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…

 

 

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The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’