A final year medical student acknowledges that empathetic communication is not always intuitive, but through her own experience of miscarriage, shows how empathy is critical for patient care. 

Content warning: Discusses miscarriage and mental health

I stared at the faint pink line, barely visible next to the darker one. Surely not. Pregnancy test after pregnancy test, the answer was the same.

I was a medical student approaching the start of my final year. I had completed a term in obstetrics and gynaecology. How could I have been so incompetent as to unwittingly become pregnant? The truth of course is that no contraceptive method, short of abstinence, is one hundred percent effective.

Although I would never judge someone for choosing to terminate a pregnancy, I could not bring myself to end this one. I realised that I loved that tiny life already. The pregnancy was invisible to the outside world, but it already felt very tangible to me; unnervingly present in the ways it had changed my body and mind. I was amazed that something so tiny could cause such an avalanche in my world, yet so much devotion in my heart. I fought hard to create a path for us both.

Quickly, my partner and I had to form new plans across all aspects of our lives. Surprisingly, the medical school was willing to be flexible with my rotations. I remain immensely grateful for the support of the medical school staff, especially my cohort’s subdean. If you find yourself in this position as a student, my advice would be, make your own detailed plan with contingencies. Present it assertively and cite your protective factors such as good grades to support your case.

However, the best-laid plans cannot defend against the course of nature. Days after we first saw and cherished the tiny heartbeat on ultrasound, I knew something was wrong.

It started as an instinct. Despite the nausea and overwhelming fatigue, I didn’t feel pregnant anymore. I tried to remain optimistic; after all, the overt pregnancy symptoms remained present. But at night, my dreams had turned to nightmares. I had no bleeding, no pain – only a growing sense of unease.

A few weeks later, my morning sickness disappeared. I could no longer ignore my intuition.

I was on rural placement, hours away from home. The only doctor in town was also my supervisor. I called a telehealth GP, who referred me for a reassurance ultrasound. Cautiously optimistic, I drove to the nearest big town, hoping that I was simply a fretful first-time mother. 

The sonographer didn’t introduce himself, but told me to lie down and started scanning my uterus. “Can you see the baby?” I asked. He didn’t answer, but cleared his throat awkwardly and turned to inspect the adnexa instead. 

Moments passed, in which I realised – and denied – what my own eyes had seen. Returning the probe toward my uterus, he replied, “Sorry, there’s no heartbeat, and it’s measuring behind. It must have stopped growing the day after your last scan.” 

News like that makes time slow down. Shock, denial, numbness. This can’t be real. I could barely breathe, let alone think. Faced with my distress, the sonographer just kept talking and demonstrating the technical details, as if trying to convince me of his diagnosis.

“What do I do next?” I asked helplessly. I knew the options – expectant management, medical management, or a dilatation and curettage (D&C). But as a patient I had no idea how to initiate any steps, so far away from home, with no symptoms to warrant an ED visit. The sonographer sighed and squirmed, not making eye contact. “I don’t know. You have retained products.”

The sonographer told me to leave and made his own hasty retreat. I broke down in tears outside the radiology clinic, sitting on a bench amid countless passersby. There was no space in the clinic to recover from the news; no referral pathway; not even information brochures. I felt utterly alone.

Instead, the obstetrician gave me ‘fun facts’ about miscarriage, accompanied by a wry grin. He did not seem to understand that my role at that moment was a patient and grieving person – not a medical student or health professional.

That day, I ended my rural placement and made the long, lonely drive home. The vastness of the Australian bushland had never seemed so barren to me.

On my return, I did not sleep for several days and nights. The grief remained acute to the point of physical pain – wordless and inescapable.

Then I picked up the phone and made an appointment.

While still standing in the doorway, in earshot of the waiting room, the obstetrician jauntily opened the conversation.  “So you've had some bleeding, have you?” I felt keenly the lack of privacy and respect. The question, too, felt like a slap in the face, given the silent and bloodless nature of this loss.

As the appointment went on, I was stunned by the lack of empathetic communication. There wasn’t even a “sorry for your loss”, or any of the conventionally sympathetic things that one human being might say to another who is hurting. Instead, the obstetrician gave me ‘fun facts’ about miscarriage, accompanied by a wry grin. He did not seem to understand that my role at that moment was a patient and grieving person – not a medical student or health professional.

All I wanted to be told was, “I see how hard this is for you. It is a real and painful loss. We will help you with the first steps to get through this.” 

Nevertheless, he helped me access those pathways: medical, surgical, or expectant. I already knew I wanted medical management. I needed to experience the miscarriage as real, as a physical correlate for the pain in my heart.

For a ‘missed’ miscarriage, misoprostol alone isn’t sufficient. So it was with a sick irony that I found myself buying the same abortion drugs I had chosen to decline; mifepristone to block progesterone, followed by misoprostol to expel the contents of my uterus. Despite my own conflicted feelings about termination, I was grateful to have prompt access to the drugs that are denied to so many other women across the world. Access to termination also means access to the management of miscarriage.

My mum held my hand as I took the first pill that evening. “Wait,” she said. “Do you want to name your baby?” So I named her, sobbing my half-formed hopes and dreams for that unknown person onto my mother’s shoulder. Then I took the pill.

The physical and emotional experience of the next few days was agony. ‘Moderately severe period-like cramps’ does not begin to describe the acutely severe pain I felt during the first few hours after misoprostol. Nor does ‘heavy bleeding’ adequately describe what passes. I will spare you further details, except to recommend taking analgesia before misoprostol, rather than waiting for pain and vomiting.

Despite the awfulness, I would choose medical management again. It gave me closure and catharsis in the privacy of my own home, with my partner at my side. I saw and held what my body had carried. I returned her to the earth.

In the subsequent weeks, I grieved.

The emotional pain does not end when your body stops bleeding. Nor is the path to recovery a straight line. I learned that the five stages of grief are not a road but a quagmire, all muddied together, pulling you back in again when you least expect it.

He does not ask how I am coping. He doesn’t ask about ‘red flags’ such as suicidal ideation. His eyes remain fixed on the computer screen.

Amid the follow-up blood tests and appointments, my family GP tells me that it’s not so sad after all. Easy for him to say. When I disagree, he echoes my mother-in-law’s patently useless sentiments – that it happens for a reason, that it was meant to be. Better luck next time. He does not ask how I am coping. He doesn’t ask about ‘red flags’ such as suicidal ideation. His eyes remain fixed on the computer screen.

How do you complete the ‘tasks of mourning’ when your grief is unacknowledged – not even considered a loss?

In the ‘five stages of grief’ model, there is anger.

I am furious. I am surprised and disappointed by the utter lack of empathetic communication from several health professionals, including an expert in women’s health. How much worse would my experience have been, if I were more vulnerable or had less medical knowledge?

Nevertheless, it is important to share the positive experiences too. I am grateful for the empathy of my new GP; the midwives at my local emergency centre; and my family and friends. These supportive interactions meant so much to me.

Empathy is important. It is analgesia for the soul. It is a tool for healing. There is a growing body of evidence that the empathy of health workers is prognostically important, across a variety of both mental and physical health outcomes. 

Cure sometimes; relieve often; comfort always – isn’t that what we strive for?

As a medical student, I know that empathetic communication is not always intuitive. I have experienced my share of awkwardness and the struggle to find appropriate words. This is the reason we learn how to communicate – why empathetic behaviour is taught, studied, and practised. This is the reason for tools such as the ‘SPIKES’ and ‘NURSE’ acronyms, which I have found useful in my nascent clinical experience.

Now I am trying to mould something constructive from the clay of my grief. I have sent individualised and respectful feedback to the doctors I interacted with, because feedback is how we improve. To their credit, they seem to have taken it on board. Next, I am writing this article in the hopes that you will respond with empathy for the patients and people around you. Please don’t forget the task of being human.

Above all, I want to do better. I will do everything in my power to be a doctor who deals sincerely with grief and other difficult emotions, and who has the humility to grow from constructive feedback.

I hope that when I sit across from a young woman facing the loss of her pregnancy – or with any patient experiencing grief – they will feel seen, heard, and not alone.

DRS4DRS promotes the health and wellbeing of doctors and medical students across Australia. For more information go to www.drs4drs.com.au