Posts Tagged ‘healer’

New Pap Smear Guidelines & Why The Holistic Health of Women is in Jeopardy

Friday, November 20th, 2009

docpatientGood morning, Pinkies.  I just heard the news (calm down, Lissa. Breathe…) In the wake of the U.S. Preventative Services Task Force’s new guidelines for mammography screening, the American College of Obstetricians and Gynecologists just announced new recommendations that cut back on Pap smear screening. My blood is boiling, Pinkies. WHAT IS GOING ON? Why are we recommending cutting back on women’s health screening? Don’t get me started (yet). Let me fill you in on the news.

New Pap Smear Guidelines:

  1. Instead of recommending that Pap smear screening begin after you’re sexually active, new guidelines say that even a sexually active 13 year old should wait until 21 for her first Pap.
  2. After 21, Pap smears are recommended every 1-2 years until age 30.
  3. After 30, if you’ve had three consecutively normal Pap smears with no history of a seriously abnormal Pap, new guidelines say you only need to do Paps every three years.
  4. If you’ve total hysterectomy for benign reasons, new guidelines say you can skip Paps altogether.
  5. New guidelines recommend quitting Paps sometime between 65-70 if you’ve had three consecutively normal Paps with no abnormal Paps in the past 10 years.

Why the Change?

There is evidence to support the changes.  The truth is that you’re unlikely to go from having a normal Pap smear to having cervical cancer in 3 years, even if you contract HPV. Because cervical cancer grows slowly, it’s still likely to be precancerous by the time it gets picked up. And yearly screening does increase the number of procedures performed, and some of those procedures- such as cryotherapy and LEEP procedure can affect fertility and pregnancy in rare cases.  Plus, cutting back on Pap smears saves precious health care dollars. And if we’re not saving lots of lives and potentially causing harm by implementing procedures that may not be necessary, why do annual Pap smears?

So these guidelines aren’t positively ludicrous like the new mammogram guidelines that threaten to kill hundreds of thousands of women. I understand why they’re recommending pushing back the age of first Pap smear.  HPV, the virus that causes cervical cancer and abnormal Pap smears, is almost ubiquitous among teens. As such, doing Paps will lead to many abnormal results and require colposocopies, biopsies, and possibly treatment such as LEEP procedures, which can affect their pregnancies in the future, leading to scarred cervixes and preterm labor. And many of those abnormalities, if left untreated, would have resolved themselves without treatment.

I can also see why they’ve said that women who have had a hysterectomy can stop getting Paps. After all, they don’t have a cervix. And while there may be scant cervical cells left at the surgical scar inside the vagina, the risk of cervical cancer is exceedingly low.

BUT (and this is a gigantic BUT) there is a GINORMOUS problem here that carries far-reaching consequences for women’s health, and I can’t keep this quiet. Though women come to the gynecologist under the guise of their annual Pap smear, they actually come for WAY more than that.

Here are some examples of issues I handle under the guise of an annual Pap smear exam:

  • Sexual problems that threaten your relationship
  • Debilitating depression and anxiety
  • Chronic fatigue that prevents you from living vitally
  • Pelvic pain, often as the result of sexual abuse you have never confessed to anyone until I hold the sacred space for you and invite you to tell the truth
  • Urinary incontinence that causes so much shame and embarrassment that you might not leave the house, much less exercise or pursue your dreams
  • Menstrual disorders like hemorrhaging or menstrual cramps that cause you to miss work and other important life functions.
  • PMS/PMDD that may be hampering a happy life
  • Interstitial cystitis symptoms that make you feel like you constantly have a UTI
  • Menopausal symptoms that threaten a woman’s relationships, sleep, work, and life
  • Relationship counseling
  • Parenting advice
  • Losing your mojo

And that doesn’t even include the oh-so-necessary annual breast exam, internal pelvic exam to check for ovarian tumors and such, and the opportunity to make sure a woman is up to date on other cancer prevention procedures, such as colonoscopy in older women, or the HPV vaccine for teens.

Now, ACOG does say you should still talk to your doctor about getting an annual pelvic exam. (Thank you ACOG.)  But are insurance companies going to cover a routine pelvic exam in the absence of a Pap smear?  Are women going to go? So many women will hear these new guidelines and think, “Cool! I can skip the gyno for 3 years!”

By changing its guidelines, ACOG is going against the other main authorities on cervical cancer. The American Cancer Society and the U. S. Preventative Services Task Force both recommend that women get their first Pap test within three years of having sex, or at age 21- whichever comes first.

I respect evidence-based medicine and understand the rationale for these guidelines. I went to Duke and Northwestern and learned all the ivory tower beliefs about  practicing based on evidence, not anecdotal speculation or emotion-based care.  BUT….

What Do I Think?

Hmmm…I guess I think all the guidelines that have come out this week are missing something critically important in medicine.   As leaders in women’s health, what messages are we putting out there? Somewhere along the way, governing bodies in medicine have forgotten the most vital aspect of what we doctors do. When they are reviewing data to make these guidelines, they are focusing only on what “cures” someone. But they have forgotten that there is a difference between healing and curing.

Let’s take a huge leap and assume that cancer screening is completely worthless and doesn’t prevent cancer at all. Is there not some value to the other types of healing work we doctors provide under the pretext of the annual Pap smear? Women don’t make separate appointments to talk about their sex life or whether they’re living as vitally as they might.  They lump those things under the umbrella of a Pap smear.  Many women feel like they’ve been handed a “You’re worthless” card at birth.  I try to extract that card and replace it with a hot pink one that says, “You’re lovable, valuable, beautiful, and worthy.” This kind of work cannot be proven in a scientific study. But is taking away a woman’s excuse to visit her gynecologist taking away that hot pink card as well?

I’m not suggesting we do unnecessary testing or procedures just for the sake of getting a woman in the door. Ultimately, you have to be your own advocate for your health and wellness. But I worry about the far-reaching effects these kinds of guidelines will have for women who misunderstand and fail to hear the part about annual exams still being a critical part of women’s wellness.  What if they get lost in the system? Especially underprivileged women, who may not be educated enough to advocate for their own well-being.

My fear is that cutting back on cancer screening will not only increase a woman’s risk of cancer. It may also limit a woman’s access to the kind of healing good doctors can provide.  For most of my young patients, I am their primary care provider.  The Pap smear is what gets them in the door.  If you hear that you only need a Pap smear every three years, you may go three years without anyone talking to you about whether you’re living as healthfully and joyfully as you possibly can.

And you can be sure that insurance will cut back your coverage. If ACOG says you don’t need a Pap smear, your visit will likely only get covered if you have an ICD-9 code diagnosis like endometriosis or fibroids. And let me tell you- there’s no ICD-9 diagnosis for losing your mojo or cancer prevention.

You may think I’m biased. After all, I’m a gynecologist. It’s my business to have people come in for Pap smears, so of course, I would oppose these new guidelines. But the truth is that most gynecologists lose money by doing a Pap smear. The cost of the visit exceeds what insurance companies will reimburse most of the time. And since Medicare already doesn’t cover annual Paps, we usually eat the cost for older women who want to get Pap smears but don’t have coverage. So trust me, for most gynecologists, this is not about money.  One of my dear friends in San Francisco (a total Pink God) is closing his practice- declaring bankruptcy- because he simply can’t make ends meet with a busy insurance-based practice. It breaks my heart. He is one of those doctors who, like me, practices love, with medicine on the side.  Why does the system not embrace him? Why have we replaced doctors like him with technology, scientific data, and task forces? (*crying now*)

And why are they cutting back on only women’s health screening? Why not PSA testing for men? Not to be all conspiracy-theorist on you, but you can’t convince me that there aren’t some sexual politics caught up in all this. With all the advances we’ve made in women’s rights and women’s health over the years, why are we going backwards? Won’t somebody please stand up and shine the light on the Emperor’s new clothes?

I get that we need to cut back on health care costs. But come on, people. Must we do it at the expense of women? Can’t we focus our energy on tort reform or capping profits for insurance companies. Is this really the way?

For me, it’s all about advocating for holistic women’s health- the big kind, the kind that looks at a whole human being, not just a breast or a cervix. The only way we can help women holistically is to get them into our offices, provide a safe, sacred space for healing, and show up- fully present- to help them get in touch with what their body needs to be whole.

What Will I Do In My Practice?
I think you should be given a choice. The way I see it, it’s my job to present the data and help you understand the risks and benefits of cancer screening. If you want to get a yearly Pap smear and mammograms after 40- Fine. If you’d prefer to stretch out your screening or skip it altogether, no problem. It’s your body- your choice. I’m just here to help you understand your options and deal with whatever comes up.

The Bottom Line
Please, Pinkies, regardless of what you decide to do about your Pap smear or your mammogram, please don’t stop seeing a doctor every year.

Our Broken System

Thinking of how these new guidelines may limit your access to health care breaks my heart.

This system is so BROKEN. Hand me the suture and a needle driver. I want to stitch the fragmented, fractured, hemorrhaging heart of medicine back together again.sutured heart

Waiting, with hand outstretched- “Suture, please,”

Lissa

Owning Today: What Would You Do Differently If You Didn’t Have Long to Live?

Thursday, November 5th, 2009

lissaprayingI just found out that a doctor/healer I admire, Dr. Lee Lipsenthal, who coached me through a brief but difficult moment in my life, has metastatic cancer with a 10% chance of surviving. My heart broke when I heard this news. And yet- no surprise to me- Lee wrote about this experience on the Huffington Post in a characteristically uplifting fashion. He found himself, rather than depressed, free. With only a small chance to live, he no longer feels tied to obligations he didn’t really feel like doing in the first place. After a life of watching his weight, he can indulge in Ben & Jerry’s ice cream. And after raising his children to be people he deeply admires, he realizes that he must let them go, trusting that they will thrive, even if they have to do it without him.

Blessings, Prayers & Healing Juju to You, Lee

After I wiped away the tears, I thought about how we respond to bad news.  The characteristic Kubler-Ross stages, as Lee reminds us, are not linear, but chaotic and circular. We jump from denial to acceptance to anger to bargaining and back to denial again. Ultimately- hopefully- we accept what is and release the rest, but even then, the old stages may pop up from time to time.

Owning Goodness

In my personal life, there has been so much good news lately. My dreams of Owning Pink are becoming real. Two of my books will be published in 2010. My private practice is growing. My family is thriving.  My long-awaited art show is about to open in January. Life is good. It’s easy to fall into fear, wondering when the other shoe is going to drop.  But I don’t see a reason to go there. Yes, bad news will come.  But as Tama Kieves said in yesterday’s post, if goodness is a bubble about to burst, so is sadness. Why wait in dread for what might go wrong when life is peaceful, joyful, and full.

When bad news does strike, I can only hope I will face it with the inspiring courage of Dr. Lee Lipsenthal.  I hope I will revel in life’s joys and face the bad news with grace. I hope will be able to realize that the rough times are fertile periods of transformation, not only for me, but for those who face the rough times with me- my family, my friends, even you Pinkies. I know that, should I be diagnosed with cancer or lose a family member or go bankrupt, you will walk beside me, just as we all walk beside each other in our Pink Posse community when rough times hit any one of us.

dadlissasienasm

Hearing about Lee got me thinking about what hit me when I lost my beloved Dad almost four years ago.  If I knew I was probably going to die, what would I do differently in life? Four years ago, when I asked myself this question, I was shocked at my answer. If I knew I was going to die, would I be doing what I was doing then? The answer was a resounding HELL NO!  If I knew I had only one year to live, I would change almost everything about my life. But why must we wait for catastrophic news?  Why do we spend so much time and energy living lives that don’t suit us? Life is simply too short.

If I Knew I Was Dying, I Would Keep On Keeping On

Which is why I quit my job, moved, launched Owning Pink, and began this path of exploration that has led- four years later- to the life I am living now.  Now, I can honestly say that if I knew I was going to die in a year, I would do exactly what I’m doing now (only I might do it in Italy, just for the hell of it. But then again, on second thought- no. My tribe is here).

Did you see the movie Last Holiday? Queen Latifah is working a dead-end job and pining over a guy who doesn’t even know she’s in love with him, when she finds out she has a fatal disease. She decides to spend her life’s savings on a trip to the Czech Republic, where she stays in a suite, goes base jumping, and confesses her love to the guy who chases her halfway across the earth. In the process, she finds the joie de vivre she lost long ago. In the end, she discovers that her doctor made a mistake- that she was not going to die- and she had just spent her life’s savings. So did she do the right thing, or not?

Do You Consider Taking Risks Reckless?

You might argue that Queen Latifah was reckless. After all, what is she going to retire on, now that she blew it on a grand European adventure?  Of course, in the movie, it all ends happily, and you know she’s going to be okay. But in real life, we ask ourselves these questions. We fear. We limit. We shrink.  We skip the grand adventures in favor of safety. Then we wonder why we live lives of quiet desperation.

When I found out Dad was going to die, I decided to go for the adventure and take a Pleap (Pink leap of faith). I spent my life’s savings to buy my freedom, and I don’t regret a penny of what I no longer have in the bank. Instead, I have faith in the process. I have confidence that I will land butter-side-up. I believe that the Universe will meet my needs. And every day, I feel blessed to know that I would change nothing if I knew it would all end soon.

Wow. Things have changed. When I think back to four years ago, I have to smile. What a long, strange trip it’s been.

What about you Pinkies? If you knew you had a fatal diagnosis, what would you change about your life? It’s a very clarifying question.  Maybe some of you have been there before and survived.  Maybe you’ve lost something or someone dear to you and it had the same profound affect.  Must we wait for tragedy to strike? Can’t we start now?

Living like I might die tomorrow,

Lissa

LeeLipsenthal

Dr. Lee Lipsenthal

Live, Love, Heal

Sunday, November 9th, 2008

Who’d have thunk that I’d have to study more, after twelve years of medical education? Don’t get me wrong. I knew I’d have to put in my CME hours (continuing medical education). I’d like to say I read all of my journals, but truth be told, I only read some of them, cherry picked for the articles that tickle my fancy of the day. (We do get LOTS of journals). I know it’s important to stay abreast of medical research, so I study all the annual articles the American Board of Obstetrics and Gynecology sends me every year, not just the ones you have to read to keep up your board certification. This scheduled maintenance of professional development is key. After all, you don’t want us doctors to get all slack on you.

But I’ve discovered that this is not enough to keep me growing as a physician. Whether or not calcium supplementation helps to prevent severe preeclampsia (it appears not to) fails to delve deeper into my ultimate goal- becoming a better physician. I’m not just talking about improving my doctor book-learning. Well, I guess that’s not entirely true, since I’m reading a lot of books, but they’re not the kind of books you might imagine. The books I’m reading are gently and lovingly encouraging me to be a different kind of doctor, maybe even a healer.

I started by reading Anne Lamott, who I now affectionately term Annie, as if she’s my oldest friend from high school and we regularly have tea on Tuesdays. I wish. But Annie’s books allow you so deeply into her inner world that you feel like you know her. I hadn’t read any of Anne Lamott’s books until I was writing the last two chapters of I Don’t Do Men: Confessions of an OB/GYN. So when Barbara summed up my book as “Elizabeth Gilbert and Anne Lamott, but with lots of vaginas,” I couldn’t have been more delighted if someone had given me the Pulitzer Prize. It’s as if I had channeled Annie without ever knowing her work. I just read the first of her books in March, and since then, I’ve steadily plowed my way through most of them- Operating Instructions, Bird By Bird, Traveling Mercies, Plan B, and now, Grace (Eventually). It’s impossible to pick favorites- it would be like Sophie’s choice- but if a Nazi forced me to, I might have to choose Operating Instructions, if for no other reason than I am a new mother and an obstetrician, and the book is a memoir about her son’s first year. Touching, honest, revelatory, and funny as hell, Operating Instructions was the second book I read and the first of her books I started giving away regularly to women about to have a baby. It’s hard enough to be home with an infant, peering all to frequently inside your own spazzy brain, without feeling like you’re the only woman who ever wondered what possessed her to think becoming a mother was a good idea. Annie makes me feel less alone, in questioning faith, in hating the Mommy fanny pack that has taken up residence where my waist used to be, in seeking joy and beauty in strange and mysterious places. If I can learn some of this skill from her, the ability to make a complete stranger feel less alone, more inspired, imagine what I might be able to do with my patients!

And then there’s Elizabeth Gilbert’s Eat, Pray, Love. This book is such a runaway bestseller that to say I love this book makes me a cliché. But I’ll say it anyway. I love this book. Talk about making you not feel alone. I recommend this book to everyone who has ever been through a divorce, a career change, a life transition, a loss, or a time of painful self-reflection. Isn’t that all of us? I devoured the first half of this book in about 24 hours and then I took the rest of the month to finish it because I didn’t want it to end. I would glance at it on my nightstand, tempted to pick it up, to catch up with my old friend Liz, but I didn’t want to say goodbye to her, so as long as she lay on my nightstand, I felt a connection, as if someone else understood me. So there it is again, that beautiful sense of being gotten, that somebody sees your quirks and insecurities and not only understands but loves you all the more for what makes you uniquely human. If I can impart this to my patients, if I can make them feel just a wee bit the way Liz Gilbert makes me feel, won’t they be in a better place to heal, to be well?

You might be wondering why I’m reading Anne Lamott and Elizabeth Gilbert as part of my medical education, but you have to understand- they didn’t teach us any of this stuff in twelve years of book-learning. We learned organic chemistry and psychopharmacology and Mendelian genetics and journal club statistics, but nobody taught us how to help people from the inside out. I always assumed they would teach us the art of medicine when I went to medical school. How to intuit illness, how to touch someone’s spirit, how to heal. I never realized I had been trained to be merely a technician of the human body, like a good mechanic. Instead, I bought into the indoctrination, not questioning it, not demanding more. I graduated second in my class, won awards and membership in honor societies, and got accepted to a fabulous OB/GYN residency program at Northwestern University, where the black-and-white thinking prospered, while I stayed in my box.

Thoughts of enlightenment, spiritual awakening, and holistic healing never even occurred to me then. The closest I came was the yoga class I took at my gym. For the first ten minutes of the hour-long class, we breathed, big breath in through your head, big breath out from your heart. Breathe in, breathe out. I’m good at following instructions, so I breathed in and out, but after a few minutes, my brain started racing, yelling, screaming at me. “When are we gonna get some exercise! We only have one friggin’ hour this whole week to exercise, and you gonna sit here and breathe?” My flexible ballet dancer’s body caught on to the poses easily, but the breathing part? I sucked. After that one class, I swore off yoga and switched back to step aerobics.

When it comes to being a physician with an open mind towards holistic healing, I grew up with one giant strike against me- my Dad. A physician trained in the classic Western medicine style (which means lots of academics, very little intuition, and loads of scorn for anything you don’t understand), Dad made fun of any medical modality that didn’t fit neatly into his black leather medical bag. On the flip side, I had Aunt Trudy, the only hippie I knew before I moved back to California when I was thirty years old. Trudy wore muumuus, talked about “making space” for people, traveled to Santa Fe often, and believed there were crystals in our feet that needed to get broken up. Trained as a psychologist, Trudy practiced sand play therapy, with an office decked out with a sand box and lots of toys and figurines you could arrange in a particular order, which could help Trudy analyze your psyche. She cut out articles from magazines for me and bought me books about art and medicine when she found out I was passionate about painting. When her young son, my concert cellist cousin Corry, committed suicide, Trudy sought solace from a Christian psychic, who helped her communicate with her beloved son and helped her learn to stop blaming herself.

While Dad loved his brother’s funky, nutty wife, he harassed her constantly, for believing in “all that crap.” Trudy must have believed Dad needed healing most of all, since he returned from most visits to her house with various forms of holistic remedies. For months, the top of our refrigerator sported some stinky mushroom tea that Trudy swore would help Dad with his multiple sclerosis, and she tried really hard to let her work on the crystals in his feet. When Dad was diagnosed with a brain tumor, Aunt Trudy called me, conspiratorially, about launching a full-out intervention to get Dad on a macrobiotic diet, in addition to a host of other holistic health remedies that might help him. She knew it would be a tough sell, and it was. The minute I mentioned a macrobiotic diet, Dad ordered spicy chicken wings and an ice cream sundae.

When I was young, all the healing mumbo-jumbo struck me as a bit odd. I wasn’t sure about the stinky mushroom tea, and while I liked foot rubs, I wasn’t sure they could cure Dad’s neurological condition. But I adored my wacky aunt and her special yarn-braided art creations and her soul-driven musings and her exploring spirit. While the other members of the Rankin clan droned on about world politics or the best new SUV or what was happening in the Florida Conference (Trudy’s husband- my Uncle Larry- was a Methodist minister, of all things), Trudy would ask me about my feelings. After living in Costa Rica, where she and Larry were involved in missionary work, Trudy grew to love ethnic art and music, and when I became an artist, we had even more to talk about. The more I aged, the more curious I became about the things she believed- the mushroom tea and the psychic and the crystals. But my Dad never created an environment that left me feeling supported in my growing curiosity. I didn’t feel safe confessing my feelings to Dad, since he might have made fun of me the way he did when I tried to learn Spanish and he mocked my bad accent. Plus, I got wrapped up in my own self-centered life and never took the time to explore the inner-workings of Aunt Trudy.

Other than Aunt Trudy, no one ever exposed me to anything mystical, transformative, or healing outside the box of academic medicine. If it couldn’t be tested with a randomized, double-blind, placebo-controlled clinical trial, it didn’t exist, as far as I was concerned. The only exception was God, who I couldn’t prove but believed, nontheless. But even God was housed in a boxy church, with enrobed preachers and a dutiful congregation. My religious upbringing didn’t allow much room for a God who inhabits strange guises. While I knew there were psychics, who wrapped their heads in turbans and surrounded themselves with crystals, I didn’t know about medical intuitives or energy medicine or shamanic journeys. I had heard of acupuncture, envisioning it as some sort of Chinese torture device, but I had never heard of naturopathy or feng shui or reiki therapy.

But I think we missed something in our medical training by ignoring these modalities of healing. I only recently began thinking outside my doctor box, the one that told me that these things were, if not a bunch of bunk, not practitioners I wished to include in my treatment plans. Now, that has changed. I took a five-day writing workshop at Esalen Institute in Big Sur with a fabulous teacher, Nancy Aronie. I live near Esalen, and for years, I had been feeling its draw, but aside from touring the grounds and spending my wedding night in their hot springs at 1am, when the public is allowed to visit, I had never experienced Esalen I finally indulged the magnetic allure and took the writing workshop because, of all the fabulous workshops available, that one sounded the least scary. I wasn’t quite ready for Tantric Sexuality or Vision Seekers (although now, that sounds kind of fun!) When I arrived, a whole slew of wonderful, mysterious things happened (they’re described in I Don’t Do Men) that inspired me to veer off the traditional path and learn more about how to become a healer. If only I could combine what I learned from Anne Lamott and Elizabeth Gilbert and mix it in with what others have learned about healing outside of the box, maybe I could do something really beautiful with my life.

At Esalen, I met many holistic health providers. And not only were they happier than any of the doctors I know these days, it seems that maybe they are even healing people, more than we are. I’m not talking about curing your urinary tract infections. We doctors do just fine with that. But so many chronic conditions plague my patients- endometriosis, infertility, chronic pelvic pain, irritable bowel syndrome. And we have so little in our doctor box that can truly help these women. Yet, these holistic practitioners seem to have accepted something critical-the mind-body connection. Plus, they’re listening and touching and honoring people, in a way we doctors find it hard to do in 7 1/2 minutes of a busy managed care practice. I found myself wishing I had studied acupuncture. Don’t get me wrong- I’ve got a lot of good tricks in my doctor box. But I think that’s only a piece of the puzzle. It shouldn’t have to be either/or. Why can’t Western trained doctors work in concert with holistic healers, as partners, rather than as competitors. It’s thrilling, really. And what if I saw fewer patients, made less money, and spent more time listening, inspiring, and holding space for these women who come to me, wanting to be whole?

So now I’m reading everything I can find that’s written by an MD who has climbed out of the traditional doctor box and explored another path. Judith Orloff’s Intuitive Healing, Christiane Northrup’s Women’s Bodies, Women’s Wisdom, and Rachel Naomi Remen’s Kitchen Table Wisdom and My Grandfather’s Blessings are the first books I raced through. I’m also exploring How Doctor’s Think, by Jerome Groopman, and Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science and Better: A Surgeon’s Notes on Performance. And I just read Kris Carr’s fabulous Crazy Sexy Cancer Tips. But more on all of those later…

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