Let's be absolutely clear about this

I would like to open this particular post by stating the following very clearly. This is not a post about politics. This is not a post about abortion. This is not a pro-life or pro-choice post, and to use it as such is to misrepresent what I am about to say. This is long, but I ask that you read all of it.

As most of you probably are aware by this point, Rep. Todd Akin (R-MO) made some comments on Sunday (August 19, 2012) that have caused a great deal of controversy. Rep. Akin possesses a college degree in management engineering and a Masters degree in divinity. He worked as an engineer for IBM. He is currently a member of the U.S. House of Representatives (has been for 12 years) and is currently a candidate in the race to be the next U.S. Senator from Missouri. In the House, he serves as a member of the Committee on Science, Space, and Technology.

In short, Todd Akin is an educated and accomplished man. And that is why these remarks concern me so much:

"Jaco: So if abortion could be considered in the case of a tubal pregnancy or something like that, what about in the case of rape? Should it be legal or not?

Akin: Well you know, people always want to try and make that as one of those things, 'well how do you slice this particularly tough ethical question?'. It seems to me first of all, from what I understand from doctors, that's really rare. If it's a legitimate rape, the female body has ways to try to shut that whole thing down. But let's assume that maybe that didn't work or something. I think there should be some punishment, but the punishment should be on the rapist and not attacking the child."

While Rep. Akin has apologized for his remarks, saying he "misspoke" and that what he said was "ill-conceived" and "wrong," it does show an underlying and recurring assumption that may be more prevalent than I realized: that somehow, women's bodies can recognize a rape and prevent resultant pregnancy. What bothered me is that several commentaries I saw refused to comment on the FACTUAL ACCURACY of what Rep. Akin said. For example, Philip DeFranco, who is known for speaking his mind, stated "I am not a doctor or a scientist, so I cannot say if the female body automatically prevents pregnancies during rapes."

This is ridiculous! You should not have to be a doctor to know that Rep. Akin's statement is totally 100% false, anymore than you should have to be a doctor to know that smoking is bad for your lungs. I find it extremely unnerving that so many people were not totally sure whether or not his remarks had some basis in reality.

And I'm not the only one. The American Congress of Obstetricians and Gynecologists (ACOG), a group of licensed physicians who care for women, released a special statement the following day attempting to dispel this myth that the female body can prevent pregnancy following rape. It's fantastic and awesome and blunt and you all need to read it. I'll wait while you go do that. Back? Okay, moving on.

According to one paper from 1996, an estimated 32,000 pregnancies result from rape, but as ACOG's statement shows the actual number is impossible to discern. One paper even found that the rate of pregnancy after rape may actually be higher than pregnancy following consensual sex. Can psychological trauma or stress affect a woman's menstrual cycle? Yes. Is there any evidence, any evidence at all, to suggest that this idea can be extrapolated to a single stressful incident immediately prior to sperm exposure preventing ovulation/fertilization of an already released egg? No. I could go into the science of why this is literally impossible, but this post is already very long.

To suggest that the extreme emotional trauma of a rape will make a pregnancy impossible says one of two things to these women. Either there is something physically wrong with your body and you were unable to prevent your pregnancy like a normal rape victim, or you couldn't have been that emotionally traumatized by your rape (i.e. it is not "legitimate") because it clearly wasn't enough to kick your body into Prevent Pregnancy Mode.

Abortion in this country is a hotly debated issue. But when lawmakers and the lay public do not have an understanding of the basic, fundamental facts surrounding said issue, it limits our ability to have productive discourse. It devolves into people yelling at each other over the inaccuracies and lies being passed around as truth. I believe it is our responsibility as physicians to provide clear information on topics like this, and I'm proud of ACOG for doing so.

But what's WRONG with her?

I've been on a pediatrics rotation for three weeks now. I've encountered several frustrations on this rotation, but one that I've found rather surprising is our inability to always answer the question that every parent wants to know when their child is sick: what is wrong with them? WHY does he have a fever? WHAT is causing her rash? HOW did he get sick? Often the answer is something no one wants to hear: We don't know.

One case that sticks with me is a patient we sent home recently after she was admitted for a "rule-out sepsis workup". We do this in little babies for several reasons. One is that they really can't tell us what's bothering them, so we have to check everything. But another is that babies can get some scary infections from birth despite the best precautions, like HSV encephalitis or Group B Strep sepsis, and they require a spinal tap or blood cultures to diagnose these life-threatening illnesses, not to mention inpatient treatment at a hospital. Not all babies who are 4 weeks old who get a fever will have one of these scary infections. Many will just have viruses. But we can't sort out the not-scary ones from the scary ones, so they all get the workup.

This was my patient's second workup. She'd had one earlier in her little life with no obvious source of infection and she recovered well. Even though she was older than our usual cutoff she was very sick when she came to the emergency department, so she was actually admitted to the intensive care unit for a few hours until she was stable enough to come to a less closely monitored floor. Mom was very frustrated with her stay, since her blood, urine, and spinal fluid cultures weren't growing any bacteria and her viral swab was negative.

Just two of the many tubes used in a rule-out sepsis workup.

"It's most likely a virus," my attending (aka head doctor) told her. "There are hundreds of viruses out there. We can only test for a few of them, and all of those have come back negative. But we've ruled out the scary stuff."

"But is it my fault?" Mom asked. "Is it something I'm doing? We're very careful with her, we don't let her around many people, we boil her bottles, we wash her clothes separately. What else can I do? Don't tell me it's just another virus, I want to know why she keeps ending up in here!"

I wish I had an answer. Going into medicine, I thought that if I studied hard enough I would learn about all the diseases it was possible to have, and would be able to diagnose any patient. I think a lot of patients have this perception, too. If you don't know what's wrong with them, you're simply not smart enough. Shows like House perpetuate this myth each week with the brilliant doctor who figures out what everyone else missed. There's always an answer.

What was hard for me to learn in medical school is that in real life, it doesn't matter how smart you are or how much you know. The fact is that we never find an answer for many patients. It's extremely unsatisfying, both for the patients that recovered on their own and for the patients that are still sick with no obvious cause. For many, not having an answer is worse than a terrible diagnosis.

I'm still coming to terms with the uncertainty of medicine. As one physician I know put it, "I used to think medicine was like simple math. You plug in all the variables for the equation, all of their symptoms, and you end up with the answer." If only it were that simple.

Have you or someone you know ever been the subject of a medical work-up without an answer? Have you ever taken care of a patient who never received a diagnosis? How do you deal with uncertainty in medicine?