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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Medicine and Ideology

Some things are more definitive than others –less ambiguous, more predictable. Reliable, in other words. They lend themselves to yes-no answers, right-wrong judgements, good-bad characteristics. And some people prefer to see the world in black and white like this. Uncertainty is uncomfortable for them; they crave cognitive closure in the opinion of Arie Kruglanski, a professor of psychology at the University of Maryland.

It would seem that there are times in a life –usually inter regna, times of transition- when this eschewal of indeterminacy is more powerful: adolescence, retirement, divorce, and so on. And at those times, when everything seems unstable and unfamiliar, shelter from the maelstrom under any unmoving roof seems prudent. Rules and unequivocal, unchanging answers are tempting accessories. That something is either right or wrong can be comforting in times of stress.

One problem with this bichromatic need however, is that things are rarely static. They are continually modified by circumstance and context; the questions that need to be asked, and especially their answers, expand and mutate. They evolve over time, in other words. So, for example, that someone is, or is not pregnant, may be unambiguous and beyond dispute. But whether that pregnancy continues or miscarries, is healthy or complicated is not. Things change, are unpredictable, and answers –facts?- obtained at one stage may not obtain later. Life is flux -an ever moving current.

And, of course, context is almost as relevant as substance. Nothing is separate from its surroundings. A pregnant woman, say, is a member of a group –however tenuous- or at the very least, a member of a society. A culture. There are obligations and expectations unique to her milieu that may not be immediately apparent –especially to someone not a member of that group. And these conditions do not often lend themselves to a one-time appraisal, a permanent and unbending judgement, or a right/wrong approach. A rigid doctrine -established on whatever principles- does not always work. In fact it imprisons; it imposes an unchanging view on a constantly unfolding reality. It is dogma.

So it was with some concern that I read an article in the Sept.16/14 Canadian Medical Association Journal –in the news section- entitled ‘US politics and ideology enter exam rooms’. In it was outlined some of the requirements in certain states that seem to impose political or moral ideologies on both patients seeking assistance, and medical staff trying to provide it –an arena that one would expect to be free of bias and coercion.

There are some American states, apparently, that require a woman seeking a pregnancy termination to be shown –not just offered-  a view of the ultrasound of her fetus. In my opinion, this is just cruel –a punishment thinly disguised as help. Disclosure. An admonition clothed in the scarily garish colours of useful information. That there may have been extenuating circumstances –whether personal or social- that led to her decision to terminate would seem to be irrelevant. The choice the woman has to make is a painful one –it is seldom capricious, rarely if ever carelessly taken. That someone should be available to help her with her decision and counsel her before and after if she wishes is a given. But it should not be an impediment.

As the article observes, ‘In such cases, it’s not just the doctor and the patient in the room. In effect, it’s the state government, too.’  This is the not-so-thin edge of a wedge that seeks to modify behaviour –even behaviour condoned in law- by mandating seemingly reasonable adjuncts to the process. ‘What could be wrong with offering to show the woman her fetus on an ultrasound?’ one can almost hear them pontificate mellifluously with fists all the while clenched tightly behind their backs. But the operative word here is ‘offer’. The term suggests choice.  Not coercion. Bullying. Threat.

I recognize that I’ve chosen a contentious issue –pregnancy termination- to illustrate a much more fundamental point: the relational autonomy that should be a cornerstone in our dealings with others. And yet it forms –must form- an essential foundation if we are to reach out to those who, constrained by their own beliefs or cultures –their own experiences- are reluctant to seek our help. It seems to me that it is only humane to enable them -actively encourage them- to access whatever aid we are able to provide. It is not merely magnanimity on our part. Not generosity. Not accommodation. It is empathy; a recognition that despite our differences, we are all struggling. All seeking some path through the chaos of one transition or another. And the cognitive closure need not be punitive. Nor dogmatic.

In fact, it can be instructive. Insightful. As Shakespeare observed, It is not in the stars to hold our destiny, but in ourselves. And we must help others to see this. We must enable them, and so enable ourselves.

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?”