A good job

October 8, 2010

"You did a good job, doc," the unit clerk called out as I put my coat on to leave the hospital. Simple words but profoundly meaningful at this time in my professional life. I had just delivered one of my OB patients, and it had gone exceedingly well. This delivery meant a lot to me and to my patient because she had suffered a stillbirth the summer before she became pregnant with this baby.

Obstetrics was a specialty I wasn't at all interested in pursuing when I entered my family medicine residency training-something I was determined to gut through while it was required and quickly abandon upon graduation. My third year medical school OB rotation was spent on the labor and delivery ward of an inner-city public hospital. Many of the patients I delivered were HIV positive or addicted to crack or heroin. A birth in these circumstances seemed almost a cruel addition to lives already brimming over with stress and hardship-babies who seemed doomed from their first breaths.

Later, as a resident in a military community hospital, I fell in love with my former enemy-obstetrics-as I celebrated delivery after delivery for patients I had gotten to know and grown to care for. I took pride in successfully managing both difficult and easy deliveries and gaining comfort with what can be a potentially frightening part of the family physician's professional role. After graduation, I sought a clinical position where I could continue to deliver babies, and I continued to love this part of my practice above all others.

I also recall a harried delivery as a second-year resident. The baby wasn't coming, the heart rate was dropping, and I was thinking: "Where is the supervising physician?" I wasn't supposed to be doing vacuum-assisted deliveries on my own at that point in my residency, but I didn't see another option and successfully delivered a healthy baby with the vacuum. "Good job" and "nice work" surrounded me as the nurses congratulated me on my decision and skill.

I am neither prideful nor foolish enough to believe that it has been clinical skills alone that have kept a horrible outcome from my experience. I've walked that road with 3 of my close friends, each of whom did the "right" thing for her patient but lost him or her anyhow-a stillbirth, an infant death, and the unexpected death of a young father. They were haunted by the inevitable "what ifs" and endless replaying of their actions, always with an imagined different outcome. As an objective, although invested, observer I could truthfully offer platitudes such as, "I would have done the same thing," or, "You had no control over what happened," and my most commonly uttered response, "Bad things just happen." Of course, no words ease the pain of a loss you carry forever.

My own brush with absolute fear came recently during an otherwise peaceful morning. Ella was in her late 20s and about 1 week past her due date. She came in early that morning with contractions. The labor and delivery nurse found that her cervix was almost completely dilated. The resident and I were called to the hospital urgently. I didn't change into scrubs, at first because I didn't think there was time, and later because I did not anticipate that I would be doing anything other than watching from the corner. The resident I was supervising was particularly skilled in obstetrics.