Thursday, April 21, 2016
My experience of the 4th year of medical school has been a whirlwind of clinical work, late-night writing sessions laboring over applications and letters of interest, dreams of the next stage of my life as a doctor as I traveled and completed interviews, and now plans for a move across country to begin my residency in my chosen field of OB/GYN. Like many, if not most of my classmates, the intensity of the year left little time to process the personal lessons learned during this long marathon of hopes, dreams, and hard work. Unlike most of my classmates, this year had an additional feature in my life: the birth of my first child, my daughter Margalit Reva. Her birth allowed for a unique perspective; so many of my experiences were seen simultaneously through the lens of the medical practitioner and at the same time, the patient. Next year will have its own set of challenges; so, before I forget, before this year’s lessons lose their potency, here are some of the lessons I learned:
Lesson Number 1: Giving birth is painful
While on one of my interviews, one of the OB/GYN attendings said, “labor is called labor for a reason”. How very true. But while an epidural can mitigate the pain during actual labor, no one talks about the pain afterwards—regardless of if you had a C-section or a vaginal delivery. As a third year clerk on my OB/GYN rotation we divided postpartum rounds into two groups: the vaginal deliveries and the C-sections. And we were taught, rightly so, to pay careful attention to the C-section recovery: they had undergone major abdominal surgery and needed to monitored more closely and for longer than their vaginal delivery counterparts. And because of this, I worked under the assumption that vaginal deliveries were no big deal. That you just “bounced back” immediately following delivery. When my OB came to discuss my postpartum instructions the morning after I delivered my daughter, he instructed me to hold off on exercise for 4 weeks. I remember thinking, why? I had had a vaginal delivery, I was young and strong, I had exercised regularly up until the day I delivered. I should be up and running in a day or two. There is no way I'm going to be able to wait 4 weeks. But recovery was long and slow. And when 4 weeks rolled around, I was still in a significant amount of pain. It hurt to sit, I was afraid to cross my legs for fear of re-tearing, my legs were still swollen. I could barely walk down the block. I found myself wishing my doctor had told me to hold off for longer. And, talking to my friends who had babies already, every single one of them said there was no way they were going for a run after 4 weeks. 8 weeks maybe...but that was a big maybe.
Lesson Number 2: Doctors know a lot, but much wisdom can be gained from a network of female friends
The swaddle and white noise machine
A few days after I came home from the hospital a friend of mine, a recent mother herself sent me a package. In it was a set of baby swaddles and a white noise machine, accompanied by a note with the instructions, “put these on and go to sleep.” It was the soundest advice I have ever received.
On day 4 post partum, as I was lowering myself onto a chair with a wince, my mother said "there is this thing called a donut, a little inflatable inner tube you can sit on, so that there isn't any pressure on your bottom. You can buy them at any drug store that sells medical equipment." My husband went out and got me one that moment. It was bliss. I carried it with me for a good 6 weeks. Why, I thought, did I not know about this on my OB/GYN rotation? Why do we not discharge women with such a donut? And my mother was the only one privy to this secret. When my friend, who had a baby 8 months before I came to visit, she saw me sitting on the donut and said "oh yeah! I forgot about that thing. I had two of them!" "Who told you about it?" I asked. "I guess my mom," she said.
A day or so after that, I went to borrow sugar from my new next door neighbor. She had just had a baby herself, a day or so before me, and it was her 4th. She was a pro. Fully dressed and caring for her large and active family, I would have never known she had just had a baby. I stood next to her in amazement, with my sweatshirt hanging around my pajama clad shoulders, hair and teeth unbrushed, spit up in my hair. As she handed me the sugar, she hesitated, leaned in and whispered "And I sat on this round thing...like a donut." As I left, I wondered, what is this secret world that I have just entered into? This world outside of what I see on the hospital wards. This world that physicians don't seem to know anything about? This secret world of motherhood?
Lesson 3: Keeping another person alive
That’s a heavy task and a weighty responsibility. I remember thinking the weight of this responsibility must be akin to the responsibility physicians bear.
Lesson 4: How to balance shared decision making with clinical expertise
Margalit had reflux. It wasn’t terrible reflux—she wasn’t losing weight or dehydrated, but it kept her up at night and she looked miserable. Desperate, I took her to our pediatrician’s walk in hours. The doctor on call listened to my story, did a thorough exam, and reiterated the literature on reflux that I had learned in my 3rd year: if she is gaining weight and adequately hydrated, there is no indication to treat the reflux. I nodded my understanding and left. When we went for her two month visit a few weeks later, my pediatrician asked about the reflux. Not much had changed; she still spit up after every meal and she still woke up about every hour or so due to the reflux. He listened, and offered the option to start medication. “What do you want to do?” he asked. I hesitated. Intellectually I knew the other pediatrician’s plan was an appropriate recommendation. But I was also so tired, and my baby seemed uncomfortable. I had no idea what to do, and I felt guilty that I didn’t-- I was in medical school after all, and this was just a simple case of reflux. My pediatrician saw my hesitation. “Do you want to know what I think?” he asked very gently. I nodded in relief and appreciation. And then he outlined what he thought the best plan would be based on his clinical experience. I think about the way he asked me that question often—it is a tone and manner I hope to emulate next year.
Lesson 4: Everything is Personal
We are always taught never to take anything personally. But that is never possible—at least not for me. When Margalit went on a nursing strike, I took it as a personal affront. When she stopped crying after I handed her to her Dad, I worried she had forgotten who I was. When I pumped a little less one morning, I took it as a reflection on myself and my capabilities. Every time I knew I was being irrational, but I couldn’t help it. I think it is hard to not take things personally; everything about becoming a parent is personal, but sometimes it’s nice to have an outside party tell you to not be so hard on yourself, or at least that you are not crazy for feeling this way.
Lesson 5: Giving birth uniquely touches the boundaries where life and death merge
Margalit is named for a grandmother I never knew. And I think Margalit’s name was a way for me to connect to a woman I had heard stories about but never met-- and a way to pay respect to or show appreciation for that woman, and the daughter she raised, who grew up to raise me.
In Judaism, a baby girl is named within the context of a prayer for the mother and child’s health: “May He who blessed our fathers… bless the woman who has given birth (mother’s name) together with the daughter who was born to her in an auspicious time, her name shall be called in Israel: (child’s name)…” After which the mother recites a second prayer, a prayer one says after surviving a near death experience, a prayer a mother is instructed to say after a safe delivery: “Blessed are You, oh Lord…who bestows goodness upon the accountable, who has bestowed every goodness upon me.” These two prayers, simultaneously acknowledge all the risk and the possibility of labor-- on one side is joy, life, and birth but on the other side is death and sadness. When I recited these prayers aloud as a new mother, I was struck by the juxtaposition of life and death, and intimately aware of the intense love a mother feels towards her newborn. She embodied “every goodness” I had ever known and future joy I could imagine.
Acknowledgment of both extremes has been shared through time and space by different cultures across the world, most recently through the global health committee’s decision to make one of their millennial objectives the improvement of maternal health. But women’s health takes many shapes and forms. Rotating through various sites for my Women’s Health block, I saw a myriad of ways women seek medical care, and I was reminded of a line from Yate’s poem Adam’s Curse:
That beautiful mild woman for whose sake
There’s many a one shall find out all heartache
On finding that her voice is sweet and low
Replied, ‘To be born woman is to know—
Although they do not talk of it at school—
That we must labour to be beautiful.’
I said, ‘It’s certain there is no fine thing
Since Adam’s fall but needs much labouring…’
An alarming trend toward legalized discrimination in employment, housing and public accommodations against the LGBT community seems to be emerging in parts of the United States with the introduction of anti-LGBT bills in 28 state legislatures. A new North Carolina law that has captured significant media attention requires transgender people to use bathrooms based on their birth certificate sex, not their gender identity, and other "bathroom surveillance" bills are pending.
A controversial Mississippi religious freedom bill espousing a 'moral conviction' about traditional gender identity and stereotypes is scheduled to take effect on July 1 to “protect people, religious organizations, and some businesses who object to recognizing the gender identity of transgender people and/or refuse service based on their religious opposition to same-sex marriage”.
Here are some of the Mississippi law’s provisions:
- protect anyone who believes that marriage is between one man and one woman from discrimination claims
- “male” and “female” pertain only to an individual’s immutable biological sex as objectively determined by anatomy and genetics at time of birth
- sexual relations are reserved solely for marriage
- religious organizations can deny LGBT people marriage, adoption and foster care services; fire or refuse to employ them; and decline to rent or sell them property.
- medical professionals can refuse to participate in treatments, counseling and surgery related to "sex reassignment or gender identity transitioning"
- employers and school administrators can establish "sex-specific standards or policies concerning employee or student dress or grooming," including dictating access to bathrooms and locker rooms
- clerks and their deputies can recuse themselves from licensing marriages, and judges, magistrates, justices of the peace and their deputies will be given a similar process for recusing themselves from performing marriages, based on their religious beliefs.
- businesses can deny services to same-sex couples
Equally disturbing, in both Mississippi and Georgia it is already legal for businesses to discriminate on the basis of sexual orientation in housing and employment decisions.
One wonders about the direction our country is heading. After finally achieving a significant step forward with the legalization of same sex marriage, are we now taking two steps back?
Judith Wolf, MD
Associate Director, WHEP