A Picture is worth…

Communication -explanation- in Medicine is so important that one might even consider it paramount. Except in circumstances where the patient receives a treatment of which she is unaware because of an accident or the severity of the illness, her understanding of the reasons for the therapy and the side effects it may engender often determines whether or not the prescribed regime will be followed – and sometimes whether or not it will even have the desired effect. A cure is not necessarily the same as the elimination of all symptoms: think of eliminating a headache only to be left with a fuzziness in the head, a feeling of fatigue, a ringing in the ears… In order to adjust her expectations appropriately and help her to understand what the concept of ‘cure’ might entail -in order to understand what it is not, in other words- there must be an explanation she can understand -especially if there is a process or mechanism she can visualize. An anatomical correlate with which she can identify. An algorithm, even. In many instances, this necessitates the use of diagrams.

The Diagram has always fascinated me; its etymology (loosely rendered as ‘explanation by lines’) less so: there is a magic in its enlightening power that transcends mere lines, outstrips even the most eloquent vocabulary. It is the Word Incarnate, as it were. And yet there are problems: we each see the world through different eyes. The past influences the present; so does fear… And although diagrams are often drawn to allay anxiety, sometimes they merely distract. Whatever I’ve drawn is open to interpretation and confusion if it is not both clear and commensurate with her own notion of what her internal organs look like. And most people have no idea… I sometimes show my post-op patients  pictures taken during their operation -the ovarian cyst that I have removed, for example, or the spot of endometriosis I have coagulated. Unfortunately I suspect that for most, it is a ‘Where’s Waldo’ puzzle -everything is strange but similar and mixed together randomly; for some, an ovary is merely a white meatball in a bowl of extra large fettuccine noodles. Or sausages, maybe. We see what we are used to.

The  idea that my diagrams may not be adding to someone’s understanding of their condition is uncomfortable for me, though. Anathema, maybe. I mean, my uterus looks really similar to the pictures I’ve studied, and I can draw a fairly recognizable Fallopian tube. But if the patient has never seen an ovary, or maybe even thought about a fibroid, the drawing may be totally devoid of meaning for her. She might nod politely as I doodle on about how the end of the Fallopian tube grasps the ovary like little fingers picking up a ball, and hear me explain that it’s why they call them fimbria: Latin for ‘fingers’… but if she wasn’t linguistically inclined -or was simply nervous- the words might still be meaningless. Unhelpful. Perhaps all she was really seeing were two wiggly lines becoming ragged and imaginatively bankrupt at what might be a ball, or a poorly drawn circle. And since she would know that an ovary should contain eggs she might be wondering why I didn’t draw them as well. Two people crossing a bridge and each seeing a different bridge. Two worlds, two paradigms… one diagram.

I was reminded of this the other day when a patient that I had not seen for some time, immediately smiled when she saw some of the photocopied diagrams I keep on my desk for immediate explanatory reference. The one most visible is of a uterus with its two Fallopian tubes arching conveniently far from its side like arms from shoulders. Of all my reference diagrams, I have always been attracted to its simplicity. That it is unmistakably a uterus with Fallopian tubes I thought was obvious; it is so utterly characteristic and self-explanatory there is nothing else it could be mistaken for.

“I see you still have the drawing of the cow,” she said matter-of-factly, and smiled again.

“Pardon me?”

“The cow,” she said, rolling her eyes as if I’d have to be blind not to see it. She sat back in her chair for a moment, to give me time to follow her words, but when I didn’t say anything, she leaned forward again to study it more closely. “Well, I suppose it could be a goat, or something, but…”

She tried, unsuccessfully, to disguise a sigh but when she saw me staring at her, she shrugged and pointed to the uterus. “The head,” she said slowly and carefully, so I could follow her finger on the diagrammatic womb. “And here are the horns.” She enunciated clearly, like a teacher explaining a difficult concept. “See? The tubes are like long, skinny horns sticking out of the top of the head…” She smiled, obviously proud of her explanation.

Two different bridges, I suppose. But the converse can also obtain: the bridge sometimes determines who crosses it. Another patient I hadn’t seen for a while -not the same one, I don’t think- brought in a beautiful black-and-white photo she’d taken of a mountain range. She seemed quite excited about it and immediately plopped it on my desk as she sat down.

I looked at it and smiled. “Beautiful picture,” I said, somewhat taken aback by the irrelevance of its arrival on my desk. I even tried my best to look grateful, in case it was a present. “Did you take it?”

She smiled, but I couldn’t help but notice that behind the smile was a hint of disappointment.

“Can you see them?” she asked, hope creeping into her voice. As if maybe I could redeem myself.

“Uhmm, well I really like the shadows of the trees… Sort of like an Ansel Adams photograph,” I added lamely. “Incredible detail.” I was staring intensely at the picture, not sure what more I could add.

“But what do you see?”

I felt like a child on a school tour of an art gallery. Evidently there was more to the picture than the trees and the mountains. I’d been really proud of my mention of the shadows, but I’d obviously missed the mark.

“Breasts!” she said finally, exasperation evident in the tone of her voice. She pointed to a couple of peaks in adjacent mountains, and waited for any sign of recognition in my face. I suspect what she wanted was a show of admiration for the perspicacity required for her to spot the resemblance.

She was, I knew, a visual artist and becoming quite well known. I tried to pretend I saw the breasts, but the trees kept bringing me back to earth. And for some reason, all I could think of was my cow diagram.  In a feeble attempt at humour I told her I saw a cow -a feeble attempt to diffuse the situation, really.

“A cow?” Her eyes widened in admiration. “Really..? Where?”

I sort of randomly moved my finger around the photo, pausing on a tree after skimming over a rather angular mountain.

She sat back, clearly impressed. “You know it’s really amazing how we all see different things, eh?”


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