Monthly Archives: May 2015

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PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.

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Resistant Organisms

I’m not sure that patients are any smarter than they used to be, but they certainly come pre-loaded with more facts. Sometimes these are relevant, often they are contextually unrelated to the reason for their visit. Contiguous, perhaps, yet only distantly attached –second cousins once-removed. Sometimes they seem to be variations on a word, a disease, or a belief; Google’s explanation for one symptom drawn from a bouquet of  complaints  –helpful maybe, but only in the setting of an accurate diagnosis of the cause: the condition responsible.

This is not to admonish the patient for trying to help, nor to disparage the often disparate droplets of assistance, but merely to acknowledge that it is possible to drown in a wading pool. Quantity does not equate to quality when it comes to facts. Nor does it equate to knowledge, unfortunately. If not intelligently –knowledgeably- selected, only some of them are flowers worth looking at; most are weeds.

But weeds are often what grow the fastest, and once they’ve taken hold, they are hard to get rid of.

“My doctor told me I have yeasts,” said Janice, the tiny woman sitting across the desk from me. She had seemed pleasant enough at first, and had even smiled at me as I shook her hand in the waiting room and led her down the corridor to my office. But once  the door was closed and she was settled in a chair, her face hardened and she glared at me as if she were going to attack. She was dressed in an ankle length patterned skirt with a white blouse. It was fraying at the cuffs, but she wore it so ostentatiously that maybe it was supposed to look like that. Her brown, pony-tailed hair was pulled so tightly across the top of her head from her forehead, I wondered at first if her facial expression was because her skin was hurting.  Actually, it was anger.

I had a peek at the referral letter to soften the interrogation her face was attempting. ‘Recurrent yeast infection’ it said. ‘Nothing works’. Great: an offload.

Before I could say anything, I felt the desk move as she leaned against it to sigh. “I’ve been on at least six forums about yeast, and I’m convinced I don’t have yeasts in ‘there’. She said the word ‘there’ softly, warily, so as not to shock me. “So I didn’t take any of the medications she prescribed.” Janice studied my face carefully for a reaction. I think she was disappointed I didn’t react to the dropped gauntlet.

But it was meant as a challenge. An audit. I was being screened.

I tried my best to take a history from her, but it was like trying to pry water out of a box. She knew what she had and anything else about her that didn’t directly address it she deemed irrelevant. I could understand why her family doctor had referred her. She only admitted to feeling itchy ‘down there’, and immediately closed her eyes as if she’d given away a secret. “But there’s nothing else, doctor,” she added quickly, lest I suspect some lack of regional care on her part.

I glanced at the the referral information again, but it was running a close second to Janice in disclosures. “Ahh… well, did your family doctor send off any swabs from the area?” I thought I’d better not use anatomical terms, because she hadn’t.

She eyed me suspiciously, no doubt wondering whether I was trying to prove her wrong. Then, after a long, contemplative pause, she nodded. “Only grew normal flowers…” She considered it for a moment, “I’m sure she said ‘flowers’ but I think she used the wrong word,” she said, obviously contemptuous of anybody who would do that.

“Flora, she meant,” I suggested as humbly as I could manage without laughing out loud. “The normal kinds of bacteria that grow in the region,” I added, to assuage her skeptically tight brow.

“But not yeasts,” Janice added to hammer home her point. “I’m very particular about cleaning myself, so there’s no way stuff like that could have crawled in.”

I tried not to react, and when the horror had receded from her face, I suggested I would like to see if I could resolve the issue for her, once and for all.

Another suspicious glance, a moment of closed-eyed silence, and then a nod. “But I want your nurse in with us,” she managed to whisper through gritted teeth and lips that looked as though they’d been sewn shut. I readily agreed; I was going to suggest it myself.

As it turned out, I was unable to find any evidence of a yeast infection when I looked at samples from the vagina under the microscope. Just some areas that appeared white, like a thin veneer on the skin near the vagina. She was so elated at the vindication and the wisdom of those online forums that she even agreed to let me do some cultures and a couple of biopsies.

A different Janice walked through the door a week later to discuss the results. Her face was relaxed, and so was the hair that now hung loosely and in curls to her shoulders. No more frayed blouse, no ankle length skirt –just jeans and a grey, baggy sweat shirt. Maybe it was the real her.

“Well, doc, what’s the news?”

“No yeast,” I answered, scanning the reports. “And no STIs,” I added with a grin, that was magnified by a chuckle on her part. “No cancer…”

She sighed loudly and a bit theatrically. “I didn’t come back here to discuss what I don’t have, doctor.” But she said it with a twinkle in her eyes. ‘At least we don’t have yeasts,’ they whispered to each other almost conspiratorially, as only eyes can do.

“The biopsies showed a skin condition called lichen sclerosus,” I explained. “It’s a thinning of the skin, probably caused by the immune system…”

“Not an infection?” She was immediately suspicious again.

I shook my head.

“So what’s the treatment?” Wariness once more surfaced on her face, hardening it into little wrinkles.

I smiled to diffuse the tension. “A steroid ointment you have to apply daily to the area for a few weeks. It turns off the immune response causing the skin problem.” I had to tread a bit carefully with this; to tell the truth I wasn’t sure this was the entire mechanism.

“Does it affect yeasts?” her face knotted up even further. “Because you have to be careful about that, you know.”

I raised an eyebrow as a form of silent question –one that I hoped would encourage her to expand on her concern.

“You know what we’re doing to bacteria..?” I wasn’t sure whether she wanted me to answer, but fortunately she resolved the question by answering it herself. “We use so many antibiotics we’re encouraging resistant germs: Superbugs!” She said the last word with such horror, it was as if she had just mentioned the Devil. I almost expected her to cross herself as a protection. “It’s all you read about nowadays. And we’re running out of effective antibiotics!” She stared at me with needle eyes, daring me to contradict the wisdom of her forums.

I scuffled around inside my head for the proper expression to wear. I finally settled on a serious, yet hopeful demeanor. Then I decided to draw her out. “Yeast are not bacteria, Janice… And anyway, they’re not your problem.”

“Doesn’t the immune system keep yeasts in check?”

“Well, in the vagina, lactobacilli help a lot…”

“What about people who get AIDS? Don’t they get overwhelming yeast infections?” She crossed her arms, certain she’d scored a point. “And don’t they have a turned-down immune system?” she added as a finishing coup.

I sat back in my chair, wondering where she was going with this. “And what is it you are concerned about, Janice?” I said when she seemed satisfied she had bested me.

“Superyeasts!” she answered defiantly. I could almost feel the italicization.

I had to chuckle; I couldn’t help myself. “You mean a yeast infection that is resistant to every known treatment?” I knew I was going to need to look that concept up later.

She nodded, satisfaction written across her body in bold letters. “Can you imagine a life lived with a permanent itch? Where scratching doesn’t work?” She had finally made her point –and, she hoped, maybe another convert. She knew she had to spread the word. Save the world from resistant stuff…

http://www.ncbi.nlm.nih.gov/pubmed/17906120 Candida drug resistance

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC105901/  Candida resistance in HIV

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The Polarization Bias

Okay, I have to admit to living an unbeknownst lie –unbeknownst to me, at any rate. Sometimes it is easy to coast, to accept help where it is offered and feel almost foolishly grateful for suggestions that foster the dependence. Advice is seductive, guidance addictive. But more importantly, it is insidious. Critical thinking -critical analysis- suggests that we process whatever information we are offered by considering its validity when compared with other sources, other viewpoints, other contexts. It is what we should do; it is not what we usually do. Time constraints, biases, laziness –they all conspire to let us float on the tide. Drift.

I suppose my awareness of the current may have started when I was casting about for a book to read. Like many of us, I have a passion for reading that is naively open to recommendations. The online Amazon book store is an almost limitless cornucopia of books. And when you click on one, a section appears just beneath your choice that says: Customers who viewed this item also viewed… And a list of similar books on similar subjects is just a click away: a topic-specific, yet unrequested bounty spilling onto the screen. And all with seemingly different approaches but eerily similar viewpoints to the book you’ve chosen. A coincidence? Or a recognition that you have a particular worldview whose advocates you are more likely to read? And buy.

At first, I was both pleased and amazed that Amazon could find so many different authors and topics that I found compelling and place them before me like a waiter with a dessert tray. So easy to choose from only what is offered –too easy… What I initially thought of as a diverse array of well-considered opinions, I began to realize was an artfully arrayed selection that fostered my already-held biases. A compass that always pointed north, no matter the coordinates.

I suspect that most of us, even offered the choice, would find no compelling reasons to change allegiance, or flirt with opinions we have been taught to mistrust. We feel uncomfortable accepting that the opposition feels the way it does on grounds that are equally persuasive for it. Rather than being open even to thought-provoking alternative ideas, we rust into positions that further restrict our ability to move.

But what if the news we so avidly ingest nowadays could be similarly sorted to our tastes and presented to us as a fair representation of what is really happening? How would we know of the manipulation? How could we become aware of the slanted viewpoint when it so closely agrees with our own –when it is what we want to hear? Confirmation bias is difficult to resist even at the best of times.

http://www.huffingtonpost.com/2015/05/12/facebook-study-polarization_n_7245192.html?utm_hp_ref=world&ir=World

I hadn’t realized that many people actually read those snippets on Facebook that purport to inform. I had thought most of them were not terribly well disguised ‘infomercials’, but perhaps that is my bias -the boreal plain to which I am unwittingly confined. But that our serving of news should be chosen for us according to our likes and dislikes is anathema. And that our meal of information should be expurgated and mashed into a small, more easily digestible aliquot of words smacks of propaganda. Control. Handling… I would like to digest unchewed information in my own way, thank you. I can deal with heartburn; I’m not good with starvation.

http://www.bbc.com/news/technology-32707014

The dilution of mainstream media and its as-yet relatively unfettered ability to pretend to present both sides of an argument is worrisome. Similarly, the accretion of our sources of information into a few huge monolithic blocks with their own interests to serve is dangerous. Especially when they presume to know what opinions will keep us quiet.

“Let every eye negotiate for itself and trust no agent,” says Claudio, in Shakespeare’s Much Ado About Nothing. Bravo!

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The Medical Student

She was not old for a medical student I suppose, although her face spoke of experience far beyond her years. But how do you measure age in a profession that cherishes the wisdom and equanimity that so often accompany Time’s passage? No, she was not old, but nor did she possess the naïveté that so often colours the awkward period of youth; she was, in a way, just Maria: confident, inquisitive, but neither gullible nor easily swayed from an opinion once she had weighed the evidence.

Short, with straight brown hair to match, she was dressed in what I would call an unobtrusive fashion –not meant to draw attention to herself but to enable her to emerge from the shadows with dignity should it be required. Only the short white coat so indicative of her student status and which I suggested she remove before seeing patients, would have marked her as out of place in an office that otherwise spoke of the ordinary. I’ve always felt that patients would be more accepting of the student’s presence if they were perceived as being part of the process of consultation with a specialist, not an artifice. Not an appendage. Not an add-on.

Maria sat politely against the wall, legs crossed and a smile tattooed on her lips as she listened to the first of my patients describe how she had finally decided she needed another checkup and a pap smear. For some reason, her family doctor had not felt comfortable in acceding to her request. Maria studied her so intensely it made me nervous.

“What are you using for contraception?” I asked as part of the history.

Janet, who looked  forty or so, but was really 28, just shrugged. She was comfortable with the question; she was comfortable with men who asked them. “I try to get them to use condoms, but…” Maria’s eyes opened wide at this, but she refrained from saying anything. I could see it was an effort for her, though.

As I progressed through the history, it became obvious that Janet was struggling with many issues, but I was impressed that she was trying to solve them bit by bit. Life was not easy for her but she was obviously trying to take control of what little she could. I was just one stage in that process…

After I had examined her, done the pap smear and cultures for infection, and given her the form for the lab to take some blood to rule out other conditions to which her lifestyle had made her unduly susceptible, I sat her down in the office again to discuss her needs.

A broad smile creased her face and her eyes narrowed almost seductively. “Is this where you try to convince me to stop the drugs, and follow the straight and narrow, doc?” There was a fatalism in her tone; she’d heard it all before –many times. Too many times. “…‘Cause you know it’s not gonna happen. I’m just trying to keep myself alive until I decide to change. If I decide. Nobody understands…” Her expression didn’t waiver, but I could tell she was on the brink of tears as she reached for the faded coat she’d draped over the chair. “And there’s nothing you can do until I decide, you know.”

And she was right –all I could do was support her until she was ready. We lived on separate sides of a river that was so wide in most places that it couldn’t be bridged. I felt like reaching across the desk and touching her hand to show her I understood, but I stopped myself. However well-intentioned my gesture, it might be misinterpreted –it was a prologue for most of the men she had encountered… So I just smiled in a lame attempt at encouraging her. “If you ever need to talk, Janet…” I said as she stood up before we could discuss anything further. I don’t even know why I said that -it seemed so utterly inadequate to her needs. I told myself I was only a gynaecologist and that she would require far more than I could ever hope to offer. But I still felt humbled and my specialist arrogance melted away as she left the room.

But just as she was about to leave, she turned and smiled briefly at me. Not seductively –not even out of politeness- but there was gratitude in that smile. Maybe she was just happy that I hadn’t tried to change her like her GP, or that I was willing to wait for her -treat her like an adult capable of making her own decisions. I fancied I could see some hope in her eyes before they hardened to face the world outside.

I’d intended to engage Maria in the conversation with Janet but it all happened so quickly I didn’t get a chance.

Maria stared at me as Janet disappeared through the door. She seemed angry. “So what are you going to do now?” It was not said with kindness. It was not said out of curiosity; she had embedded an accusation in it. A condemnation. The tone was polite, but the insinuation was contempt. I was reminded of that speech by Macbeth: ‘Curses, not loud but deep, mouth-honour, breath which the poor heart would fain deny and dare not…’

“Janet has to want to change,” I said. It was a weak reply, but I already felt depressed.

“And until then..?” She said it sweetly enough, but I could hear the anger in her voice.

I sighed and looked at her. “What would you do, Maria?”

I sensed she wanted to throw up her hands and pace around the room, but I could see she was trying to control herself. “Well, talk to her social worker, for one thing…”

“And tell her what, exactly? That Janet took a small first step to help herself? That she seems to be developing a little bit of insight? That I, for one, see the glimmerings of hope that she will change?”

Maria’s eyebrows shot up. “Change?” –she almost spit the word at me. “How can you say that? We’ve been facilitating her, not trying to help her!”

I took a deep breath and relaxed my face. Maria was not as mature as I had thought. “We’ve been listening to her, Maria.” I smiled to diffuse her eyes. “How often do you think somebody has actually listened to her before? Not tried to change her, warn her, or use her?” I softened my expression even more. “The initial step in any change is actually hearing what the other person has to say. Hearing what she thinks and why. Listening; not judging. Not continually interfering, continually trying to impose our idea of the world on her.”

Maria’s whole demeanour tensed with the injustice of it all. “But we didn’t even get a chance to listen! She walked out of here before…”

“Before I had a chance to advise her? Tell her what she should do?” I shook my head slowly.

“But…”

“But sometimes we have to be patient, Maria. Advise when asked; help when needed.” I shrugged to indicate how hard that was. “She may never change –never want to change. We need to try to understand that… Understand her.”

I don’t think Maria understood; I don’t think she felt her own opinion was acknowledged either. I could tell that in her eyes, I had failed as a doctor. Failed as a person. I had committed with her the same sin that I had committed with Janet: not acting on what I had heard.

Maybe she’s right; maybe one’s own principles should be subsumed in those generally held by a society. And yet… And yet I can’t help thinking of Shakespeare again -this time, Polonius in Hamlet: This above all: to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man… –or woman, in this case…

If age has taught me anything, it is that we live in our own worlds for a reason… I think we must sit with the door open. And if Janet wanders back..? Well, I will be here.

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Please and Thank you

Please and thank you –isn’t that what we were all taught? Perhaps it was my prairie upbringing, but it seemed the norm when I was growing up. There was no asking why –no need to, in fact- we all just did it. Indeed its absence was noticed and noticeable –like maybe wearing a suit without a shirt. Nothing dangerous, nothing threatening, but just not done, all the same. Maybe in another culture or in a different era, it might have been passed off as an eccentricity, or perhaps mental illness –but not in my youth. And not now either, I had assumed. Polite is polite. Period.

But mores and folkways are fickle creatures, it seems -pragmatic at best, capricious at worst. At times, they seem rooted in tradition and ancestral wisdom, but increasingly, they smack expediency, fashion –borrowed from somewhere else like a hat for an occasion. And as with trends on social media, they are ephemeral –tales told by an idiot full of sound and fury, signifying nothing…

Or am I being too critical? Too unwilling to accept change? Too… old?

*

Judith was an angry person –or maybe I just met her on an awkward day. But she held her body stiffly, as if any movement might reveal a secret. She had an accent I couldn’t place, but her demeanour didn’t really invite my inquiring about it -another secret she needed to conceal, I suppose. The referral note said only that she had pain but had refused to let her doctor examine her. Judith wouldn’t let me examine her either; she was certain it was caused by an ovarian cyst and she just wanted to talk about it.

I could see her peeking at my computer screen with suspicious eyes. The way I’ve had to configure my temporary desk to accommodate both the ability to access the monitor as well as well as the patient’s face, lends a certain intimacy to the little makeshift office. No longer can I afford to write a note to myself that the patient I’ve been asked to see seems unduly anxious or irritable; I dare not suggest that she is being evasive in her answers to my questions; I cannot even intimate that she doesn’t appear to trust me. All is open to scrutiny during a renovation.

And that’s fine. She can have access to her chart; I have nothing to hide. But as well as her answers to my questions, what I write are merely impressions, conjectures: colours. The subsequent consultation letter to her referring doctor is a collation of these -a considered appraisal of what I have observed and heard. The initial chart is a first draft of things that will later become an opinion. An assessment.

But Judith was persistent. Like someone reading my book over my shoulder on a bus, I have to admit I did feel some boundary issues. I toyed with the idea of turning the screen so she could read it more easily, but my long-held prairie rules of decorum prevented me. Instead, I contented myself with an obviously self-conscious stare at her face. She paid no attention to my discomfort except to wrinkle her face at what I had just written.

I was filling out the reasons for ordering a pelvic ultrasound –outlining what questions I hoped could be answered, and what, specifically, I hoped they would address: The patient has complained of right lower quadrant pain for several months. She may have a right ovarian cyst. Please assess ovaries and characterize cyst if present. Thanks. It seemed a perfectly straightforward request, but I could see Judith shaking her head.

“You’ve got to be more forceful in your request, doctor,” she said, her face tight with concern. “I told you I have a cyst so why don’t you just say so?”

Her response took me by surprise. “I was just outlining my suspicions for them to confirm or refute on the ultrasound…”

Her eyebrows stayed lashed to her hairline. She was shaking her head again, but whether in disapproval or disbelief I couldn’t tell. “And why do they have to know about the pain? That seems to be a breach of patient confidentiality, don’t you think?”

I sighed quietly. “It’s not a breach of confidentiality, Judith, it’s a medical document outlining the questions I want answered, and so it has to have pertinent details about the condition. If it is an ovarian cyst, not all cysts cause pain and not all pain is caused by cysts. I need to know the details of what they see.”

You’d think that would have appeased her but I could tell she was still troubled by what she saw. “And why do Canadians insist on using ‘please and thank you’ all the time? It’s just a request for an ultrasound…”

I sat back in my squeaky chair and smiled. “What would you write, Judith?”

She thought about it for a moment, obviously caught off guard. “Well… How about: I’d like you to describe the cyst on her right ovary.”

“ ‘I’d like you to..?’ Isn’t that just a longer way of saying ‘please’?”

Her eyes narrowed and I could almost hear the gears grinding in her head. “Then… why not just: Assess the pelvis?”

I squeaked my chair again. “Seems to me that’s just a command to do something without explaining why. The more information they have, the more they are able to tailor their study.”

A little smile fought for the stage on her face. She was getting into this. “Okay, so: Cyst suspected in pelvis. Confirmation and characterization required.”

I nodded, then turned back to the screen to amend it. “I can accept that, Judith,” I said, as I typed her words onto the requisition. “But I can’t say I agree with it.” I looked up at her. “It seems  too impersonal and uncaring, somehow.”

Her face softened with bewilderment and I could feel her eyes searching my face for an answer. “What do you mean?” she asked after sifting through my words for clues.

I shrugged, not at all sure I could explain. “I guess it’s sort of like the Golden Rule: If a person is standing in a doorway talking to a friend and I want to get past, I could say ‘Get out of my way!’ or I could smile and say something like ‘Would you mind if I squeezed through?’ Experience tells me I’m likely to get more cooperation with the second way. Maybe even a smile…” My chair squeaked again. “I like smiles, even if I’m not there to see them.”

Suddenly her whole body relaxed and a laugh lit the room like the sun coming out from behind a cloud. She reached out in the tiny room and touched my arm. “When I said I didn’t want to see a male gynaecologist, my family doctor said you were different…” She sat back in her chair looking the most relaxed I’d seen her. “Put the ‘Please and Thank you’ back in the form if you want. I think I’d like to see the smile on the technician’s face when she reads it, too.”

The prairie in me sighed. I suppose she meant well- meant it as a compliment… Thought she had gained a unique perspective on a world she had never trusted and maybe never thanked. And yet I don’t think she really understood. What I considered thoughtful, she saw as weak. Not polite. And it bothered me. Am I really so different in being accommodating and respectful when I request a service from someone? Is the concept now so unusual that it draws attention to itself? Attention to me? Thank you, but I cannot let myself believe that. Please let me be right…