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Emily Silverman: This is The Nocturnists. I'm Emily Silverman. Today's episode features Alejandra, a fourth-year medical student whose path into medicine was shaped by an experience she never expected to have as a patient. As a college senior, Alejandra discovered she was unexpectedly pregnant. Seeking an abortion, she trusted a referral from her primary care clinic, only to find herself at a crisis pregnancy center, where she was met not with the care that she had requested, but with misinformation, prayer, and pressure to continue her pregnancy.

In my conversation with Alejandra, we talk about reproductive health care, trust, and the lasting impact a single clinical encounter can have. We also explore how that experience ultimately inspired Alejandra's commitment to family medicine and to becoming the kind of physician who helps patients make their own decisions, free from judgment or coercion. Here is me and Alejandra.

[music]

I am sitting here with Alejandra. Alejandra, thanks so much for coming on the show.

Alejandra: Thank you so much for having me. It's a pleasure to be here.

Emily Silverman: Alejandra, what was it like to stand on stage and tell your story?

Alejandra: It was quite the experience. I had never done anything like that before, but it was also a huge, huge release. It was a story that I had been living with for 10 years at this point. To be able to share such a vulnerable story with an audience, of course, friends and family that already know the story, but also complete strangers that I've never met, it was a big leap of faith, but it was incredibly, incredibly rewarding.

Emily Silverman: It was an important story for us at The Nocturnists too, because we did a whole series called Post-Roe America. After Roe fell, we went to red states and blue states and purple states and talked to clinicians about the impact of the Supreme Court decision on their practice and their day-to-day and things like that, but I don't think we got any stories in that series of individuals who were referred to these crisis pregnancy centers, and I had never met someone who was openly talking about that.

We were really grateful that you were able to tell the story and then come on the show and talk a bit about it. I was wondering if you could maybe bring us back. You said 10 years you had been living with the story, but even before that, tell us a little bit about growing up, your family, and your community, and what were the conversations around abortion and reproductive health when you were growing up?

Alejandra: Yes, I grew up in primarily Los Angeles. Family moved to conservative Southern California, Inland Empire. I think that's where I actually first started to hear or learn about what abortions were. I remember at the time it was-- oh, I'm blanking on the name for the prop that was on the ballot to legalize abortions. I remember I was in 9th or 10th grade, and the big statement of the time was one in four women get abortions. I remember standing there with my four girlfriends, and we were just giggling, "Oh, it's going to be one of us four."

I don't know if the other three ever got an abortion, but I definitely was that one of the four. As for my household, although I do come from a conservative Latina religious, mainly Catholic background, conversations were still very open, which I'm very grateful for. I remember I have a family member who had had an abortion, and it was a secret, but my grandmother actually shared that secret with me when I was probably around 14, so around the same age.

I was very aware that this was an option. I was very aware that this is okay, and something that can be done if needed. Luckily, I had a very positive language around it. Even then, of course, there's still the Catholic guilt, if you will, of having to need one, go through one, and more so when going through the crisis pregnancy route, which of course I was not aware of at the time, but yes, I think that was my exposure to reproductive justice health.

Emily Silverman: When you were growing up, were you interested in medicine and healthcare, or have any healthcare people in the family, or was that on your radar at all?

Alejandra: Not at all, actually. I hated the doctors because I spent all my summers visiting my grandparents in Mexico. For some reason, I was always getting sick. I hated going to the doctors because it meant I would get a shot. I think it was antibiotics. I don't know what it was, and that's my association with doctors. Then in high school, once I could drive, I was taking my grandparents to their healthcare appointments, and I was their interpreter, which is a big problem, interpreting at 16 for grandparents using medical language that I've never heard of.

That's a separate issue, but that was my first exposure into medicine, into being curious of what is diabetes, what is hypertension, how did this happen, how can we reverse it, can it be reversed? I think just being in the patient room with my grandparents, I think that was my first exposure, and thankfully had some really great opportunities in undergrad that I could explore what being a Spanish medical interpreter could be beyond my family, and that really set off my journey.

Emily Silverman: Tell us about undergrad. Were you pre-med yet, or still exploring?

Alejandra: I was pre-med. At least I knew I really enjoyed biology. My AP biology teacher had completed medical school, but decided not to do residency, and the stories he would share were just fascinating to me. That was a big inspiration. I knew I wanted to study biology with the hopes of doing medicine, but of course they always scare you your first year, your first quarter, and tell you, "Look to your right, look to your left. Neither of you are probably going to get into medical school." It was awful. It's absolutely awful. Yes, I didn't know its specialty yet. It wasn't until I had that Spanish medical interpreting experience that I decided family medicine, and haven't looked back. [laughs] Yes, then especially after this experience too.

Emily Silverman: You were a college student when you got pregnant, is that right?

Alejandra: Correct.

Emily Silverman: Tell us about learning you were pregnant. I think you mentioned in the story that you were really tired, but you were also really busy. You were studying. How did you figure out what was going on?

Alejandra: I was a fourth-year biology major at that point, very pre-med. I was three months from graduating, so I was just wrapping everything up, busy with research, busy with commuting, busy with tutoring after classes, and volunteering. Very busy schedule, and so yes, I really thought I was just exhausted. I was not eating well. Had very little access to kitchen and food, so I really just thought maybe anemic, maybe low in some other key vitamins.

I remember calling my mom and telling her I'm so tired. I don't know how I'm going to get through finals. I just want to be done. She was very worried, being my lovely mom, and she said, "Okay, well, let me help you out. I'm going to make an appointment for you before you go back for your spring quarter." This was spring break time. I really just thought I was going to go in for a physical exam, find out what I was low in, take the supplements, and yes. It was a very big shock when I found out that I was pregnant.

Emily Silverman: Was this the school doctor or an outside doctor, just someone in the community?

Alejandra: Yes, it was someone in the community. Back home in my conservative town. It was the doctors that I would take my grandparents to. It was the doctors I would go to in high school, but I had no idea that they were affiliated with a religious institute until that day.

Emily Silverman: Affiliated with a religious institute, I know there are different hospitals that are called Saint this, Saint John's, and things like that. Was it like that, or was it like affiliated more concretely with a church or something? Do you know?

Alejandra: I think it was affiliated with a church, but I'm not too sure. [laughs]

Emily Silverman: They don't make it obvious.

Alejandra: They don't make it obvious at all. I know the medical school and the university; I know their affiliation with their religion, but the clinic that we go to is a street name. It had no indication that it was affiliated with that medical school health system.

Emily Silverman: Was it primary care, family medicine, or internal medicine?

Alejandra: It was family medicine and NP. Yes, that's all I can really remember.

Emily Silverman: It's hard to remember. You show up to this place, you have an appointment, you show up thinking that this is the appointment where they did the pregnancy test. You go in, and she does the tests, and she says-- I think you said in the story. She says, "Congratulations, you're pregnant." Can you bring us into that moment in the exam room? What was that interaction like?

Alejandra: At this point, it was routine that every time you go to primary care visit, you have to pee in a cup, and then they do something with it. At that time, I didn't know what they were doing, so it was a complete shock. I didn't even know that I was going to give a urine sample for a pregnancy test. When she came in through the door, she, with a big smile, shared, "Congratulations, you're pregnant." I just completely froze. I am sure I dissociated.

[laughter]

It was not at all the news I was expecting, and also completely taken aback by her tone, her presentation of this really big news. At the time I knew it felt bad as the patient, but now as a trainee, I just really understand how deeply flawed that presentation was.

Emily Silverman: Do you think she could tell that you weren't happy to be pregnant?

Alejandra: I would hope that that's how I presented as the patient, just with the long pause. To me, it felt like a five-minute pause. It could have been a 3o-second pause, but I was in complete shock. After coming back to myself in the room, I remember telling her, "I don't plan to keep this pregnancy. Can we talk about my options? How can I get an abortion?" I very explicitly, directly shared that this was not what I wanted. This was not what I was ready for. If my body language didn't show it before, I asked those very direct questions.

Emily Silverman: It was very direct.

Alejandra: I was very direct.

Emily Silverman: Then, what happened? You said that, and it sounds like in the story, she gave you a pamphlet, guided you out of the room. Tell us what happened.

Alejandra: After I told her that, that's when I found out that she couldn't provide the service or even talk to me about my options because she was working at the religiously affiliated institute. I asked her, "Okay, if you can't talk to me about this, can you please direct me to some place that I can." Again, I was visiting home, very conservative Inland Empire, so I had never seen a Planned Parenthood ever in my town around my town. Because I didn't know how far along I was, I needed to take care of this ASAP.

I thought I could trust her, but instead, she, or I should say, she did share a resource with me. It was this pamphlet to the crisis pregnancy center. Obviously, it was not called that on the pamphlet, but there was a flare of urgency and support, and this clinic is here for people who are in need. I thought it was my lifeline. Okay, I couldn't get it here today, but I'm going to call this number right away, and we'll take care of this as soon as this appointment is done.

Before I even left the room, she went on and reminded me which prenatal vitamins to buy, where to buy them. Costco has the best deal. Even as I'm walking out to the reception area, she finds the OB/GYN in the clinic and introduces me as his future patient, and in front of him reminds me, "Don't forget to make your first prenatal appointment." That was the whole interaction.

Emily Silverman: Then, what happened? You called the number on the pamphlet.

Alejandra: Yes, I got back in my car, and I was like, "Oh, thank God, I'm safe. I'm out of there."

Emily Silverman: You're out of there.

Alejandra: "I'm safe. This is my lifeline. We're going to get this done." I called the number. Thankfully, they were very available. I was able to make an appointment for like the very next day, and yes, I was ready to whatever process was going to be needed to get the abortion.

Emily Silverman: This other clinic is in a different location. You show up there the next day. What does it look like? What is it? Is it big? Is it small? Is it in a strip mall? Is it in a bigger building? Where is it?

Alejandra: It's in same business area of town where the clinic was a few streets over. I was like, "Okay, this is all checking out. Okay, this is where clinics are." When I walked in, I noticed that it was smaller. I noticed that there was no waiting room, and I noticed there was no receptionist. As soon as I walk in, I am greeted right away. They know my name, and they lead me to another room.

This is a very lonely clinic, and as anyone in healthcare knows, clinics are never lonely. [laughter] There is always a very busy waiting room. That should have been my first alarm of like, "Hey, this is probably not where you think you are supposed to be." I didn't know any better. I just needed help, and I thought that's where I was supposed to go.

Emily Silverman: The person who greeted you and led you to a room was a nurse, a doctor, or unclear?

Alejandra: Unclear. I tried to think back of how she introduced herself, but all I could remember was her introducing herself as her name, and that she was going to do my ultrasound.

Emily Silverman: She takes you to the room. She does the ultrasound. She says, I think in the story, "This is the baby's heartbeat. Congratulations." It's more of that. Then walk us through what happens next.

Alejandra: Initially, I was grateful that I was getting an ultrasound. I was like, "Okay, I need to know the date. I need to know how far along I am." When I heard the seven weeks, four days, I was like, "Okay, thank God." I still have time. We're still within the 10-week window. Then, as soon as she finished the measurements, she wanted to walk me through the little anatomy that you can see at the time, and she wanted me to hear the heartbeat.

I think that's when I realized, "Oh, this is inappropriate. Considering I am here for an abortion, I'm not sure why I am being forced to listen to my baby's," because my fetus was constantly referred to as my baby, my baby. Yes, I think that was the turning point of everything when I heard the heartbeat and when she printed me my first ultrasound pictures for me to take home, and handed them to me very excitedly, even though I told her, "Oh, I don't want these." That was the emotions in the room of we are here for very different reasons.

[music]

Emily Silverman: Before all this, you knew what an abortion was. You knew that they existed. You had had conversations with people in your family. I think you said your grandmother, so it had been normalized, even though you were growing up in this more conservative Catholic community. Did you know about the existence of these clinics? Did you even know that there was a thing where young women would be taken to these places, and that this could happen? Were you like, "Oh, I'm at one of those places," or you just didn't even know that those places existed?

Alejandra: Yes, it was the latter. I had no idea-

Emily Silverman: Okay, that's so confusing.

Alejandra: -these places existed, so yes, it was a very, very confusing process

Emily Silverman: Super disorienting. She gives you the images that you requested not to have, and then later, I think you go to another room, and then there's another person, and then they pray over you. Tell us about that part.

Alejandra: I'm told to redress. She's waiting for me on the other side of the door, and she leads me into the front room. This front room is a lot bigger, and there's a new woman who I haven't met, and she's already sitting on a chair. There's a chair next to her, I think, for the other person, and then a couch. I go to my place, and I think in my head, this is where we're going to talk about my options. This is where--

Emily Silverman: Still holding out.

Alejandra: Yes, like we know the date. We know that it's a viable pregnancy to get a medical abortion. We're still in the 10-week window. I know the steps, and instead the woman introduces herself, asks me how I'm doing. I'm actually really proud of myself that despite the disorientation, I was always very clear of, "I'm here to get an abortion. Can you please walk me through the process?" Yes, that's completely when everything flipped. They didn't explicitly say that they weren't a clinic that doesn't offer abortions.

They were very open about options, but talking through those options meant praying over me, and that's when a lot of the prayer is lost. I definitely dissociated in that prayer. One thing I do remember very, very clearly was that they asked God to guide me to help me make the right choice. That's when I was back again in the room. It was the fluttering of the heartbeat in the ultrasound room, and it was the--

Emily Silverman: Did it work? Did they induce feelings of guilt and shame in you, or were you resistant to that? A young woman [crosstalk]

Alejandra: Yes, I wish I could tell you that it didn't induce guilt, but it absolutely did. Especially in a-- again, me thinking this is a reputable clinic, healthcare professionals who are looking for my best interests as their patient. I was very disoriented, very confused. That is definitely when the guilt set in, and I got very scared. Why are they preventing me from getting an abortion? Is it unsafe? Is this the right decision? Do I look at other options, adoption, or keeping the baby?

That was the first time I had those thoughts. Before, granted, it was only a day difference, but in the clinic the day before, I was very set. Walking into the clinic that morning, I was very set, but that was the first time that, for the length of the prayer, I started to question, "What am I doing?" Thankfully, I snapped out of that [laughs] quickly once I was out of their hands. In the moment, I felt very vulnerable and scared that I don't know these people, and they clearly have other plans that are completely different from mine.

Emily Silverman: After the prayer, there's not much else they can do. They let you go after?

Alejandra: Yes, but not before giving me some pamphlets. More pamphlets.

Emily Silverman: More pamphlets.

Alejandra: More pamphlets on adoption and daycare, and yes, at that point they very friendly, very smiley, and they wish me good luck, and I am released into the wild. [laughs]

Emily Silverman: You go back to your car, and you're like, "What just happened?" Then what? Did you tell your family, or did you keep it to yourself, or--?

Alejandra: Yes, I walked to my car, and it's a beautiful spring day, and I almost feel like the heat, the sun, shocked back into reality and to that clarity, and into that righteous rage of how did I end up here? I came here for a reason, and I didn't get what I came here for, but I'm going to still get it. I don't know if it was because I was so burned and scared at that point that my sense of trust in others was very fractured. I didn't tell my family.

I just took care of it on my own. I knew the plan. Once I was back in my college town, I knew exactly where that Planned Parenthood was.

Emily Silverman: You had seen it.

Alejandra: I had seen it. I had driven by it. I knew friends who had gone to that Planned Parenthood. I knew it was a safe place. I just took care of it on my own.

Emily Silverman: Then earlier in this interview, you said that you had been living with the story for 10 years. Bring us into that 10-year arc. It sounds like you graduated. What did you do after college? You go to med school, or did you take some time off?

Alejandra: I took some time off. This experience was very traumatic. I lived with PTSD for two years after this experience. I knew I was not ready for medical school, and I also was very-- I really needed money. Undergrad was a very financially stressful time. I actually worked for five years at a genetics company to save up for medical school and to save up for the application process. I say I lived with it for 10 years because it took a very long time to regain some control, some voice in the story. So much of it was taken away first at the primary care office and then at the crisis pregnancy center. I regained it at Planned Parenthood, but again--

Emily Silverman: Yes, I was going to say, was there some repair that happened there where they could say to you, like, "This is what happened to you, and some meaning-making."

Alejandra: I was so again fractured at that point, so vulnerable-

Emily Silverman: Hard to take in new information.

Alejandra: -hard to take in new information. Honestly, I couldn't even tell you if I shared with Planned Parenthood of what had happened, I think I was just-- at that point because it actually took two weeks to get my Planned Parenthood appointment.

Emily Silverman: Ooh.

Alejandra: I know. At that point--

Emily Silverman: You mentioned in the story that, in addition to these crisis pregnancy centers inducing these horrible feelings in women, that another problem with them is that they delay. With all of these situations, there's a ticking clock. If you make an appointment thinking you're getting one thing, and then you realize that's not what it is, then it's like, "Oh, I've wasted time."

Alejandra: Thankfully, I had only wasted one day going to the crisis pregnancy. As soon as I called Planned Parenthood, they couldn't see me for two weeks, and at that point, I was nine and some change before 10 weeks. At that point, I think it was more desperation of I just need to get this taken care of.

Emily Silverman: Survival mode.

Alejandra: Yes, for sure, survival mode. Thankfully, it was not a traumatic experience going to Planned Parenthood. I don't know how much is shared about the actual medication abortion experience, but it's also very hard, and it can be very traumatic. At this point, I really cocooned, so I went through the whole process alone. I shouldn't have. I really shouldn't have.

Emily Silverman: That's where you were at the time.

Alejandra: That's where I was at. That's why it lived in me for so long because there was shame, there was points where I wish I would have reached out for help, but it wasn't until many years later that I finally found my voice again in the story.

Emily Silverman: What was the five years working, you said, in genetics? What kind of work was that?

Alejandra: Yes, it was a clinical genetics lab. My title was clinical genetic molecular biology scientist. Very long name for someone who processes patient samples. It was a big oncology institute. It was important work. I enjoyed it, but I also knew medical school was always on the horizon. I was very transparent with everyone at the company, who were always so supportive of every step of my journey to get to medical school. Yes, that's what I did.

Emily Silverman: Are you still in medical school?

Alejandra: I am, yes. I'm a fourth year right now.

Emily Silverman: Finishing up?

Alejandra: Finishing up. I do have a master's that I'll be starting in fall, so not going into the match this year, but yes.

Emily Silverman: I'm sure you did OB/GYN rotations and family medicine rotations in medical school. Do you feel like that was a moment to, like, reprocess a bit what had happened, or because by then it had been much later, and you probably had more context? How did it come up again for you later?

Alejandra: It didn't come up in family medicine because my rotation was at a federally qualified health center, so no government dollars can fund any abortions there. No exposure there, but I did have some in my OB clinic experience. Then, the summer before my master's in public health, I'll be doing a whole month in family planning. I'm really looking forward to that. That will be really healing.

Emily Silverman: Yes, I imagine.

Alejandra: In OB/GYN, I do remember one particular patient who she was at a crossroads. She wasn't sure if she wanted to keep her baby or if she wanted to have an abortion. I'm very grateful that, as a medical student, some attendings are very lenient with time, and they can see two, three other patients while the medical students sees that one. I was really grateful that I did have that extra time to talk about options, talk about where she was at, and it was truly a very healing experience.

Emily Silverman: Moving forward, you said family medicine. Are you thinking about making reproductive health or abortion health like a significant part of your practice? I know there's always a little bit of it in family medicine, but I know some people choose to focus on that.

Alejandra: Absolutely. As painful of an experience as it was, it also was the fire and guiding light in pursuing my medical degree. A big portion, of course, was my early experiences with my grandparents. To be the patient who lost trust in the system, lost trust in their physician, it was truly an eye-opening experience of what kind of doctor I hope and plan to be. Absolutely, I can't wait to be that provider who provides that safe, supportive environment where these discussions can be had, without any assumptions, without any judgment, and just with the patience and calm of, "This is your choice, and let's talk about everything."

Regardless of what way you go, also talking about the supports because I think that's one thing that I didn't really have at the time, and something that I always emphasize. I did a medical school abortion 101 talk, and I shared part of my story and talked at length about all the amazing resources there are for either getting abortions or abortion doulas and all these other support systems to help anyone going through that experience.

Emily Silverman: Wow. Thank you so much for sharing that story with The Nocturnists audience and the audience of peers that you shared it with on that night. I think it's just a powerful story about how these interactions with healthcare can be so profoundly healing and constructive, or can be so profoundly harmful and destructive, and lead to longstanding impacts. We really can make a difference in those moments for people. Thank you again for sharing your story with us. For people listening who are interested in reproductive health care, abortion care, or family medicine, any final messages that you want to share? Storytelling?

Alejandra: Sure.

Emily Silverman: Sharing personal stories with an audience?

Alejandra: Yes, I think storytelling is such a beautiful outlet for these deeply personal stories, and also it can really help others who have either gone through similar experiences, whether as a patient or as the physician. I think these opportunities really give us some insight and some time to reflect and see how can we do a little better in certain situations that are sometimes hard to talk about and very vulnerable to talk about. I hope that's what people hear in hearing my story and hopefully inspire others to share their own stories because I know there's a lot of people who have fallen into the traps of the crisis pregnancy center because they present as a regular clinic.

Emily Silverman: What are the signs to look for? It's kind of a vibe, I imagine, but are there any other signs to look for?

Alejandra: There was no other signs that I saw visibly outside of the clinic. The only visible sign I saw inside the clinic were the Bible verses that were on the walls where they were praying over me, but besides that, and even then, that could be fine in other clinic settings. Besides that, there was no other indication that it was a crisis pregnancy center.

I know in talking with other family physicians about my experience, they have shared that if they're sending a patient to a Planned Parenthood to get the abortion service, they will pin it in their phone and make sure that is not sending them to a crisis pregnancy center because apparently that's something that Google does. If you type in Planned Parenthood, it'll actually send you to the crisis pregnancy center that's right next to it or a few stores away. Just being very careful and letting patients know this can happen and trying to help as much to make sure that they go to the right place.

Emily Silverman: Even just raising awareness that these places exist, because some people, like when you went, you didn't even really know what it was. I think you know at least, having it on your radar that there are these places and they exist and what to look for is really important for our patients as well.

Alejandra: Yes, exactly.

Emily Silverman: Great. Alejandra, thank you so much for, again, coming on the show and speaking with us. I've learned a ton, and really wishing you luck for the rest of medical school and for your master's degree and for your great work ahead.

Alejandra: Thank you so much for having me. It was a pleasure, truly an honor to be invited to speak here, and just so grateful for your work and for this platform for physicians and healthcare professionals to share their stories. It's really, really beautiful.