Unregarded Age in Corners Thrown

I worry too much; I didn’t used to, but it kind of crept up on me along with my aches and pains over the years. Age is something that has always been fraught with tensions as we stumble through the calendar first wanting more, then less and then, I suppose, trying to forget about it altogether -ignore it when it clearly needs to be addressed. Demands recognition.

Age –especially old age- is one of those concepts that is very much contextually driven. Age-driven, in fact: where one sits on the spectrum very much influences age perception. An elder would live many fewer years if it is a teenager, rather than a senior who is canvassed.

But a good case can be made that age is not a mono-dimensional concept. Chronology does not come in one flavour; not all eighty year olds, say, are tied to the same constraints. Age might better be considered as a quartet with the other members consisting of Biological –we all age differently, Psychological –some aged people retain their faculties better than others, and Social –some elderly people, whether by fiat, or necessity, no longer work outside their homes and are no longer as connected to social networks. Indeed, in times past, ‘old’ might well have been related to usefulness rather than chronology.


So there we have it: usefulness. Purpose! Self-worth. All contingent concepts to be sure. And retirement, despite the positive connotations that Society has tried to foist upon it, is still a denouement –however it is rationalized. However many cosmetics are applied. Wallpaper may fool strangers, but it is still wallpaper…

So, you see why I worry. It is not that there might not be new opportunities available in retirement -new venues- but simply the realization that it is a final chapter of a thoroughly read book. An epilogue.

But I digress. It is something of a fool’s errand to attempt to encapsulate Retirement under one banner. It is a chapter as yet unprinted, and at best only sketchily conceived. There are also portions of it written, even if unwittingly, by someone else.

There is a store I visit every so often to buy dog food. It is a large and perhaps corporately criticized chain, but my dog is fussy and became addicted when she was only a puppy to a brand only they seem to offer. To tell the truth, I enjoy the store; I enjoy wandering the aisles and feeling -what? – pride at resisting things I do not need and casting a cold eye on those I do not want. It is a juvenile thing, I suppose, but maybe that’s the point: a recapitulation of past temptations seen through different eyes. Different years…

But on my way in, I saw a face that seemed familiar. It wore the uniform of the store and yet it seemed out of place somehow. A bush growing in a patch of vegetables –or more aptly, perhaps, a tree standing all alone in the middle of a field of wheat. Staid and stolid, watching, bemused, the tender stalks waving frenetically around her feet.

It was not so much her age that separated her from those around her as her composure, her calmness in the Storm of Store. In the eye of the hurricane of shoppers intent on their own missions, her smile was like a shrine erected at the doorway, a refuge offered, but seldom taken. Seldom noticed: the store was not a temple –just another place to visit when the need arose, a series of shelves to inspect. There were no sacred places here, no altars, no need to reflect on the meaning of it all. The store fulfilled a function, not a curb-side meditation.

I have to admit, the face was so unexpected, so completely out of context that I passed it by with barely a thought, although I did stop halfway down a nameless aisle and wonder why. And it was there that it –she– caught up with me.

“Doctor?” she asked tentatively, clearly uncertain from behind at least, that it was me. And when I turned to face the voice I remembered somewhat shakily from the past, she smiled broadly. I could see it was all she could do to refrain from hugging me; instead, she proffered a bony hand, its skin replete with veins and the brown patches of age.

“Doris!” I somehow managed to retrieve the name from a long closed memory drawer -although not without an awkward pause because it was not the Doris I remembered, but an older, frailer model. Doris had been well into her seventies when I had last seen her in consultation but this face, this figure, was a worn and crumpled copy of that older woman I had once filed away.

Her smile looked painful it was so wide and welcoming, but it was her eyes that immediately captivated me. Like delicate pale blue figurines trapped behind the glass of an old cabinet, they begged for release, and when she opened their cages they flew to my face and rested there. “It’s so nice to see you again, doctor,” she said with her joy so evident I was almost taken aback.

Her frailty dissolved as I watched, and the younger Doris emerged as if it had been hiding all the while. I remembered her now as the vibrant woman who had quoted poetry to me when I was trying to take her history. Who had dismissed the referral from her GP as ‘misguided over-concern’ from a young doctor uncomfortable in dealing with a patient older than his grandmother. And as a result she had brokered the compromise of seeing an older specialist. When I also agreed that she really had no cause for concern, she’d bonded with me and even showed up at the office the next week with flowers. I suppose we all like our judgements to be validated.

But on that occasion it had led to a discussion of age, and whether or not to succumb. Whether, as Dylan Thomas had written, to go gentle into that good night. Or to… Rage against the dying of the light. She most emphatically was with Thomas, whereas I, in an uncharacteristic disclosure, had expressed uncertainty as to whether with identity obscured and purpose thwarted, I would be forced to go gentle into whatever the good night hid in retirement.

“Nonsense!” I still remembered her saying that, her face fierce, her eyes locked on mine. “Is ‘Doctor’ your last name? Age and function do not change who you are –just what you do…” Then her expression softened and her eyes unlocked from me and twinkled when they had returned to her face. She got up from her chair with an enigmatic smile and turned to me as she was walking out of the room. “Do not become what Shakespeare called Unregarded age in corners thrown. I would be very disappointed.”

I took a long hard look at her, standing in the aisle with her uniform proudly displayed and I smiled. “You’ve certainly taken your own advice, Doris. Not too many people your age would have chosen your path. You look happy.”

“Have you ever read any Robert Frost?” she asked after observing me quietly for a moment.

I nodded, suspecting what was to come.

She closed her eyes and a beatific expression emerged as if she were about to pray.

“Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference.”

There are forks in every road. Maybe she was praying -praying for me…

Disparate Opinions

I am always puzzled by assumptions of equivalence. Does success in one field attest to the quality of an opinion about another? I am usually suspicious of the value of, say, a celebrity commenting on the significance of a particular product. It may be interesting, but does that actually certify its worth?

I realize that when it comes to health topics outside my specialty, I am sometimes rather late to the post. But occasionally topics are forced on me by my more curious patients who want to know what I think about them. Moles, for example.

Now, of course gynaecologists are called upon to comment on some dermatological issues –but often by default, and even then, mostly about areas that many dermatologists are reluctant to examine. Fair enough, I suppose –somebody has to be in charge. And yet even here, diagnoses are difficult without a biopsy. Especially here, in fact. It would be nice if there were some reliable rule-of-thumb that would sometimes obviate the need for an often painful and certainly anxiogenic procedure like sampling the tissue in question. Something like: oh, if it’s smaller than a dime, or not blotchy, leave it alone. But, alas, there are no such rules that work for us in the nether parts.

But the arm? Well, that seems to be a different matter: http://www.bbc.com/news/health-34551467

I have to admit, that until a rather starchy patient told me, I had never heard about it. I understand that it was all the rage when it was first reported, though: simply count the number of moles on your right arm and if there are more than 11 of them… well then you have a higher than average risk of getting skin cancer. The obvious corollary to that being that if you don’t, then you don’t… have an increased risk, that is. She liked the simplicity of the approach, and the proof that her being forced to learn the basics of arithmetic in school so many years ago was finally paying off.

But why, she demanded, and not too kindly, had we not found a similar rule applicable to the ‘private parts’ as she termed them in a barely audible whisper that I had to lean across the desk to hear?

“They’re made of skin as well, doctor,” she added in a more normal voice.

“Well…” I stalled, trying to think of a good answer to a rather naïve question -something that wouldn’t embarrass her. I hadn’t read the article she’d been describing and so I had to come up with something general. “Moles are just collections of pigment cells –‘melanocytes’,” I added to lend a little more credibility to my response. “They are a way the skin can protect itself against UV damage from the sun. The arm is exposed to the sun a lot…” I decided to leave it to her to decide why the arm might be different from that other area that seemed to be concerning her.

But she continued to stare at me as if I had only begun to answer her question. “And…?”

“Well, the more moles on the arm, the more it has likely been exposed to damaging UV light…” It seemed obvious to me. And yet her eyes never left my face and in the absence of any sign of understanding on her part, they were beginning to hurt. “The idea, I suspect, is that the more moles there are, the more that arm –or maybe the whole body- has needed to protect itself against the sun.” She blinked. “And so maybe that means it wasn’t able to protect against some of the damage…”

She rolled her eyes impatiently. “I understand that, doctor!” she said with a stern look on her face. “I’m not stupid, you know,” she added helpfully.

I smiled to disarm her, but I think she took the change of expression on my face as an attempt at refutation and a storm gathered in her eyes.

“Look. Moles are a protection mechanism against the sun, right?” she said testily. I nodded, glad of the chance to show I agreed with her. “So if you have moles somewhere, that means they’re there to help. Correct?”

I wasn’t completely sure if that followed –moles are just collections of melanocytes in the skin. They’re not necessarily related to sun exposure, either. Maybe some just appeared in an area by chance. It was an increasing number that suggested they were there for a particular reason. Counting them merely acknowledged that there was some sort of increased risk that demanded their presence. It was a crude, but easy way of quantifying that risk. But I smiled to show she was on the right track. “Yes, but especially if there are a lot of them –more than usual, I mean.”

“So there are usually less than 11 on the right arm…?”

“A little out of my area of expertise, but yes, I suppose so…”

It was her turn to smile –she was finally getting me to understand her point. “And how many down there” –and with that she pointed to where she was sitting- “How many down there,” she repeated to make sure I was still following her, “would you say was ‘usual’?”

“On the labia?” It was time to call a spade a spade.

She immediately blushed and unleashed her eyes once again to punish me. “We were doing quite well without using that disgusting word, doctor!” Then, realizing how silly that sounded, she softened her face and called off her eyes. “On the…” she forced herself to whisper the offensive word. “labia, yes. How many?”

I’d never really thought about a number before. “Well, it’s an unusual area to find a mole -it usually doesn’t get much sun…” I had a quick peek at her face and caught another blush in the making. “So I’d have to say even one would raise my suspicions.”

She looked uncomfortable when I said that. “So… three would be even worse…?”

I nodded –but slowly. Carefully. Now I understood why she had brought the subject up in the first place. Why that article had made her aware of the function of moles. “Have you noticed some on yourself… down there?” I said more respectfully this time, finally realizing how difficult it had been for her to introduce her concerns to me, a stranger -and a man.

She nodded bravely, but I could see tears gathering in those previously formidable eyes.

I smiled reassuringly and reached across the desk to touch her hand. “Would you like me to check, Esther?”

The relief was noticeable and a smile –a real smile this time- surfaced on her lips. “Please,” she said and actually squeezed my hand. “But I want you to come up with a three-or-less rule, okay?”

That sounded reasonable to me; maybe I could even get it published in the BBC News as well…

Consequences: the Smacking Laws

Ahhh, spanking, the dreaded consequence of miscreance meted out in retrospective fairness by loving parents anxious to create an appropriate conscience in their child. Anxious to establish that there are consequences to behaviour that have not gone unnoticed. Will not go unnoticed. It is one end of a spectrum running between reward and dissuasion all in the name of, well, persuasion. Encouragement. Manipulation.

But words matter, don’t they? Depending on how I wished to portray it, I could easily have used more pejorative words, punitive, violent words such as, oh, coercion, intimidation, threats, or even assault. The devil is in the words. The message. The intent.

So it was with much curiosity that I was drawn to a BBC article on the Irish Smacking law that seems to have drawn the ire of the European Committee of Social Rights. http://www.bbc.com/news/world-europe-32887584 Well, in truth, it was a complaint from the UK’s own Association for the Protection of All Children in 2013 that launched it all. As the article points out: ‘Corporal punishment was banned in Irish schools in 1982 and, by 1996, it was a criminal offence to hit schoolchildren.’ but it apparently still allowed ‘reasonable chastisement’. So in a recent decision, ‘the European Committee of Social Rights said none of the Irish legislation referred to it expressly banned “all forms of corporal punishment of children that is likely to affect their physical integrity, dignity, development or psychological well-being”.’ As a result, the ‘Irish Minister for Children James Reilly told the state broadcaster, RTÉ, that ‘his department has started talks with the Department of Justice and Equality on removing the defence of reasonable chastisement from Irish law.

Well, that’s that, I suppose -another spoke in the wheel of human rights; another barrier to violent punishment… But hold on a moment. What just happened here? The UK association maintained that ‘[…] the existence, under Irish Common Law, of the defence of reasonable chastisement “allows parents and some other adults to assault children with impunity“.’ Fair enough criticism, perhaps. But failing the ability to spank, what are the other options that remain? Well, said the Minister, ‘in recent years, most parents have used other ways of disciplining their children’, but ‘he said he wanted to see the options available on abolishing the reasonable chastisement defence before considering any new legislation to ban parental smacking. The minister added that he has instructed his officials to prepare regulations that would explicitly ban corporal punishment of children in foster homes or in the care of the state.

Uhmmm. I think he should be worried about the content of the European denunciation that proscribed –as quoted above- punishment of children (in this case corporal) likely to affect their physical integrity, dignity, development or psychological well-being. So, is verbal abuse acceptable as an alternative to physical punishment? How about withdrawal of love or affection… or proper care? Would none of these affect development or psychological well-being?

I suppose there is always the option of ignoring the misbehaviour. But if the behaviour was a cry for help –a cry for attention- then looking the other way doesn’t seem appropriate, nor likely to change the behaviour. Nor would it, either, if it is a naïve attempt to find boundaries –or for that matter to have them delineated more clearly. More forcefully.

Transgression is fraught with penalties; order is sewn together by laws and consequences. I would be the last one to condone violence to a child –or anyone else, for that matter- but I am honestly at a loss to know how to deal effectively with recalcitrance. I am, to be sure, of an other era when the mere threat of retribution –spanking, or the ‘strap’- was enough to deter behaviour. So was withdrawal of privileges, I suppose -but that engineered manipulation rather than change: either ransoming the privilege, or misbehaving anyway as in Macbeth’s ‘Lay on, Macduff, and damned be him who first cries, “Hold, enough!” as he defies Macduff when Birnam Wood comes to Dunsinane.

Anyway, I’m not sure how one would police spanking. Physical violence, yes: bruises, fractures -or worse- on visits to the doctor’s office or the emergency department. But it would certainly be even more difficult to uncover –let alone gather enough evidence to prosecute- non physical violence, though. So, I wonder whether it is a terrible thing to retain ‘reasonable chastisement’ as a more benign response than what is left: a letting off of steam to prevent the otherwise impending explosion.

I don’t know that it is punishment that I condone, however –I think it is rather the consequences that should follow the act that would otherwise be disciplined. I would prefer to let my own opinion lie fallow while the dust settles on the Irish thing, and merely quote George Bernard Shaw’s observation of the wages of deceit: ‘The liar’s punishment is not in the least that he is not believed, but that he cannot believe anyone else.’ Consequences!

Scientific Gynaecology

Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

The Problem of Puberty

Puberty is alchemy, don’t you think? Like the chrysalis of a butterfly, the girl emerges from the pupal case of her childhood into an adolescent -an almost-woman- with hormones ablaze. It is a magic time of change, both in growth and physiology, but also in cognitive development. It is a time of evolving expectations, but more slowly developing judgement –the brain, too, is undergoing renovations. Hence our oft-aggrandized memories of the time –not deceptions, exactly, but distortions. To paraphrase Napoleon: history is the version of past events that I have decided to agree upon.

Many of the manifestations we see of puberty are the confusion of autonomies –the challenges to the boundaries that society imposes. I think Wikipedia has summarized the issues quite succinctly: ‘Psychologists have identified three main types of autonomy: emotional independence, behavioral autonomy, and cognitive autonomy. Emotional autonomy is defined in terms of an adolescent’s relationships with others, and often includes the development of more mature emotional connections with adults and peers. Behavioral autonomy encompasses an adolescent’s developing ability to regulate his or her own behavior, to act on personal decisions, and to self-govern. Cultural differences are especially visible in this category because it concerns issues of dating, social time with peers, and time-management decisions. Cognitive autonomy describes the capacity for an adolescent to partake in processes of independent reasoning and decision-making without excessive reliance on social validation.’ It is obviously a special and bewildering, albeit a magical  time. A time for planting the crop that is to come…

Because there are so many physiological processes involved, the actual start of puberty has always been approximate. Genes no doubt play a major role in its onset, but nutrition and general health are obviously involved as well because puberty is changing –it’s starting earlier. As an article from BBC news reports: The age of puberty is changing around the world. In the UK it is currently starting about one month earlier every decade. In China it is more than four months earlier every decade. http://www.bbc.com/news/health-33168864

Of course, we have an almost obsessive need to analyze every change –to match every nuance with some overly reductionist, albeit plausible, explanation. Meat, for example. Yes, I’m serious: http://www.bbc.com/news/10287358  Although it’s an older study, and Vegan-unreferenced, I have to wonder if they could have equally successfully used milk consumption, or perhaps eggs, or even Starbucks coffee… 

But whatever the causes of earlier puberty, that very change may have unexpected –and perhaps unwanted- ramifications as the MRC Epidemiology Unit  at the University of Cambridge recently published using the data of almost half a million people from the UK Biobank: http://www.nature.com/srep/2015/150618/srep11208/full/srep11208.html

Doesn’t it seem strange that improving health and nutrition could have untoward, unintended consequences, although somewhat removed in time and maturity? Perhaps targetable with preventive interventions to be sure, as the authors point out in their abstract, but nonetheless ironic –the Red Queen needing to run faster and faster to stay in the same spot…

The most convincing evidence of the effect of an earlier puberty, apparently, is in its association with higher risks for type 2 diabetes and cardiovascular disease in women. A simple reasoned path to the type 2 diabetes (and its well known association with obesity) might be that: ‘early childhood rapid growth and overweight precede early puberty timing in both sexes, but in turn early puberty timing leads to subsequent rapid gains in weight and adiposity during adolescence and early adulthood’, but this may be an over-simplification of one of many factors that may be contributing –longer exposure to hormones, say, or life-style decisions altered by earlier maturation than peers: ‘environmental stressors may precede early puberty, but in turn early puberty leads to more risk taking behaviours and poor school performance.’ Intriguing, but speculative to say the least.

And on the more optimistic side of changing pubertal age? Well… there is a trend towards a lower risk for breast cancer in those with a later onset of puberty –although in fairness, this is likely related to a decreased time of exposure to hormones, so I’m not sure if it isn’t just a bit of trade-off… And anyway, trend is often what you call something that is not statistically significant (and yet perhaps lends credence to your hypothesis?).

But are we simply treading water in storm-tossed seas?  At risk of drowning in the details of semi-focused data swirling around us –most of which, at least in this case, was dependent on self reported medical histories and events that happened years before? Admittedly, the age of the first period is probably recalled with fair accuracy by most women –it is an event like few others- but aren’t researchers as seduced by this form of reasoning as the rest of us: the development of diabetes just begging for a scapegoat? So, choose the goat, widen the parameters, and voila…

An illustrative example of how easy it is to be led astray: many years ago, before we knew very much about the causal agent for cancer of the cervix (it is now known to be the human papilloma virus) but had pretty well decided it was something infectious –something sexually transmitted at any rate- the herpes virus came under scrutiny. It was infectious; many women exhibiting it also had abnormal pap smears suggesting precursor lesions for cervix cancer; and it was obvious –women who developed herpes were almost always aware of it. Herpes was easy to blame, because it was fairly straightforward to date the pap smear problem to some time after the event of acquisition. Everything fit –except it was not the cause. Not only did people who had never experienced herpes also develop abnormal pap smears, but similarly, not all people with herpes developed pap smear changes. The recall was an easy data point -something to blame- it’s just that it was the wrong thing.

My point is, it can be misleading to attribute cause merely based on recallable events. We all require explanations -something to blame. But, Post hoc ergo propter hoc? Well, the Latin may sound authoritative but not in Medicine. It is a logical fallacy…

This is all unfair to the study I know; I don’t mean to cast aspersions on either the researchers or their methodology, and yet I can’t help but worry about reports of this kind. Huge data bases are tempting geologies for data mining. But association is not necessarily causation.

As the humorist James Thurber once wrote: ‘Well, if I called the wrong number, why did you answer the phone?’ –just in case, I guess…

Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

The Dark Night of the Canadian Soul

I hesitate to refer to the 16th century mystic Spanish poet St. John of the Cross’ dark night of the soul, but I am troubled by the political process in which I feel engulfed. Swallowed… And yes, powerless. And it’s not so much that I disagree with the ideology expressed or dislike the personalities of the leaders and their approach to solving what they feel are the problems confronting the country (according to their polls) –that is politics and universal. If it were only that, it would then become merely a matter of taste or confirmation bias that determined my vote. I might feel disappointed if I didn’t get my choice of government, but not angry.

But I feel angry now –already. Or is it helpless? I find myself powerless to change what appears to be happening around me. Mutating around me as I watch. Party after party seems to be willing to debase itself for votes, pandering to the fearful in one population and the ignorant in another. It is not a principled approach and it does not provide equality for all –or even most.

It seems to me that in a democracy –especially one that espouses multiculturalism as does Canada- it is the rule of law that must be equitable: laws that apply to all -and equally, no matter whether it is a small minority whose ethnic or geographic culture pulls it in an awkward direction, or an elsewhere-maligned religious group who chooses to dress differently from our current norm. Democracy –at least as I imagine it- is not simply the rule of the majority; intrinsic to it is an obligation to protect the minorities within it because it is the right thing to do. And because the law applies to everyone –even minorities.

The rights of all should not be subject to arbitrary or capricious revision without exhaustive and careful consultation from all those who might be affected. It should not be so much a majority decision, as an examined and consensus-driven decision. One side should not be pitted against another. As in international relations, the ideal would be for all sides to talk to each other. Communicate. And while a decision need not be unanimous, it should at least meet with the general approval of every side. Polling –no matter how cleverly conceived- canvasses only those who are polled…

But you wonder why I am angered and not simply disappointed at the political process? I seems as if I can no longer vote for the principles I hold important. Perhaps I have retrospective falsification of my memory, but I can’t remember as much divisiveness in federal politics before -as much negative advertising, as much pretended obsequiousness and crawling for power. As much casting aside of principles in a desperate grab for control. I am appalled that we, as a nation, must tolerate this fawning pretense of servility. Appealing to the lowest common denominator may seem fair to some, but it is certainly not the way to run a country for all.

I blame the current government for acceding to those who would divide the country to satisfy their agenda. I blame the political system for allowing those who stumble first past the post (FPTP) to be elected even if they have not earned the majority of votes. And I blame us all –you and me- for not demanding a more representative way of electing the government. As much as I dislike using quotes from Wikipedia, one of their summaries does seem to illustrate my frustration with FPTP: Wasted votes are votes cast for losing candidates or votes cast for winning candidates in excess of the number required for victory. For example, in the UK general election of 2005, 52% of votes were cast for losing candidates and 18% were excess votes – a total of 70% wasted votes. This is perhaps the most fundamental criticism of FPTP, that a large majority of votes may play no part in determining the outcome. This “winner-takes-all” system may be one of the reasons why “voter participation tends to be lower in countries with FPTP than elsewhere.”

In other words, in Canada, I have no option but to attempt to vote strategically -and for someone with whom I do not necessarily agree- simply to make sure that the one I disagree with even more, does not get elected. If I vote on principle, or electoral platform, my vote may be wasted.

So why do I vote? Perhaps because the devil I know may well be worse than the devil I don’t… Help me St. John of the Cross, because I find it truly dark out there.