It’s never easy to be a doctor -especially an obstetrician. Accouchement is just too unpredictable; babies are just too vulnerable, too fragile. Too many things can go wrong. Quickly. Unexpectedly. Too many people are affected -the doctor included.

Most of us travel through our days in the naïve hope that we will somehow escape unscathed; that bad things only happen to others; that there are probably no slings and arrows of outrageous fortune -not really. We will be, by and large, protected either by good fortune or statistics -we and our children. We rightly assume that with due diligence, and a good doctor, complications can be predicted and bad outcomes prevented. Otherwise why attend clinics? Why arm ourselves with knowledge, gird ourselves with expectations? Hope does indeed spring eternal.

But circumstances sometimes conspire to frustrate even the best intentions; the most thorough preparations are occasionally inadequate. In Life, nothing is certain; the unforeseen is just that, and only after the event is it predictable. Only after the tragedy is there a possibility of some elucidation, and even then, only a possibility of instruction. Of a lesson learned. Even after endless review -and it is always reviewed- it so often remains random and unfair.

Surely at this stage of our progress in Medicine, these things should not happen -not today, not in hospital.  Anticipation. Prevention. Avoidance. Isn’t that what we always preach? That if we think hard enough, monitor long enough, and analyse well enough, most things are either preventable or at the very least, avoidable? The key word, though, is ‘most’. Some things can and do slip through the fine net of surveillance no matter how hard we watch. Some situations arrive at the door unannounced and we have to do our best to deal with them before they enter -or at least minimize the damage if they manage to knock us down as they elbow past…

But while it’s never easy for anybody involved, it is the parents for whom I grieve. They have waited so long in joyous anticipation of a life with their child. That its arrival should be traumatic after all those months and all that excitement, that all that promise need be put on hold, or stored on some high shelf as Hope, is almost unbearable.

And yet, endure it we must, until the path emerges once more from the forest and we can see again. Thank god its a route I have seldom travelled, and yet each time, as if it were the first, I am lost. We are all connected; when one suffers we all suffer. And this is how it should be: the link is strong. It’s what makes us human, binds us together as a society: we care. God forbid that it could ever be different.

And even in the darkest place, there is still hope. I remember Helena trying to explain to the King how she can help in All’s Well That Ends Well:

“Oft expectation fails, and most oft there
Where most it promises; and oft it hits
Where hope is coldest, and despair most fits.”

We all need a hint of light, no matter how dim it seems when it first approaches.

Intimations of Mortality

Health care is one thing,  access to health care is another. There are many barriers to its acquisition: in some countries it is money, in others,availability of services. But for most non life-threatening health care needs, an underlying problem in all I would suspect, is fear. Not so much fear for safety as a feeling of unease: is what I have serious, will the doctor think I’m wasting his time, will he actually listen to me? So much of who we are -who we think we are- is bound up in our relationships and encounters with others. The medical visit is no different.

Illness, however serious, is still an article of clothing we wear. No matter how much of us it covers, no matter how it weighs us down, it is still we who wear it, we who peek out through the folds. It is important therefore that we meet with acceptance and respect when we finally bare ourselves enough to seek advice.

Cultural safety is one aspect of it. We are less likely to seek help if we feel that our views -cultural or otherwise- will meet with derision or condescension. I’ve always felt that my own specialty -certainly  the obstetrics side of it- is very much like the United Nations. It’s hard to miss the obvious; there’s a common theme that runs through my day; no matter the culture, the background, the social stratum, we all want the same things: our families to be happy, healthy and safe. We want that for ourselves as well. I would think it would be difficult to be prejudiced and a good obstetrician at the same time. I often learn more from my patients than they ever learn from me.

But along with the grateful acceptance of our superficial differences, I think there are other things that make the medical encounter more comfortable, less stressful. The waiting room for example. A picture on the wall, a plant in the corner, or even a carpet on the floor may seem trivial and unnecessary -I suppose they are- but they go a long way to helping the person seeking help feel less like they are about to visit a stethoscope and more that there may be a human in the other room. I realize that the physical constraints of an office impose many limits on the ability to make it look more appealing, but if you lived in that space -and most doctors do for the majority of the week- would you leave it bare and tasteless? Does it really have to look like a holding area, a resting place in a mall? A waiting room says a lot about who the patient is about to see. It can alter expectations.

If ambience is important in a waiting room, it is even more critical in the office. That is where secrets are told, trust is engendered, rapport is established. For new patients especially, what they see is what they judge. They haven’t met you yet, and they are both nervous and fearful. Putting them at their ease is part of establishing a meaningful contact, part of teasing a story out of them, part of actually helping them. It is not the Emergency Department where symptoms speak louder than words, and the diagnosis is often enabled by a wordless glance or an expressionless examination of a person lying on a bed. I’m certainly not suggesting than compassion and rapport are not important under those circumstances because they always are, but merely that the severity of symptoms and the urgency of need is often different in an office.  The approach is usually slower, more gradual -more dependent on mutual understanding and trust. The doctor is more able to explore the issues that surround the need for the visit, as much as the concern itself. He is, in short, more able to talk to the patient, understand her, listen to her -according her the respect and dignity she expects and needs from a health care encounter. It is never easy to confide in a stranger, let alone trust him with personal and often embarrassing problems. But a non-threatening environment may help to ease the transition in an otherwise awkward and frightening meeting.

I realize that considering the venue where health care is administered may seem trivial, but for some it may prove to be the difference between feeling comfortable with seeking help, and deciding to wait until it is truly an emergency. That comfort level takes time. It has to be earned and friends need to be consulted about their experiences. Many important things depend on the word of mouth: reputation, trustworthiness, honesty… and maybe health care utilization.

Health care is…