The Obstetrical Celibate

Celibacy seems so counterintuitive and aberrant to me that I’m constantly amazed how close to the surface it seems to float. Its etymology comes from a Latin word meaning ‘unmarried’ and that, in turn, is an amalgam of two proto-Indo-European words meaning ‘to live alone’, but its exact definition seems contextually influenced. For example, despite the fact that it is not the exclusive prerogative of one sex, we tend think of male Catholic priests as the prime examples, even though nuns –their female counterparts- also live a celibate life.  It is also variably regarded as being either the condition of living alone and being sexually abstinent, or merely sexually abstinent. In the Catholic church, although it was only mandated for priests in 1130 A.D., it included both lack of partner and sexual gratification of any kind.

Celibacy is usually seen in a religious context, but it need not be. A more contemporary view tends to focus on the sexual abstinence aspect or on the lack of a regular partner. It may be a temporary phenomenon and not one that is intended to be pursued, or a lifestyle choice. It is seldom related to the condition of asexuality in which the reason for the abstinence is one of indifference or lack of sexual drive –as I have discussed in a previous essay: https://musingsonwomenshealth.wordpress.com/2014/07/03/the-asexual/

Now I don’t wish to sound so dismissive as to reject the concept of celibacy out of hand. We all make decisions based on our wants and needs, often guided by doctrines or beliefs which make sense to us at the time. In a free and open society, what the rest of us may think of the decisions should be of little consequence so long as adhering to them has no adverse effects on any except the participants. Witness the spate of publicity surrounding the late Pope John Paul II and his relationship with the married Polish-born philosopher Anna-Teresa Tymieniecka, before and during his papacy: http://www.bbc.com/news/magazine-35552997  That a very human side was able to successfully coexist with his deeply religious beliefs is both touching and laudable –especially in a pope.

But this prologue was by way of an introduction to Ann, a patient of mine shortly before I retired.

As she sat in my office that first time, she seemed unusually nervous. She had short brown hair and was smartly dressed in a white blouse and grey pant suit. Ann seemed the perfect model of a corporate executive on her lunch break –which indeed she was. But she was perched bolt upright on the edge of her chair like a bird about to launch from a branch. Her face was taut and unnaturally shiny; her lips were frozen in a straight line as if she were trying, unsuccessfully, to fabricate a smile. Only her eyes betrayed a profound mistrust, bordering on aggression.

“You seem rather nervous, Ann,” I said with a smile of my own to break the ice.

She nodded politely, but remained silent. Only her proximity to the edge of her chair changed. I wondered how long she’d be able to stay balanced on it.

I have to say that the laptop screen on my desk is a wonderful tool. It not only provides me with information –consult letters, lab data, and so on- it also gives me something to hide behind when the patient has sent her eyes on a predatory mission. It is a type of blind, I suppose. I pulled up the consultation note from her GP on the screen more for something to do than for information –the day sheet from my secretary had already disclosed the secret: Ann was pregnant.

The note from the GP was rather terse I thought: ‘Pregnant. Angry’. I took a deep, albeit disguised, breath and peeked out from behind the screen. “So, your family doctor says you are pregnant, Ann. Congratulations!” This initial praise for the achievement usually disarms patients -well, confuses them, anyway. But it did nothing to Ann but harden her expression. She mouthed the obligatory ‘thank you’ silently and with barely a movement of her lips. This wasn’t the easiest consultation I’d ever been sent.

I decided to be more direct. “Are you angry about being pregnant, Ann? Or are you angry with me?”

That obviously caught her by surprise, because she suddenly dropped her eyes onto the table –her armour had been chinked.

Then, she broke her fast of silence. “Doctor, I have to explain something to you,” she said, slowly and disdainfully, again with lips that barely moved. I began to wonder if they’d been botoxed, or something. “I am 37 years old, unmarried, and unattached!” She said the last word carefully and slowly, lest I misunderstand. I could feel the exclamation mark from right across my desk. “Further, I am not in a lesbian relationship, nor am I ever intending to be dependent upon a partner for assistance.”

At this point her face actually narrowed and I could sense its muscles trying to avoid spasm. She liberated the predatory falcons of her eyes once again. “I am a celibate by choice, not necessity, doctor,” she said, this time between obviously clenched teeth. “My career is paramount…”

Her minute pause emboldened me to ask the obvious: “And the pregnancy isn’t…?”

It was not intended to be a profound rejoinder, merely an question, but her eyebrows immediately jumped up as she recalled the falcons to their home roost. They watched me from the shadows of their cage as her face gradually softened. An embarrassed smile crept slowly across the once angry lips and I thought I even detected a blush.

“I’m sorry, doctor,” she said, after a rather reluctant sigh. “It’s just that the men at work have been giving me a hard time.” She stared up at a picture hanging on the wall for a moment. “Word somehow got out that I was considering becoming pregnant…” She closed her eyes briefly to decide how to explain. “Men don’t seem to understand that…” She glanced at me quickly, and then corrected herself. “Many people –not just men- don’t seem to understand that wanting a baby is not the same as wanting sex, or a partner, or even a calculated one-night stand.” She retreated inside herself again to pick the words she wanted. “I don’t hate men, and I don’t disparage relationships, I have simply chosen to live my life differently from most: a celibate life…”

She took a deep and stertorous breath before continuing. “You wouldn’t believe the whispering in my office when the rumour spread that I was going to pay for IVF when there were so many willing donors around… The men would wink suggestively whenever I passed by, the women would get that silly smile on their faces…

“Anyway, I decided to take a few weeks off for the in vitro fertilization process, only half expecting it to succeed on the first cycle. But when it did, I didn’t know if I could stand the censure that most men would exhibit when they hear that I did it voluntarily -in other words, without them.” She shrugged and looked out of the window behind me for a minute or two. “So, I asked my GP if she knew of any female obstetricians she could send me to, but for some reason she chose you.

I hate this kind of situation –being blamed for something over which I have no control. A false negative, as it were. I linked eyes with her for a moment. “Sorry,” I said, smiling innocently. “I can probably find you a female Ob if you’d like.”

She sat back in her chair and thought about it. It almost felt like I was at a job interview and my CV was being inspected. After a few seconds, she smiled –warmly, for a change- and sent out her eyes again –this time rather than circling for a kill, however, they perched softly on my face. “After all that anger, would you still be willing to see an obstetrical celibate?”

I nodded. “I’ve always been nonpartisan.”

Prove it!

If there’s one thing that a long life has taught me, it is that most of us seldom stray far from the path. Once launched, our trajectory is largely predictable. I suppose this is necessary for co-existence –that there are societal norms is, after all, what binds us together as a group. Knowing what people want –what they are comfortable with- makes it possible to plan ahead with a reasonable expectation of success.

And yet, what if circumstances change? Even Science admits it runs on statistical probabilities. Nothing is forever the same, despite our expectations; despite the hopes of even the most enlightened that it will not deviate too much from that to which we have become accustomed. But progress depends on change, depends at least on altered perspective. That someone can look at the same data and interpret it differently –see different patterns in it, perhaps, or even apply it to something entirely different- is what we have come to expect of our modern world.

But there is often an inter regnum, that can be confusing -a time before the paradigm shift is complete; when wisdom, -no, expectations– demand that we judge the results of whatever investigations we have done, in the light of what the past, or experience, has taught us. And as a consequence, not only do we limit our inquiries to those things that seem to prop up those views, but we discard, or criticize data that fail to validate them. Same information, different eyes. It’s often called the Confirmation Bias and I’ve written about this in one form or another before: https://musingsonwomenshealth.com/2015/05/15/the-polarization-bias/

The problem is that it seems to be a Mobius strip, and the same data are used to prove opposite contentions. There are rules that can be applied, of course –methodologies that help to sort out interpretive biases:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126323/  but it’s all too easy to fall back on what seems natural to us: to assume that what has been found either substantiates what we believe it should, or to criticize it for its presumed deficiencies or mistakes if it does not.

There seems to be no end to the variations on that all too familiar theme. It’s certainly not unknown in Medicine, and a recent example springs to mind.

I remember Jerra -partly because of her unusual name, I suppose. When I saw it on the office day sheet, I assumed it was a typo and thought I would correct it as I introduced myself to her in the waiting room. She was the first patient booked for the day and none of the few other early-risers in the room looked anywhere near 62.

“Jerri,” I said with a smile, walking directly over to a thin, grey-haired woman sitting bolt upright in the only chair by the window. Her first reaction was to assess me from head to toe with hostile green eyes that, had they not been restrained, might have attacked me as I approached.

“It’s Jerra,” she said, ice congealing on the words as they approached my ears.

I blushed. “I’m sorry, Jerra,” I stammered, embarrassed at my rash decision to modify it.

“And it’s Mrs. Tandill…” she added haughtily, refusing –or perhaps not deigning– to shake my extended hand.

The waiting room went quiet, all eyes on us, as she followed me reluctantly across what now seemed a long hike over the floor and down the corridor to my office.

Once inside, she glanced quickly at the sculptures, and plants, and repositioned the chair further from my desk. She did not want to be here, and was letting me know in the bluntest possible way.

“You seem uncomfortable, Mrs. Tandill,” I said when she seemed settled in her seat. “I’m sorry we got off to a rather rough start…”

“So am I, doctor,” she said, still glancing around disapprovingly at the art work hanging on the walls. “I am only here at the behest of my GP, you understand.”

I smiled, hoping to diffuse the tension, but her face didn’t change. She was an attractive, if severe looking woman. Dressed in a loose black silk dress that brushed the tops of her shoes when she walked, tiny silver hoops in her ears, and a matching silver brocaded scarf that hid her neck, she carried herself like royalty. Even her short, greying hair sat regally on her head like a tight-fitting crown, not a curl out of place.

And me? I was still dressed in my OR scrubs –albeit freshly changed- after an unscheduled 8 AM Caesarian section that made me late for the office. The stark contrast with her apparel and the thwarted expectations of how a new specialist should present himself may have stoked her anxiety with the visit.

“My GP says I need a hysterectomy,” she said, suddenly glaring at me like a vexed mother with her child.

I checked the very thorough history her GP had sent with the consultation note. Jerra had presented to her with postmenopausal bleeding, years after her periods had finished. She had sent her for an ultrasound which had confirmed that there was a thickened lining in the uterine cavity, and had even done a biopsy of the tissue. The pathology report of the biopsy did not find cancer, but rather an overgrowth –hyperplasia- that can be a precursor to cancer.

Jerra was still staring at me when I looked up from the computer screen. “Dr. Hannah gave me a copy of the pathology report, doctor,” she said, sternly. “And I researched it further.”

“And what did you find, Mrs. Tandill?” I needed to know what she had read before I could put the results into some sort of context for her.

Her body seemed to relax at being given an opportunity to discuss it, but I could see her face was still wary. On guard. “First of all, that there are several types of hyperplasia” –she pronounced the word very carefully- “… and that some types are further along the spectrum towards cancer.”

I nodded slowly, not wanting to challenge her interpretations unless warranted.

“The type that seems most predictive of cancer, is the abnormal hyperplasia…”

Atypical,” I interjected, just so she’d know I was listening carefully, I suppose.

She managed a rigid, if fleeting smile. “Atypical. Thank you.” She referred to some notes she’d folded into her purse. “That word was not mentioned in the report, and I even showed it to a friend of mine -who is a nurse- and she agreed.” When I didn’t object, she lashed out at her GP. “I’ve been going to Dr. Hannah for several years now, and I usually trust her judgement, but I think she’s made a mistake here… I’ve never been on hormones,” she added as a kind of preemptive rebuttal of an accusation she expected to hear. “She says the biopsy may have missed a more… atypical area and so to be safe, I should have my uterus removed. You doctors always seem to want to remove things.” She settled back in her chair having made her case, and prepared to fend off the denial.

I took a deep breath while I decided how to approach the problem. I agreed with the concerns of her GP -at her age, there shouldn’t be much of a lining in the uterus at all, let alone one that was sufficiently thick to bleed. Something must have caused the hyperplasia. And yet, I could also understand Jerra’s anxiety. “I suppose our problem in cases like this is one of certainty, isn’t it? On the one hand, the pathology results as they stand could explain the bleeding and the ultrasound, but not with complete certainty. There could be some even more abnormal tissue hiding in a corner of the uterus that was not sampled with the endometrial biopsy…” I’m sure her GP had already gone over this with her, but it needed to be repeated. “And if that were the case, and we left the abnormal cells in place, we might all regret the decision later.”

She sat straight up in her chair shaking her head the whole time I was speaking. “Dr. Hannah kept saying the same things, doctor.” She sighed and stirred restlessly on the chair. I could see her clasping and unclasping her hands on her lap. “Let me be clear -as far as the pathology report is concerned, there is no cancer. I have…” she referred to a copy of the report in the bundle of papers again carefully folded in her purse. “… I have ‘simple hyperplasia’ –which, as I understand it, is far removed from the cancer end of the spectrum. I find it reassuring, and I fail to understand why you do not.” At this point she actually crossed her arms tightly across her chest and nailed me to my chair with an angry glare. “You’re looking at the same data as I am, and yet you are interpreting it totally differently,” she added, as if she were paraphrasing something she’d read online.

I smiled, again, but it did nothing to diffuse those eyes that searched for a permanent foothold on my face. “I suppose I’m just being careful, Mrs. Tandill. Experience teaches me that…”

Medical schools teach you, doctor!” she interrupted angrily. “Mentors that have been through the same system instruct you how to think about these things.”

I sighed, and I’m afraid I was not very successful at disguising it from her. “Have you had any more bleeding –since the biopsy, I mean?” She shook her head dismissively, and I sat back a little on my chair, all too aware I had also been revealing my discomfort at her anger. “Would you feel better if I did another biopsy…? To confirm the first one?” I added this in hopes of walking the middle road between her wishful thinking that the biopsy was indeed reassuring, and at least not denying the possibility that it may have missed something worse.

At that point she got to her feet, still scratching at my cheeks with her eyes. “No, I would not feel better! You would probably continue to recommend biopsies until you found the result you anticipate, doctor, and I will simply not play that game with you.”

And with an angry shake of her head she turned and walked out the door.

But maybe she was on the right track; maybe compromise -the middle ground- only re-routes the problem and detracts from whatever the data purport to demonstrate. No matter the number of repetitions, an interpretation of the results is still required. And if the data warrant it, a stand on one side or the other must be taken and we must live with the consequences. I think there comes a time when we must disagree with Macbeth when he says to MacDuff ‘Damned be him that first cries, “Hold, enough!”’

Do We Really Understand?

Okay, call me a cynic, or maybe even a curmudgeon, but I sometimes wonder just how much we understand about Information –and by extension, it’s relationship to Knowledge.

Information can be construed as the answer to a question or, seen from a different perspective, as that which has the potential to resolve uncertainty. Numbers, for example, are not information unless they pertain to something. And when we think of information in the form of data, it doesn’t necessarily require someone to receive it, but can stand alone, unwatched and unprocessed until summoned. Knowledge on the other hand can be thought of as the reception, collation, and subsequent processing of that data –requested, in other words. Whether that which stands in isolation, unprocessed and unused constitutes Knowledge is an interesting, but tricky issue –likely of the same ilk as ‘If a tree falls in the woods with no one around to hear it, does it still make a noise?’ that we all puzzled over in Philosophy 101 in University. Because data –information- has the potential to answer a question, does that automatically qualify it as knowledge even if there is no question? Even if it might not resolve any uncertainty?

I raise these issues not to transition into a discussion of information theory, but to ask how much we are furthered by information about issues that are incompletely understood –known?- even by experts in the field. I’m referring, of course, to our own DNA.

Scientists are accumulating more and more data about genes and their codes and loci on specific chromosomes. They are beginning to link particular code changes in these genes to specific conditions, and the process is just beginning. Progress seems to increase logarithmically. The promise of this information is enormous in terms of diagnosis and perhaps eventually, treatment. http://www.bbc.com/news/health-35282764

I do wonder, however, whether it is valuable or premature to offer personalized genotypes as a commercial venture to anyone who asks for them. Clearly, there are situations when the information would be helpful when questions are asked of it: risks of a genetically-carried disease, hereditary lineage, or even paternity, as examples. But do we really know more about ourselves because some company has mapped our chromosomes? Without a question being posed to which the genetic sequences are the answer, is what is received useful, or pap? At this stage of our investigation of the genetic code, is an undirected map of base-pairs on a chromosome anything other than simply that: a small scale map of largely unnamed streets of a mysterious city that happens to have the label of the requester on it? A hieroglyph?

Undoubtedly, as the data accumulate, this mapping will progress to the stage where it becomes an essential guide to a city we wish –or need- to explore. And perhaps the store of information acquired will allow retrospective analysis of things whose importance we have yet to understand. Answer questions we don’t yet have –or at least can’t yet formulate in a way that could be solved.

In the meantime, however, I worry about that very personal and private information being made available against our wishes and perhaps to our detriment. Insurance companies, for example, employers –or maybe even an untrammeled government worried about threats of terrorism or contagion may request, or perhaps legislate that the genetic information be provided –especially if it has already been obtained. Unfortunately, at least at the time of this writing, there is no protection in Canada against discrimination based on genetics. There is, however, some legislation under review (Bill S-201) that addresses this. https://openparliament.ca/bills/41-2/S-201/ One hopes that its adoption will be soon, but it is a concern that certainly needs resolution before widespread adoption of personalized DNA should be considered. Once Pandora’s box has been opened, it might be too late, so we must think long and hard about what we decide.

Well considered safeguards are essential in advance -both for governments as well as for industry that may be tempted to oversell the potential. I stand with Hamlet in this: one may smile, and smile, and be a villain.

Leave Me Alone

I have lived in a hospital as an on-call obstetrician on more days –and nights- than I can count over the years; hospitals were the grudging homes for me ever since medical school and the subsequent ages of specialty training that fell upon me like unbidden hats. And despite the palimpsest of colours I was forced to wear, hospitals have been the lodestars in my ever-changing world.

They weren’t all pleasant, although each beckoned with what seemed, from a distance at least, to be tempting endowments of knowledge and experience. Gifts are gifts, no matter the source, and I accepted each with gratitude, if not a little experientially-acquired caution. But although one must often stride boldly into the unknown to arrive at a destination, adaptation follows close behind. And then comes a fondness for what seemed, initially, to be strange. Chaotic. Frightening. And yet the utility of the situation breeds an eventual reconciliation. The disturbing, becomes assimilated into the quest for advantage. The hope for reward.

At least, that’s how an employee –a doctor or a nurse, especially- might rationalize the initial anxiety in a hospital: ‘short term pain for long term gain’, as the trite political aphorism would have it. But one can only wonder how the experience might strike a person who, travelling along the avenue of illness or accident, is forced to endure the unexpected and probably unwelcome distress.

There was an interesting article in an old BBC News article that questioned whether going into hospital might actually make you sick: http://www.bbc.com/news/magazine-35131678

A Dr. Harlan Krumholz at the Yale School of Medicine became interested in in the statistic that ‘about a fifth of patients who leave US hospitals are back within a month.’ At first glance, this may seem obvious and uninteresting –the original cause for their admission may not have been completely dealt with, or perhaps there were complications from it that only surfaced after their discharge. Indeed, in many countries ‘re-admission rates are taken as a measure of the quality of care a hospital provides.’ But Krumholz realized that ‘only about a third of patient readmissions were related to the original cause of hospitalization. Patients’ reasons for returning to hospital were diverse and linked to their immune systems, balance, cognitive functioning, strength, metabolism and respiratory systems.’ He felt this was an entity unto itself and called it PHS (Post Hospital Syndrome): http://www.nejm.org/doi/full/10.1056/NEJMp1212324

Basically, it assumes that hospitals unwittingly engender stress in patients by imposing disruptive and often intrusive regimes –some of which could safely be postponed or modified at night, for example. Patients already feel vulnerable and powerless in the face of illness or accident, and few would dare complain for fear of alienating those who are the providers of their badly-needed succour.

*

Vesna was not one of those. From the moment I saw her in the Emergency department with a severe and unresponsive pelvic infection, it was obvious she did not intend to relinquish control. Indeed, it was something of a diplomatic coup that one of the ER docs was able to convince her to allow an intravenous catheter to be inserted into her arm. She had to point out one of the only remaining veins –she knew her arm well- and direct his hands when he tried, unsuccessfully, to enter the tiny vessel that was hidden under a tattoo on the skin above her elbow.

It was around 2 A.M. when my resident called me about her, and just as I entered the little cubicle, someone dropped a large metal pan by the door. Before I could introduce myself she yelled at me. “I’m not gonna use one of those f– things, doc!” and she pointed to the bedpan on the floor.

The nurse looked up apologetically. “No, I’m just taking it out of the room, Vesna. It’s not for you.”

“Do I have to stay down here all night, doctor? It’s too f– noisy!” She said this all too loudly, ostensibly so her voice would be audible above the noise, but despite the outburst, despite the angry expression on her face, for a fleeting moment her eyes seemed to betray her when she glanced at me: they twinkled contritely, as if trying to excuse the behaviour of their owner.

My resident shook his head. There was apparently a bed available for her up on the ward so she’d be moved up shortly.

At hand-over rounds the next morning, the resident looked exhausted. Apparently Vesna had complained that the patient in the bed next to hers was snoring so she couldn’t sleep. And the nurses insisted on talking in the corridor whenever they walked by; the medicine carts they pushed were too noisy; or somebody kept coughing in the next room. So, Vesna demanded a sedative. That, of course, required the okay of a doctor first. And then, later, her IV stopped working –it had been inserted into a vein that would not ordinarily have been used- and the so the resident had been called to order the antibiotics to be given by some other route. The ones she needed were not available by mouth, so the only remaining way was by injection into her muscles. Vesna objected, of course, and so the resident had to go up to the ward again and explain things to her.

The hospital food was certainly not to Vesna’s liking –she said it made her sick- although, in fact, it was probably a side effect of her antibiotics. I’ve never liked institutional food either, but there seemed no end to her complaints while she was in hospital. We learned to tolerate her, of course, but I remember deciding to buy coffee for the resident staff when we discharged her.

I suppose I fell prey to the uncharitable assumption that Vesna was simply a grumpy person –someone whose circumstances had taught her to be suspicious of everything around her; someone who had learned to be tough and difficult to befriend. It was a wall she was forced to live behind -makeup she applied to protect the skin beneath.

She was supposed to come to my office for a follow-up visit a week or so after discharge but I have to admit that I wasn’t surprised when she didn’t show up for her appointment. My secretaries had actually double-booked me for her time, suspecting as much.

A few weeks later, I saw her name on my day sheet again but the woman who sat nervously in the waiting room pretending to be absorbed in a magazine was nothing like the Vesna I’d met in the hospital. This time she was dressed in slim black jeans with a frilly light blue cotton pullover. Her auburn hair was neatly combed and her ears adorned with enormous golden earrings that threatened to snag her curls every time she moved her head. When she saw me approaching, she smiled and stood up to extend her hand.

“I’m sorry I missed my last appointment, doctor,” she said, as soon as we were settled in my office, the embarrassment written in her eyes. “I had to be admitted to another hospital so I couldn’t make it…”

“The infection came back?” I said, concerned that we had discharged her too early.

She chuckled merrily at the thought and shook her head, making the earrings dodge in and out of her curls like it was a game of tag. Then the look of embarrassment returned. “Overdose.” She took a long breath and then shrugged. “Occupational hazard, I’m afraid.” She looked out of the window behind my seat for a moment. “Interesting, though…” she said slowly and deliberately, as if something had just occurred to her. “Same source, same amount… Never happened before and my boyfriend was okay so he couldn’t have cut it with bad shii…” She glanced at me and quickly corrected herself mid-word. “…ah, stuff… so I wonder how I could have overdosed.” She sat back in her chair and shrugged it off. “Maybe somebody’s trying to tell me to change my ways while I still can, eh?” She giggled like a school girl -and for a moment, she was.

Was she a victim of PHS or, in her case at least, the recipient of an opportunity? Were the two events even related, or in my rosy-eyed naiveté, am I projecting my own hopes on an otherwise indifferent world? I don’t know, of course, because I never saw Vesna again, but I’d like to think that something changed her. But for the better this time… Could PHS do that too?

I remembered the words of Emily Dickinson:

‘Hope’ is the thing with feathers that perches in the soul                                                                                    And sings the tune without the words and never stops at all.’

 

The Gyne Codes

We all use codes; sometimes they are simply shortcuts, at other times they identify us as part of one community or another. However, the codes I like are the ones that are attempts at disguise. Camouflage. They offer the challenges that colour my day. I have to say that I was absolutely fascinated by the codes and their uses reported in a BBC news item: http://www.bbc.com/future/story/20151217-the-secret-codes-youre-not-meant-to-know

I suppose the codes it revealed that tugged at my heart more than my intellect were the so-called hoboglyphs which are ‘a collection of symbols meant to provide information to travelling workers and homeless people.’ http://weburbanist.com/2010/06/03/hoboglyphs-secret-transient-symbols-modern-nomad-codes/ Somehow the thought that ‘Among other things, these could indicate the quality of a nearby water source, or suggest whether the occupant of a house is friendly or not’ goes at least a little way to help those that society tends to shun.

But as I said, we all use codes in one way or another; a difficulty arises when you don’t know you are being coded –or worse, you do, but you have no idea what the codes mean… Or why they are being used in the first place. I usually suspect the worst.

And the non-verbal codes people use are the trickiest: they can often be explained away as random movements –tics- and even to notice them might embarrass the user if they were indeed involuntary. Or, perhaps more awkward, if they arise from the patient’s unease itself. From time to time I am confronted with this dilemma in my practice of gynaecology.

I first met Roseita a few years ago. English was difficult for her at the time, and I remember she seemed to communicate with her eyes a lot. That first day, as she sat entombed in shadows in a far corner of the waiting room, I could sense her presence even before I saw her. She was camouflaged in a green dress on a little chair beside the large Areca palm plant that also seemed to be enjoying the subdued light. The chair –Roseita- was almost hidden under the leaves, but I felt her eyes tracking me like radar all the way across the wooden floor. Large, brown, worried eyes they seemed, already questioning whether I was the person who could help her.

I suppose there’s always that initial doubt in new patients, although most seem able to disguise their discomfort. Roseita couldn’t, and as I approached her with my hand extended in a greeting, her face said hello, while her eyes stared at me like frightened children. I didn’t know which to believe, so I chose to focus on her face. It’s amazing just how much a face can fight with the eyes; so which are mirrors of the soul…?

She trailed behind me, reluctantly I think, on the short journey down the corridor to my office at its end, and I had to fight the urge to keep turning around to see if she was still there. Her eyes certainly were; I could feel them burrowing into my back, studying my gait, judging the whiteness of the lab coat I usually wear. By the time we reached the door, I felt nervous about revealing the front half of my body again, in case it didn’t measure up to the other side she now knew so well.

After a hurried, but I suspect thorough, inspection of the room she seated herself like a monument on the chair opposite my desk. I say ‘monument’, but despite her bravado, she was more like a delicate figurine hoping to fool me with immobility. As if by sitting up straight and rigid, she could project a strength she didn’t feel. Sometimes her hands would slowly drift up to the sides of her head, like she was trying to smooth the dark black curls that dangled on her ears, but otherwise she was a statue with eyes peering out from little cages just waiting to be unleashed.

I could feel her anxiety and tried to set her more at ease with a smile and a compliment on her dress. It really was a thing of beauty and I wondered if she’d chosen it because it gave her confidence, or because she thought it would disarm me.

The compliment seemed to take her by surprise and she dropped her eyes to her lap for a moment as she decided how to react. Then, as if she’d come to the conclusion that I was being insincere –or maybe she didn’t actually understand my words- she launched those eyes at me like missiles. Hard, like stones. They actually hurt, although at the time I didn’t realize that it was my pride they hurt –rebuffing, as they were, my attempts at bridging a gap I was at a loss to understand. Doctors get injured too; relationships are a dance –a clumsy one until both understand the movements of the other. The needs of the other…

I suppose I always found that difficult; I need to feel comfortable before I can provide succour to the other. The therapeutic relationship –the doctor/patient alliance- is truly that: a tie. And what is usually considered an unavoidable imbalance of power, can be a mutual journey of discovery… If both are open to that, of course.

For my part, I wanted to understand why Roseita was so wary of me. Was it merely fear –the strange doctor of opposite gender, disparate culture, and different language pretending to offer help? Or was it more than that: mistrust? I had to know.

Wilting under the constant barrage of her eyes, I had to rest from them for a moment, so I sought refuge in the computer screen. I pulled up the consult note that I had ignored before to scan the investigations her GP had done. Often the ultrasound, for example, will tell me more about the problem than the consult note which will sometimes offer one hurriedly written and often illegible word: Pain! But in this case it was more helpful. Much more! It said that Roseita was deaf, and the effort of trying to read lips in a language she hardly understood made her anxious.

Well of course! I rekindled my smile and pointed to my ears to show I finally understood. The grin that produced almost split her face in half. She pointed to the door, touched her lips, then shrugged in a mute apology before she disappeared down the corridor. She’d left her coat on the chair, so I waited expectantly. She’d be back.

Suddenly, she reappeared with a shorter man in tow behind her. He seemed embarrassed at being in a gynaecologist’s office but was determined to help Roseita.

“Roseita… wife,” he said, hesitantly as he grasped her hand tenderly and held on for dear life. “She… no listen…” He reconsidered the word and corrected himself with a sheepish grin. “She no hear. I… talk on her,” he finished proudly.

And talk we did –although gesticulating and drawing things in the air made it seem like a medical game of Charades at times. We drew pictures on scraps of paper; we pointed; we tried words in both languages; we laughed… But, in the end, I think we all understood more about the three of us than would have occurred with words alone. We do not just speak in code, nor simply write in code. Code is sometimes informal -the inverse of what we expect. It can be what we use to reveal things otherwise hidden, the algebra that explains, the metaphor that illuminates.

I’ve never forgotten that visit. I have learned, I hope, to look beyond mere words. They are only the wrappings that cover the gift offered underneath. To paraphrase Costard, the country clown in Shakespeare’s Love’s Labor’s Lost, I have lived too long on the alms-basket of words.

 

 

 

The Colour of my Baby

What a great idea: a bandage that tells you when what it is hiding, is itself hiding something –an infection.  http://www.bbc.com/news/health-34808273

I suppose it was an idea looking for a platform. When bacteria are growing, they often invent ways to keep doing just that. Sometimes they overwhelm by sheer numbers to defeat the body’s defences, at other times it’s toxins that break down tissues and help them invade. The body, for it’s part, has its own bag of tricks. In the end, infections are often simply a kind of parry and thrust contest –a fencing match, if you will.

Most bodies are not unduly challenged by wounds, however –keep them clean and cover them with some sort of dressing, and they heal. Antibiotics are seldom required. The problem, of course, is that sometimes the foes are not evenly matched. People on immune suppressants (transplant patients), or those with already compromised immune systems –whether from disease or immaturity (babies, for example)- may not be able to mount a suitable response to bacteria in a wound and are at risk of severe infections. These are the ones in whom a timely and appropriate antibiotic would be prudent.

Sometimes, though, antibiotics are used like soap: if it looks dirty, or if it might turn out to be dirty, why not use an antibiotic? Just in case. Well, the simple answer is that the body is usually pretty good at dealing with bacteria. After all, we are all exposed to bacteria from day zero. It starts with the journey down the obviously non-sterile birth canal, and progresses to crawling along things, tasting things… none of which could be said to be free of bacteria of some sort or other. Bacteria are what we do, where we live… Bacteria live in our mouths, in our bowels, on our skin. There are more bacteria in our intestines than cells in our bodies; we simply cannot get rid of them all.

Nor should we. I’ve written before about the benefit of these usually commensal creatures and the benefits they provide both for continuing health and development: https://musingsonwomenshealth.wordpress.com/2014/05/15/the-human-microbiome/

But let’s not be naïve about bacteria –they don’t give a fig about us -they are amoral. A bacterium prefers to live with others –family. They grow and prosper with no regard for boundaries or house rules. Without suitable checks and balances they would take over. Like pouring water in a cup -too much and it merely overflows the constraints and moves on. That’s an infection. That’s when the body may need some help.

The trick is obviously intervening when it is necessary, but monitoring when it is not. Why? Well, treating every wound, say, with an antibiotic might get rid of the truly sensitive bacteria, but leave behind those that don’t respond quite as easily or quickly. The result of the treatment may therefore be to select for those bacteria that don’t mind the antibiotic –the resistant organisms. That’s how it happens.

So in those people who may not be able to deal with bacteria efficiently, it would be helpful to know when –or if– to intervene. That’s where the bandage that changes colour when bacteria in wounds begin to proliferate and infect would be helpful. There are other ways, of course: the old Latin aphorism I was taught in medical school, for example: Tumor, Dolor, Rubor, Calor – Swelling, Pain, Redness (inflammation), Warmth (infection). But sometimes it’s nice to have another tool in the kit that may detect a problem earlier -before these signs are present. Or, in the case of a body incapable of even producing the signs- when an infection would be catastrophic.

Clearly a lot of work needs to be done to detect the mischief of different types of bacteria –they don’t all produce toxins, and even if they did, there would likely be differences in their structures that would have to be accounted for in the detection mechanism. But this may be the bandage of the future –a Facebook band aid that is constantly posting. Almost like refrigerators that tell you what you need, or coffee pots that turn on when they hear the toilet flush in the morning. A brave new world.

It is ‘a hit’, as Osric, a courtier, says of Hamlet’s thrust as he is dueling with Laertes, ‘a very palpable hit.’ Let us hope so.

 

Non-Binary Gynaecology

There was a time when I thought I had a handle on gender, but things change: it’s no longer constrained by only two choices. And then I thought I understood the variations on the theme of sexual preferences. I even learned their names. Now I’ve discovered that no less an authority than the New York Times has decided to recognize that the use of ‘they’ might, at times, be acceptable in referring to a person without disclosing the sex (and therefore prejudicing the choice)–as in, say, ‘When the leader of the delegation announced the agenda, they did so in English.’

I thought I was keeping up. I thought I finally understood the intricacies of gender politics, but I realize that I am still challenged. I am still floundering in the choppy waters of an incoming tide. I’m going to have to stop reading the BBC news online:  http://www.bbc.com/news/magazine-34901704

Okay, I realize that having to use the ‘he/she’ device in the interests of universality (biversality?) makes for some tough slogging for the reader and makes an article, or a story, almost unreadable. But, in my naiveté, I assumed this was just a way of being inclusive: a way of recognizing that past generations had assumed the use of ‘he’ as a universal designation was a convention that was not meant as an exclusion –more like an unthinking shortcut that nobody had challenged.

So I have to say that I was certainly not expecting ‘they’ to evolve so rapidly into the demand for non-binary pronouns; the concept of American universities embracing signs like ‘Ask Me About My Pronouns’ caught me completely off guard. As the BBC article attests, ‘The alternatives to “he” and “she” are myriad.’ Indeed, ‘A linguist at the University of Illinois, Dennis Baron, has catalogued dozens of proposed gender-neutral pronouns, many – including “ip,” “nis,” and “hiser” – dating back to the 19th Century.’ Who would have thought…?

Fortunately –for me, at any rate- ‘[…] Baron calls the gender-neutral pronoun an epic fail and reckons that new pronouns such as “ze” may not survive. But both he and Sally McConnell-Ginet, a Cornell University linguistics professor who researches the link between gender, sexuality, and language, think the singular “they” – as used for example by Kit Wilson – has a chance of success.’

But languages change; preferences and acceptabilities mutate: ‘…English has a precedent for a plural pronoun coming to be used in the singular – the pronoun “you”. Until the 17th Century a single person was addressed with “thou” and “thee”. Later “you” became perfectly acceptable in both plural and singular.’ And then of course, the obverse ‘you-all’ (or the highly recognizable ‘y’all’ in some southern U.S. states’ dialects) -a merging of singular and second-person pronouns.

Now I suspect that much of my confusion at all of this probably stems from my perspective at the night-robed end of the age spectrum. From this spot, there is a tendency to view change as either unnecessary, or spurious -change for the sake of change. I admit my hesitation to embrace the need for even more twigs on the already-gnarled and pot-bound grammatical family tree which is already in desperate need of pruning. Perhaps it needs another pot entirely. Maybe that is what is intended.

I suppose I should have been prepared, though; I think I had a foretaste of it several years ago in my office.

Lynne and Elin were so alike, they could have been twins. Both sat entwined like ivy in a shadowed corner of the waiting room. They weren’t conspicuous or inappropriate, just, well, close. As I busied myself at the front desk with some forms I had to print, I noticed others waiting nearby stealing glances at them while pretending to be absorbed in some magazine or other. Both with short dark hair, identically-coloured light blue shirts, unbuttoned at the neck, and loose, black jeans they scattered no useful gendered clues to the increasingly curious audience.

They both shook my hand when I approached, and both quietly accompanied me down the corridor to my office. I encourage patients to invite their partners to come with them to the consultation, but in a gynaecological practice, embarrassment –or a desire for privacy- often limits the participation of one of them. But not with these two. It was like inviting the flower without the stem.

Even when they seated themselves in front of my desk, I was still uncertain of their identities. Who was Lynne, and who was Elin was only part of the puzzle. I suspected that Elin might be a male partner, but when I heard him/her speak, I couldn’t be certain. Then I entertained the possibility that they were indeed twins –although more likely not identical ones- and that, like many twins, they did things together, whatever their gender.

It was Lynne who had been referred, however, so trying to be respectful of their homogeneous appearance, I stared intently at my computer screen to avoid their eyes, and asked which one of them was Lynne.

A knowing smile passed between them, and the one on the left put up his/her hand like she/he was in a class. “I’m Lynne, doctor,” she said, looking amused. “And this is my partner Elin,” she added, looking proudly at him/her and then reached for their hand.

I was speechless for a moment, but I tried to hide it with a smile and then a nod in his/her/their direction. “I see,” I finally managed and then, looking at Lynne, promptly crossed some sort of a line when I continued with, “I glad you invited her to be with you.” I said it to be polite and inclusive, but I suppose I also said it as a way to establish Elin’s gender. They both stiffened immediately.

“Elin does not recognize gender identity, doctor,” Lynne said in a tone that brooked no contradiction.

“Nor does Lynne,” Elin tossed at me.

“I don’t want to be limited in who I am,” Lynne chimed in. She wasn’t trying to be provocative I don’t think, but I know she realized the effect it would have on me, because her eyes hardened and her forehead wrinkled like a professor introducing a new concept to a fidgeting, skeptical class. “Sometimes I’m both, and sometimes neither… I am what I am in the moment.” She said that with such fervour that one eye actually closed with the effort.

I think she was daring me to question the possibility of a modern-day Janus -the two-faced god of transitions. Instead, I was intrigued and I could see it surprised both of them.

I nodded in acceptance, smiling to myself all the while. I’d never considered the idea before, and I found it fascinating. “So, if I may acknowledge my naiveté in such things, may I ask how you would refer to Elin –in conversation, for example? Which pronoun would you use –masculine or feminine, or…?” I left it open so she/they could offer her/their preferences.

“Well,” Lynne started after a long look at Elin, “we considered ‘ze’ as kind of a neutral pronoun at first, but it sounded sort of… weird. Then we tried ‘ey’ –sort of a slurred mixture of the conventional choices- but everybody seemed to think we had just mispronounced ‘she’ or ‘he’ and tried to clarify it for us.” Lynne shrugged and squeezed Elin’s hand. “I hate binaries,” she added as a sort of postscript.

“So we’ve decided just to use our names instead of other gender-obfuscating pronouns,” Elin said and smiled, satisfied that using the word ‘obfuscating’ somehow deposited the problem behind them. “I mean, if you think about it, even the concept of ‘binary’ suggests that there are only two choices: male and female. We know that is no longer the case,” he/she/they/ey/ze concluded. And I suppose for them (I am allowed to use ‘them’ apparently), it wasn’t.

Lynne suddenly looked at her/their watch and glanced at Elin. “I’m so sorry doctor, but we have to catch a bus to the airport to meet Elin’s mother. I didn’t realize the appointment would take so long…” It was obviously a lame excuse – an escape mechanism, they’d probably used before, but I let it pass. Whatever Lynne’s gynaecological problem, she/Lynne/they felt it could clearly wait for another visit.

Actually, I didn’t think it had taken any time at all –I hadn’t even asked her/them/Lynne why she/they/Lynne thought she/Lynne/they been referred. But I guess pronouns are slow-moving beasts, so I just smiled and asked her/them/Lynne if she’d/Lynn’d/they’d like to schedule another appointment at a time when Lynne/they/Elin could stick around a little longer. I didn’t say it like that, of course –it would have taken far too long and they/Lynne/Elin were obviously in a hurry.

Lynne/Elin/They smiled at me when they/Elin/Lynne left so Elin/they/Lynne obviously didn’t feel they/Lynne/Elin were not heard. And I, at least, felt I’d taken the pulse of a new and perhaps metastasizing condition; I had learned something new about the world. I have two regrets however. One of them is that I never saw them/Lynne/Elin again so I couldn’t pursue my gender education any further; but mainly, I never was able to discover whether Elin was male or female… not that it would matter to either of them, I guess.