"The Most Difficult Conversations We Have": Resident Experiences With Pediatric Neuroprognostication

Pediatric neuroprognostication is often complicated by uncertainty and embedded in high-stakes medical decisions. For child neurology residents, participation in neuroprognostication can represent key learning experiences but also comes with emotional and ethical challenges, which poses a risk of moral distress. This study sought to describe contextual influences and impacts on residents participating in neuroprognostication.

One-on-one, semi-structured virtual interviews were conducted with senior (postgraduate year 5-6) child neurology residents. Deidentified transcripts were iteratively analyzed to develop themes and generate a narrative of resident experiences. Initial themes were shared with participants for additional feedback. Final themes were synthesized to characterize contextual influences and the emotional and professional impacts of participating in neuroprognostication.

Fifteen residents from 12 institutions across 10 states participated, representing a range of program sizes and geographic locations across the United States. Qualitative analysis identified five themes: (1) Serious neurologic pathology and decisions with high stakes, highlighting neurology teams' roles in major medical decisions; (2) Navigating uncertainty and hope, describing the difficulty of limited data; (3) Systemic barriers and challenges to prognostic communication, underscoring team- and institution-level factors; (4) Negative emotional impacts, with concerns of developing emotional exhaustion; and (5) The importance of neuroprognostication, emphasizing the gravity of this responsibility and distress when residents felt ineffective in this role.

Residents describe neuroprognostication as an emotionally salient experience carrying a strong sense of responsibility. This narrative highlights opportunities to support residents in training, improve prognostic communication, and address potential threats to resident well-being.