The Art of Medicine

The purpose of art is washing the dust of daily life off our souls’, as Picasso said. I suppose he was on to something there, but I rather fancy Francis Bacon’s take on it: ‘The job of the artist is always to deepen the mystery’. The reproductions that hang on the walls of my office have certainly deepened mine –well, to be accurate, more the patients who comment on them.

Of course not all of my visitors even look at the walls; they’re often too fixated on describing their symptoms, and watching for my reaction. Trust is awarded or subtracted in the first few moments of an interview of course, but once the merit badges have been allotted, and rank assigned, their eyes often wander to more interesting things. For some reason, I can’t seem to monopolize their attention once they have decided to relax. But, of course, art is therapeutic as well -although perhaps less helpful for most gynaecologic conditions than some more hopeful alternative practitioners might wish.

And yet it does provide a certain continuity that my more regular customers seem to appreciate. Some of them have developed unusual affinities for, say, a certain painting hanging on a particular wall. Or the smile of a character in a photograph… I’d like to think that it is actually a recognition of my taste in art, my ability to select soothing yet interesting subjects that reflect my own philosophy of life. In fact, I think Janet, one of my more perceptive patients, described it best. She was biding her time as I struggled to fill out some laboratory forms for her. And to stay awake I suppose, she began to look around the office. I glanced up once, after trying unsuccessfully to correct an egregious mistake on the screen, and saw a puzzled expression writing itself on her face. When she noticed my attention, she immediately erased any traces of concern and replaced them with those of a frustrated teacher.

And then, when she saw my eyebrows raised inquisitively, she blushed as if caught in some secret and embarrassing act. “You certainly have a…” There was a moment’s hesitation as she rummaged desperately for a more neutral word than she was about to utter. “…An eclectic taste in art…” Her eyes inadvertently strayed back to a reproduction that I’d hung on one wall. It depicted two young girls standing side by side looking in opposite directions while only partially covered by some sort of blanket or quilt. Their faces were beautiful, although one looked a bit worried about something. I saw it as, I don’t know, youthful hope, or maybe the puzzle of growing up.

“I was just thinking of an art gallery,” she said, trying to smile -and yet I could almost see the ‘buts’ slinking in the shadows behind her eyes. I sat back, hoping for a compliment. Redemption. “But, you know…” Her eyes darted from one picture to the next like sparrows looking for a roost. “…They don’t seem to illustrate any particular theme. Nothing connects one to another…” She focused her attention on a large photograph of a man holding a baby and indicated her target with a nod of her head. “I mean, you have a man with a baby in this one –nice photograph, I suppose- but then, on the wall behind me, there’s the coloured line drawing of a peasant woman leading a horse…”

I’d never experienced a critique of my art before and I didn’t know whether to feel honoured, amused, or embarrassed. I chose embarrassed. “I…ahh… Well, they just seem to accumulate over the years. I mean, I didn’t choose them to illustrate a particular theme, or anything…”

Her face believed me, and her smile tried to plaster over any unpleasant criticism. It tried to exculpate me from my tasteless choices. Her eyes, however, no longer sparrows, were birds of prey and I could see her fighting with her need to be honest and yet not cast aspersions on me. On my world. On my ability to be her doctor.

“Maybe move the Woman with the Horse to the examining room and the…” She suddenly had second thoughts. “No, I don’t think the IUD picture would be suitable in here…” She closed her eyes for a moment, trying to reconfigure things in her head. “I like the smiling woman –it’s a Rosamund isn’t it?”

The drawing was on a far wall and I had to squint to see the signature. I couldn’t quite make it out, so I was forced to shrug. I mean, who looks at signatures?

“What about that green apple picture hanging in the hall..?” It was amazing how much she’d noticed. “No, actually it adds a light touch to the corridor –sets a mood, as it were.” Her eyes alighted briefly on one of my diplomas, flitted to me, then on to her lap when she saw me watching. I could see her trying to disguise a sigh. She was not successful.

She’d told me she’d come for a consultation on the menopause and yet she was aggressively adamant that she was coping perfectly well with The Change  -and she continued to insist this even under what I thought was careful questioning. Apart from a recent and bitter divorce, things were completely under control -better than they’d ever been, in fact. I glanced at my computer screen again, and then accidentally refreshed it, for some reason. There was now a note that my secretary had just added to the referral letter section -her doctor had faxed the information to me a few minutes before before. Janet had requested a second opinion when her GP had suggested she might need to go on hormone replacement therapy for her menopausal symptoms. She’d become enraged at his lack of judgement and his inability to keep up with the current medical literature. She wanted –no, demanded– to see someone who wouldn’t judge her on insufficient evidence and wouldn’t assume that her every foible was attributable to insufficient hormones. Apparently she’d suggested that he needed them more than she did. And he’d assumed she would neither give me an accurate history nor deliver the note he’d written.

She saw me scrutinizing the screen as I started scrolling through it, and a mischievous smile captured her immediately. “Still can’t find his referral letter?” she asked, with what was another uncamouflaged smirk after one more quick look around the room. “He gave me a hand-written letter in a sealed envelope for you…” I studied her expectantly when she decided to prolong the suspense; she was not a happy woman and I fully expected her to unleash the eyes again. “I don’t think he has a computer; and anyway I threw the letter away,” she added in answer to my unspoken question. “I read it, of course, but it was all nonsense.” Her lips parted slightly in what was either a broken grin, or more likely, a sneer. I could see her hands tighten into fists in her lap. “Never trusted the man,” she said, looking again at the two little girls in the picture. “No taste.” She turned to look at the Woman and the Horse on the wall behind her and then sighed loudly.Theatrically -no attempt at a disguise…“Unlike you…”

We both laughed, but I’m not sure at what. Or at whom…

Miasmatics

Out of the night that covers me, Black as the pit from pole to pole, I thank whatever gods may be, For my unconquerable soul.  This may be how we choose to think about ourselves as we screw our courage to the sticking place. And yet, much as we hate to admit it, there is something a little frightening about things that surround us which we cannot see. Clouds that, had we not been made aware of them, would have drifted as unseen and unregarded as smoke on a moonless night.

Bacteria, at least in popular culture, have usually been associated with filth, contamination, and especially, illness. The Germ Theory, which postulates that some diseases are caused by agents (microorganisms), was first proposed in the mid-1500s and later substantiated with the advent of microscopes and public sanitation advances. The recognition of microorganisms as causes of disease supplanted the previously held disease theory of Miasma –bad air- as propounded by Galen, a Greek physician and philosopher in the mid second century CE Roman empire.

As counter intuitive as it might sound nowadays, new discoveries have lately suggested that he may well have been on to something: http://www.bbc.com/news/health-34314065. I suppose this shouldn’t come as a complete surprise, though. As the news article observes: ‘Studies have already shown that our microbiome – the collection of bacteria, viruses and fungi that live on our skin and in our bodies – outnumbers our own cells 10 to one. These can be spread through direct contact, airborne emissions and shed skin cells in dust.’ Or, perhaps more disturbing, ‘Walk through someone else’s cloud, and it will “rain” bacteria on your skin and be breathed into your lungs.’ The study, from scientists at the University of Oregon, was published in the Sept. 2015 edition of Peer J: https://peerj.com/articles/1258/ -a fascinating read, to be sure.

I suppose I found this article a timely reminder that we all approach the idea of ‘cleanliness’ in different ways, and to different degrees. Not everybody who pays attention to it has OCD.

Lisa was a good example, I think. A beautifully coiffed, tall woman in an almost obsessively ironed white, frilly blouse and perfectly pleated black skirt, she sat primly, but in isolation in the fully packed waiting room. Trying not to seem rude, she had managed to negotiate the chaos of hyperactive children and their large-tummied mothers, by contracting herself into the smallest possible dimensions in a corner. She wasn’t obvious about it, nor did she seem at all uncomfortable –just careful to avoid undue and unnecessary contact. As if everyone around her had the flu –or something else of which they might not even be aware. Yet.

As I led her down the corridor to my office I noticed she stopped at the front desk for a quick dab of alcohol hand rub from the dispenser the secretaries had placed there, probably for their own protection. Good, I thought, she’s getting her hands ready so she won’t contaminate me when we shake. Then it occurred to me in kind of uncomfortable shiver, that we had already shaken hands. So, to make her feel that it was indeed an appropriate thing to do after touching, I helped myself to a dollop from the same container. I don’t think she noticed; she was too engaged in straightening the sleeves of her blouse and then making sure no hair was out of place to ruin the effect. I put it down to nervousness.

Once she had settled into the chair across from my desk and examined my office with what seemed like polite curiosity, I asked her why she had been sent to see me in consultation. Her expression immediately changed. Her initially benign and neutral face suddenly wrinkled suspiciously, and her eyes wandered over my face for a moment searching for a safe place to stand. Or were they looking for reasons –any excuse- to terminate the visit and seek help elsewhere?

I thought I’d make it easier for her. “Well, your family doctor seems to feel you have… issues in the vaginal area that he can’t resolve. Would you like to tell me about them..?”

Her face gradually hardened. “I told him I wanted to see a female gynaecologist! But he never listens. He’s too busy to listen, I think.” She stared at a painting on the wall beside her, for a moment. “And your waiting room looks even fuller than his, I have to say.” Her eyes migrated slowly around the room stopping to feed on the eclectic tidbits I had scattered almost randomly throughout: the wooden statue of an Ethiopian woman holding a child and seeming to hide behind a plant on my desk; the terracotta woman sitting on a flimsy oak table holding a begging bowel filled with shiny coins that require constant vigilance from every mother who visits with her children; the jade apple on my desk; the multicoloured painting of a peasant woman leading a horse…

Interestingly, it was to the painting that her eyes continually returned. “But he never had pictures on his wall. Nothing at all interesting about his office except a window with a tree right outside it…” She lowered her eyes for a moment and then they flew back to my face and settled there. “So, what did you want me to tell you?”

“Dr. Grossac seemed concerned about your vaginal issues, as he put it.” I couldn’t suppress a smile at his turn of phrase and she noticed it.

“He just got fed up with not finding anything. He seemed to be a one-trick-pony: if his swabs and cultures didn’t show anything abnormal, then of course nothing was abnormal. A standoff.

“There is an odour, however –but like describing the taste of wine, words sometimes fail to capture it -or validate it… I don’t expect most family doctors will have a gas chromatograph in their offices, but I do think most noses are able to detect differences, don’t you? I mean, isn’t that what they’re for?”

She had a point.

She hesitated a moment, and then continued with a guilty expression. “I don’t mean to imply that Dr. Grossac doesn’t know his medicine -he told me he could smell something, but he didn’t know what. I guess he thought you would…”

“What have you tried so far?”

“I’ve tried scented oils in the bathwater; I’ve tried different laundry soaps, different personal products, but they only seem to help for an hour or two…”

“How long has this been going on, Lisa?”

She shrugged. “I don’t know –maybe a couple of weeks now.”

“And has this ever happened to you before?”

She shook her head, thought better of it, and then looked at me with caged eyes. “I suppose maybe something similar when I was a teenager…” She stopped, no doubt hoping I wouldn’t demand a fuller description. Sometimes you’re just not supposed to ask.

I smiled expectantly. “Oh, and what did your doctor find then?”

She blushed and looked at the horse painting once again. “Actually, I found it…”

I pretended to look at something on my desk. “And what did you find?” Sometimes I’m merciless.

She looked down at her lap, embarrassed beyond words. “I… I left something inside.” Her head snapped back upright and she unleashed her eyes on my face, daring me to pursue it. “I mean I was really young –just starting my periods, really…” Her voice trailed off in distress. This was a woman’s issue after all; she didn’t really expect me to understand.

“And this time?”

“Nope,” she mumbled to her knees. “Couldn’t find anything…”

“And your doctor?

“He never really looked in there…”

I tried not to show surprise. “Do you mind if I look?”

She shook her head –with relief, I think.

After I’d examined her and dealt with the issue, she came back into the office with an awkward smile on her face. “So,” she said, “Where there’s smoke there’s fire, eh?”

I had to smile again. “Ever heard of the Miasma Theory?”

She returned my smile. “Galen?”

I nodded. “He wasn’t entirely wrong was he?”

Food for Thought

There’s something encouraging about the fact that we are not simply our genes. We’ve moved on -evolved, I guess. They are still the recipes, the instructions, but as every chef knows, you don’t always have to include all of the ingredients to get a good result. Genes are perhaps more akin to a first draft for a project. Suggestions. Options. They are, in effect, travel guides -road maps- that tell you what you could do and how you might go about doing it, but although the tickets are bought, you don’t have to get on the bus. Who we are –what we are- is not as pre-ordained as we previously thought. Just because there is a light switch on the wall, doesn’t mean it has to be turned on unless it’s needed. There is a mechanism, as Wikipedia puts it, for ‘cellular and physiological phenotypic trait variations that are caused by external or environmental factors that switch genes on and off and affect how cells read genes instead of being caused by changes in the DNA sequence.It is called epigenetics.

Genetic evolution usually takes a long time –often a very long time- and circumstances can arise that were not originally anticipated. But there are several mechanisms to silence or inhibit those genes from carrying out their initial instructions and these allow extra opportunities for an organism to survive and adapt to circumstances perhaps not present during its initial evolution. Unfortunately, it can be a two-way street…

Food, food, glorious food -well that’s how I remember the words anyway (apologies to Flanders and Swann). It’s something that is often as pleasant in retrospect as it’s anticipation is in prospect. Something that transcends the here and now. Like culture, it involves feelings and judgments. It is a part of the fabric of our realities, part of the habits that are difficult to change without conscious effort and strong motivation. We wear our preferences as uniforms -identities. Food is not simply what we consume -it reflects a train of thought. There are allegiances, unspoken loyalties that pass from generation to generation. And it is often how others see us -evaluate us. To change or vary, risks awkward questions at the very least. So it’s fascinating to reflect on the importance of food in defining not only who and what we are, but also on it’s influence on what we might become. And what our children might become as a result…

It is not a trifling matter. Food has always had a central role in culture and what a mother eats in her pregnancy has long inspired myths about the child she will deliver. Famines have been instructive: in more recent times, the Dutch Famine of 1944 during World War ll led to intrauterine growth restriction and subsequent chronic diseases such as coronary heart disease later in the offspring’s life.

A similar twist on the importance of prenatal nutrition was highlighted in an article in BBC News: http://www.bbc.co.uk/news/magazine-34222452  ‘.A team from Britain’s Medical Research Council, which has been collecting data on births, marriages and deaths in Keneba since the 1940s, discovered some years ago that in this part of The Gambia when you are conceived makes a huge difference to your chances of dying prematurely.’

This seemingly bizarre finding is corroborated in animal experiments in which, ‘it is possible to make the genes in an embryo more active, or turn them off entirely, simply by varying their mother’s diet.’ And indeed, as the author explains, ‘the studies done in The Gambia certainly provide compelling evidence that these so-called “epigenetic changes” may also happen in humans in response to a change in diet. That if, during very early development, a mother eats a diet rich in leafy green vegetables, then this will change forever just how active some of her child’s genes are.’

There are other epigenetic ramifications that are also important: this ‘happens through a process called methylation and researchers in The Gambia have recently shown that babies conceived in the wet season have very different levels of activity of a particular gene that’s important for regulating the immune system. As Matt Silver, part of the MRC team, says: “Variation in methylation state in this gene could affect your ability to fight viral infections and it may also affect your chances of survival from cancers such as leukaemia and lung cancer.”

Prenatal influences are far greater than we had ever suspected; we were naïve indeed to feel that the importance of diet was primarily to provide nutrients for the developing fetus -ingredients for the recipe. We were too narrow in our conceptions. Too dull, maybe. There is so much about the world –about ourselves- that we are only beginning to understand. We truly live in exciting times… and yet it has always been exciting times for those interested enough to open their eyes hasn’t it? We’ve always lived at the edge of some river or other. It merely takes someone curious enough to travel down it. As Shakespeare said: We know what we are, but know not what we may be.

 

Representative Gynaecology

I have a confession to make. Nothing salacious. Nothing morally or even ethically repugnant. Nothing, perhaps, even interesting, but it needs airing nevertheless. Like a clothesline full of underwear, it may seem embarrassing at first –shocking, even- but boring if it is watched too long.

I am not talking Wikileaks here; heads will not roll, nor empires crumble. And if CSIS or NSA put me on a watch list for it, well so be it. Some risks are necessary in medicine –it’s part of what we do. Part of the Hippocratic Oath.

Some things are beyond the pale when considered superficially; they require analysis. Digestion. And like looking through a glass darkly, they are not always what they seem at first glance. The poor man in his rags may be a god in disguise: the wandering stranger. Or, a god may be the Devil in disguise… The possibilities are endless.

The point is, there are lessons to be learned from every encounter. Every person. Every drug rep. So -full disclosure- I confess that I enjoy the give-and-take, the repartee, that inevitably accompanies their visits. And even if I do not fully appreciate the benefit of the product they are blessing, it is still a show worth watching. Worth interpreting. Worth arguing about.

Marie was a regular. A young woman in her thirties, she was always smartly dressed in bright colours so she stood out in a waiting room. Her hair was usually blond, and bunned, but occasionally she wore it streaked and hanging in loose waves that curled above her shoulder like whiffs of fine smoke. She was also tall -for emphasis I imagine. I always enjoyed Marie, although she often talked too fast, and in a sometimes delightfully garbled Quebecoise accent, so I frequently ended up listening to the sound rather than the substance of her message. I don’t think she noticed; she had only a short time to promulgate her information and make her pitch so her words spilled fast and furious. Fortunately the product was usually the same each time, so I could easily relax, bathe in the sounds she was producing, surface at the end seemingly refreshed by her presentation, and then ask a few generic questions and call it a day. It was win-win for us both.

But she caught me up one time.

“So, what do you think of our new product, doctor?” she asked, her eyes starry and her face a portrait of naive expectation: a child looking at her father for approval of her grades from school. But more likely, a trap to see if I had actually understood the concept. Marie is an incredibly intelligent woman –an otherwise unemployed PhD in biochemistry- who, I suspect, took the job with Big Pharma out of necessity rather than predilection. “Our company has just decided to detail it.”

I have to admit I really hadn’t heard much that I considered ‘new’ in what she’d said –she may not have talked about her product before, but there were already several other nail antifungal treatments on the market. And I was aware of most of them. Anyway, I confess that I had been distracted more than once by the gigantic earrings she was wearing: large hoops containing smaller hoops, all encrusted with shiny gemstones that were somehow attached to a gold filigree. With each enthusiastic shake of her head they bobbled and swayed, just missing the hair that danced off the platform of her shoulders. I became preoccupied with wondering if they ever found themselves entrapped in a curl or perhaps in someone innocently passing her on the street, unaware of the danger.

I was vaguely aware of some familiar words that had caught my attention, however, so I thought I would seek redemption by reiterating them in a neutral context to avoid embarrassment. “Well, efinaconazole sounds like good product for fungal infections of toenails, but it’s also rather expensive, don’t you think?”

She shrugged and her earrings shivered dangerously close to her hair. “Ahh, yes, but finally there is a medication that works, eh?” If she hadn’t been a drug rep, I would have sworn she winked at me. “The research, the premarket testing, not to mention the production costs and promotion –they all cost money.” She stared at me, curious about my reaction to such an un-Canadian and baldly capitalist statement of the for-profit side of the health industry.

“But… I mean, isn’t ninety dollars Canadian a bit steep for 6 ml. of topical solution? And requiring daily application for 48 weeks…?”

She smiled, but I could see it was forced. “Well, I never said how much the Canadian bottle holds… But I’m happy to hear that you already knew something about it.” Then, when I blushed, her face turned even more serious. “And imiquimod, our company’s topical immune cell enhancer, is expensive as well… But it can be a game changer, don’t you agree?” I could see her eyes daring me to challenge that  assertion.

It was my turn to shrug; she was right. Imiquimod was what she usually discussed on her visits to the office.

When she saw my resistance was transient and mild, her shoulders relaxed and she crossed her legs and sat back more comfortably in her chair. “Don’t forget that you only use one drop on regular toenails and two on the big toenail. And, although drop size is determined by force of extrusion, specific gravity, aperture diameter and so on, the average drop is only around 0.05 ml. –so, a 6 ml. bottle contains about 120 drops.” Her eyes widened to emphasize the importance of what she’d just disclosed. “So, if you are treating just the big toe once a day, for example, a bottle would last you 2 months…” She added that rather hastily I thought; I don’t think she wanted me to challenge her math.

I hadn’t known the size of a drop. My face turned humble, but I tried to preserve a little bit of defiance for pride’s sake. One last attempt at redeeming myself: “Yes, Marie, but suppose you have to treat all the toes each day? Say you’re a runner. Then a bottle would only last you…” I tried desperately to do the calculation on my fingers. “Uhmm, let’s see, four… plus two… then times two…” But the mathematical solution evaded me completely. I was under pressure, though.

“Ten days,” she added quietly. Thoughtfully. “But how many people have to treat all ten toes, eh?” Suddenly I could almost see a light go on, and she stared at me –or rather at my feet under the desk- secretly at first, and then with a little grin she couldn’t suppress even though I could see she was trying. “Unfortunately we don’t offer samples of the product to doctor’s offices, however…” Her eyes twinkled; she could see right through me.

In a way, I was relieved: I suspect I’d be easy to bribe…

Screening in the Digital Age

I never thought it would happen to me, but all the same: ‘I grow old … I grow old … I shall wear the bottoms of my trousers rolled’. Or at least some days in the office feel like that. Perhaps it’s the clientel who’ve worn the years with me –people whose children I delivered who are now patients of mine, with their babies, in turn, waiting for liberation: Samsara… the eternal round of birth and death.

Or maybe its just the mood that Ellen drags along with her on her annual visits. Lennie, as she insists on being called, seems to straddle that razor edge between then and now. Like someone dressed in layers to cope with changing climate, she seems to wear Time like a jacket that she can don or shed as the mood strikes. And just when I think she has lost all contact with the here and now -that dementia has finally arrived- like a bodhisattva she doffs her jacket and enters my world again. Or is that giving both of us too much credit? We are each of an age when the past is retrospectively falsifiable to endorse the visions we have created for ourselves –our personal myths. The trick, of course, is finding a buyer. I think this is why Lennie insists on returning to me year after year for a pap smear despite my insistence that in her case, with her pristine and otherwise untouched cervix, the interval is too short. And in my region, if the pap smears have always been normal, we stop doing them at 69, so I don’t know what she’s going to do next year…

“Can’t you make and exception in my case, doctor?” she said, anticipating my usual advisory monologue. Then she moved her chair so close to the desk it hit the edge, rattling the little wooden statue I’d hidden behind a plant for some reason. She always did that. And she was always dressed the same: a black, knee-length skirt with a white frilly blouse that hugged her neck like a noose. Her hair was short and died dark brown. She managed to wear it like a bathing cap that was so impeccably arranged, it could have been painted in place. She was tall and slender –too slender perhaps, but the hair style suited her.

“You’re 69 now Lennie and your pap smears have always been normal. You won’t need them after this.”

A coy look that I’d never seen her use before, gradually crept onto her face. “You told me the reason you stop doing paps at my age is because most of us don’t get exposed to new sexual partners and the sex virus…”

“HPV you mean?” I thought I’d add that for clarity.

She brushed off my attempt at information with a dramatic flick of her wrist. “Whatever.” She stared at me sternly in silence for a moment to heighten the suspense. Then her face relaxed and the wrinkles reappeared around a broad smile. “My girlfriend, Shirley, has been helping me to learn the computer,” she said proudly. “She’s showed me how to enroll in a dating site… And she lent me her tablet… It was a gift from her daughter, but she can’t figure it out. Touching the screen makes her nervous, for some reason.” She studied my expression for a moment, then apparently satisfied that she hadn’t shocked me with her technological savvy, continued sotto voce. “Problem is, I can’t figure out what to do some of the time either.” She shook her head slowly. “Kinda gets away on me sometimes. And then when I touch the screen to try to enlarge one of the…”-she searched her memory banks for the word- “…one of the apps to see what it says, the stupid thing thinks I’ve chosen it and I get rerouted onto something I don’t want.” She shrugged, as if to admit that it’s an adventure that all techies have to endure. “Ever happen to you?” she asked -to be polite, I suppose.

I sat back in my chair, remembering my visit that morning to the cash machine. They’d installed a newer, faster model over the weekend. But, whereas on the old one –the one I was used to- you actually had to touch the screen to make a selection, the new one seemed to sense my finger when it was a few millimeters away while I was on my way to another choice. It took me a few seconds and several more attempts to figure out what I was doing wrong. I suddenly felt old.

And what was I doing discussing dating sites in the consulting room anyway? I was running an office, not a coffee shop. But she was looking at me as a child might for validation that it wasn’t just her that was struggling with technology. So I nodded.

There was a recent article I’d noticed on the IPhone BBC app I routinely read at breakfast that had addressed that very same issue: ‘The response time for icons on an Apple screen is 0.7 seconds, but the over-65s have a response time of about one second’ Or perhaps more worrisome –I’m a surgeon after all: ‘And tests suggest that if an older person has a slight tremor, it can be registered on a device as a swipe rather than a touch.’ http://www.bbc.co.uk/news/technology-32511489  Wow! Was age so apparently disabling that they realized they’d have design stuff differently for us? New apps? New screens? New innovations to deal with tremors? Were we being offered technological walkers? Worse, was Lennie trying to include me in that group?

“So,” I began, trying to change the subject -trying, in fact, to change the mood in the room, “how did we get on to this subject anyway?”

“My dating site,” she said, but seemed a bit uncertain herself. I sighed a little too obviously I’m afraid, and she noticed it. Her eyes narrowed for a second. “But I don’t trust it, you know.” She chuckled softly and looked at me. “Shirley tried it, too, she said. The guy was in a nursing home and didn’t tell her –it wasn’t in his profile… But she had trouble with the apps as well; she probably hit the wrong one.” She blinked -a cautionary flicker of her eyelids. “Scary, eh? I mean it’s not worth it to go through that just to get another pap smear.”

She stared at the wall behind me for a second. “Maybe next year I could see you for my osteoporosis…”

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”

 

The Problem of Freedom

The rough, shadowed texture of a log fallen across a meandering stream, the scattered sparkles of the water as it murmurs briefly to a rock it passes, the deep, barely moving green of the leafy tunnel that shrouds the gently dancing blue beneath -these are what I know of freedom: permission to imagine, permission to believe… Nothing else –nothing, at least, that matters more… As Voltaire said, Man is free at the moment he wishes to be…

I’m not sure what I’m supposed to envisage when the topic arises as it does sometimes in the office. I’m not sure what I’m supposed to say, or how I’m expected to react. Freedom is a charged word. A troubled word. It so often refers to an imaginary, or a that-which-is-not. It is contextually defined, and so often spiritually embossed. Like Goodness, or Happiness, it is something to which we are expected to aspire, and because we can never assure ourselves that we possess it, the search, like that for the end of the rainbow, is never done.

It is also a partitioned concept, like being freed from a cage that is locked in a closet that is locked in a room that is locked in a house… To escape from one thing is always to be imprisoned in another –the escape from the innermost Russian doll only to be trapped within the next in line. Freedom, I had always thought, is simply where and when you are; it is a frame of mind, not a frame of circumstance. But I’m not so certain anymore…

This problem of freedom surfaced one day in the office, although I didn’t recognize it at first. The more curious of my obstetrical patients often wax philosophical at unexpected moments. I didn’t think Thira was one of those, I have to admit, but pregnancy –especially the first- has a way of changing a person. Opening them up like the petals of a flower in the morning sunshine. And Thira was a flower. A thin, short woman, she was a Greek with smiling eyes, and spoke with an accent that enchanted me each time we met. I think I sometimes asked her questions just to hear her talk.

But occasionally, she felt it was her turn to ask, and one day, midway through her third trimester, when talk of contractions and labour occupied most of our time together, she suddenly turned serious and her iconic smile disappeared for a worried moment. “Doctor,” she said after I had listened to the baby’s heart beat, “What does the baby’s movement mean?”

I was busy entering in my measurements and the heart rate in the chart, so I didn’t even look up. “What do you mean, Thira?”

“Well, she used to be so predictable. She’d kick after I ate dinner and then start rolling around about ten o’clock when I was in bed. Like she sort of knew what I was doing and was signalling me to say hello. Showing off…”

I looked up for a moment from the chart and smiled. “But you said, ‘used to’…”

The worried look resurfaced. “Well, last night she didn’t stop. She just kept rolling and kicking all night. At first I thought maybe it was the way I was lying in bed, but she kept it up no matter what I did. The kicking even got worse when I got up.” She took a deep breath and looked at the floor. “Okay if I ask you a silly question?” I nodded reassuringly. “Well… I keep thinking she feels trapped in there. I mean, it’s a pretty small space and she’s growing… Wouldn’t it be like being trapped in a small elevator when the electricity and the lights go off?”

I’d never actually considered whether a fetus would –or could- feel imprisoned before. My first thought was to wonder whether the baby, rather than feeling trapped, was actually feeling stressed for some reason –an accident with its umbilical cord, for example, or maybe a change in the placental circulation. I molded my facial expression into neutral so as not to alarm her. “Well, I would think that the uterine cavity space and the darkness is all she’s ever known, Thira. She must be used to it by now, don’t you think?”

She shrugged and painted an anxious smile on her lips. “I suppose… But what if she’s panicking because she’s just discovered she’s trapped? That after all this time, she realizes she’s not actually free?”

I said that before we assumed something like that, it would probably make sense to be sure the baby wasn’t telling us it was in trouble. I reassured her as best I could and sent her right over to the hospital for a non-stress test (NST) to assess the baby’s heart rate in response to its environment; its own movements for example would be the equivalent of someone doing exercise and should raise the heart rate briefly. If there was no change in the rate, or worse, a fall in the rate, it would be unusual and unexpected at the very least. It might signify fetal distress.

The NST was fortunately completely reassuring, as was a bedside ultrasound we did to visualize the umbilical cord and the amount of fluid around the baby. Thira still seemed concerned, though. “I still think she was telling me something, doctor.”

I sat down on the bed beside her. “Well, we can’t find anything wrong, so what do you think she is trying to tell you, Thira? What does she want?”

A weary smile appeared from nowhere. “Freedom, doctor. She wants her freedom.”

I was struck by Thira’s use of the word ‘freedom’ all the time. She didn’t appear at all surprised that there didn’t seem to be any problem we could find with the baby: no umbilical cord around its neck, no decreased amniotic fluid around it, no worrisome changes in the NST. And when I once again reassured her about the findings, she responded with another shrug.

“How can any of your tests measure the need for freedom, doctor? I’m sure most prisoners have normal heart rates, normal responses to exercise…” She stopped talking and looked in my eyes for a moment. “It’s only when you look in their eyes you can tell something is missing. Freedom can’t be tested, I don’t think…”

I had to process that for a moment. “But…  But you’re only 34…” I had to look at the chart I was holding. “34 weeks and 4 days pregnant. Your due date isn’t until 40 weeks… Surely your baby is far too young to appreciate such an abstract thing as Freedom.” I was proud of that response; I thought I had her.

Her face wrinkled in curiosity at my explanation. “I can calm my baby down by talking to her. She seems to respond if there’s music in the room… That’s pretty abstract, don’t you think?”

I blinked. I couldn’t think of another response. But I wondered if this was really cause and effect, or maternal attribution.

“When do babies start to think anyway?” she asked and scrutinized my face. Then she paused for a moment. “Only as soon as they’re born –freed?” she continued after she could see I wasn’t able to answer. “And what about the increasing number of studies showing the abstract conceptual abilities of even young babies?” I must have had a blank look. “Have you read that book: The Philosophical Baby, by Alison Gopnik…?” I hadn’t, actually. “There are others, too,” she said, reading my expression.

“But…” I shook my head slowly in -what? Desperation? Frustration? Or maybe in fascination at something about which only a mother could be convinced.

“If babies only a few months old can demonstrate a sense of injustice or fairness in the studies researchers do with them; if they can be seen reacting to things that seem to them to be unusual or unacceptable, then why would it be so hard to believe they could also have a simple concept of Freedom?”

I have to admit that I didn’t have an answer for Thira, although she certainly opened up a few questions that still trouble me -a Pandora’s box. Is the desire for Freedom innate –like curiosity, the desire to learn, or the impetus to find and create Beauty? Is it so abstract that it doesn’t even exist outside the mind as I said at the start? And is it so integral to our existence, that we need to manufacture it when we don’t think it’s there? There is a problem with Freedom I think: knowing what it is… and where. But maybe Robert Frost got it right: ‘You have freedom when you’re easy in your harness.’  Maybe it’s as simple as that.