A Hard Choice

"This is so cool," said Lesley, who believed she was doing something important to address the shortage of abortion doctors. After years of defending abortion rights, she would finally learn how the procedure is done.

Ten women and three men showed up for the workshop, fewer than the organizers had expected. After heaping their plates with food and chatting about the recent test, the students cleared the lab tables for the teaching doctor to lay out her equipment and pass around photocopies of her lecture slides. Her tray contained a pair of scissors with a sharp tooth on each end, for grasping body parts during surgery, called a tenaculum.

The doctor gave a short lecture on first-trimester abortions. Then she showed the students how to grip the papaya with the scissors to hold the angle of the "cervix" straight on. With one hand, the doctor demonstrated how to administer a local pain killer, at 3 o'clock and 9 o'clock positions. She picked up different sizes of dilators used to widen the cervix and advised against pushing them in too hard, because in a soft-skinned papaya, the dilators might come out the other side. In a woman, more pressure would be needed to slide the dilator past the cervix and into the cavity of the uterus.

The doctor next picked up the suction instrument, a manually operated vacuum suction syringe. It was attached to a cannula, or thin tube, that she inserted into the papaya. She rotated it around the fruit's cavity, pulling and pushing the syringe, suctioning the papaya's contents.

"This is the most important thing and the hardest to learn," the doctor said as she pulled out lots of seeds and juice, what in a real abortion she called the "products of conception," or POC. "You put the POC into a bowl, repeat if necessary, and examine them under a microscope to make sure you got everything," she advised.

There was silence as she passed around photos of a dish with a light under it from a real abortion. It contained something that looked like a cotton ball, a yolk sac, and some blood and tissue. It was hard to make out any parts of a fetus under 3 months old, which, she said, is when more than 90 percent of all abortions are performed.

"How do you know you are done?" a student asked.

When you do it often enough, the doctor replied, you'll notice a gritty feel as you are scraping the uterus. If not, there is another tool, a rod with a spoon, one side sharp as a knife, to scrape again.

Now it was the students' turn to try the procedure in the lab next door. Imagining herself working on a real woman, Lesley looked tentative as she pushed up her sleeves and reached for the razor-sharp tenaculum.

"This just seems so awful," she exclaimed as she tried to grab the papaya with it. "Do [patients] feel this?"

Her look turned to fright when the nurse practitioner at her station answered that they do.

Why not apply the local anesthetic before gripping the cervix with the sharp instrument? Lesley asked. The answer: A doctor needs something to hold the cervix steady to administer the drug.

Lesley offered Christina the suction instrument to try first, and Christina took it without hesitation. "You can feel once you get into the hollow part," Christina told Lesley.

When Lesley's turn came, she ignored the directions and numbed the papaya before using the scissors. Then she gripped the papaya with the scissors, dilated it with the instrument in her other hand, and suctioned it with the vacuum, twice bringing up lots of seeds and pulp. Finally she tried the curet, the spoon with one sharp side, and pulled out still more pulp.

"So," she asked the nurse, "did we not suction correctly, or is this a papaya issue?"

"It's the papaya," the nurse replied.

The whole thing was over in less than three minutes, but Lesley had plenty of questions.

"Do you feel you have to distance yourself emotionally from your patients?" she asked the nurse practitioner.

"No," she answered.

"Are patients sad? Upset?"

"Many times they are sad," the nurse said, but also relieved. "They have made up their minds." Some cry afterward, she added. "I tell them it's normal to grieve. It's a loss."

"Do they ask you, 'How can you work here?' "

"I tell them, 'I meet wonderful ladies like you,' " the nurse said.

Lesley bit her lip and tried the procedure again, and this time she asked technical questions, all the while thinking of what she might say to the patient, how she would explain what she was doing.

On her second try, she perforated the papaya, but she knew the fruit was far softer than a woman's uterus would be. She put down the instruments. "Now I know how to do one, I guess, if I needed to," Lesley said.

But she seemed to be harboring reservations about the procedure. She thought using the tenaculum was barbaric: "I don't know, insensitive. You'd think there'd be something else besides digging into the cervix with a toothlike instrument."

She tried to rationalize her reaction. Second-year students were only beginning to learn procedures. She had put in a catheter the previous week and had watched a doctor intubate a patient or, in her words, "stick a blade down someone's throat." The lack of gentleness by some doctors disturbed her. She knew some chose not to use the very sharp instruments in abortion procedures, but those tools gave the doctor better control and, ultimately, the patient better care. Seeing it for the first time was "jarring."

Her first surgery was jarring, too. Maybe after seeing it a thousand times, she said, "I'll get used to it."

A few days later, thinking over the papaya workshop, Lesley concluded that something was missing: any discussion of how it might be difficult for doctors to perform an abortion. That was the way of medical school, the basic facts, not how to deal with a patient or a doctor's own feelings. Why would this be different? she asked. The doctor was probably treating abortion like any other medical procedure, to take away the stigma, the emotional charge associated with it.

"But you can't deny it," she said. "I feel they are ignoring it. I wanted more guidance on the softer side of it, the emotional quagmire of what you have to deal with every day as an abortion provider. There was no acknowledgement.

"I think it would be difficult the first time," she said, but "I feel passionate enough about the issue so I would do it."

One day not long after the papaya workshop, Lesley ran into a friend, Litty Smelter, in a hallway. Litty, the president of the medical school's Catholic students group, was carrying pizzas and was accompanied by a priest. They were on their way to a lunchtime discussion about the beginning of life. Litty urged Lesley to come. Free pizza!

Lesley was hungry. Besides, she wanted to understand where abortion opponents were coming from. This curiosity was typical of Lesley, and one reason Litty valued Lesley as a friend. "She's a fabulous person," Litty said. "And, yes, she is definitely open to other opinions."

But admiring Lesley didn't mean Litty agreed with her on abortion. For many Catholics like herself, Litty said, opposition to abortion "is an issue of the dignity of human life and God's role in the creation of it. We believe that God plays an active role in the creation and preservation of all human life, from the moment of fertilization to the moment of death." Abortion amounts to humans playing God, she argued. "Who are we to decide who lives and who dies?"

Lesley doesn't think of a fetus as a person, but Litty believes that life begins at conception. "Conception is a miracle in itself. Now I know that seems like a cliche, but to think of the natural obstacles a sperm goes through to meet and then fertilize an egg makes the act miraculous. I think nothing short of God can make that happen."

Abortion was a tough issue on both sides, Litty said, because it sometimes seemed they were arguing about two different things. Lesley and the Medical Students for Choice argued from the point of view of "a woman's body, a woman's choice," she said. "We argue from the side of respect for life. For me and so many, there is no 'choice.' I think the decisions made leading up to conception were the 'choice.' "

At the lunchtime discussion, Lesley was surrounded by people opposed to abortion. A pediatrician from Johns Hopkins was discussing her practice of refusing to prescribe birth control pills to adolescents because she is morally opposed to it.

Hearing the doctor made Lesley wince. She herself had spent many hours teaching teens about contraceptives. She had won an Albert Schweitzer fellowship to develop a health education program at Mountain Manor, a residential treatment facility for teens in Baltimore, that addressed sexually transmitted diseases, contraception, abortion and adoption. She'd shown the girls at Mountain Manor how to use a condom and urged them to carry condoms with them.

She couldn't imagine refusing to prescribe birth control pills to girls who were sexually active. "Just keep your mouth shut," Lesley said she told herself. "Don't say anything." She knew she wasn't going to change minds.

But later, before she left, she did ask the doctor one question: "How do you advise patients without appearing judgmental?"

The answer -- that appearing judgmental wasn't the doctor's concern, only doing what she felt was right for patients -- made Lesley realize that "there are people who wholeheartedly believe they are doing their patients good" by not mentioning abortion or prescribing birth control pills. She found that problematic. "You can't assume what is right for you is right for the patient," she decided.

This led her to ask herself another question: When is it appropriate to interject our judgment, and when isn't it? Nobody really knows, she concluded. Not Medical Students for Choice, not the Catholic students, not the medical school. But they were important questions to explore, she told Litty later. Litty agreed.

A few days later, the two friends agreed to co-host a conference on the ethical responsibilities of doctors when controversial procedures such as abortion are involved, and they mapped out a panel of speakers. To the women's regret, the spring semester was winding down too quickly for them to get the conference organized before their June medical school boards, the first of three important tests during their years of training.

For one month, Lesley did nothing but study, 12 hours a day. After the test was over, she and her boyfriend, David Richman-Raphael, a dental student, visited the ruins of Machu Picchu and, as they hiked through small villages of Peru, distributed toothbrushes to children. It was a fitting prelude to Lesley's first rotation as a medical student: pediatrics.

Lesley's third year of medical schoolfocused on the clinical care of patients in a variety of specialties. Her professors and fourth-year friends advised her to keep an open mind, because the process was a kind of courtship. Often, as in a relationship, what people thought they wanted at the start of the process didn't turn out to be what they chose in the end.

Her six-week pediatrics rotation began in the neonatal unit at Franklin Square Hospital Center in Baltimore, not a place where she'd like to work. "It's high stress, and babies die on you," she said. But the outpatient clinic, where she poked in babies' ears and shined lights in their eyes, was fun. Several times, she counseled teens on birth control, which she found rewarding.

Babies are wonderful, Lesley said, but "I like adolescents more. They are in a unique place in life. Little kids have parents. Adolescents have lots of influences . . . Behavior can be changed very easily. They are not stuck in their ways, not jaded yet." Adolescents, she declared, "are very high yield."

"High yield" had become Lesley's favorite phrase after the month she'd studied for her boards. When facts were labeled "high yield" in her study guides, she knew they would be on the test. Lesley's performance on her boards was dazzling. In fact, it was almost perfect. With her score, she was suddenly a candidate for the most coveted medical residencies, the ones with the best hours and pay. These are what medical students call the "high-road" specialties -- anesthesiology, radiology, dermatology and ophthalmology. Lesley knew that none of these specialties would involve abortion, but she felt she owed it to herself to explore them, anyway.

She made an appointment to follow an anesthesiologist and started to research radiology, too. Meanwhile, she readied herself to begin her six-week tour of obstetrics, still her No. 1 choice. For weeks leading up to obstetrics, Lesley had heard stories about unhappy OB residents at UMB and Hopkins: Stressed residents were unfriendly; students never ate; the atmosphere was "toxic." But Lesley had shadowed the head of OB at UMB and liked her. And classmates who took the rotation before she did reported that it was not as bad as rumored. On the eve of Lesley's tour, the excitement in her voice was palpable.

Lesley's first day in labor and delivery was tumultuous. She rose early, fighting her body clock, and arrived at 6:30 a.m., sleepy. Within two hours, she was whisked into surgery to watch a cesarean section. Later, in another delivery room, a midwife wanted her to catch the baby as it was being delivered. But when the baby's heart rate dropped, the midwife sent Lesley away. She was relieved.

"It was terrifying," she said. "I'd never seen a live birth."

All day, she was on edge. To her, the residents seemed blunt, curt, methodical, all business, even in their down time. Nobody looked up when she entered the room. That evening, she arrived at her boyfriend's home for dinner and burst into tears.

"I don't think I am going to like this," she said she told Dave.

His response made her laugh: "I can't tell you how happy I am." He wanted her to do the thing she loved, but he also hoped it wasn't obstetrics. The hours would be tough when they had their own kids. She and Dave expected to marry, and they often discussed their life together. He tried to reassure her. "It's only a job," he said.

But for Lesley, it was much more. She was choosing a profession and a lifestyle and making a moral commitment: "I want to do something meaningful."

The next day, she was back on the labor and delivery floor. It was tough to be ignored by residents when she gave patient reports, to stand in the back of the "command room" where they discussed patients.

Already she preferred pediatrics, where doctors treated her like a colleague, to the tense, hierarchical nature of obstetrics. She tried not to take it personally; maybe keeping women alive made you austere. This was, after all, a teaching hospital where many pregnancies were high-risk: women withpreeclampsia, ruptured membranes or pre-term labor. Some of them had been in the hospital for weeks and, when they did deliver, needed a resuscitation team.

Lesley knew most OB practices weren't anything like this. Still, it bothered her that residents didn't try to learn her name. Even Lesley didn't recognize herself one day when doctors called her over the intercom.

"Medical student to OR 4! Medical student to OR 4!"

"Me? Me?" she asked excitedly, pointing to herself with both hands. The residents laughed at her. This time, she didn't mind.

Ten days into her rotation, Lesley witnessed her first vaginal birth. The mother, in her mid 30s, cursed and flailed her arms until she was given an epidural. Lesley said she was "shaking in my boots" when she found out the patient was a medical professional. She was afraid of making a mistake, doing something that revealed her lack of knowledge.

It was Lesley's job to call the midwife, who didn't answer. At one point, Lesley had three midwives on the way. The patient delivered after an hour and 10 minutes of pushing, with her own midwife present. It was amazing and brought Lesley to tears. "Keep it together, Lesley," she told herself as she watched the new mother, and then the father, hold the tiny baby. "This is a job."

It was a good day, "very, very cool," she would report later. It reminded her to keep an open mind about obstetrics.

Next, Lesley moved to gynecological surgery, where she reported to work even earlier, at 5:15 a.m. Often, standing behind the residents as they examined a patient, she couldn't see what was going on. In the operating room, her back ached from bending over the table.

The last two weeks in obstetrics were in an outpatient clinic, where residents oversee the care of pregnant teens and women, many with diabetes, obesity, high blood pressure or domestic troubles. There Lesley felt she could contribute something; counseling some of the patients, she felt more independent. A pregnant woman who had been beaten by her boyfriend came in with her son, and Lesley found her shelter. She put in her first IV, getting it right on the second try. And she worried about a 15-year-old girl with an 18-month-old baby who was pregnant again. Lesley talked to her about birth control options. "Who let this happen?" Lesley said she asked herself.

It was during her time in the outpatient clinic that Lesley got to see her first abortions. OB students had a mentor they were supposed to shadow, and one of Lesley's friends had spent a day with a doctor performing abortions. The friend had held the instruments for part of the procedure, but when the doctor handed her the suction instrument, she couldn't do it. Lesley wondered what her own reaction would be. She asked to follow the doctor, too.

Most of all, Lesley was interested in the state of the patient. Would the pregnant woman be calm or crying? And how would the doctor deal with those who were emotional? What was the dynamic between patient and doctor?

"Everyone talks about the context, the morality, the politics of it," she said the night before she would observe an actual abortion, "but nobody really knows what it is like in that moment between doctor and patient."

She reported at 8 a.m. and met the doctor, whom she described as friendly but gruff. The nurses joked with him, she observed. And when she asked what she would be doing, she said he teased her, "I don't know what you'll be doing, but I'll be doing procedures." He got up and walked down the hall. Lesley whipped on a gown and gloves and ran to catch up with him.

In the procedure room, the patient had been sedated, but her eyes were open. As Lesley watched, the doctor grabbed the tenaculum, numbed the cervix with a needle, grabbed the specula for dilation, then the suction machine. He was methodical and very fast. The patient was in obvious pain. Her screams gave Lesley the chills, and she thought she might throw up.

"I'm getting dizzy," she said aloud. The doctor told her to sit down. She backed away, found a bench and sat. She was hot and sweaty.

The procedure took five minutes, and when the doctor was done, he took off his gown and threw it into the trash. Lesley apologized for being squeamish. "I don't want to seem like a baby," she said she told him.

He started to ask if she was "one of those who don't agree" with abortion, but before he could even finish the question, she interrupted. "No, no," she said she told him. "I'm one of the Medical Students for Choice. I'm not one of those."

The second procedure was easier. This time the woman had fallen asleep from the sedative. Lesley's stomach was stronger now. "I can take it," she told herself. The doctor put Lesley's hand on the instrument, his hand over hers, and she let herself be guided by him, using the dilator, the suction machine and finally a metal loop for scraping the uterus.

The abortions were over by 10 a.m., and for the first time in her obstetrics rotation, Lesley did not want to leave. She asked to stay, and she spent the afternoon following a nurse practitioner as she counseled and prepared patients for more complicated second-trimester abortions the next day.

"What about the women who come in distraught?" Lesley said she wanted to know.

A woman crying was a red flag, the nurse replied, and she'd gently ask if the woman wanted to go through with an abortion.

The only woman crying that afternoon was one who was too far along to have an abortion and was sent away. Lesley helped with that ultrasound and saw the fetus moving. It was 20 weeks, 3 days old and "pretty real" to her. In previous weeks, she had tried to keep similar-sized babies alive. This "conflict of effort" was, to Lesley, "weird, even surreal."

Another patient, whom Lesley dubbed "the faker," tried to use a false name and was told to return another day. A third patient, a 23-year-old college student wearing red high heels, had become pregnant because the patch she used as birth control kept falling off. She didn't realize she was pregnant at first. Now she needed a second-term abortion. Lesley was struck by how resolute the young woman was. She was earning a degree, and said she couldn't care for a child if she wanted to achieve her goal. She was scheduled for the procedure for the following morning.

Lesley was free early the next morning and phoned the doctor performing the abortion to ask if she could attend. The doctor hesitated, according to Lesley.

Are you sure? the doctor asked. It's really hard to watch.

Yes, Lesley answered, she was sure.

The next morning, Lesley arrived at 7:30. The woman with the red heels asked for a printout of her ultrasound and wanted to know the sex of the 14-week-old fetus. It couldn't be determined.

This time, the procedure took 10 minutes instead of five. The dilator was bigger; there was more tissue to remove; and the patient, although sedated, was awake and moving with discomfort. Lesley watched as the doctor counted the parts of the fetus, and, to her surprise, she didn't find it jarring. To her, the parts appeared doll-like.

"It was definitely gruesome," she said. "You could make out what a fetus could look like, tiny feet, lungs, but it didn't look like a person." She knew this abortion was an act that her friend Litty considered tantamount to murder. She herself expected to be very upset. She'd felt that way at her first autopsy, that of a teenage boy who'd shot himself in the head. For weeks, she could not shake the image of the boy. But this was different. She didn't regard the fetus as a person yet. She said she was happy to help the woman: "I feel like I was giving [her] a new lease" on life.

Later that morning, though, while conducting a pelvic exam, Lesley noted that she wasn't her usual slow, gentle self. That evening, discussing the second-term abortion with her mother, Lesley described a process that she found disturbingly brutal, especially the stretching of the vagina.

"It's a lot more invasive than I thought," she said. "A papaya doesn't bleed and scream." Women do.

Lesley didn't want to have to steel herself emotionally to perform abortions, and she was coming to realize that that's what she'd have to do.

The next three months of rotations left Lesley with no time to do anything but eat, sleep and wash laundry. It was grueling, thrilling and eye-opening.

In neurology, she was part of a team that had to tell a mother that her daughter was brain-dead. The mother collapsed in grief. No one, Lesley complained afterward, had prepared her for how to talk to the mother or how to handle her own feelings.

At the Maryland Shock Trauma Center, she operated side by side with the head doctor. She also flew with a transplant team to pick up a heart and lung, helping to remove them from the brain-dead donor. Obstetrics now seemed a breeze compared with the hours and boot-camp style of the transplant doctor who ordered Lesley around.

In surgery, she relished cleaning a nasty, oozing infection from a lung. "It was like peeling an orange, so satisfying," she said. Lesley loved surgery, but she didn't want to double her training, which was what being a surgeon would demand. And surgery wasn't a family-friendly specialty.

The family medicine clinic, another place where she could treat women and provide abortions, made her yawn with its routine. Anesthesiology, one of the "high-road" specialties, appealed to her. It was like a game of chess.

"You have to think what can go wrong," she said. "You have to anticipate. There are immediate consequences. You have to know about medicines and life-saving procedures." She admired the doctors, too. They were friendly, even joked, yet they lived on the edge. They kept their cool when a patient's blood pressure fell to zero.

For the first time, Lesley tried to picture herself working all day at a hospital, wearing those awful scrubs, taking care of surgical patients -- not at all what she'd been contemplating in the beginning of the year. She began considering how to separate what she did every day from her desire to make a difference in women's lives. She wondered if she was talking herself into the idea that she didn't need to be a primary care physician to change things for the better, one patient at a time. "I half believe it," she said.

As for obstetrics, the once-perfect mix of medical, surgical and preventive care for women, Lesley hadn't loved very much about it. Even as she'd shadowed the abortion doctor, Lesley knew in her heart that this would not be the right place for her to make a difference. It was a big disappointment, she said. "I really thought I'd love it."

The things she cared about -- taking care of women, seeing them through the process -- hadn't happened. It was the nurse practitioner who cared for the patient. Vacuuming out a uterus and counting the parts of the fetus did not seem like a desirable way to spend her work days. It took a unique person to do that on a daily basis, she said.

Lesley still believed passionately in abortion rights and was proud of what she'd accomplished at Maryland with her activism. She didn't want to let people down. Even so, she had to follow her heart. Somebody else -- maybe Laura Merkel, the new chapter president of Medical Students for Choice -- would become an abortion provider. But it wouldn't be her.

Patricia Meisol is a freelance writer who lives in Baltimore. She can reached at pmeisol@gmail.com.