The Concept of Sober Second Thought in Medicine

Perhaps it is the vain attempt of Age to maintain its relevance in a time of incessant, dizzying innovation, but it seems to me there is something to be said for reflection before action.

We have here in Canada, a now much-derided political institution called the Senate whose members are appointed, not elected, and whose purpose is supposedly more to reflect regional differences than voter preferences (as in the other institution, the House of Commons). Approval of both institutions is required for legislation, although the Senate rarely rejects Bills passed by the more powerful and voter-elected House. Its purpose, at least according to Canadian myth, is to be a chamber of ‘sober second thought’, unsullied as it were by recent fads or the evanescence of events that might unwisely sway popular opinion.

While in practice, there is much to criticize about the Senate as an institution, the concept of ‘second thought’ is worthwhile.  And I see this as nowhere more important than in Health Care.

Our concept of health has evolved over the years as have our expectations. We no longer tolerate the intolerable with the equanimity of a century ago; at least in more affluent nations, we don’t expect children to succumb to infectious diseases, or women to die in childbirth. We assume there will be ever more sophisticated approaches to diabetes, treatments for autism, preventative strategies against heart disease… Knowledge conquers all.

But sometimes in our headlong rush to cure, we engender unrealistic -even unnecessary- goals. We unwittingly foster an assumption that living through life’s vagaries needs to be asymptomatic -or at least should be. And while I’m sure most of us understand the need for priorities in health care, its boundaries are, at best, often vague, and usually personal. This is to be expected: we enter the world of medicine only when there is a need, a worry -a symptom.

Symptoms are puzzles waiting to be solved, questions as yet unanswered. They do not always bespeak disease, of course; many point to an underlying concern, an anxiety that needs as much exploration as the condition feared. But the solution -the diagnosis and subsequent management- is not always as straightforward as it might seem. Not all symptoms require intensive investigation; not all conditions require treatment. And while all symptoms require explanation, most conditions also require options -and that is different.

The rush to cure leads down different roads, and not all of them pleasant -not all of them even necessary. An example from my specialty, gynaecology, might be illustrative. Let’s say a 48 year old woman is discovered to have fibroids (benign overgrowths of muscle tissue in the wall of the uterus) during a routine physical examination when she has her pap smear. She didn’t know she had them, had no symptoms that concerned her, and would no doubt have carried on her with life blissfully unaware of what lurked so silently just underneath her skin… But she is told she has some uterine tumours by her well-meaning family doctor. She is then told she needs an ultrasound -just to be sure they are fibroids- and is referred to a specialist for management.

The woman is understandably concerned about the ‘tumours’ growing inside her, and has probably talked to those of her friends who have had problems with fibroids, researched the issue online, and then arrived at the office primed for treatment. And there are many treatments -or at least, many variations on the theme of the need to treat. The usual approach has traditionally been a surgical one -with all the usual permutations and combinations that depend on the prevailing wisdom of the medical center or the research project currently underway. And then, of course, there are the medical and other non-operative methods -some new and sparkled with hope, some castigated online for the side-effects. As I have said, the need for cure can be all-pervasive, all consuming. And perhaps an imperative: anything less is a disappointment -a failure.

And yet the problem -at least in the case I have outlined- is not so much the fibroids, as the attitude attending them. They were, after all, aymptomatic, aproblematic, and indeed a concern that needn’t have been. Most will shrink after the menopause when there are no longer any stimulating hormones -and at 48, that time is not likely to be in the too distant future. Doing nothing, in other words, is acceptable; a ‘cure’ is unnecessary…

Yes, they could be treated -and heaven only knows they often are- but in her case, why? She needs an explanation, reassurance, and a promise of follow-up should any new questions or issues arise. You might think I have chosen a special case, an anomaly whose rarity shouldn’t really affect our exciting and ever-evolving management strategies. And it shouldn’t -there is much to learn, much to improve. We need cures for cancer, better and more effective vaccines, more inclusive and affordable Health Care… And yet sometimes we need to step back and decide what is truly worth pursuing and to what end; decide whether our goals have blinded us to the value of perspective. Knowledge without perspective is not wisdom; it is detail… It is Hope unsummoned.

The Senate may have something to teach us after all… despite itself.

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The Miracle (part 2): a woman’s story in 2 parts

“Emily.” It was the doctor’s voice, and he was leading her into a seat in his office as if she were an old lady. “Emily, it’s good to see you again…” his voice trailed off as he inspected her. “But you were supposed to have come back to see me a month or so ago, remember?”

Why was everybody always asking her if she remembered something or other? She was here wasn’t she? And besides, he knew she couldn’t keep running back to him with every little complaint until she was sure.

“Now remember last time you were in, you said you were having some…ah…” He referred to a folder that lay open on his desk. Couldn’t he remember, she wondered? It hadn’t been that long ago. “You were having some trouble with your bowels,” he continued as if he hadn’t really forgotten. “Constipated, bloated, vague discomfort in your pelvis…”

‘Vague discomfort’? Had she really said that? She became aware that he was drumming his fingers on the desk. It was all very funny, really. He was obviously expecting her to say something but all he would do was look at her quizzically over the bridge of his glasses. His straight, mouse-brown hair was too long for his thin body, she thought. And he was wearing the same creased grey suit as last time. What kind of a doctor only owned one suit?

Finally he ventured to speak again. “What’s been happening lately?” But she only smiled. “Bill told me you’ve been quite sick…” Again the look, and again she refused to be manipulated. “He said you’ve had some more pain and have started to vomit.”

She shrugged. Damn that Bill! This was all supposed to be so different. Why did Bill care anyway? He was never around much and even when he was, he was merely there. But so was she -trees in a meadow: untouching, indifferent, one or the other always in the shade.

Doctor Brock looked annoyed and was having trouble disguising it. “Bill said you wanted to see me Emily.”

She stared at the open file in front of him filled with writing in blues and blacks. Why would he use different colours, she wondered? And some things looked as if they had been underlined; this puzzled her as well. She didn’t think she’d ever told him enough to underline. She blinked, trying to resolve whether or not the line went through or under a sentence. Even doctors made mistakes. The chart was too far away to see clearly, however, so she leaned forward slightly, and as she did he cleared his throat.

“What did you want to see me about Emily? You’re still feeling unwell, aren’t you?”

There he goes again, she thought -just like Bill: he hadn’t asked, he’d stated -accused, actually. As if feeling unwell was wrong -no… expected. She was amazed at the stupidity of the man. How could she confide in someone who couldn’t understand how she felt about it all? She should have gone to a woman.

He sat back in his comfortable leather chair, determined to wait her out. Why was he so stupid? No, obtuse; she knew he wasn’t stupid exactly, just unable to relate to a woman’s needs at a time like this. She stared at him, confronting him silently with her unblinking accusation. She needed someone else; she was sure of it.

He coughed at her quiet threat, as if the noise might dissipate it -make her blink first, maybe. But she was determined. “I’m sorry doctor, you just don’t seem to understand.”

The sudden flurry of words made him jerk forward awkwardly in his chair. She got up to leave. “But you haven’t even told me what’s wrong, Emily. How can you expect..?” She was through the door before he could finish.

“It’s a woman doctor I need,” she told Bill in the car. He may have heard, but he didn’t turn his head or even shrug; it didn’t really matter anymore.

*

Dr. Heath was very young -something the Yellow Pages didn’t mention. But at least her door had the usual trappings of confidence: a sedate, cream-on-plastic plate with the requisite number of letters after her name -a few extra, even, as if to invite entry.

As soon as she got inside, though, Emily realized she had made a mistake. It was cheery enough, with heavily carpeted floors and a large double-glazed window with a view of the city; the plants were nice, if a trifle under-watered; and there were pictures on the walls of babies: babies with hats, babies in diapers, babies at breasts… It wasn’t the office that bothered her. It was the age of the patients that seemed strewn about like clothes: teenagers -all of them. Some pregnant, some with skirts up around their waists -a rogue’s gallery of young people, all staring impudently at her as she crossed self-consciously in front of them to the front desk.

The receptionist couldn’t have been much older, and as Emily gave her name she thought she caught a fleeting smirk that never quite surfaced. “You’ll have to fill in this form for the doctor, Emily. And I’m afraid she’s running a bit late today.” It wasn’t an apology, simply a statement. Take it or leave it.

The form was simple enough: allergies, major illnesses, medications and the like. Nothing too personal -she liked that. The doctor, however, was.

Dr. Heath was a pleasant little thing of about twenty-five, blond, smartly dressed and with eyes that seemed to hunt like spotlights when they hit. She fastened them on Emily. “My nurse mentioned something about you being late for your period, Emily,” she said noncommittally.

Late? That was a laugh. But Emily nodded. “It’s been four or five months now.”

The doctor didn’t seem surprised -or at least her eyes were calm. “Were they regular before?”

Emily closed her eyes impatiently. Of course they were regular. What was she getting at? She took a deep breath. “Yes.” And then she opened her eyes and stared out the window.

“I see,” said the doctor. But Emily didn’t believe her. Her eyes were too steady to be real; nobody was that calm. Dr.Heath wrote something in the chart then looked up again. “Any other symptoms?” She actually smiled when she said that, but Emily was not taken in.

“Maybe you should just examine me, doctor.” It was a simple statement, made calmly, quietly, but the doctor’s expression immediately changed.

“I’m afraid I’ll need to know a few more things about you before we get to that.”

“I’ve filled in the form, so it should all be in there, doctor,” she said confidently. You had to get control of these things early.

Dr. Heath stared at her intensely for a moment, obviously deciding what to do, then shrugged and pointed to a narrow door that Emily had not noticed when she entered. The doctor looked smaller now -pale even. “You’ll find a gown on the table in there. Please undress from the waist down. I’ll be there in a moment.”

It was long moment and Emily could hear voices through the door, but not clearly enough to understand. The doctor’s though, sounded excited, agitated. Had she made the doctor uncomfortable? Emily thought about it for a moment and then rejected the notion: she’d been civil. They were both adults.

The examining room was cold but she stripped to her underwear and sat on the examining table huddled under the flimsy gown. Soon it would be over. Should she tell Bill? He would eventually find out, she realized, but could she count on his support? She chuckled at the thought.

Dr. Heath suddenly appeared at the door, smiled wanly, and asked her to  lie back. “Where does it hurt, Emily?” she said softly.

Emily lifted her head. “Hurt? Who said it hurt?”

The doctor straightened her shoulders a little. “I’ve talked to Dr. Brock.”

“You had no right…” she started, tears forming in her eyes. “What I told him was… just between us.” But she realized how silly that sounded and looked down at her feet.

“Emily, Dr. Brock was concerned. I’m concerned.”

“You had no right,” she repeated, fighting back a sob. “I suppose my husband talked to you as well…” The doctor nodded. “You’re all trying to make it all so… so abnormal,” she said grabbing for her clothes. “Can’t any of you accept it for what it is?” Her cheeks were wet now.

Dr. Heath didn’t move. “What is it Emily?” she said in a soft, sad voice. Emily glared at her and finished dressing. “What is it?” she repeated and grasped her shoulders.

Emily broke free and forced her way past the doctor. “A miracle,” she said between sobs.

“Emily!” There was no mistaking the tone this time. “Emily I’ve talked with your doctor…”

She was through the door but she stopped by the window, near the doctor’s cluttered desk. The cars had their lights on now and it was raining; the sky barely cleared the tops of the buildings. Why was it always like that, she wondered.

“Emily, please listen to me…”

But she just shook her head. Tears rolled gently down her cheeks and she made no effort to wipe them away. Why should she listen? She was living with the proof right here in her abdomen. Her hand reached involuntarily for the palpable swelling growing quietly inside. There. It moved again; she was certain it did. Nothing they could say or do would convince her otherwise. Perhaps another doctor… Yes, that was it, another doctor -an older, more experienced one this time.

The Feminine Perspective?

“Men and women think differently, doctor,” a patient said to me recently, shaking her head in response to some requested advice from me. “You of all people should know that.” It was stated with a look of smug authority, as if  to disagree would have been tantamount to an admission of professional incompetence. And while I don’t concede the point that to disagree with what seems to be a societal dictum necessitates a conclusion of medical bankruptcy, it got me thinking…

I suppose the first thing that occurred to me was to question the assumption that my specialty somehow enabled entrance into the heavily guarded sanctum sanctorum of my patients –female patients at that. It kind of invokes the Theory of Mind, doesn’t it: the early discovery by a child that others also have things going on in their heads, and that they may differ from her own thoughts or perceptions. It’s an important step in eventual integration into society; it’s also a recognition that because it’s different, we can never really know what someone else is thinking.

So, in that sense, no: I (a male) can’t know what my patient (a female) is thinking -any more than I could if that person were another male. I can suspect that it might differ from what is going on in my head, but given a common purpose -the solving of a medical need, say- I can intuit that we can communicate something meaningful about that.

“Ahh, but it’s not just that we live in different bodies, doctor,” -I could almost hear her response to my thoughts- “It’s more the way we approach the problem.” Really? Are the goals actually dissimilar, or is it more a difference in perspective -a choice of route? And is the perspective culturally assigned, or does it reflect a basic underlying gender difference in physiology and wiring? Is it just that we are supposed to think a certain way -an assumption- or that we, in fact, do -an innate, genetically driven imperative?

Are the perceived psychological differences in the sexes superficial and societally contrived, or are they more like two Magisteria -the approach Gould chose to describe the difference between religious and scientific knowledge and authority? It’s a difficult question obviously, but I sometimes think it has degenerated into more of a media-driven competition -each side trying to enlist support from an otherwise disinterested and unaffected Public.

I sat back in my chair and smiled inquisitively at my interlocutor. “And how would you approach this problem?” I asked, hoping to learn something from the encounter.

“Well, for one thing, I would offer more choices.”  She sat up straighter and crossed her arms defiantly, daring me to disagree.

Fair enough; I suspect we would all like more of a say in how we deal with a problem. I nodded my head in agreement. In medicine, even if there are no other viable therapeutic choices, there is always the option of doing nothing -seeing what will happen over the coming days or weeks. But I suspect that the choice of that option transcends gender, transcends the assignation in the genetic lottery…

But maybe I was missing something; maybe she was operating with a world-view that necessitated a different assimilation of Reality. For that matter, maybe there was a different reality for her -one that I could never hope to experience. Maybe what she experienced as Red, for example, I experienced as Blue and yet we both named it with the same word. How could I ever know? A troublesome thought indeed.

And yet, ever the pragmatist, even if we both meant something different by that word, but arrived at the same destination, wouldn’t the communication have been successful? The goal achieved?

She wasn’t finished with me. “And I think you were assuming I should just accept your opinion, doctor.” She obviously hadn’t liked any of my solutions, although I had offered her several. She had probably only heard the word ‘hysterectomy’ among them.

It occurred to me that although we both wanted to solve the same problem, her condition had a different meaning for her altogether. And it didn’t hinge on her sex as much as on the way she envisioned herself as a person, as the protagonist inside a personal history: her story.  She possessed an identity tied to what she currently was, and whose very existence was contingent on whom she might inadvertently become.

But we’re all like that: we are who we have been; the past drags behind us like a shadow. It’s company for us on our long trip; it’s our suitcase full of memories… So that alone cannot be what she was alluding to.

That we all see the world from our own perspective, and that it is different for each of us, is merely stating the obvious. That we each come to a problem with a different history is equally obvious. We have all been entangled in cultural webs that have conditioned the way we respond to issues. In the beginning, perhaps it was all engendered by biological constraints, but I think most of us now realize the artifice in that.

What, then, accounts for the difference, other than milieu?

Bertrand Russell, a philosopher mathematician of the last century had some small influence on my early development; I make no claim either to have read all of what he has written, or for that matter to have understood more than a small part of what he had to say, but I have always remembered one passage -one pearl- that made sense to me. Perhaps it was the only thing I could understand:  For my part, I distrust all generalizations about women, favorable and unfavorable, masculine and feminine, ancient and modern; all alike, I should say, result from paucity of experience.

Maybe I should have read more of him; there are many perspectives…

The Objective Doctor

Is there objectivity in Medicine? Is it even possible? Can there ever be a decision or an opinion that is not contingent and shaped by something not currently obvious? If we engage with someone, are we not also conversing with their past? And are they not interacting with our own shadows? I ask this because I have always wondered about just how independent our thought processes are. We play at being rational but how realistic is it? Is it just a conceit -a cosmetic we apply to hide the wrinkles even from ourselves?

Perhaps I can be provocative -and a devil’s advocate.

Take the Holy Grail of Evidence, as an example. In Medicine, we like to think that our treatments are evidence-based, objectively derived and statistically valid. This validity would issue from a series of measurements gleaned from a dispassionate consideration of  the symptoms and a treatment, compared with either another standard, recognized approach, or something similar but known to be ineffective. The patients are usually uncertain which treatment they are receiving (single blind) and hopefully so are those conducting the experiment (double blind). The methodology would seem to be objective and foolproof.

And yet… How do we decide whether we are comparing apples with apples? Previous experience? Theoretical considerations somehow divorced from confirmation biases? Can we actually envision or entertain theories that don’t, at least in part, embody remnants of what we already believe – that we suspect obtain because of the way we have modelled the problem or the way we asked the question? That we hope obtain… Is that why we chose to study it and not something else in the first place? What baggage did we bring along with it -or at least what was hiding within it? And how do we know it’s actually baggage, or that what we conclude about it is not tainted. Skewed? Biased?

I’m not trying to be malevolently iconoclastic here; I’m just trying to sift wheat from chaff. Because if I can’t be truly objective and can’t be sure whether Nature or Nurture is dictating inside my head, then perhaps any therapeutic regimen I suggest to a patient isn’t objective and unbiased either. If I only read those articles in journals that confirm my hopes -or what my professors taught me in medical school- or if, indeed, only those types of articles find their way into print… Well, you can see the problem.

And if one of my better-informed patients suggests a treatment based on her reading of whatever literature to which she is privy -or inclined- then who’s to say what I should do with that information? Especially if it is dissonant with mine – i.e. the evidence-based, objective, statistical stuff that I have decided to collect and treasure because it agrees with what I have come to believe. Should mine triumph merely because I am the authority? Or would it make more sense to talk it through and, like a politician, arrive at some sort of middle ground? After all, in medical ethics, the concept of Autonomy is predicated on respecting the opinion of those who’ve come to us for ours.

So if I can’t be certain whether what I believe is stained with history -personal or otherwise- and if the patient brings a similar bias to the table, where do we go? Now that pharmaceutical companies are able to advertise their brands on television and the internet -and to me, of course- and now that Google has more answers than a medical textbook that are readily assimilable by anybody with a mouse, this is not simply an academic exercise.

Politicians may have something to teach us here: they often get their way by obfuscation. Doctors, I submit, do not sink to quite this level, but we pontificate; we preach; we admonish. We call upon higher authorities to validate our decisions. Even our explanations are sometimes confusing. I don’t for a minute believe that this is an attempt to conceal, or mislead, nor is it likely even a conscious process. We’re taught to be opinionated in our fields, to analyse and treat accordingly. And in many things, one and only one opinion and only one course of action is necessary and appropriate: treatment of a ruptured ectopic pregnancy is not a subject for debate. But the type of contraception -or even the brand of contraceptive- may well be. Under these circumstances, there may only be opinions, inclinations. And so they should admit of compromise. We do not lose authority by listening; we do not lose credibility for considering another approach. Compromise assumes that both sides take each other seriously and common ground enhances compliance. As long as safety is not at stake, does it really matter whose bias triumphs?

My mother thought cod liver oil cured everything -maybe she was right.

Opinions

I am sometimes bewildered; I live in an ever-changing sample of opinions -often at odds with my own. In many circumstances I would welcome, even encourage this potpourri, but usually the people holding these often colourful bouquets have come to me for answers, not more flowers. But what is it that differentiates an answer from an opinion?

In the Great Age of Internet what are we to do with the information the patient brings with her problem: the carefully harvested compendium of facts that seem to apply -if only peripherally- to her condition, the assortment of variations inherent in any garnered explanation, the pastiche of expertise purporting to supply if not the answer, then at least the diagnosis? It sometimes presents as much of a challenge as the condition for which my opinion was originally sought.

I suppose I should be grateful for any help I can get. We are all unique, and diseases -conditions- manifest themselves idiosyncratically on occasion. But it is often the patient’s attachment to their research that presents the difficulty. I suppose we are all wedded to our autonomy and our ability to process and analyse any unusual facets of reality that confront us -it is why we still exist as a species, after all. And there is value in the ability to assume control of a situation, not to be overwhelmed by it -victimized by it. Characterization, classification and enumeration of symptoms are a shared responsibility after all. As a specialist, I rely on it.

But perhaps there is a threshold phenomenon at work here: it is not so much the amount of data, as its quality and relevance that obtains. The fact that a fishing net contains a hundred sundry fish, including the one salmon that I need to solve a puzzle does not necessarily increase the value of the catch. And I might even miss the seeing the very thing I want in all the bounty. Abundance is not always a luxury; it is sometimes an encumbrance, a millstone. It often carries with it the obligation to follow it even further into a morass of inapplicable detail -misleading detail, beguiling detail.

And even if there is no misdirection, no distraction, there lurks the danger of the proposed solution. While it may be obvious that there are often many ways to resolve an issue, it may be less so that not all paths are equal -either equally effective, or equally safe. Solutions are contingent on many things, one of which is the quality of evidence upon which they are based. Solutions are often multifaceted, requiring a blended approach, even a multidisciplinary one. The sheer number of permutations and combinations does not lend itself to a superficial or naïve analysis. Dragons lie that way.

So, one of the more worrisome effects of the extensively researched and therefore convincing self-diagnosis is the proposed treatment regimen. Even assuming an appropriate interpretation of symptoms and an arrival at the gates of a congruous synthesis, the suggested solution can be problematic. Where it merely involves a class of medications, I can usually suggest more readily available alternatives: safer or less expensive drugs -although even here, brand names often accompany an optimal resolution in whatever research to which the patient has been privy. I don’t necessarily mean to suggest conflicts of interest of the researchers so much as difficulty for the untrained and -in that respect- unsophisticated patient in separating wheat from chafe.

It is even more difficult to explain why a particular procedure, or diagnostic modality may not be available to them. Or why I do not possess the skills to perform a surgery only recently described in another country or even another region. Worse, from their perspective, perhaps I have not even heard of it.

All of this is certainly not to denigrate patient participation in their own care, or involvement in seeking a solution. It is perhaps to highlight an evolving process in which we are all partners in health care, each having contributions to make and suggestions to offer. The extent -and value- of the contribution from each party has yet to be established however, and I suspect it will be an ever-moving target for some time.

But is the era of the expert -the doctor- running its course? Will it ever be sufficient to feed one’s symptoms into a computer program (presumably one already acquainted with other unique and personal biometric and physiologic attributes) and await the diagnosis and treatment? There are programs right now that purport to facilitate such things for doctors; is it just a matter of time before they escape into a more public domain?

Or is there truly something more important and distinctive about the doctor-patient encounter: the listening, the body language, the obvious empathy? Is it only the doctor’s opinion that is so important, or is it something else as well? Of course the opinion must be rooted in fertile and appropriate soil; of course it must embody a well-considered analysis of the data presented. But if that were all, would it suffice for most of us? Or do we want -no, require- more than that? To be heard by another..?

Cause: an Effect?

The real world: that’s where we are all supposed to live. The place where everything has a readily identifiable cause and everything makes sense -or would, if we were to delve sufficiently deeply. It’s a place where the absence of answers suggests inadequate investigation.

I’d love to live there -in that particular world- but I suspect we all live in different worlds. I’m reminded of the psychotherapeutic contention that we live two lives: the past and the future. It’s the past where problems arise, and the future where they are inevitably diagnosed and solved.

In fact, in our quest for certainty, in our search for rules to apply and names to clarify, we exist in neither. And labelling something that was hitherto vague and fuzzy often goes no further than assigning it a name. Chronic Fatigue Syndrome comes to mind. Sometimes labelling gathers things together to allow them to be considered as an investigatable entity; sometimes it gathers things together for convenience. Sometimes it merely gathers things together. I suppose that’s progress.

But it can be misleading in medicine.

“Doctor, my periods always used to be regular but not anymore.” The patient, an attractive, well-groomed woman in her thirties was clearly concerned.

“How have they changed?”

She cocked her head and looked at me as if I wouldn’t understand. How would a man ever know what she meant? “They used to last for five days -I mean I could count on it…” She stopped and stared at me with an intense expression suddenly nailed to her face, wondering if it was worthwhile proceeding.

“And now?”

“And now they could last for…” She sighed and rolled her eyes at having to be so specific: her periods were not regular. Enough said. But she could see that I was poised to write something in her chart, so she needed to explain her concern. “…For, I don’t know… between four to six, maybe,” she continued, curling her voice up at the end. “Sometimes with a little spotting added on.” She stiffened in the chair. “That’s never happened before, either.”

“But they’re regular: they come once a month, despite the number of days you actually bleed?”

A knowing shake of the head. “Yes, but that’s not regular, doctor. Not for me.”

I  proceeded to write it down to show I was paying attention and taking it seriously. “And how long have you noticed this?”

Her eyes seemed to recede into her head as she searched around in there for an answer. The answer. Then a shrug. “I don’t know; they’ve kind of changed over time.”

“Have they changed in any other way? I mean are they painful, or particularly heavy..?” I left the question open to encourage her to organize a reason why she had consulted me.

She shook her head thoughtfully. “No, nothing like that… They’re just irregular and I’m worried.”

I looked at the information her family doctor had forwarded to me along with the consult request. “Your doctor has been very thorough,” I said, looking through the detailed blood work and ultrasound reports. “And it all seems quite normal.” I wanted to reassure her.

Her face brightened. “That’s why she wanted to send me to a specialist.” She pinned me with her eyes for a moment and then let go. “She couldn’t find a woman gynaecologist to see me soon enough, though… But she said you were okay.” She added that quickly -too quickly- but clearly as a gesture of politeness.

I continued with the history, and subsequent physical examination but I could find nothing abnormal -nothing that even hinted at disease or malfunction. When we were finished, and she was once again sitting across the desk from me, I reassured her that from a gynaecologic perspective at least, she seemed normal and healthy. I offered it to her like a present: something that would please her.

And yet, she was obviously disappointed -as much in me for failing to find the cause of her problem, as having to endure the continuing changes in her periods. “But there has  to be a reason they’ve changed, doctor.” She said the last word sibilantly -as if it had to be forced through a jaw that didn’t want to open, teeth that got in the way, anger that tried to get her to say something else entirely.

I risked a subliminal sigh and smiled at her. “Well, all the investigations that your doctor has done so far have been reassuring,” I thought ‘reassuring’ sounded better than ‘normal’ under the circumstances. “And my examination today is in keeping with those investigations…” Her face wrinkled and her eyes narrowed a touch. “We all change as we mature,” I continued, trying to stay upbeat. “Nothing stays exactly the same…”

But there was a cloud in the room. “The periods are not heavy or painful; is there something that bothers you about the change?” I thought maybe she considered any change a harbinger of disease and I could reassure her about that.

“Doctor, they’re irregular now, and I want to know why they’ve changed! There has to be a cause!” The unstated assertion, of course: ‘But you can’t find it because you aren’t looking hard enough.’

I tried to keep a fatherly expression off my face -that would have destroyed even the slight rapport we enjoyed. “Julie, sometimes things just change over time. Yes, there’s probably an explanation, but it may be all wrapped up in the changes our bodies undergo as we age.” He face hardened even further, and I could see she was not happy with my opinion. I decided to throw in a little home-grown wisdom. “You know, there are times in medicine when we can’t explain why something happens, but we’re pretty good at ruling out any bad things that might cause it…” I thought maybe that would help her to accept my inability to label her problem and solve it.

But it only frustrated her further. Clearly, I had not tried hard enough. She stood up and thanked me perfunctorily, but after she left the room I heard her whisper to her friend in the waiting room “I knew I shouldn’t have gone to see a man!”

And maybe she was right; maybe she would have accepted the opinion had it come from a woman. But it would have been the same opinion I suspect -just dressed differently.

I’m not so agnostic as to believe that some things don’t have causes or that some things are not worthy of further investigation. I realize that we all have different priorities in our lives and what is important to one may be trivial to another. But the relentless and obsessive pursuit of Cause can be counter-productive at times. Sometimes, perspective is more beneficial: the thoughtful accounting of context and significance. The frame is everything.  As Hamlet said: There is nothing either good or bad, but thinking makes it so.

Amen.

Early Morning Musings

There are times -often early in the morning after just getting to bed and then being awakened again to go to the Operating Room for some emergency, or more commonly, the Case Room for a delivery- when I wonder why I chose the field I did. After all, I could have gone into Pathology where microscopes never phone, or maybe Dermatology where a rash can usually wait until daylight to be evaluated. Things seem so much worse in the middle of the night.

But then dawn rolls around and things don’t seem so bad. I reconsider and re-evaluate the malevolence of the night and in the new light, I find I have new thoughts. Fresh thoughts. Happy thoughts, though seen through the aching of fatigue and the haze of bleary, reddened eyes. I am, I realize again and again, a Morning person. I relish the colours that spill over the sky from the newly born sun; I look forward to the world self-lit. I am an unabashed pantheist with respect to the freshly washed day. And I realize anew what a privileged life I live and what I have still to learn.

There are daily happenings I struggle to express -little things perhaps, but deeply meaningful in their context. Profound, even. Like the delivery of a child in the wee small hours to a woman with a major cardiac anomaly -one that may have ended in death in a setting less prepared than ours. My role as an accoucheur was admittedly minor -a technician really- but still, I was caught up in the moment. The woman smiled so loudly when I handed her the healthy infant that I just had to say to the beaming husband that he really had a special wife. There was a language barrier to be sure, but he shook my hand, looked me in the eye and said “Of course she’s special!” as if it was so obvious it didn’t even need to be said. I had to turn away so he wouldn’t see the little tear forming in my eye.

Or the time, a world away in Newfoundland, when I tried to bring some Western Canadian Wisdom to a staunchly self-reliant culture. I was working in the small little village of St.Anthony at the Grenfell Mission -a mission dedicated to ‘improving the health, education, and social welfare of people in coastal Labrador and northern Newfoundland’. I was a freshly minted specialist and too full of training to be mindful of the situation. I’d just seen a middle-aged woman with extremely heavy and frequent menses. She’d come to see me along with her obviously concerned husband, a local fisherman. I did what I had been taught in the big city schools and proceeded to discuss the differential diagnosis with them and the various treatment options available. After what must have been a lengthy monologue I asked them what option they preferred. I remember they both looked at each other for the longest time, and then at me. “Well, the way I figures it,” the husband said glancing at his wife, “When my family’s hungry, I don’t ask them fish in my boat what they wants. I jes do what I needs to do, boy. So do what you needs to do; fix my wife!”

Sometimes a difficult decision has to be made, and although the situation mandates explaining the reasons to the patient and their loved ones, and their opinions canvassed, in the final analysis they expect me to make a decision in their best interest. They have no way of knowing all the background that goes into making the best decision; ultimately and for better or worse, the buck, the expert opinion, really does stop with me -and the treatment if they agree. It’s a weighty thing to have to be a final arbiter; after all, they may disagree and seek a second opinion. But ultimately, a decision must be made by somebody. And that’s what they want: however onerous the responsibility, most are seeking someone to take charge of the situation. To do something.

But you know, it’s not all death and taxes. There are some truly delightful moments, even in the dead of night. I had been following a friendly couple through their labour and in the course of my visits as the night wore on, I discovered that he was a violist in the Symphony Orchestra. Although they were playing that evening, he didn’t want to take the chance of missing the delivery of his first and anxiously awaited child. But in case she delivered early, he’d brought his viola and it sat in its little black shell in the corner. He never so much as glanced at it as far as I could tell. Unfortunately, labour did not progress as we had hoped and so somewhere around three A.M. I decided she needed a Caesarian Section. They were both disappointed, of course -so was I, in fact- but were both reassured by the ability of being together in the OR. And yet as I checked to make sure her epidural was working and then made the skin incision, I wondered aloud where he was. It had seemed so important to him to be there with her. I asked her about it. “Oh, don’t worry about him,” she said from behind the drapes. “He’s got it all planned.”

I could see the anaesthesiologist grinning behind his mask: he was obviously in on a surprise. For me, the only surprises so far were the father’s absence, and the fact that the doors to the OR were wide open -something that would never be allowed during the busy daytime hours. So I continued with the operation and in a few minutes extracted a big, healthy and screaming baby. Suddenly, echoing along the empty corridor outside I could hear a viola playing Happy Birthday. You can’t wipe your eyes when you are scrubbed -a nurse had to do it. But only after she’d wiped her own. I still can’t listen to the tune without a sigh and a deep breath.

My field is hard and at times difficult, but there are moments… Many of them, in fact.