Cohabitation is the bête noir of some cultures and the realization of a belle époque for others. Lascivious as it sounds, it doesn’t necessarily exemplify freedom and liberation, though -it is a direct and unsubtle abnegation of long held moral and religious values for many. But why? Why would the decision to share one’s life need justification? Exculpation? And who should even dare claim the authority? Or, for that matter, the need to consecrate it? Given the rising divorce rate –even in strictly Muslim countries such as Iran where the rate currently sits around one in five- one would think it would make sense to recognize the need for more experience of the shared responsibilities of relationship, more knowledge of the partner, more time to adjust before a final commitment.

I have to admit that I approach the concept of relationship from a liberal Western perspective –more particularly, a Canadian view- where there are state-sanctioned civil ceremonies that bypass the need for a religiously approved union, and where once cohabitation has existed for more than 18 months, with dissolution, there are requirements to divide and allocate any assets –including children-  as if a legal commitment had been undertaken. A recognition, in other words, that because cohabitation is likely to occur whether or not sanctioned by some authority, there are still legal responsibilities that accompany it. From my perspective, that seems a fairly pragmatic and ecumenical way to mete out justice for something that, whether or not officially blessed, cannot be prevented.

So why the resistance? An unwillingness to acquiesce to moral depravity? A fear of loss of authority, either secular or religious? The all-pervasive concern of elders that the old ways are under threat? Or maybe just an underlying distrust of other ways of doing things, other ways of being in the world? After all, societies that have segregated themselves and become distinct have developed customs that are also distinct. Their foundational myths and folkways have hardened into inviolable practices that others don’t share. It’s what binds a culture together –like the nation state, like patriotism, like the sure and certain knowledge that the forbearers had a reason to think and act as they did- a deeply held belief that others are not like us.

We are all like this to a greater or lesser extent. We fear what is new, or different –especially if it comes to us from them. With their seal of approval. And unless we want to become like them, and assume all their mistaken and misguided beliefs –in essence actually become them- we must resist. And resist with the guidance and blessings of whatever authority we most respect. Indeed, it is their duty to justify and sanctify our resistance.

But I am drawn ineluctably to the notion of relational or relative values: the idea that what a society or group determines is appropriate, also determines the values of members of that group. A simple and organic concept to be sure, but one that is too often neglected in our assessment of the beliefs of the larger society to which the group belongs. Or perhaps more importantly, of the beliefs of the authorities who purport to speak on behalf of the state. Of the constraints they impose -or attempt to impose…

Of course, many will argue that some things are simply wrong; to think of them in any other way is self-evidently immoral –sinful, if the concept of sin as opposed to iniquity exists in the cultural framework. But that merely pushes the argument into another dark alley: why is something immoral in one culture and acceptable –or at least tolerated- in another? Is the other culture necessarily and unequivocally mistaken –even depraved- by default? If one side is right, is the other side therefore completely wrong? Partially wrong? Or just different?  It seems to me this is an important distinction: difference can be tolerated as a rule; being wrong cannot. It opens too many other doors. Escape routes for the less committed. The fringe-dwellers.

And yet, history has shown that if enough people begin to do something –even something that was anathema to previous generations- it can dwell unmolested in the shadows, camouflaged in the background and eventually emerge as something new and exciting for the young, its offence muted by a generational wink.

It seems to me that Iran, among others, may be changing like that.

Homogeneity is deceptive; immerse yourself in a culture, dive below the surface and it is boiling, fermenting, swirling with difference that is often invisible from above. Generalizations about it are just that: macroscopic observations that miss the microscopic, the constituent parts that are so essential to the whole.

So, is the cookie the result or the cause of the recipe?

The Solopsist

I have always been influenced by something Lewis Thomas, the American polymath writer-physician once said at a lecture I attended. He felt he would be better served by a doctor who had read Shakespeare than someone who had merely focussed all of his formative years on learning medicine. His point, I think, was that to really help people you had to understand who they were, what they thought, how they lived. We are all more than our bodies.

Me? I have always loved philosophy, cherished its Greek etymological roots: love of wisdom, and at least pretended I understood how it might help me to interact with my patients: to accept all points of view with equanimity –or to spell it as Sir William Osler did in his famous essay, Aequanimitas –imperturbability.

Philosophy helps you to do that, but only if you don’t get too enmeshed in the details. Only if you don’t privilege one tenet over another. Only if you never accept that you are at the end of the journey. Or meet someone who is

My conversations with patients have changed over the years from that of an expert trying to impress, to a teacher trying to listen -the difference between an encyclopedia and a manual, I suppose. Part of it is age, I’m sure, but a better part is the belief that, as Osler put it: “Listen to your patient, he is telling you the diagnosis.” And although directive listening works best, sometimes the topic turns an unexpected corner and a tangent is entered. I like tangents but not in the office -they can terminally entangle the discussion. They are like blackberry bushes in a field: I try to stay away from them.

There was a patient who wouldn’t let me, though. A PhD candidate in Philosophy, she had come to see me because of pelvic pain. And while she readily conceded that she was under considerable stress writing her dissertation, she felt that her problem was reality-based. I should have just written it down; I shouldn’t have asked what she meant…

“Reality is the sum total of all that is,”  she said, settling back all too comfortably in her chair. “The question, of course, is does it include potentiality –all that might be, or could be imagined to be?”

Of course.

She closed her eyes, for a moment as if digesting the profundity of what she had just said, and then opened them suddenly and stared at the ceiling. “But our realities differ, don’t they? I mean, you inhabit a different mental world than me; you can no more apprehend my sensations than I can yours. We are on different sides of a wall.”

She had to be kidding; I didn’t ask anything like that. But nonetheless, I felt it incumbent upon me to defend my profession –my humanity, for that matter. I decided to sit back in my chair as well- fight opaque answer with precise question. “But surely if you really believed that I couldn’t appreciate your pain, you wouldn’t have come here.” I then pasted on my most innocent smile. “And anyway, I don’t have to feel your pain, just accept that you are experiencing it and take it from there.” I put on a more contemplative, but satisfied smile.

My answer didn’t faze her in the slightest. I think she had her rebuttal ready before my smile had even fully blossomed. It started with a deep theatrical sigh. “Do you ever wonder if we define the world, doctor –our own world, that is?” She was sitting on the opposite side of the desk from me, but suddenly she leaned forward and put her elbows on it to fix me with a stare that would have done Medusa proud. I even stiffened reflexively.

“Don’t we all define our worlds?” I said, rather proud of my response.

“Yes, but differently.” She looked as intense as her words. “Pain has a different meaning to each of us: a different feeling, a different impact… it is only an If  to anybody but myself: If, as you say, you have pain; if as you assert, the pain is seven out of ten… If all of these things are as you tell me, I have only your word to go on. There is no objective way of demonstrating your thesis. So aren’t you left with the same undefinable as you started..?”

Wow. And to think I was only going to ask her how long she’d had the pain. She ended her explanation rather tentatively, thank god, because I had lost her shortly after her first attempt at clarification. I began to wonder if this dissemblage was a PhD syndrome: full of sound and fury, yet signifying nothing –practice for the defence of her thesis. Equivocation. Obfuscation. Playing with words like others play with cards.

Sometimes, however, it is necessary to find out more about the pain than its meaning. I wanted to pin her down on the more mundane aspects of her symptoms: more like where than why. Or when, not if. It occurred to me that her road to if  was not the road to solution and I was trying to figure out how to phrase it more philosophically when she straightened in her chair as if she’d suddenly received an electric jolt and stabbed me with her eyes.

“I realize that my approach to pain is different from yours, doctor, but the reason just occurred to me: I have defined it that way. Not you; not your reality. Mine… I am the one at fault.”

I tended to agree with her, although I probably wouldn’t have put it that way. “So…” -I sensed an opportunity when her face wrinkled as she thought through the ramifications of her enlightenment… A word-gap- “Where, exactly does…”

But she saw through my plan, and the door closed again. “You see I create the reality in which I suffer…” She paused, but not long enough for me to remember what I was going to ask, let alone to say it. “And so by coming here, I define you in a way… Both you and your response… Do you see what I mean?” She said it with such hope in her face that I almost said yes.

And then, just as suddenly, her face fell on hard times and the intensity disappeared. “But despite my solopsism, I still have pain.” Gradually, her expression refocussed like a magnifying glass and I could see her deep brown eyes dissolve in tears. “Can you help me even from your side of the wall?”

Solopsism? I smiled a real smile and nodded. I looked up the word as soon as I got home.

The Loneliness of Social Media

There comes a time when solitude is not enough. When weekends are deserts that must be crossed to get to people on the other side. Where there are eyes that welcome, ears that hear, voices that desire a response. When your own voice is not rusty with disuse and your mind not imprisoned inside a page you’ve just read twice.

That, almost word for word, is what a patient told me recently after a routine gynaecologic examination at my office. She’d had no need to visit me other than getting a pap smear that wasn’t due for another year. She’d asked her family doctor for a referral but I’m not sure what she told him –there was no letter. I suspect she simply took up too much time. Was too vague to slot into one diagnostic category or another.

Doctors are busy; we deal in diagnoses, descriptions we can place in algorithms that lead to conclusions and thence to prescriptions… We are computers, but not as fast. And without recognizeable data to input, goal-oriented analyses, interpretation and even investigations are difficult to devise. Especially in the fifteen or so minutes usually alloted for their resolution.

I don’t mean to disparage my colleagues with this quick dissection –I, too, am prey to its siren song. But sometimes, the scramble for parsable phrases, or attributable words, leads nowhere but to confusion. Sometimes the only thing necessary is listening. Patience. Time.

Strange isn’t it? The answers usually surface, bubble to the top, when you least expect them. When you haven’t even asked. When you yourself are often at risk of capsizing in the turbulent sea of emotive misdirection. No, not misdirection exactly –the patient truly wants help- but more like multidirection. Stochastic: random observations from the maelstrom in which they are living.

And the diagnosis for my patient? Well, I am certainly no psychiatrist and pretend no background in psychology, but from what I could gather, she wasn’t clinically depressed (a selective differentiation I’ve never really understood)–or any more so than anyone else in her situation at any rate. If I were listening as her friend and not her doctor, I would be fairly convinced I knew what the problem was: loneliness. I certainly wouldn’t honor it with a DSM-5 categorization –even if I knew how to use the manual. Some things are just obvious. Or become obvious if you simply listen. Hear.

Her problem troubled me and I suppose one of the reasons was that although she had tried the usual methods of meeting people at work and at clubs, she had been singularly unsuccessful. A friend had suggested an online dating site and that’s where her real problems had begun. It was not that there hadn’t been an over-abundance of interesting profiles –apparently a buzz-word in that community for acceptable suitors- but that the ones she had agreed to meet were lies. Is that the right word? People who had misrepresented themselves in the categories that had most interested her. She had become disillusioned with the whole process. Exasperated. And other websites seemed no better.

While I’m sure that some dating sites are better than others –more reliable, more responsible and trustworthy- she seemed to think they all attracted the same clientel –or at least the same type of person. She had even done a reverse look-up of some of the pictures submitted (I have no idea how you do this) and discovered the same pictures on different sites –some with different names.

I had no solution for her, obviously, but it got me thinking about the issue of loneliness. It has always been with us, of course, but the prevalence in this age of ubiquitous, omnipresent social media surprised me. I had assumed –naively- that our almost universal and continuous interconnectedness would have banished loneliness to a locked, unroutered closet somewhere off the grid. But I was wrong.

If anything, social media as a solution to loneliness is an illusion, a bedtime story meant to lull us into complacency. There is an existential reality it simply does not confront: although it allows –indeed fosters- communication, it does so once-removed. You need eyes to communicate. Faces with expressions to analyse and judge. You need to be able to touch and maybe to hug in order to communicate meaningfully. That is really what socialization implies.

You can say or declare anything online, but there is still a gap. It’s the very same space where loneliness lives. And where people –real people- don’t. I wish my patient well, and all the others who come to me with masks. It is my job to look behind them, coax them off. But even after all these years, I still may not recognize what they hope I’ll see; sometimes I can only look for clues, or wait with patience painted on my face, and trust they’ll understand. We can communicate in the old way…

I can’t help but remember what Iago said in Shakespeare’s Othello: “How poor are they that have not patience! What wound did ever heal but by degrees?” Isn’t loneliness a wound?

The Goddess of Small Things

Every office needs a goddess. Every doctor needs to see one now and then to keep things in perspective. Separate the two Magisteria.

I have a goddess –not self-professed to be sure, but in a pinch, self-acknowledged. She comes to see me once a year or so, for reasons that are not at all transparent.

It began about fifteen or more years ago. It was a surprise; the referrral letter from her doctor said nothing about a goddess. It didn’t even mention her powers, as I recall. It merely said “Infection!!”  and although the writing seemed laboured, reluctant –scrawled perhaps describes it best- the exclamation marks were clear enough. In fact, they were several times the size of the writing, and burrowed deep into the page, breaking through the paper in one particularly enthusiastic area as if to justify their mission.

Judith did not come across as your average goddess at all. In fact that first time she seemed rather shy and dressed as background; I didn’t even noticed her sitting in the already crowded waiting room until she stood up when I mis-called her name. A short woman with matching short dark hair, she was wearing a dress that seemed at once plain, and at the same time almost camouflaged against the other dresses in the room. Quite a trick, really. She only stood out when she moved across the room to correct my shortening of the Judith part of her name to Judy.

She spoke, or rather commanded my attention, as soon as I closed the door. I couldn’t place her accent, but it seemed an unusual one. “I require only one thing of you, doctor, so we can dispense with the usual history taking.”

I hate it when they do that. I’m a specialist; I’m supposed to take a careful history and solve their otherwise intractable problems with the benefit of my esoteric knowledge base.

She studied my face for a reaction and, obviously satisfied with the engendered confusion, proceeded to enlighten me. “I’ve been to several specialists already, but they all seem unwilling –or perhaps unable- to help me.” I don’t know why, but I felt like a PhD candidate about to defend an assertion in his thesis. I was being examined.

“I have a recalcitrant case of Mobiluncus mulieris in my parts.”

I have to confess that I blinked involuntarily at the words. Was she a nurse? A doctor in disguise, sent by the provincial medical association to check on my competance? I had to think fast –she had just named one of the several microorganisms thought to be responsible for a rather malodorous vaginal problem. “Bacterial Vaginosis can be very difficult to treat…”

She was silent for a moment and then sat down in a chair across from my desk, a smile incipient, hiding in full view. “Very good, doctor.”

“Did I pass?”

The smile blossomed on her face like a rose opening in the morning sun; her eyes twinkled with mischief. She sat back in the chair, finally relaxed. “I had to know…”

I didn’t ask.

But from that moment, she seemed to bond –with me, with the room, with the Gestalt… And, no doubt it was my imagination, but she suddenly surfaced from the background, like a picture focussing. She shook her head like a fairy might and blinked back at me from somewhere deep inside her head. “You will be my doctor,” she said simply and then stood up.

The interview was obviously over, the threshold attained and crossed, but she stopped at the door and turned to me. “I will not come with problems I cannot solve, merely with problems I wish to discuss.” The now-famous blink again. “Is that all right?” she said, already knowing it was as she turned and left.

She would appear from time to time and tell me of her trips to places I had never heard of. Sometimes it was cloaked in the pretense of needing a pap smear, or a culture for some totally esoteric sexual disease, but we both understood that these were excuses. Dissimulations to cloak her need to connect. It was as if, when she disappeared each time through the door, she ceased to exist –much like Brigadoon –the famous musical about a town that exists for only one day every hundred years.

I told her the story of Brigadoon on a visit when she suddenly appeared in the waiting room, after not seeing her for what seemed like several years. She disappeared behind her eyes for a moment in surprise and when she surfaced again, she was a pixie. She shrugged mischievously, as if caught with a hand in the cookie jar. “I travel a lot,” she said, but not convincingly.

I realized how little I actually knew about her and when she sat down, I decided to find out more. But I suppose she could read my expression and shook her head almost imperceptively. “Magic lies not in what you can see, but in what you can’t quite make out, don’t you think?” she said innocently enough.

I smiled to conceal my embarrassment at being caught about to probe a past which, by some unwritten, unspoken understanding we had agreed should remain hidden. “My secretaries think you are a…” –I hesitated to continue, fearing she would take even the substitute word that I had decided to use the wrong way. An unintended, pejorative way. One secretary –the younger one- had actually said ‘witch’, but the other, the older worldly-wise one, a more sexually-innuendoed word.

But she merely smiled; her eyes told me she already knew what I wanted to say. “You were going to disguise their guess, weren’t you?”


“Or change it into something more… polite?” her face twinkled playfully. I have to confess I blushed at her seeming prescience. She leaned towards me over my desk. “Some have called me fey…” She thought about the word for what seemed an eternity. As if she wasn’t sure how much to disclose. “There are many words they use,” she whispered and then sat back. “Witch, enchantresss, goddess… Weird things like that, because, like you, they don’t know much about me.” She stared at me for a full minute and then at something over my head –or so it seemed. “Because I only appear long enough to influence some part of their everyday lives and then vanish, there is a touch of mystery to me, I suppose.”

The skin on her face relaxed and she suddenly seemed older. Wiser. Ancient.

She got up slowly and walked to the door. “But it’s not like that, you know. Not really…” Even from the door I could see her sigh. “No matter what they think, I don’t do very much for them.” A final blink before she turned. “I am the Goddess of small things,” she said over her shoulder as if to the wall. As if, as it turned out, I would never see her again.