Assume the Position: Memoirs of an Obstetrician Gynecologist (11 page)

     Behind every office door was a new and different patient, and a new emotional situation; an obstetrical patient in for her first visit with her significant other (joy, delight, excitement and apprehension); a newly pregnant patient unhappy about being so and requesting an abortion (sadness, determination, confusion, embarrassment, apathy); an infertility patient unable to conceive (worry, fear, depression, hope, disappointment); a third trimester pregnant patient (discomfort, anxiety, impatience);  a newly diagnosed case of genital herpes ( anger, pain, disbelief); a woman requesting permanent sterilization( relief and gratitude);abnormal uterine bleeding ( frustration and fear);a breast lump (fear); pelvic pain (pain); contraception(relief and freedom); hot flashes (hormonal changes).    And so the day went, day after day.  Not only were skills called into play to make the proper diagnosis, make recommendations, prescribe medications, offer surgery when necessary and appropriate, allow freedom of choice for continued hormonal and reproductive health, but also counseling skills were required with almost every single patient, even if nothing other than reassurance that the situation and complaint were well within the norms. Of course, emotions within me would rise and fall all day long, but keeping emotions in check and compartmentalized was an important, and difficult part of maintaining objectivity so that I could offer my patients the best advice available under the circumstances. For me this is what made the day interesting, challenging, difficult and exciting.  The patient schedule produced for me each day simply had a name and time.  It gave no clue as to what I was going to walk into when I opened the exam room door.

     Many people would often question how a man could understand and be sensitive to the complaints, trials and tribulations of an Obstetrical and Gynecologic patient.  Clearly one does not need to be a woman to be able to empathize and be sensitive. After all, as a physician, does one need to have cancer to be able to be sensitive to a cancer patient?  I have found over the years that women physicians are no more able to empathize with a female patient than a male physician.  In fact, many of our friends and patients would complain to me about the attitudes of some of the female practitioners in my office or others. Rather than the gender of the physician, what is more important is the empathic and sensitive nature of the physician, something that is not inherent only to the X chromosome, even if one has two XX chromosomes. 

     I had an unusual ability to pick up the chart from outside the door, see the name on it, and pretty much be able to recall the patient’s history regardless of time interval between visits, and visualize the patient’s face before I opened the door.  If I passed the patient in the mall the next week, or saw her in Price Club, I could not recall her name or the details of the exam or problem which was often vexing for me because patients of course remembered me and expected me to remember them, their deliveries, their surgeries, their children, etc.  But because I devoted intense individual attention to each patient when they were in front of me, then dictated my office note as soon as I walked out of the exam room, everything seemed to erase itself from my mind when I shut off the Dictaphone and turned attention to the next patient, until I saw the chart on the door the next time they were in the office.  This practice required detailed dictation with notes to myself for the next time the patient would appear in the office.   When I was in the exam room with the patient everyone received my undivided attention, and I never left the room without first asking if there were any other questions that needed to be answered.  I found that most patients were hesitant and afraid to ask questions, so I needed to tap into their fears, anticipate them, and deal with them before they left the office, which I accepted as my mission for every single office visit, no matter how long it might take.  If someone needed more time, they got it.  If it was an easy routine matter or annual exam, I offered reassurance and quickly moved on so as not to keep the next patient waiting. Every examination required differing amounts of time.  I hated to keep scheduled patients waiting, although of necessity it happened depending on the amount of time each problem would take. I would also sit myself down on the stool and stay there until all questions were asked and answered. If a detailed conversation were necessary, such as a surgery had to be discussed in detail and options given, I would ask the patient to get dressed and come into my consultation room with whomever they brought with them for a further detailed discussion.  I preferred to keep patients waiting in the waiting room than in the exam room. Thus there were never more than two patients at a time in my exam rooms; the one I was seeing, and the next patient getting ready with my nurse giving her instructions on my behalf, checking urine, vital signs, logging in the complaint, readying the exam room, laying out the gown and Pap smear, etc.  Thus I could quickly move from one room to the other, and then back again after completing the dictation.  I was constantly looking at my watch outside of the exam room because I hated to keep patients waiting, and tried my best to stick to the schedule.  Time was important to the patient as well.  The business being what it was, however, often caused delays in the schedule, whether because of frequent trips to the labor and delivery suite (there was almost always someone in labor who also required attention at unpredictable times), a phone call that couldn’t wait for some reason or another, etc. Many days there just weren’t enough hours in the day to get everything accomplished, which in itself created pressures.

     Hospital rounds were made first thing in the morning, before the OR schedule and before office hours, so usually at 6 or 6:30 AM.  It was a good time to make rounds on patients because all was usually quiet in the hospital then, there were usually few interruptions before the day got busy, and I could get through rounds efficiently, or if needed, had time to deal with any post operative complications should they arise.  One never quite knew what was going to be found on morning rounds.  Post operative fevers, wound infections, bleeding, unexpected complications, inadequate pain control were some of the more common but infrequent problems.  On weekends I would make rounds on my partner’s patients when I was on call and while they were off.  I always volunteered to work on Christmas day because it wasn’t my holiday so that partners could spend time with their families.  I remember very well one Christmas day early on hospital rounds when I walked in to see a woman who was on her first post operative day, my partner having done a major abdominal surgery on her the day before.  I cheerily said “ Good morning”.  She replied,  “ Are you Jewish?”  “ Yes “, I said.  She continued on:  “ You are going to burn in hell”.  I took a moment to think what to say next, but not too long, then replied:” You should worry about where you are going, and I will worry about where I am going”.  I had trouble seeing the Christian spirit in her greeting that morning.  I am a bit ashamed to say that when I removed her bandage, I should have done it a bit more slowly than I did.  But religious discrimination just didn’t sit pretty with me that morning.

     All my surgeries usually started at 7:30 in the morning, sharp.  This required making hospital rounds on delivered or post operative patients before surgery started, often requiring me to leave home by 6 AM daily, or if sleeping in the hospital because of a laboring patient, to arise and start rounds then. No matter what, I had to find time for a morning shower before starting the day to put me in synchrony with my biorhythms.  Among other things, it cleared the air and seemed like it gave me a fresh start to the day, even if I had been up all night. The operating room nurses knew that I was pretty demanding about a 7:30 major abdominal or vaginal operation starting at 7:30. AM. After all, it was the first case of the day and there really was no excuse for it starting at 8:00 because people were dragging their feet – or so I saw it.  Most of my cases could be completed by 9:00 so that I could start office hours promptly unless I had a delivery.  My main office was adjacent to the hospital where I did most of my deliveries so as not to waste time riding around the city in my car or rushing to get somewhere and risking an accident. Frequently I would do minor surgeries over the noon hour since they were less time consuming.  Then back to the office for an afternoon of patients and business.  It was a full and exhausting day often followed by night call! Efficiency and time management were critical and routine for me.

     We had a very interesting waiting room. We cared for patients from all walks of life; the upper crust from Scottsdale and Paradise Valley; the uninsured poverty stricken from inner city Phoenix; White, Hispanic, Native American, young and old; hopefuls who couldn’t conceive, and those who could but didn’t want to; those who had previously had abortions, and those who had no idea we did pregnancy terminations.  Everyone sat next to each other, and everyone was treated exactly alike.  Everyone also had one thing in common -two X chromosomes.  There was nothing we could or should do about controlling conversation in the waiting room.  I found the waiting room a wonderful, egalitarian place where women came for good medical care.  Not everyone cared for the patient mixture.  I suppose those who didn’t like sitting next to someone for some reason just didn’t come back. So be it.  Those who wanted to be there kept coming; those that didn’t went elsewhere.

     My practice was a group practice. When I joined it I was the third physician in the group and we all worked out of one small office.  Over the years the practice grew tremendously, became a group of 10 physicians including four nurse midwives and physician assistants, with the addition of three other offices around the city, and staff privileges at five different hospitals.  There was only one business office for the whole group that was located across the hall from the main office where I worked.  Each of the other offices was located adjacent to one of the other hospitals so that no one had to be driving around during the day.

     It was important for the patients to be able to choose which physician in the group practice they wanted to see as their primary physician.  Gynecologic patients would stay with their primary physician unless the physician was out of town or there was an emergency, and then would be seen by whoever else was available.  Obstetrical patients were requested to see the other physicians at least once so that they would be familiar with each doctor should that doctor be on call when they came in during labor. Patients then could choose to return to see their favorite physician at the office of their choosing at their next appointment.

      Concessions had to be made to accommodate physician life style and good medical practice. The physicians all had a day off.  We all had vacation time, so we all needed to cover for each other at various times, and we all needed to practice medicine in a similar fashion.  Therefore, dictated typed notes with treatment plans were essential for a number of reasons, not the least of which was readability but also so we could follow each other’s prescribed treatment plans.

     As the practice grew and expanded with a rapidly growing city, we continued to add new physicians.  My original two partners and I were East Coast males trans-located to Phoenix.  When it came time to add a fourth physician, we purposely sought out a female physician for diversity, thinking she would become busy immediately from our overflow and her gender.  We were mistaken.   Most of the women in our practice only wanted to see a male physician and were not comfortable seeing a woman, a surprise to us.  After all that is why they were already coming to the practice.  So it took some time for the new female physician to get as busy as the rest of us, which in due course did happen as she developed her own clientele from new patients we put in front of her.  When we next expanded, the best recruit was an African American man, so we offered him a position.  We thought this might be a difficult transition for our patients, but again we were wrong.  He was busy from day one, mostly because of his winning personality and demeanor.  The only patient I ever asked to leave our practice was a long time patient of the practice, newly pregnant, who refused to see our newest associate because of his skin color.  I sat the patient down one day to discuss the situation, and explain that there was a possibility he could deliver her since we rotated night call for our own mental and physical health.  She refused to even sit in the same room with him.  I explored her fears with her. Apparently her family was from inner city Detroit, had a small mom and pop grocery store, and her parents were robbed and brutalized by a gang on more than one occasion.  She not only was prejudiced against all African Americans, but also would not even sit in the same room with him. I explained to her that he was extremely competent, nice, gentle and caring. She adamantly refused even to sit across the desk with him for a discussion.  I told her to think long and hard about it, and call me back, but that if she couldn’t’ speak to him human being to human being, she would have to receive care elsewhere.  She never returned.

     Our office décor was quite upscale, nicely furnished, carpeted, with comfortable seating in the waiting room.  There was extensive artwork and warm inviting colors throughout.  We had a beautiful saltwater fish tank that was the first thing visible to people as they went from the waiting room back to the exam rooms. The fish were our ‘babies’ and required a lot of daily care and love.  But they were beautiful. After all, it was a good sign if we could keep fish alive, not always as easy as it might otherwise appear in a saltwater tank.