Assume the Position: Memoirs of an Obstetrician Gynecologist Read online

  ASSUME THE POSITION:

  Memoirs of an Obstetrician Gynecologist

  Richard Houck MD

  Text copyright 2015 Richard M Houck

  All Rights Reserved

  Inquiries to [email protected]

  Dedication

  To my wife: she has willingly assumed the position of friend, lover, supporter, and life long partner. I would not be who I was, who I have become, and who I will be without her at my side.

  Cover Art, original watercolor, by Julie Houck

  Table of Contents

  Dedication

  Table of Contents

  Preface

  Chapter 1 Africa

  Chapter 2 Background and Education.

  Chapter 3 Labor and Delivery

  Chapter 4 Office Life

  Chapter 5 Night Life

  Chapter 6 Operating Room

  Chapter 7 Abortion

  Chapter 8 Business of Medicine

  Chapter 9 Malpractice Crisis

  Chapter 10 Family Life

  Chapter 11 Life after Private Practice

  About the Author

  Preface

  Most people would assume that sitting on the stool where I have sat for many years has given me a unique view of life. However, I would argue that it is walking in my once white wooden clogs that have taken me through thousands of childbirth experiences, countless patients who have been seen in some of their most vulnerable stages of life, a multitude of surgical procedures – that it has been these steps, one by one, that have afforded me the privilege of learning everything that I have had occasion to learn over the years about the human condition. They are indeed well worn clogs, stained with all kinds of humanity, that have carried me for years from one patient to the next, one human story after another, and have allowed me the opportunity to play a small but at times significant part in the life of many women. It is to all these women, many of whose stories are recounted herein through vignettes, that I am indebted for the trust that they have placed in me over the years.

  Chapter 1 Africa

  Recently retired after four years of college, eight years of medical training and twenty years of active clinical practice, and given the unsolicited challenge of ‘change your life or change your wife’ with no clear path ahead, the future was uncertain other than I chose to change my life and not my wife. The crush of paper work, malpractice worries, unruly partners, a wife unhappy with but protective of me, managed care everywhere, increasing government interference in the practice of medicine, 80 employees, a Women’s Health Research organization, and an acquired occupational sleep disorder, I decided to offer myself up for volunteer work in medicine and go back to my medical roots- just caring for women - no hassles and no remuneration. Medicine as it should be: “The sick, the injured and the insane”, as Benjamin Franklin stated it in 1751 when laying the cornerstone at the Nation’s first hospital, Pennsylvania Hospital, where I received my training. Some might have called me the insane in this scenario for leaving it all behind at the age of 50, but so be it. It was time for me to move on and seek other challenges.

  Telluride, Colorado, located in the beautiful San Juan mountain range in the Southwestern corner of Colorado, is the county seat of San Miguel County, the most rural and least densely populated corner of the State.

  We had recently moved here after retiring from actively stewarding several thousand newborns into the Phoenix, Arizona desert. There are no traffic lights in the County. The town is located at 8500 feet above sea level and entered through the Valley Floor, home to majestic elk herds, grazing deer, foraging coyotes scouring the mounds of prairie dogs peering out of their homes on some of the most valued land in the State, occasional bears, and all surrounded by 14er’s, as the 14000 foot peaks ringing the area are called.

  (The view from ‘See Forever’ ski run to the LaSalle Mountain range in Utah and over the Telluride Airport.)

  Located in a box canyon, there is only one way in to the mines at the base of the mountain, then turn around and back out the other way. The fall Aspen trees were spectacular in their color and vibrancy.

  Ski slopes such as the Plunge drop right into downtown Telluride. Sure, one can drive a jeep up and over a narrow boulder strewn mountain pass once navigated only by mules, to Ouray, a 15-mile drive that takes three hours and risks life and limb. One really needs considerable off road driving skill and nerves of steel to undertake this venture that I would undertake when in the right frame of mind. Every year there were deaths and near deaths on this wondrous jeep trail through colorful high alpine summer wildflower fields of pink Penstemons, mauve Columbines, variegated Indian Paint Brush, purple Lupines, and Blue bells. There were old abandoned gold, silver and tellurium mines high above tree line, accessible only by the hardiest of miners with their pick axes. The road was only passable for a few of the summer months due to heavy snow depths. Hardy souls used to live up there in what is a small ghost town now, called Tomboy, during the active mining days.

  So how did I find my way to Africa to care for women from here? There were no road signs anywhere. Every path I had taken to this point in my life, including the hiking trail up from downtown Telluride, past the cool refreshing mist of Bridal Veil falls, along one of the most difficult jeep trails in the country, Black Bear pass, then up the side of glorious Ajax mountain at the end of the Valley to stand on its 14000 foot peak and look down one mile onto the Valley floor that housed Telluride, was more or less well defined for me. I had made my choices deliberately and pursued them endlessly for three decades. After taking in the gorgeous scenery, the still of the green Valley far below, the coolness of what air there was at that altitude, and Ingraham falls plunging onto the carpeted Valley Floor, it was obvious to me that the path down then forward was a path not so clear. I was not sure where I was going, or what life had in store. I felt like my two miniature Schnauzers, Rosie and Lucy, who had accompanied us on this hike, darting right and left from the trail, exhausted and aimlessly pursuing the scent of Marmots yet never finding what they were looking for, outsmarted by the shrill warning sound of the sentry ‘whistle pig’, as they are called. The poor girls smiled at me with delight when they caught up with us and sought praise for their efforts.

  Everything I had accomplished at this point in life had been a goal for me that I pursued day in and day out. I was most fortunate that I had accomplished what I had in life. But things were about to change now. It was just that I didn’t know anymore what the future would bring. I was going to create a new life for myself, start over again, and see where it led me. There was a certain amount of fear and apprehension about this path into the unknown.

  Making the decision to volunteer medical services is one thing, something I had often considered but never had the time to explore and accomplish. But how was I to begin? The Internet is a wonderful tool for researching this kind of thing. Dozens of organizations are out there that are happy to have people like me volunteer. I researched them all and considered them all, including Doctors without Borders. Being in the crosshairs of someone’s rifle in a war zone didn’t particularly appeal to me. I reasoned that if I was shot I wouldn’t be much good to anyone. There are loads of faith-based organizations. As a Jew, one popped out at me from my computer screen called American Jewish World Service, AJWS. I called and began the application process. There was no discussion of where I would go nor was there any request on my part where to send me if accepted. I just put myself in their hands to see how it played out.

  Interestingly, during the process of application and credentialing there was n
o discussion whatsoever of Judaism. They never asked if I was Jewish, I never told them I was, and we never met in person. I told them I would give a month and would go wherever they sent me. Their philosophy was based on what is called in the ancient Hebrew language Tikkun Olam, “Repairing the World”. Give and receive; social welfare; people helping people. It was a simple philosophy that appealed to me. Their funds were from donations only. I liked what they were offering, which was a plane ticket, an introduction to a country, and an opportunity to do what I did best.

  They accepted me after rounds of phone interviews, credential verification, and applications. They told me they were sending me to The Gambia. “Where?” I was somewhat embarrassed to ask. I had some travel under my belt, but I had never heard of The Gambia. Located on the Western horn of Africa, wedged between and surrounded by Senegal, it is Africa’s smallest country with just over a million people. Wolof and Mandinka are the main languages, neither one of which was the least bit familiar to me. These were ‘clicking’ languages, a most unusual sound made by clicking the tongue against the palate while speaking. 95% of the people in the country are Muslim, the rest Christian. There were few white people, and certainly no Jews. There is one city, Banjul, the capital, and within the city one public hospital and one non-governmental organization, an NGO called BAFROW, the Barkus Foundation for Research on Women. AJWS gave strong financial support to BAFROW. Why? It was a good thing to do, that’s all. It was about economic empowerment of women. Judaism really had nothing to do with it other than Jews doing the right thing for other people, in this case Muslim people. So right before I said yes to going, I had to ask what the deal was with religion. They had never asked me, nor me them, what role religion was to play in this month-long adventure for me. Their response was: ‘”That is what we liked about you. It is up to you!” So I was hooked. I chose to have religion play no role in this venture and it didn’t, other than to reaffirm my commitment to my own religious beliefs.

  (The men and women of BAFROW, the Gambia, with me second row center.)

  I learned a lot about the Gambia before going. The Gambia River goes from the Atlantic Ocean and flows in both directions several hundred miles admixing salt and fresh water. It was the lifeblood of the country. The highest elevation point in this perfectly flat country is 300 feet above sea level. There are over 500 species of birds, the main draw for white tourists. Slave trade was huge in prior centuries. Peanut farming and rice were the main crops along with cashew trees. I had never seen a Cashew tree, but I sure did like cashews. At one time Portugal had colonized the country so there was some European influence in Banjul and some admixture of Portuguese and Gambian genes. There was a King. The average man had 4 wives, permitted in Islam, and many children. HIV and female genital mutilation were both rampant.

  The average annual family income was $300 per year, half of which was spent on rice for the family. So there was no hope of these people ever leaving the country, much less the continent. It was a relatively safe country. Safe, that is, if one weren’t concerned about Malaria which everyone who lived there had the misfortune of experiencing multiple times. Many died from it. I learned about Lariam, a medication that I chose to take so that I could avoid Malaria since it wasn’t possible to avoid the mosquitos. I was a magnet for them; they had a love affair with me.

  As a country the Gambia had perhaps the world’s worst statistics for both maternal obstetrical deaths and infant mortality and morbidity. There were no Board Certified American Obstetrician and Gynecologists in the country. Almost all the women had been subjected to female genital circumcision (mutilation) shortly after puberty when they were dragged into the bush and brutally mutilated by midwives with unsterile cut glass while held down by their mothers.

  The young girls would lie in the bush without any pain medication or antibiotics until scarring began. They were brought back to civilization as women. Why did this happen? Girls were there for the pleasure of their husbands and this guaranteed that for the men. Once married a young girl would be cared for the rest of her life, so there was no escaping this horrid and brutal practice. In my prior career I had never seen the results of a genital mutilation but I read about how to surgically repair the damage since I was reasonably certain it would be staring me in the face.

  There was 50 % unemployment. Most men in Banjul stood on the street corners. Most women went to work in the fields doing the hard, backbreaking work. So this was a far cry from what I was used to, that is for sure. Off I went with my huge box filled with donated materials, plastic speculums, boxes of lubrication, a microscope, and various medications I thought would be essential.

  I was met at the airport in Banjul by the lovely folks from BAFROW and was introduced to the nurse who would be with me in the clinics as my interpreter. I was immediately struck by a unique smell heretofore unfamiliar to me. When asked what it was I smelled, the response was ‘burning trash’. There was one clinic in the city of Banjul at the one public hospital in the country, and several in the bush run by BAFROW, all of which I would visit during the month. There was also an OB-GYN resident from Uganda working in the public hospital who would be attached to me by the hip.

  (My Resident Physician)

  He was indeed a young book smart guy. But he had no supervision and was running wild in the hospital doing the best he could to keep up with the workload. He was most eager to learn whatever he could from me during the month. And I was eager to impart as much knowledge as I could. This made us a great team.

  There was one TV station in the city which blinked on and off during the day because electricity would go out on average 20 times a day. Unbeknownst to me, word got out over the TV that an American gynecologist would be in the city. The city hospital also had a unique system whereby women who had come in previously with gynecologic problems were put on a call list when help was in the country. I had no idea how they ‘called’ these women because there were few working phones but there they were, awaiting my arrival.

  My first day at the public clinic was astounding.

  (Waiting in line in the hot morning sun.)

  When I arrived at 8 in the morning, amidst unbearable heat and humidity in July, there was a long line of women, over a hundred, hunkered down in the shade outside the hospital walls. I had no idea how long they had already been waiting. These were some of the blackest people I had ever seen. The women were most beautiful with high cheekbones, lovely white teeth, dressed in beautiful dresses made of multicolored fabrics and African patterned cloths with beautiful brightly colored headdresses. The women appeared to be wearing their Sunday finest, as we would say, that brought out the best colors and styles of all the beautiful birds in the Gambia.

  (One of many beautiful Gambian women.)

  When we set up ‘office’ at the hospital in a small room with an antechamber that could hold maybe 10 people, there was a mad rush to get into the antechamber and a fierce squabbling amongst the women who wanted to be the first to be seen. Our exam room had a desk, several chairs, and a gurney with one sheet on it. There were no extra sheets to be found anywhere.

  One per day would have to suffice. My specula and lubricant came in handy. I sat the resident behind the desk with me off to the side. The day began without end until well into the evening when all the women had been seen. The lines continued every day thereafter on days when surgery was not scheduled. 100 % of the women had been ‘circumcised’. So to begin with they were all surgical candidates, and if all I wanted to accomplish were to correct everyone’s anatomy and resultant problems there would not have been the time to do so. There were so many other surgical problems facing us that it was overwhelming, with not enough hours in the day or the month. I was distraught over how to choose who should have surgery and who not. So I made the resident make the choices. I was unwilling to decide who was more needy than the next. The only stipulation to him was that short of circumcision corrections, every case that he chose should be different from the rest. If I only h
ad a month I felt this was the best way for him to learn. When I left he would be alone again, so he might as well see as much as he could and we should have as much surgical variety as possible. He was particularly interested in laparoscopy, a procedure that he had never seen. Laparoscopy is a highly technical procedure requiring specialized instrumentation and skills, a fiber optic light source and cables, and a myriad of unique instrumentation that had to be in perfect working order. There was one unsterile laparoscope in the hospital covered with dried blood. It had not been used in years and was far from being in perfect working order. So we spent time getting the equipment cleaned, sterilized, and in working order while instructing him and the operating room nurses how to use it.

  The problems we saw on the first and every day thereafter ranged the gamut in gynecology. Infertility was huge and a major issue for the women because if they weren’t able to procreate they couldn’t eat. For many of these women who thought they were infertile, they weren’t infertile at all. They might have had 3 or 4 children but if the other wives had produced more, in their minds by comparison they were infertile. Scarring and painful difficult labor and deliveries were the result of poor or no maternity care and mutilating female circumcisions. There were massive vesicovaginal fistulas, a complication of bad obstetrics that produced a communicating hole between the bladder and vagina so that urine constantly leaked into the vagina. Many of these women were cast out of their homes to reside in the corner of the villages since the smell was overwhelming and their husbands wouldn’t come near them. Pelvic abscesses were rampant as was HIV. If a woman’s husband died, his brother would become husband to them. Thus everyone was more or less having sex with everyone else with all the problems that come along with that.