Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

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Screening in the Digital Age

I never thought it would happen to me, but all the same: ‘I grow old … I grow old … I shall wear the bottoms of my trousers rolled’. Or at least some days in the office feel like that. Perhaps it’s the clientel who’ve worn the years with me –people whose children I delivered who are now patients of mine, with their babies, in turn, waiting for liberation: Samsara… the eternal round of birth and death.

Or maybe its just the mood that Ellen drags along with her on her annual visits. Lennie, as she insists on being called, seems to straddle that razor edge between then and now. Like someone dressed in layers to cope with changing climate, she seems to wear Time like a jacket that she can don or shed as the mood strikes. And just when I think she has lost all contact with the here and now -that dementia has finally arrived- like a bodhisattva she doffs her jacket and enters my world again. Or is that giving both of us too much credit? We are each of an age when the past is retrospectively falsifiable to endorse the visions we have created for ourselves –our personal myths. The trick, of course, is finding a buyer. I think this is why Lennie insists on returning to me year after year for a pap smear despite my insistence that in her case, with her pristine and otherwise untouched cervix, the interval is too short. And in my region, if the pap smears have always been normal, we stop doing them at 69, so I don’t know what she’s going to do next year…

“Can’t you make and exception in my case, doctor?” she said, anticipating my usual advisory monologue. Then she moved her chair so close to the desk it hit the edge, rattling the little wooden statue I’d hidden behind a plant for some reason. She always did that. And she was always dressed the same: a black, knee-length skirt with a white frilly blouse that hugged her neck like a noose. Her hair was short and died dark brown. She managed to wear it like a bathing cap that was so impeccably arranged, it could have been painted in place. She was tall and slender –too slender perhaps, but the hair style suited her.

“You’re 69 now Lennie and your pap smears have always been normal. You won’t need them after this.”

A coy look that I’d never seen her use before, gradually crept onto her face. “You told me the reason you stop doing paps at my age is because most of us don’t get exposed to new sexual partners and the sex virus…”

“HPV you mean?” I thought I’d add that for clarity.

She brushed off my attempt at information with a dramatic flick of her wrist. “Whatever.” She stared at me sternly in silence for a moment to heighten the suspense. Then her face relaxed and the wrinkles reappeared around a broad smile. “My girlfriend, Shirley, has been helping me to learn the computer,” she said proudly. “She’s showed me how to enroll in a dating site… And she lent me her tablet… It was a gift from her daughter, but she can’t figure it out. Touching the screen makes her nervous, for some reason.” She studied my expression for a moment, then apparently satisfied that she hadn’t shocked me with her technological savvy, continued sotto voce. “Problem is, I can’t figure out what to do some of the time either.” She shook her head slowly. “Kinda gets away on me sometimes. And then when I touch the screen to try to enlarge one of the…”-she searched her memory banks for the word- “…one of the apps to see what it says, the stupid thing thinks I’ve chosen it and I get rerouted onto something I don’t want.” She shrugged, as if to admit that it’s an adventure that all techies have to endure. “Ever happen to you?” she asked -to be polite, I suppose.

I sat back in my chair, remembering my visit that morning to the cash machine. They’d installed a newer, faster model over the weekend. But, whereas on the old one –the one I was used to- you actually had to touch the screen to make a selection, the new one seemed to sense my finger when it was a few millimeters away while I was on my way to another choice. It took me a few seconds and several more attempts to figure out what I was doing wrong. I suddenly felt old.

And what was I doing discussing dating sites in the consulting room anyway? I was running an office, not a coffee shop. But she was looking at me as a child might for validation that it wasn’t just her that was struggling with technology. So I nodded.

There was a recent article I’d noticed on the IPhone BBC app I routinely read at breakfast that had addressed that very same issue: ‘The response time for icons on an Apple screen is 0.7 seconds, but the over-65s have a response time of about one second’ Or perhaps more worrisome –I’m a surgeon after all: ‘And tests suggest that if an older person has a slight tremor, it can be registered on a device as a swipe rather than a touch.’ http://www.bbc.co.uk/news/technology-32511489  Wow! Was age so apparently disabling that they realized they’d have design stuff differently for us? New apps? New screens? New innovations to deal with tremors? Were we being offered technological walkers? Worse, was Lennie trying to include me in that group?

“So,” I began, trying to change the subject -trying, in fact, to change the mood in the room, “how did we get on to this subject anyway?”

“My dating site,” she said, but seemed a bit uncertain herself. I sighed a little too obviously I’m afraid, and she noticed it. Her eyes narrowed for a second. “But I don’t trust it, you know.” She chuckled softly and looked at me. “Shirley tried it, too, she said. The guy was in a nursing home and didn’t tell her –it wasn’t in his profile… But she had trouble with the apps as well; she probably hit the wrong one.” She blinked -a cautionary flicker of her eyelids. “Scary, eh? I mean it’s not worth it to go through that just to get another pap smear.”

She stared at the wall behind me for a second. “Maybe next year I could see you for my osteoporosis…”

The Tail and the Dog: Cause and Effect in Medicine

Does the tail ever wag the dog? Is an issue ever so compelling that cause and effect are reversed? Or at least suspended..? Sorry, I wonder about such things.

I remember reading a book many years ago by the British philospher A.J. Ayer called The Problem of Knowledge. In it he discusses a religious sect that believed its members were either born to go to heaven or born to go to hell. They spend their lives assuming and acting as if they were in the Heaven group, no doubt hoping to influence how they were born -the future influencing the past when you think about it. Effect influencing Cause. The very idea intrigued my teenage brain but I was unable to replicate the switch no matter how I tried. No matter the subterfuge, no matter the wording of the premise, I still ended up with a faulty syllogism.

But my misgivings have decreased in the intervening years and although I’ve never met a member of that sect, I believe I have encountered situations with eerie similarities. Disturbing parallels.

*

“I don’t think you’re really listening to me, doctor,” said the thin, immaculately coifed woman sitting across the desk from me. She’d been talking without interruption for five minutes or so. Sixty-five, and well into her menopause, she had short, greying hair, and a severe, noticeably-wrinkled face. She stared at me as if I had just insulted her and I could see her pale bony hands forming fists and silently massaging her lap as she spoke.

I’d just met her and was trying to understand why she’d been referred to me. “I’m sorry,” I said with a smile. “I was just trying to get a more complete history…”

“I’ve told you the relevent history doctor,” she interrupted impatiently. “You have to learn to listen!” I could tell she was deliberately italicizing words. The sigh that I tried to disguise did not go unnoticed, however, and her eyes sharpened like knife blades and attacked my face. “My doctor assured me you would listen to me.” She sounded almost petulant.

“Well perhaps I was too focussed on background details,” I said to mollify her, then sat back in my chair to indicate that I was, indeed, listening now.

“I have cancer, doctor. Nobody can find it, but I know its there as surely as I know this desk is hard.”

I kept my expression neutral and nodded for her to go on and explain things yet again.

“My sister died from squamous cancer of the cervix and my mother died of adenocarcinoma of the stomach,” she said, the terms obviously well-rehearsed. “And my uncle had some other kind of cancer that nobody could find until he died…”

That was certainly a lot of cancers I had to admit, but I couldn’t think of any obvious connecting factors. Stomach and skin derive from different tissues embryologically but the cervix cancer was almost certainly related to HPV –a sexually transmitted virus. And she didn’t know what type of cancer had killed her uncle.

Apparently satisfied that she had made her point, she straightened up in her chair and folded her arms tightly across her chest.

I nodded my head to encourage her to continue, but she merely slashed at me with her eyes, the skin of her face now tied so tightly I wondered if it would tear. I could see she was challenging me to contradict her. I managed a little smile but I didn’t really feel like it. “What makes you so certain you have cancer, Emily?” I thought maybe using her name might soften her face. “Is it the family history of so many cancers, or some symptoms you are experiencing?”

That seemed to catch her off guard and she unlocked her arms so her hands could wander back onto her lap. “It’s more of a feeling, doctor; it’s hard to explain.”

I sighed audibly and studied her face. It had gradually lost its anger and the skin seemed looser, older. She looked fragile now. Frightened. “Let me see what tests your doctor has done so far…”

“They’re all normal,” she said softly before I could even look at the referral letter. “I’ve been pestering my doctor for several years about my concern…” Emily looked almost embarrassed. “She did both abdominal and pelvic ultrasounds because I told her I was having pain. Then she did a whole bunch of blood tests to check my liver and kidney function but nothing showed up.” She stared at her hands for a moment. “I even convinced her to do a CAT scan of my head…” She looked up at me with a shy little smile hovering about her lips. “Headaches,” she said to ward off a question she could tell I was about to ask. And then she buried her eyes in her lap again. I could almost see her trying to think of something to convince me to keep searching.

“I’m tired all the time and I’ve been losing weight…” But even she didn’t seem convinced. Sad, burrowing eyes peeked out at me from behind deep ridges of skin that had come out of hiding as her anger dissolved. She chuckled half-heartedly. “I’m becoming so neurotic about this that sometimes I wonder if I’m creating a lot of these things out of whole cloth…” Her face brightened at the idiom.

Then she shook her head slowly. “You know, my cancer is almost like a religion: you have to take some of the tenets on faith alone. They don’t make sense, and you’d rather just ignore them, but something makes you go on. You still believe, because there’s something to it, something you suspect is true, even if you don’t understand why.”

I’d never thought of undiagnosed illness like that. I looked through the test results I’d been sent, but found nothing suspicious. No clues. Nothing that even suggested a direction for further investigations. Her pap smears were up to date and all normal; she’d  had a colonoscopy and had somehow convinced a gastroenterologist to investigate her stomach and esophagus. And a dermatologist had done some biopsies a couple of years ago because she had a few moles on her arms and legs. “Would you mind if I examined you?” I thought I’d better ask.

She shrugged and shifted in her chair. “You won’t find anything, but yes. You’re my last hope.”

Given the history, I have to say she had no more hope than I did of finding something. Anything. But I did a thorough examination –I took her blood pressure, I listened to her chest and checked her breasts for lumps. I palpated her abdomen for masses and pain. Lymph nodes filter out infections, but sometimes also tumor cells in the process of spreading, so I even felt for the lymph nodes in her groin to see if they were enlarged. People who run frequently have the occasional small lumps in their groins from incidental cuts on their toes, but she had some that were really quite large and painless, and on one side only.

Curious, I asked if she did a lot of running, or if she’d injured her foot or leg recently. She shook her head. “Do I look like a runner, doctor?” She had a point.

I was puzzled by the lumps, so I redoubled my search for an explanation. What had caused them? The only thing I could find, after doing the usual gynaecological examination, was a multicoloured, dark mole hidden in a labial fold near her vagina. It was on the same side as the lumps.

I finished my examination and asked her to come into the other room when she’d dressed.

“Did anybody mention they’d seen a mole near your vagina?” I asked, when she returned.

She shook her head. “I have moles everywhere,” she said, rolling a sleeve of her sweater past her elbow and showing me her arm. “I think everybody has been more focussed on my cervix because of my sister.” She couldn’t help smiling. “Even my GP just whips a speculum in whenever she’s in the area.”

“What about the dermatologist you saw?”

She chuckled. “He wouldn’t go anywhere near there.” Suddenly she stopped talking and looked at me. “Why? Is there a problem? The other moles were just benign nevi…” She had obviously been reading about her diagnoses.

“It’s an unusual place for a mole,” I said, somewhat hesitantly. “I think it should be removed.”

She studied me for a moment, nodded her head slowly, purposely, while the skin on her face tightened and then relaxed. Her eyes softened and she reached across the desk to grasp my hand.

“Thank you, doctor.”

I must have looked puzzled, because the smile on her face broadened in response.

“All these years…” she said, slowly, softly, and almost to herself. “I knew there was something; I just didn’t know where.”

“But…” I hadn’t even mentioned my concern about malignancy in the mole. If anything, I hoped I’d underplayed it so she wouldn’t panic.

She squeezed my hand. “I’d rather be on a path –any path- than wander around, lost.” She sat back in her chair, almost satisfied at the turn of events. “Our remedies oft in ourselves do lie, which we ascribe to Heaven.”

Wow: All’s Well That Ends Well. I wonder if she’d memorized that for just such an occasion. Perhaps she felt that discovery was tantamount to remedy for her… Vindication. Validation. I also wonder if Ayer would have understood.

HPV

Cancer of the uterine cervix is a sexually transmitted disease; it is the second most common cancer of women in the world and it is spread sexually. Who would have guessed? The clues were there all along, of course: it was more common in sex workers, and women who had become sexually active at an early age; it was rare in nuns… But it took a while to connect the dots -and for technology to catch up with suspicions: viruses couldn’t even be visualized until the invention of the electron microscope, although their existence was suspected much earlier using filters with holes too small for bacteria to pass through. And then their DNA had to be identified in cervical cancer cells… and classified. It was a long journey all right.

But sexual transmission? The jump from abnormal Pap smear to the bedroom was -and is- a hard sell.  The fact that more than 80% of sexually active humans have been exposed to the virus was hard enough, but add to that the knowledge that the vast majority of teenage infections will clear on their own because of the vigorous immune response at that age, and you have a recipe for confusion. Or complacency.

Cancer of the cervix is rare before the age of 25 -the virus has a long prodromal developmental period- so after telling women how important Pap smears were in preventing, or at least detecting, this infectious cancer, raising the age of the initial Pap smear from the time of first sexual activity to age 21 in North America, did little to foster understanding. And then playing with the frequency and mode of surveillance for the rest of the age groups… Well, it was almost a breach of trust; changing the rules after years of teaching was just not on.

I mention this only to put the contemporary problems of counselling young women into some perspective. Especially now that vaccination against some of the more common and troublesome varieties of Human Papilloma Virus is possible. Vaccination has always had its opponents, and HPV is no different. But for my practice, there seem to be two major questions that arise: the need for continuing screening after vaccination, and the need for vaccination if a woman has already had a pre-cancerous condition treated.

These are confusing, if not vexing questions. There are at least 15 types of HPV that cause cancer but only two major varieties that account for the vast majority of cases in the community: types 16 and 18 (they’re numbered, rather than given cutesy names). These are the strains that are incorporated into the current vaccines. So if a woman has already had dysplasia -the pre-cancerous condition caused by the virus- it will have been caused by only one of those types and she is still vulnerable to the other. And therefore she still needs to be vaccinated. I get asked this every day, I think. Fortunately the schools in my province have incorporated the HPV vaccination into the early grades at school -hopefully before sexual exposure- so the question may well be an anachronism in the foreseeable future.

But the need for continuing screening in a vaccinated population is more difficult to understand in an era brought up on the concept of herd immunity: the idea that the more people who are vaccinated, the less prevalent the virus, and hence the less chance of being exposed to it. What tends to get forgotten, however, is that there is never a completely protected group: we are a heterogeneous society with new, unprotected people entering it from outside; immunity may wane; less common strains or perhaps novel viruses might gain prevalence and not be incorporated into the contemporary vaccine products. No, there are many reasons not to let down the guard of vigilant surveillance.

But a problem still persists: HPV doesn’t behave at all like a sexually transmitted infection in the minds of most people. We have come to expect cause and effect to be temporally accountable: the unprotected sexual encounter last week results in identifiable symptoms this week. Blame is assignable; lessons are learned. But with HPV, cause and effect are often separated by uncharted and imponderable years of time. There are seldom symptoms, seldom acquired wisdom. No one -or everyone- seems culpable: a difficult take-home message indeed. As I have already suggested, the voyage from Pap to Prevention is a stormy one.

But maybe this is just a generational thing: what we find difficult to assimilate today, will be greeted with a knowledgeable shrug tomorrow. We are creatures of more than structural evolution; more than linear accrual. As Shakespeare says: We know what we are, but know not what we may be. Or even better: Lord, what fools these mortals be!