Tag Archives: endometrial biopsy

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Trolling for a Cause

Okay, full disclosure: in my day, ‘trolling’ was either dropping a baited fishing line in the water behind the boat as you cruised, or watching out for Billy Goat Gruff villains under the next bridge. I didn’t realize just how much I was in need of a more recent update. I mean why does everything now seem to have an online reference? A diktat. That which was once perfectly happy as a denotative word, complete with papers as an official definition, has since wandered onto the wild side beyond the tracks and reinvented itself as a ‘connote’ –or whatever the noun for its once respectable verb might be. I suppose I could look upon their ilk as metaphors, but I suspect they are a little too slippery to be confined like that.

Maybe what has drawn my interest this time is an article I saw a while back on my BBC news phone app: http://www.bbc.com/news/world-asia-38267176 That I am being critical of matters to which I may, online at least, be naively party, has not escaped my notice. Irony, if not denotatives, can sometimes coexist, I suppose.

At any rate, it’s the issue of media advice I wish to address here. And the issue, I must confess, is problematic to say the least. In brief, a young London woman, Dami Olonisakin, began to write a sex and relationship blog, Simply Oloni, in 2008 because she felt that a lot of women didn’t have anyone to speak to. ‘It began as a personal lifestyle blog and she wanted to be the person that someone could speak to without being – or feeling – judged.’ Fair enough. She wanted ‘to give out impartial advice – something she believes can be more valuable than the opinion of a friend or a relative, who could be too emotionally involved.’ The identities of the participants and their problems were kept confidential and indeed she did not set herself up as an expert, merely an intermediary, as it were. She posted the problems on her Twitter account for her ‘26,000 followers to also share their advice and tips on the dilemma.”

It became quickly apparent, as she herself admits, that not every reader was happy with reporting the sorts of problems she receives. ‘”Not everyone has accepted that women are allowed to talk about sex freely, and we are allowed to embrace our sexuality; whether it’s choosing to keep your virginity until you’re married, or wanting to have casual sex, or wanting to be friends with benefits,” she says. “Your sex life is not a decision for other people to dictate.”’ And the critics were apparently not kind in their responses -they ‘trolled her’, to lapse into the vernacular for a moment: ‘”I’ve had trolls online telling me I’m ‘disgusting’ for suggesting that girls dating more than one man [at a time] is fine,” she says.’

A lot of things can be said under the cloak of online anonymity, to be sure and I suppose venting it serves some purpose or other… but as the inadvertent recipient of ‘trolling’ for writing a supportive comment on a news item a friend had posted online, I can attest to the concern –and even fright- that the vitriolic response elicited. It was almost as if someone had entered my house while I slept and spray-painted a hateful epithet on the bedroom wall. Perhaps I deserved it for daring to evince support for something in public -sorry, online; nobody agrees with everything, after all, but it was the emotions, the hatred, oozing from the words that felt threatening. And yet, maybe that’s just my age talking -presumably most youth today have evolved an internet shell under which they can shelter. But as the devastating effects of internet bullying have demonstrated, the shell is far from impervious. Far from universally distributed.

As bad as ‘trolling’ and internet bullying may be, however, I am more drawn to the courage of Oloni in recognizing the need that women –all of us, really- have a desperate wish to be heard. And to be heard impartially, non-judgmentally. Friends, clergy, and even doctors have the unfortunate habit of diagnosing and then advising; sometimes the person doesn’t want a diagnosis, let alone a treatment –she just wants someone to listen. Often the simple act of describing something to a dispassionate ear, is in itself a cure –or at least a relief. We don’t always require advice either –sometimes just a respectful silence. An acknowledgment.

This is often readily apparent in the privacy of my consulting room. I am a gynaecologist by trade, but occasionally ‘sounding board’ would describe it better. Deborah, a normal-appearing 38 year old Caucasian woman, was a good example.

She had been sent to me by a worried family doctor because of her heavy periods. Nothing the GP tried seemed to be working, so in desperation she had sent her reluctant patient to me to see what I could do for her. All of her tests were normal –iron stores, haemoglobin level, ultrasound of the uterine lining, and even a biopsy of those same cells (just in case) as she put in brackets.

On taking her history, Deborah assured me that her periods were quite regular and predictable, and on the whole, not any different from what she had experienced for years.

“I shouldn’t have mentioned them to Dr. Cameron,” she said once I had finished the history. “My mother and her sister both have heavy periods, so neither of them seemed at all worried when I was a teenager. But my GP seemed adamant: they were too heavy. In fact, she put me on all sorts of pills to decrease the flow…”

“And did they work?” I’m not sure why I interrupted her at that point, except for her eyes. They kept wandering to the pictures on the wall, or out the window to the tree outside. It was almost as it they feared to seek shelter on my face.

She shook her head at first, and then grinned. “Well, actually I didn’t take them -they were samples anyway, so…” She thought about it mid-sentence, and then suddenly revised it. “Well, actually I did take one and it made me feel sick, so that was it for the pills, I figured.” She shook her head sadly and then sent her eyes to explore the wooden carving of a woman holding a baby I’d positioned on my desk behind a plant to make it look as if she were hiding. “I felt like that woman,” she said, pointing at the carving. “You know, like I needed to hide from all her well-meaning advice.”

She was silent for a moment, so I waited. “I think Dr. Cameron had a thing about periods, actually. Each time I’d return for follow-up, she would smile and shake her head in that conspiratorial way women have –you know: ‘what a life we have to live’, and all that. She tried several contraceptives that I never took. And then she suggested a progesterone IUD that I refused.” Deborah finally allowed her eyes safe passage to my cheeks. “I only let her do the biopsy because she felt so upset about her treatment failures. She needed to find something. An explanation. Or better still, a solution.

“But I started to get really worried when she began to hint that I might need surgery. ‘Maybe just an ablation to get rid of the lining cells of the uterus,’ she added –probably because my face went pale.”

Deborah sat back in her chair and scrutinized my face, obviously more relaxed than when she’d entered the office. “Dr. Cameron suggested I see a gynaecologist that she was going to recommend, but I didn’t recognize the woman’s name. And anyway, I wasn’t so sure I wanted to discuss it with another woman…” A mischievous grin surfaced on her lips. “I figured I needed a non-participant… Neutral territory,” she added, her eyes twinkling. “And anyway, my mother sees you and she’s still got her uterus at seventy-three, so…” She blinked; it was my turn, apparently.

I shrugged and tried to suppress chuckling at her posture. She was comfortably ensconced –slouched, actually- in the far-from-comfortable wooden captain’s chair across from my desk, looking like she didn’t have a care in the world. I couldn’t remember anybody owning the chair –owning the office– like she did at that moment. “Well, Deborah, I have to say that I’m not worried about you.”

“No ablation? No hysterectomy…?” She pretended to pout. “Nothing?”

I smiled. “Well, if the periods get worse, you could always come back…”

The mischievous look returned. “Don’t worry, my mother would make me.”

 

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Prove it!

If there’s one thing that a long life has taught me, it is that most of us seldom stray far from the path. Once launched, our trajectory is largely predictable. I suppose this is necessary for co-existence –that there are societal norms is, after all, what binds us together as a group. Knowing what people want –what they are comfortable with- makes it possible to plan ahead with a reasonable expectation of success.

And yet, what if circumstances change? Even Science admits it runs on statistical probabilities. Nothing is forever the same, despite our expectations; despite the hopes of even the most enlightened that it will not deviate too much from that to which we have become accustomed. But progress depends on change, depends at least on altered perspective. That someone can look at the same data and interpret it differently –see different patterns in it, perhaps, or even apply it to something entirely different- is what we have come to expect of our modern world.

But there is often an inter regnum, that can be confusing -a time before the paradigm shift is complete; when wisdom, -no, expectations– demand that we judge the results of whatever investigations we have done, in the light of what the past, or experience, has taught us. And as a consequence, not only do we limit our inquiries to those things that seem to prop up those views, but we discard, or criticize data that fail to validate them. Same information, different eyes. It’s often called the Confirmation Bias and I’ve written about this in one form or another before: https://musingsonwomenshealth.com/2015/05/15/the-polarization-bias/

The problem is that it seems to be a Mobius strip, and the same data are used to prove opposite contentions. There are rules that can be applied, of course –methodologies that help to sort out interpretive biases:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126323/  but it’s all too easy to fall back on what seems natural to us: to assume that what has been found either substantiates what we believe it should, or to criticize it for its presumed deficiencies or mistakes if it does not.

There seems to be no end to the variations on that all too familiar theme. It’s certainly not unknown in Medicine, and a recent example springs to mind.

I remember Jerra -partly because of her unusual name, I suppose. When I saw it on the office day sheet, I assumed it was a typo and thought I would correct it as I introduced myself to her in the waiting room. She was the first patient booked for the day and none of the few other early-risers in the room looked anywhere near 62.

“Jerri,” I said with a smile, walking directly over to a thin, grey-haired woman sitting bolt upright in the only chair by the window. Her first reaction was to assess me from head to toe with hostile green eyes that, had they not been restrained, might have attacked me as I approached.

“It’s Jerra,” she said, ice congealing on the words as they approached my ears.

I blushed. “I’m sorry, Jerra,” I stammered, embarrassed at my rash decision to modify it.

“And it’s Mrs. Tandill…” she added haughtily, refusing –or perhaps not deigning– to shake my extended hand.

The waiting room went quiet, all eyes on us, as she followed me reluctantly across what now seemed a long hike over the floor and down the corridor to my office.

Once inside, she glanced quickly at the sculptures, and plants, and repositioned the chair further from my desk. She did not want to be here, and was letting me know in the bluntest possible way.

“You seem uncomfortable, Mrs. Tandill,” I said when she seemed settled in her seat. “I’m sorry we got off to a rather rough start…”

“So am I, doctor,” she said, still glancing around disapprovingly at the art work hanging on the walls. “I am only here at the behest of my GP, you understand.”

I smiled, hoping to diffuse the tension, but her face didn’t change. She was an attractive, if severe looking woman. Dressed in a loose black silk dress that brushed the tops of her shoes when she walked, tiny silver hoops in her ears, and a matching silver brocaded scarf that hid her neck, she carried herself like royalty. Even her short, greying hair sat regally on her head like a tight-fitting crown, not a curl out of place.

And me? I was still dressed in my OR scrubs –albeit freshly changed- after an unscheduled 8 AM Caesarian section that made me late for the office. The stark contrast with her apparel and the thwarted expectations of how a new specialist should present himself may have stoked her anxiety with the visit.

“My GP says I need a hysterectomy,” she said, suddenly glaring at me like a vexed mother with her child.

I checked the very thorough history her GP had sent with the consultation note. Jerra had presented to her with postmenopausal bleeding, years after her periods had finished. She had sent her for an ultrasound which had confirmed that there was a thickened lining in the uterine cavity, and had even done a biopsy of the tissue. The pathology report of the biopsy did not find cancer, but rather an overgrowth –hyperplasia- that can be a precursor to cancer.

Jerra was still staring at me when I looked up from the computer screen. “Dr. Hannah gave me a copy of the pathology report, doctor,” she said, sternly. “And I researched it further.”

“And what did you find, Mrs. Tandill?” I needed to know what she had read before I could put the results into some sort of context for her.

Her body seemed to relax at being given an opportunity to discuss it, but I could see her face was still wary. On guard. “First of all, that there are several types of hyperplasia” –she pronounced the word very carefully- “… and that some types are further along the spectrum towards cancer.”

I nodded slowly, not wanting to challenge her interpretations unless warranted.

“The type that seems most predictive of cancer, is the abnormal hyperplasia…”

“Atypical,” I interjected, just so she’d know I was listening carefully, I suppose.

She managed a rigid, if fleeting smile. “Atypical. Thank you.” She referred to some notes she’d folded into her purse. “That word was not mentioned in the report, and I even showed it to a friend of mine -who is a nurse- and she agreed.” When I didn’t object, she lashed out at her GP. “I’ve been going to Dr. Hannah for several years now, and I usually trust her judgement, but I think she’s made a mistake here… I’ve never been on hormones,” she added as a kind of preemptive rebuttal of an accusation she expected to hear. “She says the biopsy may have missed a more… atypical area and so to be safe, I should have my uterus removed. You doctors always seem to want to remove things.” She settled back in her chair having made her case, and prepared to fend off the denial.

I took a deep breath while I decided how to approach the problem. I agreed with the concerns of her GP -at her age, there shouldn’t be much of a lining in the uterus at all, let alone one that was sufficiently thick to bleed. Something must have caused the hyperplasia. And yet, I could also understand Jerra’s anxiety. “I suppose our problem in cases like this is one of certainty, isn’t it? On the one hand, the pathology results as they stand could explain the bleeding and the ultrasound, but not with complete certainty. There could be some even more abnormal tissue hiding in a corner of the uterus that was not sampled with the endometrial biopsy…” I’m sure her GP had already gone over this with her, but it needed to be repeated. “And if that were the case, and we left the abnormal cells in place, we might all regret the decision later.”

She sat straight up in her chair shaking her head the whole time I was speaking. “Dr. Hannah kept saying the same things, doctor.” She sighed and stirred restlessly on the chair. I could see her clasping and unclasping her hands on her lap. “Let me be clear -as far as the pathology report is concerned, there is no cancer. I have…” she referred to a copy of the report in the bundle of papers again carefully folded in her purse. “… I have ‘simple hyperplasia’ –which, as I understand it, is far removed from the cancer end of the spectrum. I find it reassuring, and I fail to understand why you do not.” At this point she actually crossed her arms tightly across her chest and nailed me to my chair with an angry glare. “You’re looking at the same data as I am, and yet you are interpreting it totally differently,” she added, as if she were paraphrasing something she’d read online.

I smiled, again, but it did nothing to diffuse those eyes that searched for a permanent foothold on my face. “I suppose I’m just being careful, Mrs. Tandill. Experience teaches me that…”

“Medical schools teach you, doctor!” she interrupted angrily. “Mentors that have been through the same system instruct you how to think about these things.”

I sighed, and I’m afraid I was not very successful at disguising it from her. “Have you had any more bleeding –since the biopsy, I mean?” She shook her head dismissively, and I sat back a little on my chair, all too aware I had also been revealing my discomfort at her anger. “Would you feel better if I did another biopsy…? To confirm the first one?” I added this in hopes of walking the middle road between her wishful thinking that the biopsy was indeed reassuring, and at least not denying the possibility that it may have missed something worse.

At that point she got to her feet, still scratching at my cheeks with her eyes. “No, I would not feel better! You would probably continue to recommend biopsies until you found the result you anticipate, doctor, and I will simply not play that game with you.”

And with an angry shake of her head she turned and walked out the door.

But maybe she was on the right track; maybe compromise -the middle ground- only re-routes the problem and detracts from whatever the data purport to demonstrate. No matter the number of repetitions, an interpretation of the results is still required. And if the data warrant it, a stand on one side or the other must be taken and we must live with the consequences. I think there comes a time when we must disagree with Macbeth when he says to MacDuff ‘Damned be him that first cries, “Hold, enough!”’

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Why do we Know something?

Knowledge is interesting. But what is it, exactly? What does it mean to say you know something? Plato defined it as being justified true belief, but is it? Take Bertrand Russel’s famous thought experiment: the ‘stopped clock case’, for example. Alice looks at a clock and says it is two o’clock. Well, because the clock does indeed confirm that it is two o’clock, it seems justified; and because it is, in reality, two o’clock, it also seems a true belief. She could therefore be said to know that it is two o’clock… But, unknown to Alice, the clock had actually stopped working exactly 12 hours previously, so did she know that it was two o’clock? Or was it a fortuitous guess and not knowledge?

All this is a little out of my comfort zone to say the least, so I’m not even going to attempt straying into such philosophical realms as the ‘Gettier Problem’ (whether something that happens to be true but is believed, as with Alice, for incorrect or flawed reasons should be counted as knowledge). It is truly thought-provoking, though, isn’t it?

But Knowledge is not just a list of facts that happen to be true –whatever truth is- nor a compilation of disparate evidentiary items. It is not only an encyclopedia, it is a diary as well: the story of why it exists. There is often a purpose to it –or at least in its acquisition there may have been a reason, even if you stumbled upon it by accident.

In other words, there is another way of approaching the concept of knowledge other than how we know something to be true –the Scientific Method, for example- and that is why we know it. And I don’t mean to stir the lid of Pandora’s box with the ‘why question’, nor to intimate some sort of heterodox Creationist linkage, but merely to introduce something that I learned from a patient a few years back -a professor of philosophy at one of the local universities.

Nancy was a thin, forty-seven year old woman who had been sent to me for a recent episode of irregular menstrual bleeding. She was otherwise healthy and somewhat embarrassed at having to see me for something her mother and aunt had managed to work through without having to seek medical advice. Her family doctor had ordered an ultrasound of the pelvis and it had not revealed anything suspicious. In fact it had stated that no abnormalities had been seen to explain the bleeding.

I suggested it would be a good idea to sample the uterine cells with an office endometrial biopsy as a final reassurance that nothing had been missed. But I could see that she was uncomfortable with the idea.

“What are you hoping an endometrial biopsy will find, doctor?” she said suspiciously.

“Actually, I’m hoping to find nothing,” I said in my best, confident voice. “The ultrasound didn’t see anything to worry about…”

An eyebrow slowly crawled up one side of her forehead. “I realize that; my GP showed me the result.” The other eyebrow shot up to join its sister. “So… Why would you want to do a biopsy?”

I get asked this a lot. “Well, the ultrasound is not a microscope. It can’t tell anything about the type of cells that are in there.” She still looked unconvinced, I have to say, so I pulled out another of my usual analogies. “I suppose it’s something like trying to make a diagnosis from a shadow. You can guess a person’s height and perhaps her weight from her shadow, but even if you could tell she had long hair, you would have no idea of its colour. Nor would you know anything about her heart.”

Nancy was quiet for a moment, obviously thinking it through. I could tell from her face that she thought it was a rather clumsy explanation -not well conceived, and not terribly illustrative of her problem. “So,” she finally said, looking up at the ceiling for help, “The ultrasound is normal, the blood tests my GP did suggest I’m in the menopausal transition now, the abnormal bleeding only occurred in one menstrual cycle a few months ago, and I’ve been doing well since then…” She dropped her eyes onto my face and left them hovering there for a moment as she shook her head. “Tell me again why you think a biopsy would be a good idea.”

I have to admit that when she put it like that I had second thoughts, but nevertheless I pushed on, regardless. Was I just trying to save face, or was there truly a principle at stake? “Well… clearly there are different ways of approaching your bleeding… But if we do the biopsy, and it is normal, then at the very least we will have a baseline that reassures us that if it happens again in the near future, we can probably assume the cells are still normal…”

Nancy was good; she could read the hesitation in my voice. She smiled gracefully, but it was a polite smile. “Wouldn’t it make equally good sense to wait and see if it starts to happen more frequently and then do the biopsy?”

She had me. “Yes, I suppose that is an equally acceptable option.”

She sat back in her chair, crossed her legs, folded her arms across her chest and stared at me –not unkindly, not aggressively, but curiously, like a mother might watch a mischievous child. “I won’t ask you how you came to that conclusion, or how you know that a biopsy might be justified. Those are all fairly standard medical teachings, as I understand…” Her face wrinkled in concern. “But I’d be curious as to why you know that.”

I returned her stare. Why I knew that? Why does anybody know something? Because they read it, or were taught it, or figured it out… Why indeed?

“We all have options in our learning,” she continued. “There are many opinions to which we are exposed, rival paradigms, competing theories. And they all promise success; they all answer the questions differently. Like a hundred people crossing a single bridge, it’s not the same bridge for any of them. It’s a hundred bridges…”

Her face softened, like a teacher that realizes she has confused her pupil. “From all that reality has to offer, we have to decide what to privilege. There are just too many routes to the truth to take them all. We have to choose…

“But why do we choose one view, one approach instead of another? That’s what I’m asking.” She sighed, as if even the question, let alone the answer to it, was hopeless. “Why do you know one thing and not something else?”

Her question still troubles me. I had no answer for her then; nor do I now. I still wallow in the permutations and combinations of perpectives I confront daily and wonder how I manage to choose my direction without getting lost. Maybe it’s a confirmation bias: I have come to believe in the correctness of a particular viewpoint over the years and so only consider the evidence that confirms it. The diagnosis that points that way. And if the results don’t justify the approach? Well, there’s always rationalization to light the path I’ve chosen.

But do I really know why I know what I do, believe what I believe, think what I think? No, not so far… and yet the fact that I’m even aware of the discrepancy, and see the signs to other roads, is a good start isn’t it? As Marcel Proust wrote: The real voyage of discovery consists not in seeking new lands but seeing with new eyes.

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Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.

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Elder Gynaecology

I love old people. Sounds a bit patronizing I suppose but I’m becoming one of them, so I have vested interests. And anyway, even the most reticent among them have had a unique, personal view of history. A well tested perspective of Time and its evolutionary ravages. They have grown an almost uncanny ability to step outside and look at their lives as one might their house from the sidewalk.

Talking with them is an adventure, a journey. A long journey. I have travelled part way along the collective path –the common trail from which each has wandered looking for their the way -their destination- but I am ever fascinated with their routes. Never bored, yet usually intrigued by the roundabout ways they have found to describe it. Camouflage it, really. It is seldom a direct road –more frequently a series of detours that require patience to navigate.

As the family doctors who refer to me get older, I sometimes think they have my name written down on some old Rolodex in the top drawer of their desks, so it’s readily at hand when an elderly patient whose baby I may have delivered asks them if I’m still in practice –or at least, still alive. I may not remember them, but for some reason they remember me. It’s nice to be remembered, but it usually comes with an expectation of reciprocity. No one, especially of advanced years, wants to walk down a one-way street. We all crave familiarity. Recognition. Memories we can share.

Unfortunately, charts are not kept forever and computerized records are relatively new kids on the medical block. So when I see them, it’s frequently with a blank slate -a tabula rasa  as it were. But when I think more clearly about their reactions to this cognitive gap, I have to admit that most of them are not at all nonplussed. They merely tell me all about it; they fill me in about the intervening years. I love it; it’s like going to a history tutorial.

Emma. The name rang no bells, sounded no alarms; I had no idea if I’d ever seen her before, in fact. I glanced at the referral letter before I went to meet her in the waiting room: Please see this delightful, loquacious lady for a gynaecologic check. You saw her 10 or 15 years ago apparently. Well, no clue there. No old chart. No information about why or exactly when I’d seen her before. I have to admit I cheat before I greet them in the waiting room –I look at their old records and try to pretend I remember some of the details about why I once saw them. I’m sure they all know I do that, but it’s an acceptable crib, I expect. No one calls me on it. They pretend that they have a special place in my practice. My memory. Everybody wants to pretend that there is a statue of them somewhere. A commemoration. But there was nothing on Emma. I would have to plead unwilling and embarrassed ignorance.

“Doctor,” she said in a strong, loud voice as soon as she saw me. “Dr. Stegal was sure I saw you before…” she said, all the while hoping he was wrong. I could hear it in her voice.

She was a thin woman with tightly coiffed, short white hair that she wore almost like a toque over her ears. Quite becoming, I thought: it enclosed her face like one of those little ornate frames you see sitting on desks all over the world. I have to admit I didn’t recognize it, but wrinkles are a good disguise. Like one of those Russian dolls, her eyes were set within wrinkles within yet more and deeper grooves on her skin when she smiled. She never stopped smiling.

I led her into the consultation room and sat her down opposite my desk. As soon as she settled in the assigned seat, and adjusted the bright red dress she’d worn for the occasion, her face lit up with the expectation of a good talk with an old friend. She couldn’t help looking around the room for a moment, no doubt comparing it with scraps of memory. Her smile waxed and waned in concert with fragmented recollections; her eyes would focus on a picture and recede within to riffle through her files then emerge, satisfied she had classified it correctly, then fly to another branch, another picture, another piece of my aging, chipped furniture. Her eyes said she was beginning to remember the old visit, but her face told me she didn’t know what it had been for.

“I see you still have that old metal desk, doctor.” This was clearly an opener. A gambit to facilitate my entrance into her world. I smiled lamely; what could I say? I liked the desk. “My daughter reminded me of the desk, and those little magnetic signs you had on one side. Fridge magnets she called them.” She shifted on her chair and craned her neck to look at the side near to the door. “Yes, I see they’re still there.”

I shrugged good-naturedly. “I’d forgotten about them…”

“But you certainly have a beautiful office, doctor,” she added as if I hadn’t spoken. “I remember that picture behind you. The woman only partially drawn?” she said as if I’d forgotten that as well. “Do they still make those?”

I wasn’t sure if it was a real question, or merely an observation that I hadn’t much changed things over the years. I turned around to look. It gave me time to consider how I was going to lead her into telling my why she’d come to see me.

“I saw one just like it in Kresge’s a while back…” she said to soothe things over. It must have been a while back because I think the store chain changed its name to Kmart before my daughter was born.

“Well, it’s good to see you again, doctor,” she said tentatively, getting comfortable in her chair again. “My daughter says to say hello…” She didn’t really finish the sentence, but did temporarily immobilize me with a stare that dared me to ask her who her daughter was.

“Oh, that’s nice of her,” I responded, proud of my quick, noncommittal answer. “Please say hello to her for me.” It was lame, but I was trapped by her eyes. I had to say something.

Emma’s face changed from happy to wicked. “Do you remember her?” I shrugged. “I told her you wouldn’t, but she wouldn’t believe me. ‘After all the problems I had, he’ll remember, mom,’ she said.”

I could  see the hint of a smile trying to force its way through her wrinkles. It looked like work.

She shrugged resignedly, as if her shoulders had felt the weight of the world before and this one more disappointment was not going to do her any harm. “Judy was always a drama queen-always worried about something. Always thinking she was sick, ” she said, sighing loudly. I assumed Judy was her daughter, but it opened no doors. I mean how many Judys are there in an average gynaecologic practice? “I remember when she was a little girl, Henry made her a tiny doll house to distract her, and she’d lie on the floor for hours and play with it. Henry was good with his hands. He could fix anything. We never called a plumber, you know. Didn’t have to… Well there was that time something got stuck in a drain and we had to call one because he had one of those metal snakes, but he was way too expensive. And it was just hair that was blocking it.” She stared at me again briefly and only let go when I smiled in submission. “It wasn’t Henry’s hair, though; Henry was bald as a table…”

I smiled again and picked up the referral letter and examined it. Maybe that would work. “Dr. Stegal says…”

“Well, he shouldn’t really say anything. I never really saw him for more than two minutes before he suggested I go to see you…”

I sensed a perfect, but rare opportunity. “And what did you want to see him about?”

She sat up straighter on the chair and crossed her arms. “I didn’t want to see him, doctor…”

“My mistake. Why did you go to see him, then?”

She settled back into the chair; she was looking entirely too comfortable. “Well Judy came over a couple of weeks ago…” She considered this for a moment. “It was just after the anniversary of Henry’s… departure. So I guess that would be three Saturdays ago…”

It seemed important to fix the date, so I waited patiently. I stole a glance at my watch; my secretary would be panicking if I didn’t surface pretty soon. I prodded her gently. “Why did Judy come over to see you?” A stupid question, I suddenly realized. I could hear the answer before she even opened her mouth.

“We were going to go to the cemetery and then stop at his favorite restaurant for lunch.” She focussed her attention on my face, so I couldn’t interrupt her train of  thought. “Have you ever eaten at the MacDonald’s on Fourth?” When I didn’t reply –didn’t even try to reply- she finished her thought. “Well, we both ordered the chicken nuggets and we started talking about the Menopause.” I could hear her capitalize it. “She asked me what mine was like. Well, I said, it was a long time ago… ‘And did you have any problems  with it then?’ No, I said, but then I remembered –I’d had a bit of bleeding three or four years after my monthlies had stopped. That really seemed to alarm her. ‘Did you go to see the doctor?’ For some reason, I couldn’t remember if I had, so she immediately made a phone call to Dr. Stegal. ‘You can’t let these things go,’ she said. So, I saw Stegal –but hardly long enough for him to open my chart.

Now we were getting somewhere!

“But now that I’m here, guess what..?” Her expression had changed.

I hate it when people do that. I’m supposed to be asking the questions.

“When I saw the office today, it began to come back to me.” I put a purposefully puzzled expression on my face and left it there. “I’d seen you for the bleeding. You did a biopsy and cleared me. ‘Don’t worry about it’, you said. ‘Get on with your life’ –I remember you said that, and I thought it was so nice. So sensitive. After all the pain of that biopsy, it was the right thing to say. Almost an apology…”

She was about to continue when I interrupted as gently, but as quickly as I could. While she was taking a breath. “So is that why Dr. Stegal sent you to see me today?”

“I think so. The only person he really spoke to was Judy…” She looked around the room nostalgically for a moment and then at me again. This time with some concern on her face. “We don’t have to do another biopsy do we? Judy thought we would.”

I graced her with my most benevolent smile. “Have you had any more bleeding, Emma?”

She shook her head solemnly. “None since I saw you and that was probably twenty years ago.”

“Then I think we can just watch things for now. I closed her empty chart and got up from the desk –but slowly, so she wouldn’t think I was rushing her.

Her face turned sly. “But Judy has. Now she wants to come and talk to you.” She stopped when she saw my expression change. “Oh not now! No, she has an appointment for next month.” She got up from her seat and walked toward the door. Suddenly she stopped. I hoped she hadn’t changed her mind about leaving.  But her face, when she turned to look at me, was beaming. “You look worried, doctor,” she said with obvious concern. “Don’t worry,  I’ll come with her and help to explain things.”