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Mississippi Does Not Really Care about Patient Safety

19 Apr

Mississippi’s governor has just signed a TRAP law that may well shut down the state’s only abortion clinic. Like many TRAP laws, on its face the regulation looks reasonable and aimed at patient safety. Abortion providers in the state will have to be board-certified in obstetrics & gynecology, and will have to have admitting privileges at a nearby hospital. However, dig a little deeper and it becomes clear that this is yet another of many laws that have nothing to do with safety and everything to do with restricting women’s access to a legal medical procedure.

First of all, although the majority of physicians who provide abortions are obstetrician/gynecologists, any doctor with the appropriate training can provide abortions. Although national numbers are hard to come by, in 2010 in Minnesota, family physicians performed over 1/3 of abortions (compiled by @wentrogue). Surgical abortion is considered an advanced skill for family medicine residents by the American Academy of Family Physicians (Dr. George Tiller was a family physician). Medical abortion (using medications to induce abortion) requires less training than surgical abortion and fits well within the scope of practice of general family medicine. Multiple studies have shown that abortion care performed by family physician is as safe and effective as abortion care by obstetrician/gynecologists. (Some pediatricians, emergency medicine doctors, internists, and surgeons have completed extra training to be able to provide medical and surgical abortions, although the numbers are low). There is no medical reason to restrict the practice of abortion to doctors certified in obstetrics & gynecology; this move is clearly political and aimed at preventing women from getting the medical care they need.

Secondly, although on its face the requirement that a physician performing abortions have “admitting privileges” at a nearby hospital appears to be important for patient care, such a requirement is unnecessary and again only serves to decrease access to abortion care. Admitting privileges, or the right for a doctor to take care of his or her own patients in the hospital, are granted by hospitals based on multiple criteria. Doctors who do not have their own local practice or cannot be available to take “call” (to be on-site or nearby to admit patients who have no physician) may be denied such privileges. Also, because such privileges are granted at the discretion of the hospital, they may be denied for purely political reasons (for example, the fact that the doctor applying provides abortions).

Abortion is a very safe procedure; complications are rare. Complications serious enough to require hospitalization are even more rare, occurring after less than 0.1% of first trimester cases. In those rare cases that require hospitalization, a transfer agreement with a nearby hospital is more than sufficient to ensure that patients requiring a higher level of care have appropriate continuity of care. Doctors around the country perform other comparable surgical procedures (such as incision & drainage of wounds and suturing of injuries) without the additional burden of a requirement of admitting privileges to a nearby hospital. Only abortion providers are being singled out, and safety is clearly not the motivating factor.

This becomes even more clear on close reading of the law. Abortion is defined as:

“The use or prescription of any instrument, medicine, drug or any other substances or device to terminate the pregnancy of a woman known to be pregnant with an intention other than to increase the probability of a live birth, to preserve the life or health of the child after live birth or to remove a dead fetus.” (Emphasis mine)

The procedure used to “remove a dead fetus” is the same as the procedure used to perform an elective abortion. Exact same procedure, exact same risks, fewer unnecessary regulations.

Does anyone still want to argue this is about safety?

Women are already waiting

7 Mar

A bill that recently passed in the Utah house would triple the current required waiting time for an abortion from 24 hours to 72 hours. One of the supporters of the bill, Rep. Steve Eliason, stated:

“Why would we not want to afford a woman facing a life-changing decision 72 hours to consider ramifications that could last a lifetime?”

But 72 hours is just the time between clinic visits. Women are already waiting far more time than that when they make decisions about pregnancy.

I recently saw a woman who had done a lot of waiting. I’ll call her Maria. She realized she was pregnant as soon as she missed her period, but I didn’t meet her until over a month later. Maria had spent that month hoping she would reconcile with her estranged husband, hoping her Section 8 application for housing would go through so she and her 2-year-old daughter could move out of her mother’s cramped 1-bedroom apartment, and hoping her hours as a home health aide would be increased so she would have a little more money in her monthly budget. But none of those things happened. She spent a month waiting for her life to change in such a way that she could imagine
going through another pregnancy and caring for another child, but it didn’t. So she decided to have an abortion.

Maria had waited a week for an appointment with me and was entirely certain of her decision. She was 9 weeks and 1 day pregnant when I met her. Unfortunately, that one day ended up meaning more waiting for her. Had she been exactly 9 weeks or less, she could have had a medical abortion that day. Since her pregnancy was more than 9 weeks, I had to make her an appointment for another day when she could have an abortion procedure. When I broke the news to her, she immediately burst into tears. Because it was the day before a holiday weekend, the soonest I could get her in for the procedure was a week later. Because our medical system is not set up to meet women’s needs, Maria would once again have to call out of work, once again find a baby-sitter for her daughter, and spend another week feeling exhausted and nauseous.

Maria waited 4 weeks for her life to get easier, 1 week to see me, and another week to have her abortion. This waiting is not uncommon. Even if she had decided to have an abortion as soon as she was sure she was pregnant, she would have had to wait a few days, or possibly as long as a week, for her clinic appointment. All this in a state with no waiting period at all, with Medicaid paying the cost of the abortion for her, and with a clinic down the street from where she lived. I think about Maria’s challenges and then imagine what life would be like for someone in a similar situation in a state like Utah where insurance is banned from paying for most abortions, where 97% of counties have no abortion provider, and where, soon, all women will have to wait an additional three days to have a legal medical procedure, just because their legislators think maybe they haven’t waited long enough already. It’s a frightening thought.

Women want to know: Does using hormonal contraception increase HIV risk?

17 Feb

Women everywhere want, need, and deserve to know if their contraceptive method increases their risk of acquiring HIV.  This question is not new; for years, there have been equivocal studies on the topic, some pointing towards a potential association, others showing no association.  The topic got new attention in July 2011, when results were presented at the annual AIDS conference in Rome that indicated a potential two-fold increase in HIV infection rates among women using an injectable form of contraception, DMPA (brand name Depo-Provera, a kind of contraceptive that uses a hormone called “progestin”) compared with women who used no hormonal contraception and again in October 2011 when it was published in The Lancet Infectious Diseases. (The study failed to show a significant increase in risk of HIVamong women who used oral contraceptive pills, but it’s not clear if that has more to do with a lack of effect or was simply because so few women in the study were using pills).

In response, a meeting was convened by the World Health Organization (WHO) from January 31st – February 2nd, 2012 to reassess the state of the evidence and to determine if recommendations about the utilization of hormonal contraceptive methods should change for women at high risk of HIV.  Currently, there are no restrictions on the use of any hormonal methods for women at high risk of HIV.

At the meeting, the expert group determined that there was insufficient evidence to change who is eligible for using all methods of hormonal contraception, including “progestin-only” methods like DMPA, although they did add a strongly worded clarification statement reminding health providers and programs that women at high risk of HIV must use condoms consistently and correctly in order to decrease their risk of acquiring the virus.

So, does hormonal contraception, and specifically DMPA, increase HIV risk?  Unfortunately there is no clear answer to that question.  There have been studies in animals that have pointed to potential biological mechanisms for an increased risk of getting HIV while using injectable progestin contraceptive methods like DMPA, so there is a plausible reason to expect an effect.  However, many animal studies of HIV have led us astray in the past.

Looking at the research that has been done looking at humans, some studies show a connection, some show none.  Further muddying the water is that all the studies are observational, not randomized controlled trials (Wikipedia has a good explanation of what a randomized controlled trial is here, but for our purposes it’s a study where people are randomly assigned to a treatment group, in this case either DMPA or oral contraceptives, or an IUD, or condoms.  The main strength is that all the many variations in behavior and biology that can impact results should be equally distributed between the groups and in a way cancel each other out).

When we rely on observational studies, it is much harder to feel confident that we’ve taken into account all the individual factors that can affect the results.  For instance, perhaps women who choose to use DMPA as their contraceptive method are less likely to use condoms than women who use only condoms as their contraceptive method (in fact, we have good evidence that this is true).  When you compare the two groups, you may find more HIV infections in the group using DMPA, but it could be because they are less likely to use condoms than the group of women who rely solely on condoms to avoid pregnancy. There could also be other factors of which we are unaware that are different between the two groups and explain the difference.  The researchers often try to “control” for factors like this statistically, but it is extremely hard to know whether data on condom use (or other sexual behaviors, like number of sex partners or frequency of sexual activity) has been accurately reported.  Just like I exaggerate how often I floss my teeth every time I go to the dentist, and my diabetic patients don’t always spontaneously report the cookie they ate right before coming to the office and having their blood sugar checked, women who are seeing medical staff may not give an accurate description of how often they use condoms and with how many partners they have sex, especially if they have been told over and over how important condom use and having fewer sexual partners is to reduce their risk of HIV.

So where does this leave us?  The disappointing news is that, in 2012, science still doesn’t have a clear answer for us on whether use of hormonal contraception, and specifically DMPA, increases a woman’s risk of contracting HIV, although the experts at the WHO were reassured enough by the evidence that we do have to continue to recommend unrestricted use of hormonal contraceptives for women at high risk of HIV.  Also on the bad news front, many women in high HIV
prevalence settings have few or no other contraceptive options, so they can’t simply hedge their bets and switch to something else with a more clearly established safety profile (like oral contraceptive pills), or to non-hormonal methods (like copper IUDs or sterilization).

However, there is lots of good news.  What we lack in clear answers regarding injectable contraceptives and HIV acquisition is made up for in knowledge of other ways to impact the epidemic of sexually transmitted HIV.  We know that people who know they have HIV are more likely to use condoms, so we need to work on getting voluntary testing for everyone, everywhere.  We know that people who are on treatment are much less likely to transmit the virus to their partners, so we need to get everyone access to treatment; shockingly, less than half of people in need of treatment worldwide currently get it.  And we know that consistent, correct use of condoms greatly reduces the risk of HIV transmission, so we need to work much harder at helping people get over the many barriers that exist to using condoms all the time.

We need to keep offering women as many options as possible for family planning.  Women can safely continue to use DMPA.  The bottom line is that, whether DMPA increases HIV risk or not, condoms are an absolute necessity for all women at high risk of HIV, whether or not they are using hormonal contraceptive methods.

Rectal exams for men and abortion restrictions for women are not the same thing

2 Feb

It always comes up. Usually the argument goes as follows: why do men get Viagra paid for by their health insurance, while women are stuck paying out of pocket for birth control? Senator Janet Howell’s recent proposal to require a rectal exam and cardiac stress test prior to offering prescriptions for erectile dysfunction drugs in order to highlight the invasiveness and over-reach of a Virginia law that proposes to require a woman undergo and view an ultrasound is the most recent and creative iteration of this theme.

While I heartily agree that a state legislature has no place telling doctors which procedures their patients must undergo, and I recognize that the Senator is trying to make a point in a political theater, I think in the end making comparisons such as these do us a disservice. They minimize what a pregnancy truly means in the life of a woman.

Sexual dysfunction is a serious matter that can affect a man’s emotional and sexual well-being in important ways. However, pregnancy affects women in a more profound way. It affects not only a woman’s emotional and sexual well-being, but also her general physical health, and her financial health. If she continues the pregnancy and gives birth it affects every minute of her day for many years to come.

The idea that medical treatment for male sexual dysfunction is a fair analogy to medical treatment to prevent or treat undesired pregnancy has always bothered me. It minimizes the profound impact pregnancy has on women’s lives. I can’t think of any event common to the male experience that compares. And perhaps that is exactly the problem.

What is really at stake in Mississippi?

7 Nov

Mississippi’s “personhood” amendment – up for a vote on November 8th – would certainly be damaging to women’s reproductive health and rights. But the media has consistently reported its implications incorrectly. Even if passed, emergency contraception using levonorgestrel (Plan B) and IUDs should still be accessible.

According to the New York Times, the amendment, if passed, “would declare a fertilized human egg to be a legal person.” The Times goes on to report that abortion, in-vitro fertilization, and even IUDs and emergency contraception might become unavailable as a result. The Guardian relays the same message.

But here’s the thing. IUDs and emergency contraception do not do anything to fertilized eggs. All the most recent science shows this. Both contraceptive methods prevent fertilization (the mainstream media has continued to repeat this flawed interpretation). In fact, just this week yet another study showing that Plan B works by preventing ovulation was published. The study measured women’s hormone levels to determine where they were in their menstrual cycle at the time of unprotected sex. They identified 103 women who had sex in the 5 days prior to ovulation, and 45 who had sex in the 5 days after ovulation. Among the 103 who had sex prior to ovulation and took plan B, none got pregnant, though statistically if Plan B doesn’t work 16 should have gotten pregnant. Meanwhile in the other group 8 got pregnant, while statistically 8.7 should have gotten pregnant. In other words, Plan B only works if you haven’t ovulated yet. If you’ve ovulated, the hormones don’t do anything to prevent sperm and egg from joining and implanting in the uterus. It has no effect on fertilized eggs.

The IUD is a bit more complicated because it works in multiple ways, and there are 2 different kinds of IUDs. However, the preponderance of evidence shows that the IUD also does not do anything to fertilized eggs. Rather, it prevents fertilization. The copper IUD alters the cervical mucus, making it nearly impossible for sperm to enter the uterus to meet an egg. If sperm do enter, their motility and ability to fertilize an egg are reduced due to the inflammatory reaction induced by the IUD. Those few studies that have looks at intra-uterine sperm after IUD placement have found that there are many fewer sperm and that they aren’t able to move like those sperm found in the uterus of a woman without an IUD. The copper IUD works by keeping sperm from getting to and fertilizing the egg; no evidence suggests it has any effect on fertilized eggs. The levonorgestrel IUD (Mirena) is less well-studied than the copper IUD, but evidence suggests it also impacts the cervical mucus, decreasing the number of sperm that enter the uterus, and decreases the chance of ovulation by releasing levonorgestrel into the bloodstream. In other words, it prevents fertilization. No fertilization means no blastocyst, which means no embryo, which certainly means this amendment has no bearing on IUDs.

Yes, there are some unanswered questions. What happens if you insert an IUD between the time an egg has been fertilized and it has implanted, or if it has just implanted? Nobody knows, and nobody ever will know, because it’s just too hard to study. It’s possible that there are some little embryos out there that get dislodged without anyone ever knowing it during IUD insertions. We also don’t know nearly as much about the new emergency contraception pill, Ella (ullipristal), as we do about Plan B, and it’s possible it works by preventing implantation of a fertilized embryo. Probably because of these uncertainties, and because it was approved by the FDA years ago before we had this recent research, packaging for products like the IUD and emergency contraception often perpetuates misconceptions about their mechanism of action. But all the recent science points away from any effects on fertilized eggs, and frankly, I’m not losing a lot of sleep about those rare situations where a fertilized egg might be affected. Every medical procedure or drug has the possibility of a negative impact. If I were to lose sleep about things like this, I’d never be able to practice medicine. I’d always be worrying if the person I recommended a cholesterol-lowering drug to was one of the rare people who would develop liver failure as a result, or if the person I recommended to start biking to work for more exercise would be one of the few people to get hit by a car. I’m certainly not going to worry about the theoretical possibility of disrupting a fertilized egg.

In medicine, we can’t allow speculation and worry about what might be to overshadow the facts. The facts are that, based on the most recent science, IUDs and emergency contraception do nothing to fertilized eggs, much less embryos or fetuses, and the mainstream media needs to stop repeating tired, disproven theories in reporting on this amendment.

Want more abortion providers? Offer them training!

15 Sep

The ongoing shortage of abortion providers is blamed on many culprits: the stigma attached to abortion provision, the hostile and sometimes dangerous practice environment, and even a perceived lack of interest in abortion provision. One of the less known problems, however, is the lack of training opportunities. If medical students and residents don’t have the chance to learn how to provide abortions, they simply aren’t going to be providing them when they’ve finished their training.

Prior studies have shown that an increased amount of abortion training in residency is associated with an increased likelihood of abortion provision in the future. A recent study showed that, in addition to having training available, integrating abortion training into residency training for obstetrician-gynecologists may be key to reducing the abortion provider shortage.

The study followed residents at two different programs. At one of the programs, OB/gyn residents had the normal exposure to family planning (contraception and abortion). In the other program, a structured specialty family planning rotation was instated. Those who participated in the structured program were much more likely to report planning to perform abortions after graduating from residency than the other group. In addition, at the beginning of the rotation only 1/3 of residents planned to perform abortion after residency, while after the rotation all of them stated they would perform abortions.

Results like these show us that although many in the abortion community attribute the decreasing numbers of abortion providers to lack of interest on the part of younger doctors, the situation is much more complicated than that. There aren’t enough training opportunities for those who seek them out, but clearly even those who don’t seek out training find they are interested in providing abortions when they have a high-quality experience with family planning. Abortion training needs to be a regular, structured part of all OB/gyn and family medicine residency programs.

Unfortunately, political resistance to abortion education is only growing. In May, the House approved the Foxx Amendment, which would have prevented residencies receiving federal funds from providing abortion training. Since all residency programs are almost entirely funded by money from Medicare, such a restriction could essentially end all abortion training in residency programs, shutting down the pipeline of new abortion providers. (The Foxx Amendment was not approved by the Senate, granting programs a temporary reprieve).

Several programs are working assiduously to improve training opportunities. If you are a medical student interested in training, Medical Students for Choice has resources to help you increase training at your school, externships you can apply to (some with funding), and guides to help you pick the right residency. Residents can contact the National Abortion Federation for help finding training opportunities if such opportunities are unavailable at their residency. Such initiatives are, however, a drop in the bucket. As the studies above show, leaving residents on their own to pursue abortion training leads to few if any choosing to be abortion providers. Routine training leads to doctors who want to perform abortions after graduating residency. If we want to fix the abortion provider shortage, we have to focus more closely on training opportunities.

Diagnosis: Female?

16 Aug

Lots of people are talking about the decision on the part of HHS that all forms of contraception be covered for all insured men and women for “free” as basic preventive services under health reform. This decision came not a minute too soon. Recently I found myself having to call in a prior authorization for birth control for one of my patients. At first I figured it was just that the insurance didn’t pay for the birth control patch, Ortho-Evra, but did pay for other methods. However, it turned out to be more complicated. The entire conversation took a half hour and went more or less as follows:

Me: This is Dr. Pro Choice. I’m calling to get a prior authorization for ortho-evra for my patient.

Customer Service Associate: OK, let me look into that for you…(5 minutes of terrible muzak later) I’m showing we don’t cover that medication.

Me: Right, that’s why I’m calling. Can you tell me why you don’t cover that medication?

CSA: Let me look into that for you… (5 minutes of even worse muzak later) We don’t cover any contraceptive methods.

Me: What? Are you sure?

CSA: Yes Ma’am, this plan that your patient signed up for does not cover contraceptive methods.

Me: (after a moment of disbelief) So how can I get this for my patient? She can’t afford it on her own. She has Medicaid.

CSA: You can make an application.

Me: Great, let’s do that.

CSA: What is the diagnosis?

Me: Diagnosis?

CSA: Yes, what is the diagnosis?

Me: (long pause) Female?

CSA: That is not an accepted diagnosis

Me: Human? Able to get pregnant? Sexually active?

CSA: Those are not accepted either.

Me: Umm, OK, menorrhagia [not the real reason but a ‘real’ diagnosis].

[1 minute on hold]

CSA: Your request has been approved.

I wish I could say I made this up, but it happened just a few weeks before this decision came from HHS. There IS no diagnosis code justifying contraception as a way to avoid pregnancy, because diagnosis codes are built around illness. Avoiding pregnancy usually isn’t about already being sick, it’s about preventing something from happening. So birth control clearly belongs in the list of preventive services.

I fear politics will get in the way of the HHS ruling that all contraceptive services be covered free of charge under all insurers starting next year, but if not, women with private or public insurance will not have to pay for their birth control. This is a huge step for all women, and a small step for doctors like me who will no longer have to have conversations such as the one above.

IUD insertion immediately after abortion: Time to break down the barriers

30 Jun

Although women get abortions for many reasons, the majority of women choosing abortion do so because they got pregnant when they didn’t want to be. It stands to reason that at the time of the abortion is a perfect time to help women start using highly effective contraceptives. One of the most effective methods, the IUD, is an ideal choice for women without plans to become pregnant in the short-term because once inserted it is effective for 7-12 years (depending on which IUD is chosen) and requires no ongoing maintenance, unlike other methods which require visits to clinics and remembering to take a pill daily, change a patch or ring, or get a shot every 3 months. All of this ongoing maintenance requires time and money.

So the IUD offers women a simple, long-term, easily reversible contraception that is as effective as tubal ligation (having one’s tubes “tied”). It is also the most cost-effective method available (when used long-term; the costs over the first few years are higher than other methods). So what’s the hold-up? Why do only 5.5% of Americans use IUDs?

Women do not get the most effective contraceptive care for the same reasons that many Americans don’t get the most effective health care in general. We have a system built on a fee-for-service model that relies on short-term membership in private insurance plans, which disincentivizes investment in preventive, cost-effective care that has up-front costs. We have a system that bills per service rather than for caring for a patient. We have a system in which pharmaceutical and device companies raise their prices significantly with impunity. (We also have a culture that systematically misinforms teens and adults alike about sex and contraception, but you can read about that here, here, and here).

Many women with private insurance find that their insurance does not cover one of the most effective, and the most cost-effective, methods available. The IUD itself can cost over $800, with the insertion fee from the physician easily bringing the cost to $1200 or more. Because many young people will change from insurer to insurer as they change jobs, the companies generally do not want to invest that kind of money into pregnancy prevention for their members. What makes sense for the individual, or even our society as a whole, often does not make sense for a profit-driven insurance company.

Billing is another barrier. Unfortunately, all clinics providing reproductive health care must pay attention to their bottom line. They can’t provide the vital services they offer if they don’t stay afloat. So unnecessary requirements, such as lack of reimbursement from insurance companies for IUD insertion done on the same day as an abortion, substantially hamper access for women. The result has often been that women have to wait until their follow-up appointment to get their IUD inserted, meaning they have to go through another procedure (when the IUD could easily have been inserted in less than 1 minute if done immediately after the abortion) and also have to make it to a follow-up appointment, which means more time off from work, more money for child care and transportation, and often more money for the visit to the clinic.

Barriers within the medical system also get in the way; some physicians believe that inserting an IUD immediately after abortion is more likely to cause complications and more likely to self-expulse (or fall out).

Because of these barriers, many women who want to use an IUD for contraception after an abortion are leaving without one. Although they are given follow-up appointments and theoretically should as a result have good access to IUDs, the fact is that many women are slipping through the cracks.

Fortunately, a new study shows that IUD insertion immediately after an abortion is safe and effective, and most importantly prevents repeat unintended pregnancy. 575 women who wanted an IUD after their abortion were randomly assigned to two groups: one group that had the IUD inserted immediately while the other was given a follow-up appointment for the IUD two to six weeks after the abortion. Not surprisingly based on prior studies, the group that had the IUD inserted immediately after the abortion had a slightly higher expulsion rate (5% vs. 2.7%) than the delayed insertion group. Though this might sound like an argument against immediate insertion of IUDs after abortion, what’s actually important is how the individual woman is affected. Despite this higher expulsion rate, NONE of the women in the immediate insertion group were pregnant within six months, as opposed to FIVE in the delayed insertion group. All of those pregnancies occurred among the 29% of women who never managed to get their IUD after their abortion.

Bottom line: immediate IUD insertion after abortion is safe, effective, saves money, and most importantly, prevents unintended pregnancy! I hope that policy-makers and doctors will take note of this study and take action to break down the medical, policy, insurance, and financial barriers that keep women from getting the best care possible.

Why Later Abortions Must Always be an Option

7 Mar

A brave couple shared their story of the consequences of being denied an abortion in the Des Moines Register last week. Danielle and Robb detail the heartbreaking weeks they endured after finding out the fetus that in their minds was to become a healthy baby girl would most likely die, and would never have anything resembling a normal life.  Because they were past 20 weeks gestational age, a newly-enacted law in Nebraska prevented them from obtaining an abortion.  Eight days later, a severely premature infant was born and died within 15 minutes.

I had a patient in a similar position.  But her story ends differently.

Maria’s* early ultrasound showed a normal pregnancy, and everything went according to plan until her 20-week ultrasound.  That ultrasound looked abnormal, and she returned for a more detailed look a week later.  That was when she found out the fetus she was carrying, the baby girl she was dreaming of holding in a few months, had severe brain and spine abnormalities.  At this point Maria was at 21 weeks. She had two choices in front of her: have an abortion or continue the pregnancy.  We talked about her options, and she decided that the prospect of waiting for the fetus to die inside her, or giving birth to an infant who would know nothing but pain for no more than a few days in her life, was a more heart-wrenching option than an abortion would be for her.

Continue reading

Dr. Gosnell and William Saletan: Bad Medicine

18 Feb

Kermit Gosnell was a bad doctor.  He practiced outside the scope of his capabilities, employed unqualified staff, did not appropriately dispose of medical waste and failed to use aseptic technique.

Unfortunately, there are other bad doctors out there.  Lots of them. On February 17, 2011, Dr. Rey Bello of New Jersey surrendered his medical license for performing unnecessary tests, fraudulent billing, and incompetence.    Dr. Conrad Murray will soon go on trial for his role in the death of Michael Jackson; his alleged activities include administering IV narcotics and medications used only in surgery. Dr. Hellfried Sartori has a near 30-year record of using dangerous, ineffective treatments all over the world despite multiple revocations of his license to practice medicine.  Delaware pediatrician Dr Earl Bradley was indicted last year for sexual abuse of over 100 children.

The good news is that although there are a few bad doctors out there, there are a lot of great ones.  My colleagues and I are kind, caring, sensitive, and so devoted to taking the best possible care of our patients that we literally will reach out to people from all over the country for help if we encounter any unfamiliar scenario.  We go to medical conferences several times a year and spend hours every week reading medical journals to make sure we are on top of the latest research.  We study every aspect of abortion provision to continuously improve our services, from the experience in the waiting room to the best way to provide follow up care.  We go to bat for our patients both in the exam room and on Capitol Hill, and are involved in regulatory efforts on both local and national levels to improve access to family planning services.

William Saletan described what he deems a similar situation to the fiasco surrounding Dr Gosnell in Florida 20 years ago, and comes to the conclusion that physicians were complicit because they were too afraid to point out unsafe conditions at an abortion clinic:

“As little as the good providers trusted the bad ones, they trusted the government less. Nothing would make them break their silence. Not even a woman’s death.”

The suggestion that any of us would not act on the knowledge of a doctor providing dangerous care is insulting to us all.  We work tirelessly to make sure all women have access to safe abortion care. We are anything but silent in the face of the many challenges women face and we expect all abortion clinics to provide the highest quality of care to everyone.

Our patients trust us, as should Mr. Saletan.