Tag Archives: expectations

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The Tresses of Her Hair of Gold

I wish I could tell for sure, you know. I’m even afraid to compliment my friends on their hair nowadays for fear of getting it wrong –the colour, I mean. I’ve never been very good at colours, though; to me, hair is red, brown, black, or blond… and grey, of course –although I seldom see that except in roots anymore. Words like ‘auburn’, ‘chestnut’, ‘strawberry’, or ‘caramel’ are wasted on me. And, apart from the obvious camouflaging appeal of a foreign word, I confess I’m not sure why a brunette doesn’t just have brown hair.

Be assured that I appreciate the rich palimpsest available today, it’s just that I can never remember the names –or, except in some of the more fluorescent hues, know if it is their cheveux de naissance. And, yes, I share with Longfellow, a delight in the gold of long blond hair: Her cap of velvet could not hold the tresses of her hair of gold, that flowed and floated like the stream, and fell in masses down her neck. But I have to say that for me, at least, beauty has never resided in hair length, or presumed intelligence or desirability in hair colour. All these things are mere adjectives to the noun of personhood.

And yet, I say this as a retired, older man, unplugged from the business world, and I accept that from the other end of the spectrum, things may seem different –perhaps are different, for reasons I no longer have to accept. Take the case of Eileen Carey, a successful 30-some year-old CEO in Silicon Valley who, naturally blond, now wears glasses and brown hair: http://www.bbc.com/news/magazine-41082939

‘Carey was told that the investors she was pitching to would feel more comfortable dealing with a brunette, rather than a blonde woman. “I was told for this raise [of funds], that it would be to my benefit to dye my hair brown because there was a stronger pattern recognition of brunette women CEOs,” she explains. Pattern recognition is a theory which suggests people look for familiar experiences – or people – which in turn can make them feel more comfortable with the perceived risks they are taking. […] “Being a brunette helps me to look a bit older and I needed that, I felt, in order to be taken seriously,” Carey says.

‘”People are more likely to hit on me in a bar if I’m blonde. There’s just that issue in general. “For me to be successful in this [tech industry] space, I’d like to draw as little attention as possible, especially in any sort of sexual way.”’

Forgive me, I don’t wish to appear unduly benighted about this –I’m just trying to understand. Just trying to put it in some sort of context, albeit probably an outmoded one. Is the need to dye one’s hair similar to the need for a man to don a shirt and tie for a successful interview? And would going in blond be like arriving in jeans and sweatshirt? Just how are people –women, in this case- judged? Unless she was auditioning for a waitress job at the Cactus Club, how could the otherwise successful possession of whatever criteria were advertised for the position be invalidated by hair colour? Come on!

Of course, if she freely chooses to dye her hair, and decides she prefers glasses to contacts, then that is a different matter, but it seems suspiciously akin to changing your name on an application form to disguise your nationality –or skin colour… or even sex– just to get through the door, no matter your qualifications.

It reminds me of something that Janice, a family doctor once told me about hiring her secretary. She was just opening her medical practice in a new city and had advertised for a someone to work at the front desk and answer the phone. She wasn’t having much luck, apparently. She’d asked for a résumé from each candidate before their interview, and none of them seemed to invite further consideration, until she received one from a Gerri Coland who, at 27, had apparently been trained as a social worker, and although she’d already worked at it for several years, felt it was time for a change. She still wanted to engage with people and help them whenever possible, she had written, but without needing to take their problems home with her each night. Perfect, Janice thought.

The résumé had arrived via Email, so Janice replied immediately with a request for an interview the next morning, if Gerri could make it. But she didn’t receive a reply, so the next day, Janice phoned the number provided. A very pleasant man answered.

“Hi, this is Dr. Janson,” she said. “Is Gerri there?”

“No… actually Gerri’s at work right now. Can I take a message?”

“Well, she sent in a résumé to my office and I wanted to interview her for the job.”

There was a slight hesitation before he answered. “Well, I’m Gerri’s partner, so I’ll pass the message on. When is the interview?”

“Would nine o’clock tomorrow morning work for her? I know it’s rather short notice, but I’m trying to start up my new practice as soon as possible.”

He chuckled into the phone. “I’m sure tomorrow morning will be fine. Gerri’s only filling in for someone right now…”

The job of a secretary in her office, Janice informed me, would merely be to greet and register the patients, and organize appointments over the phone. But it was an important first impression of the office. So, she needed someone pleasant, understanding, and able to cope with the different attitudes and moods patients often staple to their illnesses.

The next morning, ten minutes early, a smiling young man arrived at the office dressed in grey slacks, and a dark blue sports jacket over a pale blue shirt. Janice assumed Gerri was in the washroom, and smiled at the friendly man who was fairly obviously Gerri’s partner.

He glanced at his watch and stood up to shake her hand. “Sorry we’re a bit early, but my partner thought the traffic might be heavier coming across the bridge…” He glanced around the newly furnished office. “Wow, this is well-designed,” he added, walking up to the front desk after admiring a large Areca palm in an earthenware pot by the window. “I like the way the waiting room is furnished. The comfortable chairs, the pictures on the wall, and the box of toys for kids is so welcoming. So calming.” He allowed his eyes to rest on her face. “Did you design it, Dr. Janson?”

She nodded. I’ve always felt that the last thing a person needs is a sterile, airport-style waiting room when they’re already stressed with whatever problem brought them to the doctor.”

The man nodded in agreement and walked up to examine one of the pictures on the wall. “A Carol Grigg! I’ve seen some of her other work down in Oregon. She’s a Cherokee artist I think, isn’t she…?” But he seemed to be talking more to himself, than Janice.

This was a man who was obviously at ease with new situations, Janice thought, no longer caring, where Gerri was.

Suddenly the man stopped and looked at her. “Look, I’m sorry about this…” He stared down at his feet for a moment, and then rested his eyes on her cheeks as softly as small birds on a branch. “Perhaps there was a little confusion with my résumé… I’m Gerri.”

Janice broke out in a wide, reassuring smile, and touched him gently on the shoulder. “I was hoping you were…”

 

 

 

 

 

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The Myth of Medicine

The concept of the myth has always intrigued me. Not, as it is historically characterized – the fabulous stories of gods and heroes- or the more populist idea of an untruth or counterfactual, but rather as a metaphor. Myth as a way of explaining something that is difficult to put into words, that defies rational explanation: the meaning behind the meaning. Like those Russian nesting dolls, they are multilayered, with understanding hiding within significance which is in turn hiding under context hiding behind appearance… A myth is the meaning of a flower. It is a poem.

And yet it need not be so abstract, so elusive. All of us have myths: they are our stories –who we are, or at least how we have come to understand ourselves. As the famous Swiss psychiatrist Carl Jung said in his autobiography: Thus it is that I have now undertaken, in my eighty-third year, to tell my personal myth. I suppose the challenge, however, is to disentangle the reality from the fantasy… Or does it really matter? And are they both merely different colours of the same myth? Joseph Campbell, the author of many books about mythology, said: “…the only way you can describe a human being truly, is by describing his imperfections. The perfect human being is uninteresing… Aren’t children lovable because they’re falling down all the time and have little bodies with heads too big?”

We are, for all intents, our mistakes. Our foibles. Our myths. And that which we appear to be, we are not –or at least that may not be how we see ourselves. So, for the doctor, which is the more important –because to treat the person, we have to find them first?

I am reminded of a patient I saw  long ago when I was a freshly washed gynaecologist just setting up my practice in an era of militant feminism. Ms Debrashen –that was her title, she insisted, just like mine was ‘doctor’- was a frail-looking eighty year old but dressed in jeans and a sweat shirt that had I’m Talking to You written in Gothic script on the front. I suppose I should have been intimidated, but her smile was so disarming, I couldn’t help but return it as I greeted her in the waiting room. She extended a bony hand to shake before I could even free my own from her chart, and would have led me  down the hallway to my office if I hadn’t stepped in front of her to make sure she went through the correct door.

“So what can I do for you Mrs. Debrashen?” I said, still smiling, as she plonked herself down on a chair beside my desk.

“Ms Debrashen,” she corrected me, but not unkindly. “I want you to do a pap smear. I haven’t had one in years, and my family doctor refuses to do one on me.” As she said this, she replaced her smile with a flinty stare that brooked no nonsense. I will be obeyed, it said for a moment, and then relaxed into a more Canadian, please. “I don’t know what got into him; I’ve gone to him for years, but he just climbed up onto his doctor horse and said I was too old.” She sighed theatrically and shrugged angrily. “Too old? Too old to be screened for cancer..?” She shook her head in disbelief. “Does he think I’ve lived long enough already?”

I took a carefully disguised deep breath and let it out slowly. Quietly. I decided to start with a thorough history in case there were some extenuating circumstances. Most cancer agencies throughout the world, and certainly the one in my own province here in British Columbia, have said that there is no indication for continuing to do pap smear screening after the age of sixty-nine. Only if there were recent abnormalities in the pap or as a followup to recent treatment for abnormal cells would it be justified. And of course, then it wouldn’t be screening, per se, but followup.

I took what I felt was a complete history and then, as a tactical decision, asked about her pap smear history at the very end. But no, all of her past pap smears were normal, she insisted.

She sat back in her chair, folded her arms across her chest and stared at me with a rather smug but expectant expression on her barely-wrinkled face.

“The Cancer Agency in British Columbia usually recommends not doing any more pap smears after you turn seventy,” I said, rounding it off for simplicity.

A curiously satisfied smile captured her face –as if she were laying a trap for me, but had to be careful not to give it away. “And why is that, doctor?”

“Well…” I started, not totally comfortable explaining to a woman of her age about the increasing belief in those early years of virology, that the abnormalities of the cells of the cervix registered by the pap smears were in fact the result of some sexually transmitted agent.

Her smile turned into a chuckle when she noticed my obvious embarrassment. “We are not always as we appear,” she said, the merriment evident on her face. “We write our own myths, then wear them, you know… Doctors no less than their patients.” I suppose I must have looked puzzled, because she sat back in her chair as if she were settling in to tell me a story. “Both you and I are Matryoshka dolls, and we only unveil the deeper ones when and if it serves our purposes.” She softened the severity of her latest array of smiles. “You are only looking at one of the dolls –the one you expect to see.”

I smiled the tolerant doctor-patient smile, and started to say something, but she waived it away with a flick of her hand.

“You didn’t ask me much about my sexual history, did you?” I think I blushed and she immediately seized upon it. “Too embarrassing, right? And yet had I been twenty or so, you would have jumped on it immediately when I told you I wanted a pap smear.” I didn’t have to answer –she had me. “But despite my age, and my failing eyesight, I can still read…” She pretended to look out of the window behind my desk to ease my discomfort, but I could tell she was actually watching me out of the corner of her eyes. “The current thinking is that abnormal pap smears are the result of sexual transmission, I understand. Like a disease.” She risked at direct glance at my face and when she could see the astonishment on it, she left her eyes resting there. “So, how would you get a new sexual disease, I wonder?” She let her words dangle for a moment to tease me. “I suspect there are only two mechanisms –either my partner is dallying in another realm, or I myself have strayed into a new kingdom.”

I tried to keep my mouth from falling open -I loved her words.

“But suppose I knew all this, but was unwilling, or afraid to share that aspect of my story with you because it didn’t conform to what I have always wanted to believe about who I am? And what you wanted to believe…” She stared at me for a while with innocent cow-eyes. “Or, on your side of the curtain, suppose you didn’t want to risk offending me because it would be like talking back to your grandmother. Belittling her. Disrespecting her…” She straightened herself in the chair as if she were about to get up. “So you see we are both trapped in our stories.” A huge smile spread from ear to ear as she rose to her feet. “But we’re only trapped as long as we don’t recognize them as surfaces. Clothes…”

She pointed at the examining room. “Let’s do the pap smear, now. I’m going to be late for my friends,” she said, and then started for the door, as I still sat immobilized in my chair.

“I was a Social Anthropologist in my previous life,” she said, looking back over her shoulder and winking. “Just thought you’d like to meet one of my deeper dolls…”

 *

I’ve never forgotten Ms Debrashen over the years. She taught me to question assumptions. Interrogate them. But it made me wonder just how much I can know about anybody. Some of those deeper layers are inaccessable even to the person from whom I’m trying to obtain a history. So overlayered with hope and retrospectively altered memories, some are forever hidden in the myths they have become. Perhaps for clearly displayed symptoms and signs, my medicine can work. I can treat a prolapsed uterus, or an elevated blood pressure, but in a way, that is almost like mending a sweater, or washing a shirt. It is hard to see the skin they hide beneath. And I am at a disadvantage peering through the murky water in which they stand to find something they’ve dropped or hidden. …

She made me appreciate the words of Hamlet when he repudiates his mother for insinuating he is pretending grief merely to get attention:

Seems, madam? nay, it is, I know not “seems.” ‘Tis not alone my inky cloak, good mother, Nor customary suits of solemn black, Nor windy suspiration of forc’d breath, No, nor the fruitful river in the eye, Nor the dejected havior of the visage, Together with all forms, moods, shapes of grief, That can denote me truly. These indeed seem, For they are actions that a man might play; But I have that within which passes show, These but the trappings and the suits of woe.

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What’s in a name… Cancer?

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

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

I was therefore intrigued -although not altogether surprised- at the e-publication of a paper to be published JAMA Intern Med ( http://dx.doi.org/10.1001/jamainternmed.2013.8405 ) that dealt with how the use of the word ‘cancer’ influenced the way patients made decisions about their treatment options -even when the condition they were asked to consider was pre cancer, not actual cancer. Just that word, in whatever context, was enough to alter their choices. In many instances -especially in medicine- the words we utilize are maladapted, anachronistic and, in fact, misleading…

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

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

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

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

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

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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.

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Words and Names

Words are important, let’s face it; they help us address those most existential of all entities: concepts. They describe things, modify things, name things. Without them, we’d no doubt be reduced to gestures -limited descriptors at best. The richness that is reality would still be there, but unexpressed, identified perhaps, but somehow unrepresented. To an extent then, we, the world -everything- is partly  how it is described. Words are powerful.

By now I’m sure you’re wondering what all this has to do with women’s health. Why is an obstetrician pretending he’s a philosopher? Words again, you’ll notice… Well, when we name something -a process, a condition- it engenders a certain expectation. If you name an experience, the name comes to represent what was experienced. Pain comes to mind. Or laughter. We know how it felt to experience these and if someone were to suggest that they were going to occur again, we’d probably have a pretty good idea what to expect. It’s what names are for, after all. Of course, what we call pain might be different from what someone else experienced, but we know what that experience meant for us. We would be able differentiate it from, say, tingling, or maybe fatigue. And if someone were to say you were going to experience pain, the very word would likely engender an expectation of something fairly identifiable and even relatively specific.

Okay, how about ‘labour’? You are a woman in your second pregnancy; your first labour was terrible. Maybe the contractions were deemed inefficient despite their pain, and augmentation with oxytocin was necessary. It seemed slow and interminable, punctuated with frustrations you could never have anticipated, delays that seemed unnecessary, maybe even resulted in something you wanted to avoid: forceps perhaps, or a Caesarian section. You have all that to look forward to (backward to?) again.

But do you? Well, we use the same word for second labours, sixth labours, whatever. So with minor variations on the theme, you expect the same thing. You know what to expect; you know what mindless suffering awaits, and if there was some trouble with the actual birth process, you know it will repeat: you haven’t changed. Your pelvic measurements are the same and this baby measured even bigger than your last baby on the ultrasound you had a month ago. So if anything, it’s going to be worse. Your midwife or obstetrician has tried to reassure you that second labours are quicker, more efficient creatures than first labours. Different creatures, in fact. But despite the rhetoric, something tells you they’re wrong. After all it’s still called ‘labour’ isn’t it? And you know what that means; you’ve experienced ‘labour’…

So why don’t we call subsequent labours by a different word if they really are different? Like the apocryphal description of different kinds of snow by the Inuit using different words: not all snow is the same, obviously, so if you were to hear a different description, a different word, you would expect that what you were going to see and experience was going to be different as well. Words are powerful.

I tell this to my patients and they usually laugh, politely to be sure, but secure in their knowledge that it’s all going to turn out the same no matter what I say. For one thing, I’m a man, so how would I know? And for another, and an even more convincing certainty, if it were truly different, there would be a different word for it.

I have struggled for years to come up with another word, but alas, with no success -no Nobel Prize for advancement of women’s psychological health, no media attention whatsoever.  I suspect I’ve not even been particularly convincing, coming at it as I do from the ‘other side’… But Hope springs eternal, eh?

Any suggestions?