Is there ever a correct answer?

“Doctor, can I still get pregnant?” -a seemingly straightforward question, I suppose: quote her some statistics derived from her age, past history and current medical status. But in reality, it’s probably not a single question she’s asking. In many respects, it’s a philosophical question with many facets to consider; it requires a thoughtful reply.

Philosophy, as Michael Blake, a philosopher from the University of Washington once put it, is thinking in slow motion. I like that; it suggests that to answer something, to comprehend the various competing facets of a question, we need to take some time to consider both what is really being asked and whether our answer to it is relevant, sensitive, and in this context at any rate, representative of current thinking.

To make it through even a single day, we all have to make many unexamined assumptions about reality, not to mention about people and their beliefs, hopes and aspirations. Sometimes we assume they share our own opinions, see the world as we do, have the same or similar doubts, exhibit our own biases. But I suspect that this assumption will never properly address the question my patient posed. It may not even come close to answering it.

The question is a tree: it has roots and branches; and rather than existing in isolation, it is probably surrounded by other questions. To understand the tree, you have to understand the forest -or at least look at it in context.

“Can I still get pregnant?” -the very construction of the sentence suggests some of the worries and concerns that she has. It is, on first consideration, merely a question about her ability to conceive and if answered in that framework, is a number. A percentage. It is the product of an algorithm into which you feed her age, past history of pregnancies or diseases, and her current medical status and a type of answer appears. It is a type of answer, because it is really only a statistic -useful for a population of 40 year olds, say, but not necessarily this 40 year old. And what does 20% or even 50% really mean? The question, after all, was “Can I get pregnant?” -not, can a forty-year-old woman get pregnant. Not really; she is asking in effect: “Given what you know of me  and my circumstances, my health, my body, do you think I can still get pregnant?”  And she is asking for your opinion, not a legally binding statement. She is asking what you think…

And “still get pregnant” is important. In itself it hints at other questions: “At my age, is pregnancy even advisable?”; “What might be the problems I will encounter if I do become pregnant?” And “What would a pregnancy under those circumstances look like for me? And for the baby?”; “Are there disadvantages -long and short-term- that you can foresee, doctor?” Once again, you are being asked for an opinion -perhaps even a personal perspective (with all it’s biases and cultural nuances).

There is an uncertainty built into the very question that demands consideration. Perhaps she is unsure about whether even to consider pregnancy; perhaps it was something someone else had asked her -or even demanded she ask. Maybe she is asking for permission not to become pregnant…

What is inserted into an equation, determines it’s answer; the background of a question, the milieu -the forest in which it lives- should suggest the thrust of the response. There is often no correct solution; in fact that may not even be what is sought. Sometimes a question is more of a search for someone to listen, a hope for acknowledgement, a quest for agreement, than a need for an accurate reply. The skill is in recognizing what is being requested; listening not so much to what is being asked, as to what is meant by the question in the first place.

So the importance is in properly and sensitively analysing the question; recognizing that it is a series of probes for which a thoughtful response is required. It is usually not just a number that is wanted -although that may help to give some perspective to the subsequent analysis- it is a respectful appreciation of the concern and a realistic appraisal of the context. “Can I still become pregnant?” requires not only a judgment -even though that is certainly a part of it- but also an opinion: a thorough appraisal and a considered response; it is not necessarily even final: things evolve -questions as well.

It is thinking -and answering– in slow motion.

How different are we?

As I get older, it occurs to me with increasing urgency that I do not necessarily inhabit the space that others do. Often I do not have the same beliefs or share the same customs; I value different things, organize my thoughts a different way; I see the world through eyes that have feasted and grown old on different sights. My experiences are necessarily unique, trapped as I am by genetics and circumstance. I should not claim to speak for anything or anybody but myself.

And yet I do. We all do. We speak from everything that has affected us, all that we have endured -or learned. We extrapolate from what has made us unique and try to make it encompass what we encounter, thinking that our own expectations and opinions are not only justified, but likely to be valuable and helpful to others. We long to meet ourselves in a crowd…

But this worries me as a doctor, charged as I am with helping others who cannot be the same as me nor want to. Why would they? What I offer them, what Medicine offers them, is a view-point, a world-view that may be at odds with their own. They come because they want help, and their need usually allows -requires- them to transcend their feelings for a while -help requires sacrifice. But even this necessity, however imperative, often stumbles at two nodes, two doors that are sometimes locked -or at least difficult to open.

The first is an impediment to seeking help in the first place, no matter how serious the problem. If the patient thinks my views are too distinct from hers, too disparate, she may not even seek help. In some contexts this concept is described as cultural safety. Simply put, will the person feel safe in disclosing her needs? Will her difference or her views be recognized and respected, or will they be marginalized and considered irrelevant, unimportant, or even silly? If she comes from a tradition that respects alternative therapies, say, -alternative to us, of course- or perhaps that prioritizes spirituality but expects this to be denigrated in her encounter with the doctor, is she even likely to make an appointment? If her friends tell her of racial, cultural, or socio-economic profiling at a particular hospital, or that the type or even quality of care seems to depend on what stereotype she fits, might this affect her decision to seek help, or at least delay it until she is desperate? I think so.

Or the if doctor is solidly imprisoned in his own views and so convinced of their truth and validity that he cannot or will not listen to your discomfort and try to see your problems as you do, will he be able to help even if you agree to see him? For many people, the concern, the fear, that their own opinions will be mocked, or not taken seriously is an impediment to treatment. Health, wellness, is in many respects subjective. How we feel about ourselves, how others feel about us is part of the equation that defines health. Disease apart, we are how we feel; we are the sum total of a multiplicity of parts that we somehow integrate into a functioning body, a sensing organism. Our opinion matters, if only to hold things together, grant them their eccentricities, tolerate their distinctive habits to which we have long grown accustomed. Who better to know me, than me?

A doctor ignores this at his -and your- peril. It is a difficult world for some to enter; some of us merely talk through a sort of window from the safety -the authority- of our office: encounters at a distance, diagnoses from the opposite side of the desk. Others pretend to understand but only outwardly -thoughts easily readable through body language by anyone nearby. There are a few doctors truly gifted with agape but most of us, try as we might, are creatures of our past.

And so what’s the answer? How can a doctor ever hope to help anyone? Surely each of us is an other, a stranger to anyone but ourselves. We all come from disparate backgrounds so what we hear is filtered, what we encounter: a confirmation bias; it makes us fallible and closed. And yet…

And yet if we take the time to listen to the other and listen with respectful curiosity -dignify their thoughts and opinions with our considered silence- we have come a long way. A hard part of illness is just being heard. After all, listening is how we form opinions in the first place; its how we learn; its how we connect; its how we understand… Listening enables relationship. It’s part of how we heal -a larger part than we may think.