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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A Patient Named Cindy

I enjoyed Cindy (not her real name); how could I not? Short, plump, with uncertain hair of indescribable colour that was tossed on her head like a salad begging for dressing, she captured my interest the first time I saw her in the waiting room.

She was pretending to look at a magazine, all the while sneaking amused glances at the more staid and nervous patients waiting for their turns on the obstetrical pedestal. Her heavily made-up eyes whispered fashion but her dress screamed Walmart. I could see others in the room look away in embarrassment –confusion, more likely- but Cindy just smiled: a queen supremely aware of the distance between her and her court. Regally bemused at their furtive glances, she would sometimes confront the faces hiding behind their own pretended reading, inadequately camouflaged with turning pages, or pointing out a picture to a curious child.

Something about her made them uneasy. Maybe it was the hem of her sequined dress that she wore distressingly close to the edge of her more brightly coloured panties. Or the tattoos on her legs that stretched ever upwards even beyond the hem. But I suspect it was that she knew they were looking and didn’t care. Relished the attention, actually…

And yet the attention her clothes seemed to invite was as unimportant to her as the screen in a movie theater: you needed to stare at it, but it wasn’t really the center of your attention. It was the vehicle necessary for you to appreciate the show. And Cindy knew she was the show.

It was hard to be formal with her –she was so… out there. She did not invite –she would not permit– the usual power pyramid so rampant in a medical office: she was Cindy, and I was the doctor –with a small ‘d’. She needed advice, and I was its purveyor. Period. If she needed shoes, or a dress, she would have gone somewhere else. I was merely the seller of medical suggestions; she could pick and choose from the assortment offered.

When she sat in the chair by my desk that first time –provocatively again, over-revealingly again- she stared at me for a moment, probably wondering if I would react. But I only smiled, kept my eyes riveted on her eyes, and asked her why she had been referred.

A hint of a smile touched her face briefly and then immediately exploded into a delightful and disarming laugh. “Guys never know where to look when I sit like this,” she said, adjusting her posture to a more socially acceptable form and sliding her hem back down over her knees. “You can judge a man by where he puts his eyes, don’t you think?”

“And..?”

“And I suppose I can trust you,” she said with an expression that seemed older and wiser than her twenty-three years.

“Well,” I said, carefully avoiding the mine-fields she had already sprinkled around the conversation, “what can I do for you?” I thought it was the most direct way to elicit a usable response.

A smile so large it nearly split her face in two suddenly materialized. “You know, doc, your question almost makes me dizzy… It’s usually my question. The one I  have to start with as well.” I have to admit that I shifted uncomfortably in my seat. She noticed it, of course. Cindy would. She straightened politely in her chair and dropped her smile to a category B and shrugged. “Sorry. Everybody says I’m a bit direct. I think it goes with the job.”

“Which is?” I asked when I recovered a bit of my usual equanimity.

The smile turned wicked. Naughty. “I’m a hooker.” She thought about the word for the briefest of moments and then added: “Well, actually I usually use the word ‘escort’ but I figured you’d see through that right away. Most men don’t –or at least pretend they don’t. Guys are like that –they like to pretend that you’re not doing it just for the money.” She stared at me for a moment, as if waiting for me to respond. Then she shrugged dramatically. Theatrically.

I casually picked up my pen as if I were going to write it all down and, as with everything I did, she noticed. It was almost as if she felt she could control me with her words. She did, I suppose…

“You want me to stop wasting your time and tell you why I’m here,” she said with a loud sigh and leaned forward across my desk. Normally I feel a need to protect the space on my desk –over the years it has become an extension of my authority, my personal space- but she did it so naturally, it caught me off guard. Anyway, before I could react she said “I want to have a child,” and sat back, retreating into neutral territory.

I must have looked puzzled –You couldn’t hide anything from Cindy, because she answered my expression before I had even framed a question. “Even strumpets want babies, doc.” Then she smiled at my apparent amusement with her vocabulary. “We also read sometimes…”

“Anyway, I came more just to size you up today…” She tittered at her unintended trade-talk pun. She was silent for a moment –something I came to realize was an uncommon jewel with Cindy – and then her eyes twinkled and her whole body smiled. “I think you’ll do, doc. I think I like you.” Praise indeed.

I never succeeded in helping Cindy with her infertility issues, but all the same, she became a regular distraction in the waiting room. She modified her clothes and hair styles, of course, but I had the impression they were all for the same effect. She found ‘regular’ people banal, uninteresting, and so she teased them. Goaded them, really. She seemed to relish harsh looks, and her body language spoke novels about the seating arrangements she usually provoked. She was the only relaxed one in the room, and she knew it. Loved it. Craved it, maybe.

One day, when I peeked around the corner to see if a particularly obnoxious patient had arrived, I noticed Cindy sitting in the corner seat with a heavy looking briefcase. She had placed it between her lewdly open legs, almost daring anyone to try for it. And she had an oddly satisfied look on her face.

When her turn finally came to be invited into the office, she started talking –as usual- before I could open the chart. Not that I needed a chart for her. After preliminary investigations had suggested that the reason for her failure to conceive was that her Fallopian tubes were no longer open –blocked, perhaps, by one of the many episodes of infection she had encountered in her life on the street- I had tried to refer her to an infertility clinic. She hadn’t liked their attitude after one visit, so she kept coming back to see me.

“Got something for you, doc,” she said, positively beaming. “I wrote a novel,” she said, anticipating my question. “I thought you might like to read it before it’s published,” she continued. My eyebrows must have twitched, because she immediately continued. “Yeah, one of my…friends is a publisher; we did a trade.” I didn’t ask.

But I did read it when I got home that night. It was short –fifteen chapters and more of a novella- but amazingly well-written. It didn’t surprise me – Cindy was obviously bright and a shrewd observer of mankind (I use the word advisedly). What did surprise me, however, was the subject matter: the medical system in general and me –disguised, of course- in particular.

It was a story of the life she knew best: she and her friends in the business –the violence of the street, the drugs, the john-encounters, but more poignantly the unsuccessful attempts of the women to be taken seriously. To be treated as needful humans, not occasionally-moving receptacles. Her words were street-harsh, but no less effective. Certainly no less persuasive. It was a book written from the heart, not from the mind, and this made it all the more compelling to me.

The story was one of suspicion of life outside her world. How it disappointed and disparaged the protagonist and her friends; how they mistrusted outsiders by necessity –survival was knit by acquiescence and tribe. Even in illness and need, they felt themselves alone, bereft of help from a mistrustful and unkind society whose judgments were cruel and who forced impoverished expectations of treatment on them.

Then the woman decides her need for a child is so great, and her attempts to become pregnant so unsuccessful, she needs some outside help. So she visits various clinics where the doctors don’t take her seriously. Her friends just shrug and shake their heads. Of course there’s no help out there for people like her –people like them.

But she persists and manages to get a referral to a specialist –a male specialist is all she could get, but she decides to visit him anyway. The waiting room she finds herself in is middle class and she thinks the women sitting there are so intense she is amused. Not a good sign, she figures, but she has gone this far so she is determined to persist.

When the doctor finally leads her into his office she is struck by one thing: a tall carved wooden statue of a thin native woman holding a baby. It is sitting on his desk and there is a plant beside it through which it peeks with curious eyes. And it is smiling. The carving seems to talk to her about refuge. Safety. And it comforts her. This is the man who can help her, she decides. He’d put the carving on his desk beside a beautiful plant for a reason.

And the story ends with her feeling hopeful. No, he can’t help her, although he tries. But that is the point for her: he tries. And that’s what really matters. Not the result, not the abnormal tests, not even the fact that she probably can’t have a baby. Somebody heard her cry of desperation; somebody listened. And maybe that’s what she really wanted all these years: someone who cared.

I have to admit I cried. My god, is taking notice of someone that important? Is what some of us are searching for merely to be heard? Noticed? To be distinguishable from the background?

You know she never returned to the office after that. Maybe she was too embarrassed, or maybe she had no further need, but I really hope her novel was published. And I hope the man who had promised her a voice, became one and not just another moveable shadow in her life.

Performance Anxiety

I have recently developed performance anxiety -no, not the wide-eyed, heart-thumping, late night Viagra-requiring variety… although that does sound interesting. And not the more artistic type you would expect to get while standing behind the curtain backstage before walking into the spotlight to the expectant applause of a full theater. I don’t have that kind of talent. And anyway my more immediate concern there would be tripping. No, it’s far more… digital than that. Perhaps I should explain.

Ever since my days as a high school nerd, pocket protectors have epitomized my calling. True to the role, I tried to stay at the cutting edge of social ineptitude, but as I aged and morphed into an adult, I became aware that the plastic protector pouch looked silly and that, like a tail,  carrying too many pens was vestigial. The age of the nerd was ending and there seemed no one but me around who was at all nostalgic for it. It had become anomalous -a quaint but naive time in a world that had evolved beyond it.

I was able to keep up with the social awkwardness, however, thanks to my annoying habit of not watching sufficient TV to be able to talk sports at the parties to which I’m no longer invited, or by not using the latest slang expression properly -if at all- at work. I still can’t bring myself to say “No worries,” if someone bumps into me, and am more likely to excuse myself for being in their way. I have trouble knowing how to respond to a ‘high five’ gesture, and when introduced to someone new, have an amazing penchant for immediately garbling her name and then promptly forgetting it.

So it was with high hopes that I felt I would be riding a new and different wave with the Electronic Medical Records system I was reluctantly forced to install in my office. In spite of my hesitation, I felt I was about to reincarnate into Geek, the twenty-first century equivalent of my high school name.  I loved the word and immediately tried to parse it.

I have been writing for years on a computer, so I didn’t anticipate any problems with the transition. I do have to admit to a certain nostalgia for paper, though; crumpling it when you make a mistake is one of Life’s irreplaceable pleasures. Even the subsequent necessity of throwing it into some sort of receptacle -and hitting the target- is a form of release. A silent Cognitive Behaviour Therapy.

But I very much suspected that not having something to shuffle in front of me, to rumple up or underline with emphasis, not being able to free-hand a diagram with curved lines and arrows and otherwise describe difficult and obscure anatomical features in full view of a curious patient would prove disappointing. Nerds -extinct or not- have always been complex integrators -visual as well as cerebral. We didn’t just carry all those different coloured pens around for show. We used them -all of them- on different occasions, each with a purpose, like actors in a play.

And indeed, writing, drawing, and underlining while the written-about watched was part of the show. Part of the interactive play. By changing pens, or circling something scribbled on the paper, the person across the desk knew she had said something important. Something helpful. It encouraged her to continue, often with details she would not otherwise have supplied. And it’s a full eye contact game: the nodding head, the subtle but respectful smile, the slow reach for a lab requisition -all signs to the patient that she has succeeded in conveying her concerns. All boding well for an auspicious climax for the interview.

I had difficulty imagining that the clack -or lack of clack- of my fingers on the keys would elicit the same response. Somehow, restricting my interactions to a screen that only I can view seemed anathema to the relationship I was trying to foster. Since everything is printed and filled out in the secret bowels of the computer, there would be no moment of hesitation and then deliberate reaching for different coloured forms -each one invested with authority; no more wide-eyed admiration for the amount of  information I had been able to extract that she could see in her shared view of the chart from across the desk; and no more wonder at the ability of doctors to read their own handwriting -all part of the magic and method that is Medicine.

But when the moment came to transform the interaction from the smooth hiss of a pencil drawing a diagram, from the silent mating of pen on paper, from the sweeping elegance of an encircled thought, or an underlined, obviously critical datum -from, in other words, personal to digital- an unexpected problem arose. Something I could not have anticipated. Something not all the preparation, all the latest technology, nor all my previous experience with computers would have suggested: I simply could not type with another set of eyes staring at my fingers. I could feel the criticism with every pause to check the keys, the judgement whenever I slowed down, the silent mirth in her eyes whenever I chanced a look in her direction and made a mistake… And the more I thought about it, the clumsier I became. I typed like someone wearing gloves. I kept flashing back to the piano lessons I had as a child when I first discovered, to my shame, that I was distressingly ametronomic.

My older patients seemed to understand -I don’t think they even noticed my almost stochastic approach to the keyboard. They were too busy searching for my eyes. Feeling my pain. Like they had come to help me. No, it is the young who notice. But they are usually too polite to criticize openly, too amused at the unexpected levelling effect of shattered hubris to do other than smile. It is I who feel discomfited, I who feel I must apologize… And I who inadvertently delete the page trying to recoup my composure. Re-establish my rhythm.

Performance anxiety now has new meaning for me. It is the wave I am riding as I attempt to surf into the new époque. But I am philosophical about it, and I had a thought: could it be keyboard performance and not the other stuff that is really what separates the young from the grey? Something you don’t need a pill for because it improves with time? And hope sprung eternal… The golden age is before us, not behind us –as Shakespeare wrote, probably typing the whole thing without a mistake -assuming no one was watching from across his desk, of course…

Patient Ethics.

Lately, I’ve been thinking a lot about ethics; I’m not sure why, although I suppose it’s a common attribute of age: a way, perhaps, of appraising one’s own affect on the world. I’ve written before about the usual constituents of an ethical assessment: Respect of Autonomy -respect, in other words, for a different opinion; Justice -or fairness in decisions and judgments; Beneficence -acting in someone’s best interest; and Non-maleficence -doing no harm.

The value and importance of these principles is hard to deny. I suspect the thrust of them is much the same as that of politeness and consideration in dealing with others -a more complicated re-wording of the Golden Rule: the ethic of reciprocity that seems to have appeared in all of the great religions. It is a set of precepts that should apply equally to both parties in a relationship of whatever kind.

Ethics are certainly a requirement in a medical relationship: a doctor/patient duality. It is a recognized and appropriate expectation on the part of the patient, of course… But what about the doctor? Does the artificially engendered inequality ( the fact that it is his opinion that has been solicited) obviate the reciprocal duty to behave ethically in response? Or, put another way, do patients have an implied obligation to be polite -ethical- in their dealings with the person from whom they sought help? It is a vexing question, to be sure.

Of course there are those who will insist that the very inequality inherent in the encounter, the power asymmetry implied in the act of requisition, excuses the petitioner from the need to adhere to the same principles as the petitioned.

Perhaps my expectations are unrealistic, but it seems to me that it is reasonable to expect a complementary gain in my encounter with the patient. It is of a different kind, for sure, and no doubt is assessed as more trivial than hers, but it is, nonetheless, of value to me and therefore, in my mind at least, helps to neutralize the power inequity between us.

As I see it, understanding -or attempting to understand- another person is an experience that should not be trivialized, or underrated. It is a gift to be allowed the opportunity to share another’s world; it is not given lightly, nor freely. It is obviously a privilege not accorded to everybody, a recognition that the opinion sought is valued. Important. And although not immediately evident, thoughtful consideration of the relationship suggests there is reciprocity inherent in the transaction…

Or am I deluding myself in expecting a relational reward? Am I too bound by the process, too inextricably entwined to assess it impersonally? Objectively? Realistically? Is it even possible to judge from the other foot?

And yet… If I do my part, shouldn’t they do theirs? Do we not both share responsibilities as constituents of a contract -however loosely defined? Is there not a moral obligation to deal ethically with each other? Do I also have a right to feel slighted if we do not… Or more to the point, if my patient does not?

I suppose these are merely the ruminations of a person who expects civility to be reciprocal, responsibilities to be shared and ethics to be the warp and weft of a consultant practice. When they are not it is a disappointment that I sometimes feel more keenly than perhaps I should. Who would have thought that I would even have an expectation of bicameral courtesy in such a profession?

Thankfully, the vast majority of people -doctors and patients alike- share these values, but that only makes their occasional absence all the more evident and egregious. Respect for each other is important: something to embrace. It is what we expect of each other…

Virtue, perhaps, is nothing more than politeness of soul (Honore de Balzac). Who could disagree?