Chapter 1: What is the main topic discussed in this episode?
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This is Fresh Air. I'm Tanya Mosley. A new book by Portland doctor Mary Fariba Afsari opens with a vivid image of her trying to fit a red gynecology table in the back of a Mini Cooper.
It's 2021, and she's 15 years into her career as a board-certified OBGYN who walked away from a traditional practice, bought a 31-foot RV, taught herself to drive it, and turned it into one of the country's only mobile gynecology clinics. She parks it in communities with few health care options. Undocumented families. Survivors of medical trauma.
People who need reproductive care and have nowhere else to go since the landmark Dobbs decision in 2022 overturned Roe v. Wade. But the RV is only part of the story. Dr. Afsari is the daughter of Iranian immigrants who left Iran ahead of the Islamic Revolution when she was three years old.
She's named after her grandmother, Meri, a woman she never met who died attempting an illegal abortion in Iran, leaving behind four young children. That loss shaped her family and the doctor's career. Her new book, Labor, One Woman's Work, comes at a moment when abortion access has been stripped from millions of American women.
Maternal mortality is rising, and OBGYNs are leaving states where they can no longer practice medicine without fear of prosecution. Dr. Afsari, welcome to Fresh Air.
Thank you, Tanya. I'm so happy to be here.
I want to start inside of this RV clinic because you had a thriving practice. You were a surgeon. You delivered babies. By every measure, you had built really exactly what every doctor is supposed to build. So what was it about this day-to-day reality of medicine that made you think, I need to blow this all up and start over in a parking lot, basically?
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Chapter 2: What inspired Dr. Afsari to start a mobile OB/GYN clinic?
I think there's a perception out there that OBGYNs live in a world of celebration, bringing a new life, welcoming babies. And that's not all entirely false. That's true. That's a huge part of my motivation for going into this line of work. But when you're practicing In-N-Out, where you're actually caring for people who need comprehensive reproductive care –
So what that means is from the time somebody is old enough to cycle periods, get pregnant, have to prepare for that potential, have to face their own sexuality issues. and have to find people that can provide for them the kind of care that meets them where they are. It's really important to have places and physicians and institutions that can meet them where they are.
And it's not that I didn't feel like I was doing that in my own office space. It's just that I felt like I could do it better. I felt like looking down the pipeline, even 10 years ago, at what was going to happen with reproductive access, it was pretty clear to those of us that were working in the world. The Dobbs decision, and I say this in my book, it didn't come as a big surprise to me.
on that day. We had seen that this is what the groundwork was being laid towards. We also knew that historically in this country, even pre-Dobbs decision, even with Roe v. Wade, there were folks in certain communities from certain ethnicities. There was this implicit racism that happens in the health care system that we are aware of.
And so we knew that there were already people that were not being met and that it was just going to expand and just affect more people over time.
And right now, we know that 13 states now have total ban abortion bans. Thirty five percent of U.S. counties in particular are what's being now called maternity care deserts. Can you describe, though, what makes what you do better with this RV? Can you describe the inside of your mobile clinic? When patients walk in, what do they find?
Oh, yeah. I mean, even just as recently as yesterday, people walk into this RV that from the outside is pretty unassuming. It was something that came from Camping World. And they step inside and they're greeted by me, the doctor in normal clothing. And my medical assistant, who is always there with me because we like to have a second person there for procedures, for blood draws.
We want to try to do as much inside the walls that we can. There is a couch up front that we haven't changed. It's just the regular RV living room that you walk into. We have fairy lights. We have curtains that were sewn and designed by my good friend.
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Chapter 3: How does the Dobbs decision impact reproductive healthcare access?
And we have a little exam room in the back where there's normally a bed. that we ripped out and we just put an exam table back there. But we also have wall hangings that let our community know that they are welcome and safe within those walls, no matter who they are.
In a way, it sounds like a therapeutic experience, the complete opposite of what I associate with going to the doctor. What have you seen in the way your patients relate to you that might be different than when you're in a clinical setting, in a hospital or an office setting?
Yeah, you know, I was in a traditional office for a decade and we provided really good care and a good number of my patients in the RV followed me from that clinic. So they know who I am and we already had a very good doctor-patient relationship. But in the clinic, I had three exam rooms that were running all at the same time. They had that sort of sterile exam room feel and I would have to
hop from one to the next to the next with my computer in my hand and my white coat on. And I'd come in and we would have, you know, sometimes a 10-minute appointment, sometimes 30, depending on the situation.
Chapter 4: How does Dr. Afsari's Iranian heritage influence her practice?
But there was always a sense that there was a waiting room of people that were waiting to be seen. And you have to keep things ticking along. And I just decided when I started this RV clinic that I was going to do it the way that I wanted to provide care, sort of my daydream idea of a clinic.
And in doing that, not only are my patients receiving this sort of individualized care, but I am sort of healing whatever it is that happens when you're a physician and you've worked for 15 years and there's elements of burnout and exhaustion that can happen in the traditional medical setting. My patients are healing me.
There is a story in the book, a teenage girl and her mother brings her in with severe abdominal pain. And she hasn't even had her period yet. Can you take us into that day?
Yeah.
Chapter 5: What personal story shaped Dr. Afsari's perspective on reproductive health?
So I think this girl was about, you know, 14 or 15. You would have expected that she probably would have started her periods and she hadn't. And what I realized over the course of the appointment was that she had a congenital anomaly where the outlet which allows blood to flow out, the hymen, had not ever opened, and so there was blood that was trapped inside.
So most people have a tiny little, at least a pinpoint opening from the time they're young, and that's when women start their menstrual cycles, girls start their menstrual cycles, the blood is allowed to escape. And that hadn't happened for her. And I thought in the moment, well, this is a really simple solution.
I just have to take you to the operating room and we'll put you to sleep and we'll just open that little tissue layer and we'll allow the blood to come out and it's going to give you immediate relief. And then her monthly cycles would be able to start. And what I didn't expect to encounter was the pushback from her father and a real concern that a surgery like that would deem her not a virgin.
And so we ended up in sort of a, you know, I would say maybe it's sometimes it's a faith-based conversation. It could sometimes be cultural. It depends on sort of the family background. It's different for everybody. But that was the conversation that we ended up having with the parents in order to determine the right path to take for this teenager.
You know what I was struck by in that story is something I think we all know, but we may not think about when we think about your job. You're not only just a doctor, you're a social worker, you're a therapist. You are also someone who's kind of giving cultural and medical competency and knowledge to people. your patients.
You knew going to medical school that intellectually you'd need to hold all these things and you'd be meeting with patients. But how did that come up against the realities of the situations that you have come up against during your career?
I mean, it's a huge part of medical training that at least when I was going through my training, and I know that things have improved, I know things are getting better here, but it wasn't a big part of my training.
I actually was explaining to somebody the other day that nobody taught me how to tell a woman or two parents that I had just done an ultrasound and the baby didn't have a heartbeat because that is something we encounter more often than anybody would like to think.
And I had to do that for the first time once I got out of my training and I did an ultrasound and I had to walk back into the room and let that family know that their baby wasn't going to survive the pregnancy. And so in order to do that well, I think we have to first be listeners. I think we have to learn from our patients and we have to pay attention to the stories they're telling.
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Chapter 6: How does burnout affect physicians in the medical field?
I mean, how did you hold those two truths to come to this understanding of how she died and how that actually drives your purpose?
I really think that my grandmother serves as a moral conscience for our time. And that when we understand what our ancestors suffered, it teaches us what we can do to prevent that moving forward. And yet we are still faced with the similar challenges today. So that's an interesting part of this for me.
I mean, what was amazing is as I engaged with my grandmother's story, we had a patient present to one of the hospitals that I work at who was near death with sepsis.
And as we took her to surgery and went through all of the steps that were required to save her life, it slowly dawned on me that that had been my grandmother's story and that in a different time and a different place under different circumstances, she could have been saved.
And so when you lose a mother and you lose an entire family system, especially when you have young children, a baby died that she was carrying. The one-year-old child ultimately ended up dying as well just from sheer inability to care for him. And so my mother, her brother and sister at a very young age lost a sibling and their mother and a future sibling all within a year.
And I can't say that they are not still impacted by that today, more than 50 years later. And that gets passed on now to me. And so that moral conscience, that understanding how critical it is to be able to provide women with life-saving care in order to prevent this type of tragedy to an entire family system, I mean, that's what came to light to me and for me.
over the course of engaging with the ghost of my grandmother, essentially.
Our guest today is Dr. Mary Fariba Afsari. Her new book is titled Labor. We'll be right back after a short break. I'm Tanya Mosley, and this is Fresh Air. You knew you were going to be a physician of some sort, and you initially dreamed of being a pediatrician until you spent time in Bolivia. I'd love for you to tell us just a little bit about what you saw there that made you change course.
I went down to Bolivia for a one-month rotation as a third-year medical student. I received a fellowship, and I flew down there for this great adventure. And the pediatrics rotation was incredible. We were in orphanages and in hospital settings and in outpatient clinics with indigenous folks, and we were in the main cities. And yet—
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Chapter 7: What unique challenges do patients face in maternity care deserts?
I want to ask you about the realities of being an OBGYN under the Trump administration, the CDC, which tracks maternal mortality. They're the people who help us understand why American women are dying in pregnancy. A whole team of researchers there at the CDC were placed on administrative leave earlier this year, and that data collection has stopped.
And I'm wondering, as a doctor who relies on this research, what does it mean to practice medicine when the country is actively choosing not to measure what's happening to women?
I mean, all of this could feel like an impossible situation until you're on the ground. That is terrifying. I heard about an OB-GYN who had an ankle bracelet because she was being accused of committing some sort of crime just for trying to provide standard of care, life-saving care in another state.
I have heard from multiple colleagues in other states who are not able to even advise their patients about to maybe leave the state in order to obtain, we're talking about truly life-saving care, like women who might not survive a pregnancy if they were to continue it. For me, I work with people, fortunately,
who on a local level and a hospital level and then a regional level and then a state level, we are tracking. I mean, we are still doing all of the data collection. And we meet sometimes weekly. We definitely meet monthly. We have quality review committees. We are on top of what is happening weekly. for the women and the patients that walk onto our units.
So I am fortunate enough to be a part of a hospital system and a greater system within the state where we are doing this work every single day. And so what's happening locally is still really good work.
Our guest today is Dr. Mary Fariba Afsari. Her new book is titled Labor.
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Chapter 8: What does the inside of Dr. Afsari's mobile clinic look like?
We'll be right back after a short break. I'm Tanya Mosley, and this is Fresh Air. You write about how, I mean, you used to shake and sob after caring for patients. But somewhere along the way, you kind of have to stop that. Because if you do it every single time, every single day, I mean, just everything would be taken out of you.
I mean, it just also made me wonder, is numbness inevitable in the work that you do? And how does that impact the work?
I mean, it's such an important question. And people don't necessarily know how much the burnout of physicians impacts their overall sort of mental state and physical well-being. Physicians in this country and especially so female physicians in this country have four times the suicide rate of any other profession.
Really?
They absolutely do. And why do you think that is? I know. I'm always asked, like, what is that? And I don't have the exact answer for it. I don't have the statistics or the data or the understanding of why that is.
But I do know that there's something about the compassion fatigue that I believe happens alongside sort of the expectations of what it is to be a working woman in this country or working mother in this country. And I think...
There's got to be something in that tension that has made it even more difficult for female physicians, even though I know plenty of male physicians who have also felt that emotional burden. And, you know, we don't do a very good job of taking care of our doctors. We don't have a lot of support. We tend to go from trauma to seeing the next patient within minutes.
There's not a lot of recovery because physicians, for the most part, they're a pretty resourceful bunch. They have a pretty high resilience. And so if physicians are feeling the burnout, I really think it's from a lack of advocacy for what needs to happen in order to support the doctors who you are putting out on the front line, things like technologic support.
Things like having more time with patients, things like not expecting somebody to work for 24 hours. People don't realize that we still take 24-hour shifts as OBGYNs. And some of us will do a 24-hour shift and then we'll show up at our clinic the next day and see patients for another 12. That is the type of thing that is sort of under the radar right now.
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