In a darkened operating room, Dr. Holly Casele watches a TV monitor intently as she inserts an exploratory instrument with a light and a camera at the end into one of two long tubes protruding from the abdomen of a 39-year-old woman with an ovarian cyst.
The on-screen journey begins with the bright white of the inside of the tube. Casele moves the laparoscope down.
Suddenly, the white tunnel gives way to a tangle of yellow, fatty-looking tissue covering the intestines and thin, transparent scar tissue. This is the woman’s pelvis, where the cyst is obscured behind the scar tissue from a hysterectomy.
This is Casele’s destination on this morning, and for her professional life. Casele is a resident physician at Northwestern Memorial Hospital, training to be a specialist in obstetrics and gynecology.
She is entering a field that attracts public debate and controversy as trees draw lightning. From abortion to issues such as the age at which women should start getting mammograms, the practice of obstetrics and gynecology has been at the center of some of society’s most vexing questions.
In vitro fertilization, prenatal testing, hormone replacement therapy after menopause, the rate of Caesarean sections-these issues have been debated by everyone from members of Congress to the pope.
Indeed, Casele is finishing her fourth year of training just as obstetrician/gynecologist Dr. Henry Foster is preparing to defend himself-for performing 39 abortions during his 35-year career-in Senate confirmation hearings on his nomination to be U.S. surgeon general.
“There are so many areas in obstetrics and gynecology that really make the strings vibrate in the public,” said Dr. Sharon Dooley, professor of obstetrics and gynecology at Northwestern University Medical School and director of the obstetrics and gynecology residency program.
And the strings have occasionally vibrated right into residency programs, as when the Accreditation Council for Graduate Medical Education recently ruled that accredited residency programs must offer training in performing abortions, prompting a hailstorm of criticism by abortion opponents.
At Baylor College of Medicine in Houston, residents now rotate through the Houston Planned Parenthood, where, like other physicians, they are escorted from their cars by volunteers or armed off-duty deputy sheriffs. The clinic has a metal detector, and all bags are searched before someone can enter.
Residents there have received mailings of joke books about doctors who perform abortions from a Texas anti-abortion group, said Larissa Lindsay, spokeswoman for Planned Parenthood of Houston and Southwest Texas. One is titled, “The Bottom Feeder.”
“They’re doing anything they can to discourage any medical students or residents from doing abortions,” Lindsay said.
Still, none of the nine residents assigned to the clinic since the program began in July has declined to participate. The regulations allow a resident who has moral or religious objections to be excused.
“Our residents have found it to be a worthwhile experience,” said Linda Mader, academic coordinator of the residency program.
Though Northwestern residents do not face such pressures, Casele is dismayed at the extent to which controversy over abortion has invaded the practice of obstetrics and gynecology.
“If we’re not training people to perform abortions, who’s going to do them?” she asked. “We’re doing to be back to the situation where women were dying after back-alley attempts.”
She has not shrunk from that part of her training.
“It’s not something I enjoy doing; it kind of bothers me a little,” she said. “But it’s important for me to do it. I’m going to be specializing in high-risk pregnancies, and dealing with a lot of women with fetal anomalies. It’s something I am going to need to know how to do.”
In addition, she said, she needs to be able to care for women whose pregnancies endanger their health. The debate that surrounds her field has not dampened her enthusiasm.
“I’ve always wanted to treat women,” she said.
Other women apparently agree; for the first time in its 43-year history, the American College of Obstetricians and Gynecologists reports that more than half the nation’s residents and newly graduated doctors are women.
“This is a really uplifting field,” Casale said. “You have a lot to offer people.
“There are definitely some tragedies-people losing a baby, or having a baby who has problems, or a woman who has infertility.
“But for the most part, for a lot of people with infertility, you are able to help them get pregnant. Or people with terrible obstetrical histories-you can help them stay pregnant longer. It is really rewarding.”
And with the exception of the abortion controversy, she welcomes the public attention.
“To the extent that a lot of attention is brought to (these issues), I think it’s good,” she said. “Women care about their health care. Maybe if there wasn’t so much attention given to it, insurance companies would have a lot more leeway to dictate things.”
But for a resident like Casele, public health policy debate generally takes a back seat to the main order of business: cramming an enormous body of knowledge, some of it from specialtized areas such as infertility and genetic testing that didn’t exist 15-20 years ago, into four years of training.
Every six weeks, a resident rotates onto a different service, such as labor and delivery, gynecology, oncology, reproductive endocrinology and high-risk obstetrics.
Northwestern has eased the infamous long hours of a resident by establishing day and night shifts in the most hectic service, labor and delivery. The longest a resident now works without interruption is 15 hours.
Under the supervision of a faculty physician at Northwestern, residents, who are full-fledged doctors but not yet certified as experts in their specialty, learn by doing.
They serve as the primary doctors for patients from clinics affiliated with Northwestern, most of whom are low-income, and help attending physicians treat patients at Northwestern and at Evanston Hospital, which is affiliated with Northwestern.
Most patients have no objection to being treated by a resident. But Casele frequently fields questions about her age. She looks far younger than her 29 years.
“I had a 15-year-old patient who introduced me to her grandmother as her `little doctor,’ ” she said, grinning.
The “little doctor” has had to learn procedures that didn’t exist when her more senior physicians were training.
One is laparoscopy, the surgery that Casele, under the supervision of Dr. Magdy Milad, director of gynecological endoscopy at Northwestern, performed on the woman with the ovarian cyst.
“This requires a much different level of skill, and different types of skills, than (traditional) surgical training,” Dooley said.
“If you surgically open up an abdomen and can hold a diseased organ in your hand, that takes a very different kind of skill than looking on a TV screen while you are doing blind maneuvers . . . and manipulating organs by implements instead of touching them directly.”
Indeed, Milad and Casele did not take their eyes off the TV monitors as they worked with instruments inserted through tubes in the woman’s abdomen. Casele snipped scar tissue; Milad cauterized it. Smoke wisped upward.
They cut and prodded their way through the scar tissue until they finally uncover the rounded, whitish cyst. Casele guided in a needle; a yellow fluid filled the syringe. Tests on the fluid later revealed that the cyst was benign.
Because of the scarring, the operation, which normally takes an hour, took twice as long, and called for considerable hand-eye coordination. Casele has it, Milad said admiringly.
Casele beat out stiff competition to get this position. Northwestern gets about 350 applications every year for eight positions.
And this despite well-publicized turmoil throughout the medical profession.
“When I was applying to medical school, everyone was saying, `Don’t go into medicine unless you really can’t imagine doing anything else,’ ” Casele said. “This was from older physicians, basically talking about all the red tape and preapprovals.
“But I think younger physicians don’t know anything different. The things that are great about medicine are still great about medicine. You’re still taking care of patients. So you have to jump through more hoops.”
The most difficult part of her profession, Casele has found, is dealing with patients’ personal tragedies.
Residents must learn to break unspeakably bad news. To Casele, one of the worst cases is when a baby dies in the uterus at the end of a normal, full-term pregnancy.
“(Women) come in because they don’t feel the baby move,” she said. “You have to tell them their baby is dead. It’s the most horrible thing expectant parents have to go through.
“You feel sort of helpless. The parents want to know why, and very often there is no reason. It’s not that there was a problem with the baby or that they did anything wrong; it’s just one of those awful things that happen.”
And other horrors arrive at her specialty’s door. Casele recently completed a rotation in pediatric gynecology at Children’s Memorial Hospital that included treating young girls who have been victims of sexual attacks.
She was shaken when she and the attending physician examined a little girl who appeared to have been molested.
“She was just terrified,” Casele said. “She couldn’t even tell us what had happened. She could only tell her mother, loudly enough that we could hear. Even just examining her-not touching, just looking-was a terrifying experience for her. It was just horrifying.”
Next year, Casele will move on to a two-year fellowship in high-risk obstetrics at the University of Pittsburgh’s Women’s Hospital.
The public turmoil about issues in obstetrics and gynecology does not worry her; she regards it as the product of the field’s universality and importance.
She hopes to spend her career in academic medicine, treating patients at a teaching hospital, doing research and teaching.
“The look on someone’s face when they’re learning something for the first time is totally great,” she said.
She expects to see it again and again in the young residents who follow her.
