Tuesday, February 2, 2010

Job description

I am a doula. My job is to take care of the emotional aspect of women while they labor and give birth, making sure that they feel safe and attended to and have their nonmedical needs met. Generally speaking, there are too few nurses in the hospital to guarantee personal attention to all childbearing women, and that -- having someone attend to them personally -- is why most women hire me, far more than wanting to get through childbirth without an epidural.

I am knee deep in my first Statistics class. Our first project was to conduct an informal survey on a topic of our choice, mostly to learn about bias and data analysis. I chose childbirth, since that is my field, and asked questions regarding how well-supported women felt during the birth of their first child, whether they had a doula present, and generally how they felt about the experience.

Nearly every person I surveyed responded with some variation of the same criticism: the medical staff was not kind enough, did not pay enough attention to the mother's emotional welfare, either by saying something inconsiderate or inappropriate or overlooking something that would have been nice (in one case, a nurse forgot to bring a sandwich to the mom, and she described it as the worst part of her unmedicated experience!).

It is understood, or at least should be, that when we enter a medical environment such as a hospital, our emotional health takes a backseat to our physical health. What matters the most is that we are alive and healthy, and secondarily (or even sometimes less) how we feel. Doctors and nurses are not required to be nice people or to get along swimmingly with their patients.

And yet we feel a great amount of betrayal when we are treated with less than sterling service. As if hospitals were akin to upscale shoe departments.

Now, I'm not saying that we should expect to be treated rudely. I wish it never happened, but it does, in every environment.

What I am wondering, though, is why so many feel free to hold nurses and doctors to this standard, and whether that means that it SHOULD be included in the service we receive when we seek medical care. No nurses have in their job description to treat their patients with impeccable emotional attention. But I think many of us expect it, get hurt or angry when we don't receive it, and still feel that it was their job to provide it, even though it isn't.

It seems apparent that emotional wellbeing is wrapped up with physical wellness, whether we rationalize it away or not. My question is, well, should it be included in the definition of health care? Should psychological care be a recognized aspect of medical care in every practice? Are we losing anything by continuing to go forward with this hit-but-mostly-miss way of treating patients, or is this a crucial element of health care that needs to be addressed differently?


  1. I think that the emotional care of patients is critical, and somewhat overlooked. My (very limited) experience with hospital care suggests that 1) many or most nurses are in this line of work because they wish to care for people including providing emotional care and comfort, and 2) doctors set the overall tone of the place.

    I think that doctors who work in hospitals must feel constantly aware that the hospital is a business that provides critical care to the sick and injured. As you point out, making people feel safe and cared for is a lower priority than preventing death and disability. This is probably exacerbated by the imbalance of power between doctor and patient. A sick or injured person who knows little about medicine is in a poor position to threaten to take his business to another hospital. Consequently, keeping customers happy is not ever-present in the minds of hospital staff.

    To stereotype, I think that it may be that doctors are more likely to get a sense of personal satisfaction from applying their technical expertise and from being respected. Giving people comfort may be a fairly weak motivator for doctors. And, I do think that doctors set the tone for the hospital. Thank goodness for the nurses.

    Obviously, though, it's not enough. Doula's can make a living precisely because the hospitals are doing an inadequate job of caring for customers. In one sense the hospitals are leaving money on the table, because they are failing to provide the service and capture the value that doulas are.

  2. (Great to see you now as an official blogger here, on the side pane and all!)

    I completely agree there should be more of a place for emotional care. My take is that there is not nearly enough diversity in the health care system. Not that I have visited lots of hospitals (I have not been to even a regular doctor in years) but the ones I have seen all were similarly discomforting, uninviting, and emotionally hazardous.

    Medical people I think would argue that you need the place to be a certain way for cleanliness and sterilization, but it seems to me there should be a lot more diversity of choice not just in health care practitioners but in the total environment where you receive your care -- particularly for women in labor. As you say, mental and physical health are closely related -- this I strongly believe.

  3. Unfortunately, I have received a lot of medical care over the years, and I vote a RESOUNDING yes to including psychological care with the standard definition of health and health care in the US.

    I was pre-med in college and one of my classes addressed this specifically. Not only is it considerate as you mention, psychological well-being has a significant effect on a patient's physical health and recovery.

    The reverse is true as well: physical health has a substantial effect on our emotional well-being, (more than any other commercial service, I'd guess). Being sick, helpless, incapacitated, or in pain takes a psychological toll, and I'd wager that just about every patient would benefit from assistance in processing and responding to changes in their physical well-being.

    In the class my prof said that hospitals are beginning to recognize this and many have hired psych professionals to be on-hand, ready to do rounds and consult with patients along-side the medical doc. The example I remember from class is a patient hearing she has diabetes. When someone learns that she has to change her diet, take blood tests regularly, or be on medication the rest of her life, she is going to have a big emotional reaction that will probably make it difficult for her to hear everything the doc has to say, to think of and ask important questions, and to process how these changes will affect her life. She NEEDS, at that moment, help adjusting and processing the information. While some docs are sensitive to this need, many are time-pressured and do not have the training necessary to address those emotional needs.

    This is has been true for me many times in my personal experience, and above all for the birth of my son. While I felt the actual birth process and postpartum was better than I had expected, the NICU experience was a complete disaster. For me, the ONLY positive aspect of the NICU at Dixie Regional was the help of their social worker. She made it possible for me (a brand-new post-partum first-time mother right after an extremely difficult delivery) to have a relatively calm and sane discussion with the doc about why Elijah's care was inappropriately handled. Crucial!!! for both me and the doc.

  4. Robert, I agree with you. I have heard many nurses mourn the drive-thru aspect of medical care and wish they could spend more time doing what they love instead of taking notes and following paperwork procedures.

    And I think you're right about what doctors may find fulfilling. In my field of work, it makes sense that doctors might glean a great deal of satisfaction from a successful cesarean, but only a little bit from a woman who births on her own without taking even a whiff of pain medication.

    I agree it isn't enough, but really, how can we change it, when, as you echoed, it isn't really a priority?

    And, yes, if nurses were good doulas, I'd be out of a job.

  5. Thanks, Justin!

    That's interesting, about diversity. So how do you imagine it? One hospital that prides itself on sterile technique, one that provides more of a touchy-feely approach along with the good medical care?

    Choice would certainly be welcome. I had both of my babies at a hospital that fully supported every kind of birth, provided for emotional support and every aspect of physical comfort, and it was fantastic. Lovely experiences. Unfortunately I haven't seen anything even remotely like it since.

  6. Sarah, thank you!

    I didn't know you were pre-med. You're amazing.

    And I completely agree with everything you said. But I wonder, is it enough? Is having a psychologist/LCSW present enough to help address the emotional care of patients? A doula for every setting?

    Maybe it is, actually. But how much did it improve your happiness with your NICU experience?