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Who's right on health-care cost projections?

Brookings Institute -- Medicare - Mon, 07/27/2015 - 4:30pm

The sustainability of the U.S. fiscal outlook depends on the path of health costs, particularly Medicare, the health insurance program for the elderly and disabled.  If health costs continue to rise more rapidly than gross domestic product, then Medicare will be increasingly unaffordable. The recent slowdown in Medicare spending has been touted as evidence that the health cost curve has finally "bent" and that the Medicare financing problem can be managed with modest changes in policy.

The Medicare Trustees report, released last week, basically confirms this view. Under the trustees' baseline projection, Medicare spending increases from 3.5% of GDP today to 5.5% by 2050 and 6% by 2080. In contrast, the Congressional Budget Office, in June, projected much larger increases in Medicare spending over time, with spending reaching 7% of GDP by 2050 and over 11% by 2080.

How can projections by the government's best experts be so different? And which should we believe?

Both the trustees and the CBO assume that the growth both of public and private health spending will slow over time, as the incremental benefit from additional health care becomes less valuable. Where they differ is in what is assumed about Medicare spending growth relative to growth other health spending.

The trustees assume that per capita Medicare spending will rise more slowly than other health spending; CBO assumes that Medicare spending will rise more rapidly.

The trustees look at the provisions of the Affordable Care Act governing provider reimbursements and conclude that Medicare payments under the Affordable Care Act are increasingly likely to fall below reimbursement by private insurers and Medicaid (the state-federal program for the poor) over time. Thus, they expect Medicare spending to rise more slowly than other health spending.

CBO economists believe future health spending is too uncertain to be modeled. They consider the effects of legislation only over the ten-year budget window—that is, from fiscal years 2015 to 2024.

After that, they use a mechanical rule to project Medicare spending per beneficiary. But this mechanical rule assumes that, under current law, Medicare will have less flexibility than private insurers and Medicaid to take measures to slow health spending growth. Thus, CBO assumes that per beneficiary Medicare spending increases faster than other health spending.

Which of these should be believed? Neither. Health spending is almost impossible to predict. Assuming that past trends continue indefinitely produces nonsensical results, as it implies that health spending will eventually consume all of GDP. But forecasting how the future will be different from the past is not something we know how to do. The large wedge between these two arguably sensible projections of Medicare should be taken as evidence that we really don't know how big a fiscal problem health spending will be 25 or 50 years in the future.

A version of this post appeared on the Wall Street Journal's Think Tank blog.

Authors Publication: The Wall Street Journal Image Source: © Finbarr O'Reilly / Reuters         
Categories: Elder

When And Where Do You Stress? Ambitious Project Aims To Map Daily Life, Whole City

CommonHealth (WBUR) - Mon, 07/27/2015 - 2:14pm

Passengers squeeze aboard a Red Line train at the Porter Square MBTA station. (Robin Lubbock/WBUR)

By Marina Renton
CommonHealth intern

Would I make it to the train station in time? Or would I miss my train home? The concern gnawed at me as I fidgeted on the uncomfortably warm and crowded subway platform. As I anxiously scanned the tracks for approaching lights, the watch on my wrist buzzed. It was telling me to check my stress levels. I pulled out my phone. High, it said; surprisingly high.

That may sound like the first draft of a science fiction novel but, in fact, it’s describing events from last month, when I tried out a watch that has sensors to measure the autonomic nervous system, which regulates our fight-or-flight response.

Neumitra, a Boston-based startup, developed the technology, and plans to launch an ambitious project this fall that would use it to chart the stress not just of individuals but of professions and institutions — even of a whole city. It may be a no-brainer that catching a train is stressful, but how does stress at Harvard compare to stress at Northeastern? North Shore to South Shore? Emergency room at Boston Medical Center to Massachusetts General Hospital?

“We’re using data from the body and data from mobile phones to understand how everyone is affected by stress,” said Rob Goldberg, co-founder of Neumitra and a neuroscientist formerly at MIT. “Our aim here is for thousands of people in Boston to be using these technologies, so we can understand the difference between a veteran, a police officer, a student, a mother, a nurse — and sometimes you belong to multiple of these categories, so what are the combined effects?”

Sync to see your stress

“I’m so stressed!” is a frequent response to the innocuous, “How are you?” The exclamation, or variations thereof, can be overheard at the office, between classes, at home…practically anywhere.

But it’s one thing to verbally express feelings of stress, and quite another to quantify those sensations. That’s where Neumitra comes in.

You can track your stress level in real time through an app that displays the data that the watch collects. The app syncs with your calendar and GPS, so you can also look back to see which events and locations cause the most stress. When your stress spikes, the watch vibrates — an alert that it might be time to take a step back and recalibrate.

The app displays stress using a color gradient: Blue means relaxed or restful, orange and red signify increasing tension. During my entire subway ride, I was either in the dark-orange or red zone. Once I was back home, I spent more time in the blue regions. Exercise brought me back into the orange (among other things, the watch measures skin conductance and temperature, so physical exertion can register as stress), but it didn’t exceed the stress I demonstrated while standing (read: trying not to fall on anyone) in a crowded subway car.

This technology is certainly fascinating, but does it really tell us anything we didn’t already know? Goldberg’s answer is an emphatic yes. “We think we [know how we feel], but we’re very detached from that,” he said.

Science at a new scale

In this age of “smart” or “connected” everything, we’re getting used to devices that monitor us, but Goldberg says Neumitra’s plans for the technology’s use on a large scale might lead to a whole new understanding of the effects of daily life on stress.

“We don’t understand what we’re all struggling with on a day-to-day basis, and with data of this type it allows it to become much more visible,” he said.

This coming fall marks the planned launch of the Boston Stress Study, which aims to “quantify brain health across an urban population,” according to its website.

Goldberg compared the Boston Stress Study with the landmark Framingham Heart Study, which began in 1948 with over 5,000 participants and continues to this day with subsequent generations. The Framingham Heart Study has been crucial to the identification of risk factors for cardiovascular disease.

The data gathered as part of the Boston Stress Study will be aggregated, with the goal of showing the differences in stress level by profession and, in the long term, by socioeconomic status, gender, even university.

“We’ve all heard stories about what does it mean to feel stress at MIT, or Harvard, or at Boston University,” Goldberg said. “But what would it mean to quantify that?”

The study’s data will come from participants who are willing to have their anonymized biofeedback information uploaded to the cloud. From day one, researchers will be able to begin analyzing the results, but Goldberg says users’ confidentiality will be protected.

“Physiological data doesn’t really have much personally-identifying within it,” he said. So, showing the stress level of the city at, say, 9 a.m. — or during a cold snap or heat wave — shouldn’t be a problem. Most privacy concerns would arise with location data being aggregated and released to the public. “We want to take our time to make sure we get that absolutely right,” Goldberg said.

(Courtesy of Neumitra)

“Our goal is to do science at a scale and in a way that’s never been possible before. These technologies, worn computers, really do make that possible,” he said. “The longer-term goal is to understand the relationships between stress and chronic health conditions as well as stress and performance and productivity issues.”

Already, he says, with the few participants in a pilot phase aimed at refining the design and algorithms, “we’re pretty impressed by what we’ve been able to see so far. And, for those folks who are using our technologies, it becomes pretty clear how simply visualizing what you’re experiencing every day becomes immensely valuable to help you understand yourself better.”

“Supporting the individual”

While Goldberg expressed excitement about the possible big-picture implications of the Boston Stress Study’s results, he emphasized that the primary purpose of the technology is to benefit the individual. The integration with the app allows for very personalized visualizations. For instance, you can see how that beloved mellow song or dreaded dentist appointment affected your stress level.

“If we don’t do a good job of supporting the individual, then all of our grand ambitions, all the great questions we want to answer, won’t ever come to fruition,” Goldberg said.

The individual benefit of the technologies is compelling to Dr. Joseph Kvedar, vice president of Connected Health at Partners HealthCare. “Stress is one of those things that’s hard to measure, and having something like this to help us measure it…may help us combat stress and cope with it better,” he said.

Regarding the citywide analysis of stress, Kvedar said, “I’m not sure it’s going to be as compelling as it would on an individual basis, but I could be wrong.”

Time to recover

The results of the Boston Stress Study might influence workplace policies, Goldberg said.

The stress experienced on a morning commute can be equivalent to exercising, and “If we thought we were out for a run, we would give ourselves an hour or two to recover,” he said. “We don’t give ourselves an hour or two to recover from our commute, from a difficult meeting at work, from medical appointments.”

“What if it turns out that commutes are one of the most stressful times of day for a city?” Goldberg added. “Will companies take more seriously the fact that their people are showing up already highly revved up?” Beginning the day stressed might impede productivity, which employers could take into consideration when scheduling meetings or setting work hours, he said.

Finding participants

Rather than continue to manufacture a watch, Neumitra is working on incorporating the stress-measurement technology into lightweight “biomodules,” which could be incorporated into participants’ existing accessories, Goldberg said.

The watch loaned to me costs a hefty $1,500 — although its quality is on par with $20,000 medical equipment, Goldberg said — and would be out of reach for many people. Neumitra aims to make the biomodules more affordable.

The Boston Stress Study is still getting under way; participants are still being recruited and Neumitra is still refining the technologies and lining up funding.

Neumitra has partnered with a combination of commercial, nonprofit, and academic organizations to fund the study and recruit participants. The variety in partnerships is necessary to obtain a representative sample, Goldberg said.

“To do science at this scale, where every citizen both becomes a scientist and helps us to answer these questions as part of the organizations they belong to, this is really going to come from a mix of supporters,” he added.

Neumitra is currently working with clinical organizations in the area to find participants, and Mayor Walsh has written a letter in support of the Boston Stress Study.

“The data from your study could provide us with vital insight into the various causes and effects of acute and chronic stressors in the daily lives and work of Boston residents,” he wrote.

Lessons learned

While I knew the subway commute was stressful, I didn’t perceive just how stressful until I used the watch. Not only that, but it taught me how strong an effect simply remembering a stressful event can have. The app can generate a line graph to illustrate your stress, and I could see clear spikes in the line that aligned with my recalling a stressful situation or embarrassing incident from earlier.

Stress triggers such pronounced physiological changes that it’s no wonder it takes a toll on the physical self as well as the psyche. From my time wearing the watch, I realized the power of being able to visualize the physiological response to stress.

On the other hand, I did find that watching my stress level rise second by second contributed to a heightened sense of anxiety. Yet, I also began to notice that consciously changing my thoughts allowed me to manage my physiological response.

I come away with a new note to self: When work piles up, or you have to run to catch the train, or you’re waiting in anticipation for a response to a text message, remember to make time for stress-relieving activities to allow yourself to recover from the strains of the day.

Readers, reactions?

Neuroscientist Rob Goldberg mapped his stress levels as he went to make a presentation at the Pentagon. He managed the stress of the airport well, he recalls,”But when I arrived at the Pentagon, I was overwhelmed in a way our collaborators at Harvard said later they had never seen before in over 30 years of using the research technologies.”

Categories: Health Care

Comics and the Law

In Custodia Legis - Mon, 07/27/2015 - 1:56pm

It is the current fashion, both in academics and popular culture, to convey information about more serious topics, such as war, chemistry, military life in a combat zone, autobiography, cancer, and pandemic preparedness in graphic novels. As a librarian and a reader, I’ve enjoyed the ability of graphic novels to communicate dense non-fiction material in a way that scarcely seems like work to absorb. Recently, a copy of The Illustrated Guide to Criminal Law landed in the office, and the arrival of this new acquisition seemed like a great time to highlight items in our collection that cover law and comics and graphic novels.

The Illustrated Guide to Criminal Law is Nathaniel Burney’s “attempt to debunk … [the many popular myths about criminal law]” (p. 7). Burney blogs regularly in graphic form at his website; you can find out how attention and memory work in criminal cases, view a Fifth Amendment flowchart, and read about traffic stops. He covers the basic principles of criminal law “in a way that was more accessible to a high school kid than my wordy and obscure law blog.” The content from the book is similar to the content of the website: purposes of punishment, mens rea, entrapment, and other basic concepts of criminal law are explained with humorous illustrations and movie quotations. Burney draws in occasional commentary from Lady Justice, a virago whom he depicts as “a sort of modern Athena/Roma.” He also employs stick figures (“Stickie McFigure” in the rape explanation) and anthropomorphic maps (England wearing a Union Jack top hat in the history of Blackstone’s influence). His cartoons are reminiscent of Marvel comics, Joe Palooka, and in at least one instance, George Herriman. Readers seeking a better basic understanding of criminal law would want to include this volume in their research bibliographies.

Similarly, readers of Trevor R. Getz’s and Liz Clarke’s Abina and the Important Men: A Graphic History can learn quite a bit about colonial law, the history of slavery in England and Ghana, Ghanaian history, English colonialism, and 19th century women’s history for a class of women whose voices are not often heard. Documents from the Gold Coast Colony Supreme Court Records, Regina v. Quamina Eddoo 1876, were used in the writing of this book, making it an interesting starting point for legal scholars and historians; the actual transcript from the case is included in the second part of the text. Abina Mansah, a native of the Gold Coast (the former name of Ghana), was the plaintiff in the case in which she charged a wealthy local planter, Quamina Eddoo, with enslaving her, which was against English law at the time. Mansah was pursuing her freedom as well as punishment for Eddoo for enslaving her. The book is designed for classroom use, so it is accessible to a wide variety of users. The volume is accompanied by Clarke’s illustrations, fully colored realistic drawings of the actual history of Abina Mansah’s life as narrated by her testimony given in Eddoo’s trial. Viewing the panels adds a new dimension of content to the history.

Excerpt from Abina and the Important Men [Photo by Kurt Carroll]

Lawyers, legal scholars and artists who are interested in law as it pertains to comics and intellectual property can find relevant print material in our collections as well. Thomas A. Crowell’s The Pocket Lawyer for Comic Books: A Legal Toolkit for Indie Comic Book Artists and Writers provides legal guidance for independent cartoonists, promising that “[r]eaders will learn to protect their trademarks, hire artists so everyone wins, and learn the ins and outs of contracts with this helpful resource. ” Marc Greenberg’s Comic Art, Creativity and the Law discusses law and the creative process, copyright law as it applies to comics, the formation of the Comic Book Legal Defense Fund, the First Amendment and comics, and instances of censorship of comics. Whether you are a visual thinker or a verbal one, there’s material here to engross your attention.

Categories: Research & Litigation

Zombies Against Medicare

Medicare -- New York Times - Mon, 07/27/2015 - 12:00am
Arguments that have already been shown to be false are still used by conservatives to attack a program that has done rather well.
Categories: Elder, Medicare

Helping Patients and Doctors Talk About Death

Medicare -- New York Times - Sun, 07/26/2015 - 12:00am
Doctors soon may be reimbursed by Medicare for talking with patients about end-of-life treatments. It’s a change in policy that’s long overdue.
Categories: Elder, Medicare

Roxbury Center Targets Health Disparities In Boston’s Poorest Neighborhoods

CommonHealth (WBUR) - Fri, 07/24/2015 - 5:00pm

Whittier Street Health Center opened its community vegetable garden on June 24. (Courtesy of Chris Aduama)

By Marina Renton
CommonHealth Intern

When it comes to health in Boston, it’s hard to deny there’s a great divide across neighborhoods.

Need proof? A 2013 Boston Public Health Commission report found that, from 2000 to 2009, the average life expectancy for Boston residents was 77.9 years. But in the Back Bay, it was higher — 83.7 years — compared to Roxbury, where the average life expectancy was 74.

If you want to get even more local, you can analyze the same data by census tract, where life expectancy varies by as many as 33 years: 91.9 years in the Back Bay area between Massachusetts Avenue and Arlington Street, and 58.9 years in Roxbury, between Mass. Ave. and Dudley Street and Shawmut Avenue and Albany Street. That’s according to a 2012 report from the Center on Human Needs at Virginia Commonwealth University in Richmond.

The Whittier Street Health Center in Roxbury is trying to tackle the disparities in a very concrete way. With the launch of a new fitness club and community garden, the center is trying to make healthy food and exercise opportunities available and affordable to all, despite geography.

“What we’re trying to do is to remove those social determinants and barriers that are causing these [health] disparities,” said Frederica Williams, president and CEO of the health center.

‘If I Sweat, I’m Doing Something Right’

The fitness club and garden initiatives just launched June 27, but the Whittier Health and Wellness Institute is already drawing in community members.

Eight months ago, Wanda Elliott weighed 256 pounds. On a visit to her Whittier Street physician, she learned her blood pressure was high — high enough that she had to start taking medication. That was the wake-up call that motivated her to change her diet and start exercising.

“I was dragging,” she said.

Elliott began exercising at a local Y but joined the Whittier Street fitness club when it opened. In eight months, she has lost 52 pounds, leaving her 4 pounds shy of her 200 pound goal weight.

“I have two knee replacements, so I have to keep active every day,” she said. Trainers at the center helped her learn to use the exercise machines, and now it feels like a routine, she said.

“I feel addicted to working out. I feel like if I sweat, I’m doing something right,” she said. “From 256 to 204, I feel like a model. I can walk the runway; that’s how energized I feel now.”

Elliott is now off her blood pressure medication. She is working on making changes to her diet “slowly but surely,” drinking more water, eating more salad, and cutting back on red meat.

Josline Cespedes has been coming to this fitness club for about a week, after leaving a gym where the environment didn’t work for her. “I wanted something quiet,” she said.

Before Cespedes joined, she said, “I had a lot of health problems. My job is all day on my feet…and by the time I got home in the afternoon, I was tired, my legs were swollen.”

Now, “I have more energy,” she said. “I’m up all the time…I want to do more stuff with my kids.”

Prescription For Healthy Behavior

The Whittier Street Health Center currently serves around 28,000 residents (up from 18,000 in 2012) and hopes to reach 40,000 by 2017, president and CEO Williams said. Its patients, all living in socioeconomically disadvantaged and urban communities, are predominantly African-American and Hispanic. The center offers medical and public health programs, including primary, eye and dental care, podiatry, endocrinology, smoking cessation, mental health care, substance abuse counseling and urgent care, in addition to community education programs, Williams said.

“We believe that a significant portion of what comprises good health is our behaviors and lifestyles and, of course, access to quality health care,” she added.

The center takes an integrated, coordinated approach to providing care, “because you cannot separate a diabetic person that has depression, you cannot separate their depression from the diabetes,” Williams said. “We’re sensitive to the many social factors that hinder our residents…You have to be really patient-centered and community-centered to really get people to be engaged and activated in taking care of themselves.”

Obesity is a major issue in these communities, Williams said; only about 20 percent of adult patients and 35-40 percent of children had a healthy body mass index (BMI) in 2012. By 2017, the center hopes to be at 70 and 80 percent healthy BMI for adults and children, respectively, which would help reduce the incidence of weight-related chronic conditions, she added.

Hence the launch of the Whittier Health and Wellness Institute, including a new level of health care coordination, the wellness and fitness club and the community garden.

The fitness club, a $1.2 million investment, is over 6,000 square feet and includes the equipment you’d expect in a gym, along with space for people who need to exercise at a slower pace and studios for aerobics, yoga and Zumba classes. The center will also offer classes on stress reduction and fall prevention (for seniors).

Paging The Health Coach

A pivotal figure in the fitness club is the health coach, a nutritionist and fitness trainer who will work with patients to develop their personal goals. “They serve as the motivator,” Williams said.

Patients are referred to the fitness center via a “Prescription for Health” from their primary care physician, psychiatrist or other clinician at Whittier. Thus, a fitness regimen becomes incorporated into a patient’s medical record, and physicians can track clinical outcomes at the same time, to get clearer information about the effects of increased exercise.

“Your doctor will see the information and track how you’re doing…what type of progress you’re making,” Williams said. “And after your first visit with the health coach, they will work with you to develop your self-management goals.”

Fitness club membership for Whittier Street Health Center patients costs $10 per month; the fee is meant to encourage accountability, Williams said. Members of the community who don’t frequent the health center are permitted to join as well.

The fitness club is “not going to be a moneymaker,” Williams said. The membership fees aren’t enough to fund its operation. About half the money to build and equip the facility came from grants, and the other half from the Whittier Street Health Center’s operating funds. To keep the club open, they will have to raise money through annual fundraisers and additional grants.

Community Garden

In addition to addressing the physical fitness of community members, the center wants to address their nutrition.

“We are in a food desert. People don’t have easy access to affordable fresh fruits and vegetables,” Williams said.

That’s where the community garden, managed by a nutritionist, comes in. Patients of the health center can help tend their own plots. The produce grown in the garden — including tomatoes, peppers and cucumbers — will be given away to community members when they attend a nutritionist-led cooking demonstration, Williams said.

The goal is that patients who benefit from the fitness club and community garden will take their newfound self-management skills back to their communities, Williams said.

“We’re looking to not only impact the patients we serve, we’re looking to impact their immediate and extended families, their friends and their neighbors, and we envision that ultimately this will contribute to wellness and fitness in this community,” Williams said.

As part of its Boston Health Equity Program, the Whittier Street Health Center has a series of outcomes it uses to measure the success of its programs, including patients getting regular checkups and improving BMI. Those clinical outcomes — for instance lowering blood pressure — will be achieved in part by individuals visiting the fitness club and community garden and making improvements in their fitness, stress level and nutrition, Williams said.

Avoiding The New Year’s Resolution Effect

A big challenge is not only getting patients to start making lifestyle changes, but encouraging their maintenance, Williams said. In other words, how do you avoid the tapering-off that follows the Jan. 1 rush to the gym?

Because health care providers coordinate the changes and track their patients’ progress, the hope is that it will be harder for the patients to stop coming back, Williams said.

If a patient receives a referral to the fitness club and they don’t come to work out within two weeks, the health coach will follow-up with him or her, Williams said. Similarly, if a patient stops showing up, someone from the Whittier Street Health Center will get in touch.

“The key for us to get people engaged and to maintain it is for us to stay connected to them,” Williams said. “Our job is to make sure we keep that connection and that excitement and empowerment and look for creative ways to keep them focused on changing their lifestyles.”

In a pilot program a couple years ago, the Whittier Street Health Center hosted Zumba classes, and around 600 people came and stuck with it, Williams said, making her feel optimistic about the fitness center’s retention rate.

While some people do stop coming regularly after an initial period of enthusiasm, “I’m just motivated to do it because I love myself,” Elliott said. “And I hate high blood pressure.”

Categories: Health Care

Medical Residents Confide Their Feelings On Performing Abortions

CommonHealth (WBUR) - Fri, 07/24/2015 - 12:10pm

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol July 9 in Austin. (Eric Gay/AP)

Abortion can be hard for the patient. But it can also cause turmoil for the doctor performing the procedure.

Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, found herself acting as a confidant in many discussions with residents about abortion.

“Over the years, when a resident felt confused, overwhelmed or thrilled about something to do with abortion care, they often came to me to discuss it,” she says.

Tricky questions continued to arise: Where does life actually begin? How do doctors’ personal beliefs play out in their clinical care? And, what’s really best for mothers?

(KateLMills/Flickr)

Singer thought the general public would benefit from hearing more about the complexities of the young doctors’ experiences. So she asked four residents to write about their feelings about abortion training and services, or as one resident characterized it: “one of the most life-changing interventions we can offer.”

These personal stories are published in the July issue of the Journal of Obstetrics and Gynecology, headlined: “Four Residents’ Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect.”

I asked Singer to offer a bit more background on the project, and here, edited, is her response, followed by some excerpts from the residents’ narratives:

Janet Singer: The abortion debate in the U.S. is so divisive, making everything seem black and white; but the real life experiences of doctors and women are much more complex. I am a nurse midwife and though personally committed to increasing access to abortion services, I believe that abortion is not a black and white issue. I speak openly about my personal beliefs with the obstetric residents I work with.

My thinking about the grey areas surrounding abortion care are the result of many conversations with colleagues and residents. One came to me overwhelmed on a day when she had done a late-term abortion and then been called to an emergency C-section for a fetus/baby just a week further along.

She needed to talk about how overwhelming it felt to try to decide where the cusp of life was, why it was OK to take one fetus/baby out of the womb so it wouldn’t live and one out so it might. 

Following that conversation, a few of us decided to form a resident abortion providers support group so that the residents getting abortion training would have a safe space to talk about the complexity of abortion. At the same time, I started checking in, informally, with each resident during their abortion training block. I gave the resident an opportunity to talk — no agenda, no judgment, just a forum for exploring how they were feeling in their new role as abortion provider.

Some had little to say, but most were pondering big questions about what they were doing, why, how it affected them, how satisfied they felt. Conversations on this charged issue occur frequently among the residents. The residents who chose not to get abortion training also revealed the struggles they faced — feeling like they weren’t offering comprehensive care to their patients or realizing they had to rely on colleagues to take care of this part of reproductive health care. And both groups had to confront the fact that the political rhetoric their side used just didn’t fit the coworkers they loved and respected. The pro-choice group knew that their pro-life colleagues weren’t “women haters.” And the pro-life group knew their pro-choice colleagues weren’t Hitlers.  Each group was working from conscience, truly doing what they thoughtfully believed in.

I asked three residents — one committed to doing abortions, one who got training but was deeply conflicted about it, and one who had decided not to get training — if they would write about their experiences. We came up with a set of guiding questions and I told them not to censor, but just to spill. They poured their hearts out. The pro-life resident ended up doing one abortion — a late one because he understood the woman’s plight and that the fetus was unlikely to survive.

After that, I decided we needed one more voice from someone who would never do an abortion, so we added a fourth resident.

The narratives revealed that the clear distinction between being pro-life and pro-choice often breaks down when one is faced with the real-life prospect of caring for pregnant women. (Though, as it happens, three of the four narratives are by men.) We hoped our writing would open a new dialogue about abortion, one that acknowledges the complexity of the issue.

Here are a few excerpts:

Resident 1:

When I started residency, I was open to the possibility of providing terminations. I was and remain uncertain about when life begins, and I used to hope that a deeper understanding of fetal development might help me make such a decision empirically. Over the course of internship, I came to understand embryonal development as a fluid yet constant march toward being human in which an embryo at 6 weeks is an entirely distinct entity from an anatomically formed fetus 2 months later. Unfortunately, this acquired knowledge has failed to help me fully define my position.

Increasingly, I have found myself caught up in an endless array of rhetorical questions. Is there not a more profound difference between 10 and 20 weeks than between 20 and 30? If my first task as a physician is to do no harm, how can I justify harming a fetus? I do not pretend to know the answers to these questions, but given what I perceived to be an abyss of ambiguity, I chose not to provide elective terminations. Our program director supported my choice, saying, “If anyone makes you feel uncomfortable about that choice, I need you to tell me right away.”

Discussions with co-residents have helped me consider the individual woman who has the courage to request an abortion. Since opting out, I have realized that my line of thinking has been feto-centric at best and over-intellectualized at worst. Nonetheless, in the absence of a clear moral understanding of abortion, I can only do no harm.

Resident 2:

At the start of residency, I was not sure if I was ready to perform elective terminations. I realized that the lion’s share of my reluctance was driven by “what would my mom think of me?” I struggled with my own faith, and with what God would think.

On my third-year obstetrics clerkship in medical school, I had my first experience with abortion in a patient with severe preeclampsia at 20 weeks of gestation. There was no provider in the city who felt adequately trained to perform an abortion at this gestational age, and I remember feeling helpless as we watched the patient get sicker. Twenty-four hours passed while a provider was flown in from out of state.

The woman’s clinical condition improved shortly after the procedure. When I was wavering about opting in for abortion training, I thought of this patient many times…One particular conversation with a senior resident was instrumental in my decision to participate in the abortion training. She explained that, for her, abortion is not “black and white”; it is not a “feel-good” procedure, but it changes the course of a patient’s life. It was so helpful to know that my apprehension was normal. That affirmation, along with my desire to gain gynecologic experience, gave me the confidence to pursue abortion training.

I was nervous about my first day at Planned Parenthood. I envisioned protesters chanting and throwing objects at me. After my first morning of early abortions, we performed an 18-week termination. Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core. I thought maybe I had made the wrong choice, and I could not stop thinking about what my family would think if they knew what I had done.

Later that week we had an informal gathering of residents who had struggled with abortion training. It became apparent that others shared similar feelings. Many of us felt more comfortable with early abortions and struggled with second-trimester cases. Regardless of whether we performed abortions or not, it had to do with patient care and, in this case, our patients are the mothers. After listening to the struggles of fellow residents, I convinced myself to return to the clinic.

There, I soon realized how powerful it was to be able to comfort and assure such vulnerable patients. I began to frame my interventions at the clinic as life-changing for women.

Resident 3:

Although I might not always understand an individual woman’s choices, if she feels that she cannot be a parent for whatever reason, I will support her in that decision. I see little role for my personal values in the shared decision-making process.

The truth is that being involved in this work scares me. I am fearful of the violence and taunting that protesters have inflicted against providers. Assaulting providers in the name of “protecting life” disgusts me, especially because abortion is legal. This fear for my family and me has affected my interest in pursuing a family planning fellowship.

Abortion is a necessary procedure that I feel morally obligated to make available to my patients. The future of this service hinges on our society’s ability to support its practice, prevent undesired pregnancy, and ensure the safety of abortion providers. I have worked through my own internal struggles, but these broader societal issues will shape how I practice in the future. Participating in abortion services has left me fulfilled and honored, and I consider the provision of this care a privilege.

Resident 4:

I am a Born Again Christian, and I believe that life begins at conception. I believe that since I do not have the power to create life, I do not have the power to take it. I am proud of my choice and do not apologize for it, but that was not always the case.

I love obstetrics and gynecology — the breadth and depth, the bonds between patients and providers, and the lifelong relationships that are formed. However, I once heard someone say that an ob-gyn who did not provide terminations was not offering their patients the best, most complete care. Initially I shrugged this off as her opinion and deemed it irrelevant to me and to what my practice would become. But as I replayed that statement in my mind, I began to wonder, would I be providing the best care to my patients if offering terminations conflicted with my personal beliefs and passions? Would my patients feel judged and unsupported if I told them that I could not provide a service that they needed? Could I be truly impartial in my counseling?

Categories: Health Care

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