She’s a joyful, jubilant, glowing 27-year old, and she tells me that just 12 weeks ago she received the best news of her life.
“You are pregnant! You are going to be a mother!”
I wasn’t there, but I close my eyes to imagine the excitement. I imagine the physician coming back with the results of the urine pregnancy test, and I imagine her clenching her husband’s hand until its red, white, and blue, like Raynaud’s phenomenon. I imagine them as they hold their breath to listen, so that not even a whisper of air can distract from this moment. I imagine the tension, the electricity, the anticipation, the anxiety.
Just 12 weeks ago, they had plans of bringing a baby into this world.
Just 12 weeks ago, they began to think of names.
And just 2 weeks ago, she began to feel the ‘fetus’ move, and she became even more aware that a baby, complete with 23 maternal and 23 paternal chromosomes, was growing inside of her uterus. It had a heart beat. It had life. It had a name.
She visits the clinic – alone – at 18 weeks gestation for her routine prenatal checkup. She tells the doctor and me that, recently, she hasn’t been feeling the baby move as much. And even more concerning, she had an episode of bleeding two nights ago. And she’s worried.
She’s worried. And she’s alone.
The doctor tells her that she needs to check-in to the hospital to get a non-stress test done to assess for fetal reactivity. She agrees. I know she’s worried, so I tell her that I would be at the hospital in the afternoon, and that I will check on her. She’s thankful.
When I get there in the afternoon, she is just getting to the hospital. I walk in, and we chat. We talk about the snowstorm that we are supposed to be getting over the weekend. She jokes that meteorologists are always wrong, and that we probably won’t get more than an inch. We joke and laugh, as the nurse begins to set up the doppler and tocodynamometer. I decide to step out and allow her to finish setting up the non-stress test.
I walk to the nurses’ station, and, oddly, the nurse follows behind me. She tells another nurse to call the doctor in the clinic.
Something is off.
A few minutes pass, and I get up to go to the bathroom. As I exit the bathroom, I hear a shriek from the other end of the hallway, the type of shriek that’s filled with passion and pain, the type of shriek I’ve only heard once before in my life. And in that moment, I remember that’s the noise my father made at his grandmother’s funeral.
I walk into her room to see her balled up on the hospital bed, with the doctor holding her hand. And somehow, I know what has happened. I take one look at her eyes - filled with grief, pain, anguish, agony – and one solitary tear gently runs down my cheek onto her sheets.
The doctor holds her hand, and tells her that there is nothing she could’ve done to prevent this from happening. He explains what is going to happen next. He tells her that most of the time, it is due to anomalies that are incompatible with life. She asks questions, and he takes his time to leave none unanswered. She’s tearful, and asks if she can call her husband. We leave the room to give her privacy.
After a while, she is wheeled down to the OR to ‘evacuate the products of conception’ – a phrase that I utterly despise. To her, it is more than a ‘product of conception’. To her, it is more than just a ‘fetus’.
To her, it was her baby. It had a name. It had a life.
And just then, I become disgusted with some of the medical terminology we often use in our notes. We often dehumanize and assign expressions based on legalities and constitutionality, rather than emotions and humanism.
The ‘pregnancy’ is ‘viable,’ as to not imply life.
The ‘fetus’ is not yet a baby, as to avoid an emotional attachment.
We wheel her out of the OR, and her eyes speak an indescribable pain. A pain, that if she had read my post-operative note calling her baby an ‘aborted fetus’, she probably would’ve spit in my face. And I would not blame her.
I take one look at her eyes, and I can’t stomach what I just wrote in the chart. I feel dirty, unclean, dishonest, deceitful. And I want to take my post-operative note and rip it out of the chart. And I want to tell the resident and attending that I will not refer to her baby as an ‘aborted fetus’, and that I demand that we start using terms that illustrate the emotions that this woman is experiencing for her lost baby.
But I don’t.
And I don’t know why.
The white coat ceremony is a common practice at many American and European medical schools. Current justification for the ceremony is mainly based on the good will felt by participants and an assumed connection between the ceremony and encouraging humanistic values in medicine. Recent critiques of the ceremony faults its use of oaths, premature alignment of students and faculty, and the selective appropriation of meaning to the white coat itself. This paper responds to recent critiques by addressing their misconceptions and arguing that the white coat ceremony is a contemporary medical ritual with a key role for students and faculty in developing a professional identity.
Since its inception in 1993, the white coat ceremony (WCC) has become a national and international phenomenon. It is now practised at the beginning of the year at more than 100 American medical schools and is supported by foundation grants dedicated to endorsing and encouraging professional development and humanism in medicine.1 While some literature addresses the symbolism and history of the white coat itself, few sources consider the meaning of the ceremony.2–4 A common appeal is to the emotion and good will felt at the event.1,5 Although feelings are important, a deeper justification is called for.
Criticism of the WCC is more explicit, charging that the ceremony: (1) uses the Hippocratic Oath inappropriately or, at best, prematurely; (2) fosters improper student faculty relationships, and; (3) interprets the meaning of the white coat selectively.6,7 Critics suggest either that students not be asked to swear an oath together because it might conflict with personally held beliefs, or that students not be allowed to take the oath until they have demonstrated competence as physicians.6 Some also say that the WCC aligns students with faculty and against patients.6 The third category of criticism asserts that the historico-anthropological meaning of the white coat itself includes more than virtue and humanism and, in fact, represents an imbalance of power, separatism, entitlement, and paternalism in medicine.3,7 To address only the positive connotations of the white coat in a ceremony is deemed disingenuous.
Though critics have suggested that the WCC is misused, improper, an affront to professionalism, or even unethical, these objections have serious flaws of their own.6,7 I will examine three criticisms and, in response, offer an interpretation of the WCC as a contemporary medical ritual that holds a beneficial place in the professional development of a medical student.
This article reminds me of a situation when a patient’s primary care physician (PCP) and myself colluded to not tell a patient about a suspicious x-ray finding — for a little while.
Behind the Medic: The TSK of when Cranquis Paternalized a Patient.
I’d seen 50-something “Bob” in the urgent care, and he was in bad shape. As far as I could tell, his stomach pains and nausea were due to gastritis, secondary to a mixture of excess NSAID use for his chronic pain + his recent resumption of a heavy alcohol habit (He was back to drinking a fifth of vodka every night, after being sober for 3 months — “There’s so much stress in my life right now, doc. My mom and I have been fighting, and I couldn’t stay sober and deal with the stress.”). The only reason I did a chest xray as part of his workup was because his lung-sounds were suspicious for fluid around the lung bases (a possible secondary effect of “abdominal ascites,” fluid collecting in the abdomen after liver failure).
The labs and xrays looked ok for him to go home instead of being admitted to the hospital, and he was happy about this because he didn’t have health insurance and was already stressing about the cost of that day’s Urgent Care visit. But I arranged for him to see his PCP early next week, and admonished him to start cutting back on his alcohol in preparation for getting off the sauce again. He said all the right things: “I’ll go to AA tomorrow morning, my brother will drive me home and stay with me for a couple days,” but it was hard for me to take him seriously. After all, I’d felt the metal flask in his cargo-pants pocket while I was examining his stomach.
The radiologist’s report came in the next morning: “Chest film shows a small irregularly-shaped density in right lower lobe, concerning for soft-tissue malignancy vs overlying chest-wall abnormality, cannot rule out old rib fractures in this area.”
Oh great. What am I supposed to do now? Follow my usual routine — call the patient, inform them of an irregular finding on the chest xray, and arrange for ASAP follow-up with their PCP? This would just give Bob even MORE stress, which would shoot down any attempts he might be currently making to cut back on the alcohol use.
When I spoke with his PCP about the situation, he agreed with my hesitancy: “Bob’s anxiety and alcoholism can’t handle this extra piece of stressful news right now. I’ll call and remind him to keep the appointment on Monday, and break the news to him then and order a chest CT.” I felt relieved that Bob’s PCP was going to take over and handle it, but I felt a little dishonest at not notifying the patient of his results myself immediately, as I usually do with any tests that I order. But there was more at stake here than just “being transparent and honest” and “upholding the patient’s autonomy.”
Were his PCP and I being paternalistic? Yeah, a bit — but I hope that it was in the best sense of “behaving as a father”: making a hard decision on his behalf, a decision which would protect him from carrying increased (and out-of-his-control) stress during a difficult moment in his life. Bob was hurting, and he was striving to hide the hurt in a way which was killing him. He couldn’t even turn to his mother for peace, since she was one of the major causes of his stress. What he really needed was a Father, but the best I could offer him was my own fatherly instinct.
(Note: The chest CT came out clean, but as of Bob’s most-recent visit with his PCP, he’s still drinking.)
— Downie, R. S. “Literature and Medicine.” Journal of Medical Ethics 17.2. (1991): 96
Jaye, C., Egan, T & Parker, S. (2006). ‘Do as I say, not as I do’: Medical Education and Foucault’s Normalizing Technologies of Self.Anthropology & MedicineVol. 13, No. 2, August 2006, pp. 141-155. (pp. 143 - 144). (via shrinkrants)
Wow. So I don’t know much about the context this quote came from, but it sounds so interesting that I’m going to go find the article and read it. If you’re interested, here’s the abstract of the paper:
But in the meantime, what do you all think and feel about this? I get the “fierce competitiveness” and “emotional detachment.” But the “maleness” I’m not so sure of, and isn’t “activism and antipathy for weakness” a paradox?
What do you all think?
(P.S. Go follow shrinkrants too, because he always has interesting posts!)
The article that goes with this abstract focuses on the importance of doctors listening to the stories that people want to tell as well as the more narrow and technical stories that standard medical education teaches doctors to gather, document, and focus their work around. For my taste, this is better than many narrative medicine articles because it emphasizes how doctors should listen rather that focusing on the doctor’s empathy and humaneness while taking the spotlight off the “patient.”
I posted a link to the video by Chimamanda Adichie yesterday.
Commentary: Narrative Lessons From a Nigerian Novelist: Implications for Medical Education and Care
Joseph Zarconi, MD
In her TED Talk entitled “The danger of a single story,” Nigerian novelist Chimamanda Adichie shares stories about her life that illustrate the natural human tendency to interpret the lives of others in the context of what she describes as narrowly constructed and often stereotypical “single stories.” These single-story views often portray others as wholly different from those constructing the stories, thereby diminishing the possibilities for genuine human connection. Referencing Adichie’s talk, the author describes the narrative dissonance that so often distances patients from their physicians. He illustrates the dangers to patients that can result from single-story caregiving by physicians, sharing an example from his own experience in which unnecessary harm came to his patient because of his own single-story thinking. The author argues that these single-story dangers must be openly and consciously addressed in the training of doctors to counteract the tendency for their clinical and educational experiences to inculcate single stories by which physicians come to interpret their patients. He offers suggestions as to why single-story thinking arises in clinical practice and how to mitigate these forces in medical education. The author concludes by contending that the education of physicians, and caring for the sick, should be aimed at preserving the dignity of those being served, and he argues for an “equal humanity” model of the patient– physician relationship that engages patients in all dimensions of their multiple stories.
Acad Med. 2012;87:1005–1007.
Cheryl Mattingly is an anthropologist who has spent her career studying the culture of occupational therapists who work in large inner city hospitals. This is “exoticizing the domestic” rather than the more traditional cultural anthropology which “domesticates the exotic.” She has a lot to say about the culture of hospitals in general, the politics of class and race in urban hospitals, and the poetics of encounters between professionals and patients. Reading her work gives me hope for the future of medicine. She sees “clinical encounters” as dramas in which each participant is actively and collaboratively making up the lived story of the meaning of what has come before and of what’s possible in the next moment. I am moved by this long paragraph from her book Healing dramas and clinical plots. She is talking about what she has learned in the course of her studies.
“There was more generosity than I was prepared for. I saw small kindnesses rather than life-saving interventions. These went almost unnoticed by the therapists themselves. Generosity and small attentions are not the stuff of the medical chart. Even when something more dramatic (trying to help a despairing person find a reason to stay alive), there is no place to formally record these actions. They are undocumented exchanges, not part of the official purview of the occupational therapist. Therapists personally valued their own kindness and their imaginative capacity to link their interventions to the lives of their patients, but because there is almost no language within biomedical discourse for recognizing and examining exchanges which address the illness experience and because this is not a “reimbursable” part of treatment, the phenomenological aspects of treatment are quite neglected, carried out almost furtively. these attentions to the illness experience constitute an “underground practice” in occupational therapy and doubtless many other health professions. Taking careful note of the narrative structure of clinical interventions reveals “hidden values” within biomedical practice which run counter to the dominant metaphor of body as machine that holds such persuasive force in Western medicine. Put differently, it reveals how some health professionals, some of the time, recognize a physiological body which is inextricable from the imagined and lived body, the body which carries a person through social space and time.”
-Mattingly, Cheryl (1998) Healing dramas and clinical plots: The narrative structure of experience. p 22. Cambridge University Press, New York.
I love Harlene Anderson.
Thanks to Christopher Kinman and Rhizome Network for making and sharing this excellently crafted video of Harlene explaining in clear, plain language one of the foundational principles of Collaborative Language Systems Therapy. In Narrative Therapy, we come at this same territory when we emphasize the importance of noticing (whenever possible) our assumptions and questioning them. We spend more time and effort in trying to unpack and understand the historical, social, cultural influences that support particular assumptions, but both not knowing and questioning our assumptions are stances that have the intention of supporting a non-impositional, client-centered, present-to-future kind of psychotherapy.
“You can’t learn ethics or compassion. You either have it or you don’t.”
I’ve often thought of her statement in the years since. Is bedside manner something we are born with, or is it something we can learn?
While most of medical education and training is about the nuts and bolts of clinical care — how to treat hypertension, how to manage a ventilator, how to take out a gallbladder — the process also involves learning how to be “a doctor.” As opposed to lessons covered in textbooks and classrooms, this kind of learning is done through modeling, or what medical sociologist F. W. Hafferty has called the “informal” or “hidden curriculum.”
- Autonomy - a patient has the right to have an opinion and be able to make decisions for themselves, as long as the patient is in a position to understand the relevant information in order to make an informed decision.
- Beneficence - a doctor must do good and act in the best interests of the…
It’s possible that a drug may help awake the minimally conscious. It affects the medical ethic debate of the vegetative state and pulling the pull. It’s a long article, but a short video worth watching! Amazing story.
Artificial Happiness: The Dark Side of the New Happy Class
Ronald Dworkin, Fellow at the Hudson Institute, has written a book of social commentary that combines the politics of healthcare and medical ethics with several momentous changes that have dramatically altered the relationship among…
Hi there, Stephen — thanks for writing. I’m not sure which of the 2-3 questions in your post you’re wanting my opinion on? Since I’ve written a post before about physician-assisted suicide and my thoughts on interventions that focus on “prolonging life” above “improving quality-of-life” for terminal/poor-prognosis patients, I’m gonna just talk about my definition of compassion in this reply.
To me, Compassion is:
- The Golden Rule in one word — Doing unto others as I would have them do unto me.
- An integral part of what makes a person a person. People who cannot feel compassion are not living up to their potential as an intelligent being. One of the scariest things about a sociopath is his/her inability to demonstrate compassion and empathy.
- One of the best clues to look for in another person, to tell you that they are worth spending time with (as a friend, romantic partner, boss, employee, etc).
- The most effective sermon I can live. (“Preach the gospel at all times — if necessary, use words.” St Francis of Assisi)
- Impossible to get reimbursed for in the healthcare system, yet probably the most valuable thing that a doctor can give to a suffering patient.
- A very worthwhile organization that provides child-sponsorship programs around the world (I’ve been sponsoring a boy in India for the past 10 years, and it has been SO enriching to my life. Consider it as a way to exercise your compassion muscles and practice daily giving.)
- Used liberally in the field of Palliative Medicine — I strongly encourage any future doctor with a tender heart to consider this as a future specialty!
***Pending Cranquis-Mails: 3; Ask Box: Closed***
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