Thursday, May 19, 2011

When Your Patient Can't Get Pregnant- And You Are


Now that I am again expecting, I am wondering how to approach potentially difficult clinical situations in my Internal Medicine practice. It’s too early right now for my pregnancy to be obvious, but I know that it will soon be very obvious to my patients who are struggling with infertility issues or pregnancy losses. Not only that, but I am struggling with my own emotions when I counsel patients through miscarriages or pregnancy complications.
Last pregnancy, when I walked into the exam room at 6 months to see my patient with a cough, it was painfully, massively obvious that I was pregnant. This patient is a lovely woman, about 42 years old. She and her husband had been trying to conceive for several years. She had tried Clomid, in utero insemination (IUI), and several cycles of in vitro fertilization (IVF). They had used up their infertility treatment insurance benefits and a large chunk of savings on the project. We had spoken of her issues before, and I had provided referrals for her to a new fertility center, to try again. But that day, she was only in for her cough.
When I was at 6 months, almost anyone who saw me commented on my pregnancy. Patients would almost invariably enthusiastically ask: A query as to how it was going, how I was feeling, did I know if it was a boy or a girl, etc. I welcomed this banter and enjoyed the opportunity to chat with patients, as most times the banter led to some memories from the patient on their own pregnancies, or expressions of hopes for future pregnancies, or descriptions of beloved nieces and nephews or grandchildren. In short, a pleasant time was generally had by all.
But this patient was clearly pained by my state, and the visit was strained to the max. As soon as I walked into the room, she seemed shocked, silenced, and took some time to get composed. It did not occur to me right away what the issue might be, so I asked her some questions about her illness. The visit progressed, I took care of her cough, but she never once commented or said anything about my state. She kept looking at me as if I had somehow betrayed her. She fairly fled the room at the end of the visit, clutching her prescriptions. I felt terrible.
Afterwards, I asked colleagues how I could have handled this better. It had seemed as if there was an elephant in the room- and at my size, there literally WAS an elephant in the room. They suggested that I acknowledge the elephant, say something like, “It’s possible that my state is upsetting to you right now, and it’s no problem at all for me to find another provider to care for you, if you like” type of thing. I think that with this pregnancy, I’ll be more sensitive to these situations, and likely offer something like that. I’m curious as to what other providers do, especially the OBs, who much encounter these situations far more often than I do.
Now, I am 9 weeks along. I’m exhausted, emotional, and a tad nauseated, but other than being various shades of green during exams, I don’t think anyone would know that I was pregnant. However, it comes up for me, on my end, with the emotions I have in caring for my patients who are having pregnancy issues. Two weeks ago, I counseled one patient through an early miscarriage. She had had a hard time getting pregnant, and the loss was such an overwhelming disappointment to her and her husband. I couldn’t help imagining what it would be like for me, for us, to go through the same thing; as a result, it was difficult for me to contain my own tears in front of them.
I have another wonderful young patient who is struggling with a complicated early pregnancy, right now. She has numerous health issues, and hers is a very much desired pregnancy that has been a long time in the trying. Our LMPs were close to the same date. She does not know that. My pregnancy has progressed pretty normally thus far; hers has been fraught with vaginal bleeding and erratic HCG levels; an early ultrasound showed a small gestational sac with no heartbeat, and she was counseled to hope for the best, but prepare for the worst. This week she has had more vaginal bleeding, and a followup ultrasound showed a fetus, alive, with a heartbeat, albeit a slow heartbeat. She was again counseled to hope for the best, but prepare for a possible miscarriage. I cannot imagine the limbo she must be in. I worry that I will run into her at the OB’s, as we both are going to the same OB office for care. I wonder what I will say, or what I should say, what I need to say.
How do other physicians cope with these difficult situations? I do not believe that a complete dissociation into professional identity is possible here. These issues hit the deepest emotional, irrational parts of us. For so many women, being pregnant or trying to get pregnant can represent a whole future; hope and loss, life and death, and is life-CHANGING, regardless of the outcomes.
What do people do?

16 comments:

  1. Ah, I'm a nurse and on my unit, another nurse lost a twin pregnancy, suddenly, at 23 weeks, after being on fertility meds for 1 yr & 2 months. She and I were good friends. I was only 12 weeks at the time, but we had been just lively talking about her new cribs, colors for her walls and pretty bedding. Now that she's back to work and I'm 23 wks, she gives me the dirty eye, doesn't talk to me and says that she is going to make her schedule around "all those" pregnant people (who are just 2 nurses on the unit including me). I don't know how it feels to talk to a patient who's struggling with fertility while being pregnant yourself, but I can definitely tell you that having a co-worker suffer a double loss and having to work with her on a constant basis (and in the ICU, we truly depend on each other's help frequently) plain sucks. But I can't send her elsewhere. :(

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  2. Having been on the other side of things, i don't think anything you can see will really make it better. If anything because many physicians wait to start their families, we can relate to our patients losses more often than not. I think our pregnancies make us more human to our patients and that is usually a good thing.

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  3. Ok, third try! First, a disclaimer and apology for what will be a long post. I am a single, childless ObGyn, almost 40. Last year, I found out that barring a miracle, I will probably not be able to have kids naturally.

    On a daily basis, I get to see women and kids in various stages of pregnancy. I also get to see women riding the infertility rollercoaster. On any given day, I can choose to be abrupt with the 17yo on baby number 3 or cry with the the 42 year who had multiple terminations in her 20s and 30s now facing infertility. Honestly, I have done both. During residency, I offered to see the pregnant clinic patients for my colleague who had just returned from leave after suffering miscarraige number 3.

    I say you just need to be who you are. If it would make YOU feel better to not see these patients while pregnant, then don't. No snark intended, but it is what it is. No way can you spend weeks 20-40 hiding your pregnant belly. Maybe your patients with poor reproductive want to still see you, because it will give the hope or they will just be happy for you. I am not advocating flashing your OB ultrasounds or having a discussion on baby names, just be the physician that you are that makes these women keep returning to see you.

    Last week had the pleasure of sending a term patient to the hospital to have baby number 4. At the end of the visit, her 2 youngest kids begged me for hugs. I quickly grabbed each one and gave them long hugs. My heart overfilled with joy as I inhaled their little boy smells. I thank God for giving me moments like this. I also have to admit that I was a little weepy right before going in to see my next patient.

    Normal human female physician or just PMS? I'm gonna say normal. :)

    P.S. I also have had the pleasure of working in a office with a male OB who suffered from infertility. He didn't want me hanging baby pixs in the office so as not to offend the women suffering from infertility. WTF? No baby pixs in an OB office? Needless to say, the culture of this office did not mesh with my personality for long. lol

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  4. When I was pregnant I didn't know my OB/Gyn was pregnant, and only a month ahead of me until a few weeks before she delivered. When I asked her about, she said she preferred not to let her patients know, since it can make some of them uncomfortable. So she wore really baggy scrubs and an over-sized white coat, and it hid it fairly well for a while. Maybe you can try the too big clothes thing for your patients with infertility issues.

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  5. As an infertile physician, I strongly recommend allowing your infertile patients their privacy/pride and make no comment if they seem taken aback by your pregnancy. I can't stand it when anyone feels pity for my situation! Infertile people do have to learn to get along in a fertile society but pointing out their barely hidden grief is often not going to be appreciated.

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    Replies
    1. i agree, we have to BEHAVE in society, it is not our fault if someone has medical considtions and we do not have those same conditions, heck, we may have OTHER conditions..!

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  6. I'm in a similar situation - I'm a family doc and 23 weeks pregnant. I see pregnant patients regularly. Today I saw a patient who suffered a miscarriage at 10 wks, and I counseled her through that. I covered my belly with my white coat, hoping she wouldn't notice.
    I also saw several of my advanced pregnant patients today, and now that my tummy is showing quite a bit, I tried to hide my tummy again with their chart or my coat. Ugh. I can't say it's easy. I certainly don't want to go in there flaunting my belly to patients that aren't pregnant either. I guess I just don't like the discussion of my personal life taking up a patient's exam time. I know a lot of patients enjoy this, and I'm fine with that if they do, but I'd rather not.
    As per dealing with patients with a miscarriage, I find that this is just like anything else in life...you see someone with something that you want, it's not their fault...I'd like to think my patients would not think badly of me if I was pregnant and they could not get pregnant. And if they did, it's something they have to deal with unfortunately.

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  7. Im an OB. When I was pregnant with my first baby, one of my sweetest patients was diagnosed with anencephaly at 18 weeks. She declined termination and then she PPROMed at 33 weeks. I was 30 weekes pregnant at the time. She still didn't want to be induced but spontaneously went into labor and eventually delivered a stillborn. I asked her if she would prefer another provider in "my state" but she said she really just wanted someone she could trust to be there.

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  8. You do not owe your patient an explanation or apology. I would agree with one of the comments to not acknowledge the sensitive situation, as you cannot change it. If patient is that uncomfortable, it is her right to not see you. I also agree with many above it is unfortunately person's job to adjust in the society.

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  9. I completely agree with anon at 9:25AM and anon at 10:14PM. Don't acknowledge. As someone who has had several miscarriages, the second worst thing you can hear is pity from another person. (The worst is blame, which is unfortunately very common.)

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  10. Having been on both sides of your scenario, I would say that it does not matter whether she saw that you were pregnant or not.

    Processing the fact that other women are having babies while you are loosing yours is painful. But it is something that needs to be gone through one way or another.

    Feelings of sadness, jealousy, anger, it's all normal. Hopefully, in the end, we get to a place where we can accept what happened, and, besides sadness for ourselves and our lost one(s), we can feel grateful that others are spared the same, and be happy for them.

    As for what you should do, it would vary from patient to patient, and where they are at in the process of healing at the time. While one patient might be too upset and hurt to even want to talk about it, it might be a cathartic moment for another that helps her along in gaining acceptance.

    One size does not fit all, and it may just not be possible to always do the right thing.

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  11. You cannot manage other peoples emotions, just help them through it. The worst thing will be walking on eggshells in your own practice. Be the very best doctor you can be to every patient. If they dont bring it up, dont start a converstaion about it. People react differently. I agree that the only way you can help the situation is to be professional, understanding and sensitive. Hiding your pregnancy may even piss some people off more.... I have a 45 y/o so far infertile sister, we are 6 sisters and 2 brothers and have 12 kids between us. Her response to this has been very positive. Again, people react differently.

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  12. Kellie (general surgeon)May 20, 2011 at 5:41 PM

    Having been the infertile multiple miscarriage patient, it is not YOUR fault that I (or your current patient) had or has had problems with gettign pregnant. However, it is not abnormal for the person with infertility to react as she did. It is painful to see pregnant women when all you want is to have a baby. But again, it's not your fault. Treat her like any other patient and let her make the decision if she is going to continue to see you or not.

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  13. As an OB, I have also been on both sides of this difficult situation.

    For most patients, I would agree with the others who recommended not acknowledging your pregnancy.
    However, if you have a specific patient , such as the one you mentioned, that you have been through a lot with and you KNOW the sight of your belly is going to throw her for a loop, perhaps having the nurse give her a gentle heads up before you come in, might be appropriate.

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  14. "For so many women, being pregnant or trying to get pregnant can represent a whole future; hope and loss, life and death, and is life-CHANGING, regardless of the outcomes."

    I believe that one of the essence of women is being a mother as well giving birth to a child/children. For me, being a mother is the greatest fulfillment of a woman, thus being pregnant is definitely a representation of the whole future, not just of the mother but also of her child. There are people who are blessed with the capability to be pregnant but there are also women who can't bear a child, and this is a very sad fact. However, I believe that "hope" is eternal, and while still living there's always hope. But it will be good to accept things as they really are, for there are some things that we can't control, eh.:(

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  15. CardioMom is right.. No one can actually manage other peoples emotions. All you can do is understand what they are going through and show that you are always ready to help them when needed. And for doctors who might meet patients with this same problem, your responsibility is to tell them whatever the outcome your diagnosis is but make sure it is delivered nicely and in a professional way.

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