Meanings

Can we ever understand each other? Know what is being asked of us? It’s not just a medical problem; it’s universal, I suspect. And it’s one that entails far more than simply comprehending the meaning of a word in both its denotative (definitional) as well as its connotative (secondary, or evocative) usage. It involves apprehending -truly appreciating – whatever is intended in the communication.

In a sense it is often a relational concept: we are linked in a sort of symbiosis and inherent in that is the empathetic interpretation of what is being conveyed. Friends potentially have this: Don’t listen to what I say; hear what I mean. We all hope for this, I think -especially when things are hard to express, when words fail, as it were. When we need the other person to grasp something we cannot adequately articulate, we are at a loss -or perhaps more accurately, at a disadvantage- in terms of receiving their help or advice. Words, large or small, can be impediments.

And this is particularly salient in medical encounters where both unfamiliarity with appropriate terminology as well, perhaps, as embarrassment, conspire to camouflage the reason for the visit. Where you say pain, but really mean cramp, or perhaps irregular -referring to your menses, for example- when you actually mean totally unpredictable, or maybe that you’ve even stopped trying to keep track of them… Where cancer could mean something you think your grandmother had -but nobody would talk about it with you- or that in fact it’s what you think you have but are afraid to verbalize it. Heavy is what your periods are not -even though you are anaemic- because they’ve always been like that, and so were your mother’s: They are normal, doctor

I realize this is not usually a major obstacle to doctor-patient relationships, because over time doctors learn to listen to what is not being said; the encounter is frequently more valuable than the words in it -no matter how descriptive. It is also why it is often so difficult to address problems over the phone.

Through the years, I have struck by the need not only to be a good listener, but a good and careful observer. There is as much meaning in silence as in conversation; as much information in examination as description. Words are susceptible to challenge, or misinterpretation; unimportant ones can be uttered with emphasis, significant ones mumbled sotto voce. Comfort level is privileged and not summonable at will. Words escape from the top of the tongue, or are inadvertently trapped behind the teeth; meaning is sometimes a prisoner to safety -be it cultural, or personal. And it can be as unpredictable as the weather; as fickle as a mood…

So then, how can we understand each other -especially in moments of crisis? How can we ensure that others know what we intend -what we need to convey? Is it as simple as choosing the right words, the right syntax? Is it a vocabulary issue, or something more complex? More profound? From the doctor point of view, I would argue for the latter; I think that the essence that underscores all communication, that underlies all meaning, is engagement: being present in the situation at hand; imbedded in the message -both obvious and covert, intended and accidental; alert to context; aware of the unspoken. Words, after all is said, are just drawings in sound; to understand, to really comprehend, we must listen with more than our ears, see with more than our eyes. To listen fully, we must hear.

It is not an arcane prescription, not something requiring years of training; it is what we all attempt when we truly care; it is what is missing when we do not… And absence of the effort is something Shakespeare noticed so many years ago (Henry IV part II):

It is the disease of not listening,
the malady of not marking,
that I am troubled withal.

The Guardian

To anyone watching from a distance, they were both very much in love. Hands entwined, bodies linked at hip and shoulder, they clung to each other like moss to a tree. Her eyes sought his for sustenance, energy, approval; their movement along the corridor and into the office was sinuous and choreographed. Synchronized swimming came to mind.

After I shook their hands and introduced myself, they moved the two available chairs together and sat, linked by wood and sleeve across from me.

I glanced at the consultation request from her family doctor and smiled to welcome them. Pain was what the doctor had scribbled in barely legible letters across the page -no other explanation, no other information- as if the word itself was justification enough for a consultation. I looked up from the almost-empty page and saw them staring at me.

“What does it say?” He sounded suspicious, concerned; his curiosity was evidently dominant. Contingent.

“Well,” I started tentatively, “It doesn’t say much at all -just ‘Pain’.” He seemed relieved and glanced at his partner with a now-soft face. “Perhaps you can tell me more about it,” I said, pointing my eyes directly at her.

“She’s got pain all the time, doctor,” he responded, clearly used to being asked the question first. “It started out with her periods, but now she seems to have pain no matter when I ask her.” He looked at her as a teacher would his pupil. “Isn’t that right, Grace?” She nodded dutifully, perhaps relieved to have the substantive part of her history out of the way.

“How long..?” But he didn’t let me finish my question.

“It’s been going on now for…” -he glanced at her as if to refresh his memory- “What..? Six months now?” She smiled and said ‘Maybe’ to me with her eyes.

I nodded encouragingly, but groaned inwardly: taking the history was going to be painful. “Is that right, Grace?” I asked.

She looked up into his face, smiled, and then back at me. “Yes,” was all she said, and yet her eyes seemed troubled. Only her eyes…

He took over again. “I’d say six months, because that’s when we got into a little financial trouble; Grace is very sensitive to stress.” He turned to her and said, “Aren’t you, honey?” She nodded -of course.

I played with the pen I was holding. “So are you suggesting that stress might be playing a role in your pain?” The question obviously made her flustered; she didn’t seem to know how to answer. I thought I’d try to get at  least some information I could use. “Where is this pain that you’re having, Grace?”

Again she looked at him. I thought I detected a concerned expression.

“Well…” She started too slowly and it gave him time to respond.

“She gets it in her pelvis doctor. Isn’t that right Grace?” She sort of smiled. “All over her pelvis… into her back, down her legs… It’s terrible.”

“I see…” But I didn’t. “And when did you say you get this pain, Grace?” I tried to direct my questions to her, but she kept looking at him for -what?- approval?

“She gets it with her periods, but also…” This time he looked at her and they exchanged knowing but otherwise undecipherable expressions. “She also gets it when we’re making love…” He stopped, feigning embarrassment.

This was obviously why they’d come; why he’d come with her… “Well, then I think I’m going to need to get a little background information.” He looked at me as if I was going just a little bit too far. “So, let’s start with when you first started having periods…”

I took what history I could get from her, but he kept interrupting and correcting her. And when I suggested that I needed to examine her he refused.

“She’s having her period now, doctor.” He stared at her, concern evident in his body language. “And anyway, Doctor Jonas said you probably wouldn’t have to.” He blinked nervously. “She said we’d only need to talk about it.”

I took a deep breath and put down my pen. “It’s pretty difficult to come up with an appropriate diagnosis without an examination.” My turn to stare at him.

He shrugged -triumphantly, I suspected- and put on an apologetic face. “Dr. Jonas was pretty certain it was Endometriosis…”  I could almost see the capital letter in the word. He pretended to be tentative, but his manner suggested confirmation and agreement. “She thought maybe you could just prescribe something and see how it worked.”

“And did Dr. Jonas examine you, Grace?”

Another glance at him and a resigned sagging of her shoulders. “No. Jim…” She stopped suddenly with his quick almost-hidden tug on her sleeve and let her glance stall briefly on her feet before it again climbed his body to his face. “…I was having my period then, too.”

He smiled and blinked slowly -too slowly I thought- and then sighed. “We always seem to choose the wrong time for these appointments, don’t we?”

I sat back in my chair, and looked at them both for a moment. “Well, I’m not willing to prescribe anything until I have a better idea what’s going on.” I leaned over the desk and closed the chart slowly. “Maybe you should come back and see me next week when your period is over, Grace,” I said. “And you probably don’t need to take time off work to come then, Jim…” I added hopefully, letting my eyes rest on his.

They looked at each other, but this time her eyes were harder, sterner. She was about to say something when he squeezed her hand. “No, I don’t mind coming, doctor…” He gazed lovingly at her. “We go everywhere together.”

The Humility of Age

There is a humility that accompanies age, shuffles along beside it, tugs on its sleeve to attract attention. Or is it insecurity? Or maybe resignation? It’s a gradual thing -for me at least- and it surfaces mainly after a busy and sleepless night on call when the stark, brutal demons of decisions made, or actions taken, stalk the leaf-bare branches of my exhausted mind. Thoughts, undefended in the early dawn, creep like lengthening shadows disguising all the colours that attend each birth and decorate each soul that cries out from its unintended visit to an over-crowded Emergency Department.

These are not the shadows of mistakes, nor the visitations of guilt for broken trust; they are not the heart-heavy burdens of ignorance, nor the all-too-frequent penalties of stolen time… These could be the excuses, of course: none of us is perfect, nor omniscient. Feet do drag, spirits do wane with over-use. To deny that Responsibility is obese with obligation and liability, or that it is uniquely manifested each time would be to deny humanity -and Medicine itself…

No, the spectre that haunts my night and follows me into each room is more subtle than that. It has no name – or none that I have ever heard at any rate. It sits in the corner smirking each time I enter a room; it holds its tongue and yet follows me with its eyes; it pins me to the wall with unanswered questions, hand waving impudently to ask its own. I don’t know why it’s there…

And yet I do; we all do: any of us who offer knowledge or presume to. It’s the monumentally Existential Question, the true moment critique: am I what I say I am? Not who I claim to be -that is easily verified. There are others as accredited as myself around to vouch for my identity. No, rather, am I the proper one to solve the problem: the Magus? The Shaman? Or am I a fraud, and my opinion merely that: one approach out of an infinite number, chosen at random from the hat I happen to be wearing at the time? Or worse, the only opinion I possess -pinned and pressed into legion shapes as the occasion demands? Sufficiently disguised, would it fool even me..?

I wonder about these things not because I suspect their truth, nor even concede their possibility, but rather because not every problem I encounter is sui generis. There are commonalities that link many situations in Obstetrics -and Gynaecology as well, for that matter- and one solution, sufficiently moulded, will often suffice. Recycling an idea -dressing it up in different clothes- does not necessarily negate its value. Using the same keyboard design on a typewriter and a computer does not invalidate the usefulness of either.

Experience teaches me that a calm analysis of each interaction, a survey of the data available, and a decision based on the findings presented to me, more often than not lead to an acceptable solution. With that, I am not haunted: I can peer however obliquely into the past for innumerable examples of its success. I do not bathe in this; I merely acknowledge it.

In the cool dawn after-glow of endless decisions and a night of dodging the panic-thrusted knives of patients and their concerned loved-ones, I am more troubled by -No! I am amazed at- the trust accorded me despite the often panic-laden atmosphere I enter. And I ask myself what makes these strangers take me into their confidence? Why should they trust me: another stranger, an unknown quantity? Is it desperation? Or Hope?

And can I, once again, perform as I have in the past..? Not just with babies -there are also many questions born of a busy night. Each requires context; each requires thought… When I was younger, I used to read Carlos Castaneda -you know: stuff like The Teachings of Don Juan…– and I remember something from one of his books: “We either make ourselves miserable, or we make ourselves strong. The amount of work is the same.” I think he had something there. Maybe he, too, was on call for something important…

Harm Reduction

I have always been suspicious of zero-tolerance; it implies intolerance as much as anything else. A thousand people crossing a bridge, are a thousand people crossing a thousand bridges… We are simply not all the same, nor are our worlds, our needs, our perspectives. And even if some issue could be proven beyond a reasonable doubt, there would always be those for whom it was still not acceptable -or even relevant. Our views are just not theirs.

Many of us see things through cultural and socioeconomic lenses, parental filters, and with confirmational biases in full bloom, assume that we have good and verifiable evidence: what we accept is universally applicable, validated and therefore reasonable.

This leads to various problems, both ethical and legal however. Take smoking as an example. If we accept -as most of us do- that smoking is a major health hazard, what should we do about it? What can we do about it? Well, at least two options suggest themselves. We could ban cigarettes outright, make them illegal -zero-tolerance- much as we do for other undesirable drugs.  Or, in Canada (or any other country with universal health benefits), we could sell the cigarettes (and profit from the sales) but deny tax generated health benefits to smokers with conditions caused by the cigarettes… Even if the smokers are themselves contributing to those taxes.

Perhaps a better and more useful, more benevolent approach might be to change societal attitudes towards the problem: make it unfashionable, undesirable, say, to smoke. This is widely seen as the answer nowadays -albeit a plodding and often unpredictable approach. The results are slow in coming, and often different from what we had originally intended. And there is the ever-present danger of intolerance and prejudice -a new, self-righteous view of the way things should be…

I see this in obstetrics. Alcohol, which in other circumstances is acceptable -even the norm- is very much stigmatized in pregnancy. There are certainly many good and evidence-based reasons for concern -the Foetal Alcohol Spectrum Disorder (FASD) among the most serious of them. And the fact that there is no unequivocal evidence of a threshold for alcohol intake below which it is safe in pregnancy adds to the worry of both doctor and public alike -to say nothing of the mother. Clearly, it would be safest for mother and foetus not to consume alcohol at any level.

But how realistic is this? I advise my pregnant patients not to drink, and yet I try to do it in a non-judgemental fashion; the last thing I want to do is make it difficult for them to talk to me about it. Many are reluctant -even ashamed- to admit their alcohol consumption for fear of criticism or censure. And in hospital, they are even afraid of their baby being apprehended if their behaviour were detected and judged by someone in authority.

One way to approach the problem is routine screening of all patients for alcohol consumption -letting them know that this is standard practice, not a judgment. This is helpful in many ways: promoting awareness of the problems sometimes seen in pregnancy with alcohol, and dealing with what might be termed ‘problem drinking’ early so that a reasonable plan can be formulated.

The standard brief intervention -and endorsed by the SOGC (Society of Obstetricians and Gynaecologists of Canada)-is simple, brief, and helpful: Assess, Advise, and Assist -quite self-explanatory, really. But it does not equate to zero-tolerance of alcohol in pregnancy -that would alienate, not assist. Those that had an alcohol problem would simply not admit it for fear of censure or the other ramifications that attend suspected, or potential foetal abuse…

No, we must aim for harm reduction, and set realistic and achievable goals if we truly want to help. Yes, it’s a compromise, but one that will likely keep the woman in antenatal care. The important thing is trust; if she feels she can talk to me about things and that I won’t judge her unfairly if she admits to issues that usually engender societal censure, she is more likely to be amenable to suggestions, maybe even motivated to change or modify her behaviour.

At least this is what sustains me in those hours between dusk and dawn when, sleep denied, I try to convince myself that anything is possible… That someone is actually listening.

Ignorance is the curse of God; knowledge is the wing wherewith we fly to heaven.

I can only hope.