Opinions

I am sometimes bewildered; I live in an ever-changing sample of opinions -often at odds with my own. In many circumstances I would welcome, even encourage this potpourri, but usually the people holding these often colourful bouquets have come to me for answers, not more flowers. But what is it that differentiates an answer from an opinion?

In the Great Age of Internet what are we to do with the information the patient brings with her problem: the carefully harvested compendium of facts that seem to apply -if only peripherally- to her condition, the assortment of variations inherent in any garnered explanation, the pastiche of expertise purporting to supply if not the answer, then at least the diagnosis? It sometimes presents as much of a challenge as the condition for which my opinion was originally sought.

I suppose I should be grateful for any help I can get. We are all unique, and diseases -conditions- manifest themselves idiosyncratically on occasion. But it is often the patient’s attachment to their research that presents the difficulty. I suppose we are all wedded to our autonomy and our ability to process and analyse any unusual facets of reality that confront us -it is why we still exist as a species, after all. And there is value in the ability to assume control of a situation, not to be overwhelmed by it -victimized by it. Characterization, classification and enumeration of symptoms are a shared responsibility after all. As a specialist, I rely on it.

But perhaps there is a threshold phenomenon at work here: it is not so much the amount of data, as its quality and relevance that obtains. The fact that a fishing net contains a hundred sundry fish, including the one salmon that I need to solve a puzzle does not necessarily increase the value of the catch. And I might even miss the seeing the very thing I want in all the bounty. Abundance is not always a luxury; it is sometimes an encumbrance, a millstone. It often carries with it the obligation to follow it even further into a morass of inapplicable detail -misleading detail, beguiling detail.

And even if there is no misdirection, no distraction, there lurks the danger of the proposed solution. While it may be obvious that there are often many ways to resolve an issue, it may be less so that not all paths are equal -either equally effective, or equally safe. Solutions are contingent on many things, one of which is the quality of evidence upon which they are based. Solutions are often multifaceted, requiring a blended approach, even a multidisciplinary one. The sheer number of permutations and combinations does not lend itself to a superficial or naïve analysis. Dragons lie that way.

So, one of the more worrisome effects of the extensively researched and therefore convincing self-diagnosis is the proposed treatment regimen. Even assuming an appropriate interpretation of symptoms and an arrival at the gates of a congruous synthesis, the suggested solution can be problematic. Where it merely involves a class of medications, I can usually suggest more readily available alternatives: safer or less expensive drugs -although even here, brand names often accompany an optimal resolution in whatever research to which the patient has been privy. I don’t necessarily mean to suggest conflicts of interest of the researchers so much as difficulty for the untrained and -in that respect- unsophisticated patient in separating wheat from chafe.

It is even more difficult to explain why a particular procedure, or diagnostic modality may not be available to them. Or why I do not possess the skills to perform a surgery only recently described in another country or even another region. Worse, from their perspective, perhaps I have not even heard of it.

All of this is certainly not to denigrate patient participation in their own care, or involvement in seeking a solution. It is perhaps to highlight an evolving process in which we are all partners in health care, each having contributions to make and suggestions to offer. The extent -and value- of the contribution from each party has yet to be established however, and I suspect it will be an ever-moving target for some time.

But is the era of the expert -the doctor- running its course? Will it ever be sufficient to feed one’s symptoms into a computer program (presumably one already acquainted with other unique and personal biometric and physiologic attributes) and await the diagnosis and treatment? There are programs right now that purport to facilitate such things for doctors; is it just a matter of time before they escape into a more public domain?

Or is there truly something more important and distinctive about the doctor-patient encounter: the listening, the body language, the obvious empathy? Is it only the doctor’s opinion that is so important, or is it something else as well? Of course the opinion must be rooted in fertile and appropriate soil; of course it must embody a well-considered analysis of the data presented. But if that were all, would it suffice for most of us? Or do we want -no, require- more than that? To be heard by another..?

Medical Mysteries

I’ve always known that there is more to Medicine than Agape, more than a wish to provide succour, more than a desire -a need– to help, to solve, to heal. It provides, for example, an opportunity to learn about others, extend one’s boundaries, explore and experience the Theory of Mind, not to mention the wisdom that accrues to practicing Biology.

But for me, one of the side benefits -and the one that keeps me coming back to the office each day- is the mystery of it all: the Sherlock-Holmesean challenge that confronts me, teases me, each time a new patient walks into the waiting room, or appears as if by fortuitous accident in the Emergency Department needing consultation. I don’t mean to make light of the problem expressed, nor diminish in any way the need for its resolution, but at the same time, it doesn’t always have to take on the sombre hues that surround it. This is not to impute Schadenfreude -although I love the word; it is merely to enjoy the hunt.

One of the joys of a Teaching Hospital is, well, teaching, and I think that one of the few things that I, as an older obstetrician can transmit that isn’t immediately dismissed as quaint by my Residents, is the sheer pleasure of solving ‘Situations’ as if they were puzzles. I’m always up for a Gordian Knot. I like mystery novels, and when I am actually able to follow what’s going on, constantly attempt an early solution. To the credit of the author, however, I rarely succeed and am forced to read to the end of the book for what always ends up as a surprise. Sneaking to the last pages doesn’t even work for me, because… uhmm, I don’t understand the ending without the clues. I suspect that it’s primarily for people like me that these kinds of books are able to stay alive and relevant.

But with Medicine and Medical Mysteries, I like to think I have a certain advantage however -a flair, if you will. On a good day and after a cup of coffee, I can sometimes make a diagnosis after only a few cleverly worded questions, and usually consider myself almost akin to a medical student if I don’t know what’s going on until I have the lab tests back. Back when I was one, we were told to answer any question in an oral examination with the preliminary disclaimer phrase: Well, after a complete history, a thorough physical examination and the intelligent use of laboratory and ancillary aids, I would… They didn’t like the idea of Mystery in those days, or at least didn’t want to let slip the notion that one might exist: patient confidence and so on… They still had a lot of unknowns then as I recall, though. But at any rate, as a result, I had to learn the art of reading the more subtle clues pretty much on my own.

As you might have guessed already, I like to present cases as mysteries to my Residents… on-going mysteries that require clue-gathering and inductive reasoning… or is it deductive? -I can never remember. Anyway -case in point- there was a ‘situation’ that lent itself to this approach the other night when I was on call in the Delivery Suite. We were called to the room of a woman who my resident and I had been following in labour. Things had been proceeding normally until the nurse noticed that the baby’s heart rate on the monitor began having episodes where it would drop to an eye-and-ear-catching level and then recover again as if it were all a mistake.

By the time we arrived, things had reverted again almost to normal; there were still some heart rate changes, but less severe, less worrisome. On further examination we determined that she was almost ready to commence pushing to deliver the baby. So, confronted with a more reassuring pattern and having access to the previous heart rate deceleration pattern on the seemingly infinite paper strip that disgorges itself from the monitor, we retired to the corridor outside the room to discuss it. I proceeded to probe the Resident’s grasp of the clues to which we were privy.

“So, what do you think Sheena?” I thought it was a clever way of asking her opinion without actually putting her on the spot for a diagnosis.

She looked at the heart rate tracing and then at the floor for a moment as she ran the possibilities through her mind. “Well…” she started somewhat tenuously, “The heart rate decelerations all seemed to occur with contractions and then recovered when the contractions finished…” She looked at me to see if she was on the right track.

I grabbed the tracing from her with what I hoped was a delicate move. Actually, I hadn’t noticed the relationship at first because the contraction pattern had been pretty well destroyed by the nurse moving her from side to side on the bed before we came. But when I thought about it, of course it made sense. “Very good, Sheena,” I said, nodding my head in agreement. “And what would that mean?”

“That the umbilical cord was being compressed by something -the head, I suppose- during a contraction.”

“Compressed against..?”

She stared at me trying to guess what I was after, but she remained silent.

“Compressed between the head and the pelvic bones, Sheena…” Gotta get them to follow the clues wherever they lead, so I didn’t feel bad for pointing the direction at this stage. She was young and inexperienced; she’d learn to follow them.

But she seemed to be enjoying solving the mystery so I smiled wisely and continued. “Anything else it could be?”

She looked puzzled, but just for a moment. “Well, the contractions are really close together now… So maybe there could be a separation of the placenta and the baby’s not getting enough oxygen…”

I tried not to roll my eyes. “See any blood? A placental abruption would likely show up with some visible bleeding from the vagina.” She shook her head. “And if there were something like that going on, why wouldn’t the baby’s heart rate just stay down and not recover like it did?”

She shrugged and looked at the floor again. “Anything else you think it might be, Sheena?” I didn’t want to push her too hard and discourage her from enjoying the game.

“Well, sometimes head compression itself leads to a heart rate deceleration with contractions.”

“So, is that what you diagnose then?”

After considering the problem for a moment, she shook her head. “No, I think it is related to the umbilical cord…”

I blinked slowly -for emphasis, I think- and opened the door to the room for her. “Of course it’s head compression on the cord,” I said with a smile. “Couldn’t be anything else when you see that particular pattern!” I tried not to sound too cocky and followed her into the room. The patterns on the monitor had become normal again and we could see the head appearing at the perineum as she pushed. “Heart rate patterns are like clues in a mystery novel; you have to solve them in context,” I said to the Resident and then turned to the patient as we put on our gloves and got the instruments ready for her imminent delivery. “We were just discussing how to read the clues that the monitor tracing gives us about what is actually going on in a labour.”

The patient looked concerned, despite the current normality of the fetal heart tracing and the reassuring metronome-like cadence of the heart beat that the machine produced. “We’re pretty confident that the cause for those heart rate changes was temporary compression of the baby’s cord by its head against the pelvic bones as it comes through the birth canal. Quite common actually; doesn’t seem to have any long-lasting effects on the baby either.” She still looked doubtful, so I added, “Just listen to how regular the heart beat is now…”

I turned to Sheena. “Learn to read the clues, Sheena,” I said softly, and the heart beat descended again as the patient gave a mighty push and delivered the head. “It’s satisfying to be able to reassure the patient about the cause with confidence, don’t you think?”I added in a whisper.

Sheena delivered the now vigorous and crying baby and put it on the mother’s chest as I busied myself with getting some instruments for her to clamp the cord. I couldn’t find the scissors and was hunting around for them with my back turned when I felt a little nudge from her elbow. “Ahh, doctor…” she said with an interesting tone in her voice.

“Yes Sheena?” I said as I continued my hunt for the evasive scissors.

“I’m not sure about those clues, actually…”

“Here, I found them,” I said as I handed the scissors to her, now searching for some more clamps to get the umbilical cord blood gases. “Clues are clues, Sheena,” I continued confidently, and turned triumphantly with the extra clamps in my hand. “You just have to learn how to read them…”

“I guess, but sometimes maybe we read ’em incorrectly…”

“Mmmh?” I mumbled, still living the victory of instrument discovery.

“Look at the baby’s umbilical cord,” she said, glancing at my eyes above my mask. “There, just a couple of centimeters from where it enters the baby’s umbilicus…”

I glanced at the baby and then the cord, wondering why she was questioning the way I had interpreted the clues; they were obvious. Even a medical student could have done it. But there, in the cord, not three centimeters away from the skin of the baby was a knot: a true knot in the cord itself. Any stretching of the cord would tighten the knot and decrease blood flow through it -would cause the baby’s heart rate to fall…

I looked back at the Resident, now grinning behind her mask, and blinked slowly. Confidently. Undeterred. You can’t always solve a mystery beforehand, you know. It’s why we read the books, after all.

Cause: an Effect?

The real world: that’s where we are all supposed to live. The place where everything has a readily identifiable cause and everything makes sense -or would, if we were to delve sufficiently deeply. It’s a place where the absence of answers suggests inadequate investigation.

I’d love to live there -in that particular world- but I suspect we all live in different worlds. I’m reminded of the psychotherapeutic contention that we live two lives: the past and the future. It’s the past where problems arise, and the future where they are inevitably diagnosed and solved.

In fact, in our quest for certainty, in our search for rules to apply and names to clarify, we exist in neither. And labelling something that was hitherto vague and fuzzy often goes no further than assigning it a name. Chronic Fatigue Syndrome comes to mind. Sometimes labelling gathers things together to allow them to be considered as an investigatable entity; sometimes it gathers things together for convenience. Sometimes it merely gathers things together. I suppose that’s progress.

But it can be misleading in medicine.

“Doctor, my periods always used to be regular but not anymore.” The patient, an attractive, well-groomed woman in her thirties was clearly concerned.

“How have they changed?”

She cocked her head and looked at me as if I wouldn’t understand. How would a man ever know what she meant? “They used to last for five days -I mean I could count on it…” She stopped and stared at me with an intense expression suddenly nailed to her face, wondering if it was worthwhile proceeding.

“And now?”

“And now they could last for…” She sighed and rolled her eyes at having to be so specific: her periods were not regular. Enough said. But she could see that I was poised to write something in her chart, so she needed to explain her concern. “…For, I don’t know… between four to six, maybe,” she continued, curling her voice up at the end. “Sometimes with a little spotting added on.” She stiffened in the chair. “That’s never happened before, either.”

“But they’re regular: they come once a month, despite the number of days you actually bleed?”

A knowing shake of the head. “Yes, but that’s not regular, doctor. Not for me.”

I  proceeded to write it down to show I was paying attention and taking it seriously. “And how long have you noticed this?”

Her eyes seemed to recede into her head as she searched around in there for an answer. The answer. Then a shrug. “I don’t know; they’ve kind of changed over time.”

“Have they changed in any other way? I mean are they painful, or particularly heavy..?” I left the question open to encourage her to organize a reason why she had consulted me.

She shook her head thoughtfully. “No, nothing like that… They’re just irregular and I’m worried.”

I looked at the information her family doctor had forwarded to me along with the consult request. “Your doctor has been very thorough,” I said, looking through the detailed blood work and ultrasound reports. “And it all seems quite normal.” I wanted to reassure her.

Her face brightened. “That’s why she wanted to send me to a specialist.” She pinned me with her eyes for a moment and then let go. “She couldn’t find a woman gynaecologist to see me soon enough, though… But she said you were okay.” She added that quickly -too quickly- but clearly as a gesture of politeness.

I continued with the history, and subsequent physical examination but I could find nothing abnormal -nothing that even hinted at disease or malfunction. When we were finished, and she was once again sitting across the desk from me, I reassured her that from a gynaecologic perspective at least, she seemed normal and healthy. I offered it to her like a present: something that would please her.

And yet, she was obviously disappointed -as much in me for failing to find the cause of her problem, as having to endure the continuing changes in her periods. “But there has  to be a reason they’ve changed, doctor.” She said the last word sibilantly -as if it had to be forced through a jaw that didn’t want to open, teeth that got in the way, anger that tried to get her to say something else entirely.

I risked a subliminal sigh and smiled at her. “Well, all the investigations that your doctor has done so far have been reassuring,” I thought ‘reassuring’ sounded better than ‘normal’ under the circumstances. “And my examination today is in keeping with those investigations…” Her face wrinkled and her eyes narrowed a touch. “We all change as we mature,” I continued, trying to stay upbeat. “Nothing stays exactly the same…”

But there was a cloud in the room. “The periods are not heavy or painful; is there something that bothers you about the change?” I thought maybe she considered any change a harbinger of disease and I could reassure her about that.

“Doctor, they’re irregular now, and I want to know why they’ve changed! There has to be a cause!” The unstated assertion, of course: ‘But you can’t find it because you aren’t looking hard enough.’

I tried to keep a fatherly expression off my face -that would have destroyed even the slight rapport we enjoyed. “Julie, sometimes things just change over time. Yes, there’s probably an explanation, but it may be all wrapped up in the changes our bodies undergo as we age.” He face hardened even further, and I could see she was not happy with my opinion. I decided to throw in a little home-grown wisdom. “You know, there are times in medicine when we can’t explain why something happens, but we’re pretty good at ruling out any bad things that might cause it…” I thought maybe that would help her to accept my inability to label her problem and solve it.

But it only frustrated her further. Clearly, I had not tried hard enough. She stood up and thanked me perfunctorily, but after she left the room I heard her whisper to her friend in the waiting room “I knew I shouldn’t have gone to see a man!”

And maybe she was right; maybe she would have accepted the opinion had it come from a woman. But it would have been the same opinion I suspect -just dressed differently.

I’m not so agnostic as to believe that some things don’t have causes or that some things are not worthy of further investigation. I realize that we all have different priorities in our lives and what is important to one may be trivial to another. But the relentless and obsessive pursuit of Cause can be counter-productive at times. Sometimes, perspective is more beneficial: the thoughtful accounting of context and significance. The frame is everything.  As Hamlet said: There is nothing either good or bad, but thinking makes it so.

Amen.

In Praise of Painted Toenails

I went to a celebration last night, an acclamation of an event so unique and yet so common as to defy -almost- the need to single it out and frame it in the usual infinite regress of hyperbole it inevitably invokes: a birth.

I have to admit that I enjoy birth, although as an obstetrician my perspective is necessarily more technical, adjunctive, facilitative. The less I have to do, the better the result, and as a consequence, the more peripheral I become. It’s an interesting role -and a humbling one- in which success is measured by anonymity. The goal is not being noticed, and after the usual thanks proffered by the overwhelmed parents, retreating quietly to the background to join the other shadows flitting silently around the room.

Birth is a special occasion; it is in turns both intimate and private and yet inclusive and universal. To finally meet the person with whom you’ve shared your body, your thoughts and your dreams after all those months, to finally know and greet the intimate stranger living in your house defies all words; it floods the mind. It is a happy, giddy moment; it is a confusing moment as reality crashes over you like an ocean wave. It is a moment that, as a man -and more distant still, as an accoucheur- I can merely acknowledge from the distance of an acquaintance, a guide hired for the trip. The joy, the wonder, the amazement is vicarious; it is victory by proxy. And yet is deeply satisfying and not at all disappointing to be suddenly in the background.  It is enough to know that journey was successfully concluded, and the destination is all that was promised so long ago.

It is what we sign up for as obstetricians: of necessity, we are creatures of the Gestalt. We are umbral-beings, content with whispering advice, treading carefully on territory we do not possess. We are the Guardians, in a way, of the chosen unborn, the yet-to-speak minority that lives so silently among us. It is an interesting career to aspire -in part at least- to relegation to milieu… To be noticed au moment critique only when there is a critical moment… And to rest content with only that.

But I suspect there is more to it. An absence of obstetrical complications has to result in more than a mere abyssal assignation and a consequential banishment to the margins. If that were the end of it, there would be little reward for the months of coaching, the commiseration, the common concern… Money is not enough of an inducement; it is never enough.  There is an infectious commonality to pregnancy: a shared joy of anticipation, an as yet unrequited expectation, a primal appreciation of ontogeny. There is magic in the hidden life, the unintroduced guest.

And yet I sometimes hope for more, but never ask: inclusion in the party. Recognition, somehow, of an important place in the process, while conceding all the while that it would and could proceed without me. It is no doubt a Sartrean hope, doomed like Sisyphus to repeat again and again, resolution receding forever backwards as the role requires.

But last night, for the briefest of instants, it changed: I became a part of the Wheel: Samsara. For a moment, I was included. I was Family. Sitting sleepily in the middle of a particularly dark and busy night in the artificial brightness of a numbered room in the Delivery Suite, my eyes happened upon some toes. Not just any toes, of course -they are rarely displayed as such in winter here. They were parturient toes, and decked out as if for Hawaii, or some closer summer sand. Rich reds, and tiny stars, with little flecks of yellow and blue -very festive. Very cheerful. I commented on them, naturally; it seemed an essential break from my repetitive admonitions to aid -no, speed– the progress of her delivery.

And between the contractions, between her pain and obvious exhaustion, she giggled. “I did them for you, doctor,” she said, before another contraction seized the words and buried them in her mouth. She could manage no more until the baby arrived, screaming and worming its way into the bright fresh new world. Then, after the congratulations and the shaking of various and sundry hands, she grabbed hold of mine. “I really did, you know,” she said, tenderly caressing her long-awaited baby on her abdomen with her other hand and tearing her eyes from it for a hurried second to look at me. “You once told me that a delivery was always special for you…” She squeezed my hand to make sure I was hearing her in the noise that surrounds a new baby. “…And I wanted to make sure it stayed special. Thank you so much!”

It was… It will always be special.

HPV

Cancer of the uterine cervix is a sexually transmitted disease; it is the second most common cancer of women in the world and it is spread sexually. Who would have guessed? The clues were there all along, of course: it was more common in sex workers, and women who had become sexually active at an early age; it was rare in nuns… But it took a while to connect the dots -and for technology to catch up with suspicions: viruses couldn’t even be visualized until the invention of the electron microscope, although their existence was suspected much earlier using filters with holes too small for bacteria to pass through. And then their DNA had to be identified in cervical cancer cells… and classified. It was a long journey all right.

But sexual transmission? The jump from abnormal Pap smear to the bedroom was -and is- a hard sell.  The fact that more than 80% of sexually active humans have been exposed to the virus was hard enough, but add to that the knowledge that the vast majority of teenage infections will clear on their own because of the vigorous immune response at that age, and you have a recipe for confusion. Or complacency.

Cancer of the cervix is rare before the age of 25 -the virus has a long prodromal developmental period- so after telling women how important Pap smears were in preventing, or at least detecting, this infectious cancer, raising the age of the initial Pap smear from the time of first sexual activity to age 21 in North America, did little to foster understanding. And then playing with the frequency and mode of surveillance for the rest of the age groups… Well, it was almost a breach of trust; changing the rules after years of teaching was just not on.

I mention this only to put the contemporary problems of counselling young women into some perspective. Especially now that vaccination against some of the more common and troublesome varieties of Human Papilloma Virus is possible. Vaccination has always had its opponents, and HPV is no different. But for my practice, there seem to be two major questions that arise: the need for continuing screening after vaccination, and the need for vaccination if a woman has already had a pre-cancerous condition treated.

These are confusing, if not vexing questions. There are at least 15 types of HPV that cause cancer but only two major varieties that account for the vast majority of cases in the community: types 16 and 18 (they’re numbered, rather than given cutesy names). These are the strains that are incorporated into the current vaccines. So if a woman has already had dysplasia -the pre-cancerous condition caused by the virus- it will have been caused by only one of those types and she is still vulnerable to the other. And therefore she still needs to be vaccinated. I get asked this every day, I think. Fortunately the schools in my province have incorporated the HPV vaccination into the early grades at school -hopefully before sexual exposure- so the question may well be an anachronism in the foreseeable future.

But the need for continuing screening in a vaccinated population is more difficult to understand in an era brought up on the concept of herd immunity: the idea that the more people who are vaccinated, the less prevalent the virus, and hence the less chance of being exposed to it. What tends to get forgotten, however, is that there is never a completely protected group: we are a heterogeneous society with new, unprotected people entering it from outside; immunity may wane; less common strains or perhaps novel viruses might gain prevalence and not be incorporated into the contemporary vaccine products. No, there are many reasons not to let down the guard of vigilant surveillance.

But a problem still persists: HPV doesn’t behave at all like a sexually transmitted infection in the minds of most people. We have come to expect cause and effect to be temporally accountable: the unprotected sexual encounter last week results in identifiable symptoms this week. Blame is assignable; lessons are learned. But with HPV, cause and effect are often separated by uncharted and imponderable years of time. There are seldom symptoms, seldom acquired wisdom. No one -or everyone- seems culpable: a difficult take-home message indeed. As I have already suggested, the voyage from Pap to Prevention is a stormy one.

But maybe this is just a generational thing: what we find difficult to assimilate today, will be greeted with a knowledgeable shrug tomorrow. We are creatures of more than structural evolution; more than linear accrual. As Shakespeare says: We know what we are, but know not what we may be. Or even better: Lord, what fools these mortals be!