I’m filling in as a locum, at a local general practice, for two sessions a week. The usual fare is on offer: coughs and colds; arthritis; annual bloods; minor fractures; sprains; hypertension; sleep apnoea; diabetes.
Three-quarters through yesterday’s session, I see a 39-year old woman following up with pathology results and needing of some regular prescriptions. At the end of a rather short consult she says: “Do you do Pap smears?”
Continuing to look at my computer screen, I reply, “If people are happy [read comfortable] and don’t insist on a female doctor, I’m happy to …
“Because I booked for a Pap smear”, she interrupts.
I turn to face her. “For today?”, I ask.
“Yes”, she replies.
“Oh. Sure”, I say rather surprised. (The receptionist had not told me that the patient was having a Pap smear.) “I wasn’t aware that you were booked for a Pap”, I offer.
“Yep”, she nods.
She sounds matter-of-fact so I dispense with the airs and graces and ask her to get herself ready on the examination couch behind the curtain.
It is only my second session at these rooms and there is no drape at hand, at which point I say that I will just go into the next room to get one.
“Oh, it’s fine. We can do without it.”, she says. “You’ve seen it all before, haven’t you?”.
“I’ve been doing this for long enough”, I assure her.
Before I know it, she’s lying on the couch with the lower half of her body bare.
“Just give me a minute”, I say, “while I get prepared”. I turn to get the gloves and slides and speculum, spatula, and gel and begin to label the slides while glancing up at her file on my screen.
“Lesbian”, says the Warning Bar.
Ok, perhaps that explains her carefree attitude. I don’t give it another thought. Instead, all set, I move over to the examination couch.
She promptly shows me a 5 cm diameter patch of what looks like “ringworm” (tinea corporis) on her inner left thigh which she has been treating, to-date unsuccessfully, with topical Betadine. I suggest we try some Lamisil (terbinafine) cream instead.
I ask her to bend her knees and bring her ankles together while slowly letting the knees fall apart, and warn her that the gel (lubricant on the speculum) will be cold.
She relaxes nicely but I initially have difficulty bringing the speculum onto the cervix, the walls of her vagina collapsing. I note a typical but more copious than usual discharge, and tell her so.
I ask her if she is uncomfortable. She says that she isn’t.
Still having difficulty visualising the cervix, I ask her to make a fist with both hands and put each under her respective buttock. That manoeuvre tilts her pelvis nicely and helps bring the cervix, and os, into view. I take a high vaginal swab and perform the smear without too much trouble.
I hope that wasn’t too uncomfortable, I say to her as she’s dressing and I’m smearing the slides.
“Not at all”, she swiftly replies.
Quick to get up and dress, she comes over to the desk to sign the pathology form and the billing voucher.
“We’ll have results in a week”, I say.
Up and half-way out the door she looks back ingenuous but with a smile and says, “It was the best one ever.”
This story is not meant to be rude, crude or unseemly but rather to share the whimsy of everyday medical practice. It is a true story during my session yesterday (July 7, 2017) and shows how different people will appropriate different discourse, perhaps as part of a defense mechanism, during the doctor-patient relationship and for more intimate examinations. In other situations, a clinician may well be reluctant to perform the procedure without the presence of a chaperone. Every patient is different and comes to the consultation with different experiences and world view. The good clinician remains flexible but cautious.
Image: DES Daughter, Flickr