Learning the difficult tasks of caring for dying children

models; experience being the teacher and experience also inuring the doctor to the pain. Might it also be that senior doctors reading the questionnaire feel they ‘ought’ to be comfortable because they are senior? The word comfortable may have the wrong resonance for others. Comfortable is not the same as confident or competent. In fact, a doctor who feels comfortable may appear to the desperate family to be nonchalant and not communicating well. The family do not want the doctor to be comfortable. They want those caring for them and their child to be caring and competent. This is clearly the intention of the authors of this study. One is reminded that it is always wise to pilot a questionnaire with a few members of the target participant population to ensure that their understanding of the terminology accords with the researchers’ intentions. Before addressing what appropriate end-of-life care training might look like, it is worth taking a closer look at what this study found to be the impact of experience and the impact of education. Experience helped to improve comfort in some duties of paediatricians caring for the dying child, but they remained uncomfortable with others until some years later in their career. A pattern emerges. The times when experience failed to make paediatricians more comfortable were when there was the potential of conflict with their young patient’s family. These tasks included discussing options. One can imagine that a difficult experience involving conflict might only serve to highlight deficiencies and make a doctor feel less comfortable. Comfort did, however, increase with experience in the technical skills of prescribing at the end of life and confirming death. Likewise, prior education did improve comfort for this set of doctors in all except two tasks. One was managing the difficult family and here not even the most experienced paediatricians felt comfortable. The other was confirming The paper by Arzuaga and Caldarelli [1] in this issue illustrates the principle that in at least some aspects of medical education, being thrown in at the deep end is not the best way to learn to swim. They found that paediatricians can learn difficult things—in this study, to care for dying children—by experience, but for the most difficult aspects a lot of experiences are needed. The risk is that patients and their families can be harmed during this learning process. If families may be left scarred by the trainee’s mistakes, however much the trainee may learn from the experience, ‘One Chance to Get It Right’ [2] applies. It is therefore reassuring to find that prior education in end-of-life care doubled the comfort levels of trainee paediatricians with a set of difficult end-of-life tasks. Arzuaga and Caldarelli provide evidence that comfort levels correlate with competence. The conclusion is that education in end-of-life care accelerates the acquisition of competence; therefore, we need to ensure that we minimize harm by providing appropriate education. But comfort is an incongruous term in the context of tragedy and perhaps doctors never (and should never) become comfortable with some situations. Do we expect doctors helping a dying child plus family to ever say that they felt comfortable with these tasks? One can think of reasons for increased comfort as the years go by—discussions/debriefings helping to enhance coping mechanisms; watching role