musings on women's health

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..?