Thursday, March 30, 2017

To the Woman I Can't Remember

So this morning, I'm sitting in grand rounds (a weekly, department-wide lecture series we have to keep us learning), listening to this speaker on trauma, women, and addiction. And she brings up a slide on symptoms of PTSD providers don't always think to look for, and of course that includes pelvic pain and chronic GI symptoms.

Listen, I am a psychiatrist. One who particularly focuses on trauma. I've been in mental health for a decade, and my interest in trauma precedes that by at least five years. I'm well aware of this connection and frankly rolled my eyes a bit that the speaker brought it up as something we don't think about (but, in all fairness, the talk was also aimed at obstetricians). But in that moment, looking at that slide, I suddenly was not the Assistant Professor in Psychiatry, and instead was connected to my sorrowful, worn down intern self from many years ago.

Because of course, I was not always the wizened mental health provider. Twelve years ago I was a bedraggled intern in a terribly abusive situation in a malignant OB/GYN program. It was a Thursday, like today, and I had clinic in the morning and academics in the afternoon, which included the conference where we discussed surgical cases for the upcoming week. On my schedule that morning was a woman coming in for a pre-operative visit. I can't quite remember if her surgery was scheduled for the next day or the following Monday, but it was soon. The patient before her didn't show, so I took a moment to look at her chart.

I will tell you that I would not recognize this woman today. She could walk into my office tomorrow and I wouldn't make the connection. I cannot remember her face, or her name, although I definitely remember our interaction and conversation, and how I felt. However, for some reason I have two very distinct images that still stick with me. Strangely, I still vividly remember her ultrasound. She was having a laparoscopic cystectomy, so I looked at the pictures, and...well, there it was. Not a terribly small cyst, but definitely not large, maybe 3cm, oblong, thin walled, full of translucent fluid. I looked at this thing for a while thinking, this is a physiologic cyst. Like, something that happens sometimes around ovulation. Next month it'll probably be gone. Huh. Why were we cutting into her? Well, okay, she had chronic pelvic pain, so maybe they were worried this was an endometroma? Or something not benign? I remember staring at the screen thinking, why aren't we just watching this?

The other picture still in my head is a snapshot of her medical record. Something didn't feel quite like it fit, so I flipped over to see if I could find some other piece of history, and lo and behold, she had a long string of notes from GI detailing her longstanding symptoms and ultimate diagnosis of irritable bowel.

This raised a large red flag for me.

So I go in to see her, and she's a delightful woman close to my own age. She looks tired and uncomfortable, but was well engaged and appropriately anxious about surgery. She asked thoughtful questions and we went over my checklist and her medical history and I inquired about the GI symptoms ("I manage") and got a more detailed timeline of her pelvic pain. Both started pretty concurrently.

Now, let's also step back for a minute and appreciate that, in all fairness, I was secretly already a psychiatrist, I just didn't know it yet. This manifested in my GYN days as me getting in repeated trouble for (among other things) asking questions that generated more work. Do you feel safe in your relationships? Do you feel like sometimes you have issues around food or eating? Has anyone ever forced or coerced you into doing something sexually you didn't want to do? In the buttoned up region where I lived, women would often say, no, no, of course not. But, two weeks later they would end up back on my schedule to be evaluated for a "yeast infection" that inevitably was an excuse to double back and discuss those difficult issues. So you can imagine where I went with this woman. "Sometimes we see this cluster of symptoms - pelvic pain, sleep issues, stomach trouble - in women who've had traumatic things happen to them, particularly if they've been sexually assaulted. Has that ever happened to you?" And you can imagine that of course it had, shortly before these symptoms developed. "Have you ever seen a psychiatrist or a therapist for this?" Well, you know, once, right after it happened, but, you know "I manage."

Oh, dear girl. I know you were managing. You managed well. I'm just so sorry that you had to.

I thanked her for sharing her story with me. I asked if she was okay, having done so. She nodded and half-chuckled in that anxious way and said, "you know, no one else has ever asked me about that."

And then I went on to the next patient, sat through grand rounds, grabbed some lunch, with her story gnawing at me. And eventually I'm sitting on the floor of the conference room in my surgical greens, eating cafeteria nachos, listening to the discussion of the benign gyn cases coming up in the next seven days. We come to her chart, and her ultrasound is staring down from the projection screen, looking even more like a plain old luteal cyst. One of the attendings makes a comment to that effect, and the case attending sort of nods and then shifts the discussion to surgical technique and which resident is going to be doing what with which trochar, etc. I was so uncomfortable. It was stuffy in the conference room. I was on the floor. I was tired, and though I didn't know it yet, I was close to having had enough of the situation, and it was less than a month until I would leave the program. I was running on fumes, both physically and emotionally. I knew pretty much anything I said or did those days was inevitably going to be the wrong thing. So when the question was posed to me about her fitness for surgery, I might not have been as thoughtful about my answer as I would be today. Did everything go okay during her pre-op check? Yeah, medically she's clear.

But...um...did it seem relevant to anyone that she was gang raped three years ago?

The room was silent but thick with discomfort. People were looking at me. I babbled a little. I mean, that was a few months before the pain started, and all of her GI symptoms manifested. She hasn't really had any treatment for that. We know these things can be connected. This doesn't look like a cyst of any particular import in terms of her pain. Do we, I mean, should we maybe have her see psych first? Should we maybe postpone the surgery?

Someone asked where I'd found that in the chart. I, well, I didn't. I asked at this morning's visit. I saw one of the male residents roll his eyes. I reiterated that I was worried we were going to cut into her and cause adhesions and give her a reason to have more pelvic pain. What should we do? Should we wait?

I was still hopeful enough at that point that my elders would lead me, you know? I had just enough of that idealistic spark left that I thought maybe I could save her - and indeed all of us - from a procedure that wasn't addressing the real cause, or if it was indicated, they would teach me why this was still a good idea. From the floor, and from my station in the room, I felt a little like Oliver Twist asking for more gruel. Please, sir, could I have some more acknowledgment and collaboration and learning? Just a drop? I would've accepted pretty much any reasonable argument - that the cyst was oddly shaped and may be causing intermittent torsion, that I should think of this as an exploratory procedure to look for endometriosis, whatever. This procedure may well have indeed been indicated, I just wanted to know why. But instead, one of the senior residents simply asked, wasn't I interested in learning how to do surgery?

I truly don't remember if my answer - "Not by mutilating healthy tissue, I'm not." - ever actually left my mouth. What I do remember was slumping back against the wall, back into invisibility, as the conference continued without me from that point on. I was checked out, deflated. The hospital nachos sat like a lead ball in my stomach and tears prickled at my blinking lids. I wanted to go home. I wanted out of this place, out of this life. At that point, however, I felt like I had absolutely no power to do anything else at all but keep my head down and ride the current. I felt like I had no rudder, no oars, I was just beholden to the forces around me. And unfortunately, that day, I felt like her canoe was also at their mercy, and I could do nothing to help.

I don't remember the outcome of the surgery, in terms of her pain (I remember discussing the shape of the cyst and that it was, indeed, benign, and that they didn't see any endometriosis). It is entirely likely that she felt better and life improved. That is certainly the course my canoe took (...eventually). But clearly, a piece of her has stuck with me, such that 12 years later, in a different state, a different specialty, a different life, I wished I could know how she was doing. And I would say to her, I'm sorry. I wish I could've offered you more. I wish I would've had the energy to do something other than slump back onto the floor, like maybe refer you to a competent therapist. I wish I would've had a better sense of the resources back then. My concerns about the way the trauma and the pain interacted were truly less about the surgery itself and much more about the attitudes with which that juxtaposition was viewed (or, as it were, not). And I'm sorry that was and is the prevailing culture in women's health - not because it's my fault, but in a way that it makes my heart hurt for all of us. I hate that medicine is still to a large degree ignorant and avoidant and victim-blaming.

But, brave woman, know that you and your story are still with me. Know that our fifteen minute conversation changed the course of my career, and the way that I practice today. Know that I'm fighting the good fight as best I can. I've tried to become that competent therapist. I've tried to become a better resource and, indeed, a better survivor myself. I hope that healing found you in ways physical, emotional, and spiritual. And I hope that medicine continues to get a clue, and soon. We're working on it.

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