My last day of my third year clerkship rotations perfectly encapsulated much of what I love about academic clinical medicine and much about it that breaks my heart.
This final day began on the labor and delivery (L&D) service at the UCSD county hospital in Hillcrest. As the morning progressed, I found myself unconsciously checking off the boxes in my mind as tasks were completed. “Shut off my alarm at 3:30 am for the last time (for a few months at least), check. Awaken women who have recently delivered a baby at insanely early hours to ask how they are doing and do a targeted physical exam, check. Frantically write my notes to get ready for rounds, check. Try not to look like an idiot on rounds, mostly-check.”
After the morning routine that becomes all-too familiar during third year, we ran the board on the L&D deck. The L&D unit was offering all the chaotic glory it had to offer that day: high risk-pregnancies, scheduled and unscheduled c-sections, and low-risk vaginal births attended by the certified nurse midwives were all in the cue. As I wondered where to get involved, my resident suggested I assist with the vaginal delivery of a woman, Mrs. Tran, who had just been examined and who felt ready to start pushing.
We walked over together, and as we entered the room, I felt an ambiance I had not yet experienced during my time on the L&D service. It was one of complete tranquility. Mellow, soft, flute and chime music played in the background. The shades were low, and the lights were dimmed. Mrs. Tran lay on the bed relaxing, with a peaceful disposition, as if she were awaiting her turn on the massage table. Was this a spa or a hospital room? Her husband stood by her side, holding her hand, and frequently spoke kind and encouraging words to her. The nurse was on the other side of the bed, monitoring the status of her IV lines and epidural.
My resident and I left the morning’s chaos at the door, and dropped to the pace, feeling, and volume of Mrs. Tran and her delivery. We introduced ourselves, asked if it was okay if I assisted with the delivery, and questioned if she was feeling ready to push. After a look to her husband, a smile, and two answers in the affirmative, we prepared to deliver the baby and she started pushing. She pushed almost effortlessly for ten minutes, after which a beautiful baby girl transitioned from life in the womb to life outside. The joy mom and dad felt was palpable. As my resident and I cleaned up, I thanked God in my heart for the opportunity to experience in my small way of this important family bonding moment–what I had come to call “a family glue moment” by the end of my rotation.
Still basking in the idyllic feeling from Mrs. Tran’s delivery room, I was snapped back to reality as I reached the L&D deck. A woman I’ll call Linda had brought herself to the L&D triage unit, which is basically the Emergency Room for pregnant women, because she felt like her baby was moving less than it had been previously. My resident connected me to the Certified Nurse Midwife (CNM) who was managing the triage assessment, and she said she would love to have me help with the patient.
I began reviewing Linda’s chart, and soon my heart broke. She had been seen several times in prenatal care, so we already had a fair amount of good information to help us assess her and the baby. But it was also clear that she had numerous personal and health risks that we needed to check out. Now in her mid-30’s, she had a complicated pregnancy history, though we didn’t have much detail; she was in an narcotic addiction recovery program, and was currently taking the medication that helps with that called Methadone; and while stable now, she had recently had problems with being homeless. Perhaps the point where these problems started was in her childhood, when she had been the victim of sexual abuse and had turned to and was victimized by prostitution and drug abuse for many years thereafter.
The chart made it clear that Linda was making great efforts to stay off drugs and out of legal trouble so she would be permitted to keep her baby. And on that day, it was the job of me, the CNM, and the whole hospital system to make sure that she and her baby were healthy and safe.
The CNM introduced me to Linda and asked if we could get a better idea of her history and how she and her baby are doing. Linda agreed, and she shared that she had actually had two deliveries in the past. One was in Florida to twin girls that were born prematurely, helicoptered to another hospital where they could get life-saving care. After they were placed on the helicopter flight, she signed the adoption paperwork and never saw them again, because of her legal and personal state. Her other birth was to a boy in New Jersey, with whom she was able to spend a couple of days before putting him up for adoption as well. Even though Linda shared with me her story with the callous of a woman who had experienced life-shattering traumas, it was evident she still harbored sadness. It was also clear the great efforts Linda was taking to try and be a good mom and to be able to keep her this baby.
After further discussion, an ultrasound, and other tests, we were able to reassure Linda that her baby was moving well, that she and her baby appeared healthy, and that she could return home. Linda thanked us for the care and attention we gave her and her baby, and began preparing to go on her way.
After my encounter with Linda, two verses from a hymn in my Church’s song book came to mind:
Who am I to judge another
When I walk imperfectly?
In the quiet heart is hidden
Sorrow that the eye can’t see.
Who am I to judge another?
Lord, I would follow thee.
I would be my brother’s keeper;
I would learn the healer’s art.
To the wounded and the weary
I would show a gentle heart.
I would be my brother’s keeper–
Lord, I would follow thee.
(“Lord, I Would Follow Thee”, LDS Hymnal #220)
Leaving the hospital later that afternoon, I felt grateful to have been able to participate in my small way in the care of my sisters, Mrs. Tran and Linda. While reflecting on how one brief day had provided opportunities to help women who were on opposite ends of the socioeconomic and social determinants of health ladders, the image of Harvey Dent and “Two Face” came into mind.
On one hand, I appreciated the role of academic medicine, and how as an institution, in its ideal though imperfect form, it strives to care for all people regardless of background; on the other hand, I was troubled at how familiar Linda’s story had become to me by the end of my third year clerkship rotations–that of traumatic childhoods, struggling families that too frequently break, the long-term health effects of terrible, selfish acts committed by others, the harmful minute-by-minute influences of one’s community and environment, and a society and healthcare system that rather than being one step ahead is more often than not is two steps behind.
We all know medicine is imperfect and needs major overhauls. And it’s not just medicine–the recent killings by police, the recent killings of police, the increased frequency of mass shootings (to name a few)…it makes one wonder, where is the hope? Rather than try to unpack each of these issues in this post, and without touching on all of the approaches that need to be taken to fix these issues, let me focus on one thing that has been on my mind.
The hope is in each one of us to grow, change, and influence the world around us for good. Let me apply the case of Harvey Dent to our current discussion: is Harvey Dent all good, or is “Two-Face” all bad? One reason his character strikes so close to home is that we subconsciously realize that we are all like him: looking good and trying to do good in our best moments, while appearing monstrous and almost unrecognizable in our worst ones. This is why we extend compassion and understanding to Dent so easily, for we all recognize the wort of us in ourselves as well. Hence the relief we feel at his death, because we are glad the darkest side of him is no longer around to wreak havoc. Perhaps this is also why we accept Dent’s portrayed martyrdom as a hero in exchange for Batman’s antagonizing sacrifice, because we too want to be remembered for our good deeds rather than our destructive ones.
The analogy can be extended to our spheres of influence in clinical medicine, and our day-to-day contributions to society. In similarity to Harvey Dent, each of us who fulfill a role in clinical medicine–big or small–is responsible for tremendous acts of individual care: lives saved, diseases prevented or cured, hearts and minds strengthened, along with many more examples. On a personal note, my orthopedic surgeon gave me my ankle back after I had a traumatic fall and fracture five years ago. Each time I step onto a soccer field or run around with my kids, I wonder at how my mobility could be very different without my surgeon’s knowledge of mechanics, bones, and pins.
But let’s not allow the “Two-Face” within each of us to hide behind the martyred Harvey Dent. How do we feel when caring for a Trump supporter? When the door to the resident workroom is closed, what are we saying about our patients, and perhaps more importantly, in what spirit are we saying it? Are we pushing ourselves to engage in those kinds of conversations that promotes understanding with others, including our patients, who look, think, or act differently than us? I went back to President Obama’s speech he gave at the Dallas Police Officers’ Memorial Service to grab the bit where he says we need to have difficult conversations about race and other issues with those outside of our circles. But reading through it, his moving remarks are connected to the Harvey Dent analogy, the socioeconomic determinants of health issues brought up by Mrs. Tran and Linda’s stories, and our individual responsibility to change ourselves and strive to make change around us. It’s long, I apologize, and I know it was considered by some to be a controversial speech, but it’s too important to not highlight. Recall that this speech was given at a memorial service for slain police officers in Texas. I’ll let him do the talking, and close using his pleadings (bold added for emphasis):
“We can’t simply dismiss [the black community’s calling attention to persistent inequities in how they are treated compared to their white counterparts] as a symptom of political correctness or reverse racism. To have your experience denied like that, dismissed by those in authority, dismissed perhaps even by your white friends and coworkers and fellow church members, again and again and again, it hurts. Surely we can see that, all of us.
“We also know what Chief Brown has said is true, that so much of the tensions between police departments and minority communities that they serve is because we ask the police to do too much and we ask too little of ourselves.
“As a society, we choose to under-invest in decent schools. We allow poverty to fester so that entire neighborhoods offer no prospect for gainful employment. We refuse to fund drug treatment and mental health programs.
“We flood communities with so many guns that it is easier for a teenager to buy a Glock than get his hands on a computer or even a book.
“And then we tell the police, “You’re a social worker; you’re the parent; you’re the teacher; you’re the drug counselor.” We tell them to keep those neighborhoods in check at all costs and do so without causing any political blowback or inconvenience; don’t make a mistake that might disturb our own peace of mind. And then we feign surprise when periodically the tensions boil over.
“We know those things to be true. They’ve been true for a long time. We know it. Police, you know it. Protesters, you know it. You know how dangerous some of the communities where these police officers serve are. And you pretend as if there’s no context. These things we know to be true. And if we cannot even talk about these things, if we cannot talk honestly and openly, not just in the comfort of our own circles, but with those who look different than us or bring a different perspective, then we will never break this dangerous cycle.
“In the end, it’s not about finding policies that work. It’s about forging consensus and fighting cynicism and finding the will to make change.
“Can we do this? Can we find the character, as Americans, to open our hearts to each other? Can we see in each other a common humanity and a shared dignity, and recognize how our different experiences have shaped us? And it doesn’t make anybody perfectly good or perfectly bad, it just makes us human.
“I don’t know. I confess that sometimes I, too, experience doubt. I’ve been to too many of these things. I’ve seen too many families go through this.
“But then I am reminded of what the Lord tells Ezekiel. “I will give you a new heart,” the Lord says, “and put a new spirit in you. I will remove from you your heart of stone, and give you a heart of flesh.”
“That’s what we must pray for, each of us. A new heart. Not a heart of stone, but a heart open to the fears and hopes and challenges of our fellow citizens.” (President Barack Obama, June 12, 2016)
** all images taken from either Google Images or Bing