All That Is Left Unsaid

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I wrote this after seeing a patient postpartum from a 22-week spontaneous preterm delivery. As someone who has gone through a similar situation, there was so much I wanted to tell her. Never could I have imagined the depth of grief I would feel. I wanted to prepare this patient for what she would face, but I felt I should stick with the same script I had learned as an intern and avoid letting my experience color the discussion.
Counseling a patient through a complication is always challenging, and, as obstetricians, we manage the gamut of complications from infertility to pregnancy loss, from fetal complications to delivery complications. When physicians have experienced this themselves, it provides unique insight into the patient's situation but it also presents a unique challenge. At what point does sharing become burdening? When does empathizing become imposing?
Although the Accreditation Council for Graduate Medical Education recognizes patient communication as a core competency,1 our medical training often involves little training in counseling through a complication or an unexpected or even expected poor outcome. We try to focus on concrete things like depression scales to direct care.2 Personal experience is a powerful tool that can be intimidating to employ. A recent study of resident education in the Netherlands found that residents felt that, beyond any formal education, “life events had the deepest impact and brought about the most profound changes in their frame of reference. These changes almost always led to an improvement of their ability to empathize with patients…”3 The ability to employ these life experiences in patient interactions takes practice, as does every skill in medicine. Care must be taken to allow space for the patient to engage in her own experience and share her own feelings. This type of practice in communication skills and technique should be explicitly encouraged.3–5
Our training in these situations should go beyond a depression scale and social work or therapy referral. Although those tools are very important, they overlook the effect a health care provider can have. When providers go through this type of difficult experience themselves, they should reflect on not only their feelings afterward, but how their feelings will affect their patient care. This includes considering how a patient situation may cause renewed feelings of your own grief or anxiety, how you can confront this situation with a patient while not imposing your own feelings on her, and how you are in a unique position to know the fears and anxieties the patient may be experiencing and can address them directly. You will not always say the right thing to every patient, but you should not be afraid to explore a communication path that goes beyond simple condolences.
Although each patient will have her own unique perception of grief, I have realized that a shared experience brings us closer together, builds trust that I truly understand and care about her, and shows that there is a way to come out the other side—if not whole at least hopeful. This comes not from sharing my personal story, although in certain cases I will, but from using my experience to better understand my patient's position and bring up potential issues she may be hesitant to acknowledge herself.
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