A Medical Dilemma

Here’s an outrageous assertion: there are some things that we just cannot control. Worse, sometimes they are undefineable – or at least so vague as to defy placing them on some scale or other. Ranking them in terms of importance either to us, or to others. Naming them for future reference. And if we cannot even assign a name, categorization is slippery, too.

All of us experience these uncontrollables. Sometimes we are suddenly enveloped –a fog that obscures direction so completely that we are lost, abandoned in a terrifying limbo- but as often, we wade in from familiar territory until, over our depth, we panic.

Doctors, among others, seem to gather these fractious elements like apples in a basket we scarcely notice we are carrying. Its not that we are incompetent –although circumstances often determine competency, don’t they? It is that situations pile up like obstacles -and detours, of necessity, require changes in direction. Unintended changes. Routes that, until they are explored and charted, make regaining the original destination difficult, if not time consuming.

A recent example from my practice: suppose, for a moment, you are a gynaecologist who has been referred a young woman with a benign tumour, a uterine fibroid, say. Even though fibroids –benign overgrowths of uterine muscle tissue- are fairly common in middle age, fibroids of significant size are unusual in young women. You are reassured by many factors in your investigations thus far, however: the ultrasound appearance, the blood tests measuring tumour markers, and her general good health. She has no pain; she has no symptoms, and the fibroid is small -only 1 cm in diameter. And, as important, a clinical examination does not hint of cancer, or demonstrate a lack of mobility of the lump in her pelvis that might indicate malignant attachments. She has simply been plucked from the realm everyday existence by a test done for something else but which found a tiny mass on her uterus.

She is barely out of her teens and as yet unattached, but dreams of a relationship and children –the proverbial girl next door. Her life has been turned upside down in an instant, and intimations of mortality that should not be collecting outside her door for years are suddenly apparent -a tree branch scratching her window in the night.

You discuss the features of fibroids, show her what she has on a diagram, then answer her questions and attempt to calm her down. Finally, after considering all the factors in her case, you speak to her of what you would recommend: observation and reassessment with another ultrasound in 6 months. Perhaps sooner if she develops any symptoms –pressure, or pain with sex, for example.

But she is worried, and all of your explanations have only served to reify the alien lump, hitherto hidden and unnoticed. It is real for her now, and it shouldn’t be there. The fact that her mother required a hysterectomy for them in her forties after years of heavy periods and pelvic pressure, has always weighed heavily on her.

You put down your pen, and listen as she tells you how she has researched the various therapeutic options online. You have already discussed them, of course, but have counselled against their use because of the small size of the lump. She smiles at you, because she agrees she is not a candidate. No, she wants the lump surgically removed –a myomectomy- before it gets too big. Before it causes symptoms. Before it interferes with becoming pregnant.

It is always difficult to disagree with a thoughtful person who presents her arguments in a cogent and reasonable fashion, but one always has to help the patient weigh the risks and the benefits more objectively. More contextually. Especially when you feel that surgery is not indicated. There are risks to surgery –major risks. Risks that are obviously assimilable under certain circumstances, but in your expert judgment, not hers. Fibroids grow slowly, so there is certainly time to consider less invasive options. Some sort of a compromise is in order.

You attempt to do this, to help her stand back and consider her request within the landscape of her actual needs. You try to help her to separate her concerns about the fibroids her mother had to have treated when she was much older, and her own situation.

But she is adamant. It can be done laparoscopically –belly-button surgery- so she will not even need much time off school, she points out.

When you still are hesitant, she breaks down in tears and heads for the door, sobbing. You relent and say you are willing to refer her for a second opinion, secretly hoping the other surgeon will be able to convince her to wait. But she is not listening any more; you have failed her.

But have you? At what point can failure be assigned? Does a reluctance to acquiesce to demands which are predicated on fear and misunderstanding constitute failure? Or is failure actually the opposite: going against your considered judgment to please the patient?

Years ago, I saw a very similar person –the daughter of a doctor in another part of the country she immediately informed me. She was adamant about wanting surgery –felt she was entitled to it, in fact. And encapsulated in the trappings of my recent specialist status, I was equally certain of my opposition to it. She was quite verbally abusive to me when I wouldn’t change my mind and also walked out of the office, but not in tears… She had a smirk on her face.

She was a heavy woman, a smoker, and although in her twenties, not in the best of health. We weren’t doing many difficult laparoscopies in those days, so any surgery would have required a large incision –her abdomen was obese and pendulous- and several days in hospital to recover. In her case the fibroid was only 2 cm in diameter –still small. Still observable over time.

I was puzzled by the expression on her face until I learned from my secretary that she was actually scheduled for a myomectomy with another surgeon in another town –but not for a month or two. She had been hoping I could schedule it sooner in my hospital.

I felt guilty, although I couldn’t really understand why. She was a poor operative risk despite her age, and the surgery was unnecessary anyway. I wondered whether I had made the correct decision, or whether I had been unduly influenced by her being rude to me when I’d tried to present the reasons for my opinion. Had pride clouded my judgement? Had she been right all along?

So, did I fail her? Or did the other surgeon? Were we both manipulated?

There is a condition called pulmonary embolism that occurs when a clot formed in a vein breaks free of its source and travels to the lungs to obstruct the blood supply. Some factors increase the risk of forming clots –major surgery, obesity, smoking, immobility… An embolus can kill if not treated immediately. Nowadays, we recognize these risks more readily and will prophylactically employ anticoagulation –blood thinners- to decrease the likelihood of clot formation. We ambulate patients more quickly and educate them about the risks.

In those days, I think we were more concerned with the risks of anticoagulation –bleeding internally, for example- than we are today. And so, especially in the non-teaching hospitals in small towns, prophylactic anticoagulation was not a routine standard of care. In fact, it was usually only considered in patients with more extreme and identifiable risks –cancers, for example. The regimens and even the choices of medication were limited then; surgeons were rightly as afraid of the treatment as of what it prevented. Risks had to be balanced. Managed.

I mention pulmonary embolus, because that patient died from one. I only found out weeks later when the surgeon phoned me after he discovered my consultation letter that the referring GP had forwarded to him. He was devastated, as were we all.

It’s easy to be revisionist in retrospect –especially years hence when protocols have changed, not to mention knowledge and available medications. We see the world through modern lenses and judge in the light of current knowledge. Things change. It was –and is- a tragedy that it happened. And it’s a burden which that family –and that surgeon- will carry forever. But in fairness, how critical can we be? Should we be? The assimilability of risks varies over time and things we might consider preventable nowadays, were understandably viewed differently then. Not only do things change, things happen.

Hopefully we learn from them.









The Cleanse

Sometimes, if I have the chance, I like to review the list of referral letters before I see any patients for the day. It tells me what to expect; how to allocate the time for the consultations; whether any of them might be particularly interesting. Surprises happen. The other day, one letter about a patient caught my attention. It was short and to the point: Chronic yeast infection. Tried everything. Nothing worked!

Great. I noticed she was booked for the end of the day so there was always the chance that she wouldn’t show up. The thought sustained me all that morning.

But of course, she did.

Quite an confident looking young woman in her early thirties walked into the office accompanied by her partner. Tight jeans and a bulky grey tee shirt announced her presence on the chair, a too-loud voice from an un-makeupped face made it echo around the room.

“I’ve just done a cleanse, but I thought I’d keep the appointment anyway,” she shouted defiantly. I suppose it wasn’t technically a shout, but it made my ears vibrate nonetheless. She glanced at her partner to underline the proof of the assertion, and then they both glared at me, in case I dared to disagree.

I’d never actually knowingly talked with anybody who’d confessed to a cleanse, and to tell the truth, I was a little vague on what it entailed. I thought I’d ignore the gap, and ran my eyes over the referral paper to make sure I had the correct patient. “So…” I said, noisily unfolding the referral letter on my desk -I often start this way, to demonstrate beyond a doubt that I am in possession of their doctor’s opinion- “Your doctor tells me you’ve had a yeast inf…”

Both their eyebrows shot up in unified derision of whatever it was that the letter contained. “Oh, don’t listen to her!” the partner interrupted in a softer, angrier voice. “She had no idea what was going on with Marcie…”

“Was..?” There was hope in my tone.

“I told you I did a cleanse!” Marcie said, almost reverently. And slowly, as if she were spelling the word out in her head.

I must have looked puzzled, because she produced an overly-tolerant look on her face, and smiled at me, the only slow one in the room.

“Cleanse!” She said it so slowly she seemed to caress the sound on the way through her lips. “It’s a way of ridding your body of its built-up toxins.” When my expression didn’t change, she continued after a maudlin sigh that her partner obediantly repeated. “The colon contains all sorts of toxins that build up over the years and stop the body from fighting off things like yeasts…” She rolled her eyes at the need to explain it to a specialist like me.

“So it worked?” I had meant it as a tentative acceptance of her information at first, but by the time the sound made it out of my mouth it had turned upwards into a question.

Her partner, Grace, seemed offended. “Of course it worked!” she said indignantly. “We both tried it,” she added proudly and smiled broadly at Marcie.

“The theory makes sense, when you think about it,” Marcie bellowed at the picture on the wall behind me. I could almost feel it rattle.

“Oh? Why’s that?” I was trying to be polite –there’s absolutely no evidence for its benefit in the standard medical literature. In fact the fecal microbiome is important for proper immune functioning- but I’m afraid that, once again, my words came out suggesting I was doubtful at best.

Her eyes narrowed and her face tightened –both faces tightened, actually- and she straightened her tee shirt as shocked as if I had sworn in church.

“There’s evidence,” she said and crossed her arms defiantly, satisfied that she had bested me.

I tried to look neutral –neither judging, nor rejecting her statement. “I…” It was all I could get out before she launched into a tirade.

“You doctors,” she roared, somehow managing to make ‘doctors’ sound like a disease. “You restrict your information to narrow little unreadable journals. You never read anything that disagrees with what you already think you know… Or, if you happen on it, you never read the whole thing…” I used the opportunity between her breaths to think about that one. Maybe she had something there… Confirmation bias is something we all struggle with.

She quickly turned to Grace who nodded in support. “There was a website I saw just last week that proves it…” She hesitated momentarily when I picked up a pen to write it down. In fact, she lowered her voice to encourage me.  It’s  http://www.tylervigen.com/

And then she laboriously spelled out each letter, including the forward slashes -in case I got them backwards, I suppose. “I just looked at a couple of them, but they were stuff you’d never find in your medical journals –and all statistically proven.”

I must have raised my eyebrows, because she quoted an example. “Did you know, for example, that the per capita consumption of chicken in the USA is correlated with the total USA crude oil imports? Don’t you find that strange? I mean stuff like that is proven, but they don’t want us to know about it.” She crossed her arms again.

I just concentrated on keeping my expression neutral, all the while trying to figure out how oil imports had anything to do with cleansing.

“And what about the margarine one, Marcie?” Grace added to overwhelm me with evidence.

Marcie nodded, somewhat annoyed she had chosen the chicken example, I thought. “Anyway, I’m betting it’s the same with colon toxins!”

And with that, they both rose in unison and thanked me for listening, all the while glancing furtively at each other. “We’ll come back if it doesn’t work out, though,” Marcie added as a sop to my dignity as she left the room.

As for my part, I felt disappointment at my inability to defend myself. Sometimes naivete is attractive, but usually it is just annoying. Incapacitating…

Out of curiosity, I looked up the website that night. Marcie must have skipped over the title, though -it was called Spurious Correlations. Or maybe she read it as ‘Curious’ Correlations… Anyway, I managed to find an article on it in the BBC News Magazine  http://www.bbc.co.uk/news/magazine-27537142

Somehow, I think they both missed the point of the website -written by a student at Harvard- that correlation does not equal causation. But maybe it wouldn’t have mattered: I didn’t read the whole thing…











Another Advantage of Breast Feeding?

As Mark Twain observed: What a good thing Adam had- when he said a good thing, he knew nobody had said it before. I don’t know about you, but I am getting tired of the media reporting on studies that contain nothing new and passing them off as fresh and enlightening. Even more upsetting is the fact that we often don’t even notice -or care… Studies that say nothing fresh or merely recycle what we already know, do not contain information so much as noise.

Time, then, to ask a more searching question: why is it important that we study this? And this is not to denigrate pure science, nor to suggest that investigations that are not directly goal-oriented are worthless. There is much value in answering the question by asserting that we were simply curious how it worked. Or why. Or under what circumstances -all of which are adding to our understanding of the world. Curiosity, after all, is merely a yet-unaswered question. A piece of the knowledge jigsaw puzzle. And its answer may well be worthy of reportage…

But to investigate the wheel and then conclude that it likely works by rolling, does nothing to inform. Indeed, publication of the results does little even to entertain, let alone educate… Or perhaps it does entertain -like those endless cat videos on Youtube, maybe there is value to a mindless occupation of the time that stretches between otherwise meaningful events. But the whole endeavour smacks more of playing cards until someone turns out the lights…

What is it that has me so vexed? So frustrated at banality uncleverly disguised as news? Well, I happened upon an article in the BBC ‘News’ about breast feeding and how it decreased the risk of depression.  http://www.bbc.com/news/health-28851441   It seemed a reasonable hypothesis; almost 14,000 mothers were studied and the results published in the online journal Maternal and Child Health (Aug. 21/14).

It’s a rather complicated statistical paper, but in summary it suggests that the risk of depression after delivery decreases considerably  if the mother was healthy to start with, intended to breast feed and found that she could. Okay, I could have predicted that. But, if she had been healthy, intended to breast feed, but found she couldn’t for some reason, her risk of depression more than doubled. Oh yes, and they found that  “the beneficial effects of breast feeding were strongest at 8 weeks after birth and that the association was weaker at  8 months and onwards.”  Uhmm… am I missing something here? Has something hitherto unsuspected slipped past me? Something, at least, that would change attitudes to breast feeding, or management plans for pregnancy?

Post partum depression is a serious problem in our society, with up to 10% (or more) of women at risk. That’s why we screen women during early and mid pregnancy to anticipate that risk and attempt to set up support systems for those who we judge are on that path. Anything that might ameliorate the danger is therefore a valuable addition to our management strategies. I’m not sure this study has even re-invented the wheel, however. It seems to demonstrate that if a mother’s plans work out, she is happy, if they don’t, she isn’t… Is it helpful to know this? Perhaps -but does it change anything? I suspect we will all continue to encourage mothers to breast feed and regard the oxytocin it engenders -the bonding hormone- a plus. But not an unanticipated one. Nothing has changed…

But then again, maybe constant reiteration –permananent recycling- is what we want. What we deserve…Maybe a society that tolerates laugh-tracks on comedy programs to help them to know what is funny, and that thinks apparently spontaneous applause in a talk show demonstrates the merit of the discussion, needs to be apprised of the obvious.

Am I being too cynical? Too arrogant? Well, perhaps. And yet…

It was early Thursday evening, and I was sitting in the OR lounge waiting to do an emergency operation. A surgeon and her resident were sitting nearby, their faces glued to the ever-changing TV images in front of them. I thought at first it was a talk show but they were staring at the screen as if it were a parental avatar, their expressions religious, their attention rapt.

I had been too preoccupied until that point to notice, but they seemed so intense I suspected something of profound significance was being discussed so I turned to watch. It was actually a cooking show and some celebrity that I didn’t recognize was being shown the basics of barbecuing a hamburger. “First, you want to get the grill good and hot,” the serious looking man in the chef’s hat was saying, pointing at the thermometer on the hood. “Then, you carefully place the patty on the grill –use a spatula with a long handle so you don’t burn yourself- and sear one side just enough to keep the juices sealed in…” He said this in a hushed and reverent tone as if it were one of the Ten Commandments. The studio audience clapped in delight at this little pearl of wisdom, and I noticed the surgeon restraining herself from doing the same. Her resident, ever mindful of imitative protocol, actually did manage a clap after glancing furtively at her mentor.

The surgeon suddenly became aware of my presence in the room and smiled with an expression I used to see in church after a sermon. She seemed surprised at my composure in the face of the Revelation. Or maybe annoyed that I hadn’t understood. Actually, I was disappointed; I felt as if I’d just been told the earth was round.

And it wasn’t even the vapidity of the program that made me remember the incident –maybe some people don’t know how to barbecue hamburgers, so maybe the show deserved prime time. Maybe the information it contained truly was important and not just another example of mildly entertaining celebrity fluff. Not having watched what went before, perhaps it was just an inter regnum… But no, it was more the reaction to it. The surgeon and her acolyte seemed overly awed by its significance -as if they wouldn’t have been at all surprised if it were the subject of a research paper in a prestigious journal.

I suppose the depressing reality is that it is me who is so far off-kilter that I cannot appreciate something of value. That I mistake the important for the banal. Knowledge for noise. But I can’t help wondering who decided that a celebrity learning how to cook a hamburger should occupy prime time. Or wondering why a study showing that people may get depressed if things don’t work out as they planned surprises anyone.

We all need a time out, for sure: a time when we just unbutton the brain and let it sit on the couch beside us eating popcorn. But surely we also need a time in. I’m with Shakespeare on this: We know what we are, but know not what we may be.



Aboriginal Women Deserve a Public Inquiry.

We Canadians have always been proud of ourselves; we are a democratic society ruled by the will of the people. We vote and the majority governs, represents our interests, and crafts the laws accordingly -or does it? We have a say in what happens in our several levels of government –a voice in what is done to us… Unless we are a minority. Then we must depend upon the goodwill of those in power to understand and protect our interests. We must trust that, in their blinkered majority, they will not abuse us. Neglect us. Forget us.

But suppose they do. Suppose they surround themselves with their own advisors and see the world through their own lenses, their own authority, their own priorities? Suppose they don’t even understand that anyone could see things differently..? History, after all, is written by the victors, and culture by the dominant.

A case in point is the growing concern in Canada over a series of  missing and murdered aboriginal women –over 1000 in the past 30 years: http://www.nwac.ca/files/download/NWAC_3D_Toolkit_e_0.pdf

There have been various attempts to address the problems of  our First Nations –from a 1996 Royal Commission on Aboriginal People (http://www.aadnc-aandc.gc.ca/eng/1307458586498/1307458751962 ) which did not address the issue of the missing women, to a Royal Canadian Mounted Police (RCMP) Task Force in 2011 (http://www.rcmp-grc.gc.ca/pubs/mmaw-faapd-eng.pdf ) which apparently did…

But the problem remains and the perception that it is not really being addressed is building. In fairness, though, solutions are not only complex, but also expensive and so excuses are rife and rationalizations abundant. Missing women –murdered women- are crimes, not sociological phenomena, says the Prime Minister. Then why are aboriginal women –only one of several minorities in Canada- over-represented in the list, says the other side? An inquiry will tell us nothing new so we should put the money  into solving the problem instead, says the government. http://www.huffingtonpost.ca/chelsea-vowel/missing-and-murdered-women_b_5729738.html?utm_hp_ref=email_share  The cheque’s in the mail in other words; we’re looking into it -you might get it tomorrow… Maybe.

And on and on it goes –I am reminded of Macbeth’s Tomorrow, and tomorrow, and tomorrow, creeps in this petty pace from day to day, to the last syllable of recorded time…  Authority versus Minority. Civitas versus Communitas

But hold on; I think both sides are missing something: a conversation closes when one side or the other is adamant that only their view is the correct one.  Dialogue is an exchange of ideas on a particular issue whose aim should be to reach a consensus, an amicable settlement agreeable to both sides. Dialogue is communal, discursive at times, but inclusive. It does not stem from authority, nor resort to it especially when all have not been heard.

Autonomy -the right to make an informed choice- is a difficult issue in politics, of course. And because in this context choice usually involves large groups of people, there has to be an accommodation, an appreciation of how any decision might affect the well-being of the rest of the population. It has to be fair, in other words. But more than that, it has to be seen to be fair. And for that to occur, the issue cannot always be resolved by simply resorting to a vote. The majority and its own world-view bias will always win. Some things require discussion. Consensus. Open, accessible and representative input from all affected parties.

A Public Inquiry, by its very nature, invites public participation -a dialogue between those in power and those who aren’t- and a chance for all who are interested to have a say, voice their own opinions. It is healing to be heard –especially for a minority. To discuss things openly and publically often exposes underlying issues that need addressing: poverty, access to services, educational gaps, cultural safety, discrimination… A problem that has been swept under a carpet of denial or ignorance cannot be solved until it is uncovered for all –not just the minority affected- to see and appreciate.

I have discussed relational autonomy in a previous essay. It involves considering information in the cultural context, societal values, and the community needs of the groups involved. It is the expectation of cultural safety that will allow the people to express those needs without fear of ridicule or disdain. And it is what a representative democracy should encourage. Nothing less will do.

It seems to me that we all need to sit around a table somewhere and talk with –not at– each other. Remember Summer Camp when we were kids? As soon as the lights were turned off and the adults had left, we regaled outselves for hours with stories and discussions about what really mattered. Everybody had something to say, and everybody listened. We felt heard; we felt known. And slowly, by the end of the week, no matter our differences and annoying ideosyncrasies, we felt bonded in a community. Although we still remained individuals with different pasts and different futures, and although there were still disagreements we were, at least, no longer strangers. And, if the need arose, we could talk again – and actually listen. Friends can do that.