An Interview with Chavi Karkowsky, Author of HIGH RISK: A Doctor’s Notes on Pregnancy, Birth and the Unexpected

Dr. Chavi Eve Karkowsky is a maternal-fetal medicine specialist. That means she is the ‘high risk’ doctor who ends up seeing women sometimes on the best day of their lives but sometimes on the worst day of their lives. Her debut, HIGH RISK: A Doctor’s Notes on Pregnancy, Birth and the Unexpected (W.W. Norton & Company, 2020) has just been released and it is a brilliant response to the infuriating Hollywood myth that pregnancy means ‘happily ever after.’ Even more, through a series of careful essays she shows that in her immense experience almost nobody (not even many doctors) knows what actually can go wrong during, before, or after a pregnancy.

Writing with a clear love for her patients and work, Dr. Karkowsky has organized the book as a mirror of pregnancy itself, starting with the First Trimester and taking her readers through to Postpartum and Beyond. In each section she explains the risks and issues that her patients might face from personal decisions and hospital policies to larger politics. All of this is highlighted by actual examples of patient situations (the best part!) and unlike fluffy, unsatisfying staples like WHAT TO EXPECT WHEN YOU’RE EXPECTING, Dr. K treats her readers, and patients, with the assumption that they deserve better, deeper explanations. My favorite section, by far, was her description of a night spent on call at the hospital.

The soul of Dr. K’s book lies in the adoration she has for her work and for her patients. The way she argues for patient rights and better procedures, for awareness of what happens in Labor and Delivery kept me reading late into the night. Read HIGH RISK because being born is the one thing every single one of us has in common. Read it too because Dr. K pulls back the curtain and goes where WHAT TO EXPECT never dared to go. We at DeadDarlings were thrilled when Dr. K agreed to this interview, so let’s get to the good stuff:

Dr. K, I was surprised to learn that you often don’t find out what happens to patients you treat or babies you deliver. I hated not knowing what happened to some of the women you talked about in the book but I was just a reader. How do you – their doctor – deal with not knowing?   

Sometimes I do get to see what happens — the patient stays with us for the whole pregnancy; or even, in some wonderful examples, I get to work with her through a whole new pregnancy. But the nature of the work I do and the women I work with means that none of this is ever about me – I work with women who have big complicated lives, and their obstetric and medical care is always just a small part of their much larger story. They go on to their wider lives, as it should be!

So I guess the way I deal with the not-knowing is to care a lot, but also to have perspective: I got to be there for the middle of this story, and what an honor that was.  (And then, sometimes, I see a patient years later, or even once, I got to meet a healthy toddler I helped deliver in the small furniture aisle in Ikea! So you just never know.)

On this subject, you start the book by saying, “Patients lose out because women’s health is segregated into its own universe. I could tell you a thousand stories of delays in patient care because the emergency room doctor didn’t perform a gynecological examination on a bleeding patient because they ‘didn’t feel comfortable,’ thus allowing her to hemorrhage longer in the ER.” Is this a part of that not knowing you experience, or is this different? 

No; I’m speaking about something different here. What I’m describing is a too-common failure of our medical professionals to do their jobs.

Many – even most – medical providers are wonderful, committed, and caring. But on occasion, I still see providers who don’t feel comfortable with women’s health, and that’s a problem.  Taking care of women can include gynecologic exams and asking very personal sexual questions, for example; this is intimate, careful work, but it also needs to be something a trained medical provider knows how to handle.

When I find that patients are not receiving timely urgent care for their female reproductive system – whether it’s an exam, or contraception conversation or a pregnancy test — it can lead to real, concrete gaps in care, such as a woman bleeding for longer in the Emergency Department because nobody “felt comfortable” examining her.

As medical professionals, we do rectal exams, and ear exams, and swab mucus-laden throats. That’s the job. We are responsible for the entirety of the human body. Why would any provider feel that there is an opt-out for this particular organ system in these particular patients? It makes me angry when it happens, and I think it should make you angry too.

You wrote that informed consent is a mess and almost impossible to do correctly. You point out that one of the problems with informed consent is that doctors must ask for it sometimes when a patient is in the middle of the worst day of her life. I want our readers to hear your voice, to read a sample of how you think about these sorts of topics. Would you mind telling us a little more about it here, what you struggle with when it comes to informed consent?

I’ve come to believe that consent for a medical procedure is more than a piece of paper, or even a single discussion: it’s a process, a relationship by which I learn what the patient values and wants. During that process, I try to help them understand what we can — or too often, can’t — provide that can help them achieve those goals. Sometimes, for example, in a patient who is in labor at a very early gestational age, when her baby may or may not survive,  all our options are bad ones. In those cases, the best I can offer is the clarity to say that. I’ll say: “I have no good choices for you here; I’m so sorry. But here are the choices you do have, and I’ll help you understand them.”

That being said, obstetrics is, on occasion, a profession where we don’t have time for nuanced complex discussions: trying to approximate a thoughtful process while someone is laboring or bleeding is never perfect. But knowing what consent can and should be helps us, regardless, to try to aim for what we should have, even if it’s an imperfect solution in an imperfect world.

In the section in which you address home birth you write, “Many of these women are searching for a way out of the systematization, standardization and bureaucratization that the modern medical system represents.” Can you talk more about this? Any ideas on first steps towards fixing the broken medical system that women seeking home birth are trying to escape? 

A large part of that chapter also reviews what is powerful – and often very right – with our medical system! I really tried to give the full 360 degree view: the good, the bad, the ugly. The truth is that when you really, truly need help, the giant medical center is amazing and irreplaceable, and sometimes unimaginable to the layperson.

And I think my patients deserve all that: all those resources, all that personnel, all that equipment, all those educated brains thinking about their problem.  I can see why the lack of personalization can be really difficult – I’ve been a patient, more than once! And that same systematization that gives modern medical care its power is often hard on the people within the system, too, though of course in a less profound way.

There is more and more interest and research about how the medical system is trying to fix itself. I work on a lot of that, and I hope to continue it. And I think part of the message I have for women is that there’s good stuff here, too – I hope we can find a way that you can stay in the system, and advocate for yourself within in it, and not deny yourself all that we can do – while we work on fixing it.

You reveal that pregnancy-related mortality rates for black women were 3.2 times that for white women in 2014. Holy crap. Why isn’t that statistic in every single book about pregnancy and birth – and at the forefront of issues the medical community is addressing? Is this something you and your colleagues talk about often? Do you hit a brick wall when you bring it up?

This is a huge discussion – and finally a really transparent one. All the major professional organizations have research, and task forces, as do many cities; many presidential candidates have platforms to address this issue. Right now, it is an issue that is deservedly front and center in the public eye, thankfully – and that comes with a real freedom of speech and with increased resources.

I don’t hit a brick wall when I bring this up. There’s no shame about this right now in medicine – it’s a crisis, and we’re going to fix this. Medical and public health professionals want to talk about this. We want to work on it.  We want to make it better. In fact, we can’t go on like this, so things are going to have to change. And I really have hope that they will, because some of the most talented people I know are on the case.

Moving along to craft, we at DeadDarlings don’t interview many non-fiction authors, but we have many, many non-fiction writers who read our blog and they want me to get to the nitty gritty. Can you tell us about the craft of writing HIGH RISK? How did this book come together? Did you work with an outline? 

I involuntarily worked with an outline! Non-fiction sales begin with a book proposal, which involves an annotated table of contents. That means you need a table of contents, with a paragraph or so explaining what each chapter will be about. This, by far, is the hardest part for me – coming up with ideas is so much worse for me than the actual writing. And the book ultimately diverged from the proposal markedly. But I had an outline provided by the proposal, essentially because it was required. And I was grateful I did have it – it kept me on track.

So many of the most compelling parts of your book are illustrated with real world examples, actual situations. Can you tell us about your process of choosing examples? 

The thing is that I do this work every day; I’m at work right now, writing this after my day is done! Which means that every day there are new stories; every day, I’m privileged to be present for seminal events in many family’s lives. I live and work in a tremendously rich environment in that way – which is part of why I find it so boggling that it’s been neglected by novelists and memoirists.

I usually choose stories that best illustrate the point I’m trying to make, but because I’ve been doing this work for so long, I often have more than one story that would suffice. I generally use one where some small detail – something the patient said, or something she did – drove the point home. This means that for every story in the book, there are others that were clinically almost exactly the same – but the human element is always different, always unique, and always fascinating.

Non-fiction is sold oftentimes with a proposal – not a full draft. Can you share with us how much of a draft you had when you found your agent? Or when she sold it?  

When I pitched to my agent, I had a relatively complete book proposal, which included an “Overview” (which later became the basis for the introduction) and two sample chapters. Interestingly, though I worked so hard on those chapters, I think they are – to me – some of the weaker chapters now (please don’t guess which). It’s a testament, I guess, to how much I learned through the process itself.

What advice can you give our non-fiction writers out there who are about to search for agents? And for those who have agents and are about to go out on submission?

One, follow instructions. I submitted to a lot of agents while ignoring their format instructions. Why would I do that? I’m sure it means that whoever opens the mail just threw my proposal directly into the trash.

Two: target your agent. I think it’s helpful to look through Publisher’s Marketplace and find an agent that has worked on books that mean s/he might really like yours. I found my agent because she worked on science, explicitly stated she wanted more women’s voices – and liked stuff that was a little bit funny.  I wrote her an email that highlighted all those parts of my voice, and it worked.

Finally, let’s get personal. What are you reading now? What books do you recommend? 

I finished my friend Ilana Kurshan’s fascinating memoir-slash-Talmud journey and I think everyone should read it. I just started the Wolf Hall novels – I’m so behind that I’m just on time for her to publish the third one! I also read a lot of YA novels (my kids are devouring Rick Riordan’s various mythology series, and so am I), and I adore Rainbow Rowell right now – she really believes in love and good banter, and sometimes that’s what you need.

About Chavi Karkowsky: Doctor Karkowsky is a high-risk pregnancy doctor (also known as a Maternal-Fetal Medicine specialist) who practices in New York City. She writes about medicine, women’s health, policy, and occasionally her kids. Her work has appeared in Slate, Daily Beast, the Atlantic, the Washington Post and a variety of other publications. She is represented by Jessica Papin at DG&B.

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