Monthly Archives: August 2015

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The Gyne Weed

I think most of us have a rather Schadenfreude relationship with weeds: on the one hand, they are undesirables, illegal aliens usurping land otherwise dedicated to something useful; but on the other, some of them are quite pretty -even beautiful. Especially in someone else’s garden. Of course it’s all a matter of context, isn’t it? It’s a weed here, but not there -a productive member of one society attempting, uninvited, to switch allegiance to another. In a way, you have to admire their resourcefulness and courage. It must take a lot of self-confidence to show up where you’re not wanted and then make a success of it.

Weeds, however, are not often seen as courageous –quite the opposite: they insinuate themselves into an unsuspecting and vulnerable population and spread dissent. They’re obvious targets for discrimination. Persecution. They are generally regarded as anathema everywhere they go. Period.

I am more ecumenical when it comes to weeds, however. As a male gynaecologist, I too am in foreign soil; I too am a weed. But the idea never occurred to me at the beginning of my career. I thought anybody was welcome to grow there.

And then I met Suzy. I liked her as soon as I saw her in my rather under-populated waiting room. She would have stood out even in a full one. With pig-tailed, red-brown hair, face done up in freckles and a toothy smile, I was immediately reminded of Anne of Green Gables. But she was rather short and plump and was wearing severe black clothes that belied her expression and said ‘Back off’.

And yet we’re all a study in contrasts aren’t we? At that time, I had a mop of long curly brown hair that barely covered the single earring in my left ear. Oh yes, and a reddish beard that fought with the hair for attention. Looking back those many years, I’m surprised the Department even hired me. Equal opportunity stuff, I guess. But I digress.

Suzy did not seem at all surprised when she saw me walking across the empty waiting room to greet her. In fact, she seemed almost relieved at being seen before her appointment time. Well, perhaps ‘curious’ describes it better.

When her eyes interrogated mine for the reason, I muttered something about the last patient not showing up. Actually, the last three had not showed up either, but I wasn’t going to admit that to her. Her eyes then toured my body and flitted back to rest in their little cages, twinkling at their efforts.

“These things happen, doctor,” she said to break the tension, but I could tell she understood.

“So why did you come to see me, Suzy?” I said as she settled down in an uncomfortable wooden chair across from the desk in my office.

This seemed to take her by surprise. It was if there were preliminaries that hadn’t been observed before settling in for business. Like the weather, I suppose –or maybe what she did for a living. “I’m an actress,” she said as if I’d asked the question. I nodded politely and put on a fresh smile to show her I found that interesting. She studied my reaction for a moment and then settled back into the chair as if she could make it more comfortable. “I try to take on roles that challenge me…Challenge Society…” She left the sentence dangling for some reason. “You know, gender stuff…” Another dangle.

“I see,” I said to show that I was listening, but I wasn’t sure why she was telling me this.

“I’m a lesbian,” she suddenly blurted out, and checked my face to see if she had shocked me. It was a time before people were as open and proud of it as they are today.

I have to say I blushed at her honesty, but I wasn’t shocked and she could tell. A huge grin exploded on her face and I could see her snuggle further into the chair. “So, I’ve never had sex with a man…” She stared at me in obvious defiance, and then relaxed into the the smile once more. “But my GP insists I have another pap smear.”

I sat back in my own more comfortable chair and put down my waiting pen. “Did you tell your GP you are a lesbian?”

Her eyebrows shot up. “You kidding?” I sat up straighter. “Our whole family goes to see her. She even delivered my younger brother. So, even though I’m twenty-four, I know she’d tell my parents.” She blinked as if she couldn’t believe my naïveté. My innocence. “We live in a small town, doctor. There’s religion bubbling up everywhere. Serious religion!” She smiled and looked out the window for a moment. “That’s why I asked to see someone in the city…” She thought about it for a minute or two, wondering whether or not to elaborate, I suppose.

Then she locked eyes with mine again. “I’m a weed, doctor. They don’t want anybody like me to take root there; I’d endanger their carefully cultivated crop of souls… Spread the seed…”

I hadn’t thought about gender preference like that before -or more accurately, I hadn’t thought much about it at all. I suppose it must have shown in my expression because she immediately smiled again. This time, mischievously. The twinkle was back in her eyes, and a dimple I hadn’t seen before suddenly appeared in one cheek. “We’re both weeds though, aren’t we doctor? We both crossed a line somewhere.” She sighed and straightened up. “I think I just needed to tell someone who’d understand.”

My expression must have reassured her she was right because she immediately started to button up her coat. “I agree there’s probably no rush to do a pap smear, Suzy…But what should I tell your GP?”

Suzy shrugged and stood up. “You’ll think of something, doctor. Weeds are nothing if not resourceful.” She hesitated before going through the door, looked over her shoulder, and winked at me conspiratorially. “Tell her I wouldn’t let you. Maybe I’ll get her to do it -after all, I’ve already sewn the seed…”

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Aphantasia?

We are a culture of categorists. Slotists. Namists. It is a society of Nomino, ergo sum. It’s as if we can sleep more securely knowing we have named and categorized everything we have seen that day –no matter how bizarre, no matter how unimportant. No matter, even, how mistaken the belief that by so doing, we have added something of substance to the world at large. I suppose what concerns me, though, is when to stop the naming? How finely do we divide the gradations before asking if we are really labelling something different?

And, does the act of naming something reify it –make it a real thing, in other words? Or does it merely select it from an otherwise amorphous background where it existed all along? Or, to identify yet another permutation, is it more like taking a shape, say, from a Rorschach ink blot and privileging one interpretation as gospel?

We are all different in many ways –some, interestingly so, others not as noticeably until pointed out by otherwise underemployed taxonomists. I accept this, but still question whether each variation from a norm is deserving of a separate name. Might we put ourselves in greater danger of muddying the water the more we stir it? Losing what we could previously identify in its depths? And for what? Are there really ‘more things in heaven and earth, Horatio, than are dreamt of in your philosophy’? as Hamlet might have asked – More things requiring unique and quirky names?

So, what provoked this mini Jeremiad? Well, I suppose I am as much to blame as the taxonomists in my relentless search for novelty. As I poked and prodded my way through –what else?- the BBC News app, I came across an article on Aphantasia. http://www.bbc.com/news/health-34039054 At first, I wondered if it was a reminiscence about that Disney film which was set to classical music. I was about to scroll past it, but the ‘Ph’ spelling aroused my etymological curiosity.

It turns out that Aphantasia is a neologism that borrows from both Greek and Latin roots: a –meaning ‘without’, and phantasia –meaning ‘image’, or even ‘a making visible’. It refers to the inability to produce a voluntary mental image of something when it is not actually present. So remembering a mental picture of a face might be a problem for someone with aphantasia, although they would still be able to remember non-visible facts about the face –things that stood out, perhaps, like a large nose or a patch over an eye… Attributes, not images.

It may well be a spectrum of loss, however, as Professor Zeman, at the University of Exeter, points out in his study: ‘..the majority of participants described involuntary imagery. This could occur during wakefulness, usually in the form of ‘flashes’ (10/21) and/or during dreams.’ http://medicine.exeter.ac.uk/media/universityofexeter/medicalschool/research/neuroscience/docs/theeyesmind/Lives_without_imagery.pdf  I find this interesting; their capacity to form the internal visual memories is not lost apparently –more the ability to retrieve them at will.

But the very acknowledgement –and naming– of this edge of the normative Bell curve set the neuroscientists scurrying to find its other perimeter and they found it: hyperphantasia –perhaps more easily described as hyper-imagination. I have less faith in this category as a distinct entity, though –I would suspect it wanders terribly close to the edge of more classically defined psychopathology, as in the outer border of bipolar disease, for example, or the imaginative excesses often found in schizophrenia.

So, what has this study purported to identify? Boundaries. After all, up to a certain point, we classify difference as merely a variation from the mean –a quirk of behaviour. A nuance, not an epiphany. And yet boundaries are slippery and once determined, are heavily scented with unintended consequences. As the BBC article pointed out, ‘One person who took part in a study into aphantasia said he had started to feel “isolated” and “alone” after discovering that other people could see images in their heads.’ After all, a boundary had obviously not existed until it had been defined, and then, sadly, the person found that he was on the wrong side of it. What is normal and unremarkable to one, is alien, or at least unexpected for another.

But all of us are on one side or another of some line, aren’t we? Our very uniqueness requires it. It is something to celebrate, something to admire. And yet, not to appear unduly Cassandroid, there are dangers in names –in difference– unless Society learns to honour the mosaic. Cherish it for the montage it weaves into our cultural fabric. Accept the ever changing clothes despite any unwanted flesh it may expose.

I may sound like I’m against the free and unexpurgated pursuit of scientific curiosity -I’m not. Against the inductive method of interrogating nature -again, I’m not. Nor am I content to drift with the tide, happy to land wherever wind and water direct. But curiosity is a watchful cat that lurks in our shadows with hungry eyes and eager claws. It needs to be fed and nurtured constantly, but sometimes carefully. Respectfully.

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Pregnancy Stress

Curiosity is a curse sometimes. It strikes in the most unusual circumstances and often with little warning. Some little thing will set it off and bang, you’re hooked. I’m an obstetrician, so procreative issues are constantly surfacing in my life. Environmental stressors and reproductive failure also seem to be de rigeur in the social media nowadays so there’s no escaping it. The worry may have started with animal data -animals are the easiest to study so we often look at what evidence they provide and then extrapolate. I’m thinking of those dark mysterious star-filled nights at summer camp when there is howling in the distance, and everybody huddles together with questions.

And worst of all are those important things that don’t have ready answers, or the answers have different explanations each time you look for them. Different causes. The secondary sex ratio has always been that type of enigma for me: why isn’t the ratio exactly 1:1 in humans? Well, first of all, some definitions. The primary sex ratio is the ratio between the sexes at fertilization, and the secondary sex ratio is their ratio at birth. There’s even a tertiary ratio -the sex difference in mature organisms.

In the past, the gender ratio at conception was unknowable, so the only useful ratio was the one at birth -and that seemed to favour males (1.1 males for every 1.0 female). So did that mean that male sperm somehow outswam the female ones or damaged them on the way to the egg? Did it speak to the quality of the gametes or merely suggest that to balance tertiary sex ratios (the ratio in sexually mature organisms, remember) more males were needed because, unlike females, they were less able to make it through childhood..? Until recently, as I mentioned, there was no way to measure the primary sex ratio, so it remained a mystery. Now it seems there is, and, surprise surprise, there would appear to be an equality of sexes -at conception at least: http://www.pnas.org/content/112/16/E2102.full.pdf  This fascinating study tracks gendered mortality during development in the uterus. There is a theory (the Trivers-Willard hypothesis) which posits that more males are born in a favourable environment and more females in an unfavourable one because just one sex will be better at ultimate reproduction under those differing conditions.

So what conditions might effect the secondary sex ratio? Well, amongst other things, there is some evidence that major stressors may influence it. Large disasters have certainly been implicated -earthquakes, for example: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881738/  And then, of course, there were the changes in secondary sex ratio immediately after the 9/11 World Trade Center attack in 2001… One explanation that has been offered to explain how this could occur is that males typically attain a critical fetal weight earlier than do females (the average weight of newborn males, for example, is ∼100 g greater than females) and this might exert a higher metabolic demand on mothers. So, depending on the gestational age and the extent of the stress, the mothers may be able to abort the male fetuses, but maintain the less physiologically demanding female ones. In other words, evolution would seem to have selected for those females that can regulate the sex of their offspring… Really?

That explanation seems rather contrived to me. Exactly how would the mother accomplish this feticide? And avoiding direct maternal involvement by referring it back to changes in placental function merely pushes the question back another layer. Of course, some have tried other approaches -for example citing the epigenetic environment (factors influencing the functionality of genes): http://humrep.oxfordjournals.org/content/20/9/2662.full But even when I force myself through the commentator’s words, the explanation still seems a little strained.

And yet, statistically, there does seem to be reason to believe that something is happening that relates to stress.

Of course pregnancy itself is a stress -levels of stress hormones increase as pregnancy unfolds: (http://www.jogc.ca/abstracts/full/201505_Editorial_1.pdf) -although, as the editorialist explains, ‘as a pregnant woman approaches term, environmental stress has less effect in triggering the usual response in the hypothalamic-pituitary-adrenal axis, and she becomes less responsive to the effects of stress’. Uhmm… So, pick your answer from a hat?

Well, in the rubble of destroyed answers and ever blossoming questions, what are we left with? Is there something special about violence that triggers it? Or does any stress threaten the ratio? And what constitutes a stress anyway? All imponderables, I suppose, but at least a recent article in the JOGC (Journal of Obstetrics and Gynaecology of Canada) brings it closer to home: http://www.jogc.ca/abstracts/full/201505_WomensHealth_1.pdf  And in an ‘Only in Canada, eh?’ fashion it demonstrates that we, too, can participate in the secondary sex ratio debate -on our own terms, of course. I mean, who would have thought that our two referenda on Quebec secession from Canada could provoke such a response? I’m almost proud that it did –it shows how involved we are in our country. How much it matters. And how we don’t need earthquakes, either.

And maybe the slight increase in female births that the worries about the referenda caused says something about our growing appreciation of women in Canadian society as well… I live in hope. But you gotta love this stuff, eh?

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Gynicles

I’m not sure why I’m so much against what are now politely referred to as listicles. Maybe they’re too much like sound-bites and too little like enjoyable prose; maybe it’s because if I gloss over the word quickly, it always looks like testicles…

I have nothing against lists –pithy reminders of what I need to buy at the grocery store, or as memory aides if I have to do some task in a particular order- but I object to having information sufficiently divorced from its source that it seems already chewed and partially digested –a dictionary substituting one word for another with little or no background. As nourishing as junk food.

It seems to me that information, to be reliable, must have depth. Context. Credentials. And to be believable, it needs substantiation –evidence to support its content, and proof that it wasn’t just made up to fill the final position on the list.

I’m sure that lists have been around since writing began –before maybe- but they were seldom confused with substantive writing. A possible exception might be Homer’s detailed catalogue of ships in the Iliad… but my attention was drawn to this by reading it in a listicle: https://timeline.com/stories/list-of-listlces-hammurabi-luther-homer -so I’m not contending that they are completely without value. And yet, if I were to want to pursue it further –lecture about it, for example- this ‘facticle’ would only deserve a Powerpoint asterix as a reminder to elaborate further on the topic and prove my contention that Homer did indeed say that, and that he meant it as literature (or not…). On its own and unexplained, it could qualify as a rumour, a joke, or even a mistake.

David Leonhardt in the New York Times, attempted to defend the listicle as a more efficient way to convey information –referring to a listicle by Aaron Carroll titled simple rules for healthy eating As Leonhardt put it, ‘…it was a better, more useful piece than it would have been as a 1,000-word essay or news article.’ http://www.nytimes.com/2015/04/25/upshot/in-defense-of-the-listicle.html?_r=0&abt=0002&abg=1

Perhaps, but listicles can also be excuses for lazy, slovenly researched journalism. Unfortunately, the ones my patients have been quoting to me, or bringing in on their tablets for me to read, do little to bolster my confidence in what is out there.

The one I remember the best, perhaps, was from the Huffington Post: http://www.huffingtonpost.ca/2015/02/02/university-of-vagina-lessons_n_6591506.html and delivered to me from Lucy like a bible…

Lucy was an occasional patient of mine who seemed prone to recurrent vaginal problems of one sort or another. Forty-five years old, or so, she was entering the time of her life when her hormones were beginning to misbehave and she seemed to blame it all on her vagina. It hurt one time; it itched on another; sometimes too small, the next too large, I was always on tenterhooks with each of her visits as to what else could go wrong. On the most recent visit, however, she informed me that it even bothered her husband… It was almost like a poorly trained, but as yet unnamed, pet.

I saw her in the waiting room clutching an electronic tablet –not reading it, merely clutching it, readying it for me to see. I took a surreptitious deep breath before I crossed the room to greet her. She usually relied on Google or Wikipedia for her diagnosis and presented it to me as a fait accompli. Incontrovertible evidence to support the fact that others, too, suffered from similar problems but only received adequate diagnoses and helpful remedies after multiple visits to multiple doctors led them to experiment with alternative strategies: alternative healers using esoteric knowledge of plants and energy fields.

When she finally made it into my office after fiddling with the tablet while walking down the corridor and bumping into things on the way, she looked at me with a satisfied but condescending expression on her face. And before I could even ask her how she was, “I found an article online that was very helpful,” she said, unable to contain her enthusiasm for the discovery any longer. She held the tablet to her breast so I couldn’t spoil her surprise. “Superficially, it seems quite humourous, but the insights in it are…” she launched her eyes at the ceiling for a moment as she rummaged around for the best word to describe it. “Well, they’re profound!”

I could almost see the italicization; I could certainly hear the exclamation mark. She was preparing me for something, I could tell. I steeled myself for some testimonial from a vaginal victim who had finally discovered a cure somewhere unexpected.

“Now I want you to read this carefully, doctor,” she said as she loosened the tablet from her abdomen where it had taken up residence after sliding from her bosom. “Read between the lines…” She knifed me with her eyes and left them there, pinning me to my seat, for emphasis. She was taking no chances.

The first thing that grabbed me was the picture of the perineum as the gateway to a university building and I have to admit I chuckled. Softly, though. Respectfully. The problem came when I was expected to appreciate some of the wisdom. I really couldn’t decide what she felt was profound and valuable information. I have to admit that a louder and unmistakeably improprietous laugh escaped at the ‘sword holder’ part at the end.

She immediately snatched the tablet back from me and nestled it safely on her lap. She did not appreciate my levity and seeming inability to extract the kernels of wisdom however cleverly disguised. In fact, her look was one I remember from my teacher in grade school whenever I made one of those rude noises with a hand in my axilla. I was about to be expelled as a healer if I didn’t think of something to assuage the insult.

“It’s a very…” -I, too, had to hunt for a word- “..clever article, isn’t it?” I said with due humility at my gaff. “Which point did you find the most valuable, Lucy?” I certainly wasn’t going to commit myself.

She took a slow, unnecessarily noisy breath, and sat up as straight as a ruler on the hard wooden chair. “Well,” she finally deigned to answer, all the time thrashing me with her eyes as if she shouldn’t really give me another chance, “I’m torn between learning the number of orgasms it is capable of –I mean, who would have thought…?” She blinked in a brave attempt to get back to her original line of reasoning. “And the bacteria thing. Maybe that’s where mine goes wrong –it never seems very clean…” She paused for a little self reflection before finally deciding on the most influential point she took from the listicle. “But I suppose if I had to choose…” –she didn’t really. I was just curious- “If I had to choose,” she repeated herself, as if her credibility depended on it. “I think I’d go for the self-cleaning aspect. But I mean if it really is self cleaning like they say, then why are there still bacteria in there, for goodness sakes?” She shook her head and shrugged as if she’d finally discovered what had been wrong with her all these years. “The self-cleaner must break down a lot in others, too, or they wouldn’t have mentioned the bacteria…” She hit me with her eyes again, but this time more softly.

“Anyway, I solved the problem with a nightly vinegar douche .” I smiled, relieved at the news. “But my husband won’t go near me now.” For some reason a tiny trace of a smile raced across her lips and disappeared into her makeup.

I knew there had to be something. “And why’s that, Lucy?”

“Says it hurts.” She shook her head as someone used to the bludgeonings of Chance. “There’s always something, isn’t there..?” she said, accepting her fate with another shrug.

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What’s in a Word?

Alexithymia. Ever heard of it? Me neither. It sounds like one of those words you’d get in a national spelling bee when they’re trying to off you. Fortunately it has a rather pedestrian etymology: ‘a’ meaning ‘without’; ‘lexis’ –speech, or words; and ‘thymos’ – soul, or emotions. In other words: no words for feelings. Hmm… Who would have thought it was a condition? Mind you, since there’s one called anhedonia, the gloves are off.

I’m fairly certain that its shadow would never have darkened my office door, had not a patient pulled it deliberately from her purse while reaching for her phone. Pandora comes immediately to mind, but this lady’s name was Alexis – or, rather, Alexisse as she quickly corrected me- with the accent on the last syllable would you believe? She seemed innocent enough sitting in the waiting room, but in retrospect, she was more a pier in the currents of a hectic room than a middle aged lady. The usual waves of noise and confusion seemed to break over and around her with as little effect as a storm on a breakwater. Throughout the maelstrom, she maintained a smile on her face, but she later admitted to me that it was a well-practiced artifice –a mask that she would always carry with her to help her to blend in.

Her clothes certainly helped as well –a grey skirt worn just below the knees, white blouse buttoned tight around her neck, but loose at the wrist, and black shoes with just a hint of a raised heel. Her light brown hair was short and tidy and her nails long and uncoloured. An average height, she would have melted into any crowd without a trace. Indeed, she followed behind me to my office like a shadow.

I’m describing her like this in the full light of retrospect, however. We always tend to remember things in ways that make sense to us I suspect, although at the time, only the word stood out. She presented as a model patient, and was not at all upset that I was running behind time and was almost an hour late before I was able to see her. “These things happen,” she said with the same smile she’d worn through the whirlwind out front. “I carried a book with me, just in case.”

I brought up her file on the computer as she sat contentedly across the desk inspecting the art work on the walls. I’d not seen her before, but the only thing the family doctor had sent me was the result of a pap smear she’d done recently. Alexisse was a new patient for her as well, and apparently had not had a pap done for over ten years. But worse, the smear was read as showing some malignant cells.

“Did you find the pap smear results?” she suddenly asked, the smile still on her face.

I nodded and looked at her for a moment before speaking. She didn’t seem at all upset so I assumed her GP hadn’t discussed the results with her. Of course the diagnosis was unlikely to be firm until a biopsy of her cervix had been done, so perhaps she had decided to wait until I did that before discussing it with Alexisse.

“Dr. Mandel said you’d be able to confirm the diagnosis with a biopsy.”

The smile never left her face but I was drawn instead to her eyes –they were totally neutral. Cool, if anything. “What did Dr. Mandel say about the pap smear?”

Alexisse shrugged. “Well, for a start, she tried to downplay everything. She said that pap smears are only screening tests and so sometimes they are mistaken…” She stopped for a moment and stared at me with an unchanged expression. “But even when somebody goes to great lengths to paint a black paper white, you know it still ends up looking grey.” Her eyes sought mine to see if I understood.

I approached the topic carefully. “So… What do you think she was trying to tell you?”

Another shrug. “That I have cancer of the cervix.” She said it as if I had asked her about her last period.

I was speechless for a moment. There was no sign that she was upset. No tears. No tightening of her facial muscles. Just the smile –the mask. “You don’t seem very upset. Your family doctor must have done a good job of discussing it with you.”

Alexisse shook her head. “She seemed a little confused about what to say. She asked me if I had any questions, and when I didn’t, said she’d send me to see you.” She stared at me for a while and when she saw that I looked puzzled as well, sat back in her chair.

“I have alexithymia,” she said as she reached nonchalantly into her purse to turn off a phone that was ringing. I must have cocked my head, because her expression intensified. “It’s a condition that makes it difficult to feel emotions –even identify them as such. I’ve learned to put a smile on my face along with my makeup in the morning.”

I started to ask if it was a type of autism, but she saw the word forming in my mouth and waved it away. “Only half of us with the condition are autistic, if that’s what you’re going to ask…” She took a deep breath and let it out slowly. “I’m sure it’s a spectrum disorder –worse in some, less in others.” The smile appeared again. “And the next question you’re going to ask is about my name. Isn’t it a little suspicious that my name is almost the same as the condition? I mean I can almost see everybody thinking it. Go online and you’ll see the community calls its members ‘Alexes’. It’s why I’ve started pronouncing my first name differently…” She sighed briefly. “I don’t think the condition is even accepted by mainstream psychiatrists yet. It wasn’t in the DSM IV at any rate… But I have to admit I haven’t looked lately.”

“So…”

She crossed her arms and stared out the window. “I’ve always wondered about why everybody except me seemed to get excited about things. I can’t remember ever being angry, or crying at a movie. People thought I was weird.” She shifted her position on the chair. “Anyway, I looked up the etymology of Alexis –which is how my parents spelled the name- and realized it came from the Greek for ‘without speech’. It didn’t take Dr. Google very long after that to introduce me to alexithymia.

“And no, I haven’t had a formal diagnosis. Dr. Mandel asked me about that.”

I sat back slightly on my chair to get the computer screen out of the way. “Well, frankly I’m more concerned with doing a biopsy as soon as possible than with any personality disorder you might have…” I wanted her to know that the most important thing to think about at that moment was her health. I meant well, but her facial expression changed immediately. She looked almost angry –hurt, at the very least.

“Personality disorder? And that I might have?” Her whole body tensed at the perceived insult. “I think you’re being entirely too insensitive, doctor!” She shook her head slowly. “Just like my family doctor. Now you see why I don’t go to doctors very often.” She started to get up from her seat. “Your secretary can let me know when you’re going to do the biopsy,” she said, still shaking her head in disbelief. “You all seem to ignore who I am for what I have…” She fixed me with a glare that almost pinned me to my seat then left the room with a toss of her head… Anger?

She never showed up for any of the biopsy appointments despite multiple phone calls from both our office and her family doctor’s. I can only hope she sought help from someone who listened to her pleas for understanding. I don’t know whether she actually had alexithymia or some other mental issue such as schizophrenia, but it clearly seemed to interfere with her ability to process information appropriately. I’ve since learned that alexithymia is often associated with other psychiatric disorders, so perhaps she had decided to fixate on a more acceptable but obscure variation. Maybe she’d been wearing another mask -one that even she had not suspected. Or one that she found too difficult to acknowledge…

I also Googled the word and discovered that the BBC had an article on it that was dated a month or so prior to her visit: http://www.bbc.com/future/story/20150818-what-is-it-like-to-have-never-felt-an-emotion I remain open to convincing, but I keep remembering what Iago said in Shakespeare’s Othello: ‘I will wear my heart upon my sleeve for daws to peck at. I am not what I am.’

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The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’

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Placentaphilia

Finally! Somebody has had the courage to think the unthinkable and say what most of us have been too shocked to verbalize, too nauseated to contemplate: that eating your baby’s placenta is not a plus. My risen gorge has been vindicated.

An article in the BBC news http://www.bbc.com/news/health-33006384 reports on a review article on placentaphagy (the practice of eating placentas) from Northwestern University http://link.springer.com/article/10.1007/s00737-015-0538-8#page-1 (published in the Archives of Women’s Mental Health) that suggests that there are no proven benefits and no research on the potential risks.

Uhmm… Well, okay, no blinding epiphany there. I mean even if you saute it and hide it under a leaf of lettuce between two slices of toast, you would think it would still lack that magic je ne sais quoi. But, alas, you would be wrong. There has long been a fascination with the placenta and its powers, no doubt rooted in its dual role in both sustenance and connection. It is, after all, neither baby nor mother, and yet an essential workshop serving the two worlds. A mythological creature, its function does not cease with the accident of birth.

Name the culture, and there’s probably a tradition. Some of the aboriginal peoples of the Pacific Northwest of Canada, for example, have the belief that if the placenta is placed in a tree and then carried off by a raven, the child will travel. The New Zealand Maori suggest that the placenta has a link with the earth and should be returned to it when it is no longer needed. There are even those who believe it was alive and functioned as a companion for the baby but then sacrificed itself so the child could be born –I like that one.

My point, I suppose, is that given the magic surrounding the placenta, it should not come as a total surprise that some might feel that the power it wielded might be transferrable if it were consumed. Or, perhaps, that some of its constituents may be beneficial. But I wonder if it’s the same kind of logic that Macbeth’s three witches used. It’s certainly a stretch to suggest that the placenta offers something that isn’t more readily and efficiently available in some other more acceptable format. The fact that it came from within the body and has served as a treatment plant in utero does little to recommend it in my opinion.

But I am more than a little disappointed with my own Medical culture’s lack of imagination. Its lack of narrrative. We are a society of stories –it’s not only how we impart information, its how we value it. Evaluate it. Surely we could have made something up as well… Tradition wrapped in metaphor is far more meaningful than facts trapped in lists. Sometimes facts must wear scratchy and uncomfortable clothes to attract attention. Gather adherents.

Once upon a time when I was young and still wore a stethoscope around my neck, I found myself in the midst of nothing less than an epidemic of placenta-eaters. Wave after wave of them swept into the case room, teeth sharpened, and bread sliced. They couldn’t wait to enter the Kingdom of the Enriched –some even partaking before they left the delivery suite. Usually they were discreet and waited until we had left them alone in the room to bond; sometimes they seemed in a rush.

I’m not certain what started the practice –it was, as I recall, before the days of social media- but start it did. Suddenly, and with an enthusiasm I had never witnessed, it was upon us. But until I saw my first bite, it was a horror that lived in legend alone.

*

The hospital nurse assigned to the couple was an English-trained midwife and she shooed us out of the room as soon as we doctors had congratulated them and put away our instruments. I should have known something was up when I was even led away from the little window in their door.

“They need some privacy, doctor,” the nurse informed me as she grabbed my elbow and steered me away. “This is a really important time for them,” she added, winking at me cheekily and then hobbling into the lounge to get a coffee.

I wandered over to the ward desk and pulled out the chart to enter the usual description of the delivery and write some orders when I discovered I didn’t have a pen. I checked the counter and even riffled through some drawers, but to no avail. It was around two-thirty in the morning, and no one else was around. I decided I must have left mine in the delivery room, so I walked down the corridor to their room and pushed open the door.

Mistake. The father was lying on the narrow bed beside his wife who was holding the swaddled baby on her chest. Three things struck me: the baby was preternaturally quiet; the parents both had silly, embarrassed smiles on their faces; and he looked like he had been practicing with bright red lipstick. He’d even got it on his teeth.

I quickly looked away so I wouldn’t embarrass them in their intimacy. “Sorry to disturb you like this,” I said, a bit uncomfortable that I had maybe caught them in flagrante delicto as it were. “I left my pen in here,” I mumbled and searched around on the floor for it. It was then I noticed the umbilical cord suspended from the edge of a blood-tinged sheet on the bed. I was horrified; I thought perhaps the placenta had somehow gotten mixed up with the blankets after the delivery.

I stood up suddenly beside the bed. “I’m so sorry,” I said, in my most apologetic voice. “Did we forget to clean up your bed after everything?”

He looked up at me sheepishly, still holding a fragment of placenta in one hand. “I’m afraid it was us…” His voiced trailed off as his wife looked at him with hooded eyes. A profound silence blanketed the room suddenly. No one spoke; the baby snortled; and I could hear all four of us breathing. Labouriously. Expectantly.

The husband broke the tryst. “Not what I expected, actually,” he mumbled cryptically. I could see his wife giving him a poke under the covers. “Wouldn’t recommend it to anybody, that’s for sure…” She sighed loudly and glared at him over their still sleeping baby.

I thought it was unusual for the baby to be so quiet –they usually cry a fair amount after delivery to fully open their lungs and adapt to life outside the womb. I reached over and vigorously rubbed its back through the blankets he’d been swaddled in –at that time the parents weren’t taught the importance of skin-to-skin contact for mom and baby like they are nowadays, so it would have been difficult to spot breathing problems in the infant through all of the layers.

The baby made a weak attempt to cry while mother sat up immediately and demanded to know why I had attacked her baby. She pushed the bell for the nurse at the same time. By the time the midwife had arrived with angry eyes, I had transferred it to the bassinet and was fiddling with a suction tube preparing to suction out the baby’s mouth.

When the nurse heard the grunting of the infant and saw what I was attempting she smiled at me and took over.

The mother, in the meantime, was distraught. “Why did he wake my baby up?” she screamed. “We were having a little quiet time when he barged in here and grabbed my baby.”

The nurse handed a screaming infant back to the mother and touched her gently on the arm. “You should be glad that Doctor came in, Emily. Your baby was having trouble breathing with all that mucous in its mouth.”

The husband looked embarrassed. “I think we were too focussed on that weird placenta stuff,” he said and smiled at Emily to sooth things over. She blushed and cast a loving glance at her screaming baby.

“It wasn’t very tasty was it, honey?” she whispered. “Not at all like that book promised…” She reached over and kissed him warmly on his cheek.

He returned the blush. “I… I spit mine out into this,” he admitted and pulled out a little plastic K basin he’d hidden under his pillow. “Couldn’t swallow it,” he said and shrugged. “How about you, sweetheart?”

“Terrible heartburn, dear…” She glanced at the midwife, in case she had transgressed on some sort of midwiffic tradition. “But maybe it just needed more salt, or something,” she added quickly to try to make the best of a bad situation.

The room filled with the cries of the baby. “Maybe it just needed to stay in the metal bowl where the doctor put it,” he said in a brief lull as the baby sucked in a lungful of air and he returned his wife’s kiss.

The midwife was all smiles. “I couldn’t eat mine, either,”she said, winked, and cast a knowing shrug towards them. Then she walked slowly over to a sink in the room, picked up a couple of towels and, ever the nurse, dampened one edge of each.  “Anybody want to clean up a little?”

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Staying in Touch

In the endless dark of night, belief that there will be a morning is sometimes all that sustains us. Hope springs eternal in the human breast, as Alexander Pope declared in one of his essays -and that is occasionally all there is. When Medicine fails, the understandable temptation is to turn to alternatives; when inductive reasoning seems insufficient (compilation and collation of observations to arrive at a tentative conclusion) then perhaps the converse might be helpful: deductive reasoning (start with a conclusion and then look around for supporting evidence). The Scientific Method tends to use more of the former than the latter to test hypotheses, although to be honest, it is often a melange. But to start with a conclusion and then to attempt to prove it can be a recipe for failure –or worse, deceit.

Alternative Medicine appears to be guilty of the latter -although whether by intent or naivete can be argued, I suppose- but it does seem to attract a certain edge of the population. I, for one, am not a believer, but to set the stage, perhaps a definition of alternative medicine would be helpful. The description in Wikepedia (sorry!) is as good as any I’ve seen: ‘Alternative medicine is any practice that is perceived by its users to have the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science. It consists of a wide range of healthcare practices, products and therapies, ranging from being biologically plausible but not well tested, to being directly contradicted by evidence and science, or even harmful or toxic.’

In this essay, I don’t intend to debate the merits or harms of alternative strategies for health, but merely to illustrate the pitfalls that can result when they are espoused too vigorously -when hope triumphs over experience. When, to paraphrase Macbeth, Physic is thrown to the dogs.

*

I really liked Loretta; I could tell that as soon as I saw her in the waiting room chatting to her neighbours. A slender young woman barely grazing her twenties, she had short brown hair and was dressed in jeans and a yellow tank-top. Her face was all smile –or, rather, all teeth and tongue, with large, brown eyes occasionally mobilized to emphasize some point or other. The whole room seemed alive with laughter and focussed on her every word, her every gesture –and there were a lot of those. Her body was in constant motion, sometimes pointing with a ring-laden hand, then gesticulating with her arms as her bracelets clinked and ran up and down her forearms like beads on an abacus; even her legs were integral as she swung them back and forth to illustrate a point with her dainty sandal-clad feet – an actress playing to an adoring audience. I almost felt embarrassed as I crossed the room to lead her offstage. She actually waved to them as she left; I half expected her to blow kisses.

She sat on the edge of her chair in my office clutching a backpack in one hand and a phone in the other as if to relax was anathema to her. “You seemed quite popular out there,” I said, nodding towards the corridor that led to the waiting room.

Her smile broadened at the compliment. “I like to stay in touch with everybody… and everything,” she added, as if it were a necessary addendum, then filled the time between our words with safaris into the uncharted depths of her pack. “I’ve come here for a pap smear,” she said as she saw me scrolling on the computer. “That’s what my GP says, but it’s really because he doesn’t know what to do with me…” She let the sentence dribble to a close without a firm indication she was finished with it. Like it was still a work in progress. So I waited. A text arrived on her phone and she blinked at me and proceeded to thumb a rapid, practiced reply almost as if she was scratching her leg without thinking about it.

Still she said nothing, but instead inspected the room, starting with the pictures on the wall and then progressing to the the plants on my desk, inspecting them one by one, perhaps thinking I was going to quiz her about the office. “What is it that concerns your GP, Loretta?” I felt I had to say something.

She shrugged goodnaturedly and her eyes migrated to my face. “I suspect she thinks I’m too self aware…” She giggled at the thought, then noticed the puzzled expression that I had tried to disguise. “I like to be on top of things…” She immediately blushed and corrected herself. “You know, like my health and stuff.”

I smiled to encourage her to explain.

“Like, you have to be careful about what you put in your body. I mean they’re putting additives in everything. Bodies need help getting rid of all the toxins that build up: detox regimes.” I grimaced inwardly, but maybe she saw the shadows. “My GP said that was nonsense, too, but I know I feel better after a cleanse,” she said, momentarily dropping the smile and folding her arms across her chest with the bracelets following close behind for emphasis.

I tried to disguise a deep breath. “I see…” –but actually I didn’t– “Is there any reason he felt that a gynaecologist could be of some help?”

“Help?” she said with a sharp intake of breath, as if I had really not understood a word of what she’d been telling me.

“You know,” I quickly added, “Help with something that you’ve been unable to deal with using your…” I hurriedly rummaged around in my head for an appropriate word –one that wouldn’t seem to insult her, yet wouldn’t suggest acquiescence either. “…Your strategies.” I thought that sounded neutral and not overly critical. I wanted to keep her on my side to see if there really was anything I could do to help. She could sort out the knowledge base for herself later.

Before she could respond, another text arrived, prompting yet another seemingly mindless flurry of thumbs to resolve the issue. She didn’t apologize and I realized that this was just part of the background in her life -like traffic noise, or maybe someone bumping into her in a crowd. She found time to shrug at me again, but whether to acknowledge the text she had just answered or as a way of answering my question was hard to tell. “I’ve been getting a lot of yeast infections lately, so I tried another cleanse.”

Her eyes jumped onto mine to see if I needed any clarification, and rested there when my face didn’t light up sufficiently with comprehension. We live in different worlds they said.

“Toxins,” she added, like she was talking about the elephant in the room. “The bowel walls get encrusted with stuff and overgrowth of candida is one of the crusts.” She smiled innocently, almost as if she was going to admit to sneaking a cookie between meals. “I tried dietary modifications for months: fruit fasts, fiber-only diets… but no matter, I still got itching down there. So I tried a coffee enema once a week for a month. Then a probiotic one for almost three months.” She jangled her bracelets again as she thrust her arms upwards to suggest what else could she do. “Nothing worked, so finally I tried an enema using an antifungal solution that my girlfriend told me about. Jeez, try to keep one of those puppies inside for 15 minutes! I only managed 8…” She noticed the horrified expression that I’d tried desperately, but unsuccessfully to camouflage. “Eight minutes, doctor –not eight enemas!” She shrugged again –it was another form of speech for her, evidently. A sort of body text, I suppose. “But when I told my GP about it, he got really mad. “Of course there’s yeast in the bowel; we all have yeast in our bowels, he said… No he yelled that at me,” she added after thinking about it for a second.

“So I told him about the enemas they’re using nowadays for –I forget the infection…”

“Clostridium difficile,” I added helpfully, and also to show that I was still listening.

“Those are special fecal enemas, he yelled back at me, and only for a special problem!  Anyway, you can’t get rid of vaginal yeast with those silly health-product enemas, he added. Not even the probiotic ones. He said ‘probiotic’ more softly, though, as if maybe he wasn’t so sure about that one.” Her face perked up again as the indignation faded and the verbal catharsis revived her spirits. “The yeast down below isn’t so bad right now –it seems to come and go. But no thanks to him -none of his prescriptions helped…” She shrugged a text at me. “That’s why I tried colonics dead last. I mean I believe in probiotics, and I hate enemas.” She studied my face for a moment. “Hey, I was desperate.” Another jingle from her arms. “There’s gotta be another way to go. Despite what all my friends say, I still think enemas are unnatural, don’t you?”|

I have to say it was hard not to roll my eyes. I realized I had a chance to convert her to our side of the fence if I was careful. And tactful. “I agree with you about probiotics, Loretta.” She smiled and nodded her head at my unexpected response. “The idea, of course, is to adjust the biota –the bacterial flora of whatever organ- to be able to suppress other unwanted organisms. But you can’t just use off-the-health-food-shelf probiotics –one type doesn’t do all jobs, just like one antibiotic doesn’t fit every occasion.” I glanced at her face to see if she was listening or playing with her phone again. She was listening. Staring at me in disbelief, actually. But in this Google age, I knew I had to be careful -I could only remember one article I’d read and that might already be outdated. For that matter, I couldn’t even recall where or when I’d seen it –the Canadian Medical Association Journal, maybe. But then again, she probably didn’t really have a yeast infection anyway…

“And the other thing is that good studies in this field are hard to find.” I hesitated a moment for effect -timing is everything. “I seem to remember there are a couple of probiotic regimes that have undergone scientific investigations. They were published a few years ago in…Ahh, the Canadian Medical Association Journal. You can look it up, I imagine.” The long-winded, but welcome news had forced her back into the chair, her phone into her pack, and the pack onto the floor. Then a look of concern replaced the incredulous rictus. “But how are the new bacteria going to be able to compete with all that toxic stuff in the area now? It might poison them, or overwhelm them before they even get a chance to set up a new colony.”

It was my turn to look concerned –well, at least curious. I’ve never understood the toxin theory promulgated by many of the alternative medicine practitioners. “How do you know there are toxins, or whatever, in the area, Loretta?” I sat back in my chair, convincing myself I had her.

Her eyes rolled as her hands reached into the pack at her feet in response to a muffled text. I assumed she was reacting to the disturbance, but suddenly realized it was me they couldn’t believe. She closed them slowly, patiently, in a slow motion blink and then opened them again, this time filled with all the sure and certain knowledge of youth. Her body texted me before any words left her mouth. “How do I know there’s still stuff living there now after months of using my colonic ‘strategies’ as you put it? Ever had a retention enema, doctor?”

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Dealing with Women

“The sky is falling! The sky is falling!” cried Chicken Little running around frantically when confronted with an unexpected knock on her head. There are any number of versions of the story but all, seemingly, involving females who misinterpreted some benign event as being catastrophic. Fearful. Outside of their comfort zones. In other words, acted inappropriately given the circumstances. Worse, they acted hysterically. The message as I read it being twofold: the obvious and more polite one is that sometimes we overestimate a danger and panic; but the covert, unstated, and more troubling one, is that it never seems to be the rooster that is panicking.

It is interesting that we seldom notice this; the observation seems trivial because of the folk tale’s obvious purpose of decrying overreaction. And yet that is the point: it seems trivial because we are distracted by the message; the messenger is merely the vehicle for its dissemination: a believable advocate for jumping to unwarranted conclusions, reacting with alarm, not intellect. Bewilderment, not analysis… And looked at through this lens, I see stereotyping –undeclared, of course, and easily ignored, and yet like a persistent but faint shadow, visible when pointed out.

We still live in a barely camouflaged misogynous culture where unattractive attitudes are often left unbathed and then dressed in cleaner clothes. Things unsaid are still implied; it is a kingdom of the once-removed. The wry smile. The innuendo. Of course it’s a thin line that separates description from interpretation and I don’t wish to be accused of usurping Chicken Little as a twenty-first century Rooster Little, but I think it is becoming increasingly obvious that roles –as well as expectations- are ripe for change. The old allusions are wandering from the mark and ring hollow, even when they hit. It’s hard to understand why it has taken so long to notice -or am I, too, overreacting? Seeing things I am convinced exist -a flagrant example of Confirmation Bias? Perhaps, but every once in a while, even in quiet corners, I sense a change in attitude -and  I hope, like a row of dominoes, once one male bastion falls, the rest will follow, however slowly. However reluctantly…

And yet, it is not the weakness in the castle walls that surprises me so much as the attitude of its inhabitants. Behind those ramparts, cultural beliefs and self-serving, unquestioned suppositions, are guarded like Samson’s hair, because to modify them, even in the slightest way, courts a potential diminution of power. A waning of privilege. A loss of control. Or maybe, worst of all, a loss of quality.

Stuff and nonsense! Too long have we been satisfied with the low-hanging fruit while the tree, unconcerned with gender all along, has been offering so much more. And yet for some reason it still seems to come as a surprise that females, given the opportunity, can be the equals of males. A good example, I think, was the recent nuclear talks with Iran.

I was drawn to an article in BBC News that felt it had to point out that there was a significant and necessary role played by women in the negotiations: http://www.bbc.com/news/world-us-canada-33728879 I loved the fact that somebody noticed the role they played, but I have to confess I was a little disconcerted by the fact that it had to be pointed out at all –as if to say ‘Look what they can do if we let them…’ As if negotiations –serious negotiations, important negotiations- were the sole prerogative of men. A male-only club.

In fairness, however, I suppose there were other constraints to the active involvement of women in these particular negotiations that are obvious only on closer inspection –those of religion and the customs both it and its culture impose. For example: ‘When an agreement is struck among parties, it is standard practice to “shake on it” in order to seal the deal. But when a historic nuclear accord was reached in Vienna, Austria, on 14 July between Iran and the P5+1, the Iranian negotiators could not shake the hands of their female interlocutors due to the country’s strict religious customs.’

When compared to the historic accord that was reached, these are minor things, however. As Wendy Sherman said (‘She was one of the chief architects of the Clinton administration’s North Korea nuclear policy and had taken the lead on the US team’s nuclear talks with Iran since 2011’): “I grew up in Baltimore where there’s a large Orthodox Jewish community where the same is true, but I think we all understood how to speak to each other without shaking hands and understanding each other to the extent that we got an agreement.”

Bravo! The excuses for excluding women were always a house of cards. Let’s hope that not only do the cards fall, but to paraphrase Macbeth’s tortured description of the by-then-dead Duncan: that ‘After their life’s fitful fever they sleep well’. And this time, there should be no guilt. Only hope and celebration.

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The Myth of Medicine

The concept of the myth has always intrigued me. Not, as it is historically characterized – the fabulous stories of gods and heroes- or the more populist idea of an untruth or counterfactual, but rather as a metaphor. Myth as a way of explaining something that is difficult to put into words, that defies rational explanation: the meaning behind the meaning. Like those Russian nesting dolls, they are multilayered, with understanding hiding within significance which is in turn hiding under context hiding behind appearance… A myth is the meaning of a flower. It is a poem.

And yet it need not be so abstract, so elusive. All of us have myths: they are our stories –who we are, or at least how we have come to understand ourselves. As the famous Swiss psychiatrist Carl Jung said in his autobiography: Thus it is that I have now undertaken, in my eighty-third year, to tell my personal myth. I suppose the challenge, however, is to disentangle the reality from the fantasy… Or does it really matter? And are they both merely different colours of the same myth? Joseph Campbell, the author of many books about mythology, said: “…the only way you can describe a human being truly, is by describing his imperfections. The perfect human being is uninteresing… Aren’t children lovable because they’re falling down all the time and have little bodies with heads too big?”

We are, for all intents, our mistakes. Our foibles. Our myths. And that which we appear to be, we are not –or at least that may not be how we see ourselves. So, for the doctor, which is the more important –because to treat the person, we have to find them first?

I am reminded of a patient I saw  long ago when I was a freshly washed gynaecologist just setting up my practice in an era of militant feminism. Ms Debrashen –that was her title, she insisted, just like mine was ‘doctor’- was a frail-looking eighty year old but dressed in jeans and a sweat shirt that had I’m Talking to You written in Gothic script on the front. I suppose I should have been intimidated, but her smile was so disarming, I couldn’t help but return it as I greeted her in the waiting room. She extended a bony hand to shake before I could even free my own from her chart, and would have led me  down the hallway to my office if I hadn’t stepped in front of her to make sure she went through the correct door.

“So what can I do for you Mrs. Debrashen?” I said, still smiling, as she plonked herself down on a chair beside my desk.

“Ms Debrashen,” she corrected me, but not unkindly. “I want you to do a pap smear. I haven’t had one in years, and my family doctor refuses to do one on me.” As she said this, she replaced her smile with a flinty stare that brooked no nonsense. I will be obeyed, it said for a moment, and then relaxed into a more Canadian, please. “I don’t know what got into him; I’ve gone to him for years, but he just climbed up onto his doctor horse and said I was too old.” She sighed theatrically and shrugged angrily. “Too old? Too old to be screened for cancer..?” She shook her head in disbelief. “Does he think I’ve lived long enough already?”

I took a carefully disguised deep breath and let it out slowly. Quietly. I decided to start with a thorough history in case there were some extenuating circumstances. Most cancer agencies throughout the world, and certainly the one in my own province here in British Columbia, have said that there is no indication for continuing to do pap smear screening after the age of sixty-nine. Only if there were recent abnormalities in the pap or as a followup to recent treatment for abnormal cells would it be justified. And of course, then it wouldn’t be screening, per se, but followup.

I took what I felt was a complete history and then, as a tactical decision, asked about her pap smear history at the very end. But no, all of her past pap smears were normal, she insisted.

She sat back in her chair, folded her arms across her chest and stared at me with a rather smug but expectant expression on her barely-wrinkled face.

“The Cancer Agency in British Columbia usually recommends not doing any more pap smears after you turn seventy,” I said, rounding it off for simplicity.

A curiously satisfied smile captured her face –as if she were laying a trap for me, but had to be careful not to give it away. “And why is that, doctor?”

“Well…” I started, not totally comfortable explaining to a woman of her age about the increasing belief in those early years of virology, that the abnormalities of the cells of the cervix registered by the pap smears were in fact the result of some sexually transmitted agent.

Her smile turned into a chuckle when she noticed my obvious embarrassment. “We are not always as we appear,” she said, the merriment evident on her face. “We write our own myths, then wear them, you know… Doctors no less than their patients.” I suppose I must have looked puzzled, because she sat back in her chair as if she were settling in to tell me a story. “Both you and I are Matryoshka dolls, and we only unveil the deeper ones when and if it serves our purposes.” She softened the severity of her latest array of smiles. “You are only looking at one of the dolls –the one you expect to see.”

I smiled the tolerant doctor-patient smile, and started to say something, but she waived it away with a flick of her hand.

“You didn’t ask me much about my sexual history, did you?” I think I blushed and she immediately seized upon it. “Too embarrassing, right? And yet had I been twenty or so, you would have jumped on it immediately when I told you I wanted a pap smear.” I didn’t have to answer –she had me. “But despite my age, and my failing eyesight, I can still read…” She pretended to look out of the window behind my desk to ease my discomfort, but I could tell she was actually watching me out of the corner of her eyes. “The current thinking is that abnormal pap smears are the result of sexual transmission, I understand. Like a disease.” She risked at direct glance at my face and when she could see the astonishment on it, she left her eyes resting there. “So, how would you get a new sexual disease, I wonder?” She let her words dangle for a moment to tease me. “I suspect there are only two mechanisms –either my partner is dallying in another realm, or I myself have strayed into a new kingdom.”

I tried to keep my mouth from falling open -I loved her words.

“But suppose I knew all this, but was unwilling, or afraid to share that aspect of my story with you because it didn’t conform to what I have always wanted to believe about who I am? And what you wanted to believe…” She stared at me for a while with innocent cow-eyes. “Or, on your side of the curtain, suppose you didn’t want to risk offending me because it would be like talking back to your grandmother. Belittling her. Disrespecting her…” She straightened herself in the chair as if she were about to get up. “So you see we are both trapped in our stories.” A huge smile spread from ear to ear as she rose to her feet. “But we’re only trapped as long as we don’t recognize them as surfaces. Clothes…”

She pointed at the examining room. “Let’s do the pap smear, now. I’m going to be late for my friends,” she said, and then started for the door, as I still sat immobilized in my chair.

“I was a Social Anthropologist in my previous life,” she said, looking back over her shoulder and winking. “Just thought you’d like to meet one of my deeper dolls…”

 *

I’ve never forgotten Ms Debrashen over the years. She taught me to question assumptions. Interrogate them. But it made me wonder just how much I can know about anybody. Some of those deeper layers are inaccessable even to the person from whom I’m trying to obtain a history. So overlayered with hope and retrospectively altered memories, some are forever hidden in the myths they have become. Perhaps for clearly displayed symptoms and signs, my medicine can work. I can treat a prolapsed uterus, or an elevated blood pressure, but in a way, that is almost like mending a sweater, or washing a shirt. It is hard to see the skin they hide beneath. And I am at a disadvantage peering through the murky water in which they stand to find something they’ve dropped or hidden. …

She made me appreciate the words of Hamlet when he repudiates his mother for insinuating he is pretending grief merely to get attention:

Seems, madam? nay, it is, I know not “seems.” ‘Tis not alone my inky cloak, good mother, Nor customary suits of solemn black, Nor windy suspiration of forc’d breath, No, nor the fruitful river in the eye, Nor the dejected havior of the visage, Together with all forms, moods, shapes of grief, That can denote me truly. These indeed seem, For they are actions that a man might play; But I have that within which passes show, These but the trappings and the suits of woe.