Questions and Answers in Medicine

Questions, questions, questions… They are the scaffolding that surrounds any medical encounter. One could almost phrase it semi-mathematically: patient/doctor = question/answer. And the success of the relationship -at least at the start- is largely dependent on the answer part of the equation. Patients usually come armed with both a problem and questions about it. That is natural, but sometimes the latter are as thickly layered as bees around a hive and actually obscure the issue to be addressed. Not all questions have answers; not all problems have solutions -not at first, anyway and sometimes not at all. This seems all too often the case in obstetrics.

Many questions arise out of what seems at first to be mild, symptom-related curiosity: vague, and only occasionally experienced sensations in pregnancy such as, say, leg cramps, fatigue, or maybe even shortness of breath. Most are relatively common complaints, the causes of which are not well characterized and don’t admit of a detailed, scientifically validated explanation. Indeed the answers need sometimes to be experientially based and may therefore vary from patient to patient, and even doctor to doctor -a point readily noted by the more concerned couples who have often consulted friends with similar symptoms.

I have to admit that I sometimes feel evasive, or even fraudulent answering some questions as if I was in possession of the one correct answer: there may not be one. But I know that behind each question is a concern, a fear only thinly disguised with a smile, that there is something wrong with the pregnancy. And of course, sometimes there is, so each question has to be considered in the context of a reasonable differential diagnosis. The leg cramps could herald a phlebitis, the shortness of breath an infection, or even a pulmonary embolus. And nowadays the patient often knows this and seeks reassurance.

And of course, not everything is pregnancy-related: nausea and vomiting could be signs of a viral hepatitis, increased frequency of urination could be a bladder infection… Questions -problems- can be Hydra-headed; to view them in monochrome may be a mistake. There is a balance required: not every headache is a sign of pregnancy induced hypertension, nor every dizzy spell an anemia. Not every symptom is pathological, and as I am fond of telling my patients, pregnancy is not a disease.

Still… To miss something serious is unacceptable -incompetent, even- but to alarm unnecessarily has its consequences as well. There is a middle road, even with complex and alarming questions: it is to listen carefully and compassionately and to consider each query in context. Often the patient doesn’t want a detailed academic answer, just a thoughtful reassurance mindful of her own particular situation. The fact that a concerned stranger on the bus said that she looked a little pale, or perhaps puffy in the face calls for a different level answer than a question about newly acquired cramps early in the pregnancy. That much is fairly obvious.

But what may be less appreciated especially on a busy day in the office is that even trivial questions are asked for a reason. She may, in fact, already know -or intuit- the answer and feel silly bringing it up. But she needed to ask -just in case… And her concern deserves attention, not merely a quick, reflexive reassurance that might seem to her both insufficiently analysed and dismissive. Even pausing briefly before answering suggests a more detailed and therefore considered analysis of her worry.

Answering questions is a skill and one which benefits and matures with experience; one has to be mindful of the reason for the question, as well as the depth of the answer expected. It is an art; it should not be artful -we have politicians for that.

The Feminine Perspective?

“Men and women think differently, doctor,” a patient said to me recently, shaking her head in response to some requested advice from me. “You of all people should know that.” It was stated with a look of smug authority, as if  to disagree would have been tantamount to an admission of professional incompetence. And while I don’t concede the point that to disagree with what seems to be a societal dictum necessitates a conclusion of medical bankruptcy, it got me thinking…

I suppose the first thing that occurred to me was to question the assumption that my specialty somehow enabled entrance into the heavily guarded sanctum sanctorum of my patients –female patients at that. It kind of invokes the Theory of Mind, doesn’t it: the early discovery by a child that others also have things going on in their heads, and that they may differ from her own thoughts or perceptions. It’s an important step in eventual integration into society; it’s also a recognition that because it’s different, we can never really know what someone else is thinking.

So, in that sense, no: I (a male) can’t know what my patient (a female) is thinking -any more than I could if that person were another male. I can suspect that it might differ from what is going on in my head, but given a common purpose -the solving of a medical need, say- I can intuit that we can communicate something meaningful about that.

“Ahh, but it’s not just that we live in different bodies, doctor,” -I could almost hear her response to my thoughts- “It’s more the way we approach the problem.” Really? Are the goals actually dissimilar, or is it more a difference in perspective -a choice of route? And is the perspective culturally assigned, or does it reflect a basic underlying gender difference in physiology and wiring? Is it just that we are supposed to think a certain way -an assumption- or that we, in fact, do -an innate, genetically driven imperative?

Are the perceived psychological differences in the sexes superficial and societally contrived, or are they more like two Magisteria -the approach Gould chose to describe the difference between religious and scientific knowledge and authority? It’s a difficult question obviously, but I sometimes think it has degenerated into more of a media-driven competition -each side trying to enlist support from an otherwise disinterested and unaffected Public.

I sat back in my chair and smiled inquisitively at my interlocutor. “And how would you approach this problem?” I asked, hoping to learn something from the encounter.

“Well, for one thing, I would offer more choices.”  She sat up straighter and crossed her arms defiantly, daring me to disagree.

Fair enough; I suspect we would all like more of a say in how we deal with a problem. I nodded my head in agreement. In medicine, even if there are no other viable therapeutic choices, there is always the option of doing nothing -seeing what will happen over the coming days or weeks. But I suspect that the choice of that option transcends gender, transcends the assignation in the genetic lottery…

But maybe I was missing something; maybe she was operating with a world-view that necessitated a different assimilation of Reality. For that matter, maybe there was a different reality for her -one that I could never hope to experience. Maybe what she experienced as Red, for example, I experienced as Blue and yet we both named it with the same word. How could I ever know? A troublesome thought indeed.

And yet, ever the pragmatist, even if we both meant something different by that word, but arrived at the same destination, wouldn’t the communication have been successful? The goal achieved?

She wasn’t finished with me. “And I think you were assuming I should just accept your opinion, doctor.” She obviously hadn’t liked any of my solutions, although I had offered her several. She had probably only heard the word ‘hysterectomy’ among them.

It occurred to me that although we both wanted to solve the same problem, her condition had a different meaning for her altogether. And it didn’t hinge on her sex as much as on the way she envisioned herself as a person, as the protagonist inside a personal history: her story.  She possessed an identity tied to what she currently was, and whose very existence was contingent on whom she might inadvertently become.

But we’re all like that: we are who we have been; the past drags behind us like a shadow. It’s company for us on our long trip; it’s our suitcase full of memories… So that alone cannot be what she was alluding to.

That we all see the world from our own perspective, and that it is different for each of us, is merely stating the obvious. That we each come to a problem with a different history is equally obvious. We have all been entangled in cultural webs that have conditioned the way we respond to issues. In the beginning, perhaps it was all engendered by biological constraints, but I think most of us now realize the artifice in that.

What, then, accounts for the difference, other than milieu?

Bertrand Russell, a philosopher mathematician of the last century had some small influence on my early development; I make no claim either to have read all of what he has written, or for that matter to have understood more than a small part of what he had to say, but I have always remembered one passage -one pearl- that made sense to me. Perhaps it was the only thing I could understand:  For my part, I distrust all generalizations about women, favorable and unfavorable, masculine and feminine, ancient and modern; all alike, I should say, result from paucity of experience.

Maybe I should have read more of him; there are many perspectives…

Health Care Provisos

I think one’s occupation tends to encourage a tightly focussed view of only one lane on the road, and a trust that it and it alone will lead to the intended destination. In my hitherto tunnelled vision, it had always been the Medical Model that dominated -to the exclusion of any rival Magisterium. But as time matures, I have come to realize that what makes you well has less to do with Medicine than life style, apportioned genes, good luck… The doctor plays only a minor and maybe incidental role in the spectrum that is a healthy life. Health care, then, is not only ‘doctor’ care, or ‘nurse’ care, or even hospital care -it is Society care.

Is our currently extended life expectancy the result of doctors and technology? Partly, no doubt, and yet of all the six billion or so people now extant, how many have been saved by organ transplants throughout the world? How many by dialysis? How many spend time in an ICU? It is an insignificantly small fraction of humanity and yet in many -most- countries we are living longer. I would submit that this is a result of better sanitation, better hygiene and better nutrition -as well as better doctors…

It’s interesting to me that one could correctly attribute several causes to, say, tuberculosis. There is the one we doctors seem to prioritize: the tubercle bacillus. And yet although it may qualify as a necessary cause -a sine qua non for the disease we label TB- is it a sufficient cause? If I have a positive skin test for TB but do not have the disease, and yet the poor homeless woman begging on the corner with the same positive test does, why is that? One could be forgiven for wondering if TB is caused by malnutrition, overcrowding, or poor hygiene -poverty, in other words.

For health ministers, QALYs (Quality Adjusted Life Years) have been in and out of vogue for a while now.  I do not pretend to understand all the intricacies of their assignment, but the concept does seem a bit too heavy on John Stuart Mill’s Utilitarianism for me. Let’s say, for example, you give a person in a wheel chair only 0.5 QALYs because of her limited mobility -compared to a ‘normal’ individual (who gets 1). Doing a renal transplant on her would still not result in the same number of QALYs for that treatment that you would get if you transplanted a kidney into an otherwise ‘normal’ woman because no matter the new kidney, she would still be in the wheelchair… So if you were trying to utilize those scarce resources to maximize QALYs, who would you pick? And would that be fair?

On the other hand, there is the theoretical ‘black hole’ phenomenon that political bioethical philosopher Jonathan Wolff describes: if you were to spend all the health care dollars on the worst off or the most needy, it would not much benefit the rest of that society who also have needs -and it would consume the entire budget as well… The compromise, of course, is to prioritize the most needy and yet acknowledge others in the resource allocation… And consider additional needs that at first glance, might seem peripheral to wellness.

What am I getting at? Well, it has been suggested that an alternative to throwing all the limited resources even a rich society has available for health care at the ill (traditional health care provision, medicines, new and expensive technologies) would be to spend some of it on improving housing and opportunities for the poor -the proverbial ounce of prevention… The ultimate cost of preventing illness would be less than having to treat it. So: affordable housing; education; the provision of contraception for women in situations where they might wish or require it; new vaccines instead of (or at least in addition to) new medicines to treat the diseases they might have prevented; affordable daycares to allow single mothers to work, decent minimal wages; provision of breakfasts and lunches at inner city schools for disadvantaged children… The list is even longer of course, and yet it is cheaper than the alternative in the long run.

We have to get away from the idea that Health Care is just treating illness, visiting clinics, or getting tests. It is an attitude of caring and providing sustenance for those in difficult circumstances; it is anticipatory intervention long before the overt manifestations of sickness or disease. It is the recognition that illness can arise as much in the situation, the milieu, as in the body. John Steinbeck summarized it well, I think: A sad soul can kill you quicker than a germ.

The Medical Illustrator

I am an illustrator, a drawer of pictures, if not by aptitude, then by necessity. Many of the concepts I am required to explain beg for diagrams, for pictures, for some sort of visual representation. It is amazing, for example, how many people do not know what a uterus looks like, what’s attached to it, or what lurks in its vicinity. Its exact locality is often a mystery, its constituent parts as unfathomable as the inside of a computer; even its lunar duty and occasional lapses are frequently misunderstood.

I would have thought that Google and Wikipedia would have solved all that, but they oftentimes provide riddles wrapped in mysteries inside enigmas, to mangle a trope. And besides, you need to know how to spell something before you can research it… Adenomyosis, and submucosal leiomyomata spring to mind.

I used to pride myself on my drawings until a patient that I hadn’t seen in a few years resurfaced in my office the other day. I noticed her looking at one of the drawings I keep on my desk -the standard uterus at the top of a vagina with its Fallopian tubes coming out each side like little arms. I use it to depict the myriad gynaecologic conditions from fibroids (leiomyomata) to polyps, to pregnancies… It looks for all the world like a fat T with drooping crosspieces. She, however, immediately laughed and reminded me that she had always seen it as a cow -the uterus as the body and the tubes as horns. And this from a professionally-created, printed illustration.

It reminded me of the early days when I hadn’t thought of pre-made diagrams and had trusted my skill as an artist to depict whatever I happened to be describing. I would do it on sheets of foolscap that I could tear off and hand to the patient -presumably to remind them of the details later when they were called upon to describe it to a significant other. A patient returned to see me after just such a scholarly pictorial adventure the week before, brandished the drawing and flattened it out carefully on the desk. It was the uterus and tube foray, again; it was my favorite illustration, the organ with which I felt the most artistically at home. I had, of course, over the years refined it sufficiently to feel confidence in its explanatory powers, its verisimilitude.

“My husband wondered why you drew this for me, doctor,” she said with a weak but forced smile on her face.

I glanced at the diagram, inwardly pleased that it was one of my better models, and looked up at her for an explanation.

“He says it was rude to accuse him of something you hadn’t talked to him about.” She looked down at the floor as she said it, obviously embarrassed at having to confront me like this.

I studied the diagram for clues. “I’m sorry, I don’t…”

“We looked up some of the words but we couldn’t find one of them and he was annoyed.”

The paper was crumpled and creased from storage in her pocket, but the words were clear enough: I had been trying to illustrate the reason her cervix bled when she slept with her husband and had labelled the structures and the region quite expertly I thought. I mean, what could be more clear than cervix, glands, and vagina with arrows helpfully indicating each structure? As a bonus -I often include these for further clarity for my most curious patients- I had even drawn an arrow to the top part of the vagina behind the cervix and printed (so there could be no mistaken identity) posterior fornix. Simple, concise, illustrative: a reward for them, redeemable in discussion points with whomever they were describing it to.

She had by now ventured a stare at my face, daring me it seemed, to deny the folly of my words, the error of my drawing. When she noticed my puzzled expression, she immediately withdrew her eyes and pointed to a word. “He didn’t think you should have used that word,” she said, almost afraid to say it. “Fornix,” she whispered.

When I still didn’t seem to understand, she merely shook her head -sadly, I thought- and stood up. She was still shaking her head when she left.

That I have to be more sensitive in my diagrams was the lesson, I suppose. It’s something we should all consider. For a while, I assumed it a one-off -an anomaly. It took one more example, however, to sear the need for examined delicacy onto not only my desk but my walls as well.

I had always prided myself on my examining room. As well as the requisite diplomas and awards in clear and easy view over the sink, and the pictures my kids drew on the ceiling over the examining table, diagrams festooned the walls: illustrations of IUDs, pictures of the stages of pregnancy with actual sizes of the fetal passenger as it matures, pictorial explanations of the uterus in various phases of its menstrual cycle… I even had a picture of the urinary systems of both males and females near the head of the bed -a mural Wikipedia.

The proof of my insensitivity surfaced yet again one day when a patient came storming out of the examining room fully dressed and face tense. “I refuse to lie in there under that.”  She almost spat the words at my face.

I tried to smile at her, but I have to admit I was too traumatized to pull it off successfully. “What..?” I stammered, trying to look over her shoulder at the offense, wondering if there was a tear in the paper sheet I’d given her to cover herself with.

She saw that I was looking at the table and not at the wall. “Not there,” she said impatiently. “There!” And she pointed with a shaking finger at the two urinary systems.

I took them down after she left -they’re still in a drawer along with a few other pictures I thought might offend. I left the one of the IUDs though, but I think I’m only getting away with it because I call it a Pasta Poster (they do kind of look like pasta I’m told) and make a joke of it when a patient first enters the examining room. Anxiety changes perception, I suppose, and I haven’t meant to startle already nervous people.

But I can’t help but think my new, pre-printed diagrams will add a certain veracity to my explanations. I can guide patients through the thornier parts, and steer them clear of the more confusing -and to me hidden- moral aspects of the subjects I am desperately trying to explain. I have avoided inflammatory and suggestive words wherever possible, and limited any free-hand illustrations where trespass might be construed. Autonomy acknowledged…

But I haven’t avoided risk entirely, you understand -retreat is permissible; surrender not: there is still a large black and white photograph of a man holding a baby skin-to-skin on his chest prominently displayed on the wall where the trangressive urinary systems had hung. I’m not sure of the message I’m trying to convey nor its educational value, but it avoids all the urinary pitfalls. So far it has been greeted with smiles and only one raised eyebrow. It’s a statement though, don’t you think?

Mother-Baby Units in Prisons

Mothers keeping their babies while in prison -a great idea? I have to admit that I hadn’t thought much about it until the Media publicized a case being considered by the British Columbia Supreme Court. A mother-baby program was cancelled at a regional institute in 2008 and the contention is that this not only violated an infant’s right to a mother’s care, but discriminated against the mother as well. There is also a Federal facility in the area however; it is still open, also offers a mother-baby program, and is theoretically available to those who meet the criteria.

This was not an across-the-board right for all female prisoners who were mothers, it must be noted; it was supposedly available only to those who were serving terms of less than two years, and was for those where it was judged the baby would not be at risk. The regional officials felt that there were safety concerns apparently.

Mother-baby programs in prisons are not new, and certainly not a uniquely Canadian compassionate innovation. In fact the Bedford Hills Correctional Facility for Women (a maximum security prison in New York) first opened a prison nursery in 1901 and there are similar programs in other U.S. states as well as in Europe.

Although criteria for acceptance seem to vary depending on region -in some, for example, the woman has to be pregnant when sentenced, as opposed to already having a newborn child- many of the principles seem roughly similar: the baby is eligible to stay with the mother for a year to eighteen months (presumably because of some developmental data that suggest any benefits to the child that derive from being with the mother after that are offset by the detrimental effects of being in an institution); there must be no threat to the child either because of the mother or the surroundings; the mother is required to attend parenting classes of one sort or another; and she must be serving a relatively short sentence usually.

Of course after the eighteen months, if the mother is still in prison, the baby is then taken away -either to relatives, or foster care. In a way, this is a two edged sword, isn’t it? Bonding occurs and then it is severed with probable consequences for both parties. So what are we to conclude? Do the benefits of the close mothering outweigh the subsequent schism? Are there data that substantiate its worth?

What few studies I have been able to find seem conflicted on the effects of the units. The hope, of course, is that they will reduce the likelihood of the mother re-offending; that by showing understanding and compassion, she will be convinced to change the way she apprehends the world. Unfortunately the units do not improve the environment into which she will be released, nor alter the conditions that led to her crime in the first place. But we need to take one manageable step at a time. To be sure, many things need to change, but punishment per se rarely extinguishes a behaviour as quickly as reward. For that matter, allowing a new mother to stay with her baby is not a reward, it is what a just and empathetic society should facilitate! We are what we do.

Most centers are adamant that the process exists not so much for the mothers as for the babies who, as Mark Thompson, governor of the Eastwood Park Unit (one of 8 units in the 13 women’s jails in the UK) says “Have not done anything wrong and who deserve to have a good start in life.” In that unit at least, women are taught parenting skills; they’re taught how to cook; they’re supported in breast (or bottle) feeding, shown how to change diapers and sterilize bottles and even how to play with their babies…

Clearly the opportunity to learn many of these skills might not have been accessed had they not been in prison. And yet, balance that with the thought that a prison might not be able to offer other things for the baby that are necessary for it’s development. The Prison Service leaflet from that same British unit advises the mother “Your baby will miss having contact with normal daily life, such as family, traffic, shops, parks and animals.” Socialization, in other words. This is mentioned, even though in that unit the staff apparently take the babies out to parks and supermarkets, etc. as an attempt to normalize things. Wow!

I suppose my interest in this -apart from being an obstetrician and a father- is in examining what we hope to accomplish in our penal system. Is the aim of incarceration merely Retributive Justice -revenge by another name? In other words, the woman committed a crime and doesn’t deserve to have her baby with her! (There are letters and online comments to that effect.) Is it public safety -keeping them off the streets (out of sight, out of mind)? And if the latter, one has to wonder why anyone would be jailed for a victimless crime like, say, a drug offense, or petty theft. If it is a non-violent offense, is the right place for them really behind bars? And for that matter, what about all the so called ‘white-collar crimes” that are clogging the cells? Surely there are other, better uses for the public purse.

I have always treasured the notion that where incarceration is necessary, rather than hardening the inmates against whatever system put them there and teaching them how to avoid getting caught the next time, it would incorporate some attempt at rehabilitation: education, retraining, and re-motivating. Teaching normal and acceptable life-skills to a captive audience would seem to be an obvious benefit not only to them but to society at large -an obvious opportunity.

And I don’t think I’m being unduly naïve in intuiting that being able to keep their babies with them must be a highly motivating factor for most mothers. Motivating and humane. To waste an opportunity that might potentially benefit everybody -mother, baby, and society- is in itself a crime.