It would be hard to miss her. She walked into the atrium, towering tall in a bright orange jumpsuit. She was led down the hallway, her handcuffed arms held straight out in front of her, palms parted as though to grasp a bouquet of flowers.
When we saw them later that afternoon, they were uncuffed, poking through flimsy sleeves of the hospital gown she was given. Without her body wrapped in its orange uniform, or the security guard sitting at the foot of her bed, you wouldn’t know she came from the prison. She now matched her neighbors, donning that sad sky blue material, that pitiful excuse for a color. The one decorating most healthcare facilities, the one that is supposed to warm up sterile rooms and hearts alike while failing at both. Continue reading “Welcome to Third Year”
Recently, I wrote this email:
Hi Dr. W,
I was a patient of yours in 2006 when I started at Scripps college.
I’ve thought about you many times as the years have passed, how lucky I was to receive such wonderful care. I am proud to say I have never relapsed since, and am strong, healthy and happy. In fact, I am now a medical student at Tulane, hoping to pay it forward.
Thank you for your work,
I’ve heard a lot about the self-pathologizing that happens in medical school. How everyone will start to think they have the various diseases we learn about. With my own family history of hyperchondriasis, I too, have been waiting to find my rare diagnosis. Waiting to learn about the condition that pieces together all the symptoms I didn’t even know I had. Luckily, by now we’ve gone those most of the bodies systems, and my bones, blood, and organs have come out “unremarkable”.
Then we started on the brain.
The first day of my externship I arrived to a sweet little 3 story clinic tucked between mom and pop shops in a residential neighborhood in Mexico City’s Avante neighborhood. I showed up ready and eager. I had done my research: spoken to previous students who had attended the clinic, read up on procedural standards, researched the history of reproductive rights in Latin America, and familiarized myself with the current policies that highlight Mexico City as a sanctuary within the country at large*. This new information added an extra pep to my steps alongside the pro-choice activism I’ve been engaged with through medical, political, and social spheres. These two weeks were to be an officiation, a baptism of sorts; a way to fully immerse myself in the work I’ve been so passionate about.
The experience was structured for me to follow patients throughout their visits. First, was the medical consultation where clinical histories were taken, ultrasounds performed to confirm gestational ages, and discussion were had about birth control options moving forward. Second, was the counseling session with the psychologist. Recognizing that most patients arrived resolute, the purpose was not to help women make a decision. Rather, it served as a space to reflect on a woman’s ability to decide, to have control over her life and body, to help strengthen her ability to confront fears and conflicts, both internal and external. At the end of the session patients received their medications. As preventative measures, a dose of antibiotics and ibuprofen; as preparatory, a dose of misoprostol**. Lastly, they moved to the operating room for a 15 minute procedure that started with paracervical anesthesia***, then cervical dilation, and lastly manual vacuum aspiration.
Like a mute shadow, I followed along, observing. Each stop through the process showed a new depth of compassion offered by members of the clinical team to the women that passed through their care. I was touched, inspired really.
Until I saw my first abortion. Halfway through the procedure I had to dismiss myself and sit in the hallway outside. I heard the nurse speak softly to the patient, “Breathe in, hold for 3, breathe out,” and I followed along.
When it was over, the doctor came out and met me with just as much kindness as he did his patients. Just breathe, sit down whenever you need to. Let us know if it ever becomes too much, he told me. This happens everyone’s first time, he said with a smile. But that was just the problem. See, I wasn’t supposed to be this grossed out. This is the work I had come here to do, this is what I had prepared myself for. I wanted so badly to be a model student, to not be everyone else.
Like most falls from hubris, the fact was I was just disappointed in myself. Disappointed that I couldn’t handle it, and even more disappointed that I had assumed otherwise. The truth is that there are some experiences no amount of work can prepare you for. Some journeys have no shortcuts and the only one road to take is the one that passes through. So it was and I continued down the path.
I wish I could say that each day it became easier. But that is not what happened. I did not learn to disconnect myself, nor to stop imagining the sensations of what I saw. I did not learn how to still my focus on the procedure or concentrate on the anatomy involved.
And as the days turned to weeks, I learned this was okay. These are skills that can come with time and practice. Instead, the experience taught me more important lessons.
I learned that abortions are not pretty, they are not fun, and they are not a desired procedure. But they have always been necessary, and as long as human continue to mate, they will remain necessarily. That women will always need access to abortion services is not up for debate. Rather, the question is always how, where, and in what conditions they occur. Quality care goes beyond safety. It requires honesty, trust, and difficult conversations, as much as it does tender handholding and empathy.
I learned not to minimize abortions; that the experiences they bring are as varied as the women who have them. As a physical procedure, they can bring the pain of invasion as much as they can an ecstasy of liberation, a reclaiming of one’s body. As a process, abortions span an ocean of emotions where despair and relief, fear and gratitude, loneliness and solidarity are tangled up like seaweed.
As future abortion providers, our job involves more than a procedure. It requires meeting women where they are at, walking with them and providing a safe space to support them through their process, whatever form theirs might take.
* In Mexico, similar to the U.S., states are able to regulate the national abortion law, which only mandates approval for abortions in cases of rape or incest. Although other exceptions exists such as when the life or health of the mother is at risk, for socioeconomic security, or for the health of the fetus, these vary on a state by state basis. Then 2007 rolled around and Mexico City brought with it the decriminalization of all first trimester abortions. As of now it sits in the middle of a country as a quasi sanctuary city for women seeking safe abortions. Women come from other states of Mexico and other countries, as far away as Brazil and as close as El Paso, Texas.
** Depending on the gestational age, misoprostol was taken either sublingually (when less than 12 weeks) and buccally (when over 12 weeks), to contract uterine muscles, helping preventing perforation, and to dilate the cervix.
*** For pregnancies over 15 weeks general anesthesia is used.
Monday morning she was back in the waiting room. With the nervous look of a girl embarking on her first sleepover, she had her pink backpack on her lap, ready for however many days the hospital would be her new home.
She would have to initiate and terminate her pregnancy under the careful watch of the hospital. First, they would administer a dose of misoprostol vaginally to stimulate uterine contractions. After six hours, an anesthesiologist and Ob/Gyn would perform a D&C (Dilation and Curettage); in reality, a procedure that is longer and more invasive than most protocols recommended for her pregnancy of only 7 weeks.
The reason for this? Like most questions of “why?” here, the answer is unclear. Maybe this is for her safety. Maybe the hospital doesn’t have access to the Mifepristone or vacuum aspirators typically recommended. Or maybe the additional procedures offer financial incentives that outweigh the health of the patient.
Time certainly wasn’t the issue. They had no problem keeping her in a room waiting for a doctor to see her with the misoprostol to begin the abortive process. The problem was that when he rounded on patients he skipped her room, repeatedly. What she thought was first a mistaken overlook, it became clear the doctor was actively avoiding her. Dr. B doctor warned her to be prepared for these so-called conscientious objecters. So she waited, hoping the next doctor on-duty would be more empathetic. But day 1 passed and still no one came to see her. She closed her eyes and prayed tomorrow would bring better luck.
Dr. B told her to be strong, but as day 2 came and went her patience turned to desparation; she had a daughter to take care of, a job to work, and a life she wanted to get back to normalcy. When she could wait no longer, she called Dr. B, alerting her team to what was happening. Phone calls were made, words were exchanged and on day 3 the patient was finally attended to and discharged from the hospital.
Maybe the invasiveness and time consuming nature of the procedure will serve as a reminder to be more careful next time.
Maybe next time she shouldn’t talk to strangers, shouldn’t drink, shouldn’t go out at night, shouldn’t leave her daughter with her parents.
Maybe she should be a better mother, a better daughter, a better woman.
Yes, maybe this time she would learn her lesson.
(a strength within Fortaleza)
Two women from Fortaleza walk into a clinic.
Their lives outside the door existed worlds apart in the same city. But walking inside, their differences became trivial in the new situation they found themselves in.
They were both young mothers, both had been raped, and both wanted to terminate the pregnancy that resulted from the assault. They both were being drawn through the onerous path of seeking a legal medical abortion in Brazil*. They were both resolute in their decision. They had to be, or it’s unlikely they would make it through the process.
A process, which forces them to divulge the details of the violent event multiple times, to multiple people; to meet with a psychiatrist, a social worker, and a nurse, who then pass her on to the doctor, who then passes her to the ultrasound specialists. There, they insert a large probe into her vagina to measure the gestation age of the fetus in order to verify her story and timeline as truthful. She lies in the dark, eyes pinned to the ceiling above, as the fetus’ heartbeat plays from the machine, echoing off walls around her.
From there she is passed back to the doctor, who then passes her back to the psychiatrist, social worker, and nurse who have her sign multiple documents to double, triple and quadruple check that she understands her decision. Even after all this, today will not be the day both of them had prepared themselves for. There will still be time to change their minds, four days in fact, or weeks even, if they wanted to ponder this longer.
They both shook their heads.
They would be back after the weekend.
Why the weekend? The doctor and staff who oversee at these cases of pregnancy terminations do not work on the weekends. In the rare case that a patient had to stay in the hospital, they wouldn’t want her care to be taken over by just whoever was working.
As doctor explained to them both:
know that while you are with our team, everyone you pass through is here to help and care for you in any way we legally can. But not every medical profession will support the decision you are making, and some of them will make sure to tell you so. In these cases, tem que ter fortaleza [you have to be strong].
Two women from a clinic walk into fortaleza
*There are three legal exceptions Brazil has to its strict anti-abortion laws: (1) in the case of sexual violence, (2) when the life of the mother is at risk, or (3) when the fetus is “incompatible with life”, which is only considered for anencephaly.
That day I was supposed to be the patient.
The nurse putting the blood pressure cuff on me was the same one who always takes my vitals. She likes to chew gum; you can see her tuck it between her teeth and cheek as she walks into the exam room. A slight bulge pumping against her straight hair. Today it is dyed a reddish-brown.
As her hands wrapped around my arm, my eyes landed on small blacks on her left wrist.
“Is that a semicolon?” I asked.
“It is,” she replied as she shimmied her stethoscope up around her ears.
“Can I ask if there’s a story behind it?”, a tactless way of indirectly asking the question anyways.
“It is for suicide awareness,” she replied. Continue reading “the girl with the semicolon tattoo”
The million do$$ar question:
What do you think your voice and sense of social responsibility is as a physician-in-training?
A first year medical student’s answer:
I would not say that I stumbled into medicine. It requires too much hard work to be an accident. But it was an unanticipated deviation from the original career path I had started down. The latter was a life in the non-profit world, centered around social justice with a focus on women’s international human rights. My move towards medicine was not a break from this work, but rather an opportunity to address it from another direction. I believe that healthcare, as a basic human right, is foundational to any fight for justice. As such, I came to see how the practice of medicine is the use of set tools to effect tangible change.
I love the notion medicine as a practice of the art of healing. It is a precarious balance of holding compassion in one hand and objective decision-making in the other; it is a creativity to read between the lines, hear between the breaths, and feel the silence of emotions between words. Much of the art cannot be taught in a textbook, or a lecture, but from the humility of failing over and over and over again in the hopes that maybe next time you will get it right.
Amidst these lessons, our training places us at a unique intersection of our hippocratic oath, legal mandates, and our own moral codes. Sometimes these align, sometimes they stand in staunch opposition. Sometimes we must suspend our personal beliefs at the door to provide the best care for a patient, but to also not forgetting to to pick them up on our way out.
It is an difficult role for it requires numerous character changes: a patients’ confidant at the bedside, an advisor to a business, an expert at a court hearing, as well as a friend, a lover, a caregiver, a family member, and an ordinary citizen. In choosing this career, one necessarily chooses involvement in issues they have never experienced and is confronted with questions they have never had to answer. Sometimes they are small, like helping a patient figure out transportation options to ensure they make their next appointment, or finding a free clinic for an uninsured patient to get affordable prescription medication. Sometimes they are much larger, like how to respect a family’s religious requirements for burial while also complying with state mandated autopsy orders or organ donations.
As physicians-in-training, we are no longer isolated to the problems and injustices that impact us personally. When we commit ourselves to the care of a patient, we must seek to address their well-being. Our white coats with embroidered names place us in a unique social hierarchy that values our voices. While we cannot take on every struggle nor pick every fight, we can, and should, advocate for our patients. To do so it to take on someone else’s struggle as our own. And when we speak out from a truth rooted in their stories, whether at an institutional, local, or national level, we help amplify their voices, moving them beyond to walls of the exam room.
This work is not about being a do-gooder, or completing a class requirement; it is about committing to a job that requires more than diagnostic skills and memorization of medications. As we discover our strengths and weaknesses, we learn better what tools are available, figuring out how and when to use them. And it is in this creative process that perhaps we will master the art of practicing medicine.