How I Learned that One Mistake Does not Define Me

As genetic counseling students, we learn about the importance of protecting a patient's confidential health information and the perils of disclosure without consent. I remember wondering, “How anyone could make that mistake? How could someone fail at one of genetic counseling's most fundamental principles?” However, in my second year as a genetic counselor, I did just that. I was referred a G5P1A3 woman (I will use the pseudonym Mrs. P) whose current pregnancy showed multiple anomalies on ultrasound. Her obstetrician sent me a summary of her obstetric history, which included two late-gestation intrauterine fetal deaths that occurred in her home country in Africa. When she presented in my clinic with her husband, I reviewed this history with the couple in an attempt to elicit more information about these past losses, particularly in the context of the ultrasound findings in the current pregnancy. While I asked questions regarding her history, I watched as her body language and demeanor completely changed. She became silent and would not elaborate when I attempted to draw out what she was feeling. I interpreted her reaction as her past losses being too difficult to discuss, especially given her current situation. We arranged a follow-up appointment for the following week. The following day, Mrs. P's husband came to my office alone and unannounced. He explained to me that he had been unaware of his wife's first pregnancy loss, as this had occurred prior to them being together, and she had never shared this with him. Mrs. P had kept this loss a secret for almost 15 years. She had never allowed him to be present for any of her prenatal medical appointments, and he felt that this was due to this secret first pregnancy. When I realized that I had disclosed this woman's secret to her husband, my initial reaction was panic. I had made one of the fatal errors in genetic counseling. I felt embarrassed and guilty for having failed in my role as a genetic counselor. I was so lost in these feelings that I didn't notice Mr. P was still talking. He expressed that he wasn't angry with his wife, but that he did not know what to do with this new information. His wife refused to talk about it, so he was contemplating discussing the situation with her brother. At this point, I took an approach of “damage control”; I wanted to prevent Mrs. P from being harmed any further. This decision resulted in me being much more directive in counseling Mr. P than I typically am. I began to tell him what he should say to his wife and how to approach the situation. I indicated that by no means should he discuss this with anyone else. He agreed to keep the secret to himself and he asked that I not tell his wife that he had come to see me. When I met the couple the following week, Mrs. P did not bring up the disclosure and, since I had agreed to keep my conversation with her husband confidential, I had to act as if I was unaware of my indiscretion. Sadly, their pregnancy did not go to term. After some follow-up with my patient, I filed her chart and decided to forget the whole experience. I did not want to revisit this case, as the mere thought of it was enough to make me feel physically ill. However, in the 6 months that followed, her husband would occasionally phone me for support or a face-to-face meeting. Every time that I was contacted by Mr. P, the same feelings of shame, guilt and anxiety would resurface. In retrospect, I better understand how these feelings were detrimental to the counseling relationship I had with this man. The anxiety I felt about this case and my need to try to protect his wife from further harm affected my ability to empathize and attend properly to Mr. P's experience. I was no longer capable of objectively counseling him, and I continued to be too directive. I also see now how the secrecy of these meetings affected me. While I respected Mr. P's request for confidentiality, the fact that I was unable to speak to his wife about it affected me greatly. I truly wanted to apologize for my mistake and for the pain I caused her. I now realize that not being able to approach her with an apology also means that there is no way I could be forgiven by her. After many months, I began to understand that continued contact with Mr. P was not in either of our best interests, and I decided that if he were to phone me again, I would have to pass the case to another genetic counselor. When Mr. P did contact me, he said that it was for the last time; that while he and his wife had never discussed the secret, their relationship was much improved and they were moving forward in their life together. This conclusion to the case allowed me to take a step back and reflect on how it had affected me and my practice. This case forced me to evaluate how my feelings regarding a particular case can cause me to lose sight of my role as a genetic counselor. In this situation, the counseling given in this context was more about what I needed (i.e., relieving my guilt) rather than attending to Mr. P's needs and being present for him. I now believe that in order to circumvent my feelings of guilt, I felt I had to somehow make it up to Mrs. P for having caused her pain. I also felt that that I owed it to Mr. P to support him in matters unrelated to their pregnancy loss, given what I had put him through, causing me to step outside of my usual boundaries as a genetic counselor. I have learned to listen to how I am feeling about a particular case and to recognize if these destructive feelings begin to surface. Regardless of the shame I might feel, I now discuss the challenging situation with trusted colleagues. Their input and experiences are invaluable and allow me to get an objective opinion about whether or not the way in which I am counseling is appropriate. Although I initially struggled with my feelings of having failed at something so fundamental to our profession, I eventually learned from my response and realized that this mistake does not define me as a genetic counselor.