Blow, Blow, Thou Winter Wind

There is a time, a dark time, when normal daylight thoughts are banished. A time when what remains are skeletal shadows, atavistic remnants of ancestral fears, unbidden fragments of anchorless dread which in the fullness of a sunlit day, are sheer cotton. -translucent at their best. It is when doors are left ajar and watchmen sleep. It is a time when filtering is impossible, and  vetting unreliable. It is the time of night when even the moon is asleep, or hiding…

And normally, so am I, but age and diet sometimes conspire to rearrange diurnal rhythms –shuffle the deck- and if I allow the shards of my imagination any attempts to organize unsupervised, the resultant patterns are not ones I would recognize in the light. Nor accept. It is an existential angst, a dark time of the soul.

A few weeks ago, I awoke sweating, and in the nocturnal silence of a moonless night, seemed trapped in an airless blanket of dread. I couldn’t see, and everything around me was still. Unmoving. Mute. If it had been preceded by a dream, I couldn’t remember it; all was numbed by the intensity of the terror, and I was helpless in the current swirling noiselessly around me. Suddenly, the sure and certain knowledge that I would be blinded from complications of impending cataract surgery gripped me like the jaws of an unseen, unexpected predator, and the ensuing silence convinced me of the extent of my coeval deafness. I was, and would be for all time, trapped in a silent darkness -solitary confinement on the authority of cast dice.

Of course the feeling passed, and my daylight remembrance of the event was suitably tailored in the sun, but the feeling lingered. What would it be like to be forever trapped in both silence and darkness, I wondered? What would be left of life? And for that matter, what would be the use of a gift I could no longer use? No longer experience… except as a living, solitary hell?

I suppose I’m being overly dramatic about a highly unlikely confluence of events, but even the possibility makes me shudder -makes me fearful about the fragile egg-shell in which I am encased, and the delicacy of the components it is charged with protecting. It is perhaps a wonder that we as a species –and more specifically, I as an individual- have survived at all, let alone this many years.

With this in the back of my mind, I am surprised I had not heard of Usher syndrome before, although perhaps my specialty of Obstetrics and Gynaecology quarantined me from an extremely rare condition that results in both blindness and deafness as well as a host of other non-gynaecologic impairments. But it was the subject of a BBC article that caught my eye and quickly brought back the horror of my panic attack: http://www.bbc.com/news/disability-38853237

It’s the story of a young girl, Molly, who ‘was born severely deaf and learned to lip read. But, at the age of 12, she was diagnosed with Usher syndrome, a degenerative disease which causes sight and hearing loss. Now aged 22 she has just 5% of sight left in one eye.’ The eye condition is called retinitis pigmentosa which progressively affects peripheral vision and results in night blindness as well.

And, as if deafness and blindness were not enough, she was also a teenager struggling like every other teen, to negotiate the serpentine interstices of social life. She did receive speech therapy, so communication was possible, but as she admits, ‘”I have to strategise everything I do. I am night-blind and so when I go out I would often ask to hang onto a friend. I will only go out with the close friends who do not make me feel a burden.”’

There are also mental health issues with Usher syndrome, not surprisingly, and Molly has a bipolar disease which can complicate her ability to cope with her disabilities at times. Also, ‘Her experiences are often dictated by the support she receives. While she says college restored her faith in humanity, she left university early due to a lack of assistance. “Lecturers didn’t have the time to understand my condition. Training and awareness sessions were set up for staff and nobody turned up. I just needed materials to be made accessible – large text, for lecturers to wear a radio aid that connected to my hearing aids – it’s as simple as that.”’

Some people are truly special, aren’t they? I suspect I would have sunk into an irremediable depression and yet ‘Molly has set up her own charity – The Molly Watt Trust – to support others with Usher and has spoken at prestigious institutions including Harvard University and the House of Commons [UK] outlining how capable people with Usher are.’

But perhaps the spirit soars, even in captivity –or maybe especially in captivity. I’m reminded of Victor Frankl’s book Man’s Search for Meaning and his thesis of ‘tragic optimism’: ‘How […] can life retain its potential meaning in spite of its tragic aspects? After all, “saying yes to life in spite of everything […] presupposes that life is potentially meaningful under any conditions, even those which are most miserable. And this in turn presupposes the human capacity to creatively turn life’s negative aspects into something positive or constructive. In other words, what matters is to make the best of any given situation. […]an optimism in the face of tragedy and in view of the human potential which at its best always allows for: turning suffering into a human achievement and accomplishment […] and deriving from life’s transitoriness an incentive to take responsible action.’

I suppose that it is difficult to judge a response like Molly’s from the outside, though; I suspect that true empathy –experiencing something through another’s mind- is nigh on impossible for most of us in her case. After all, it would require relinquishing all of that which we have come to accept as normal –sight for as many years as we have lived, and the sounds that have accompanied us through the years… An existence unimpeded -until now, perhaps- by significant impairment. The contrast between then and now would be overwhelming, I think.

And yet, as Helena says in Shakespeare’s All’s Well That Ends Well, ‘”Oft expectation fails, and most oft there where most it promises; and oft it hits where hope is coldest, and despair most fits.”’

Thank you Molly!

 

 

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The Trigger Warning

Call me naive, if you will, or maybe even uninformed, but not insensitive. Not indifferent; I am neither.  Unaware, perhaps comes closest. And, until recently, the concept of trigger warning was not one that I thought would have arisen in the day to day world of office gynaecology. But I was wrong.

A trigger warning, I have since discovered, is an alert to the audience (or patient) that what you are going to say might inadvertently offend or upset them –especially if they had experienced a related trauma. Theoretically, at least, it gives them an opportunity to prepare themselves beforehand, or inform you that they would rather not hear that part of your discussion. Many university lecturers have taken to issuing these warnings in their preparatory notes, or at least at the beginning of their lectures, I understand.

And at first glance, it seems the reasonable thing to do. If something in the lecture might offend or distress some students, then they should have the opportunity to opt out of that particular lecture without punitive consequences. On the other hand, to withhold some of the contents from the entire class in case it offends someone, seems like censorship. So I think that a prophylactic warning beforehand is in everybody’s best interest.

I suppose it could get out of hand, however.

Jennifer was a patient that I had seen for the first time in the hospital colposcopy clinic for  a rather long history of abnormal pap smears. I had looked at her cervix through a colposcope (a microscope with a long focal length so it can visualize the cervix even high up in the vagina) and biopsied an area that was likely responsible for the pap smear change; she had come to the office to discuss the findings.

A young woman in her late twenties, she seemed quite self assured as she sat quietly in the busy waiting room reading a magazine oblivious to the noise around her. Dressed in black designer jeans and a baggy yellow sweat shirt that said ‘Really?’ in bold blue letters, she looked capable of weathering any disturbance. But, as absorbed in the intricacies of the magazine article as she seemed, her eyes immediately locked on mine when I appeared in the room. Brown, curious eyes, as I recall; eyes that, once engaged, held their target until it turned away –or responded as I did, with a proffered hand.

When we were settled in my office, and she had inspected the room, a sudden and unexpected smile appeared on her face. It was, I suspect, an attempt to force me to give her good news about the biopsy. “So what did you find, doctor?” she said, with a lilt in her voice.

It’s often difficult to discuss an abnormality with someone who seems sure that nothing is wrong. Obviously her GP had chosen not to. “Well, you remember that the pap smear that brought you to the colposcopy clinic in the first place was abnormal…”

“Yes,” she interrupted, “but it was only mildly abnormal…”

I smiled in what I hoped was a reassuring fashion and nodded. “Pap smears are an early part of a screening system that helps us to decide whether or not to investigate further. They’re just cells that we collect by scraping the surface of the cervix after all.”

Her expression immediately changed and her previously cheerful face tightened. “What are you trying to tell me, doctor?” she said, and straightened in her chair. She stared at me for a moment, but before I could formulate an answer, words tumbled from her mouth. “Do I have cancer? Is that why you brought me in today instead of letting my GP tell me?”

I kept my eyes calm, and shook my head. “No, far from it.” Once someone has used the C word, I often find it’s important to disavow them of it immediately or it festers in the background. “You have a moderate abnormality on the biopsy I took.” I avoided using the Bethesda system’s alternate label of ‘high grade’ to help her to process the news. “It’s definitely not cancer, but if you left it for a while, it might certainly take that route…”

“Left it how long?” she asked, trying, unsuccessfully, to keep the panic out of her voice.

I shrugged, to show her that I wasn’t particularly worried. “Years, likely… but we usually treat it soon after we diagnose it… Just in case.” I added thoughtfully.

Her eyes were dinner plates and her mouth was trembling; I thought she might burst into tears, so I handed her a tissue.

“And… How do you treat it?” She managed to look out the window behind my back for a moment. “Surgery?”

I nodded reassuringly. I was about to describe a small five or ten-minute operation we do in the outpatient’s department under local anaesthetic when she exploded in tears.

“I will not let you take my uterus out, doctor!” she said between sobs. “We’re trying to get pregnant!”

“I won’t let me take your uterus out either, Jennifer,” I said, trying to lighten her mood, I guess. But it backfired.

“You seem to be taking this whole thing rather lightly, doctor. I would have hoped you would be more sensitive…”

My face fell. “I’m sorry, Jennifer. I was just trying to reassure you that removing your uterus was not the kind of surgery I had in mind. It was a rather clumsy attempt, though. I’m sorry…”

Her forehead softened and she grabbed another tissue and relaxed a little on her chair. “Remember, we want to get pregnant soon,” she said, her words tentative now. “We’ve already lost one… I had a miscarriage last year,” she added hastily for fear I might not understand. She stared at me for a moment. “Could I wait till after I’ve had a baby and then do the surgery?

I looked at the findings from the colposcopy once again. She had a rather large lesion and the pathology report suggested that some areas of the biopsy might be more severe -not cancer, but certainly meriting treatment. “You always have a choice, Jennifer…”

“But…”

I realized she probably felt there might be different opinions for management so I sat back in my chair to show her I was willing to listen, but she just continued to stare at me with a mixture of anger and disbelief on her face. “Would you like me to ask your GP to send you to another gynaecologist for a second opinion?”

She didn’t say anything, so I decided to describe the operation I usually perform for her abnormality: a LEEP (Loop Electrosurgical Excision Procedure). It involves taking the abnormal cells off the cervix by removing a thin disk of tissue. I drew on a diagram of the cervix and uterus as I was describing it so she could understand it a little better. I even gave her the diagram to take home with her.

As I was finishing, she looked up from the paper and locked eyes with me again. “And the complications?  Am I going to be able to have children?”

I smiled at her again. I had been about to discuss possible complications with her. “Well, hopefully it won’t interfere with that, but if you look it up online, you’ll see a few complications listed. In my experience they’re not very common, though.”

My attempt to put the complications into some kind of perspective for her obviously didn’t reassure Jennifer. “What are they?” She said, rather harshly I thought.

“Well, in pregnancy, the cervix has to remain strong enough to hold the baby inside until it’s ready. If too much of it is taken away with the surgery, then it might open prematurely –incompetent cervix it’s called- and the pregnancy might be lost…” Her mouth fell open and her eyes narrowed. “But,” I continued before she could say anything, “nowadays that first ultrasound you get in pregnancy can look at the cervix and pretty reliably reassure us that it’s not likely to happen.” I kept my face as neutral as I could in an attempt to disarm her growing distress. “And if it seemed likely that the cervix was shortening, or if we discovered a problem later in the pregnancy –the baby’s a lot bigger then, remember, and so it exerts more pressure on the cervix- we could put a stitch called a ‘cerclage’ around the cervix to keep it closed. Then, near the end of pregnancy when the baby is old enough to be born safely, we untie it…”

She could barely speak, she was so angry. She glared at me through predatory eyes and then, with clenched teeth and a barely open mouth, she managed to say something. “You know, I’m really disappointed in you doctor! With all your experience and with all I’ve heard about you, I’m really disappointed.”

I suppose my expression changed to one of puzzlement –astonishment, really- because she immediately began to put on the coat she’d kept on her lap.

“You knew I’d had a miscarriage –it’s on that form I filled out in the hospital for that clinic. And I told you here in the office just a minute ago. You could see I was worried, and yet you still kept talking as if it was simply business as usual…!” She grabbed another tissue and dabbed both eyes again. “I had a hard time recovering from the pregnancy I lost… But you didn’t care!”

“I’m sorry… I…” But she wasn’t listening.

“Any doctor who was sensitive to their patients –anybody for that matter- would have known to give a trigger warning…” she said and stood to leave. “I’m going to ask my GP to send me to someone more empathetic,” she said and turned on her heel and stomped angrily out of the office.

I felt terrible too; I felt I’d failed her -even though there’s no easy way to tell people things they don’t want to hear. Thinking back on it, I suppose I was insensitive to her needs. And yet…

It’s hard to be anything but humble in this field…

 

 

The Empathy of Age

I am intrigued by the concept of empathy. Variously defined as caring, psychological identification, or even sharing another person’s feelings, it is nevertheless a quality incumbent upon those of us in the health profession in whatever capacity.

Empathy is a word that has, in some minds, become synonymous with other altruistic traits such as sympathy, compassion, or even pity, but it is broader than those -and perhaps that is what makes it so valuable -so unique as a descriptor. Sympathy, for example, is more restricted in emphasis: more of a feeling of concern for another who is in need; compassion, on the other hand is what we may feel when another requires our help –a motivator.

Empathy encompasses these, and more. I like the definition in Wikipedia: Empathy is the capacity to understand or feel what another person is experiencing from within the other person’s frame of reference.

But is empathy something like a genetic gift? Something that pushes those who possess it to self-select into the helping professions? Or is it more like courage: you don’t know if you have it until it becomes necessary?

No, apparently it can be taught –although I must say I must have missed that lecture in medical school because, along with things like ethics and cultural safety, it was an assumed quantity. If you were going to be a doctor, that meant you had it… But, like St. Thomas Aquinas’ understanding of Time, it was an entity that was only definable when you didn’t try -or the philosopher Krishnamurti’s objection to naming God, because it confined the concept…

Over the years, though, I have tried to confine it –or at least experience its various manifestations. And although these are no doubt legion, I am still thirsty. Readers of these essays have perhaps already had their fill of my insatiable insistence on the art of listening before speaking (For example: https://musingsonwomenshealth.wordpress.com/2015/06/30/when-silence-is-golden/ ) But I’m afraid there was yet another news article that caught my eye: http://www.bbc.co.uk/news/magazine-33287727  and I thought I’d try it out at the first opportunity. I’m always looking for new tricks.

Radical listening –that sounded easy. And familiar: “…be present to what’s really going on within – to the unique feelings and needs a person is experiencing at that very moment” and, in practice, “Let people have their say, hold back from interrupting and even reflect back what they’ve told you so they knew you were really listening.” Perhaps that’s what I have been doing all along, but not consciously aware of it, though. Or maybe not –maybe all doctors think they listen, but possibly what we are actually listening to is ourselves –our prepared judgements, our sure and certain feeling that we have the answers. Or, at least an answer… Science uses inductive methods: start with the data and then establish a theory that seems to fit. But maybe, despite our protestations to the contrary, we sometimes resort to a type of deductive reasoning: start with a theory and then make the data fit -or at least search around until we find some that do. Because if we don’t have an answer… what good are we?

Time for awareness. I thought I’d start with someone with a relatively common problem –a non-gendered one so I could more easily slip into their shoes, as it were. I scanned my list of patients for the day but none seemed suitable. I simply could not easily cohabit a mind filled with fibroids or endometriosis.

Loren was different. A woman with persisting hot flushes seemed initially excludable from my naïvely chosen criteria, and yet it soon became apparent that the hot flushes were a sort of proxy. She was a young looking 62 with barely a wrinkle on her face. Fashionably thin and elegantly dressed, she seemed to have ignored the years that have exiled so many others -stranded them, as it were, on a foreign, uninviting coast. No, Loren was a professor at one of the universities here in the city, and much in demand both for her human rights advocacy and her several books on the subject that seemed to be quoted whenever federal immigration policies were in the news.

“I get these hot feelings in the most unfortunate circumstances, doctor. They usually occur when I’m in a social situation where my reaction to them would be noticeable –giving a lecture, for example. Or an interview. I’ve never embarrassed easily, but if some commentator manages it, I find myself almost overwhelmed by a need to wipe my forhead –not a sign of strength.”

She paused, no doubt waiting to judge my reaction as to whether that was a common feature. Mentally rubbing my hands and determined to try my new tricks, I smiled reassuringly. “So these hot flushes occur in social situations where to acknowledge them would be awkward..?”

She nodded, and then as if she’d been given permission to speak again: “I’m worried, frankly. I never used to be like this.” She considered it briefly, and her eyes turned inward for a moment. “I’m beginning to see it as a type of physiological dementia –a sort of bodily facsimile… an early protoype of things to come…”

The thought seemed to bother her and she studied my face for a refutation. “I can see you’re worried, Loren,” I replied slowly. “I’ve never heard hot flushes described as a type of nascent dementia, though.” Good; I was proud of that succinct encapsulation of her thoughts and looked at her contentedly. This wasn’t so hard.

She sighed, but I wasn’t sure whether it was out of satisfaction at finally being heard, or frustration. “And words don’t come as easily as they used to any more. I’ve been blaming it on the hot flushes because the two seem… coeval.” She glanced at me, her eyes frightened birds huddling in their cages. “Like just now –I couldn’t think of another word that meant ‘at the same time’ quickly enough, so I substituted ‘coeval’…”

Another long pause; I wondered whether this was the time to reiterate –the word ‘regurgitate’ entered my head and I almost smiled, but her face looked so anguished I decided to go for it. “Words don’t come easily anymore –and you blame it on your hot flushes… I like the word ‘coeval’ I have to say.” I blushed at my amateurish attempt at precis this time…

She didn’t sigh this time, but I could tell her eyes were about to leave their nest. “I suppose all of us experience this after a certain age…” She diverted her attention to the picture of a peasant woman leading a horse that hung on the opposite wall. “But words have been my world, and their loss –or at least their current drying up to a trickle- terrifies me.” She continued to stare at the picture, as if the answer lay in the coloured sketch, its almost random lines a reminder of her words. Suddenly she turned to stare at me. No, to study my reaction. I could sense her dividing me into grids, mathematically precise areas for analysis. “Hormones didn’t help before… Do you think it would help to go back on them?”

It was a plea, begging for an answer. A solution. Anything to give her hope. It was going to be hard to stick with my radical listening approach… Or had I already done it? I tried to smile intelligently at her, tried to find some words to help, but like her, I was struggling. “Words…” I started hesitantly, aware that I was blushing at my sudden blank. It was like my head was an empty screen. “…don’t come easily to you anymore…” The look of frustration at my repeated attempts to incorporate her own words into my response was becoming glaringly obvious, and I could almost feel her anger. I sighed and abandoned my tactics. “Words don’t come easily to any of us after a certain age, and its not only embarrassing, it’s frightening. They are my world as well –they’ve been what have defined me not only as an explicator of the arcane, but also as a person. Words are friends I’ve called on whenever the need arose. They’re still there, but as with you, the words that arrive in response are often friends of friends. Acquaintances from books I’ve read and long since forgotten. Clumsy words. Opaque words with only approximate relevance that people merely skip over when they hear them, thinking I’m just being clever. Metaphorical.

“And then the words, like branches floating past in a slowly moving river, make way for others –more familiar, perhaps, but moving all the same. And the conversation continues with probably only me who noticed all the substitutions…”

Loren sat back in her chair with a look of satisfaction on her face. Her eyes, caged once again, sat twinkling at me from their lairs. “You know,” she said, apparently finding her words with ease, “I should go to doctors more frequently.” And with that, she reached across the desk and squeezed my hand. “That’s all I needed to…” -a slight pause, almost unnoticeable- “assimilate…”

We looked at each other and smiled. We were of an age.

The Miracle (part 2): a woman’s story in 2 parts

“Emily.” It was the doctor’s voice, and he was leading her into a seat in his office as if she were an old lady. “Emily, it’s good to see you again…” his voice trailed off as he inspected her. “But you were supposed to have come back to see me a month or so ago, remember?”

Why was everybody always asking her if she remembered something or other? She was here wasn’t she? And besides, he knew she couldn’t keep running back to him with every little complaint until she was sure.

“Now remember last time you were in, you said you were having some…ah…” He referred to a folder that lay open on his desk. Couldn’t he remember, she wondered? It hadn’t been that long ago. “You were having some trouble with your bowels,” he continued as if he hadn’t really forgotten. “Constipated, bloated, vague discomfort in your pelvis…”

‘Vague discomfort’? Had she really said that? She became aware that he was drumming his fingers on the desk. It was all very funny, really. He was obviously expecting her to say something but all he would do was look at her quizzically over the bridge of his glasses. His straight, mouse-brown hair was too long for his thin body, she thought. And he was wearing the same creased grey suit as last time. What kind of a doctor only owned one suit?

Finally he ventured to speak again. “What’s been happening lately?” But she only smiled. “Bill told me you’ve been quite sick…” Again the look, and again she refused to be manipulated. “He said you’ve had some more pain and have started to vomit.”

She shrugged. Damn that Bill! This was all supposed to be so different. Why did Bill care anyway? He was never around much and even when he was, he was merely there. But so was she -trees in a meadow: untouching, indifferent, one or the other always in the shade.

Doctor Brock looked annoyed and was having trouble disguising it. “Bill said you wanted to see me Emily.”

She stared at the open file in front of him filled with writing in blues and blacks. Why would he use different colours, she wondered? And some things looked as if they had been underlined; this puzzled her as well. She didn’t think she’d ever told him enough to underline. She blinked, trying to resolve whether or not the line went through or under a sentence. Even doctors made mistakes. The chart was too far away to see clearly, however, so she leaned forward slightly, and as she did he cleared his throat.

“What did you want to see me about Emily? You’re still feeling unwell, aren’t you?”

There he goes again, she thought -just like Bill: he hadn’t asked, he’d stated -accused, actually. As if feeling unwell was wrong -no… expected. She was amazed at the stupidity of the man. How could she confide in someone who couldn’t understand how she felt about it all? She should have gone to a woman.

He sat back in his comfortable leather chair, determined to wait her out. Why was he so stupid? No, obtuse; she knew he wasn’t stupid exactly, just unable to relate to a woman’s needs at a time like this. She stared at him, confronting him silently with her unblinking accusation. She needed someone else; she was sure of it.

He coughed at her quiet threat, as if the noise might dissipate it -make her blink first, maybe. But she was determined. “I’m sorry doctor, you just don’t seem to understand.”

The sudden flurry of words made him jerk forward awkwardly in his chair. She got up to leave. “But you haven’t even told me what’s wrong, Emily. How can you expect..?” She was through the door before he could finish.

“It’s a woman doctor I need,” she told Bill in the car. He may have heard, but he didn’t turn his head or even shrug; it didn’t really matter anymore.

*

Dr. Heath was very young -something the Yellow Pages didn’t mention. But at least her door had the usual trappings of confidence: a sedate, cream-on-plastic plate with the requisite number of letters after her name -a few extra, even, as if to invite entry.

As soon as she got inside, though, Emily realized she had made a mistake. It was cheery enough, with heavily carpeted floors and a large double-glazed window with a view of the city; the plants were nice, if a trifle under-watered; and there were pictures on the walls of babies: babies with hats, babies in diapers, babies at breasts… It wasn’t the office that bothered her. It was the age of the patients that seemed strewn about like clothes: teenagers -all of them. Some pregnant, some with skirts up around their waists -a rogue’s gallery of young people, all staring impudently at her as she crossed self-consciously in front of them to the front desk.

The receptionist couldn’t have been much older, and as Emily gave her name she thought she caught a fleeting smirk that never quite surfaced. “You’ll have to fill in this form for the doctor, Emily. And I’m afraid she’s running a bit late today.” It wasn’t an apology, simply a statement. Take it or leave it.

The form was simple enough: allergies, major illnesses, medications and the like. Nothing too personal -she liked that. The doctor, however, was.

Dr. Heath was a pleasant little thing of about twenty-five, blond, smartly dressed and with eyes that seemed to hunt like spotlights when they hit. She fastened them on Emily. “My nurse mentioned something about you being late for your period, Emily,” she said noncommittally.

Late? That was a laugh. But Emily nodded. “It’s been four or five months now.”

The doctor didn’t seem surprised -or at least her eyes were calm. “Were they regular before?”

Emily closed her eyes impatiently. Of course they were regular. What was she getting at? She took a deep breath. “Yes.” And then she opened her eyes and stared out the window.

“I see,” said the doctor. But Emily didn’t believe her. Her eyes were too steady to be real; nobody was that calm. Dr.Heath wrote something in the chart then looked up again. “Any other symptoms?” She actually smiled when she said that, but Emily was not taken in.

“Maybe you should just examine me, doctor.” It was a simple statement, made calmly, quietly, but the doctor’s expression immediately changed.

“I’m afraid I’ll need to know a few more things about you before we get to that.”

“I’ve filled in the form, so it should all be in there, doctor,” she said confidently. You had to get control of these things early.

Dr. Heath stared at her intensely for a moment, obviously deciding what to do, then shrugged and pointed to a narrow door that Emily had not noticed when she entered. The doctor looked smaller now -pale even. “You’ll find a gown on the table in there. Please undress from the waist down. I’ll be there in a moment.”

It was long moment and Emily could hear voices through the door, but not clearly enough to understand. The doctor’s though, sounded excited, agitated. Had she made the doctor uncomfortable? Emily thought about it for a moment and then rejected the notion: she’d been civil. They were both adults.

The examining room was cold but she stripped to her underwear and sat on the examining table huddled under the flimsy gown. Soon it would be over. Should she tell Bill? He would eventually find out, she realized, but could she count on his support? She chuckled at the thought.

Dr. Heath suddenly appeared at the door, smiled wanly, and asked her to  lie back. “Where does it hurt, Emily?” she said softly.

Emily lifted her head. “Hurt? Who said it hurt?”

The doctor straightened her shoulders a little. “I’ve talked to Dr. Brock.”

“You had no right…” she started, tears forming in her eyes. “What I told him was… just between us.” But she realized how silly that sounded and looked down at her feet.

“Emily, Dr. Brock was concerned. I’m concerned.”

“You had no right,” she repeated, fighting back a sob. “I suppose my husband talked to you as well…” The doctor nodded. “You’re all trying to make it all so… so abnormal,” she said grabbing for her clothes. “Can’t any of you accept it for what it is?” Her cheeks were wet now.

Dr. Heath didn’t move. “What is it Emily?” she said in a soft, sad voice. Emily glared at her and finished dressing. “What is it?” she repeated and grasped her shoulders.

Emily broke free and forced her way past the doctor. “A miracle,” she said between sobs.

“Emily!” There was no mistaking the tone this time. “Emily I’ve talked with your doctor…”

She was through the door but she stopped by the window, near the doctor’s cluttered desk. The cars had their lights on now and it was raining; the sky barely cleared the tops of the buildings. Why was it always like that, she wondered.

“Emily, please listen to me…”

But she just shook her head. Tears rolled gently down her cheeks and she made no effort to wipe them away. Why should she listen? She was living with the proof right here in her abdomen. Her hand reached involuntarily for the palpable swelling growing quietly inside. There. It moved again; she was certain it did. Nothing they could say or do would convince her otherwise. Perhaps another doctor… Yes, that was it, another doctor -an older, more experienced one this time.