Medical Revisionism

Words -that’s all they are: sounds that by their very presence magically communicate meaning. They are more than mere noise or background. They are not the wind rustling through the leaves, nor the sounds of a frog in a pond; in a way, they are entities that resolve uncertainty, and in as much as they can be interpreted, contain information. Data. So, in a sense, they transcend Time: the information in the words of an ancient document still exists. But information is subject to interpretation; the same data may be seen as having different meaning as time and societal norms change. But does that change the information conveyed? I think not.

I’ve covered this topic in previous blogs (for example: https://musingsonwomenshealth.wordpress.com/2013/11/01/whats-in-a-name-cancer/ ) but the topic is a source of continuing intrigue for me, so I was once again interested in seeing it broached in an article in the BBC News last fall: http://www.bbc.com/news/blogs-ouch-34385738  It seems we are constant and insatiable revisionists. It’s as if by changing the descriptor, we somehow alleviate the pejoration its ancestor accumulated. And yet the information remains; only the colour changes.

I suppose that this is useful, but I can’t help but wonder if there is some other way of doing it. Of course, some words seemed to have been coined originally with a belittling intent -Cripple springs to mind- and even without our penchant for viewing the machinations of history through modern eyes, the word is disparaging; it is simply not fair. It derives from the Old English word crypel which has the suggestion of creeping. It was a condition in clear need of a new term.

Other words were more naively-attempted descriptions –designations that were no doubt thought to help others picture what was being named. There was unlikely to have been any attempt at denigration -despite how they might now offend or upset us. Mongolism is one such term. According to the New Oxford American Dictionary:mongol, or Mongoloid, was adopted in the late 19th century to refer to a person with Down syndrome (named after John L. H. Down [1828–96], the English physician who first described it), owing to the similarity of some of the physical symptoms of the disorder with the normal facial characteristics of eastern Asian people. The syndrome itself was thus called mongolism.’ But the problem remains –what happens when the term ‘Down Syndrome’ itself also becomes offensive?

Sometimes, it seems to me, the words will also change for no apparent reason. Think of the various expression changes for sexual diseases over the years and the somewhat clumsy attempts to strip the prejudice out of them. When I first started medical school, the expression was ‘venereal disease’ –or VD. Then, when that became too pejorative, or at least discriminatory, it morphed into STD (‘sexually transmitted disease’), and currently STI for ‘sexually transmitted infection’… Or am I already out-of-date? The reason for any of these transformations, however, is totally beyond me.

Words, it seems –or maybe it’s me– just can’t keep up. Maybe, like Fashion, they’re bound to change because of user-boredom or a need for novelty, but I think it’s probably deeper than that. I suspect that it relates more to societal attitudes than societal ennui. And I think that it may be a lost cause to expect consistency of usage. As we change our approach to issues and our opinions, so we change our words to describe them. It starts off with the more curmudgeonly amongst us –usually those for whom tradition provides a stable and secure platform- proclaiming the changes to be ‘political correctness’- to use the current phrase. But then, gradually, sometimes imperceptibly, the expression achieves a common parlance and not using it courts sideways glances, or even incomprehension. It is, perhaps, an aurally measurable example of society’s changing attitudes, if not its mores.

My biggest complaint, however –although minor in the scheme of things- is that it seems a waste of perfectly good words. One of my favourite ones ‘awe’ and its brother ‘awesome’ which used to bespeak a form of reverence, was ripped from my useful vocabulary only a few years ago and I’ve never really gotten over it. The words now have little value -they’re the scrapings from a different, grander time. Crumbs. Leftovers.

I am reminded of the words of Moth, the page of the soldier Don Armado in Love’s Labour’s Lost by Shakespeare: ‘They have been at a great feast of languages, and stol’n the scraps.’ 

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The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’

Another Advantage of Breast Feeding?

As Mark Twain observed: What a good thing Adam had- when he said a good thing, he knew nobody had said it before. I don’t know about you, but I am getting tired of the media reporting on studies that contain nothing new and passing them off as fresh and enlightening. Even more upsetting is the fact that we often don’t even notice -or care… Studies that say nothing fresh or merely recycle what we already know, do not contain information so much as noise.

Time, then, to ask a more searching question: why is it important that we study this? And this is not to denigrate pure science, nor to suggest that investigations that are not directly goal-oriented are worthless. There is much value in answering the question by asserting that we were simply curious how it worked. Or why. Or under what circumstances -all of which are adding to our understanding of the world. Curiosity, after all, is merely a yet-unaswered question. A piece of the knowledge jigsaw puzzle. And its answer may well be worthy of reportage…

But to investigate the wheel and then conclude that it likely works by rolling, does nothing to inform. Indeed, publication of the results does little even to entertain, let alone educate… Or perhaps it does entertain -like those endless cat videos on Youtube, maybe there is value to a mindless occupation of the time that stretches between otherwise meaningful events. But the whole endeavour smacks more of playing cards until someone turns out the lights…

What is it that has me so vexed? So frustrated at banality uncleverly disguised as news? Well, I happened upon an article in the BBC ‘News’ about breast feeding and how it decreased the risk of depression.  http://www.bbc.com/news/health-28851441   It seemed a reasonable hypothesis; almost 14,000 mothers were studied and the results published in the online journal Maternal and Child Health (Aug. 21/14).

It’s a rather complicated statistical paper, but in summary it suggests that the risk of depression after delivery decreases considerably  if the mother was healthy to start with, intended to breast feed and found that she could. Okay, I could have predicted that. But, if she had been healthy, intended to breast feed, but found she couldn’t for some reason, her risk of depression more than doubled. Oh yes, and they found that  “the beneficial effects of breast feeding were strongest at 8 weeks after birth and that the association was weaker at  8 months and onwards.”  Uhmm… am I missing something here? Has something hitherto unsuspected slipped past me? Something, at least, that would change attitudes to breast feeding, or management plans for pregnancy?

Post partum depression is a serious problem in our society, with up to 10% (or more) of women at risk. That’s why we screen women during early and mid pregnancy to anticipate that risk and attempt to set up support systems for those who we judge are on that path. Anything that might ameliorate the danger is therefore a valuable addition to our management strategies. I’m not sure this study has even re-invented the wheel, however. It seems to demonstrate that if a mother’s plans work out, she is happy, if they don’t, she isn’t… Is it helpful to know this? Perhaps -but does it change anything? I suspect we will all continue to encourage mothers to breast feed and regard the oxytocin it engenders -the bonding hormone- a plus. But not an unanticipated one. Nothing has changed…

But then again, maybe constant reiteration –permananent recycling- is what we want. What we deserve…Maybe a society that tolerates laugh-tracks on comedy programs to help them to know what is funny, and that thinks apparently spontaneous applause in a talk show demonstrates the merit of the discussion, needs to be apprised of the obvious.

Am I being too cynical? Too arrogant? Well, perhaps. And yet…

It was early Thursday evening, and I was sitting in the OR lounge waiting to do an emergency operation. A surgeon and her resident were sitting nearby, their faces glued to the ever-changing TV images in front of them. I thought at first it was a talk show but they were staring at the screen as if it were a parental avatar, their expressions religious, their attention rapt.

I had been too preoccupied until that point to notice, but they seemed so intense I suspected something of profound significance was being discussed so I turned to watch. It was actually a cooking show and some celebrity that I didn’t recognize was being shown the basics of barbecuing a hamburger. “First, you want to get the grill good and hot,” the serious looking man in the chef’s hat was saying, pointing at the thermometer on the hood. “Then, you carefully place the patty on the grill –use a spatula with a long handle so you don’t burn yourself- and sear one side just enough to keep the juices sealed in…” He said this in a hushed and reverent tone as if it were one of the Ten Commandments. The studio audience clapped in delight at this little pearl of wisdom, and I noticed the surgeon restraining herself from doing the same. Her resident, ever mindful of imitative protocol, actually did manage a clap after glancing furtively at her mentor.

The surgeon suddenly became aware of my presence in the room and smiled with an expression I used to see in church after a sermon. She seemed surprised at my composure in the face of the Revelation. Or maybe annoyed that I hadn’t understood. Actually, I was disappointed; I felt as if I’d just been told the earth was round.

And it wasn’t even the vapidity of the program that made me remember the incident –maybe some people don’t know how to barbecue hamburgers, so maybe the show deserved prime time. Maybe the information it contained truly was important and not just another example of mildly entertaining celebrity fluff. Not having watched what went before, perhaps it was just an inter regnum… But no, it was more the reaction to it. The surgeon and her acolyte seemed overly awed by its significance -as if they wouldn’t have been at all surprised if it were the subject of a research paper in a prestigious journal.

I suppose the depressing reality is that it is me who is so far off-kilter that I cannot appreciate something of value. That I mistake the important for the banal. Knowledge for noise. But I can’t help wondering who decided that a celebrity learning how to cook a hamburger should occupy prime time. Or wondering why a study showing that people may get depressed if things don’t work out as they planned surprises anyone.

We all need a time out, for sure: a time when we just unbutton the brain and let it sit on the couch beside us eating popcorn. But surely we also need a time in. I’m with Shakespeare on this: We know what we are, but know not what we may be.

 

 

The Medical Illustrator

I am an illustrator, a drawer of pictures, if not by aptitude, then by necessity. Many of the concepts I am required to explain beg for diagrams, for pictures, for some sort of visual representation. It is amazing, for example, how many people do not know what a uterus looks like, what’s attached to it, or what lurks in its vicinity. Its exact locality is often a mystery, its constituent parts as unfathomable as the inside of a computer; even its lunar duty and occasional lapses are frequently misunderstood.

I would have thought that Google and Wikipedia would have solved all that, but they oftentimes provide riddles wrapped in mysteries inside enigmas, to mangle a trope. And besides, you need to know how to spell something before you can research it… Adenomyosis, and submucosal leiomyomata spring to mind.

I used to pride myself on my drawings until a patient that I hadn’t seen in a few years resurfaced in my office the other day. I noticed her looking at one of the drawings I keep on my desk -the standard uterus at the top of a vagina with its Fallopian tubes coming out each side like little arms. I use it to depict the myriad gynaecologic conditions from fibroids (leiomyomata) to polyps, to pregnancies… It looks for all the world like a fat T with drooping crosspieces. She, however, immediately laughed and reminded me that she had always seen it as a cow -the uterus as the body and the tubes as horns. And this from a professionally-created, printed illustration.

It reminded me of the early days when I hadn’t thought of pre-made diagrams and had trusted my skill as an artist to depict whatever I happened to be describing. I would do it on sheets of foolscap that I could tear off and hand to the patient -presumably to remind them of the details later when they were called upon to describe it to a significant other. A patient returned to see me after just such a scholarly pictorial adventure the week before, brandished the drawing and flattened it out carefully on the desk. It was the uterus and tube foray, again; it was my favorite illustration, the organ with which I felt the most artistically at home. I had, of course, over the years refined it sufficiently to feel confidence in its explanatory powers, its verisimilitude.

“My husband wondered why you drew this for me, doctor,” she said with a weak but forced smile on her face.

I glanced at the diagram, inwardly pleased that it was one of my better models, and looked up at her for an explanation.

“He says it was rude to accuse him of something you hadn’t talked to him about.” She looked down at the floor as she said it, obviously embarrassed at having to confront me like this.

I studied the diagram for clues. “I’m sorry, I don’t…”

“We looked up some of the words but we couldn’t find one of them and he was annoyed.”

The paper was crumpled and creased from storage in her pocket, but the words were clear enough: I had been trying to illustrate the reason her cervix bled when she slept with her husband and had labelled the structures and the region quite expertly I thought. I mean, what could be more clear than cervix, glands, and vagina with arrows helpfully indicating each structure? As a bonus -I often include these for further clarity for my most curious patients- I had even drawn an arrow to the top part of the vagina behind the cervix and printed (so there could be no mistaken identity) posterior fornix. Simple, concise, illustrative: a reward for them, redeemable in discussion points with whomever they were describing it to.

She had by now ventured a stare at my face, daring me it seemed, to deny the folly of my words, the error of my drawing. When she noticed my puzzled expression, she immediately withdrew her eyes and pointed to a word. “He didn’t think you should have used that word,” she said, almost afraid to say it. “Fornix,” she whispered.

When I still didn’t seem to understand, she merely shook her head -sadly, I thought- and stood up. She was still shaking her head when she left.

That I have to be more sensitive in my diagrams was the lesson, I suppose. It’s something we should all consider. For a while, I assumed it a one-off -an anomaly. It took one more example, however, to sear the need for examined delicacy onto not only my desk but my walls as well.

I had always prided myself on my examining room. As well as the requisite diplomas and awards in clear and easy view over the sink, and the pictures my kids drew on the ceiling over the examining table, diagrams festooned the walls: illustrations of IUDs, pictures of the stages of pregnancy with actual sizes of the fetal passenger as it matures, pictorial explanations of the uterus in various phases of its menstrual cycle… I even had a picture of the urinary systems of both males and females near the head of the bed -a mural Wikipedia.

The proof of my insensitivity surfaced yet again one day when a patient came storming out of the examining room fully dressed and face tense. “I refuse to lie in there under that.”  She almost spat the words at my face.

I tried to smile at her, but I have to admit I was too traumatized to pull it off successfully. “What..?” I stammered, trying to look over her shoulder at the offense, wondering if there was a tear in the paper sheet I’d given her to cover herself with.

She saw that I was looking at the table and not at the wall. “Not there,” she said impatiently. “There!” And she pointed with a shaking finger at the two urinary systems.

I took them down after she left -they’re still in a drawer along with a few other pictures I thought might offend. I left the one of the IUDs though, but I think I’m only getting away with it because I call it a Pasta Poster (they do kind of look like pasta I’m told) and make a joke of it when a patient first enters the examining room. Anxiety changes perception, I suppose, and I haven’t meant to startle already nervous people.

But I can’t help but think my new, pre-printed diagrams will add a certain veracity to my explanations. I can guide patients through the thornier parts, and steer them clear of the more confusing -and to me hidden- moral aspects of the subjects I am desperately trying to explain. I have avoided inflammatory and suggestive words wherever possible, and limited any free-hand illustrations where trespass might be construed. Autonomy acknowledged…

But I haven’t avoided risk entirely, you understand -retreat is permissible; surrender not: there is still a large black and white photograph of a man holding a baby skin-to-skin on his chest prominently displayed on the wall where the trangressive urinary systems had hung. I’m not sure of the message I’m trying to convey nor its educational value, but it avoids all the urinary pitfalls. So far it has been greeted with smiles and only one raised eyebrow. It’s a statement though, don’t you think?