Wisconsin’s Strange History of State-Sponsored Sterilization

“It would be a rare phenomenon if the progeny of two mentally deficient parents were not likewise deficient. Yet in every state there are hundreds such in the pauper class free to bear children of whom a large percentage are certain to have criminal tendencies, murderous proclivities or vicious social traits. The public expense and private property loss they cause is beyond computation, and their presence at large is a menace that grows with the spreading branches of their family tree. What’s to be done?  ‘Well’, says Mr. John Average Public, ‘Why not try a safe and sane compulsory human sterilization law conservatively administered as in Wisconsin?’”

Frank C. Richmond, State Director of Psychiatric Field Services, 1934

The Law

People tend to be shocked when I tell them that the last state-sponsored sterilization in Wisconsin took place in 1963. It gives one a lot of cognitive dissonance imaging that some surgeon could have performed a coerced salpingectomy one afternoon and then popped over to the cinema to watch The Birds.  But so it was, and the law that permitted such operations actually stayed on the books until 1978. Although estimating the exact number has proven difficult, between 1,500 and 2,000 people were sterilized by the state under the Wisconsin Sterilization Act.

The passage of the act in 1913 was a victory long in the making for proponents of the practice of eugenics.  Wisconsin prided itself on using science to guide state policy, and eugenics was endorsed as science by representatives from the University and beyond. Writing a half-century later, Rudolph J. Vecoli documented in fascinating detail how “the congruity between  the eugenic doctrines and  certain aspects of the Progressive mentality,” including the Wisconsin Idea of connecting university and government, folded neatly into the creation of a law to restrict the freedom of its citizens to reproduce. Nonetheless in the early years of the 20th Century sterilization remained controversial and politically risky.  A law preventing the unfit from marrying had been passed in 1907, but it was unpopular and fated to be overturned in the courts the following year.  In the intervening years, two bills that would have codified state-sponsored sterilization had been defeated in the legislature. The 1913 bill succeeded in part because it was promoted as a conservative approach that would not take the extreme measures that had been seen in other states (then as now, a lot could be achieved in Wisconsin politics with by rallying around shared distaste for Illinois).

EugenicsPoster1926

Education poster from 1926 (source)

Wisconsin was the eleventh state to legalize compulsory sterilization, but it was not the last.  Thirty-two states passed sterilization laws in the 20th century, and five more generated a historical record of involuntary sterilizations without the blessing of the legislature. Wisconsin is an instructive case precisely because it kept the scope of its sterilizations narrow.  While other states defined the unfit broadly or loosely, and some used sterilization as a punishment for criminals and sex offenders (in Oregon men could be castrated for having sex with other men), Wisconsin separated the concept of sterilization from punishment.  The law outlined only three conditions that justified it: epilepsy, insanity, and “mental deficiency.”

Wisconsin’s law represents one of the least extreme cases of government regulation of fertility, and as such it is among the most instructive. In his book Breeding Contempt: The History of Coerced Sterilization in the United States, Mark Largent notes that in historical debates surrounding sterilization, “Even the most aggressive opponents of coerced sterilization often set aside some particularly problematic group for the procedures,” and the same might be said to be true today. People with cognitive disabilities are often made to occupy that role of the particularly problematic group for whom an exception might be made to the concepts of autonomy and the right to reproduce, opening a back door to legitimization of coerced sterilization.  Of the three medical conditions made explicit in the law, mental deficiency provided the rationale for surgery in the overwhelming majority of cases, perhaps because it was the most acceptable.  As it was put by one prominent supporter of the law, University of Wisconsin professor of sociology E.A. Ross, “The wedge should have a very thin end indeed. Sterilization should at first be applied only to extreme cases…As the public become accustomed to it, and it is seen to be salutary and humane, it will be possible gradually to extend its scope until it fills its legitimate sphere of application.”

The Institution

Right about here is where I would like to plunk a picture of Dr. A.W. Wilmarth, M.D., who will be playing the role in tonight’s blog post of Guy on the Wrong Side of History. But since I would have to pay for the rights, here’s a link to the Wisconsin Historical Society’s picture of him instead. Wilmarth was the first superintendent of the Wisconsin Home for the Feeble Minded in Chippewa Falls, which was later called the the Northern Colony and Training Center, and still exists today as the Northern Center for the Developmentally Disabled. The Northern Center was the site of Wisconsin’s state sterilization program. It was created by state law in 1895, under the bureaucratic oversight of the State Board of Control, which administered the prison system as well as institutions for people with varying types of disability, and mental hospitals.

From the first, the Northern Center’s founding was tied to the prevention of procreation.  In his first report to the Board of Control in 1898, Wilmarth wrote, “The three objects that prompted the foundation of the ‘Home’ are already being largely realized. First, the relief of over-burdened families…Second, the curtailment of the increase of the feeble-minded and epileptic by the sequestration of feeble-minded women of child bearing age…Third, the education of the imbecile to his highest sphere of usefulness.” Within a few years the number of applications had grown larger than the Center’s capacity, and the Board of Control gave its highest priority to women of childbearing potential.

NorthernCenterFootballTeam

Members of the Wisconsin Home for the Feeble Minded’s 1910 football team, which competed against area high schools.

The sterilization procedures were vasectomies for men and salpingectomies for women.  They were performed by the Northern Center’s consulting surgeon, first J.V.R. Lyman and then after his death, S.E. Williams.  Lyman and Williams were general surgeons for whom sterilization was only a part of their service at the Center; in the center’s 1932 biennial report Williams is reported to have performed appendectomies, hemorrhoidectomies, herniotomies, a mastectomy, and two leg amputations.  In several cases, salpingectomies are known to have failed.  Records of the operations, housed at the Wisconsin Historical Society and publicly available through 1935, show that twelve women sterilized before 1935 were subsequently known to be pregnant; of these three underwent the operation a second time.

The Diagnoses

From the end of the 19th Century to the beginning of the 20th, the concept of feeble-mindedness was shaped into something that overlaps to a great extent with our contemporary concept of cognitive disability.  For a thorough history of this topic I recommend James W. Trent’s Inventing the Feeble Mind.  I will emphasize just a few relevant points.

Feeble-mindedness was divided into three categories based on mental age or IQ.  The most severe was the idiot, followed by the imbecile, and then the highest functioning, the moron. Though these words are still in common usage, few people know their origins as the R-word of their time–knowing makes you not want to use them.  In addition to these categories of cognitive ability came the innovative concept of the “moral imbecile,” who was deficient less in cognition than in the sense of right and wrong. The moral imbecile was defined not even by anything as pseudo-objective as an IQ, but by failure to live within socially approved codes. From a diagnosis for aberrant behavior it was a short leap to connect feeblemindedness to societal “ills.” The idea became so entrenched that a Board of Control statistician could claim, “This defect is responsible for more pauperism, delinquency and crime than any other one force.”

Although mental deficiency was understood to arise in some cases from environmental factors such as congenital venereal disease and traumatic brain injury, it was generally acknowledged that hereditary factors were responsible for the majority.  “The certainty of heredity has been so thoroughly established,” Wilmarth wrote in the 1918 board report, “That the tendency to transmit mental weakness, or instability, is no more to be disputed than the accuracy of the multiplication table.” The Northern Center routinely published the results of pedigrees tracing familial feeblemindedness alongside with more familiar statistics such as institutional censuses and causes of inmate deaths. Thus sterilization came to be understood as a response to not only intellectual disability, but to depravity and antisocial behavior.

Complex Motives for Sterilization

Sterilization in Wisconsin was first and foremost a eugenics program, but the practice of sterilization at the Northern Center was not entirely consistent with a eugenic rationale.  Most glaringly, 91% of the patients who were sterilized were women, despite women constituting 49-55% of the patients in a given year.  If mental deficiency were truly a Mendelian trait, then men with mental deficiency had just as much potential to affect the societal gene pool as women. To be fair, that basic genetic fact is frequently forgotten.  Wilmarth wrote in 1914, “The women especially, not only carry and scatter loathsome disease, but reproduce and multiply their kind.” Men’s role in procreation and transmission of STIs is minimized in American culture in such a breadth of contexts that it would be surprising if it were otherwise at the Wisconsin Home for the Feeble Minded.  Nonetheless, one of the hallmarks of the eugenics movement is its frequent recourse to biology and dismissal of any argument not founded in science.  This departure from rational principles is telling.

The concept of the moral imbecile was inherently gendered.  In the same screed in which he made reference to women carrying disease and procreating, Wilmarth described the moral imbecile as essentially comprising two categories: male thieves and female prostitutes.  “The boys are familiar figures at the juvenile courts,” he tells us.  “The girls begin vicious practices early and frequently commercialize their vice.  Most careful investigation over a large field demonstrates that the majority of women who gain their living on the streets are of this class.”  Although moral imbecility was understood as an inherited condition, to my knowledge, no one in Wisconsin claimed that theft or other male malfeasance was remediable by sterilization.  Fertility was, however, considered highly relevant to female promiscuity.

The Board of Control’s Director of Psychiatric Field Services, Frank C. Richmond, wrote an article for the Journal of Criminal Law and Criminology in which he suggested that the discrepancy in male and female sterilization was attributable to men falling through the cracks in the system. “Many more  females  have  been  sterilized  than  males,” he wrote, “Because  as a  rule only  non-delinquents  have  been  sterilized  while  the  mentally deficient  criminal  population  has  been  exempt  from  such  procedure. Were  mentally deficient criminals  to  be  dealt  with  adequately by  way of  sterilization  the number of  males  sterilized  as  compared to  females would  be  evened  up  or  reversed.” Here maleness is constructed as a determinant of criminal behavior, and it is possible that that is what Richmond literally meant.  It is also possible, however, that he was not including female promiscuity under the umbrella of criminal behavior because it was a problem that could be solved by sterilization itself–a disease with a cure.

In the earliest days of coerced sterilization, its champions often claimed the operations were of therapeutic benefit, primarily through reducing patients’ sexual desire.  Trent cites a letter written by Wilmarth in which he suggest that oophorectomy would reduce sexual desire, but since salpingectomy was ultimately chosen instead, it is not clear that the staff of the Home believed that the operations would directly affect sexual behavior.  They were probably exposed to evidence that it was not a bulletproof cure for promiscuity; there is record of at least one patient whose parole was terminated because she “had begun to lead an irregular sexual life”—perhaps that was code for having sex with women, but it is difficult to tell.  Whether or not sterilization was considered medically therapeutic, it was often argued that prevention of pregnancy was in female patients’ best interests. “No woman should be allowed to become the mother of nineteen defectives,” Wilmarth wrote in 1906. “The State must protect such women from themselves, and incidentally the public purse and public morality.”

There does seem to have been recognition that women with cognitive disabilities were especially vulnerable to sexual assault, although the historical concept of consent for such women is a complex topic in itself. Viewed from this angle, the sexually indiscriminate, morally imbecilic female became the victim of sexual predators. Most of the time, in fact, the two concepts of sexuality were reconciled.  A woman could be simultaneously the victim of a sex crime and the perpetrator of a social crime. “In a feeble-minded person the animal passions are usually present and are often abnormally developed,” wrote Irene Beier in 1938 in The Operation and Administration of the Northern Wisconsin Colony and Training School. “The feeble-minded woman is perhaps the worst offender.  She cannot resist the persuasions and temptations that beset her.  Society needs to be protected from her…Irresponsible and innocent of intentional wrong, she brings to our very doors the most destructive and insidious of evils.”

Here again it would be most surprising if the Home for the Feeble Minded were found to have been sheltered from the cultural construct of victim blaming.  In a world where preventing rape was and is considered the responsibility not of future rapists but of potential victims, where sexual assault was and is treated as a known risk of being born female, and where legal consent to sex was and remains presumed, something less than Olympic-level mental gymnastics are necessary to hold a woman as simultaneously a criminal and a victim of the same crime.

CarrieBuck

Carrie Buck of Buck v. Bell fame was raped in 1924 and became pregnant. The pregnancy was used as evidence of her moral imbecility and led to her commitment and sterilization in Virginia

Moreover the capacity to consent to sex and the capacity to consent to surgery are intertwined.  It was an aim of the 1913 law and its application that all of the sterilizations be consensual.  The Sterilization Act laid out the rules for due process, requiring both the consent of the inmate’s family or guardian and the assent of the patient. Richmond estimated that “Objection is registered in about 20% of the cases by parents, relative or guardian. Perhaps one inmate out of 25 personally refuses to consent to sterilization.”  Of course, where consent was withheld, “Detention or segregation continues indefinitely,” making the whole concept something other than consensual. The law also required certain procedures for contacting the patient’s family for this purpose, but if the family could not be found, their consent was presumed.  So proponents of this model had motive to insist that where a mentally deficient person failed to prevent incursion into her body, she should be judged a willing participant.

As the Home for the Feeble-Minded evolved into the Northern Colony, its mission came to include rehabilitation and reintegration as an alternative to permanently isolating inmates, and sterilization came to be seen through a new lens, neither eugenic nor moralistic but pragmatic.  Trent has written about how the demand for care for the developmentally disabled far outstripped the capacity of state facilities, making parole an increasingly attractive option, and sterilization took on a new role as it was deemed crucial to reintegration.  Consistent with that reading, 72% of the Wisconsin inmates whose records are publicly available were at some point paroled or placed in paid positions. On the other hand, that means that more than a quarter of the sterilized inmates were never paroled. Sterilization was not performed on inmates who were slated for parole; rather inmates to be paroled were selected from among those already sterilized. 

Richmond’s article suggests another motive for sterilization related to the freeing up of space. “A  small  number,” he tells us, “Has  been  transferred  to  county asylums  for  the  chronic  insane  whose  transfer  otherwise  would  have been  objectionable  and  impracticable  since  they  are  prone  to  escape from  and  cause  complications  at  the county  asylums.” Transfers perhaps represent the mirror image of the parolees—patients whose condition is considered so hopeless that they are unlikely to benefit from continuing at the Northern Center.  At this end of the medical classification scheme, too, sterilization is an integral part of the plan of care.

The gender imbalance among the sterilized meant that a man admitted to the Northern Center had a much smaller chance of leaving than did a woman.  In the gendered framework of the “moral imbecile,” such a pattern makes sense.  An innate proclivity for theft has no cure, but a salpingectomy—well, if it doesn’t prevent promiscuity or sexual assault, it does help to make them invisible.

The Stories of the Sterilized

The sterilization books from the Northern Center, spare as they are, nonetheless hint at the biographies of the patients who underwent these operations.  Of the 452 whose records are in the open books, 71% were initially paroled to relatives or placed in employed positions.  Of these, 59% were ultimately discharged.  Among the remaining parolees, fifteen escaped, five died, 18 were returned to the Center, 19 were ultimately transferred to other facilities, and 86 were still paroled or placed at their last notation.  Of those who were not paroled, 67 inmates were transferred immediately after their operations, and three immediately escaped. Twenty-one died before leaving the center, and sixteen are not noted to have left or died, and thus are assumed to have stayed.

Fourteen women were listed in the sterilization books with the title “Mrs.,” presumably indicating that they were married at the time the operation was performed.  Titles were not routinely used, so it is not clear that this constitutes a definitive list.  Many women were admitted to the facility with their children or while pregnant.  A full accounting of these numbers is not possible without access to the full archive, but these mothers are recurring figures in Wilmarth’s laments.  Seventy-nine patients, all of them women, are recorded as having been married after their operations.  Four of these were escapees who were married within days of running away—one can impose on such a structure narratives of escaping in order to be married or marrying to avoid being returned.

WisconsinFeebleMindedChildren

Child Inmates at the Wisconsin Home for the Feeble Minded, date unknown (source)

And now…

Eugenics, of course, is no longer a mainstream part of science or politics, though many of its precepts persist in other guises and under other names.  So what place does sterilization occupy today in the care of the cognitively disabled?

It seems to be a received idea that the practice remains quite common, but empirical estimates of its prevalence are difficult to find.  Two peer-reviewed studies estimate that the prevalence of sterilization is 22% among developmentally disabled women in both Belgium and Mexico, but to my knowledge there are no comparable estimates available for women in the United States in general, or for Wisconsin specifically, and there are no estimates for men anywhere.

The official position of the American College of Obstetrics and Gynecology (ACOG) is that, for patients with cognitive disabilities who choose contraception or have it chosen on their behalf, the method that restricts future reproductive choices the least should be preferred. To the extent that ACOG represents the mainstream, medical culture has come a long way from Wilmarth’s heyday.  But the mere fact that such a guideline is necessary highlights the ways in which fertility occupies a different place in the lives of people with cognitive disabilities than it does for those without them.

As late as 1997, a mailed survey to special educators in Virginia (a state with its own complex history of coerced sterilization) found that many of the ideas articulated by early 20th Century eugenicists have persisted. “The majority of respondents “felt that sterilization should be encouraged  for  persons  with disabilities,” the author found.  One of the reasons cited was “protection from rape or assault.”  Moreover, “Another reoccurring subtheme at the center  of the issue of  sterilization  was the  ‘burden’  the  situation  would  place  on  taxpayers  and  society  at large.  These  respondents …felt  that by not enforcing sterilization  for persons  with disabilities,  more  special  education  students  would be produced and have a need for financial  assistance.”

With the advent of the current generation of long-acting reversible contraceptives, one might wonder why sterilization continues to loom so large in reproductive health for patients with cognitive disabilities.  Perhaps it speaks to the depth of what Largent calls, “our ongoing compulsion to locate the source of complex problems within certain citizens’ testicles and ovaries.”  It seems that in a time of very real threats to the social fabric of the United States, the prospect of cognitively disabled parents still inspires fear that can only be soothed by permanent intervention.

What I Learned on my OB/GYN Rotation

OB/GYN happened a few months back, but I haven’t blogged about it yet. Area medical student discovers blogging difficult to schedule during third year. Story on page 12. Ahem. Anyway, here are some more lessons learned:
saying-vaginas-could-save-your-life

  1. The human body is freakin’ amazing, and female bodies are amazing in specific ways. I mean, the human ovary, man. This is an organ that ruptures and heals itself once a month for like thirty years. The first time I saw an ovarian cyst removed, I was confused about why we were closing up when the de-cysted ovary still looked like a frittata, but the attending told me, “In a month or two it will have completely remodeled and repaired itself, like you never know we were here.” That’s pretty wild.
  2. I am not a future surgeon. Yeah I could have told you that before, but I am so strongly interested in reproductive health (this is the one rotation during which I actually looked forward to studying for the stupid SHELF exam) that part of me thought maybe, just maybe. I liked my residents, I loved the patient population, I was interested in the diseases, but I just don’t love the OR. I really like to talk to my patients, which is less fulfilling when they’re unconscious. And I can’t get used to the practice of avoiding contamination by resting my hands on an anesthetized patient as though they were a table.
  3. Here is a list of surgery-adjacent activities that are acutely physically painful: Standing for hours, sitting for hours, holding retractors in the same position for hours, keeping ones hands sterile for hours by folding them over ones thorax as though preparing to break into a chorus of How do you Solve a Problem Like Maria?, being the first person awake in your whole neighborhood (mediated by emotional pain). Have I mentioned I’m about to start my surgery rotation?Miranda
  4. Ovarian cancer really sucks. I’ve made a pest of my self on every rotation since OB/GYN trying to get my superiors to test for ovarian cancer in patients who are in the hospital for, say, psychiatric disorders. As you probably know, the biggest challenge is getting a diagnosis early, because the symptoms are not very specific and are often ignored. If you haven’t yet, tell your gal pals, your girlfriends, your wives, your sisters, and your moms over 40(ish), not to ignore digestive, urinary, or abdominal symptoms. Meanwhile I’ll try to work on their doctors (not the OB/GYNs, though, they’re on it).
  5. Spanish skills are in short supply around here (see the photo below, taken in the surgeon’s lounge, of the cup of soup that had been reserved for a chief resident). Because of cost, interpreters were sometimes only requested on the L&D floor when there were at least three Spanish-speaking patients. The thought of going through labor surrounded by people who can’t understand you gives me chills. As far as my education went, having enough Spanish to hang got me a lot of opportunities to work with patients. But I also found out the hard way while rounding on a patient the morning after her c-section that I didn’t know how to say “pass gas”–I racked my brains unsuccessfully for a Spanish translation of “fart,” and finally wound up acting it out. I figure there’s about a 30% chance the patient in question just wanted to see what I would do. IMG_0421
  6. Among OB/GYNs, gender was a weaker predictor of awesomeness than I expected. The only clinician I observed exhibiting true indifference to patients’ comfort was female. There were certainly some male OB/GYNs who truly believed themselves to be the victims of discrimination, and that was, ahem, frustrating. As one of my female colleagues put it–and in order to honor her original wording while preserving this blog’s PG rating I will be making use of the French word for seal–“Oh, they’re at a disadvantage in one field? Boo Phoque3-ing hoo.”  On the other hand, one of my awesomest male colleagues really clicked with this rotation, and I’m psyched about it, because of things like this: When one of the attendings found out he was considering OB, she encouraged him to talk to some of the male doctors about their experience. “Why would I need to do that?” he answered. “I already talked to the female doctors.” Basically a doctor with humility trumps a doctor whose genitals and/or gender identity matches your own.

Six Times Psychiatry was Accurately Represented in TV or Film

This post was brought to you by my psych rotation. I won’t be telling you anything, really, about my experiences on the psych unit, because these are some of the most vulnerable patients in all of medicine and it doesn’t feel appropriate. Media representations of psychiatry, on the other hand, I will talk about all day. It’s been on my mind ever since the morning I got to sit in on some ECT sessions. ECT, if you’re not familiar, is Electroconvulsive Therapy, colloquially called shock treatments, and if you are familiar it’s probably because you’ve had some. Otherwise chances are you’ve been exposed to some wildly inaccurate conceptions of this medical procedure.

I haven’t experienced ECT as a patient, and wouldn’t presume to speak for those who have. As a rule, however, modern ECT is not represented in media from the patient’s perspective, and for good reason: that would be hard to film, and boring, because patients go through this procedure under anesthesia. In fact it’s kind of boring to watch IRL, in the best possible sense. ECT is performed with the patient 1) asleep and 2) medically prevented from having muscle spasms associated with some types of naturally occurring seizure. The patient points their foot, and makes a face (caused by involuntary muscle contractions, not pain, see above asleepness), and that’s the whole show. Well I guess the machine also makes an inoffensive beep to make sure everyone knows the shock is being administered. But there’s just…not much to see. Do these important details come through in the way ECT is represented in, say, Homeland?

HomelandECT

Haha, not likely! No, Homeland wants you to know that mental health treatment not only ruins careers, it looks and sounds like a living nightmare. At least that’s how it seems by the end of Season 1; I stopped watching after that because of this scene. Also because of the more than slightly exploitative approach to its protagonist (as this blogger put it, “It says a lot that for the most part the obsequious wannabe terrorist was a more sympathetic character than the mentally ill woman he was conning”), because of its casual islamophobia, and because it is a major pet peeve of mine when supposedly hardened, CIA-employed characters say nonsarcastic lines like, “My god. You’re in love with him!”

Look ECT isn’t magic, though TBH it can feel that way when a really sick patient who isn’t responding to medications or therapies starts to get better after having this treatment. This isn’t going to be a summary of the evidence base surrounding its use, though please feel free to post one on your own blog. I raise this issue because I think it typifies the representations of psychiatry and mental health care in popular culture. In contrast to the way medical doctor characters are so often written as relatable heroes (Grey’s Anatomy, E.R.), or at worst as lovable scamps even when their behavior is sociopathic (Scrubs, House), our baseline cultural understanding of psychiatry is pretty different. I object to the double standard. There are deep historical reasons for the mistrust between the public and psychiatrists, but yo, there are deep historical reasons to distrust anyone remotely connected to medicine (paging Dr. J. Marion Sims). I don’t believe the double standard is fair or accurate. The stigma attached to mental illness is bad enough–do we have to stigmatize the treatment of those illnesses too?

And so, by way of counteracting the trope of the sadistic power-mad and also just vanilla-mad shrink, I have assembled a collection of representations that I believe give a more realistic picture of psychiatrists. They’re not hero-healers, they’re just folks, and sometimes they help their patients live with incurable and potentially life-ruining diseases. This is list is by no means comprehensive–hello, I’m in medical school, I don’t have time to watch good TV, much less shows I hate like The Sopranos–but let me know if you’d like to do an updated content analysis some day. Here is a link to an out-of-date scholarly analysis if that’s your bag.

Below the jump the entire post is spoilers. Continue reading

What I Learned on my Radiology Rotation

1. Radiologists are, on average, pretty chill, happy people. They also, on average, swear a lot, which relaxes me and frees up the 25% of my mental effort that usually goes toward not dropping F-bombs, for learning.

2. Most kinds of images are not taken by radiologists themselves, they’re done by radiology technicians. I already knew that, but I’d never thought about it before. An experienced and knowledgeable tech makes all the difference in the world. Incidentally it takes them a buttload of time to train, and they’re highly specialized to the kind of images they take. Most of the techs I asked said that good communication with the doctors was everything. Also they would like the doctors to appreciate that some pictures are just really hard to take, and that they are doing their best.

3. Imaging is a consultation, not an order. The x-ray doesn’t spit out an answer; what you get is another doctor’s assessment of the patient’s condition.

4. Therefore, radiologists really, really, really, really, really, want clinicians to provide a clinical history when they order imaging. What they are looking for and how they interpret what they find are both influenced by the patient’s story. You know, like, everything else in medicine. And no, they can’t look it up in the patient’s chart. Another med student on this rotation with me ran the numbers and figured out that if the radiologists at UW took two minutes for each patient to look into their charts, it would add 7 hours to their day.

5. MRA can stand for Magnetic Resonance Angiography. I now plan to imagine the uglier corners of the internet as arteries.

MRA-Kidneys

6. The experience that trained me the best for reading images is taking Art Humanities in college. In case you were looking for another reason why premeds should get a liberal arts education.

7. ALARA, as you may know, stands for As Low as Reasonably Achievable, and it is the principle that guides exposure to radiation from medical imaging (and other things). I checked, and the number of US babies named Alara is on the rise. How many of their parents are radiologists, and how many are teenagers that are into Magic the Gathering? We’ll never know.

AlaraBabies

One Scholarly Article and One Comic about Talking Pills

First, the serious. One of the papers that came out of my dissertation work has just been published at Annals of Epidemiology (wide grin) and is available here. The paper takes advantage of a historical event, which is the halting of on arm of the Women’s Health Initiative Trial in 2002, after the trial found that the use of estrogen and progesterone in midlife women modestly increased risk of coronary heart disease. After that announcement a lot of women quit their hormonal medications cold turkey, and if you happen to be hooked up with a study that was following a cohort of midlife women before and after that date (which I am), that abrupt shift in prescribing and use of medications creates a natural experiment. My adviser said I can’t call it that but I’m doing it anyway cause I already have my PhD and they can’t take it back. Anyway, point is, we used these conditions to look at an outcome that has never been examined well in a large randomized trial of hormonal medications: sleep apnea. We found that up until the Women’s Health Initiative made its announcement, hormone use was associated with less sleep apnea. After that date, though, the association disappeared. The biology of the medications didn’t change, but its social context did. We argue that is evidence for what we epidemiologists call a Healthy User Bias; in the early period, hormonal medications were a marker for healthiness, and created a spurious association between the meds and lower risk of sleep apnea. So if this is your kind of thing, feel free to check it out at the link above.

And now, the silly.

PillAuditions

[click on comic to see it larger]

I’ve been doing a lot of book learnin’ lately, and I keep getting hung up on this phrase that I see a lot. “This medication/procedure/practice has no role in the treatment of this disease,” is how it goes. It’s code for, “I don’t care how they taught it when you were in med school, stop doing this now before you hurt someone.” It’s always struck me as a sort of odd euphemism. So I made a comic about it.

Why I Don’t Need a Mirror

Like a lot of things that have made my life better, this one started by accident. When we moved into our current apartment, we decided to take the doors off the closets, and the closet doors happened to be where the full length mirrors were installed. I fully intended to put them back up, but in the time it took us to unpack, I began to notice that not having mirrors was changing my behavior. And it was good.

I’m not sure I was fully aware of the Socially Acceptable Outfit Vortex until I was well out of it. But it would go something like this. I would get dressed. I would stop to check myself in the mirror. Something about what I saw made me unhappy–the look I thought was classic turned out to be dowdy, the color combination was too hard to pull off, the length of the hem made my knees look wide. So I would change my top. Back to the mirror. This combination looks weird. Go change into different pants. Back to the mirror. Pretty soon I was just looping between the dresser and the mirror, rejected clothes piling up on the bed. I have been late to work because of this behavior. I have lost so many hours I could have spent doing literally anything else. The cycle never ended in my leaving the house feeling like I had nailed the right outfit, and was ready to take on the world. In fact it almost never left me feeling okay.

SleepingBeauty

When we moved my mirrors to the basement, this behavior essentially ceased. The frankly pretty nutbars routine I’d been performing since early adolescence just fell out of my life. And I did not miss it. In place of the “how do I look” ritual, I was checking in with how the clothes felt. Over time I proved to myself that I could trust my own judgment. It turns out I am sufficiently competent at getting dressed that it’s not usually necessary to check my work.

Life without a full length mirror requires some changes, but some of them I had already made. For example I had gotten rid of the clothes that didn’t fit me. The range of possible sartorial disasters is actually pretty limited when all your clothes fit. On two or three occasions, I got to the office and found that my bike shorts were a tad too long for my skirt. And one time I wore my shirt inside out until 2 in the afternoon. But nothing bad happened because of those mistakes. I turned my shirt right side out and moved on with my life. Eventually I stopped wearing that skirt, and I didn’t miss that either. I began to gravitate to really reliable, low-maintenance garments that required no thought because I knew I liked how they looked on me. Then I went further.

One day I was complaining to my husband about the unfair double standard in professional dress for women and men. I pointed out that his entire process for getting dressed in the morning was 1) Grab the shirt on top of the shirt stack 2) Grab the pants on top of the pants stack. And he has never once tried something on and then come to me for an opinion on whether looks too masculine, or not masculine enough. I told him I just wanted what he had. “Well,” he asked me, “What’s stopping you?”

I took that question seriously. The double standard is real, but it’s up to me how much I choose to bend to it. I started asking myself what, actually, was the point of getting dressed. I’m not using clothes to attract a mate or make a best-dressed list. If I want to intimidate my enemies, I have a better weapons.
Gloria

My work clothes in particular only have one job, which is to perform professionalism. I resent that I am graded on my ability to dress preppy (see also this important piece by Jacob Tobia), but that’s a post for another day. Point is, I do not work at Vogue. Nobody cares if I curate a tasteful capsule wardrobe in a variety of neutrals, or wear a giraffe-print jumpsuit to clinic every day, as long as my cleavage is covered and I don’t wear jeans. If there is a professional advantage to looking trendy, or having a varied and creative wardrobe, the payoff is pretty small proportionate to the amount of time, money, and stress that it requires. I think it’s awesome when other people express themselves creatively through their clothing, but when I looked at it hard I had to admit that most of the time I wasn’t expressing myself, I was just trying to pass for acceptable. So I opted out.

I now wear a black sweater and a black pencil skirt pretty much every day (sub in black jeans on the weekend). Every now and then I have the urge to change things up, but I usually regret it. I can now get ready for work in under ten minutes, and usually don’t have to think about my clothes for the rest of the day unless a baby barfs on me. I don’t wonder how I look cause I know my clothes really well, and I also know my own body.

I always thought of people who didn’t have full-length mirrors as people who couldn’t stand to look at themselves. But I’m pretty sure there are a lot of people with mirrors who also can’t stand to look. I can’t speak for anyone else, but I find I treat my body with more respect when I skip the daily appraisal. I don’t need a mirror to tell me how I look if I know how I see myself.