Monday, June 18, 2007
Fully clad in black, she walked the hall toward my office carrying a cane but not using it, accompanied by a daughter and grand-daughter, the latter to be her translator, the former her guide. Clouded over and looking like ivory, her eyes were blind; her face worn and wrinkled, weary and severe; yet her posture was erect and her dignity so profound that I felt as if I were in a regal presence. Her family treated her with deferential honor, and it was clear that I was expected to do so as well. It wasn't hard. If I didn't, it seemed, I might be struck by lightning.
This part of the Pacific Northwest is a melting pot. Forty-seven languages are spoken in our school district. Every day, give or take, a new ethnic deli or exotic restaurant opens; I salivate thinking about them. My patient population included many with whom communication was difficult, if fascinating. (My middling Russian, po moyemu nye plokho, comes in handy.) This lady, it was made apparent, was to be referred to as "Persian," not Iranian. And she absolutely would not allow me to see or touch her skin.
With clear-cut lab and sonogram and a classic history, that her gallstones were the problem was not in doubt. I didn't feel bad about doing a no-frills physical exam (like a surgeon!), through her clothing. Explaining the situation, describing the needed surgery and its aftermath were the most important issues of the encounter. It would be necessary, I said, stating the obvious, that when it came to surgery there'd be a need for exposure and more intimate touching. As long as it all happened after she was asleep, she was OK with it. Reluctantly.
She arrived in the pre-op area garbed as the day we met, and remained so while wheeled into the OR, and as she went off to sleep. No one in the crew had a problem with it. In exposing her for the operation, I raised her clothing to above her ribs, while keeping her lower body covered with a blanket. My patented mini-gallbladder operation went quick and slick; on her post-op visit to my office her gratitude and satisfaction were indicated by her grand-daughter. I took her word for it: the lady's demeanor never changed, not a crack.
Recently I had a conversation via email and comments with a reader about body-exposure during surgery. It's an interesting topic. I think it's true that there's more recognition of the issue recently than there has been in the past, but as with much about surgery, there are no straight lines from thought A to thought B. There's more dissonance now when I see a completely naked body on the OR table than I felt in training. There are times when the visage has caused a lump in my throat and moist eyes. Frailty, total vulnerability, responsibility, honor, beauty, are words that come to mind when I consider it. Callousness? Crassness? I don't think so. Sexuality? Does that fall into the category of beauty? Perhaps. But what, more than the sight of a human being having laid him- or herself before you, naked and paralyzed, bespeaks the responsibility and trust a surgeon is given?
Finally, it's just "let's put on the paint and get to work." Been there, seen that. I know it's a concern for many people. Whereas I can't say that modesty and dignity are maintained at all times in all operating rooms, exposures are pretty universally met either with decorum or boredom. As long as it happens after going to sleep, is it OK?
I think I've always empathized with my patients, whatever the situation. Dress -- or lack thereof -- was a thing of unspoken concern, and I don't recall it ever being mentioned in training. It was matter-of-fact, job at hand, not an issue. Even then, though, I never uncovered any more than absolutely necessary, even after the patient was asleep. And I was always very careful in my office: I've never had people fully undress, usually waiting till the last minute to expose anything. Hernia: lower the pants, not remove them. Rectal exam: slide 'em down, keep 'em on, lay on your side. Given the number of women I saw with breast problems, and the time constraints of keeping the office running, I did have them put on vests before I formally met them (when I brought them into the room myself, I'd introduce myself, confirm a bit about why they were there, hand them the vest, then exit for a few moments.) The vests -- unfashionable as they may have been -- did allow the preservation of modesty.
I once recommended a surgeon to my dad, who went to see him for a pretty routine, minimalist sort of operation. The surgeon's nurse instructed my dad to strip completely and lie down on the exam table to wait for "doctor." When they first met, dad was totally naked and supine. Angry more than embarrassed, he never forgave that surgeon. Nor did I.
When I was in the military a fellow doc said he had a sure-fire way of dealing with a self-important officer who'd come in and try to pull rank. "Remove all your clothes, Colonel," he'd say. "I'll be back in a minute." Guess it cuts both ways.