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. 

My GP...

We all need a family doctor. My GP is very important to me. A married man with 4 kids, a wife who had a stroke and parents that live with him; his mother with Chronic Kidney Disease and his father with end-stage Alzheimer's Disease.

He called me yesterday for a small favour and by God, was I happy to hear from him. I really miss talking to him. He really fancies my car and one of his daughter's crashed one of his cars and he needs a new one. So he wanted to borrow my car for a couple of hours to see how it was and to show his family the car he likes.

I told him of course. We arranged a time for the Sunday afternoon and we went from there.

After work, I was on my way home and I called him.

He sounded pre-occupied, as if he was worried or stressed and he probably was.

Could we do what we planned for today another time please?


He obviously didn't want the people to know what we were talking about and I said sure, any weekend you like.

When are your exams?


I didn't know the exact dates - in about three weeks.

Okay well why don't we hold it off until afterwards?


I am still happy to meet with you whenever you're free.

Sure. But only when you're not busy. Okay?


I almost broke down there and then. How is it that nobody except my GP, who is one of the busiest people that I have ever met, can understand me and the demands I have to meet, but my family and girlfriend cannot?

Where is it that life is taking me? What does this even mean? It was a relief to know that he understood but also that it feels rude for me to sound busy to him. He himself is so busy and for me to make time for him takes priority - that's my perspective.

I miss my mentors.

On my Knees

I cried a few days ago and after thinking about it for a few days, I understood why.

In the cold wind of the Brighton Beach, I realised that most of the Surgeons at my hospital were an inspiration to me. One of them in particular, MHK, really can relate to me. He is one of the smartest, most relaxed people I have ever met and he too started out to become a Surgeon. He had it in him the whole time and went through the motions to become now Professor of Surgery.

I understand how hard it must have been. Working so often. He writes about how a Surgeon works hours on end and is still expected to functional socially. He recalls falling asleep in countless theatres and being woken up by a disappointed date. He talks about working 16-18 hours a day and coming home to work on his PhD, the two other Bachelor degrees and a Masters degree he has.

So here I am - a third year medical student in General Practice who hasn't studied anything in 3 weeks; other than seeing patients, I haven't done anything for my upcoming exams in three weeks.

I think about MHK and his study routine. He told me once that he was a Taxi driver as a medical student.

He is from the same part of the world as me - and it is tradition that when someone starts working in a family for the first time, the first payslip should be spent on gifts to the family. We were in the operating theatre one day and he looked at me and said:

Do you know what I bought my parents with my first payslip? I bought my father some socks and underwear, and my mother a jacket. 


Look how lucky I am. I've got a computer, the internet and a car to get me from one side of Sydney to the other several times a week. I can't live up to anything he is.

I can't study, I am an average student and I too want to become a Surgeon in the Public Hospital System. How am I supposed to do that?

Last week, my GP supervisor invited me to a play at the local Anglican College and I fell asleep for a few minutes before the classical music woke me up. I realised what had happened and I could share MHK's pain of social participation. In the intermission, I decided to message him and tell him what had happened.

He wrote back: Hang in there. 


How? There's so much going on. How am I supposed to perform?

I am really struggling to study, to do anything on a routine basis. My exams are so close and I haven't studied. I barely see the people I love and when I do, I am expected to carry out errands.

Did you remember to do this?

What about that?

Can you pick me up?


We should go to that party tonight.


Sometimes I really think life is cruel. I really fucking do. I have done everything in my power to help as many people as I can and I will continue to do so, but the criticism and the expectations are overwhelming.

I think back on MHK and wonder how I am ever going to get there. How am I ever going to survive?

Then as I was reading about the entry requires into the College of Surgeons, I stumbled across the requirements of a Fellow in General Surgery. The number of operations that are expected to be performed independently and alone are tabulated over 11 A4 pages. Where do I start? How do I study?

I am so far behind, is it really worth starting?

All the people that speak highly of me, what will they think when I am unsatisfactory? What will I do when I have to come home and tell people that depend on me that I can't earn money for another year or more? How will I ever pay my bills back? How can I ever be a provider?

28 in 48

The Brass

Inspired by a good friend, I decided to spend two days in the NSW Ambulance Service as part of my Community Placement in the General Practice rotation. I know now that if I had done this in high school - I definitely would've chosen it as a career. It was everything I expected it to be. We are dispatched to help people in dire need when they need it - prioritising only them. Individualised pre-hospital medical care.

The dedication required takes me back to the laziness that has infected medical students: some of us don't show up to rounds, don't assist the interns and residents despite knowing that our help would help them and thus help patients, finish early and of course let's not forget those who do not show up at all unless they have to. The Ambulance Officers work 12 hour shifts and based on my limited experience, do not finish on time - making their shift closer to 15 hours.

As a medical student, it was very important for me to see the role of the Ambulance Service. I loved it and sparked my passion for emergency medicine not for the adrenaline but the principle of dropping everything making that person in dire need the priority.

It reminds me of all those people talking about Alternative Medicine and its importance. Yes, I'm sure there is a role in the care of patients, but when the chips are down and the most crucial physiologies in the body are dysfunctional, we forget our beliefs, how much money we have, whether we're hungry or what assignment is due. We are reminded of cruciality: family, loved ones, our future. Nothing else matters.

I was assigned with the Intensive Care Paramedics - Hardboiled, desensitised men and women who respond not through panic but through logic; something I sincerely lack in my career as a medical student. We had many conversations about protocols, management and interventions. Some of the conversations ran deep...

Have you witnessed any miracles?

They paused for a moment and I could sense that this brought back memories for them.

We have seen people die that should have survived. We have also seen people that should have died but survived.

That's not to impose judgement - they were referring to their gut feeling of survival rather than whether people should have died because they were evil. No dirty hands there.

The comment made by T-man, one of the IC Paramedics moved me greatly: Call it a miracle, call it fate or chance. Call it God. It's all talking about the same thing. The same phenomenon.


That will give me a lot to think about. I'm sure I'll be lost in thought about it when I can focus.

They came up with a nickname for me as well: D-Rok.. and don't ask me how it got to that.

You know D-Rok, sometimes we perform CPR not because the patient has any hope of surviving, but to give the family some closure. When we arrive at the scene, we assess the family and see how they are coping with their relative's decline. If we see that they are hopeful or want everything to be done... despite knowing that they have barely any chance to live, we still carry through with it. At least then the relatives feel some form of closure that everything that could've been done was done and that nothing could have stopped what happened.

Azrael

It took me a while to fully appreciate the gravity of those words. Paramedics are the warriors that fight the physiology of death - delay it by prolonging life until they cavalry is reached.

We, as medical practitioners, often forget the efforts made by others and as a medical student, I will not forget this experience with the Ambulance Service. Those people are incredibly important, crucial, quintessential.

The lives of the population in need are not in the hands of the hospital - they are in the hands of the Paramedics.

I honour them.

Pressure

Not exercising for almost two weeks can really make you feel disgusting, particularly if you enjoy it and crave it. The downside is I know I should go to manage my weight and also because it's a good form of release - but I can't. Something's holding me back and I don't know what it is. The same thing prevents me from studying until it's too late.

Yesterday during my day of sorrow without reason, I decided to do some exercise. I went for a walk by the beach. It was so very cold. With 4 layers, scarf and gloves, the weather really reminded me of how lucky we are to live here in Australia. The winter may be cold, but it's still near melting point compared to other countries such as Russia, America and England. But that didn't stop it from being downright ice-cutting.

It's become almost impossible for me to experience the extremes of emotion without particular music. Every time I write on this blog, drive or study - there's always something playing in the background, usually the same song on repeat for many hours before I need a change in scenery. Yesterday's walk needed my favourite song - a song that I have listened to almost every day for the past 4 years. I still can't get past it - it is so beautiful to me.

While listening to this song, I was thinking about my tutors in the past. Men and Women that have prevailed through medical school, internship and residency - there they are: up in the ranks of the Physicians, Surgeons and Doctors.

Watching them now, being the successful people that they are with families, routine and practice dedicated to helping their communities, I really wonder how I am ever going to get there. Most of them were consultants by the time they were my age because of the wonders of undergraduate medicine.

So I broke down, crying while listening to my song, wondering if I'll ever be half of those people at the pinnacle of my career. I am not even sure I will pass my exams, let alone deliver the care required of me in 18 months' time.

There is only one way to success for me and for most if not all of us in medical school. We cannot deviate from the common path of becoming general doctors when we complete our degrees. Medical school exams definitely scare me and there's plenty of errors to be made and much feedback to be received because truly, I cannot believe that an exam tests my competence. Which is why I'm so confused.

What truly scares me is being out there, as a 'Doctor' and finally managing illness independently and knowing truly that there's plenty of roads to choose from in the light of career choice, number of hours per week, management protocols and many other fields of thought.

All I know is that I am far from ready.

Today

I gave my second lecture to the first year medical students this morning. Given my background in medical imaging, I am suited to the job - a job I created for myself: develop methods of education through interactivity rather than didactic methods to increase the knowledge and experience of first year medical students.

Like most tasks in my life, I put it off until the last possible moment: the night before. I slept well, waking up at 0900 for the first time in some time and got ready to go to my hospital to help a small group of first years fill out some of their assessment forms in clinical examination. They have to fill out two forms to assess their competence in examination. One form has to be signed by a doctor, the other by a senior medical student. And since we were buddied up at my hospital (i.e. the third years and first years developed professional bonds), I made a commitment to help my buddy and his friends. That took up my morning and afternoon including the 2 hours of driving to get me there and back. When I came home, it was time to give the presentation a serious go, which meant finishing it by midnight and rehearsing it least once before 0300.

Mum was happy to see me back home, but I haven't been happy to be home. There is tension in the house between my parents and when I come to visit, I seem to be stuck in the middle of it.. So these past few weeks of visiting at the end of laborious weeks in General Practice has not been pleasant. My dad looks me in the eye and lies about his drinking habits. Why do I care? It's just stuck with me.

Sitting down at my laptop finally and being able to be productive felt good. Productivity is always a form of therapy for me regardless of which context it is in. This is probably because I have been procrastinating so much this year.

The clock struck 1800 and I was confident I could be done in a couple of hours to squeeze in a coffee with my old friend from high school. All of a sudden, I got a call from a very close friend that doesn't keep in touch all that often - DV. She was sorry she hadn't been in touch but really needed my help.

I've had my migraine since Saturday and it's never been this bad. I'm not sure what to do. Can you help?


I told her I would be there in 20 minutes. By the time I got there she was already vomiting and this, to a medical student, didn't look good at all.

Pushing my feelings aside for my friend, I forced myself to be objective and not mention the terms tumour, subarachnoid haemorrhage and meningitis. I simply said it is best to be seen by a doctor in the Emergency Department. To double-check this, I called my GP and explained the history:

I've got a 23-year-old female with right parietal headache for 2 days with some paraesthesiae in the ulnar distribution of the left arm, which has resolved. She feels warm but is oriented to time and place. However she has just vomited clear fluids 10 minutes ago. She has a background of migraines, however states that this time the pain is different and is not relieved by rest or sleep. 


My GP listened to me and also pushed his feelings aside and said: since neither of us know this patient, you should consider sending her to the emergency department.


Sure, I'll take her myself.


A few hours later, we were seen by a Clinical Nurse Specialist and she triaged DV into "to be seen in 4 hours" category. After half an hour, she felt better after the panadeine forte and we left after letting the nurse know. I took her home and shared a cup of tea with her before leaving for home to finish the presentation.

It's almost 2100 and I just finished dinner. My parents are drinking and arguing about trivial bullshit at the dinner table "keeping me company." So after that I finally sit at my desk to tackle this presentation.

I'm finally finished and it's 0130. I'm supposed to be up at 0630.

---- Fast Forward ----

We're in the lecture theatre, almost 300 students and I. They're all fixated on me and I'm there to give them a talk. I break into a cold sweat thinking that I'll look like a total idiot and my presentation will be a stand-up comedy show. I was scared and finally, after delivering the talk for 90 minutes straight, it was over. I received an applause, but I could barely smile. People's feedback was great but I was struggling to be happy.

After another 45 minutes of answering questions by enthusiastic colleagues, I was finally able to get out of the theatre and breathe some fresh air. Mum was with me: I'm so proud of you. I didn't know how to feel. My girlfriend messaged me to tell me that I was great as well - she attended too. Somehow we managed to put our differences aside and keep the relationship alive. Not sure if that was the best outcome, but at the moment, "we're happy."

Mum wanted to take me to lunch and we ate well. Though during the whole time, I refused to let mum share her joy of watching her son's lecture. I can understand that I might be the only third year student to give a lecture to a first year medical cohort, but right then and still now, I just didn't care. On my way home, I called my General Practice supervisor and let him know that I wasn't coming in this afternoon because I would still be on campus for other work... I lied.

So I came home and did absolutely nothing for several hours, feeling the same. Not being able to shake this feeling of presence of absence.

I decided to go for a walk and once again, thought of so many things to write and have forgotten most. I did cry because I felt so helpless.

Today, I think I am back into a depressed state of mind. I cannot call it Depression because I don't think I meet the criteria for diagnosis. I am considering going back on the medications, but do not want to.

I want to call someone to talk about it, but it won't change anything. It won't change how I feel. In fact, I do not think I have the vocabulary to describe what it is I'm feeling, other than unwell.