I met Cassie on the first day of my longitudinal “high-risk” obstetrics clinic. Diagnosed with type 2 diabetes, she would require intensive counseling, treatment and monitoring during her pregnancy. Cassie was a big personality with a refreshing honesty and a quick laugh. We immediately hit it off, joking about our shared weakness for French fries. We also explored more weighty subjects like the disproportionate rates of pregnancy complications for Black women in America. On her medical history, though, it was hard to pin her down. Her responses to my questions were contradictory sometimes, a mixture of gaps in her health literacy and obfuscation. People are complicated, I told myself, and trust has to be earned. While it made it more challenging to decide on the initial treatment approach, I chose to let it ride. One thing was clear: She had felt unheard and misunderstood by the medical system for years and wanted the best outcome for her future child. This, I could work with.
In the Branches, the third and fourth years of medical school where students are able to pursue electives and career interests, students can choose to have a longitudinal clinic for 6-12 months. They work with the same provider each week and get the rare opportunity to see the same patients multiple times, build relationships and watch the arc of their medical concerns play out. Thus, in an obstetrics clinic, I have the opportunity to follow a patient through the entirety of their pregnancy. Because the patients have complex medical needs, I can also watch the ways their unique comorbidities affect their experience.
Cassie’s pregnancy went smoothly, however as she progressed her blood sugars became more difficult to manage. She had strongly wanted to avoid insulin, shots a pregnant patient has to give themselves multiple times a day to control their sugars. Insulin administration is uncomfortable, expensive and needs to be given at specific times: it is not an easy treatment. Cassie had been on a pill to control her diabetes before pregnancy, why couldn’t we just keep using that? And why did her sugars get so difficult to manage after weeks of being stable? With these questions in mind, I explored the use of oral diabetes medication during pregnancy for my Patient-Based Scientific Inquiry (PBSI) presentation. In PBSI, students research the basic science behind a clinical question and give a 15-minute presentation. With the help of a pharmacy faculty member, I learned about blood sugar regulation during pregnancy, the mechanism of Cassie’s medication, and the research into its effects on the fetus. While she eventually chose to use insulin, I left with a much stronger understanding of diabetes and its management.
But Cassie didn’t stop teaching me there. Later in her pregnancy, she had concerning symptoms and came to the hospital. There, she had an interaction with staff that upset her so much she left against medical advice. The next week I saw her in clinic. While the symptoms resolved safely, I was concerned because she had numerous risk factors for having pre-eclampsia, a condition that would require immediate delivery. Given her perception of poor care at the last visit, would she present next time she had a concern? Her response was non-committal. The United States has high rates of pregnancy complications and death, and researchers have thus far struggled to entirely understand why. What we do know, however, is that women like Cassie, women of color with multiple comorbidities, experience poor outcomes at disproportionately higher rates than their white peers. As part of my interest in maternal mortality, faculty mentors and I had been exploring ways to improve clinical encounters for patients of color. With Cassie in mind, I turned back to this work, which had begun to flounder under the stresses of COVID, with new energy and focus. Yet again, Cassie had taught me something: an important factor in poor pregnancy outcomes is the extent to which patients are comfortable sharing their concerns.
In June, Cassie delivered. While the birth required emergency surgery, she and her child were safe and healthy when I stopped by the room the next day. In spite of the intensity of the previous 48 hours, and the complete lack of sleep, she was just as funny and ebullient as always. That day, she taught me about resilience. She had had a complex, high-risk pregnancy, and we had made outrageous demands of her: Told her what to eat and how to sleep and to give herself shots twice a day and to come to clinic twice a week for monitoring and to keep working and to take a handful of medications every day and on and on and on. She didn’t do it perfectly, but she did it extremely well and now she and her partner were growing their family. I was so overwhelmed in the room that day: by their happiness, by the near misses, by the intensity of every clinic visit over the previous six months. Cassie had made a (future) doctor out of me: she taught me about prenatal care and diabetes management, and challenged me to think differently, to step back, build trust and ask big questions. They say your best teachers are your patients, and after Cassie, I believe them.
*To protect her privacy, the patient’s name and identifying details were changed.
Yoni is a fourth-year medical student interested in ob/gyn. For the 2020-21 academic year, he will be temporarily stepping away to pursue a Masters of Public Policy. He has over 50 species of plants in his apartment, and feels bad for them on cloudy days.