The other side of the fence

pregnancy testThis column was written in October 2014…

Countless consultations start with the words “I’m pregnant.”

I quickly learned not to jump in with an enthusiastic “Oh congratulations, I’m delighted for you!” Make no assumptions.  Sensitively ascertain the patient’s state of mind before celebrating or condoling.  A new pregnancy can generate a range of emotions in the mother-to-be, from despair to ecstasy, but in my experience indifference is rarely, if ever, predominant.

Likewise, I imagine that for many GPs the news of a patient’s pregnancy also triggers an emotional response in them.  The emotions felt may be simply a case of transference, they might be an inherent sense of wonderment at the creation of a new life, or they may be complex, perhaps intertwined with feelings surrounding the GP’s own reproductive history.

Barring the occasional faux pas as a result of an incorrect assumption, I think we GPs are, on the whole, very good at managing both our own and our patient’s emotions surrounding a desired pregnancy, and mostly pretty good at handling those surrounding an undesired one.  From what I’ve observed, however, many of us are far less comfortable handling those involved with a lost or non-pregnancy.

Admittedly, it is very hard to know how to respond to a desperate patient who wants nothing more than parenthood, but for whom this dream has remained elusive.  While the drive to procreate differs between individuals, for many of us, myself included, it can be an overpowering one.  The primal reproductive instinct is at the core of many people’s sense of identity and life purpose, as well as having cultural, social, spiritual, financial and familial implications.

After nine years and five miscarriages, I’m sitting here typing this as my 23 week daughter moves around in my distended abdomen, reassuringly.  On my joyful and life-changing journey through this so far remarkably straightforward pregnancy, I’ve had many new experiences.  I’ve relished discovering that my clothes are too tight.  I’ve been relieved beyond words to get the “all clear” on the 18 week morphology scan.  I’ve discovered that, despite my best efforts, I have become one of those annoying super-gushy types of pregnant women.

The most surprising aspect to me, however, has been the reactions of friends and colleagues.  Without exception their responses have been overwhelmingly positive and supportive, for which I’ve been immensely grateful.  What has intrigued me though is that many have started to treat me more inclusively, seemingly because I’m now “one of them”, a member of the “parenthood club”.  When I’ve gently explored this with a few, they’ve reflected that it has been difficult for them to juggle their desire to talk freely about their kids while being sensitive to my situation, and that at times it has been easier not to engage at all.  I know I’ve played a part in this too.

In my experience, both as a patient and as a medical educator observing doctors-in-training, many GPs face a similar struggle when interacting with patients with infertility and/or miscarriage.  Either resorting to platitudes or avoiding the heart-of-the-matter can leave vulnerable patients even more isolated and unsupported.  Unlike disorders like cancer, disclosing and discussing infertility and miscarriage publically is somewhat of a social taboo, and this, I believe, is part of the problem.

While we are told, for good reason, that it is important to leave your personal baggage at the door of your consulting room, it’s not always that easy.  We all have things in our past (and/or present) that can potentially influence how we feel about, and interact with, certain patients.  Being aware of these factors and their effects is vital, but is it always necessary to neutralise them?  Not only is complete objectivity impossible in the kind of work we do, but judicious and thoughtful use of our life experiences can make us better clinicians – and better teachers.

I hope that I can use my experience to help support both patients and other doctors in managing the complex emotions surrounding fertility issues, and also encourage more open discussion in the general community.

While immensely thankful and blessed to now be on the green side of the reproductive fence, I will never forget how painful and isolating it can be on the other side.

First published in Medical Observer, 17th April 2015

The ending to my pregnancy story was not a happy one. You can read about what happened here

https://genevieveyates.com/2015/04/27/lived-experience/

 

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Scripted Role Play on Jargon/ Breaking Bad News

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Scripted Role Play Material is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

This scripted role play is useful in sessions on communication skills especially when trying to illustrate how medical jargon can be problematic and / or the skills involved with how to break bad news.  I’ve found it very useful when working with OTDs (Overseas Trained Doctors) as many OTDs need assistance with communication skills, particularly around inappropriate use of medical jargon.

scripted role play

It is well established that the use of role plays in communication skills training can be of great value, however unscripted role plays in group settings can be terrifying for participants, often more so for OTDs than their Australian counterparts.  Some will disengage and/or use avoidance strategies, impeding their access to learning opportunities.

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

Workshop structure (approx. 45mins to 1hr):  

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read)

2)  Introduction to session

3)  Scenario (projected via PowerPoint or provided on a handout to all audience members)

4)  Reading of dialogue by volunteers

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scenario:

Sally is a 32 year old pregnant woman who presented to the emergency department with a story of PV spotting this morning.  She saw Dr. Jones.

His notes read:

11/40.  G1P0.  PV spotting for 1 day.  Rh+ve.   No other medical problems, no medications, no allergies.

On examination

  • Afebrile
  •  No pelvic tenderness,
  • No blood seen, Cervical os closed.

Reassured that PV bleeding common in early pregnancy

Plan –USS to exclude miscarriage. Review after scan.

The ultrasound report reads:

OBSTETRIC ULTRASOUND

Clinical Details
PV bleeding. ? viable pregnancy.

Report
Contained within the uterine cavity was a gestational sac. A foetus
was identified. CRL = 14.7mm = 7 weeks 6 days. Mean sac diameter =
43mm = 10 weeks 1 day.
No foetal heart was definable.
No myometrial abnormality or adnexal abnormality was identifiable.

Comment
The appearances are consistent with a non viable gestation

Dr. Jones’ shift has ended and you have been asked to discuss the test results with Sally.

Script:

SALLY: So what did the scan show doctor?

DOCTOR: I’m afraid the news isn’t good. The ultrasound revealed that your gestation is non-viable.  There is no cardiac activity.

SALLY:  The heart isn’t beating?

DOCTOR: That’s right. I’m very sorry for your loss.

SALLY: Are you saying my baby has died inside me?

DOCTOR: Yes.  I’m sorry.

SALLY: When did it happen?  I had a scan just over three weeks ago and everything was fine.

DOCTOR: There is a discrepancy between your gestational dates and foetal size which seems to indicate that the foetus stopped developing some time ago – maybe two to three weeks.

SALLY: I’ve had a dead baby in my uterus for two or three weeks?!

DOCTOR: Perhaps, impossible to know though. The good news is that the PV bleeding you’ve had indicates that the body has realised that this has happened and is getting ready to expel the products of conception.  If you prefer, we can offer you a D and C and remove the products surgically.

SALLY: Are you trying to say that I can wait and let my body deal with it naturally or else have a curette?

DOCTOR: Exactly. There are pros and cons with each approach.  Most first trimester spontaneous abortions sort themselves out and do not technically require a curette…

SALLY:  An ABORTION!  I haven’t had an ABORTION!

DOCTOR: No, no, I don’t mean a termination.  A spontaneous abortion is the medical term for a miscarriage.

SALLY: Oh.

DOCTOR: … so as I was saying, we don’t have to rush into a curette as most early miscarriages resolve without intervention, but many women decide to have the procedure. It avoids having to go through prolonged heavy bleeding and severe cramping and also, most women don’t like the thought of retaining a dead foetus for any longer than they have to.  They get “cleaned out”, so to speak and can move on.   Of course there are risks with having a D and C.  Infection, bleeding, uterine damage- even rupture, anaesthetic complications etc.  So what do you want to do?

Discussion points:

What did the doctor in this scenario do well?

What jargon did he/she use?

What would have been more appropriate terminology?

What are other things he/she have done better?