Wednesday, December 8, 2010

A Christmas Carol - The Other Ghost

It was just before Christmas about 9 years ago. I was at the Streets at Southpoint, an indoor-outdoor mall in Durham, NC. It was a pretty mall, with a pedestrian street that was lined with stores glittering like Rockefeller Center. The bounty of the season was everywhere. The aroma of hot cider from the kiosk and the carols swelling up from the speakers disguised as rocks along the path, enveloped the crowd, bundled like they were trekking on an expedition to the North Pole itself.

I was trying to figure out what to get my mother, my father, my brothers, my sister, and my wife for Christmas. I confess that I rarely find things at the mall which make suitable gifts; however, I’ve always taken comfort in browsing and confirming my suspicion that this was not where I wanted to make my purchases. I guess this sort of made me an outsider, in a way. While I was glad to be surrounded by the holiday cheer, I did feel a bit disconnected. If I was honest with myself, I was actually a little sad and I couldn’t put an exact finger on the reason.

Then, as I walked down the path past a Crate and Barrel, I saw The Children’s Store. Moms and dads were bustling into and out of the store. As I stood outside the store, peering in the display window at the reindeer jumpers, elf pajamas and angelic ball gowns for little girls, I could see my reflection in the glass. Looking through my own reflection at the warm holiday interior, I began felt like a ghost: empty, vacant, barely a whisper. I felt like the Ghost of the Christmas That Would Never Be.

For people who have lost a loved one, for those separated from their families, for those without a family, with financial woes, with illness … we all know this is a tough time of year for some people. Watching other people, happy families apparently living the life of which you’ve been deprived can seem particularly unfair, or make you feel like a failure if you’ve not achieved these things.

This time of year can be especially difficult for people suffering from infertility. All the hopeless feelings, all the lonely feelings of isolation that infertility brings are magnified by the merriment of the season, the energy and bustle, the long lines at toy stores, by the crowds of twittering kids waiting to sit on Santa’s knee. All the holiday cheer can seem to just mock the pain of childlessness.

To make matters worse, if you feel like you’re on the outside of all of this Holiday fun and you see someone who is apparently blessed in ways that you are not, and you hear them complain about what seem to you trivial issues of the season… it can just make you mad.

In the end, most of us really do want to be happy. The question is, how is a person to rescue themselves from the sadness the season besets upon them?

Few solutions are perfect, but here are some things I have tried. Here are my suggestions, and I’m open to new ideas:

Own your feelings. Acknowledge them for what they are and ask yourself if you want them. If so, embrace them. Sometimes we need to do this first, before we can move on. It may be a miserable December, but it may be the first step to healing.

  1. If you do not want these feelings, you should recognize that you may not be able to completely shake them. You may go for hours or days without the negative feelings resurfacing; however, it doesn’t mean you’ve been defeated when they do.
  2. Focus on what the season is really about, for you. In my family’s tradition, Christmas, the season is a reminder of the gifts we have received – even though we were not worthy to have received them. Because of the gift already received, the season is about giving to others. (I know we all have different backgrounds and beliefs, but I do think the spirit of the holidays, Joy and Peace, can be enjoyed by all. When I was at my lowest, and thought I’d never have a child I would pray. I did pray that we would be given a child, but more than that I prayed that I could find peace in the event that we never did.
  3. If being around children is too much for you, some people say you should avoid areas that are likely to be filled with them. I find this to be an impractical solution for many people, but you should not feel guilty for protecting yourself.
  4. Consider devoting your time to someone else in need. This can be healing for you can for them.
  5. Get plenty of rest. (Fatigue makes nearly everything worse.)
  6. Get plenty of exercise. (This makes you feel vibrant and boosts your metabolism.)
  7. Surround yourself with supportive people.
  8. Seek counseling. If needed. If you’ve wondered if you should get counseling, then you probably should. I know a lot of wonderful people in the Chattanooga area and can make recommendations.

For some people this year, the Christmas season is going to be something to be survived, not enjoyed.

If this is you, plan ahead. If you need to, give me a call…. do something to help reclaim your life.

Wednesday, December 1, 2010

The Patient I Failed

Part 1: The First Digression

We doctors don’t always take failure too well.

I’ve talked with some colleagues about this and have heard lots of good theories as to why. The arguments go something like this: To get to medical school and through medical school, residency and then fellowship training, you have to negotiate a tough series of hurdles, and for most of your training and professional life you will successfully clear those obstacles. Bottom line, doctors aren’t accustomed to failure.


On the other hand, I’ve talked to some friends outside of medicine and I think they are only half-joking when they say something akin to: Most doctors hate being reminded they are not God.

Perhaps that’s true, too.

Something tells me though, that it’s more than either of those two things. First, I don’t think the hating failure is unique to medicine. No one likes failure.

I think that’s one thing that’s so frustrating for couples with infertility. What comes so easily for some couples is so elusive, that it frequently causes one or both partners to feel like a failure, like they have let their partner down. This brings me to a key point: I think most of us can handle small failures pretty well. It’s when those failures are tied to another person, that’s when they become difficult.

For example, kids who play sports know someone has to lose. By and large it’s the kids who feel excessive pressure to win from their parents are the ones who are bothered the most by failure. They feel like they’ve let their parents down.

It’s particularly painful when you didn’t just let yourself down, but another person as well. I think this is the hardest part about medical failures… someone was counting on you and you didn’t deliver.

Part II: The Second Digression

When I first began the practice of infertility, I thought most patients were going to be like me and my wife – saddened by failure, but undaunted. We had our failures, but we kept trying, even after some people encouraged us to just stop.

In some ways, we had an advantage over most patients. Since my wife had no fallopian tubes our choice was simple: do IVF or don’t have our own biologic child. This is in contrast to a lot of patients with unexplained infertility. In those cases there is nothing to say that they can’t get pregnant on their own. While my wife and I knew for a certainty that we needed help to get pregnant, many patients don’t have that certainty and it leads to uncertainty regarding if they should continue therapy.

These patients are at risk for quitting treatment because, theoretically, they could get pregnant on their own. Sometimes these patients will take very long breaks from treatment. Sometimes they get pregnant. Sometimes they return years later only to find out their chances of pregnancy are actually much worse.

Part III. The patient I failed.

A few years ago, I was treating two women with PCOS. Neither woman ovulated on her own or with oral medications, so both needed injections to conceive. Each of them completed one cycle of injections and IUI (intrauterine insemination) without success.

Both women had an excellent chance of pregnancy if they had elected to continue on their current path, but both of them were extremely frustrated by their failure to conceive.

The first patient told me that this failure was more than she could handle. The idea of doing another cycle was overwhelming her and she said she just could not handle the stress of doing another month of treatment. She quit treatment and I have not seen her again. The sad part is, she might decide to try again one day. When she does, she’ll be much older, and her chances of success will have decreased substantially.

The second patient also told me she couldn’t do another cycle. She said she could not handle the waiting. She asked to do IVF. I tried to reassure her that she most likely didn’t need IVF, that she was good prognosis. She could not be swayed, she’d had enough. She was determined to do IVF. So, we did IVF. She conceived. Now she has a beautiful child.

In some ways, I think I failed both of these patients…. but I think it’s pretty obvious which patient I failed the most… the first patient.

I failed her because I assumed that most patients would be stubborn like me and my wife. I had failed to assess her emotional tolerance and fortitude prior to recommending treatment. If I had learned this about her, I would have warned her and perhaps have offered her the therapy that would have given her a very high chance of giving her a child.

Part IV: The Aftermath

Every patient reacts to failure differently. There are patients even more stubborn than me and my wife. But many are not. For many, the burden of the infertility is so heavy, that one failure is just too much to bear.

Realizing this has forever changed the way I counsel my patients. These days, I do my best to warn patients that any failure will strip some people of their will, of their hope, of their emotional reserve. I alert patients to this fact. I tell them that they need to be very honest with themselves and with their partner about how much emotional and physical energy they have in their tank.

If they are running on fumes, they should start with the therapy that gives them their greatest chance of getting pregnant.

Ultimately, I’m fine if a patient decides to walk away from treatment, especially if they have exhausted the options which they find acceptable choices for them.

Walking away by choice, I’m fine with that.

It’s when a patient can’t walk back… and they’ve left viable options on the table…

That is hard to handle. Those are people I ache for.