From the Wards
Leave a comment

Prescriptive Autonomy

An anxious, 36-year-old Hispanic female lays on the exam table, her feet in stirrups. A sleeved arm juts out between her tented legs as she stares resolutely at the ceiling. I wonder if she is afraid of what the amorphous black and white structures shifting on the ultrasound monitor may reveal. The doctor conducting her exam points out her right ovary for my benefit and moves the wand to search for her uterus. Here, she pauses. 

The doctor, a second-year fellow, informs her patient that she is going to take some measurements and waves over the attending from across the room. They murmur amongst themselves before the attending turns to the patient. He gently informs her that it is possible that she will miscarry and that she should continue to monitor her bleeding and take Advil for the pain, as needed. They will follow up with her in two weeks. 

What we had seen on the monitor was an embryonic sac containing a yolk sac but no embryo — an anembryonic pregnancy. In the hallway, the fellow questions the attending’s decision not to emphasize to the patient  that the pregnancy is not viable. He suggests counseling her on the use of misoprostol to hasten her miscarriage. “She will think that we gave her an abortion,” he says. “Better to let her body pass the tissue on its own.” There is neither a conversation of the relative risks of expectant versus medical management nor a discussion of the possibility of misdiagnosing a nonviable pregnancy.

I have thought back to this scenario a number of times. I do not doubt the attending’s intentions or his empathy. He had guided his patient through fertility treatment for months before I ever stepped foot in the exam room. I do wonder, however, if this woman would have preferred to take misoprostol. I wonder whether it may have saved her time taken off from work or shortened the duration of her pain. Would it have given her back agency over her body that she had lost somewhere in the process of coercing it to create and harbor a new life? I wonder if she would have appreciated simply having the choice. 

Womanhood is both an experience and an institution. Patienthood is no different. To be a patient is to be prescribed a dress code and a language with which to discuss your condition. It is to accept the notion that those with authority should be trusted to tell you what is happening to your body, even when it does not align with your interoception. Too often, to be a patient means to relinquish your autonomy.

Months after this patient encounter, on an otherwise unremarkable Saturday morning, I walk towards the doors of Planned Parenthood to the chants of protestors, my heart beating in my throat. I train my eyes on the friendly clinic escorts in their yellow vests as strangers admonish and attempt to persuade me to leave. 

Like many Saturdays prior, I try to imagine what will happen if I stop in front of the man holding out “Jesus Saves” pamphlets. I try to imagine what he might say if I tell him about the patient who sobbed as she disclosed to me the abuse she had endured that led her to seek an abortion, or the patient who so badly wanted a pregnancy that threatened her own life. These mental exercises often feel futile, particularly in light of the recent slew of heartbeat bills seeking to ban abortions, even as early as six weeks from conception.  

Now as I find myself more entrenched in the health care system, I am reminded time and again of what my mother told me about her intern year in her internal medicine residency — how she, three months into her pregnancy with me, was scolded by her attending for “being stupid enough to get pregnant.” I am reminded too often of how women are defined by their reproductive capacity, and I am cognizant of the myriad of ways in which this framework has disadvantaged female patients. From the ancient Greek idea of ‘hysteria’ as a uniquely female condition caused by a wandering uterus, to more recent under-diagnosis of conditions which manifest in female pelvic pain, such as endometriosis, gender health disparities rooted in sexism persist. To this day, women face longer emergency room wait times than men when their primary complaint is abdominal pain, and they are more likely to be prescribed anxiolytic medications.

Worse still is the fact that United States medical schools are not required by the Liaison Committee on Medical Education (LCME) to include clinical abortion education within the four-year medical school curriculum. Beyond medical school, many obstetrics and gynecology residency programs continue to offer abortion training on an “opt-in” basis. What sort of message does it send when our nation’s medical institutions and governing bodies don’t hold medical abortion training to the same standard as other routine obstetric or gynecological care? I can’t help but wonder, when medicine itself remains enmeshed in this patriarchal perspective, how can we hope to influence the national discourse on abortion rights? How can we ensure that our patients receive the care that they need, the care that they have a constitutionally protected right to access? 

For three years prior to starting medical school, I had the honor of serving as a volunteer abortion doula to women in the District of Columbia and Virginia. I also worked as a medical assistant in an outpatient obstetrics and gynecology clinic. I held patients’ hands and helped them focus elsewhere when their pain seemed too great to bear. I talked them through the sensations occurring in their bodies and helped guide their breath through their pain. I affirmed that they were more than a moment in time, more than a single decision, and that they were the only individuals qualified to make that decision for themselves. In the process I learned immensely, both from my patients and from the physicians with whom I worked, how to cultivate trust and ensure that a patient’s choices and beliefs are respected in the process of providing them with the care that they need.

Our attitudes and perceptions guide and influence the way we approach and solve problems. More urgently, they influence how we interact with others. For physicians, those interactions influence patient outcomes. As a doula and as a medical assistant, I have cared for patients by affirming the choices that they make for their bodies, promoting their sense of agency and bearing witness to their pain. As a physician, I will do no less. I will strive to foster an environment that affirms the autonomy of my patients by educating them on all of their treatment options because I have witnessed how restoring autonomy to an individual improves their mental and physical well-being.

Author’s note: Identifying details have been changed to maintain patient anonymity.

Aleisha Khan (1 Posts)

Contributing Writer

Medical College of Georgia

Aleisha Khan is a first-year medical student at the Medical College of Georgia in Augusta, Georgia. She graduated from Duke University in 2015 with a Bachelor of Science in Neuroscience. As a non-traditional student, she conducted neurocircuitry research on chronic pain in the lab of Dr. Yarimar Carrasquillo at the National Institutes of Health before obtaining her Master's degree in Physiology from Georgetown University. She also worked as a medical assistant in obstetrics and gynecology prior to starting medical school. In her free time, Aleisha enjoys running, yoga, tending to houseplants, and hanging out with her two rescued Whippets, Bleu and Sammy. She is currently undecided about her future medical specialty, but is interested in internal medicine, pediatrics, and neurology.