The Ripple Effect

Yesterday, I started my morning with a very angry email from a patient’s son.  I won’t go into the details due to patient privacy, but they don’t matter.  He had a reason to be upset, but the reality is that I hadn’t truly done anything out of the norm of standard patient care to warrant that type of reaction.

When I read it, and starting telling my colleague about it, I lost it.  I start crying.  We were just starting our morning, and our first patients were getting roomed.  But my colleague knew I was not in a good state to see patients, so she called over our lead (our mini-chief in our location), and they redistributed my patients for part of the morning to other doctors’ schedules.

For that part of the morning, and honestly all day, I was extra emotional.  As I would start to talk about what happened to other colleagues who were concerned, I would start crying again.

On a logical level, I know this email wasn’t something I should have gotten this upset over.  My reaction to it was a reflection of my state of mind.  I’ve been chronically overworked, and when I feel like I’ve been working so hard, sincerely doing the best I can for my patients, and then the thanks I get is this angry email?  It’s completely demoralizing.  I was already mentally and physically tired.  And that’s why it broke me.

The chief of my department happened to be at my office location in the afternoon and came to speak with me.  I appreciate that she’s aware that our current workload for those of us in the office only full-time is not sustainable.  She is trying to make changes within her power.  But she’s limited by the fact that we’ve been short doctors for the last several years, and it’s not that easy to hire good quality doctors that quickly.  She’s also limited by the powers that be- those above her making decisions that affect what we’re all mandated to do, such as how many patients we see per day.

I told her about this article I came across recently in the New York Times:

It was written several years ago, but they recently re-posted it in their daily email.  It’s still just as relevant today.  It talks about what employees need to feel happy and engaged at work.  Value- feeling cared for by your supervisor.  Focus- being able to focus on one task at a time.  Purpose- deriving meaning and significance from one’s work.  Renewal- taking a break every 90 minutes.  When these needs are met- surprise, surprise- employees are happier and more productive.

I found the renewal part interesting because I definitely don’t get breaks every 90 minutes.  What tends to happen is that I keep working throughout the day.  Even during the lunch hour, if we don’t have a meeting, I’m eating and catching up on results and emails from patients.  Apparently in the end, the constant working makes me less efficient than if I completely stopped working to take a break.

So what I really need during my office day is a forced meditation break in the middle of my morning and again in the afternoon of seeing patients.  It’s kind of like when I used to get breast milk pumping time.  Except I usually spent that time concurrently typing and doing work.  It would take a significant cultural shift, and probably a monetary incentive, to not only give us the time to spend 10 minutes on a meditation app or the like, but to get us to actually do it.  It’s a hard habit to break, when we’re used to continuing to work, work, work to get the job done.

The main reason I wanted to write about the nasty email I received is that there is more I wish I could say to the patient’s son who sent me that email.  I did write him back to courteously respond to his concerns and explain things from my perspective.  What I really wanted to say to him was:

Dear [Patient’s Son],

I understand that you are upset about what happened with your mother, resulting in the email you sent me.  I want you to know what happened after that email was sent.  I read the email, and I started crying.  I was so upset that I could not see the patients I was scheduled to see that morning.  Other doctors had those patients added to their already busy schedules.  My husband was very worried about me after I texted him that I had a breakdown at work.

It’s natural to lash out with angry words and call me negligent when you feel the way you do.  I’ve felt that way, too.  Next time, I hope you take a step back to think about how those words might affect others.  Those words affected not only the intended recipient, but also her patients, her colleagues, and her family.  This same effect can occur whether you are speaking to a doctor or a telemarketer.

A more productive way to communicate would have been to explain why you were upset, and then to ask more.  “Doctor, why did you respond the way you did?  What was your thought process?”  Yes, doctors make mistakes and sometimes they are big ones.  But most likely, there is more to the story.  Finding out more before lashing out fosters learning on both ends, rather than angering and distancing both sides.  I hope you keep this in mind the next time you feel this way.





Stress in Pregnancy

I’ve mentioned before that I’m a huge fan of the Headspace meditation app.  I find it to be very well-designed, and makes it much easier and fun for me to meditate on a daily basis.  They have sessions on various topics such as stress, sleep, relationships, even creativity.  I was very excited that they recently introduced a new session on pregnancy- worked out perfectly for me, timewise.  The sessions evolve during the course of 30 days, and involve visualizations for yourself as well as focusing on the baby.

Per the narrations, the basis of the sessions is that it’s beneficial for you and the baby to have a more calm, positive mindset and that stress is bad for you and the baby.  While I don’t disagree with that, it did get me wondering- how much do we really know about how bad stress is for the pregnancy?

Like most things in pregnancy, I figure it’s hard to study.  You can’t exactly split a group of pregnant women, subject half to significant stress and half not and see what happens.  I’m not one to go searching through all the evidence, so I went to two of my go-to sources.  One is UpToDate, a website many of us clinicians subscribe to that gives us current evidence and recommendations from experts.  It’s generally reliable, and most of us use it as a higher-level Google.  The other resource is ACOG, the organization that oversees us OB/Gyn docs in the US and gives us practice guidelines (how to manage patients based on the current evidence).

According to UpToDate, there is evidence that stress is associated with preterm birth.  They say that major maternal physical and psychological stressors, including anxiety and depression, can activate the HPA axis (involved in the stress response), and it’s been associated with a slightly higher rate of preterm birth.  One study showed that women who had depression early in pregnancy had a higher rate of preterm birth, and there was a “dose-response” effect, meaning that the worse the depression, the more it was correlated with preterm birth.  They talk about the various mechanisms thought to be related to this, and even have the graphic below.


Pathogenesis of preterm birth

HPA: hypothalamus-pituitary-adrenal; ACTH: Adrenocorticotropic hormone 16-OH; DHEA: 16-hydroxydehydroepiandrosterone; E1 – E3: estrogen, estradiol, estrone; CRH: Corticotropin releasing hormone; Cox-2: Cyclooxygenase 2; PG: Prostaglandin; MLCK: Myosin light chain kinase; PROM: Premature rupture of membranes; PGDH: Hydroxyprostaglandin dehydrogenase

Don’t ask me to explain it in detail, as I’m certainly no expert in it.  Bottom line is, stress apparently causes certain factors to be released, which are then thought to cause physiologic changes that lead to preterm labor and preterm birth.

ACOG doesn’t specifically have any articles on stress and pregnancy that I found.  When I looked at their practice bulletin on preterm birth, they didn’t mention stress as a risk factor.  Unfortunately, there is a lot that we still don’t know about preterm birth, or we’d be better at preventing it.  The biggest risk factor is if one has had a prior preterm birth.  There are other things, like underlying infection that have been correlated with preterm birth, but then again treatment hasn’t been shown to prevent preterm births.  Some cervical procedures, like conization of the cervix which is performed to remove cervical dysplasia (advanced precancerous changes), were traditionally thought to increase risks of preterm birth, but they also wonder if there are other factors that contributed to the dysplasia in the first place that also put one at risk for preterm birth.  There are some behavioral factors like smoking and substance abuse that increase risks.

So how do I approach the topic in real life?  July was a brutal month work-wise, working nearly 60 hours a week consistently the whole month.  I can’t say my mindset was exactly Zen as I’d be finishing yet another long work day.  But am I worried that this is going to significantly affect my pregnancy?  No.

My patients often worry about the stress in their lives affecting their pregnancies, and I think it’s generally unnecessary.  While I wouldn’t advise volunteering for combat and voluntarily going to a war zone, most of us experience normal life stressors throughout the pregnancy, and that’s fine.  That’s life.  I can’t imagine that from the caveman days to now, that women have ever been able to get through 9 months of pregnancy without normal life stressors.  And sometimes my patients have more significant stressors- some of them have lost family members during their pregnancy.  Do they all go into preterm labor?  Nope, their babies do just fine.

As a doctor, my goal is to make sure that my patients don’t need a higher level of care for what’s going on.  If they are significantly depressed or anxious, then they may need to see a therapist or psychiatrist.  I certainly wouldn’t want their underlying condition to affect their behaviors, such as eating or substance use, which would then affect the pregnancy.

I do agree that there is potential benefit in working on handling stress levels, such as meditating and exercising.  But rather than doing that, many of my patients worry that their stressful work situation is going to affect their pregnancy, and then they come to me asking for notes for work.  While work modifications are reasonable for patients who have physical pains and limitations, I do think some women are misguided when they think they need to modify because of “stress.”  One extreme example is a patient who works as a school bus driver, driving 2 hours in the morning, and 2 hours in the afternoon.  She felt like this was too much, and asked to reduce her hours.  This is the kind of behavior that will make your doctor roll her eyes and complain about you behind closed doors.

My thoughts are to do what you can to handle your normal life stresses while you’re pregnant.  Meditation is a good use of your time if you are so inclined, but it’s not for everyone.  If there are significant issues going on, they need to be taken care of.  But worrying about how much your normal life stressors are affecting your pregnancy is unnecessary and just increasing your stress.  You have enough to worry about in pregnancy; make this one less thing.