Facilitating a Correction

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity ** 

Working in a women's correctional facility over the past week has been a very insightful learning experience. In many ways, there are no differences between care on either side of the barbed wire. Patients present for treatment of hypertension, diabetes, GERD, thyroid dysfunction, asthma, irregular menses, UTIs, and general health maintenance. Labs can be ordered on-site, and a relatively large formulary is utilized. Patients attend all appointments and are 100% compliant with medications. As in an "outside" clinic, patients with surgical needs are referred to the hospital. If not for the homogenous uniforms and locking steel doors, one would never know the clinic was in a prison.

I was allowed to examine Monica, a very friendly middle-aged woman following up with several chronic illnesses. Aside from her shackles, she could have been any patient seen in outpatient clinic. As we lightly conversed about the weather and the prison food, I realized that I had been previously acquainted with Monica. Several years earlier, I met her under a front page headline of the daily paper, her smiling mugshot juxtaposed by the grisly details of a cold-blooded murder. Her arrest and subsequent trial had been sensationalized in the media, due to the sheer cruelty and brutality of the crime. Oh yes.  

That Monica.

During my first year of medical school, we completed an exercise to identify possible prejudices we may have toward different groups of patients. We discussed the reactions we may have to treating homeless patients, welfare recipients, drug and alcohol abusers, criminals, unmarried mothers, racial supremacists, undocumented immigrants, and other difficult social populations. Through that exercise, I learned that I was uncomfortable with murderers and sex offenders. It seemed rather contradictory to provide love and care for someone who deliberately preyed on vulnerable people, or who ended a life in a planned, methodical manner. Would treating these offenders facilitate them to commit more crimes? This dilemma was discussed, but not resolved. We were advised to be cognizant of our biases, and maintain professionalism. 

Personally, I believe the doctor-patient relationship to be the crux of primary healthcare. Forming a bond with a patient is the key to obtaining an exhaustive history, and unearthing previously overlooked details crucial to treatment. How could I connect with a person who committed such a heinous act?

How was I going to effectively serve this patient? Employment of a defense mechanism seemed most appropriate. While I listened to Monica's heart and lungs, I considered my options:

• Denial - believing I had the names confused, and Monica was not the killer I recalled
• Intellectualization - considering the pathophysiology of Monica's chronic diseases 
• Conversion - involuntary development of blindness in order to avoid completing the exam
• Reaction formation -becoming overly accommodating and friendly to compensate for my negative feelings
• Idealization - convincing myself of Monica's innocence
• Suppression - curbing my thoughts and focusing on completing the exam
• Rationalization - believing that Monica had a justifiable reason for her crime
• Humor - joking with the patient to circumvent the elephant in the room

While I contemplated this and moved to test Monica's reflexes, she intuitively asked me how I liked working in the prison. "Are you OK with treating all these crazy people in here? That's gotta be hard." Without hesitation, I replied. "It's not so bad. Really, patients need care no matter where they are — hospital, clinic, prison, nursing home, on the street. I love helping folks, and making life a little easier for them". Wow. Where did that answer come from? I have no doubt that divine intervention was in play. How humbled and blessed I felt to realize that the Most High had used Monica to teach me such an important lesson. Monica was no more or no less deserving than any other patient. My calling is to heal and serve, not to judge. As a physician, my role is to provided objective, empathetic care to help my patients live with good quality of life and optimal health. After accepting this call, my objections to treat patients are moot points. It only took a day in prison to facilitate this realization, and correct my attitudes. 

Thank you, Monica. 

The will of God will never take you, 

where the Spirit of God cannot work through you, 

where the wisdom of God cannot teach you, 

where the army of God cannot protect you, 

where the hands of God cannot mold you

~ Author Unknown

Nulligravida

As I near the end of my Pediatric rotation, I can say that I have seen close to 200 parents with their children, and at least half of them have asked if I have children, or plan to have them. I'm always surprised at the reaction I receive after disclosing my plans to remain nulligravid. Even the most liberal, who accept homosexual parenting, abortion, and artificial insemination, seem to find it unacceptable that I have made this decision. Typically, the response is some combination of shock, confusion, and condescension. Some insist that my youth clouds my judgment, and I will feel differently as I age. Others say that my maternal instinct will engage once I find a viable mate. Another percentage relates my decision to a troubled childhood or negative experience. None of these are the case.  

I have never seen myself as a future mother. My goals have always been directed towards finding my calling, and using the gifts I was given by the Most High to make the world a better place. I have come to find my ultimate purpose in global and rural health. With this premise, there is no room for the requisite sacrifice, commitment, devotion, and patience to be a parent. My time has been invested into medicine, and I expect to use my attained MD to heal and educate, not to stay at home changing diapers, if even for a year. I have immersed myself in the practice of medicine, and intend to continue this mission. To me, the opportunity costs are far too great to spend time raising a child. When a natural disaster occurs, such as the 2010 earthquake in Haiti, I want to be prepared to help. It becomes exponentially less feasible to travel overseas while pregnant, or with prior obligations to children.

I frequently hear the argument that I should "leave a legacy", something to be remembered for after I expire. That being an only child, I owe my mother grandchildren based on the sacrifices she made for me, and to continue the family name. I disagree with this premise. What great person is remembered for their children? Rosa Parks never had children, but is certainly remembered for her contributions to the Civil Rights Movement. Many famous women have not had children, and are perfectly content with the legacy they have left through their work, including Mother Theresa, Harriet Tubman, Florence Nightengale, Susan B. Anthony, Dr. Elizabeth Blackwell (first female doctor in the United States), Dorothea Dix, Mary Eliza Mahoney (first African-American professional nurse), and Jane Addams. Even entertainers and businesswomen such as Helen Mirren, Margaret Cho, Oprah Winfrey, Betty White, Stevie Nicks, Rita Rudner, Katherine Hepburn, Dolly Parton, Coco Chanel, Julia Child,  and Joan Jett are content with their choices not to have children. Will these womens' contributions be forgotten since they never bore children? 

Some suggest that I should have a child, since there are many women who cannot. This follows the skewed logic of finishing dinner for the sake of the starving Ethiopian children. One situation has no bearing on the other. Every woman is granted the choice of what to do with her body. Simply having the capacity to reproduce does not mandate that it occurs. I have also heard the inference that my decision stems from an inability to find a worthy husband who would father the children, or that my decision would change if my husband wanted children. My feeling is that a man who desires children would not be a compatible match regardless of other attributes, and if a man could manipulate my decision to suit his wants and needs, the relationship itself is unhealthy and should be relinquished.

Over the past year, I have noticed a drastic increase in the number of blog posts, websites, and discussions authored by women who have chosen not to have children. Gradually, this option is becoming more accepted. Choosing not to have children is generally an educated, well-thought-out decision. It is not simply a whim to be discounted or attributed to a bad relationship or lack of experience. Not reproducing is a reproductive choice, yet most physicians refuse to implement permanent birth control to women who are under 35, and who have never had children. Hopefully, as more and more light is shed on this topic, women who choose not to have children will not be judged and ostracized, but respected and accommodated for their reproductive choice.