Monthly Archives: September 2012

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The Intrauterine Device

I’ve got a poster in my examining room that captures a lot of interest; I call it my pasta poster. It’s a picture of a random assortment of interesting IUDs throughout history -including a couple of stones (Yes, stones have been used!). It often serves as a springboard for discussion of contraception back in the consulting room. Of all of the paintings, diagrams and anatomical pictures I have hanging on my walls, it seems to be the most popular -or at least elicits the most comments. Perhaps it’s the poster equivalent of an accident at the side of the road slowing traffic: morbid curiosity. And yet it seems to get patients thinking about birth control.

Inevitably, the stones at the very bottom of the picture get the most questions -or should I say incredulity. “I thought those were only for camels, doctor.” is a common observation, referring I suppose to the apocryphal use of stones as contraception for camel caravans crossing the desert. “I have no idea if they ever used stones in camel uteri,” I usually reply, and then, depending on the level of interest, go on to tell them of my own experience with them.

“Many years ago,” I often start, lapsing into my best story-telling voice, wondering if I should actually say ‘Once upon a time’. I half expect them to sit cross-legged on their chairs and fold their hands on their laps. “Many years ago a middle-aged woman was referred here to remove her IUD. It had been inserted several years before in a country somewhere in East Africa. She’d already had a few children and had been desperate to prevent any more until she and her husband had the means to support them properly. They’d moved to Canada shortly thereafter and only recently had decided to try for another child.

“She didn’t know the type of IUD that had been inserted, but had not experienced any problems with it over the intervening years. She was told it contained some sort of mineral, though, so I assumed it was a copper IUD. There are various types of IUDs that use copper -usually ones that are T-shaped (the inside cavity of the uterus is also T-shaped so the IUD conforms and is retained in a relatively stable position). She’d never been able to feel a string, and when she’d gone to her family doctor to have it removed, he’d been unable to see a string either. The doctor had felt I might be able to retrieve it.

“IUDs have strings attached to the shaft of the T -typically monofilament nylon so it doesn’t act like a wick and draw moisture (and bacteria) from the vagina into the uterus- and the strings are usually trimmed to stick out of the cervical opening  just enough for a patient to feel them and know the IUD is still in there, but not too short or her partner might be annoyed by the ends… But if the strings are not visible to the doctor using a speculum in the vagina, the IUD has to be removed with special instruments that actually go into the uterus to retrieve it.

“So I discussed this with her and prepared her for the possible cramps that inserting an instrument through the cervical opening and into the uterus would cause. ‘Just get it out, doc,’ she said. ‘Never mind me!’ She had clearly gone through a lot in her life, and when compared to that, nothing I could do in the office was likely to impress her.

“So I took her into the examining room, gave her something to cover herself with, and told her to call me when she was ready. When I came back into the room, I saw her looking at the IUD poster and smiling. ‘Sure a lot of those things, doc,’ she said pointing at the poster. ‘Which one you figure I got?’ I shrugged and pointed at one of the traditional copper T’s. I really had no idea.

“When I got her ready for the examination and inserted the speculum into the vagina I could see that the GP had been correct: no strings were visible. But maybe because of the light source I use to illuminate the cervix, I saw something else that he had apparently not noticed: a faint blue opalescent glow coming through the cervical canal from the uterus. And I knew what had been inserted those six long years ago in the little East African village health center: a semi precious stone.

“I have no idea how they did it, or whether it was pre-sterilized or maybe chosen off the beach, but there it was. I removed the speculum and when she sat up, pointed again to the poster but his time to one of the rocks at the bottom. You’ve got one of those, I said. I can’t remove it here in the office; I’m going to have to remove it in the hospital.

“I noticed she was smiling and nodding her head as I talked. ‘They told me it would be permanent,’ she said, ‘And they charged me extra…'”

In fact, I did eventually remove it under an anaesthetic in the hospital. I asked the pathology department to save it for me so I could give it back to the patient -or at the very least, put it on display near the poster to show other patients. But you know, I never got it back. Is it now a legend in the Pathology department and enshrined in a little glass box in a special corner? Or is some pathologist wearing it around her neck as I write?

I must visit the department again some time… Or would the presence of a gynaecologist -or any non-pathologist- arouse too much suspicion? After all the intervening years, though they’d probably think I was merely lost.

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Doctor on Call

“Are you going to be there to deliver me, Doctor?” It is a question I hear each time I see a new obstetrical patient and one for which I have to admit I am never prepared. After all, the patient has come to see me because either they or the referring doctor feel that I have something to offer. And however mistaken they may be, a choice was still made. Expectations engendered.  After doing whatever research you felt was necessary for your choice, you do not choose a red car and expect to drive home in a blue one, even if it’s just as good.

So the answer to that question is a difficult one for both parties: she bonds with me, but I also bond with her. And given the exigencies of a call schedule, there is bound to be a disconnect. No matter the desire, I simply will not end up delivering all of my patients; the odds are just not there. The patient has to decide if she wants to invest in a long-term relationship of trust and respect with someone who is  possibly going to abandon her when she really needs it: at the apotheosis of the entire process.

But nowadays, no matter who she chooses -family doctor, midwife, obstetrician- they are all on call schedules. No one can be available all the time. In my particular practice there are seven other obstetricians, so the chances are only one in eight that I’ll be the one she’ll see on that special occasion. I’ve tried answering their question like that, but the look on their faces when presented with the odds have taught me that it’s helpful to alter the perspective somewhat: same answer, different context.

Pregnancy is a long road, and like any journey, it’s important to be well-informed along the way about what to expect and what to avoid. Guide books do this, don’t they? That’s one of the reasons we consult them; and the more relevant and assimilable information they offer, the better they are. The trip is almost as important as the destination. If the one is enjoyable, if we know a little bit more about the places we pass, it certainly doesn’t detract from where we hope to end up. Reassurance and advice along the way may not shorten the journey, but give us confidence we’ve taken the correct route.

And in my centre, whoever is on call, lives in the hospital for 24 hours, so if my patient were to present herself to the Delivery Room with an unanticipated problem in the middle of the night, or have some worrisome symptoms that need investigation after office hours -and isn’t that when they usually occur?- there is always a specialist available. No need to worry if their own doctor can get through the rush hour traffic in time, or whether his phone is turned on; someone is always there to help, no matter how grave or trivial the problem. And I trust my colleagues’ judgments; I suspect -I hope- this is not unique. In fact many of them were my residents in past years, so I know how they perform in emergency situations. I think sharing this with my patients helps to alleviate at least some of their frustration at a system that seems to franchise obstetrical services to strangers.

In fact, when I am on call and delivering a colleague’s patient, I sense an understanding, an acceptance of the delegation of responsibility to someone else and I try to be mindful of the fearful joy attendant upon the delivery they have so long anticipated. I try to be respectful of their expectations, their customs, and yes, even their idiosyncrasies. God knows I have enough of my own.

I try, in other words, to show them that it isn’t an abandonment, an uncaring assignment of their health to a surrogate simply because I choose not to be available all the time. But I suspect they know this. Neither the doctor nor the midwife, is the pregnancy. And neither of us is the delivery. We -I- am merely the person riding shotgun on the stagecoach making sure that the strong-box makes it safely to Dodge… Where did that metaphor come from..?

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Choosing a doctor

There are age-old dilemmas in choosing a doctor, aren’t there? Choices often have a way of seeming problematic, even insoluble, when considered in the abstract and all the more so when they have to be made for real. Theoretically, I suppose, they should be made after due-diligence, as the lawyers would say. One merely sets out a series of criteria and then assesses whether or not they have been satisfied. We all do this, to some extent, but often the only criterion that has to be met is whether or not a friend liked the doctor, or perhaps had a good result from him or her. What her scar looked like -never mind what went on underneath it?

But even considering it like this suggests further and more contentious questions: should one choose on the basis of personality -bedside manner, if you will- or results? After all, you still need to interact with the doctor, explain your problem, have it considered and assessed in a sympathetic and respectful manner. A skilled surgeon may be only that – and as I’ve pointed out in previous blogs, surgery isn’t always the answer, but often merely one of many options. If you’re not given the choice, how would you even know there was one?

Do you choose the academician, or the clinician? Knowledge isn’t always translatable into skill. My senior residents usually have the academics down pat -they need to write exams to prove it, after all- but it takes time for them to master the skills that enable them to put it into practice, especially under pressure at three AM or in an emergency where conditions may not be text-book clear. Knowledge is the possession of facts about something; wisdom -skill- is the ability to contextualize them. Use them, in other words.

Oh yes, and then there’s gender -a particularly vexing problem for the male gynaecologist. It seemed especially so when I first started in practice, but I was younger then -more naive. A female colleague and I opened an office together soon after we achieved our specialist fellowships, and I remember feeling hurt (is that the right word?) that our new patients chose -insisted- on seeing her. Finally, and after what seemed like months of empty day-sheets for me, she became so busy that new appointments, even emergencies, had to be deflected. I began to get what I used to call the left-overs: patients who were initially angry that they too had been given a left-over.

Eventually, however, things settled a little and people began to choose on the basis of other criteria than merely gender. Quite simply, males often see things differently. Things that my partner had less patience for -perhaps because she had lived through some of the problems she was being asked to solve and saw them more as complaints than issues needing a solution- I  saw through inexperienced eyes and from a different perspective. I could sympathize with someone having debilitating pain that returned like the moon month after month, year after year. I could understand the need to find a contraceptive that didn’t engender mood changes, or headaches, or intermittent bleeding, or require strict adherence to a schedule so as not to forget to take it. I could sense the tiredness that would be brought on by the demands of breast-feeding, of needing to be constantly alert to the infant, or child’s needs, no matter what else my life required.

But a choice is just that: singling out one from a line up of often similar faces where even the criteria require yet other choices. I suppose if the difference between them is truly small, the choice is even more difficult, but less likely to result in later self-recrimination. One does not -one cannot- choose retrospectively, so any choice could be argued to be the correct one under whatever circumstances it was made. The fact that choice is even possible is a luxury not afforded to everyone, everywhere.

Obviously I have no answer that transcends personalities and specific needs; I would not presume to speak for someone who sees the world from a different background or a different culture. I can only suggest that respect is something that I would look for; that is usually evident on the first encounter. It is in the eyes, on the face and in the gestures. It is woven into the cadence of speech, the words chosen, the smile that, unbidden, lights up the interface between two individuals who are no longer strangers.

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The Doula

For some reason, there are opposing sides in this issue and it’s hard even to approach the topic without raising the eyebrows of one side or the other. It’s not at all clear to me why there should have to be this division, but I’ll attempt a dispassionate consideration of the concept and then venture an opinion for what it’s worth…

First, a definition of sorts: a Doula is basically a labour coach -hopefully one with experience and knowledge that she can draw upon. I suspect the Doula originated in the mists of time because of the needs of women, usually in their first labour, who were beset by a bewildering number of myths, stories, and expectations all encased in a smothering blanket of pain. With no guide but the previously instilled rumours of hours of agony followed by horrid disfigurement if the baby was able to successfully negotiate the birth canal, the idea of a calming presence who could offer guidance and reassurance throughout the travail was appealing. Originally, no doubt, this would have been an older woman in the village who had some experience with labour, probably with a child or two of her own. She would therefore be able to approach childbirth with both compassion and empathy, her very presence reassuring, and her experience proof that there was not only and end to the process, but that a successful conclusion was possible. That the pain was worth it.

It’s still the same process, of course: hours of painful uterine contractions trying to force the baby down a previously untried birth canal; it still takes time for dilatation of the cervix, and descent of the presenting part -the usual definition of progress in labour; it still can go awry. And it’s all of these things but especially the last, that jeopardize the ability of even the bravest to cope.

Some things have changed, though. Effective pain relief is usually available if requested; monitoring of the labour and the baby’s heart rate help to determine if and when interference is warranted; intervention skills and techniques have improved. In most settings both mother and baby are probably safer now than they have ever been. Also, education about pregnancy and labour are widely available: there are prenatal classes, books and magazines full of helpful advice -albeit of sometimes dubious quality, and of course the ubiquitous internet with its plethora of opinions.

The point is, few women approach their delivery entirely ignorant of expectations and fears. I would submit that there is no tabula rasa for labour: everybody, even in direst poverty, has heard something about it; the Doula, if employed, should put those things into context for her client, dispel the harmful myths, provide reassurance and compassion. A friend might provide a similar service. Or a midwife. Or a nurse… We all need a hand to hold.

Why not just have the partner in there providing sustenance and support? That’s ideal if he (or she) can, but let’s face it, the partner is often just as excited and in turn dismayed and frustrated as the one in labour. They are, by and large, a unit with the same expectations and concerns. A knowledgeable outsider is probably better positioned to provide reassurance especially if the labour is long and difficult. A Doula should be a welcome addition to the team.

If I sound like I have reservations, it is because I do. The concept is great. Who would argue with support? A calm and reassured woman is likely to tolerate the problems of labour better than one who is beyond herself with worry and concern over various aspects of it that she cannot process or even understand in the circumstances. Pain and fatigue rarely dispose one to rational analyses. But it’s the experiential component that is often missing in the support -the objective assessment of the situation and the ability to change expectations accordingly. I have heard Doulas vociferously regurgitating their pre-labour instructions not to allow their client to ‘give in’ to the pain, despite its possible role in slowing the progress or tolerability of labour. I suspect that a more experienced coach might better understand that earlier, more naive instructions are not always sustainable in the light of changing circumstances. Many Doulas are sensitive to this and act accordingly -most Doulas, perhaps. But they are not nurses and shouldn’t try to function as such. They are there for support, not to interpret symptoms or read fetal heart rate monitors. They are not there to interfere with their client’s management.

In my center, there is a trained obstetrical nurse assigned on a one to one basis for each labouring patient. They can and do provide support and professional advice as part of their function. They are objective and compassionate, experienced and empathetic. And they are definitely patient advocates, making sure that any management decisions are in their patients’ best interests. Maybe their multiple roles should be more widely advertised. Maybe they are the best Doulas.

I realize that I am coming from a Western medical model, and that as a man, I am someone who could never truly understand what a woman experiences in labour, the support she needs, the encouragement that will help her achieve her goal. My views are biased by my own expectations, my model, my gender it’s true. I can’t escape them.

But I can advocate for safe and compassionate care that helps to ensure the well-being of both mother and baby. That minimizes unnecessary suffering. That strives for a rewarding experience free of fear or untimely intervention.

And so can the nurse… But wait, isn’t that what the Doula was hired to do?