Case and Commentary
Aug 2010
Case
Stuart and Beth awaited the arrival of their first baby with great anticipation. Testing weeks earlier had revealed that the baby would be a girl. Excitedly, the couple prepared their house for Belinda’s arrival. The nursery was beautifully adorned with pink walls and yellow flowers and a baby bed handcrafted by Stuart’s father.
Beth’s pregnancy had been uneventful, and she opted for a natural birth without anesthetics. In the delivery room, Stuart stood by to capture every moment on video.
When the nurse said, “Push harder,” Beth made a final effort and sighed with relief when at last her baby arrived. The umbilical cord was cut.
The obstetrician first emphatically and then cautiously exclaimed: “Belinda is such a beautiful…baby.” There was whispering among the nursing staff. Exhausted, Beth wondered what was going on.
The doctor took a moment to choose his words: “Congratulations on your new child. We are not exactly sure of the sex at this point, so we’d like to run some tests. One test in particular will look at levels of 17-hydroxyprogesterone, which can be a marker for a condition called congenital adrenal hyperplasia (CAH). This is a common cause of individuals’ being born with genitalia that does not aid us in determining their sex.”
Stuart stopped the camera’s filming as Beth cried.
Commentary 2
A medical student’s experience in his or her clerkship rotations can be fraught with embarrassing situations, unexpected news, and surprises, by virtue of his or her relative lack of experience. These situations have an upside—they can engender seeds of genuine compassion, empathy, and understanding. It largely depends upon the student’s adaptive response to novel situations and circumstances and the time a student makes for reflection.
A critical provision of many oaths in the modern medical field stems from the Latin phrase primum non nocere, or first do no harm. “Harm,” in this sense, can come from looks of surprises or phrases of exclamation in response to unexpected or emotional information. I have seen many physicians who choose to wear a mask of objectivity or indifference when communicating emotional news with patients. One explanation for this might be the routine nature of delivering unexpected news, but perhaps these physicians think the mask protects them and the patient from the news. A student might choose instead to model his or her professional behavior on a physician who, rather than masking fear, disappointment, or embarrassment replaces that expression with one of kindness, warmth, and understanding. If the medical student in the case under discussion had taken time to get to know the family before the delivery, he might have been able to place his hand on the father’s shoulder and say, “You have a beautiful baby,” providing some reassurance to the family without making any promises.
Timing is also critical. The physician could have refrained from making statements about testing the infant until the family had time to adjust to the news that there was uncertainty about their baby’s sex. Individuals are often drawn to medicine because of their desire to do something to alleviate the suffering of humankind, and this desire can “kick in” automatically in times of distress, shock, and surprise. Hence physicians may be too quick to offer to test and find answers or “fix” the problem. Instead, the remedy may be allowing everyone time to adjust to the new information or situation. When the latter is the case, a medical student, physician, or nurse may allow the family time alone before suggesting treatment or testing options.
Whispering in particular is completely unprofessional. Should information need to be communicated privately between staff, there are polite ways for caregivers to briefly take their leave of patients. I have heard professionals say, “Please excuse us for a minute while we talk shop.” This may allow for clarifications and explanations to ensure accuracy. Sometimes the patient or family is invited to hear if they wish to.
Addressing the matter directly and in a timely manner often successfully opens communication between patients and health professionals. When the topic involves unexpected or sensitive material, such as Belinda’s ambiguous sex, compassion, empathy and a direct approach, properly timed, are best.
