Afterwards



Sometimes it floods over me

That remembrance

Brought on by a baby’s cry

Or a smell

Or a taste

Or a smile

Love of any kind

Leaving me with that familiar guilty longing 

And the feeling that I have betrayed 

Your memory

Somehow

By finding joy in something

Without you

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The Immortal Vagina



“Ma’am I am going to put my hand on your left thigh and then I will move it up to your vaginal area.”

I did it.

“Now, you will feel me place the speculum into your vagina and move it into position. I apologize if anything pinches.”

I did that. 

They told us to place the speculum in sideways so the duck bills were standing up and down, and then rotate them into the correct position. Mine was the fourth speculum in her vagina that afternoon and the perineum was slick with lube.

There was a preceptor, a female physician, standing over my shoulder making sure that I said the words exactly right and moved my hands and the speculum exactly as dictated.

My hands shook. This felt so stupid and wrong. This is not how I would want it done to me!

Thankfully, the woman spread eagle on the table could not see my hands or my face.

“Alright, now I am going to remove the speculum.” There was a sucking noise and a little jump. I had pinched her. I looked over at the preceptor to see if she had seen. She had. Damn. There would probably be a mark down.

“Do you have any critique for the student doctor?”

The woman sat up in a rustle of paper gown so she could look me in the eye.

“If you are going to do, do it with confidence. In and out. You want to be fast. You did fine you just need confidence. No one wants someone taking their time in their vagina. Do what you have to do and get out.”

I nodded and stepped over to wash my hands.

“We have seven more to go this afternoon,” the preceptor said from the corner.

“No problem!” The patient sounded happy, almost as if she relished the job. 

Curiosity was eating at me. I needed to know what would possess someone to volunteer for this most undesirable thing on earth done to them over and over again. Were they paying her $25 each like the prostate fellows? Equal pay did not seem appropriate somehow in this setting…

So I asked.

She smiled.

“I was your first. You will always remember me. I can teach you how to do it right.” She glanced quickly over at the preceptor who was writing out my score card, not really paying attention. The woman leaned in close and whispered, “Don’t do the twisty speculum or hands on the thigh thing, either. That is just creepy.”

And she was right.

There were whispers afterwards among the medical students about whether she and the other professional vagina patients were drawn to this as an erotic experience. Why do we say/think crap like that about women? 

I don’t remember her face, or her name, or even what her vagina looked like anymore. But I remember the experience in great detail. It made me a better doctor. 

All these years later, I no longer question her sanity or motives. I now understand completely. 

Someday, I just might volunteer for that immortality myself, so she can live on in another generation.

Photo: Dinosaur Valley, Glenrose, Texas.

My Alternate Reality

San Antonio sky scraper.

Yesterday,  Miss Understood asked what would be my second choice profession if I were not a physician?

Some might think author/writer. I dunno. There was a time I might have said yes, but after I realized there were people who hate Harry Potter (Who can hate Harry Potter?!??!?), I was pretty sure I did not want to have my life’s work trampled about like that.

I made jewelry for a number of years. I like to think I was pretty good at it. But unless you are sleeping with Robert Redford and can get into his Sundance catalog, it is hard to make real money doing it without shameless self promotion. I am awful at self promotion. Plus, after a while people wanted me to do commissions. It is fun when I make what I want to make. It is work when I make what someone else wants me to make.

A teacher? I love to teach. In fact, I adore it, but ultimately I don’t want to work that hard…

Attorney? I like to argue so maybe. I also like to win. I like to win every damn time. I am afraid it would consume me in a bad way…

I joked that I would pick lottery winner but truthfully, I would make a crappy woman of leisure. Given a weekend and a couple of snow days and I stopped bathing. I puttzed around all day in PJs with no make-up. Stubble built up on my legs until I resembled a hedgehog. Hell, I don’t even remember if I changed my underwear. It was downright gastly.

Ok. 

Here it is, my secret heart’s desire…

I would dearly love to be a photographer/writer for National Geographic. 

I would be skinny as hell from all of the parasites I picked up on assignments. I would wear a khaki vest with dozens of pockets and wield my giant telephoto lens like a club. I would make love to each country, taking my time to learn the people and lore and food. My long braid would reach halfway down my back and I would not have to wear make up. My face your be weathered (from my neglect of sunblock) but people who knew me would still call me beautiful. At times I would fear for my life. I would have had breathtaking love affairs in Morocco and Argentina and Istanbul (not necessarily with the same man), but would die young and alone, tragically in a hotel room in some obscure place. They would find me with a smile played out upon my cold, blue lips because I died richer than anyone ever realized…. I learned all of the world’s secrets and saw humanity at its worst but also at its best.

Don’t Touch My Things!

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“Your blood pressure is a bit high today. What has it been running for you at home?”

She giggled and grinned at me sheepishly.

“You know, Doc, I don’t check my blood pressure!”

I sighed my exasperated sigh and laughed with her. I knew, but I wanted to make a point.

“I know but if your blood pressure is running this high all the time, we need to start you on meds. If you were checking it at home, I could save you a copay for a follow-up visit….” I trailed off.

A puzzled look had crossed her face.

“But, Doc, I’m already on blood pressure medication.”

No she wasn’t. I had checked her med list before entering the room…

Then I remembered the office visit with the general surgeon the previous week that was on her record. On a hunch I clicked the convoluted series of tabs to pull up the list of deleted meds. 

There it was. 

Her blood pressure medication had been cancelled on the day of her visit with the surgeon by staff in their office.

We are all on the same electronic health record so they can mess with my med list, my medical and surgical histories, family histories, problems list…. Everything. 

And they do.

This is hard for someone like me who will freely admit that I have OCD and control issues.

Cue mustachioed face, spittle, wild eyes, and a dark Victorian suit ensemble: “I just don’t like other people touching my things!!!!” (From the movie Moulin Rouge in case you needed a frame of reference.)

This happens all too often and it worries me. Beyond being a major inconvenience, it is one of the hidden dangers of universal charting. 

Fiesta… Lost.

San Antonio 089
I had not fully appreciated until yesterday what a blessing it was to have grown up at a time when the teacher could not email homework on snow days. 

My children were robbed. 

How are we supposed to bake cookies with three worksheets and a list of spelling words hanging over our heads?!?!?! 

Sigh.

We get such rare time off together the last thing I want to do is wrestle and fight over homework!

Crumble

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“Her primary care doctor, Dr. X, knew that she was experiencing post menopausal bleeding for three years but only recently worked it up. She has now been diagnosed with endometrial cancer and presents today to discuss surgical intervention and the possible need for adjuvant therapy.”

I seethed.

The jerk did not even look at the record.

He had access to my entire record since he was on the same electronic health system. All he had to do was scroll down the screen and take a few minutes to see that I had first met her six months ago. When I heard on that first visit that she had been experiencing post-menopausal bleeding for the past three years, I referred her immediately to gynecology for biopsy.

She did not keep the appointment.

At every visit every month for the next six months as I saw her to get her uncontrolled blood pressure under control and treated her sinus infection and allergies, I begged and pleaded with her to follow up with that gynecologist, to get the biopsy done, explaining and documenting each each time that she may have cancer, that she could die if she continued to ignore this.

Finally, after I made her call the gynecologist to schedule the biopsy yet again, this time while she was still in my office and standing next to me (I dialed the number for her and passed the phone to her), she actually kept the appointment.

That was how she was then referred to this man, a gyn-oncologist.

My hands shook as I dialed his number, burning with anger. He had sent this note to the hospital, to the gynecologist, to the radiation oncologist, to everyone… saying I had dropped the ball.

Bastard.

I was not going to let this go. Oh, no.

His assistant answered.

“I’m sorry. He is in the OR today. Is there something I can do to help?”

I explained to the young woman what had occurred.

“Please communicate to him how upset I am.”

She was extremely apologetic and said that she would call me right back. I was not going to hold my breath. No one ever calls me back after this sort of thing.

I saw a few patients, trying to focus my brain on them. I glued a smile onto my face and worked hard to maintain my perky voice. I willed my hands to stop shaking as I moved the stethoscope around each chest… heart… lungs…

My mind kept wandering back, though, to conversations where I told this oncologist what I thought of him and his lazy ass charting skills…

In exactly 90 minutes I received another call from his assistant.

“I spoke to him and he apologized. He will amend the consult note and send the corrected note to everyone involved.”

“Thank you.” I breathed a sigh of relief.

“Doc? I really am sorry this happened,” she said.

“Me, too. Thank you for following through, I really appreciate that. I will await the amended note.”

Twenty-four hours later, there it was:

“The patient was seen by a new primary care physician and subsequently worked up for her long standing post-menopausal bleeding…”

I still hate him.

The Bigger Picture

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My passport is about to expire.

This is bittersweet. It is exciting looking back on all of those stamps, to see how far I have come, but I still have too many blank pages for my satisfaction.

Now I will have to start over.

To begin the process of renewal, I ran to the drug store to get my passport photo redone. As I parked and trekked inside, I noticed a very clean, very new, cream colored luxury SUV. It was parked halfway in the handicap spot and halfway in the undesignated neighboring parking space. Straddling. Worse, there was no handicap placard or license plate visible.

Prick. Who the hell would park like that?!??!?

This is particularly upsetting having grown up with a father crippled by polio, knowing how hard it was for him to get around and how hard it was, and still is, to find parking close enough for him.

I contemplated going vigilante, snapping a picture with my smart phone so I could send it to the police. Maybe I could make a citizens arrest? A note in the windshield? Post it online. Not that I have ever actually done those things. I haven’t. But I do like to fantasize about it…

Bastards. Wealthy people who feel entitled and don’t give a damn about anyone else but themselves. Don’t they know there are people who really need those spots?

It is a pet peeve of mine.

I got my photo made (meh), paid, and headed back to my vehicle. The SUV was still there, straddling the two spaces. Oh, well. I decided to let it go. It is not my job to police after all. Let their own conscience deal with them…

If they have one.

I paused in the parking lot to answer a blog comment before I got back to the craziness of the ninja wars going on back home, then I put the engine into gear, backing up.

Then I saw them.

An elderly couple.

She was in a nightgown, clinging to his arm as they both tottered out to the SUV with a small bag from the pharmacy. She looked to be in quite a bit of pain.

Oh.

Maybe that was as well as they could park. Driving in the dark is hard at that age. Maybe she just got out of the hospital. Maybe they were too proud to ask family or friends for help? Maybe they do have a handicap placard and got flustered, forgetting to put it up. Maybe they don’t have one but he felt he needed to use the spot so she could get in and out of the pharmacy easier. Maybe he took that risk for her to protect her because he loved her.

Again I was reminded how first impressions are often faulty. How I need to take a step back to get the full story before making judgements.

I needed that reminder.

Clickety-Clack Don’t Talk Back

Notre Dame Cathedral

“Doc. You need to stop all that typing! It’s like texting on cell phones. It’s a pet peeve of mine!”

He was upset already because I had asked him why he was physically punishing his teenage son.

“Seeeee…. I don’t need you to tell me how to discipline my kids. I can spank or hit them if I want.”

He had a point.

Not about the hitting.

About the typing.

Patients text all of the time during office visits and it is terribly distracting. I worry that they are not hearing me.

Uh-huh, doc….

I try to do as much charting as I can while I am in the room with the patient. I am a pretty good typist and can type in a whole paragraph of what a patient is saying without breaking eye contact. I have several reasons why I do this:

First, if there are more than two items of business (average is 3-7 issues per visit) things can get confusing very fast. This way I can document the history and input orders and meds as we go. Decreases errors.

Second, I feel like doing it there in the room instead of stepping out after a few minutes so I can chart the rest of the appointment time gives me more time with the patient and maybe improves patient satisfaction. We can joke and laugh and talk about their family while I am putting in orders and such.

Third, if I do as much as I can while I am in the office, I have more time at night for myself instead of spending a couple of hours a night charting after the kids go to bed.

This was the first time I had a patient complain, but my keyboard clicks loudly while my fingers fly. Maybe it bothers people more than I realize and they are just being nice?

So I thought I would ask you all what you think. Would you rather have a longer time with a typing doctor or less time with no typing?

A Few of My Favorite Things…

Snow in the trees

Having started with the meditating I have been able to recognize other things that give me that same peace and calm:

Sunshine on my face, especially with my eyes closed and birds singing and a cool glass of pinot grigio in my hand…

Deep blue skies with fluffy white clouds.

A hike in the woods.

Hugs or cuddles from my kids.

Snow. Especially thick snow. (Probably because I rarely ever get to see it and never have to shovel it…)

Beautiful art.

A lavender bath.

The scent of roses.

Certain music (Exactly what moves me always changes EXCEPT for Beethoven’s “Ode to Joy”. That is a constant.)

I knew they relaxed me. I knew I enjoyed them. I just never realized exactly how profound and healing they actually were. I need to get exposure to these things more often…

The Professional Patient Reprise

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In honor of C. S. Boyack’s extreme courage and bravery for posting his “Public Service Announcement” yesterday, I would like to again, with Mr. Boyack’s permission, pay homage to my first prostate….

“Alright, Mr. Smith. I am going to need to have you drop your drawers and bend over with your elbows on the table.” I was using my perky voice.

I placed a box of Kleenex down apologetically on the exam table in front of him.

“You are going to do what?” He stared incredulously at me. He was an older man with a receding hairline and an uncanny resemblance to my father.

“I am here to check your prostate.” I tried to maintain the perky tone even though my hands shook and my palms sweated as I pulled on the latex gloves.

“Like hell you are.” His voice was raised and I could detect a hint of distress. He stepped menacingly toward the door.

Taken aback, I stood up quickly getting out of his way.

The shadow lurking in the corner stepped forward.

“Mr. Smith, if you do not allow this exam, you will not get paid the $25…”

He looked at the shadow.

Then at me.

Then back to the shadow.

“Fine,” he growled. In no time, his pants were down around his ankles.

It was then that I felt my first prostate…

Special Note: Professional patients for prostate exams in medical school were pulled from a halfway house and not really informed upfront about what exactly they were going to have to endure. Sometimes as a patient, it feels like this and you face the decision to flee or see it out. Congrats to Mr. Boyack for seeing it through and coming back with good test results. High five!