The Med Student's Tale

Inspired by Sherwin B. Nuland's The Soul of Medicine: Tales from the Bedside, I want to tell you a short story. Dr. Nuland's book offers a variety of tales from his many esteemed colleagues, detailing some of the most memorable patients that they have worked with over their long careers. My "career" (if you can call it that) in clinical medicine has been brief - barely consuming the entirety of my third year of medical school. However, there is one patient encounter that I am sure never to forget. I have not told this story before, as I was so bewildered by the whole experience in the moment. But I think enough time has past, and I have collected my thoughts (though my bewilderment continues). The central character of our tale is a young 20-something named Jamie (her pseudonym from henceforth), whom I met in our Gynecology clinic. Before even knocking on the door, I knew the encounter would proceed poorly. I could hear her crying loudly from down the hall.

Before I go any further, I should self-admit that I was initially terrified of my six weeks on Obstetrics and Gynecology. Having finished six weeks on Surgery, I was transitioning from my probable career choice to a specialty that was the lowest on my potential vocational list. I had no prior experience in the field, and the entire "vaginal vault" remains a mystery to me even to this day (even more mysterious is why the medical profession deems it necessary to use the term "vaginal vault" - the female gentalia bears no resembles to a safehouse for banks to hold their valuables). Never being accused of having too little to say, one of my close colleagues likes to remind me to this day of how silent and ghostly pale I was on that first day - frightened with apprehension. Had it not been for starting off in the operating room on Gynecology-Oncology, the transition would not have been nearly as smooth. Ultimately I learned some valuable lessons during those six weeks; the most important being that I had no desire to pursue a career in female reproductive care, or the birthing of babies.

I knocked on Jamie's door already assuming the worst. However, I did not assume enough.

Knock, knock. Ms. Johnson? My name is Robert... Hey now, what's wrong? Oh! The nurse just told me... (sob)... I'm pregnant... again!

She proceeded to be stricken with tears, which gave me just enough time to get my wits about me so as not to stutter. Still to this day, I'm not sure what I should have said... "Congratulations?"

Okay, well why don't we talk about it? No. I just can't deal with this right now. I JUST CAN'T!
I assume this wasn't expected? No... just... I... just get out! LEAVE!

I really had no other choice at this point. I told her I would be back, and that I was going to give her some time to herself. I needed some time as well. There was no way I was going back in there by myself, so I waited expectantly for my Chief Resident to finish up in one of the exam rooms down the hall. He must have known something was wrong from the look on my face. Change of plans. My Chief decided that given the circumstances, he would do the pelvic exam and pap (since Jamie was many months overdue following up on her last abnormal pap smear). He proffered that we should first take a look at her chart.

Jamie was 24 years old, and this was her fifth pregnancy. We scoured the records and saw that each of her four previous children had a different father. It was also noted in her chart that according to her "principles," she did not believe in using birth control, and would not consider having an abortion. Numerous doctors' written records were filled with quotes of how she had referenced not particularly caring for her children, and saw them as more of a burden than her responsibility. Nonetheless, she lived at home with all of them (the oldest now being 7 years old), and was working as a waitress.

Most bewildering for me was her number of sexual partners. To this day I will never forget her written answer, mostly because it was given as a "range." Despite her principles regarding contraception, Ms. Johnson listed a range of sexual encounters from 100-120. It might as well have been written in red pen, highlighted, italicized, and bolded, because it made that kind of impression. Herein lies the disconnect that I still to this day cannot comprehend.

100-120. Five children. No birth control.

We walked back in the exam room, nurse in tow to chaperone. Jamie had recovered, and had moved on into her five stages of grief. Somehow in the past 10 minutes she had moved past denial and gone straight to anger. Brows furrowed, her distaste was palpable throughout the exam. She sat cross-armed and fierce, head cocked to the side, staring at the wall as her legs lay apart in the stirrups. The Chief asked her what she was going to do with her pregnancy. She stated that she would keep the child, and her live-in-boyfriend / FOB ("father of baby" - pronounced "fob" as one word), would be paying for "all this shit." Medicaid would pay for the child's health care. She would deal. Life goes on.

It is here that I must reflect on the current situation. It seems to me that she should either choose the multiple partners, but take care to have safe practices, or have her "principles," but be willing to bear the consequences of what such actions may entail. It is sex and birth control vs. abstinence. This lady falls somewhere in the between, wanting to have her cake and eat it too. But these four, now five, children are caught in the middle, being brought up in an environment that no child should have to suffer.

In the room, it pained me to watch her so upset and angry at an opportunity that so many couples would cherish. The consequences of her actions are so precious. I think about all the individuals who are denied children, either for reproductive or legal reasons, who would fight tooth and claw for this chance. This case made such an impression on me because it is a worldview which I do not understand. It is so far out of my scope, I could only watch in astonishment. So many questions are raised about education, ethics, and justice, but I guess those will have to be considered at another date.

As the Chief Resident stood up with her legs still askew, the drape barely providing any modesty, he decided to broach the subject of contraception one more time - this time in a perfect southern twang. This was not the first time they had had this battle; it was one of many. Her response was definite, even if it was provided with such little forethought...

Hunny, what are we going to do with you? And what are you going to do about birth control?
I'm going to kick my boyfriend in the FUCKING nuts is what I'm going to do. I'm going to keep kicking that fucker until he has no balls left!

Ah, the miracle of life.

There was nothing left to do except exit stage left.


(As always, numerous details have been changed to preserve patient confidentiality. I have been assured that all identifying elements have been eliminated.)