The Pap Smear

From Shadows to the Light of Life

The end of July has brought me to a specialty that I've long wanted to avoid in my career. Obstetrics & Gynaecology, otherwise known as Perinatal & Women's Health, is the Medical and Surgical specialty of exactly what the name describes. It is one of few specialties where consultants are actually both Physicians as well as Surgeons.. if they choose to be.

Yesterday was orientation day and we were introduced to the various sub-specialties - a firm reminder of the flooding of knowledge over the past years in all specialties as the ever-increasing demand for research persists.

Today was my first day on the wards - Antenatal and Postnatal care. Looking after women in high risk pregnancies as well as those who are about to reach labour with some co-morbidities; or simply women who have other medical issues during or around the time of partuition. I attended ward rounds and that was fine.

I was also rostered with a consultant in his private rooms to see patients. Dr. JP, a well-known and highly reputable Obstetrician & Gynaecologist, was a charismatic man in scrubs consulting but also waiting to be called to the private delivery suite for obvious reasons. He had a rare degree of compassion towards patients and I admire him greatly for retaining most if not all of it since he graduated - that takes a great deal of energy both physically and psychologically.

Jane was one of our patients, who was a pleasant 46-year-old lady presenting for a Pap Smear. I asked why she presented to her O&G for this (as it is done by GP's in the community), to which Dr. JP interjected: I'll show you.

For me, the Pap Smear is a very awkward and dignity-stripping, invasive investigation. Not invasive in the sense of complications; but more in the sense of total self submission in the lithotomy position. Dr. JP asked the patient to get changed and insisted to me that we remain out of the room while she did.

Why do you think I leave the room to let her undress when I'm going to be seeing her pretty much naked anyway?

It was an interesting question and my answer was to preserve her dignity. He agreed and expanded: in some if not most cultures, the act of getting undressed creates a greater feeling of vulnerability than actually being undressed. This was most interesting.

Yes, I had seen Pap Smears performed in General Practice, but this was my one opportunity from someone who did them as often as they do.

We entered back into the room with Jane sitting in the chair, legs clamped together with a cloth over her lap. She thankfully consented to my presence, which was not common even on my first day. The first thing Dr. JP asked her to do was to just relax your left hand for me and the result was the patient wobbling her whole arm, then placing her hand in her lap over the cloth.

What just happened? he asked me.

She moved her whole arm?  I asked in return.

Yes she did! But why?

**Pause**

At this point I had no idea what the answer was, but it's so bleeding obvious now.

She didn't fucking know where it was in space. And yes the swearing took place in front of the patient. Apparently they knew each other well.

**Pause**

Cortical inhibition. There's so much going in the environment that it is impossible to register everything, even if it is a part of you. So by asking her to relax her arm, she realised in a split second that she wasn't consciously aware of it earlier. 


Holy shit - I thought... That's amazing! But how is it relevant to a Pap Smear?

Are you wearing underwear? 


Yes. -- I'm wondering how he would have reacted if I said "No"...

Do you feel them? 


**Pause**

Yes

Ahh yes. But it took a moment to figure it out, didn't it? 


My facial expression obviously made it clear that I had no idea how all this was relevant to the procedure.

So what GP's do is they ask women to relax their pelvic floor. I asked Jane to relax her arm, an organ that all of us clearly use every moment of everyday and she had no idea where it was when I asked her to relax it. How the fuck is she supposed to know where her pelvic floor is and even if she did, how can she relax the muscles? 


**Pause**

That's why it's so painful when GP's force the speculum into the vagina, demanding the patient relax and not thinking twice about why there's so much resistance!


He tipped the chair back and Jane almost naturally assumed the lithotomy position after the end of the chair folded down. At that point, he inserted his finger and asked Jane to squeeze my finger... okay now relax. Now squeeze my finger as tight as you can.... Good, now relax. He turned to look at me.

Did you see that? She is now completely relaxed. 


The speculum caused her absolutely no pain and the procedure was over in about 30 seconds. It was absolutely amazing. Jane had a smile on her face at the end of it, knowing that nothing hurt at all.

What is the point of medicine? He asked me then.

To reduce harm and improve quality of life.

To reduce harm is one of it's fundamental principles and there are certain patient's quality of life you cannot improve. So there's more to it. 


**Pause**

It's really all about happiness. Patients need to leave here happier than they arrived and they present for two reasons: A) to be reassured they are not going to die; and B) to make a problem go away. It is not their illness that should be centralised; they must be central. What you often see are doctors getting off on the intellectual bullshit of clinical medicine and that is inappropriate because their interest is then central, meaning the illness is central and the patient is peripheral. 


It reminded me of a colleague of mine studying medicine. I asked him why he chose to do it. His response was: I enjoy a challenge and I think medicine is very challenging. Disgusted, I asked him the next question: What about the patient?

His response was: If they get better it's a bonus. 


So this was my first ever Pap Smear and it involved more than the lithotomy position, the endocervical brush and consent. It went into the depths of cortical inhibition, anxiety and complete bodily submission. It explored the importance of the purpose of medicine and the practice of these principles through compassion that lead to better patient outcomes, that is happiness rather than prognosis. Of course, in the ideal world, both would be achievable. But the practice of medicine, as I'm sure we've all seen, is far from ideal.

Dancing

The Cambridge Dictionary describes Dance succinctly: to move the body and feet to music. I have a few friends that enjoy dancing as a hobby, others as a cultural practice and definitely a form of entertainment for the dancers as well as the audience. 

What do I know about dancing? Not much - just that I can't do it for the life of me and the modern view of dancing by the majority of the adolescence may just be some form of sexual practice in public that may or may not be appropriate. Yes, that is me being judgemental because every time I watch a music video, it involves gorgeous women in lingerie thrusting their hips this way or that and I can't make any sense of it. 

My mum used to talk to me about Turkish dancing and its wide varieties, which I found interesting but not enough to make me want to learn it. I was a lazy kid. The girlfriend occasionally brings it up with me when we go out, that we can't dance very well and that we should learn. Maybe we should, but I can't make time for it... or maybe I won't. 

I'm in with one of my GP Supervisors, Dr. MT, and he asks me to take a history of a man who presents with left calf pain. He has a history of a femoral bypass on the same side, complained of pain on exertion relieved by rest, but it was unilateral. I was asked for my provisional diagnosis and I said unilateral intermittent claudication. I was right, but then I was asked then to differentiate between claudication and osteoarthritis on history, which I did successfully. After examination, we concluded that the patient, Paul, really needed to see his Vascular Surgeon again for assessment of the graft and the remaining peripheral  vasculature. Paul agreed, but was reluctant to have another operation and I didn't blame him, his medial femoro-tibial scar was very impressive and I'm sure nobody would want such a reminder of their arterial insufficiency. 

After Paul left, Dr. MT asked me about dancing... My response was quite reactive: huh? 

He then described a scenario, where two people met for the first time on a dance-floor and were now expected to dance to an unexpected tune. Neither knew each other's dancing experience, style or preference, but would subconsciously expect their posture to direct the other where to go and what to do. With the occasional smile and nod, as well as exchanging a laugh, an unknown couple would work out a way, through multiple communication methods, to synchronously move to the rate and rhythm of the tune in a unified sense to achieve harmony. At that moment, you don't know who the person is, what their beliefs are and why they are dancing with you on the dance floor. But eventually you realise, it doesn't matter... it's all a part of the journey.

At that point, I was in awe of dancers - how they could improvise and acquire so much subconscious information, process it and express it so thoroughly. It was profound and suddenly, I was thinking of how wonderful that feeling must be. 

As much as I enjoy drifting off into my imagination - I didn't grasp the significance of Dr. MT's suggestion of dancing. He waited patiently for it to click... and then it was clear to me. The symmetry was clear. 

Clinicians and patients dance together. Each party encounters the other in a foreign environment (be it the road for the ambulance, the emergency department for the patient, etc) and the ultimate idea is to establish trust, rapport to reach the same common goals of medicine - to reduce harm, improve health and through evidence, prescribe some form of treatment. 

What a beautiful symmetry!

Dr. MT was smiling. It was clear to both of us we were feeling the same sense of peace right at that moment. Of course, we spoke about the General Practitioners of today in the context of dancing. Dr. MT compared it to "Speed Dating" - in and out, getting what you want, rather than what you need. 

It reminded me somewhat of Dance Dance Revolution - a game that supposedly lets you dance for points. But it's simply compliance - it shows you where to step at what time and you have to react appropriately. So posture, communication and  harmony is lost. It becomes cold, dry and didactic - where someone (or some guideline) iterates what needs to be done. 

Don't get me wrong, I didn't say that Dance Dance Revolution was easy. Perhaps it is easier than dancing properly, but it still requires some registration and practical knowledge. 

I must also remember that it is easy for me to judge 

other clinicians, but it is important to give them the benefit of the doubt. 

All in all, this beautiful symbolism made me think of a type of Turkish/Islamic dance called Sufi Spinning, where Semazens, or known in English as Dancing Dervishes, spin in a very specific posture and meditate. 

I don't know their history, except that they have survived through centuries. Their dancing is both beautiful and profound. 

They can spin for hours and hours - it is beautiful to watch, though I have never seen them live. My father once told me about their principle, which sparked my curiosity:

Their posture (from the image on the left) shows receipt from God (hand pointing up), be it knowledge, wisdom, health or prosperity; and through them, these gifts are distributed to the people (hand pointing down) without discrimination, or any hesitation. 

And I thought: this is how we must practice Medicine. We require some acknowledgement of a higher order - God, Miracles, Science, People. We receive our knowledge, experience and wisdom through these higher orders and with these attributes, we are responsible for their distribution to the public, for the public. 

In the meantime, whilst looking after patients and continuously  learning, we must meditate ourselves to maintain our sanity. And above all else: our love and compassion for those around us must never wane.