Assume the Position: Memoirs of an Obstetrician Gynecologist (12 page)

(Halloween in the office was always a fun time.)

    Life in Arizona was good to us.  I was busy and the medical practice flourished. As if we didn’t’ have enough to do, one of my partners and I established Women’s Health Research of Arizona which kept us on the forefront of new developments in the specialty.  We tested multiple FDA sponsored protocols for clinical trials testing new medications and procedures in Obstetrics and Gynecology.  I had several articles published in medical journals all referable to a new in-office sterilization procedure we had begun to perform.  The clinical research kept us in the forefront of emerging medicine in the field, and we developed a local and national reputation for innovation.  My partner and I frequently travelled to give lectures, attend investigator meetings, and make presentations to other OB GYN physicians.  Scrupulous record keeping was essential since the FDA could appear at any time, and frequently did, to audit our charts to make sure everything we were doing was in compliance with their protocols.  It also necessitated having a full time nurse coordinator for both patient education and care in these investigative studies. It was challenging, interesting work, new medicine that was not yet taught in medical schools or residency programs.   In fact, we had resident physicians from throughout Arizona often spend time with us for weeks at a time to see procedures and techniques for treatment of abnormal bleeding that in their hands and those of other private practitioners would result in a hysterectomy. Teaching was just a routine part of the day, every day. However, in our hands these patients could be handled either in office or in a short outpatient surgical procedure with the patient going back to work the next day without major surgery, a major clinical advancement for the patients.

     I found that brutal honesty was often the best way to deal with unpleasant diagnoses.  Most patient’s could understand and appreciate bad news if delivered forthrightly without sugar coating, deal with the emotion in whatever time needed to clear the air, and then the discussion could begin with all the options presented in a step wise fashion.  It was a strange set of circumstances that caused me to deliver my first cancer diagnosis to my own father.  While early in my second year of medical school, my dad developed a problem that was not being managed well by his local physician.  I implored him to come to Philadelphia to see my professor of Urology at Hahnemann, which resulted in a biopsy on a Thursday afternoon.  Saturday morning he and I were waiting all morning in his hospital room for the Professor to make rounds and deliver the biopsy diagnosis, but for some reason he was delayed.  I went out of the room to the nurse’s station to inquire his whereabouts and found the Professor’s resident also sitting and waiting for the urologist to come.  He informed me of the diagnosis – prostate cancer.  I guess I was gone for five minutes or so and then came back into my dad’s room.  He asked me what I found out.   I could have simply lied and said ‘nothing,’ the doctor will be here soon, which would have been the easy way out.  But despite my discomfort, I chose to tell him the truth.  He handled it quite well, perhaps because he expected as much, perhaps because he could read my face.  Once one tells their parents an unpleasant diagnosis, nothing else is particularly difficult after that.  So for me, I learned the lesson and the technique early on. Straightforward honesty and truth delivered with sensitivity gets the job done.

     Nothing, however, was as difficult for me as having to tell a pregnant patient who presented to the office complaining of lack of fetal movement that she had a dead baby inside of her.  In most cases where expectant Mom’s feel lack of movement, it is usually short lived and a quick ultrasound in the office confirms a good heartbeat and all is well.  But there were those times when the patient would be lying on the ultrasound table, watching the fetal monitor with me awaiting my reassurance.  Although I could tell instantly the baby was not living because I knew where to look for the heart beat, the mother would not know as fast as I would.  It was always a difficult few seconds having this knowledge before the apprehensive patient who was anxiously lying in front of me. I would use the time to scan some more and to collect my thoughts and anticipate how best to deliver the news to the particular patient, all of whom took the news the same way – disbelief, shock, tears, sadness.  Many patients would question whether or not I was sure, and of course I would never deliver that news if I weren’t.  It just didn’t get easier over time, and was one of the worst parts of the specialty.  These obstetrical accidents happened, fortunately rarely, and there was never fault attached although most patients would begin by trying to blame themselves.  Hugs, hand holding and a quiet period of reflection were usually helpful; I would wait for the patient to speak first, then begin the process of answering her questions and discussing what the next steps were.

     Infertility patients presented their own set of emotional and gynecologic problems all of which needed to be dealt with in an orderly fashion.  The first issue at hand was of course a complete history and physical exam to help ascertain whether the medical definition of infertility was indeed met, or whether the patient just needed to go back out and keep trying, or whether correcting anything with a simple discussion was all that was necessary. Blame to one partner or the other had already been assigned in most cases before the patient ever arrived at the office, however incorrectly.  Some people just assumed that having intercourse six times a day was all that was necessary, which was of course part of the problem.  Others simply needed to stop using contraception.  Others needed to understand the menstrual cycle and when fertility was highest.  Others needed to return with the husband in tow and the investigation would begin there.  Everyone needed to produce a sperm specimen for analysis before anything else was done.  The reality is that the male system is relatively easy to investigate.  If a man were producing sperm with an adequate sperm count, and putting it in the right place, which interestingly wasn’t always the case, often his investigation would end; conversely, if the sperm count was inadequate, he needed a more detailed urological evaluation.  The female reproductive system is much more complex, and needs a stepwise evaluation including a menstrual history, ovulatory history, an examination for anatomical abnormalities, hormonal and blood tests, tubal patency and x-rays, and occasionally a laparoscopic or hysteroscopic exam of the internal female anatomy.  It was often a laborious and time consuming evaluation, but when the cause was ascertained, male or female or occasionally both, it often could be corrected to the utter joy of the patient, some of the happiest and most loyal patients one could ever hope for.

     Of course, all kinds of fears had to be addressed in the office setting, perhaps none of which caused more apprehension for most people than getting naked to some extent before a complete stranger.  This of course applies to physicians as well, since we, too, become patients from time to time, and find ourselves similarly exposed.  But a woman getting naked in front of a strange man is a unique set of circumstances that requires sensitivity and understanding.  We always had long cloth gowns that served much as a bathrobe, and gave the patient some sense of dignity. I would always meet a fully clothed new patient in my office first for her medical history, then escort her into the exam room and let my nurse explain the disrobing and robing procedure.  I would usually give the patient several minutes before entering the room, then upon entering the room begin with a general physical exam, thyroid exam, listen to the heart and lungs before doing a breast exam and reserving the pelvic exam for last.  When finished, I would begin a discussion with the patient seated on the table, and me seated on the exam stool, so that she was above me rather than me standing above her or leaning on the door like it was time for me to run out of the room and see someone else.  I never gave the patient a sense that I had other things on my mind or needed to be somewhere else.  Simply put, it was just common sense to do these things to put the patient at ease as much as possible.

     For some people, however, no matter what one did to try to ease the discomfort of the situation, nothing was enough.   Discomfort was also a two way street. When in medical school as a second year medical student, I was sent to Reading, Pennsylvania for my very first obstetrical and gynecologic rotation.  As a second year medical student, I knew nothing about clinical medicine yet, having spent the entire first year in academic training and labs.  We had practiced pelvic exam on latex pelvic models, but never on a live breathing human being with normal female pelvic anatomy staring me in the face.  So I was petrified of my first pelvic exam.  The attending physician with whom I was working was very liberal and sent me in for the history and exam unaccompanied.  I found an attractive young woman sitting on the exam stool, leaning forward, robe open in the front with most of her breasts indiscreetly showing.  She didn’t seem to care one bit. I did my best not to be flustered and proceeded to find out that she was there for a routine exam.  Lucky me, I could get this over with and get out of the room quickly.  When she got her legs in the stirrups and she slid down to the end of the table, I proceeded to do the speculum exam as skillfully as I could without hurting her and as if I knew what I was doing.  I then proceeded to perform a bimanual exam, with one gloved hand in the vagina and the other on the lower abdomen so as to be able to feel the pelvic organs (I really was just going through the motions and trying to get out of the room).  I saw her hand slowly slide down over her abdomen and gently squeeze and massage my hand that was on her belly.  I didn’t know what to do or say, finished the exam and left the room.   I never discussed what happened with the attending physician.  He simply asked how it went and I said ‘fine’.  I had been petrified.  She dressed, smiled at me on the way out, and left.  It was amazing that this first pelvic exam, my first pelvic exam, began and ended this way.  To this day, I have no idea whether he set me up, whether she set me up, whether they were in cahoots together, or whether she just wanted to hold my hand.

     My office was on the fifth floor of a building across the parking lot from the hospital, so that when one looked through the small vertical windows of the exam room it was perfectly obvious that unless one was on five story stilts peering in the window from the outside parking lot, or was in their hospital bed across the way with binoculars, no one could see into the windows.  Imagine my surprise one day when I walked into the exam room and found the room pitch black, lights out, and window blinds closed in broad daylight.  I asked if Mrs. Jones was still in the room, and she said yes, then I asked if there was a problem.  She replied she couldn’t run the risk of anyone seeing her naked so she closed the blinds and turned off the lights.  I asked her if she realized she was on the fifth floor and no one could see into the windows, and of course she said she was aware.  She also didn’t want me to see her naked.  I had to gently explain to her that I couldn’t examine her without being able to see, that she did have on a gown and drape across her lap which covered her, that I was a physician who was there to care for her, not look at her.  She ultimately relented, the room lights came on, and we managed to get through it without too much further trauma.

     Then there was the opposite extreme.  One day in the midst of a busy office session a new young patient presented herself to me with complaints of a vaginal infection.  I interviewed her fully clothed in my consultation room first as was my custom, then escorted her to an exam room where I asked her to disrobe, put on a gown and I would return in a few minutes.  I performed an exam, and she did indeed have an infection for which I prescribed medication and off she went.  Two days later she was back again with the same complaints of itching and discharge.  Of course I always felt badly when someone returned for a recurring problem, and assumed my diagnosis was incorrect.  A repeat exam, a new prescription and off she went again, only to return for a third time a few days later with the same complaints. Again, back in the exam room to await my return.  She was asked to disrobe and put on a gown. Five minutes later I knocked on the exam room door and walked in to find her standing stark naked, bright lights on, robe folded on the exam table, smiling, facing me, with no attempt to cover up anything, not the usual course of events in my day.  I now couldn’t help but notice her youth, her appearance, her body, her demeanor, and I bolted.  I asked my nurse to go in, tell her to get dressed, to leave, and never to come back.  Of course I documented the whole episode thoroughly in the medical chart and forgot about it.