Sometimes, I feel like a fake. I suppose the ability to see oneself from various angles is a gift of age, but I rather enjoyed myself more when I was sure of who I was –or at least didn’t trouble myself with the question. And yet, to dig for the core is to taste the apple on the way.
It was easy to be a doctor when, primed with knowledge, experience was something displayed in a shop window, not something I wore. It was an outfit I didn’t need -an extravagance, really: a luxury you only donned when the facts you’d learned were threadbare and outdated. It was a costume of authority, a camouflage for waning certitude: Moira.
And yet as I plough through the years as steadily as a man walking through waist-high water, I have come to realize that experience is more than subterfuge, more than mere artifice; it is Age. Nothing less. And following in its wake is all the jetsam tossed overboard to lighten the journey, all the flotsam through which we, as sentient beings, must wade in order to progress. A dirty passage protected only by the hull of maturity. But enough metaphor.
All of this somewhat depressing prologue is to introduce an incident that occurred a few years ago when I was teaching a medical student in my office. Stephanie was very good, really –very perceptive and knowledgeable- and she carried herself like someone who had already graduated. It was not hard to integrate her into the chaotic machinations of my busy office.
We were seeing a woman sent to me from a well-respected family doctor who sometimes attracted patients with very dissimilar world-views. She had come to see me for a second opinion about the management of her menopausal symptoms. Or rather, she had been sent to see me by the GP when she refused to accept the treatment offered by the first specialist.
A very well-dressed woman with neatly brushed hair, she sat across the desk from me looking quite confident. She smiled at Stephanie, and then straightened her shoulders and stared at me defiantly. “My doctor wanted me to see you about the menopause…”
I smiled and waited, pen poised to write down her complaints so I could address them later, but she sat back in her chair, obviously finished, and stared at the calendar hanging on the wall behind me. “So, are you having any problems?” I asked after a rather awkward silence.
She shook her head and shrugged. “Am I supposed to?”
I glanced at Stephanie, who was sitting on the edge of her seat, fascinated at the exchange. “No…” I said, looking at the referral letter that just said ‘MENOPAUSE!’ in giant capital letters followed by an even bigger exclamation mark. “But I rather thought your doctor must have had some reason to send you to see me.”
The woman smiled –at least, I suppose that’s what she wanted me to think, but actually it was a smirk. “I’m managing my menopause very well, doctor…” It was a challenge: a dare to be contradicted.
“So… there are at least some symptoms you’re feeling a need to manage.” I said this carefully, not wanting to provoke her.
She immediately straightened in her chair and her eyes hardened. “Why would you say that?”
My turn to shrug. “Well, is there anything I can do for you, then?” I kept the smile on my face.
She took a deep breath to contain her obvious irritation. “My doctor thinks I should be taking hormones… And so did that other doctor she sent me to.”
I started to write in her chart –it often helps patients to think they are saying something important. “Why is that?” A simple question; no sense confusing her.
Silence, and then a prolonged blink. “I told her I wasn’t sleeping and was becoming irritable at work.” She pinned me to the wall with a sudden glare and then, just as suddenly, relaxed the intensity. A little grin crept onto her lips, but she erased it almost before it flowered. “And I mentioned I was having the occasional hot flush.” Her face hardened. “Why do we always medicalize things and make them into illnesses?”
She was silent for a moment and I put down my pen. She looked at my now dormant chart, for a moment.
“I do not want hormones, doctor,” she said shaking her head angrily. “I’ve solved the issues myself.” And she crossed her arms across her chest as if to ward off any criticism.
I picked up the pen again and her expression softened a little.
“Ginger and lemon juice three times a day…” she said and then stared at me: the dare again.
“It helps?” An innocent question I thought.
“Of course it helps!” Her arms tightened across her chest. “You don’t always need hormones, doctor.”
I tried to keep smiling and sat back in my chair. “I certainly agree with that, Sandra. Sometimes we pathologize things unnecessarily.”
The change in her body language was dramatic and she unfolded her arms and loosened her shoulders. “So you think it’s okay to continue with my lemon and ginger?”
I nodded and wrote something in her chart. “As long as it’s doing the job, why not?” I started to put the pen down and she noticed.
“There’s a lot of stuff in there that you haven’t filled in yet,” she said with an increasing grin on her face and stared at the almost blank history sheet in the chart. “You can ask me some questions –I won’t bite.”
I proceeded with the usual consultation and then looked up at her. She was beaming.
“You’re the first doctor who actually listened to me…” she said, clearly surprised. “Still think I’m okay with the juice?”
I smiled at her -my face was beginning to ache with the effort. “It won’t hurt, “ I said, and sensing she was satisfied with the interview I got up from my chair to open the door for her. “But just let me know if you need to discuss some other options, eh?”
As soon as she was out of the room, Stephanie rolled her eyes; she was obviously troubled.
“So what do you think, Stephanie?”
She took a deep breath and looked at me. “She needs hormones…”
I sat down and waited for her to explain. “I mean, she was obviously describing estrogen withdrawal symptoms: hot flushes, night sweats, sleep disturbance… And did you see how irritable she was? Classic menopausal stuff.”
I smiled patiently. Stephanie was young and enthusiastic. Full of knowledge. “So what would you have done if she’d walked into your office?”
She thought about it for a moment; that she didn’t want to offend me was obvious in her face. “Well… First I would have taken a detailed history like you…” She politely ignored the order in which I had proceeded. “And then I would have told her about how estrogen –and progesterone, I guess, because she still has a uterus- would help alleviate her symptoms.” She looked at me, whether for approval or permission to deviate from my approach I couldn’t tell.
“And if she told you she didn’t want to take hormones? That she felt they were too dangerous, or maybe she didn’t believe she needed them..?”
Stephanie didn’t even blink. “I would have been more insistent…”
“And if she still didn’t agree?”
That stumped her for a moment. “Well… uhmm, maybe I would have sent her to a specialist for another opinion.”
“To validate your opinion, you mean?” I said it lightly and with a grin to defuse the tension I could feel increasing in Stephanie. “She already saw another specialist, who validated her GP’s view… Now what? Give up on her?”
Stephanie stared at me, but it was clear she didn’t have an answer.
“Look,” I started, gently, carefully, so as not to appear to contradict what we both knew to be true: many menopausal symptoms are related to hormonal changes and many of the symptoms do disappear when you prescribe hormones. “Why was she sent to me?”
Stephanie rolled her eyes again –an annoying habit she was prone to use at the slightest provocation. “To treat her menopause…”
“Didn’t she tell us at the very beginning that she was already managing her menopause?”
“Yes, but not the way you would like?”
I could see that Stephanie was becoming exasperated. “But surely you could see that she wasn’t. I mean, she was obviously really irritable and…”
“Wouldn’t you be irritable if nobody listened to your opinion?”
Stephanie’s left eyebrow suddenly took over half her forehead –another trait I had noticed during her time in the office. “But there’s no data on ginger and lemon juice. No studies…”
“She seems to think it’s helping her.”
“Yes, but that’s just a placebo effect. It’s going to wear off…”
I broadened my smile. “And when it does –if it does- who will she decide to talk to about it? The doctors who were unwilling to accept her approach, or the one who admitted she had the right to try another way?”
I’m not sure I convinced young Stephanie, and I’m certain that she’ll succeed in whatever field of Medicine she chooses. But I do hope that she learns that the paths we need to follow are not always straight and that even detours usually end up where we want…