Here’s ado to lock up honesty

Sometimes I think we want to simplify things too much; we crave bichromality: on or off, yes or no. We want certainty, not a spectrum. An answer, not another question -a decision, in other words. And yet if we stop to look around, it seems obvious that things are seldom black or white -there are colours everywhere.

Relationships are no different -how could they be when two unique individuals are involved? When evaluated over any period of time, they are in constant flux. Contingent. Their often turbulent waters involve negotiation -one might even say navigation. There are no reliable maps -and unless there is local knowledge, ‘Here be dragons’ like those drawn on medieval charts in areas where there was insufficient information to avoid dangers.

Even initial reassurance may require sudden modification depending upon the conditions -we cannot always know in advance how things will work out. Indeed, the very fragility of the substrate is one of the important reasons why we are so enamoured with fine porcelain, with delicate lacework, with Trust.

But relationships, except in a legal and sometimes transactional sense, are seldom maintained by official written contracts -it’s more of an understanding, verbal or otherwise. This is fine, of course, but susceptible to misunderstanding or deliberate deception. Vulnerable to sudden, unexpected changes in either partner. Difficulties in effective communication…

Words, words, words,’ says Hamlet to Polonius. It almost doesn’t need an explanation, does it? Similar to his ‘That one may smile, and smile, and be a villain’ -although admittedly in a different context. But the meaning is clear: one can hide behind a curtain of sound, or a reassuring appearance, so that what is being conveyed may be confusing -purposely, or accidentally.

The problem, I suppose, is in knowing the intent of either one of the participants and its effects on the other. This is especially important in sexual matters where effective communication often lags behind the actions, and frequently is restricted to vague, initial permission followed by hormonal dictates.

It is a subject that people often feel reluctant to talk much about beforehand. Meanings of words and actions can change in the heat of battle, making prior negotiation -setting ground rules, and such- important. Sexual dialogue is not something taught particularly well in School Health Classes, so I was pleased to find an article in Aeon that was willing to tackle it head on.

The author, Rebecca Kukla, is professor of philosophy at Georgetown University and senior research scholar at the Kennedy Institute of Ethics. She explores the language of sexual negotiation. ‘Philosophers who specialise in what is known as ‘speech act theory’ focus on what an act of speaking accomplishes, as opposed to what its words mean.’ She writes that, ‘all speech acts are governed by what philosophers call ‘felicity norms’ and ‘propriety norms’. Felicity norms are the norms that make a certain speech act a coherent possibility… I can’t name someone else’s baby just because I feel like it, by shouting a name at it. These would be infelicitous speech acts. ‘Propriety norms are norms that make a speech act situationally appropriate. So, although I have the authority to order my son to clean his room, it would be a massive norm violation for me to walk into his classroom at school and shout at him to clean his room in the middle of class.’

‘In public discussions about the ethics of sexual communication, we have tended to proceed as though requesting sex and consenting to it or refusing it are the only important things we can do with speech when it comes to ethical sex… Consenting typically involves letting someone else do something to you. Paradigmatically, consent (or refusal of consent) is a response to a request; it puts the requester in the active position and the one who consents in the passive position. And in practice, given cultural realities, our discussions of consent almost always position a man as the active requester and a woman as the one who agrees to or refuses him doing things to her.’

And yet, ‘Autonomous, willing participation is necessary for ethical sex, but it is not sufficient. We can autonomously consent to all sorts of bad sex, for terrible reasons. I might agree to do something that I find degrading or unpleasantly painful, for instance, perhaps because I would rather have bad sex than no sex at all, or because my partner isn’t interested in finding out what would give me pleasure.’

‘Usually, when all goes well, initiations of sex take the form of invitations, not requests… But when I’m trying to establish intimacy with someone as I am getting to know them, an invitation is more typical and likely more conducive to good, flourishing sex than a request… Invitations create a hospitable space for the invitee to enter.’ An invitation to dinner, for example. And ‘An interesting quirk of invitations is that, if they are accepted, gratitude is called for both from the inviter and the invitee. I thank you for coming to my dinner, and you thank me for having you.’

‘A sexual invitation opens up the possibility of sex, and makes clear that sex would be welcome. Invitations are welcoming without being demanding… Notice that if I invite you, appropriately, to have sex with me, then consent and refusal are not even the right categories of speech acts when it comes to your uptake. It is not felicitous to consent to an invitation; rather, one accepts it or turns it down. So the consent model distorts our understanding of how a great deal of sex is initiated, including in particular pleasurable, ethical sex.’

Kukla goes on to talk about when and if invitations are appropriate, and then about such issues as ‘gifts’ of sex in long-term relationships, as well as the sociology of gifting. But her discussion of ‘safe words’ I think is one of the most important topics she covers. So, ‘Even if we freely consent to a sexual encounter, or otherwise enter it autonomously (for instance, by accepting an invitation), we also need to be able to exit that activity easily and freely. Entering autonomously is not enough; sexual activity is autonomous only when everyone understands the exit conditions and can stop at will, and knows and trusts that they can do this. This requires shared linguistic norms for exiting any activity. Safe words, properly employed, provide a framework that allows everyone to understand when someone wants to exit a sexual activity.’

‘Part of what is interesting about safe words is that they let someone exit an activity at any time without having to explain themselves, or accuse anyone of transgression or any other kind of wrongdoing (although they can also be used when there has been a transgression)… One reason they are important is that inside a sexual encounter, speech is frequently nonliteral… We need very clear ways to be able to tell when someone wants to leave this nonliteral discursive context.’

And, as she suggests, ‘Safe words are powerful discursive tools for enabling sexual autonomy, pleasure and safety, in at least two senses. Most straightforwardly, they offer a tool for exiting an activity cleanly and clearly, with almost no room for miscommunication. But even more interesting to me is the fact that safe words allow people to engage in activities, explore desires and experience pleasures that would be too risky otherwise. When we want to experiment with something that might give us pleasure, but also might make us uncomfortable or put us at risk, we need to be especially sure that we can exit the activity easily.’ But, of course, ‘safe words should never become the only way that someone can exit a scene or activity – all participants need to remain flexibly responsive to other discursive cues as well.’

Unfortunately, the ‘strong social tendency to focus our discussions of sexual negotiation on consent and refusal has resulted in a narrowed and distorted view of the pragmatics of sexual communication. Correspondingly, we have tended to focus on rape and assault, understood as nonconsensual sexual activity, as the only sexual harm we need to worry about. In fact there are many ways in which sex can go ethically wrong, other than by violating consent.’ Kukla feels that ‘sexual autonomy also requires the ability to engage in clear, pragmatically complex, fine-grained sexual communication – including uses of language that go well beyond consenting to and refusing requests for sex.’

There is so much more to communication than words, isn’t there -and so much more to words than meets the ear?  Hamlet again: ‘There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy…’

The Cloth of Words

Sometimes I wax nostalgic. Sometimes communication itself seems drab, with none of the makeup, none of the panache that identifies it as the look of someone I have grown to know.  Emails, like strangers in standard-issue suits, knock at my door then talk from the other side of the threshold, neither wishing nor invited to enter. They were hired for the job -messengers only; they do not expect a handshake or a hug, only an acknowledgement of delivery. And whether or not you are thankful for their service, or acquiesce to whatever their graphemes convey, is nothing to them.

It is everything to me, however. Often, if I cannot look into the eyes of whoever writes, I do not know their thoughts -there are too few clues to allow me into their head. A typed sentence, however thoughtfully composed, can disguise a world of difference, hide be-clothed thoughts, and without a face, is no more helpful than a dictionary.

Perhaps it is just my age that asks for more than words… and yet maybe there is more to know about a word than how it is defined, or whether it is polite. I do not care so much about the grammar or whether it is properly spelled, as I do about its intent. Information is more than message; it is often more than just the tapped collection of recognizable phonemes strung together across the screen. ‘Words, words, words’, Shakespeare’s Hamlet answers when asked what he is reading by Polonius. There are times when that’s all they are -hardly more.

But at least in those days, they were likely handwritten in cursive, marred by hasty smudges, the ink itself affected by whatever visible trembling the message caused. Readable as much by appearance as by content, in other words. That the writer actually touched the page as they felt the emotion they’ve conveyed, is one of the ineffable attributes of a handwritten note.

Recently, while cleaning out a cardboard box stuffed in the corner of a little-used closet, I found a wrinkled envelope written with now-faded ink in a hand that made a chill run down my spine. It was a letter written to me just after I first went away to university a thousand years ago. The writing was unmistakably my mother’s, with her carefully tailored ‘b’s and precisely dotted ‘i’s, the loop of her ‘q’s a set distance below the line to precisely match those of her ‘y’s and identical in length to the downward stroke of the ‘p’ -Grade school exactitude, like she had taught me and her students so many years ago.

In those days I had required lines to guide me horizontally across the page without any hint of slope -it’s how we were marked. It’s how she marked, at any rate. But, of course, she no longer had need of lined paper after so many years… and yet, lines were how I remembered her notes to me. I always assumed they were reminders of proper form: Address at the top right hand side of the page, and then the ‘Dear’, one line below that on the left (or sometimes two lines, as if she were granting me that styles were changing).

Maybe that’s why this letter was so unusual: it was unlined, and her customary measured loops and dips were erratic, although still readable. At times they seemed hurried -like she needed to get to what she wanted to say, but had to prepare things first. Prepare me

She had surrendered to custom and was using a ballpoint pen by that time, but even though the ink flowed freely from its tip, I could see areas on the page where she had dug it more deeply into the paper as if she had been tempted to underline a word for emphasis, but had thought better of it.

I suppose anyone else simply glancing at the page would have judged it neat, and yet I could tell as soon as I opened it that there was something wrong. Everything was in the correct order, and in a quick peek at the bottom of the page, I saw the reassuring ‘Love, Mom.’ in its designated place, but with far more than the requisite number of ‘xo’s lining the space below the ‘Mom’.

And she still used my childhood nickname, but it looked forced, artificial -as if the news she was about to tell me demanded an adult name, an adult tone. I was, after all, a grown-up now in university, and no longer living at home. I sensed she hesitated over her choice, but wanted –needed– to maintain a mother’s reassurance to her little boy. We were still a family, no matter where I lived.

‘I tried to phone you several times,’ it started, ‘but I suppose you are at evening classes a lot, and there’s been nobody around to answer the phone in your room. So I decided to write.’ Her words were becoming hurried, I could tell, because the spaces between them were decreasing. She even forgot to dot an ‘I’ which, as I’ve suggested, is almost anathema to her.

I raced through the letter, more and more distressed by what I saw.

‘You know how much we all loved Boots,’ was when it hit me, and the tears started. The past tense! The dog I had grown up with, slept with, taken with me on innumerable walks, the dog who was as much ‘me’ as my reflection in the mirror, whose warmth I could still feel, whose eyes forgave me whatever I’d done -the dog whose tongue I can still feel all these many years later… Past tense!

‘He had been slowing down, remember, sweetheart? You used to carry him up the steps to bring him inside.’ There was something resembling a smudge on the page, but I couldn’t be sure -ballpoint ink doesn’t readily smear- but nonetheless, I remember touching the page in that spot just to check.

‘Dad put him on his blanket a few nights ago, and he must have died in his sleep, because he was gone when we woke up the next morning.’ Then she started a new line, so I’d understand how important it was. ‘His face was wonderfully peaceful, and he looked the way he used to when he had just fallen asleep as a puppy: relaxed and happy that things had gone so well.’

Even now, reading the wrinkled note, I felt the tears welling up again. Some things you just can’t help. Some things are more than just the words. More than just the message…

The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.


The Mistaken Identity

Communication is a fascinating thing. It enables descriptions of the world in different sounds, different gestures, different expressions. A shrug of indifference in one culture is a greeting in another. A nod can convey a myriad of intentions -context is everything. Only the smile seems a common currency. As a gynaecologist, I am ruled by boundaries, beyond which I dare not venture without, at the very least, the permission of a smile.  It is a sign hung upon the face that needs no words -the Rosetta Stone that unlocks the mysteries of culture and walks the unfamiliar language like a bridge.

My office is a tiny United Nations, with a rainbow range of clothes on display, and skins to match. The waiting room is impossible to ignore, but equally difficult to understand. Words are encrypted by language, and intent masked by the panoply of expressions encoded in millennia of habitual use. It is a place of pleasant noise. Expectant. Pregnant, if I may say, with expectations both imminent and anticipated. Now is just a passing fancy; it is the future they await: a baby, a diagnosis, or just the reassurance that they are in not imminent need of help. It is a place of smiles, both nervous and shy -signals that they understand their different reasons for sitting side by side.

But it is sometimes a more confusing world once they have entered my consulting room. Words matter there. Meanings are crucial, explanations need context, symptoms require a modicum of description. Except for the more flagrant and visible aberrations of bodily integrity, diagnoses require detail. Language. And patients who are adept at simple conversations in English often struggle with words they would not encounter in the home. What is hidden from sight, is usually hidden from discussion: there is seldom a need to talk about an ovary nor, for that matter, a vagina -even in their own language. It is more often passed over with a blush, or an anxious smile.

I tell the referring doctors to ask their patients to bring a translator with them if they think it may be a problem, but too often it is a family member with similar language skills who accompanies them -a daughter who is too embarrassed to say the words, or a husband in front of whom she is ashamed to admit the problem. Everyone smiles, but often with incomprehension or discomfort.  I love the challenge.

Sometimes the challenge is of a different sort, however; sometimes it is me who is embarrassed.

There were just two of them in the waiting room -sisters, likely, and not too far apart in age. As I walked into the room to greet them, they were huddled together whispering loudly about something and didn’t notice me until I was standing right beside them.

“Wei?” I said in a rather tentative voice, reading the name off the referral letter that was written on a piece of paper, but not certain I had pronounced it  correctly.

I was immediately greeted by a smile -two smiles- and they both stood up. Neither made eye contact, but they followed me down the corridor to my office -normally a good sign. I felt confident that one of them was Wei.

“Wei, you sit in this chair by the desk,” I said, addressing the space between them, and hoping for clarification in the assigned seat. But instead, they seemed confused and I could almost feel the mental flipping of coins as to who sat where. I addressed the Wei seat first. “Wei?” I said, to cement the relationship.

They both smiled -nervously, I thought. The Wei seat answered for them both. “Wai,” she said -by way of correction I assumed. Even though I’d taken conversational Cantonese many years before, I never mastered even the rudiments of the many variations of pronunciation, let alone meanings of words that seemed otherwise identical. But I was happy at the confirmation of identity and smiled my acknowledgement.

“So why are you here today, Wai?” I said, careful of my pronunciation. And careful to differentiate her from her sister. Apart from the name, the referral letter was illegible.

They exchanged glances, apparently trying to decide who should answer. Obviously one of them was better at English, and they wanted to make sure I understood. It was Wai in the assigned patient chair who answered. She seemed pleased that she was able to speak, but she, too, seemed to need to clarify the situation before proceeding any further. “She my sister,” she said pointing at the other chair.

I smiled and nodded at the information. “How do you do?” I said to each of them. Clearly there was a series of preliminary introductions and small talk that were deemed necessary. Polite. I decided not to rush things, but after conferring briefly with her sister, she got right to the point.

“Me?” she said, pointing to herself. I nodded in assent. She smiled broadly and looked at her sister. Proudly, I thought. I could see her struggling to find the correct words. “Baby,” she said, and her smile almost split her face in two. “First baby!”

I could tell this was going to be a difficult. Her sister stayed quiet, merely nodding whenever Wai said anything. “Do you speak English?” I said, politely turning to the sister. Hope springs eternal. But she shook her head smiled. “Only little,” she added after a moment and an inquisitive glance at Wai.

It was Wai’s turn. “I the good English,” she said confidently and not without an ill-disguised condescending glance at her sister.

I wasn’t really sure how to proceed. Taking an adequate history was impossible -even finding out if there were problems with the pregnancy so far seemed remote. But Wai appeared so enthusiastic and happy, I thought I’d try for a few basics. “So, when is the baby due?” I immediately regretted the word ‘due’ because her face fell. I decided to try a more basic form: “When baby come?” I felt embarrassed to say it like that -it too, seemed condescending- but Wai understood and smiled again.

“Seven,” she said, holding up seven fingers.

Encouraged, I considered pressing on with more detail. I thought I’d try for the date of her last period -that would  help me plan what to do next in terms of ultrasounds, blood tests, and so forth. “When did your last period start?” I said as slowly as I could without sounding silly. But I quickly realized I’d framed it poorly. “When last bleeding?” I tried, blushing at the clumsy attempt.

Again the smile. “June one,” she said, this time holding up one finger confidently.

Great, I was getting somewhere at last.  But when I then tried to ask her if she’d had an ultrasound yet, it became immediately apparent that I had reached the bottom of the well. I shrugged and put on my best smile. “I’m going to need more information…” I sighed to show I knew how difficult it must be for her. “You’re going to need to bring an interpreter next time, Wai…” She looked disappointed, so I think she understood. She turned unexpectedly to her sister and quickly said something to her that sounded like she was confused. They both looked at me for a moment, and then huddled together in quiet conversation, occasionally risking a puzzled stare and then submerged themselves in words again.

“So, you not talk to Wei?” she said, pronouncing the name as I had in the waiting room and pointing to her sister.

“Are you not Wai?” I said, confused at the pronunciations, then glancing at my watch.

She nodded vigorously and smiled. “I Wai; my sister Wei,” she said, touching her sister gently on the arm. Then they both began to laugh. “You make mistake..?” said Wai -I think it was Wai; I was becoming quite confused. But I have to admit I blushed all the same.

I managed to chuckle along with them; they seemed quite amused by the whole encounter.

“Not problem,” said Wai, glancing at her watch. “We come back.”

And so began another day at the regional section of my own United Nations Gynaecology division… Do you see why I love what I do?

When Silence is Golden

Silence is golden; it can also be difficult. Many of us find it uncomfortable -awkward if it continues for too long. In communication, silence is a benefit that diminishes with time, a value that becomes a penalty. A schism that is counterproductive.

We all want to be heard; we all need to be recognized, and yet that acknowledgment requires reciprocation. Otherwise, we might as well talk to a wall. Listening is not just silence; it is attending.  Listening is not the same as merely being in the same room.

A doctor is often called upon to be a multifaceted creature: she must first be sensitive to her patient’s concerns, and attentive to the sometimes lengthy explanation. She must demonstrate some empathy and understanding of the problem and yet remain calm and reassuring. Equanimity in the face of seemingly intractable issues is usually seen as a hallmark of competence. But, after a suitable time spent listening and incorporating all of the relevant symptoms into a reasonable diagnosis, it is the doctor’s turn to speak. And the art is so often in the timing.

As soon as I saw her in the waiting room, I could see she was going to be difficult. She was an older lady, probably in her late fifties, who was sitting in the corner by herself like an angry statue. Cemented to her seat, the infants crawling on the rug in front of her might as well have been ants on a lawn for all she noticed. Her face was puckered into a tense scowl, her hands were clasped into a tight, unmoving ball on the lap of her long black dress. Were it not for her short, white hair, she could have been mistaken for a shadowed monument, a memorial placed inconspicuously in the corner so as not to frighten the children.

Only her eyes betrayed her presence and they fixated on me like a hawk as soon as I entered the room.

“Gladyce?” I said walking across the carpet and trying to avoid the toddlers.

Her eyes hardened into marble slits and her face into granite. “Mrs. Ardess,” she said, italicizing the sirname through lips that barely moved. I’m surprised she could actually speak through them.

I extended my hand to introduce myself, but she barely touched it. One of my maternity patients across the room rolled her eyes.

I started to walk down the corridor to my office, expecting Gladyce to follow, but she remained seated, perhaps waiting for instructions. “Mrs. Ardess,” I said, turning to her with a smile. She sighed noisily and stood up. She seemed reluctant, though.

I indicated a seat across from my desk and waited for her to settle into it. And as I busied myself with the computer, I could feel those eyes on me again, burrowing into my skin. I returned the favour once I had opened her chart and discovered there was no referral letter.

I was about to ask her why she had been sent to see me, but before I could even open my mouth, she hardened again. “You doctors never listen, do you?” She almost spat the words through her clenched teeth. “I saw a new GP, and I told her I wanted to see a woman gynaecologist!”

This is not new to me, and certainly not an unreasonable request, but sometimes my female colleagues have longer waiting lists than me. I’ve learned not to take it personally. “There is a woman gynaecologist that works with me in the office,” I said with a slightly forced smile. “Would you like me to…”

“That’s hardly the point,” she interrupted. “I told the GP I wanted to see a woman in the first place, not waste my time being shunted around. Doctors never listen. They ask a lot of questions, but it’s like they just pick out what they want to hear from what I say and discard the rest. My first doctor didn’t even seem to understand that I was really worried.

“I told her I have an itchy red lump and that it’s in an area that is very personal. Very scary.” She scanned my face for a reaction, but I was too intent on what she was saying to react. “I’m not very sexually active anymore, so I try to be careful with my partners. You know, ask them questions, assess the risks…”

I only had time to nod before she continued. “So I was frightened that the lump was related to that… encounter.” She almost whispered the word. “It came up a few days later, so I phoned him to reassure myself again.” She softened her expression briefly and for a moment I saw a different woman. “He was so gentle with me, I didn’t really suspect he’d been lying, but I had to check. I was really worried.

“I waited a few more days thinking everything would go back to normal, but when it didn’t, I began to panic. What if it was syphilis or something? Or that HPV thing everybody’s been talking about?” Her eyes, now far from angry, fastened on my face like birds clinging to a branch. “I phoned my GP, but her receptionist said she couldn’t see me for almost a week. When I asked her to check with the doctor to see if she could fit me in sooner, I could hear them talking and laughing about it in the background.” Gladyce was silent for a second, and even unlatched her eyes from my face.

“Doctor Forster eventually came on the phone to ask me why I needed to come in so urgently… But I couldn’t convince her to change her mind. She just told me to take warm baths for a few days and if that didn’t help, to phone her back.” Suddenly Gladyce pinned me to my seat with a glare. “Dr. Forster was just too busy to listen to my concerns. I could tell she was having a bad day herself. So I managed to find another doctor –another female doctor- at a walk-in clinic.

“Maybe I chose the wrong place, but they were so busy at this one they could only see me for a few minutes.” She looked up at the ceiling for a moment. “Actually ‘see’ is probably the wrong word: the doctor never examined me. Didn’t have time, I guess. And when she asked me why I had come to the clinic, I got about two or maybe three sentences to explain and as soon as she heard the word ‘lump’ and ‘non-healing’ she began mumbling about sexually transmitted infections and grilled me on prevention. Then it was PAP smears and how necessary it was to have them regularly. Finally, she managed to segue into cancer and after hemming and knotting her face up said I needed to see a specialist. When I insisted it be a woman, she merely shrugged and said she’d try but that I needed to see whoever it was as soon as possible.

“But she obviously wasn’t listening either. No time. She had other patients to see…”

Gladyce studied me for a moment, obviously thinking about something, her eyes painting wide swaths across my face and chest. Analysing. Deciding. And then her demeanour suddenly changed and a different person emerged. I thought it might be an opportunity to ask her a few questions –finally meet her, in fact. “Well, Mrs. Ardess,” I started somewhat hesitantly, “I can see why you’ve lost some faith in us…”

“Gladyce,” she interrupted with a smile. “Call me Gladyce.”

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 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.

A Picture is worth…

Communication -explanation- in Medicine is so important that one might even consider it paramount. Except in circumstances where the patient receives a treatment of which she is unaware because of an accident or the severity of the illness, her understanding of the reasons for the therapy and the side effects it may engender often determines whether or not the prescribed regime will be followed – and sometimes whether or not it will even have the desired effect. A cure is not necessarily the same as the elimination of all symptoms: think of eliminating a headache only to be left with a fuzziness in the head, a feeling of fatigue, a ringing in the ears… In order to adjust her expectations appropriately and help her to understand what the concept of ‘cure’ might entail -in order to understand what it is not, in other words- there must be an explanation she can understand -especially if there is a process or mechanism she can visualize. An anatomical correlate with which she can identify. An algorithm, even. In many instances, this necessitates the use of diagrams.

The Diagram has always fascinated me; its etymology (loosely rendered as ‘explanation by lines’) less so: there is a magic in its enlightening power that transcends mere lines, outstrips even the most eloquent vocabulary. It is the Word Incarnate, as it were. And yet there are problems: we each see the world through different eyes. The past influences the present; so does fear… And although diagrams are often drawn to allay anxiety, sometimes they merely distract. Whatever I’ve drawn is open to interpretation and confusion if it is not both clear and commensurate with her own notion of what her internal organs look like. And most people have no idea… I sometimes show my post-op patients  pictures taken during their operation -the ovarian cyst that I have removed, for example, or the spot of endometriosis I have coagulated. Unfortunately I suspect that for most, it is a ‘Where’s Waldo’ puzzle -everything is strange but similar and mixed together randomly; for some, an ovary is merely a white meatball in a bowl of extra large fettuccine noodles. Or sausages, maybe. We see what we are used to.

The  idea that my diagrams may not be adding to someone’s understanding of their condition is uncomfortable for me, though. Anathema, maybe. I mean, my uterus looks really similar to the pictures I’ve studied, and I can draw a fairly recognizable Fallopian tube. But if the patient has never seen an ovary, or maybe even thought about a fibroid, the drawing may be totally devoid of meaning for her. She might nod politely as I doodle on about how the end of the Fallopian tube grasps the ovary like little fingers picking up a ball, and hear me explain that it’s why they call them fimbria: Latin for ‘fingers’… but if she wasn’t linguistically inclined -or was simply nervous- the words might still be meaningless. Unhelpful. Perhaps all she was really seeing were two wiggly lines becoming ragged and imaginatively bankrupt at what might be a ball, or a poorly drawn circle. And since she would know that an ovary should contain eggs she might be wondering why I didn’t draw them as well. Two people crossing a bridge and each seeing a different bridge. Two worlds, two paradigms… one diagram.

I was reminded of this the other day when a patient that I had not seen for some time, immediately smiled when she saw some of the photocopied diagrams I keep on my desk for immediate explanatory reference. The one most visible is of a uterus with its two Fallopian tubes arching conveniently far from its side like arms from shoulders. Of all my reference diagrams, I have always been attracted to its simplicity. That it is unmistakably a uterus with Fallopian tubes I thought was obvious; it is so utterly characteristic and self-explanatory there is nothing else it could be mistaken for.

“I see you still have the drawing of the cow,” she said matter-of-factly, and smiled again.

“Pardon me?”

“The cow,” she said, rolling her eyes as if I’d have to be blind not to see it. She sat back in her chair for a moment, to give me time to follow her words, but when I didn’t say anything, she leaned forward again to study it more closely. “Well, I suppose it could be a goat, or something, but…”

She tried, unsuccessfully, to disguise a sigh but when she saw me staring at her, she shrugged and pointed to the uterus. “The head,” she said slowly and carefully, so I could follow her finger on the diagrammatic womb. “And here are the horns.” She enunciated clearly, like a teacher explaining a difficult concept. “See? The tubes are like long, skinny horns sticking out of the top of the head…” She smiled, obviously proud of her explanation.

Two different bridges, I suppose. But the converse can also obtain: the bridge sometimes determines who crosses it. Another patient I hadn’t seen for a while -not the same one, I don’t think- brought in a beautiful black-and-white photo she’d taken of a mountain range. She seemed quite excited about it and immediately plopped it on my desk as she sat down.

I looked at it and smiled. “Beautiful picture,” I said, somewhat taken aback by the irrelevance of its arrival on my desk. I even tried my best to look grateful, in case it was a present. “Did you take it?”

She smiled, but I couldn’t help but notice that behind the smile was a hint of disappointment.

“Can you see them?” she asked, hope creeping into her voice. As if maybe I could redeem myself.

“Uhmm, well I really like the shadows of the trees… Sort of like an Ansel Adams photograph,” I added lamely. “Incredible detail.” I was staring intensely at the picture, not sure what more I could add.

“But what do you see?”

I felt like a child on a school tour of an art gallery. Evidently there was more to the picture than the trees and the mountains. I’d been really proud of my mention of the shadows, but I’d obviously missed the mark.

“Breasts!” she said finally, exasperation evident in the tone of her voice. She pointed to a couple of peaks in adjacent mountains, and waited for any sign of recognition in my face. I suspect what she wanted was a show of admiration for the perspicacity required for her to spot the resemblance.

She was, I knew, a visual artist and becoming quite well known. I tried to pretend I saw the breasts, but the trees kept bringing me back to earth. And for some reason, all I could think of was my cow diagram.  In a feeble attempt at humour I told her I saw a cow -a feeble attempt to diffuse the situation, really.

“A cow?” Her eyes widened in admiration. “Really..? Where?”

I sort of randomly moved my finger around the photo, pausing on a tree after skimming over a rather angular mountain.

She sat back, clearly impressed. “You know it’s really amazing how we all see different things, eh?”

What’s in a name… Cancer?

Words are important. Quite aside from meaning, each has its own shade, its own temperature. Rose calls forth a mood, an emotion, an expectation that is quite distinct from, say, daisy. Words are little coloured post cards that tell stories and paint pictures; each word elicits a miniature portrait in the brain. Together, they tell stories, individually they hint at direction: plot.

We must never underestimate words. Strung together, they are greater than the sum of their parts; considered separately, they are the clothes of narrative: the shoes and socks so necessary for travel. Science, however -more specifically Technology- has travelled so quickly along the route, it has left words trailing in its wake. Unable to keep up with the pace, and often frazzled at the pace, words, tired and dishevelled, have often done double duty: the same old articles of apparel keeping up appearances and providing some continuity for those watching breathlessly from the sidelines. A narrative is difficult to follow, let alone understand, if there are no recognizeable links with what went before. Even neologisms build on standard and widely understood words or phonemes: retrologisms, as it were…

I was therefore intrigued -although not altogether surprised- at the e-publication of a paper to be published JAMA Intern Med ( ) that dealt with how the use of the word ‘cancer’ influenced the way patients made decisions about their treatment options -even when the condition they were asked to consider was pre cancer, not actual cancer. Just that word, in whatever context, was enough to alter their choices. In many instances -especially in medicine- the words we utilize are maladapted, anachronistic and, in fact, misleading…

In the days when cancer was, by and large, only detectable as a fait accompli, who would have thought it necessary to create a word describing a ‘not-quite cancer’, or a ‘not-yet cancer’? And yet there are precedents; although in not quite the same context nor perhaps an entirely appropriate analogy for a sequentially evolving concept, the Inuit of northern Canada have always used different words for different types of snow, for example. To a southerner, snow is snow; it all seems the same to an inexperienced observer, and not worth the picayune divisions. And yet the unique words help identify each type as separate, and behaviourly distinct… Often temporally distinct, as well.

I see this confusion not only among my patients but even with some of the non-specialist doctors who are confronted with a pathology report containing words like adenocarcinoma in situ, or perhaps just carcinoma in situ describing the biopsy of a cervix from a woman sent to my Colposcopy Clinic because of an abnormal pap smear. The cancer (carcinoma) word is there for sure, but some how the suffix in situ -meaning not invasive, or ‘contained’ is missed. And even if it is seen and deciphered, the phrase seems to imply that it is in fact a cancer that has been serendipitiously discovered before it has spread… although it is not! But so emotionally charged is the word -the idea of a cell, a process out of control- that it automatically elicits such a response; it’s almost involuntary: the quick withdrawl of a finger from a flame even before the brain has had time to process the sensation. A triumph of atavism over intellect.

While not necessarily, nor even predictably so, we like to think of cancer as having a precursor. In other words, we like to think there are early stages on its path to malignancy where the cell is not yet out of control and where this identification may allow modification -or elimination- of its otherwise inexorable progress. The explanation often chosen is that in its normal state, a cell is controlled by a series of checks and balances: how it grows and how quickly; how it differentiates and under what circumstances; how it adapts to changing conditions; how and when it dies and under what influences or instructions, and so on. If that control is lost -or even modified- the cell will undergo changes accordingly. And thus, the malignant transformation theory goes, at the beginning of the journey it is under control, and at the end of the road, out of control. So, the trick is to find it as it travels along that route -before it arrives at the other end.

And just as the destination is not the same as the stops along the way, those intermediate steps should not have the same names. If I start in Vancouver and end up in Calgary, why should I call Kelowna, or Banff pre-Calgaries? No, it would be too confusing, not to say misleading. They are what they are… And what they are not is Calgary.

We need different words, new words, words untainted by the whiff of dread, and unsullied by the expectation of disaster. “What’s in a name? That which we call a rose by any other name would smell as sweet.”… Really, Juliet? “The lady doth protest too much, methinks”.


Can we ever understand each other? Know what is being asked of us? It’s not just a medical problem; it’s universal, I suspect. And it’s one that entails far more than simply comprehending the meaning of a word in both its denotative (definitional) as well as its connotative (secondary, or evocative) usage. It involves apprehending -truly appreciating – whatever is intended in the communication.

In a sense it is often a relational concept: we are linked in a sort of symbiosis and inherent in that is the empathetic interpretation of what is being conveyed. Friends potentially have this: Don’t listen to what I say; hear what I mean. We all hope for this, I think -especially when things are hard to express, when words fail, as it were. When we need the other person to grasp something we cannot adequately articulate, we are at a loss -or perhaps more accurately, at a disadvantage- in terms of receiving their help or advice. Words, large or small, can be impediments.

And this is particularly salient in medical encounters where both unfamiliarity with appropriate terminology as well, perhaps, as embarrassment, conspire to camouflage the reason for the visit. Where you say pain, but really mean cramp, or perhaps irregular -referring to your menses, for example- when you actually mean totally unpredictable, or maybe that you’ve even stopped trying to keep track of them… Where cancer could mean something you think your grandmother had -but nobody would talk about it with you- or that in fact it’s what you think you have but are afraid to verbalize it. Heavy is what your periods are not -even though you are anaemic- because they’ve always been like that, and so were your mother’s: They are normal, doctor

I realize this is not usually a major obstacle to doctor-patient relationships, because over time doctors learn to listen to what is not being said; the encounter is frequently more valuable than the words in it -no matter how descriptive. It is also why it is often so difficult to address problems over the phone.

Through the years, I have struck by the need not only to be a good listener, but a good and careful observer. There is as much meaning in silence as in conversation; as much information in examination as description. Words are susceptible to challenge, or misinterpretation; unimportant ones can be uttered with emphasis, significant ones mumbled sotto voce. Comfort level is privileged and not summonable at will. Words escape from the top of the tongue, or are inadvertently trapped behind the teeth; meaning is sometimes a prisoner to safety -be it cultural, or personal. And it can be as unpredictable as the weather; as fickle as a mood…

So then, how can we understand each other -especially in moments of crisis? How can we ensure that others know what we intend -what we need to convey? Is it as simple as choosing the right words, the right syntax? Is it a vocabulary issue, or something more complex? More profound? From the doctor point of view, I would argue for the latter; I think that the essence that underscores all communication, that underlies all meaning, is engagement: being present in the situation at hand; imbedded in the message -both obvious and covert, intended and accidental; alert to context; aware of the unspoken. Words, after all is said, are just drawings in sound; to understand, to really comprehend, we must listen with more than our ears, see with more than our eyes. To listen fully, we must hear.

It is not an arcane prescription, not something requiring years of training; it is what we all attempt when we truly care; it is what is missing when we do not… And absence of the effort is something Shakespeare noticed so many years ago (Henry IV part II):

It is the disease of not listening,
the malady of not marking,
that I am troubled withal.


Several years ago, I noticed a lump in my neck; I was no longer young, and I was terrified. The differential diagnosis was given to me by a colleague I greatly respected, but I had not expected the presentation to be so matter of fact. I don’t know what I had anticipated, but somehow there was a gap between her words and my condition, between her and me, I suppose. That something so important to me could be offered as mere words seemed inadequate. Incomplete. When I looked into her eyes hoping I had misheard, I could see the compassion and the empathy, but it was more like reading a story in a book: the information was there, the meaning clear, but it required an effort on my part to extract it. The story, in other words, was incomplete.

And then she did something that I will always remember -something that for me, proved I had gone to the right doctor: she reached across and touched the hand I had placed on her desk to steady myself. That little gesture of reassurance, that small reminder of the link we all share was enough to see me through that day. And it taught me something about medicine -no, about humanity. About Life.

Words are sometimes simply not enough; explanations, however thorough, are often incomplete.

There’s something magical about touch. I saw a patient in the office on whom I had recently operated. After asking her the usual questions about how she was feeling now that her much-anticipated and dreaded surgery was over, she settled back in her chair with a smile.

“You know, doctor,” she said, placing her hands on my desk for emphasis, “Everybody was so nice in the hospital… I never imagined it would be like that.”

I smiled in return, thinking she would comment on how thoroughly we had discussed the procedure the day after surgery, or the care we had taken to alleviate her pain… Maybe the smiles we had brought to her on our twice-daily rounds… Our constant reassurance, our patience in answering her questions… Our willingness to listen to her. “A hospital can be a frightening place, can’t it?” I said, more as a statement than a question.

She nodded. “Especially at night when all the visitors and doctors have left. It’s a time when you’re all alone in the darkness and those scary thoughts of cancer and bleeding and infection come swirling around like bees to a hive. I remember lying there, staring at the ceiling and worrying. I was wide awake despite the pain medications and a nurse came in to see how I was doing. She was young -about my granddaughter’s age maybe; I hadn’t seen her before. I guess she thought I would be asleep, but when she noticed my eyes were open, she came over to the bed. And you know the first thing she did?”

I could see a tear beginning to form in one of her eyes, so I leaned forward to show her I was listening.

“She took my hand and held it. And you know, for the first time in there, I realized I wasn’t alone. Somebody, a stranger, noticed that I was afraid and came over to comfort me. She didn’t say anything; she didn’t have to…”

There is a dark corridor we all must walk; touch is often inappropriate, damaging. And yet it can be therapeutic, a bridge between the empty, cold empire of words and the warm land of feeling, understanding and empathy. It is an opportunity for communication that can not be taught, only felt -the word itself a testament to its importance. No, I’m not advocating a radical new approach to medicine, an ill-advised crossing of the line. And I’m not so naive as to believe that it is always necessary as proof that a concern has registered. But a hand briefly resting on a shoulder on the way out of the door is sometimes okay, don’t you think?