The Grief that does not Speak

How weary, stale, flat, and unprofitable seem to me all the uses of this world!

Like Hamlet, we all recognize this mood: the black dog lying in the noonday sun, the cloud that even hides the moon. It is the tear that defeats the wavering smile –and yet… And yet, there is often something more behind the grief, something that is hidden beneath the first impression. Shakespeare, again, understood this over four hundred years ago: ‘Give sorrow words. The grief that does not speak whispers the o’erfraught heart and bids it break.’

I suppose we all impose our own reality; we all see the world through our own experience. But, sometimes we see through that glass darkly. Things are not always what they seem.

Alethea looked calm and happy as she sat in my waiting room. In fact, she was smiling and talking with a little child who’d toddled over to her in his diapers with a toy. She was bending over in her seat, her long black hair almost reaching the little boy, as she tried to make him laugh. Her full-length black, cotton skirt and her blue silk blouse contrasted sharply with his bulky white diapers –a chiaroscuro worthy of a picture, but he waddled off to another woman as quickly as he’d arrived. The waiting room is like that here: a work in progress; an evanescent scene of fleeting beauty.

Alethea smiled again when I greeted her, and examined me with friendly eyes. I had anticipated avoidance, or at least timidity from a woman referred to me with recalcitrant depression. A woman, according to a rather extensive explanatory note, who seemed refractory to multiple attempts at treatment. But I’m a gynaecologist, and although we’re sometimes involved on the edges of depressive illnesses, most of us lay no claim to the territory. We’re adjuncts –often last-minute guests- invited to the therapy just in case; we’re seldom primaries.

But in my office, she seemed less at ease, her eyes flitting from the plants in their pots to the eclectic pictures hanging on the walls. They spent some time inspecting a terra cotta sculpture of a woman begging with a bowl that I’d positioned on a little oak table.

“You certainly have wide-ranging tastes, doctor.” I don’t think she meant it as a criticism, so I took it as the long missing compliment I have yet to hear from my staff.

I smiled, and opened up the computer.

“I’m afraid my GP wrote a rather long note justifying the referral to you; she seems quite worried –or maybe frustrated with me.” Alethea rested her eyes on me for a few seconds. “I asked to see you rather than a psychiatrist.” And then she chuckled. “She was not happy about that, I’m afraid.”

I pushed the computer to one side and sat back in my chair. “Do you mind if I hear your version, first?” I asked.

“Thought you’d never ask,” she said as she made herself more comfortable in the sturdy, old wooden captain’s chair that I insisted on keeping across from my desk, her eyes twinkling with amusement at my suggestion, but still cautious.

“Well,” she started, obviously trying to place the events in their proper order, “A few months ago, I went to see my GP because of some problems I was having –you know, coping stuff,” she added when I wrinkled my forehead. “Anyway, I was in tears when I sat down in her office and had trouble even talking to her without crying.

“She got very clinical and I could tell she was trying to remain an objective observer.” Alethea rolled her eyes and sighed. “She does that sometimes when all I need is a hug or something.” She risked a quick glance at my expression. “But I realize that’s not what doctors are supposed to do…

“Anyway, she asked me all the usual questions about my work, and my home life…” Alethea blinked and looked away. “I think she felt a bit uncomfortable with that part because my partner also used to go to her.” Suddenly she stared at me and I could feel the anger in her eyes. “I really don’t know why that would matter…”

She quickly snatched a tissue from my desk and wiped her eyes. “I’m sorry, doctor, I guess my GP is not the only one who gets frustrated.” She took a long, deep breath and exhaled it slowly. “She said she’d never seen me like that before, and that whatever might be going on, I was seeing it through the lens of depression.” She glared at the begging lady statue for a moment. “She actually said ‘lens of depression’ for god’s sake! Like no matter what I said, or experienced, it was somehow misinterpreted through that bloody lens, or whatever.”

Alethea seemed uncomfortable and kept readjusting her body on the hard chair so I pointed to a more comfortable one nearby. That got her smiling again, but I could tell she was still angry.

“She insisted I go on one of those new antidepressant medications –you know, the ones that aren’t supposed to make you tired. The ‘no side-effects pill’ she called it. ‘Just try It for a few weeks and let me know if it helps,’ she said and escorted me to the door, all buddy-buddy.”

She brought the comfortable chair close to the desk and helped herself to a handful of tissues. “But it only made things… worse.”

I leaned forward on my chair, detecting something she was implying in the way she said that word. “How do you mean, Alethea?”

A tear rolled down her cheek and she dabbed it with the tissue. “I didn’t feel at all like sex, when I was taking it and…” She hesitated for a moment. “And that really made her mad.”

I was confused. “Made who mad?”

She was staring at her lap, but her eyes wandered up to my face for a brief look before she called them back. “My partner.” She sighed again. “So I decided to go off the antidepressants after a while and went back to the GP. She seemed upset that I had only given them a month, and said I was still acting depressed. At that point she said I needed to see a psychiatrist, but I refused. ‘You have a chemical imbalance,’ she almost screamed at me, and implied that if I didn’t get help soon, there might be dire consequences.” Alethea glanced at me again. “I suppose she thought I might try to off myself or something.” She giggled at the thought and when I looked puzzled, she smiled and continued. “Maybe it’s your birth control pill, Alethea. I don’t know why you insist on taking them anyway.’” Alethea’s face turned mischievous and her eyes twinkled like when she first came in. “Because I’m Bi, you stupid woman!” she said and laughed. “Well, I didn’t actually say that to her, but I felt like it…

“Anyway, I convinced my GP to send me to you.”

I squirmed a little uncomfortably in my own, soft chair. “Why me?”

A playful smile emerged. “My aunt and cousin see you… They said maybe you’d listen.”

I think I blushed. “And what about your partner? Did she think you were… depressed?” I hesitated before using that word. “Did she listen?”

Alethea’s face suddenly tensed. “She was abusive,” she said between gritted teeth, and sent her eyes to scout my face again. “She used to scream at me and throw things around. I hated going home after work.”

“Did you tell that to your GP?”

She shrugged. “I told you, she felt uncomfortable about it. And anyway, she had a diagnosis –and a treatment,” she added, with a wry smile. “That’s what medicine is about nowadays, isn’t it?” The smile disappeared, to be replaced by a sweet grin. “And once you have a treatment, it’s… Next!” she said, rolling her eyes, and we both laughed.

“And so what’s happening now? Are you still with your partner?”

Her face beamed and her eyes sparkled. “Now, I’m back with my old boyfriend -it takes a long time to get in to see you,” she explained with a chuckle. “We’re even planning to have a child soon, maybe.” Her eyes hovered under the ceiling for a second or two. “I guess I wasted your time, doctor, but my aunt was right -it does help to talk about it… And I thought I should meet you anyway,” she added, and decided to make eye contact again. “You delivered my cousin last year…” The twinkle returned. “Care to see me again –in a while?”

I think my smile told her I’d love to see her again.

And as she left, I couldn’t help but think of that wonderful metaphor of Khalil Gibran: ‘Sadness’, he said, ‘is but a wall between two gardens.’

It certainly is.

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.

The Wisdom of Experience

Sometimes, I feel like a fake. I suppose the ability to see oneself from various angles is a gift of age, but I rather enjoyed myself more when I was sure of who I was –or at least didn’t trouble myself with the question. And yet, to dig for the core is to taste the apple on the way.

It was easy to be a doctor when, primed with knowledge, experience was something displayed in a shop window, not something I wore. It was an outfit I didn’t need -an extravagance, really: a luxury you only donned when the facts you’d learned were threadbare and outdated. It was a costume of authority, a camouflage for waning certitude: Moira.

And yet as I plough through the years as steadily as a man walking through waist-high water, I have come to realize that experience is more than subterfuge, more than mere artifice; it is Age. Nothing less. And following in its wake is all the jetsam tossed overboard to lighten the journey, all the flotsam through which we, as sentient beings, must wade in order to progress. A dirty passage protected only by the hull of maturity. But enough metaphor.

All of this somewhat depressing prologue is to introduce an incident that occurred a few years ago when I was teaching a medical student in my office. Stephanie was very good, really –very perceptive and knowledgeable- and she carried herself like someone who had already graduated. It was not hard to integrate her into the chaotic machinations of my busy office.

We were seeing a woman sent to me from a well-respected family doctor who sometimes attracted patients with very dissimilar world-views. She had come to see me for a second opinion about the management of her menopausal symptoms. Or rather, she had been sent to see me by the GP when she refused to accept the treatment offered by the first specialist.

A very well-dressed woman with neatly brushed hair, she sat across the desk from me looking quite confident. She smiled at Stephanie, and then straightened her shoulders and stared at me defiantly. “My doctor wanted me to see you about the menopause…”

I smiled and waited, pen poised to write down her complaints so I could address them later, but she sat back in her chair, obviously finished, and stared at the calendar hanging on the wall behind me. “So, are you having any problems?” I asked after a rather awkward silence.

She shook her head and shrugged. “Am I supposed to?”

I glanced at Stephanie, who was sitting on the edge of her seat, fascinated at the exchange. “No…” I said, looking at the referral letter that just said ‘MENOPAUSE!’ in giant capital letters followed by an even bigger exclamation mark. “But I rather thought your doctor must have had some reason to send you to see me.”

The woman smiled –at least, I suppose that’s what she wanted me to think, but actually it was a smirk. “I’m managing my menopause very well, doctor…” It was a challenge: a dare to be contradicted.

“So… there are at least some symptoms you’re feeling a need to manage.” I said this carefully, not wanting to provoke her.

She immediately straightened in her chair and her eyes hardened. “Why would you say that?”

My turn to shrug. “Well, is there anything I can do for you, then?” I kept the smile on my face.

She took a deep breath to contain her obvious irritation. “My doctor thinks I should be taking hormones… And so did that other doctor she sent me to.”

I started to write in her chart –it often helps patients to think they are saying something important. “Why is that?” A simple question; no sense confusing her.

Silence, and then a prolonged blink. “I told her I wasn’t sleeping and was becoming irritable at work.” She pinned me to the wall with a sudden glare and then, just as suddenly, relaxed the intensity. A little grin crept onto her lips, but she erased it almost before it flowered. “And I mentioned I was having the occasional hot flush.” Her face hardened. “Why do we always medicalize things and make them into illnesses?”

She was silent for a moment and I put down my pen. She looked at my now dormant chart, for a moment.

“I do not want hormones, doctor,” she said shaking her head angrily. “I’ve solved the issues myself.” And she crossed her arms across her chest as if to ward off any criticism.

I picked up the pen again and her expression softened a little.

“Ginger and lemon juice three times a day…” she said and then stared at me: the dare again.

“It helps?” An innocent question I thought.

“Of course it helps!” Her arms tightened across her chest. “You don’t always need hormones, doctor.”

I tried to keep smiling and sat back in my chair. “I certainly agree with that, Sandra. Sometimes we pathologize things unnecessarily.”

The change in her body language was dramatic and she unfolded her arms and loosened her shoulders. “So you think it’s okay to continue with my lemon and ginger?”

I nodded and wrote something in her chart. “As long as it’s doing the job, why not?” I started to put the pen down and she noticed.

“There’s a lot of stuff in there that you haven’t filled in yet,” she said with an increasing grin on her face and stared at the almost blank history sheet in the chart. “You can ask me some questions –I won’t bite.”

I proceeded with the usual consultation and then looked up at her. She was beaming.

“You’re the first doctor who actually listened to me…” she said, clearly surprised. “Still think I’m okay with the juice?”

I smiled at her -my face was beginning to ache with the effort. “It won’t hurt, “ I said, and sensing she was satisfied with the interview I got up from my chair to open the door for her. “But just let me know if you need to discuss some other options, eh?”

As soon as she was out of the room, Stephanie rolled her eyes; she was obviously troubled.

“So what do you think, Stephanie?”

She took a deep breath and looked at me. “She needs hormones…”

I sat down and waited for her to explain. “I mean, she was obviously describing estrogen withdrawal symptoms: hot flushes, night sweats, sleep disturbance… And did you see how irritable she was? Classic menopausal stuff.”

I smiled patiently. Stephanie was young and enthusiastic. Full of knowledge. “So what would you have done if she’d walked into your office?”

She thought about it for a moment; that she didn’t want to offend me was obvious in her face. “Well… First I would have taken a detailed history like you…” She politely ignored the order in which I had proceeded. “And then I would have told her about how estrogen –and progesterone, I guess, because she still has a uterus- would help alleviate her symptoms.” She looked at me, whether for approval or permission to deviate from my approach I couldn’t tell.

“And if she told you she didn’t want to take hormones? That she felt they were too dangerous, or maybe she didn’t believe she needed them..?”

Stephanie didn’t even blink. “I would have been more insistent…”

“And if she still didn’t agree?”

That stumped her for a moment. “Well… uhmm, maybe I would have sent her to a specialist for another opinion.”

“To validate your opinion, you mean?” I said it lightly and with a grin to defuse the tension I could feel increasing in Stephanie. “She already saw another specialist, who validated her GP’s view… Now what? Give up on her?”

Stephanie stared at me, but it was clear she didn’t have an answer.

“Look,” I started, gently, carefully, so as not to appear to contradict what we both knew to be true: many menopausal symptoms are related to hormonal changes and many of the symptoms do disappear when you prescribe hormones. “Why was she sent to me?”

Stephanie rolled her eyes again –an annoying habit she was prone to use at the slightest provocation. “To treat her menopause…”

“Didn’t she tell us at the very beginning that she was already managing her menopause?”

“Yes, but…”

“Yes, but not the way you would like?”

I could see that Stephanie was becoming exasperated. “But surely you could see that she wasn’t. I mean, she was obviously really irritable and…”

“Wouldn’t you be irritable if nobody listened to your opinion?”

Stephanie’s left eyebrow suddenly took over half her forehead –another trait I had noticed during her time in the office. “But there’s no data on ginger and lemon juice. No studies…”

“She seems to think it’s helping her.”

“Yes, but that’s just a placebo effect. It’s going to wear off…”

I broadened my smile. “And when it does –if it does- who will she decide to talk to about it? The doctors who were unwilling to accept her approach, or the one who admitted she had the right to try another way?”

I’m not sure I convinced young Stephanie, and I’m certain that she’ll succeed in whatever field of Medicine she chooses. But I do hope that she learns that the paths we need to follow are not always straight and that even detours usually end up where we want…

 

 

 

 

 

 

 

 

The Doula

For some reason, there are opposing sides in this issue and it’s hard even to approach the topic without raising the eyebrows of one side or the other. It’s not at all clear to me why there should have to be this division, but I’ll attempt a dispassionate consideration of the concept and then venture an opinion for what it’s worth…

First, a definition of sorts: a Doula is basically a labour coach -hopefully one with experience and knowledge that she can draw upon. I suspect the Doula originated in the mists of time because of the needs of women, usually in their first labour, who were beset by a bewildering number of myths, stories, and expectations all encased in a smothering blanket of pain. With no guide but the previously instilled rumours of hours of agony followed by horrid disfigurement if the baby was able to successfully negotiate the birth canal, the idea of a calming presence who could offer guidance and reassurance throughout the travail was appealing. Originally, no doubt, this would have been an older woman in the village who had some experience with labour, probably with a child or two of her own. She would therefore be able to approach childbirth with both compassion and empathy, her very presence reassuring, and her experience proof that there was not only and end to the process, but that a successful conclusion was possible. That the pain was worth it.

It’s still the same process, of course: hours of painful uterine contractions trying to force the baby down a previously untried birth canal; it still takes time for dilatation of the cervix, and descent of the presenting part -the usual definition of progress in labour; it still can go awry. And it’s all of these things but especially the last, that jeopardize the ability of even the bravest to cope.

Some things have changed, though. Effective pain relief is usually available if requested; monitoring of the labour and the baby’s heart rate help to determine if and when interference is warranted; intervention skills and techniques have improved. In most settings both mother and baby are probably safer now than they have ever been. Also, education about pregnancy and labour are widely available: there are prenatal classes, books and magazines full of helpful advice -albeit of sometimes dubious quality, and of course the ubiquitous internet with its plethora of opinions.

The point is, few women approach their delivery entirely ignorant of expectations and fears. I would submit that there is no tabula rasa for labour: everybody, even in direst poverty, has heard something about it; the Doula, if employed, should put those things into context for her client, dispel the harmful myths, provide reassurance and compassion. A friend might provide a similar service. Or a midwife. Or a nurse… We all need a hand to hold.

Why not just have the partner in there providing sustenance and support? That’s ideal if he (or she) can, but let’s face it, the partner is often just as excited and in turn dismayed and frustrated as the one in labour. They are, by and large, a unit with the same expectations and concerns. A knowledgeable outsider is probably better positioned to provide reassurance especially if the labour is long and difficult. A Doula should be a welcome addition to the team.

If I sound like I have reservations, it is because I do. The concept is great. Who would argue with support? A calm and reassured woman is likely to tolerate the problems of labour better than one who is beyond herself with worry and concern over various aspects of it that she cannot process or even understand in the circumstances. Pain and fatigue rarely dispose one to rational analyses. But it’s the experiential component that is often missing in the support -the objective assessment of the situation and the ability to change expectations accordingly. I have heard Doulas vociferously regurgitating their pre-labour instructions not to allow their client to ‘give in’ to the pain, despite its possible role in slowing the progress or tolerability of labour. I suspect that a more experienced coach might better understand that earlier, more naive instructions are not always sustainable in the light of changing circumstances. Many Doulas are sensitive to this and act accordingly -most Doulas, perhaps. But they are not nurses and shouldn’t try to function as such. They are there for support, not to interpret symptoms or read fetal heart rate monitors. They are not there to interfere with their client’s management.

In my center, there is a trained obstetrical nurse assigned on a one to one basis for each labouring patient. They can and do provide support and professional advice as part of their function. They are objective and compassionate, experienced and empathetic. And they are definitely patient advocates, making sure that any management decisions are in their patients’ best interests. Maybe their multiple roles should be more widely advertised. Maybe they are the best Doulas.

I realize that I am coming from a Western medical model, and that as a man, I am someone who could never truly understand what a woman experiences in labour, the support she needs, the encouragement that will help her achieve her goal. My views are biased by my own expectations, my model, my gender it’s true. I can’t escape them.

But I can advocate for safe and compassionate care that helps to ensure the well-being of both mother and baby. That minimizes unnecessary suffering. That strives for a rewarding experience free of fear or untimely intervention.

And so can the nurse… But wait, isn’t that what the Doula was hired to do?

Health

Do we expect too much Health? Or perhaps less controversially, do we expect too much of Health? Are our expectations realistic or even attainable? Do we really know what Health is -or for that matter, is not? It’s an important point and one that should not be dismissed as mere academic quibbling. Perhaps, to paraphrase St. Thomas Aquinas, we all know what Health is until we are asked to define it.

Should we, for example, define it as an absence -an absence of illness, for example? Or maybe suffering? If that sounds too tautological, how about defining it as something positive: say the presence of well-being or -god forbid we stray into this- even happiness, contentment, or comfort?

But unfortunately, the concept of Health has strayed for a lot of us. In many respects, we equate good health with the absence of discomfort in our bodies – and for some, any discomfort. That we should have to think about our bodies in any way other than that they are ready and able to perform -or at the very least, potentially capable- is disconcerting and disappointing: unhealthy. That there should exist constraints such as pain or weakness may therefore be construed as unacceptable.

An extreme view? Well, consider a patient I saw for consultation recently. She had come in complaining of fatigue before her menses -a symptom certainly worthy of investigation, I think. Anemia, some form of menstrual dysphoria, or possibly even stress came to mind immediately as possible villains, but I was not unmindful of other, more serious conditions for which fatigue could be a herald. So, after taking what I hoped was a thorough history and completing a detailed physical examination to provide me with further clues, we went back into my office so we could discuss things.

“So what do you think, doctor?” she asked, her eyes locked on mine.

“Well, fortunately the physical examination was reassuring – I couldn’t find anything wrong…”

“But there must be something wrong, doctor. Something has to be causing the fatigue!”

I thought about it for a moment. “You say your periods are not particularly heavy; they’re not painful; they’re on time each month… You’ve always felt tired before your menses, and you feel well otherwise…”

“But doctor,” she almost shouted at me, “It’s not healthy to be tired before your periods. None of my girlfriends are…”

I started to write something on a form and looked up at her. “So, I’m going to order some blood tests and…”

She rolled her eyes and straightened up in her chair. “My GP has been ordering blood tests for years now and they never show anything. I want to know what you’re going to do about it.”

I could tell she was about to leave. “What are you afraid might be going on with your body?” I asked, thinking she might have some fear of cancer, or disease in her mind. But there was no family history of any cancers or heart disease and they were all still living, well into their late sixties. And for her, there had been no personal, sexual, or relationship problems that I had been able to elicit in taking her history. I was truly perplexed.

“That’s what I came to you to find out, doctor,” she answered with a stare, almost spitting out the word ‘doctor’. “You doctors are so busy trying to cure disease, you have no idea what Health is.” And then she walked out.

And you know, maybe she was right. Maybe we do define Health in the negative: an absence of things that shouldn’t be there. Or even use a ‘Be thankful it’s not worse’ approach. But I’m not sure she’s on the right track either. Surely Health is a more relative, a more consequential construct. Maybe it’s simply the condition that allows us the freedom not to think about it, worry about it. Maybe it’s neither a positive nor a negative concept. It’s something that’s there only when we don’t question it -something that, if it were not there, would have consequences.

But more than that, it must be a relative condition as well. If you break a leg and then are eventually able to walk again, albeit with a limp, you are probably healthy even though things are not like they used to be. So Health is not necessarily an absolute phenomenon either -something that withstands comparisons with others.

Clearly there are subjective and objective components to consider, and neither have an unassailable priority. Health is what we want it to be, and that’s going to vary depending on who’s considering it. We may never come to consensus. And yet I think there is considerable merit in trying anyway -attempting to look at it from both perspectives at the same time. Health is surely the ability to carry on with our lives with minimal impediments, minimal distress, and minimal need to wonder whether we can.

Minimal is approximate as well as contingent of course, but it does not mean zero.