A Plague on All Your Houses

 

 

I still remember a seminar I went to years ago in university. It was part of a nebulous course on ‘Health’ that some of us took as a soft route on the way to a bachelor’s degree. It was reputed to consist of essays and a true or false final examination. Also, because the class was small, it was amenable to division into even smaller numbers for several interactive sessions.

There were five of us and a teacher’s aide at the one I remember so well. We were all fresh from high school and, at least in those faraway days, used to being lectured at, rather than actually contributing to the subject matter. The topic that day was Disease, and I remember being mildly interested, but expecting only a list of the usual culprits, complete with causes and treatments -memory fodder for later regurgitation, I suppose.

“What is disease?” the TA started, as soon as we were seated around a rather small wooden table.

One of us -I don’t remember his name now- rolled his eyes and smiled. “Sickness,” he answered, rather smugly.

She smiled in return, as if he’d fallen into her trap rather too easily. “Okay, but haven’t you just used a synonym -defined it in terms of itself?”

He stared at her for a moment, obviously confused. “Well… then, how about saying disease is an abnormality of an organ or a system caused by germs -probably particular germs depending on the disease.”

Her face relaxed and her smile broadened. “Now we’re getting somewhere.” She leaned forward on the table. “Let’s get more specific for a moment. Let’s take tuberculosis… Anybody know the cause for TB?” She glanced around the room, determined to involve us all, apparently.

I looked up at the wrong moment, and she brushed my face with her question and pinned me to my seat with another smile. “Do you know the cause of TB…?” she said, locking eyes with me.

There was no escape. “Uhmm…” I felt embarrassed at being singled out, but the question seemed fairly straightforward. “It’s the tubercle bacterium, isn’t it?”

She sat back in her chair, and shrugged nonchalantly. “Is it?” She said, softly and with just a hint of gentle sarcasm. But her eyes were still sitting on me, and I could tell they meant no harm.

“Tubercle bacillus?” I corrected myself, remembering that people sometimes called it that.

“So…” she glanced around the table again, lifting the weight off my shoulders. “Would you all agree that TB is caused by a bacterium -a bacillus?” she added, looking at me once more. Everybody nodded.

“But don’t some healthy people have a positive skin test for it -the Mantoux test?” she continued.

We all nodded, most of us unwilling to show that we hadn’t known what the test was called.

“So, why is that?” She paused to see if any of us had an explanation, but when nobody said anything, she continued. “If the bacterium Mycobacterium tuberculosis is present…” she slowed down even more for effect. “… if some of us have it… and it causes TB… then why don’t those people have TB?” She straightened in her chair and leaned on the table with her elbows as she searched our faces for the answer.

But she was greeted by blank, albeit confused expressions around the table.

“If disease is caused by the acquisition of a bacterium, then what stops some people from acquiring the disease?”

This was new territory for us, and yet, her eyes stopped at me again. “Our defense mechanisms -the immune system…?” I suppose it wasn’t exactly a scholarly response -even in those days we’d all heard of vaccinations and antibody production.

She started nodding. “Okay, but what makes the immune system strong enough to resist?”

“VSG?” someone said, and immediately blushed because he had obviously taken a leap in the dark with the initials.

She smiled reassuringly. “BCG -Bacille Calmette-Guerin, to give it its full name?” He nodded, presumably relieved. But even in those days, there was some doubt as to its effectiveness, so she merely shrugged again. “But the person may never go for the skin test and so never know she has the bacterium…”

She stared at me again, for some reason. “Well, suppose they’re in good condition -healthy, I mean?” To tell the truth, I didn’t really know what I meant.

“But doesn’t ‘healthy’ mean free of disease? Isn’t that another tautology…?” She walked around the table with her eyes again, but this time more slowly. “So, might there be other causes of disease -apart from the infecting agent, I mean?”

I remember some of us looking at each other, as if we were beginning to understand where she was going with this.

“Where -or maybe under what conditions- do we see a lot of diseases like TB?”

I suppose I remember the seminar so well, because she kept looking at me when nobody else answered. “You mean if somebody’s poor, or living in unfortunate circumstances? Poverty…?” I managed to mumble, hoping that was what she was after.

I still remember her smile.

It was a seminal moment for me, and maybe one of the reasons why I eventually went into Medicine. But it all resurfaced when I happened upon an article in the CMAJ (Canadian Medical Association Journal) from January 22/18 with the rather long and certainly uninviting title, Effect of provincial spending on social services and health care on health outcomes in Canada: an observational longitudinal study: http://www.cmaj.ca/content/190/3/E66

Its thesis, was that spending on health care is escalating so significantly it will soon be unaffordable. The question then, was what to do about it. The study ‘used retrospective data from Canadian provincial expenditure reports, for the period 1981 to 2011, to model the effects of social and health spending (as a ratio, social/health) on potentially avoidable mortality, infant mortality and life expectancy.’ And after using various methods to analyze the figures that I didn’t even try to understand, like ‘linear regressions, accounting for provincial fixed effects and time, and controlling for confounding variables at the provincial level.’ decided that ‘Population-level health outcomes could benefit from a reallocation of government dollars from health to social spending […].’ Or, as they worded it more succinctly in their concluding paragraph: ‘The results of our study suggest that spending on social services can improve health. Social policy changes at the margins, where it is possible to affect population health outcomes by reallocating spending in a way that has no effect on the overall government budget.’

It made me wonder, though, why, if I learned the same thing many years ago, did it still need investigation? Were we so wrong back then? So naïve…?

 

 

 

 

 

 

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Risk Perception

Risk is something we all need to assess from time to time. The problem lies in how we do it. If there are factors we fail to take into account that affect our risk perception then our evaluation may as likely be wildly unrealistic, as appropriate. Emotion tends to skew things in one direction or other, as does as the degree of perceived asymmetry between the benefits and dangers –if we really desire or enjoy something, we might be less risk averse than if we were not keen on it in the first place. The status or acceptance acquired from smoking for a teenager, say, might counterbalance the long-term dangers; it might not be seen that way by an older, more confident adult. And immediately experienced risk –driving a car with faulty brakes- may be more influential than future risk such as lifestyle changes for cardiac disease prevention. And then, of course, there are cognitive biases –our own subjective mythologies, expectations and intuitions- not to mention cultural biases, all contributing to the overall assessment of the acceptability or not of the risk.

But I suspect that a major obstacle in risk perception lies in its probabilistic nature. People have enough difficulty in understanding the simple Bell Curve distribution of likelihood let alone the mathematical Baye’s theorem which ‘describes the probability of an event based on conditions that might be related to the event.’ Our estimates are more intuitively driven than statistically. Understandable, to be sure, but unreliable in most appraisals. Misleading. Dangerous, even.

It’s hard to grasp the concept that even doubling a risk when it is almost imperceptably low already, still leaves it almost imperceptable. So, at what stage does it become unacceptable, if it wasn’t really perceived to be that in the first place? Is any risk acceptable if we know about it, no matter how small and unlikely? What about the background risks that are inherent in most things –be they visible and published or not? Riding a bicycle, for example, or running on a treadmill, walking to work… At what point do we merely turn off and get on with life?

The problem is certainly manifest in Medicine. Most of us invest health –especially our own- with an appropriately significant amount of concern. But it is more of an emotional than intellectual process, and we tend to interpret the concept ‘improbable’ as the much more personal ‘but possible’. Shadows, despite their insubstantiality, hide ‘what-ifs’ –or worse still, unrealistic fears that favourable probability cannot disguise.

Martha was one of those. I would never have guessed it to look at her, though. She sat relaxed and confident in the waiting room, surveying her adopted realm like a tall queen. Crowned with long brown hair, the curls danced from her shoulders as she stooped to pick up a child’s toy, then returned it to him with a smile that would have melted an older stranger. Fifty-ish and surprisingly thin, she was dressed in loose, faded jeans, orange sneakers and a light blue designer tee shirt that said ‘Dare Me, eh?’ She was in control of all she surveyed: monarch of the room.

She stood when she saw me approaching and extended her hand before I was half way across the floor. “I’m so glad to meet you, doctor,” she said loud enough for all to hear, and squeezed my hand like she was doing an exercise in the gym. A full head taller than me, I had to look up to see her face. For a moment, I felt like that little boy whose toy she had rescued, and as I led her back down the corridor to my office I had the distinct impression that, despite her being behind me, nonetheless it was me being taken for a walk like a small dog on a leash.

She sat down on the chair opposite my desk and waited for me to settle into mine before starting the interview. That’s how it felt: she was interviewing me like a reporter hot on a story.

“I’m here,” she said without the usual preliminary pleasantries, “because of a disagreement with my family doctor…” She left her thought unfinished so she could study my face for its reaction, and when she saw nothing but curiosity written on it, continued. “She seemed to feel that my worries about hormone replacement therapies were unfounded.”

She immediately folded her arms across her chest to -as her tee shirt invited me to do- dare her to defend herself. I wondered if she’d chosen it specifically for the visit. I smiled to diffuse her arms, but her body had hardened into place; everything remained on guard, and her eyes perched on her face like a pair of eagles watching me from their aerie in a tree.

I thought I’d keep it simple. Basic. “She felt you needed hormones?” A regal, no-nonsense nod. “And why was that?”

“Hot flushes.”

I duly typed this on my laptop, although I sensed it might be only the tip of a rather unpredictable iceburg. So I waited.

I could sense she was testing me, and the eagles shifted impatiently on their branches. “I don’t need hormones, doctor. I was just going in for my pap smear and she asked me about hot flushes.” A smile passed across her face like a shadow crossing a stage. “I think she just wanted to compare notes with me…”

I tried to concentrate on her mouth, her eyebrows, hair –anything but those unnerving eyes that seemed constantly on the verge of attack. “So you’re not bothered by them?”

She shrugged, but if I hadn’t been staring at her, I might have missed it. I sat back in my chair, wondering where the thread-bare conversation was taking us.

She could see my confusion, although I had tried to hide it behind an Oslerian mask of Aequanamitas. I sometimes find it doesn’t quite cover everything, no matter how I wear it. “Look, she’s a nice woman and I think she was just trying to be kind.” She hooded the eagles and looked over my shoulder at something for a moment. “It was a girl thing, I suspect –you know, an attempt at empathy, wearing my shoes, or something.” One of my eyebrows started to move before I could rein it in and she noticed it and grinned sheepishly. “After I left her office, it dawned on me that she’s probably on hormones herself. An example of the play within the play of Hamlet: The lady doth protest too much, methinks.”

Martha was obviously not your average patient –she even put the ‘methinks’ at the end, where its supposed to be. I was impressed. “You think she was trying to convince herself that hormones were safe?” Might as well cut right to the chase.

She nodded. “I made the mistake of arguing with her and it rolled downhill from there. I shouldn’t have been so righteous, but from my reading, I felt she was mistaken.”

I could tell being a referee in a contest where one party has done extensive research on the subject, and the other was speaking to the contrary out of vested interests would not be easy. Martha had probably read more Shakespeare than me as well. I approached the issue carefully. “What did you find troubling about her opinion?”

She smiled; her trap was laid. “Well,” she started equally carefully, “for a start, the risk of phlebitis is increased by about three hundred per cent on hormone replacement therapy…”

I inclined my head slightly –it was meant to acknowledge the number, but not succumb to it. “Well, in fact the exact incidence of DVT” –I used the acronym for deep vein thrombophlebitis, to show her I had some trifling knowledge of the subject- “is unknown because of the inaccuracy of clinical diagnosis, but if you want to look at another way, its incidence is up to six hundred per cent higher in the first year of use…”

Her smile broadened –she’d been validated. She had been right to worry.

“But,” I added when her smile looked as if it was going to split her face in two, “Six hundred per cent of what?” I let it sink in; I didn’t expect an answer.

“Well, six hundred per cent higher than in non-users…” Her eyes were hunters again –hawks this time, I think. The tone of her voice said that it was obvious. “Six hundred per cent higher, doctor! Six hundred…”

I briefly flirted with some sort of aerial fight, our eyes meeting each other somewhere over the desk in a dominance combat . But I’m not like that. “So, six hundred per cent higher than in non-users in the first year? Otherwise, -what did you quote, three hundred per cent higher?- after the first year of use, I guess you mean?” She nodded impatiently, as if she was being patronized. “And the rate in non-users?”

This time I did expect and answer… Or did I? Three times anything seems like an awful lot more. And six times…? She shrugged as if it were not that important. The relative increase was what mattered. “Well, given that I said that the exact incidence was hard to determine, the figure in many studies has been estimated at around 80 cases…” -I stretched it out for effect- “ 80 cases per 100,000 people. Give or take.” I paused for a moment again. “So, even six times that is –what?- 480 people per one hundred thousand. That’s…uhmm… 0.48 cases per hundred people per year?” It sounded about right… But I have trouble with decimals sometimes.

“Whether I’ve got the numbers exactly right is not the issue, really. The point is more that six times very little, is still very little.”

I could see her mulling it over in her head; doubt lingered on her face, but at least she’d put the hawks away for the day. “An interesting way of looking at it, I have to say… but certainly not intuitive at all, is it?”

I allowed myself a smile that I hoped was non patronizing. “Probability –statistics- is not very intuitive.” Her face stayed neutral. “If I told you I had a way of increasing your chances of winning the lottery by 100% would you be interested?” She nodded, as I knew she would. “It’s simple, really…” She rolled her eyes –no eagles there anymore. “Just buy two tickets.”

She sat back, but I couldn’t tell from her expression whether or not I’d convinced her –or even held her interest. “So tell me, doctor, if I were your sister, would you suggest I go on hormone replacement?”

I sighed; she’d asked for honesty, not medical rhetoric. I locked eyes with her. “If you were my sister?” She nodded –earnestly, I think. “No.”

She seemed surprised after my attempt at explaining probability and risk. “Why not?”

“You’d argue with me every time we met…”

Diet in Pregnancy

There was a time when the prevailing dietary wisdom was simple: food contained calories, weight was a function of caloric imbalance. If you used less calories than you took in you gained weight, and vice versa. It was intuitively appealing and it still is; anybody with even an elementary grasp of mathematics understands. But it is becoming increasingly apparent that all calories are not equal. Health uses a different equation than hunger. So should the pregnant woman.

Of course, this comes as no surprise: it has long been apparent that a diet of potato chips and cola does not often foster a healthy newborn. Unfortunately, it has been far too easy to attribute more of the blame to other competing lifestyle factors. And it has always been difficult to separate the effects of smoking, diet, illicit drug use, alcohol, obesity and a myriad other lifestyle factors that have to be teased, strand by strand, out of the morass. They all contribute in their own ways, of course, and yet I sometimes think that we treat food choice as merely a weight regulating phenomenon -caloric intake once again.

But amongst a host of other similar investigations that seem to be appearing recently, the British Medical Journal published a review of over 66,000 women from the Norwegian Mother and Child Cohort Study linking dietary choices to -in this study- premature delivery. Preterm delivery is responsible for a large proportion newborn infant deaths, not to mention health problems both long and short-term. It is a significant problem that has multiple causes to be sure, but diet is one that may be more easily amenable to manipulation.

http://www.huffingtonpost.com/2014/03/05/healthy-diet-lower-preterm-birth-risk_n_4906407.html

The original article was enlightening, albeit a little dense, so I will refer to the brief summary of the parameters of the study from the Huffington Post:

The researchers classified the women’s diets as “prudent,” “traditional” or “Western.” A prudent diet consisted of raw and cooked vegetables, salad, fruit and berries, nuts, vegetable oils, whole grain cereals, poultry and water to drink. A “traditional” diet, by contrast, was mainly composed of boiled potatoes, fish, gravy, margarine, rice pudding, low-fat milk and cooked vegetables. Lastly, a “Western” diet contained a lot of salty snacks, chocolate and sweets, cakes, French fries, white bread, ketchup, sugar sweetened drinks, processed meat products, and pasta.

Anyway, guess which diet was the healthiest? When asked in this rather black and white format, the correct answer is easier to see than in the supermarket or fast-food outlet where cost is often the biggest determinant of choice.

One has to be careful not to attribute cause to something that may be only an associative phenomenon, however. Maybe women who make unhealthy choices can only afford a certain diet -are only exposed to certain ways of eating. Maybe they have other characteristics that might lead to premature delivery. Why one makes certain dietary decisions is often -if not usually- an indication of the river in which the individual is already swimming. And it would be naïve to assume that merely changing what she eats will solve the other health and lifestyle issues that may affect the foetus developing inside her. But pregnancy is a time when most women are motivated and open to suggestions that might help their babies. It is an opportunity that should not be wasted: education has ripples that extend far beyond the health clinic.

It seems to me that food choice is one of those things that can be taught without seeming to impose a moral -or social- structure to the lesson. Wise but economic choices can be outlined and promulgated without seeming to judge other decisions she may have made. It is a confidence building manoeuver which suggests that, however small they might seem, there are things she can do that might have long term benefits for her unborn child. And if this develops rapport and trust, it may help her to make other more difficult choices.

In the health care field, we are not wardens: we carry very few weapons; we depend more on persuasion than force. We are merely guides, educators, comforters, and encouragers. It is not the stick that persuades, but the smile, the attempts to understand her situation, the willingness to listen without undue prejudice, offering suggestions where possible, or expectant patience until a better opportunity arises. This more patient approach does not abrogate the authority inherent in the more traditional antenatal healthcare system -or discourage trying to correct and modify other detrimental behaviours in the pregnancy; it merely acknowledges the necessity of a firm bridge and an open gate to gain access to the other side.

So many factors play a role in prematurity, and correcting just one of them is not likely to be a panacea. But it is a start. A wedge. A present, perhaps, to the next generation.

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.

Victim

One of the things about illness is that it seems unfair -especially if it involves pain or limitation. To some degree, I suspect we all give in to self-pity in the throes of the process; maybe it’s a coping mechanism: a world view that allows us center stage for a while, an excuse to treat ourselves to some unaccustomed luxury. And why not? It’s only a temporary aberration, limited not only in duration, but in magnitude as well. Tomorrow will undoubtedly be better – the flu will have diminished, the sprain begun to heal. Reality -Life- will peek around the corner and beckon us.

But suppose it’s not; suppose its the same -or worse? Suppose the pain and debility persist and we find ourselves powerless in the grip of something we cannot understand, let alone control? What then? What if you seek help and are told there’s nothing to be done, or that the treatment, even if successful, will come at a once-unacceptable price? At what point do you become someone else? Something else? At what point do you somehow become a victim –someone demeaned? Disempowered? At what point, in other words, do you give up? Assign blame -or assume guilt?

These are vexing questions to which I have no clever answers. But they are problems -dilemmas- that we all encounter as we travel through our days. Certainly the chronicity of pain is a problem in gynaecology. A problem in endometriosis in particular. Perhaps in some future blog I will discuss the condition more fully, but for now suffice it to say endometriosis has the potential for becoming a chronic source of on-going pain with treatment regimes that might include surgery and affect fertility. It is surrounded by myth and misinformation that adds to the burden; it has variable clinical presentations making diagnosis or even suspicion difficult. It can be over-diagnosed on the basis of inadequately investigated symptoms carrying with it the inevitable worry and concern about the future. It can be under-diagnosed leading to multiple unsuccessful treatments and distrust of the medical establishment and their lack of effective medication -a gold mine for alternative therapies.

All understandable I suppose, and yet treated or untreated, I have concerns for the person behind all this -the person experiencing the pain, the person who is experiencing this by herself, as we all must experience pain. I remember an ad in a medical journal years ago. It was an advertisement for a medication for endometriosis and it was a picture of a beautiful woman in an alluring nightie curled up in the fetal position on a rumpled bed. The caption read: “Trapped in her own body!” I was sufficiently disturbed by it to fire off a letter to the company. What it had assumed -indeed encouraged everyone to think- was that she was a victim, someone on whom a punishment, or at the very least an unfair condition, had been imposed.

Unfair? Of course it is unfair -but the word, the description, is inapplicable, really. Pain, diseases, injuries are not judgeable as fair or otherwise. Some are perhaps preventable, some avoidable, all undesirable but unfair..? I suppose I take issue more with the powerlessness of the woman implied in the ad, though. The message is to surrender, I think, like in one of those police shows where the criminal is surrounded with no chance of escape. For him, we are led to believe, the chances of anything he does that might result in his freedom are non-existent. He must give up, not only his freedom and perhaps how he would like to see his life unfold, but also hope.

The analogy is wearing thin here, for sure, but I’d like to think that hope is not what that woman in the ad has lost, that she does not think of herself as merely an undefended receptacle for pain, a defenseless body being assaulted and beaten on a bed somewhere. I’d like to think that she still sees herself as a person, a subject. Not an object: a thing acted upon, something incapable of acting on its own behalf -powerless. I realize that I say this from the  safety of my own health, as an unexperiencing voyager upon the surface of someone else’s disease. And yet despite the distance imposed I can still feel the suffering, however dilute. I can still encourage her to take some control, if only of very little. Any control, any sense of being able to influence direction is important. Even if the outcome, the destination, is unknown, walking along a path wherever it leads, is better than staying lost. It is hope renewed. It is the first step to recovery.

Listening

I used to think I was a good listener. I could watch the person speak, hear the words, and keep silent long enough for them to finish. And then, if it was a problem, I’d solve it. If it was a question, I’d answer it. It was easy, really: analyse the sentences, watch for ambiguities, filter out the noise -the anxious, non-essential stories, the nervous laughter- and there, stripped of unnecessary clothing and obscuring adjectives was the reason for their visit. It was a conversation reduced to pragmatic algorithms, one-side to be sure, but no less effective for its simplicity…

Or was it? I had occasion to question the effectiveness of my approach only a few years into my specialty. A young woman had been sent to me by her GP with pelvic pain. She’d seen several other gynaecologists by that time, and the usual tests had been done, accompanied by an exploratory laparoscopy or two. All with the same result: no one had been able to find a source for her pain. She had been put on antidepressants by one of them, but she was not happy with this.

As she sat fidgeting in front of me, inches away from tears, I wondered what I could possibly suggest that had not already been tried. She began describing her problem, glancing at me from time to time, waiting, it seemed, for me to interrupt. But for the life of me, I couldn’t think of anything to say, so I kept silent. Ears never get you into trouble, it’s the mouth that usually destroys rapport.

Finally she stopped, her face neutral, and she stared directly into my eyes. “Well, what do you think, doctor?”

Still puzzled about how to approach her problem, I just smiled a sad smile and said, “What do you think, Judy?”

Her eyes seemed to open for the first time. Now she was at a loss for something to say. She sat back and took a long deep breath. “You know, you’re the first doctor who ever asked me that…” She stopped fidgeting with her notes -yes, she’d brought some notes to the office so she wouldn’t forget anything- and leaned forward. “My mother died of ovarian cancer, my sister is undergoing tests…” She stopped for a moment to collect herself. “Do I have cancer, doctor?” There it was.

It occurred to me that many of us are so solution-oriented, we tolerate listening only until we have solved the word puzzle presented to us. No matter that we have been hearing metaphor and have interpreted it literally. The fact that I’d not been able to solve the problem she’d presented, that I’d had nothing to suggest, required me to keep listening -by then hopelessly entangled in her story. And even hearing things that seemed accusatory and sometimes unreasonable, I was forced by the simple fact that I had no answers, to listen further. To understand, more than to solve. Or rather, to hear more than a litany of symptoms, and a list of treatment failures.

But even now, I occasionally think I don’t have the time to remain silent, to hear the story unfold as my patient wants it to. I want to jump in at her first pause and dazzle her with my solution. It’s often myself I’m dazzling. Sometimes it’s the unheard story they’ve come to tell.