Clinical, Featured, Health Policy, OB/GYN, Pediatrics
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Ugly


 
The following manuscript was published as part of the February 2019 Social Medicine theme issue.


The baby’s hat is bright orange, knit with vertical ribbing to mimic a pumpkin’s ridges, and topped with a tiny green stem. The cheeks below it bulge in perfect crescents. I turn to the mother to ask if she made the hat herself. Her eyes don’t leave the muted cartoons bouncing across the television screen as she mumbles, “The nurse or someone gave it to her.” She’s propped up in bed, her postpartum belly protuberant, the wound from her cesarean section weeping through its gauze dressing. As a medical student with only a few clerkships behind me, I’m not yet accustomed to the mild gore that will eventually feel commonplace. I’m even less versed in the carnage of life that can leave brutal scars or sometimes no visible scars at all.

The mother is 24 years old and this child her fifth, with three other pregnancies ending in termination. She’s had little in the way of prenatal care and as yet has no doctor for this baby. She doesn’t like the health center where her other children get their shots, but hasn’t found another place to go. Complications with Medicaid and the social services office got in the way. The baby’s father was uninvolved, unwilling to help. In the meantime, the baby arrived.

The mother’s appearance is as striking as her story. The dark skin on her neck is embossed with a jagged pattern — huge swaths of scar tissue rising and falling in ruts resembling the swipe of a giant bear claw. When the attending pediatrician has finished examining the baby, she takes me — perhaps all of us in the room — by surprise, asking, “I don’t mean to pry, but those are some serious scars on your neck. Would you mind telling me how you got them?”

The mother looks our way for a second before turning back toward the television. “Yeah, it’s okay,” she says neutrally. “The father of my first child tried to kill me. While I was pregnant.”

At first I expect my week rotating through the newborn nursery to be cheerful and exciting. The attending physician and pediatrics resident are friendly, engaging and eager to teach. I thrill at the privilege of examining babies who are just hours old and offering guidance to their parents: how often to feed the baby, how to position them for safe sleep, what symptoms should prompt a call to the pediatrician — all pointers that I soak in and store away for that nebulous point in the future when I hope to become a mother.

But I begin to dread the encounters with families. I am suddenly privy to the intimate details of strangers’ lives: babies born to mothers who live in homes crammed with 10 or more family members, to women whose charts and rooms are labeled with pseudonyms to protect them from partners whom restraining orders might not keep away. Babies that show signs of withdrawal, their systems no longer flushed with the painkillers and other drugs that had spilled into their blood from their mother’s blood. The poverty, disadvantage, lack of education and lack of planning and preparation for these babies stun me. My own lack of exposure to such realities leaves me without the tools to digest them and to respond with anything other than outrage and anger.

Ugliness swirls in my head. How could these innocent, beautiful babies be born to women who just couldn’t be bothered to use birth control or who decided to have another child when they needed help from social services to feed and clothe the ones they already had? And yet women who could afford to raise children and give them every advantage in life, women who could nurture them in stable homes tucked away from danger — women like the attending, like the resident, like me one day — we put off having children so that we can care for the children of others. And when we are done training, we are left with such a narrow window of time to have any of our own.

Not so many years before, I had written medical school essays about how I wished for nothing more in life than to help those who desperately needed care. I had spoken passionately during interviews about my desire to provide medical assistance to anyone in need, regardless of their station in life or their ability to pay. But this feels so different, so appalling. So real.

Often the families with these stories seem reluctant to engage with the medical team when we visit each morning on rounds. The mother of pumpkin hat baby rarely offers more than one-word answers, which only harshens my judgments of her. We remind her daily of the importance of scheduling an appointment for her baby with a pediatrician. She nods but day after day makes no move toward accomplishing this task.

I begin to disengage. When I pre-round on patients, I make little effort to exchange pleasantries with those whose stories distress me, and in fact I do my best to avoid spending time with them. When the resident and I divide the patient list in the mornings, I pretend to pick patients at random when each choice is actually a deliberate attempt to avoid families I don’t want to see.

Near the end of the week, I reach the nursery a few minutes late. The resident has already gone off to examine babies and left half of the day’s list for me. I glance at the names and sigh, steeling myself to see the baby with the pumpkin hat. The notes in the chart tell me that the mother spiked a fever overnight; she and her baby are not going home today after all.

When I enter their room, I murmur a cursory greeting and head toward the bassinet to examine the baby. For the first time, the mother makes eye contact and answers with more than one word. Her frustration pours forth, filling the space between us. “I don’t want to be here anymore! I got this fever, and my belly hurts” — she pulls down the sheet and brandishes her swollen abdomen at me — “and they’re not telling me what it is and not doing nothing about it!”

“I’m sure that’s very frustrating,” I say cautiously, pausing over her sleeping daughter, unsure how to proceed. “Have they told you when you might be able to go home?”

“No! They keep saying it’s one thing and then another and I don’t know why they don’t just go fix it! I just want to leave — I got other kids at home! They gotta meet their sister. I want to just take my baby and walk right out and get on the bus.” She sighs. “But I want to do things the right way, you know?”

“I understand,” I say, looking out the window at the gray day dawning through drizzle. I picture her and her newborn huddled in the damp November chill, waiting for the bus. “I think the most important thing is that you stay until you are well enough to take care of your daughter.”

She nods, slumping back into bed and training her gaze on her infant daughter as I undo her swaddle and examine her. As I pull my stethoscope from my ears, I ask, “Have you been able to make an appointment with a pediatrician?” because I’m not quite sure what else to say.

“I did!” she exclaims, swinging her legs over the side of the bed and grabbing at her IV pole to stand. “I still have to work out the Medicaid, you know, but I got an appointment.” She reaches toward a pile of papers on the windowsill.

“It’s okay, you don’t need to show me–”

“No, I want to.” She shuffles through them, then triumphantly waves a napkin bearing a date, time, and office location in blue ink.

“This is great,” I say, really meaning it. “I’m so glad.”

She eases back down onto the bed and I wait as she settles back under the covers.

“Get some rest. I’ll be back in a few hours with the whole team, like usual.”

“Thank you,” she says. “For listening. Sometimes you gotta let it out, you know?”

I do and I don’t. The specifics trials of her life — young single parent with multiple children, history of intimate partner violence, financial insecurity — are utterly foreign to me. But as she makes eye contact with me, as she lets down her guard in a way that I haven’t seen her do with the medical team or during my own abbreviated checks — during which my guard was undeniably up as well — I wonder how she perceives our differences. Is she embarrassed to tell her story? Does she feel judged? Does the vast distance between her own experience and that of most of the care team keep her from asking questions, expressing concerns, conveying needs?

No huge paradigm shift occurs in my mind and heart that day. But a new understanding of, and respect for, people with backgrounds utterly different than my own begins to emerge. I start to see that the differences between her path and my own were not forged by simple decisions, intentions, and only a small amount of luck. In the examination of life, it’s as if she and I were given entirely different sets of questions and possible responses.

As my clinical rotations continue to unfold and I listen closely to my patients’ stories, more and more assumptions and judgments begin to fall away. For my residency, I choose to practice in a setting where I provide care almost exclusively to underserved communities, to children whose families are caught in a swirl of low income levels and lack of education, food insecurity, unstable housing, and the threat of violence. And as I grow to know them, it is confirmed over and over that none of these families love or want less for their children than I do for my own.

But I also learn over and over that I can’t truly help unless I face head-on the circumstances of their lives and the challenges they face. That I must work to adapt the advice and counsel that I have to offer with the realities they face as a family. It’s an ongoing lesson, one that started with the mother of the baby in the pumpkin hat.

Image credit: Lil’Pumpkin Patch Hat Crochet Pattern” by Tara is licensed under CC BY-NC-SA 2.0.

Rebecca E MacDonell-Yilmaz, MD, MPH (3 Posts)

Fellow Physician Contributing Writer

Rhode Island Hospital/Brown University


Becky is currently a fellow in pediatric hematology/oncology at Hasbro Children’s Hospital/Brown University in Providence, RI. She completed her residency in pediatrics and fellowship in hospice & palliative medicine at the same institution. She received her BA and MPH from Dartmouth College and her MD from Stony Brook University School of Medicine. Her work has been published in Pediatrics, Annals of Internal Medicine, Journal of the American Geriatrics Society, and The Huffington Post, as well as on the blogs Kevin, MD and Mothers in Medicine. Her personal blog is entitled The Growth Curve (www.thegrowthc.com). She lives in Rhode Island with her husband and two sons.