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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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?”