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.

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