Abstract
Abstract
Women physicians are becoming more numerous, with the majority of active hospice and palliative medicine physicians under the age of 50 being women. While this trend has appropriately led to discussions of supporting, recruiting, and retaining women physicians, there is little literature about the effect of women physicians on patients. In particular, little has been written about the effect of a physician's pregnancy. Drawing on psychotherapeutic literature, the authors present seven cases illustrating how pregnancy of the palliative care physician affects patients and families. By recognizing the responses of patients and families and understanding the underlying meaning of the pregnancy, which drives those responses, palliative care physicians can utilize the pregnancy to select therapeutic interventions for the patient and family.
Introduction
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Current literature examines how existing structures impact women physicians' decisions in choosing an employer, pursuing career advancement, and considering family planning, as well as how those structures might be altered to retain and recruit women.3–6 There is also a limited amount of research on physicians' pregnancy outcomes, particularly during training. 7 However, while there is growing interest in differences in patient outcomes according to physician gender, 8 little in the biomedical literature comments on how a physician's pregnancy affects patients.
In contrast, the pregnant clinician has been a rich area of research in the psychotherapeutic literature, 9 which can be grossly divided into three major areas of study in the therapeutic dyad: the transference, countertransference, and psychotherapeutic frame (Table 1). It has been found that, overall, pregnancy actually facilitates rather than impedes the therapeutic process.10–12
Glossary of Psychodynamic Terms
Palliative medicine is a unique subspecialty that utilizes both biomedical and psychotherapeutic tools for supporting patients and their families in a therapeutic process specific to palliative medicine. Life-limiting illness is a reality stimulus that evokes deep-seated conflicts, worries, or wishes 12 within the patient and family. Palliative care clinicians utilize operationalized communication skills 13 to assist patients in recognizing their emotional reactions, or affective responses, to the illness stimulus, attributing meaning to those responses, and making decisions that meet needs and values communicated by that meaning.
Pregnancy is another reality stimulus, one that becomes an unavoidable self-disclosure on the part of the physician and prompts an unconscious affective response from patients and families. In the unique semiotic space of palliative care, in the context of life-limiting illness, the reality stimulus of pregnancy carries additional existential significance, theoretically provoking heightened intensity of the unconscious response.
We present the following seven cases to demonstrate that, by identifying the type of response the patient or family has to the clinician's pregnancy, the clinician can glean useful information, which can then be utilized to guide clinical interventions. To aid in the discussion of the psychotherapeutic concepts, Table 1 provides a glossary of psychodynamic terms used in this article. These cases occurred on a palliative care consultation service at a tertiary academic medical center, involving one of three women physicians during HPM fellowship: two with a background in internal medicine and one in psychiatry.
Case Descriptions
Case 1
Y, a 72-year-old man with metastatic prostate cancer, presents with pain and delirium. His wife/surrogate decision maker has consented to hospice although remains overwhelmed. The palliative care team, including the pregnant physician, follows up with her for support. She is tearful as she recounts the hardships of their marriage, then asks when the baby is due.
Physician: “July.”
Wife: “My birthday is July 29, and his the 24th, and my cousin's is in July too. We would go to the movies every year together.”
P: “What's the last movie you all saw together?”
W: [starts laughing] “Oh it was crazy! What was it called? He and I hated it. My cousin loved it…”
[pause]
“I see what you're doing. You got me to remember the good stuff. Thank you.”
Case 2
G, a 76-year-old man with AML is actively dying but still awake and interactive. When meeting with him and his five adult children, G asks the physician questions about her pregnancy. After answering briefly, the physician asks his advice for raising children. His primary piece of advice is to “become interested in what your kids are interested in.” His children then share stories about the role their father played in their lives.
Case 3
L, a 55-year-old man with metastatic pancreatic cancer, is actively dying. The physician meets with his friends the day she goes into labor. She is actively having contractions during her visit and planning to present to labor and delivery after rounds.
During her visit, L's friends and the physician talk about the baby and how she is going into labor. They are ecstatic to hear that a baby will be born on the day their friend is dying. They describe L as an amazing, positive force in the world, stating that he loved kids and would have loved the fact that, as he was dying, a new life was coming into the world.
Case 4
A, a 29-year-old woman with newly diagnosed carcinoid presents with uncontrolled symptoms, including persistent hypoglycemia. During her initial visit with the pregnant palliative care physician, she asks:
A: “Now that I have the right diagnosis, of the patients you've seen with a case like mine, how do they deal with it?”
P: “Deal with the symptoms? Or is there a bigger question that you're asking?”
A: “…I believe in miracles too. I know a woman who was treated for cancer and was told she would never have children, and now she has three beautiful daughters. And another friend, who was told she wouldn't have children after treatment, and now she's pregnant with her first.”
P: “Are you worried about your fertility?”
A: “No, not my fertility exactly. I know it will be okay. But, you know, when my belly started swelling, I thought, this must be what it's like to be nine months pregnant!”
Throughout the course of their interactions over several weeks, A never mentions the physician's pregnancy.
Case 5
M, a 42-year-old woman with BRCA1+ ovarian cancer and significant family history of breast and ovarian cancer, presents with progression of disease. She meets with the palliative care team to discuss her goals and options. Ultimately, given her desire to spend time with her teenage son, she decides to enroll in hospice.
M shares deep feelings of grief and guilt at hurting her living family members, but also excitement at being reunited with her loved ones who have already died of breast or ovarian cancer. As the team bids her farewell, she wishes the pregnant physician luck with the rest of her pregnancy and delivery. Although they had only met that week, M insists that they met many times during the course of the pregnancy, such that she “feels like they have watched the baby grow and develop together.”
The physician asks M's advice for raising a son, and M responds, “Let him do him. There will be times you have no idea why he's doing the things he's doing, but he's finding his own way.”
Case 6
K, a 32-year-old woman with a history of multiple suicide attempts, presents with liver failure following an intentional acetaminophen overdose. She is not a transplant candidate and is now hypotensive and in renal failure. Her family is at her bedside, and they all stand and offer their chairs to the pregnant physician when she enters the room.
As the physician answers K's parents' questions about the withdrawal of life-sustaining therapies, K's fiancé stares blankly in the direction of the physician's gravid abdomen and becomes tearful. The physician places a hand on his shoulder and reminds him and the rest of the family that the palliative care team is available to support them as well. The fiancé then admits that he is going to need additional psychological support after the withdrawal, and the physician recommends that he meet with the palliative care team social worker. K's parents and brother then add their support, reminding him, “We're your family now.”
Case 7
R, an 82-year-old woman with a history of multiple strokes and renal cell carcinoma, presents with delirium and evaluation for a G-tube. The palliative care team is following for management of delirium and assistance with clarifying goals of care. As the physician is actively going into labor, R's adult son, who has been her primary caregiver for decades, yells at the physician about how she is incompetent and does not belong in the workplace. He comments that the physician is going to leave her patients uncared for to go deliver her child and then neglect her child when she returns to work. The physician, who delayed presenting to labor and delivery to attend this meeting, struggles to control her anger and resentment at the son's outburst and hide her growing physical discomfort, while also reassuring the son that the palliative care team as a whole will continue to care for him.
Discussion
The cases described exemplify four typical patient/caregiver behaviors in response to pregnancy: curiosity (cases 1–3), ignoring (case 4), caretaking (cases 5–6), and anger/aggression (case 7). These four responses can be construed as paired opposites: curiosity versus ignoring (i.e., the apparent lack of curiosity) and caretaking (beneficence) versus aggression (maleficence). Underlying these behavioral responses are affectively charged themes, including merger, separation, and envy (Table 1), 14 all of which are unconscious fantasies stimulated by the image of the ideally intimate mother–infant pair. How the clinician chooses to respond (or not respond) can facilitate how the patient or family copes with and begins to work through their imminent loss.
The communication skills learned in palliative care training prepare palliative care physicians to implement certain psychotherapeutic techniques, meaning “typified, verbal, or nonverbal behavior on the part of the therapist, which intends to affect the patient in the direction of the goals… of treatment.” 15 In contrast to psychotherapy, in which the intermediate goals include insight and the final goal is transformation, 15 the primary goal of palliative medicine is to comfort. To this end, palliative care clinicians use four psychotherapeutic techniques: suggestion (inducing ideas, impulses, emotions, or actions in the patient), abreaction (prompting emotional discharge or catharsis through expression, often verbal), manipulation (leveraging emotional systems for the purpose of achieving therapeutic change), and clarification (aiding the patient in articulating conscious or preconscious (Table 1) feelings). 15
These cases demonstrate how the stimulus of pregnancy carries meaning specific to the patient/family, based on their past experiences and relationships. During the clinical encounter, the astute physician can glean that meaning from the behavioral responses described above. This can then assist the physician in choosing a therapeutic intervention. The physician is, in effect, utilizing the pregnancy and the affect it stimulates to guide patients' and families' coping and mourning in the context of life-limiting illness.
For example, in case 1, the physician's direct response to the curiosity (behavior) of the hospice-bound patient's wife, regarding the infant's due date, allows the wife to experience a merger (theme) of herself and her husband with the infant. The physician's explorative manipulation (technique), in which she asks what movie they last saw strengthens the wife's identification (Table 1) with her husband. This provides abreaction as she laughs and recounts the story and, in turn, expands her process of mourning.
In case 2, the clinician promotes her own merger (theme) through identification with the dying 76-year-old man with AML by asking for parenting advice, prompted by his curiosity (behavior). This manipulation (technique) stimulates the entire family in the clarification of their relationship with their father, which becomes a comforting curative process. 15
Curiosity (behavior) is again the response demonstrated by the friends of the man dying of pancreatic cancer in case 3. The physician volunteers information about her current physical experience of labor to them. Her self-disclosure suggests (technique) conscious associations of birth and death, poetically allowing his friends to associate separation (theme) from their loved one with his merger with her child, which brings them comfort.
In case 4, the physician is struck by the extent to which the young woman with carcinoid ignores (behavior) the physician's pregnancy, although the patient's associations to pregnancy and fertility are overt. The physician's attempt at clarification (technique) of the patient's fears is met with repression (“not [worried about] my fertility”) and denial (“I know it will be okay”), unconscious adaptive defenses (Table 1) against unwanted affects, likely envy (theme). The physician therefore chooses not to further challenge these protective defenses at the present time.
Case 5 is replete with themes of merger (with the woman's loved ones who have already died of the same disease) and separation (from her living loved ones, including her son). The former is transferred to the physician in the patient's conviction that she has been merged with the physician throughout the course of the pregnancy. Rather than argue the reality of the situation, the physician accepts the merger and engages the patient's caretaking (behavior) response to the pregnancy by asking for parenting advice. This therapeutic manipulation (technique) leads to associations of separation and mourning of the patient's real mother–son dyad, a process that began with her son's birth.
The physician in case 6 recognizes the common reaction formation (Table 1) of caretaking (behavior) when the family is in need of receiving care but not necessarily able to ask for it in the face of yet another separation (theme) in the final loss of their chronically suicidal family member. Through suggestion (technique) of the palliative care team's resources, the physician facilitates a family member's request for help. She also stimulates the conscious transfer of the parents' caretaking response to the patient's fiancé, in which they explicitly merge him with their family, just as he is losing the family he had imagined starting with the patient.
The aggression (behavior) demonstrated by the son who has been caring for his mother in case 7 is objectively the most difficult to bear and therefore utilize effectively. Although immediately interpretable as misogyny, the physician can recognize it as a manifestation of the son's envy (theme) and a defense against separation (theme). The son has psychologically suffered decades of a reversal of the ideal, symbiotic mother–infant fusion, in which he had to become the caregiver, and the pregnancy stimulates the transference of his anger at his own mother for abandoning him onto the physician.
The physician, actively in labor, is likely contributing her own guilt about imminently abandoning her patients to the unconscious communication between herself and the patient's son. 16 Additionally, the son's behavior invites her to abandon him out of anger. Careful and active attention to the transference and countertransference are needed to guide the physician's intervention, 13 which may include delaying any intervention until she or a different clinician is capable of interacting with the patient's son without reacting emotionally to his threats. 12 For now, she attempts to address his fear of abandonment, despite her own anger and discomfort.
These cases demonstrate the cyclical process of affective stimulus, meaning making, and action. 17 Essentially, palliative care clinicians are always attempting to understand this process for each patient and family member, but the introduction of the physician's pregnancy can make the process unfold more rapidly and intensely. These cases make that intensity and the resulting opportunity for assessment and intervention clear.
Further exploration would include examining the role of pregnancy in other patient–clinician relationships, in different clinical contexts and medical disciplines, and studying the effects of other reality stimuli that are also experienced by male clinicians, such as serious illness or physical disabilities. Further work might also include refining palliative care clinicians' intentionality and choice of intervention in similar situations. Ultimately, these cases demonstrate the uniquely beneficial potential of pregnancy in a physician and draw attention to our own psychological experience of major life events, which we necessarily bring with us into the clinical encounter.
Footnotes
Acknowledgments
The authors would like to thank Dr. Gregory Clark of Belmont, MA, and Dr. Charles Jaffe of Chicago, IL, for their contributions.
Author Disclosure Statement
No competing financial interests exist.