The Stand

“So, do you have a stand on that, then?” She was smartly dressed in jeans and what looked to be an expensive white silk blouse and divided her eyes between my face and a little notebook in her lap. Whenever I said something she liked, she would scribble furiously and noisily in it. Otherwise it was silent -a non-attributable form of media manipulation? The noise amused me more than anything.

“I thought we’d already established that I like to hear what the patient is saying and then try to diagnose…” -I thought I’d sprinkle a few medical terms at her- “… what it is that she is trying to tell me.” I stared at her silent notebook and then added: “There’s more to conversation than words.” Her face took on the look of a dog that hears a noise it can’t locate. I could tell I was losing her. “You know: tone of voice, cadence of speech, body language…”

Her expression softened, and there were a few cursory scratches of pencil on paper. “A bit wish-washy. I’m trying to get at what you actually believe.” She said the word as if there were discrepancies in my answers so far.

“I believe…” –I thought I’d italicize the word as well- “…that it’s important to understand what my patient believes -read between her lines, if you will.”

“Her lines?”

Well, that metaphor was lost on her. “The lines, then.” Silence: pen gripped tightly but motionless, eyes fixed, breath held. More was expected: an addendum. “I mean that sometimes a person says one thing , but actually means something else that they’re afraid to say… Or maybe haven’t really decided what they think.”

Her brow crinkled -rather cute,  I thought. “But you’re the doctor! Wouldn’t you have an opinion on what she was telling you?”

I took a deep breath but tried to disguise it in case that would somehow get translated into pencil scratches. “If I knew what she was telling me, I suppose it might help me to direct my subsequent questions more appropriately…”

“But,” she interrupted, pencil at the ready, “let’s say the woman has already come in to see you with… a situation…” I suspect she thought she was being sensitive with that choice of words. Politically neutral. “Wouldn’t that in itself give you the information you need?”

I shifted into my bland I’m-not-sure-what-you-mean mode that I often find helpful in the office. “Information, yes; solution, no.”

“But…”

I’m still not sure why I had agree to be interviewed. Not really. Superficially I suppose it was because one of my colleagues was doing abortions and had a recent complication with the procedure -through no fault of his own, I might add. The woman had tried to self-induce a termination of her pregnancy, failed, become seriously infected, and then sought medical help from my colleague. He performed his job admirably and saved her life through his own skill and knowledge, but someone had leaked the ‘complication’ to the press and the whole event had been misconstrued. So perhaps I’d wanted to set things straight. But that’s not what this journalist saw as her mission. I suspect she actually wanted to know the opinion of a gynaecologist who worked in an ostensibly Catholic hospital.

I’d tried to dissuade her from that approach at the start, but to no avail. Now I was becoming a little annoyed at her persistence. But if the truth be recognized, it was her agenda that bothered me the most. I put on my best doctor smile and sat back in my chair. “Perhaps it might be a good time for you to be more specific. What is the question that you are leading up to?” Somewhere inside I blushed at my ending the sentence with a preposition and wondered if that might be one of the few sentences that she would quote in her article.

She gripped the pencil tightly; I could see the bones in her hand standing at attention just under her skin. “Doctor, you work at a Catholic hospital, do you not?” I nodded, but it was one of her conditions for the interview in the first place. “What do you think of abortions, then?”

My smile continued without interruption. I knew that was what she wanted, and had expected it at the beginning. And yet the question, at least for me, was irrelevant: where I work does not determine what I think. And what I think does not interfere with how I manage a patient with a problem. The journalist was staring at me, pencil poised, a subsequent question rolling around in her mouth just waiting for my answer. “Would you care to contextualize that?” I said, knowing full well she would have no idea what I meant.

“Pardon me?”

I crossed my arms and leaned forward on the desk that I had been careful to sit behind at the start of the interview. “You asked me what I thought of abortion. You might as well have asked me what I thought of fibroids…”

“I… I don’t see…”

“No, you don’t do you? Well let me put things into context for you, then. Abortions? I wish they were unnecessary. But then I also wish that people only became pregnant when they chose. And if they chose. In life, things happen, and not always for the best. I don’t much approve of smoking either, but that doesn’t mean that if a person were to become ill because they smoked I wouldn’t try my best to help them. Or in my own field, if they were to develop chlamydia or gonorrhea that I wouldn’t help them because they hadn’t used a condom, or maybe adhered to my own person moral preferences.

“Am I an ethical relativist? You might better ask me if I am a doctor. If you were to walk through that door looking for help, my first question would not be whether we had the same belief systems or the same cultural norms. No, it would be what can I do to help you? In other words, how are you suffering? And if I asked you about your sexual practices, or preferences it would not be to criticize, but to help in the diagnosis and treatment of the condition for which you had sought my help.”

“Are you Pro-Choice then?” I could see the words forming on her lips before she uttered them.

“We all have choices and I respect that. It’s not for me to interfere; I am not the person who has to make them. But I prefer to think of myself as Pro-Help… Perhaps I am the sounding board that helps you to make the Choice for yourself.”

With that she tucked her pencil and the notebook in a little shoulder bag and stood up. She sighed deeply and demonstrably. I had wasted fifteen or twenty minutes of her time. Now she was going to have to find another doctor to interview, I supposed. I stood up and extended my hand to shake, but she took it somewhat reluctantly, I think. “I’m sorry you decided not to commit yourself, doctor.”

I’m assuming it was a subtle put-down, but I allowed my smile to dance a moment longer on my face until I tucked it carefully away. “Actually, I think I did,” I said, and ushered her out of the room.

Hormone Replacement Therapy

Do you remember those Once-upon-a-time stories from when you were a child? They seemed to promise so much and yet, when considered in the light of the next day, offered so little. Sometimes I think that the story of hormone replacement therapy (HRT) has a lot in common with those faerie tales. I mean it all seemed to make so much sense: replace what is no longer there. I even remember likening estrogen lack -menopause- to diabetes with its relative or absolute insulin lack: a disease for which good health mandates a replacement.

And it made sense that those things which seemed uncommon during menstrual life -heart attacks, memory loss, dementia and so on- should be treatable, if not in fact preventable with a mere whiff of estrogen. But of course, it was quickly appreciated that estrogen, as powerful as it seemed, was only half the equation; it needed its partner Progesterone to prevent inadvertent over-stimulation of estrogen sensitive cells like those in the uterus -and maybe elsewhere. Who knew?

That of course led to a struggle between the two giants: some people developed mood changes, irritability, or even depression with progesterone. And some synthetic progesterones carried their own baggage: they changed cholesterol and sometimes even triglycerides to levels that might indicate an increased risk for heart attacks and maybe strokes.

It quickly became a delicate dance of two partners, both used to control -or at least being controlled. Like two teenagers constrained when at home, managed as they were growing up with recognizable top-down authority, they were noticeably different when their parents were away: no rules. Even their roles were vague. Should enough progesterone be given to inhibit bleeding? For years it was administered  cyclically in an attempt to mimic the normal monthly pattern of periods. Then it became apparent that cyclic bleeding was not only unnecessary, but also confusing: could the bleeding be a sign of something other than progesterone withdrawal -cancer, for example? So continuous administration of both hormones became the norm.

Then the breast cancer scare. Progesterone seemed to have the special task of inducing cellular growth in normal breasts, so could it go one step further and..? Well, the dance continued -and continues. It’s a kind of Three -make that two- Bears story now: Just right baby bear. Not too much progesterone -just enough to do the job without getting into any other mischief.

Several large prospective studies were done that sort of took the wind out of the hormonal sails and the prospect of eternal youth with cardiovascular and neurologic protection as a bonus seemed to evaporate like early morning fog. Not only did they not protect against the ravaging teeth of age or dementia, there seemed to be a higher risk of heart attacks and strokes for at least the first year of their use. Not what anybody wanted to hear.

More recent evidence suggests that if the hormones are started early enough, there may be some degree of protection for maybe five years or so, but are you beginning to see a pattern in the retrenchment? We are determined to salvage some degree of credibility for hormone replacement even where the evidence is underwhelming.

And yet, it’s perhaps not that HRT is not helpful, but merely that it is not helpful enough in the areas where we had our greatest hopes: prevention. The elixir of youth was never attainable, but it did seem reasonable to hope that those things that often accompany the withdrawal of hormones -or maybe just the age at which it occurs- could be forestalled. Eliminated. Conquered. Youth, when hormones are raging, is seldom bothered by heart attacks, Alzheimer’s or strokes. There is a different world-view, a different expectation…

But menopause can be a traumatic time both psychologically as well as physically. There is a realization, sometimes resisted, that a different era has begun. A different life, even: one without the prospect of pregnancy, or natural periods, or even comfortable sex in some cases. A life that some might be tempted to live in retrospect: what was, and not what is… The tripartite curses of hot flushes, memory loss, and sleepless nights are for many, significant and insufferable.

Fortunately, that’s an arena in which HRT plays comfortably. No, there’s no magic potion; Ponce de Leon never visited this country. But hormones are fairly efficient at relieving hot flushes and the other menopausal symptoms that make daily life so uncomfortable. There are bonuses with maintaining bone health, and perhaps skin health, and maybe even vaginal health. Everybody’s different -all doctors say that (just in case)- but one could certainly argue that HRT should only be used for symptom relief and not preventative therapy. Know the risks and balance them with the benefits -another truism.

HRT has its place as do alternative therapies. But obviously if the alternative therapy wishes to address an estrogen lack, it has to have an estrogen effect and therein lies the problem. A phytoestrogen (plant-derived), for example, can be just as dangerous, unopposed by progesterone, as another more mainstream form of estrogen. The piper has to be paid. There are risks to all hormones, whether estrogen-substitutes or the real thing. Some are helpful in the short-term, and some are probably placebos but there is at least a choice -none miraculous, none infallible, some of even questionable value, but all are available for the choosing. Or not.

One can choose not to choose. All choices come with pitfalls; I certainly cannot make the choice. I am reminded of  Hortensio in the beginning of that delightful Shakespearean play The Taming of the Shrew. The context is irrelevant, but his comment is not: There’s small choice in rotten apples. Well, maybe, but at least there are apples…

Midwifery

Perspective is a mysterious thing: a thousand people crossing a single bridge is a thousand people crossing a thousand bridges. We can only see the world through our own eyes; none of us is exempt.

When I first graduated, doctors were a cult, and immersed in it as I was, I would not have thought of it as such. We were doctors and they -everybody else- were, well, others. And at the time, I remember well that the very idea of entrusting the care and delivery of a woman to someone outside of the medical profession was anathema. We were the Guardians of science, and only we realized that things could go horribly wrong in a pregnancy if not guided by someone on a first-name basis with disease -someone not necessarily experienced with the vagaries of the process, but one who could at least recognize that it was going wrong and take an alternate path to its successful resolution: forceps, arcane manuevers, Caesarian Sections… Of course the obstetrician was never as threatened as the family practitioner because only we could perform the complicated stuff. Our training was longer, more intensive. Put another way, we were even more indoctrinated.

Why do we fear the other side? Why is there an other side? I suppose we mistrust those who come from different traditions -those whose perspectives do not entirely conform to what we have been taught. We are parochial creatures; it’s where our comfort lies. Seldom do we have the patience -or wisdom- to attempt to frame the world differently. And why should we, if we believe we possess the Truth, that we alone walk the Path? But of course we don’t. There are as many paths as there are destinations and how dare any of us assume we know the best one?

I am reminded of a patient I saw in consultation earlier in my career than I care to remember. She was in her second pregnancy and had been referred to me by a family doctor in town because she had required a Caesarian Section for her first child. She was only four feet ten inches tall and as the doctor had tried to explain to her, the first baby was too large for her pelvis, so the second would be as well. But she wanted to go to a midwife for her antenatal care. What was the harm? As she explained to me, if the second baby didn’t fit and the labour didn’t progress, the midwife would be able to refer her to the obstetrician on call and she’d have the Caesarian then: win-win.

“But doesn’t it bother you that you may go through all that work and distress for nothing?” I asked, incredulous at the very idea, and clearly insensitive to what she was trying to tell me.

I remember she sat up straight in the chair and stared at me, equally incredulously. “For nothing? Doctor, no offense, but do you see why I want to go to a midwife?”

I didn’t understand it for a long time. I had to mature enough to realize that although we both wanted the same thing -a healthy baby- there were different routes to the same place. One of my favourite poems describes it best, I think. Do you remember the one by Robert Frost: The Road Not Taken? It starts: Two roads diverged in a yellow wood/ And sorry I could not travel both…

And how it ends? Two roads diverged in a yellow wood, and I-/I took the one less traveled by,/And that has made all the difference.

I don’t mean to suggest that one of them is better, or preferable, or even less chosen, merely that I shall be telling this with a sigh/ Somewhere ages and ages hence.

I suppose I should have known…

The Hormonal IUD

A few of my readers and a not inconsiderable number of my patients have encouraged me to comment on the hormonal IUD (IntraUterine Device). In the UK, it is often known as the intrauterine system, but here in Canada it is best known as Mirena. It is a plastic T-shaped device containing a synthetic progesterone (levonorgestrel) inside a semipermeable membrane that allows a small and predictable amount of the hormone to diffuse through it and into the uterine cavity. The cavity, by the way, is also T-shaped -hence the shape of the device. Two thin monofilament nylon strings attach to the shaft of the T and protrude maybe a centimeter out of the cervix. If they are trimmed to an appropriate length, the man won’t notice them, but the woman can feel them to assure herself that the device is still in place. They are also how the IUD is removed.

The amount of progestin liberated is minute and shouldn’t have much effect on the rest of the body, but because progestins decrease the effect of estrogens on growth of the lining cells of the uterus, periods are often less heavy. Occasional spotting occurs in a small minority of wearers, but usually this disappears within a few months of its insertion. The device is good for five years and provides extremely good contraception that, unlike with oral contraceptives, is not affected by other medications that may be taken, and is not something that requires a daily smart-phone alert to remember.

In other words, it is by and large a well tolerated form of contraception, so I was surprised at the controversies swirling around it. True, the copper IUD has had its problem times. Quite a few years ago now, I think that too little thought was put into the selection of patients and IUDs were inserted into women with multiple sexual partners, or with a history of pelvic infections -both conditions which have since been shown to increase the risk of subsequent infections. Hopefully doctors are more careful about that nowadays… And anyway, those were copper IUDs which work by the copper ionizing and causing a (hopefully sterile) inflammatory reaction in the uterus. Sperm hate that, but germs often welcome the extra blood supply. Progestins, as I mentioned, don’t cause inflammation and in fact actually quieten uterine activity. So, apart from a very small risk of infection in the first month of use (perhaps from bacteria being introduced at the time of insertion) the device seems safe.

I also wondered if the controversy was related to the well-intended advice provided by the manufacturer about the risks. As one might hope and expect, pharmaceutical companies are supposed to disclose risks related to any of the components in their products. The Mirena contains a synthetic progesterone, so naturally other progesterone-containing products had their side effects listed. Depo Provera is one such medication and is well-known to have weight gain, spotting and even occasional irritability associated with it. Another product containing progestins are birth control pills. They sound even worse -especially when stripped of context: heart attacks, strokes, phlebitis -estrogen issues, mostly. But what a cursory reading of these problems misses, I suspect, is the minute dose of progestins that are being deposited only in the uterus without the need for huge amounts arriving from elsewhere that might really cause the unwanted effects.

In fact, I remember a patient that I had seen previously for contraceptive counselling who glared at me from the door, then sat down opposite me and pounded angrily on the desk. “I’m not going to let you shove a Mirena in me,” she said, as if she were going to leap over the desk and throttle me.

I tried to hide my startled reaction, all the while watching her other hand to make sure it wasn’t going for a weapon. “Why’s that?” I asked -somewhat timidly I have to admit.

The glare hardened. “Because it would be like wearing a bomb!” she screamed and walked out.

I put it down to too much media terrorist coverage at the time, but now I think I understand: we, as health professionals, should be helping our patients to navigate the labyrinthine halls of the internet complex. Not discouraging this, but helping them to read contextually instead. Carefully. Knowledgeably. Making them aware of the untrammelled pitfalls of naive searches; of Confirmation Biases that will limit their reading to what they want, or expect to find; and of agenda-driven blogs that may attempt to undermine any well performed research that hasn’t met with the writers’ experience.

The IUDs are not for everyone; they are merely members of a tool-kit of options, and as long as these are sensitively explored and adequately explained, they expand the choices in an admittedly personal and emotionally charged aspect of relationships nowadays. I’ve always hoped that the more choices there are, the more likely it is that one will actually be chosen. And used.

The use of the hormonal IUD is by no means confined to contraception either. I have to tell you that it has been one of the most useful tools I have at my disposal for patients with heavy, and otherwise uncontrollable menstrual bleeding. This can be especially troublesome in the years leading up to the menopause. It was, I suspect, why so many hysterectomies were being performed in that age group in years past. Progestins, remember, slow down the growth of cells in the uterine lining, so the less cells to shed with the period, the less heavy the period. Not a bad trade for hysterectomy. I make less money as a surgeon perhaps, but then again, I find that I sleep with less troubled dreams…

Choice

What do you do if you just don’t like someone -or in the context of a doctor/patient relationship, what should you do? It’s a vexing question at the best of times, but perhaps even more so if you are a patient that has been referred to a specialist. Or you are that specialist…

The question assumes a different dynamic when it is viewed from the perspective of non-urgent healthcare -something with which I suspect we are all familiar. Not to be misunderstood: all healthcare is important. Health is not trivial, nor is the individual perception of it. Nuisances loom almost as large as burdens or hazards in many of our otherwise unthreatened lives. And the very concept of Health itself could likely use a more compelling definition. But that aside, the problem remains: having decided that something requires a diagnosis and hence a remedy, and having been informed that the help in question is only available outside the warm and reassuring nest of the family doctor, what if there is an unbridgeable gap? What if you feel that you simply cannot confide in the specialist? That he will not listen to you? That he will not take your condition or your suffering seriously? That you, in the final analysis, don’t like him?

There are many facets to this problem certainly, but in the end most of it boils down to trust, not to mention respect. On both sides.

In an emergency -an accident, say- the problem of trust is perhaps more secondary: if you’re bleeding, you need someone to stop the bleeding, attend to whatever injuries have been sustained -fix the problem as it were. Only in the recovery phase -the sober reflection phase- does trust re-enter. But that’s after the fact; analysis is usually suspended in the face of dire need. In other situations, things are in many ways more complex: there is time for choice -time, in other words for preference. Trust. Belief. Much in medicine depends on belief: belief that there is help, belief that you can be helped and of course, belief that the doctor is capable of helping you. Think of belief -trust- as being the Supreme Placebo. It is the underlying understanding that hope for recovery is justified. Some situations require less of it -an appendectomy will likely cure appendicitis whatever you think; some situations more: chronic pain, for example. Most conditions probably fall somewhere  between and within this spectrum, and the results of treatment therefore, as well. And treatment is usually a two-way street: an unwriteable contract between care-giver, and care-receiver. Both need to trust each other; both need to respect each other or it won’t work. There are just too many variables.

Let’s return to the original question, however. What if, after waiting for three months or more to see the specialist, you find you do not like him? Well, I suppose in our system, you could refuse to go back to him and request a second opinion. There may be a delay in finding another doctor, and there is always the chance you might not like her either, but at least there is a choice, an option… For you…

But what about the specialist? What should I do if a person has been waiting to see me for several months and I have trouble relating to her? Not because of her race, or creed or sexual orientation; and certainly not because she comes into the office poorly dressed, or seems preoccupied with something else… These things to me are irrelevant. A medical practice is like a UN membership: toleration and respect for differences is part of the relationship, part of the expectation. I do not need to become friends with those that have been sent to me, although I don’t preclude it. And while I hope that my diagnosis of their problem will be accepted or at least considered helpful, I don’t demand to have the final say in their ultimate treatment if they don’t wish it. But there is a core expectation on my part that is integral to my continuing role in their health: not necessarily that I should like the person, but rather that I must not dislike her -not what she stands for, not what she may profess to believe, nor even who, in fact, she is -but her!

There’s a difference, isn’t there? We don’t all get along, but if we do, things flow more smoothly. There can be a give and take of ideas, a path of mutual understanding: on my part, that I think I can help; on the patient’s part, that she agrees that I may very well be able to accomplish what she needs. It’s a mutual thing, and both must be present for the contractual obligations of the referral to be fulfilled.

Admittedly, if there is dislike on one side of the desk, it very likely extends to the other side as well. But that begs the question doesn’t it? The patient may be reluctant to ask for another opinion: there is often a discomfort in that; she may not know what to do or how to extricate herself from the situation. And it is difficult for me to suggest she see someone else as well -especially if it’s not evident that she feels similarly. But in her interest -and mine, to be sure- I feel it has to be done. Fortunately it is uncommon -rare, in fact. I can’t remember more than two or three occasions in all my years in practice where I felt it was essential for a successful outcome. But it is an important option, and one that I think the patient ultimately, if not immediately, understands and accepts. Deserves. A medical relationship should be a space -a room- that both agree to enter. It’s certainly a place where I live… Both of us should be comfortable in the same milieu.

As Jose Ortega y Gasset has written: I am I plus my surroundings and if I do not preserve the latter, I do not  preserve myself. Nor, I would add, the patient herself…