Monthly Archives: April 2013

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It’s never easy to be a doctor -especially an obstetrician. Accouchement is just too unpredictable; babies are just too vulnerable, too fragile. Too many things can go wrong. Quickly. Unexpectedly. Too many people are affected -the doctor included.

Most of us travel through our days in the naïve hope that we will somehow escape unscathed; that bad things only happen to others; that there are probably no slings and arrows of outrageous fortune -not really. We will be, by and large, protected either by good fortune or statistics -we and our children. We rightly assume that with due diligence, and a good doctor, complications can be predicted and bad outcomes prevented. Otherwise why attend clinics? Why arm ourselves with knowledge, gird ourselves with expectations? Hope does indeed spring eternal.

But circumstances sometimes conspire to frustrate even the best intentions; the most thorough preparations are occasionally inadequate. In Life, nothing is certain; the unforeseen is just that, and only after the event is it predictable. Only after the tragedy is there a possibility of some elucidation, and even then, only a possibility of instruction. Of a lesson learned. Even after endless review -and it is always reviewed- it so often remains random and unfair.

Surely at this stage of our progress in Medicine, these things should not happen -not today, not in hospital.  Anticipation. Prevention. Avoidance. Isn’t that what we always preach? That if we think hard enough, monitor long enough, and analyse well enough, most things are either preventable or at the very least, avoidable? The key word, though, is ‘most’. Some things can and do slip through the fine net of surveillance no matter how hard we watch. Some situations arrive at the door unannounced and we have to do our best to deal with them before they enter -or at least minimize the damage if they manage to knock us down as they elbow past…

But while it’s never easy for anybody involved, it is the parents for whom I grieve. They have waited so long in joyous anticipation of a life with their child. That its arrival should be traumatic after all those months and all that excitement, that all that promise need be put on hold, or stored on some high shelf as Hope, is almost unbearable.

And yet, endure it we must, until the path emerges once more from the forest and we can see again. Thank god its a route I have seldom travelled, and yet each time, as if it were the first, I am lost. We are all connected; when one suffers we all suffer. And this is how it should be: the link is strong. It’s what makes us human, binds us together as a society: we care. God forbid that it could ever be different.

And even in the darkest place, there is still hope. I remember Helena trying to explain to the King how she can help in All’s Well That Ends Well:

“Oft expectation fails, and most oft there
Where most it promises; and oft it hits
Where hope is coldest, and despair most fits.”

We all need a hint of light, no matter how dim it seems when it first approaches.

Intimations of Mortality

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Memories

She looked familiar; you have to give me that. And my receptionist nodded and smiled as I picked up the chart from the rack by the waiting room; I knew that nod -obviously I’d seen her before. I’ve seen so many patients over the years, and I don’t remember them all, so I appreciate these little cues from my staff. After all, many of the patients have come back because I’m familiar to them; they comfort themselves in the feeling that we both share something, if only memories… I had a quick peek at the chart to refresh mine.

As luck would have it, the chart was empty, however:no history, no impressions scribbled in the margins -no memories. But after a few years, charts get lost I suppose: misfiled; they even get shredded after whatever the ever-changing legal limit happens to be so I wasn’t concerned. Stuff happens. And I’m pretty good at pretending.

I glanced at the first name: Candace. Nothing rushed into my mind, except that it always seems more intimate and friendly to call a patient from her seat as if we were on a first-name basis. It implies a shared trust, a history.

I once addressed a similarly seated woman in a busy waiting room as Mrs. Rangapurampti -I was afraid to attempt her even more difficult first name- and she scowled at me. “You’re so formal, doctor,” she added once we were walking alone down the corridor to my office and she’d recovered her composure. “I remember you as much more approachable than that…” I begged her forgiveness but felt shamed at being caught out; I hadn’t remembered her either.

“Candace?” I said rather louder than necessary, and in an unneeded question format: she was the only person in the room. A strikingly beautiful woman with long blond hair and a powder blue dress, the name fit her like stockings.

She smiled, looked up from the magazine she was reading, and stood up slowly and deliberately in an almost practiced way. I noticed this, but mentally shook my head at the thought: nobody needs to practice standing up. And yet I felt like applauding her style. I was sure I couldn’t rise from my chair like that…

We shook hands and I introduced myself as if it was actually unnecessary because, of course, she already knew me. And I knew her… I do this just in case. She accompanied me down the corridor at a safe distance -not too close, not to far: a just-right distance, it seemed to me when I noticed it. The strange thing is, I couldn’t remember ever thinking to notice this before.

When we had seated ourselves in my office, I opened her empty, blank chart and realized I’d have to fake the memory-thing, or play my old-age-forgetfulness card. Lately, the latter has been the more successful strategy and as long as I don’t seem too doddery or forgetful, it seems to call forth a bit of the parent in the patient. I think it helps them to realize that we’re both in this together…

 I sat forward, in my chair, pen hovering over her chart: a picture of anticipation. “So what can I do for you Candace?” I said, smiling and looking for all the world, I suspect, like a lens focussing. When her face took on a curious expression, I pointed to the empty chart. “The referral from your doctor doesn’t seem to have arrived yet.” And it hadn’t -yet another obstacle to gaining her trust.

Her eyes twinkled and her forehead raised just enough to show some little lines that I hadn’t noticed before. “Oh, I think that’s because my GP sent it to another gynaecologist. But I realized that I’m travelling at the end of the week and she couldn’t see me before then.” An absolutely disarming expression crept onto her face. “And you had a cancellation, so…”

I almost blushed at the thought of my otherwise empty waiting room. “It happens,” I said, hoping she hadn’t noticed.

“I only need a Pap smear,” she continued, “But with my busy schedule, I’ve been putting it off. And because it was abnormal last time, my GP didn’t want to do it.”

I nodded and wrote something in the chart. “Well, I’m going to need to take a more complete history again, so I hope you don’t mind me getting a bit of background.” She didn’t mind a bit, she said, and as she spoke her hair bounced almost playfully on her shoulders. I proceeded to go through a complete medical, surgical and gynaecologic history, duly noting it in the chart.

When I was finished, she sat back in her chair and looked at me. “You certainly are thorough, doctor. I don’t think anybody has ever asked me some of those questions.” She blinked slowly and sat up straight. “I’m impressed.”

I did blush that time, but I wasn’t sure why; I always ask those questions. They’re the way a doctor finds out if there are other factors that need to be considered in treating the patient. Pretty standard stuff, I thought.

After I’d done my usual complete physical exam and subsequent Pap smear in the adjacent examination room, she joined me at my desk. I was still writing in her chart when she sat down, but I glanced up briefly to ask her if she had any questions.

A soft expression settled on her face and she smiled at me. “You’ve answered all my questions…” She hesitated as if she was searching for some words. “You know, I just have to say, I’ve never felt so normal as in this office. It’s the first time in many years that I’ve felt that I was actually being seen and treated as who I actually am, not who I’ve become.” She almost looked embarrassed and for a moment I thought she was going to lean over and hug me from across the desk. “Thank you, doctor. You don’t know how much I appreciate this!”

I smiled lamely in return. I had no idea what she was talking about, although I did wonder if I’d missed something in the history I’d just taken. I nodded my head in polite acknowledgement of the compliment and walked down the corridor with her.

When she’d left the waiting room and the door had shut behind her, my receptionist and her assistant jumped to their feet. “What was she like?” the younger one said excitedly and grabbed her phone to post something on her Facebook page. My receptionist, an older woman, rolled her eyes and then looked at me. “Well..? What was she like?”

I stared first at the younger assistant and then at her. “Excuse me?”

“Candace!” the younger one said with what seemed like reverence.

When I didn’t answer -couldn’t answer- my receptionist sighed. “Didn’t you see those signals I was giving you before you picked up the chart?”

“You mean the not-so-subtle nod to remind me that I’d seen her sometime in the past and to pretend I remembered her? That signal..?” I shook my head. “Because, I really didn’t remember, you know. Not even after taking her history.”

Two pairs of eyes rolled in unison. “It was the TV star nod…” My receptionist glanced at the younger one. “And she’s done a few movies, too, hasn’t she?”

Another maudlin eye rolling session from the assistant. “Wait till my friends see this on Facebook!” She began to type frantically on the phone with her thumbs again.

“You’re not going to tell me you didn’t recognize Candace?“ the older one said shaking her head in disbelief.

“Uhmm…”

“She was probably so stunned you didn’t recognize her that she’ll never come back,” the assistant mumbled, obviously disappointed.

I smiled and then shrugged indifferently. “Actually, I’m not so sure about that,” I said and walked slowly back to my office, still wondering who I’d seen.

 

 

 

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The Great Divide

Is there a Great Divide? Strange, perhaps, that the question has continued to haunt me all these years; but you see, if there is, it matters. As I’ve written about before, we each see the world through our own eyes and bring to that perception our own acculturated expectations, our own history, and yes, our own prejudices.

Philosophers have argued about this for centuries: do our sensations carry accurate information about the world, or are they so riven by internal conflicts and so rerouted along personally-determined neural pathways that they are uniquely what we make them? Representative only in that we have defined them as being such.

I do not want to mix up this thought with Plato’s; I’m not talking about his contention that we can only perceive ‘chairs’ -physical objects- but fail to identify the actual reality: ideal forms –chairness, if you will. I am not meaning to confuse the particular with the general.

Nor am I referring to the philosophical conundrum of Names. If I see a colour as red and yet you see that very same colour as blue in your brain, it may be interesting, but not particularly important: we’ve both learned to call it by the same name -a point not lost on Shakespeare, albeit in a changed analogy: ‘A rose by any other name would smell as sweet’… There’s no problem with this, largely because we assume the other person is seeing the same thing -she says she is, after all; why would I have reason to doubt it?

The world is sui generis in its apprehension, but does it necessarily follow that this can be attributed to things like differences in age, culture -even gender? Or is it merely that we inhabit different brains? And if so, is this gap bridgeable, or do we forever have to watch each other from opposite sides of the river?

I worry that even if we use a common vocabulary, and agree on definition and assignation, we’re not really out of the woods. Pain, for example: the pain of childbirth. It carries with it a melange of colours: the frustration of its temporal duration, the joy of anticipation, the determination that comes with motivation, but also the agony of contractions straining to overcome the body’s resistance to tissue stretch and damage, the hard-earned, unforgettable lesson and life-long experience that pain is a warning -a warning to stop what you’re doing and escape… Can I as an outsider, as a doctor, as a non-participant, ever truly understand the experience, let alone the meaning of what I see? And if not, where do I fit in? And when? To act without understanding is to risk acting inappropriately, insensitively: the Inadvertent Charity…

So, is there a Divide, and does it matter? If I respond to your pain -if I relieve it even though I can only guess at the depth of its effect on you, does it matter that I could never experience it? Because, as a male, I will never know what it’s like to have, say, irregular, heavy, or painful periods, does it really diminish the adequacy of my response, or change my ability to attend to your world? Does my inability to pass through the door, somehow detract from the action? Demean it?

Yes, I suppose I’ve passed middle age -left it behind the hill, perhaps- and no, I haven’t actually grown up with the same cultures, or traditions as those I see in my office; I am undoubtedly a product of my era, my generation. But how much does that separate me from those I see? Along with accreted knowledge, there is something that comes with age, comes with living in a room long enough to recognize and treasure the things in it. It’s something that used to be valued. Honored. Something that transcends gender, rises above mere culture and tradition. It is experience; it is acquaintance and comfort with difference; it is, I suppose, wisdom.

I will never be a woman; I will never be the same as anybody I see; I will only ever be a person reaching out…

A rather small Divide when you think about it.

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Medical Ethics 1

Ethics in Medicine should be fairly obvious, don’t you think? Primum non nocere – variably translated as something like: ‘Most importantly, do no harm’- pretty well sums it up. And yet even that can be difficult..

Although there have been several formulations of various ethical tenets throughout the years, there seem to be four main principles involved: Nonmaleficence –as I have already suggested above; Beneficence- acting in the best interests of the patient; Autonomy -allowing the patient herself to act in her own best interests; and finally, Justice –acting in a fair and equitable fashion to all.

I’m not an ethicist, merely a practitioner trying to navigate the labyrinth of ethical considerations that obtain in my sometimes lengthy sojourns with patients. I do not pretend to have mastered them, nor do I consciously run through them like a checklist at the end of each visit. But they are there, unstated, like the unseen concrete in a wall. And like the wall, there can be hidden flaws that test its strength.

Trust is one of these. Much of the effectiveness of Medicine throughout the ages has been rooted in Trust as much as in Hope. Without trust, there would be no dialogue; without trust, there would be no hope. And trust, unlike the four ethical principles, is not something that can be taught. It is rooted in ethics to be sure, but not confined to it, or by it. It is a feeling shared, an aura that permeates a room; it is non-verbal.

And yet even trust can be betrayed. That is where Ethics enters like the big sister who listens and watches unseen in the corner. I would like to contextualize her importance in everyday encounters in a medical practice.

Perhaps Justice -the fourth principle in my list, is a good place to start. While it is not often emphasized as much as the others in ethical discussions, it certainly does make the headlines in today’s climate of fiscal restraint. The seemingly inequitable apportioning of scarce and expensive medical resources is frequently brought to our attention as a way of castigating a particular political ideology, or highlighting our slow but inevitable descent into moral depravity. It is the elephant in the room: we realize that something needs to be done, expectations modified, and yet it is difficult to confront without seeming callous and uncaring. As a society, it is to our advantage to be seen as attempting to be just for all, and yet excuses are equally advantageous. And distracting.

Prejudices, often hidden and unstated, can modify responses. Street people are frequent beneficiaries of this penalty, especially if they have had the temerity to step outside the pattern. Drugs are illegal, so any problems they engender are self-inflicted, voluntary… Resources must be sustained, conserved; allocation should be prescriptive and privileged. They are the benefits that accrue to normal behaviour. If exceptions to the equality of largesse must occur, if our resources really are limited, should those who have chosen to depart from the established societal conventions be the first to be rationed? Should that be one of the consequences meted out to those who won’t comply? Won’t play by our rules? One would have to be hard-hearted indeed to subscribe to that, and yet the punishment is insidious and often invisible -or ignored. Rationalized. Like any illness, it is easier for the Well, to pass by on the opposite side of the street rather than dealing with it. Only when they are ill and need the compassion entailed in obtaining a slice of those resources does it enter their lives with any clarity or meaning. Hence the need for Justice in our dealings with everybody -and especially the less fortunate among us who, sometimes through no fault of their own, cannot access medical help.  I suspect that most of us don’t intend to be insensitive to others in need, and yet it is easy to forget what we do not experience. It is easy to be unduly influenced by Media hyperbole. Unexamined claims play to our confirmation biases: there is no pressing need to critically analyse what we have always felt to be true…

But these bold and often unsubstantiated allegations are abstruse and usually peripheral distractions in everyday medical encounters. They engender fear and apprehension in some perhaps, but are almost always secondary to the problems at hand. They are usually forgivable.

Take for example the occasional need to juggle the order of surgical waiting lists to accommodate unforeseen emergencies or more truly urgent cases. The usual marketplace First come, first served is clearly inapplicable in these circumstances; most of us recognize this and hope that we too would be treated the same way if the need arose. The juxtaposition may be inconvenient, even poorly received, and yet it is understandable. Condonable: Justice perceived.

Some are more trivial: the appointment that has to be cancelled, or more probably moved to another time because of an emergency, the arrival at the office later than expected for the same reason… All somewhat minor, perhaps, and pallid in comparison to the larger Health agendas that are so compelling and momentous, and yet in their own fashion, equally exemplary of Justice applied.

And yet there are more serious concerns that arise in practice as well: Justice has many faces. In any system, resources are limited: there are only so many hospital beds available at any given time; only so many operating theatres that can accommodate unanticipated needs. Choices have to be made, some with foreseeable albeit unavoidable consequences. These are obviously trying times and decisions contextual. Blame can explode like fire long after it has died down; embers are never inconsequential. Justice is not meant to be relative, malleable or adjustable and yet in retrospect it often seems so -maybe because it is still an evolving concept. It was once seen merely as an ideal to be striven for: a goal not yet attained or even possible. We now -correctly, I think- view it as a right. Or more: a necessity to treat all with compassion and fairness regardless of their status in the hierarchy. And yet, we can only work with the tools we are given; we can only try -then try again…

As Shakespeare’s Iago said: What wound did ever heal, but by degrees? We can hope.