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Reflections on Trauma-Informed Abortion Care

A few weeks ago, I was working at a high-volume abortion clinic and was handed a chart for a 32-year-old woman, Alice*, with a history of one previous miscarriage and a previous medication abortion, who was here for an abortion at 13 weeks’ gestational age. Nothing in her history or intake stood out to me or the staff. She was very pleasant and chatty, with blonde hair tied back in a ponytail and nails bitten down to the quick.  As we started the exam, she became increasingly anxious and jittery. She found the pain of every movement almost impossible to bear, and her eyes would glaze over as she writhed and pushed back against the footrests. I stopped, offered her more pain medication (which she accepted), let her know that she could reschedule to another day (which she declined – she wanted to get it over with), and asked her a little more about herself. I learned that she had recently moved to California to get away from a controlling and physically abusive partner in New York, had no local support system, and was currently making money doing live webcam porn.  With her trauma history in mind, we proceeded.

The private and invasive nature of abortion care can be triggering to patients with trauma histories. Alice was fine and calm when we were talking, but with every dilation, she became very uncomfortable and fearful, retreating up the exam table and  not responding well to instructions. Emotionally, she felt very far away.  In these situations, our job is to help our patient come back into herself and find her way out of the trauma groove. My first impulse with Alice was to assertively try to pull her back into reality. But Allison Briscoe-Smith, a psychologist specializing in mental health programs for children experiencing trauma, suggests the opposite. When children become triggered through therapy or in school, she recommends backing up, giving space, and attending to basic needs, like food, water, and warmth, instead of approaching aggressively or even rationally. This tactic may not seem feasible during an abortion, but, with a creative approach, it can be. If you are at a safe place in the procedure, you can stop what you’re doing and give the patient space and time to calm down. If it’s safe with her level of sedation, offer her a sip of water. Let the patient control the pace by developing a signal that lets her indicate that she wants a break or that she’s ready for the next step of the procedure. Give the patient permission to experience all emotions, including pain, fear, sadness, frustration, and/or relief, and remind her that you respect her and will help her through this. Remind her to wiggle her toes and fingers to release tension. Give her tools to control her breathing. Most importantly, listen to and remain present for the patient, regardless of what she is going through.

With the amazing support of my medical assistant, we allowed Alice to control the pace of the procedure, giving her time to recover her composure and breath between steps. I safely finished the procedure and let the nurse in the recovery area know that Alice might need a little extra support. We made sure that she had information about Exhale and All Options (formerly Backline), talk-lines that provide nonjudgmental emotional support around an abortion. While my care for Alice was based on a trauma-informed perspective, even women who have not experienced trauma may experience having an abortion as stressful and invasive. We can take what we’ve learned from trauma-informed care and apply it to patient-centered care for all women, in all aspects of sexual and reproductive health care.

*The patient’s name and some details have been changed to protect her privacy

Lealah P

Unconscious Bias

Race and Reproductive Justice

On June 1st, 2017, a team of CREATE graduates presented a poster at the Rodnick Colloquium on the ‘Race and Reproductive Justice’ workshop held in 2016. This piece has been abbreviated for purposes of publishing in the Beyond Training Blog. For the original version, including citations, click here.

Race and Reproductive Justice:
An argument for focused advocacy and implicit bias training in reproductive health curriculum

As a resident physician, I recall seeing a young Latina mother of 6 children for a second trimester prenatal visit. I checked in with my supervising physician before letting the patient go, and he said, as we were finishing up, “so, is she getting an IUD or a tubal after this delivery? See what you can do to convince her.”

Such well-intentioned, off handed, but woefully biased comments shaped many facets of my medical training. While believing that my attendings, now colleagues, are among the best patient advocates you will find, I also recognize the ways our biases seep into our work, and shape our care. As physicians, we are taught to present patients with multiple categorical identifiers (age, race, gender, etc.), and while attempting to locate a patient in a base of evidence, medical training itself may inadvertently reinforce biases.  If we hope to offer truly non- prejudiced and equal care, we can start by identifying, exploring, and unpacking our own biases.

Implicit bias in reproductive health care
The field of reproductive health care suffers with clear and documented health disparities. In fact, in a country with a history of supporting eugenics programs and forced sterilizations, reproductive health care is perhaps one of the areas in which bias has been most troubling. It was just two decades ago when recipients of state welfare benefits were given cash bonuses for getting Norplant, a 5-year contraceptive implant, and one decade ago when inmates in California were coerced into sterilization.

Current research has shown that physicians are more likely to recommend LARC to poor women of color than to white women of the same socioeconomic status, that Latina women were more likely than white women to be counseled about sterilization, and that women of color were less likely to be counseled on or receive fertility treatments.

What can we do about it?
Our own implicit biases, built up and ingrained over lifetimes of exposure to media, family, friends, and professional environments, are clearly not absent in our doctor patient relationships.  As a family medicine physician, reproductive health practitioner, advocate and educator, the idea that I might be treating people differently based on the color of their skin is horrifying. But the idea that one can be well meaning, committed to social justice, and rife with implicit bias all at the same time, does give one pause and a window for change.

To combat the learned categorization of our professional training, and the lifetimes of exposure to media and other racially biased systems, we at TEACH recently partnered with family medicine physicians from UCSF and Physicians for Reproductive Health to create a training for residents to explore their own implicit biases and then give them tools to better advocate around these disparities.

We held our training on a Saturday, with the implicit bias session first, followed by an advocacy session in the afternoon. TEACH invited two family medicine doctors to facilitate their anti-oppression workshop on unconscious bias and allyship for health professionals. They customized the workshop to address specific issues in reproductive healthcare.

Participants in this pilot seminar generally reported, on the likert scale surveys, increased comfort with concepts of implicit bias, tools to effectively manage situations where prejudice, power and privilege are involved, physician advocacy, and using patient stories to form advocacy messages.

In reflecting on the most helpful aspects of the training, one resident said they gained a “deeper understanding of all the concepts from implicit bias to advocacy and concrete tools to build on each of these for the future.” Several other residents reflected that the case examples and opportunities for discussion in the implicit bias training were the most helpful part. One resident wrote that it was “the discussion points of my colleagues, and the sharing of the personal perspectives” that was most helpful.

Conclusion
Bias among even well-intentioned healthcare professionals is real, and while not the primary driver of health disparities, it certainly contributes. Exploring our own biases can be the first step to tearing down the systems of oppression that affect us all.  This Race and Reproductive Justice training gave residents a greater understanding of implicit bias and tools for advocacy, with a focus on reproductive justice. This seminar is an incremental but important step in residency education to combat the structural racism affecting our patients daily.

We hope to continue offering this workshop as part of the advanced training and leadership curriculum (CREATE) here at TEACH.

– Dr. Baltrushes-Hughes

Collaborators:
Diana Wu, MD
Lamericie St. Saint-Hilaire, MD
Libby Benedict

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Reproductive Healthcare Advocacy in D.C.

This past February, I spent a whirlwind month as a visiting scholar at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. The four-week elective in Washington DC solidified my interest in research; my one day of lobbying reinforced my commitment to advocacy.  Thanks to encouragement from co-residents, attendings, and TEACH faculty, I joined a Lobby day with Physicians for Reproductive Health (PRH) and the National Abortion Federation (NAF). As part of the group, my role was to discuss how a 20-week abortion ban and a repeal of Roe vs. Wade would impact my patients. Having had numerous advance training days with TEACH, countless reproductive health related clinic visits, and working in a safety-net clinic, one would think that coming up with a single anecdote would be quite easy, but I found myself really struggling with what patient anecdote would be appropriate, meaningful and powerful to share with Senate staffers. How does one pick from the hundreds of clinical encounters that are all meaningful and powerful in their own way? How can one speak to the multitude of social injustices that our patients face? I felt like a complete novice; it was the first time I was serving as an abortion provider representative, but I was well supported by the group members, and it was an amazing opportunity that I would highly recommend!

In the first meeting, I discussed a clinic patient who was struggling to care for her infant while in an abusive relationship. She made the difficult decision to have a medication abortion, wanting to focus on her young family and enable her to leave her violent partner.  In another, I talked about my 16-year-old patient who wanted a family in the future, but was focusing on finishing school and building her life for that family in the future. In the last meeting, I discussed difficulties with birth control access. I recalled a patient, during my time in medical school, who was getting a planned repeat C-section, but was ineligible for many forms of birth control due to co-morbidities, and therefore wanted a tubal ligation. Unfortunately, because this patient was being cared for at a catholic hospital, she would need a separate operation, at a different hospital, if she wanted a tubal ligation.

Ultimately, we did not come close to discussing the breadth of reasons women choose to get abortions, but the need for powerful patient anecdotes to help inform discussions and politics is clear. All of the stories were well received, and staffers seemed keen to have specific narratives to take back to their Senators. All of our patients deserve the right to choose, and I hope to continue serving my patients and providing comprehensive care, while working to protect access and health equity. I am extremely grateful to have had the opportunity to speak on behalf of providers and patients, and to have mentors, such as through TEACH, to help guide me through advocacy. I hope to become an even stronger voice for reproductive rights and invite you to join me in this important work.

– Emilia

If you would like to support TEACH’s continued advocacy efforts, become a donor today! Donations can be made online here. Stay up-to-date on our advocacy work through our Current Policy page. As always, we appreciate your support!

 

 

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Lobby Day: the importance of active advocacy!

Each spring, TEACH partners with Physicians for Reproductive Health (PRH) to sponsor a legislative lobby day in Sacramento.  Our aim is to engage members of our community in local advocacy and state politics. In March 2015, we lobbied to repeal California’s Maximum Family Grant (MFG) Rule. In preparation for the coming lobby day on April 7, 2017, Shannon reflects back on our 2015 success.

For over two decades, the MFG Rule denied aid to impoverished children who were born into families already receiving aid through the CalWORKs program. While proponents of this law argued that the MFG would prevent individuals from expanding their families as a means of getting more public aid, the true effect of the MFG Rule was that the most vulnerable and impoverished children and families in California were further disadvantaged.

In 2015, over twenty practicing physicians, residents, and medical students from across California – including myself – gathered together for a half day of advocacy training followed by meetings with legislators in Sacramento to discuss our concerns with the MFG Rule.  We donned our white coats and used patient stories to help legislators and staffers understand the impact that this type of legislation has on our patients. The day culminated with a visit to the Governor’s Office, where we highlighted our own experiences working with patients who were struggling to make ends meet.

In the summer of 2016, Governor Jerry Brown signed that year’s California budget, which repealed the MFG rule, marking an end to this discriminatory piece of legislation. TEACH and PRH were delighted that their efforts directly improved state policy.

Two years later, I am still struck by how powerful that day was: certainly political advocacy is one of the most impactful ways that I can improve the lives of my patients. Today that statement holds even more true. Civic involvement over the next four years is going to be critical to ensuring that our patients’ voices are heard.
Shannon
Family Doctor
Los Angeles

WASHINGTON, DC - JUNE 27:  A podium awaits pro-choice speakers in front of the U.S. Supreme Court  on June 27, 2016 in Washington, DC. A ruling is expected in Whole Woman's Health v. Hellerstedt, a Texas case the places restrictions on abortion clinics, as well as rulings in the former Virginia Governor's corruption case and a gun rights case. (Photo by Pete Marovich/Getty Images)

The Day After the Election, I Went Back to Work as an Abortion Provider, and I Won’t Stop

For December’s blog, we are proud to share this reflection written by a TEACH graduate. This article was originally published in Rewire News on November 18th, 2016. We are sharing it here with the permission of the author.

Now more than ever, TEACH needs your financial support to ensure that family medicine residents, like this author, are trained to provide. Please consider donating here. For $100, we will happily send you a mug; for $150 we will happily send you an insulated thermos. 

I woke up on Wednesday, November 9, like many Americans, with feelings of emptiness and dread in my stomach, my eyelids crusted from tears and a night of restless sleep.

After about an hour of self-indulgent scrolling through social media posts and news articles, I moved forward. I had a shift scheduled at the abortion clinic where I work as a physician. And I knew that my patients, the clinic administration, reproductive rights advocates, and Hillary Clinton would want me to get out of bed and go, and to do what I had set out to do.

On my drive to work, I sobbed all the way across the Golden Gate Bridge as I listened to Hillary’s concession speech. The bright blue sky and majestic red bridge felt oppressively beautiful, incongruous with the sadness of the day. I couldn’t believe that, given the options, our country had chosen a record of exclusivity and regression over empathy and progress.

When I arrived at work, there was a communal despondence in the air, as all of us—the medical assistants, the nurses, and the doctors—shared wordless hugs and knowing glances from pink, puffy eyes.

The subject of the election came up with a few of my patients. One young couple asked what a Trump presidency would mean for the right to an abortion. I had to admit that I didn’t know, but that, at least today, her right to end a pregnancy was still intact.

Another patient asked me during her abortion procedure how I felt about the election outcome. Without pausing to reflect on whether it was inappropriate to answer this question honestly, the word “sad” just slipped past my lips. An awkward silence followed, and I asked how she felt. She stated that she didn’t really care, as she didn’t like either candidate and didn’t feel like there was a difference between them.

I shuddered with the realization that many women and men of this country do not understand the extent to which reproductive freedom will likely be under attack in the new administration. I thought about how often I have heard Trump promising actions that might overturn Roe v. Wade or affect access to the very procedure I was performing, even possibly jailing patients like her and providers like me if abortion is made illegal.

My thoughts drifted to my 2-year-old daughter, whom I assumed would spend her early childhood years under the leadership of our nation’s first female president.  Instead, she will almost certainly grow up in a culture where the president degrades women, where politicians try to control our lives and bodies. That morning before work, when I walked into her room, she beamed up at me, still hot from her sweaty toddler sleep. I immediately teared up at her sheer innocence, her innate desire to express and receive kindness. When she asked, “Are you a little bit sad, Mommy?” I struggled with how to respond.

On the day after Donald Trump won the presidency, my patients were similar to any other day. There was a 24-year-old Black mother of two, who, until calling out sick for this procedure, hadn’t taken a day off of work since her baby was born six months ago. Then, there was a 19-year-old student who had just started college, the first member of her family to attend a university. One patient was a recent immigrant who had an ankle monitor in place, at high risk of being deported in the coming months and separated from her husband and two children.

All day, in between patients, I glanced at social media and opinion pieces that made two distinct points about the path forward. The first spoke of coming together, of healing our nation from this vociferous election that has divided us so dramatically, of finding compromise with our fellow Americans.

This message does not resonate with me. I am confident in this moment that I share no ideological common ground with Donald Trump and those of his supporters who wish to severely restrict reproductive rights in a presidency ruled by misogyny.

The other type of message, the one that began to pull me out of my depressive funk, was that of resilience. I received email messages from friends, colleagues, and all the reproductive health organizations that I support. In just two short months, it seems safe to say our work and values will be under attack by Republican-controlled executive and legislative branches of government. We will need to organize now to fight like hell for the next four years to protect women’s basic rights.

At the end of my day, as I drove back across the bridge in the golden glow of sunset, I resolved to do just that. I’ll continue to fight for the rights that I believe in and support, and to reject the kind of hatred and fear that landed Mr. Trump in the White House. As Hillary implored, I will “never stop believing that fighting for what’s right is worth it.”

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Doing More

I grew up in a family of reproductive health advocates. In particular, the women in my family — from my mother to my cousins and grandmother — remembered a time pre-Roe v. Wade and were always staunch supporters of choice.

It was natural, then, when I entered into a career in Family Medicine, that I would work to incorporate reproductive health services into my practice. Through the TEACH and CREATE programs, I was able to gain the experience during residency that I needed to go on to become an abortion provider following graduation. I love my work as a provider, and I feel grateful for the opportunity to help women get the health care they deserve and lead the lives they wish to lead.

But after a year in practice, I realized that providing direct services for abortion care wasn’t enough for me; I needed to fulfill my duty as a reproductive health rights advocate. Living in an urban area in California, my patients are fortunate to have relatively ready access to abortion care covered by Medicaid, and I am fortunate to have the opportunity to provide abortion services without fear of harassment or retaliation. But I am aware that most women and providers in this country are not so fortunate.

Last year I completed the Leadership Training Academy through Physicians for Reproductive Health, and had the opportunity to share stories with abortion providers from all across the country. I was surprised by how frequently my colleagues who work in anti-choice regions cited safety concerns when publically supporting choice. And so it became clear to me that my responsibility is not just to provide direct services, but also to be a strong advocate and provide a voice for my patients and colleagues.

Beyond writing Op-Eds, TEACH and Physicians for Reproductive Health encouraged me to become an advocate within my professional organization, the American Academy of Family Physicians. Last winter, I had my first experience with resolution writing for the CAFP (California Academy of Family Physicians). Inspired by my adolescent patients with unintended pregnancies due to poor access to birth control, I worked on a resolution in support of over the counter access to birth control for women of all ages. Through the writing process, I had the opportunity to collaborate with other like-minded physicians from across the country. Colleagues eagerly shared resources, suggestions, editing ideas, and thoughts on how to present arguments most effectively, never asking for anything in return. Rarely in my professional life have I felt so embraced and supported by a community.

In the Spring, I attended the California All Member Advocacy Meeting (AMAM) to present our resolution. Walking into the conference hall, I was struck by the discrepancy of scale: this small group of about a hundred family doctors would be responsible for determining policies of our entire professional organization. AMAM was well attended by our reproductive health community, and we argued persuasively for a number of resolutions. If we hadn’t taken the time just to be present and speak out, women’s reproductive rights would not have had a voice that day. Our resolution passed through our state and was brought to the national level, where it now awaits review from the board of the national academy.

Standing up in front of the physicians at AMAM was initially intimidating, but also exhilarating. Having worked on the resolution with so many experienced advocates, I felt confident in the points that I wanted to make, and in the intent and importance of the resolution. It drove home for me that making policy change really is about showing up — about being “in the room where it happens.”

This year we are working on a resolution to encourage the AAFP (American Academy of Family Physicians) to oppose the Hyde Amendment. As long as there are women in this country whose access to safe, legal abortion is restricted, I will continue to do what I can to provide, teach, and advocate on their behalf. I implore you to join me!

history

Rewriting History

In this election year, I’ve been thinking about how democrats often argue that abortion should be “safe, legal, and rare.” Like most women, reproductive health care has permeated so many aspects of my life. But like many, my life experiences have confirmed how common, positive and empowering abortion can be. 

Growing up, my family openly spoke about the benefits of Roe v. Wade; my mom had known women who had gotten dangerous abortions and was proud of the progress our country had made. During and after college, I routinely relied on Planned Parenthood to get my healthcare and recognized the important work they did for me – and so many others.

When I went to medical school in Cuba, I saw how the provision of abortion services directly benefits women. Because abortion is safe, legal, and less stigmatized, Cuba has a low national fertility rate, high rates of educated women, and no violence towards frontline providers. When I made the difficult decision to have an abortion myself during medical school, I felt well supported by family and friends, a national health care system, and more broadly, Cuban society.

But because of medical school politics (they trained a large number of providers from other Latin American countries that strongly opposed choice), abortion was not part of our curriculum.  Consequently, I sought out a residency program that would train me to provide full spectrum reproductive health care.  The TEACH advanced training curriculum, CREATE, offered me the perfect opportunity to develop competency in first trimester procedures.

 So now I have integrated comprehensive care into my career: I do early abortions in an office setting and have daily discussions about options counseling and contraception. I’m happy to continue empowering my patients by normalizing abortion. I hope that together, we can rewrite history.

-Brea

 

 

 

 

 

 

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Lobby Day Experience

As primary care providers, we do not consider ourselves to be political experts, but we have a unique perspective to bring to the political arena and a responsibility to share our voices in order to advocate for our patients. Getting out of the clinic to go to Capitol Hill is an enriching experience for resident training and adds a unique angle to advocacy efforts.

Thanks to the support of TEACH and All* Above All, I had the opportunity to participate in the EACH Woman Act Lobby Day in Washington D.C. on October 22, 2015. All* Above All is a public education campaign that unites organizations and individuals who support lifting the bans that deny abortion coverage to many women. I joined 200 delegates representing 25 states to advocate for restoring public insurance coverage of abortion care. The aim is for every woman to have access to affordable, safe abortion care when she needs it.

The Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act is a bill written by Representative Barbara Lee (Democrat – California) with over 100 co-sponsors in the House. The bill responds to the restrictions enacted by the Hyde Amendment in 1976 that prohibits federal dollars being used for abortion care. The EACH Woman Act would restore coverage for abortion services to those enrolled in a government health insurance plan or a government-managed health insurance plan. It would also prohibit political interference with decisions by private health insurance companies to offer coverage for abortion care. In our recent climate where Planned Parenthood has been attacked and advocates for choice have been on the defensive, it is powerful to have a positive piece of legislation.

During our Capitol Hill day, I worked with a team of advocates from Northern California to meet with members of the House and Congress to voice our support for the EACH Woman Act. I was surprised to realize that as the only doctor in the group, I had unique experiences to offer to the discussion. I was equally inspired by the knowledge of the other members of my group: I learned a lot about advocacy and abortion coverage throughout the day.

Seeing the growing support for this bill made me hopeful that we will see positive change for abortion coverage. Even if the bill is not passed this year, the day made me realize the importance of gradually changing opinions by making our voices heard and garnering support. I left Washington D.C. energized and excited to continue to include advocacy as part of my future career as a primary care doctor.

– Anna L.

Narrative Medicine

Telling Stories in Reproductive Health, Part One: Narrative Medicine

How do you balance the intentions of maintaining the necessary privacy and safety of providers while also pushing the envelope to tell stories about a stigmatized subject in order to undo that very stigma?

I will be exploring this question in a series of articles, highlighting individuals and organizations that use Narrative Medicine to de-stigmatize experiences in reproductive health care.

Narrative Medicine is a powerful tool for community building, with applicability to health care teams, educators and colleagues in academic environments, and activists working in social justice movements and community organizing. Narrative Medicine is a meeting place where people gather to explore how storytelling functions in relation to health and social issues.

In an article, “Narrative Medicine Isn’t the Same Old Story,” the author describes it in terms of how the field relates to medical humanities and greater criticisms of medical systems,

At first glance, narrative medicine might appear to be a slight encroachment of the “soft” sciences upon steadfast medical empiricism – or, dare I say it, “some New Age shit.” But those involved in the field – students, teachers and allies – are proving that narrative medicine poses both a credible threat and a powerful alternative to the medical-industrial complex, which began with the corporate takeover of US health care in the late 1980s and early 1990s, and has only become more institutionalized since.”[1]

One of the most important aspects of Narrative Medicine, especially in how it relates to reproductive health, is the assertion of Narrative Humility.

Dr. Sayantani DasGupta, professor in the Program in Narrative Medicine at Columbia University and the graduate program in Health Advocacy at Sarah Lawrence College, flipped Cultural Competency on its head: Narrative Humility implies an internal focus, i.e. what are my beliefs, assumptions, prejudices, and fears, and how do they contribute to my interactions with others? Humility, in this context, means we know we are very limited in our knowing of any Other.

This is a stance from which to witness stories, based in the recognition that:

  • Each person’s story belongs to them
  • We cannot claim to know the totality of another or their story
  • The primordial ethical act is to answer the call of another

As Dr. Sayantani DasGupta puts it,

“Narrative humility means understanding that stories are not merely receptacles of facts, but that every story holds some element of the unknowable. It simultaneously reminds us that there are larger sociopolitical power structures that marginalize certain sorts of stories and privilege others. Narrative humility suggests an inward orientation, requiring not only that we learn about others, but that we begin by learning about ourselves—how our past cadre of life stories has built our prejudices and preferences, and how by the very act of listening, we ourselves are always changed into different kinds of listeners.”[2]

Narrative Medicine, and the concept of narrative humility in particular, asserts the importance of storytelling and maintains an ethical stance as it examines the way in which stories get told — who has the right to tell a story, whose stories get listened to, whose stories are ignored, and so on. Stories are shaped by multiple layers of social, situational, cultural and political factors.

When we apply this concept to reproductive health, we see stories as tools for change. What happens when many people share their stories? When patients tell their stories about getting an abortion or early pregnancy loss? When residents tell their stories of trying to incorporate comprehensive reproductive health services into their practice post graduation? When providers, from physicians to advanced practice clinicians, tell stories about how people react when they find out their profession?

I will continue to explore these questions in future installments, highlighting how a handful of powerful individuals and organizations are working to create space for more stories to be told.

– Elsa Asher

Elsa is a writer, full spectrum reproductive health advocate, and Narrative Medicine educator. She holds an MS in Narrative Medicine from Columbia University and is a current TEACH intern. www.elsaasher.com

[1] “Narrative Medicine Isn’t the Same Old Story” by Hannah K. Gold
[2] “Narrative Medicine, Narrative Humility” by Dr. Sayantani DasGupta, Narrative Medicine, Creative NonFiction. For more exploration, check out “Narrative Humility” TEDx Talk by Dr. Sayantani DasGupta at TEDxSLC, Narrative Humility TEDx Talk
Reflections: opt-out curriculum and inclusive approach with residents

Reflections: opt-out curriculum and inclusive approach with residents

The TEACH approach to training is based on the value that all providers have a place in promoting accessible comprehensive reproductive health care. Our program offers an opt-out or alternative curriculum, which allows for residents to tailor the abortion training rotation in the context of values clarification, a process each resident undertakes with a faculty trainer. Like other researchers in family medicine1 and obstetrics,2,3 we found that even when residents chose to opt-out of specific aspects of patient care, they reported a positive experience with the rotation, gaining exposure, counseling, and valuable gynecologic procedural skills4.

I recently talked with Jennifer, a family medicine physician who participated in TEACH during her second year of residency. Through the values clarification process with her faculty trainer, Jennifer decided that she would participate in ancillary procedures and opt out of performing abortions. Most opt-out residents train in ancillary procedures, including ultrasound, cervical blocks, and miscarriage management.

“[Opting-out] was not a political or religious choice, it was a personal one… It was a difficult decision and ultimately it was not because of my values, but out of doing the best I could [given my personal circumstances].” During a medical school rotation when she observed abortions without much orientation, she felt overwhelmed and, as a student, invisible and unable to find the support she needed to debrief. She recalls, “there were counselors, but the cultural phenomenon of competition in medical school was all-encompassing. I had worked so hard to get in. I didn’t want to be the squeaky wheel, the one who couldn’t handle whatever was in front of me.”

Jennifer told me that she wishes that there were a program like TEACH in medical school. “It is so important for medical students’ introductions to abortion care be done with support. Be gentle, take it seriously, do values clarification before clinic, and talk through what was experienced after. Start with first trimester procedures and then go from there. It needs to be structured and thoughtful.”

It was in the TEACH program that Jennifer began to feel heard. She remembers, “[her trainer] was understanding, she met me where I was at. She did a lot of listening, and encouraged me to seek counseling.” Jennifer feels that the training she received during her rotation was essential to her current work as a primary care physician. It provided her the opportunity to engage in mentorship, deepen her knowledge of reproductive health, and refine her family planning skills, such as contraception services, reproductive health counseling, and the importance of good referral making 5. Now, one of the mainstays of her practice is family planning services and she maintains a close referral relationship with the nearby Planned Parenthood, which sends their patients to her clinic for gynecological care.

Residents who participate in the alternative curriculum track have many reasons for doing so. The program’s approach is to meet residents where they are and support them to more fully integrate comprehensive reproductive health into their primary care practice. As in Jennifer’s story, this integration of services looks different for each provider, but ultimately is essential in building strong clinical and counseling skills, referral relationships, and continuity with patients.

As Jennifer reflected back on her training, she said, “I don’t see things as black and white… I have a lot more experience taking care of patients who don’t have access to care, and I have a much greater understanding of how difficult it is to prevent pregnancies. I also understand how unintended pregnancies can really derail lives. I have a harm reduction approach. Yes, for me, abortion is a complicated moral issue, but at the end of the day, I see the faces of my patients who need these services and I know it is the right thing to do.”

– Elsa Asher

Elsa is a writer, full spectrum reproductive health advocate and Narrative Medicine educator. She holds a MS in Narrative Medicine from Columbia University and is a current TEACH Intern. www.elsaasher.com

1. Nothnagle M. Benefits of a learner-centred abortion curriculum for family medicine residents. J Fam Plann Reprod Health Care. 2008 Apr;34(2):107-10.
2. Steinauer JE, et al. Opting out of abortion training: benefits of partial participation in a dedicated family planning rotation for ob-gyn residents. Contraception. 2013 Jan;87(1):88-92.
3. Steinauer JE, et al. Impact of partial participation in integrated family planning training on medical knowledge, patient communication and professionalism. Contraception. 2014 Apr;89(4):278-85.
4. Goodman S, et al. An Unexpectedly Positive Experience: Utilizing Opt-Out Provisions in Abortion Training for Family Medicine Residents. 31st Annual NAF Conference, 2007.
5. Zurek M, et al. Referral-making in the current landscape of abortion access. Contraception. 2015 Jan;91(1):1-5. http://www.arhp.org/publications-and-resources/contraception-journal/january-2015