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.