Friday, April 20, 2007
Some would say I was asking for trouble.
In my office practice, on any given day the plurality of patients were women with breast problems. Conservatively, fifteen hundred to two thousand a year. With a receptionist or two out front, in the work area it was only me and my medical assistant. She was a wonder of efficiency (me too!), but had lots to do: scheduling surgery and followup visits, talking to insurance companies, fielding calls from patients. Plus getting patients in and out of rooms. I helped: when necessary, cleaning rooms, bringing patients from the waiting room to the exam rooms, getting them settled and properly attired. There simply was no way Trish would have had time to chaperone while I did breast exams. So, with rare exceptions, I did it alone.
We used to have nice cloth garments: like a mini-poncho, they'd slip over a woman's head and were, I think, comfortable. When it became cheaper to use disposable items (yes, I contributed to trash, too. Were it up to me, I'd have kept the cotton. The clinic overlords demanded otherwise) we had to switch to scratchy paper vests. "Undress from the waist up and put this miserable thing on," I'd tell them, on my way out of the room. "So it opens in front, like a vest." About one out of six, I'd find on re-entry, had put it on backwards. Since the paper wasn't particularly pliable, it was hard to maneuver under them that way, so I'd ask patients to switch them around, while I discreetly turned away. Some didn't care if I turned away or not: "You're going to see it all anyway."
With the rest of their clothing on, and with the vests being large enough to provide good coverage, I think most women felt as if they were still dressed while we talked. They sat on the exam table; I sat in a chair, lower than their eyes. Maybe that helped to get things going in a non-threatening way. Sometimes there were vibes: the bra hadn't been removed; eye contact was lacking; various non-verbal clues. So I'd either ask if they'd like my assistant to be present during the exam, or just invite her in without asking. That happened less than once a month. Mostly, after talking, I'd do the exam. Life being as it is, it amazes me that I never got any complaints, any claims of indiscretion. Mind you, there was none. But there are crazies out there, and we were generally alone.
My standard breast exam was four ways. I'd examine initially while the woman lay down, first with her arms above her head, then by her side. And then I'd have her sit up, and I'd re-examine, again with arms up and then down. While sitting, it was bi-manual; that is, my left hand would elevate the breast, and the right would palpate, like a human mammogram. That maneuver struck me as both intimate and mechanical: intimate because it was unexpected, since most women hadn't been examined that way and may not have know what to make of it; mechanical because it was done in the most matter-of-fact way. It also often led to the most detailed findings.
After any office visit, I dictated the note immediately. For breast exams, I never failed to use the phrase, "She was examined erect and recumbent, arms up and arms down." Our stenographers were headed by a highly, uh, extroverted woman. On the occasions when I'd wander into the steno room -- usually to share a joke or two with the boss lady and catch up on office gossip -- she'd announce, "Ladies, Dr. Schwab is here." At which point they'd stand in unison, throw their arms into the air, whip them to their sides, then sit and do it again.