Know Thy Patient
Updated: Jan 11, 2020
My medical specialties lie in birth (obstetrics) and death (palliative medicine).
Of course, palliative medicine isn't just end of life care. Pulmonologists can provide palliative care to patients with COPD. Cardiologists can provide palliative care to patients with CHF. Hospice physicians can provide palliative care to patients at the end of life.
The principles that encompass quality palliative care are the same principles that could be applied to obstetrics and gynecology.
Palliative care physicians have two roles: the alleviation of suffering, which includes symptom management, and the alignment of a patient's health care with their goals. We get to know our patients on a very personal level before we make medical recommendations, if at all. Given the needs of complex symptom management in gynecologic malignancies and the challenging decision-making process that goes into the treatment of any cancer, it's easy to understand palliative care's role in gynecology oncology. But the question I'm constantly faced with is: What aspects of palliative care could possibly overlap with obstetrics?
The truth is that there are countless ways in which principles of palliative medicine can benefit birth.
My wife and I recently made dinner for Deborah Flowers, one of the midwives on The Farm, Ina May's legacy in Summertown, TN. Deborah told us a casual story about a routine prenatal visit, in which the patient insisted that she wanted to birth in a hospital, and, after listing her myriad reasons for preference of a hospital birth, Deborah responded simply, "I would never push you to do anything you weren't comfortable with."
These twelve words sum up compassionate patient care and epitomize palliative medicine.
In all our efforts to fix problems for our patients, review imaging, run tests, and write prescriptions, we lose sight of the experience of the person in front of us. Our patients are not always seeking answers but rather permission and a safe space to process their emotions, and many clinicians don't learn the importance of holding this space in the face of fear or illness.
I don't treat birth as illness, but, after attending over 700 deliveries, I do realize that active labor is a force to be reckoned with. The portal through which women step as they transition into motherhood is paralleled only by death itself, and many women have described this to me as such: birth forced me to face my own mortality. With this in mind, our role as clinicians in the care for pregnant or laboring women is often best fulfilled as listeners and advocates for their wishes.
If you're wondering about how this can be best accomplished, refer back to Deborah's story. The conversation with her patient commenced with a long period of listening followed by alignment with her patient's wishes. This doesn't mean that you have to sacrifice all of your medical knowledge or safety concerns. You shouldn't ignore her high blood pressures. And you should recommend cesarean delivery when medically appropriate. None of this changes.
The change is in how you approach these recommendations, and your approach is naturally going to fall flat and leave them feeling talked at as opposed to cared for if you don't know the person sitting in front of you.
Compassionate patient care starts with a conversation, a conversation that expounds their story, meaning her past experiences as well as her anxieties about what's ahead. This conversation isn't easy, but good medicine rarely is, and the benefits abound, from reducing the emotional underpinnings of protracted labor to decreasing the trauma of a cervical exam to easing the anxiety that comes with a deviation from her birth plan.
As at the end of life, this must become a priority in our care for pregnant women: know thy patient.