On the penalties you pay for believing in women

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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)

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“The women aren’t here for us.”

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I was in a meeting after some horror show had played out in the birthing unit. It featured a ruptured uterus, a dead baby and multiple units of blood, and the STAFF were traumatized. We were planning a debriefing session: the venue, the time, the invitee list. One of the managers thought we were taking things a little too far. She said, “We have to remember, the women aren’t here for us”.

Are the women here for us? Not exactly. But care is not a one way street, and we need to talk about that.

I listened to Dan Ariely’s TED talk “Our buggy moral code.” Dan spent months; stretching into years, in the hospital after third degree burns affected most of his body. During that time he had to have many painful wound dressing changes. You may have heard that having burn wounds attended to is one of the most painful things imaginable. Dan said that the nurses would rip off the dressings quickly. And, they would start cleaning the most painful parts and work their way towards the least painful. They would rush through the work as quickly as possible. He would beg them to do it slower, give him a rest, save the worst parts for last, but they said “No, its better this way. It would be much more traumatic, if we did it the way you suggest”.

Once Dan got well he started doing research into whether what people believed about pain was true. He did a number of experiments using small electric shocks, plunging ice baths, vice grips on fingers, things like that. He rigorously measured the responses to the degree of pain his subjects experienced. Dan found that the average overall pain that people experienced was much reduced if things were taken slowly. His work revealed that many of the things that health care workers did to burn patients as a matter of their intuition were wrong and should be changed.

There are two powerful messages in Dan’s story. The first is the message that the patient is often right. We should listen to our patients much more than we do.

But I’d like to deal with the second message, made very clear went Dan went back to the hospital and spoke to the staff who looked after him. He explained his results to his favourite nurse. She said that there was one very important thing that Dan didn’t measure. He hadn’t looked at how the treatment made the nurses feel:

She said, “Of course, you know, it was very painful for you. But think about me as a nurse, taking, removing the bandages of somebody I liked, and had to do it repeatedly over a long period of time. Creating so much torture was not something that was good for me, too.”

In obstetrics we are the creators of torture. We often are witness to suffering, many times we, like the nurses who looked after Dan, are the ones inflicting it. We are regular bystanders, harbingers, creators of pain: we are victims of vicarious traumatisation and perpetrators of violent acts. It is true that sometimes we save lives in the process. But these uglier views of typical clinical events must be faced and examined carefully.

It is not good for staff to come to work and harm patients in the course of their care: intentionally or unintentionally. But the nurses did hurt Dan, they felt they had to, as part of their job. The pain they inflicted affected them so deeply they could not listen to what Dan was saying. Some part of their selves disengaged.

The day of the horror show, a mother was hurt and a baby died. I’m not getting into the fault of it. The thing is we were the audience and the cast of a tragedy. We need to review that play and not only to find out what scenes might have been better acted.

I think that when the manager said “the women aren’t here for us” she was extorting us to remember our non-starring role: the women aren’t here for our entertainment. She felt we should keep this professional distance, keep our emotions in check, toughen up and get back to work. The implication was there that if we didn’t, there was something wrong with us. But there is something more wrong when we don’t take the time to consider not only what happened, but how we feel about what happened.

There are times, I get called in to look at a tracing, or to give some advice, to births I have no other business being at, and when I get there, I realize that my services are not required. The woman is being supported, the midwife and family are there, and whatever they called me to do was a false alarm. Still, it is very hard to leave. I mean, it’s easy to leave a place where you are not wanted….but in this case, there’s a feeling of going out into the cold rain from a warm hearth, and you would like to linger, you would like to be invited to stay. But I don’t. That women wasn’t there for me. It’s enough for me to know that the warm hearth exists.

Instead, I’ve got a permanent invite to the parties that no one wants to attend. There’s a rush of adrenaline with all the drama of a five alarm fire. There’s a ruptured uterus, a dead baby and multiple units of blood. Like they say, it’s a crazy job but someone’s got to do it. Turns out that women want that someone to be a person who cares deeply about them.

Why Do Bad Maternity Systems happen to Good People?

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The truth is that just because there is a better way doesn’t mean that’s the way it’s done.  I had an “aha” moment about why crappy care prevails in health care—-in particular, why women are still being abused and traumatized when they come to hospital to give birth— when I listened to this podcast  on the “religious” CBC radio programme Tapestry.  In the podcast, Mary Hynes interviews Gretta Vosper, an ordained minister of the United Church of Canada. Gretta tells the story of a particularly bitter conflict which had emerged within her church community and the pain that conflict had caused her.  She questioned why it is that in so many church settings, the meanest voices seem to own the podium.  What is peculiar to our humanity that this happens so often?

The reason, Gretta said,  why the bullies often win is that they exploit a loophole in our human nature.  Most of us want to get along and not be confrontational, so even in a place like a church where you would think people are mandated—commanded even— to get along and have empathy with each other, the bullies are set up to win.  Even in a place like church.  One bad apple can and does spoil the whole bunch.   A cursory look elsewhere in human history confirms this.  Why don’t we speak up? Why don’t we call evil out wherever it happens?

If churches can at times be hotbeds of hatred, is it really a surprise that health care workplaces are so often such unhealthy places for both the sick and the people who care for them?  Is it really so strange that hospitals are the institution where vulnerable people go to be healed but all too often come out further wounded?  That working in health care feels like being cast into both roles of an abusive relationship?  We are perpetrators, and sometimes victims.  We should perhaps be more often surprised under the circumstances when we get things right.

Since health care workers are the workforce of hospitals as well as being  members of the caring profession you would be forgiven for assuming that hospitals should automatically be workplaces filled with kindness and empathy. Indeed, kind people are attracted to the health care field but kind behaviours are often suppressed.  Horizontal and vertical violence are rife.  There is a combustible mix of people with the “disease to please” and one or two power brokers ready to exploit that: taking advantage of the softer nature of others as increasingly a certain management model and style has set in.  Staff are overworked and underpaid as managers are rewarded and in some cases paid bonuses for balancing the budget on their backs.  We are told that the patient comes first, and we have to do more with less, we understand that—-and people are being stretched beyond their capacity.  If we don’t look after our staff at a very basic level, they can’t look after anyone.

Once, I was finishing a caesarean section late at night.  My house officer assistant and I were both very tired. When we went to apply steristrips before putting the final dressing on the wound, we were clumsy with fatigue, accidently pulling off the steristrips we were trying to put on, making them stick to each other, having to redo some, and dropping swabs and equipment on the floor.  We were moving in slow motion, and screwing up out of sheer exhaustion.  The scrub nurse was watching us, and suddenly, she got so frustrated and angry that she lost it. She snarled at us to get out of her way, slammed on the dressing, and proceeded to very roughly take down the sterile drapes.

When that nurse ripped off those drapes, the drain I had put in the woman’s abdomen pulled out partway and I had to take down the whole dressing in the recovery room and remove it. It wasn’t a big deal, but maybe it could have been.  There might have been some sort of consequence for the woman, the newly minted mother at the end of the drain.   Infection, a missed haemorrhage. Certainly it was unkind.  And it is a million little unkindnessnesses that stack up together and make us all victims of the bad maternity system: the patient, the nurse and me.  I was too exhausted and too afraid to tell this nurse that her bitchy behaviour had caused a problem for the patient, because, in one part, the confrontation was just going take too much energy for me to muster up.  The next time I’d see that nurse she might make trouble for me.  In another part it was also because this small seemingly insignificant example of crappy care is a lot more common than you’d think.

Maternity care in too many parts of the world is an assembly line of impersonal care, provided by wounded healers working in a broken system.  We must do something different than we are doing now.

PS. I wrote this after reading this excellent post of Sheena Byrom’s here (where you can also download her awesome presentation about maternity care in the UK).  In it she asks why we aren’t following the evidence and changing the maternity system for the better.  And it got me thinking.