University of Rochester School of Medicine
My mind was racing in between patient visits one afternoon on the ambulatory week of my OB/GYN clinical clerkship as I quickly finished notes and reflected on all of the things I was seeing and doing for the first time as a third-year medical student. Next up on the schedule was “Maribel, 24-year-old female- Nexplanon removal.”
“Well, that’s weird…” my preceptor, Dr. P, mumbled as she glanced at the next scheduled patient visit. “Didn’t she just deliver not too long ago? Oh, that’s right, I put in her Nexplanon about 6 months ago... Alright let’s go.” We quickly walked over to the patient room and Dr. P explained to me that this patient had moved from Puerto Rico about a year and a half ago and was predominantly Spanish speaking. I was immediately excited as a native Spanish-speaker to utilize my medical Spanish and was also pleasantly surprised to learn that Dr. P was fluent in Spanish as well.
“Hola, Maribel,” we said as we walked in and Dr. P introduced me. Maribel declined using the interpreter service phones and said she was ok with speaking to us directly in Spanish. I was glad to see Dr. P give me the “go-ahead” nod from across the room, indicating that I could begin taking the patient’s history. I asked Maribel why she wanted her birth control implant removed and she explained that she had been feeling very down, tired, and had decreased libido over the past few months. She asked if the hormones from the birth control implant could be contributing to her distress. She went on to say that friends, family members, and even her husband had heard that birth control implants’ hormones could affect women’s emotions and sex drive. I asked Maribel a series of questions related to side effects and other symptoms, but her only complaints were feeling down and having decreased libido; otherwise she was very happy with her birth control. Between glances with my preceptor across the room, I reassured Maribel that her implant was not the cause of her symptoms, and quickly realized that this visit was not at all going to be a quick implant removal, but something else entirely.
I rattled off the questions that I had learned to ask related to depression, and Maribel’s answers became more elaborate as she told us about how much she had struggled in the past 6 months. She described her family’s financial hardships, how she had had to stop working to take care of her 1 year-old son and 3 year-old step-daughter full time, and how guilty and sad she felt about her diminished sex drive, especially because she was worried that it was affecting her relationship. We learned that her only social supports were her husband, who worked exhaustively to bring in enough income, and a couple of his family members and her son’s godmother, who all lived over an hour away. Tears rolled down her face as she told us that she felt defeated because she was struggling so much and felt like she couldn’t complain to her family because it was expected for her to be a full-time mom. Maribel’s feelings of sorrow, frustration, and relief in finally being able to open up filled the room as Dr. P gently handed her a box of tissues.
I thought of all of the women in the world who were going through the same thing that Maribel was. The women who have no choice but to serve their traditional maternal roles, abruptly giving up their careers, hobbies, and social lives to become full-time caregivers when the time comes. I thought of how isolating this must be, especially for immigrant women like Maribel. I thought of all of the gendered expectations that women have, especially in Latino communities, related to taking care of children and the house. I wondered how many other Latina immigrants, like Maribel, felt “encerrada en [su] casa,” a common Spanish phrase which means to feel locked-in and confined at home. I also felt incredibly lucky that my own Latina immigrant mother had had extensive social support throughout my upbringing.
Finally, before Dr. P began to wrap up the conversation and discuss next steps, I asked Maribel the most important question of the entire visit- “have you had any suicidal thoughts?” She nodded in tears and responded that she did. She said she had thought out plans for suicide before but did not want to act on them and that she felt safe at home. Despite the overwhelming melancholy in the room, I was so glad that I had asked the right questions and given Maribel the opportunity to ask for the help that she really needed. I was also grateful our visit was able to be done in Spanish, and I wondered if Maribel would have felt comfortable enough to have opened up otherwise.
After making sure that Maribel was safe enough to come back for a follow-up visit, we scheduled an appointment for her to meet with the clinic’s behavioral health specialist. I was able to go to this appointment later in the week and felt grateful and valuable for being able to provide continuity of care and support for Maribel as her journey in seeking mental health services continued. Maribel reminded me exactly why I decided to go into medicine- to address health myths and teach patients about their health, to learn about patients as a person in order to provide the best care, and to give back to Latino and immigrant communities to provide the culturally sensitive care they deserve.