Weight and See

 

Obesity and dietary issues have been seen as major contributors to diabetes and cardiovascular health for some time now. No longer regarded as outward manifestations of status or wealth in most societies, they are now often subjects of disparagement, and those carrying extra weight frequently stigmatized and derided. As if the very fact of being overweight was an act of moral depravity, or at the very least, a manifestation of weakness. Self-neglect.

Smoking –especially in North America- suffered a similar fall from grace when it became evident that it was a cause of major health problems. But it is much easier to hide a smoking habit than an overweight or frankly obese body. And whereas public measures to stigmatize smoking and outline the health risks may have some effect on smoking behaviours or smoking persistence, they seem to be counterproductive in successfully encouraging exercise for weight loss according to a large study from Britain: http://bmjopen.bmj.com/content/7/3/e014592

This was a long term study starting in 2002 of 5480 participants of both sexes, all at or over 50 years of age, and carried out by Dr. Sarah Jackson from University College London. ‘In summary, these results provide evidence that weight discrimination may be associated with lower participation in regular physical activity and higher rates of sedentary behaviour. Through this mechanism, weight discrimination may be implicated in the perpetuation of weight gain, onset of obesity related comorbidities and even premature mortality.’

The BBC News also reported a perhaps more easily assimilable summary of the study: http://www.bbc.com/news/health-39191100. The point being, evidently, that shaming or drawing attention to the weight a person is carrying is less likely to get them to exercise than a welcoming and supportive attitude. And environment -‘Exercising when you are overweight can be daunting, and the fat-shaming attitudes of others do not help.’

I suppose this study is much like carrying coal to Newcastle, but nonetheless it is important to hold a mirror to societal attitudes and prejudices. It’s often not so much that we mean to denigrate people who hold different values, or who do not seem to espouse the image we find attractive but rather that we hold ourselves apart. Withholding approval can be as devastating as active discrimination and, at least in this case, seldom leads to positive changes.

Unfortunately the problem of excessive weight sometimes slips by in a gynaecology office as well –noticed, but unmentioned- because of fear of upsetting the patient. Occasionally, an opportunity will present itself, however. One has to be alert –and sensitive.

Janina was a new patient to me. I first saw her in the waiting room sitting in the corner seat which was partially obscured by a large, leafy Areca palm. Her head and face were further hidden behind a magazine whose pages never seemed to turn. A large lady by any estimation, she attempted to camouflage it as best she could with an extra-large, loose fitting brightly patterned sweat shirt and bulky jeans. The effect was really quite beautiful –and so was Janina when she finally lowered the magazine. Her large, brown eyes were captive birds that fluttered delicately behind the bars of exquisite eyelashes. Her face was soft and her smile, although timid and infrequently offered, was captivating. She wore her hair long and auburn waves flowed slowly and gently over her shoulders like water on a beach whenever she moved.

She made a show of being nice in the waiting room, but I could tell that she was uncomfortable as she followed behind me to my office. She closed the door quietly behind her but before she sat she moved the chair as far away from the desk as the room allowed.

I smiled at her in an attempt to put her at her ease, but she had already dropped her eyes onto her lap and refused to retrieve them.

“Dr. Blackstock says you are having some problems with your birth control pills,” I said, when it became evident that she was not going to volunteer any information.

She sat perfectly still, her hands clasped motionlessly where her eyes still lay. Finally, she took a long, slow breath, looked at me, then slowly nodded her head. It was a sad movement, and for a moment, I wondered if she was going to break into tears. But she remained silent.

“What kind of problem are you having, Janina?” I asked, after another sepulchral moment.

She sighed again, but her face changed. “Isn’t it obvious, doctor?”

I raised an eyebrow to indicate that it wasn’t.

“Ever since I started on the pill, I’ve continued to gain weight,” she started. “I was never this heavy before…” She paused briefly to let that sink in. “Never…” She let her eyes drift around the room for a moment, finally settling them on a terra cotta statuette of a seated woman with a begging bowl that I’d placed on a little oak stand in the corner. “I don’t want to end up like her,” she said, pointing at the woman. She sent her eyes back to perch briefly on my face. “But even she isn’t as fat as me…”

As the words sank slowly into silence, a tear began to run down her now quivering cheek. I rose from my desk and walked across the room to hand her some tissues. She seemed to appreciate the gesture and her face softened for a moment. In fact, she used the opportunity to examine me as I walked back to my desk.

“You have no idea how people look at a fat person like me…” she finally volunteered and then her eyes focused on a wooden figurine on my desk behind a plant; it was a woman holding a child and peering out as if she were hiding. “I feel like that woman,” she said, nodding at the plant with her eyes.

I must have let a worried expression escape onto my face, because Janina seemed to focus on it. “It’s a different world when you’re fat, doctor. That’s all people see…”

I sighed. I couldn’t help it; she seemed so sad. “I see beauty,” I said –it just escaped from my lips. I hadn’t planned it…

Suddenly she smiled, and her hair danced once again over her shoulders. She straightened herself on the chair, and then with a gentle shrug stood and moved it closer to the desk.

 

 

 

 

Is there really Something in a Name?

What’s in a name? That which we call a rose, by any other name would smell as sweet.

So said Shakespeare’s Juliet. And yet even then –especially then- it mattered. Tribes have always mattered; we have always been known by our tribes: we are all either us or them aren’t we?” And little has changed despite the agglutination of the numberless tribes into tightly knit societies; there are still passwords.

I suspect I have lived in a bubble somewhere all these years; I really did think things were improving –that we were becoming less prejudiced- but I suspect it is just one more of those parochial shadows obscuring our vision here in Canada. Names, religions, skin colours, gender –appearance– all are code words for acceptance or rejection. We may fantasize that we live in a meritocratic land where Justice is blind and deaf, where we are all judged by our abilities and not our backgrounds, but alas we are deceived –or, rather, we deceive ourselves.

And so, more thoughtful societies have cast about for solutions to those biases so deeply ingrained, and often so hidden that we scarcely notice them anymore. The idea of ‘blind recruitment’ might offer one way to help resolve unconscious (or not) biases that plague many employers. Symphony orchestras were among the first to try it as the following CBC news article points out: http://www.cbc.ca/news/business/blind-recruitment-marketplace-1.3462061 -‘When the Toronto Symphony Orchestra began to audition musicians blindly in 1980, putting them behind a screen, the result was profound. While the hiring committee could hear an applicant’s performance, they not see what he or she looked like. They even put down a carpet so high heels couldn’t be heard. Now the orchestra — which was made up almost entirely of white men in the 1970s — is almost half female and much more diverse.’ Another news article, this time in the BBC News echoes this: http://www.bbc.com/news/magazine-34636464

Talent will out, if that is the sole criterion; but it isn’t. Unfortunately, our judgments are not entirely determined by merit; we sometimes are distracted by other, unrelated issues. Gender, seems an obvious one, but topping the list, is race. Foreign-sounding names seem to discourage interest in the further exploration of a CV: ‘Studies in the U.S. and Canada reveal that job applicants with ethnic-sounding names are less likely to get a response than more Anglo-Saxon names, despite having the same experience and credentials.’ So, unless ‘name blind’ applications are mandated, applicants with foreign-sounding names are at a distinct disadvantage in the job market. This is such a blatant waste of talent and opportunity that –at least anecdotally- some career advisers have suggested that their clients harmonize the names they use on job applications to more societally acceptable ones. Or more pronounceable: ‘Luxshiani Ganeshalingham says her friends automatically change their names when they’re looking for jobs. “We shorten our names to get a better response, or more responses.”’

Hiding things on the initial application may allow people the chance for an interview, but it is obviously far from the solution to racial, gender, or religious bias in hiring, however. ‘”… the reality is that people carrying out interviews, at the next stage on from applications, are humans,” says Azmat Mohammed, director general of the Institute of Recruiters. “The thing is for them to be able to analyze their own biases. Everybody has them and businesses are working to address this issue.”’

And nowadays in most Western countries, where discrimination is prohibited by law, or even discouraged by popular media, the biases have been driven underground. ‘”Modern prejudice is the transformation of our biased attitudes,” says the students’ professor Michael Inzlicht. “[About] 40, 50 years ago, one could express overt hostility or antipathy toward a group — ‘No, I’m not going to allow a black person into my golf club,'” he says. “You politically can’t say that any more.” Modern racism is less overt, Inzlicht says, but we see “very clear” biases. “It’s more dangerous … if you’re not aware of it,” he says.’

I can remember sitting on a rather crowded bus last year and feeling grateful that I had found the last unoccupied seat. A young woman with sparkling brown eyes in the adjacent seat seemed to be absorbed in reading and writing notes on some loose papers in a folder, and as she read I could see her sigh, or at times, chuckle at their contents.

Although I tried to be discreet, she obviously noticed my interest and turned to me with a smile. “Students nowadays are so funny,” she said, glancing first at my face, and then back at one of the papers. “They think they are inventing the wheel each time they answer… But, you know, sometimes they come to the question with such an innocent perspective, they really are… The world is different for them –new, exciting… They’re not muddied by the old methods we bring to questions -the old thoughts that channel us like pipes.”

I looked at her more closely when she said that. She was a young woman, in her late twenties perhaps, with dark hair, and a nut-brown complexion. She was actually excited by what she was reading. I smiled at her enthusiasm and, as strangers will, we began to talk of other things as the bus honked and jolted its way through rush-hour traffic. Just before the journey’s end, we exchanged names. Hers was Alice. I smiled at the name –it has always been one of my favourites and I told her so.

She returned the smile. “I have always liked it, too,” she said, almost wistfully. “Maybe it was Lewis Carroll’s influence –sorry, I mean Charles Dodgson’s,” she corrected herself academically with an embarrassed grin. “My mother always read to me in English at night when I was a little girl growing up in Tehran, and I used to ask for Alice in Wonderland all the time…”

“So you mean Alice was a name you chose for yourself? It’s not your birth-name?”

Again, she seemed embarrassed. “No, my real name is Aza; Alice is pretty close though, don’t you think?” The almost childish delight returned to her face and she smiled so brightly, her teeth seemed to sparkle in the sun coming through the window.

“But…” I was confused. “But Aza is such a beautiful name. Why would you want to change it?”

Her expression changed for a moment and she looked puzzled. She tried to disguise it, but her eyes inspected me to determine if I was patronizing her. As if I, of all people, should know why she’d changed her name. For that brief moment, I was one of her less gifted students. But it passed like a cloud and suddenly her smile returned.

Her stop was coming up so she reached up and pulled the cord. Then, in an effort to atone for her doubts about me perhaps, she touched my hand. It was a gesture of friendship at the very least. “Names, not credentials, get you interviews,” she said with a sad smile as she stood up to leave. “And I wanted to teach…”

 

Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

A Feminist Resurgence?

Women’s Liberation -that’s what we used to call the women’s movement when I was a teenager. It sounded like a good idea to me, even though I didn’t really know what it was all about. Girls had always seemed to bring out the best in guys, so I was all for it. I still am. But I have to confess I never dreamed there would be a fifth column. Feminism v. anti Feminism? I didn’t even know there were two sides to the issue until the Cat thing surfaced: http://www.cbc.ca/newsblogs/yourcommunity/2014/07/confused-cats-against-feminism-lampoon-online-anti-feminist-movement.html  I have to admit that the humour sucked me in…

Like most men, I know only some of the basic facts about the Feminist movement. For example, I know about the three waves: the First one got women the vote; the Second was the Sexual Revolution of the sixties; and the Third one… Uhmm… Maybe I’ve got it wrong, but I think it tried to make us all the same somehow – apart from genitalia everything else was culturally engendered. I suppose that all three are all equally important, but it seems to me that the first two were progressive –goal-oriented- while the third was…well, speculative at best, ideological at worst. A dogma.

As a male who loves and respects women, that last wave sort of washed over me. I always thought we made our own paths through life according to our unique talents and motivations. Where there was discrimination, we challenged it; where there was misinformation, we educated; and where there was something for which we were not suited, we adapted. Life is compromise –for both sexes.

But I fear I am embarking upon a road where even angels fear to tread –male ones, anyway. I mean no harm, and I take no sides, but I am truly baffled. The Movement, as I understand it, was an attempt to redress the obvious inequalities in societal attitudes to women. Such things as voting rights, education, safety from violence and equal pay for equal jobs are obvious. They needed a voice –time on the dais. What was perhaps swept under the cultural carpet, however, was a woman’s right to have a say in personal things: life style, contraception. Abortion. The right to make an informed choice when something affected her. And not just a right –rights have a habit of disappearing aux moments critiques– but a mechanism of enforcement. Laws that work. Feminism was a boon: not only did it lay the ground work for legal protection, but by dint of its strident voice, made it heard by those in power.

But rights must also extend to those who disagree. And as a movement ages, it risks a continuing evolution of the needs of those it was originally intended to serve. It risks having to justify itself to its adherents. In other words, it risks having to change along with them. And, increasingly, this does not necessarily entail cultural or political confrontation so much as cooptation: if the other side has something valuable, or is doing something worthwhile, make it look as if it was your idea all along… and then make it your own.

Times change. When I first started in practice as a specialist in gynaecology, I had the good fortune of having a female colleague as partner in the office. But it was a time of assumed misogyny, I’m afraid. A time of confrontational politics and patients. The prevailing wisdom seemed to be mistrust of male doctors. Mainstream Feminism was struggling through the brambles of disparate ideologies –some were conciliatory and accommodating while others were, well, reactionary and contumacious. I was young and inexperienced in the specialty and the times were aflame with societal struggles.

“The tables are turned, eh?” one of my recalcitrant patients said after refusing to be examined. She had agreed to see me when my partner’s waiting list became too long and her pain too great.

I sighed, closed her chart, and sat back in my chair. I didn’t know what to do.

I could see a worried look creep onto her face. “Look, I’ve told you my problem and you’ve seen the ovarian cyst on my ultrasound… Why can’t you just book me for the OR?”

I smiled bravely. “I suppose I could, but if you don’t trust me enough to examine you, why would you trust me to operate on you?”

She thought about it for a moment. “Well, you delivered my friend’s baby…”

“From the doorway?”

Her eyes narrowed for a moment, and then she laughed. “You turn tables back, too, eh?” And with that she got up and walked into the examination room. “Changed my mind,” she said and closed the door behind her.

A reputation is only as good as the first mistake; an ideology only as relevant as the experience it serves. I am a feminist if it serves my patients; I reserve the right to disagree if it does not. But I live in hope that I have misunderstood, and that evolving feminism is still as relevent and as crucial for society as ever. And I can wait -will wait- as Shakespeare advises: “How poor are they that have not patience! What wound did ever heal but by degrees?”