This summer I spent one month in Northern Ontario on a medical elective. Over the month I was given considerable autonomy to practice my clinical skills and interviewing, and was granted a unique view of complexly foreign part of the country. The following patient encounter was one of the most shocking and influential events of my elective.
My preceptor for the day had assigned me one examining room and given me a third of the patients. After seeing each patient I would give her a summary, discuss a management plan, and we would then go in to see the patient together. I grabbed my first chart of the afternoon, a 16 year old female patient was presenting to the clinic with what she suspected was a Chlamydia infection.
I knocked on the door, walked in and introduced myself to a nervous looking girl who seemed far to young to be worrying about STIs. We started talking, she had a previous episode of Chlamydia 6 months ago (the reason why she was so certain it was Chlamydia again) which another doctor at the clinic had treated. She had been sexually active since 13, used the birth control pill for two months when she was 14 (she stopped because she could never remember to take the pill) and had since used no forms of contraceptives. At this point alarm bells were ringing in my head and I asked her when her last period was. The answer was informative to say the least: over 7 weeks, and it had not occurred to her that she could be pregnant. To complicate matters, the patient normally drank several drinks a day, and I was seeing her the Monday after Canada Day Weekend, where she had been drunk for most of the weekend. At this point I obtained her consent to test her for STIs and pregnancy, and then made a beeline for the doctor’s office.
I summarized the patient for my preceptor and to my surprise didn’t bat an eye – it was a fairly standard story I guess. One urine dip later and my preceptor turned to me and said, “Ever told someone that they are pregnant?” I replied with a shaky no and then injected slightly more confidence into my voice and said that I would like to be the one to tell her. So tasked with relaying this all-important news, I went next door, with my parting instructions to break the news and find out if she wanted to have the baby.
I entered the room, and said, “I have some big new. You’re pregnant.” I gave her a moment, and then asked her how she was feeling. She said she was shocked. Now the tricky part – the key would definitely be in the phrasing. I cleared my throat, collected my thoughts and blurted out something wonderfully awkward along the lines of “Do you want to carry this baby to term?” She beamed back at me – the answer was a definite yes. The rationale was certainly not to my liking: Dad was in jail, not speaking to the young girl, and she wanted the baby to remember him. But it was her choice. The clinical encounter wrapped up quickly: my preceptor came into the room, we treated her Chlamydia infection (a single dose of 1 gram of Azithroymycin given orally, for those who are curious), gave her some general prenatal recommendations, and set up a follow up appointment.
The patient left the office happy, but I was left with some serious doubts. Aside from being concerned about her prospects for the future, two nagging issues stood out to me. First, this young girl was a high risk pregnancy with significant risk to both mother and fetus (mainly Fetal Alcohol Syndrome). I was aware of it as was my preceptor, but it is unclear how adequately we relayed that message to the patient. It is possible that the patient was unaware of her risk. Should we have directly laid out the risks for the patient before asking about having an abortion? Would it still have been appropriate to discuss risks and offer alternatives after her expressed desire to have the baby? Does pregnancy count as a “medical procedure” for which complications, and alternatives must always be discussed and then offered to the patient?
I was also struck both by how preventable the situation had been and the clear signs that this patient needed help before she showed up at the clinic pregnant. After this “routine” event, there was no discussion of how to adapt or alter the practice, and I am quite positive that similar outcomes will continue to occur. I learned considerably from this encounter, and even more from my time up north, but left my elective cognizant of enormous gaps in our health care system, which unfortunately have no easy solution.