Monthly Archives: September 2013

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Are Secular Values Different?

I am concerned. I am concerned that how I dress, where I come from, or even what values I hold dear will be held against me. I am concerned that who I am will matter less that how I appear. To paraphrase a recent Ontario ad, I am concerned that what I wear on my head will be construed as more important than what is in it.

Doesn’t fit the image of the multi-ethnic, pluralistic Canada we have been led to expect? No it doesn’t.

I’m referring, or course, to the ever-changing Quebec Charter of Values (originally the Charter of Secularism) -Quebec, for those not living in Canada, is a province whose linguistic and cultural background is French, but whose largest city, Montreal, has long had a well-deserved reputation for being a truly cosmopolitan center. The Charter is a proposal to restrict public sector employees (including doctors, nurses, teachers…) from wearing anything conspicuously religious in nature. This would include things like the hijab, turban, kippah, and even crosses… not little ones, mind you -just ones big enough to offend… ( http://www.nosvaleurs.gouv.qc.ca/en#propositions ) Just how such things could adversely affect health care, or students in a classroom it doesn’t explain. The qualities that I expect in a nurse or a doctor haven’t been affected by their appearances so far -and I have no reason to believe they will in the future either. In fact, the hospital where I work, not to mention the Delivery Suite where I seem to live, is a virtual United Nations. And I love it! We all learn from each other, enjoy each other -especially a prairie boy like me. So… 

The proposal has rightly stirred up a debate throughout the province, of course -but mainly, it seems, in the largest urban center, Montreal, where foreign born immigrants make up 23% of the total population. That is where the biggest opposition to the charter exists. So the government, caught with its pants down, has started waffling about what it might be willing to allow to opt out, and under what circumstances. But that seems to defeat their original reason for proposing the charter. Indeed, if there are things so unimportant as to be allowed to be dis-included, doesn’t that suggest that their importance has all the while been of questionable significance?

On first glance, the ideas behind the proposal might seem reasonable in a society where there had never been any religious roots. But Quebec’s history is a Catholic one, a religious one where, at least until recent years, it was not unusual to see the night-black gowns of priests and nuns in any crowd, on any street, and in any city or town. It’s a province where churches and cathedrals abound and where no village could hide inconspicuously in any terrain because its steeple would give it away long before any other buildings would.  A recent poll suggested that a majority outside of the urban area of greater Montreal are actually in favor of the idea of dispensing with religious symbolism. One suspects, however, that the responses were not deeply thought through and that what was really meant was the banning of the religious symbols of others.

Perhaps people outside of an urban cultural mosaic like Montreal are less used to the hijab or turban -and with the problems in the Middle East and even Africa now, I suspect also a little afraid of them. So, one of the charter’s proposals is to ‘Make it mandatory to have one’s face uncovered when providing or receiving a state service.’ And, ‘To establish a duty of neutrality and reserve for all state personnel’. But wait a minute, a turban covers the hair but not the face -so do most hats, for that matter; and the hijab…? The hijab is merely an attractive scarf around the head and hides nothing of the face either. The government of Quebec even went so far as to ban turbans in their soccer teams -until not only the soccer federations but also the rest of the soccer-playing world chastised them for their silliness. They changed their prohibition, but obviously didn’t learn from the outrage. http://www.theglobeandmail.com/news/politics/charter-of-quebec-values-expected-to-limit-religious-accommodations/article12911107/

The niqab -which covers the entire face except for the eyes- might be a bit more frightening to some, but there are variations even with this. And behind every niqab is a voice, a woman, a person -no more or less to fear than any other. We speak, after all, more with our eyes than our faces; they are what hold our attention and focus in a conversation… They are what a doctor learns to trust.

So, are we offended that some people look different from us? Think differently; behave differently? Do we really possess omniscience? Only us? How parochial! How monochromatic! The whole thing reminds me of the famous film, The Wizard of Oz. Remember how it started out in black and white -the Kansas sequences? And because it started that way, it seemed entirely normal and complete… until it suddenly blossomed into Technicolor. and we realized what we had been missing, and how drab the world had looked before. It is a wonderful metaphor to describe the multicultural experience. Life, in colour, is so much more interesting.

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The Ageing Gynaecologist: a Paean

I grow old… I grow old… I shall wear the bottoms of my trousers rolled. Well, maybe not, but I do think that things unfurl differently with age. The world is just that little bit more tinged with memory, red-shifted as it were, softened with colours no longer as bright, but deeply embedded and integral. Constituent. Fundamental. I think apperception is what makes age unique… and valuable: the epiphany on the journey Northward.

Age is insightful, and wisdom springs from having seen most of it before -in different iterations, perhaps, but nonetheless engendering that Delphic facility of predicting consequences from seemingly disparate observations. The collation, in other words, of subtle details, trivial evidence, and past experience. Diagnosis, after all, is merely the compilation of relevant  information and insightfully categorizing it. And of course what is chosen for the algorithm determines its worth.

But perhaps this is an unrealistic assessment of what age contributes to a profession like medicine; perhaps the increase of years merely serves to isolate the individual in long-buried concepts, world-views that no longer obtain, knowledge that has since been superseded. The world is round, whether or not we grew up thinking it flat –knowing it flat… Knowledge changes, and unlike Fashion, it changes for a reason: the concretion and assimilation of evidence.

And yet to assume that age is somehow tethered to a stake -a chain that stretches only so far- is to dismiss the opportunity to lengthen the chain. Like a plant, enlightenment requires  two directions to grow, and we neglect at our peril, the roots underpinning  what we see -what we know– in our zeal for the fruits of the visible. The now. Current apprehension, after all, is built on something…

I would like to think that, in general, age recognizes itself -recognizes, that is, that its role has shifted. In some ways it is like the move from player to coach: experience teaching the inexperienced. It’s a natural progression and often subtle, requiring a restructuring of identity, a reshaping of expectations, a shifting of goals. As I look back on my own career I can discern temporally invisible phases ranging from the overly -and insufferably- merely knowledgeable, to the practically-acquired functionality necessary for independent performance of surgically appropriate tasks, to the realization that these same tasks need not be selfishly virtuosic but could be shared. Should be shared. This latter aspect, I suppose, is the belated awareness that wisdom entails distribution: dissemination of what time and experience have endowed.

I am more and more drawn to the value of those who have been deemed elders in traditional societies: people who are considered repositories of what is considered important in their respective cultures. They bring not only memories of things past, but the expectation that the past may be of use -if only by way of example- to the present. Without what was, what is remains rootless. Lost. It is a person with only a first name: bereft of family identification, unvalidated and uncredentialled in the larger picture.

As time passes and experience accretes, I think those of us senior enough in our chosen specialties can choose what procedures we wish to perform and refer the others to younger, more eager members with reputations to solidify -those who will become us in turn as the years roll past. We become their mentors -coaches- in the ever changing world of medicine. No less valuable for the alternate roll, there is nonetheless an understanding, an unspoken assignation. A different authentication.

Age in Medicine brings with it benefits not only to the Specialty but more importantly, to the patient as well. It brings among other things a willingness to talk and listen, a disposition -sometimes- to share stories and commiserate as only someone with long experience and a wealth of misfortunes can accommodate. It brings, one hopes, a thoughtful response to seemingly intractable problems, a measured approach to issues, untethered by current fashion, that may seem merely philosophical on a cursory appraisal, but ultimately profound and satisfying when considered dispassionately and with the benefit of the passage of time. It brings things that are often difficult to teach: bedside manners, respect for differing perspectives and, maybe, recognition that when we cannot cure, when we cannot fix, we can still be human. We can be understanding. We can still be a voice for hope.

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The Health Care Paradigm

The Middle East has been in the news a lot; the Middle East is the news, with its tentacular failures reaching out to all and sundry, near and far, friend and foe. It sticks like Velcro to anything that has ever passed; it is the spider at the center of a web whose boundaries are still enlarging, still entangling.

At times I am reminded of Health Care -that primitive god appeasable only with sacrifice, but beset with failed diplomacy and feints and posturing. The intentions are laudable but the reality -or the contingencies surrounding that reality- too complex to allow much change. It’s almost as if the assessment were so constrained by circumstance, by need, by good intentions, so shrouded in expectation that no one could see that it was naïve. Unworkable. Even the most optimistic approach is unpalatable to many and dangerous to a few. And in the end, no one, let alone the participants -the victims- are satisfied.

Both situations are subject to similar biases: the ultimate goals are probably unachievable without radical changes –paradigm shifts. Thomas Kuhn in his book The Structure of Scientific Revolutions (where the concept of paradigm shifts -world-view changes- was most forcibly presented) suggested that system changes occur more readily when so many anomalies accumulate in the usual approach it has to be abandoned. Unfortunately, unless another more appropriate theory is ready to jump in and replace the old one, things can drag on inefficiently, often with disastrous results. Be careful what you wish for.

Health Care, like politics in the Middle East, requires a new approach, a new paradigm. When we come home from a long and vexing day, wearing all the unresolved issues it wove, we are comforted by the predictability of our house -the orderliness of a room, say: the vase on the table, the juice in the fridge, the magazine where we left it on the shelf by the couch. It is an oasis tucked away from the world, safe and unchanged. Most of us desperately want -need- the world to be like this: predictable, reassuring, changing little and only within our comfort zones. All therapeutic perhaps, but nonetheless beside the point. Irrelevant. It’s just not how things develop; there is an evolution inherent in issues that is beyond our ken. Our desire for refuge solves little. And yet…  By taking us out of the fray, it may allow us a more dispassionate view of what we left behind. Contrast is sometimes the way out of a paradigm: a sudden light flashing in the dark.

The old way of looking at it has not worked. Our objectives may be noble; our solutions, however, are necessarily coloured by reality. Economics. Politics. For example, in Canada at least, our Health Care motives seem to be laudable: let no one go untreated, unnoticed, uncared for. And yet we know many are. Politicians insist they are pouring more money each year into the system -and no doubt that is the case. But it seems to me that it is akin to bailing a boat with a hole in the bottom; it is doomed to sink. What is needed is a new boat, not a new patch… A new design. A new fabric to make the boat.

And yet, rapid change often begets rapid and usually unanticipated problems. Even new paradigms do not come with guarantees; new clothes -beautiful and desirable ones included- do not always fit. Sometimes one has to measure for need as well as appearance. And measurement is an interesting concept; it entails viewing something in a new way: not how it appears superficially, but rather assessing its components and calibrating them in some consistent and verifiable manner. Not so much the size of the problem -that can be dealt with separately- but the components of the thing measured and the way they aggregate. The way they work. The size of a molecule is one thing, but the way it is put together may more successfully determine the way it interacts with the things with which it is mixed. That may be a better thing to measure… Reality rarely comes uncombined, unmixed, unassembled.

So in the case of Health Care, the situation is often reduced to its ever-increasing expense, its insoluble complexities; or it becomes mired in the mud of one problem or another adding yet another passage to the labyrinth… All, it seems to me, measuring the wrong things: the appearance, the effects, not the way it is put together. We know what we want it to do, not how to make it perform. So in geopolitics as well as in Health Care, maybe we have not yet talked enough to the other side -listened to its opinion, modified the equation. Maybe we’re so intent on what we want to be the answer, we miss the fact that it isn’t. For an equation to work, what appears on one side of the equal sign has to be in balance, in harmony, with what is on the other.

And what, after all this, is my response? Perhaps only the observation that, despite the desperate need, the paradigm has not yet shifted -it is still the same old worn out animal dutifully charged with clearing the pasture. But, more alarmingly, that perhaps we don’t even realize it is just a paradigm… and not the only one.

 

 

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Take my milk for gall

Come to my woman’s breasts and take my milk for gall. Even Lady Macbeth was not without an opinion on the uses of a woman’s breast… And so it continues to this day; almost everybody has an opinion on breast feeding. This runs the full gamut from the harangue of Elisabeth Badinter in her March 2012 article in Harper’s Magazine: The Tyranny of Breast Feeding to the quasi-religious sermons published by the La Leche League that engender parent-like guilt for even considering alternatives.

It is, as they say, a Motherhood Issue: something valued in principle, honored for its obvious benefit to baby, and yet often abandoned in the frustrating weeks and months after birth when the glow has faded along with sleep and patience. There are data from various national surveys which show that on average although around 90% of Canadian mothers start out with good intentions and exclusively breast feed their baby -i.e. offering only breast milk (plus or minus vitamins, medicines, etc.) and no supplementation with other liquids, (formula, juices, etc.)- less than 25% continue with it. The World Health Organization recommends exclusive breast feeding each infant for the first six months of its life. Yes, the benefits to baby are that important!

Interesting though, despite the obvious benefits, there are various impediments to the practice: Culture -or is it country and its customs?- for one. The WHO has a global data bank on breastfeeding and some of the figures reveal startling differences by country alone -and not all related to social disparities in health, education or economics.

But admittedly, there are Canadian studies that suggest that breast feeding is chosen less often among single mothers, women with less education, or lower incomes. Some may not even choose to start breast feeding, let alone abandon it early. And when it is chosen, almost 50% of the ones who choose not to continue, stop within the first six weeks… So given this finding, is there anything that might help support, or lend itself to intervention in that critical window of time?

There is an article in the Canadian Medical Association Open Access Journal in January of this year (cmajo january 16 2013 vol.1 no. 1 E9-E17) that looked at just that, in 2 regions in the province of Nova Scotia between 2006 and 2009. Their exclusive and dropout breastfeeding figures were different from the Canadian average, but even so, they did identify “four potentially modifiable risk factors: prepregnancy obesity, smoking during pregnancy, no intention to breast feed, and no early breast contact by the infant.”

It’s that latter factor -the “no early breast contact by the infant” (read skin-to-skin contact, I would imagine) that intrigues me, though: that such a simple thing -placing the baby on the mother’s skin near her breast after delivery- could create so much difference! This is a policy I would have thought would be universal by now: we even encourage it after extraction of the baby during a Caesarian section in our hospital if the baby is healthy. Its what almost every woman craves -and baby as well- so why not?

And yes, the other modifiable risk factors loom large as potential targets -especially the ‘no intention to breast feed’ decision. One wonders whether frequently bringing up the topic in a respectful and sensitive manner as the pregnancy progresses (and her trust and bond with the health-care provider increases) might be helpful.

The other interesting thing I learned from the paper was that “educational interventions are more effective if focused on improving maternal self-efficacy than on enhancing knowledge.” Most women nowadays know why they should breast feed; it’s how to breast feed, especially with difficult infants and problems latching once they’ve left the hospital, that frustrates them and causes them to stop trying after a few weeks -or even days… Small communities seem particularly at increased risk, often because of a scarcity of easily accessible resources. Recognizing that continued support is very important in the early days after delivery is obviously an important key. So postpartum enthusiasm for breastfeeding on the part of the nurses and staff before the woman even leaves the hospital is the first step. Ideally, a 24 hour breast feeding hot line (perhaps utilizing the existing hospital maternity ward) would be helpful -night time is when the woman is tired and irritable and more prone to frustration. Lactation consultants -maybe also recruited from maternity nurses in the local hospital- would be another important resource. Of course, a knowledgeable and empathetic family doctor or midwife -and an understanding and patient partner- complete the readily accessible communal facilities… Support and understanding are what a community can supply with very little extra resources: the ounce of prevention strategy, I suppose.

But preemptive encouragement is even cheaper; so is motivation -prenatal motivation especially. It doesn’t take much time for the doctor or midwife to inquire about it, and often merely the willingness to listen to her concerns about breast feeding -or her doubts about her abilities- is enough to get the woman thinking.

No… I suspect that breast feeding is not for every new mother… but who knows, maybe it could be.