Freelance, Los Angeles
Jun 30, 2010
|Your Brain is Green|
Wednesday, June 30, 2010
Tuesday, June 29, 2010
But this isn't about "Drs. Wonderful", or "Dr. Grouchy" or any other kind of doctor. It's about communication, or the lack thereof, and time, and patient expectations, and reality.
I'm the last one to deny that most doctors don't have "bedside manners" worth a damn. At Your Cervix has already finished one year of her CNM course [MA, I believe] and until now it's all been about communication. I keep waiting for her to get to midwifery -- I suppose it will show up at some point. Doctors never take courses in how to talk to patients, and to be honest, frank discussions are usually not viable for several reasons. The patient has to trust the doctor, yet he wants the doctor to be somewhat distant and objective, before he can open up and ask "What was that you just said? Can you repeat it in English?" or "Why are you advising this treatment and not that treatment?" because the patient fears the doctor will be annoyed with him for doubting his [the doctor's] pronouncements. [And the doctor, all too often, is. He wants to stay on his pedestal as much as the patient wants him to remain there]. So there is a very fine line in the interaction between patient and doctor. Add to this the fact that in OB the patient is a woman, and the doctor is very often a man, and having a baby is not only emotional but related to sex, and the line can be very fine indeed. One man's compliment can be another man's sexual harassment -- this is the reason all intelligent male doctors will have a female attendant in the room if an internal exam is likely. Females, be they nurses, midwives, or even female physicians, are perceived by the female patient as being less threatening. Those of us in the business know that the most obnoxious doctors [at least as far as their staff colleagues are concerned] can be women, who often need to prove they are tougher than the men, incidentally.
So patients can feel intimidated even when there's no overt intimidation going on, and insensitive doctors can think the patient is entirely satisfied with her treatment unless she signals that she is. The signalling is often misinterpreted as hostility. Trust, and communication, again.
But, the nurses and the midwives, one hears, "listen to me when the doctor doesn't". It depends on what the patient's talking about. It isn't the doctor's job to instruct the patient how to use her glucometer; it is a waste of time to do so, but it is a task the nurse is educated to do. The patient then perceives the nurse as being more interested, more supportive. On a ship, it would be a waste of time for the Captain to shovel coal in the boiler room; he delegates that to the appropriate people. The same thing applies here. The nurse can't determine what the insulin dose should be for a gestational diabetic; the doctor does that, and the nurse shows the patient how to administer it. It's called division of labor.
Now, about time, and reality. Ideally, I would have a half hour with each new patient, to open their pregnancy follow-up card, take a history, chat about the progress of the pregnancy, ask if there are questions, etc. At Your Cervix is interested in bringing the delights [!?] of unmedicated "natural" childbirth to low-income women. Do poor, uninsured women take private midwives? No, they don't. They go to clinics run by teaching hospitals. If a CNM sees a woman, she is a staff midwife, who doesn't pick and choose her patient caseload, she works in a clinic X days a week, or in L&D for X shifts a week. Right away, the one-on-one patient/midwife relationship is compromised. Ms. Hernandez will probably see a number of different midwives through her pregnancy and labor and, because the clinic is almost always crowded, will have only a brief time to speak with one. When doctors are accused of giving their pregnant patients short shrift, the patient doesn't usually know how many patients the doctor has to see within a given time: in my clinic, in a 5 hour stretch, a doctor usually has to see between 40 and 75 women. No time for cozy chats, is there? It's not uncommon for me to be supervising two women having NSTs [fetal monitoring], be teaching a woman about gestational diabetes, and have half a dozen women waiting in the hallway for their BP/weight/urine tests before going in to the doctor. It's a madhouse. And, oh yeah, the phone keeps ringing [usually with asinine questions like "I forgot my pill today but he didn't come inside. Can I get pregnant?" or "I'm 6 weeks pregnant but I'm bleeding and having cramps. I don't have a babysitter. Do I really need to see a doctor?"] The phone queries take more time than anything else.
Whether a woman gives birth in hospital or home, if she retains a private midwife, of course she gets a great deal more attention. She's paying for it [or in some cases, her insurer is]. Most CNMs who don't work in hospital work with a medical group, and depending on how much overhead there is, and how much profit her medical partners want to make, her caseload can be extensive. It often presents a dilemma. Whereas a doctor can relinquish on-the-spot care to the L&D nurses and only get to the hospital when the patient is nearing delivery, or will briefly pop in from time to time, thus being able to manage his office hours as well, the CNM is expected to accompany her patient, acting more as a doula than as a doctor, especially in early labor. Meanwhile, her clinics for her antenatal patients must be cancelled and all the patients rescheduled. The patients really love this, believe me. [Or the practice has several midwives, who cover for each other, which patients, used to seeing a particular midwife, also dislike]
Homebirth midwives make a big point of describing the huge amounts of attention they give their patients. Well, that's because of the infinitesimal number of patients they deliver. Two deliveries a week, 100 a year, is a really heavy caseload for a midwife delivering babies at home, and a midwife with a caseload like that is a physical wreck pretty soon, from exhaustion. Two deliveries a month is more like it, and while sometimes she might have a busy month, with four or five deliveries, she is also likely to go several months without a delivery. Most homebirth midwives can't make a living from this, no matter what they charge, and also work as instructors or doulas [or their partners support them].
So the bottom line is that although a midwife ought to be  a CNM,  carry a reasonable caseload which allows at least half an hour for each patient,  be linked to a major medical facility or have medical back-up which is sympathetic to the idea of promoting the midwife's ideology for birth,  has an income commensurate with her education and committment -- the chances are that it's all a long way off. Noticed any flying pigs in the neighborhood recently?
In the present, you do what you can. When I have an obviously distressed patient, I shoo everyone out and close the door, even occasionally lock it [but that doesn't stop patients banging on it anyway] and try to disconnect the phone [but the switchboard operators get antsy with the secretaries because they can't put "emergency" calls through] and give some quality time to the patient. But as the saying goes, until you've walked a mile in a man's shoes, don't judge him -- wait until you're in practice, At Your Cervix, before you make judgements on how patients are treated by their Health Care Providers. BTW, hope the day you begin your new career isn't far off.
In general, I give books with female authors and sensuous pictures on the cover a pass – Danielle Steel, for example, doesn't interest me in the least. So I have often passed over the audiobooks of Susan Howatch available on Audible.com, but when I read the reviews of "Glamorous Powers", I was intrigued, and the audio sample was very well read. It was fantastic. In quick order I ordered the first and third books of the first "Starbridge" trilogy ("Powers" being the second) and devoured them. I also listened to "The Rich are Different", and "Sins of the Fathers", which belong to an earlier, "historical romance" phase. I don't really think that's a good description, but I don't know what else to call the Caesar/Cleopatra/Antony/Augustus story, set in the 1920s to 1950s, with Paul van Zale/Caesar an investment banker. Sounds awful, doesn't it? In the hands of another writer, it might be, but Howatch carries it off magnificently. I'm currently waiting for three more of her books in this genre: "Cashelmara", "Penmarric", and "Wheel of Fortune", which, I understand, are based on Plantagenet history, transplanted to the 19th century.
The "Starbridge" novels, consisting of two trilogies, the first in the 30s and 40s, and the second ending in the 60s (I believe) are followed by a third trilogy, the "St. Benet" trilogy, which carries the story into the 90s. At the heart of all the books are Jonathan Darrow and his son, Nicholas. Both clergymen in the Church of England's "High Church" end of the spectrum, both are unusually psychically sensitive and involved in spiritual counselling and healing. The first two trilogies are mostly concerned with clergymen in various states of nervous and spiritual breakdown; the third set of books has more of an emphasis on those secular persons who Nicholas attempts to heal. In my opinion, while interesting, it is the weakest set of the books, and I personally gravitate more toward Nicholas' mentor and assistant, Lewis Hall (the great-nephew, incidentally, of Nicholas' father's mentor), who is an older, rather curmudgeonly man which a sex drive which gives him problems (since he's divorced, and C of E clergymen are expected to be either married or celibate). It's not that Nicholas is a nonentity, but he's a pale shadow of his father, who is a very charismatic and forceful personality. There is a strong psychological component in the discussions of spiritual direction, but the language, most of the time, is religious rather than psychological, and I'd be happier if the "healing" was in the name of God (which, actually, it is, most of the time) rather than Jesus, who, for me, is a false god. I don't really have a problem with the idea that "demonic forces" are synonomous with neuroses. The implication is that, if there IS spiritual healing which happens in the name of a false god, then  either the real God is doing it regardless of the religious orientation of either the patient or the healer, or  it would have happened without any recourse to any divinity whatsoever. Once or twice in the books there are scenes in which phrases and actions associated with exorcism are invoked ("Depart, Satan!" or "In the Name of Jesus Christ, leave this person!") with a cross being flourished, and one of the "villains" cannot speak Jesus' name (why wouldn't she, probably with an expletive attached? Plenty of wicked and highly neurotic people do call on Jesus all the time, without ill effect [or beneficial effect, for that matter]. The whole concept that there is something unique about Christian healing (what happens if a Christian is prayed for by a group of Hindus?) makes me uncomfortable. As anyone who reads this blog regularly knows, Christianity makes me uneasy in a lot of ways. I'd be interested in knowing what clergymen think of Howatch's books.
In any case, I highly recommend her work.
Wednesday, June 23, 2010
Tuesday, June 15, 2010
Sunday, June 13, 2010
Friday, June 04, 2010
Jun 4, 2010
Jun 4, 2010
Jun 4, 2010
Wednesday, June 02, 2010
The past couple of days, to keep my blood pressure more or less normal, I've avoided them. I don't know which upsets me more, the real implications of the Gaza flotilla, or Israel's response to it.
As is so often the case, the flotilla is merely a symptom of a much larger and more serious underlying condition, and for this one has to study history. It's not an accident that the Turks are funding the enterprise, and that should be worrying a lot of folks in Europe and the US.
Equally worrying is the degree to which Western countries are being hoodwinked in relation to the true situation in Gaza and the true aims of both Hamas and the so-called PA "government".
And lastly, just how dangerous it is for Israel to believe its own mythology.
The flotilla itself was created to be a provocation, not a solution, because the problem it ostensibly is addressing -- the lack of "humanitarian goods" in Gaza -- is a false one. The Jerusalem Post today has an article showing that the goods found on the boat have already been supplied by Israel for some time and there is no need for them to be brought specially now. Nor was there any reason for the ships not to have complied with Israel's demand that the flotilla dock at Ashdod for inspection. Israel announced prior to the sailing that it would transfer all humanitarian aid to Gaza. No, the organizers wanted to be martyred for a fake cause -- and Israel gave them what they wanted. Silly Israel.
What is going on now in the Middle East began around the time of the Crusades, although it can be argued that the real beginning began when Shi'a Islam split from Sunni Islam. During the Crusader period there was a virtual civil war between the two Islamic factions (which was one reason the Crusaders managed to succeed in the First Crusade). The Caliph in Baghdad was Shi'a; so was the Caliph in Cairo. The Sunnis, who had been ascendant, and were the majority, were, for a time, swept aside by the Shi'ite "heretics". But that had been reversed by the time the Ottoman Empire was established. But the Shi'ites have long memories, and a big chip on their shoulders.
It is important to remember that the Iranians, Syrians, and Turks are Muslims but not Arabs. Traditionally these countries, together [sometimes] with Iraq and Lebanon, have formed a distinct axis which is ethnically very different from Saudi Arabia, Egypt, Jordan, and the Gulf States. In the 1920s Kemal Ataturk forced Turkey, then the "Sick Man of Europe" to modernize, and become a secular state. But the West has largely rejected Turkey's overtures as inadequate, and there is an Islamic backlash growing. Iran has been all to eager to "assist" Turkey to find its true Islamic "self" because, together with Syria/Lebanon, that forms a bloc which  isolates Iraq, which is also a target for the nascent Iranian hegemony and renewed "Caliphate", and  can split the Islamic world in two. Iran's ultimate goal is to be the most powerful state in the Middle East. If Iran can site its missiles in Turkey, after Turkey expells NATO and the US bases there, it cripples the West's ability to control Afghanistan, or any other region nearby, and threatens Europe directly.
Hamas has come to make common cause with Hezbollah, as well as Al Qaeda, and therefore is allowing itself to be influenced and supported by Iran, possibly directly although I don't think that right now there is any real proof. So Iran's sinister finger must be sought when looking behind the scenes. Iran encourages Turkey, who funds the Gaza flotilla, to help Hamas. The fate of the Gazans is almost irrelevant. And anything which embarrasses the Israelis is just icing on the cake.
The timing is also interesting because Obama is hosting this "Jewish American Heritage Month" right now, because he desperately needs the Jewish vote in the US this November. Bibi is drumming up support for his policies in the States and is somewhat preoccupied. Whoever planned the Israeli response to the flotilla (assuming anyone actually did) was acting without guidance from the PM, and the Turkish organizers are not loath to embarrass Obama as well. In the Muslim world he is regarded as weak and ineffectual; a bit of a joke really.
For a long time, Israelis have patted themselves on the back and felt that they are very clever; certainly they are a lot cleverer than stupid Arabs. Unfortunately this in itself is a dangerous trap. Arabs are not very intelligent about certain things, but very shrewd indeed about some things, and not all Jews are intelligent at all. Arabs are very adept at telling others what they wish to hear, and do not scruple to lie. It's all part of the game, and of their culture. And they are believed by the gullible. I was told just the other day that Israel faked the Karin A incident, when a boat carrying 80 tons of arms tried to dock at Gaza and was seized by the Israeli Navy. Palestinians moan about how Israel "doesn't want peace" but use schoolbooks whose maps show Palestine from the Jordan to the Mediterranean and use the Arabic version of Sesame Street to extoll child martyrs and a Micky Mouse figure talks about murdering Jews. That's all right. They complain about security fences and borders keeping them out of Israel, but no Israeli dares go to Palestinian territory for fear of being lynched. They want free and unlimited access to Israeli territory but they claim to want their own sovereign state and don't want Jews in it. Borders work both ways, habibi.
The question remains what to do about future flotillas, because the Hamas folks are planning them. The first thing is that there must be no doubt that Israel will not allow them to dock at Gaza, but that it is made absolutely clear that all aid will be transshipped to Gaza after inspection at an Israeli port if the ships come in peacefully. If they do not, the aid will be confiscated or returned to its country of origin. Netanyahu should hold a prime time news conference with as much of the international media as possible and this message must be spread as widely and reiterated as often as possible. Foreign journalists, and UN observers, if it can be arranged, should be on Israeli navy ships. Live filming and broadcasting should begin from the first hailing of any flotilla vessel until it is escorted into port. If networks choose to put foreign correspondents on Palestinian ships but not on Israeli ships, the credentials of correspondents working in Israel should be revoked. [I also think the major news networks should have a correspondent resident in Shderot permanently, btw] If there is a live TV feed, it will be obvious who is attacking whom and with what. Israel has got to realize that the world wants to believe the worst of the Jews at all times. Film released after the event will be called "fake".
During the Second World War, the acronym SNAFU was common. It stands for "Situation Normal, All F**ked Up". It is still applicable.