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.

Health

Do we expect too much Health? Or perhaps less controversially, do we expect too much of Health? Are our expectations realistic or even attainable? Do we really know what Health is -or for that matter, is not? It’s an important point and one that should not be dismissed as mere academic quibbling. Perhaps, to paraphrase St. Thomas Aquinas, we all know what Health is until we are asked to define it.

Should we, for example, define it as an absence -an absence of illness, for example? Or maybe suffering? If that sounds too tautological, how about defining it as something positive: say the presence of well-being or -god forbid we stray into this- even happiness, contentment, or comfort?

But unfortunately, the concept of Health has strayed for a lot of us. In many respects, we equate good health with the absence of discomfort in our bodies – and for some, any discomfort. That we should have to think about our bodies in any way other than that they are ready and able to perform -or at the very least, potentially capable- is disconcerting and disappointing: unhealthy. That there should exist constraints such as pain or weakness may therefore be construed as unacceptable.

An extreme view? Well, consider a patient I saw for consultation recently. She had come in complaining of fatigue before her menses -a symptom certainly worthy of investigation, I think. Anemia, some form of menstrual dysphoria, or possibly even stress came to mind immediately as possible villains, but I was not unmindful of other, more serious conditions for which fatigue could be a herald. So, after taking what I hoped was a thorough history and completing a detailed physical examination to provide me with further clues, we went back into my office so we could discuss things.

“So what do you think, doctor?” she asked, her eyes locked on mine.

“Well, fortunately the physical examination was reassuring – I couldn’t find anything wrong…”

“But there must be something wrong, doctor. Something has to be causing the fatigue!”

I thought about it for a moment. “You say your periods are not particularly heavy; they’re not painful; they’re on time each month… You’ve always felt tired before your menses, and you feel well otherwise…”

“But doctor,” she almost shouted at me, “It’s not healthy to be tired before your periods. None of my girlfriends are…”

I started to write something on a form and looked up at her. “So, I’m going to order some blood tests and…”

She rolled her eyes and straightened up in her chair. “My GP has been ordering blood tests for years now and they never show anything. I want to know what you’re going to do about it.”

I could tell she was about to leave. “What are you afraid might be going on with your body?” I asked, thinking she might have some fear of cancer, or disease in her mind. But there was no family history of any cancers or heart disease and they were all still living, well into their late sixties. And for her, there had been no personal, sexual, or relationship problems that I had been able to elicit in taking her history. I was truly perplexed.

“That’s what I came to you to find out, doctor,” she answered with a stare, almost spitting out the word ‘doctor’. “You doctors are so busy trying to cure disease, you have no idea what Health is.” And then she walked out.

And you know, maybe she was right. Maybe we do define Health in the negative: an absence of things that shouldn’t be there. Or even use a ‘Be thankful it’s not worse’ approach. But I’m not sure she’s on the right track either. Surely Health is a more relative, a more consequential construct. Maybe it’s simply the condition that allows us the freedom not to think about it, worry about it. Maybe it’s neither a positive nor a negative concept. It’s something that’s there only when we don’t question it -something that, if it were not there, would have consequences.

But more than that, it must be a relative condition as well. If you break a leg and then are eventually able to walk again, albeit with a limp, you are probably healthy even though things are not like they used to be. So Health is not necessarily an absolute phenomenon either -something that withstands comparisons with others.

Clearly there are subjective and objective components to consider, and neither have an unassailable priority. Health is what we want it to be, and that’s going to vary depending on who’s considering it. We may never come to consensus. And yet I think there is considerable merit in trying anyway -attempting to look at it from both perspectives at the same time. Health is surely the ability to carry on with our lives with minimal impediments, minimal distress, and minimal need to wonder whether we can.

Minimal is approximate as well as contingent of course, but it does not mean zero.

The surgical option

I’m not opposed to the surgical option, it’s just that there are many roads to Rome, and sometimes an indirect route is more satisfying. Don’t misunderstand; I’m an Ob/Gyn surgeon. It’s what I do, but not to the exclusion of everything else. There are times when surgery is necessary, life-saving, difficult to avoid. There are few ethical or acceptable options available in the case of a ruptured tubal pregnancy, for example. The patient presents in the emergency department bleeding internally, often in shock, sometimes requiring an immediate blood transfusion. Things do not go favourably for her if there is any delay in stopping the bleeding -operating, in other words.

On the other hand, fibroids -benign uterine muscle growths- present a different spectrum of choices. In the past -admittedly with fewer therapeutic tools at their disposal- surgery was the favored option if they were at all symptomatic. Medications meant to slow their growth or decrease vaginal bleeding, were fraught with side effects and seldom satisfactorily resolved the problem. Pain, anemia, or increasing symptoms from the ever-expanding tumours were often the only alternatives to surgery. And because there was a long-honoured tradition of removal, surgery was expected, maybe even desired. If all the female members of your family had hysterectomies, you might be inclined to view yours as inevitable, even if undesirable.

But there is a profound difference between life-saving surgery, and elective surgery. In the latter, options become important. The ability, and knowledge to be able to choose solutions, to see if they will work or even lessen the burden of the condition is an important step in problem solving. Moving from a simple attempt at life style or diet modification for, say, painful periods, to medications of increasing sophistication -and cost- to a hormone-containing intrauterine device, to laparoscopic investigation of the pain in the operating theatre might be a sensible route to follow. Or at least to know about.

For fibroids causing heavy menstrual bleeding -they don’t all do this, by the way- the use of antiprostaglandin medications (ibuprofen being the most widely known of these) to attempt to decrease the bleeding, maybe followed , if necessary, by the progesterone-containing intrauterine device if appropriate, and then if that fails, blocking off the blood supply to the artery that is responsible for providing nutrients to the growing fibroid (embolization)- all of these could be considered before resorting surgery.

Clearly there are features of each problem that might suggest other creative adaptations, although my point is not that they should be chosen, but rather acknowledged. We all have a right to determine our own unique paths through the thorns of life, and we should be given enough background and knowledge to allow us to make informed choices -choices whose logic and consequences we can understand. In  non-life threatening situations we may make a choice we regret, but if there are a series of progressively more serious options, we would probably be more accepting of their side-effects than if we had been forced into the treatment before we were ready.

Yes, I am a surgeon, and if surgery were the correct choice all along, then you will work your way along the path and eventually realize that for yourself. And come to accept it. It’s not my place to force you there. I am neither your father nor your boss. I do not possess absolute knowledge of the inevitable consequences of your actions. I see myself as merely a guide through a dark and often confusing forest, pointing out each fork in the road and offering suggestions that years of experience have taught me about the smoother trail.

It is, I hope, what doctors do.