Dr. Lise Fortier
On a typical day in the office of Dr. Lise Fortier, the waiting room is full of women of every age—so many of them that there are not enough chairs to go round. The office is located in Montreal’s comfortable Outremont district, but Dr. Fortier’s patients cut across social and ethnic lines. Frenchand English-speaking Canadians, Greek and Italian immigrants, orthodox Jews—all are patients of the tall, auburn-haired doctor who, besides being a busy practising physician, is one of the country’s most trenchant critics of the medical profession itself. A past president of the Society of Obstetricians and Gynecologists of Canada and of the Family Planning Federation of Canada, Dr. Fortier was a leading figure in the campaign to promote birth control in Quebec, a drive that has resulted in the province having the lowest birthrate in Canada instead of the highest. Today she is an associate professor of gynecology at the University of Montreal and senior assistant in the department of obstetrics and gynecology at Montreal’s Notre Dame Hospital. Her provocative and controversial views range from a critique of medical arrogance—especially in the attitudes of male doctors toward female patients—to the belief that it is time for society to question the right to have children. She talked to Toronto journalist Ben Rose.
Maclean’s: You have said that Canadian doctors are conservative and that among them there are few intellectuals and fewer revolutionaries. How does this affect Canadians as consumers of medical services? Fortier: Doctors are likely to be good citizens, to be very respectful of the law, and there’s nothing wrong with that, mind you. But their respect sometimes turns to timidity and fear. They will respect the law so much that they won’t do anything to try to change discriminatory laws, laws that are making life miserable for people—for example the abortion law.
Maclean’s: What were you referring to when you once used the phrase “surgical prima donnas”?
Fortier: When I started in surgery, surgeons would throw instruments through the windows, yell at everyone and maintain in the operating room a climate of terror. They would hit you on the fingers if you didn’t do something right, they would call you names and they would do whatever was spontaneous for them to do, even if it was not civilized at all. This has tended to diminish for many reasons. One is that interns and residents, who were also
treated as servants and were subjected to all kinds of humiliation, finally got to be considered as human beings. They could even ask for a salary. I remember a surgeon who used to hit his resident on the knuckles with an instrument every time the resident did something that the surgeon didn’t like. Most residents submitted to that, very foolishly I should say, but after a while
some of them didn’t. Once I saw that surgeon rap a resident on the knuckles and the resident just pulled off his gloves and walked out. Well, after this happened a few times the surgeon didn’t dare behave that way anymore. And because now all the people who work in hospitals are syndicated [members of unions] you cannot treat anybody like this anymore. This is a very good thing, but now we are going into the opposite situation where the people who work for the surgeon are being just, you know, so unpleasant it is difficult to work with them.
Maclean’s: Is this “prima donna” attitude more prevalent among gynecologists? Fortier: No, the worst of them are the neurosurgeons. They are terrible. They have a very stressful job, many of their patients die, so part of it can be excused by
that. Neurosurgery draws to it people who are very strong-minded and often they are very bad-tempered. Gynecology is mostly a surgical specialty too, and as such has attracted people with the surgical temper. These people are not so interested in helping patients as in doing things, proving how good a technique they have, how good they are with their fingers, and what wonders they do. and the problems of the patients are something else.
Maclean’s: Do male doctors tend to disparage women obstetricians?
Fortier: Yes, I hear a lot of comments about lesbians from them. I wonder if they consider all urologists to be pansies. Maclean’s: Are sexist attitudes prevalent among Canadian doctors?
Fortier: Many have a double standard, like Archie Bunker who hates racists and blacks. Males do not change their attitudes or their ways of thinking when they become physicians. They have been brought up to think that women are there to be their servants, that a woman’s only career in life should be to produce children and take care of a husband, that she has no right to personal aspirations. Furthermore, as physicians, their attitude has been reinforced by the fact that they are constantly working with a class of people who are subservient, these persons being the nurses. They are used to having nurses attend to their wishes on their knees, and it’s only recently that nurses have objected to being servants. I have seen physicians in the operating room throwing their gowns on the floor, their dirty dressings at the nurses, and having temper tantrums. This has gone on for years. In their minds they are kind of Godlike creatures and the nurses are there to serve them, so it’s not amazing that they should consider every woman like this. Many assume their role is to teach women to be wives and mothers. Do urologists teach men to be husbands and fathers? Women do not want their destiny decided by men. They want control over their own bodies, and if the men in the medical profession do not give it to them they will study their own anatomies and do their own abortions.
Maclean’s: You have expressed concern that only 3% of the obstetricians and gynecologists in Canada are women. Is this changing?
Fortier: When I was in medical school in a group of 120, there were three or four women. Now I think 30% of the medical students are women. Because girls are good students, the doors of the medical faculties are opening to them. But they still
MANY GYNECOLOGISTS ARE LESS INTERESTED IN HELPING PATIENTS THAN IN TECHNIQUE
face a number of problems. One of them is how to lead a physician’s life and also lead a woman’s life. I’m not speaking of a woman’s life in terms of what we think a woman should usually do, you know, cooking and sewing and cleaning, but in terms of having a sexual life, an emotional life. Because you have to look very far and very long to find a man who will accept that his wife should be completely free to look after her professional career without feeling that he is being gypped in life. Maclean’s: How can women ensure they get fair treatment from male doctors? Fortier: Well the first thing I would suggest is that they ask questions. First of all, there is the relation between the woman and the physician, which is a relation of dominance on the part of the physician. The physician is supposed to know everything and to know what to do and not have to explain to you what he’s doing. This applies regardless of who the physician and the patient are, but it’s worse if the physician is a man and the patient is a woman. I get patients here and they say “Well, I’ve been operated on by Dr. So-and-So” and I say “What for?” and they say “I don’t know” and I say “Why didn’t you ask?” “Well, I asked but he didn’t answer. He won’t answer, you cannot talk to him, he’s always in such a hurry.” Well, I think this is a common sin. I am often in a hurry too, but I’m certainly not above explaining the truth and making it easy for my patients to understand. I think it is part of the physician’s duty to educate.
Maclean’s: Do women prefer men or women physicians?
Fortier: I’ve known patients to come to see me because I wasn’t a man, but that is not too common. I have women friends who are physicians and who treat men and women and I’ve never heard of a male patient who refused to be treated by a woman just because she was a woman. Most of the women physicians I know have patients who are very devoted to them. You see, I think there is a certain warmth, affection and tenderness that you will find with the female physician and the male patient that could be lacking between the male physician and the male patient. She is kind of a motherly figure, she is not only likely to give help but to give tenderness and love too.
Maclean’s: Where has the medical profession failed to meet the needs of women? Fortier: In the whole field of contraception and in the attitude of male physicians to women’s suffering. They take it for granted that women must suffer when they have babies. And a woman’s painful period is no problem of theirs. I think that anesthesia in obstetrics has been lagging behind for one good reason: the anesthetists were men. They say, “A woman can deliver without anesthesia. This has been proven centuries ago, so why bother?” I think that most obstetricians will agree that the best kind of anesthesia for obstetrics is the epidural anesthesia. But it’s only
very recently that it became available in the obstetrical departments of many hospitals, although it’s been around for a long time. I’m quite sure that if men gave birth to babies it would have been available long ago. I’ve known professors who worry that we are cutting maternal mortality so much that there won’t be any high risk cases to use for instructing medical students. Maclean’s: Why did you say on one occasion that gynecologists consider women a gold mine?
Fortier: This doesn’t apply especially to gynecologists; there are other specialties where women have been hostages to unscrupulous physicians and exploited through unnecessary treatment and un-
necessary operations.But certainly in gynecology you had this type of well-known surgeon who would operate for the slightest reason and without any reason, just because it was very lucrative. If the mother is sick, the father is still working and able to pay and he’s very eager to get her back home and looking after the kids and the house, so that it is more likely that you are going to get paid if you are looking after those kinds of patients than if you are looking after male patients who have fractures and things like that. Also, look at another special type of physician, the illegal abortionists, who used to make fortunes out of poor women’s misery.
Maclean’s: Is there a place for midwives in Canada?
Fortier: Yes. As gynecologists and obstetricians we have had much too good a training to sit and wait through a normal delivery. I think it’s a waste of talent and
knowledge. We should be kept in reserve for when something goes wrong and this is done in some countries. In Holland, for example, most of the obstetrics is done with midwives and Holland has the best record on maternal mortality. I don’t think the physician who is busy with a practice and does obstetrics on top of it can give the attention he should. Midwives can give their whole time and call in a specialist if there is a complication.
Maclean’s: You have said that as long as the medical profession continues to be highly remunerative, men will continue to dominate it.
Fortier: Sure, to dominate it and to keep it for themselves. Last spring I attended a symposium run by McGill University and the University of Montreal on “Sex, Culture and Sickness.” A young man presented a study he had made in Mexico of faraway tribes that had a kind of witch doctor, and this witch doctor was highly regarded by the whole tribe. But as the modern era came in the witch doctor lost his aura, so there were fewer and fewer of them to be found, and then women invaded this field. I think this is the story all over the world: as soon as a profession gets to be less well considered, the men desert it and the women move in because it is the only way they can change their situation. If 70% of the physicians in Russia are women, as claimed, then medicine must be kind of despised in Russia, or it’s not that important, because I don’t believe one bit that socialist countries have done that much for women. I think what is probably very important in Russia is engineering. Maclean’s: In view of its suspected side effects, do you consider the Pill is a safe contraceptive?
Fortier: Oh yes, I do. It’s much safer than pregnancy.
Maclean’s: But compared to other forms of contraception?
Fortier: On the last statistics I saw, if you take every type of contraceptive and project the number of pregnancies you will have from failure of that particular contraceptive, and consider the number of deaths resulting from that number of pregnancies compared to the number of deaths from complications of the Pill, it was easily proven that the Pill was the safest. With the Pill you have almost no pregnancies. Maclean’s: Do you think male physicians or male researchers discourage research on male contraceptives?
Fortier: Well, I don’t think I could say that. I can easily see that it is much more difficult to find a good male contraceptive than a female one. There is also another point. I know a doctor in Brazil who is very busy working with male contraceptives and he keeps saying: “Yes, but when I find a good one they won’t use it, they are not motivated.” I feel this too. Unless I was dealing with somebody I trusted completely, how could I be sure that he is looking after me not getting pregnant? He would not be the one to be pregnant if he does not take his
IN THEIR MINDS, MANY DOCTORS ARE GOD-LIKE PERSONS, WITH NURSES THERE TO SERVE THEM
pill. I would be. So I think there will always be something to be said for female contraceptives. But I’ve been very upset by the attitude of male physicians to male sterilization. They will go out of their way to discourage patients from having it. Maclean’s: Having a vasectomy?
Fortier: Yes, they will frighten their patients with all kinds of possible complications, yet they won’t say anything to the woman who is having a tubal ligation, about the dangers and complications possible from this. Oh, it goes on all the time. Almost every week I have a couple come in: they have been sent by a doctor for the wife to have a tubal ligation and when I question them I find it’s a kind of elective decision; they could go on using something else, but they’ve just come to the decision that this is better to do. Since it’s a free choice, I feel I must tell such a patient: “Do you know that a tubal ligation is a major operation, that there can be major complications?” “Oh, no, nobody told me about this.” So I describe what it is and then I say, “Well, vasectomies for men are much less dangerous,” and when I explain that very often the man will say, “Sure, why shouldn’t I have one, I’ll go back to my doctor and ask him to look after this.” He goes back to the doctor and the doctor starts telling him about all sorts of things that are not proven about vasectomies. It’s really a double standard.
Maclean’s: What are the most urgently needed reforms in over medical services? Fortier: I’ve never looked at it in that way; maybe I’ve been narrow-minded and looked too much at the things that should be changed in my own specialty. But in general I would like to see us going more into preventive medicine.
Maclean’s: I understand the women who have the highest risks in pregnancy, and who have the highest risk of children with defects, are not coming in for prenatal care. How do you propose to reach them? Fortier: Can we reach them? No. We had a report from a government task force saying we are doing too many cytology tests for cancer of the cervix on low-riskwomen and not enough on high-risk women. But how are you going to reach the high-risk women? It’s a real mystery to me because I think it’s part of our culture, our political culture. I think most well-to-do women are motivated and are aware of what they are risking and so they come in for checkups. But with poor women it is very difficult. They don’t know about it, and even if they did they have so many more problems that maybe this problem loses its importance; they are the women who are always being looked after in emergencies. There is no such thing as preventive medicine for them because they won’t go to a doctor to prevent something; they will only go when they are sick.
Maclean’s: You have said that society should be reexamining the right to have children.
Fortier: I think we are living in an over-
populated world. We are damaging our environment more and more by being so populous and by using this environment the way we use it. I think that the population of the world will have to stabilize very quickly if we don’t want to run into a disaster. In this light, I think that we soon will come to the point that having a child will be not a right but a privilege. We have to get rid of the social pressures on people to have children. It’s a very difficult job to raise children. Society can teach you how to type and to write and to count, but it won’t teach you how to bring up your children. Probably we will encourage some kind of people to have children more than others because they seem to have the know-how and the talents. I am sure this seems rather far-fetched, but I don’t think
it is that far away. Already there are places like Singapore where you are punished if you have more than two children. Maclean’s: What kind of punishment? Fortier: Oh, taxation and loss of privileges. If you have more than two children you lose your right to low-rental housing, free education, free medical care and your pension plan, so that in the end it’s almost impossible to have more than two children, unless you are very rich.
Maclean’s: A re you also afraid that our genetic pool is being weakened?
Fortier: Yes, because now people survive who before would live only a few days or a few months. They grow up and they become able to reproduce themselves and they can give those defects to their own children. An example of this is pyloric stenosis. In a child with this defect, the muscle
that closes the opening of the stomach is hypertrophic [excessively large], so that the stomach is completely closed. When the child drinks, the stomach doesn’t empty. The child starts vomiting and dies very soon. We found that it is very easy to treat— you just cut the muscle, that’s all, and the child is cured. But what we didn’t know until recently is that it is an inherited trait so that this will be increasing by 12% every generation. You can foresee a time when almost every baby will be born with pyloric stenosis. Naturally, in a country like ours, we can say, “That’s nothing, we can look after this, it’s such a small operation,” but I don’t think this could apply to the whole world. In the Dominican Republic, one of their big problems is that they don’t have enough electricity. The operating rooms sometimes don’t function because they don't have any electricity. Can you imagine that? Well, from what we hear now about the cost of energy we can foresee a world where we will have to curb our expenses in every way and I think that one way is to stop children with congenital defects from reproducing and another is to stop our fight to keep them alive. We keep them alive, but sometimes they just lead a very miserable life. For example, children with cystic fibrosis of the pancreas used to die in their first year of life. Now we keep them alive to age 21, 22 or 23. But in what way? They are tied to their hospital beds; they must always have oxygen and antibiotics or they choke and die. Why are we doing this?
Maclean’s: Are there other pitfalls of this kind in modern medicine?
Fortier: There certainly are. The worst scandal in my opinion is how we treat neurological defects like spina bifida. These children are born paralyzed and they are incontinent, but if you operate on them and you put a kind of a valve in their brain instead of dying they keep on living. Some of them are almost completely cured. But most of them will end up being able of mind, but completely paralyzed in their lower limbs, and incontinent. In England they have decided that these children should be in special schools; naturally they won’t be tolerated by other children since they are incontinent. But to look after all these cases they will have to build one special school a month in England for the next 25 years. At the moment they have something like three or four schools, so all the other children with spina bifida are left without the special care they really need. Why are we doing this? Why not let these children die instead of saving them for this kind of life?
Maclean’s: But many people will argue that these children deserve a chance to live. Fortier: This way? I agree with you that people deserve a chance to live, but living for living is not everything. You must consider the quality of life that we will give them. Children have the right to live in a normal way, in a happy way and a healthy way, but not as handicapped as this. ??
WE CAN KEEP CHILDREN ALIVE TODAY WHO ONCE WOULD HAVE DIED. BUT SHOULD WE?