An Abortion Provider Speaks Out: “Being Patient-Centered is Being Pro-Choice”
I do love this work, and I learn new things every day from my residents and my patients. One of the comments a resident said to me a few years ago has especially stuck with me. She said, “being patient centered is being prochoice.” The more I thought about it since then, however, the more I think it is true.
Linda Prine, MD, gave a shortened version of this speech as she accepted the 2012 William K. Rashbaum, MD, Abortion Provider Award from Physicians for Reproductive Choice and Health earlier this week.
Published in partnership with Physicians for Reproductive Choice and Health (PRCH).
I feel very honored to be the recipient of the Rashbaum award. I was lucky enough to have had the opportunity to get some training from Dr. [William K.] Rashbaum up at the old Jacoby Hospital, back when I was a resident at Montefiore in the late eighties. Those sessions were very memorable for me. Because I had been an operating room nurse before I went to medical school, I had a sense of how an operating room setting was usually run. But these days with Dr. Rashbaum were nothing like that. He was basically by himself in this ancient OR suite. He would go to a waiting room and fetch the patient and walk through a maze of corridors to the OR and instruct her to position herself on the table and then do the procedure, talking her through it, and then walk her to another area where she would sit until she felt ready to leave. I suppose there must have been some staff checking these women in and out, but I rarely saw anyone else.
This was basically the same setup when I trained with Dr. G in that Women’s Pavilion at Montefiore, so I just came to understand that, if you were going to provide abortions, you were on your own. When I had been an OR nurse, in the seventies, there was a circulating nurse and a scrub nurse and an anesthesiologist for every procedure, including early abortions (and I was even working in a Catholic hospital!). In the intervening 10 years there had been a shift in the country and my training in abortion taught me in not-so-subtle ways that abortions were now separated from other surgeries.
I understand that, in the beginning, feminists created abortion clinics in order to make sure that women got their abortions in a supportive and caring environment. Some of my friends got their first jobs in these feminist clinics as lay advocates — women who did the counseling and then accompanied the patient through every step of the abortion process. Ultimately, however, this separation allowed abortion to become a marginalized aspect of medical care, and made it possible to not teach the skills in medical schools and residencies because the procedures were performed outside of the institutions of mainstream medicine.
By the time I was doing my gyn rotation in medical school, there were no abortions on the OR schedule anymore. And by the time I became a resident, I had to seek out abortion training from brave physicians like Dr. Rashbaum and Dr. G who were doing them in deserted wings of medical buildings with virtually no staff.
Years later, when I became faculty in a residency program, I wanted to have abortion training for my residents. At first we were able to, through the Clinician Training Initiative at Planned Parenthood NYC. My residents would rotate during their gyn block through PPNYC to get abortion training and because we weren’t able to offer abortions in our health center, we’d refer our health center patients needing abortions to ourselves at PPNYC. But offering abortions at a place other than our health center didn’t always work for our patients.
What woke me up to this was my patient, Samantha. She was bringing her one year-old daughter to me for her check-ups. We had concerns about this child: she wasn’t gaining weight properly and she had a rash on her body that looked suspiciously like burns. I got more suspicious when I learned that Samantha’s two older children were not in her custody but were in foster care. Then, in the midst of this, Samantha tells me she’s pregnant. I offered her an abortion and she was relieved and admitted she truly could not cope with another child. I made her an appointment to come to PPNYC on the day I would be there. But she didn’t show.
Three months later, when she finally came back to see me, she was five months pregnant. I asked her what happened. She just couldn’t go to an abortion clinic, she tells me. It scared her. She was afraid there would be protestors. I asked her, if I had been able to do her abortion in my office, would she have had wanted it? She said, “Of course.” It made me realize that sometimes, abortions need to be really easy for women to access. Especially for women whose lives are so troubled, like Samantha.
I’ve seen how important ready access is many times since then, as we make every effort to accommodate women at our health center with medication abortions offered mornings, afternoons, evenings and weekends, fully integrated into our schedules of sore throats, check-ups, children, the elderly. I worked the Sunday of Memorial Day weekend and did three medical abortions. None of the women had scheduled appointments. One I had counseled a few weeks earlier at our student-run free clinic. She wasn’t sure what she wanted to do, she had to ask her abusive boyfriend. She wasn’t ready to leave him. She had met with our social workers and been offered shelters and all. I gave her my phone number and told her I’d be working over Memorial Day weekend. I think she had to find a way to get away from him.
Another woman that day was a new immigrant from Russia. We have a bit of a Russian underground at our health center because several of our nurses are Russian. She told me that, although abortion is very available in Russia, really easier to get than birth control, that she never expected to be treated nicely when she came for the abortion, so she’s very happy to be in the United States. I didn’t have the heart to tell her that walking into to a clinic on a Sunday and being treated nicely when you ask for an abortion isn’t really so common in the United States, either. But we’re working on that.
It’s not only the patients’ stories that motivate me to do this work, it’s also teaching the residents and helping them see how important it is, and how integral it needs to be to family medicine. Through my work with the Reproductive Health Access Project, I connect with residents and family physicians all across the country and we have created a community that started with a list serve and has grown to be an amazing network. De-stigmatizing abortion by making it part of mainstream medicine makes it easier on the women and on the physicians. I mean, what kind of message do we give to women if we say that we can take care of them if they are continuing their pregnancy but that they have to go somewhere else if they want an abortion? How can we pretend to be pro-choice and not offer them care?
If we are really all about creating healthy families, we need to help women make those families only when they are ready to. And in the process of coming to us for unintended pregnancies, we have to let women know that we respect and support their decisions. For example, one day I had a teen who was being seen by my chief resident, and one of our newer junior residents had sat in on the counseling. The teen had asked if her mom could come in for the MVA procedure, and of course we said, “yes.” This mom was really so wonderfully supportive — she sat with her daughter and held her hand during the procedure and kept her distracted. At the end of the procedure I complimented the mom for being so there for her daughter and told them what a contrast it was to what we sometimes see. (In fact, just a day earlier I had witnessed parents telling their 16-year-old daughter she could not return to their home when she told them she was pregnant.)
When the residents and I left the room after the procedure I explained to them that it’s really important for us, as physicians, to use our power by giving respect and support back to our patients, and to be sure to say something affirming when we saw good family interactions like we’d just witnessed with this mother and daughter. My junior resident, who had watched this very warm interaction and the very gentle abortion the more senior resident had done, said to us, “Yeah! I really want to do this work.”
I do love this work, and I learn new things every day from my residents and my patients. One of the comments a resident said to me a few years ago has especially stuck with me. She said, “being patient=centered is being pro-choice.” When she first said that, it took me by surprise and I had to think about it a bit. It seemed so radical, to say that doctors who were not pro-choice were actually not patient-centered. The more I thought about it since then, however, the more I think it is true.
How can we, as physicians, possibly presume to know what is best for our patients when it comes to their decision-making about when to have a child? How could we possibly, in good conscience, withhold information about their options for ending an unwanted pregnancy or tell them that they are making a bad decision?
There is one other thing I’ve started doing, that I would love to share with you. I have been asking my residents to write a short narrative about their thoughts as they begin their month-long rotation with me, and then another piece at the end. It’s been amazing to look at the pieces they have written, really — I should make a book. They are so moving. Most recently, for example, my resident had written a somewhat judgmental piece as she started the rotation, saying something along the lines of “why can’t women be more responsible…” Then, at the end, she wrote this short narrative that I really just have to read to you because it is so beautiful:
“One patient that made an impression on me during my during my gyn rotation was a young lady I saw with an unintended pregnancy. She was very scared and came in with a lot of pre-formed ideas about abortion and about what she ‘should’ be doing. It seemed like, to her, that her options were continuing the pregnancy vs. hoping and praying that she wasn’t in fact pregnant. She was pregnant, and as I started discussing her options it quickly became clear that none of it was registering. I decided I would probably be more help to her just listening at this point, and after about a minute of silence, she started unpacking: about her thoughts on abortion, about how she wasn’t sure if those were her thoughts or her mother’s, about how she really didn’t feel ready to be pregnant. She ended up choosing a medication abortion, and when I saw her back the next week she seemed like she was 100 pounds lighter, smiling and relaxed. I know this is a pretty romantic story, and not everyone’s experience is like this, but the special part for me was just being able to be with her through this. To be able to sit with someone while they find the path that’s right for them and then help them carry it out is such a privilege. ”
In conclusion, I want to thank PRCH for this brilliant idea of having awards for those of us who teach and provide abortion care. It’s not often in our lives that we get honored for this work, most of it is an incredible uphill battle and most of the time we’re described as being too uncompromising or strident or pushy. It does take a thick skin sometimes to do this work, so it’s really nice for a change to get an award!