Episode 17: You have a say

Dr.Sophia:
Hello everyone. Welcome to the Dr.Sophia Obgyn podcast. I'm an obgyn practicing for over 15 years in my native New York City, and I love to help women learn about their bodies, empower them, and embrace themselves. On this podcast, we talk openly and with heart about all things affecting women from pregnancy, menopause periods, sexual health, fertility, and so much more. Disclaimer, this is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician.

Hello everyone and welcome to the Dr.Sophia Podcast. Today we're gonna talk all about you and how you have a say so when you go see your doctor or your obgyn. I am joined with my good friend and co-host Touseef Mirza.

Touseef Mirza:
Hi everybody. So yes, today we wanted to talk about it, it's actually something that happened today when we were having a conversation together. And during the conversation, Dr.Sophia got a call.

Dr.Sophia:
Yes, I did.

Touseef Mirza:
From one of her patients. And from there we just started to realize that this is really something that would be good to share with all of you. So first, could you tell us a little bit about what your patient called you about?

Dr.Sophia:
So, one of my patients, I hadn't seen her for some time, and she called to actually ask me about a question for her sister and that her sister is having a gynecologic issue, and that the doctor said to her, well, she has a mass, and in order for them to determine what the mass is that they would have to do a hysterectomy.

Touseef Mirza:
So when we say a mass, we don't know if it's benign or malignant. So we need to make sure whether it's cancerous or not?

Dr.Sophia:
Yes. So the point is definitely trying to figure out whether or not this is what we call a benign condition, something that is not necessarily life-threatening versus a cancer situation. She said, Dr. Lubin, I don't know, it seems to me that a hysterectomy seems so extreme in order to try to figure out what this thing may be. And I said to her, I think it may be that it could be extreme. I can agree with you that maybe there's more that could be done in terms of trying to figure out what it is before we get to that point.

Touseef Mirza:
Of hysterectomy?

Dr.Sophia:
Of a hysterectomy. Right. And a hysterectomy, meaning that they take out your uterus. So she said to me, well, what do I do? What should she do? And I said, well, she should ask, she has a say so in what goes on in her care, and she should ask more questions as to why that is the only option. Why is that the only way in which they can try to look for other signs or symptoms or things that are happening that can help determine whether or not this is a benign condition versus a cancerous condition? And she says, well, I don't know. It feels like that's all, that's her only option.

Touseef Mirza:
To have his hysterectomy?

Dr.Sophia:
To have this hysterectomy.

Touseef Mirza:
So when Dr.Sophia was telling this to me, me being not in the medical field, I can completely understand her patient because if the tables were turned and I would be in that position, I don't know if I would like just come out and say, well, I don't know if I want to, is there another way that we can address this problem? Because I would just think that what the doctor is saying is basically that way or the highway almost. So when you reply back to your friend, well, she has a say. I was like, well, that's interesting because I think most of us don't realize that we actually have a say in these types of situations.

Dr.Sophia:
Well, it's even more so than just having a say. I think it's a matter of understanding the concept that you can ask questions, you can say, is a hysterectomy my only option? Can you explain to me the steps in which, how did we get here? How did we end up here in terms of, this is my only option. For a lot of women, first of all, when they hear the term hysterectomy, it can really bring them down a pretty significant emotional rollercoaster, especially if that's not what they were thinking as a treatment option or management or, you know, in this particular case, just to try to make a diagnosis. Now, granted, there are conditions where this is the only possible possibility, and in all fairness, I don't know what we were dealing with. But at the end of the day, she is still owed an explanation that she can understand. It's reasonable for her to ask the question if this is in fact her only option.

Touseef Mirza:
Because it's a big, it's a big procedure.

Dr.Sophia:
It's a major abdominal surgery. In some cases, there are minimally invasive ways in which to have a hysterectomy. But at the end of the day, when we're thinking about it in terms of, especially when we're thinking about it from trying to make diagnoses, oftentimes we're talking about a big surgery. So it's important for women to be able to say how they're feeling, how they feel about it, and have we exhausted all the other things? It's something we have as gynecologists deal with this all the time in terms of hysterectomy versus other procedures.

Oftentimes women have a very common condition, like fibroids for example. These are benign tumors of the uterus that can weak all kinds of havoc in the sense that they can cause women to have pelvic pain, what we call bulk symptoms, or just make them look like they have a pouch or just a mass that they can feel through their abdomen, give them urinary frequency, certainly bleeding issues with their periods or when they're not on their period even.

So oftentimes, even things that are benign can cause pretty serious symptoms. But for women in terms of dealing with those conditions, just saying, oh, you just need a hysterectomy. You just need to take it out. It's like, no, can we look at other options? Have we thought about the woman's goals and other things that she wants in terms of her future fertility? For example, does she want children? Has she had children? These are questions that a woman should be able to have answered when she goes to see her doctor in terms of having a major procedure. And certainly, it shouldn't be the first step, it should be the last step.

Touseef Mirza:
There's two levels, I think, in terms of what we're talking about here. The first level, which it should quote unquote be the responsibility of the doctor to actually present those options.

Dr.Sophia:
Yes. Because we don't know that you as a patient, like if I were a patient and I went to a doctor for, I don't know, let's say a cardiologist, I'm not a cardiologist, so I would need to know what my options are if I were having a heart condition.

Touseef Mirza:
Exactly. So that should be, in general, the first step would be-

Dr.Sophia:
Just the explanation, right? Actually doing that.

Touseef Mirza):
But not all doctors do that. So then the second level is if that doesn't happen, then the patient themselves need to take that on in terms of their own responsibility.

Dr.Sophia:
Again, it just goes back to asking questions. Being able to ask questions. And then also if you know what you want, walking into a conversation kind of armed with information in the sense that you say to yourself, okay, these are the things that are very important to me. I know that in the future I do wanna have children, or I know in the future I don't wanna have children, or I want to have what's called a definitive surgical intervention maybe, or management or treatment option. Meaning that I want to make sure that whatever needs to happen, is the last step. That's what I want. Or I want us to make it a stepwise thing in terms of I wanna stop whatever the issue is for now, and hopefully, I can make other lifestyle changes if that's an option or a possibility.

Maybe there are medical things that I could be doing, meaning medications or like I said, changes in my diet, exercise, et cetera, that could help me with whatever the condition is. But the bottom line is it should all be a part of the conversation and the best way that you can help yourself is knowing yourself. Knowing, having a real honest conversation with yourself so that way when you walk into a situation and your doctors are saying, well, you have to do X, Y, and Z. Well, you say, have you considered that these are my long-term goals?

Touseef Mirza:
So I think one of the things that can catch us off guard is we don't know what the doctor's gonna say. So when they say something that's coming out of the blue, and so we don't know how to react to it. So maybe a general way of replying to that situation is just to ask, okay, is that my only option? At least ask that regardless of whether you know exactly where you stand, at least have that, that you have a say in understanding what are my other options. I've been in a situation where I didn't know how to react, and then I asked, well, what are my options? I wasn't prepared to make a decision right then and there. Like, I have to absorb that information. I have to get in touch with my intuition. I have to recognize what I want out of this. I can't just be on the spot and decide what I want.

Dr.Sophia:
And I fully agree with you short of an emergency. I think that you as the patient, if you're given too much information all at once, you actually haven't had an opportunity to think about what's happening. It makes sense to say, thank you for giving me this information. Is it okay if we make a follow-up appointment in a few days in order to review the decision here? And that is very much reasonable. That is reasonable.

Touseef Mirza:
Do people do that a lot though, like in your practice? Do people have a tendency to just make the decision there or do they take the time to think about it and come back? How does that go?

Dr.Sophia:
I'll tell you about a patient situation that I had very recently. And, I guess in this particular situation, perhaps it happens a little bit more often than not, but I had a young woman, she recently delivered just a few months ago and then finds herself to be pregnant again. And at that moment when she realized that she was pregnant, I said to her, you need to think about this, how you'd like to move forward. And she was very much appreciative. She came back, actually, not once, but three times before she actually came up with the decision of whether or not she wanted to continue the pregnancy versus let's say, terminate the pregnancy. And I had to give her the space to do that. Right. I had to give her the space to be able to feel comfortable and confident in her decision and to accept that the decision was hers.

It's not my decision, it's not up to me. And to be able to offer her all of the possibilities, for example, in that case, that continuing with the pregnancy is an option. Terminating the pregnancy is an option. Continuing with the pregnancy and offering the baby up for adoption is an option. These are all things that definitely require some thought. It's one that most women don't take lightly anyway. But that's only one example. But let's just say I have a patient who has a bleeding problem because of some uterine pathology, something that's wrong with her uterus, whether it's fibroids or polyps or hormone issues. And we'll give the example, she's like, I don't know, 37. She's had two children. And the bleeding is so significant that it causes her to become anemic. Meaning her blood counts are very low.

Touseef Mirza:
Do you mean like during her period?

Dr.Sophia:
Like during her period, she bleeds so much that it causes her blood count to be low. And we finally get to the point of identifying what the problem is. She has fibroids. It can take one or two sessions for us to identify what is going to be the best course of action for her. And it takes that time because we need to understand what her future goals are. Yes, she may have two children, but does she want more? Yes, she's bleeding now, but can she take time off from her job in order to have major surgery? Yes, she’s bleeding, but is there a step in between that we can take before we get to a surgical intervention that will help minimize the symptoms that she's feeling? So there are so many little nuances in that sense. And if the only thing I say is, oh, well you're bleeding. It's too out of control. You have fibroids. You just need a hysterectomy. Not only have I taken away the trust that we have, but she's gonna walk away feeling like I'm a tyrant. I think I have a God complex that I'm just taking things into my own hands and that I know what's best for her. No, we have to work together. And it's important for patients to realize that they can work together with their physician.

Touseef Mirza:
So I think, I like the word that you use, which is nuance, because I think that's part of the issue when you have the patient-doctor relationship, is that maybe as a patient we feel it's too black and white, and that actually there's a lot of shades of gray. If the doctor says something, that that is the only-

Dr.Sophia:
That's the end. That's the end all be all.

Touseef Mirza:
Exactly. So we need to always have that. I think as patient, even like myself as I'm talking to you, it's almost like we need to sort of brainwash ourselves before we go in, to recognize that. And it's not to say that the doctor isn't qualified in terms of where they're coming at, but they're coming at it from, they might be coming at it from a different angle, but you in that relationship count as much because you are the receiver of the care. So you actually do have a say. And I think that the way that we're brought up in the healthcare culture is that we give so much power to the doctor to make those decisions for us, that I think we forget that we actually have that level of agency.

Dr.Sophia:
It's interesting because coming from this as a-from the perspective as a black woman, not just as a doctor or a black doctor, but really as a black woman, I walk into the situation and feel, or the scenarios and think about it for myself. Do people look at me and say, ah, she doesn't know what she's talking about or what she really needs, you know? As a patient, I would imagine that probably there's some angst about that intimidation, and for me, as a black woman, just the disparity, right? Like the implicit bias that can happen. And so if we are not aware of it, it's funny because I get to talk about it from both sides of the coin.


If we're not aware of it, then we're not gonna address it, and we're not gonna have on both sides compassionate care. So compassion for yourself in the sense that, hey, I have agency over myself. I can advocate for myself, I can be, and I can have a conversation about the care and what happens to me. And I can do that confidently because this is my body. And then from the physician standpoint, if I give care with explanation, it's not because a patient cannot understand and it certainly isn't because they're black or they're female or you know, that they somehow won't understand. No, that's not it. We simply have to break down the medicine. That's not, that's why we went to medical school. We are the ones with the knowledge. And when presented in a way that people can understand, they too can see the picture and, then, you know, paint the one that makes sense for them.

So I guess the point of this conversation is really addressing the concept of yes, the patient has a say, so it is a doctor-patient relationship. And within that relationship, there's a trust that needs to happen. There is a dialogue that needs to happen. And yes, you as the patient, you have a say, and I as the doctor, have an opportunity for education, for presenting you with information that you can understand so that we can come to a decision that is best for you.

Touseef Mirza:
So I think one of the things that comes through from our conversation is when we have the doctor-patient interaction, it's that it's not transactional. It's not, I give you this, you give me that, it's more of a conversation. So I think even from that perspective, to start changing how we view that relationship is a good step. The second thing I wanted to say is, let's say you do ask your doctor or your obgyn, I'm not sure that's how far I wanna go. That makes me feel uncomfortable, or I'm a little scared about it. What other options are there? And let's say the reply is, that's the only thing. What should I do? Do I say, okay, I guess that's what it is, and I just have to accept it? Or do I need to get a second opinion? What would you recommend in that situation?

Dr.Sophia:
I think whenever women are going through some major procedures or treatments, I think it's very fair to seek a second opinion, especially if you don't feel like you've been heard or you don't feel like your questions have been addressed, or you just need to have more confidence in your decision. And as a physician from my perspective, I never take it personally. When a patient says to me that they would like to get a second opinion, I actually encourage it because then I know that they are coming-if they come back to me, they're coming back armed with more information, and then now they're confident in their decision and their choice. And when you have a patient in front of you who completely trusts you because they're confident in their decision and their choice, it just makes it so much easier. So I never take it personally when someone says to me, I think I may have to get a second opinion on that.

Touseef Mirza:
You know, you mentioned a couple of times the word confidence, like to show up with confidence. I think that might be a little bit too grandiose of a word when you're showing up and talking about an area that you don't really know about. Confidence, I feel is a little bit, it's like big shoes to fill. I would say it's more from a perspective of entrusting. I did my research, or I talked about it, or I thought about it, but I'm not a doctor, so I can't be fully confident. So I'm entrusting the doctor to show me the way, but I'm entrusting them because you've taken into account all my fears, all my desires, all the different things that I had in terms of questions, and I'm in. So for me, it's less about confidence, it's more about trust.

Dr.Sophia:
I can totally understand what you're saying. And I definitely think that a part of our job is to address what are the fears. What are the myths? What are the things that make you feel hesitant? What does your intuition tell you? If we can address those things, then we can get to the point where you feel definitely more trusting of the care you're receiving, of the treatment options that you have and to move forward with whatever the treatment or management has to be. I know there are times when a patient will say, I've done my research.

Touseef Mirza:
They're coming fully loaded.

Dr.Sophia:
And that is a tricky situation. Because oftentimes the research that they've done is a quick Google search and I often have to say, okay, Dr. Google here may not have all the answers, so why don't we have a conversation about it instead? Or sometimes you have to, just as a physician, give your patients at least reputable sources for them to actually do that quote-unquote research in order for them to come back with the questions or their concerns. And then you can have a much more robust dialogue and then get to the end goal, which is that they come out of their situation healthier and feel like they've been treated with respect and that their concerns were addressed. But certainly in the age of the internet and all the things that are accessible, at the end of the day, though, it still doesn't take away or really have the same impact as experience as what your doctor has actually lived through and the different patient scenarios that they've seen.


Also if they've been taking care of you for some time, just their observation of you over time. But at the end of the day, it's still a dialogue. It's still like any other relationship. And it requires you talking, your doctor, talking and recognizing what you want to get out of it, and knowing that you both want the same thing. And yes, you may have differences of opinion, and yes, maybe that particular doctor is not the right one for you. Or maybe it's something that you're asking for that may be completely out of their scope of practice. Maybe that's why they're only offering you a specific thing. So this is also where the concept of the second opinion comes in because sometimes your doctor is only limited by what they're trained in.


It may come to the fact that someone else has to take care of you. It's not because that doctor is not thinking about you or cares about whatever could be the best options for you or the things that you verbalized, but you also want doctors who are taking care of you to work within their scope of practice or the thing that they feel the most comfortable and confident doing. So there are so many layers and factors to this, but ultimately I want patients to walk away feeling like they were seen, they were heard, and they have a say in what happens to them.

Touseef Mirza:
I would say also as we're talking about it when we say ‘we have a say’, I think especially as women, a lot of us culturally and in this society, we've been taught to be nice, not to be loud, to kind of go along with what's happening. And so I think it sort of plays out actually when you come in a situation where you don't know as much information and you mentioned it briefly, but society views doctors as gods. What they say has tremendous gravitas. And so it can feel very intimidating. I've been in that situation where I feel, I wanna say something, but I'm just like, who am I to say something in that situation? As I've gotten older, I am not as intimidated. I actually come more from a perspective of curiosity and I’m okay if I'm wrong. But that wasn't always the case. So I think that we have to as women being brought up in this type of society to recognize that if it's hard for you to do that, it's understandable because of the world that you-

Dr.Sophia:
That we live, yeah. That we're living in.

Touseef Mirza:
Give yourself a little bit of grace as you go through this because we're not saying, it's like you come in and you just do it and everything will be fine. It can feel difficult, it can feel intimidating. So you could start by taking some baby steps. Can you tell me more? Maybe you start to talk about that and would there be another option? And without saying that you want another option, because that might feel a little bit more direct, but just trying to see how you can start to open up that dialogue and conversation that we've been talking about. It doesn't have to go from zero to 100. You can start at least by doing baby steps.

Dr.Sophia:
I really like the fact that you mentioned that because you're right, I'm coming from a place where when I go see a doctor, I know at least some things. It's knowing that you can say things the way you put it. Can you tell me a little bit more about that? I'm not sure I understood. Or can you tell me a little bit more about what is available to me?

Touseef Mirza:
Or I'm feeling a little bit, I'm feeling-

Dr.Sophia:
Overwhelmed. I'm overwhelmed, I'm overwhelmed. Uneasy.

Touseef Mirza:
This sounds a little scary, is that how it is? But to try to say it in a way that you still don't feel like you're putting yourself on the spot, but you're having more of a conversation. And it might take a little bit of practice to do it, and that's okay. You're allowed to experiment as well. You're not supposed to get it right all the time. So this is what I mean by giving ourselves some grace, is that space. I guess the first thing is to become self-aware that, oh, this feels a little off, or I'm a little uncertain about this. There's an unease. So that's your first signal, right? And then after that to try to see, well, how do you feel comfortable to actually just start the engagement and just start there? If you can't get it all the way through, that's okay, but at least you're starting somewhere that's already big considering the type of world that we live in.

Dr.Sophia:
I'm in a hundred percent agreement with that. I think I, for one, appreciate when a patient asks questions. For me, it's also a space where I get a chance to kind of educate on something specific, whether it's body parts, topics, or medical conditions. And sometimes the patients just want to understand. They really just wanna understand and they need it explained to them in a way that is simple or is gonna come across so that it doesn't feel like it's over their heads. And I like being able to do that, to bring it down and I, excuse me, not bring it down because it's not like I'm trying to say that there's some upper level, lower level type thing, but rather-

Touseef Mirza:
To make it understandable.

Dr.Sophia:
Making it understandable. I personally feel like it's a part of our job, the education piece of it.

Touseef Mirza:
So it is up to us now as the patients to take this baton and I really hope that we gave all of you the space that you can start to explore in this area. And even if you need to take baby steps because you have a say.

Dr.Sophia:
You definitely have a say so in your care. Thank you for joining us on the Dr.Sophia podcast. Until next time. Bye. This is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician. Until next time, embrace your body. Embrace yourself.