Exposure, constraint, and repair: How child abuse pediatrics fellows navigate strain and restore purpose

Background Child Abuse Pediatrics (CAP) fellows train in a subspecialty marked by repeated exposure to child maltreatment and high-stakes clinical and legal demands. Objective This qualitative study examined how CAP fellows describe and make meaning of emotional strain and restorative experiences during training. Participants and setting Participants were 13 fellows enrolled in U.S. CAP fellowship programs, all practicing in urban settings. Methods Semi-structured interviews were conducted via Zoom between May and August 2024 and analyzed using reflexive thematic analysis. Vicarious resilience sensitized the analysis to restorative experiences; the job demands-resources model informed interpretation after themes were constructed. Results Three themes were constructed. Carrying What Cannot Be Left Behind described secondary traumatic stress as an accumulating presence that affected relationships and prompted protective silence. Procedural Continuity, Eroding Presence captured accounts of emotional numbing, constrained agency, and cumulative exposure that strained emotional presence even as fellows described continuing clinical tasks. When the Work Gives Back described how children's recovery, family recognition, and perceived accountability renewed meaning. Conclusions Fellows linked strain and restoration to exposure, supervision, and opportunities for recovery. Their accounts identify workload organization and supervisory support as areas for evaluation alongside individual coping.