Neither scalpel nor laser can divide the psyche from the soma. As technical skills have improved and multiplied, robotic surgery has become commonplace, and comprehensive care of the gynecologic patient has declined.
However, a knowledgeable and compassionate PA (physician's assistant) can be invaluable to both the surgeon and the patient. Increased emphasis on scientific and procedural care usually means less time in the consultation room and more time in the examining or procedure rooms. This is unfortunate for all concerned, because it takes time to explore the concepts, fears, and psychological wellbeing of the individual patient both before and after surgery.
It takes time to scan the books and magazines women read, to search the same Internet sites, to listen to the voices of their advocates, and to evaluate, critique, and learn from their sources of information; but it is important
P.35 to make the effort. Otherwise, you run the risk of being out of touch, or worse still, appearing arrogant and
condescending. Women in general have a sixth sense about these attitudes, and women about to undergo surgery or those recovering from surgical trauma to their bodies are hypersensitive to all manner of psychological stimuli.
The medicolegal climate has also potentiated perioperative anxiety. When you inform your patient, as she prepares for surgery, that she can bleed to death, be subjected to blood transfusions, have an adverse reaction to anesthesia, or sustain bowel or urinary tract injuries, you augment her innate fear of surgery. Some patients experience strong pressure from extreme feminist groups to seek and maintain a controlling role in her life, over her destiny, and over the surgeon. Under these circumstances, it is more necessary than ever for the pelvic surgeon to take the time to explore the patient's psyche in
the preoperative and postoperative periods in order to avoid undesirable psychological sequelae. Having personable, competent health care workers in your office who assist in preparing your patient for surgery is also indispensable. Anatomical charts have become works of art, and they, as well as videos and other teaching aids, are useful in explaining the technical details; however, despite all the educational tools and staff assistance, the most important person remains you, the doctor. Unless you sit and answer questions on a one-to-one basis, you are neglecting your responsibility to her.
Much of the time, the questions will deal with information the patient has gleaned from literature, popular talk shows, and the Internet. Some of the opinions she reads or hears will frighten her or make her suspicious, and a few patients may initially come to your office thinking of you as a potential enemy. A staunch feminist may
express the belief that you are just another insistently prosurgical doctor out to highjack her womb and add it to your trophy collection.
Popular literature today often stresses sexism, ageism, and greed on the part of doctors. The Silent Passage and Our Bodies, Ourselves were among the first widely read books on which patients depended for their gynecologic information. In these, they read that “for well over a century in the United States, women's uteri and ovaries have been subject to routine medical abuse,” and “one should not be railroaded into hysterectomy nor onto hormones.” Hysterectomy is described as “devastating” surgery, and for some women, it certainly can be.
These books found a wide audience and led to the publication of other books, which took an even more radical approach, all in the name of protecting women from castrating medical experts who might use their position of authority to hurt, not help, them.
The Ultimate Rape: What Every Woman Should Know About Hysterectomies and Ovarian Removal was inspired after the author underwent a hysterectomy. She suffered extreme physical and emotional trauma following the surgery, but when she complained to her physicians, they advised her to go see a psychiatrist, because all her symptoms were in her head. The book's title is evidence of the rage she felt at their
pronouncement. Now her voice is joined by others who believe every woman has the right to be thoroughly informed about procedures and consequences before consenting to gynecologic modifications. And certainly, a woman should.
In No More Hysterectomies, touted as the first living textbook on the Web, the reader learns how the male-dominated medical profession and the insurance industry have sanctioned millions of unwarranted
hysterectomies. One testimonial to the ideas presented in the book describes the current medical environment as a “woman's hormonal holocaust.”
The enlightening news is that interest generated by these sources and their legions of followers has had a positive and direct effect on women's health research. Global studies are numerous and are concentrating on traditional as well as alternative methods of treatment for menopause, hysterectomy, hormone replacement
therapy (HRT), cancer, endometriosis, fibroids, and dementia. For the first time in the history of medical science, research is being conducted on a large scale to determine how women of various ethnicities and cultures and with differences in their physiology react to menopause, gynecologic surgery, hormone therapy, and sexual function. The ENDOW Study has found ethnic/racial differences in women's perceptions of hysterectomy and their decision making regarding elective surgery. Negative connotations were found to be more prevalent among African-American women, thus indicating a need for added support and preoperative information. Future
generations of women will reap the benefits from this research, but the overwhelming aura that prevails in today's gynecologic patient is one of confusion.
After reading just a sampling of the lay literature, some women feel that surgical removal of their female organs and commencement of hormonal therapy constitutes an unnatural, chemotherapy-like assault on their physical bodies. It is the task of the physician to admit into evidence the medical facts necessary to correct any gross misconceptions that could affect patient care. Sometimes, it may seem as if the patient, armed with advice about natural remedies for her severe pelvic pain, heavy bleeding, or hot flashes, wants to drag you with her back into the Dark Ages. Be patient and also prepared, if necessary, to explain the medically sound benefits of life lived outside the cave.
Be compassionate. No matter how routine the job becomes, compassion is a vital requisite to becoming an exceptional communicator and healer. Empathy often follows experience, and those times when you are able to make a noticeably positive difference in your patient's life are inspirational. To try the one new thing that might help many patients in the future, it is necessary to earn the trust of a single patient in the present.
The days are gone when a doctor was considered omnipotent, when he—and rarely, she—received a hock of ham for the birth of a child or had to tell a woman that she would have to live with the eventual hump on her back because it was a natural process of aging. Patients know about osteoporosis and heart disease and about reproductive technology and brain neurotransmitters. The media have turned every living room into a medical school. Some patients present videos and clippings detailing current research and experimental treatments relative to their specific diagnoses. They know a little, and they want to know more. Many patients want to participate in their health care and absolutely should be encouraged to do so. Unlike the doctors of old, who, for the most part, had to contend with an uneducated populace, the modern physician must form a partnership with the modern patient. Mutual responsibility, respect, and trust eventually strengthen this bond.
The cornerstone of the initial work is truth. Use good judgment about when to tell all the facts, particularly those that point to a devastating diagnosis, but never lie. In 1961, 90% of physicians surveyed in a single, large urban hospital stated that they withheld the diagnosis of cancer from their patients. Today, the position has been totally reversed, with 97% reporting that they reveal the true diagnosis of cancer.
Doctors, however, are not the only members of the team with ethical obligations. Patients also have the responsibility to tell the physician the truth relative to their symptoms, medications, allergies, and past medical histories and to relate any significant traumas or family history that could affect their current situations.
Question your patient specifically about stressful life events. Did she respond to these in a positive or negative way? Of all inquiries, this is the most important indicator of how the patient will respond to any current stress.
Once the physician knows the answer, psychological preparation for diagnosis or surgery can begin in earnest.
Researchers in the United Kingdom have compiled data from multiple trial studies confirming that psychological preparation for surgery is effective. The general hypothesis was that communication and counseling are
important determinants of numerous factors, including the following:
Accuracy of the diagnosis
Effectiveness of disease management
P.36 Disease or problem prevention
Patient satisfaction
Adherence to treatment Psychological well-being
Patient understanding of procedures
Professional satisfaction and levels of stress
Information about each of these parameters was compiled, and considerable evidence existed to support all the hypotheses. In review, Davis and Johnston reported that psychological preparation is effective in reducing negative effect, pain, medication, and length of hospital stay and in improving behavioral recovery and physiologic functioning.