Tag Archives: Macbeth

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Remembering Forgetting

We have to be careful, don’t we? Sometimes, we have to force ourselves to step back for a moment. When we want something –need something- to reassure us that we will be okay despite signs to the contrary, it’s all too easy to believe. All too easy to slip back into the warm, reassuring arms of a parent who tells us what we want so desperately to hear: that everything will turn out all right…

And I suppose that each of us has her favourite skeleton. However farfetched it may seem to others, it is a source of undue angst whenever the subject is broached, albeit innocently. With my mother, it was her curls. She lived in the sure and certain knowledge that when she got old, her hair would turn as straight as hay. It didn’t, but then again, I was never privy to whether or not her hairdresser was an accomplice.

My father, on the other hand, worried about God –but only, it has to be revealed, after I began to bring home my university textbooks on Philosophy to try their arguments out on him. At the time, I think I felt I was sharing my newfound freedom of ideas, but in retrospect I realize it was unkind.  His background religious beliefs had not prepared him for the convincing effectiveness of rhetoric in destroying what clever minds had decided were untenable arguments. He had not learned to step back; he had not learned to consider the source. Nor had I, for that matter…

It is why I have to be careful. It is one thing to cherish words and venerate ideas, and another to be convinced by those which foster only those with which I have formed an allegiance. Perhaps that’s unfair not only to me, but to the ideas, and yet there is something distinctly unsettling about pernicious change. It’s why, throwing critical thinking to one side on occasion, I revel in reassurance. I want to believe in good-news experiments that cradle me, however briefly, in their arms.

There was a brief summary in a CBC News Second Opinion section with the title ‘Remembering forgetting could be a good thing.’ Now, how could that not attract the attention of someone whose bête noir is just that? Someone who chafes at the declining powers of a once proud memory? Someone who wants to blame it on age, and yet dares not –and whose mind, scrabbling among shards of memory, is persistently reassured that it can still remember the lament of Macbeth before his battle with Macduff at Dunsinane: ‘My way of life is fall’n into the sere, the yellow leaf, and that which should accompany old age, as honor, love, obedience, troops of friends, I must not look to have, but, in their stead, curses, not loud but deep, mouth-honor, breath which the poor heart would fain deny and dare not.’ Some things burrow deeply into the unguarded psyche, however irrelevant.

But the article, reporting on a study published by Dr. Philip Gerretsen (a clinician scientist at Toronto’s Centre for Addiction and Mental Health) in the Journal of Clinical Psychiatry: http://www.psychiatrist.com/JCP/article/Pages/2017/v78n08/16m11367.aspx said that ‘Using brain imaging data and other clinical information from more than 1,000 patients with early cognitive decline, his new study suggests there’s a relationship between a person’s level of awareness of memory issues, and their risk of future disease.’ I cling desperately to fragments like this. ‘”Most intriguingly it’s the patients that seem to be hyper-aware of having some cognitive problems relative to their caregivers that actually don’t go on to develop dementia,” Gerretsen said, adding that those people might be suffering memory loss for other reasons, including anxiety or depression.’

And not only do I derive some satisfaction from his findings, I’ve also learned a new word that I hope to sprinkle surreptitiously into a conversation if I can actually remember it long enough: anosognosia — a neurological term for not knowing that you’re sick. Not realizing, in other words, that you’re forgetting things. ‘Gerretsen says there’s a suggestion that Alzheimer’s disease might be affecting the brain regions involved in illness awareness.’ I’ve decided that’s what I now think, too. It’s another straw to grasp, I suppose.

And yet, true to its etymology, the concept of anosognosia is not very well known. I was in a hospital elevator one afternoon on my way to the subterranean parking lot after visiting a friend. Normally crowded, there were only two older, but tired-looking nurses huddled in the corner of the little chamber leaning heavily on the walls, and one was shaking her head slowly. “I get so annoyed with myself, Fran,” she continued, hardly noticing the novelty of my presence.

Fran, a stout woman with short, messy hair, managed to raise her eyes enough to rest them on her friend’s face. “Why’s that, Judy?” She didn’t really sound that engaged in the conversation –just polite.

Judy, equally stout, but perhaps because of her bright red dress, looking the more refreshed of the two, sighed. “I always forget where I parked the car.”

The thought seemed to perk Fran up a little. “Happens to me all the time… I guess we park here so often, one space seems just like any other.”

“Yeah, but I really tried this morning… I did something or saw something I was sure would help me remember…”

Fran chuckled, more fully awake at the thought. “And now you can’t remember?”

Judy shook her head, smiling. “Worrisome, eh?”

They were both silent for a moment, and then Judy rescued her body from the wall in preparation for leaving, and glanced at her friend. “Do you think remembering that I’m forgetting things is a good sign…?”

Fran thought about it for a moment. “I would think that forgetting that you’re forgetting things would be worse…” she said as the elevator door opened and the two of them got out, giggling like schoolgirls.

Maybe some things are intuitive. Maybe hope is one of those things.

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The Feast of Fools

It’s hard to switch sides, isn’t it? Hard to cross the tracks. And even if you do, does welcome await, or merely sidelong glances and mistrust -or as Macbeth feared, curses not loud but deep, mouth honour, breath which the poor heart would fain deny and dare not…?

It’s a brave person who crosses over –who dares to live the other life. But can one ever feel what one has only watched from afar? Would the experience be real, or only a tawdry simulacrum? A Halloween costume? True, only we know for sure how we perceive something, but we can intuit how someone else might feel –and realize that they might also have a different understanding of what happened. A different reality. So, are we unalterably barred from that room?

I ask this as a man peering over the fence and wondering about what I see. It always seems so… so like my side –so like the cover of the book I’m reading. I suppose that’s where it gets confusing. I know the story is different, and yet I don’t really understand why. But then again, perhaps I’m as naïve a reader as I am a contributor –or is that merely a pretence of innocence? An expected social conceit?

And if I were to attempt a disguise in a situation that even I could see might be demeaning for a woman, would that help me understand? Or would it merely seem weird, and elicit the confused and embarrassed reactions that cross-dressing usually does? Would it take me closer to the lived experience? Or would it be yet another variation of the male Weltanschauung?

An article in the CBC news on sexual discrimination in the workplace made me wonder: http://www.cbc.ca/news/canada/ottawa/workplace-sexual-discrimination-men-heels-union-613-1.3483305 ‘The male staff decided to dress up after a CBC Marketplace story  […] on restaurant dress codes and found that many women felt compelled to wear sexy outfits —including high heels, tight skirts and heavy makeup — to keep their jobs.’

I have to say that at first glance, I was reminded of the Medieval Feast of Fools. This, as you may recall, was a festival usually held at the beginning of the new year (especially in France) in which a mock bishop or pope was elected, ecclesiastical ritual was parodied, and low and high officials changed places. And, according to the Encyclopedia Britannica, by the 13th century these feasts had become a burlesque of Christian morality and worship. But nobody was fooled; everybody realized it was just a charade…

In the case of the restaurant, ‘The men lasted only an hour or two in the heels, which ran the gamut from red stilettos to cheap, black, strappy numbers. But aside from the physical pain, they also described feeling vulnerable and uncomfortable as they worked.’ And understandably so –they were pretending to be something they most decidedly were not. Everybody –customers and staff- knew it and no doubt played along. ‘”Guys were making comments, jokingly of course, because that’s what we were going for — to show light to it — but even those jokes that they were making were, after a while, still very uncomfortable to be faced with,”’ said one of the servers.

A few of the customers were women who also worked as servers at other restaurants with similar dress codes where they were told to look like they were going to a party, not coming home from it. One of them, who had recently quit one of those places after being sent home for not wearing enough jewellery on her shift, said: ‘”I came here tonight because I love the idea of reversing sexist dress codes required in some restaurants to male colleagues. Seeing them wearing heels and short skirts is really something. I wanted to come down and be a part of it,” she said.

‘”It reinforces how ridiculous it is. Seeing men walk by in tight miniskirts and heels really just hits it home how crazy it is to ask women to do that.”’

The consensus among the women servers watching was that within limits, dress should be about choice. If they felt comfortable with dressing like what they were seeing, that was fine. But many of them didn’t. The doctrine of contra proferentem might apply, perhaps, but I doubt that many of them would go so far as to hire a lawyer to press their cases.

So, apart from some interesting publicity and a bit of teasing, what did the cross-dressing actually accomplish? For guys, dressing like women and trying to balance on high heels they’d never been acculturated to wear -and never had the opportunity to practice on- can only give them the barest whiff of what many women have to endure on an ongoing basis. They weren’t women that night, just actors rehearsing a drama they would never get to play.

Clearly, what the article was pointing out was the tip of a very large iceberg. Highlighting this form of sexual exploitation was merely a way of hinting at the way women in general are regarded in our society –and maybe not just ours… You can legislate fair hiring practices, but it is far more difficult –impossible, actually- to legislate attitude.

It is true, however, that unless the issue is publicized in a manner that shocks people into seeing it, there is unlikely to be any change. Some are hoping the protest might go national, with similar events taking place in various cities across the country. But I worry that, although the cause is worthwhile, too frequent repetition of the burlesque, is also a way of making it seem just confrontational -turning a good idea into a parody, and losing the point it was originally intended to make.

As long as shareholders and owners of companies see profit in sexualizing young women –and men, for that matter- the battle for change will be an uphill one. We are already seeing a backlash against ‘political correctness’, to the extent that many of the gains made in the past few decades are being sidetracked, or even eroded. I suppose it was inevitable that direct confrontation with the status quo would be resisted as would any threat.

But the solution, it seems to me, lies not in confrontation, but in changing what we accept as normal –as proper. And it is already being done with some success nowadays through both social media and advertising strategies. Just look at the change in attitudes about, say, smoking in restaurants, or driving home after a night at the pub. There are already recent, albeit tentative steps in various TV and internet-streamed programs –sitcoms and the like- to portray women less as sexual objects, and more as equal partners in their dealings with men. Some episodes have even attempted, as did those male servers in that Ottawa restaurant, to depict the humiliation that men would experience were the roles reversed. And people are watching and getting used to the idea because the characters on the screen are making it seem, well, normal. Accepted, not contentious. And certainly not antagonistic.

Nothing happens overnight, of course, and although we are understandably impatient for more progress, change that is too rapid often leads to rebellion -especially if that change is precipitate. Unexpected -or worse, abnormal!

“How poor are they that have not patience!” says Iago in Shakespeare’s Othello. “What wound did ever heal but by degrees?”

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Grapple them unto thy soul with hoops of steel.

What is a friend? I think I could parallel St. Augustine’s answer about Time: ‘What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.’ Friendship is such a universal concept, such an acknowledged need, I’m not sure why it is difficult to define. Perhaps it is so much a part of our Umwelt that the only aspect of it that becomes consciously discernible is its absence. It is our air…

But of late, it seems to me that its meaning has been further eroded, further diluted, by its use in social media. It is now a verb as well as a noun –all well and good if we are willing to enrol people as friends much as we might solicit them to join a political party, or consider anybody that smiles at us as worthy of the designation.

Obviously, friendship is a spectrum and simply because we use the same word to designate the entire range does not reveal much about the meaning or the importance of its constituents to us. In a sense, if used generically and without a more descriptive adjective, the word is an empty shell –‘Full of sound and fury, signifying nothing’ as Macbeth said of Life. And that life is actually not so full of friends -‘Which the poor heart would fain deny and dare not.’ to quote Macbeth out of context once again. We do not have as many friends as we think –nor is it even possible to sustain the emotional effort necessary to acquire and succour more than five, or so, close friends. http://nyti.ms/2baJQPL

So, I suspect we should be careful how we use the term and in what context –for what purpose. The number of ‘friends’ we think we have are akin to the denominator of a fraction. It’s the numerator –the number of close friends- that determine the size. The value… I would have thought this was so obvious as to be almost trite. Uninteresting. But maybe the idea that a friend is someone requiring at the very least, an ongoing personal, non-virtual, interaction is a generational thing. Am I just having a semantic argument with myself; am I merely a Cassandra unable to understand that it is only my opinion that is being contested, and that its tenets have already been superseded? Food for thought…

And yet, there are consequences. Sometimes it is best to check in the rear-view mirror from time to time.

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I’ve always liked Jennifer. She is a twenty-something year old woman I have known for several years now. I first met her because of a minor abnormality of her pap smear, and have seen her every year or so since then. I think she sits in the same place in the waiting room each time, too; I always associate her with the seat in the corner by the window –the one partially hidden by the Areca palm. She’s a small person, and her never-varying outfit of jeans and sweatshirt seem to blend beautifully with the green of the plant. Even her dark, shoulder-length hair sometimes resembles the type of shadow I imagine the plant would cast if it could… I don’t know why I think that; maybe because they’re both quiet. Both still. Both background.

The other day when I saw her in her usual spot, she was typing away furiously on her cell phone. She looked on edge, and the troubled expression did not disappear even when she saw me smile and walk across the carpet to greet her.

There’s often an easy-to-spot anxiety in some patients –the kind I usually can’t hide when the dentist ushers me into his chair- but I knew Jennifer, and the referral note just said she was back for a repeat pap smear.

“You look worried today, Jennifer,” I said when we were both seated in my office. “Are you concerned about the pap smear?”

She’d put the phone in her pocket and was staring absently at a terra cotta woman sitting on an oak stand with her begging bowl. I’d had it there for years, so Jennifer had certainly seen it before. She shook her head, but left her eyes gently stroking its contours. “She always makes me relax… I’m glad she’s still here.” I could see her trying to disguise a sigh. “It’s nice that some things stay the same…” She was quiet for a moment as she thought about it. “…Stay the way they’re supposed to be,” she added to herself as she moved her eyes slowly over to my desk like sleeping birds and left them lying there. They didn’t see me, I don’t think.

I waited for her to continue, but she merely repositioned her attention onto her lap. “What do you mean?” I asked, when it became clear that she needed to talk about it.

Up flew the eyes to the box of tissues on the desk and she grabbed a handful to wipe away some tears. “It’s nothing about my pap smears,” she said in a hoarse voice. “I don’t need to take up your time…”

“The pap smear talk can wait for a bit, Jennifer. Tell me what’s upsetting you.” I smiled reassuringly, but her eyes never reached my face.

She took a deep and stertorous breath and then decided to send them on a reconnaissance flight in my direction. “Oh, it’s just my ‘friends’,” she said, making sure I understood that there were quote marks around the word. “I invited all 147 of them to like a business website that I’m starting…”

I have to admit that I was a bit confused. “Like? As in Facebook ‘like’ you mean?” I had no idea what message that sent. A friend had once asked me to ‘like’ her barbershop on Facebook and I had duly complied –it seemed simple enough… and if it made her feel good, what the heck, eh?

She nodded, although I could tell by her face that perhaps I shouldn’t have needed to clarify such an obvious point.

“And…?”

She took a deep breath and shrugged. “And, well I guess I don’t really have 147 friends.”

I didn’t ask her how she knew -I figured that was probably obvious, too. But I must have looked surprised, because she giggled at the notion. “I mean I didn’t really think they’d all like the page, but…”

I had to chuckle –I couldn’t help myself. “I don’t even know that many people, Jennifer. I mean not counting patients…” I quickly corrected, as her face interrogated me in disbelief.

“How many friends do you have on Facebook, doctor?”

I shrugged. “I don’t know… I mean, counting my kids and a few close friends… twenty, maybe…?”

She thought about that for a few seconds. “I don’t know how I got so many.” She glanced at the statue again. “Sort of like collecting tee shirts, I guess. They look so nice in the store, but I hardly ever wear them.”

A thought suddenly occurred to me. “Do you know how many ‘liked’ your… uhmm, page?” I tried to sound knowledgeable about the words, but to tell the truth, I was on slippery ground and I think it showed.

She caught her eyes, before they completed a roll and managed to salvage a serviceable smile out of what I’m sure was headed for a smirk. Then her eyes twinkled without her planning on it, and she giggled with delight at my expression. “Only seven, so far…”

It was my turn to nod, and I sat back in my chair as I did so. “Well maybe you come out the winner, then…”

She tilted her head, as cute as a button, and I could see the adult stirring behind the mirror of her eyes.

“Now you know what ‘friend’ really means…” I said, smiling.

Her eyes hovered around my face for a moment before they returned to their owner, and I think she blushed.

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Statistics and Gender

Statistics, the collation, analysis and ultimately, the interpretation of data, have never been easy – at least for me. They have never reached the level of intuitive and, indeed, have barely climbed past manipulative in my head. And I readily admit to occasional cognitive dissonance even when they are used to support what I already believe. Or, rather, want to believe… I wonder if the sources from which I have accessed the numbers might be those that already pander to my own biases. In the cloud of assertions that cover me, everything is obscure and up for grabs.

I suppose it’s like that for us all, though –we hear what seems important to us and sift clumsily through the rest, filing most of it somewhere else, if at all. Especially if what has been measured is not crystal clear –or at least what has been reported is not. A classic example was that of a survey of shared parental leave in the UK. It was initially reported that only 1% of men were opting for this –much less than the rest of Europe. In fact, however, the figure reported was 1% of all men, not 1% of men who had just had a baby.

We have to examine what we read before we arrive at our conclusions; most of us don’t. Most of us have neither the interest, nor the tools to know if what is presented to us is reasonable, or at least free of bias – especially our own confirmation biases. A lot slips through the net.

A good example of this are the statistics on women and girls: http://www.bbc.com/news/magazine-36314061

‘There is a black hole in our knowledge of women and girls around the world. They are often missing from official statistics, and areas of their lives are ignored completely.’ For example, a record of their participation in the labour force in various countries. The data are often biased towards employment in the formal sector, which in those countries, is where men work. ‘Buvinic [an expert from the Center for Global Development, a think tank] argues that many women get missed out because they consider themselves primarily as housewives, when in reality they work on farms, do part-time jobs and seasonal work or run their own businesses.’

‘There are other problems too, Buvinic says. Not all countries collect statistics on other aspects of women’s lives, such as domestic violence or maternal mortality rates, and when they do collect this data they often do it in different ways, making international comparisons difficult.’ And, ‘There are many statistics that are collected without being broken down by sex, which makes it hard to tell when women are not being treated equally.’ For example, “Until recently, very few banks disaggregated their customer data by sex, leading to difficulties in understanding reasons behind the persistent gender gap in access to and use of financial services,” says Megan O’Donnell, one of Buvinic’s colleagues at the Center for Global Development.’

That I find all of this surprising speaks to my naïveté, I suppose, and yet I have my doubts that many of us would take the time from our busy lives to consider what this neglect might mean. David McNair – Director of Transparency at the One Campaign, a group that fights poverty- even uses the weighted ‘sexist’ epithet and summarizes the problem succinctly: “The reason why it is sexist is that women and girls are disproportionately left out of data collection. They are uncounted, therefore they don’t matter.”

Roughly half the population on the planet doesn’t matter? And it’s the half that has gestated and succoured that other half -the only half that is counted? Even if I try my best not to be an historical revisionist, it does not make sense to me.  Perhaps McNair, again, had the best explanation: “If you have robust data then you can be held to account for your decisions. There are people who have a vested interest in not having that information in the public domain.”

But I suppose we have to look for any encouraging little cracks in the imposing male edifice: ‘Recently the UN’s International Labour Organisation (or ILO) held a conference, where labour statisticians agreed how to start collecting data on unpaid and domestic work, for example time spent cleaning your house. Ten countries have volunteered to take part in a pilot to use this new framework to measure unpaid work.’

Whoa, ten countries have decided to put their toes in the water…? Or rather, their statisticians in the water? How brave. Maybe Macbeth was on to something when he said that ‘tomorrow creeps in this petty pace from day to day.’ It’s the end of his soliloquy that has me worried though: ‘It is a tale told by an idiot, full of sound and fury, signifying nothing.’

Oh, I hope not…

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Prove it!

If there’s one thing that a long life has taught me, it is that most of us seldom stray far from the path. Once launched, our trajectory is largely predictable. I suppose this is necessary for co-existence –that there are societal norms is, after all, what binds us together as a group. Knowing what people want –what they are comfortable with- makes it possible to plan ahead with a reasonable expectation of success.

And yet, what if circumstances change? Even Science admits it runs on statistical probabilities. Nothing is forever the same, despite our expectations; despite the hopes of even the most enlightened that it will not deviate too much from that to which we have become accustomed. But progress depends on change, depends at least on altered perspective. That someone can look at the same data and interpret it differently –see different patterns in it, perhaps, or even apply it to something entirely different- is what we have come to expect of our modern world.

But there is often an inter regnum, that can be confusing -a time before the paradigm shift is complete; when wisdom, -no, expectations– demand that we judge the results of whatever investigations we have done, in the light of what the past, or experience, has taught us. And as a consequence, not only do we limit our inquiries to those things that seem to prop up those views, but we discard, or criticize data that fail to validate them. Same information, different eyes. It’s often called the Confirmation Bias and I’ve written about this in one form or another before: https://musingsonwomenshealth.com/2015/05/15/the-polarization-bias/

The problem is that it seems to be a Mobius strip, and the same data are used to prove opposite contentions. There are rules that can be applied, of course –methodologies that help to sort out interpretive biases:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126323/  but it’s all too easy to fall back on what seems natural to us: to assume that what has been found either substantiates what we believe it should, or to criticize it for its presumed deficiencies or mistakes if it does not.

There seems to be no end to the variations on that all too familiar theme. It’s certainly not unknown in Medicine, and a recent example springs to mind.

I remember Jerra -partly because of her unusual name, I suppose. When I saw it on the office day sheet, I assumed it was a typo and thought I would correct it as I introduced myself to her in the waiting room. She was the first patient booked for the day and none of the few other early-risers in the room looked anywhere near 62.

“Jerri,” I said with a smile, walking directly over to a thin, grey-haired woman sitting bolt upright in the only chair by the window. Her first reaction was to assess me from head to toe with hostile green eyes that, had they not been restrained, might have attacked me as I approached.

“It’s Jerra,” she said, ice congealing on the words as they approached my ears.

I blushed. “I’m sorry, Jerra,” I stammered, embarrassed at my rash decision to modify it.

“And it’s Mrs. Tandill…” she added haughtily, refusing –or perhaps not deigning– to shake my extended hand.

The waiting room went quiet, all eyes on us, as she followed me reluctantly across what now seemed a long hike over the floor and down the corridor to my office.

Once inside, she glanced quickly at the sculptures, and plants, and repositioned the chair further from my desk. She did not want to be here, and was letting me know in the bluntest possible way.

“You seem uncomfortable, Mrs. Tandill,” I said when she seemed settled in her seat. “I’m sorry we got off to a rather rough start…”

“So am I, doctor,” she said, still glancing around disapprovingly at the art work hanging on the walls. “I am only here at the behest of my GP, you understand.”

I smiled, hoping to diffuse the tension, but her face didn’t change. She was an attractive, if severe looking woman. Dressed in a loose black silk dress that brushed the tops of her shoes when she walked, tiny silver hoops in her ears, and a matching silver brocaded scarf that hid her neck, she carried herself like royalty. Even her short, greying hair sat regally on her head like a tight-fitting crown, not a curl out of place.

And me? I was still dressed in my OR scrubs –albeit freshly changed- after an unscheduled 8 AM Caesarian section that made me late for the office. The stark contrast with her apparel and the thwarted expectations of how a new specialist should present himself may have stoked her anxiety with the visit.

“My GP says I need a hysterectomy,” she said, suddenly glaring at me like a vexed mother with her child.

I checked the very thorough history her GP had sent with the consultation note. Jerra had presented to her with postmenopausal bleeding, years after her periods had finished. She had sent her for an ultrasound which had confirmed that there was a thickened lining in the uterine cavity, and had even done a biopsy of the tissue. The pathology report of the biopsy did not find cancer, but rather an overgrowth –hyperplasia- that can be a precursor to cancer.

Jerra was still staring at me when I looked up from the computer screen. “Dr. Hannah gave me a copy of the pathology report, doctor,” she said, sternly. “And I researched it further.”

“And what did you find, Mrs. Tandill?” I needed to know what she had read before I could put the results into some sort of context for her.

Her body seemed to relax at being given an opportunity to discuss it, but I could see her face was still wary. On guard. “First of all, that there are several types of hyperplasia” –she pronounced the word very carefully- “… and that some types are further along the spectrum towards cancer.”

I nodded slowly, not wanting to challenge her interpretations unless warranted.

“The type that seems most predictive of cancer, is the abnormal hyperplasia…”

“Atypical,” I interjected, just so she’d know I was listening carefully, I suppose.

She managed a rigid, if fleeting smile. “Atypical. Thank you.” She referred to some notes she’d folded into her purse. “That word was not mentioned in the report, and I even showed it to a friend of mine -who is a nurse- and she agreed.” When I didn’t object, she lashed out at her GP. “I’ve been going to Dr. Hannah for several years now, and I usually trust her judgement, but I think she’s made a mistake here… I’ve never been on hormones,” she added as a kind of preemptive rebuttal of an accusation she expected to hear. “She says the biopsy may have missed a more… atypical area and so to be safe, I should have my uterus removed. You doctors always seem to want to remove things.” She settled back in her chair having made her case, and prepared to fend off the denial.

I took a deep breath while I decided how to approach the problem. I agreed with the concerns of her GP -at her age, there shouldn’t be much of a lining in the uterus at all, let alone one that was sufficiently thick to bleed. Something must have caused the hyperplasia. And yet, I could also understand Jerra’s anxiety. “I suppose our problem in cases like this is one of certainty, isn’t it? On the one hand, the pathology results as they stand could explain the bleeding and the ultrasound, but not with complete certainty. There could be some even more abnormal tissue hiding in a corner of the uterus that was not sampled with the endometrial biopsy…” I’m sure her GP had already gone over this with her, but it needed to be repeated. “And if that were the case, and we left the abnormal cells in place, we might all regret the decision later.”

She sat straight up in her chair shaking her head the whole time I was speaking. “Dr. Hannah kept saying the same things, doctor.” She sighed and stirred restlessly on the chair. I could see her clasping and unclasping her hands on her lap. “Let me be clear -as far as the pathology report is concerned, there is no cancer. I have…” she referred to a copy of the report in the bundle of papers again carefully folded in her purse. “… I have ‘simple hyperplasia’ –which, as I understand it, is far removed from the cancer end of the spectrum. I find it reassuring, and I fail to understand why you do not.” At this point she actually crossed her arms tightly across her chest and nailed me to my chair with an angry glare. “You’re looking at the same data as I am, and yet you are interpreting it totally differently,” she added, as if she were paraphrasing something she’d read online.

I smiled, again, but it did nothing to diffuse those eyes that searched for a permanent foothold on my face. “I suppose I’m just being careful, Mrs. Tandill. Experience teaches me that…”

“Medical schools teach you, doctor!” she interrupted angrily. “Mentors that have been through the same system instruct you how to think about these things.”

I sighed, and I’m afraid I was not very successful at disguising it from her. “Have you had any more bleeding –since the biopsy, I mean?” She shook her head dismissively, and I sat back a little on my chair, all too aware I had also been revealing my discomfort at her anger. “Would you feel better if I did another biopsy…? To confirm the first one?” I added this in hopes of walking the middle road between her wishful thinking that the biopsy was indeed reassuring, and at least not denying the possibility that it may have missed something worse.

At that point she got to her feet, still scratching at my cheeks with her eyes. “No, I would not feel better! You would probably continue to recommend biopsies until you found the result you anticipate, doctor, and I will simply not play that game with you.”

And with an angry shake of her head she turned and walked out the door.

But maybe she was on the right track; maybe compromise -the middle ground- only re-routes the problem and detracts from whatever the data purport to demonstrate. No matter the number of repetitions, an interpretation of the results is still required. And if the data warrant it, a stand on one side or the other must be taken and we must live with the consequences. I think there comes a time when we must disagree with Macbeth when he says to MacDuff ‘Damned be him that first cries, “Hold, enough!”’

by

The Most Unkindest Cut of All

It was the best of times, it was the worst of times…

I’m a surgeon, so for me, the operating room has always been a haven of sorts. It’s one of the few places where I feel safe from interference from out there. Where, for a brief but immeasurable time, there is no outside –no politics, no traffic jams, no rainy days- just the task at hand. It is a magic place where we all work as a team –all interdependent, all focussed on our mission, all oblivious to anything else. A world unto itself, it exists briefly -like Brigadoon- then vanishes as suddenly leaving only remnants glimpsed through a door: soiled sheets being secreted away into plastic bags, or paper drapes being crumpled into even noisier containers by relative strangers -a different team- busy with wiping and washing… And then the room is empty, barren of meaning –its sacred purpose subdued by the evanescently profane. A sanctuary no more.

I say ‘no more’, but that is hyperbole because it always begins again: samsara. It is an organism that cannot be fully assessed from outside the doors. In the room it is measured in the steady pulse of a beating heart, the razor thin stroke of a piece of steel, the strength and tightness of a length of string.

There are, of course, distractions inside, but they are like traffic noises in the night and soon forgotten, hidden in blood or quickly acclimatized as more urgent problems –often unexpected- surface in the morass of organs vying for attention. It is a stormy sea, the opened body, and to navigate requires immersion in the troubled waters.

But absorption, however deep, demands surfacing from time to time to take stock, to breathe deeply –to assess and plan. And it is then, when the spirit needs whatever succour it can find, when distractions finally disturb -bewilder. It is then when the team finds solace in music.

Ay, and there’s the rub. http://www.bbc.com/news/health-33771022

There are as many tastes in music and what soothes, as there are people in the room -as there are people in the world, probably. So what knits up the raveled sleave of care for one, is definitely not the nourisher of life’s feast for another (Sorry, Macbeth). The article I’ve linked is from the BBC News and suggests that music in the operating room may be counterproductive.

But it is more of a ‘Just right, baby bear’ story I think -obvious stuff that seems almost too obvious to study: if the music is too loud, people can’t communicate with each other; dance music with drums or whatever, definitely distract, although they didn’t elaborate. But the BBC report partially retracted the condemnation towards the end of the article and suggested a compromise approach that fits more closely with my own Confirmation Bias: a link to a 2011 study reported in The Journal of Anaesthesiology and Clinical Pharmacology: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161461/ This was a prospective, questionnaire-based cross-sectional study -a survey- that tried to pin down elements of music that might be acceptable both to those who were standing or sitting in the operating room as well as the silent one who wasn’t.

For example, ‘…62% thought that music helped in reducing anxiety of patients before anesthesia’ – or to completely obfuscate the observation and clothe it in scientific attire: ‘According to the gate control theory which is based on the fact that pain is an integrated sensory, affective, motivational system that modulates noxious input and attenuates the perception of nociceptive inputs, it has been suggested that pain and auditory pathways inhibit each other. Perhaps the activation of auditory pathway by music during surgery inhibited the central transmission of nociceptive stimuli.’

And also: ‘Our study revealed that 59% of the respondents thought that music helped in reducing their autonomic reactivity in stressful surgeries thus calming them down and allowing them to approach their surgeries in a more thoughtful and relaxed manner.’

It goes on to suggest (with references) that: ‘Music has been used to achieve a wide range of outcomes not only in the hospital, but also in the community and residential care settings. It minimised anxiety levels of patients during hospitalisation and during unpleasant or invasive procedures. It helped people relax. Its effect has been measured in terms of its impact on the person’s heart rate, blood pressure and respiratory rate. It reduced the severity of pain and the need for analgesia in people with acute or chronic pain. It was found to improve cognitive function in terms of behavior, eating and minimised the need for physical restraint for people with dementia. The effect of noisy environment produced by medical equipments in OTs [Operating Theatres- or ORs] and critical care units on patients was also found to be minimal, when music was played in such settings. Patients and hospital visitors were more satisfied with the care provided. It improved mood and feeling of well being for a range of different patient groups. It enhances tolerance level of people to unpleasant or invasive procedures, such as insertion of intravascular lines, surgical interventions, burns dressings and chemotherapy.’

Then there was an attempt to prescribe tempo: ‘Tempo of music around 60-80 beats per minute was found to be the best for creating relaxation. A higher tempo acted like a “driving input”, which resulted in increased heart rate, blood pressure and respiratory rate.’ So, since I prefer the classical music I usually bring to be played in the OR, this meets with my approval, and as long as the team doesn’t nod off during the more lugubrious passages I think I satisfy those criteria.

But of course, volume is the elephant in the room. As the authors of the study put it: ‘The volume of the music played also had a tremendous effect on the mood of the OT staff. Of the total study population 59% of the respondents preferred medium volume while 41% preferred low volume of music in the OT. It was evident that the staff would not let music compromise or interfere with the technical aspects of patient care or competence.’

Although I think it’s hard to turn a symphony up too loud in an OR, I’ve found that violin or even -dare I admit it- piano passages tend to elicit angry, but accidental, elbows in my ribs if played other than sotto voce. I tried out opera once as well, only to discover that the musical device I used was missing for the next case… So I hesitate to draw any firm conclusions… Except that it kept the team awake, I guess -I mean you have to be alert to plan where to hide an iPod.

But I will leave the final words to Shakespeare again –this time from Henry IV: ‘Let there be no noise made, my gentle friends; Unless some dull and favourable hand Will whisper music to my weary spirit.’ A simple request -but this time from a king. They outrank even surgeons.

by

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.