The DO Book Club, Feb. 2022: It’s All in the Delivery and Motherhood, Medicine & Me
One DO details his quest to improve patient communication, and another shares her experiences as a mother and OB-GYN, in this month’s featured reads.
Feb. 1, 2022 February 2022 issue
To celebrate The DO’s new physician- and student-centered direction, this month I am reviewing two short and impactful books that were self-published by osteopathic physicians: It’s All in the Delivery by Anthony Orsini, DO, and Motherhood, Medicine & Me by Rebecca Levy-Gantt, DO.
Most of us realize that we learn an incredible amount from our mentors. We model the way they dress, how they speak and how they interact with their patients. Paradoxically, we sometimes learn what not to do. When young Anthony Orsini, DO, was a neonatology fellow, he witnessed a much-admired attending physician deliver bad news to a patient’s father in the most blunt and insensitive way. The attending knew he botched it and Dr. Orsini realized that there had to be a better way.
Such was the birth of his lifelong interest in improving the patient experience through better communication. Dr. Orsini pulls together elements of a personal memoir and the communication teaching techniques he has developed in this book. The result is a short but impactful read that should resonate with all physicians and health care professionals.
After recalling his own history as a child with a seizure disorder, Dr. Orsini offers his view of how physicians have become too emotionally detached from the patients they are treating. This approach was literally taught and modeled for us during the internship and residency years. The effects of sleep deprivation and the intrusion of computer screens between us and the patients seem to have detached us both physically and emotionally from our patients.
Dr. Orsini writes that empathy plus imagination equals compassion. We have to imagine what our patients must be going through. Regarding having difficult conversations with patients, he writes, “It is easy for us to get caught up in the rapid pace of the day and become task oriented. We can forget that we’re about to change a patient’s life forever, and to them, we are the most important person in the room. Before any meaningful conversations can take place, you must take a moment and place yourself in the patient’s shoes. Stop to take a breath and imagine. This is half the battle. By doing this, your non-verbal language will be consistent with your words and the patient will genuinely feel a connection with you.” (pp. 47)
Dr. Orsini introduces his approach to breaking bad news, which he has honed through personal experience and devised a way to teach to the staff at his hospital. After learning of a training program using actor patients so prospective doctors could practice delivering bad news, Dr. Orsini went a step further, engaging professional actors and setting up realistic situations for training residents and senior physicians.
This facilitated the gradual design of The Orsini Way, also known as “Breaking Bad News: P.R.O.G.R.A.M.” The acronym stands for Plan/Position, Review, Observe, Gradual/Genuine, Relationship, Accountability, and Meet. These steps are based on three essential principles: the patient/family should feel that the medical practitioner understands and cares, that he or she is the expert and will lead them to the next steps, and that he or she will not abandon them. Dr. Orsini instituted this program for his own program and established a robust business conducting workshops for other organizations.
Dr. Orsini goes further with lessons for improved communications on day-to-day issues in the medical office or ward setting. His five principles of communication for a positive patient experience are introduced with evidence of effectiveness in improving patient satisfaction scores, more positive patient perceptions and anecdotal illustrations.
The final sections review what to do when something goes wrong because inevitably, it will. Better communication reduces errors and malpractice suits. The author reviews how to form relationships quickly and effectively, even under stressful circumstances.
Osteopathic physicians will agree that, “It comes down to this most fundamental of tenets–how you say something is more important than what you say. Every word has both definition and a connotation that evokes a unique feeling to the person receiving it.” (pp. 143)
Dr. Orsini advises getting away from scripts that sound insincere and trying to build genuine rapport with our patients or their parents. For many young professionals, however, genuine rapport has never been modeled, and they actually have to start with scripts that might gradually, over the course of years, become second nature and honestly sincere.
As a neonatologist, Dr. Orsini speaks with a wealth of experience about the high emotions of the neonatal ICU. He speaks of the jarring experience of receiving worrisome news in an insensitive way from another physician about his own son’s health condition. All of us will find ourselves in the position of the patient or the family trying to make sense of a terrible diagnosis or incident that seemingly comes out of the blue. Some of the basic “rules” of effective communication are just not intuitive or obvious to us or our colleagues, particularly during times of stress. When that day comes for me, I hope my physicians and nurses will have read Dr. Orsini’s book. Because as he says, “This is where the real miracle of medicine happens.” (pp. 191)
In her follow-up book to A Womb with a View, Dr. Levy-Gantt picks up where she left off with entertaining cases from her office and the delivery room. This time she mixes in a bit more of her own experiences as a pregnant resident and as a mother advancing through her training and becoming an attending physician. The stories of her own pregnancies highlight how difficult it is to know when labor starts, even as a highly trained professional.
The author uses her wealth of patient interactions to highlight some highly dramatic deliveries, including her own. She discusses what it was like as an osteopathic medical student and then a resident in an OB-GYN training program. Along the way, she makes note of what techniques and approaches she would like to incorporate into her own future practice. More importantly, she notes quite a few practices she would work hard not to replicate. For example, she saw the rough and impersonal way women were moved around in the operating room once they were put to sleep. She vowed not to let her future patients get treated that way.
As she progressed into clinical rotations, she observed that motherhood would prepare her for residency. She was working, nursing, pumping and parenting. “The consistent lack of sleep combined with constantly trying to learn new things, and putting the needs of others before my own were givens in both arenas. Being a third-year medical student and having an eight-month-old at home was a combination that I at times felt very ill-equipped to handle.” (pp. 116)
Despite the sleep deprivation and the difficulties, she found that the specialty of OB-GYN kept piquing her interest. When one gifted teaching attending invited her into the operating room to learn up close the anatomy and approach to a seemingly routine hysterectomy, she fell in love with “the beauty of an exquisitely done surgical procedure.” The special interest of this mentor planted the seed of the future OB-GYN she would become.
Dr. Levy-Gantt includes many of the nightmare scenarios that surely keep EM physicians, OB-GYN residents and attendings up at night: retained placenta, uterine rupture and crash deliveries. She tells a story about one patient’s stubborn placenta, which kept bleeding and bleeding and seemingly didn’t want to detach from the uterine wall.
In addition to retelling stories from the delivery room, Dr. Levy-Gantt uses the chapter “Painful Insertion” to educate and dispel myths around the insertion of an intrauterine device as a method of contraception. In a specialty where a lot of information and misinformation is passed around the lunch rooms and hair salons of the world, the doctor tries to set the record straight. Her next book could easily address all the misinformation around various contraceptive methods.
The last chapter, “Emthonjeni,” follows the doctor on a medical mission to a remote South African village where competent gynecologic care is scarce. While a group of dentists worked in folks’ mouths, Dr. Levy-Gantt served as the “lady doctor” so many women in the village so desperately needed. I could have read two or three more chapters about her work there.
Many osteopathic physicians will recognize their own struggles trying to balance parenthood, childcare and training. Hopefully, our students and trainees will recognize an excellent role model in Dr. Levy-Gantt, who demonstrates how well it can be done.