How to be a good doctor: counseling your patients on abortion

In medical school, abortion counseling is not part of our education. Here is a life-changing moment, when a woman is most likely in shock, vulnerable, and in need of medical guidance, and we don’t learn how to present her options to her and counsel her? In the mudpit of politics about transvaginal ultrasoundsabortion clinic regulationsdumb right-wing politicians, and anti-abortion groups masquerading as help sites, doctors should be the ultimate resource for every woman. I personally don’t advocate for abortion, but I believe it MUST be an option for women with an unwanted pregnancy.

In looking for sources on abortion counseling, beyond the bread-and-buttereducational resources, I came across religious blogs and websites about “survivors of abortion” and “abortion is murder” stuff. Some of it is vomit-worthy, and some actually worth reading. (I’m not going to get mired in the discussion of religious views on abortion. The artificial polarization of “pro-life” and “pro-choice” infuriates me, and would take a book chapter to explain.)

In this post, Bryan Kemper asks the question, what would I say to one of my daughters if she came home and told me she was pregnant?

“Our words, especially our first words, to a girl who gets pregnant can determine the path she takes and can be the difference between life and death. As a father of three daughters I do wonder how I would react if one of my daughters came home one day and told me she was pregnant. What would I say? Would I blow up and lose my temper? Or would I love her no matter what mistake she made?

When we go to God in prayer and confess our sins, do you think He screams and yells and has a huge fit? I don’t think so. Do you think he yells at us and tells us how horrible we are, and how much of a disgrace we are to the family? I don’t think so. When we go to Him, He is faithful to love and forgive us. I pray that I never have to go through this with my daughters, but if I do, I pray that my first words to her are those of love.

Yes, we do know that abortion is the act of killing a human person and can never be permitted. Yes, we know that abortion is a sin and is detestable in God’s eyes. Yes, we know that we need to stand up against this evil and be there to try to help people from making such a tragic and horrific mistake. But more importantly than all of that, we know those people need Christ and we need to love them as Christ would.

I think this is a pretty good attitude to have when counseling, regardless of faith. I won’t be quoting John if I have a patient who is considering an abortion, but I hope that I will be able to show her that the doctor’s office is a non-judgmental space, that I will do what is best for HER, and that I want her to make the choice that she feels most comfortable with.

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Dr. Smartphone

 

The NYT had an interesting read about the use of technology in medicine. Given that we were required to buy iPads before coming to med school, I found it really relevant. (The iPad ended up being a glorified way to check my email and fact-check during class.) But I can imagine a smartphone being useful on the wards for the very reasons discussed in the article: being able to calculate values quickly, being able to reference UptoDate anytime you want, and as the Think Like a Doctor case shows, being able to look up common causes of conditions to try to make a differential.

Abraham Verghese has made a brilliant case for making the physical exam the centerpiece of medical education. In so doing, he argues that technology threatens to distance physicians from patients, to cut the humanity out of medicine. There is some truth to what he says, but I don’t like this argument because it refers back to the “touchy feely vs. technical” debate, which in turn goes back to the Two Cultures, which is an unproductive way to think. Instead, we should be thinking about ways that technology–all sorts of technology, not just the newest bells and whistles from Pfizer or Medtronic–can improve medicine and add to the fundamentals that we learn about in training.

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Stillbirth

The topic of stillbirth and birth defects is one of those things that freaks out every female medical student, and many males, too, on a personal level. I can only imagine how difficult it must be to go to the maternity ward for labor, knowing that you won’t have a baby at the end of all the pain, or looking at baby clothes that friends and family bought for you that won’t warm a baby anytime soon.

Heather Teysko has written a very practical, honest, and moving blog entry on Open Salonabout how to prepare for a stillborn birth. As this website dedicated to helping parents of Edwards Syndrome (trisomy-18) babies shows, there are so many details that you have to get in order, and it really does change your life forever.

Learning fetal pathology has been difficult in multiple ways. No matter when you think life begins, it’s heart-breaking to look at aborted and miscarried fetuses, or stillborn infants with terrible dysmorphisms splayed out on the pathology table, at any stage of development. Did they experience pain? Did they die mercifully? At the same time, I ate my lunch just fine while looking at slides of amniotic band strangulation, amniotic tissue stained with meconium, gross holoprosencephaly, and aneuploidic fetuses. I wonder if that makes me some kind of monster.

I found Edith Potter’s, the namesake of Potter’s syndrome, words clarifying: “The description of the body of the dead infant is of no value as an isolated piece of information, but if it is integrated with the various aspects of heredity, conception, development, intrauterine and extrauterine environment and behaviour, it becomes part of an important chronicle.” It’s important work. It doesn’t change the disease. It doesn’t change the fact that the parents won’t have a baby at the end of this. But it does offer predictions for future pregnancies, and some degree of closure for parents who may just want to understand, what the hell happened?

Because of the nature of adverse birth outcomes, in obstetrics, like in no other specialty, the medico-legal system is seen in all its sticky emotional entanglements, paranoia, grief and bitterness, and unpleasantness. This New York Times article about stillbirth malpractice cases only scratches the surface of the nightmarish situation. At one of our teaching hospitals, all OB residents are required to sit in on a malpractice case during their training because they fully EXPECT to be sued at least three times over the course of their career. I feel like our lecturers in the Ob/Gyn block end every lecture by saying something to the extent of, “And the reason it’s important to know how to [evaluate physiological changes, know the timeline for development of abnormalities, etc] is for legal protection.”

This attitude distances me from the patient and makes all my education seem like something I have to be able to recite when something goes wrong and the patient wants to take me to court. It’s unfortunate, and it’s unfair to doctor and patient. But in our lawsuit-happy country, it’s necessary, even if it comes at the expense of doctors’ relationships with their patients.

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Supporting people with Down syndrome

This paper discusses how the increasing life span of people with Down syndrome has created the need for more resources for teen and adult recognition and support. (This paper was written in 1996, so there may be more institutional support for Down syndrome partnerships now, but I haven’t kept up with the literature.) It always strikes me that the same arguments used to advocate for people with disabilities are/could be beneficially used for abled individuals, too. Encouraging partnerships and marriage because it promotes longevity and provides social support? Social equality? Yes please, for everyone!

There was a really moving anecdote the author described when, after a focus group meeting for parents with children with Down syndrome, a mother came up to him and said, “Thank you for involving me because this is the first occasion since my son was born that I had had any concept that my son might have a future.”

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How are babies made? And other questions about sex I have Googled as a medical student 

I was chatting with a patient (let’s call her Liv). Liv was a pleasant young woman who had just gotten married a few months ago. She came into the office for a complaint of indigestion. Like any good medical student, I diligently took her history, silently congratulating myself for getting details like the specific foods that caused her problems (pizza, pepperoni, and breadsticks). She answered all my questions politely and spoke well. I liked Liv.

When we got into her social history, I asked her about her sexual activity. Just fine, of course. But then she dropped the bomb on me:

Liv: “So, we’ve been thinking about having kids.”
Me: “That’s great! When are you thinking of planning for?”
Liv: “Sometime after the holidays. But…I was wondering…do you know the best way? To, you know, get pregnant?”
Me: [blank stare] “Uh…I think it would be a good idea to have Dr. Z talk with you about that. So, are you using any forms of protection during sexual intercourse right now?”

What made it worse is that she couldn’t ask the doctor that question, because the appointment was scheduled for 15 minutes and we were already at least 30 minutes behind schedule. The counseling on its own would have taken 15 minutes, and her more immediate problem was the heartburn. I could have been helpful if I had known the answers to her question, and talked with her while the doctor was seeing another patient–but I didn’t. So while the doctor talked her through the different options for treating heartburn, both of us sat there knowing that she had longer-term questions on her mind that there was no time for.

FAIL. All she wanted to know was, how should I be trying to get pregnant? I feel like these are things that every girl should know. Passed down to them by their mothers and grandmothers, whispered among friends, read in Cosmo, etc. I didn’t want to misinform her, but I had NO idea what to say. Now, having taken a month of Human Reproduction, I have quite a lot to say about how to get pregnant, but shouldn’t topics like these be taught to every high school girl (and boy)?

Thinking back on my own sex ed, I have to say that there was almost none. In sixth grade, our math teacher sat with the girls in one auditorium while we watched a video from the 80s about getting periods and breast growth. That is the last bit of formal sex ed I had. Sex is something that was not discussed in my house; I think my parents would have been fine if I thought a stork delivered me to the front door. Everything I knew about sex up until I went to college was gleaned from rumors about who did what with who and some surprising Google searches.

In college, I went to parties, I took classes on gender studies, I had friends who were passionate about sexual freedom, safe sex, and dealing with sexual assault, so I learned a lot about sex from a theoretical academic POV and an advocate-empowerment POV. But not so much from the practical “how can I get pregnant faster?” POV.

Working with patients has shown me that I know nothing about sex from a very practical POV. What’s the best kind of birth control for me to use if I got mood swings using Yaz? Is it safe to have sex while I’m pregnant? Do Kegels really work? There are a fair number of teen moms at the family medicine clinic, so to talk about these things matter-of-factly with 16 and 17-year olds has been an awakening for me. Why didn’t I know about these basic concerns when I was in high school? And why don’t these girls know either?

It must have to do with the way sex ed is taught. While the US has made improvements in teaching comprehensive sex ed at a national level, there are definite regional setbacks, and overall mediocrity. After all, sex ed is not just education about contraception and abstinence, but also sexual health and to a certain extent, family planning. Teens don’t know what they’re getting themselves into.

At the risk of exposing all my privileges at once, I feel that, at the very least, as a magnet program high school student, with an Ivy League education, in medical school, I should have learned about these sorts of issues a while ago. In a way that was medically legitimate so I wasn’t pulling factoids out of Cosmo and presenting those to patients.

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Congratulations on your new baby–please don’t sue me

The Ob/Gyns who lectured me in medical school ALL mentioned malpractice or using clinical guidelines because you have to be able to justify yourself legally at some point in their lectures. All OB residents at the hospital were required to attend a malpractice case at some point in their training because they’ll be sued on average three times in their career. I know malpractice suits happen to everyone, but the Ob/Gyns take it really seriously.

The well-filmed documentary “Freedom for Birth” raises some interesting questions about the toxic consequences of malpractice. One of the major arguments of this movie is that in the doctor-pregnant patient relationship, the doctor wants to “force” women to do things they don’t want to do, like get c-sections.

It’s terrifying that the doctors can actually threaten Child Services on women who don’t give consent, but consider this from the doctor’s POV: if they don’t take the route with the highest promise of a good outcome, the mother could sue for poor birth outcome, if not now, then several years down the road.

Malpractice varies by state: some places have great malpractice rates and lenient policies, while other places are avoided like the plague. A really interesting article that warns residents that they, too, are liable to being named in malpractice cases. That’s really scary, because you’re not even an attending, and you could have the equivalent of a scarlet letter on your record.

I think the movie doesn’t appreciate the incredible amount of pressure that doctors are under from the hospital AND the patients they are trying to help. It also doesn’t offer solutions for how we might give future OBs more experience with natural births and home births outside the hospital, because the curriculum is pretty constrained already.

Malpractice suits destroy careers and render useless years of training and the chance that that OB could ever help other women deliver, because of a single case. The OB oftentimes has multiple patients in labor at the same time, and even if there are midwives and residents and nurses assisting, is LEGALLY responsible for whatever happens to mother and baby in the hospital.

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Pathological yawning as a sign of brain injury

…is the title of a really fascinating paper that describes two cases of pathological yawning that turned out to be a sign of brain stem injury. Yawning is an action of “accessory muscles,” which are muscles that can be called upon to assist during deep inspiration. What are accessory muscles, you ask?

Normally, your diaphragm can control quiet breathing at rest, and for deep breaths, you may use your external intercostals, which pull your ribs up and push your sternum out. For strenuous activities, like running away from a grizzly, your accessory muscles expand your thoracic volume even more. Accessory muscles include the the sternocleidomastoid (turn your head to the side. Feel that tendon sticking out of your neck? That’s the SCM), scalene, and sometimes even pectoralis major muscles.

When you yawn–taking a large, sharp breath inward–you are using accessory muscles. So what do these accessory muscles have to do with the brain stem?

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It is postulated that the midbrain and reticular formation, part of the brain stem, exert some control over the cervical nerves that control accessory muscles (C2, C3, etc). In the cases described above, yawning was associated with ischemic brain lesions that resolved when the brain lesions were treated.

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