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Tuesday
Jul252006

Keep Talking (even when it's hard)

This article from Medscape's Ob/Gyn & Women's Health discusses whether a physician who has made an error (in medication, judgement, etc.) should disclose the error to the patient or not.

"Disclosure of Medical Errors: What Factors Influence How Patients Respond?" says in part:

Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact.

A particularly important passage in the "Discussion" states:

Studies have found that patients and family members pursuing legal action subsequent to an error are often motivated by the desire for explanations and apologies; however, such studies do not provide evidence that full disclosure can prevent legal action.

Taking a sharp turn towards midwifery, I will say that, most of the time, we have a very intimate and detailed relationship with our clients. We spend months and months, hours and hours getting to know them before they are in labor, where we spend more hours and hours serving them in their homes. Much of this "getting to know you" allows each of us to see how we respond over time, how we respond during times of stress (as every pregnancy invariably endures) and what kind of relationship the parents have with each other or, in the absence of a partner, how mom responds to her support system.

This information is invaluable as we each find ourselves together, mom in labor, sometimes very tired, the midwife, sometimes also tired, relatives either supportive or derisive, an assistant poking around a mom's house for needed supplies, and just a general invasion of mom's privacy during her intimate birthing moments.

If I have a mom that weeps during the pregnancy because she suspects her husband had an affair, it won't be so surprising for her to cry during her labor. If she began shoveling food in or wanting to knock back swigs of alcohol (hyperbole) instead of crying, I would be pretty concerned.

If I have a mom who verbalizes well during the pregnancy, is able to tell me what the baby is thinking today and how her dreams are coming along, yet, in labor, finds herself mute, confused and sobbing, I know this mom is needing an anchor to help her find her center again.

None of this is to say women aren't allowed to do something uncharacteristic when in labor. I don't mean that. I do mean that getting to know a woman during many months of care allows me to "get" her personality and find a place of "knowing" when all is well and normal versus when she is being tossed in a storm on the sea of birth.

So, when a midwife makes a mistake - forgets to call the client with an abnormal result, doesn't think about doing a procedure that was routine and could have kept her home before sending her to the doctor or hospital, made a supreme error in judgement such as a baby's size that caused physical damage during birth - our clients know pretty quickly that it was our fault and we did it. They can usually read it on our faces because they know us so well.

The "getting to know you" goes both ways.

I have had a couple of seriously difficult births that I really expected to see played over and over again in a courtroom. Not because of anything negative (or wrong) that I did, but because the labor/birth/outcome was so dramatically different than we expected. One shoulder dystocia in particular continues to haunt me. (Ask anyone around me - I'm sure I bring it up at least once a month.)

Listening to women in the middle of their birth traumas, I learned one thing LOUDLY - and that was to talk to the women. Talk, talk, talk. Share. Explain. Apologize. And apologize again. And again.

During that one particular experience (and we'll just use that as an example since it is my most vivid thought at the moment - feel free to insert your nightmare/fear/mistake here), I most certainly would have rather run... as far away as I could... to avoid listening to the mother's anguish... to not have to hold her as she wept about how close her baby came to dying... to shove the memory in my head as far under as possible because I nearly lost a baby. It didn't matter that the baby lived. It didn't matter that the baby wasn't permanently damaged.

It mattered that mom and dad were in shock and I was, too.

Instead of running, I forced myself to continue communicating with mom and dad. I offered myself in a myriad of ways. I called, emailed, sent a couple of cards and letters in the mail - I always told them how important they were to me and I was always here to discuss things should they ever want to.

They nearly severed communication with me. Pleasant when we talked (well, polite anyway), they were more curt in emails and never answered snail mail.

I didn't walk away.

I knew we had to do the baby's birth certificate and used that reminder once a month to do my part and keep the lines open. Once the baby was six months old, mom was ready to see me again (she'd never said she didn't want to see me... it was just something I felt happening) and we went for the birth certificate. Kind and pleasant, the experience was nice and then, at lunch, mom began to unload her burden.

She felt I'd done damage to the baby during the resuscitation. She didn't think the shoulder dystocia was as dramatic as we said it was. She felt abandoned (?!) when I had to relinquish her care to a physician because of a very serious medical condition that developed postpartum. The waterfall of feelings began at lunch and continued in multi-paged emails we bounced back and forth between us.

I gave her explanations. I sent her links that were relevant to the shoulder dystocia as well as why I sent her to a doctor for her medical condition. I owned up to what I had done, even if it was the right action to save both of their lives. I apologized that things scared her so badly. I apologized that she had to have that experience. I apologized for the things I did that made her angry. Even if they were justified because I had to do them for their health and life. She still deserved/deserves my compassion and apologies.

The bursts of emails slowed and then trickled as mom was able to reframe the situation/birth/experience with the added information and my humility that formed a pretty decent basis for a new beginning together.

I knew there was something wrong - for those first six months. I knew it. Everyone around me told me I was crazy, that she was fine or she'd say something, to just forget it. But, I knew.

I cried about that birth for all of those six months. Once the letters between us began, I stopped crying. I haven't cried since. We, both mother (and father) and I, are healed.

When I speak to student midwives, I share this experience with them. I tell them how easy it would be to just turn around and let the lapse in communication guide the flow of energy. I tell them that they MAY NOT do that. They will be brave. They will remain strong. They WILL face any demon they encounter, even if it is a phantom to them.

I have known - still know - midwives who think silence is the best option for a woman angered by her birth experience. I am in school to be a therapist to their clients - damaged beyond words, more by the lack of communication and apology than any wrong-doing could ever have caused.

It is crucial for student/apprentice midwives to hear what I am saying: DO NOT ACQUIESCE TO THE SILENCE - DO NOT ALLOW YOUR FEAR OR SHAME KEEP YOU FROM YOUR PAINFULLY DAMAGED (emotionally/spiritually/physically/mentally) CLIENT.

Make yourself stand in the fire. Take it.

Your client has to.

So should you.

So, heading back to the beginning where doctors might not be sued if they owned up to their mistakes, I am willing to bet the relationships could never endure the intensity some women need in order to process their difficult births. I think an apology is all well and good - and might satisfy some women, but more, I believe, the women should be able to sit down with the doctor and perhaps a mediator to go over the details mom remembers and have the doctor explain himself or herself and the why's of what s/he did.

I can hear physicians laughing their heads off. As if they had the time to do that? If they even had the desire, who would pay for that lost time?

I'm willing to bet the time would better be "lost" in a counseling session than a many-year'd lawsuit that launches premiums upwards and scars the record of the doctor in question.

Maybe the doctor needs to reframe things a bit.

Oh, and those midwives, too.

Reader Comments (10)

It wasn't a mistake but the fact that my OB ackowledged and apologised that I didn't get the natural birth he knew I so badly wanted the day he told me it would have to be a c-section (weeks before it was due to happen)still means the world to me 2.5 years later. After the event everyone else told me how lucky I was to have two healthy babies and I knew I was lucky... but I still hated how they had to be born and he was the only one who ever said sorry.... it is so powerful.

July 25, 2006 | Unregistered Commenterkatef

What you describe here is what I consider to be fundamental requirement for a professional -- taking responsibility for your work. Beyond that, taking responsibility for the OUTCOME of that work, even if you didn't necessarily cause the outcome. Not only does this speak to strong moral fibre, but it shows you to be trustworthy and compassionate. Your patients are lucky to have you.

July 25, 2006 | Unregistered CommenterAndrew

i am a firm believer that when i feel like i've done wrong - even if the client doesn't feel like it was a big deal - i own up to it.

it's too much to carry a lie or a cover-up. i can no longer do it.

:) this was a great entry, Barb!

July 25, 2006 | Unregistered CommenterSage Femme

Your post has me sitting here in tears. There is too much I want to say, but in this moment I want to say, that you were strong enough not to run away and abandon your client.

I can't even express to you how painful abandonment feels, when you have gone through the entire process of getting to know a midwife and building a relationship with one another. Building trust.

A woman never forgets the person who attended her births. Be it a doctor, nurse, midwife. At least for me, even my first child's birth leaves me with memories imprinted in my mind of what I said when she was born, and what the doctor said to me. The first cry. The first time you call out your baby's name.

I had a midwife literally abandon me at the end of a pregnancy that went into distress. When my husband and I tried to express our pain to her, her reaction was to immediately remove her web page and not respond to us.

I don't know how I can get over the pain, without a sense of closure from her. But it looks like I will have no choice now.

She abandoned me at the hour I needed her most, and she continues to abandon me.

When reading about how you cried over the experience you had with your client, it made me wonder, did my midwife ever cry over what happened to me? Did it even affect her in this way? Not that I want her to feel pain, but maybe I want her to own up to her part.

I'm not good with words here. I just want to say thank you for sharing. It helps me to see a midwife's perspective of this kind of issue, and it really helps more than you know.

Tabitha

July 26, 2006 | Unregistered CommenterTabitha

If ANYTHING, I think that acknowledging and facing your actions and their impact on your client/patient (?) validates their emotions. They feel such and such because of the events - and when you express your side, they are no longer alone with their side. Even if they disagree or feel you are at fault, it would be nice to have that acknowledged - like having your humanity acknowledged.

July 26, 2006 | Unregistered CommenterHollyRhea

I start nursing/midwifery school in a month, and this post really made me think. Thanks!

July 26, 2006 | Unregistered Commenter"Loving Pecola"

Thank you for this post. You've inspired me to write a long overdue letter to my MEDwife.

July 26, 2006 | Unregistered CommenterAnonymous

katef: I can imagine how helpful that would have been to be acknowledged for your disappointment and sadness. What a wonderful OB you had. Why aren't there more?

Andrew: Thank you! And considering your profession (I went and poked around your blog), I am very honored that you feel I am on the right track, trust-wise, with my clients.

Sage-Femme: Thanks so much for the kind words and I am glad I am not alone in the "owning up" department.

Tabitha: I am so sorry your midwife abandoned you. I just do not understand the mindset that allows that to happen. I see it happen all the time, sadly... very sad.

I hope that your sharing here and privately can help ease some of the pain. I wish I could make it all better for you and all the others who have been so hurt.

Holly: exactly. It *is* merely acknowledging their humanity! It is nothing less than I would like happen to me.

I was stripped when I was pregnant with Baby 2 and when I confronted the doctor about it, he lied, over and over, even in front of the head of the department that he'd stripped my membranes. I *knew* he did, without my permission; I still remember that violation 20 years later.

Anon: I am so, so glad you are going to write the letter to your Medwife. I am so proud of you for pushing through the pain of it and just doing it. You go girl.

I hope it offers even a little bit of healing.

July 27, 2006 | Unregistered CommenterNavelgazing Midwife

As a third year nursing student, we discuss this briefly before each new clinical rotation. It is never this poinant and should be. Thank you for the detailed description of why you own your mistakes and why you dont get to just be silent and walk away-its not our right to do that. Thank you so much for the post and for the comments it has already generated. I will share this with my nursing student friends.

August 1, 2006 | Unregistered CommenterIntelinurse2B

"A woman never forgets the person who attended her births. Be it a doctor, nurse, midwife."

I disagree with that statement, and the underlying feeling I'm picking up from it. The undercurrent I'm getting is "If you have a horrible birth experience you are going to be emotionally scarred for the rest of your days, it will affect your relationship with the baby, etc.", and I don't believe that either.

My firstborn was delivered into a giant crowd of docs and nurses, because we knew Something was wrong but weren't quite sure what. The entire time I labored, I was terrified I'd lose my baby before I got to hold him and feel him move in my arms--and there was no one there who could honestly reassure me that this scenario was unlikely.

There are nurses to this day who stop me as we go to Clinic with my son, telling me, "I was there the day he was born, I was the one who did x." And all I can do is smile and nod and say thank you, since I have no recollection of anyone there except me, my husband, and the wriggly little fella that showed up 6 weeks early.

For my second round in the labor ring, I was induced. It was not a pleasant experience at all--we were essentially choosing to get the little guy out "on time" because his older brother needed surgery and we weren't sure when I'd go into labor. It was the right decision for us, but it was still a frustrating one to have to make--do I choose to put my toddler's needs or my unborn baby's needs or my own needs first?

The second birth "hurt more", physically. But, compared to the emotional and mental terror of the first birth, it was a cakewalk. And I have no idea who was at the second birth, either.

August 1, 2006 | Unregistered Commenterfrostedlexicharm

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