writer by putting the distress caused by the situation described within a broader perspective of their learning. Getting their thoughts down will bring a new depth to their understanding of themselves and how they relate to others and to similar situations. Other reflective strategies such as de-briefing with nursing staff, effective peer mentoring and supervision provide the student with a safe place to discuss their fears and concerns, allow the student to realise they are not alone and hopefully provide the student with the support and confidence required to give the procedure another try on a different occasion.


Easing distress associated with procedures in paediatrics is an important issue. We advocate an organised approach to procedural pain management to prevent and alleviate suffering for the child and family, and reflective practices to address the student's concerns. Kissing paediatric patients is not recommended, as the underlying complexity of this act means it may easily be misunderstood.


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  • Contributors Both authors made substantial contributions to the paper.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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