The Gyne Codes

We all use codes; sometimes they are simply shortcuts, at other times they identify us as part of one community or another. However, the codes I like are the ones that are attempts at disguise. Camouflage. They offer the challenges that colour my day. I have to say that I was absolutely fascinated by the codes and their uses reported in a BBC news item: http://www.bbc.com/future/story/20151217-the-secret-codes-youre-not-meant-to-know

I suppose the codes it revealed that tugged at my heart more than my intellect were the so-called hoboglyphs which are ‘a collection of symbols meant to provide information to travelling workers and homeless people.’ http://weburbanist.com/2010/06/03/hoboglyphs-secret-transient-symbols-modern-nomad-codes/ Somehow the thought that ‘Among other things, these could indicate the quality of a nearby water source, or suggest whether the occupant of a house is friendly or not’ goes at least a little way to help those that society tends to shun.

But as I said, we all use codes in one way or another; a difficulty arises when you don’t know you are being coded –or worse, you do, but you have no idea what the codes mean… Or why they are being used in the first place. I usually suspect the worst.

And the non-verbal codes people use are the trickiest: they can often be explained away as random movements –tics- and even to notice them might embarrass the user if they were indeed involuntary. Or, perhaps more awkward, if they arise from the patient’s unease itself. From time to time I am confronted with this dilemma in my practice of gynaecology.

I first met Roseita a few years ago. English was difficult for her at the time, and I remember she seemed to communicate with her eyes a lot. That first day, as she sat entombed in shadows in a far corner of the waiting room, I could sense her presence even before I saw her. She was camouflaged in a green dress on a little chair beside the large Areca palm plant that also seemed to be enjoying the subdued light. The chair –Roseita- was almost hidden under the leaves, but I felt her eyes tracking me like radar all the way across the wooden floor. Large, brown, worried eyes they seemed, already questioning whether I was the person who could help her.

I suppose there’s always that initial doubt in new patients, although most seem able to disguise their discomfort. Roseita couldn’t, and as I approached her with my hand extended in a greeting, her face said hello, while her eyes stared at me like frightened children. I didn’t know which to believe, so I chose to focus on her face. It’s amazing just how much a face can fight with the eyes; so which are mirrors of the soul…?

She trailed behind me, reluctantly I think, on the short journey down the corridor to my office at its end, and I had to fight the urge to keep turning around to see if she was still there. Her eyes certainly were; I could feel them burrowing into my back, studying my gait, judging the whiteness of the lab coat I usually wear. By the time we reached the door, I felt nervous about revealing the front half of my body again, in case it didn’t measure up to the other side she now knew so well.

After a hurried, but I suspect thorough, inspection of the room she seated herself like a monument on the chair opposite my desk. I say ‘monument’, but despite her bravado, she was more like a delicate figurine hoping to fool me with immobility. As if by sitting up straight and rigid, she could project a strength she didn’t feel. Sometimes her hands would slowly drift up to the sides of her head, like she was trying to smooth the dark black curls that dangled on her ears, but otherwise she was a statue with eyes peering out from little cages just waiting to be unleashed.

I could feel her anxiety and tried to set her more at ease with a smile and a compliment on her dress. It really was a thing of beauty and I wondered if she’d chosen it because it gave her confidence, or because she thought it would disarm me.

The compliment seemed to take her by surprise and she dropped her eyes to her lap for a moment as she decided how to react. Then, as if she’d come to the conclusion that I was being insincere –or maybe she didn’t actually understand my words- she launched those eyes at me like missiles. Hard, like stones. They actually hurt, although at the time I didn’t realize that it was my pride they hurt –rebuffing, as they were, my attempts at bridging a gap I was at a loss to understand. Doctors get injured too; relationships are a dance –a clumsy one until both understand the movements of the other. The needs of the other…

I suppose I always found that difficult; I need to feel comfortable before I can provide succour to the other. The therapeutic relationship –the doctor/patient alliance- is truly that: a tie. And what is usually considered an unavoidable imbalance of power, can be a mutual journey of discovery… If both are open to that, of course.

For my part, I wanted to understand why Roseita was so wary of me. Was it merely fear –the strange doctor of opposite gender, disparate culture, and different language pretending to offer help? Or was it more than that: mistrust? I had to know.

Wilting under the constant barrage of her eyes, I had to rest from them for a moment, so I sought refuge in the computer screen. I pulled up the consult note that I had ignored before to scan the investigations her GP had done. Often the ultrasound, for example, will tell me more about the problem than the consult note which will sometimes offer one hurriedly written and often illegible word: Pain! But in this case it was more helpful. Much more! It said that Roseita was deaf, and the effort of trying to read lips in a language she hardly understood made her anxious.

Well of course! I rekindled my smile and pointed to my ears to show I finally understood. The grin that produced almost split her face in half. She pointed to the door, touched her lips, then shrugged in a mute apology before she disappeared down the corridor. She’d left her coat on the chair, so I waited expectantly. She’d be back.

Suddenly, she reappeared with a shorter man in tow behind her. He seemed embarrassed at being in a gynaecologist’s office but was determined to help Roseita.

“Roseita… wife,” he said, hesitantly as he grasped her hand tenderly and held on for dear life. “She… no listen…” He reconsidered the word and corrected himself with a sheepish grin. “She no hear. I… talk on her,” he finished proudly.

And talk we did –although gesticulating and drawing things in the air made it seem like a medical game of Charades at times. We drew pictures on scraps of paper; we pointed; we tried words in both languages; we laughed… But, in the end, I think we all understood more about the three of us than would have occurred with words alone. We do not just speak in code, nor simply write in code. Code is sometimes informal -the inverse of what we expect. It can be what we use to reveal things otherwise hidden, the algebra that explains, the metaphor that illuminates.

I’ve never forgotten that visit. I have learned, I hope, to look beyond mere words. They are only the wrappings that cover the gift offered underneath. To paraphrase Costard, the country clown in Shakespeare’s Love’s Labor’s Lost, I have lived too long on the alms-basket of words.

 

 

 

The Colour of my Baby

What a great idea: a bandage that tells you when what it is hiding, is itself hiding something –an infection.  http://www.bbc.com/news/health-34808273

I suppose it was an idea looking for a platform. When bacteria are growing, they often invent ways to keep doing just that. Sometimes they overwhelm by sheer numbers to defeat the body’s defences, at other times it’s toxins that break down tissues and help them invade. The body, for it’s part, has its own bag of tricks. In the end, infections are often simply a kind of parry and thrust contest –a fencing match, if you will.

Most bodies are not unduly challenged by wounds, however –keep them clean and cover them with some sort of dressing, and they heal. Antibiotics are seldom required. The problem, of course, is that sometimes the foes are not evenly matched. People on immune suppressants (transplant patients), or those with already compromised immune systems –whether from disease or immaturity (babies, for example)- may not be able to mount a suitable response to bacteria in a wound and are at risk of severe infections. These are the ones in whom a timely and appropriate antibiotic would be prudent.

Sometimes, though, antibiotics are used like soap: if it looks dirty, or if it might turn out to be dirty, why not use an antibiotic? Just in case. Well, the simple answer is that the body is usually pretty good at dealing with bacteria. After all, we are all exposed to bacteria from day zero. It starts with the journey down the obviously non-sterile birth canal, and progresses to crawling along things, tasting things… none of which could be said to be free of bacteria of some sort or other. Bacteria are what we do, where we live… Bacteria live in our mouths, in our bowels, on our skin. There are more bacteria in our intestines than cells in our bodies; we simply cannot get rid of them all.

Nor should we. I’ve written before about the benefit of these usually commensal creatures and the benefits they provide both for continuing health and development: https://musingsonwomenshealth.wordpress.com/2014/05/15/the-human-microbiome/

But let’s not be naïve about bacteria –they don’t give a fig about us -they are amoral. A bacterium prefers to live with others –family. They grow and prosper with no regard for boundaries or house rules. Without suitable checks and balances they would take over. Like pouring water in a cup -too much and it merely overflows the constraints and moves on. That’s an infection. That’s when the body may need some help.

The trick is obviously intervening when it is necessary, but monitoring when it is not. Why? Well, treating every wound, say, with an antibiotic might get rid of the truly sensitive bacteria, but leave behind those that don’t respond quite as easily or quickly. The result of the treatment may therefore be to select for those bacteria that don’t mind the antibiotic –the resistant organisms. That’s how it happens.

So in those people who may not be able to deal with bacteria efficiently, it would be helpful to know when –or if– to intervene. That’s where the bandage that changes colour when bacteria in wounds begin to proliferate and infect would be helpful. There are other ways, of course: the old Latin aphorism I was taught in medical school, for example: Tumor, Dolor, Rubor, Calor – Swelling, Pain, Redness (inflammation), Warmth (infection). But sometimes it’s nice to have another tool in the kit that may detect a problem earlier -before these signs are present. Or, in the case of a body incapable of even producing the signs- when an infection would be catastrophic.

Clearly a lot of work needs to be done to detect the mischief of different types of bacteria –they don’t all produce toxins, and even if they did, there would likely be differences in their structures that would have to be accounted for in the detection mechanism. But this may be the bandage of the future –a Facebook band aid that is constantly posting. Almost like refrigerators that tell you what you need, or coffee pots that turn on when they hear the toilet flush in the morning. A brave new world.

It is ‘a hit’, as Osric, a courtier, says of Hamlet’s thrust as he is dueling with Laertes, ‘a very palpable hit.’ Let us hope so.

 

Non-Binary Gynaecology

There was a time when I thought I had a handle on gender, but things change: it’s no longer constrained by only two choices. And then I thought I understood the variations on the theme of sexual preferences. I even learned their names. Now I’ve discovered that no less an authority than the New York Times has decided to recognize that the use of ‘they’ might, at times, be acceptable in referring to a person without disclosing the sex (and therefore prejudicing the choice)–as in, say, ‘When the leader of the delegation announced the agenda, they did so in English.’

I thought I was keeping up. I thought I finally understood the intricacies of gender politics, but I realize that I am still challenged. I am still floundering in the choppy waters of an incoming tide. I’m going to have to stop reading the BBC news online:  http://www.bbc.com/news/magazine-34901704

Okay, I realize that having to use the ‘he/she’ device in the interests of universality (biversality?) makes for some tough slogging for the reader and makes an article, or a story, almost unreadable. But, in my naiveté, I assumed this was just a way of being inclusive: a way of recognizing that past generations had assumed the use of ‘he’ as a universal designation was a convention that was not meant as an exclusion –more like an unthinking shortcut that nobody had challenged.

So I have to say that I was certainly not expecting ‘they’ to evolve so rapidly into the demand for non-binary pronouns; the concept of American universities embracing signs like ‘Ask Me About My Pronouns’ caught me completely off guard. As the BBC article attests, ‘The alternatives to “he” and “she” are myriad.’ Indeed, ‘A linguist at the University of Illinois, Dennis Baron, has catalogued dozens of proposed gender-neutral pronouns, many – including “ip,” “nis,” and “hiser” – dating back to the 19th Century.’ Who would have thought…?

Fortunately –for me, at any rate- ‘[…] Baron calls the gender-neutral pronoun an epic fail and reckons that new pronouns such as “ze” may not survive. But both he and Sally McConnell-Ginet, a Cornell University linguistics professor who researches the link between gender, sexuality, and language, think the singular “they” – as used for example by Kit Wilson – has a chance of success.’

But languages change; preferences and acceptabilities mutate: ‘…English has a precedent for a plural pronoun coming to be used in the singular – the pronoun “you”. Until the 17th Century a single person was addressed with “thou” and “thee”. Later “you” became perfectly acceptable in both plural and singular.’ And then of course, the obverse ‘you-all’ (or the highly recognizable ‘y’all’ in some southern U.S. states’ dialects) -a merging of singular and second-person pronouns.

Now I suspect that much of my confusion at all of this probably stems from my perspective at the night-robed end of the age spectrum. From this spot, there is a tendency to view change as either unnecessary, or spurious -change for the sake of change. I admit my hesitation to embrace the need for even more twigs on the already-gnarled and pot-bound grammatical family tree which is already in desperate need of pruning. Perhaps it needs another pot entirely. Maybe that is what is intended.

I suppose I should have been prepared, though; I think I had a foretaste of it several years ago in my office.

Lynne and Elin were so alike, they could have been twins. Both sat entwined like ivy in a shadowed corner of the waiting room. They weren’t conspicuous or inappropriate, just, well, close. As I busied myself at the front desk with some forms I had to print, I noticed others waiting nearby stealing glances at them while pretending to be absorbed in some magazine or other. Both with short dark hair, identically-coloured light blue shirts, unbuttoned at the neck, and loose, black jeans they scattered no useful gendered clues to the increasingly curious audience.

They both shook my hand when I approached, and both quietly accompanied me down the corridor to my office. I encourage patients to invite their partners to come with them to the consultation, but in a gynaecological practice, embarrassment –or a desire for privacy- often limits the participation of one of them. But not with these two. It was like inviting the flower without the stem.

Even when they seated themselves in front of my desk, I was still uncertain of their identities. Who was Lynne, and who was Elin was only part of the puzzle. I suspected that Elin might be a male partner, but when I heard him/her speak, I couldn’t be certain. Then I entertained the possibility that they were indeed twins –although more likely not identical ones- and that, like many twins, they did things together, whatever their gender.

It was Lynne who had been referred, however, so trying to be respectful of their homogeneous appearance, I stared intently at my computer screen to avoid their eyes, and asked which one of them was Lynne.

A knowing smile passed between them, and the one on the left put up his/her hand like she/he was in a class. “I’m Lynne, doctor,” she said, looking amused. “And this is my partner Elin,” she added, looking proudly at him/her and then reached for their hand.

I was speechless for a moment, but I tried to hide it with a smile and then a nod in his/her/their direction. “I see,” I finally managed and then, looking at Lynne, promptly crossed some sort of a line when I continued with, “I glad you invited her to be with you.” I said it to be polite and inclusive, but I suppose I also said it as a way to establish Elin’s gender. They both stiffened immediately.

“Elin does not recognize gender identity, doctor,” Lynne said in a tone that brooked no contradiction.

“Nor does Lynne,” Elin tossed at me.

“I don’t want to be limited in who I am,” Lynne chimed in. She wasn’t trying to be provocative I don’t think, but I know she realized the effect it would have on me, because her eyes hardened and her forehead wrinkled like a professor introducing a new concept to a fidgeting, skeptical class. “Sometimes I’m both, and sometimes neither… I am what I am in the moment.” She said that with such fervour that one eye actually closed with the effort.

I think she was daring me to question the possibility of a modern-day Janus -the two-faced god of transitions. Instead, I was intrigued and I could see it surprised both of them.

I nodded in acceptance, smiling to myself all the while. I’d never considered the idea before, and I found it fascinating. “So, if I may acknowledge my naiveté in such things, may I ask how you would refer to Elin –in conversation, for example? Which pronoun would you use –masculine or feminine, or…?” I left it open so she/they could offer her/their preferences.

“Well,” Lynne started after a long look at Elin, “we considered ‘ze’ as kind of a neutral pronoun at first, but it sounded sort of… weird. Then we tried ‘ey’ –sort of a slurred mixture of the conventional choices- but everybody seemed to think we had just mispronounced ‘she’ or ‘he’ and tried to clarify it for us.” Lynne shrugged and squeezed Elin’s hand. “I hate binaries,” she added as a sort of postscript.

“So we’ve decided just to use our names instead of other gender-obfuscating pronouns,” Elin said and smiled, satisfied that using the word ‘obfuscating’ somehow deposited the problem behind them. “I mean, if you think about it, even the concept of ‘binary’ suggests that there are only two choices: male and female. We know that is no longer the case,” he/she/they/ey/ze concluded. And I suppose for them (I am allowed to use ‘them’ apparently), it wasn’t.

Lynne suddenly looked at her/their watch and glanced at Elin. “I’m so sorry doctor, but we have to catch a bus to the airport to meet Elin’s mother. I didn’t realize the appointment would take so long…” It was obviously a lame excuse – an escape mechanism, they’d probably used before, but I let it pass. Whatever Lynne’s gynaecological problem, she/Lynne/they felt it could clearly wait for another visit.

Actually, I didn’t think it had taken any time at all –I hadn’t even asked her/them/Lynne why she/they/Lynne thought she/Lynne/they been referred. But I guess pronouns are slow-moving beasts, so I just smiled and asked her/them/Lynne if she’d/Lynn’d/they’d like to schedule another appointment at a time when Lynne/they/Elin could stick around a little longer. I didn’t say it like that, of course –it would have taken far too long and they/Lynne/Elin were obviously in a hurry.

Lynne/Elin/They smiled at me when they/Elin/Lynne left so Elin/they/Lynne obviously didn’t feel they/Lynne/Elin were not heard. And I, at least, felt I’d taken the pulse of a new and perhaps metastasizing condition; I had learned something new about the world. I have two regrets however. One of them is that I never saw them/Lynne/Elin again so I couldn’t pursue my gender education any further; but mainly, I never was able to discover whether Elin was male or female… not that it would matter to either of them, I guess.

 

 

 

 

 

The Trigger Warning

Call me naive, if you will, or maybe even uninformed, but not insensitive. Not indifferent; I am neither.  Unaware, perhaps comes closest. And, until recently, the concept of trigger warning was not one that I thought would have arisen in the day to day world of office gynaecology. But I was wrong.

A trigger warning, I have since discovered, is an alert to the audience (or patient) that what you are going to say might inadvertently offend or upset them –especially if they had experienced a related trauma. Theoretically, at least, it gives them an opportunity to prepare themselves beforehand, or inform you that they would rather not hear that part of your discussion. Many university lecturers have taken to issuing these warnings in their preparatory notes, or at least at the beginning of their lectures, I understand.

And at first glance, it seems the reasonable thing to do. If something in the lecture might offend or distress some students, then they should have the opportunity to opt out of that particular lecture without punitive consequences. On the other hand, to withhold some of the contents from the entire class in case it offends someone, seems like censorship. So I think that a prophylactic warning beforehand is in everybody’s best interest.

I suppose it could get out of hand, however.

Jennifer was a patient that I had seen for the first time in the hospital colposcopy clinic for  a rather long history of abnormal pap smears. I had looked at her cervix through a colposcope (a microscope with a long focal length so it can visualize the cervix even high up in the vagina) and biopsied an area that was likely responsible for the pap smear change; she had come to the office to discuss the findings.

A young woman in her late twenties, she seemed quite self assured as she sat quietly in the busy waiting room reading a magazine oblivious to the noise around her. Dressed in black designer jeans and a baggy yellow sweat shirt that said ‘Really?’ in bold blue letters, she looked capable of weathering any disturbance. But, as absorbed in the intricacies of the magazine article as she seemed, her eyes immediately locked on mine when I appeared in the room. Brown, curious eyes, as I recall; eyes that, once engaged, held their target until it turned away –or responded as I did, with a proffered hand.

When we were settled in my office, and she had inspected the room, a sudden and unexpected smile appeared on her face. It was, I suspect, an attempt to force me to give her good news about the biopsy. “So what did you find, doctor?” she said, with a lilt in her voice.

It’s often difficult to discuss an abnormality with someone who seems sure that nothing is wrong. Obviously her GP had chosen not to. “Well, you remember that the pap smear that brought you to the colposcopy clinic in the first place was abnormal…”

“Yes,” she interrupted, “but it was only mildly abnormal…”

I smiled in what I hoped was a reassuring fashion and nodded. “Pap smears are an early part of a screening system that helps us to decide whether or not to investigate further. They’re just cells that we collect by scraping the surface of the cervix after all.”

Her expression immediately changed and her previously cheerful face tightened. “What are you trying to tell me, doctor?” she said, and straightened in her chair. She stared at me for a moment, but before I could formulate an answer, words tumbled from her mouth. “Do I have cancer? Is that why you brought me in today instead of letting my GP tell me?”

I kept my eyes calm, and shook my head. “No, far from it.” Once someone has used the C word, I often find it’s important to disavow them of it immediately or it festers in the background. “You have a moderate abnormality on the biopsy I took.” I avoided using the Bethesda system’s alternate label of ‘high grade’ to help her to process the news. “It’s definitely not cancer, but if you left it for a while, it might certainly take that route…”

“Left it how long?” she asked, trying, unsuccessfully, to keep the panic out of her voice.

I shrugged, to show her that I wasn’t particularly worried. “Years, likely… but we usually treat it soon after we diagnose it… Just in case.” I added thoughtfully.

Her eyes were dinner plates and her mouth was trembling; I thought she might burst into tears, so I handed her a tissue.

“And… How do you treat it?” She managed to look out the window behind my back for a moment. “Surgery?”

I nodded reassuringly. I was about to describe a small five or ten-minute operation we do in the outpatient’s department under local anaesthetic when she exploded in tears.

“I will not let you take my uterus out, doctor!” she said between sobs. “We’re trying to get pregnant!”

“I won’t let me take your uterus out either, Jennifer,” I said, trying to lighten her mood, I guess. But it backfired.

“You seem to be taking this whole thing rather lightly, doctor. I would have hoped you would be more sensitive…”

My face fell. “I’m sorry, Jennifer. I was just trying to reassure you that removing your uterus was not the kind of surgery I had in mind. It was a rather clumsy attempt, though. I’m sorry…”

Her forehead softened and she grabbed another tissue and relaxed a little on her chair. “Remember, we want to get pregnant soon,” she said, her words tentative now. “We’ve already lost one… I had a miscarriage last year,” she added hastily for fear I might not understand. She stared at me for a moment. “Could I wait till after I’ve had a baby and then do the surgery?

I looked at the findings from the colposcopy once again. She had a rather large lesion and the pathology report suggested that some areas of the biopsy might be more severe -not cancer, but certainly meriting treatment. “You always have a choice, Jennifer…”

“But…”

I realized she probably felt there might be different opinions for management so I sat back in my chair to show her I was willing to listen, but she just continued to stare at me with a mixture of anger and disbelief on her face. “Would you like me to ask your GP to send you to another gynaecologist for a second opinion?”

She didn’t say anything, so I decided to describe the operation I usually perform for her abnormality: a LEEP (Loop Electrosurgical Excision Procedure). It involves taking the abnormal cells off the cervix by removing a thin disk of tissue. I drew on a diagram of the cervix and uterus as I was describing it so she could understand it a little better. I even gave her the diagram to take home with her.

As I was finishing, she looked up from the paper and locked eyes with me again. “And the complications?  Am I going to be able to have children?”

I smiled at her again. I had been about to discuss possible complications with her. “Well, hopefully it won’t interfere with that, but if you look it up online, you’ll see a few complications listed. In my experience they’re not very common, though.”

My attempt to put the complications into some kind of perspective for her obviously didn’t reassure Jennifer. “What are they?” She said, rather harshly I thought.

“Well, in pregnancy, the cervix has to remain strong enough to hold the baby inside until it’s ready. If too much of it is taken away with the surgery, then it might open prematurely –incompetent cervix it’s called- and the pregnancy might be lost…” Her mouth fell open and her eyes narrowed. “But,” I continued before she could say anything, “nowadays that first ultrasound you get in pregnancy can look at the cervix and pretty reliably reassure us that it’s not likely to happen.” I kept my face as neutral as I could in an attempt to disarm her growing distress. “And if it seemed likely that the cervix was shortening, or if we discovered a problem later in the pregnancy –the baby’s a lot bigger then, remember, and so it exerts more pressure on the cervix- we could put a stitch called a ‘cerclage’ around the cervix to keep it closed. Then, near the end of pregnancy when the baby is old enough to be born safely, we untie it…”

She could barely speak, she was so angry. She glared at me through predatory eyes and then, with clenched teeth and a barely open mouth, she managed to say something. “You know, I’m really disappointed in you doctor! With all your experience and with all I’ve heard about you, I’m really disappointed.”

I suppose my expression changed to one of puzzlement –astonishment, really- because she immediately began to put on the coat she’d kept on her lap.

“You knew I’d had a miscarriage –it’s on that form I filled out in the hospital for that clinic. And I told you here in the office just a minute ago. You could see I was worried, and yet you still kept talking as if it was simply business as usual…!” She grabbed another tissue and dabbed both eyes again. “I had a hard time recovering from the pregnancy I lost… But you didn’t care!”

“I’m sorry… I…” But she wasn’t listening.

“Any doctor who was sensitive to their patients –anybody for that matter- would have known to give a trigger warning…” she said and stood to leave. “I’m going to ask my GP to send me to someone more empathetic,” she said and turned on her heel and stomped angrily out of the office.

I felt terrible too; I felt I’d failed her -even though there’s no easy way to tell people things they don’t want to hear. Thinking back on it, I suppose I was insensitive to her needs. And yet…

It’s hard to be anything but humble in this field…