Tag Archives: choice

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Learned without Opinion…

Sometimes we are almost too confident, aren’t we? Encouraged by something we’ve just read, and recognizing it as being already on file in our internal library, we congratulate ourselves on the depth and breadth of our scope. Perhaps it’s the title of an abstruse article, and even the picture at the top of the page that helped identify it. Or… was it something online, whose excellent graphics made it memorable? And, of course, what does it matter where you saw it? You’ve remembered it; it’s yours. Anyway, you know where to find it if the details are a bit fuzzy.

So, does that mean you know it -have thought it through? Analyzed it? Understood it…? Unfortunately, the answer is too often no. It’s merely filed somewhere, should the need arise. But knowledge, and especially the wisdom that might be expected to accompany it, is often lacking.

This was brought -worrisomely- to my attention in an article in Aeon. https://aeon.co/ideas/overvaluing-confidence-we-ve-forgotten-the-power-of-humility

Drawing, in part, on an essay by the psychologist Tania Lombrozo of the University of California –https://www.edge.org/response-detail/23731– Jacob Burak, the founder of Alaxon, a digital magazine about culture, art and popular science, writes ‘The internet and digital media have created the impression of limitless knowledge at our fingertips. But, by making us lazy, they have opened up a space that ignorance can fill.’ They both argue that ‘technology enhances our illusions of wisdom. She [Lombrozo] argues that the way we access information about an issue is critical to our understanding – and the more easily we can recall an image, word or statement, the more likely we’ll think we’ve successfully learned it, and so refrain from effortful cognitive processing.’

As Lombrozo writes, ‘people rely on a variety of cues in assessing their own understanding. Many of these cues involve the way in which information is accessed. For example, if you can easily (“fluently”) call an image, word, or statement to mind, you’re more likely to think that you’ve successfully learned it and to refrain from effortful cognitive processing. Fluency is sometimes a reliable guide to understanding, but it’s also easy to fool. Just presenting a problem in a font that’s harder to read can decrease fluency and trigger more effortful processing… It seems to follow that smarter and more efficient information retrieval on the part of machines could foster dumber and less effective information processing on the part of human minds.’ And furthermore, ‘educational psychologist Marcia Linn and her collaborators have studied the “deceptive clarity” that can result from complex scientific visualizations of the kind that technology in the classroom and on-line education are making ever more readily available. Such clarity can be deceptive because the transparency and memorability of the visualization is mistaken for genuine understanding.’

I don’t know about you, but I find all of this disturbing. Humbling, even. Not that I have ever been intellectually arrogant -that requires far more than I have ever had to offer- but it does make me pause to reflect on my own knowledge base, and the reliability of the conclusions derived from it.

So, ‘Are technological advances and illusions of understanding inevitably intertwined? Fortunately not. If a change in font or a delay in access can attenuate fluency, then a host of other minor tweaks to the way information is accessed and presented can surely do the same. In educational contexts, deceptive clarity can partially be overcome by introducing what psychologist Robert Bjork calls “desirable difficulties,” such as varying the conditions under which information is presented, delaying feedback, or engaging learners in generation and critique, which help disrupt a false sense of comprehension.’

To be honest, I’m not sure I know what to think of this. Presentation seems a key factor in memory for me -I remember books by the colours or patterns of their covers, for example. Seeing a book on a shelf often helps me remember, if not its exact contents, then at least how I felt about reading it. But I suppose the point of the article is that remembering is not necessarily understanding.

And yet, the book I see on the shelf may, in some fashion, have been incorporated into my thinking -changed something inside me. I’ve read quite a few books over the years, and been surprised, on re-reading them -or later, reading about them- that what I had learned from them was something totally different from what I suppose the author had likely intended.

A good example is Nobel Prize laureate Hermann Hesse’s Magister Ludi (the Glass Bead Game), which I read in the early 1960ies. I completely misremembered the plot (and no doubt the intention of the narrative) and for some reason was convinced that the whole purpose of this story was to suggest that a young student, Knecht, who had devoted his entire life to mastering the Game, comes to realize that his ambition was meaningless in the grand scheme of things -and near the end of the rather long novel, drowns himself as a result. Anybody who has actually read Magister Ludi, blinks in disbelief if I tell them what I remember of the story: I hadn’t really understood what Hesse had been trying to say, they tell me…

But, nonetheless, the novel had quite an effect on me. Because I remembered it the way I did, I began to realize how we come to rank our beliefs -prioritize our choices compared to those around us. So, was it worthwhile to train for years, dedicate his life, and eventually succeed in becoming the Master of a Glass Bead Game, for goodness sakes? And if he did, so what? Would that really make a difference anywhere, and to anybody?

For that matter, are there other choices that might have mattered more? How would you know? Maybe any choice is essentially the same: of equal value. I thought Hesse’s point terribly profound at the time -and still do, for that matter, despite the fact he probably didn’t intend my interpretation…

Perhaps you see what I am getting at: ‘understanding’ is multifaceted. I learned something important, despite my memory distorting the actual contents of what I read. I incorporated what I remembered as deeply meaningful, somehow. Was what I learned, however unintended, useful? Was it not a type of understanding of what might have been written between the lines? And even if not, the message I obtained was an epiphany. Can that be bad?

I’m certainly not arguing with Lombrozo, or Burak -their points are definitely intriguing and thought-provoking; I just worry that they are not all-encompassing -perhaps they overlook the side-effects. The unintended consequences. Maybe knowledge -and understanding- is less about what facts we retain, and more about what we glean from the exposure.

So, did I understand the novel? Perhaps not, but what I learned from it is now a part of me -and that’s just as valuable… What author, what teacher, could hope for more?

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I had as lief have been myself alone

Just because something is missing, does that mean it should be there -or would be there under normal circumstances? Suppose someone does not realize it’s missing and has no thoughts about it. Under those circumstances, is it really missing -or does that description apply only when it’s noticed? Is the evidence of absence the same as the absence of evidence?

I have to say, this all reminds me of the philosopher Bertrand Russell’s teapot analogy that attempts to suggest that the burden of proof lies upon the person who is making unfalsifiable claims, rather than shifting the burden of disproof to others. ‘He wrote that if he were to assert, without offering proof, that a teapot, too small to be seen by telescopes, orbits the Sun somewhere in space between the Earth and Mars, he could not expect anyone to believe him solely because his assertion could not be proven wrong.’(Wikipedia)

Loneliness is something like that: a social expectation that in the absence of people, one should feel lonely. Value judgements are seldom provable, and yet it sits there like a normally hidden blemish under a shirt, just waiting for a morning mirror.

Perhaps it is important here to distinguish between solitude and loneliness, and an essay by the writer and historian Fay Bound Alberti in the online publication Aeon helped to delineate the boundaries: https://aeon.co/ideas/one-is-the-loneliest-number-the-history-of-a-western-problem

‘The term ‘loneliness’ first crops up in English around 1800. Before then, the closest word was ‘oneliness’, simply the state of being alone. As with solitude – from the Latin ‘solus’ which meant ‘alone’ – ‘oneliness’ was not coloured by any suggestion of emotional lack. Solitude or oneliness was not unhealthy or undesirable, but rather a necessary space for reflection… Skip forward a century or two, however, and the use of ‘loneliness’ [is] burdened with associations of emptiness and the absence of social connection.’

‘The contemporary notion of loneliness stems from cultural and economic transformations that have taken place in the modern West. Industrialisation, the growth of the consumer economy, the declining influence of religion and the popularity of evolutionary biology all served to emphasise that the individual was what mattered – not traditional, paternalistic visions of a society in which everyone had a place.’ But there has also arisen a social stigma associated with being lonely. ‘While loneliness can create empathy, lonely people have also been subjects of contempt; those with strong social networks often avoid the lonely. It is almost as though loneliness were contagious.’

And indeed, it has long been recognized that belonging to a community seems to be associated with mental as well as physical health. So ‘loneliness can exist only in a world where the individual is conceived as separate from, rather than part of, the social fabric.’ Only in a society, perhaps, where individual efforts are recognized as contributions, not anomalies. A bit of a mixed bag, isn’t it: damned if you do, damned if you don’t.

I like to think that I am selectively ‘onely’ -that there is a choice. But as I get older, and wear my years less confidently than my clothes, I find that the options are sometimes rescinded. People -strangers, often women- smile at me when I am sitting alone. And while I have always enjoyed a smile, lately I have come to see it as a harbinger of something else. Something more than just holding a door open for an older man: I hesitate to call it pity, so perhaps I’ll suggest that it is transference -in an almost-psychoanalytic sense. I don’t really think I look that fatherly, but perhaps sitting alone at a table in a restaurant, I evoke not entirely buried feelings of guilt for the infrequent visits to parents. Or is it a premonitory dread of my own anticipated fate?

I was coming back from a visit to some friends a while back, and decided to stop in a little town for some coffee and a snack. I suppose the place was too small for a Tim Horton’s or even a MacDonald’s outlet, so I opted for a generic version on the only main street. It wasn’t at all busy, and there seemed to be a wealth of tables available, so I chose one in the window overlooking the mildly busy street.

For some reason, a woman walking past on the sidewalk outside suddenly caught my eye and smiled at me. Short grey hair, with a dark red ankle-length coat, she seemed not unlike any of the others who had strolled past unaware of me on the other side of the glass, so I promptly forgot about her until I saw her standing beside my table with a coffee in her hand.

“You must be a stranger in town,” she said, not unkindly.

I smiled as an answer, hoping she was just on her way to another table.

She shook her head slowly, as if trying to decide what to do. “You look so much like my father,” she added. “I thought maybe he had decided to come out for a coffee again…”

“Come out?” I said, wondering if that was a good thing or not.

Her smile broadened. “I had to put Dad in a care home last year because he kept wandering off.” She performed a quiet sigh and sat down in the other seat at my table. “He still walks out occasionally. The staff say he gets lonely and decides to go looking for me.”

I nodded sympathetically. “There must be lots of other people there, though. Don’t they help with the loneliness?” I suddenly realized that sounded terribly naïve.

But she nodded politely. “With Alzheimer’s you can be lonely in a crowd, they tell me.” She stared at me for a moment and then had a sip of her coffee. “Apparently it can be more than just frightening for them,“ she added, glancing at me again. “It makes me wonder what it is about being alone that terrifies them -or the rest of us, for that matter.”

I shrugged. “Being alone isn’t always a bad thing,” I said, sitting back in my seat. “Sometimes it can be a choice.”

Her expression shifted just a little, and I could see she was examining my eyes. “Or sometimes what starts off as a choice turns into a sentence, don’t you think…?”

She smiled enigmatically, and after we engaged in a bit more small talk, she apologized for bothering me and then walked slowly over to another table filled with friends.

I don’t know whether she’d been proselytizing or just being kind, but I kind of envied her, you know…

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In choice, we are so oft beguiled

It’s interesting just how important categories are in our lives, isn’t it? I mean, let’s face it, often they’re just adjectives –subordinate to their nouns. Add-ons. And yet, they can frame context, colour perception, and even determine value. Some, like, say, texture or odour may be interesting but trivial; some –size, or cost, for example- may be more important although optional in a description. There are, however, categories that seem to thrust themselves upon an object and are deemed essential to its description, essential to placing it in some sort of usable context. To understanding its Gestalt. These often spring to mind as questions so quickly they are almost automatic. Gender is one such category, age, perhaps another. And depending, I suppose on the situation, the society, or even the category to which the listener belongs, there may be several others that are deemed necessary to frame the issue appropriately.

The automaticity of a category is critical, however. If the category is felt to be of such consuming importance that it needs to be established before any further consideration can be given to the object, then that object’s worth –or at least its ranking- is contingent. It is no longer being evaluated neutrally, objectively. It comes replete with those characteristics attendant upon its category –intended or not. Age, for example, wears certain qualities, incites certain expectations that might prejudice acceptance of its behaviour. Gender, too, is another category that seems to colour assumptions about behaviour. So, with the assignation of category, comes opinion and its accompanying attitude.

One might well argue about the importance of these categories, and perhaps even strategize ways of neutralizing their influence on reactions, or subsequent treatment. The problem is much more difficult if knowledge of the category is so necessary it is intuitively provided as part of what is necessary to know about, for example, a person.

I suspect that in my naïveté, I had assumed that foreknowledge of many of these categories was merely curiosity-driven. Politeness oriented. Important, perhaps, so that I wouldn’t be surprised -wouldn’t embarrass the person at our initial encounter. But I am a doctor, and maybe see the world from a different perspective. A piece in the BBC, however, made me realize just how problematic this automaticity had become. How instinctive. http://www.bbc.com/future/story/20130423-is-race-perception-automatic?ocid

The article dealt mainly with its effects on racism, and the difficulties of countering it if we accept, as some evolutionary psychologists seem to believe, that it is basically intuitive. Evolved for a reason. Wired-in. ‘[…] if perceiving race is automatic then it lays a foundation for racism, and appears to put a limit on efforts to educate people to be “colourblind”, or put aside prejudices in other ways.’ But, as Tom Stafford, the author of the BBC article puts it, ‘Often, scientific racists claim to base their views on some jumbled version of evolutionary psychology (scientific racism is racism dressed up as science, not racisms based on science […]). So it was a delightful surprise when researchers from one of the world centres for evolutionary psychology intervened in the debate on social categorisation, by conducting an experiment they claimed showed that labelling people by race was far less automatic and inevitable than all previous research seemed to show.

‘The research used something called a “memory confusion protocol” […] When participants’ memories are tested, the errors they make reveal something about how they judged the pictures of individuals. […] If a participant more often confuses a black-haired man with a blond-haired man, it suggests that the category of hair colour is less important than the category of gender (and similarly, if people rarely confuse a man for a woman, that also shows that gender is the stronger category). Using this protocol, the researchers tested the strength of categorisation by race, something all previous efforts had shown was automatic. The twist they added was to throw in another powerful psychological force – group membership. People had to remember individuals who wore either yellow or grey basketball shirts. […] Without the shirts, the pattern of errors were clear: participants automatically categorised the individuals by their race (in this case: African American or Euro American). But with the coloured shirts, this automatic categorisation didn’t happen: people’s errors revealed that team membership had become the dominant category, not the race of the players. […] The explanation, according to the researchers, is that race is only important when it might indicate coalitional information – that is, whose team you are on. In situations where race isn’t correlated with coalition, it ceases to be important.’

I don’t know… To me, this type of experiment seems so desperate to appear to be wearing a scientific mantle, that it comes across as contrived –kludged, if you’ll permit an equally non-scientific term. But I take their point. If there is some way of diffusing the automaticity of our categorizations –or at least deflecting them into more malleable descriptors –teams, in this case- perhaps they could be used as exemplars –wedges to mitigate otherwise uncomfortable feelings. Placeboes –to put the concept into more familiar language for me.

Stopgaps, to be sure, and not permanent solutions. But sometimes, we have to ease into things less obtrusively. Less confrontationally. A still-evolving example -at least here in Canada- might be gender bias in hockey. Most Canadians have grown up exposed to hockey, and might be reasonably assumed to have an opinion on the conduct of games, players, and even rules. And yet, until relatively recently, the assumption was that hockey players –good ones, at least- were male. For us older folks, it was automatic. No thought required; no need to ask about gender. But no longer is that the case. For a variety of reasons, there is still no parity, and yet it is changing –slowly, perhaps, but not conflictually. And so, despite any initial challenges, is likely to succeed.

Am I really conflating success in the changing mores of hockey with gender equality? Or basketball teams and how we view their members, with racial equality? Am I assuming that diminishing discrimination in some fields leads to wider societal effects? Yes, I suppose I am. A blotter doesn’t care about the kind, or the colour, of the ink it absorbs; it’s just what it does. What it is. And, in the end, isn’t that what we all are, however vehemently we may protest? However much we may resist the similarities that bind us in relationship for fear of losing our own identities?

But if we step back a little, we may come to appreciate that the correlation need not be like that of a blotter -need not involve a team, or a marriage… I am reminded of the advice from one of my favourite writers, the poet, Kahlil Gibran: Love one another, but make not a bond of love: let it rather be a moving sea between the shores of your souls.

It’s the way I prefer to see the world, anyway…

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Eeny Meeny

I have always been fascinated by the idea of choice –the philosophy of choice. What does it mean to choose? Does the act of embracing one thing necessarily exclude the other, or merely prejudice it? Blemish it? Dishonour it? Alternatively, given an either/or situation, is it possible to throw the pair into a box and merely choose the box? After all, that’s (sort of) what Set Theory allows mathematicians to do –group together unlike things with common properties for analysis.

It seems to me there are several types of choice that range from necessary to frivolous, each with its own particular reason for being made, and each with its own particular set of consequences. Some choices are imposed from without, and some from within; some have to be made, while some are voluntary. Personal. The most compelling ones –for me, anyway- are those in that box –that set…

The issue surfaced again for me after reading another BBC news article on non-binary gendering: http://www.bbc.com/news/magazine-37383914  I published another essay on this topic in July, but there I was more concerned with managing its language eccentricities: (https://musingsonwomenshealth.com/2016/07/13/non-binary-gynaecology/ ) I realized even then that there was much more to it than language, but the more recent BBC article really brought that home. How can you choose between two things when you are both? It would be like choosing between your son and your daughter –a Sophie’s Choice.

And yet, it would seem that Society feels more comfortable with identifiable categories –in this case, they’re usually anatomically assigned, so from that perspective, they’re not exactly arbitrary… Just unfair. Insensitive. Closed…

Perhaps my long career as an obstetrician/gynaecologist has blurred the gender boundaries as thoroughly as it has the social, economic and ethnic ones. When you get right down to it, we’re all more alike than we might like to think, and categories eventually leak like unwaxed paper cups.

I take the bus a lot nowadays –I’m not sure why, really, except that I enjoy watching those around me. And listening. Sometimes I feel a little like Jane Goodall, only my country is the bus, and my subjects, are people, not chimpanzees in deepest Africa. The other day, I happened to be on a rather crowded vehicle just after the local public schools had opened their gates. Standing next to me in the aisle were two young girls, both around eleven or twelve years old judging by their looks. Each was wearing jeans, sneakers, and coloured ski jackets, and both were hugging their backpacks to their chests, for some reason. One, a rather tall girl with short, brown hair and horn-rimmed glasses, was rummaging in her pack for something while her friend –a blond with hair that she had tied into a rather messy ponytail, watched with interest.

“Do you have any gum in there, Cindy?” the blond said, peering into the caverns of her own pack.

“No… I was just looking for some lipstick,” she said proudly, glancing at me as she said it.

“What! Your mom lets you wear lipstick?”

The tall girl blushed at the response. “Well it’s just reddish Chapstick, but it, like, reddens my lips, too…”

The blond nodded collegially, and then pointed at the two seats in front of me that had just been vacated. After that, only scattered bits of their conversation filtered back to me.

“Yeah… sometimes, I do Cindy,” the blond said, nudging her friend.

“But you said…”

“I said sometimes!”

Then Cindy elbowed her softly, as if she understood completely. “I’ve sometimes wondered what it would be like…”

“It’s kinda confusing -every so often, anyway…”

“You mean choosing which…?” Cindy seemed puzzled.

I could tell that the blond had to think about that. Then she shook her head thoughtfully. “No, more like who I am when I try to think about it…”

Cindy looked at her for a moment and then straight ahead, as if she was suddenly embarrassed. “Aren’t you just ‘Connie’? I mean no matter what you feel like, aren’t you still a Connie?”

Connie was quiet for a moment. “I guess…” They were both silent for a bit. “I don’t think names really matter though, do you Cindy?”

Cindy shrugged and looked at her. “I suppose as long as you answer…”

I could hear Connie giggle at that. “I’m still Connie… But whatever you call me, it’s still me inside.”

Cindy nodded slowly but I could tell she was still perplexed about her friend. “Have you…Have you told Father Simms?”

Connie immediately shook her head vigorously and the little ponytail almost came undone. “No way! He’d just tell my parents.”

“How about your mom and dad then?”

“Mommy thinks it’s just a phase –hormones kicking in or something…”

“Well…”

“Cindy I’ve always felt like this; I just didn’t say anything.” She glanced out the window and nudged Cindy again. “Better pull the cord. It’s the next stop.”

Cindy looked up and then obliged. But as they passed me, I could hear Cindy’s concerned whisper -as if it wasn’t something she dared to say it in a normal voice. “But how come you don’t think like the rest of us in the church?”

“How do you know I don’t?” Connie said with a laugh, and they both stepped off the bus, giggling.

I thought about it for a while before my stop came. If I hadn’t just read the BBC article on non-binary gender, I would have assumed they were simply talking about God. But now that I’ve had more time to replay the conversation in my mind… I’m not so sure. Maybe I was granted a privileged audience with someone very special.

 

 

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The Medical Student

She was not old for a medical student I suppose, although her face spoke of experience far beyond her years. But how do you measure age in a profession that cherishes the wisdom and equanimity that so often accompany Time’s passage? No, she was not old, but nor did she possess the naïveté that so often colours the awkward period of youth; she was, in a way, just Maria: confident, inquisitive, but neither gullible nor easily swayed from an opinion once she had weighed the evidence.

Short, with straight brown hair to match, she was dressed in what I would call an unobtrusive fashion –not meant to draw attention to herself but to enable her to emerge from the shadows with dignity should it be required. Only the short white coat so indicative of her student status and which I suggested she remove before seeing patients, would have marked her as out of place in an office that otherwise spoke of the ordinary. I’ve always felt that patients would be more accepting of the student’s presence if they were perceived as being part of the process of consultation with a specialist, not an artifice. Not an appendage. Not an add-on.

Maria sat politely against the wall, legs crossed and a smile tattooed on her lips as she listened to the first of my patients describe how she had finally decided she needed another checkup and a pap smear. For some reason, her family doctor had not felt comfortable in acceding to her request. Maria studied her so intensely it made me nervous.

“What are you using for contraception?” I asked as part of the history.

Janet, who looked  forty or so, but was really 28, just shrugged. She was comfortable with the question; she was comfortable with men who asked them. “I try to get them to use condoms, but…” Maria’s eyes opened wide at this, but she refrained from saying anything. I could see it was an effort for her, though.

As I progressed through the history, it became obvious that Janet was struggling with many issues, but I was impressed that she was trying to solve them bit by bit. Life was not easy for her but she was obviously trying to take control of what little she could. I was just one stage in that process…

After I had examined her, done the pap smear and cultures for infection, and given her the form for the lab to take some blood to rule out other conditions to which her lifestyle had made her unduly susceptible, I sat her down in the office again to discuss her needs.

A broad smile creased her face and her eyes narrowed almost seductively. “Is this where you try to convince me to stop the drugs, and follow the straight and narrow, doc?” There was a fatalism in her tone; she’d heard it all before –many times. Too many times. “…‘Cause you know it’s not gonna happen. I’m just trying to keep myself alive until I decide to change. If I decide. Nobody understands…” Her expression didn’t waiver, but I could tell she was on the brink of tears as she reached for the faded coat she’d draped over the chair. “And there’s nothing you can do until I decide, you know.”

And she was right –all I could do was support her until she was ready. We lived on separate sides of a river that was so wide in most places that it couldn’t be bridged. I felt like reaching across the desk and touching her hand to show her I understood, but I stopped myself. However well-intentioned my gesture, it might be misinterpreted –it was a prologue for most of the men she had encountered… So I just smiled in a lame attempt at encouraging her. “If you ever need to talk, Janet…” I said as she stood up before we could discuss anything further. I don’t even know why I said that -it seemed so utterly inadequate to her needs. I told myself I was only a gynaecologist and that she would require far more than I could ever hope to offer. But I still felt humbled and my specialist arrogance melted away as she left the room.

But just as she was about to leave, she turned and smiled briefly at me. Not seductively –not even out of politeness- but there was gratitude in that smile. Maybe she was just happy that I hadn’t tried to change her like her GP, or that I was willing to wait for her -treat her like an adult capable of making her own decisions. I fancied I could see some hope in her eyes before they hardened to face the world outside.

I’d intended to engage Maria in the conversation with Janet but it all happened so quickly I didn’t get a chance.

Maria stared at me as Janet disappeared through the door. She seemed angry. “So what are you going to do now?” It was not said with kindness. It was not said out of curiosity; she had embedded an accusation in it. A condemnation. The tone was polite, but the insinuation was contempt. I was reminded of that speech by Macbeth: ‘Curses, not loud but deep, mouth-honour, breath which the poor heart would fain deny and dare not…’

“Janet has to want to change,” I said. It was a weak reply, but I already felt depressed.

“And until then..?” She said it sweetly enough, but I could hear the anger in her voice.

I sighed and looked at her. “What would you do, Maria?”

I sensed she wanted to throw up her hands and pace around the room, but I could see she was trying to control herself. “Well, talk to her social worker, for one thing…”

“And tell her what, exactly? That Janet took a small first step to help herself? That she seems to be developing a little bit of insight? That I, for one, see the glimmerings of hope that she will change?”

Maria’s eyebrows shot up. “Change?” –she almost spit the word at me. “How can you say that? We’ve been facilitating her, not trying to help her!”

I took a deep breath and relaxed my face. Maria was not as mature as I had thought. “We’ve been listening to her, Maria.” I smiled to diffuse her eyes. “How often do you think somebody has actually listened to her before? Not tried to change her, warn her, or use her?” I softened my expression even more. “The initial step in any change is actually hearing what the other person has to say. Hearing what she thinks and why. Listening; not judging. Not continually interfering, continually trying to impose our idea of the world on her.”

Maria’s whole demeanour tensed with the injustice of it all. “But we didn’t even get a chance to listen! She walked out of here before…”

“Before I had a chance to advise her? Tell her what she should do?” I shook my head slowly.

“But…”

“But sometimes we have to be patient, Maria. Advise when asked; help when needed.” I shrugged to indicate how hard that was. “She may never change –never want to change. We need to try to understand that… Understand her.”

I don’t think Maria understood; I don’t think she felt her own opinion was acknowledged either. I could tell that in her eyes, I had failed as a doctor. Failed as a person. I had committed with her the same sin that I had committed with Janet: not acting on what I had heard.

Maybe she’s right; maybe one’s own principles should be subsumed in those generally held by a society. And yet… And yet I can’t help thinking of Shakespeare again -this time, Polonius in Hamlet: This above all: to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man… –or woman, in this case…

If age has taught me anything, it is that we live in our own worlds for a reason… I think we must sit with the door open. And if Janet wanders back..? Well, I will be here.

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Sex Selection… or Any Selection

Another day, another march. This time it was the March for Life in Ottawa where the usual Pro-Life rhetoric was rebranded as being against sex-selection abortions. A worthy cause, for sure, and probably more universally palatable than condemning all abortions -whether done for medical, genetic, or even social reasons- as they have in the past. And by aligning themselves with the Feminist movement -protecting female fetuses and ‘more progressive human rights movements’ as the news media report it- they are no doubt hoping to appeal to that segment of the public that has hitherto merely watched from the sidelines.

As a member of that Public for many years now, I am intrigued to say the least. I am -and remain- firmly pro-choice, and yet I cannot deny my concern about sex selection. Quite apart from any argument about the sanctity of life or the morality of abortion, sex selection seems a self-defeating concept. I don’t wish to state the obvious here: like the huge loss of potential, the necessity of a female perspective to balance that of -what?- Testosterone? Or even the more obvious one: who would have the next generation’s children if there were no women? I just think it is inappropriate and short sighted to select on the basis of gender. It simply does not make any sense to me; it wouldn’t in a male-dominated society either: why would they want even more competition..?

I realize these are rather superficial observations on a topic that deserves a much deeper analysis, but I am struck by the emphasis in all this protestation on what we do not have in common. It is perhaps one way to capture attention and engender Media headlines but I would submit that confrontation usually entrenches positions more solidly. If nothing else, it defines an us and a them –a line to cross. It necessitates a backing down by one side -a loss of face, if you will- before there is a victory. And indeed, even to see it as a victory rather than a change is to diminish the other side and those that were adherents. In a way, it is to colonize that other world.

Drawing attention to a cause is one thing; convincing and educating an otherwise indifferent opponent is another. I think that all too often, the terms of battle are such that winning means incorporation: absorption of the entire spectrum of views and opinions of the successful side, and denigration -or at least abandonment- of those of the opposition. Colonization by default, if you will. It’s all politics: you have to convince the Public before you legislate. No smoke-and-mirrors. If there is an imposed settlement, rather than one achieved by both enlightenment and then consensus, it is a short term gain and one that will likely be resisted and maybe even eventually overturned again.

Even my dim recollections of History attest to the wisdom of compromise after conquest: the Roman empire was stabilized over the years almost as much by the accretion of foreign customs and religions as by the continued imposition of force.

I’m not trying to assert that obtaining such important and inalienable goals like Women’s Rights -or Human Rights- are somehow akin to foreign conquests; that we must always be satisfied with compromise. That we must always and forever sacrifice some issues to achieve others. But let’s face it, there truly is a wedge effect: achieve one thing and it often makes it easier to move on to the next on the list. I suspect that those gender selection protesters in Ottawa are well acquainted with that possibility.

But you know, even if it stops somewhere -as it always must in a diverse, multicultural and multifaith society like ours- it is an accomplishment. A blend of opinion, a mixture of viewpoints is ultimately to everybody’s advantage: no one will accept everything -our society is simply too heterogeneous to be of one mind. And ultimately, hopefully -probably, even- in the fullness of time, we and even our presently-held viewpoints might become different shades -ripples- in the melange that bathes us all.

If I may be allowed to cut-and paste from Shakespeare (Antonio in The Tempest): We all were sea-swallow’d, though some cast again (And by that destiny) to perform an act Wherof what’s past is prologue. We must resist the things we cannot abide and advocate for change. But whether, as things progress, we still feel the same or even settle on a middle ground, the expression of the opinion is what is important. A Society grows by increments; it is a work in progress -never finished, never complete. Nor are we, the Public, meant to be displayed for all time in a stone carved years before.

As with Evolution, whatever happens can only be judged in context and we -and even our opinions- in the larger scheme of things, are contingent…

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Baby Boxes

Baby Box. The term itself is innocuous enough -cute, even- but the controversy it has engendered is far from benign. The concept is a simple one: instead of abandoning an unwanted baby, it is possible to leave it safely and anonymously in an incubator, often associated with a hospital, and usually inconspicuously accessible via a little door outside. At my hospital, when that outside door opens an alarm rings at the nurses desk, but it is delayed for 3o seconds or so, to allow the mother to leave and remain anonymous. The UN Committee on the Rights of the Child is asking for them to be banned, at least in Europe (where they are legal in many countries and available in many others), ostensibly because they violate children’s rights to identify their parents.

A German pastor, Gabriele Stangl, seems to have come up with the idea of the box in 1999 in response to the killing of a baby by the distraught mother. I find it hard to argue against the concept of such a refuge but because of the UN concern, perhaps it merits further analysis.

The argument that a child has the right to know its parent is a reasonable one, and yet it assumes that the child in question survives to ask the question. One implication therefore is that the problem lies not so much with the Baby Boxes, as with the need to abandon the baby in the first place. Unplanned pregnancies with the attendant need for contraception, health care programs available for all and social policies that care for people unable to survive otherwise… These, rather than the embarrassing Box that exposes the issues for all to see, are the real problems, so I suspect that the thrust of their argument rests on the need for psychologic, social and medical support for the community in general -and the mother in particular. But these services must not only be available but also accessible to all who require them -in other words, in a culturally and socioeconomically acceptable format that will not threaten those so marginalized that they have dropped out of other well-intentioned public and community programs. Sensitive, in other words, to their needs, however disparate from the norm.

And this is a tough sell to people who have learned not to trust the System with all its bureaucratic and legal constraints. They have realized there is usually a price to pay, whether in pride or criticism of a way of life they had not intended. The prejudice runs deep and subtle and often unnoticed by everyone except the people it purports to help. Having a program in place is one thing; making it effective and useful is another. Canada prides itself on its public health care system, its inclusivity, it’s universality, and yet there are many women who do not avail themselves of it except in dire emergencies, if then. It is not so much the availability of a service, in other words, but more its acceptability, and until we find a way to make it more sensitive to the needs of a population which lives on the edges of an otherwise oblivious society, there will be tragedies.

A wiser government -a wiser UN- would recognize the dissonance and, for the time being at least, prepare for those who, through no assignable fault of their own, do not choose the room it has prepared. The Baby Box is just another room, just another choice. There is no coercion in this, no implied change of policy abrogating the responsibility of a society to care for its less fortunate or less motivated members; it does not mean condoning the abandonment of unwanted babies. It does suggest a pragmatic approach, however: one that recognizes there will always be those who either do not want to be under the umbrella, or maybe cannot even find it. I remember a poem by Emily Dickinson: The soul selects her own society, then shuts the door; on her divine majority obtrude no more. It is a plea for the right of all of us -any of us- to have a choice. And it is a plea for the rest to recognize that there is a choice.

It’s not the choices we must work to change, but the reasons we make them.

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Choice

What do you do if you just don’t like someone -or in the context of a doctor/patient relationship, what should you do? It’s a vexing question at the best of times, but perhaps even more so if you are a patient that has been referred to a specialist. Or you are that specialist…

The question assumes a different dynamic when it is viewed from the perspective of non-urgent healthcare -something with which I suspect we are all familiar. Not to be misunderstood: all healthcare is important. Health is not trivial, nor is the individual perception of it. Nuisances loom almost as large as burdens or hazards in many of our otherwise unthreatened lives. And the very concept of Health itself could likely use a more compelling definition. But that aside, the problem remains: having decided that something requires a diagnosis and hence a remedy, and having been informed that the help in question is only available outside the warm and reassuring nest of the family doctor, what if there is an unbridgeable gap? What if you feel that you simply cannot confide in the specialist? That he will not listen to you? That he will not take your condition or your suffering seriously? That you, in the final analysis, don’t like him?

There are many facets to this problem certainly, but in the end most of it boils down to trust, not to mention respect. On both sides.

In an emergency -an accident, say- the problem of trust is perhaps more secondary: if you’re bleeding, you need someone to stop the bleeding, attend to whatever injuries have been sustained -fix the problem as it were. Only in the recovery phase -the sober reflection phase- does trust re-enter. But that’s after the fact; analysis is usually suspended in the face of dire need. In other situations, things are in many ways more complex: there is time for choice -time, in other words for preference. Trust. Belief. Much in medicine depends on belief: belief that there is help, belief that you can be helped and of course, belief that the doctor is capable of helping you. Think of belief -trust- as being the Supreme Placebo. It is the underlying understanding that hope for recovery is justified. Some situations require less of it -an appendectomy will likely cure appendicitis whatever you think; some situations more: chronic pain, for example. Most conditions probably fall somewhere  between and within this spectrum, and the results of treatment therefore, as well. And treatment is usually a two-way street: an unwriteable contract between care-giver, and care-receiver. Both need to trust each other; both need to respect each other or it won’t work. There are just too many variables.

Let’s return to the original question, however. What if, after waiting for three months or more to see the specialist, you find you do not like him? Well, I suppose in our system, you could refuse to go back to him and request a second opinion. There may be a delay in finding another doctor, and there is always the chance you might not like her either, but at least there is a choice, an option… For you…

But what about the specialist? What should I do if a person has been waiting to see me for several months and I have trouble relating to her? Not because of her race, or creed or sexual orientation; and certainly not because she comes into the office poorly dressed, or seems preoccupied with something else… These things to me are irrelevant. A medical practice is like a UN membership: toleration and respect for differences is part of the relationship, part of the expectation. I do not need to become friends with those that have been sent to me, although I don’t preclude it. And while I hope that my diagnosis of their problem will be accepted or at least considered helpful, I don’t demand to have the final say in their ultimate treatment if they don’t wish it. But there is a core expectation on my part that is integral to my continuing role in their health: not necessarily that I should like the person, but rather that I must not dislike her -not what she stands for, not what she may profess to believe, nor even who, in fact, she is -but her!

There’s a difference, isn’t there? We don’t all get along, but if we do, things flow more smoothly. There can be a give and take of ideas, a path of mutual understanding: on my part, that I think I can help; on the patient’s part, that she agrees that I may very well be able to accomplish what she needs. It’s a mutual thing, and both must be present for the contractual obligations of the referral to be fulfilled.

Admittedly, if there is dislike on one side of the desk, it very likely extends to the other side as well. But that begs the question doesn’t it? The patient may be reluctant to ask for another opinion: there is often a discomfort in that; she may not know what to do or how to extricate herself from the situation. And it is difficult for me to suggest she see someone else as well -especially if it’s not evident that she feels similarly. But in her interest -and mine, to be sure- I feel it has to be done. Fortunately it is uncommon -rare, in fact. I can’t remember more than two or three occasions in all my years in practice where I felt it was essential for a successful outcome. But it is an important option, and one that I think the patient ultimately, if not immediately, understands and accepts. Deserves. A medical relationship should be a space -a room- that both agree to enter. It’s certainly a place where I live… Both of us should be comfortable in the same milieu.

As Jose Ortega y Gasset has written: I am I plus my surroundings and if I do not preserve the latter, I do not  preserve myself. Nor, I would add, the patient herself…

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Choosing a doctor

There are age-old dilemmas in choosing a doctor, aren’t there? Choices often have a way of seeming problematic, even insoluble, when considered in the abstract and all the more so when they have to be made for real. Theoretically, I suppose, they should be made after due-diligence, as the lawyers would say. One merely sets out a series of criteria and then assesses whether or not they have been satisfied. We all do this, to some extent, but often the only criterion that has to be met is whether or not a friend liked the doctor, or perhaps had a good result from him or her. What her scar looked like -never mind what went on underneath it?

But even considering it like this suggests further and more contentious questions: should one choose on the basis of personality -bedside manner, if you will- or results? After all, you still need to interact with the doctor, explain your problem, have it considered and assessed in a sympathetic and respectful manner. A skilled surgeon may be only that – and as I’ve pointed out in previous blogs, surgery isn’t always the answer, but often merely one of many options. If you’re not given the choice, how would you even know there was one?

Do you choose the academician, or the clinician? Knowledge isn’t always translatable into skill. My senior residents usually have the academics down pat -they need to write exams to prove it, after all- but it takes time for them to master the skills that enable them to put it into practice, especially under pressure at three AM or in an emergency where conditions may not be text-book clear. Knowledge is the possession of facts about something; wisdom -skill- is the ability to contextualize them. Use them, in other words.

Oh yes, and then there’s gender -a particularly vexing problem for the male gynaecologist. It seemed especially so when I first started in practice, but I was younger then -more naive. A female colleague and I opened an office together soon after we achieved our specialist fellowships, and I remember feeling hurt (is that the right word?) that our new patients chose -insisted- on seeing her. Finally, and after what seemed like months of empty day-sheets for me, she became so busy that new appointments, even emergencies, had to be deflected. I began to get what I used to call the left-overs: patients who were initially angry that they too had been given a left-over.

Eventually, however, things settled a little and people began to choose on the basis of other criteria than merely gender. Quite simply, males often see things differently. Things that my partner had less patience for -perhaps because she had lived through some of the problems she was being asked to solve and saw them more as complaints than issues needing a solution- I  saw through inexperienced eyes and from a different perspective. I could sympathize with someone having debilitating pain that returned like the moon month after month, year after year. I could understand the need to find a contraceptive that didn’t engender mood changes, or headaches, or intermittent bleeding, or require strict adherence to a schedule so as not to forget to take it. I could sense the tiredness that would be brought on by the demands of breast-feeding, of needing to be constantly alert to the infant, or child’s needs, no matter what else my life required.

But a choice is just that: singling out one from a line up of often similar faces where even the criteria require yet other choices. I suppose if the difference between them is truly small, the choice is even more difficult, but less likely to result in later self-recrimination. One does not -one cannot- choose retrospectively, so any choice could be argued to be the correct one under whatever circumstances it was made. The fact that choice is even possible is a luxury not afforded to everyone, everywhere.

Obviously I have no answer that transcends personalities and specific needs; I would not presume to speak for someone who sees the world from a different background or a different culture. I can only suggest that respect is something that I would look for; that is usually evident on the first encounter. It is in the eyes, on the face and in the gestures. It is woven into the cadence of speech, the words chosen, the smile that, unbidden, lights up the interface between two individuals who are no longer strangers.