Originally posted at RH Reality Check.
In a sane world, abortion would be included in medical school curriculum where appropriate, just like any other common, safe procedure. As recently as six or seven years ago, abortion was included in my medical school's curriculum, but no longer. The comprehensive curriculum I naively expected that would provide medical students with the knowledge to meet the common needs of their female patients simply does not exist. At a party last weekend I asked a few second years, four twenty-three-year-old men, to report back to me if they hear the "A" word at any time this semester.
They gleefully dubbed themselves the "Medical Student Moles for Choice." Abortion is a shadow that wisps in and out of medicine, much like the quiet shadow of abortion in many women's lives, not addressed directly, not discussed in coffee shops or over family dinner.
Medical
school is, in many ways, a language school. Someone told me once that
a medical student learns over 20,000 new words in their first two
years of school, and in addition to the new vocabulary, I soon became
capable of saying things over dinner that one should never say.
“Rectum” no longer induces giggles and “vagina”
is boring, not sexy or empowering. And yet, the word “abortion”
is still said with a pause, a nod, a little quieter than the rest of
the sentence. I’m happy when we talk about it at all: for me, the
problem is the deafening silence. That a procedure more common than
an appendectomy would never be named: In the halls of science and
healthcare, that to me is an abomination.
At one time at my
medical school, a state institution of strong reputation in the Deep
South, the physician responsible for the classroom teaching in
women’s reproductive health, “Dr. L,” included a full hour
lecture on the medicine and science of abortion care in the OB/Gyn
curriculum. She included her own stories of patients, the hooks on
which we medical students hang all this physiology and chemistry in
our overtaxed memories. Even so, the students of this relatively
conservative locale responded with powerfully reproachful marks on
the course feedback forms. As student feedback influences not only
the next year’s teaching of any course but also the tenure and
performance assessment of the teachers, physicians, themselves, Dr.
L. was forced to remove the lecture. During the following few years,
including my turn with her, she managed to sneak in ten minutes on
abortion safety when discussing contraception. “Abortion is
safe,” was the message I heard, “but if you have a problem
with it, you better be sure you know how to offer your patients
appropriate birth control.”
The real blow didn’t come
until the following year. Dr. L. moved on to another institution.
With her went any mention of the science and medicine of abortion;
the ethics class debate on the subject remains. This is how abortion
education disappears from our medical schools – subtly and quietly.
The students come and go, teaching physicians come and go, and few of
us notice this loss from the classroom, the laboratory, the hospital
room.
Is it hopeless? Of course not. I have a dream
curriculum, and I believe it can be attained. Including questions on
abortion and other aspects of comprehensive reproductive healthcare
in national medical board exams would re-enforce to medical schools
that the subject should and must be taught. Recommended curricula
from professional bodies like ACOG (the American College of OB/Gyns)
could encourage directors of curricula at both the medical school and
residency level to include abortion care requirements. Specific line
item requirements from the national accreditation bodies could remind
medical school deans every eight years that abortion is part of
normal medical care. Until that day comes, with the support of
Medical Students for Choice, we students will continue to fight for
our own education. At the University of Alabama at Birmingham, we’ve
invited abortion providers to talk with us about their careers and to
teach us about the practicalities of the abortion procedure and
running a practice, shadowed providers at a local clinic, and lobbied
the administration for permanent, sustainable curricular change.
And
what kind of curricular change would we endorse? No medical student
can expect to graduate proficient in any single surgical technique,
including abortion. But medical schools do spend four years preparing
us to do anything in medicine, and preparation requires at minimum
that one can say the word. The ethics of abortion can be discussed.
Along with lectures on infertility and ovarian cancer, there would be
lectures on the medical facts, the evidence-based medicine, of
abortion. Specific training would be required on options counseling,
just as we learn specific phrasing for eliciting a sexual history, or
helping a patient quit smoking. The pharmacology of mifepristone
(medical abortion), Plan B, and hormonal contraceptives would be used
to help students understand the complexity of hormonal changes that
result in the menstrual cycle. Electives would be available in the
history of women’s reproductive control, family planning, and
abortion. And lastly, as part of the OB/Gyn rotation completed by
every medical student, they would observe an abortion (with an
opt-out option only), just as they observe birth, assist in
C-sections, and perform routine Pap smears. This is the reproductive
health curriculum I dream of at night, where students who do not wish
to comprehensively serve their patients are forced to defend their
position. Quite simply, this is a curriculum where abortion is
included where appropriate, just like any other common, safe
procedure.
Medicine today is “evidence-based.”
Treatments must be proven, tested, and extensively evaluated — the
application of the scientific method for the benefit of consumers of
medicine. In this way we protect our patients from damaging or
unproven treatments. But in my medical school experience, it is very
specifically the evidence surrounding abortion care that is omitted.
We would like to think that medicine is a special place, constituted
exclusively with those passionate about healing, not judging. The
fact is, medicine is a community of human beings, every member
carrying their own perspectives and prejudices. Our lack of abortion
education has little to do with the choice of institution, or
location, and everything to do with the universal issues of politics
and fear.
Every activist for choice faces possible retaliation
and danger; it is a risk we know well. In medicine, however, a
relatively benign level of sidelining can suddenly block a physician,
or nurse, or any healthcare provider from the community altogether.
Without sanction from the professional field, in the form of a
practice license, or training opportunity, or job, we cannot offer
ourselves to the women and families we are here to serve. By nature
an outspoken person, I sometimes now choose silence myself, thinking
to the far-flung future, and my someday patients. Sometimes, without
the support I get from my fellow students through Medical Students
for Choice, I suspect my anxiety would win and I would never speak up
at all.
I’m listening to Ani DiFranco’s “Hello
Birmingham.” The song is for me a sort of lullaby, sung from the
city of Buffalo to my city, Birmingham, recognizing the anti-choice
violence survived by both cities. I listen to it when I’m angry, or
moreover, when I need to remember to be angry. I turn it on when I
find myself becoming numb to the norms of silence and misinformation.
Sometimes, I turn it on when I get afraid, when I wonder if someone
has me on a hit list. Would they even bother? I’m only a student. I
have not yet performed an abortion, not yet had the chance to walk
away from a day’s work knowing I have changed someone’s life, gave
them myself, my hands, my years of training, as the tool they need to
empower themselves, take back their control, perhaps just begin to
unravel this one moment in their life. I cannot imagine any greater
privilege.
Louisa Pyle is the President of Medical Students
for Choice, a bi-national grassroots nonprofit organization that
focuses on creating tomorrow’s abortion providers and pro-choice
physicians by improving reproductive education in medical
schools.
Her day job is as an MD and PhD student at the
University of Alabama at Birmingham.