On the first day of my first obstetrics rotation as a medical student, I got to attend a birth. I was assigned to shadow one of the staff obstetricians. We waltzed in unannounced to the room of a labouring woman, who was pushing, feebly, ineffectively, with her feet in stirrups, legs encased in drapes. The doctor turned to me and rolling his eyes said, “At this rate, we could be here all day. Nurse, get me a pair of forceps.” And then, for what seemed to be no reason at all, other than impatience, he pulled the baby out. It was awful and I remember feeling terrible for everyone….the mother and her baby, the nurse who had to “obey” and for myself for having to bear witness to this thing.
What did I do with those feelings? Did I report this behaviour to the proper authorities? No, I certainly did not. It was clear to me that this was how it was going to be, that shocking things like this were – shockingly – forbidden to be viewed as shocking at all. The way everyone else around me was acting it seemed to be the expected norm. The staff doctor was my boss, and he was at least in part responsible for my grade during that rotation. I was in no position to complain.
To be fair to the obstetrician, as a student, I didn’t understand everything that was going on. It could have been that there was some other reason to deliver the baby that way that I didn’t fully appreciate. Maybe the fetal heart rate tracing wasn’t optimal. Still. I’ve had many other experiences of the same kind in my training and beyond, enough to know that this kind of casual approach to violent events is commonplace.
By looking at me and speaking to me in that way, including me as a sort of a peer… “we could be here all day” ….. I was being asked to take sides. It was as if I was being groomed for something. Grooming can be quite flattering. You don’t want to speak out because you are afraid of being humiliated. This doesn’t change the fact that you are complying with the abuse of women. But you are complicit in an act of oppression for the same reasons everyone complies with oppression, because you are weighing the risks and the benefits of non-compliance. You are performing complex calculations in your head, below the level of your cerebral cortex. Who would have known the brainstem can do this kind of math?
It’s a survival mechanism though. We need to suppress this information from our conscious selves to function in this system. We are helped to suppress our empathy in so many ways. In the hospital setting we make the patient seem “other” than ourselves. The patient gets a hospital gown and an arm bracelet to segregate and anonymize her. The patient I described in that story above didn’t even have a name.
We do these things in part because at times we have to do horrible things to people in the name of helping them….for example, most days I’m cutting into the flesh of women which could—perhaps even should– be repulsive and frightening but I have learned not to think about it in that way. It is easier to think you are cutting into a piece of some sort of material and not, you know, an actual woman.
The problems happen sometimes when the patient seems too much like us. As long as the patient comes from some sort of difference: age or race or socioeconomic class, it’s okay*, but then, someone comes along and bam—-all of a sudden we have trouble. For example, I once had a lot of problems staying out of grief with a dying woman who –though not related to me—happened to have the same last name, and children around the same age as mine. (For the record, staying connected to her as she died was a transformative event in my medical life, which is to say, my actual life.)
And then there are the very scary things that happen. Like when patients bleed to death and babies die. After half a dozen or so of these sentinel events as they are called, we start maybe exhibiting some of the signs of post traumatic stress disorder. We shut off even more. We abuse patients, for better or worse, we are perpetrators. We become that obstetrician that I followed on the first day of my obstetric rotation.
Not much is written about the perpetrators of violent crimes. They aren’t usually the ones seeking therapy. I read a book recently called The Birth Wars by Mary-Rose MacColl, which highlights the terrible relationship – the war – between midwives and doctors in Australia where tragic outcomes for women and babies have become a sort of collateral damage. She doesn’t offer us any solutions but it seemed to me, since she called it a war, we can maybe learn something from the studies of soldiers who have been in combat. I think the comparison is apt because they are both perpetrators and victims.
Judith Herman, who wrote the book Trauma and Recovery about the survivors of violence, political terror and sexual abuse, writes that every soldier has a threshold of resilience that can be exceeded fairly quickly: most “tours of duty” exceed this threshold. And given a horrific enough event, no one is immune from the consequences of traumatization. Judith points out that the trauma of combat takes on greater force when the soldier can no longer rationalize it in terms of some higher value or meaning. Doctors like me feel a little bit this way when we question the evidence behind our practice.
There is a solution. Herman also writes about the healing power of connection. And so it is the connection that provides the recovery. It is disconnection, in some cases perhaps a merciful act of the brain to minimize memory of horrific events, which becomes the problem.
Therapists say that when we make connections, whether it is in our relationships or in our professional lives, we can talk about anything. What they don’t seem to talk about is the cost of connection. Each of us needs to weigh in that cost. If you disconnect, it seems that you will probably pay later: depression, anxiety, PTSD. With connection, you pay now: anger at everyone who makes the system suck for women. Anger at yourself for not being able to change it.
For me, one of the penalties in believing in women is to live alone in a world of wounds. The choice is to harden my shell, or to make believe that the consequences of intervention and obstetric “scare” are none of my business[i]. I can’t seem to do either one.
I am in the operating room, about to do a caesarean section. The baby is exceedingly premature.
A paediatrician stands waiting to take him away. The baby is breathing on his own, and very vigorous, and so, I say to the mother, go on, reach up and touch him, it is really important; they may not let you hold him for a while. She reaches up and grabs his little foot in her hand, and afterwards I am sewing up her skin she is still looking at her hand and marvelling at the warmth of him, and how wonderful his skin felt. “He was hot as, cuz he came from inside me, and his skin was so freaky, soft,” she is saying. But the anaesthetic technician has just noticed her fingers are covered in blood and amniotic fluid. Frowning at me over the top of the drape, he hastily puts on gloves, and gets a bunch of tissues to wipe it away.
[i] Aldo Leopold described this wounding from the view of an ecologist living a world of exploitation of the land, in his book, A Sand County Almanac Oxford University Press 1949
*(of course, this is NOT even remotely okay)