Dr. D is a silver-haired gentleman who has a manner soft spoken and calm, even when he is tearing you apart. He is the one I was quizzed by in surgery. Dr C is a young doctor, handsome, quick to move and quick on his feet. He is the doctor who surprised me in the middle of one busy afternoon. We were about to go into a case, a rather intriguing affair that involved a young - my age - woman and an ovarian mass. She'd been seen in the ER and they'd failed to diagnose her torsion, so when she crawled into the OB's office two days later there was nothing to be done for the one ovary. Now the tumor that had caused the first ovary to twist was back- this time on her remaining one. It had been there at the first surgery, but small, easily removed. Now it was a monstrous thing, growing into the flesh. There was only the hope of some ovarian tissue remaining to save this woman from a lifetime of hormone therapy or a very early menopause.
"She's had twins already," he comments. ''A blessing, I suppose." The chance of her becoming pregnant on a fraction of an ovary is vanishingly small. In this case, he's called in a reproductive endocrinologist to help with the surgery and the hopes of keeping enough tissue. It is these two who surprise me. They are conversing, considerate enough to involve me, discussing the case to come. "This is our charity work," one of them comments. Dr. C. explains. It seems that the girl is a Medicaid patient. Dr. C is getting paid at the usual Medicaid rates - the other doctor not at all. The group I am working with is the only group in town who takes Medicaid, it seems. Dr C is dismissive. "Someone needs to, they can't get good high-risk care through the clinics," he explains, referring to the sliding-scale clinic the residents run. "And anyway. You can't run medicine just about money. It's about the patients. The patient care." It's a view I have missed hearing from doctors, who are a disillusioned lot. The endocrinologist chimes in his agreement, and the next five minutes are a mini-lecture on the need for a balance in one's professional life.
Then we get down to business, on the comfy coaches in the doctor's lounge of this non-profit monolith that calls itself a hospital. The endocrinologist asks what kind of doctor I want to be when I grow up. I tell him, with the mental and physical tightening I have come to use as my armor against all except family physicians. He nods slowly, and I brace for impact. "wow," he says to me, softly. "That's great. I can't imagine having to learn and remember all that stuff." In my mind, I hear you're too smart for family medicine; it takes a moment to process the complinont fully. By the time I have, Dr. C has joined in. "She wants to do it with OB, too." They give me an ear in to a discussion I rarely hear, all the fields that FP's must be expert in. There is real respect in their voices. These are doctors I don't have to excuse myself to, people who find my career choice to be a good one for a good student. ''All that stuff to remember."
The surgery itself is fascinating, as they peel a huge, cystic thing off of the remaining ovarian tissue. The trick, the hard part, is to keep from leaving any bad flesh behind while salvaging the good. And they are so very careful at their work, and at the end, they close up a snow-pea-pod of flesh with quick sutures. Is it enough? We'll know with time. How much is enough? When I ask the endocrinologist, he gives me a solemn look."I hate to answer a good question with a funny answer. But it's 'enough'. We don't know."
Dr . C is a kidder, a fun and enthusiastic doctor. Dr D frightens me with his cynicism. He is not so enthralled with my career choice - long hours, hard work, chronic disease, unhappy patients. He shakes his head. "This woman has been in the hospital two days. Her bill is better than six thousand already. And do you know who's paying it? We are. She has no insurance, no job, she'll never pay a cent." He has plans, they're building a surgery center, they'll only take insured patients there. No more billing the insured to eat the cost of caring for the uninsured. That's where he puts the cost of healthcare, on the patients who must be subsidized by others. "You'll do some gratis work," he tells me. "Everyone does. But the money has to come from somewhere." We're at the post-op dictation of an urgent exploratory laparoscopy, rule out ectopic pregnancy. Ruled out. This woman's pelvis is pristine.
No, I'm serious. This one's painful.
And Dr. B. Merry, never serious, who compliments me at every turn. He is my backup doctor, when the others are in clinic. I try to avoid clinic; I am avoiding being treated like a shadow. I would rather be in the OR where I am at least not facing a patient who knows I have nothing to contribute. We have a good time in the OR, we do. And he likes to have me at C- sections, tubals (he got out the video just for me; he normally works with a hand scope), and yesterdays procedure - a laser condyloma removal. That is, O Best Beloved, the process of burnins off genital warts. And she had a lot of them. In fact, every woman in the room was wincing in sympathy with this poor unconscious patient as he traced a line around labia, rectum, and surrounding, then filled in the space with smooth passes - like a coloring book came the comment, black humor. Almost as black as the way Dr. B looked up at us, laser in his hand. "What shall I write? Any messages?" We had none, not for this anonymous woman, a blue-draped mannequin. Just a vulva with sterile surroundings.
Nervous laughter. "We should film this, show it to middle schoolers," one of us - it might have been me - suggests. Someone else chimes in. "Call it 'See what happens?'" There is speculation about where one might acquire such a large collection of warts. All of it is to take our minds off the sure, steady hand that is now methodically erasing flesh behind a smoke screen of burns. Imagine a vagina, O Best Beloved, or borrow a loved one's for visual needs. Now go out a fair finger's width from each labium, around the rectum, over the clitoral hood. Now erase all that tissue with a laser searing over flesh. I saw this laser burn initials info a tongue blade as a warm-up test, uncomfortably reminded of summer camp and burning ants with a magnifying glass. How long to heal? Three to four weeks, he says. This isn't going to be comfortable.
Post-op meds: Darvocet, silvadine cream, and lidocaine gel.
Think on that, O Best Beloved.