Blushing in the Office

Girls blush, sometimes, because they are alive, Half wishing they were dead to save the shame.

I’ve always liked those lines from Elizabeth Barrett Browning’s Aurora Leigh;  I have no idea how I came across them, because I have never read the work –nor likely ever would. I even had to look them up to find the source. Some words are burdock, I suppose, and merely walking past them risks a life-long passenger.

The blush can also be adherent –an unwelcome internal repatriation to a country from which one’s recent escape did not go unnoticed. A reminder that we live our lives in glass and walk the days observed. It is a reminder that we do not live alone.

When I was younger blushing seemed a way of life, a price levied on daily interactions. Unpredictable as a rule, they came upon me as I went about my day and I learned to live with them as I might a limp or minor speech impediment. I could compensate, work around them. They became background. But I realize I say this as an adult well practiced in retrospective memory alteration. Survival to maturity is seldom marked by adaptive failures.

But a gynaecologist is privileged to deal with all ages, including those who have not yet discovered equanimity with the world. Despite elaborate facades of insouciance, there is a fragility that surrounds them like a gauze veil –only muddily transparent and easily deformed. It opacifies with age, of course; it hardens into walls of varying thickness that are sometimes impossible to penetrate, but in their malleable phases, they are frames for guileless beauty. Innocence. Naivete. Blushes.

And it is the latter of these that is often so beguiling. And awkward.

Sometimes –often, in fact- the blush is a signpost with a different message on each side: as you approach it announces a warning not to go any further along the road; but on the other side, if you look back, it thanks you for proceeding. For persisting. For understanding how difficult it is to talk about. Few wish to strip themselves sufficiently bare to risk being unfairly judged, and that is what a blush may presuppose. The path is heavily mined with fears and expectations –and hope.

*

Her face suddenly reddened. I couldn’t tell if she was blushing or angry –maybe it was both. “Why did you ask me that, doctor?” she said, glaring at me from behind the stop signs of her eyes. It had been a perfectly ordinary visit up until that point. She had come to me with a complaint of pelvic pain which had begun only two months before. She’d never experienced it previous to that.

I smiled to neutralize her obvious concern. “Well you seemed pretty certain about when it started…”

Her eyes changed signs. “Things have to start somewhere. Sometime.”

I nodded in agreement. “Very true. So, was there something you can think of that might have started it? Caused it?” I tried to keep my expression hopeful. Open. Innocent.

The reddness deepened and her cheeks looked ready to burst into flame –this time there was no mistaking it for anything but a blush of embarrassment. She looked down at the desk, avoiding any eye contact. “Well, we were trying something new…” she said in an almost inaudible whisper to her hands that had finally materialized on her lap.

I waited silently to give her an opportunity to explain, but she began to put on her coat instead. There were tears in her eyes and she was obviously uncertain what to do. “If you tell me about it, maybe I can help,” I said, but softly. Carefully.

She looked up with an angry expression on her face. “You’re a man!” she almost screamed at me. “I didn’t want to see a male doctor; I told my GP it wouldn’t work…” She lowered her voice a little. “I’m sorry doctor, but you just wouldn’t understand.” Her mouth trembled as she said that and her brow stayed furrowed, but her eyes were pleading. Frightened.

“Sometimes we men are a problem Janice, but sometimes we can just listen.” I was instantly embarrassed that I hadn’t thought of anything else to say –something profound and wise. Something to indicate that I was different. I have to admit that I even blushed in shame.

The effect on her was immediate -her face relaxed and her cheeks coloured again, but this time in reply to my obvious discomfort. We had a connection now. A shared link. And she needed to talk.

The Peanut Trap

You know, there are times when the cart should precede the horse and not follow blindly behind it along the same old paths. We are too often seduced by the roads that others have made simply because we know where they go and what we might reasonably expect to encounter along the way. The problem, of course, is that another reasonable expectation of taking the same route is ending up in the same place.

Sometimes the detours that others have taken, whether through ignorance or design, have ended up in far more interesting places. More significant destinations. We might do better if it was them we followed, not the horse.

Childhood allergies have always puzzled me: are they all genetically determined, or is there something else going on? Because their prevalence seems to be increasing –especially peanut allergy. As an editorial in The New England Journal of Medicine (Feb.26/15) suggests: ( http://www.nejm.org/doi/full/10.1056/NEJMe1500186 ) ‘In the United States alone, the prevalence has more than quadrupled in the past 13 years, growing from 0.4% in 1997 to 1.4% in 20081 to more than 2% in 2010. Peanut allergy has become the leading cause of anaphylaxis and death related to food allergy in the United States.’ But why?

As the editorial goes on to say: ‘In 2000, largely in response to outcomes reported in infant feeding trials conducted in Europe and the United States, the American Academy of Pediatrics (AAP) recommended that parents refrain from feeding peanuts to infants at risk for the development of atopic disease until the children reached 3 years of age.’ And yet despite that, the number of cases of peanut allergy still continued to rise…

So, ‘In 2008, after reviewing the published literature, the AAP retracted its recommendation, stating that there was insufficient evidence to call for early food avoidance.’

Then, a fortuitous observation: ‘Du Toit et al.6 noted that the prevalence of peanut allergy among Jewish children in London who were not given peanut-based products in the first year of life was 10 times as high as that among Jewish children in Israel who had consumed peanut-based products before their first birthday. In addition, subsequent studies that evaluated the early introduction of other allergenic foods, including egg7 and cow’s milk,8 showed that earlier introduction of egg and milk into an infant’s diet was associated with a decrease in the development of allergy.’ A different path.

The subsequent study, known as LEAP (Learning Early About Peanut allergy), was a truly courageous and, dare I say, a lodestar one: http://www.nejm.org/doi/full/10.1056/NEJMoa1414850

The investigators hypothesized that early introduction of peanut-based products (before 11 months of age) would lead to the prevention of peanut allergy in high-risk infants. More than 500 infants at high risk for peanut allergy were randomly assigned to receive peanut products (consumption group) or to avoid them (avoidance group). Approximately 10% of children, in whom a wheal measuring more than 4 mm developed after they received a peanut-specific skin-prick test, were excluded from the study because of concerns that they would have severe reactions. At 5 years of age, the children were given a peanut challenge to determine the prevalence of peanut allergy. The results are striking — overall, the prevalence of peanut allergy in the peanut-avoidance group was 17.2% as compared with 3.2% in the consumption group.’ As a result, the study found that ‘the early introduction of peanut dramatically decreases the risk of development of peanut allergy (approximately 70 to 80%).’ The immune system –and what it considers ‘foreign’ and hence dangerous- develops early in life. Early exposure to something may therefore render it more acceptable –not an allergen…

But, as in all scientific inquiries, one has to be careful not to generalize the results too liberally. Perhaps, despite all their precautions to be representative and mindful of conditions that may differ among populations sampled for the study, it may not obtain universally. For example, the editorialist points out: ‘Should we recommend introducing peanuts to all infants before they reach 11 months of age? Unfortunately, the answer is not that simple, and many questions remain unanswered: Do infants need to ingest 2 g of peanut protein (approximately eight peanuts) three times a week on a regular basis for 5 years, or will it suffice to consume lesser amounts on a more intermittent basis for a shorter period of time? If regular peanut consumption is discontinued for a prolonged period, will tolerance persist? Can the findings of the LEAP study be applied to other foods, such as milk, eggs, and tree nuts?

All good questions –and ones, it should be noted, that troubled the authors sufficiently that they have designed a followup study to assess: ‘The question of whether the participants who consumed peanut would continue to remain protected against the development of peanut allergy even after prolonged cessation of peanut consumption requires further study and is under investigation in the LEAP-On study (Persistence of Oral Tolerance to Peanut; ClinicalTrials.gov number, NCT01366846).

I am impressed with the study because of the determination of the investigators to journey down a road not well travelled -in this case the sure and certain one that Society had come to believe: that you should avoid all possible allergens from birth or risk irreparable damage to your child. Once something has been generally accepted, to transgress, to wander from the road, is anathema. Folkways have a habit of becoming incontrovertable Laws. Unexaminable tenets. Incontestable. Indisputable.

We humans are like that: we follow the horse because it’s easy. And if the route it takes is falling into disrepair, we merely shrug because we know we are on the road we are supposed to be on. The one everybody knows is safe… But it is a trap -almost like that apocryphal conditioning experiment with pigeons: when one happened to turn around a few times before the food arrived, it continued to do so each time before it got fed… Why take any chances?

In the case of allergens, it seems less silly, though. Less arbitrary. If one child develops a severe allergy to, say, peanuts, most people would feel it would be reasonable to avoid exposing the next child to peanuts. It may not work, but why take any chances? To do any different would be madness. Everybody would agree with that…

I am reminded of something Mark Twain once said: ‘Whenever you find yourself on the side of the majority, it is time to pause and reflect.’ There is, no doubt, a degree of wisdom in the crowd, but we must beware conflating the wisdom of our crowd, with its blindness.

Depression and Inflammation

The practice of obstetrics and gynaecology is normally a kaleidoscope of colours –from the pale red blush of an embarrassed face, the bright green flash of twinkling eyes, to the panoply of skin colours proudly arrayed like just-washed clothes in the waiting room. There is no rank to the colours, no special prize for the one most displayed, no arbitrary preference, but I am wary of grey…

You don’t have to be a psychiatrist to spot the clouds, nor possess a doctorate in psychology to feel the angst. Depression is a fog whose periphery shades and obtunds everything and everyone nearby. Its boundary is indistinct and to approach is to be enveloped. Obscured. Affected. It has the strange property of contagion.

Not to pretend an exact analogy, but I have often wondered about the resemblance of depression to how many of us react to an acute illness like, say, a ‘cold’ or even a headache –so-called ‘sickness behaviour’: fatigue, apathy, loss of focus, withdrawl… All of these are vaguely reminiscent of the psychological behaviour in depression, although I suspect most of us have not really thought about it in those terms. Admittedly, the resemblance is tenuous and terribly non specific, and yet I find the correspondence intriguing –not least because the symptoms are caused by some physical malfunction and seem almost designed to isolate and rest the body to allow healing.

So I was excited to read about the work being done investigating the link between depression and inflammation. One of the more informative evidence based reviews I have found was published in the June 2013 edition of Current Psychiatry and the author was Dr. Maria Almond from the University of Michigan:  http://www.currentpsychiatry.com/home/article/depression-and-inflammation-examining-the-link/b436332438ceca4baabe8be08701d6dc.html

The concept of inflammation having a role in what has always been considered a mental maladjustment reminds me of the story of stomach ulcers. Remember, it was not so long ago that ulcers were attributed to stress. It seemed intuitively obvious that it would –and should- be so. And then Helicobacter pylori was discovered in a large percentage of these patients and when treated, seemed to alleviate the symptoms. Mind you, not everone with Helicobacter was symptomatic, but its undisputed role in the disease process changed our thinking about psychosomatic illnesses –opened our minds… Or at least should have.

And then there is the oft refuted contention that cardiovascular diseases may have their origin in infectious –or at least inflammatory- processes. The arterial plaques that can narrow or block important blood vessels and lead to strokes or heart attacks have been commonly attributed to cholesterol levels –too much ‘bad’ cholesterol (LDL) will form these plaques and impede blood flow past them. Observational science at its finest; but seeing them and recognizing their significance, still does not answer the question of why they formed in the first place. There have been attempts to attribute the reason for their formation to inflammation and underlying damage to the arterial wall. But it is a chicken-and-egg observation: did the damage result from inflammation –ie some infectious, or other agent- or did some other cause for damage engender inflammation and attract the cholesterol to form the plaque in an ongoing attempt to heal it?

But as a gynaecologist I admit that I am straying into uncomfortable territory here, so I will merely leave it as a sort of illustration of the There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy type assertion.

The article on depression is exciting because it opens up entirely new ways of thinking of mental illness. It proves nothing, to be sure, and there are no doubt many ways of refuting the evidence it provides –including the fact that the causes of depression are likely as multifactorial as are, say, headaches or abdominal pain. One interpretation is unlikely to explain them all, I agree, but I am still beguiled by the way the observations seem to hint at commonalities. As the article points out:

In our progression toward understanding depression’s pathophysiology, we see factors that point to a relationship between depression and inflammation:

  • depression frequently is comorbid with many inflammatory illnesses
  • increased inflammatory biomarkers are associated with major depressive disorder (MDD) 
  • exposure to immunomodulating agents may increase the risk of developing depression 
  • stress can activate proinflammatory pathways
  • antidepressants can decrease inflammatory response
  • inhibition of inflammatory pathways can improve mood.

I’m not sure how this would explain the increased risk of antepartum –and especially postpartum– depression. Would the ever-changing level of hormones in pregnancy play some role in facilitating an inflammatory process? Or would the physiologic stresses engendered by the increasing needs of the developing foetus play a role? As another observation pointed out in the paper explains:

Acute and chronic stress is associated with increased availability of proinflammatory cytokines and decreases in anti-inflammatory cytokines.3,24 One theory looks to glucocorticoid response to stress as an explanation. Miller et al25 found glucocorticoid sensitivity decreased among depressed women after exposure to a mock job interview stressor and increased among nondepressed controls. Because glucocorticoids normally stop the inflammatory cascade, this finding suggests depressed individuals may not be able to control inflammation during stress.26 At the level of genetic expression, there is increased transcription of proinflammatory genes in response to stress  […]

Heuristic, to be sure, and certainly thought-provoking, but still a long way from convincing. But in Medicine, as in Science, it pays to have an open mind; to look around as you wander along long the well-trodden path. We haven’t seen everything yet; sometimes we have not even left the trail. There is something written by Lao Tzu that I have always remembered from my youthful philosophical journeys: If you do not change direction, you may end up where you are heading. Perish the thought.

Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.

The Tampon Tax

I have to admit that I am sometimes puzzled. Not, you understand, to suggest that I am omniscient at other times, but merely that I, too, am apt to get lost in the various back alleys of our government. They seldom come with maps; they are not meant for untroubled navigation. In fact, I suspect they are purposely labyrinthine –not to encourage questions, but so you can be misdirected more effectively.

I recognize that to run a bureaucracy, decisions have to be made that may not be popular with some, and that for the sake of continuity and efficiency these should not be subject to change on a whim. But sometimes their perusal in daylight reveals egregious errors in judgement, wisdom and even fairness. I also realize that in a caring society, those less fortunate than the majority, those with unmet needs, and those who are unable to access the ears of government should be folded into its bosom. For example, items necessary for health or daily living are usually exempt from extra taxation –value-added taxes (Goods and Services Tax –GST in Canada). It is an assurance that those with special needs –incontinence products, for example- will not be unduly penalized. Admittedly, it is only a small concession, but at least it is an acknowledgement that we are all part of a community, an affirmation that we are all noticed and our differences accepted, if not totally underwritten. There are benefits accruing to membership in Society.

Of course in a democracy the majority will derive the most benefits, if only because it has chosen the government. As long as the minority is not oppressed, ignored, or denied the benefits offered to the rest, I think this is reasonable –or at least the most ethical compromise short of requiring them to abrogate their identity, or leave the country if this is not possible. No, Canada is a multicultural mosaic as we are fond of saying; we cherish difference and relish the weft and woof of our societal fabric.

And yet it seems a discrepant appreciation -an arbitrary one still rooted in attitudes so deeply ingrained that they are visible to those in power only through a public outcry when it threatens their incumbency.

I have long wondered about society’s attitude to menstruation: https://musingsonwomenshealth.wordpress.com/2014/11/26/menstrual-taboos/

Admittedly, we in the West have come a fair way already. The topic is no longer taboo in our public media and, except for the more provocative advertisements for menstrual products, barely provokes an eyebrow. Necessity is the Mother of conversation. And yet the Canadian Government –and the governments in several other countries as well, it would seem- has yet to hear it. If, as I have said, items necessary for health or daily living are granted a tax exemption, then what has it been thinking all this time? Or do Governments think?

http://www.huffingtonpost.ca/2015/02/18/no-tax-on-tampons_n_6705022.html

Why menstrual products should be ignored as necessities is beyond me. It can’t be that the issue is a minority one that can be conveniently hidden, or assuaged by a few photo-ops like those assuring a small northern community that the government is indeed looking into building a skating rink for them; this is a 50% issue. Nor could it be construed as a definitional discrepancy: if contact lenses are covered by the dikat, then there’s certainly no argument to exclude menstrual products. Except…

Well, except that those taxes are probably a rich revenue source, for one thing. But, more troubling, is it a remnant of a long-buried attitude towards women and their place in our society? The previously ignored tip of a huge iceburg? A sleeping tiger that government would rather step around –ignore but not arouse?

There are braver souls, however. Individual colours that have managed to disengage themselves from the wallpaper we all wear. Patterns previously unappreciated as they slept undisturbed and unprovoked in the background:  http://www.cbc.ca/news/canada/british-columbia/tampon-tax-petition-collects-more-than-50-000-signatures-1.2974155

It would be well for those in charge to walk carefully. The tiger is huge. Feed it. Nourish it. Befriend it.

Elder Gynaecology

I love old people. Sounds a bit patronizing I suppose but I’m becoming one of them, so I have vested interests. And anyway, even the most reticent among them have had a unique, personal view of history. A well tested perspective of Time and its evolutionary ravages. They have grown an almost uncanny ability to step outside and look at their lives as one might their house from the sidewalk.

Talking with them is an adventure, a journey. A long journey. I have travelled part way along the collective path –the common trail from which each has wandered looking for their the way -their destination- but I am ever fascinated with their routes. Never bored, yet usually intrigued by the roundabout ways they have found to describe it. Camouflage it, really. It is seldom a direct road –more frequently a series of detours that require patience to navigate.

As the family doctors who refer to me get older, I sometimes think they have my name written down on some old Rolodex in the top drawer of their desks, so it’s readily at hand when an elderly patient whose baby I may have delivered asks them if I’m still in practice –or at least, still alive. I may not remember them, but for some reason they remember me. It’s nice to be remembered, but it usually comes with an expectation of reciprocity. No one, especially of advanced years, wants to walk down a one-way street. We all crave familiarity. Recognition. Memories we can share.

Unfortunately, charts are not kept forever and computerized records are relatively new kids on the medical block. So when I see them, it’s frequently with a blank slate -a tabula rasa  as it were. But when I think more clearly about their reactions to this cognitive gap, I have to admit that most of them are not at all nonplussed. They merely tell me all about it; they fill me in about the intervening years. I love it; it’s like going to a history tutorial.

Emma. The name rang no bells, sounded no alarms; I had no idea if I’d ever seen her before, in fact. I glanced at the referral letter before I went to meet her in the waiting room: Please see this delightful, loquacious lady for a gynaecologic check. You saw her 10 or 15 years ago apparently. Well, no clue there. No old chart. No information about why or exactly when I’d seen her before. I have to admit I cheat before I greet them in the waiting room –I look at their old records and try to pretend I remember some of the details about why I once saw them. I’m sure they all know I do that, but it’s an acceptable crib, I expect. No one calls me on it. They pretend that they have a special place in my practice. My memory. Everybody wants to pretend that there is a statue of them somewhere. A commemoration. But there was nothing on Emma. I would have to plead unwilling and embarrassed ignorance.

“Doctor,” she said in a strong, loud voice as soon as she saw me. “Dr. Stegal was sure I saw you before…” she said, all the while hoping he was wrong. I could hear it in her voice.

She was a thin woman with tightly coiffed, short white hair that she wore almost like a toque over her ears. Quite becoming, I thought: it enclosed her face like one of those little ornate frames you see sitting on desks all over the world. I have to admit I didn’t recognize it, but wrinkles are a good disguise. Like one of those Russian dolls, her eyes were set within wrinkles within yet more and deeper grooves on her skin when she smiled. She never stopped smiling.

I led her into the consultation room and sat her down opposite my desk. As soon as she settled in the assigned seat, and adjusted the bright red dress she’d worn for the occasion, her face lit up with the expectation of a good talk with an old friend. She couldn’t help looking around the room for a moment, no doubt comparing it with scraps of memory. Her smile waxed and waned in concert with fragmented recollections; her eyes would focus on a picture and recede within to riffle through her files then emerge, satisfied she had classified it correctly, then fly to another branch, another picture, another piece of my aging, chipped furniture. Her eyes said she was beginning to remember the old visit, but her face told me she didn’t know what it had been for.

“I see you still have that old metal desk, doctor.” This was clearly an opener. A gambit to facilitate my entrance into her world. I smiled lamely; what could I say? I liked the desk. “My daughter reminded me of the desk, and those little magnetic signs you had on one side. Fridge magnets she called them.” She shifted on her chair and craned her neck to look at the side near to the door. “Yes, I see they’re still there.”

I shrugged good-naturedly. “I’d forgotten about them…”

“But you certainly have a beautiful office, doctor,” she added as if I hadn’t spoken. “I remember that picture behind you. The woman only partially drawn?” she said as if I’d forgotten that as well. “Do they still make those?”

I wasn’t sure if it was a real question, or merely an observation that I hadn’t much changed things over the years. I turned around to look. It gave me time to consider how I was going to lead her into telling my why she’d come to see me.

“I saw one just like it in Kresge’s a while back…” she said to soothe things over. It must have been a while back because I think the store chain changed its name to Kmart before my daughter was born.

“Well, it’s good to see you again, doctor,” she said tentatively, getting comfortable in her chair again. “My daughter says to say hello…” She didn’t really finish the sentence, but did temporarily immobilize me with a stare that dared me to ask her who her daughter was.

“Oh, that’s nice of her,” I responded, proud of my quick, noncommittal answer. “Please say hello to her for me.” It was lame, but I was trapped by her eyes. I had to say something.

Emma’s face changed from happy to wicked. “Do you remember her?” I shrugged. “I told her you wouldn’t, but she wouldn’t believe me. ‘After all the problems I had, he’ll remember, mom,’ she said.”

I could  see the hint of a smile trying to force its way through her wrinkles. It looked like work.

She shrugged resignedly, as if her shoulders had felt the weight of the world before and this one more disappointment was not going to do her any harm. “Judy was always a drama queen-always worried about something. Always thinking she was sick, ” she said, sighing loudly. I assumed Judy was her daughter, but it opened no doors. I mean how many Judys are there in an average gynaecologic practice? “I remember when she was a little girl, Henry made her a tiny doll house to distract her, and she’d lie on the floor for hours and play with it. Henry was good with his hands. He could fix anything. We never called a plumber, you know. Didn’t have to… Well there was that time something got stuck in a drain and we had to call one because he had one of those metal snakes, but he was way too expensive. And it was just hair that was blocking it.” She stared at me again briefly and only let go when I smiled in submission. “It wasn’t Henry’s hair, though; Henry was bald as a table…”

I smiled again and picked up the referral letter and examined it. Maybe that would work. “Dr. Stegal says…”

“Well, he shouldn’t really say anything. I never really saw him for more than two minutes before he suggested I go to see you…”

I sensed a perfect, but rare opportunity. “And what did you want to see him about?”

She sat up straighter on the chair and crossed her arms. “I didn’t want to see him, doctor…”

“My mistake. Why did you go to see him, then?”

She settled back into the chair; she was looking entirely too comfortable. “Well Judy came over a couple of weeks ago…” She considered this for a moment. “It was just after the anniversary of Henry’s… departure. So I guess that would be three Saturdays ago…”

It seemed important to fix the date, so I waited patiently. I stole a glance at my watch; my secretary would be panicking if I didn’t surface pretty soon. I prodded her gently. “Why did Judy come over to see you?” A stupid question, I suddenly realized. I could hear the answer before she even opened her mouth.

“We were going to go to the cemetery and then stop at his favorite restaurant for lunch.” She focussed her attention on my face, so I couldn’t interrupt her train of  thought. “Have you ever eaten at the MacDonald’s on Fourth?” When I didn’t reply –didn’t even try to reply- she finished her thought. “Well, we both ordered the chicken nuggets and we started talking about the Menopause.” I could hear her capitalize it. “She asked me what mine was like. Well, I said, it was a long time ago… ‘And did you have any problems  with it then?’ No, I said, but then I remembered –I’d had a bit of bleeding three or four years after my monthlies had stopped. That really seemed to alarm her. ‘Did you go to see the doctor?’ For some reason, I couldn’t remember if I had, so she immediately made a phone call to Dr. Stegal. ‘You can’t let these things go,’ she said. So, I saw Stegal –but hardly long enough for him to open my chart.

Now we were getting somewhere!

“But now that I’m here, guess what..?” Her expression had changed.

I hate it when people do that. I’m supposed to be asking the questions.

“When I saw the office today, it began to come back to me.” I put a purposefully puzzled expression on my face and left it there. “I’d seen you for the bleeding. You did a biopsy and cleared me. ‘Don’t worry about it’, you said. ‘Get on with your life’ –I remember you said that, and I thought it was so nice. So sensitive. After all the pain of that biopsy, it was the right thing to say. Almost an apology…”

She was about to continue when I interrupted as gently, but as quickly as I could. While she was taking a breath. “So is that why Dr. Stegal sent you to see me today?”

“I think so. The only person he really spoke to was Judy…” She looked around the room nostalgically for a moment and then at me again. This time with some concern on her face. “We don’t have to do another biopsy do we? Judy thought we would.”

I graced her with my most benevolent smile. “Have you had any more bleeding, Emma?”

She shook her head solemnly. “None since I saw you and that was probably twenty years ago.”

“Then I think we can just watch things for now. I closed her empty chart and got up from the desk –but slowly, so she wouldn’t think I was rushing her.

Her face turned sly. “But Judy has. Now she wants to come and talk to you.” She stopped when she saw my expression change. “Oh not now! No, she has an appointment for next month.” She got up from her seat and walked toward the door. Suddenly she stopped. I hoped she hadn’t changed her mind about leaving.  But her face, when she turned to look at me, was beaming. “You look worried, doctor,” she said with obvious concern. “Don’t worry,  I’ll come with her and help to explain things.”

Sleeping in the Call Room

Sometimes in the sounding night, with footsteps rushing past and light-bound shadows flashing orally under the firmly closed door, I awaken, startled, and wonder if I am next. It takes me a moment to clear the fog of that constantly unsettled semi-sleep, and understand that I am not at home. And won’t be for uncountable time. The pillow is not right, and the bed is far too narrow. And empty. There is a dusty patina on the sheets that I can feel despite the dark. It makes me cough if I pull them close. But they are old, like the room. Echoes of the others who have slept here, echoes of the phone calls that suddenly scream their warnings in the night, echoes of opening and closing doors just outside  -all those echoes are trapped in here. All clamoring for an audience.

There are more things imprisoned within this room than a person should feel. To embrace even a small fraction of the anxiety plastered on the door, let alone the shadows rushing noisily past, would be to succumb to that which we are not allowed: fear. To suspect, even, that there may be a situation so dire, so entrenched and insoluble that we could only witness it in horror, is to abrogate the right to the room itself. The right to close the door, to close the eyes in pseudo sleep.

The desk that welcomes and entices in the light, holds no promise in the dark. Holds no answers to the urgent questions from the phone. Or to the voice whispering loudly near the door. Whispering things I should not hear, and can’t because they are too quickly said. Meant for others standing just outside or passing on their ways to other things. To other doors. Here be dragons…

There is no time that passes here. It is not allowed –nor should it be. This is a place of black and void, an empty space yet full of ghosts who do not talk, or pace about. There is no room in here: it is barren ground. A fissure carved deep within the building. An abyss, a surface with no boundaries –except perhaps, the door, and those who seem to wait outside. For whom? And why?

Do they, too, wait for a phone to ring before they pound restlessly on a door? Is there anything that starts their ceaseless pacing in the corridor? Or is it random? Brownian motion? Perhaps they’re too aware to sleep, anticipating pages not yet issued, problems not discovered. Maybe they walk the hall with with text books open in one hand, pencils ready to underline another fact, but smartphones in the other, an app, finger-close… Just to check, you understand. Prepared for what, they do not know…

It is not them I fear, nor the hallway that sanctifies their life. They have other duties in the night. Responsibilities they must guard, lest someone find them wanting. They are not mine; my door is just a mistake for them, an anomaly to tempt them from their task. Nothing more. They do not belong to me; they are not my specialty. Not my responsibility. I cannot answer for them and will not let myself be distracted.

There is a sentence I read somewhere –King Lear, I think- and it surfaces now and then in the dust motes circling around the light under the door. It, too, whispers to me when I am startled by a noise outside, and nudges me if I pretend too hard to sleep: O, that way madness lies; let me shun that; no more of that. And when it sounds, it loops and twists in my head like a roundabout, the words circling like vultures, going round and round and round again looking for an exit…

But my job, for now, is to pretend to sleep. To pretend I will be ready when my duty calls, my own phone rings to silence those calls for madness from without.