Shush! This is an Examining Room!

It can't be avoided. Once a year you make the trek to the gynecologist's office for the annual exam. For various reasons, the whole experience is extremely unpleasant for me, and yet I go, because I try to take care of my health. And hey, I have health insurance! And it pays for the annual exam. Lucky me, I don't even need a referral to see my gynecologist. Though I do get to pay the higher copay for "specialists". This is especially maddening as my primary care physician, a woman I respect and dearly love, could do the exam for me - and does, for many of her other patients - but my insurance will not let her.

Ah, but I'm getting sidetracked. Let me tell you what really hacked me off about this year's pilgrimage to Stirrup-Land. Something happened that I haven't experience since I was a child.

I was shushed.

Here's how it happened.

The first part of the exam is the breast exam. The woman who was doing my exam is the same physician's assistant who mangled the uterine biopsy that caused me such pain prior to the whole D&C episode I blogged last year. She's a cheerful, friendly sort, and I like her, or want to, but this is now two strikes against her.

She started in on the right breast. "Wow," I said, "that really hurts!" "Yes," she happily reassured me, "women's breasts get much more tender as they age and get old." Thank you. Then she moved on to the left breast.

Sweet mother of Christ! I swear to you that it hurt worse, way worse, than having it mashed between the plates for a mammogram. I yelped in pain and involuntarily exclaimed "oh my god that really hurts!"

At which point, she shushed me. "Be quiet! The patients in the other rooms will hear you and be upset! They'll think I'm really hurting you!" Oh, because, yeah, this isn't actually hurting me. How dare I misrepresent reality so.

Then she said something really extraordinary: "Hopefully the person in the next room is some woman who's had ten kids and doesn't care about anything."

Because if you've given birth, especially multiple times, you know (1) what real pain is and (2) you know not to make a big deal about it. 'Cause you're a good girl, a big girl, a nice girl, a polite girl who would never think of disturbing others. Kind of like the women in the following study (thanks to Alice at Sciencewomen, who was inspired to forward this to me upon hearing about my experience) from Gender & Society, Vol. 17, No. 1, 54-72 (2003) DOI: 10.1177/0891243202238978:

Giving Birth Like A Girl

Karin A. Martin,
University of Michigan

Relational, selfless, caring, polite, nice, and kind are not how we imagine a woman giving birth in U.S. culture. Rather, we picture her as screaming, yelling, self-centered, and demanding drugs or occasionally as numbed and passive from pain-killing medication. Using in-depth interviews with women about their labor and childbirth, the author presents data to suggest that white, middle-class, heterosexual women often worry about being nice, polite, kind, and selfless in their interactions during labor and childbirth. This finding is important not only because it contradicts the dominant cultural image of the birthing woman but because it reveals that an internalized sense of gender plays a role in disciplining women and their bodies during childbirth. The feminist sociological literatures on birth are concerned with how women and their bodies are controlled, yet they have overlooked this other dimension of control that is not institutional but is a product of how gender is internalized.

I say if it hurts, you should feel free to yelp. And no doctor or PA should be shushing you. I am ashamed to say that when my PA shushed me, I let her make me feel embarrassed, and I actually apologized to her. That is just messed up.

More like this

yikes! so true: "How dare I misrepresent reality so"... put your scales back on for your own good! nothin' happenin' over here, sing a happy tune, la la la, grope away like the tits are pieces of meat!

burns my shorts doubly: "some woman who's had ten kids and doesn't care about anything", yeah, because those slutty slut sluts who can't keep their legs closed don't give a rat's ass if a nuclear holocaust hit. She obviously can take lots of pronging with all those cherubs running loose as evidence of her domination. MAN UP!

I'll pass on the article momentarily. There's only so much puke I can generate daily. [last night's laugh fest drained half my body weight through my eyes and nose, I'm weak today]

Crap. That's just unprofessional, even before you get to all of the batshit nonsense. She wasn't shushing you for anyone's sake but her own, and dishonest about it to boot.

There are only two justifiable reasons to shush someone in pain:
1) To make it possible to communicate with the patient. It's really hard to do anything about an injury if you can't get anything other than screams.
2) To make it possible to care for someone else. This very rarely comes up, but I've been there (pt with minor injury making it impossible to care for someone with serious head trauma.)

Comfort of the caregiver doesn't even make it to the radar.

Oh -- and not being trained to do proper breast exams I could so readily be wrong but: in all other forms of manual examination that I have been trained to do, using so much force that you cause serious pain makes it impossible to discern abnormalities. Which means she was not only hurting you unnecessarily, but wasn't even getting a good "read." Epic fail.

By D. C. Sessions (not verified) on 21 May 2009 #permalink

worry about being nice, polite, kind, and selfless in their interactions during labor and childbirth

I apologized to my doctor for some of the things my body did while I was trying to push my kid out. (She laughed and said it happened all the time. Still... I thought they were kinda gross.)

If the examiner was causing you enough pain that you wanted to complain then she owes you an apology - which would have helped reword her 'age' comment into something more constructive. And if examining the other breast hurt [more than the one that she should have already apologized for causing you pain with the examination] you would be absolutely correct to yelp loud enough that other patients hear you and are alerted to the fact that another human being is being subjected to unnecessary pain. Every sentient being is entitled and justified to object to being in pain.

By Anonymous Pseudonym (not verified) on 21 May 2009 #permalink

I strongly suggest you make a formal complaint against this person. It won't cost her her job, unless she's piling up such complaints by the bucketload, but it might just get her a swift kick in the ass. If something doesn't change her attitude to her patients, she's going to really damage someone one day.

Don't be embarrassed about letting yourself be bowled over, either. A physician is in a position of authority, one to which we are trained from childhood to respond, and the fact that it's always a bit scary to be at the doctor's only reinforces that power. On top of that, as you mentioned, is all the extra "be a nice girl" training that women get. Your PA took advantage of that in a most unprofessional manner. It's a *pity* you didn't puke on her shoes right there and then, but it's not your *fault*. :-)

P.S. as I keep saying, "health insurance" is a misnomer. The multi-billion dollar industry that goes by that relatively and deliberately innocuous name in this country is in fact a protection racket.

WOW. I agree that a formal written complaint is needed, both to the person in charge of the gyn office and a copy to whatever state medical board licenses PAs.

I think D.C. is spot on about the reasons to shush a patient, particularly when you're asking "What hurts?" and all you get is "aarrruuugh! *&^%$, it hurts, it hurts!" Although, when I'm on the other side of the bed, I'm a grade A wuss - so I try to be as considerate about it as possible.

Obviously this PA needs a stern talking to - breast pain during a manual exam can an important clinical finding. It is usually nothing more than the patient has sensitive breasts, but it's still something to note so you can be less of a cause of discomfort to the patient in the future. (And warn them that, if they're of age, mammography may hurt, but is really important.)

Also, not only was the age comment exceptionally rude, but it's been my experience that as women age, we tend to have LESS pain with a manual exam. This is due to the fact that breast density decreases with age and therefore the examiner doesn't have to press as hard to discern any masses in the breast. With young women sometimes you really have to wail on the breast to determine anything at all, something that always makes me cringe and feel the urge to apologize profusely.

I'll echo bill in saying that this may be something you want to speak to the physician or office manager (or whomever is in charge) about.

By Dr.FabulousShoes (not verified) on 22 May 2009 #permalink

I have had numerous experiences with PAs, and now refuse to see them (already on the list are a few MDs and all DOs). I've had PAs tell me the most asinine things, such as misdiagnosing eczema as scabies, totally missing a subcutaneous infection (with classic symptoms).

All patients need to understand that they are not at the mercy of the medical "professionals" whom they consult. The medical people work for THEM, not the other way around. You are totally within the bounds of propriety to order the biopsy-botching PA out of the room, and insist on seeing someone else, preferrably someone who has a supervisory function over the PA.

You also have the option of leaving the practice completely in favor of another one, depending on the town you live in. In mine, there is only ONE OB-GYN practice left in the entire town of 135,000 people.

Wow. I agree, an official complaint should be filed to the board that oversees her. She's injured you to the point of severe pain twice due to incompetence or errors, and then she was extremely unprofessional about it. Even if she's nice, she really should not see patients unless these problems are addressed. (And if you go back to that office, I'd make it very clear you will not let her touch you and require a different assistant!)

I'm going to pitch in to the chorus saying, you need to write a formal letter of complaint. If she is mashing you that hard, and paying that little attention, then she is filing to do her job at the most basic level, and not only is she victimising patients (you included, but not alone, I bet), but she probably isn't getting nearly as much info as she ought to be from the exam and that endangers peoples lives.

A formal letter from a well-educated and well-written individual ought to prompt at least a bit more awareness, and hopefully more of a review of best practice and patient care. But it doesn't serve anyone to let her get away with this nonsense.

Which is not a criticism of your reaction on the spot, by the way -- I relate to that too much. I was trained for years into obedience and apology for inconveniencing anyone, and apology is almost a reflex action. It has taken some serious pissed-offness to train myself out of that to any large degree.

But letters...letters are good.

By Luna_the_cat (not verified) on 22 May 2009 #permalink

Ack, failing to do her job, not "filing".

By Luna_the_cat (not verified) on 22 May 2009 #permalink

Put me in the chorus. Not only write a letter, but make a phone call to the "customer relations" dept, tell your regular physician, and anyone you encounter who is scheduled to see this woman.

Put me in the chorus. Not only write a letter, but make a phone call to the "customer relations" dept, tell your regular physician, and anyone you encounter who is scheduled to see this woman.

'Nuther vote for a formal complaint. You're not the only one she's doing this to and it needs to stop.

Why a woman who has such contempt for other women wants to work in women's health is beyond me.

By stickypaws (not verified) on 22 May 2009 #permalink

Wow! What the hell! Yes, I would complain, too. Yeesh!

Absolutely you should complain. Causing pain is bad, and IGNORING it is worse. The pain could have been an indicator of something.

And honestly, if that woman hasn't had tons of ladies yelping in her rooms, she clearly hasn't been in practice very long.

Well, I hate to pull an AOL "me, too!", but I definitely think you should say something. Even if there is no immediate reaction, then it at least starts an audit trail, and maybe you would not be the first complaint!

As far as other folks "hearing you", one would think that all kinds of noises would happen in a doctor's office. If I heard a blood-curdling scream from the next exam room, my reaction (after I came back down onto the table :-) ) would be sympathy (as in, "that poor person must have a serious problem"), not "holy crap, the doctor's mauling that person." This PA's amazingly paranoid.

Addressing the childbirth article, when my wife had our second son (and she fits the demographic exactly), all kinds of bodily functions happened, which she was incredibly embarassed about, and she still gets upset about. I was right there, and I never felt it was "gross" or thought she should "control herself". If I were passing a bowling ball, you can bet all kinds of things would happen, and I wouldn't give a damn! But of course, that is the ugly privilege rearing its head...

Wow, what a response! You are all awesome. And you have convinced me that I need to make a formal complaint. If I get any response I will let you know here.

I think my comment got eated... here's trying again...

I would also lodge a complaint and/or change doctors. Seriously, insensitivity aside, since when do breast exams hurt worse than mammograms? (granted, I've never yet had a mammogram, so I can't say for sure, but it sounds like you've got a point of reference). And the insensitivity is epic.
Since it seems appropriate, I'll go ahead and point out my favorite part of Lessons for Girls: Trust your instincts
"By that, I mean judge people based on how they treat you, not based on hypothetical models of how people behave."
This was not a nice PA; though there's no reason to assume malice on her part, you need not think of her as "nice".

Although I will say, my mental image for "let's hope the woman next door has 10 kids and doesn't care" is a woman surrounded by urchins a la Monty Python Meaning of Life in the next room. And I suppose a bit more yelping wouldn't make much of a difference in that case ;)

The bit on "politeness during childbirth" is really interesting. The Carebear is reluctant to be there for delivery, I think due to an assumption that the dominant cultural image will be the scene. I was not foolish enough to promise to be nice, but that was more because I'm going into this with the attitude that I don't really Know how it'll be then because I don't Want to be nice. Hmmm. Must puzzle over that one a bit.

Wow, what a response! You are all awesome. And you have convinced me that I need to make a formal complaint.

Thank you, Zuska [1]. Health care quality is something that affects us all, pretty much out to the limits of connection. However indirectly, you're doing us all a favor.

Besides, you deserve good care.

[1] Speaking purely selfishly; I don't pretend to represent anyone but myself.

By D. C. Sessions (not verified) on 22 May 2009 #permalink

"You might frighten the other patients"? Come on! What is this, a pediatrician's office? That was, quite literally the last time I heard that comment. (My bother had to be physically restrained to get his shots, so my job was to tell all the other kids he was a sissy and it didn't hurt.) I have certainly shouted and cried at the gyn, and all they had was sympathy.

Your PA reminds me of a dental hygienist I had once; very friendly except for the stabbing.

By JustaTech (not verified) on 22 May 2009 #permalink

As an MD, I'm telling you that you HAVE to lodge a complaint. First, if a breast exam hurts that much then there is a problem with your breasts or you are being examined by a fuckwit. Given the comments to your complaints, I am going to assume that the latter is the case.

I have shushed patients, but I'm in pediatrics. Trying to calm a fussy baby is generally acceptable behavior. And some adolescents just need to be shushed on occasion.

My best GYN story involves my brother who is in that specialty. I was complaining about my first pap smear with the cervical brush which I found uncomfortable. He said that the brush didn't hurt. I asked him when he last had his cervix brushed, and he shushed about it immediately.

Complain, please. This practice has a loose cannon they need to know about.

The Carebear is reluctant to be there for delivery,

whaaat? you tell Cb from me that this is not to be missed. not. whether you are yelling and screaming or not. be there. period. done.

By DrugMonkey (not verified) on 22 May 2009 #permalink

I say if it hurts, you should feel free to yelp. And no doctor or PA should be shushing you. I am ashamed to say that when my PA shushed me, I let her make me feel embarrassed, and I actually apologized to her. That is just messed up.

You disappoint me Zuska. On the bloggesphere you have no problem barfing over someones shoes, usually when appropriate, including mine. Yet here it was entirely appropriate, yet you did not. Come on, you can do better.

You disappoint me Zuska. On the bloggesphere you have no problem barfing over someones shoes, usually when appropriate, including mine.

Easy, Danimal. I get the impression that there are subtleties to shoe-puking protocol that may interfere in this case. Best to defer to the expert -- Zuska.

By D. C. Sessions (not verified) on 22 May 2009 #permalink

You also have the option of leaving the practice completely in favor of another one, depending on the town you live in.

And, of course, on your insurance company, who has negotiated the best deal for themselves and may well not authorize payment if you go elsewhere.

Zuska, you should definitely pursue this with the MD and/or clinic manager, and then find another practitioner. Her behavior is completely unprofessional and dangerous, especially in light of the relatively vulnerable positions we all find ourselves in at the ob/gyn. Good luck with that.

That said, your (soon to be ex-) PA sounds very like the labor and delivery nurse who was present during the 3 hour pushing marathon immediately preceding the birth of my son. In the throes of my intensely painful contractions, I, too, was 'shushed', as she sternly explained to me that I was 'wasting energy' by screaming and that I should instead internalize it all and use it to power the pushing. Being in labor is kind of like having a 'get out of fake politeness free' card, though. I emerged from my laser-like focus on delivering what felt like a 30 pound medicine ball just long enough to waste a bit more energy, roaring "Get her the fuck out of here!" at my horrified husband.

He did.

By Jennifer B. Ph… (not verified) on 22 May 2009 #permalink

This is nonsense. I've had breast exams and mammograms, and there's no reason for the first one to give you anything but mild discomfort-yes, even "as we age." She doesn't know what she's doing, and shushed you to cover it up.

She's incompetent, and could do more damage than just what you know about. I'm glad you're complaining about her. At the very least, she needs more training.

As an MD, I'm telling you that you HAVE to lodge a complaint.

Z doesn't HAVE to do anything about this incident that she doesn't want to do. Fuck you and your "I'm an MD so I get to tell you from On High what you MUST do". Sincerely, fuck you very much.

That attitude is the source of malpractice, mistreatment and mangled boobs, and its unfortunate prevalence among clinicians is why I go through 'em like tissue paper until I find one with a bit of humanity left.

I mean, can you not hear yourself? Did it really not even OCCUR to you that yet another medic trying to push her around might not be high on Z's wishlist right now? (To be clear, this is not aimed at "protecting" Z -- you pissed me off on my own behalf. It just astounds me that you didn't so much as consider the possible impact of your remarks -- or if you did consider it, you didn't care.)

Others by now have voiced how unprofessional this medical assistant's handling of your pain was. If you wish to return to this gynecologist's office, I would recommend that you talk with the doctor about this and make it plain that this behavior is unacceptable. You may need to run, not walk, to a different GYN.

Your experience reminds me of my experience with the RN the last time I saw my former internist. The RN handles a lot the work, including transferring records to other medical offices. She too is friendly and well-meaning, but scatter-brained. Last year while I was undergoing tests for leukemia/lymphoma and thyroid cancer, on two occasions the RN failed to fax over necessary records before tests. On the second occasion I showed up for a thin-needle biopsy, only to find that sonogram images & report of my thyroid had not been sent over in advance, despite my calling the RN two times to remind her to do so.

The straw that broke the camel's back, about six months ago, was when I went in for my annual well woman exam. I should tell you that even though it is amply documented that I underwent premature menopause in my 30s due to immune problems, every time I would go in this RN would ask the date of my last period. When I reminded her that my last period was about 10 years ago, the RN said cheerfully, 'Oh, how lucky you were to get it over early!' Never mind that I had fertility problems and was never able to carry a child to term. I was very shocked at her insensitivity. I realize I should have said something. I had already been thinking of switching doctors, but at this point I knew that I would never go back to this doctor. Thinking about this now in view of your experience, I realize that I need to follow up on this and make my dissatisfaction known.

Grrrr. This kind of crap is one of the reasons I often find myself apologizing to patients on behalf of our profession overall. It's not all PAs, or all DOs, or all NPs, or all MDs - it's unfortunately many clinicians of all stripes.

I have little new to add; it's true, as many have said, that clinical breast exams shouldn't hurt, and that the woman was flat-out wrong when she said breasts become more tender with age (never mind the ageist/sexist idiocy in the rest of that comment). Bill is also correct that no one has the right to tell you what you *must* do. Formal complaints may (emphasis MAY) have an impact if the system in which she practices follows up on such. If you do decide to lodge a complaint, I'd suggest addressing to the office manager of the practice with cc's to the supervising physician and your insurance company.

And, Zuska, once again I apologize on behalf of my profession. First, do no harm. Some of my colleagues just don't get that.

I really appreciate the practical advice on how to lodge the complaint.

And, I'm glad to see comments on this thread are working again!

Re behavior in childbirth: my children were born at home, and I made whatever noise I felt like. My magnificent midwives were completely blase about the racket, of course, having heard it all before many times - although one of my neighbors asked my husband if I was all right, and then - bless her heart - sent over a fruit salad.

The only time a breast exam ever hurt me badly was when an RN carried it out and then told me I was too fat to have babies. Wrong on both counts, obviously. I switched providers right away.

Best of luck in sorting out your situation. You deserve better treatment. We all do.

the RN said cheerfully, 'Oh, how lucky you were to get it over early!'

Wow. Was this the RN's first week on the job??? Because that may be one of the most insensitive things I've ever heard. I swear, after the post and these comments I'm taking in a huge bouquet of flowers to my next annual visit. I got lucky enough when I moved to my current location to find a place where all of the staff have been incredible. As an indication of the view they take towards patients, when you go in to change, the little pile of folded paper gown has a Hershey's kiss on top with a little note that basically says they know these visits suck, so have some chocolate to try and make it a little more tolerable.

I hope that didn't sound like nyah, I have a good doctor. It just really surprised me that it's so bad other places. Interestingly, most of the staff I've interacted with have been NP/CNMs rather than OB/GYNs.

The (very young, certainly pre-gravid) trainee midwife, when I was in labour and not enjoying it, kept saying "you're not doing yourself any fabours." Bless.