MS2 Terrible Twos here. New to MiM, so here is a quick introduction. I am mom to a sweet nineteen month old boy who is into everything and lacks even the faintest inkling of self-preservation. In a former life I received a Bachelor's of Fine Arts from an art school here in the Bay Area, and worked for over a decade in advertising, marketing, corporate event design, apparel, and retail packaging design until I decided that pursuing a career in medicine was truly my dream. Thanks to a lot of hard work, a loving and patient husband, and tons of emotional support from friends and family, that dream has materialized and I am (as of last week) a second year medical student in the Bay Area in California.
Having just completed MS1, one of the most challenging aspects of the medical curriculum this year has been seeing through the text books, algorithms, power points, Quizlets, acronyms, mind maps, case studies, and patient vignettes and remembering that the purpose of all this learning is to support real, actual people with rich histories and complex emotions. The majority of my patient interactions feel so forced and so awkward – so robotic, scattered, and disjointed. I hear standardized patients describe their symptoms and feel myself responding stoically, without empathy to concerns like, “is this serious?”, or "am I going to die?" as I systematically wade my way through OLD CARTS and FED TACOS and remember what a relevant ROS might include for the few differentials I know to consider.
Throughout every standardized patient interaction, every practical exam, and even every time I have performed an H&P on a "real" patient in my school's student run free clinic, I feel as though what limits me from truly developing any sort of rapport with the patient in front of me, actual or standardized, is the tunnel vision that comes from trying to dot every i, cross every t, and check off each and every box on the syllabus.
I understand that there is a learning curve with all of this. As with many professional practices, the only way to get better at them is by doing them over and over again and I recognize that I'll be working toward that for the rest of my medical career. I suppose that what worries me is the fear that throughout my medical practice there will always be a syllabus to consider, be it a QI evaluation report, an insurance audit, filling in every blank on the EMR, or tending to some other system to which I am held accountable.
I would like to believe that all the the awkwardness of MS1 will start to subside as early as this summer when I volunteer at the free clinic -- that the relief of having completed one full year will allow me to relax a little and try to integrate the systematic thinking of MS1 into just another part of my experience and knowledge. My hope is that the breadth of my other experiences prior to coming to medical school, including being a mother, will begin to materialize within those interactions, allowing me to truly connect.
When did it happen for you? When do patients, even standardized ones, cease to present solely as a collection of their signs and symptoms and emerge as actual people, and what tools have you used to transcend the awkwardness of your early medical training?
Showing posts with label empathy. Show all posts
Showing posts with label empathy. Show all posts
Monday, June 6, 2016
Monday, February 29, 2016
Because I Hated Every Second of Breastfeeding
Genmedmom here.
There have been many times when I have struggled to empathize with the patient. There are certain healthcare issues, and certain patients, that I have found consistently frustrating over the years.
I've written about this, and been pretty well chastised by readers. I don't mind, because I know that 99% of physicians have their kryptonite issues, and just don't talk about it. I'll take the heat for being honest.
My kryptonite issue has been obesity. I admit, that for many a patient encounter, I've sat there and counseled (for the millionth time) on diet, and exercise, and priorities, and wondered to myself: Why can't you do this? Why can't you just lose weight?
I know that sounds terrible. Heck, it IS terrible. My bias is based on my own experience: I gained sixty pounds in my first pregnancy, and fifty in my second. The weight didn't come off postpartum, and I found myself obese. BMI 30. I dedicated what precious little time I had as a working mom to eating healthy and exercising, and I lost it all. It took two years. It was hard. There were ups and downs. I've written endlessly about it here, and here, and here....
Of course I know that it is totally and utterly unfair to think "Well, if I could do it, why can't you?" but truth is, that's a pretty natural way to think, and many of us think like that.
So I've been making a conscientious effort to do better, to let go of the bias, and the frustration, and meet people where they are, no matter what the medical issue is.
But it was only when I was sitting with a lovely young patient of mine who was upset, grieving, actually, that she had been unable to breastfeed her infant, that I had a real breakthrough.
This poor woman had had a complicated pregnancy and delivery. Nothing had gone the way she had planned. But she held on and held it together, because she knew that if her baby survived, she would do everything right. She would take THE BEST care of this baby. She was determined to breastfeed for a full year. It had never occurred to her that that might not happen.
There were problems with the latch, with the milk supply, with pain, with baby's growth. Still, she was determined. She got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera... for weeks.
But one day when she had spent an hour and a half with the industrial-grade pump and got only about a teaspoon of breastmilk, with her nipples raw and bleeding, with her infant screaming, starving, with the pediatrician's concerns about his growth, with her consultants saying "Just push through! Keep trying!" for the gazillionth time but without any other real suggestions, and without any progress, she broke down.
She gave up.
So the baby got formula. And did fine. And grew. And she thought this burden was lifted from her.
Until the judgments came.
She was part of a social circle that especially valued breastfeeding. Friends and family would comment, say, "Don't you know breast milk is best?" or "Well, if you had only tried X, I bet it would have worked" or "If you had only HUNG ON a little bit longer" or "Those doctors pushed you towards formula, those doctors always push the formula, you shouldn't have listened" et cetera, et cetera.
It got to the point that she hid bottles and formula, or avoided socializing altogether. She felt like a freak, a failure. She worried what awful consequences there might be for her baby. She waited for some severe illness to befell her son, and for someone to blame it on her.
Oh, my heart went out to her.
Flashback. I was pregnant with Babyboy (now five and a half years old). I had a three-page birth plan outlining my natural vaginal delivery. I had a doula. I had Ina May's books on childbirth and Nancy Mohrbacher's books on breastfeeding. I had secured a highly-rated lactation consultant and booked a consult with her BEFORE the baby was born. I bought Medela breastmilk bags and a plastic organizer for the freezer. I arranged a breastfeeding room in my office.
But there were complications. The delivery- that's a story for another day. Emergency C-section for deep transverse arrest. Bradycardia. Meconium. Mayhem. I was discharged with a hematocrit of 22.
Babyboy was fine, but I grieved the loss of my dream birth. I was determined to get breastfeeding right: I wanted to breastfeed for a full year.
But. There were problems with the latch, with the milk supply, with pain, with baby's growth. I was still determined. I got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera.
Miraculously, I was able to breastfeed for a full three months.
But, I hated every single second of it.
When it got close to feeding time, I would inwardly cringe. With his latch, I would outwardly gasp, and clench my teeth in pain. The doula and the lactation consultants gave up on me. It was a nurse practitioner at Babyboy's pediatrician's office who suggested APNO (All-purpose-nipple-ointment), and it was an OB/GYN who prescribed it for me. The APNO cream helped a bit, and it got me through the three months, though nothing really helped.
Inevitably, what would come to mind with EVERY feeding were images:
Of glass-shard covered twine being pulled out of my breasts through my nipples.
Of someone pouring acid over my areolae.
Of my baby with little piranha teeth and malevolent intentions.
Oh, I hated it, and I hated myself for hating it. Wasn't breastfeeding supposed to be this wonderful bonding experience? I would rock and cry, literally cry, while stroking my baby's forehead and begging forgiveness, because I could not WAIT for this to be over.
So when it came time to go back to work, I started on a combined oral contraceptive and took Benadryl, and let that milk supply dry right up. Worked like a charm. I was done. It was such a relief.
When I told my colleagues I would not be needing that breastfeeding room, I got some eyebrow raises, but no one questioned. Many of them had made similar decisions for different reasons.
Most of my friends were understanding (very different social circle from my patient-mom) and for that I was very grateful. As a matter of fact, people came out of the woodwork with their own breastfeeding difficulty stories. I was not only NOT the only person who had struggled, I was not the only person who hadn't enjoyed it, and I was not the only person who had guilt about that.
Yes, there were a few "judgy" moments. People I didn't know well, and luckily didn't give a rat's ass about. A lady at book club gathering, a friend of a friend.
But my patient, my poor patient. Her "support network" was annihilating her. I was outraged on her behalf. I wanted to reassure her.
So I shared my own story with her, and we discussed ways to manage the hurtful comments and avoid the negative people.
For doctors, sharing our own stories and feelings about medical issues with patients is a tricky thing. Sometimes it's appropriate, sometimes it's not, and sometimes it's a mixed bag. In this case, the patient expressed relief and gratitude. She had been initially expecting me to judge her, too, she said. She was so glad to have found validation, reassurance and open discussion instead.
That's when I had my breakthrough: The patient had been expecting me to judge her, and had instead found validation and reassurance.
Wow. THAT is what I need to bring to EVERY patient encounter. Validation, reassurance, open discussion. Because that is what I would want for me, as well. It's what I want to be able to provide for everyone, especially my patients.
There have been many times when I have struggled to empathize with the patient. There are certain healthcare issues, and certain patients, that I have found consistently frustrating over the years.
I've written about this, and been pretty well chastised by readers. I don't mind, because I know that 99% of physicians have their kryptonite issues, and just don't talk about it. I'll take the heat for being honest.
My kryptonite issue has been obesity. I admit, that for many a patient encounter, I've sat there and counseled (for the millionth time) on diet, and exercise, and priorities, and wondered to myself: Why can't you do this? Why can't you just lose weight?
I know that sounds terrible. Heck, it IS terrible. My bias is based on my own experience: I gained sixty pounds in my first pregnancy, and fifty in my second. The weight didn't come off postpartum, and I found myself obese. BMI 30. I dedicated what precious little time I had as a working mom to eating healthy and exercising, and I lost it all. It took two years. It was hard. There were ups and downs. I've written endlessly about it here, and here, and here....
Of course I know that it is totally and utterly unfair to think "Well, if I could do it, why can't you?" but truth is, that's a pretty natural way to think, and many of us think like that.
So I've been making a conscientious effort to do better, to let go of the bias, and the frustration, and meet people where they are, no matter what the medical issue is.
But it was only when I was sitting with a lovely young patient of mine who was upset, grieving, actually, that she had been unable to breastfeed her infant, that I had a real breakthrough.
This poor woman had had a complicated pregnancy and delivery. Nothing had gone the way she had planned. But she held on and held it together, because she knew that if her baby survived, she would do everything right. She would take THE BEST care of this baby. She was determined to breastfeed for a full year. It had never occurred to her that that might not happen.
There were problems with the latch, with the milk supply, with pain, with baby's growth. Still, she was determined. She got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera... for weeks.
But one day when she had spent an hour and a half with the industrial-grade pump and got only about a teaspoon of breastmilk, with her nipples raw and bleeding, with her infant screaming, starving, with the pediatrician's concerns about his growth, with her consultants saying "Just push through! Keep trying!" for the gazillionth time but without any other real suggestions, and without any progress, she broke down.
She gave up.
So the baby got formula. And did fine. And grew. And she thought this burden was lifted from her.
Until the judgments came.
She was part of a social circle that especially valued breastfeeding. Friends and family would comment, say, "Don't you know breast milk is best?" or "Well, if you had only tried X, I bet it would have worked" or "If you had only HUNG ON a little bit longer" or "Those doctors pushed you towards formula, those doctors always push the formula, you shouldn't have listened" et cetera, et cetera.
It got to the point that she hid bottles and formula, or avoided socializing altogether. She felt like a freak, a failure. She worried what awful consequences there might be for her baby. She waited for some severe illness to befell her son, and for someone to blame it on her.
Oh, my heart went out to her.
Flashback. I was pregnant with Babyboy (now five and a half years old). I had a three-page birth plan outlining my natural vaginal delivery. I had a doula. I had Ina May's books on childbirth and Nancy Mohrbacher's books on breastfeeding. I had secured a highly-rated lactation consultant and booked a consult with her BEFORE the baby was born. I bought Medela breastmilk bags and a plastic organizer for the freezer. I arranged a breastfeeding room in my office.
But there were complications. The delivery- that's a story for another day. Emergency C-section for deep transverse arrest. Bradycardia. Meconium. Mayhem. I was discharged with a hematocrit of 22.
Babyboy was fine, but I grieved the loss of my dream birth. I was determined to get breastfeeding right: I wanted to breastfeed for a full year.
But. There were problems with the latch, with the milk supply, with pain, with baby's growth. I was still determined. I got the hospital lactation consultant and a private lactation consultant and every breastfeeding book on Amazon and drank Fenugreek tea et cetera, et cetera.
Miraculously, I was able to breastfeed for a full three months.
But, I hated every single second of it.
When it got close to feeding time, I would inwardly cringe. With his latch, I would outwardly gasp, and clench my teeth in pain. The doula and the lactation consultants gave up on me. It was a nurse practitioner at Babyboy's pediatrician's office who suggested APNO (All-purpose-nipple-ointment), and it was an OB/GYN who prescribed it for me. The APNO cream helped a bit, and it got me through the three months, though nothing really helped.
Inevitably, what would come to mind with EVERY feeding were images:
Of glass-shard covered twine being pulled out of my breasts through my nipples.
Of someone pouring acid over my areolae.
Of my baby with little piranha teeth and malevolent intentions.
Oh, I hated it, and I hated myself for hating it. Wasn't breastfeeding supposed to be this wonderful bonding experience? I would rock and cry, literally cry, while stroking my baby's forehead and begging forgiveness, because I could not WAIT for this to be over.
So when it came time to go back to work, I started on a combined oral contraceptive and took Benadryl, and let that milk supply dry right up. Worked like a charm. I was done. It was such a relief.
When I told my colleagues I would not be needing that breastfeeding room, I got some eyebrow raises, but no one questioned. Many of them had made similar decisions for different reasons.
Most of my friends were understanding (very different social circle from my patient-mom) and for that I was very grateful. As a matter of fact, people came out of the woodwork with their own breastfeeding difficulty stories. I was not only NOT the only person who had struggled, I was not the only person who hadn't enjoyed it, and I was not the only person who had guilt about that.
Yes, there were a few "judgy" moments. People I didn't know well, and luckily didn't give a rat's ass about. A lady at book club gathering, a friend of a friend.
But my patient, my poor patient. Her "support network" was annihilating her. I was outraged on her behalf. I wanted to reassure her.
So I shared my own story with her, and we discussed ways to manage the hurtful comments and avoid the negative people.
For doctors, sharing our own stories and feelings about medical issues with patients is a tricky thing. Sometimes it's appropriate, sometimes it's not, and sometimes it's a mixed bag. In this case, the patient expressed relief and gratitude. She had been initially expecting me to judge her, too, she said. She was so glad to have found validation, reassurance and open discussion instead.
That's when I had my breakthrough: The patient had been expecting me to judge her, and had instead found validation and reassurance.
Wow. THAT is what I need to bring to EVERY patient encounter. Validation, reassurance, open discussion. Because that is what I would want for me, as well. It's what I want to be able to provide for everyone, especially my patients.
Sunday, August 29, 2010
The empathy toggle switch
In our clinical years, our medical school has instituted a program in which we do learning modules along with our in hospital experience and didactics. I was happy to see a module on empathy for my second month of surgery. The last question to be answered in this module was: "Although the studies on empathy are very consistent other authors have indicated that medical students are really not losing cognitive empathy, rather they are learning to engage in a “toggle switch” approach to patients where one side of the switch is “associated with the patient” and the other is “disassociated from the patient” which is necessary in order to perform medical procedures. Please discuss this and use example which you have seen or in which you have been involved."
Here is my answer:
I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.
I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.
I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.
After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.
I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.
Cross posted at Mom's Tinfoil Hat
Here is my answer:
I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.
I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.
I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.
After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.
I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.
Cross posted at Mom's Tinfoil Hat
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