The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.

 

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The Grief that does not Speak

How weary, stale, flat, and unprofitable seem to me all the uses of this world!

Like Hamlet, we all recognize this mood: the black dog lying in the noonday sun, the cloud that even hides the moon. It is the tear that defeats the wavering smile –and yet… And yet, there is often something more behind the grief, something that is hidden beneath the first impression. Shakespeare, again, understood this over four hundred years ago: ‘Give sorrow words. The grief that does not speak whispers the o’erfraught heart and bids it break.’

I suppose we all impose our own reality; we all see the world through our own experience. But, sometimes we see through that glass darkly. Things are not always what they seem.

Alethea looked calm and happy as she sat in my waiting room. In fact, she was smiling and talking with a little child who’d toddled over to her in his diapers with a toy. She was bending over in her seat, her long black hair almost reaching the little boy, as she tried to make him laugh. Her full-length black, cotton skirt and her blue silk blouse contrasted sharply with his bulky white diapers –a chiaroscuro worthy of a picture, but he waddled off to another woman as quickly as he’d arrived. The waiting room is like that here: a work in progress; an evanescent scene of fleeting beauty.

Alethea smiled again when I greeted her, and examined me with friendly eyes. I had anticipated avoidance, or at least timidity from a woman referred to me with recalcitrant depression. A woman, according to a rather extensive explanatory note, who seemed refractory to multiple attempts at treatment. But I’m a gynaecologist, and although we’re sometimes involved on the edges of depressive illnesses, most of us lay no claim to the territory. We’re adjuncts –often last-minute guests- invited to the therapy just in case; we’re seldom primaries.

But in my office, she seemed less at ease, her eyes flitting from the plants in their pots to the eclectic pictures hanging on the walls. They spent some time inspecting a terra cotta sculpture of a woman begging with a bowl that I’d positioned on a little oak table.

“You certainly have wide-ranging tastes, doctor.” I don’t think she meant it as a criticism, so I took it as the long missing compliment I have yet to hear from my staff.

I smiled, and opened up the computer.

“I’m afraid my GP wrote a rather long note justifying the referral to you; she seems quite worried –or maybe frustrated with me.” Alethea rested her eyes on me for a few seconds. “I asked to see you rather than a psychiatrist.” And then she chuckled. “She was not happy about that, I’m afraid.”

I pushed the computer to one side and sat back in my chair. “Do you mind if I hear your version, first?” I asked.

“Thought you’d never ask,” she said as she made herself more comfortable in the sturdy, old wooden captain’s chair that I insisted on keeping across from my desk, her eyes twinkling with amusement at my suggestion, but still cautious.

“Well,” she started, obviously trying to place the events in their proper order, “A few months ago, I went to see my GP because of some problems I was having –you know, coping stuff,” she added when I wrinkled my forehead. “Anyway, I was in tears when I sat down in her office and had trouble even talking to her without crying.

“She got very clinical and I could tell she was trying to remain an objective observer.” Alethea rolled her eyes and sighed. “She does that sometimes when all I need is a hug or something.” She risked a quick glance at my expression. “But I realize that’s not what doctors are supposed to do…

“Anyway, she asked me all the usual questions about my work, and my home life…” Alethea blinked and looked away. “I think she felt a bit uncomfortable with that part because my partner also used to go to her.” Suddenly she stared at me and I could feel the anger in her eyes. “I really don’t know why that would matter…”

She quickly snatched a tissue from my desk and wiped her eyes. “I’m sorry, doctor, I guess my GP is not the only one who gets frustrated.” She took a long, deep breath and exhaled it slowly. “She said she’d never seen me like that before, and that whatever might be going on, I was seeing it through the lens of depression.” She glared at the begging lady statue for a moment. “She actually said ‘lens of depression’ for god’s sake! Like no matter what I said, or experienced, it was somehow misinterpreted through that bloody lens, or whatever.”

Alethea seemed uncomfortable and kept readjusting her body on the hard chair so I pointed to a more comfortable one nearby. That got her smiling again, but I could tell she was still angry.

“She insisted I go on one of those new antidepressant medications –you know, the ones that aren’t supposed to make you tired. The ‘no side-effects pill’ she called it. ‘Just try It for a few weeks and let me know if it helps,’ she said and escorted me to the door, all buddy-buddy.”

She brought the comfortable chair close to the desk and helped herself to a handful of tissues. “But it only made things… worse.”

I leaned forward on my chair, detecting something she was implying in the way she said that word. “How do you mean, Alethea?”

A tear rolled down her cheek and she dabbed it with the tissue. “I didn’t feel at all like sex, when I was taking it and…” She hesitated for a moment. “And that really made her mad.”

I was confused. “Made who mad?”

She was staring at her lap, but her eyes wandered up to my face for a brief look before she called them back. “My partner.” She sighed again. “So I decided to go off the antidepressants after a while and went back to the GP. She seemed upset that I had only given them a month, and said I was still acting depressed. At that point she said I needed to see a psychiatrist, but I refused. ‘You have a chemical imbalance,’ she almost screamed at me, and implied that if I didn’t get help soon, there might be dire consequences.” Alethea glanced at me again. “I suppose she thought I might try to off myself or something.” She giggled at the thought and when I looked puzzled, she smiled and continued. “Maybe it’s your birth control pill, Alethea. I don’t know why you insist on taking them anyway.’” Alethea’s face turned mischievous and her eyes twinkled like when she first came in. “Because I’m Bi, you stupid woman!” she said and laughed. “Well, I didn’t actually say that to her, but I felt like it…

“Anyway, I convinced my GP to send me to you.”

I squirmed a little uncomfortably in my own, soft chair. “Why me?”

A playful smile emerged. “My aunt and cousin see you… They said maybe you’d listen.”

I think I blushed. “And what about your partner? Did she think you were… depressed?” I hesitated before using that word. “Did she listen?”

Alethea’s face suddenly tensed. “She was abusive,” she said between gritted teeth, and sent her eyes to scout my face again. “She used to scream at me and throw things around. I hated going home after work.”

“Did you tell that to your GP?”

She shrugged. “I told you, she felt uncomfortable about it. And anyway, she had a diagnosis –and a treatment,” she added, with a wry smile. “That’s what medicine is about nowadays, isn’t it?” The smile disappeared, to be replaced by a sweet grin. “And once you have a treatment, it’s… Next!” she said, rolling her eyes, and we both laughed.

“And so what’s happening now? Are you still with your partner?”

Her face beamed and her eyes sparkled. “Now, I’m back with my old boyfriend -it takes a long time to get in to see you,” she explained with a chuckle. “We’re even planning to have a child soon, maybe.” Her eyes hovered under the ceiling for a second or two. “I guess I wasted your time, doctor, but my aunt was right -it does help to talk about it… And I thought I should meet you anyway,” she added, and decided to make eye contact again. “You delivered my cousin last year…” The twinkle returned. “Care to see me again –in a while?”

I think my smile told her I’d love to see her again.

And as she left, I couldn’t help but think of that wonderful metaphor of Khalil Gibran: ‘Sadness’, he said, ‘is but a wall between two gardens.’

It certainly is.

Fertility options

Some people would do anything to become pregnant: undergo painful procedures, borrow money, mortgage their homes –anything, it seems, to have a child. While this is certainly understandable –parenthood is perhaps the raison d’être of our genes- it seems a shame that fertility would be something denied to some while granted to others. Arbitrary at first  glance, it sometimes remains so even after extensive investigations. And yet there has been a lot of progress in understanding the mechanisms that both allow fertilization to occur and, maybe even more importantly, implantation of the egg and subsequent successful development of the pregnancy.

Obviously, there is a whole cascade of events each having to unroll in the proper order –such things as development of a viable and healthy egg in the ovary; its ovulation and successful encounter with a (hopefully) normal sperm; a clear and unimpeded route to an appropriately developed uterine lining… And these are just the early requirements for the long journey to l’accouchement. But, like a planning a trip, it is more likely to arrive at its destination if the car is sound and there is gas in the tank.

There are many roadblocks along the way, however, not the least of which are the body’s defence mechanisms which try to destroy foreign proteins that might pose a risk to the health of the organism. A fertilized and developing egg contains a mixture of just such foreign material from the male, and so in some cases might be construed as an attack. Although the uterine cavity is designed as an immunologically privileged site to thwart such a mistaken identity, for some reason it doesn’t always work. While this can be a subtle issue and difficult to detect, it can be an even more difficult thing to correct. There have been attempts to do this with medications to increase success during IVF (in vitro fertilization), but with few breakthroughs so far.

Sometimes my patients know more about this than I do, or perhaps pay more attention to disparate media reports that view every paper published, even in obscure journals, as fodder -landmark achievements. The job of journalists is to interest their readers, not to critically analyze the data and research whether or not the findings were merely a one-off that has not been validated by others in the field. A crash is news; a non-crash is not. Or am I being too cynical?

Last year, I remember seeing Janice, a woman who had been trying to become pregnant for several years. She told me that all of her tests that her GP had ordered had been normal as were those of her partner. Because she was already approaching 40, I immediately suggested that she would likely benefit from being assessed at an infertility clinic to see if they could expedite things. I wasn’t sure that I could help.

She shook her head. “I’ve already been to a clinic…” she said, with a sad expression on her face. “They wouldn’t listen to me.”

“Listen to you? What do you mean?”

She probed my face with her eyes for a moment to see if I was likely to listen to her. Then, apparently reassured, she sighed and sat back in her chair. “Well when they saw the normal test results they added their own versions of the same things but still couldn’t find anything wrong. So they suggested IVF. Time’s running out, they said.” She straightened in the chair and uncrossed her legs. “We can’t afford IVF,” she said, all the while staring at her lap where she was alternately wringing her hands and straightening the fabric of her dress. “They basically shrugged and told me to think about it and come back if I changed my mind.”

I waited for her to continue. There must have been some reason her doctor had referred her to me.

“Anyway,” she said after a long thoughtful pause and a quick gulp of air, “I went on the internet to do some research on other options…”

I managed to stop my eyes from rolling but I have to admit she caught me holding my breath. I never know how to react when a patient innocently offers a totally unorthodox and largely un-researched idea that they’ve found on some website lying in wait in a dark corner of the web.

But she noticed my expression and chuckled at my obvious discomfort. “You must get this all the time from desperate women, eh?” I smiled, embarrassed at being caught. “I’d been trolling through some weird stuff and then noticed a reference to a paper published in the journal Science –it was dated 2015, so not very old. It was only the abstract, though, and I wasn’t really all that sure that I understood it correctly…” she said, no doubt to head off any criticism before I could formulate it. “But there was also a reference to a BBC article talking about it so I looked at that as well.” She handed me a piece of paper with its address so I could look it up as well:  http://www.bbc.com/news/health-34857022  and then to show she meant business, the abstract from Science: http://www.sciencemag.org/content/350/6263/970

When I didn’t immediately punch it in on my computer, she decided to explain. “There’s a parasite that increases a woman’s fertility, doctor,” she said, now intently studying the panoply of expressions that flitted, untended, in quick succession across my face. “Not all of them do, of course,” she added quickly, to show me that she wasn’t that foolish. “I mean, I don’t want to try one, or anything. I just wanted to know what you thought of the idea.”

While I gathered my thoughts, she explained. “I went back to the fertility clinic and asked their opinion about the worm… Ascaris lumbricoides –I memorized the name,” she said and immediately blushed. “Anyway, when I mentioned it to the clinic doctor, he just laughed at me. I don’t think he meant to, but it just kind of escaped from his face before he could stop it…” Janice suddenly leaned across my desk with a serious look on her face. “Of course I thought the doctor was being rude and dismissive, so I walked out on him and headed over to my GP’s office. At least she was more patient with me, but I could still read the disgust in her eyes. We managed to talk about it for a few moments, and then she decided to refer me to you. You’d listen, she assured me and then walked me out of the room…escorted me, almost. I think she just didn’t know how to handle the idea so she passed the buck.”

There was a sudden twinkle in Janice’s eyes that I almost missed –a mischievous expression that flirted briefly with her mouth, then disappeared. “My GP obviously didn’t think I needed an urgent appointment –although I did remind her of my age- so it took me a while to get in to see you.” She smiled a more ordinary smile this time, although it was still nuanced. “Several months, in fact.” I could hear the italics around the word from across the desk. “You’re a busy man, doctor.” I think I blushed.

She waited for a moment to let the thought embed itself in the desk. “So, what do you think of the worm idea?”

I struggled for words initially. It was an unusual idea, but I remembered a brief flurry of rumours when I was in medical school about fashion models infecting themselves with intestinal parasites to help them to stay thin. Perhaps they were just that: rumours, but the idea at least was not without precedent. “Well, I suppose if we could be sure that it wouldn’t affect the developing baby in any way… or you!” I paused for effect. “And that we could reliably get rid of the parasite when it had done its job –again without harming you or the baby- then…” I had run out of words. I had no intention of endorsing the idea, but I didn’t want to dash her hopes entirely. Hope is what keeps us going. I leaned across the desk towards her and smiled. “Let me just say that if you were my daughter and you had honoured me by asking for my opinion, I would have to say that some things are just not worth the risk.”

“You mean you’d advise against it?” She seemed relieved.

I nodded carefully, sensing I was being led into a trap.

A smile almost split her face in two and her eyes lit up and sparkled like lights on a Christmas tree. “Well, I’m pregnant now,” she said, italicizing the important word again and leaning across the desk as well. “It took so long to get to see you, I thought I’d use the time constructively.” My eyes must have betrayed something, because she suddenly extended her hand and grasped my arm. “Don’t worry, doctor, my husband and I decided against the worms. He said he was really worried about them…”

I relaxed my expression and was about to say something about a caring partner, when I noticed another twinkle in her eyes. “Yes,” she added before I could open my mouth. “He was afraid of getting them from me.”

The Science of Answering

I suppose in this suspicious age, everything is open to scrutiny. But some things are examined at one’s own risk risk -like turning over a familiar log in the garden only to find unexpected and sinister-looking creatures lurking quietly beneath. This is fine, of course, but it can be hard to know what to do with the results of such investigations without some attributions -either positive, or more likely, negative. And, depending on our experience, a vacillation between the two.

Science by encouraging unbridled curiosity has often not been neutral in this. With some trusted and unsuspecting products that have been on the market for years, subsequent studies have occasionally determined similarities of structure, or function, with other, more bothersome effects. Aluminum in cookware was one famous example. Aluminum was found in some plaques in the brains of patients with Alzheimer’s disease so of course products containing aluminum went into a precipitous decline from which they never really recovered despite subsequent studies that failed to substantiate the risk. Or think of the autism scare after a since-repudiated 2004 article suggested that thimerosol, a synthetic form of organic mercury which has been used for many years as an antimicrobial agent and preservative in many vaccines, was the cause of autism spectrum disorder.

Once these doubts have been cast, suspicion often lingers that is hard to eliminate. Conspiracy theoreticians emerge from the shadows to sew their seeds, flaunting the seemingly obvious and intuitive conclusion that there must have been something that made the scientists find what they did. The fact that science actually encourages refutation -that nothing is ever known for certain and that they’re rather happy with that- escapes those who would rather believe there is a cover-up.

And now, there is another study –one among many- that suggests that even low amounts of parabens –preservatives used in, among many other things, the cosmetic industry- might increase the risks of breast cancer! Researchers from the University of California, Berkley have published a study in Environmental Health Perspectives that seems to demonstrate this: Environ Health Perspect; DOI:10.1289/ehp.1409200

‘Existing chemical safety tests measure the effects of a chemical on human cells in isolation. However, as these tests fail to consider that compounds might interact with other signalling molecules, the tests are insufficient, explained the researchers.

Using the naturally occurring growth factor in breast cells, heregulin, the researchers stimulated the HER2 receptors in breast cancer cells and exposed the cells to parabens. The chemical caused the oestrogen receptors to activate genes, which led to the proliferation of the cells. Moreover, the effect was significant: parabens in the HER2-activated cells stimulated breast cancer cell growth at concentrations 100 times lower than in cells lacking heregulin.’

Is nothing safe? It’s difficult to know what to do with information like this. Surely there is a middle ground between merely shrugging our shoulders and accepting that the world is a dangerous place, and railing against Science for trapping us here. Do we sometimes just use our indecision as a reason to worry? Change seems to spawn unintended consequences no matter how hard we try to anticipate them. As an enthusiastic user of modernity I suppose I am closer to the shrug camp, but I recognize that there are different world-views out there and I dare not gainsay them. Especially if they are first time patients who are a little wary of me to start with.

Jona did not trust me; I could tell by her eyes as soon as I introduced myself in the waiting room. While her face said hello, her eyes threatened me with silence if I so much as stepped on the boundary. The hand that shook mine was aggressively firm and it was all I could do to keep from wincing. I hate that. I’ve always felt that the first contact should be a greeting, not a contest. A sign of mutual respect, not a dare. I don’t feel at all competitive at that stage, but from her expression, I could see she felt it was a form of sport. I was surprised she let me lead her into my office.

When I was finally allowed to sit and open up my computer, I saw that her referral to me was for dyspareunia –code word for pain with sex. She sat on the other side of my desk with everything on guard: face, posture, fists… Everything dared me to ask her why she was here. So I didn’t. I just let her talk –debrief, as it were. Her eyes –at least the ones that she had trained to pin doctors to their chairs- were hovering around my face, waiting for me to provide the excuse for an attack.

“I know that Maria has listed my problems in the letter she Emailed, doctor, but before you start on me, I just want you to know that I refuse to take, insert, or inject any medications.” She proceeded to cross her arms tightly across her chest, as if something was trying to escape from under her blouse. “Maria wanted to put me on estrogens, but as you know, they can cause strokes, heart attacks and cancer. Sex isn’t worth that risk.” She glowered at me, still holding off the eye-attack until I said something. “Then, she suggested the low-dose variety that you merely put in your vagina… Merely?? It’s hardly a little thing to put an uninvited foreign body in there, doctor! She thinks my vaginal skin is too thin and that’s why it hurts.” She thought about it for a moment. “And how would she know? She couldn’t even get a speculum in there, so how could she say that? I’m 48, not 68 for God’s sake. I’m still having periods and tampons have never hurt.” She sighed theatrically and continued. “I’ve tried lubricants and stuff, but if you look at what they contain and then Google the contents, it’s like playing Russian roulette with your vagina. Some of them even print disclaimers and suggest medical consultation before using them. They can cause allergies, skin irritation, infections… Some are even carcinogens when you look up the pharmacology. And then there’s that article saying that the parabols might even cause breast cancer…”

‘Parabens,” I corrected her and then closed my mouth, smiled sympathetically and waited for permission to say something more. Anything.

“Whatever. My husband doesn’t understand, either. All he wants is something quick before he goes to sleep. Of course, he thinks I’m making up the pain stuff…”

The short pause, and a brief journey of her eyes to a picture on the wall gave me an opportunity to ask her something: “Do you talk to your husband?” I said, and waited for the eyes.

“He won’t even talk to me when we’re eating dinner…” She said slowly and looked down at her lap, caught off guard by the question, I think.

“How long has it been since you were able to talk?”

Jona withdrew her eyes and they disappeared into her face along with her anger. Then she shrugged, and a few words spilled out. “It’s been so long, I can hardly remember when…” She suddenly stopped talking and stared at me. “But why did you ask about him, doctor? Do you think our…?” she said in a whisper. “My GP never even asked…” Her expression changed from one of defence to one of curiosity. “Why did you wonder if I talked to my husband?” she repeated.

“Are you a Shakespeare lover?”

Her face tightened for a moment in puzzled irritation, but then she laughed. “Double, double boil and bubble; Fire burn and cauldron bubble,” she said, obviously pleased with herself. “The witches, in Macbeth, I believe.”

I nodded, then grinned. “Well, let me quote from the play-within-a-play in Hamlet –Gertrude answering Hamlet’s ‘Madam, how like you this play?’… ‘The lady doth protest too much, methinks.’ she answers…”

A little smile –the first real smile she’d shown me- blossomed like a flower on her lips. “Maria said you were good, doctor… You’re smarter than you look,” she said with mischief in her eyes this time, and her body relaxed into the chair. “What do you suggest I do?”

I readied my fingers over the keyboard and chuckled warmly. “I suggest we start by making sure there is nothing you need to worry about.” I thought of another memorable phrase, this one uttered by Hamlet himself: ‘There is nothing either good or bad, but thinking makes it so.’ But I didn’t say anything; she’d had enough Shakespeare for now I realized.

When Silence is Golden

Silence is golden; it can also be difficult. Many of us find it uncomfortable -awkward if it continues for too long. In communication, silence is a benefit that diminishes with time, a value that becomes a penalty. A schism that is counterproductive.

We all want to be heard; we all need to be recognized, and yet that acknowledgment requires reciprocation. Otherwise, we might as well talk to a wall. Listening is not just silence; it is attending.  Listening is not the same as merely being in the same room.

A doctor is often called upon to be a multifaceted creature: she must first be sensitive to her patient’s concerns, and attentive to the sometimes lengthy explanation. She must demonstrate some empathy and understanding of the problem and yet remain calm and reassuring. Equanimity in the face of seemingly intractable issues is usually seen as a hallmark of competence. But, after a suitable time spent listening and incorporating all of the relevant symptoms into a reasonable diagnosis, it is the doctor’s turn to speak. And the art is so often in the timing.

As soon as I saw her in the waiting room, I could see she was going to be difficult. She was an older lady, probably in her late fifties, who was sitting in the corner by herself like an angry statue. Cemented to her seat, the infants crawling on the rug in front of her might as well have been ants on a lawn for all she noticed. Her face was puckered into a tense scowl, her hands were clasped into a tight, unmoving ball on the lap of her long black dress. Were it not for her short, white hair, she could have been mistaken for a shadowed monument, a memorial placed inconspicuously in the corner so as not to frighten the children.

Only her eyes betrayed her presence and they fixated on me like a hawk as soon as I entered the room.

“Gladyce?” I said walking across the carpet and trying to avoid the toddlers.

Her eyes hardened into marble slits and her face into granite. “Mrs. Ardess,” she said, italicizing the sirname through lips that barely moved. I’m surprised she could actually speak through them.

I extended my hand to introduce myself, but she barely touched it. One of my maternity patients across the room rolled her eyes.

I started to walk down the corridor to my office, expecting Gladyce to follow, but she remained seated, perhaps waiting for instructions. “Mrs. Ardess,” I said, turning to her with a smile. She sighed noisily and stood up. She seemed reluctant, though.

I indicated a seat across from my desk and waited for her to settle into it. And as I busied myself with the computer, I could feel those eyes on me again, burrowing into my skin. I returned the favour once I had opened her chart and discovered there was no referral letter.

I was about to ask her why she had been sent to see me, but before I could even open my mouth, she hardened again. “You doctors never listen, do you?” She almost spat the words through her clenched teeth. “I saw a new GP, and I told her I wanted to see a woman gynaecologist!”

This is not new to me, and certainly not an unreasonable request, but sometimes my female colleagues have longer waiting lists than me. I’ve learned not to take it personally. “There is a woman gynaecologist that works with me in the office,” I said with a slightly forced smile. “Would you like me to…”

“That’s hardly the point,” she interrupted. “I told the GP I wanted to see a woman in the first place, not waste my time being shunted around. Doctors never listen. They ask a lot of questions, but it’s like they just pick out what they want to hear from what I say and discard the rest. My first doctor didn’t even seem to understand that I was really worried.

“I told her I have an itchy red lump and that it’s in an area that is very personal. Very scary.” She scanned my face for a reaction, but I was too intent on what she was saying to react. “I’m not very sexually active anymore, so I try to be careful with my partners. You know, ask them questions, assess the risks…”

I only had time to nod before she continued. “So I was frightened that the lump was related to that… encounter.” She almost whispered the word. “It came up a few days later, so I phoned him to reassure myself again.” She softened her expression briefly and for a moment I saw a different woman. “He was so gentle with me, I didn’t really suspect he’d been lying, but I had to check. I was really worried.

“I waited a few more days thinking everything would go back to normal, but when it didn’t, I began to panic. What if it was syphilis or something? Or that HPV thing everybody’s been talking about?” Her eyes, now far from angry, fastened on my face like birds clinging to a branch. “I phoned my GP, but her receptionist said she couldn’t see me for almost a week. When I asked her to check with the doctor to see if she could fit me in sooner, I could hear them talking and laughing about it in the background.” Gladyce was silent for a second, and even unlatched her eyes from my face.

“Doctor Forster eventually came on the phone to ask me why I needed to come in so urgently… But I couldn’t convince her to change her mind. She just told me to take warm baths for a few days and if that didn’t help, to phone her back.” Suddenly Gladyce pinned me to my seat with a glare. “Dr. Forster was just too busy to listen to my concerns. I could tell she was having a bad day herself. So I managed to find another doctor –another female doctor- at a walk-in clinic.

“Maybe I chose the wrong place, but they were so busy at this one they could only see me for a few minutes.” She looked up at the ceiling for a moment. “Actually ‘see’ is probably the wrong word: the doctor never examined me. Didn’t have time, I guess. And when she asked me why I had come to the clinic, I got about two or maybe three sentences to explain and as soon as she heard the word ‘lump’ and ‘non-healing’ she began mumbling about sexually transmitted infections and grilled me on prevention. Then it was PAP smears and how necessary it was to have them regularly. Finally, she managed to segue into cancer and after hemming and knotting her face up said I needed to see a specialist. When I insisted it be a woman, she merely shrugged and said she’d try but that I needed to see whoever it was as soon as possible.

“But she obviously wasn’t listening either. No time. She had other patients to see…”

Gladyce studied me for a moment, obviously thinking about something, her eyes painting wide swaths across my face and chest. Analysing. Deciding. And then her demeanour suddenly changed and a different person emerged. I thought it might be an opportunity to ask her a few questions –finally meet her, in fact. “Well, Mrs. Ardess,” I started somewhat hesitantly, “I can see why you’ve lost some faith in us…”

“Gladyce,” she interrupted with a smile. “Call me Gladyce.”

The Wisdom of Experience

Sometimes, I feel like a fake. I suppose the ability to see oneself from various angles is a gift of age, but I rather enjoyed myself more when I was sure of who I was –or at least didn’t trouble myself with the question. And yet, to dig for the core is to taste the apple on the way.

It was easy to be a doctor when, primed with knowledge, experience was something displayed in a shop window, not something I wore. It was an outfit I didn’t need -an extravagance, really: a luxury you only donned when the facts you’d learned were threadbare and outdated. It was a costume of authority, a camouflage for waning certitude: Moira.

And yet as I plough through the years as steadily as a man walking through waist-high water, I have come to realize that experience is more than subterfuge, more than mere artifice; it is Age. Nothing less. And following in its wake is all the jetsam tossed overboard to lighten the journey, all the flotsam through which we, as sentient beings, must wade in order to progress. A dirty passage protected only by the hull of maturity. But enough metaphor.

All of this somewhat depressing prologue is to introduce an incident that occurred a few years ago when I was teaching a medical student in my office. Stephanie was very good, really –very perceptive and knowledgeable- and she carried herself like someone who had already graduated. It was not hard to integrate her into the chaotic machinations of my busy office.

We were seeing a woman sent to me from a well-respected family doctor who sometimes attracted patients with very dissimilar world-views. She had come to see me for a second opinion about the management of her menopausal symptoms. Or rather, she had been sent to see me by the GP when she refused to accept the treatment offered by the first specialist.

A very well-dressed woman with neatly brushed hair, she sat across the desk from me looking quite confident. She smiled at Stephanie, and then straightened her shoulders and stared at me defiantly. “My doctor wanted me to see you about the menopause…”

I smiled and waited, pen poised to write down her complaints so I could address them later, but she sat back in her chair, obviously finished, and stared at the calendar hanging on the wall behind me. “So, are you having any problems?” I asked after a rather awkward silence.

She shook her head and shrugged. “Am I supposed to?”

I glanced at Stephanie, who was sitting on the edge of her seat, fascinated at the exchange. “No…” I said, looking at the referral letter that just said ‘MENOPAUSE!’ in giant capital letters followed by an even bigger exclamation mark. “But I rather thought your doctor must have had some reason to send you to see me.”

The woman smiled –at least, I suppose that’s what she wanted me to think, but actually it was a smirk. “I’m managing my menopause very well, doctor…” It was a challenge: a dare to be contradicted.

“So… there are at least some symptoms you’re feeling a need to manage.” I said this carefully, not wanting to provoke her.

She immediately straightened in her chair and her eyes hardened. “Why would you say that?”

My turn to shrug. “Well, is there anything I can do for you, then?” I kept the smile on my face.

She took a deep breath to contain her obvious irritation. “My doctor thinks I should be taking hormones… And so did that other doctor she sent me to.”

I started to write in her chart –it often helps patients to think they are saying something important. “Why is that?” A simple question; no sense confusing her.

Silence, and then a prolonged blink. “I told her I wasn’t sleeping and was becoming irritable at work.” She pinned me to the wall with a sudden glare and then, just as suddenly, relaxed the intensity. A little grin crept onto her lips, but she erased it almost before it flowered. “And I mentioned I was having the occasional hot flush.” Her face hardened. “Why do we always medicalize things and make them into illnesses?”

She was silent for a moment and I put down my pen. She looked at my now dormant chart, for a moment.

“I do not want hormones, doctor,” she said shaking her head angrily. “I’ve solved the issues myself.” And she crossed her arms across her chest as if to ward off any criticism.

I picked up the pen again and her expression softened a little.

“Ginger and lemon juice three times a day…” she said and then stared at me: the dare again.

“It helps?” An innocent question I thought.

“Of course it helps!” Her arms tightened across her chest. “You don’t always need hormones, doctor.”

I tried to keep smiling and sat back in my chair. “I certainly agree with that, Sandra. Sometimes we pathologize things unnecessarily.”

The change in her body language was dramatic and she unfolded her arms and loosened her shoulders. “So you think it’s okay to continue with my lemon and ginger?”

I nodded and wrote something in her chart. “As long as it’s doing the job, why not?” I started to put the pen down and she noticed.

“There’s a lot of stuff in there that you haven’t filled in yet,” she said with an increasing grin on her face and stared at the almost blank history sheet in the chart. “You can ask me some questions –I won’t bite.”

I proceeded with the usual consultation and then looked up at her. She was beaming.

“You’re the first doctor who actually listened to me…” she said, clearly surprised. “Still think I’m okay with the juice?”

I smiled at her -my face was beginning to ache with the effort. “It won’t hurt, “ I said, and sensing she was satisfied with the interview I got up from my chair to open the door for her. “But just let me know if you need to discuss some other options, eh?”

As soon as she was out of the room, Stephanie rolled her eyes; she was obviously troubled.

“So what do you think, Stephanie?”

She took a deep breath and looked at me. “She needs hormones…”

I sat down and waited for her to explain. “I mean, she was obviously describing estrogen withdrawal symptoms: hot flushes, night sweats, sleep disturbance… And did you see how irritable she was? Classic menopausal stuff.”

I smiled patiently. Stephanie was young and enthusiastic. Full of knowledge. “So what would you have done if she’d walked into your office?”

She thought about it for a moment; that she didn’t want to offend me was obvious in her face. “Well… First I would have taken a detailed history like you…” She politely ignored the order in which I had proceeded. “And then I would have told her about how estrogen –and progesterone, I guess, because she still has a uterus- would help alleviate her symptoms.” She looked at me, whether for approval or permission to deviate from my approach I couldn’t tell.

“And if she told you she didn’t want to take hormones? That she felt they were too dangerous, or maybe she didn’t believe she needed them..?”

Stephanie didn’t even blink. “I would have been more insistent…”

“And if she still didn’t agree?”

That stumped her for a moment. “Well… uhmm, maybe I would have sent her to a specialist for another opinion.”

“To validate your opinion, you mean?” I said it lightly and with a grin to defuse the tension I could feel increasing in Stephanie. “She already saw another specialist, who validated her GP’s view… Now what? Give up on her?”

Stephanie stared at me, but it was clear she didn’t have an answer.

“Look,” I started, gently, carefully, so as not to appear to contradict what we both knew to be true: many menopausal symptoms are related to hormonal changes and many of the symptoms do disappear when you prescribe hormones. “Why was she sent to me?”

Stephanie rolled her eyes again –an annoying habit she was prone to use at the slightest provocation. “To treat her menopause…”

“Didn’t she tell us at the very beginning that she was already managing her menopause?”

“Yes, but…”

“Yes, but not the way you would like?”

I could see that Stephanie was becoming exasperated. “But surely you could see that she wasn’t. I mean, she was obviously really irritable and…”

“Wouldn’t you be irritable if nobody listened to your opinion?”

Stephanie’s left eyebrow suddenly took over half her forehead –another trait I had noticed during her time in the office. “But there’s no data on ginger and lemon juice. No studies…”

“She seems to think it’s helping her.”

“Yes, but that’s just a placebo effect. It’s going to wear off…”

I broadened my smile. “And when it does –if it does- who will she decide to talk to about it? The doctors who were unwilling to accept her approach, or the one who admitted she had the right to try another way?”

I’m not sure I convinced young Stephanie, and I’m certain that she’ll succeed in whatever field of Medicine she chooses. But I do hope that she learns that the paths we need to follow are not always straight and that even detours usually end up where we want…

 

 

 

 

 

 

 

 

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.