Hemorrhaging trust 

By Laura Hanyok, MD, Johns Hopkins Medicine 

I’d been waiting for the bleeding to start ever since my IVF physician told me my eight-week pregnancy was no longer viable. However, the rush of bright red blood that appeared at 8:30pm on a Thursday was beyond what I expected. My husband took over the reading of bedtime stories to our two-year old, and I found myself unable to get off the toilet because the blood just kept coming and coming. After about 30 minutes I called a good friend, a former internal medicine residency colleague, and after some discussion we decided I needed to go to the ED. I called the on-call obstetrician to let her know, and since I was using medical terminology, I mentioned I was a physician. I also expressed some concern that my pulse was 110, to which she replied, “You’re probably just nervous.” (I’m nervous? In residency I ran codes and managed upper GI bleeds in the MICU. Worried, yes. Concerned, yes. Nervous . . . no.) 

My systolic blood pressure in triage was in the 80s and I almost passed out. Despite that, the ED physician didn’t seem particularly impressed with me. After some prodding from my friend, they started IVF and drew labs. Eventually, thanks to an observant nurse and my anemic lab results, they realized I was sick, became more aggressive with resuscitation, and continued paging the obstetrician to come evaluate me. When she eventually arrived, she took one look at me and said, “I guess I should have believed you since you’re a doctor.” 

I guess I should have believed you since you’re a doctor. 

What?!?  

Next thing I knew I was a level one case being consented for an emergency D&C. Everything from there went seamlessly—the procedure was successful, the clinicians were patient-centered and kind, the decision-making as to whether my hemoglobin of seven should be treated with blood or IV iron done collaboratively. (I chose the blood.) I thanked the resident and the attending for saving my life, as that is exactly what they did. Had I been hiking solo on a remote trail, I would not be here today.  

However, I kept coming back to the sentence the attending obstetrician first uttered to me. I guess I should have believed you since you’re a doctor. What does that mean? If you don’t believe me, the white physician who speaks in medical jargon, who do you believe? I thought of my patients—an undocumented line cook who only speaks Spanish. An African American teacher’s aide whose previous negative interactions with the healthcare system made her very distrustful. A PhD researcher who emigrated to the U.S. and who has a prominent accent. What happens to them if they have acute conditions? 

Unfortunately, we know that they don’t always do well. Recently, academic publications and the popular media have highlighted the disparities in care for pregnant woman of color, and the lower levels of pregnancy care for all of us in the U.S. as compared to the rest of the world. The U.S. has the highest rate of maternal mortality in the developed world, and our mortality rate is rising while rates in other developed countries are falling.

Some have attributed an increase in U.S. maternal mortality to the fragmented nature of the U.S. healthcare system, to medical co-morbidities such as obesity and diabetes, and to health disparities. Hospitals may not always have evidence-based procedures in place and adequate training for how to respond to maternal emergencies. Additionally, the lack of paid family leave for women to recover from pregnancy and childbirth requires many women to return to the workplace before they are physically and emotionally ready to do so.  

These are all pieces of the puzzle that must be solved to improve women’s health, and organizations such as the American College of Obstetrics and Gynecology are working to improve the health of women during pregnancy and the postpartum period. However, I propose that there is another piece to the puzzle—the culture of medical training. Our students and trainees learn in clinical learning environments where senior physicians may not always listen to or believe patients. In fact, my doctor displayed this when she acknowledged, in front of a resident, that she didn’t believe that I was really “sick.”   

Unconscious biases exist in medicine and occasionally are useful, as they allow us through pattern recognition to make more efficient clinical decisions. However, they can have many serious unintended negative consequences, and they are not simple to mitigate. Educators of medical students and residents have an opportunity to change the culture of medical training so that in the future all pregnant women receive safe, evidenced-based care.  

Here are two things all clinicians can do:
 

1. Explicitly counteract “white coat syndrome” with a patient-centered approach.

Instead of dismissing patient-reported symptoms, directly acknowledge their perceived distress and validate their experience. For instance, when a pregnant patient reports concerning symptoms, avoid assuming anxiety; instead, say, “Thank you for sharing that. Your concerns are valid, and we need to investigate what’s happening. What else are you noticing, and how are you feeling right now?” This shifts the focus from an assumed psychological state to a comprehensive clinical picture. 

2. Implement a “What I heard/What I need” check-in for symptom reporting.
After a patient describes symptoms, paraphrase what you heard to confirm understanding. Then, specifically ask, “What else do I need to know about how you’re feeling right now that might not be on my checklist?” or “Is there anything you felt I didn’t fully grasp about your symptoms?” This empowers patients to correct misunderstandings and share crucial context, especially if they’ve been dismissed previously.

 Learn more about the author here.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.