Glimpses of Pain and Joy

My clerkships in Pediatrics and Obstetrics & Gynecology have afforded me a glimpse into areas of medicine I had not spent much time exploring before. In particular, my view of medicine has always been centered on the experience of the ill, suffering patient. However, these two fields have shown me another side: the treatment and health management of patients who are well.

In Pediatrics, especially in the outpatient clinics, the vast majority of the patients were described as “well-nourished, well-developed” children. On those clinic days, most of my time was spent playing with kids during the physical exam (some seem to love stethoscopes), terrorizing healthy three-year-olds with otoscopic inspection of the ears, or determining which vaccinations were needed to help these children catch up after interruptions in health care due to Hurricane Katrina. The kids that were on the inpatient service were similarly remarkable in that most of them bounced back from illness very quickly while only a relative minority were committed to extended stays. Those young patients who did have to stay in the hospital for a long time were very sick and sometimes had superimposed difficult social situations and had to be in the hospital for months (or even a year or more).

Thus far in Obstetrics & Gynecology, I have found a similar situation: the patients are generally quite healthy. Most of the Obstetrics patients are young women in good health proceeding down relatively routine courses of pregnancy with regularly scheduled visits and sometimes the ability to plan for events in the near future. Some doctors and medical school instructors joke that pregnancy is one of the most common and oldest “diseases”: if so, it is the one for which we have a detailed account of its natural history. As a male junior medical student, I have often found myself during these early weeks of the clerkship in the situation where there is relatively little that I know beyond the knowledge of a multiparous mother (one who has given birth multiple times) about the experience of pregnancy and its complications or beyond the knowledge of a postmenopausal woman about the changing predictability of the behavior of the female ovaries and uterus.

However, I suspect that the absence of a great burden of disease (on a routine basis in general practice) in these two fields is replaced by the price of social catastrophes. How can we best respond?
• During my ten days in the PICU, I frequently visited the crib of a baby whose mother, a cocaine addict, could not properly care for the baby. Although at the age when most babies develop stranger anxiety, he always looked up at me and every other nurse and doctor with affectionate eyes and a throaty, tracheostomic giggle of greeting, a testament to both the lack of a consistent caretaker and the love showered upon him by the “Mother Hen” within each of us. Though unspoken, I think we were all determined not to let this baby fail to thrive for a lack of affection.
• As a pediatrician, how do you deal with clear displays of bad parenting? I have encountered parents who repeatedly shouted at their children to “shut up,” publicly embarrassed or simply annoyed by the noise disturbance. At what point is it a sensible and useful expense of time and energy to intervene?
• It is hard to underestimate the impact of a positive test for a sexually transmitted disease (STD). Without even considering the life-threatening nature of HIV, the common diagnoses of Trichomonas vaginalis infection, gonorrhea, or chlamydia bear an unpleasant social stigma and insert a sharp wedge between a woman and her sexual partner (usually a boyfriend or husband). These infections, in almost every case, can only be passed sexually (not from a toilet seat or clothing), and they implicate either the woman or her partner in an act of infidelity. Telling patients bad news with regards to fatal or debilitating disease is very difficult, but these diseases usually attribute no blame: many people view them as matters of chance, and we as physicians sometimes propagate this mentality by speaking about “odds” and “risks.” However, to see a woman almost instantly burst into tears upon hearing the diagnosis of a sexually-transmitted infection is heartbreaking, for both the patient and the physician who is not yet hardened to the sight.
• I observed a dilation and curettage procedure performed on a mother of advanced maternal age who previously had a spontaneous abortion (miscarriage). This time, she and her partner tried in vitro fertilization (IVF), yet their efforts yielded a fetus without a detectable heart beat. After waiting for the “products of conception” to be expelled from her uterus for several weeks, the patient and her obstetrician decided that it was time to throw in the towel and remove the conceptus surgically. Before the surgery, as I waited with the patient in the preoperative area, I wondered about the feeling of alienation that patients must feel as they lie on a stretcher with nurses and doctors engaged in a wall of conversation around them that does not include them. For better or worse, I told her that I was sorry to hear that this attempt (at pregnancy) did not work. She gave a sad smile and a shrug. After the operation, in the postoperative area, I saw her wake up in tears, the façade of strength and reserve no longer necessary to uphold.

In other fields I have experienced, disease is simply disease: the worst thing you can do is die or continue living in extreme suffering. However, Pediatrics and Obstetrics & Gynecology carry a heavy emotional burden with each abandoned or abused or neglected child, with each miscarriage or stillbirth, and with each diagnosis of an STD. Pediatricians do seem to draw strength from the innocence of their patients, and obstetricians find joy in bringing new life into the world. Are these joys enough to help us deal with the pain?

  1. seth said:

    I think diseases can be dissolved, or packaged, or compartmentalized, because they are simply instances. They simply don’t register the same weight to most people, certainly not to me (and obviously not to you). I don’t think that a life filled with so many births and deaths can be compartmentalized in the same way, at least not until many years into (or after) the position. In other words, I would think the tragedies and triumphs for those doctors would all register, but I doubt they would seem to “balance out” in any way over time. Though I guess it’s an assumption that they balance out for any medical professional.

    OB-GYN deals mostly with new lives and deaths, yes? It’s like a straddling of the two extremes of human existence, then. I’m sure all medicine encompasses moments of those extremes, but it seems OB-GYN is more of that, most of the time.

  2. Apollo said:

    I’m not sure I entirely understand what you mean about compartmentalization – can you clarify?

    As for OB-GYN, the field generally doesn’t deal much with death: most of the fetal/baby deaths tend to occur in high-risk pregnancies that ideally are treated by Maternal-Fetal Medicine subspecialists, a small subfield with OB-GYN, and most OB-GYN doctors don’t deal with death in the mothers on a regular basis. For example, it was a big deal when one of my residents had to do a “post-mortem” delivery on a baby whose mom suffered a massive pulmonary embolus that instantly killed her. Most mothers tend to be healthy, young women, so OB-GYN doctors usually see patients on the healthy end of the spectrum and the beginning of new life and don’t normally see the opposite extreme.

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