Update on "Mary"

Mary came into the office last week for her first offical prenatal appointment. That's the one we schedule at 12 weeks (give or take), right at the end of the first trimester. The reason this date was particularly significant for Mary was because the great majority of miscarriages happen before the end of the first trimester. She was past the first hurdle.

Her cone biopsy was 6 weeks ago. The margins were clear (i.e. they got all the cancer on her cervix). She hasn't had any bleeding or cramping, and has been feeling increasingly pregnant.

There are still more hurdles to overcome. She might end up with an 'incompetent cervix', which is a cervix that is unable to support a pregnancy to term. She is at high risk of preterm labour. There's no predicting how her cervix may respond to the weight of the growing fetus. She has opted to have a c-section to be scheduled a few weeks before her due date on the advice of the oncologist.

But we found the heart rate with the doppler. Mary's face softened as she heard the strong heart tapping away at a perfectly normal 155 beats per minute. She had already admitted to be that due to their reluctance to get too hopeful, her and her husband hadn't really let themselves get attached to this growing baby inside of her.

I asked her if she'd like an ultrasound. There isn't really a medically indicated reason for one at this time-- it's a bit late for a dating ultrasound, and far too early for one to check the fetal anatomy or the position of the placenta. But I thought she needed one for her own well-being... not just to confirm that all was well, but I secretly hoped that if her and her husband actually got to SEE this little miracle, they'd let themselves get excited about it. As though seeing it on a screen would make it real. She accepted.

So far, so good. In the words of Mary herself... cautious optimism.

Paternalism in Medicine

Today I had academic day, which is my only chance to sit around and compare notes with other residents. We frequently discuss cases, particularly ones that had a counselling/psychological/touchy-feely component that we were unsure about how to approach.

The case brought to the group today by one of my fellow residents was the story of a 19-year-old who came to see her seeking the birth control pill. Might have been straightforward, but she was also asking for a refill of Imitrex, a migraine medication. The birth control pill raises a woman's risk of blood clots, which will make her more likely to have a stroke. Have a certain kind of migraine (with aura, where you get visual and/or neurologic signs that preceed the headache) also raises the risk of stroke. To be taking both together raises your risk of stroke by more than either one alone.

The bottom line is that the Society of Obstetrics and Gynecologists of Canada says that migraines with aura are an 'absolute contraindication' to prescribing the birth control pill. So the group was saying that she shouldn't have prescribed the pill (she didn't in the end, but her preceptor ended up caving and giving it to her). I was the lone voice of dissention.

Don't get me wrong, I'm not in a big hurry to prescribe drugs with harmful interactions, but I wasn't sure if it was right to outright refuse the girl her prescription. I was of the opinion that if you are able to appreciate the consequences of your actions, you should be able to make the decision for yourself. For example, if I were to explain that the risk of stroke for a 20 year old woman on the birth control pill is 1 in 1000, and the risk of stroke for the same woman if she gets migraines with aura is 2 in 1000, but if you put the two together your risk of stroke goes up to 8 in 1000. (fictional statistics for emphasis)

Well, if that woman decides that the benefits of taking the birth control pill outweigh the 6 in 1000 risk of stroke, who is to say that it isn't her right to say so? The group shot me down-- lawsuits are stressful, it's ABSOLUTELY contraindicated (thanks, I got that the first time), her reasons for going on the pill were frivolous (who are we to judge her reasons?)...

I stood firm. She was an adult. If she understood the risks, I didn't see why we couldn't leave the decision in her hands. All appropriately documented, of course, to cover my ass in the event that she DID stroke out and I end up being sued.

So now my group probably thinks I'm negligent. I'll likely be voted 'most likely to be sued first' at our next dinner party.

This medicine stuff is complicated.

I am Woman... Does it Matter?

I think I'm lucky to have been born when I was. I'm way too contrary and stubborn to have been submissive and subservient, the way most women were expected to be in the past. And I was lucky to have been raised by parents who believed that women could do whatever men could do. The sky was the limit. I was never encouraged to go into any of the more traditionally female professions. At no point did anyone suggest that I become a nurse rather than a doctor, even after two unsuccessful applications to medical school.

So after growing up in an environment that taught me that I was just as good (if not better) than any man, I've often laboured under the mistaken impression that gender doesn't matter anymore. I had heard the stories about the glass ceiling, read the statistics regarding pay inequalities between men and women, but always explained them away. Glass ceiling? That's mostly in business. Unequal pay? Only because women still chose 'pink collar' jobs over higher-paying ones still dominated by men. But today gender doesn't matter. The inequality has lessened significantly over the past few decades, and will soon be history. Naive? You betcha.

Medicine is changing. The current crop of medical students in Canada is over 50% female. At my medical school (in the interest of remaining anonymous, I won't name it but it's safe to say that it's on the cutting edge of tradition) I was a member of the first medical class in the university's history where women outnumbered men. So the future is bright for women in medicine.

But we're not in the future. We're in the present. And women are still painfully underrepresented in medicine, particularly in academic medicine. Through the course of my medical career I've been interested in three specialties. I started off wanting to do reconstructive surgery. Then, my interests shifted to emergency medicine. Currently, I'm a family medicine resident. Interestingly, I started off in a male-dominated specialty and ended up in a female-dominated specialty.

Surgery often isn't an option for female medical students. The hours are long and hard, and it doesn't let up for the 5 years of residency. Even after residency, many surgeons complain that they don't fell that they're in control of the hours they work. And that's a lot of hours. On my surgical rotation it certainly wasn't unusual to see staff surgeons rounding on their own patients late into the evening or on weekends. And I'm talking about the weekends and evenings that they're NOT on call. I have yet to meet a female role model in surgery. The very few women surgeons I've encountered have either been workaholics or complete bitches, and I have yet to come across any of them that seem to have anything even remotely resembling a balanced life. Which then begs the question-- perhaps none of these 'balanced women surgeons' are around simply because such an animal does not exist.

Emergency medicine was a little better. Although the old guard was still primarily testosterone-driven, the spread of young doctors and residents is now close to 50/50. This is probably because of the 'lifestyle' aspect of the specialty-- if you're the kind of person who copes well with shift work, the idea of throwing your pager out the window for the rest of your career is awfully tempting.

Although family medicine is much more female-heavy than other specialties (with the possible exception of pediatrics and obs/gyn) it's not immune from some of the old school ideas. My preceptor, who isn't all that much older than me, actually said to me that "the problem with physician recruitment targets is the fact that they count women physicians as equivalent to men". Mind-blowing, isn't it?

His point was that women, because they have children, will work less over the course of their career. So if you're looking at replacing a retiring male physician, it would take more than one female physician to pick up his workload. I tried to point out that male physicians are also more interested in life beyond medicine, and are much less likely to subscribe to the 80-hour workweeks and 24/7 call that have traditionally been the hallmark of the family doctor. Many men today aren't content to make lots of money at the cost of their health and family life. What's the point of making lots of money if you don't have time to spend it? Your wife barely knows you, your kids hate you... it's just not worth it. My preceptor was unmoved.

"It's biology," he explained, "women have the children and act as primary caregiver. It's unlikely to change any time soon."

I was horrified, but bit my tongue. My soon-to-be-husband was brought up in a family where mom and dad split child rearing and household chores down the middle. There was no 'men's work' or 'women's work', it was just 'work' and it needed to get done. And it was. As a result, he and I are able to plan a future where we split our allowable parental leave down the middle, and share childrearing responsibilities equally. Maybe I'm underestimating the surge of maternal hormones that will make me want to give up medicine for diapers and Dora the Explorer, but this is the plan we've discussed at length. In fact, if anyone is going to do more than the other it will likely be him. Why don't people even consider this as a possible alternative?

I've started to worry that the assumption that my career will take a back seat the minute I procreate will make the legendary glass ceiling more real than I've ever believed.

Things I Would Like to Tell my Patients

1. Don't assume that every doctor in the world runs late. I rarely do. Please be on time.

2. Bring a list of your medications. If you don't have time to make a list, just throw them all in a bag and bring them with you. Please don't assume that I intuitively know what changes the specialists made to your medications, and please don't think that I'll be able to translate "you know, the white pill-- it's kind of round?" into meaningful information.

3. Don't freak out if you're in for a pap smear and you haven't trimmed your bikini line. I don't notice. I don't care.

4. Please don't bring two other members of your family with different problems and expect me to deal with them all. I like to run on time, and people who expect me to deal with their headaches, their son's asthma and their husband's depression in one time slot make this impossible.

5. If you come in with a problem and I perscribe something to fix it, don't expect the problem to resolve if you decide not to take the medication. And then don't come it two weeks later and tell me the medication 'didn't work'. It only works if you fill the perscription.

6. If you experience a minor side effect while taking a medication, call my office and let me know. Don't take yourself off of your medication so that when you come in 3 months later for follow up your previously controlled hypertension is 190/100 mmHg.

7. When you call the office and ask for an urgent appointment for a non-urgent problem, please don't reject all 3 appointment times offered and go to a walk-in clinic. We're trying to accomodate you. And when you come back in a week with the same complaint, we have no access to tests that have been done or what they tried to do for you.

8. No one is asking you to be a doctor, but PLEASE know a little something about your own medical history. Telling us that you had three operations in the past five years but you're not really sure what they were for doesn't help at all. And mentioning that they may have been for some kind of cancer doesn't really narrow the possibilities.

9. Be honest. I'm not here to judge your drinking/smoking/drug use/sexual practices, but they do affect your health care and how I approach your management. Don't lie to me. It only hurts you in the long run.

10. If you're convinced that all western medicine is evil and that all doctors are just out to medicalize everything and exploit your health problems for profit, maybe you should be seeing some other kind of health practitioner. It's a waste of my time and yours if you're just going to sit there and eye me suspiciously, then shoot down every suggestion I make with "I don't believe in taking medications/physiotherapy/lifestyle modifications". What are you hoping I can do for you?

It was a frustrating week.

Because "FAT" is a Four-Letter Word

For people carrying extra pounds, the word "fat" is often like the elephant in the room that everyone is pretending not to notice. In the case of medicine, this is a very bad thing. The fact is, being overweight (and I won't get mired down in the definition of overweight vs obese vs morbidly obese or whether or not BMI is an appropriate measurement instrument) is a medical condition. It is a significant risk factor for everything from heart disease to pregnancy complications. But no one wants to talk about it. And worse yet, people get offended when their doctor brings it up.

I have been known to spend time on a certain internet message board or two... the majority of the women on these boards are 20-35 years old and married, and are looking to start a family. A surprising number of those (as I mentioned in my last post) have had trouble conceiving. Of course, every healthy young person who wants to have a baby and can't get pregnant in a reasonable amount of time wants to know why. Fair enough.

What I'm seeing, though, are women who are coming back from their doctor's office steaming mad. Why? Because the doctor told them to lose weight, and in some cases, refused to perform invasive investigations until they did. They call their doctors 'insensitive', and 'ignorant' and insist that they know many women heavier than themselves who have gotten pregnant without problems. They demand hysterosalpingographs, exploratory laparoscopy and want to be put on drugs like Clomid. And they're very angry at the suggestion that their weight might be a contributing factor.

Part of the problem is that when someone, even a medical professional, suggests that someone is overweight (I prefer to use the terminology "carrying a few extra pounds"), women don't hear it as medical advice. It doesn't come out the same as 'your cholesterol is high' or 'your thyroid is low'. It comes out wrapped in a lifetime of insecurities and issues. It suddenly comes out in the voice of your mother, telling you at 6 years old that your sundress is 'slimming'. It comes out in the voice of your father, asking you at the age of 15 if you'd put on weight recently. If comes out in the voice of your ex-boyfriend, telling you that you'd have a 'rockin' bikini body' if you just lost a few more pounds. Worst of all, it comes out in the voice that has always shouted in the back of your head that you'd be prettier/happier/more successful if you were skinny. It's hard to separate the 'issue' from the 'issues'. And so the suggestion that losing weight is integral to your health comes out as a social judgement, rather than as medical advice.

Which is too bad. Medical research has shown that patients are more likely to lose weight if their doctor addresses the issue and supports their efforts. And in the situation I mentioned of trying to conceive, a weight loss of as little as 10% of your body weight may be enough to overcome the Unopposed Estrogen Syndrome that is most likely to be the root cause of anovulatory cycles and failure to conceive in women with a BMI over 30. And even if the problem is NOT as straightforward as losing a few pounds, wouldn't you want to try that before resorting to invasive measures that carry risks and side effects?

I wonder-- is the reluctance to accept this advice stemming from the fact that it suggests that it's the womans own fault that she can't conceive? Or is it even deeper than that? Is it because she feels that answer is "too easy" and wants medical intervention to feel that something is actually being done?

In a roundabout way, this leads us to the issue of PCOS (polycystic ovarian syndrome), a complex problem which encompasses benign ovarian cysts, irregular menstrual cycles and insulin resistance. More women are being diagnosed with this today than ever before. It's still unclear if being overweight predisposes you to developing PCOS or if PCOS causes obesity secondary to insulin resistance. But it's the same insulin resistance that is a precursor to adult-onset diabetes, a condition that is known to be caused in part by being overweight. Which came first... Chicken? Egg?

I'll get off my soapbox now. But I'm always hesitant to address the issue of weight with a patient, unless it's directly related to their reason for coming into the office (high cholesterol, knee trouble, diabetes). Maybe I'll get braver as time goes on, because I fear that continuing to ignore the elephant in the room isn't doing my patient any favours.

Sometimes, life just isn't fair.

There is a patient in the family practice where I work-- I'll call her Mary, since it's the most normal name I can think of right now. Her and her husband have been trying to get pregnant for several years. They are both in their early 30's.

(As an aside, I can't believe how many young, healthy people suffer from infertility these days... until about five years ago, I figured that anyone who pulled the goalie would inevitably get pregnant within a few months. Has getting pregnant gotten a lot harder in recent years or is this just another subject upon which I've apparently been burying my head in the sand?)

So back to my story. So Mary and her husband have been trying to get pregnant. A lot. They've both been investigated, and neither of them has any physical reason preventing them from conceiving. So they're still trying.

A few months ago, at a routine physical, Mary has an abnormal pap. Not "Oh-My-God" abnormal, just "Hmmm" abnormal. So she gets sent to the gynecologist for colposcopy (where they take a microscope of sorts and take a closer look at the pathology in question). She tells the gyne that they're trying to have a baby, and asks if they should put their efforts on hold while this whole cervix thing is being investigated. He poo-poo's her concerns, and tells her that 99.9% of the time this kind of thing turns out to be nothing.

Not so much.

Invasive cervical cancer. The good news? Largely curable with a cone biopsy of the cervix. But only if it's done right away, before the cancer has a chance to spread to the uterus. Because if it spreads, then she'd need a hysterectomy and any chance of biological kidlets would be gone. So pretty straightforward, eh? Send poor Mary for a cone biopsy!

But oops. Mary hasn't had her period since mid-December. Mary is pregnant with the desperately wanted baby that they've been trying so hard to conceive.

What a horrible situation. She could still opt for the cone biopsy ASAP, knowing that it could compromise the integrity of her cervix and put the pregnancy at risk. Or, she could hold off until after the risky first 12-15 weeks (when most miscarriages occur) and have the cone biopsy done then, knowing that there's no way to tell if the cancer would have spread to the uterus in that time frame. Or, she could opt not to have it treated at all until she gave birth, but the pathology showed a cell type aggressive enough to think that this option may put both her life AND the baby at risk.

My heart was breaking for Mary and the decision that she had to make.

In the end, she opted for what I would have done under the same circumstances. She opted for the cone biopsy. She had it done two weeks ago. So far, so good. But when I saw her today and asked her about her pregnancy, she said she hadn't thought about it... she was scared to death to grow attached to the little being inside of her, knowing that there was a good chance it would never see the light of day.

I don't know about you, but I'm crossing all of my fingers for her.