One in Five

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By Vanessa Galli, MD

Nearly one in five women have reported experiencing rape in their lifetime according to the most recent data from the CDC. Statistics never mean as much to the reader as an “n of one” or a personal testimony. I myself am the one in five, a survivor of rape. That is not the point of this article, but rather serves as a context for a larger conversation.

I bring this all up at the beginning of this article because it shouldn’t be any different than talking about any other part of one’s life story. The shame and the embarrassment that these events are shrouded in stops us from having open conversations and prevents survivors from seeking the help that they need. I also bring this up to challenge your stereotypes about rape trauma survivors and for any of you reading this who share my experience to remind you that you are not alone in this journey. One in five means that many of you reading this unfortunately share this part of my life’s story.

Sexual assault can come in so many forms, both big and small. I have always been aware of gender biases in conversation, although have become increasingly aware of these throughout medical training. Each time I was called “Sweetie”, “Honey”, and “Angel” and told that I “looked like a Barbie Doll” by patients, it became harder to just shake it off and walk away. I attempted gentle correction, changing the subject and removing myself from the conversation. I never found a “good” solution and was left feeling guilty on some level. I found myself asking the question, “What did I do to bring this on?” I was experiencing some form of survivor’s guilt.

I also began see how often we do this to one another in the work environment. I began to notice that my female colleagues are frequently addressed collectively as “ladies” or automatically by their first name in conversation, while their male colleague sitting next to them may be addressed in the same breath as doctor. In the hospital setting, I have overheard staff complementing male providers for their “bluntness” and female providers with a similar communication style accused of being “harsh and unapproachable.” We live in a world of micro-assaults that are committed innocently in the work place every day.

So what exactly do we do about this? I do not believe in being overlying politically correct as that doesn’t further the conversation and leads only to frustration and tip-toeing around the true issues at hand. I believe in being direct and open in communication, a style that was born from my Northeast roots. So on that note, I challenge each person reading this to question your own preconceived notions and stereotypes. We are in a line of work that relies on solid skills in pattern recognition and judgement, although sometimes we need to leave that judgement at the door. We need to have open conversations with each other. We need to feel comfortable and safe correcting one another, whether it be a patient or a co-worker. Only then, will we create a work environment and a patient care environment that is safe for everyone.

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 Vanessa Galli, MD is a Chief Resident in the Family Medicine Residency Program in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

 

Lessons learned (and relearned) from years of service and mission work, both locally and abroad:

 

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By Erin Mc Adams, MD

Indiana, Mississippi, Jamaica, Cameroon, the Philippines, Swaziland… these are all locations with beautiful people and cultures that I have been privileged to lead or participate in mission/service work to (and some of these locations multiple times). Most people who have ever done any type of service work have likely wrestled with their pre-service ambitions and post-service realizations, and I am no exception to that. Each experience has been enlightening and challenging, and taught me a thing or two about how (and how not) to serve, and some topics to consider for the present and future, in no particular order…

 

– Go where you are invited. (I do believe there are exceptions to this point, but I won’t get into them at this time.) Now obviously, at some point a person had to step foot on soil abroad (or locally) as an un-welcomed guest. So generally speaking, many present day opportunities and invitations to partner with local and international service teams have little-to-nothing to do with us individually. We are blessed by the people who have gone before us, built relationships, and opened up doors for us. So what I mean is that when you aim to serve with others, you should do so as a true partner with them, embracing the ideas of those you are “serving” with their invitation to do so, and showing up when your presence is desired.

 

– If you are welcomed, go back, time and time again. Build relationships, and allow the trust that is cultivated and desires that are exposed through this service to guide the future. Consider the depth of relationships in your own life. While people can have intense, short-term experiences that create inordinately strong bonds with others, most relational growth occurs over not just months, but years of life-on-life interaction and support. Why would this be any different for service-focused work? Relationships require longitudinal effort, time, and presence. This ties into my next point…

 

– Relief work has a time and place, and IS important. But long term growth and relationship building requires a focus on development. If the destination of your service is not in an immediate crisis requiring only acute care, consider what the long term needs are of the community, ESPECIALLY from their perspective. Ask them! What can be done in the immediate future to plan for growth in the distant future? What can be done to ensure these efforts continue beyond your one week, one month, or one-year experience?

 

– What service are the local people interested in seeing done during your time with them, and what can they offer of their own resources (time, talents, goods) to make this happen? Again, while there is a time for relief and “handouts”, most of the time the focus in service should be on development and “hand ups”. Come alongside ideas and goals for the people you are traveling to see (whether near or far); where there is interest and buy-in from the people you are serving (with), sustainable solutions are possible.

 

– Try to view poverty more holistically than by just quantifying and qualifying types of goods a country may have. Yes, it is possible to have a poverty of goods (some refer to this as absolute poverty). But what else is present in the community that can support the areas of desired growth? Is there a poverty or abundance of education? A poverty or richness of faith? A poverty or prosperity of health care? A poverty or plethora of employment opportunities? If the people and community you are working with desire an increase in basic goods (water, food, shelter), perhaps an abundance in one or more of these other areas may provide the answer for the next steps to take toward sustainable solutions toward this problem.

 

– BE FLEXIBLE, and humble, willing to believe that your way/opinion is not necessarily right. Consider this not only as you prepare for the work, but as you are knee-deep in the projects with the people you are blessed to be working alongside, and also as you complete and/or return from this experience. If you were raised in the United States or one of many other westernized countries, you may have been conditioned to believe more work, longer hours, deadlines, and individualism are what drive economic growth, and professional and personal gains. Do not be naïve enough to think that the entire world does or should view things through the same lens as you. If your service work takes place in a country that allows events, rather than a clock, to drive time for the day… learn to be okay with that. When you meet people who would rather see their family unit (which can be much larger than you might define) be taken care of, rather than one person break away to pursue individual desires, fight the urge to think that is wrong. When you spend months planning one aspect of how your service time should be spent, but the local pastor (who has far more weight in community decision-making than you could have imagined) directs your time otherwise, BE FLEXIBLE.

 

– Participate in the culture. I don’t mean just read books about where you will be and the people you will be working with. Although, this isn’t a bad idea before you start your experience. I mean whenever possible, share meals with the people you are meeting. When offered food you could not otherwise identify and probably haven’t tasted before? Accept it graciously. Whatever the thing is that the local people do for enjoyment… do that thing. Oh, and that thing that you grew up doing (like waving or receiving objects with your left hand), if that is seen as rude by the people you are with, make an effort to NOT do that thing. Culture greatly influences our thoughts, our perceptions, our motivations and beliefs. What better way to understand the people you are meeting than to spend time doing what they do?

 

This blog is in no way inclusive of all lessons learned regarding service work, but it does cover some of the recurrent themes from my experience. Perhaps these thoughts will be helpful as you go forward to invest in service across the globe.

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Erin McAdams, MD is a second year Family Medicine Resident at the University of Utah School of Medicine.

 

Breastfeeding

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There was never any question in my mind that I would breastfeed my children.  Not only did it seem to be logically the most natural and nutritive way to feed them, I looked forward to experiencing the profound bonding experience that was promised, the deep satisfaction of knowing that my body produced everything my baby needed to stay alive.  My formal medical education on the subject, which was limited to a single lecture by a devout breastfeeding enthusiast, only pushed me farther into my resolve.   When I found out, at 9 weeks into my pregnancy, that I was carrying not one, but two babies, I dug my heels in harder.  “I have two breasts!”  “Breastfeeding is about supply and demand!”  I knew that some women struggled with breastfeeding, but I would not be one of those women.

 

When my water broke at just shy of 36 weeks and I underwent cesarean section for breech presentation, I was unwavering in my commitment. I met the in-house lactation consultant before my surgery, my daughters were placed on my chest in the recovery room to nurse within an hour of their birth.  On our first night in the hospital, however, both my daughters began to experience episodes of apnea, typical of premature babies.  They were moved to the NICU for continuous monitoring, with a promise from the nursing staff that they would be brought back to my room for feedings.

 

The nurses dutifully wheeled my tiny babies with what seemed like an endlessly increasing entourage of medical accessories to my room every 2-3 hours.  First a sensor placed on their little feet to measure oxygen saturation and monitor for episodes of apnea, then a tiny IV to stabilize their blood sugars, and finally, two nasogastric tubes because my babies were not getting enough to eat.

 

I was crushed.  My husband began to make runs to and from the local milk bank where we would eventually spend over $1000 in donor breast milk.  I set alarms for every three hours and went to the NICU to try to nurse my girls. I pumped every three hours, two hours and then every hour for days.  The lactation consultant taught me how to express milk by smashing my breasts against the pump flanges.  My hands ached from squeezing, my back ached from slouching, and my heart ached with the looming sense of unavoidable failure.

 

Finally, after my husband and I had been boarding in the hospital for over a week the lactation consultant sat us down, reassured us that we were doing everything properly and then told us, “You know you don’t have to do this, right?”  I think back to that conversation now and recall how we expressed our appreciation for her support but explained that I needed to continue trying to make sure that I could say that I had done everything possible.

 

What will make me sad forever is the weeks that followed.  I truly missed out on the first 6 weeks of my daughters’ lives because of the pressure I put on myself to breastfeed.  While my mother and husband were caring for my daughters, I was alone in a bedroom crushing my breasts for 45 minutes at a time just to provide the greatest percentage of breast milk possible.  When they started gaining weight and then sleeping longer at night, I still set alarms to pump every two hours.  I was exhausted, lonely and incredibly sad.  Instead of holding my babies, I was holding my breast to a pump.

 

Several weeks ago, a lactation consultant spoke to our residency program about “Maternal-Infant Health.”  Unsurprisingly, the vast majority of the lecture was devoted to singing the praises about breastfeeding.  I watched with frustration as my classmates—the majority of whom are not parents—nodded in agreement with the familiar claims of superiority.  They didn’t question the validity of the statistics; they didn’t ask about the number needed to treat in studies claiming that exclusive breastfeeding prevents upper respiratory infection and diarrheal illness; they didn’t analyze the cost-benefit ratio of lost hours of work or sleep on maternal psyche.   Why would they? To someone who has never witnessed a true breastfeeding struggle, it is an obvious choice.

 

The lecturer concluded with a plea that we, as primary care physicians, not underestimate our influence in a mother’s decision to pursue exclusive breastfeeding.  She isn’t wrong.  My turning point came at my daughters’ two month well baby check when we were finally able to see our chosen pediatrician.  When she asked how we were feeding the girls and I replied that I was pumping and supplementing with formula because I just couldn’t make enough for two babies, her face changed into an expression of sincere empathy.

 

“You probably feel like you’ve already failed as a parent, but you haven’t.  I know because I felt the same way.  You are feeding your babies and you are doing a great job.  They are growing just as they should.  You know they are going to be just fine, right?”

 

I will never forget that appointment.  My relationship with my daughters, my body and my doctor changed that day.  I began to focus on the myriad opportunities I am afforded every day to help my daughters be healthy and successful, only a handful of which involve food in any form.  I continued to pump, but prioritized my mental health, my sleep and my relationships with my daughters and my husband over my pumping log.  Today, my daughters are happy, smart, healthy toddlers with fantastic immune systems who love to eat everything from roasted vegetables to Thai curry.

 

I am sharing my story as a background to my own entreaty of my colleagues who take care of new mothers and babies.  Please, take the time to educate yourself on the full scope of breastfeeding research.  Be analytical and diligent in recognizing bias and confounding.  Do not accept the enthusiastic pop statistics at face value because it is easy. Above all, help me to shift our mission as healthcare providers from encouraging new mothers to breastfeed to encouraging new mothers, period.  New parenthood is one of the rawest, most uncertain and vulnerable stages of life for many.  Go ahead and have the breastfeeding conversation with your patient—but listen more than you talk, validate whatever experience your patient is having and most importantly, make sure your patient feels supported before she leaves.  Your patient-physician relationship and clearly expressed dedication to help a family through these difficult early stages regardless of feeding choice will do worlds more for a child’s long-term health than a few ounces of breast milk.

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Rachel Goossen, MD is an Intern Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.