Thursday, March 30, 2006

Diversity: Make it Work for You!

One of the things I love about living in a diverse area is that said diversity is taken into account. I think I get better treatment in a number of ways because of it.

Case in point: I’ve been having painful menstrual cycles since day one. I couldn’t go to the ticker tape (actually office paper) parade the first time the Twins won the World Series because I was curled up around a pillow on my living room floor attempting to figure out how many acetaminophen I could take at once without pissing out my liver. As it turned out, quite a few.

Now, I had told my various doctors about this, and they basically paraphrased the Bible at me. “Almost all women have some sort of pain with their periods/childbirth/existence. Take some aspirin. There’s nothing wrong with you.” Of course, they never bothered to check if there was anything actually wrong with me.

I’ve spent years thinking I’m fat, because even though I’ve managed to get my weight down as far as 118, the dimensions of my stomach never changed. I believed I had no will power, that my “fatness” was my fault.

So when my nurse practitioner said I was just “fat,” I didn’t even react very much (Luckily for me, other people reacted quite strenuously. Thank you, Baby!). I was used to being called fat, and had pretty much given up on all pretenses toward American-style attractiveness anyway. I couldn’t change the brown or the short or the gay, and damn it, I couldn’t even be thin! However, I knew enough medical terminology to weasel a single test out of her.

When I went into a dark room with the ultrasound tech, I had no idea how much my change in community makeup was going to change my life. Because I now live in a place where 30% of the population is black, the diseases that affect black people are now on the radar. In Minnesota, where about 12% of the population is black, that’s too small a proportion (as far as I could tell) to pay attention to, so everyone gets treated according to the Caucasian model and assumptions. Unfortunately, if you’re one of the 12% it means sub-standard care.

The tech showed me my kidneys, which she imaged and measured because the black population has a higher incidence of kidney disease/failure, etc. Kidneys themselves really do resemble the beans, or vice versa. Mine looked exactly like the images of normal kidneys I’d seen in various medical journals.

She had to do some digging to find my ovaries. I wasn’t sure whether we were prospecting for organs or petroleum for a minute there. It wasn’t particularly painful, however, just pressure in odd directions bordering on “really uncomfortable”. I’d been worried about cysts, so getting a chance to look at them and confirm that they looked fine was reassuring.

When my uterus swam onto the screen, it was not so fine. The tech had to tell me what I was looking at. I’ve known what the female reproductive system should look like since I was four, so not recognizing my own was a little alarming.

The tech said, “Oh look, you’ve got fibroids. A lot of black women have fibroids. I see it all the time. This one is seven centimeters. That’s fairly good sized, you know.” In fact, there was one on each side, obscuring my ovaries from the sound waves, as well as my Nurse Practitioner.’s ham hands.

The tech was musing to herself, “Yeah that’s about the equivalent of a five month pregnancy.”

Say WHAT!?! You mean the reason I need to rebuild the front of my bike because I can’t breathe and lean over far enough to reach the handlebars isn’t because I lack self-control? My beer gut is not the result of beer? (Not for lack of trying.) I realized this winter that I’m even avoiding snowboarding because I can’t reach the binding latches behind my ankles and breathe at the same time (While naked I can reach just fine, but it’s just a little too… “invigorating” to snowboard naked). I’ve been preoccupied with losing weight for about three years now, and finding out I’ve been wasting my time gauging by my stomach size is both wonderful and infuriating.

My head nearly exploded with all the restructuring I have to do around my self esteem. I’m still overweight, but I’m not THAT overweight. The fact that my waist measurement and my inseam are the same is a ratio I now may be able to change, for the better. I haven’t believed that for at least fifteen years.

Change. Now, that’s a conundrum isn’t it. I am generally not in favor of having someone rummaging ‘round my innards with sharp steel objects. It just seems like not such a great idea. I’ll watch it on the Discovery Channel. I’ll even study to do it myself, but I have never wanted to be the subject. Then I saw those fibroids.

In about five minutes, I went from “I don’t want to have surgery” to “wheel me into the OR now. I’ll inflate my abdomen myself! Gimme that trocar! Somebody bring me a sterile bicycle pump, stat!”

Things don’t happen quite that quickly, unfortunately. I have an appointment with yet another nurse practitioner in two weeks, and I’ll probably have to say “all the right things” again in order to get anything further done. However, I finally believe something can be done. That’s no small victory.

So, thank you to last week’s NP for reminding me how the lack of diversity can adversely affect care, and a huge thank you to the tech who did my ultrasound for treating me like an intelligent human being with an actual medical problem. It is unfortunate that it took fifteen years to get me to her, but at least I finally got there.

Sunday, March 12, 2006

Roto-Rooted: A Pelvic Primer

I had an image today of my Nurse Practioner (NP) as a small child with her finger up her nose, digging away. Except the orifice in question wasn’t her nose. TMI? Stop reading now.

Okay, so I went to the gynecologist today. I still get a shiny happy feeling when I reply “No” to their query of “Do you smoke?” Unfortunately, they have moved on to new and better things about which to guilt me.

The NP made a huge deal about how much I weigh. Now, seriously, I have a pot belly. Who doesn’t? She went on about how Kaiser has weight loss programs and I thought, “Do you want to be able to see my uterus from a quarter mile away, or what?”

Frankly, I have girlfriends who make loud whining noises when I mention losing weight, and their opinions are more important to me than some Midwestern transplant nurse practitioner who I just met today and perhaps will never see again.

She did the glove thing (oh joy) and started roto-rooting My Special Place with what felt like great abandon. You know, I’ve had my entire hand in one of those before, and the recipient was not complaining as much as I would have been had I not been raised a repressed person (thanks, Mom). Yes, it’s a different context, but good grief! Is there a pot of gold somewhere in there of which I was previously unaware?

At this point, every other physician I have ever had did one of two things: blew me off saying “Well, all women have painful menses so there’s probably nothing wrong with you,” or said, “It’s due to some other body system. I’ll refer you.” Of course when I go to the other specialist, they say it’s probably OB-GYN related and send me back. It’s sorta like the first week of undergrad all over again (business office, registrar, business office, registrar).

She tried to do it too. “This is probably just gas.”

“Look, lady, I have IBS and the last two days have been…interesting. So, I’m fairly certain there’s no gas in there, and no solids, either, so make with a diagnosis or a recommendation for further testing, or leave the room quickly before I find something to throw.”

Okay, that’s what I said in my head. Let’s just say I expressed great dubiousness as to the medical usefulness of her suggestion that Gastrointestinal Inspectors R Us was a place to go, since I had already been there…and they sent me to her!

Her observation was that she could not palpate my uterus at all, despite building a 3-d rendering of a Jackson Pollock original out of whatever is residing between my belly and spine. “Why thank you. I just thought you were minoring in Sculpture.”

I also have this teaching note: Could we possibly add “The Gynecological Exam” to school health curricula? I really think the quality (and possibly quantity) of pelvic exams could be greatly improved by simply telling women what’s going on. I would feel much better knowing what it was doctors are looking for during the exam. I could think “Yes, that is my left ovary! How fascinating” rather than “Good God, how did I miss her feeding a pipe wrench through the speculum?”

There’s a really nasty twisting motion they all seem to use, which always just makes me nuts. I hate it -- no matter who is doing it or what context it’s in. I have asked people I love dearly to stop doing it, immediately. I would very much like to know if it’s completely necessary, and if not, train my gynecologist to never do it again either. This can be done. None of my last four primary care physicians ever tried to approach me with a tongue depressor. Hopefully, none will ever again.

I just want to know. I was amazed to be told that the reason your primary care doc freezes several spots on your torso with the stethoscope is because different valves opening and shutting are heard in different places on the rib cage. Well, now I have more tolerance for said procedure.

I might have more tolerance for various obstetric shenanigans if I knew why or if they were necessary, and I don’t believe I should have to go to med school in order to find out.

However, I do have this to say on Kaiser’s behalf: if you really want something, you can get it. I’ve had excruciating periods most of my life. I also have noticed how difficult it is to palpate my own innards on occasion. Thus, that this NP was having problems with abdominal auscultation was not surprising. What has never happened is that after we had that little meeting of the minds about trying to pass me off to another service, she made sure I knew which thing would be most probable on the “Worry” scale, she bit the bullet and requested an ultrasound.

So, soon there will be an indignant page or two about how awful it is to have someone smear cold goo on my distended belly and press a machine into it. Did I mention my bladder has to be full? How many obscenities am I allowed per page? Y’all better hope I don’t have an ultrasound machine anywhere other than my belly! (Those of you who have had one, stop laughing, I mean it.)

By the way, on the cold goo front. Just a thought for all the people out there giving pelvic and/or rectal exams. Wipe the patient off!!!!! There is NOTHING worse than the lube-sticky-squishiness, especially once one is back at work. Take a coupla moments and clean up your workspace. How hard can that be, we’ve been hearing it since kindergarten! Failing that, at least leave a box of baby wipes (alcohol-free, please) in the room where the patient can find them and take care of it her/himself.

I will be nicer to my patients on the receiving end of the cold goo tube, I promise, and there will be extra boxes of tissue in our exam rooms until I can figure out how to justify spending on actual baby wipes.

I have never, before last week, actually thought of pelvic exams as something I would eventually give, rather than just receive. I think I shall choose to be a very different examiner than my nurse practitioner, and I think there might just be a lot of patients whose care will be improved by my uncomfortable day.

While that is a silver (plate) lining, I still didn’t appreciate her zeal in painfully finding out nothing at all, and the fact that she blamed her failure on my “obesity”. Someone needed a transfusion of tact, and for once, it wasn’t me. I’m going off to rest on my laurels right now, since the other thing I can be said to rest on…needs a rest herself.