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.

http://www.bbc.com/news/magazine-34465190

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.

 

The Gyne Phone

The iconoclasts were people who destroyed religious icons for various reasons. It’s a practice that began thousands of years ago. And somebody’s messing with the icons again -but this time, it’s the  iconoplasts

The icon has ancient roots and the word derives from the Greek word eikon meaning ‘likeness’ or ‘image’. Originally, it was usually a religious depiction of a god, or saint, but destruction of icons (iconoclasm –clasm deriving from the Greek word Klan, meaning to break) gradually morphed into destructive acts against the status quo. However, given the ubiquity of the computer, icons today usually refer to representative symbols on the screen of different options or programs.

Before written traditions gained a foothold, the dissemination of information or tribal history depended on oral transmission –i.e. on memory. But this presented some problems in terms of the sheer volume and accuracy of what needed to be passed along. Addressing this issue, Wikipedia (sorry!) notes: “Without the use of writing systems to transmit information through time, oral cultures employ various strategies that serve similar purposes to writing. For example, heavily rhythmic speech filled with mnemonic devices enhances memory and recall. A few useful mnemonic devices include alliteration, repetition, assonance, and proverbial sayings. These strategies help facilitate transmission of information from individual to individual without a written intermediate…”

Then, with the advent of written transmission of information, one can imagine a gradually increasing dependence on this and perhaps a decline in the need for the enhanced memory techniques so necessary before:  http://www.historyofinformation.com/narrative/oral-to-written-culture.php  At the time, I suspect this phase would have been fraught with objections from those traditionalists concerned about the atrophication of memory itself. Change is worrisome; it can have unintended consequences…

Well, the Phoenix has once again been aroused: http://www.bbc.com/news/education-34454264  It seems that since most of us carry instantly –and ubiquitously- available information around with us in the form of smart phones or tablets, there is little need to memorize phone numbers or even addresses. And even less incentive, since we might remember them incorrectly. Egad!

I’ve noticed the transition over the years in my practice. At first, the patients would come in with lists –questions written on usually irretrievable little pieces of paper stuffed into their purses. Of course if they couldn’t find the lists, some of them then made desultory attempts to remember what they had written, but often to no avail. I became quite skilled at offering clues as to what they might want to ask, but alas, that too atrophied as time and computing advanced. It’s a two-way street, I guess. Use it or lose it.

But my younger patients (of course) appear to have taken it to extremes –or at least, so it seems to me… Judin was the most recent example, I think. She was a twenty-something woman of Persian extraction and she had come to me because of abnormal pap smears. Otherwise healthy, she sat proud and unmoving like a marble goddess in the chair opposite my desk. Her eyes tiptoed to my face and sat there like curious birds. She was dressed casually in a pale blue sweat shirt and white jeans, and as she moved her head from time to time, her earrings tinkled like little bells hiding inside her long, dark gleaming hair. Her phone lay dormant on her lab, but I could see her right hand clutching it like another equally precious jewel.

I commented on how beautiful and unusual I found her name and she smiled serenely, tossing her hair nonchalantly back and over her shoulders. “It’s the name of a village in Iran where my cousin was from. She came to live with my parents but died before I was born.”

“A village near Tehran?” I have to admit I was approaching the limits of my knowledge about Iran –my knowledge of its geography, at any rate.

She shook her head and the tinkling started again. “No, it’s in a very dry and poor region of the Sistan and Baluchistan province in the south east corner of my country -by the Gulf of Oman and the Arabian Sea,” she added helpfully, but she could read the confusion on my face. “Tehran is quite far north near the Caspian Sea.” She stopped for a moment to smile. “Judin is in the middle of nowhere.” Her eyes twinkled this time instead of her earrings. “Honestly!”

Judin –the woman- was obviously well versed in geography and family history, and I would have loved to pursue it further, but I realized, as did Robert Frost, that ‘I have miles to go before I sleep’… I had to press on with the consultation.

Some of the questions were background issues –housekeeping data that I needed to acquire to ensure I would not miss any other information that might be relevant to her abnormal pap smears. “When did your last period start?” I asked, assuming this would be a good place to start.

She smiled, and called her eyes back to roost while she lifted her phone from her lap like a religious icon. She tapped at it for a moment. “Just a minute,” she said sweetly enough. “Gotta find the app…” I could see her scrolling through the screen, her face intense, her body rigid. “Oh, here it is,” she said and glanced at me. “What was the question?”

“When did it start?” I prompted, fascinated by the effort she was making in her search.

I lost her eyes for a moment as they disappeared behind her lashes and then her lashes behind her hair as it fell forward when she lowered her head. “Well…” I could tell she was into it now: her voice seemed strained and I could see she was really concentrating. “…I’m having it now, and they only last 3 or 4 days since I started on the birth control pill…” Suddenly her face surfaced before she could restart a smile. “I don’t actually know… I guess I forgot to enter it.” She blushed and her smile disappeared. “Sorry,” she said, and looked at her phone again. “I’m going to say ‘yesterday’…” She thought about it for a moment. “No, it must have been the day before, or I probably would have remembered it.” She assumed the goddess pose again. “Yes,” she said, but more firmly now –more assertively. “Yes, it was two days ago!” She looked at me with an almost smug expression on her face that seemed to say “Isn’t technology wonderful?”

I nodded and entered the date in my computer –my substitute for her smart phone, I suppose. “And were your periods regular when you were not on the pill?” She looked at me strangely. “You know, once a month…?” I added.

She hoisted the phone once more and scrolled through it looking for the app again. It seemed to be taking a long time, so I pretended to bang my mouse against my coffee cup accidentally. “Yes,” she said hesitantly and without looking up. “But, you know I wish all months had the same number of days. Eyeballing the calendar to see if it’s the same would be so much easier.” She glanced at me, and then submerged her face in the phone again. “It’s easier to count the days I bleed than the ones I don’t.” Another glance to see if I was following her. “Fewer squares to count,” she added to make sure I understood.

“Maybe you should suggest that to the app-people,” I said, wondering if I’d used the correct word.

“You mean the IT people? The software engineers?” She smiled at me like a mother might to correct her young child. “What a great idea!” she said, when the idea struck home.

But I’d been skipping about in taking her history, and I thought I’d make sure I’d obtained the entire historical data before moving on to more pertinent issues. The age of menarche -or first period- can sometimes be helpful gynaecological information. “Do you remember how old you were when you first began to menstruate?” I could see a puzzled expression taking control of her face. I thought maybe English might be her second language and ‘menstruate’ might not be a word she would hear around the house. “When did you start your periods?”

The puzzled look disappeared, and a different one –an almost irritable one- replaced it. “Two days ago…” She cocked her head as if I hadn’t heard her the first time. But she was willing to forgive it, I could tell.

“No…” I paused for a moment, in order to figure out how to phrase it more clearly for her. “I mean you probably started to have your periods when you were quite young… Do you remember what grade you were in, or where you were living when you had that very first one?”

She nodded her head and stared at something on the wall behind me as if she was thinking about it. “I was young alright, but…”

I waited, for a moment or two and was just about to tell her to forget about it so we could move on when she suddenly fixed me with another puzzled stare. I could feel the weight of her eyes sitting on my glasses like two passenger pigeons that had already delivered their message.

“I can’t answer that question, doctor,” she said and sat back in her chair. My eyebrows must have moved because I could see her sigh in disbelief at my ignorance. “I didn’t have a phone then…” she said and shrugged. It was so obvious!

Facing up to the Medicine

There is something magical about a face. It is at the same time familiar and yet mysterious. And although it contains many parts with disparate functions, these are somehow secondary. We see the face as a unit, then judge the components; it is a face first, and only subsequently an aggregation of details. It is the whole which imparts meaning, stirs emotion, engenders response. Only then do the ingredients surface. As St. Jerome said: ‘The face is the mirror of the mind, and [the] eyes without speaking confess the secrets of the heart.’ So I suppose it should come as no surprise that development of reliable facial recognition technology is considered so important. http://www.bbc.com/news/technology-33199275

But there are other domains in which it matters, too. Less technical perhaps, and yet more intriguing. Sometimes it’s not just the perpetuation of facial patterns enabling recognition from encounter to encounter that garner attention so much as a metamorphosis of something far more elusive, far more difficult: the ravages of age. There is something about a face that transcends Time itself. We are recognizably who we are despite the years: My comfort is that old age, that ill layer-up of beauty, can do no more spoil upon my face, as Shakespeare has King Henry V say.

Of course we all suspect we have escaped; daily visits to the mirror cannot see the change any more than frequent glances at a clock can spot the hour hand’s slow progress. Whatever we suppose Time to be, and however we conceive of its passage, barring the before and after of catastrophic events, its gait is not fixed, nor its effects on us often noted from day to day. We mostly live our lives in relative time, and adjust our expectations so gradually they are only apparent to others who happen upon us after long and unexpected intervals. And even then, unless confronted, go unspoken by and large -undescribed, unless in favorable terms.

*

The woman on the other side of my desk looked familiar -in the way some new patients seem to do; I could almost place her. Almost… I see a lot of people –some more frequently than others, to be sure- and yet after a few months or years of absence, even those with whom I’ve had extended exposure tend to generify. Recognition often requires initiation on their part. Prodding. Reminiscing… The encounter often ends with embarrassment or pretense on my part, disappointment on theirs, degenerating into an inadvertent charade for both of us. I don’t wish it so, but alas, I have not been blessed with an eidetic memory of faces past.

Of course, it’s easier to recall some people. They adopt a position on a chair that begs for remembrance, or a way of holding their head that is unique. With Sally -the name on my computer daysheet- it was her face. I tried to analyse what made it so memorable, as I sorted through some papers on my desk. Her eyes? They were brown and calm –they did not seem hunters at the moment, nor imprisoned behind long lashes; not deep set in shadows, not  hiding behind thick distorting lenses. In fact they were far from striking or even distinctive. Her nose was neither large nor mishapen, and her mouth seemed to sit comfortably in its alloted place and smiled only when appropriate, if infrequently.

She noticed me sneaking glances at her as I pretended to play with the keys on my computer, and sighed. “You’re trying to remember, aren’t you, doctor?”

Her voice, too, was familiar, and yet only vaguely so. She was like some book I’d read years ago, whose style and mood, were immediately recognizable, and yet the story, and the ending, were obscure. Tantalizingly close, but so far irretrievable.

“You haven’t changed at all from the first time I met you,” she said, painting my face with her eyes. “Hardly any grey in those curls, still no wrinkles, and that unmistakable look of innocent puzzlement whenever the focus is deflected back onto you.”

Why would anybody remember that? I smiled to diffuse my discomfort.

“Same smile, too,” she whispered, sitting back in her chair triumphant in her recollections. I was evidently who she expected to find -the one she had remembered. Her memory had served her well so far and her face was celebrating.

Who was this anyway?

She straightened up in her chair and sat forward slowly. Deliberately. “I know I’m just here for a pap smear, and you’re a busy man, doctor, but given our history, would you mind if I asked you a personal question?”

I hate it when somebody says that. A polite request usually demands a courteous acquiescence -especially when an unrecalled ‘history’ is offered as a reference.

I nodded, but tried to indicate by my expression that I was only doing it to be –what?- polite. My forehead, I’m sure, made my point.

She noticed, and a tiny smile escaped, ran across her lips, and disappeared on the other side. I could see her amending her question on the fly. “I’m sorry, I didn’t mean to embarrass you. It’s just that you look so much the same as I remember from that first time… It’s uncanny, really.” She leashed her eyes for a moment to study my reaction. I could feel them trying to peel information off my face as they sat, hooded and dangerous on the edge of her thoughts. “I’ve been trying to figure out what it is.”

“Probably the scrubs I always wear,” I said, trying to be funny I suppose.

She shook her head and tried out another smile. “No… I don’t think so.”

Something about the varying texture of her smiles and how they each pulled differently at her eyes, caught my attention and a memory –a shadow, really- flitted like a ghost just out of reach.

A new smile, thin and toothless –an unasked question smile- appeared like a figure glimpsed through a thick gauze curtain, only to disappear again before adequate identification. She was beginning to unnerve me. But suddenly, like opening a gate, everything rushed out.

She took a deep breath and straightened herself on the chair as if she were about to answer a question in class. “I… I asked to see you for a reason, doctor. The pap smear was just an excuse…” She looked past me to stare out the window for a moment, obviously uncomfortable. Embarrassed.

“My midwife sent me to you for an urgent consultation twenty-two years ago. It was my first pregnancy and I wanted so much for everything to go smoothly –you know, home delivery, no pain killers… Anyway, one day Maryanne told me I had to see a specialist. I wanted to see a female, but for some reason I ended up with you.” She glanced at me to see how I was reacting, and then, reassured, continued. “I remember you were very nice, but you said there was not enough fluid around the baby and that it wasn’t growing so you wanted to induce labour right away. You asked me if I had any questions, but I was only thirty-two weeks along in my pregnancy then so I panicked and ran out of the office. I phoned the midwife and she assured me you had a great reputation but I didn’t believe her. I couldn’t. I was sure you were a fake, so I drove back to Surrey where I used to live. I wanted to think it over. But that night I went into premature labour and they had to deliver Melissa there by Caesarian section.

“She was quite sick when she was born –she spent more than two weeks in their nursery,” she said, wringing her hands as if it had all happened yesterday. “And you know, for some reason I blamed you. Like, if you’d decided my midwife was wrong, everything would have been okay…” She sighed and wiped away a tear. “Weird, eh? Hormones, I guess, because then they had to hospitalize me for depression. I was so paranoid I couldn’t think straight for months…”

She took a deep breath and another, different, expression surfaced. “Have you read any Oscar Wilde, doctor?” She asked, her eyes suddenly cold.

I nodded –but carefully. I had the uncomfortable feeling I was being led into a trap. “The Portrait of Dorian Gray?” she asked, her voice now soft and apologetic.

I steeled myself. It was the story of a hedonistic and dissolute man who remains handsome and young while his portrait –stored in the attic- ages and reveals all the evil he has committed.

“At the time, I thought of you as Dorian Gray,” she said, now inspecting her hands tightly kneading her lap. “All show, pretending to be kind, but all the while not caring what I really wanted… Really needed.” She shook her head slowly –maybe she did that when I saw her that time so very long ago. I don’t remember. “I apparently phoned all my friends and told them to stay away from your office… I hated you when I was sick… I tried to spread rumors…”

Well, at least it was Dorian Gray and not Jekyll and Hyde she’d read… Small comfort, I suppose.

Suddenly she sat up and leaned across the desk to grasp my hand. “But it was my portrait that was up in the attic, wasn’t it? It was me all along that was the fake.

“You know I’ve waited all these years to tell you about it -to apologize… but I was afraid.”

I squeezed her hand as a tangible acceptance of her apology and sat back trying to think of something to say to diffuse the mood. “And Melissa? How’s she doing now?”

Yet another smile surfaced briefly, changed its mind for a moment, and then re-emerged as a gigantic grin. “You delivered her baby a couple of  years ago, doctor. I was sitting in the far corner of the delivery room in the shadows for most of it, afraid you’d recognize me. I remember you kept looking over at me –wondering why I wasn’t standing beside my daughter. I didn’t quite know what to do. I kept trying to smile, but I was so ashamed, the smile kept disappearing…” She looked at me quizzically for a moment. “Did you recognize me?” Her face knotted up. “I have to know…”

It was my turn to smile this time. “No…” I said slowly, unable to suppress a blush at my failing memory. I hope that made her feel a little better. And yet, although I hadn’t recognized her then, I realized what had puzzled me about her today: she was wearing the face of a woman I’d come to know quite well; she was her daughter but through a glass darklyThe time is out of joint- O cursed spite, that ever I was born to set it right!” said Hamlet. It felt like that…

Medical Revisionism

Words -that’s all they are: sounds that by their very presence magically communicate meaning. They are more than mere noise or background. They are not the wind rustling through the leaves, nor the sounds of a frog in a pond; in a way, they are entities that resolve uncertainty, and in as much as they can be interpreted, contain information. Data. So, in a sense, they transcend Time: the information in the words of an ancient document still exists. But information is subject to interpretation; the same data may be seen as having different meaning as time and societal norms change. But does that change the information conveyed? I think not.

I’ve covered this topic in previous blogs (for example: https://musingsonwomenshealth.wordpress.com/2013/11/01/whats-in-a-name-cancer/ ) but the topic is a source of continuing intrigue for me, so I was once again interested in seeing it broached in an article in the BBC News last fall: http://www.bbc.com/news/blogs-ouch-34385738  It seems we are constant and insatiable revisionists. It’s as if by changing the descriptor, we somehow alleviate the pejoration its ancestor accumulated. And yet the information remains; only the colour changes.

I suppose that this is useful, but I can’t help but wonder if there is some other way of doing it. Of course, some words seemed to have been coined originally with a belittling intent -Cripple springs to mind- and even without our penchant for viewing the machinations of history through modern eyes, the word is disparaging; it is simply not fair. It derives from the Old English word crypel which has the suggestion of creeping. It was a condition in clear need of a new term.

Other words were more naively-attempted descriptions –designations that were no doubt thought to help others picture what was being named. There was unlikely to have been any attempt at denigration -despite how they might now offend or upset us. Mongolism is one such term. According to the New Oxford American Dictionary:mongol, or Mongoloid, was adopted in the late 19th century to refer to a person with Down syndrome (named after John L. H. Down [1828–96], the English physician who first described it), owing to the similarity of some of the physical symptoms of the disorder with the normal facial characteristics of eastern Asian people. The syndrome itself was thus called mongolism.’ But the problem remains –what happens when the term ‘Down Syndrome’ itself also becomes offensive?

Sometimes, it seems to me, the words will also change for no apparent reason. Think of the various expression changes for sexual diseases over the years and the somewhat clumsy attempts to strip the prejudice out of them. When I first started medical school, the expression was ‘venereal disease’ –or VD. Then, when that became too pejorative, or at least discriminatory, it morphed into STD (‘sexually transmitted disease’), and currently STI for ‘sexually transmitted infection’… Or am I already out-of-date? The reason for any of these transformations, however, is totally beyond me.

Words, it seems –or maybe it’s me– just can’t keep up. Maybe, like Fashion, they’re bound to change because of user-boredom or a need for novelty, but I think it’s probably deeper than that. I suspect that it relates more to societal attitudes than societal ennui. And I think that it may be a lost cause to expect consistency of usage. As we change our approach to issues and our opinions, so we change our words to describe them. It starts off with the more curmudgeonly amongst us –usually those for whom tradition provides a stable and secure platform- proclaiming the changes to be ‘political correctness’- to use the current phrase. But then, gradually, sometimes imperceptibly, the expression achieves a common parlance and not using it courts sideways glances, or even incomprehension. It is, perhaps, an aurally measurable example of society’s changing attitudes, if not its mores.

My biggest complaint, however –although minor in the scheme of things- is that it seems a waste of perfectly good words. One of my favourite ones ‘awe’ and its brother ‘awesome’ which used to bespeak a form of reverence, was ripped from my useful vocabulary only a few years ago and I’ve never really gotten over it. The words now have little value -they’re the scrapings from a different, grander time. Crumbs. Leftovers.

I am reminded of the words of Moth, the page of the soldier Don Armado in Love’s Labour’s Lost by Shakespeare: ‘They have been at a great feast of languages, and stol’n the scraps.’