"This."

Makes me that much stronger

Makes me work a little bit harder

It makes me that much wiser

So thanks for making me a fighter

Made me learn a little bit faster

Made my skin a little bit thicker

Makes me that much smarter

So thanks for making me a fighter

~ Christina Aguilera's "Fighter"

___________________________________

I'd always thought of myself as a pretty open-minded individual. You know -- the kind of person who accepts people for who they are without some deep-seated disapproval. And no--not just for pretend--but like someone who really, truly is that way. I hold so many conversations with myself that even when some kind of mean-girl thought pops up, my inner good-girl is there to smack her right back into submission.

Sounds good right?

A little too good, I know. But despite that, I let myself believe that this is who I am. . . . this doctor without a judging bone in my body. What I now have come to realize is that I'm really just an imperfect human being who wants to be this way. That physician who walks into the room of a six hundred pound patient and genuinely feels not a wave of uneasiness but instead neutrality and the exact same feelings I'd have if that patient was one hundred and sixty pounds.

Yeah.

I met a woman who turned a mirror on me one day and showed me that even those who profess themselves to be "the open-minded types" are not always that way. At least their actions aren't congruent with that. And what should be the actions of that type of person anyway? In my opinion, it means being so empathic that no matter who the person is you advocate for them, fight for them, champion their cause and go to the mattresses on their behalf. At least as a doctor, you should.

So me? I thought I did that. I really did. And no, I'm not the self-deprecating type at all and I will even say that I am quite proud of how I treat most people in most situations. But this moment was one of the most eye-opening experiences I've had with self reflection and self examination. And yet another powerful reminder that I am a work in progress.

***

Grady Hospital, Fall 2004

I was in a good mood that morning when I walked into the Medical Clinic. Back then, in addition to sessions where we supervised the resident physicians, some of the sessions were just for direct care of walk-in patients. While my preference is usually to work directly with learners, I always welcomed these detours on my schedule. These were times with brand new patients with often unpredictable and challenging concerns of an urgent nature. I was glad that this was where I'd be for the morning.

After cracking a few jokes with the nursing staff, I plopped my bag down into the physicians' room and prepared to get started. This was before our electronic medical record so there wasn't really a one-glance way to know exactly how the flow would be. That meant one thing and one thing only--getting straight down to business right away.

At this point I'd been at Grady for three good years and pretty much had the routine down. I was working two rooms and rocking and rolling along without a hitch. Somewhere toward the end of my session, I got ahead of the nursing staff. Instead of waiting for them to place my next patient into a room, I grabbed the chart and leaned my back against the swinging door to the waiting room. Next I called out exactly what was written on the identifying stamp.

"Ava Moreira! Miss. . . . terrrr. . . uhhhh. . . Ava Moreira!"  I glanced down at the sticker with the name printed across it. I recognized that it wasn't of English origin, but that wasn't what threw me. It was the patient that stood up the moment said those first two syllables: A-VA. See, this chart indicated that this patient was male--and that was not consistent with that first name or who responded to my call.

The person walking toward me looked like some kind of supermodel or movie star. Not in that red carpet kind of way but more like those ridiculously gorgeous candid photographs you see in People Magazine of Halle Berry pushing her daughter on a swing. The minute she headed toward me, I dropped my head to double check the identifying information:

MOREIRA, AVA 31YO  M

I tried to look natural as I took a closer look. There wasn't a trace of facial hair, I saw no Adam's apple, and her gravity-defying breasts were a perfect and rather envy-inducing C cup. Her glossy brown hair was like the lady on the Pantene commercial; it took every ounce of restraint to not reach right out and run my fingers through it.  Before I knew it, she was standing right in front of me.

"Are you. . .uhhh. . . Ava Moreira?"

"Yes, I am Ms. Moreira," she answered. Her voice was husky. It could certainly be the voice of a genotypic female for sure, but coupled with that big 'M' stamped on the chart, I sensed it wasn't. I tried not to study her mannerisms but couldn't help it. Perhaps it was all in my own head, but suddenly her movements seemed almost hyper-feminine and overly delicate. The way she tossed her hair over her shoulders and secured her pocketbook on her shoulder. It all seemed so deliberate--maybe too deliberate even.

Maybe.

Or maybe not. Most women don't get picked apart for how natural they are at slipping their hair behind an ear or checking their makeup in a compact. So now that I think of it, that wasn't and isn't a fair way to figure out whether or not someone was assigned a female gender from birth.

And see, I said at the beginning that I am a work in progress so I am including the unflattering parts, too.

Speaking of which-- I'll even admit the first thing that came into my head--Austin Powers' faux British accent saying:

"That's a man, baby."

Even then, I knew that wasn't nice. So I scolded myself quickly.

Tsk, tsk, tsk.

I shook that mean-girl off and assumed my good-girl, open-minded stance. You know. That one that's hypersensitive to the fact that it must be mortifying for Ms. Ava Moreira to deal with such scrutiny about how she carries a purse or crosses her legs. And the one that bends over backwards to do and say things that let Ms. Ava know that I am 100% down with seeing who she is on the inside and treating her accordingly.

"Pleased to meet you, Ms. Moreira. Is. . . . this what you prefer for me to call you?"

Uggh.

I kicked myself right after that because I knew that I was already trying too hard. That isn't usually a question I'd hit someone with right out of the gate--and by "out of the gate" I mean walking from the waiting area. It wasn't natural.

"Ava is fine."

The voice was sultry and lower in its octaves but not dramatically so. It was mostly in that Demi Moore kind of way. Nothing about it made me take notice or give her a hairy eyeball. And coupled with her narrow waistline and surprisingly fine features her convincing femininity suggested good genes more than a good plastic surgeon.

"Okay, then, Ms. Ava. You can follow me." I stepped into the room and held the door open. She sauntered after me and sat in the chair beside the desk. Ava was clearly alright with herself. In fact, she was more alright with herself than most people I know. It was impressive.

"Ms. Ava, what brings you here to see us today?"

She blinked her eyes nonchalantly and then began. "I recently relocated here from the east coast and unfortunately don't have insurance coverage anymore. I need to get a regular doctor so that I can get regular check ups and to be able to get medication refills."

That was easy enough. Establish care. Get refills. I looked at the triage sheet and noticed her perfect blood pressure reading. Her weight was also not an issue nor did it seem like there was any other underlying medical condition that I could readily make out. I felt a sinking in the pit of my stomach as I asked my next question.

"Umm. . .okay. . .were there any problems you wanted to discuss?"

There. That was safe and neutral. And somewhat openminded-ish.

"Problems? Uhhh nooo. . . .no problems that I can really think of," she replied while resting her hands in a stack on top of her purse. With a relaxed smile, she went on. "Mostly I just don't want to go without my medications so I want to get me a primary doctor to avoid that, you know? But problems? No, I wouldn't say I have any problems." She shrugged and returned to that easy expression.

Piece of cake, right?

Wrong. I knew the minute that I met her that "medications" meant feminizing hormones. I knew I wasn't comfortable with prescribing them so this wasn't going to be a piece of cake at all. I swallowed hard and got the confirmation. "What medications are you needing refilled?"

That's when she took the bottles out of her purse and showed me. High dose estrogens and anti-androgens. Three or four bottles of different hormones with no more than two tablets left in each container.

"Here is my former doctor's card from Massachusetts. He should be able to make sense of my whole process for you."  She slid a card toward me and as she did, I noticed her perfect manicure with French tips. Ms. Ava didn't flinch nor did she seem like any of this was a big deal at all. And perhaps, if I was as openminded as I professed to be, it wouldn't have been such a big to do for me either.

"Did your doctor make a specific recommendation for you to see . . . .a certain person? I mean. . .did he . . like give you a name?"

I ripple of irritation went across her precision-arched brow. "A name? I'm uninsured. He knew that so suggested I come to Grady Hospital."

Duh.

So I sat there looking pretty dumb, I'm sure, but trying hard to be cool. I wanted to be that easygoing person who normalized any and everything and who would treat this just like hypertension. So I coached myself to relax. I adopted her easy smile and leaned onto an elbow. "Okay, then. Let's look at your meds, shall we?"

Whew.  I figured that would bide me some time while I figured out what to say or do next.

I stared at the bottles and wrote them on the chart carefully. I nodded my head and periodically looked up at Ms. Ava to make sure she knew that I was just fine with all of this. Next I performed the world's most awkward physical examination. Not because of how SHE was behaving, but because of how I was acting. Jumpy. Unnatural. Scared I'd say or do or reveal the wrong thing.

Finally, I asked her to give me a moment while I checked on a few things. As soon as I got on the other side of the door, I melted with relief.

"What's up?" One of my colleagues was walking by and noticed the odd look on my face. I explained the situation and his response was similar to my initial thoughts. "Yikes."

"I don't know what to tell her. I'm not even sure who to refer her to see."

"Yeah, dude. That kind of sucks. But you have to consider the risks of clots and all that, too. I think I'd be a little nervous to write somebody all those hormones, you know?"

So that ended that conversation and something about hearing this from a trusted and responsible colleague gave me the courage to go and tell Ava that this was over my head.

"Ms. Ava? I was just speaking with a colleague about your medication refills and we both agreed that the medications that you were taking are best managed by a specialist."

"Of course," she said confidently. "My physician several years back was an endocrinologist. I figured might want to refer me. But the last person I had was just a general guy, so I guess it differs from place to place. I'd be fine either way."

"Uhhh. . . but the problem is that off hand I can't exactly think of a specific person to refer you to. Like. . .I know there are people in the city who do this. . .but umm. . . .off the top of my head, I can't think of somebody here, you know?"

"Do those 'people in the city who do this' see patients without insurance? Because I don't have coverage, Dr. Manning. That's the issue." I could tell that I was beginning to frustrate her. She had that look of someone being discriminated against and I immediately felt ashamed.

"Honestly? I'm not really sure."

"Okaaaaaay. . . .then can you find out?" Her voice was laced with a sarcasm that let me know this was going downhill fast. "And either way, you will be able to at least give me a month of refill prescriptions, right?"

"Uuuhhhh. . . . I'm concerned about these doses, you know? Hormones can lead to blood clots and can even make the chances higher of you getting certain cancers. I'm not fully comfortable writing for these medications."

There. I said it. No.

Ms. Ava looked down and smiled. Not a happy smile but the kind that goes with a phrase like "Et tu, Brute?" Then she shook her head and abruptly reached for her medications from the counter. She shoveled them back into her purse and gave it an exaggerated zip for emphasis. Ms. Ava looked back up into my face and threw the ball not only into my court but into my face. I didn't know what to do.

"I'm sorry." 

My voice was tiny and I felt like a milquetoast personified. I should have kept quiet but something about the empty silence made me feel that anemic apology was necessary. The disingenuousness of it made the situation worse.

"Sorry?" she scoffed, "What are you sorry about, doctor? Please, tell me." The sardonic grin was killing me and her Portuguese accent seemed to highlight everything I was doing wrong. No question--Ms. Ava was tough and smart and she was fed up. I was getting exactly what I deserved.

"I'm sorry that. . .  I. . . can't be more helpful."

"You mean sorry you won't be more helpful. It's pretty disappointing actually."

Disappointing. Ouch.

"It's just that this isn't my expertise, Ms. Ava. It's not." I pushed myself to make eye contact with her so that she would believe me. "I try not to move too far out of what is in my jurisdiction to treat, you know? I just don't know enough about this and don't really think it's appropriate for me to write prescriptions when I have so many questions."

She nodded and kept searing me with green eyes. I squirmed under her gaze and felt my chutzpah pooling at my feet with every second ticking on the clock.

"Dr. Manning? What do you do when you aren't comfortable with any other problem? Tell me--what do you do when new medicines hit the market or guidelines change? Do you just announce to people that you 'aren't comfortable' and 'you don't know?' Do you? Or do you go and find out? I guess it has to be a problem you think is worth treating and even acknowledging."

"That's not fair, Ms. Ava. I read a lot about many things. It's just that this isn't that simple."

"'This?' 'This?' You can't even say it! Listen, Dr. Manning. 'THIS' is my life. 'THIS' is who I am and what has saved me from a world of misery. 'THIS' is what finally allowed me to be okay with the skin I'm in and to finally feel like I wasn't in costume. 'THIS' is not just an 'oh well, tough shit' thing to me! It's as life and death as any of the other things you do to save peoples' lives every single day. The things you look up and learn and find out to keep people alive."

My face was on fire. I was speechless. Every time I tried to open my mouth, nothing came out.

"It's funny," she went on. "On the outside you seem like someone who takes pride in being all renaissance and open to all different lifestyles. You even made a point to call me 'MISS' and made sure I heard you talking to that nurse when you referred to me as a 'SHE'. But at at the end of the day, you might as well have called me 'SIR' and subjected me to a hernia exam--it would have been just as humiliating. Just as humiliating."

My foot was shaking under the desk. I started thinking of something, anything to make me not cry in front of her. Her words stung and they stung because they were true.

"I don't know what to say," I finally eked out.

"You should ask yourself why you've never taken it upon yourself to learn more about . . .'THIS'." Ms. Ava waved her hand in front of her body. "Are you even who you think you are? Maybe your feelings aren't what you think they are. Do you even know how high the risk of getting a clot is with this? Do you? My guess is that you have no idea. Just another bullshit excuse to avoid having to get involved in. . .this."

I couldn't take it any more. I stood quickly and excused myself again. Before she could even grant me permission I was out of that room and  headed for the nearest bathroom. The minute I got on the other side of the door I started to cry.

You know I did.

Do I even know who I am? Do I? I stared at my crying face in the mirror and asked myself those questions again.

How must Ms. Ava have felt? I thought of me, a black woman, and the times I've felt like a novelty or an afterthought based upon the actions of others. Folks who said and did the right things with me kind of like I did when I called my patient by the preferred pronoun. But then, through their indifference or neglect, erased every one of those things in one fell swoop.

Next, my mind drifted to the many times I've pushed to get people what they needed and what I believed they deserved. I thought of the articles I'd read over the years about various things and various topics--all with a goal to get myself proficient with treating a particular condition. I remembered the man I'd treated in the hospital the very month before with acute intermittent porphyria and how hard I'd worked to understand the pathophysiology and treatment. A lot of effort when into his care--and I was the one who treated him.

I was. Not the "porphyria expert" on call.

Why didn't I know those answers to those questions about the hormones? Why? Ms. Ava wasn't the first transgender person I'd ever seen. She wasn't. But she was the first to call my ass out for casting a judgement by my refusal to acquire more knowledge of the very thing most important to people like her.

Damn.

I rinsed my face and patted it dry with a coarse paper towel. I took a deep breath and walked down the hall to the physicians' room. Quietly I picked up a phone and got the number to the Endocrinologist on call. Once I got them on the phone, I let Ms. Ava's cutting words nudge me into action.

"This is urgent. My patient is a transgender female who recently relocated here from Massachusetts. She will be out of her hormones in three days and it is imperative that I get her linked in to someone who can maintain her feminizing hormones and androgen suppressing therapy."

I held the phone and waited. And you know what? That consultant was extremely helpful. She put me on hold and spoke with a colleague who had several suggestions. I hung up with a clear plan and a good way to bridge Ms. Ava as she got established with a new longterm provider.

And that was that. I knew in that moment that my words to that Endocrinologist made a difference. They were words of advocacy instead of apathy. And it greatly affected the outcome in the end.

So I went back to Ms. Ava and shared the plan. She looked relieved but still was not backing down from me.

"Thank you," I said. "Your words hurt but they opened my eyes. They really did."

"This is hard," she replied. "You learn to stand up for yourself."

And I got that because she was right.

So from there, for the first time, the exchange became natural. I heard about what it was like for her in her home country of Brazil and how she'd come to the Eastern seaboard to go to college. She explained how tough it was in her very Catholic household to be trapped in the wrong body and how much taunting she endured over the years. "It made me strong," she said. "It made me a fighter so I don't take nothing from nobody. I just have to live my true life so I'm not apologizing to anyone for that."

And I got that part, too, because I feel the same way. Damn, I do.

To this very day, I think of Ms. Ava often. I remember her words and let them kick me straight off of any high horse I decide to climb on top of. I examine my actions--my authentic actions--and ask what do they mean? Am I being an advocate? Am I open-minded? And if my actions are simply because of some deep-seated belief, instead of fronting like it doesn't exist, at least I acknowledge it for what it is.

Yeah.

Me? I am a work in progress. I am a human being with quirks and feet of clay. I am thankful for a place like Grady that reminds me of this every single day.

***
Happy Tuesday.

Now playing on my mental iPod. . . . "Fighter."