Crozet Annals of Medicine: Proud to Be an American (Physician)

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I have been out of the hospital for a while. The new interns have arrived and so I quietly slipped out the back. I will leave it to the nurses and patients to sand off some of the rough corners of the new grads and to the younger and more energetic attendings to bring them up to speed before I return. I am probably not the first physician role model they should see anyway. One cannot start off in medicine being skeptical of every dogma and every story. One should perhaps end up that way and that is where I come in. I am the skeptic-in-chief. But for now, I am on vacation.

Thus, I found myself last night on a warm beach watching spectacular 4th of July fireworks while Lee Greenwood’s country music anthem “I’m Proud to Be An American” blared from a nearby pickup truck. It was a quintessential American moment, high explosives mixed with Budweiser and jingoistic patriotism, and it made me reflect on what it means to be a proud American physician in these divided times. 

I am of course referring to the Supreme Court ruling that overturned Roe v. Wade. The court held that the U.S. Constitution did not contain a right to abortion and thus states were free to ban it or not. 

I am not a constitutional scholar nor a historian, so I really don’t know what the framers’ thoughts were on abortion. I do know what nature and physicians know about abortion. 

First of all, spontaneous pregnancy loss is very common. Up to 50% of all pregnancies spontaneously abort, most often before the patient knows she is pregnant.  Usually this is due to a fetal chromosomal abnormality that is ultimately incompatible with life. Nature knows what it is doing. 

Known pregnancies, diagnosed by testing, spontaneously abort in 10-20% of cases, usually before the 13th week of gestation and for the same reasons. This is why many women wait until the second trimester of pregnancy to announce the good news. 

Secondly, what physicians know. The most commonly accepted medical terminology reports all types of pregnancy loss before 20 weeks as an abortion, whether it is spontaneous or induced. The term miscarriage is a lay colloquialism that refers to what physicians label a spontaneous abortion. When talking with patients, though, physicians will usually call a spontaneous abortion a miscarriage because the word abortion carries a stigma, and miscarriage is gentler formulation. But it is precisely that stigma that physicians intentionally avoid by labeling all pregnancy loss as abortion. In providing nonjudgmental care, our linguistic tropes matter.  

Physicians also know that abortion is a complicated subject, not easily codified by law into prohibited, or not, categories. There are many types of abortion encountered in clinical practice and I frequently see them in the ER. Few of them can be definitively clinically distinguished as induced or spontaneous. It would be impossible with any clinical certainty to attribute criminal maternal conduct to any of these patients.

A threatened abortion refers to a patient with first trimester vaginal bleeding but with a viable fetus seen on ultrasound and a closed cervix. About 50-75% of these will go on to a full-term birth.

An inevitable abortion refers to a similar patient but with an open cervix. As the name implies, these do not go on to a full-term birth. 

A missed abortion refers to an embryonic or fetal death in the uterus but without sufficient uterine contractions to expel the uterine contents. These may require medical (the “abortion pill”) or surgical intervention (dilation and evacuation). 

An incomplete abortion happens when the fetal products are incompletely expelled from the uterus.  It may take up to 8 weeks for the contents to fully be expelled and so these are often managed medically or surgically.

A completed abortion is just what it sounds like and no further care is usually required beyond supportive empathy. 

A septic abortion refers to any of these with a concomitant uterine infection. I don’t see these too often in the modern era thankfully. They were more prevalent in the era of illegal abortions done in “back alleys” and the maternal mortality is high. 

Therapeutic and elective abortions are terms that are sometimes used interchangeably but also sometimes used to signal an abortion done to provide a medical benefit to the mother versus an abortion done at the request of the mother. There is a certain amount of moral judgement attached to these terms and, in general, physicians try to avoid these distinctions. 

Meanwhile, back on the beach, the fireworks are going off, literally in my case and metaphorically in the country at large. The grand finale is upon us. Sound and fury. The explosions can briefly blind and deafen us (I was very close to the fireworks), but soon I hope our compassionate vision will return and our ears will be able to hear other voices. Soon enough I will return to my practice where abortion is a part of the natural order and a shared and private matter between patients and physicians. 

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