- Email: [email protected]
THE TRAUMA OF BEING A PATIENT
1309
than twice the national average. Twice as many smoked regularly as did teenage women generally. 5 % had actively sought legal abortion but had been refused, and many more had considered abortion but not had the energy to pursue it, fatalism being one of the characteristics of this group. Over two-fifths had had episodes of depression in the first year after their baby was born. Many were themselves the children of teenage or very young parents. They were to a large extent the no-hopers of society-the girls had done badly at school, had drifted into dull, low-paid jobs, and the notion of planning and working for a steadily improving future held no meaning for them. Many seemed set to repeat their parents’ pattern. Perhaps lack of attention as children had driven them to seek affection wherever they could find it to compensate for low self-esteem; the prospects for their babies were not
bright.
Since there will be no massive social programme of reform in housing, education, and opportunity for these women in the foreseeable future, can other less ambitious steps be taken to prevent teenage pregnancy? The Government has now expressed serious concern, since a consequence of teenage pregnancy tends to be a lifetime on state benefits. One reason for this burden on the state is that threequarters of teenage births in 1988 occurred outside marriage, almost double the proportion a decade earlier. Where is the young father in all this? Mrs Gillian Shephard,s the parliamentary UnderSecretary of State for Social Security, pointed out last month that "for over three-quarters of lone parent families receiving income support, the absent parent pays no maintenance at all". She signalled the Government’s intention to make regular payment of maintenance a reality. From the point of view of equity it would be desirable if the "absent parent"-in nine out of ten cases the father-could be induced to face up to his financial responsibilities at least. This approach might also be an effective preventive measure once the news gets around that a sizeable proportion of a young man’s income will be removed from him for a period of 16 years if he gets a girl pregnant. But one must not underestimate the
difficulty of Mrs Shephard’s undertaking. The young mother needs to be persuaded to reveal who the father is, and in half these cases the couple is not cohabiting. She may not wish to provide this information fearing, with good reason, that the father might then claim malicious and unacceptable rights over the child. So there may need to be further legislation to protect the mother’s rights. The income needs to be collected at source, and paid to the woman regularly through a neutral Government agency, so that she does not have to chase the father through the courts. Since many of these fathers will be unemployed or on low incomes in unskilled or semi-skilled jobs, the amount of money
garnered by this exercise may not be very large. Its effect in combating contraceptive irresponsibility may nonetheless be considerable. No one method of prevention will be sufficient on its own. The Bristol Young Mother Information Project is an innovative idea that deserves to spread. Teenage mothers return to the classrooms to explain to schoolgirls at first hand that motherhood for youngsters is "much tougher than television adverts would lead them to believe". What is also required is a major expansion of easily accessible and publicly advertised birth control provision for the young. The Brook Advisory Centres, a successful chain of specialist birth control clinics for men and women under 25 years of age, have lengthening waiting lists of young people anxious to obtain birth control advice and supplies. Through being starved of funds, not even these expressed needs of the young are being met and, incredibly, in 1988/89 a third of central London clinic sessions had to cease.7 The Department of Health should urgently consider transferring some of its birth control funds from research to implementation. These clinics are clearly user-friendly and constitute a vital and largely unrecognised resource for combating the misery and long-term public expense of unwanted pregnancy among the very young. Abortion, as well as birth control, needs to be made more accessible. For various reasons connected with youth, ignorance, fatalism, and fear, teenagers often obtain their abortions late. The Social Services Committee of the House of Commons is now inquiring into problems caused to gynaecologists who have conscientious objection to abortion; the Committee might more -usefully be occupied considering the problems of patients rather than those of doctors, and in particular how to make earlier and safer abortions available to young people who need them. It is now five years since the publication of the Royal College of Obstetricians and Gynaecologists’ report on late abortion8-it is high time that its recommendations were acted upon.
THE TRAUMA OF BEING A PATIENT
deny that being a patient can be a nervewracking experience. Some of the anxiety is inevitable; some is probably created or worsened by doctors and by the whole apparatus of medicine. It is clearly both sensible and FEW would
humane that doctors should arrange their activities to minimise distress. Among the traditional trappings of medicine, the regular ward round by senior doctors is both the most time-hallowed and the most frequently questioned. What is the effect on a patient of a conference at his bedside between a senior, often distinguished, doctor and his 6. The
Young
Mother Information
Project,
c o
Area 11 Youth Office, Verrier
Road,
Bristol 5
5. Hansard 159 166 col 147. Nov 2, 1989.
7. Brook Advisory Centres Annual Report 1988/9, 153 East Street, London SE17. 8. Alberman E, Dennis KJ. Late abortions in England and Wales London: Royal College of Obstetricians and Gynaecologists, 1984.
1310
white-coated juniors, particularly when what is under discussion is the patient’s health and perhaps indeed his life? Attempts to examine the effect of such bedside scenes have not yielded entirely consistent results. Romano,’ using clinical indictors of stress and structured interviews, assessed the effect of bedside teaching rounds at the Peter Bent Brigham Hospital. Although most patients showed little or no signs of anxiety, the need for brief preparatory explanations about the role of teaching rounds was emphasised, together with the need to conduct rounds "tactfully and sympathetically". Kaufman et al2 compared by means of a structured interview the emotional impact of medical and surgical ward rounds. Medical ward rounds were well tolerated, although the jargon annoyed patients, whereas surgical rounds provoked more anxiety because senior surgeons tended to criticise junior house staff in front of the patient. The need for patient preparedness also emerged from a survey carried out by Linfors and Neelon,33 who found that bedside case presentations were regarded by patients as a helpful source of education about their illness. In a more extensive study, Wise et allusing rating scales and questionnaires, reached a similar conclusion. The seriousness of a patient’s illness or the presence of physiological disturbance did not seem to influence the patient’s perception of the ward round as a necessary part of hospital routine. In a study from Pennsylvania, Simons et als now confirm these findings. 20 patients were admitted to the critical care unit of the University Hospital with suspected myocardial infarction. The following day the patient’s case was presented to a senior physician by a member of the critical care team in the presence of four other members of that team. Stress was assessed by automatic measurement of pulse and blood pressure and by repeated measurements of plasma noradrenaline. In addition, the patients were interviewed and they completed an anxiety questionnaire. Only a small rise in systolic (7 mm Hg) and diastolic (3 mm Hg) blood pressure was observed. Pulse rate and plasma noradrenaline remained unchanged. When questioned, patients reported that bedside presentations were helpful rather than stressful. These results are reassuring as far as they go. The traditional ward round is a universal feature of hospital practice, yet the reassurance needs qualification. Anxiety is a repsonse to uncertainly about what is to happen to an individual. Detailed explanations from staff with time to spend with patients would seem to be an excellent prophylactic. However, it is unsafe to generalise to other situations. Mancia et alin a Milan hospital, used continuous ambulatory monitoring of blood pressure to assess patients’ reactions to their doctor. The pressor response to first measurement of blood pressure is a well-established feature of clinical practice, which is reflected by progressive fall in blood pressure on repeated measurement as patients become familiar with the procedure.’ In Mancia’s study a pressor response and
tachycardia were apparent when the doctor approached the patient’s bedside. Maximum rises of 75 mm Hg (systolic) and 36 mm Hg (diastolic) were recorded with an average rise of 26-7/14-9 mm Hg in 48 patients. This "white coat hypertension" reflected a pavlovian response to the doctors’ appearance. An almost identical pressor response
SMOKE SCREEN ROUND THE FETUS SMOKING is bad for health-a widely publicised fact and one that is clearly brought to public attention on advertisements and cigarette packets. In the UK, one of the messages from the Health Education Authority also says that cigarette smoking "may cause premature delivery of babies". At antenatal clinics mothers are cautioned, advised, and even castigated to stop smoking if they do smoke, or at least to cut down if they cannot manage to stop altogether, because of the potential dangers to their baby. What are the facts about smoking and pregnancy? Babies born to mothers who smoke are smaller by an average of 200-300 g; delivery is 1-3 days earlier than in normal controls;’ placentas show no significant alteration in sizej233 there is placental basement membrane thickening at the vascular syncytial membrane;4 cadmium levels are higher in the placentas of smoking mothers;5 children of smoking mothers have mild behavioural problems;6 and mothers are less likely to get pre-eclamptic toxaemia (PET).7 That these babies are smaller than those born to non-smoking mothers seems of little importance since the difference is generally less than 10% of expected birthweight. Although these babies grow rapidly in their first postnatal year, they still weigh less than the offspring of non-smoking mothers.’ Their lower weight has been attributed to the fact that smokers do not absorb nutrients as readily through their gastrointestinal tracts as do nonsmokers ; moreover, smokers tend to eat less and so the baby is malnourished. This may well not be the correct explanation. In a study of babies of truly malnourished wartime mothers from the Netherlands and Leningrad the babies had reduced body fatwhereas in a comparison with babies of non-smoking and smoking mothers the fat was identical in amount and distribution. The answer must lie in 1. Pirani BBK Smoking during pregnancy Obstet Gynecol Surv 1978; 33: 1-13. 2. Van der Velde WJ, Treffers PE Smoking in pregnancy the influence on percentile
birthweight, mean birthweight, placental weight, menstrual age, perinatal mortality and maternal diastolic blood pressure Gynaecol Obstet Invest 1985, 19: 57-63 3.
1. Romano J.
2 3.
4. 5. 6
7
Patients’ attitudes and behavior in ward round teaching. JAMA 1941; 117: 664-67. Kaufman MR, Franzblau AN, Kairys D. The emotional impact of ward rounds. J Mount Sinai Hosp 1956, 23: 782-803 Linfors ED, Neelon FA. The case for bedside rounds. N Engl J Med 1980; 303: 1230-33. Wise TN, Feldheim D, Mann LS, Boyle E, Rustgi VK Patients reactions to house staff ward rounds. Psychosomatics 1985; 26: 669-72 Simons RJ, Baily RG, Zeilis R, Zwillich CW The physiologic and psychological effects of the bedside presentation N Engl J Med 1989, 321: 1273-75. Mancia G, Bertinieri G, Grassi G, et al. Effects of blood pressure measurement by the doctor on patients’ blood pressure and heart rate Lancet 1983; ii. 695-98. Medical Research Council Working Party. MRC trial of treatment of mild hypertension principal results. Br Med J 1985, 291: 97-104
was
observed when the doctors visited patients on the second occasion. This response differs, therefore, from that observed in the more formal interactions involved in bedside presentation in the Pennsylvanian study. Patients expectations seem to have been different in the two cases. The lesson is simple if something of a cliche—time spent in careful explanation and discussion will set the patient’s mind and his cardiovascular system at rest.
4.
Mulcahy R, Murphy J, Martin F. Placental changes in maternal weight in smoking and nonsmoking mothers Am J Obstet Gynecol 1970, 106: 703-05 Burton GJ, Palmer ME, Dalton KJ Morphometric differences between the placental vasculature of non-smokers, smokers and ex-smokers Br J Obstet Gynaecol 1989, 96: 907-15
5. Kuhnert
BR, Kuhnert PM, Debanne S, Williams TG. The relationship between cadmium, zinc, and birth weight in pregnant women who smoke Am J Obstet Gynecol 1987; 157: 1247-51. 6. Harrison R. The use of non-essential drugs, alcohol and cigarettes during pregnancy Irish Med J 1986, 79: 338-41 7. Lehtovita P, Forss M The acute effect of smoking on uteroplacental blood flow in normotensive and hypertensive pregnancy IntJ Gynaecol Obstet 1980, 18: 208-11 8. D’Souza SW, Black P, Richards B Smoking in pregnancy associated with skinfold thickness, maternal weight gain, and fetal size at birth. Br Med J 1981, 282: 1661-63
than twice the national average. Twice as many smoked regularly as did teenage women generally. 5 % had actively sought legal abortion but had been refused, and many more had considered abortion but not had the energy to pursue it, fatalism being one of the characteristics of this group. Over two-fifths had had episodes of depression in the first year after their baby was born. Many were themselves the children of teenage or very young parents. They were to a large extent the no-hopers of society-the girls had done badly at school, had drifted into dull, low-paid jobs, and the notion of planning and working for a steadily improving future held no meaning for them. Many seemed set to repeat their parents’ pattern. Perhaps lack of attention as children had driven them to seek affection wherever they could find it to compensate for low self-esteem; the prospects for their babies were not
bright.
Since there will be no massive social programme of reform in housing, education, and opportunity for these women in the foreseeable future, can other less ambitious steps be taken to prevent teenage pregnancy? The Government has now expressed serious concern, since a consequence of teenage pregnancy tends to be a lifetime on state benefits. One reason for this burden on the state is that threequarters of teenage births in 1988 occurred outside marriage, almost double the proportion a decade earlier. Where is the young father in all this? Mrs Gillian Shephard,s the parliamentary UnderSecretary of State for Social Security, pointed out last month that "for over three-quarters of lone parent families receiving income support, the absent parent pays no maintenance at all". She signalled the Government’s intention to make regular payment of maintenance a reality. From the point of view of equity it would be desirable if the "absent parent"-in nine out of ten cases the father-could be induced to face up to his financial responsibilities at least. This approach might also be an effective preventive measure once the news gets around that a sizeable proportion of a young man’s income will be removed from him for a period of 16 years if he gets a girl pregnant. But one must not underestimate the
difficulty of Mrs Shephard’s undertaking. The young mother needs to be persuaded to reveal who the father is, and in half these cases the couple is not cohabiting. She may not wish to provide this information fearing, with good reason, that the father might then claim malicious and unacceptable rights over the child. So there may need to be further legislation to protect the mother’s rights. The income needs to be collected at source, and paid to the woman regularly through a neutral Government agency, so that she does not have to chase the father through the courts. Since many of these fathers will be unemployed or on low incomes in unskilled or semi-skilled jobs, the amount of money
garnered by this exercise may not be very large. Its effect in combating contraceptive irresponsibility may nonetheless be considerable. No one method of prevention will be sufficient on its own. The Bristol Young Mother Information Project is an innovative idea that deserves to spread. Teenage mothers return to the classrooms to explain to schoolgirls at first hand that motherhood for youngsters is "much tougher than television adverts would lead them to believe". What is also required is a major expansion of easily accessible and publicly advertised birth control provision for the young. The Brook Advisory Centres, a successful chain of specialist birth control clinics for men and women under 25 years of age, have lengthening waiting lists of young people anxious to obtain birth control advice and supplies. Through being starved of funds, not even these expressed needs of the young are being met and, incredibly, in 1988/89 a third of central London clinic sessions had to cease.7 The Department of Health should urgently consider transferring some of its birth control funds from research to implementation. These clinics are clearly user-friendly and constitute a vital and largely unrecognised resource for combating the misery and long-term public expense of unwanted pregnancy among the very young. Abortion, as well as birth control, needs to be made more accessible. For various reasons connected with youth, ignorance, fatalism, and fear, teenagers often obtain their abortions late. The Social Services Committee of the House of Commons is now inquiring into problems caused to gynaecologists who have conscientious objection to abortion; the Committee might more -usefully be occupied considering the problems of patients rather than those of doctors, and in particular how to make earlier and safer abortions available to young people who need them. It is now five years since the publication of the Royal College of Obstetricians and Gynaecologists’ report on late abortion8-it is high time that its recommendations were acted upon.
THE TRAUMA OF BEING A PATIENT
deny that being a patient can be a nervewracking experience. Some of the anxiety is inevitable; some is probably created or worsened by doctors and by the whole apparatus of medicine. It is clearly both sensible and FEW would
humane that doctors should arrange their activities to minimise distress. Among the traditional trappings of medicine, the regular ward round by senior doctors is both the most time-hallowed and the most frequently questioned. What is the effect on a patient of a conference at his bedside between a senior, often distinguished, doctor and his 6. The
Young
Mother Information
Project,
c o
Area 11 Youth Office, Verrier
Road,
Bristol 5
5. Hansard 159 166 col 147. Nov 2, 1989.
7. Brook Advisory Centres Annual Report 1988/9, 153 East Street, London SE17. 8. Alberman E, Dennis KJ. Late abortions in England and Wales London: Royal College of Obstetricians and Gynaecologists, 1984.
1310
white-coated juniors, particularly when what is under discussion is the patient’s health and perhaps indeed his life? Attempts to examine the effect of such bedside scenes have not yielded entirely consistent results. Romano,’ using clinical indictors of stress and structured interviews, assessed the effect of bedside teaching rounds at the Peter Bent Brigham Hospital. Although most patients showed little or no signs of anxiety, the need for brief preparatory explanations about the role of teaching rounds was emphasised, together with the need to conduct rounds "tactfully and sympathetically". Kaufman et al2 compared by means of a structured interview the emotional impact of medical and surgical ward rounds. Medical ward rounds were well tolerated, although the jargon annoyed patients, whereas surgical rounds provoked more anxiety because senior surgeons tended to criticise junior house staff in front of the patient. The need for patient preparedness also emerged from a survey carried out by Linfors and Neelon,33 who found that bedside case presentations were regarded by patients as a helpful source of education about their illness. In a more extensive study, Wise et allusing rating scales and questionnaires, reached a similar conclusion. The seriousness of a patient’s illness or the presence of physiological disturbance did not seem to influence the patient’s perception of the ward round as a necessary part of hospital routine. In a study from Pennsylvania, Simons et als now confirm these findings. 20 patients were admitted to the critical care unit of the University Hospital with suspected myocardial infarction. The following day the patient’s case was presented to a senior physician by a member of the critical care team in the presence of four other members of that team. Stress was assessed by automatic measurement of pulse and blood pressure and by repeated measurements of plasma noradrenaline. In addition, the patients were interviewed and they completed an anxiety questionnaire. Only a small rise in systolic (7 mm Hg) and diastolic (3 mm Hg) blood pressure was observed. Pulse rate and plasma noradrenaline remained unchanged. When questioned, patients reported that bedside presentations were helpful rather than stressful. These results are reassuring as far as they go. The traditional ward round is a universal feature of hospital practice, yet the reassurance needs qualification. Anxiety is a repsonse to uncertainly about what is to happen to an individual. Detailed explanations from staff with time to spend with patients would seem to be an excellent prophylactic. However, it is unsafe to generalise to other situations. Mancia et alin a Milan hospital, used continuous ambulatory monitoring of blood pressure to assess patients’ reactions to their doctor. The pressor response to first measurement of blood pressure is a well-established feature of clinical practice, which is reflected by progressive fall in blood pressure on repeated measurement as patients become familiar with the procedure.’ In Mancia’s study a pressor response and
tachycardia were apparent when the doctor approached the patient’s bedside. Maximum rises of 75 mm Hg (systolic) and 36 mm Hg (diastolic) were recorded with an average rise of 26-7/14-9 mm Hg in 48 patients. This "white coat hypertension" reflected a pavlovian response to the doctors’ appearance. An almost identical pressor response
SMOKE SCREEN ROUND THE FETUS SMOKING is bad for health-a widely publicised fact and one that is clearly brought to public attention on advertisements and cigarette packets. In the UK, one of the messages from the Health Education Authority also says that cigarette smoking "may cause premature delivery of babies". At antenatal clinics mothers are cautioned, advised, and even castigated to stop smoking if they do smoke, or at least to cut down if they cannot manage to stop altogether, because of the potential dangers to their baby. What are the facts about smoking and pregnancy? Babies born to mothers who smoke are smaller by an average of 200-300 g; delivery is 1-3 days earlier than in normal controls;’ placentas show no significant alteration in sizej233 there is placental basement membrane thickening at the vascular syncytial membrane;4 cadmium levels are higher in the placentas of smoking mothers;5 children of smoking mothers have mild behavioural problems;6 and mothers are less likely to get pre-eclamptic toxaemia (PET).7 That these babies are smaller than those born to non-smoking mothers seems of little importance since the difference is generally less than 10% of expected birthweight. Although these babies grow rapidly in their first postnatal year, they still weigh less than the offspring of non-smoking mothers.’ Their lower weight has been attributed to the fact that smokers do not absorb nutrients as readily through their gastrointestinal tracts as do nonsmokers ; moreover, smokers tend to eat less and so the baby is malnourished. This may well not be the correct explanation. In a study of babies of truly malnourished wartime mothers from the Netherlands and Leningrad the babies had reduced body fatwhereas in a comparison with babies of non-smoking and smoking mothers the fat was identical in amount and distribution. The answer must lie in 1. Pirani BBK Smoking during pregnancy Obstet Gynecol Surv 1978; 33: 1-13. 2. Van der Velde WJ, Treffers PE Smoking in pregnancy the influence on percentile
birthweight, mean birthweight, placental weight, menstrual age, perinatal mortality and maternal diastolic blood pressure Gynaecol Obstet Invest 1985, 19: 57-63 3.
1. Romano J.
2 3.
4. 5. 6
7
Patients’ attitudes and behavior in ward round teaching. JAMA 1941; 117: 664-67. Kaufman MR, Franzblau AN, Kairys D. The emotional impact of ward rounds. J Mount Sinai Hosp 1956, 23: 782-803 Linfors ED, Neelon FA. The case for bedside rounds. N Engl J Med 1980; 303: 1230-33. Wise TN, Feldheim D, Mann LS, Boyle E, Rustgi VK Patients reactions to house staff ward rounds. Psychosomatics 1985; 26: 669-72 Simons RJ, Baily RG, Zeilis R, Zwillich CW The physiologic and psychological effects of the bedside presentation N Engl J Med 1989, 321: 1273-75. Mancia G, Bertinieri G, Grassi G, et al. Effects of blood pressure measurement by the doctor on patients’ blood pressure and heart rate Lancet 1983; ii. 695-98. Medical Research Council Working Party. MRC trial of treatment of mild hypertension principal results. Br Med J 1985, 291: 97-104
was
observed when the doctors visited patients on the second occasion. This response differs, therefore, from that observed in the more formal interactions involved in bedside presentation in the Pennsylvanian study. Patients expectations seem to have been different in the two cases. The lesson is simple if something of a cliche—time spent in careful explanation and discussion will set the patient’s mind and his cardiovascular system at rest.
4.
Mulcahy R, Murphy J, Martin F. Placental changes in maternal weight in smoking and nonsmoking mothers Am J Obstet Gynecol 1970, 106: 703-05 Burton GJ, Palmer ME, Dalton KJ Morphometric differences between the placental vasculature of non-smokers, smokers and ex-smokers Br J Obstet Gynaecol 1989, 96: 907-15
5. Kuhnert
BR, Kuhnert PM, Debanne S, Williams TG. The relationship between cadmium, zinc, and birth weight in pregnant women who smoke Am J Obstet Gynecol 1987; 157: 1247-51. 6. Harrison R. The use of non-essential drugs, alcohol and cigarettes during pregnancy Irish Med J 1986, 79: 338-41 7. Lehtovita P, Forss M The acute effect of smoking on uteroplacental blood flow in normotensive and hypertensive pregnancy IntJ Gynaecol Obstet 1980, 18: 208-11 8. D’Souza SW, Black P, Richards B Smoking in pregnancy associated with skinfold thickness, maternal weight gain, and fetal size at birth. Br Med J 1981, 282: 1661-63