Monthly Archives: November 2015

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Hurtful Scents

I realize that to comment on odour is to confront a two edged sword –none of us journeys without a scented trail- but apart from those occasional inadvertent and indelicate smells, the time has probably arrived when we should be wary of artifice. Well, at least in those areas where there is no escape; where the air is as imprisoned as the nose; where the vulnerable may be subject to harm: the hospital.

Now, to be clear, I am not advocating the abandonment of deodorants, nor am I exculpating the voluntarily unwashed. I am merely suggesting that artificial scents may have unintended consequences, as an editorial in the Canadian Medical Association Journal points out: http://www.cmaj.ca/content/187/16/1187.full  And it would seem that, ‘According to large surveys of the general public, about 30% of people report having some sensitivity to scents worn by others. Twenty-seven percent of people with asthma say their disease is made worse by such exposures. There is emerging evidence that asthma in some cases is primarily aggravated by artificial scents. This is particularly concerning in hospitals, where vulnerable patients with asthma or other upper airway or skin sensitivities are concentrated. These patients may be involuntarily exposed to artificial scents from staff, other patients and visitors, resulting in worsening of their clinical condition.’ One has only to take the long journey to a distant floor on an elevator to know how uncomfortable odour can be.

And this danger is particularly applicable to health care facilities because: ‘Federal and provincial human rights acts require accommodation for employees who are sensitive to scents in the workplace, but not for patients in hospitals or clinics.’  As the editorialist points out: ‘Many public places promote a scent-free environment. Some hospitals also do so. But it is not policy in all Canadian hospitals, and it is not required in hospital accreditation standards. [italics mine]’ In this respect at least, the truly vulnerable are not being adequately protected.

But we all need protection; odour is one of those modalities that we have been taught to sublimate –or at least not bring to the owner’s attention lest it be misconstrued. In fact, the perpetrator may have long since been habituated and therefore be blissfully unaware of the effects of the smell on others. Or worse perhaps, wants to inflict it on the rest of us in the naive belief that it enhances their identity –or enforces it. There is a fine line between self and not-self, I think; the boundaries are subtle. How far do we extend? At what range is another person an intruder? Given that personal zones –comfort zones- are often culturally established it would seem to be a labyrinthine problem only soluble by sensitivity and, probably, trial and error.

It certainly works like that in my office.

I don’t like to characterize people –especially patients- as difficult, but sometimes I can’t help it; it is forced on me. One vicious peck from their eyes on my attire, or a facial attack on my beard and I can feel my cervical hair standing at attention… On guard, really. I’m not sure what it is about non-verbal criticism that is so difficult to take, but perhaps it is its unexpectedness, its lack of specificity that doesn’t allow for rebuttal. Whatever it is, it makes subsequent rapport more difficult to achieve.

Sometimes the office is a brutal affair with patients and complaints lined up like laundry hanging from a clothesline on a cloudy day. Even patches of sun are welcome diversions, and I had just seen a young woman who had biked across the city for her appointment. Sweating profusely but obviously proud of her achievement, her humour was a needed distraction from the long line still hanging in damp anticipation in the waiting room and I smiled fondly when she left. A flash of colour for my day.

But Elspeth, one of the last patients of the morning, was a mature lady who seemed to eschew colours, however. A large black bag sat beside her chair and she had a dark grey coat resting on her lap like a sleeping child. Her long black skirt topped with a pure white blouse complete with frilly cuffs would not have stood out in the waiting room ordinarily, but the way she wore her hair would. It was pulled so tightly off her forehead into a little raggedy tail at the back of her neck that it looked painful -her skin screaming in silent agony. Her expression mouthed the same feelings; she was not a happy person.

She stood to follow me into my office –reluctantly, I sensed- and I could feel her eyes burrowing into my back as we walked. Even in the office, her guard was up and her eyes tense and menacing.

I smiled to reassure her that I meant her no harm, but she ignored me and began to inspect the room suspiciously. She started with the walls, progressed to the various statues and plants in the corners, and finished with my desk and its contents. I wasn’t sure whether she was appraising their worth or my taste, but when she finally examined me like she was itemizing my clothing, I realized it was neither.

“There is a disturbing smell in here, doctor,” she said through her teeth.

How does one respond to that? “I… Uhmm…”

“And it’s not just in here,” she continued, “I first noticed it when I entered the waiting room.” Her eyes were angry. Mistrustful. “I thought perhaps it was somebody’s failed deodorant or a cover-up perfume so I tried sitting in several places, but it was the same everywhere.”

“I’m sorry Elspeth…”

“Mrs. Trudle please, doctor. I don’t call you by your first name.”

“Sorry.” It was all I could think of replying.

“You of all people should know about the safety hazard of injurious odours and their effects on susceptible clients.”

“Patients, Mrs. Trudle; I do not have clients! I am not a lawyer, nor a beautician.” I shouldn’t have said that –I don’t like the power implications inherent in the word ‘patient’- but I couldn’t resist. I felt attacked.

The effect, however, was almost immediate. The skin on her forehead rose briefly –perhaps to relieve the pressure- and then the ghost of a smile trickled across her face. “Touché, doctor,” she said and then chuckled. “I’m sorry if I was rude, but I’m terribly sensitive to smells nowadays. I find they give me headaches.”

I’m a gynaecologist, not an otolaryngologist, but her insistence that there was a disturbing odour in the office was worrisome –not least because nobody had commented on it before.

“Is it as bad in here as in the waiting room?” I asked, hoping it wasn’t my deodorant.

She thought about it for a moment before answering. “No… No I don’t think it is, although I can still detect it.”

“Any idea what it might be?” I wondered if it might be somebody’s perfume, or perhaps a chemical residue from the cleaning staff. We no longer had any carpets, so it couldn’t be unvacuumed dust or mold in the fabric.

“Well, many things seem to set me off… But here it was feet,” she said simply. I must have looked surprised, because the smile on her face grew larger and she sheathed her eyes.

“But…”

She nodded her head to interrupt me. “But there were only three other women in the waiting room -I know that. They must have thought I was demented to keep moving to different seats, but my headache was getting so bad I was afraid I was going to gag.” She slumped in her chair and closed her eyes for a moment. She looked uncomfortable. “Maybe it’s not the smell of feet so much as shoes…”

I just stared at her. I couldn’t make people take their shoes off at the door.

She shrugged and shifted uneasily in her chair. “I haven’t had a period for over two years, so I’m wondering if all of this is related to the menopause.” Her eyes scanned my face for some reassurance. “I’ve got an appointment to see a neurologist this afternoon, but I was hoping it was something simpler… more easily fixed.”

I smiled but I’m not sure my silence comforted her.

She sighed, and looked at me as if she felt she was wasting my time. Then she gathered up her coat and purse. “Hope is sometimes naïve, isn’t it?” She stood, started to walk towards the door and then stopped, but didn’t turn around. “Even ‘Lilies that fester smell far worse than weeds’, I guess…”

I recognized it as the ending of one of the more enigmatic of Shakespeare’s sonnets and I had the uncomfortable suspicion that she’d rehearsed it for just such an occasion.

Just as she left, she turned her head and smiled a sad smile. “I’m sorry,” she managed to whisper, and then disappeared through the door.

I was sorry as well… And all I could think of to respond was what Shakespeare’s King Lear says to Gloucester: Thou know’st the first time that we smell the air we wawl and cry… But I said nothing. Air was a continual surprise for Elspeth; and she was certainly not mad…

 

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The Caesarian Path

The Caesarian section has a fascinating, if largely apocryphal history. In all likelihood it was probably a procedure of last resort to save the unborn child when its mother was already dead or near death. That the famous Julius Caesar –like Shakespeare’s MacDuff- was ‘from his mother’s womb untimely ripped’ seems unlikely, however appealing the etymology. In fact, the name may well derive from the Latin verb ‘caedere’ –to cut- and hence the cognomen (originally a nickname). Pliny the Elder, according to Wikipedia, ‘refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, “cut from the womb” giving this as an explanation for the cognomen “Caesar” which was then carried by his descendants.’

At any rate, before the days of appropriate antisepsis let alone adequate analgesia, the survival rate for both the mother and baby would have been dismally low. And despite isolated reports of its use throughout recorded history in such diverse countries as India, China, and even Babylon, it was always a procedure of desperation. A triumph, as Samuel Johnson once wrote in another context, ‘of hope over experience.’

Unfortunately it has now become merely a triumph of experience -a default position assumed at what seems to be the slightest provocation. The fact that it is an operation that can be booked in advance under some circumstances, and therefore superimpose a degree of predictability on the scaffolding of the anticipated chaos of labor, has been seen as desirable in some quarters. And in fairness, there are those for whom labor carries undue risks for either mother or baby and its avoidance would be prudent if not lifesaving. The issue, I think, is in the interpretation of risk.

The other, perhaps more problematic concern, is that of choice. At least in a system of limited resources, or one in which the public purse is providing medical coverage, one could ask whether an elective Caesarian section for no other compelling obstetrical reason than patient choice, is a sustainable option. Or even a desirable one.

So, what about in a user-pay system? Is it merely a matter of supply and demand: build more hospitals to accommodate the needs and whims of those who can afford them? Is that an efficient use of their resources? Is it even an ethically defensible position? The matter has finally prompted the Brazilian government to wade in, as an article in the July 7/15 BBC news reports: http://www.bbc.com/news/world-latin-america-33421376

Of course, there are many reasons for elective Caesarian sections –some of which are the result of previous and unsuccessful attempts at vaginal delivery that necessitated Caesarian deliveries at that time. The desire to avoid a similar and frustrating trial of vaginal delivery is certainly understandable –if not always necessary- under those circumstances. These are the so-called elective repeat Caesarians. Others, as I indicated, are obstetrically mandated because of developing or pre-existing risk factors –once again, hard to argue against. There is an interesting and informative article that attempts to put the Canadian experience (2007-2011) into perspective –a classification system (the Robson Classification System) that can be used to make international comparisons in Caesarian section rates: http://www.jogc.com/abstracts/full/201303_Obstetrics_1.pdf

But getting back to the situation in Brazil. As the BBC article suggests, ‘Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%’. And the new government rules ‘…oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. Doctors will also have to justify why a caesarean was necessary. They will have to fill in a complete record of how the labour and birth developed and explain their actions.’ That they may not have been doing this routinely before is troubling, to say the least.

Also, ‘Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors.’ I would have thought this practice would have been universal and intuitive -without the need for a government fiat.

But, as worrisome as all of this seems, there is another, perhaps more subtle pressure on the woman to opt for a Caesarian delivery in Brazil: ‘Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed.’ And as Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brazil last year, “The best way to guarantee yourself a bed in a good hospital is to book a caesarean.”

Of course the blame does not wholly fall on the medical profession there –nor even, perhaps, on their preferred management strategies in pregnancy. ‘Researchers say many women also see caesareans as more civilized and modern, and natural birth as primitive, ugly and inconvenient. In Brazil’s body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive.’

It is always dangerous to judge another country and another culture by our own standards. Our own sensibilities. And yet the risks are transnational and universal. They do not disappear simply because of a differing national mythos. Surgery is surgery; complications are inevitable co-travellers with it in spite of all precautions, and good intentions -the hidden, unwanted occupants of every operating theatre. And while we may never be able to stem the tide of primary elective Caesarians –even education on the subject has challenges overcoming fear or fashion- we may be able to convince women that their choice does not come without baggage. Unintended risks. To journey through a new geography, it helps to have thought about it first; planned the route to avoid unnecessary problems; consulted a knowledgeable guide –someone who will travel along with you. And remember what Seneca wrote: ‘Be wary of the man who urges an action in which he himself incurs no risk’.

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The Science of Answering

I suppose in this suspicious age, everything is open to scrutiny. But some things are examined at one’s own risk risk -like turning over a familiar log in the garden only to find unexpected and sinister-looking creatures lurking quietly beneath. This is fine, of course, but it can be hard to know what to do with the results of such investigations without some attributions -either positive, or more likely, negative. And, depending on our experience, a vacillation between the two.

Science by encouraging unbridled curiosity has often not been neutral in this. With some trusted and unsuspecting products that have been on the market for years, subsequent studies have occasionally determined similarities of structure, or function, with other, more bothersome effects. Aluminum in cookware was one famous example. Aluminum was found in some plaques in the brains of patients with Alzheimer’s disease so of course products containing aluminum went into a precipitous decline from which they never really recovered despite subsequent studies that failed to substantiate the risk. Or think of the autism scare after a since-repudiated 2004 article suggested that thimerosol, a synthetic form of organic mercury which has been used for many years as an antimicrobial agent and preservative in many vaccines, was the cause of autism spectrum disorder.

Once these doubts have been cast, suspicion often lingers that is hard to eliminate. Conspiracy theoreticians emerge from the shadows to sew their seeds, flaunting the seemingly obvious and intuitive conclusion that there must have been something that made the scientists find what they did. The fact that science actually encourages refutation -that nothing is ever known for certain and that they’re rather happy with that- escapes those who would rather believe there is a cover-up.

And now, there is another study –one among many- that suggests that even low amounts of parabens –preservatives used in, among many other things, the cosmetic industry- might increase the risks of breast cancer! Researchers from the University of California, Berkley have published a study in Environmental Health Perspectives that seems to demonstrate this: Environ Health Perspect; DOI:10.1289/ehp.1409200

‘Existing chemical safety tests measure the effects of a chemical on human cells in isolation. However, as these tests fail to consider that compounds might interact with other signalling molecules, the tests are insufficient, explained the researchers.

Using the naturally occurring growth factor in breast cells, heregulin, the researchers stimulated the HER2 receptors in breast cancer cells and exposed the cells to parabens. The chemical caused the oestrogen receptors to activate genes, which led to the proliferation of the cells. Moreover, the effect was significant: parabens in the HER2-activated cells stimulated breast cancer cell growth at concentrations 100 times lower than in cells lacking heregulin.’

Is nothing safe? It’s difficult to know what to do with information like this. Surely there is a middle ground between merely shrugging our shoulders and accepting that the world is a dangerous place, and railing against Science for trapping us here. Do we sometimes just use our indecision as a reason to worry? Change seems to spawn unintended consequences no matter how hard we try to anticipate them. As an enthusiastic user of modernity I suppose I am closer to the shrug camp, but I recognize that there are different world-views out there and I dare not gainsay them. Especially if they are first time patients who are a little wary of me to start with.

Jona did not trust me; I could tell by her eyes as soon as I introduced myself in the waiting room. While her face said hello, her eyes threatened me with silence if I so much as stepped on the boundary. The hand that shook mine was aggressively firm and it was all I could do to keep from wincing. I hate that. I’ve always felt that the first contact should be a greeting, not a contest. A sign of mutual respect, not a dare. I don’t feel at all competitive at that stage, but from her expression, I could see she felt it was a form of sport. I was surprised she let me lead her into my office.

When I was finally allowed to sit and open up my computer, I saw that her referral to me was for dyspareunia –code word for pain with sex. She sat on the other side of my desk with everything on guard: face, posture, fists… Everything dared me to ask her why she was here. So I didn’t. I just let her talk –debrief, as it were. Her eyes –at least the ones that she had trained to pin doctors to their chairs- were hovering around my face, waiting for me to provide the excuse for an attack.

“I know that Maria has listed my problems in the letter she Emailed, doctor, but before you start on me, I just want you to know that I refuse to take, insert, or inject any medications.” She proceeded to cross her arms tightly across her chest, as if something was trying to escape from under her blouse. “Maria wanted to put me on estrogens, but as you know, they can cause strokes, heart attacks and cancer. Sex isn’t worth that risk.” She glowered at me, still holding off the eye-attack until I said something. “Then, she suggested the low-dose variety that you merely put in your vagina… Merely?? It’s hardly a little thing to put an uninvited foreign body in there, doctor! She thinks my vaginal skin is too thin and that’s why it hurts.” She thought about it for a moment. “And how would she know? She couldn’t even get a speculum in there, so how could she say that? I’m 48, not 68 for God’s sake. I’m still having periods and tampons have never hurt.” She sighed theatrically and continued. “I’ve tried lubricants and stuff, but if you look at what they contain and then Google the contents, it’s like playing Russian roulette with your vagina. Some of them even print disclaimers and suggest medical consultation before using them. They can cause allergies, skin irritation, infections… Some are even carcinogens when you look up the pharmacology. And then there’s that article saying that the parabols might even cause breast cancer…”

‘Parabens,” I corrected her and then closed my mouth, smiled sympathetically and waited for permission to say something more. Anything.

“Whatever. My husband doesn’t understand, either. All he wants is something quick before he goes to sleep. Of course, he thinks I’m making up the pain stuff…”

The short pause, and a brief journey of her eyes to a picture on the wall gave me an opportunity to ask her something: “Do you talk to your husband?” I said, and waited for the eyes.

“He won’t even talk to me when we’re eating dinner…” She said slowly and looked down at her lap, caught off guard by the question, I think.

“How long has it been since you were able to talk?”

Jona withdrew her eyes and they disappeared into her face along with her anger. Then she shrugged, and a few words spilled out. “It’s been so long, I can hardly remember when…” She suddenly stopped talking and stared at me. “But why did you ask about him, doctor? Do you think our…?” she said in a whisper. “My GP never even asked…” Her expression changed from one of defence to one of curiosity. “Why did you wonder if I talked to my husband?” she repeated.

“Are you a Shakespeare lover?”

Her face tightened for a moment in puzzled irritation, but then she laughed. “Double, double boil and bubble; Fire burn and cauldron bubble,” she said, obviously pleased with herself. “The witches, in Macbeth, I believe.”

I nodded, then grinned. “Well, let me quote from the play-within-a-play in Hamlet –Gertrude answering Hamlet’s ‘Madam, how like you this play?’… ‘The lady doth protest too much, methinks.’ she answers…”

A little smile –the first real smile she’d shown me- blossomed like a flower on her lips. “Maria said you were good, doctor… You’re smarter than you look,” she said with mischief in her eyes this time, and her body relaxed into the chair. “What do you suggest I do?”

I readied my fingers over the keyboard and chuckled warmly. “I suggest we start by making sure there is nothing you need to worry about.” I thought of another memorable phrase, this one uttered by Hamlet himself: ‘There is nothing either good or bad, but thinking makes it so.’ But I didn’t say anything; she’d had enough Shakespeare for now I realized.

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Mind Games

I have of late been attracted to mind games –not, you understand, the one-upmanship power struggles that are reputed to go on in corporate businesses, nor even the more hurtful kind that used to happen in high school classes, usually initiated by those who sat in the front seats. No, I refer, rather, to the surfeit of programs available online that purport to improve cognitive function –or perhaps at least to preserve it- in the ageing brain.

There was a time when the idea seemed gimmicky –a superficially tenable effort to divert pension funds into other, younger pockets. Even I (yes) was a hopeful initiate during my presenescent days and religiously attempted some of the tasks presented until I realized that my scores were not improving. So I stopped -on the theory that the evil I don’t know is probably easier to live with than the one I do…

And yet curiosity, no doubt mingled with an overflowing cup of guilt, ensured that I continued to dabble on occasion -for fun of course, and on the proviso that if I didn’t perform well, it was obviously because I wasn’t taking it seriously. And, still, it didn’t seem to improve my ability to solve the Sunday New York Times crossword puzzles.

But I do keep my toe in the water, so to speak, and on a recent, albeit random, perusal of archival BBC News articles, I came across one that seemed to suggest that I should have been more careful in what I discarded. More sedulous, if I may borrow one of the rather problematic words from the Times’ puzzles:  http://www.bbc.com/news/health-34701907

Perhaps I expect too much of people, or maybe they just don’t read the same BBC articles as me, but by now I would have thought that I would have noticed a change afoot. No longer, should I have seen those uncomfortable seats in the suburban malls crowded with pensioners grimacing intently at their over-folded and crumpled newspapers trying to solve the day’s crossword puzzle, or glancing covertly at their neighbour’s Sudoku columns. There should have been a profligate display of tablets or laptops and the sound of gnarled fingers scraping their answers on a thousand screens. But, alas, I suspect that they, like me, were too busy using their older, well-worn neural pathways instead of garnering new ones.

Of course some of us are confronted with new realities on a daily basis. Sharon was a new reality, although at first glance, there seemed nothing amiss. An older woman, she sat quietly in the waiting room, neither glancing nervously around her at the confusion of other patients, nor pretending to be absorbed in one of the out-of-date magazines that somehow surface, unsubscribed, in every office. Rather, she sat staring out of the window, serenely confident in her persona as a silver-haired, matron, largely immune to the vagaries and vicissitudes that plague the rest of us as we shuffle through our mortal coils (sorry Hamlet).

I have to admit that I was intrigued by the tranquillity that persisted even in my office. And the sharpness; she didn’t miss a thing I did.

“I see you have performance anxiety,” she said, staring at my fingers on the keyboard of my laptop.

I managed an embarrassed smile and put my fingers down on the desk. “How do you mean?” I stuttered through a particularly deep and noticeable blush.

She blinked mischievously. “You keep hitting the ‘caps-lock key’ instead of the ‘shift key’.

“Oh…”

“And you hit the ‘z’ instead of the ‘x’ once.”

I sat back in my chair –I didn’t know what else to do at that point. “You notice things, don’t you?”

The smile she produced almost cracked her already wrinkled face. “You have to keep alert at my age, young man…” Another mischievous expression surfaced –this one in her eyes. She knew only a matriarch would dare to call her newly-met specialist ‘young man’, and she revelled in it. “For example, that man holding the baby in the black and white photograph hanging on the wall behind me is not smiling…” I moved my head slightly so I could look at the man. I had put it up to make the point that men also love little babies, but I have to say I couldn’t remember whether or not he’d been smiling. “He needs to change the diapers, but the photographer probably didn’t notice. Or care…” She said this with a raised eyebrow.

“That’s impressive, Sharon…” But as soon as I said it, I realized the statement was ageist. Patronizing. Like saying ‘How could a person of your age be that aware?’

She smiled, but carefully this time –as if she suspected a trap was being laid. “Do I hear an un-vocalized ‘but’ in that sentence?”

I blushed again. “Not at all… But I was wondering how you do it…” My blush deepened as the ‘but’-word tumbled unexpectedly from my mouth.

“Mind games,” she said simply, and shrugged as if I should have known that.

I was puzzled at her reply. “You mean you are trying for…” I searched for an appropriate, yet polite word for one-upmanship.

She chuckled and reached out for my hand before I could finish my thought. “Dominance? Heavens no. I mean those brain programs you download on your computer to freshen up the mind.” She sighed and closed her eyes for a moment as if she were searching for something inside her head. “Maybe it’s just the one I bought, but it seems to train you to look for patterns and discrepancies and even remember things… When they are presented to you as problems, at least…” It didn’t really seem like a whole-hearted endorsement. She sounded as if the program had missed something important.

In the silence that followed, I felt I had to say something; and I was beginning to wonder if the program would help me. I’d love to be able to glance at a picture and know if a baby needed changing. “I may look into that, Sharon,” I said, although somewhat lamely I think. So I tried it again: “Do you think it has made a big difference in your mental performance?”

She shrugged. “I suppose so… I mean I’m beginning to get better scores on the performance evaluations, at any rate…”

“You seem a little hesitant to recommend it, if I may say.”

She smiled and a little sigh escaped before she could prevent it.”Damning with faint praise?” A tiny shrug followed. “If you need to know how to recognize a Ford from a Toyota driving by, it’s great. If you need to know whether one alarm clock stayed ringing longer than another alarm clock –or a lamp, for that matter- by all means, download the program…”

“But…?” She was clearly unhappy with the results.

“But I still forget why I went to the fridge, or where I put my keys.” She looked out of the window behind me for a moment. “And I still remember things I would rather forget…”

I was immediately reminded of Macbeth as he talks to his doctor while preparing for battle:

Canst thou not minister to a mind diseased,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain

And with some sweet oblivious antidote

Cleanse the stuffed bosom of that perilous stuff

Which weighs upon the heart?

Perhaps there are reasons a mind should grow old; and maybe what we really need is a program that helps us to remember mainly the good things. I’m going to wait for that one.

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Digiphilia

My computer seems to be constantly doing things behind my back, or under my fingers. One minute it’s performing some sort of update, the next, applying a patch or pretending to, at any rate. I have to trust that whoever makes the little signs that pop up is honest and doing things in my best interests. But how would I know -until it’s too late? There’s a lot of hope that goes into owning a computer nowadays -but sometimes it seems more like a Mafial protection racket and I do what it says so I don’t get hurt. So my data doesn’t leak out onto Facebook. Doesn’t de-encrypt on its way to the Cloud.  Of course, that’s what I pay it to do, but nonetheless it always seems busy. Like me.

Sometimes I wonder what that means, though -being busy. Is it like my computer -being occupied with a thousand thankless tasks whose relevance is probable, but unprovable and invisible? Or is busy actually more like what it does for me when I ask it to print something, or search for a particular file and display it? Something I can use, in other words.

The questions are not as odd as they seem. A patient of mine seemed to be confronted with a similarly existential angst one day as she was fiddling with an app on her smartphone trying to find the date of her last period. I’d seen Jenny a few times in the past for heavy and irregular periods, but they’d sort themselves out and I wouldn’t hear from her until the next time her family doctor became concerned. A young-looking woman in her mid-forties, she always seemed busy with something in her purse or in the depths of one of the voluminous pockets of the coat she always chose to wear. Then, like a magician extracting a rabbit from one or the other, she’d hold up a scrap of paper like it was a Dead Sea Scroll and wave it at me in triumph. “I knew I’d written it down,” she would explain, her face red with the effort. “It’s the best way.”

It was different this time, however. I hadn’t seen her for a while and her hair was longer, greyer, and piled on top of her head like she’d done it in a hurry in the dark. Her face had changed as well -more lined. More flustered. She was wearing a dark blue woolen sweater with no pockets, and her purse wouldn’t have held much more than a phone. But as agitated as she looked, she greeted me with a warm smile of recognition.

My first question, after the usual reminiscing banter seemed the obvious one. “Your doctor says that your periods are heavy and irregular again,” I began, glancing at his letter on the screen of my laptop. “When did the last one start?” This initiated a confident dip into the little purse and a rather smug look on her face. She pulled out a standard issue smart phone and started to punch in the password to unlock the screen. I could tell from her expression that it hadn’t worked. “I decided on a simple one, so I’d remember the password,” she explained with a blush. “But I think I entered it backwards…” She smiled to herself and re-entered it with much the same result. “Damn! Maybe I’m using the one for my debit card -the PIN thing…” she added for clarification. “Or could it be the..?” She punched in a few more numbers, this time angrily, then sighed noisily. She blushed again, but her cheeks were already flushed with irritation. “New phone,” she added, but more to herself than me. “Actually, my first smart phone…”

She put it on the desk for a moment while she decided what to do.

“Just tell me the approximate date your last period started,” I said to calm her down a little. “It doesn’t have to be exact…”

But I could see an idea flash across her eyes. “I wrote it down just in case,” she said and stood up to reach into a pocket in her jeans. My fingers hovered over the keyboard in anticipation. “Here it is,” she said, pulling out a crumpled piece of brightly coloured paper the size of a small post-it reminder like I used to stick on my charts to alert my secretary to do some task or other. Jenny had her backup systems.

But it wasn’t the date of her period, it was the password for the phone.  I rolled my eyes when she wasn’t looking, and smiled patiently: my backup system…

Soon she was deep in the inner mysteries of her phone hunting for an app, scrolling randomly it seemed to my watchful gaze. I glanced at my watch -eighteen minutes so far of no progress in solving the problem she had waited so long to see me for.

“I used to just remember things like this,” she said with an embarrassed shrug. “Then, when my periods became irregular, I would write the dates down…”

I couldn’t see her face as she said this -her long, greying hair had come unravelled from its original wrappings and was hanging over her nose and eyes as she stared at the tiny screen, head bowed as if in prayer, frantically scrolling through some app or other with her fingernail.

“My girlfriend convinced me to get one of these,” she said, perhaps pointing at the phone that was hidden in her lap behind the desk. She looked up briefly and smiled at me. “You remember Lara?”

It was a statement really, not a question despite the obvious verbal question mark. I decided I did not have to respond and just smiled in return. I had no idea who Lara was.

“You delivered her little girl a few years ago,” she continued almost as an aside, trying to multitask as she whacked at the screen. “Anyway she said she’d given up pencils for good and was happy about it. No more scraps of paper in her pocket, or sounding the depths of her purse for a reminder she’d forgotten she’d put in there.” She surfaced again for air, and then just as unexpectedly disappeared behind her hair. “No more worrying about where things are; everything’s in the same place…” Her hair quivered for a moment, then the moment passed and the scratching sound resumed. “You can even set an alarm on some of the apps… Not this one, though,” she added, as if to excuse her absence.

“Anyway, Lara says to say hello.” And then a whispered curse, as if her friend had joined her behind the wall of hair.

“Any word about your period?” I  asked, pretending it was a joke.

Jenny giggled nervously and waggled her hair again. “I should have written that down somewhere for you… Well, I mean I did, but I can’t find it.” Two eyes peeked timidly through the hair like children hiding in a bush. Then suddenly, her head bobbed up and the hair parted as a curtain might with a gust of wind. “Wait a minute,” she said, excitedly, “I did write it down!”  She jumped to her feet and managed to cram some fingers in another pocket in her jeans. “Hah!” she shouted excitedly. “Here it is! You always have to have a backup plan, don’t you?” She pulled out another post-it note and placed it triumphantly on my desk.

I smoothed it out and tried to read the now-smudged writing on it as she watched my every move with ill-disguised pride. When I seemed to be having difficulty she gently retrieved the tiny document from my grasp and translated it. But slowly, like a teacher trying to help an unexpectedly slow pupil. “It says nine days ago, doctor. It started nine days ago -well, probably nine and a half, because they often seem to start the night before…”

I have to say she was very patient with me. More patient than I felt. “Nine days ago Jenny?”

“Nine and a half,” she corrected me.

“But couldn’t you just have told me that in the first place? I thought maybe it might have been a few weeks ago, or perhaps a very long time ago…”

She shrugged noncommittally. “That’s why I wrote it down,” she said as if I was still being a bit slow. “I didn’t want to give you the wrong information, after all…”

“But…”

She looked at me, obviously annoyed that I was not being more understanding. “I lead a busy life, doctor. I can’t be expected to remember everything.” She softened her expression like a mother, concerned she might have been a bit hard on her child. “So I write everything down where I can find it when I need it.”

I stared at her phone for a moment and shook my head with a knowing smile. I don’t think she saw that, though, because she was obviously  pleased with her methods and was carefully folding up the password on that first piece of paper and getting ready to put it back in her pocket again. “When you’re busy, you have to have a plan,” she said proudly. “And a backup…” she added wisely, in case I hadn’t seen the wisdom in it all.