Oh, true apothecary

That we would do we should do when we would, for this ‘would’ changes, says Shakespeare’s Claudius. In other words, do what you think you should when you think of it, or you may never do it…

It seems to me that Medicine has changed a fair amount since I retired. Not only has science advanced, but so has our way of looking at the world. Our way of framing a problem has expanded, and no longer totally excludes extra-Magisterial endeavours.

Boundaries, are dissolving -or at least being redrawn. Who would have thought that we might look to, well, spirit, as an aide de camp? Or exercise as a legitimate medication? I have written about the latter in an essay I published in 2015 about Quebec doctors’ ability to write prescriptions for exercise: (https://musingsonwomenshealth.com/2015/09/12/the-uber-obvious-in-medicine/) but I am pleased to see that the tradition continues -in Montreal, at any rate: https://www.smithsonianmag.com/smart-news/canadian-doctors-will-soon-be-able-prescribe-museum-visits-180970599

‘[A] select group of local physicians will be able to prescribe museum visits as treatment for an array of ailments… “We know that art stimulates neural activity,” MMFA [Montreal Museum of Fine Arts] director Nathalie Bondil tells CBC News. “What we see is that the fact that you are in contact with culture, with art, can really help your well-being… members of the Montreal-based medical association Mèdecins francophones du Canada (MdFC) can hand out up to 50 museum prescriptions enabling patients and a limited number of friends, family and caregivers to tour the MMFA for free…  MdFC vice president Hélène Boyer explains that museum visits have been shown to increase levels of serotonin, a neurotransmitter colloquially known as the “happy chemical” due to its mood-boosting properties. But creativity’s healing powers aren’t limited to tackling mental health issues; art therapy can also help those undergoing palliative care for severely life-threatening diseases or conditions, like cancer, or suffering from diabetes and chronic illness.

‘According to Boyer, the uptick in hormones associated with enjoying an afternoon of art is similar to that offered by exercise, making museum prescriptions ideal for the elderly and individuals experiencing chronic pain that prevents them from regularly engaging in physical activity.’ Of course, there is the usual exculpatory caveat ‘that the museum visits are designed to complement, not supplant, more traditional methods.’ But still, a step forward, don’t you think? It’s a recognition that there are more things in heaven and earth than are dreamt of in our philosophy, if I may slightly paraphrase Hamlet.

“Why do you always want to drag me along to these things, Julie?” I was sitting in the warm and welcoming sunshine on the magnificent array of stone steps of Vancouver’s Art Gallery when the elderly couple hesitated near the bottom. The man looked the worse for wear and was leaning on his cane, already out of breath. Both of them were bedecked in grey hair, but while the woman sported a cool red cotton print dress, the man seemed dressed for church -he was wearing a heavily creased brown woolen suit, a white shirt, and red tie.

She stroked the lapel of his suit, trying to smooth out some of the wrinkles perhaps, but more likely trying to get him to smile. “You need to get out of the house once in a while, Edward,” she said, and then gently touched his cheek. “Ever since you broke your hip, you’ve just been sitting on the couch…”

“It’s hard to get around, Julie,” he said, somewhat irritably. “And I don’t fancy letting everybody in the neighbourhood see me with a cane.”

Even from several steps above, I could see her roll her eyes. “Do you really think they care, dear? They’re not exactly glued to their windows waiting for you to come on stage, for heaven’s sake.”

He stared at her angrily for a moment and then shrugged when she failed to react. “I get tired easily nowadays, Julie,” he said in a husky sort of whine.

She reached out and grasped his hand. “You get grumpy easily, nowadays, sweetheart.” I could see her squeeze his hand reassuringly. “You haven’t been yourself since the operation, you know. And it’s not like you to be tired all the time.”

She seemed so earnest and caring, I could see his expression soften. Clearly, they’d been married for a long time. “Well, I…”

“Come on, Eddie we’re almost there,” she whispered loudly and winked at me when she saw me watching them.

“Well, I guess since we’ve already come all this way…” He shrugged and allowed her to lead him slowly up the steps past where I was sitting. “I just hope there’s some place to sit in there…” was the last thing I heard him say as they inched their way ever upwards.

I promptly forgot all about them as the sun warmed my face while I read the pamphlet about the exhibition on current display. I was looking forward to a lazy afternoon of wandering through whatever was on offer this time. I hadn’t visited since the Musqueam artist, Susan Point’s Spindle Whorl exhibition and I remembered standing transfixed, in front of the hypnotic, wheeled patterns of her Coast Salish art.

But the sun coaxed me into staying on the steps and watching the world amble past -on a warm day, the people outside are sometimes as intriguing as the art inside. I don’t know how long I sat there, but eventually the need for a coffee and a muffin roused me from my aerie on the steps, and I sauntered into the Gallery Café to see what I could find.

There was a table emptying inside, so I carried my tray over to it and sat down. I was just tucking into the muffin when I heard a familiar voice at the next table and recognized the two who’d been standing below me on the steps.

But Edward didn’t seem as grumpy now, and Julie was smiling from ear to ear. “Well, dear, what did I tell you?” she said, stirring some milk into her tea.

“You didn’t tell me I’d see the original painting of that reproduction we have hanging in the living room wall, sweetheart…” He gazed fondly at her for a moment. “It’s my favourite painting, you know…”

Her smile grew even wider, as if, of course she knew. “Surprise, eh?”

“I’ll say,” he said, his eyes alive and twinkling. “Maybe we could look around for some other paintings by him.” He reached across the table and fondled her hand.

“Well, there’s that place on Granville -you know, the one up near the hospital? They may have some reproductions,” she said, leaning over the table and stroking his cheek with her free hand. “Want to have a look tomorrow?”

“That’s a great idea, Julie.” He stared at his cane for a moment. “Maybe we could walk -it’s not that far, is it…?”

“No it’s not, sweetheart,” she whispered, and touched his cheek again. “No, it’s not…”

 

 

 

 

 

 

 

 

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Doth the lady protest too much?

I am neither a psychiatrist, nor a psychologist, and apart from a career in medicine, hold no official accreditation in counselling. Heaven only knows, my own Black Dog is never far away, and anxiety gathers little dust as it waits expectantly in a brightly lit corner of my closet. And yet I am still a sounding board in my retirement, it seems.

A colleague from my student days somehow recognized me in a prairie coffee shop, three days drive from my coastal home. I’ve never been good at faces, but sometimes a voice will riffle through the fading file cards in my head and find a memory lightly pencilled in.

I was sitting in a dark and unobtrusive corner of a Starbuck’s near the university in Saskatoon when a voice caught my attention. It was talking quietly on a phone, so I probably wouldn’t have noticed, except that it was at the next table and its owner spilled coffee on me during a nervous laugh.

“I’ll call you back,” she whispered into her phone and quickly grabbed the few napkins in which she had dressed her cookie. “I’m so sorry,” she said, greeting me more with her hands than her voice, as she attempted to wipe the coffee off my tee shirt.

“Don’t worry about it,” I said, taking the napkins from her hands and finishing the wipe myself. “Stuff happens…”

She sat back suddenly and fastened her eyes on my face like ocular nappies. “Don’t I…”

But her name came to me first. “Susan?”

She nodded enthusiastically, still not sure of herself. Then, as I was about to remind her of my name, “G…?” she said, and touched my arm excitedly.

I nodded, surprised, but impressed that she’d remembered my nickname from medical school. I have to admit that mine was the easier task, though -Susan, the valedictorian of my graduating class, had made a name for herself in oncology, and most doctors, no matter their specialties, would probably have read at least a few of her papers. I certainly had.

We joined our tables and sat reminiscing. There was a lot of ground to cover -I had recently retired after 40 years in practice, but she still seemed to be in the thick of things.

“I’m just having a quick coffee before I have to chair a conference at the U,” she said, checking her watch. “But I still have a few minutes,” she added, and smiled reassuringly. “What have you been doing since we last met?”

I knew she’d ask, but I hesitated before replying. My career had been a satisfying one, for sure, but certainly not as illustrious as hers. “I specialized in Ob/Gyne,” I said with a little shrug. “In Vancouver, actually, “ I added, knowing she would wonder what I was doing in a Saskatoon coffee shop. So when one of her eyebrows posed the silent question, I was quick to respond. “I’m retired now, and since I was born near here, I thought I’d do a little catching up.”

“Vancouver?” She said the word with a wistful look in her eyes. “I gave a presentation out there last year, G… I’ve always loved the west coast.” She sighed and rested her eyes on me again. “I’ve often wished I’d settled out there rather than in Toronto, you know…”

“There are probably more opportunities in Toronto.” I said. “I mean, it’s the center of the universe, and everything…” I meant it as a joke, really -the quintessentially Canadian retort whenever the city is mentioned- but it had a chilling effect on her and she shrugged apologetically.

“If I were still in practice, I’d likely be picking your brains at this stage, Susan,” I said, suddenly ashamed of my thoughtless remark.

She smiled, but still apologetically, and she sat for a while, quietly nibbling on her cookie. Suddenly I could feel her eyes resting on me again. “Was there ever a time in your career when you felt like an imposter?”

I thought about it for a moment, then nodded. “Sometimes when I was trying to justify a diagnosis, or a procedure, to the young resident doctors… Especially when they’d tell me that my colleagues did things differently.”

She took a deep breath and a little smile surfaced briefly on her lips. “I feel it more and more as I get older.” She concentrated on her cookie for a few bites. “It’s like I’m supposed to be the expert, but things move so rapidly in my field it’s difficult, if not impossible, to keep up -and I’m always afraid that one day, someone is going to put up their hand at a lecture and point out that I’m not current anymore.”

I stared at my rapidly cooling coffee and nodded. That -plus age, of course- played a large role in my decision to retire.

“My psychologist partner calls it my ‘imposter syndrome’ and laughs at me,” she said, shaking her head. “He doesn’t take it very seriously -I suppose that’s why I unloaded it on you… Sometimes I just need to talk about it with someone.”

“The welcome stranger…?” I rolled my eyes to show I was kidding.

She smiled half-heartedly, but I could tell she wasn’t finished yet.

“After all these years, I wonder if the mask still fits,” she said, more to the cookie than to me. “That’s what reputation is, you know: a mask.” She finished off the cookie and sat back in her chair. “You work for years to achieve it, all the while wondering if it is starting to fray -if it still conceals the face underneath.” She chuckled, then scraped her chair back from the table. “I often think I should get out while it’s still intact. While it’s still worth something… Like a hockey player retiring after his team wins the Stanley Cup.”

She checked her watch and stood up, but as she stooped to pick up a rather heavy looking briefcase, her eyes interrogated me once again. “I have to leave for Toronto right after the conference this afternoon, but were you planning to attend? Lunch is provided. Maybe we could meet?”

I smiled warmly at her suggestion, but shook my head. I’m retired now; I no longer carry a mask. “But if you’re ever in Vancouver again…” And yet, even as I spoke, I could sense a change as she rummaged around in her head for an appropriate Saskatoon conference persona.

She nodded, hugged me briefly, and hurried out the door. But I could see her pulling her disguise back on as she left.

It’s 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.’ So wrote Saint Augustine, bishop of Hippo in North Africa, more than fifteen hundred years ago. And we’re still confused… Okay, I’m confused.

When considered philosophically, you’d think it would be a relatively simple concept: I exist right now: the Present; I remember what happened to me: the Past; I don’t know what will happen to me: the Future. That is Time. It is divided into separate Magisteria like scenes through the window of a moving train. And yet… and yet the divisions seem so arbitrary. So evanescent. It’s almost as if Time were merely an all-purpose synonym for Change. A generic label.

But things happen in time, our bodies being no exceptions, so it’s difficult to ignore. We have come to prioritize those happenings as constituting Time. The intervals between events have gradually become divested of significance, although whether it is the interval, or the event that is prime could be argued -much as whether the placement of a comma in a sentence contributes almost as much to the meaning to be conveyed as the words themselves. And yet, is it really all contingent…?

Are habits -those things we do almost without thought- or the endless train of happenings the commas? Is it actually in the intervals between things where we live? Do we inhabit the interstices, and merely mark their boundaries by events -rely on things that happen in order to count? Do we live between the nodes or does reality only exist for me when stuff happens, when I am aware of what I am doing? And if so, then what about when I’m not aware? What happens to Time then? Do you see why I am confused?

And, at the risk of sounding too Cartesian, is the reality my body inhabits different from the awareness my mind tells me about? Bodily existence seems to have been issued with different rules because it is far more contingent than my mind. Too needy. Too ad hoc, and less spontaneous. It seems overly pulled by evolution and ontogeny, unable to explore new things. It straddles the intervals like a bridge. It is a scaffolded entity, constantly in a state of repair.

No, Time, for a body at least, was always thought to be continuous. Contiguity of events allows restoration and medicine discovered this. It started on its quest to heal the body, even if the mind was not always in synchrony and did not understand. But it assumed that mind was only a by-product of body. It is… isn’t it…?

At any rate, something that has often puzzled me is the difference in prescription instructions for various medications. Of course some drugs are relatively short-acting, and need to be taken frequently, say, Q6H (every six hours), or perhaps they are more potent and require a smaller, but spaced out administration, say, Q8H. That seems fairly obvious, so instructions as to how much and how frequently to take them would therefore make sense.

But suppose the directions are to take them QID (four times per day) or even TID (three times per day)? By comparison, that seems almost sloppy, doesn’t it? I mean, what is the difference…? And how much variation is permissible between the timing of every eight hours, and three times per day? What impact would, for example, a two hour difference -or even more- have on the medication efficacy? This is not meant as a criticism, but merely an exploration of time in the administration of a treatment.

And yet, even a more precise prescription of the interval does not usually state a specific time for its consumption like, say, 8 PM. Given that our bodies (and hence probably our metabolism) are subject to a circadian rhythm, I’ve often wondered whether that might make a difference in a medication’s effectiveness. An article in Nature that I ran across addresses that very issue: https://www.nature.com/articles/d41586-018-04600-8?utm

‘The circadian clock is a remarkable system. A central timekeeper in the hypothalamus orchestrates a network of peripheral clocks in nearly every organ and tissue of the body, turning on and off a bevy of genes including some that encode the molecular targets for drugs and the enzymes that break drugs down. These clock genes are particularly important in cancer because they govern cell cycles, cell proliferation, cell death and DNA damage repair — all processes that can go haywire in cancer.’

Until recently, technology was unable to determine the genes involved, let alone the timing of their activation, and so chronotherapy remained on the fringe. But, ‘More than four decades of studies describe how accounting for the body’s cycle of daily rhythms — its circadian clock — can influence responses to medications and procedures for everything from asthma to epileptic seizures. Research suggests that the majority of today’s best-selling drugs, including heartburn medications and treatments for erectile dysfunction, work better when taken at specific times of day.’

Steroid levels, for example, ‘naturally cycle with the circadian clock. In the late 1960s, scientists found that the synthetic corticosteroid methylprednisolone is safer for treating arthritis and asthma if taken in the morning rather than at other times of the day. This is because the feedback loop in the hypothalamus, which controls the release of cortisol, is least vulnerable to inhibition in the morning.’ Other factors such as age and gender also seem to be important in circadicity. So is the inconvenience of the times when the appropriate genes might best be manipulated. Not only that, but ‘practical biomarkers are needed to help clinicians identify optimal times for treatment.’

There are many variables to account for, but clearly there is a growing appreciation of Time in understanding the body’s underlying physiology. There is a need to adjust not only the treatment, but also its provision in harmony with individually derived schedules that are often by no means intuitive or convenient. As if, by finding each body’s unique variations on the theme of circadian rhythm, we discover the hidden melody playing deep within.

Maybe Rabindranath Tagore, the Bengali polymath who won the Nobel prize in Literature in 1913, was not so far afield after all: Let your life lightly dance on the edges of Time like dew on the tip of a leaf.

I’d like to think we all dance in Time…

In choice, we are so oft beguiled

It’s interesting just how important categories are in our lives, isn’t it? I mean, let’s face it, often they’re just adjectives –subordinate to their nouns. Add-ons. And yet, they can frame context, colour perception, and even determine value. Some, like, say, texture or odour may be interesting but trivial; some –size, or cost, for example- may be more important although optional in a description. There are, however, categories that seem to thrust themselves upon an object and are deemed essential to its description, essential to placing it in some sort of usable context. To understanding its Gestalt. These often spring to mind as questions so quickly they are almost automatic. Gender is one such category, age, perhaps another. And depending, I suppose on the situation, the society, or even the category to which the listener belongs, there may be several others that are deemed necessary to frame the issue appropriately.

The automaticity of a category is critical, however. If the category is felt to be of such consuming importance that it needs to be established before any further consideration can be given to the object, then that object’s worth –or at least its ranking- is contingent. It is no longer being evaluated neutrally, objectively. It comes replete with those characteristics attendant upon its category –intended or not. Age, for example, wears certain qualities, incites certain expectations that might prejudice acceptance of its behaviour. Gender, too, is another category that seems to colour assumptions about behaviour. So, with the assignation of category, comes opinion and its accompanying attitude.

One might well argue about the importance of these categories, and perhaps even strategize ways of neutralizing their influence on reactions, or subsequent treatment. The problem is much more difficult if knowledge of the category is so necessary it is intuitively provided as part of what is necessary to know about, for example, a person.

I suspect that in my naïveté, I had assumed that foreknowledge of many of these categories was merely curiosity-driven. Politeness oriented. Important, perhaps, so that I wouldn’t be surprised -wouldn’t embarrass the person at our initial encounter. But I am a doctor, and maybe see the world from a different perspective. A piece in the BBC, however, made me realize just how problematic this automaticity had become. How instinctive. http://www.bbc.com/future/story/20130423-is-race-perception-automatic?ocid

The article dealt mainly with its effects on racism, and the difficulties of countering it if we accept, as some evolutionary psychologists seem to believe, that it is basically intuitive. Evolved for a reason. Wired-in. ‘[…] if perceiving race is automatic then it lays a foundation for racism, and appears to put a limit on efforts to educate people to be “colourblind”, or put aside prejudices in other ways.’ But, as Tom Stafford, the author of the BBC article puts it, ‘Often, scientific racists claim to base their views on some jumbled version of evolutionary psychology (scientific racism is racism dressed up as science, not racisms based on science […]). So it was a delightful surprise when researchers from one of the world centres for evolutionary psychology intervened in the debate on social categorisation, by conducting an experiment they claimed showed that labelling people by race was far less automatic and inevitable than all previous research seemed to show.

‘The research used something called a “memory confusion protocol” […] When participants’ memories are tested, the errors they make reveal something about how they judged the pictures of individuals. […] If a participant more often confuses a black-haired man with a blond-haired man, it suggests that the category of hair colour is less important than the category of gender (and similarly, if people rarely confuse a man for a woman, that also shows that gender is the stronger category). Using this protocol, the researchers tested the strength of categorisation by race, something all previous efforts had shown was automatic. The twist they added was to throw in another powerful psychological force – group membership. People had to remember individuals who wore either yellow or grey basketball shirts. […] Without the shirts, the pattern of errors were clear: participants automatically categorised the individuals by their race (in this case: African American or Euro American). But with the coloured shirts, this automatic categorisation didn’t happen: people’s errors revealed that team membership had become the dominant category, not the race of the players. […] The explanation, according to the researchers, is that race is only important when it might indicate coalitional information – that is, whose team you are on. In situations where race isn’t correlated with coalition, it ceases to be important.’

I don’t know… To me, this type of experiment seems so desperate to appear to be wearing a scientific mantle, that it comes across as contrived –kludged, if you’ll permit an equally non-scientific term. But I take their point. If there is some way of diffusing the automaticity of our categorizations –or at least deflecting them into more malleable descriptors –teams, in this case- perhaps they could be used as exemplars –wedges to mitigate otherwise uncomfortable feelings. Placeboes –to put the concept into more familiar language for me.

Stopgaps, to be sure, and not permanent solutions. But sometimes, we have to ease into things less obtrusively. Less confrontationally. A still-evolving example -at least here in Canada- might be gender bias in hockey. Most Canadians have grown up exposed to hockey, and might be reasonably assumed to have an opinion on the conduct of games, players, and even rules. And yet, until relatively recently, the assumption was that hockey players –good ones, at least- were male. For us older folks, it was automatic. No thought required; no need to ask about gender. But no longer is that the case. For a variety of reasons, there is still no parity, and yet it is changing –slowly, perhaps, but not conflictually. And so, despite any initial challenges, is likely to succeed.

Am I really conflating success in the changing mores of hockey with gender equality? Or basketball teams and how we view their members, with racial equality? Am I assuming that diminishing discrimination in some fields leads to wider societal effects? Yes, I suppose I am. A blotter doesn’t care about the kind, or the colour, of the ink it absorbs; it’s just what it does. What it is. And, in the end, isn’t that what we all are, however vehemently we may protest? However much we may resist the similarities that bind us in relationship for fear of losing our own identities?

But if we step back a little, we may come to appreciate that the correlation need not be like that of a blotter -need not involve a team, or a marriage… I am reminded of the advice from one of my favourite writers, the poet, Kahlil Gibran: Love one another, but make not a bond of love: let it rather be a moving sea between the shores of your souls.

It’s the way I prefer to see the world, anyway…

Zealandia?

Sometimes things are not as they seem and we see, as the biblical Paul wrote, ‘through a glass darkly’. Sometimes there is more than meets the eye; it is what makes the world so interesting. Maybe it’s why we wrap gifts –or give them, for that matter. They are such stuff as dreams are made on…

I have always loved New Zealand; to me, it is a gift, and so is what I’ve recently learned about its origins. To think that Aotearoa –the land of the long white cloud- is more than the ribbon I can see today, more than the Maori seafarers could see even a thousand years ago when they first arrived, is astonishing, and not a little intriguing. An article in the Guardian (https://www.theguardian.com/world/2017/feb/17/zealandia-pieces-finally-falling-together-for-long-overlooked-continent?CMP=Share_iOSApp_Other) reports on a paper published in GSA Today -the journal of the Geological Society of America: ‘Zealandia covers nearly 5m square km, of which 94% is under water, and encompasses not only New Zealand but also New Caledonia, Norfolk Island, the Lord Howe Island group and Elizabeth and Middleton reefs. The area, about the same size as the Indian subcontinent, is believed to have broken away from Gondwana – the immense landmass that once encompassed Australia – and sank between 60m and 85m years ago.’

Of course, even with satellite-derived bathymetric data, it’s hard to appreciate. And the skeptics, largely silent in their apathy, still sit in the shadows wondering what difference knowing  this  makes. After all, it’s almost all underwater, some of it way underwater –one edge of it ‘can be placed where the oceanic abyssal plains meet the base of the continental slope, at water depths between 2500 and 4000 m below sea level.’ http://www.geosociety.org/gsatoday/archive/27/3/article/GSATG321A.1.htm Would we be any the worse, the unimpressed might argue, if this remained undetected? Would the ignorance handicap us in some way? Any way…?

In the conclusion to the paper, the authors assert that: ‘As well as being the seventh largest geological continent Zealandia is the youngest, thinnest, and most submerged. The scientific value of classifying Zealandia as a continent is much more than just an extra name on a list. That a continent can be so submerged yet unfragmented makes it a useful and thought-provoking geodynamic end member in exploring the cohesion and breakup of continental crust.’ But it seems to me that questioning the value of this discovery misses the point entirely. Misses, perhaps, the point of gifts and the wrapping in which they are concealed.

Although I am now retired, I am reminded of something that happened late in my career as a gynaecologist and which continues to intrigue me. It makes me wonder just how many other assumptions limit our vision…

Sometimes in medicine, we feel the need to step back from the fray, to attempt an objectivity denied to those whom we treat. It allows us, we explain, to adopt another, more reasoned perspective -one which is unadulterated by their pain and emotion. ‘A thought which, quarter’d, hath but one part wisdom’ as Hamlet said.

And yet, looking out from the forest of my age, I realize that sometimes people don’t want to be treated as patients, but as people. Fellow travelers. What they want is a knowledgeable friend, not a textbook to which they can turn. One has to learn to gauge the needs…

Jean was not a new patient, but her visits were erratic and unpredictable. Sometimes it was for a pap smear, but more frequently it was for what she would only characterize as an ‘infection’ –“The usual one,” she would inevitably add with an embarrassed laugh. But neither I, nor any of the other doctors she had seen were ever able to find the infection, so it had become a sort of standing challenge as to who would find it first.

Jean was a very fit woman then in her early fifties, who taught both English and drama at a nearby high school. Meticulous about her appearance, I would see her in the waiting room sitting bolt upright, shoulders back, head perched on her shoulders like it was suspended on fine wires to keep it from despoiling the immaculately dressed body below. Her hair was brown and short with each strand assigned an immoveable location lest it be chastened with the brush she kept on her lap in a little purse.

That day, however, I noticed she had added another weapon to the arsenal on her lap –a little pump action plastic bottle, the content of which she would surreptitiously spray on her hands from time to time, followed by a vigorous rubbing as if she had just applied some soothing lotion.

She smiled when she saw me and extended a just-sprayed hand in greeting. “I think I’ve solved my problem, doctor,” she said as soon as we were settled in my office. “I just wanted you to check and see if there was any difference –you know, down…” She blushed before she could finish her sentence. She immediately produced the little bottle and sprayed her hands again. “No infection,” she added, regaining her composure after the little entr’acte.

“And the little bottle?” I had to ask.

“Sanitizer,” she answered proudly. “It’s antibacterial,” she added, and dived into the purse to read the label to me. “It contains triclosan… For some reason it’s really  hard to get nowadays.” Her face suggested that puzzled her. “I mean it kills bacteria doesn’t it? And they’re the troublemakers…”

I suppressed a sigh and sat back in my chair. “It also encourages bacterial resistance, Jean. And it doesn’t seem to be any more effective at cleaning than good old soap and water.”

She blinked, but whether in surprise, or disbelief I couldn’t tell. “But…” She gathered her thoughts before continuing. “We pick up bacteria from our environment and dirty hands are how we transmit a lot of diseases. We have to keep them clean… Bacteria” –she said it as if the word itself were dirty- “Bacteria are everywhere.” She pointed to an alcohol-based hand sanitizer I kept on my desk. “And I see you don’t take any chances either. ”She relaxed in her chair as if she’d proved her point.

I allowed myself the sigh I had avoided earlier. “An interesting dichotomy, isn’t it?” She raised an eyebrow. “That we live in a world jam-packed with so many bacteria that they are virtually ubiquitous…” I continued, “…and yet so few cause us trouble.”

“But…” She leaned forward on her seat.

“But we seem to want to malign them all; we act as if they were all our enemies. And yet, our own microbiome –the bacteria living in our intestines- are absolutely essential for our health in ways we are just discovering. And apparently the number of bacteria normally living in and on a healthy human body outnumber our own cells by ten to one.” I stopped and smiled at her incredulous expression. “We –our cells- are only the tip of the iceberg.”

I suppose I thought I’d just be reminding her of something she already knew, but her eyes were saucers. “Zealandia,” she said after a moment’s reflection.

“Pardon me?” I’d never heard the word, and wondered whether she was referring to the title of some obscure novel she was teaching at school.

“Zealandia,” she repeated as if she were surprised I didn’t recognize the term. “You know, doctor, the continental landmass of which New Zealand is a part? It’s 95% underwater so you can’t see it and therefore don’t appreciate it’s importance. We usually only judge what we can see, don’t we…?” she added with a wink and a big winning smile.

We all have our blind spots.

Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

Staying in Touch

In the endless dark of night, belief that there will be a morning is sometimes all that sustains us. Hope springs eternal in the human breast, as Alexander Pope declared in one of his essays -and that is occasionally all there is. When Medicine fails, the understandable temptation is to turn to alternatives; when inductive reasoning seems insufficient (compilation and collation of observations to arrive at a tentative conclusion) then perhaps the converse might be helpful: deductive reasoning (start with a conclusion and then look around for supporting evidence). The Scientific Method tends to use more of the former than the latter to test hypotheses, although to be honest, it is often a melange. But to start with a conclusion and then to attempt to prove it can be a recipe for failure –or worse, deceit.

Alternative Medicine appears to be guilty of the latter -although whether by intent or naivete can be argued, I suppose- but it does seem to attract a certain edge of the population. I, for one, am not a believer, but to set the stage, perhaps a definition of alternative medicine would be helpful. The description in Wikepedia (sorry!) is as good as any I’ve seen: ‘Alternative medicine is any practice that is perceived by its users to have the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science. It consists of a wide range of healthcare practices, products and therapies, ranging from being biologically plausible but not well tested, to being directly contradicted by evidence and science, or even harmful or toxic.’

In this essay, I don’t intend to debate the merits or harms of alternative strategies for health, but merely to illustrate the pitfalls that can result when they are espoused too vigorously -when hope triumphs over experience. When, to paraphrase Macbeth, Physic is thrown to the dogs.

*

I really liked Loretta; I could tell that as soon as I saw her in the waiting room chatting to her neighbours. A slender young woman barely grazing her twenties, she had short brown hair and was dressed in jeans and a yellow tank-top. Her face was all smile –or, rather, all teeth and tongue, with large, brown eyes occasionally mobilized to emphasize some point or other. The whole room seemed alive with laughter and focussed on her every word, her every gesture –and there were a lot of those. Her body was in constant motion, sometimes pointing with a ring-laden hand, then gesticulating with her arms as her bracelets clinked and ran up and down her forearms like beads on an abacus; even her legs were integral as she swung them back and forth to illustrate a point with her dainty sandal-clad feet – an actress playing to an adoring audience. I almost felt embarrassed as I crossed the room to lead her offstage. She actually waved to them as she left; I half expected her to blow kisses.

She sat on the edge of her chair in my office clutching a backpack in one hand and a phone in the other as if to relax was anathema to her. “You seemed quite popular out there,” I said, nodding towards the corridor that led to the waiting room.

Her smile broadened at the compliment. “I like to stay in touch with everybody… and everything,” she added, as if it were a necessary addendum, then filled the time between our words with safaris into the uncharted depths of her pack. “I’ve come here for a pap smear,” she said as she saw me scrolling on the computer. “That’s what my GP says, but it’s really because he doesn’t know what to do with me…” She let the sentence dribble to a close without a firm indication she was finished with it. Like it was still a work in progress. So I waited. A text arrived on her phone and she blinked at me and proceeded to thumb a rapid, practiced reply almost as if she was scratching her leg without thinking about it.

Still she said nothing, but instead inspected the room, starting with the pictures on the wall and then progressing to the the plants on my desk, inspecting them one by one, perhaps thinking I was going to quiz her about the office. “What is it that concerns your GP, Loretta?” I felt I had to say something.

She shrugged goodnaturedly and her eyes migrated to my face. “I suspect she thinks I’m too self aware…” She giggled at the thought, then noticed the puzzled expression that I had tried to disguise. “I like to be on top of things…” She immediately blushed and corrected herself. “You know, like my health and stuff.”

I smiled to encourage her to explain.

“Like, you have to be careful about what you put in your body. I mean they’re putting additives in everything. Bodies need help getting rid of all the toxins that build up: detox regimes.” I grimaced inwardly, but maybe she saw the shadows. “My GP said that was nonsense, too, but I know I feel better after a cleanse,” she said, momentarily dropping the smile and folding her arms across her chest with the bracelets following close behind for emphasis.

I tried to disguise a deep breath. “I see…” –but actually I didn’t– “Is there any reason he felt that a gynaecologist could be of some help?”

“Help?” she said with a sharp intake of breath, as if I had really not understood a word of what she’d been telling me.

“You know,” I quickly added, “Help with something that you’ve been unable to deal with using your…” I hurriedly rummaged around in my head for an appropriate word –one that wouldn’t seem to insult her, yet wouldn’t suggest acquiescence either. “…Your strategies.” I thought that sounded neutral and not overly critical. I wanted to keep her on my side to see if there really was anything I could do to help. She could sort out the knowledge base for herself later.

Before she could respond, another text arrived, prompting yet another seemingly mindless flurry of thumbs to resolve the issue. She didn’t apologize and I realized that this was just part of the background in her life -like traffic noise, or maybe someone bumping into her in a crowd. She found time to shrug at me again, but whether to acknowledge the text she had just answered or as a way of answering my question was hard to tell. “I’ve been getting a lot of yeast infections lately, so I tried another cleanse.”

Her eyes jumped onto mine to see if I needed any clarification, and rested there when my face didn’t light up sufficiently with comprehension. We live in different worlds they said.

Toxins,” she added, like she was talking about the elephant in the room. “The bowel walls get encrusted with stuff and overgrowth of candida is one of the crusts.” She smiled innocently, almost as if she was going to admit to sneaking a cookie between meals. “I tried dietary modifications for months: fruit fasts, fiber-only diets… but no matter, I still got itching down there. So I tried a coffee enema once a week for a month. Then a probiotic one for almost three months.” She jangled her bracelets again as she thrust her arms upwards to suggest what else could she do. “Nothing worked, so finally I tried an enema using an antifungal solution that my girlfriend told me about. Jeez, try to keep one of those puppies inside for 15 minutes! I only managed 8…” She noticed the horrified expression that I’d tried desperately, but unsuccessfully to camouflage. “Eight minutes, doctor –not eight enemas!” She shrugged again –it was another form of speech for her, evidently. A sort of body text, I suppose. “But when I told my GP about it, he got really mad. “Of course there’s yeast in the bowel; we all have yeast in our bowels, he said… No he yelled that at me,” she added after thinking about it for a second.

“So I told him about the enemas they’re using nowadays for –I forget the infection…”

Clostridium difficile,” I added helpfully, and also to show that I was still listening.

“Those are special fecal enemas, he yelled back at me, and only for a special problem!  Anyway, you can’t get rid of vaginal yeast with those silly health-product enemas, he added. Not even the probiotic ones. He said ‘probiotic’ more softly, though, as if maybe he wasn’t so sure about that one.” Her face perked up again as the indignation faded and the verbal catharsis revived her spirits. “The yeast down below isn’t so bad right now –it seems to come and go. But no thanks to him -none of his prescriptions helped…” She shrugged a text at me. “That’s why I tried colonics dead last. I mean I believe in probiotics, and I hate enemas.” She studied my face for a moment. “Hey, I was desperate.” Another jingle from her arms. “There’s gotta be another way to go. Despite what all my friends say, I still think enemas are unnatural, don’t you?”|

I have to say it was hard not to roll my eyes. I realized I had a chance to convert her to our side of the fence if I was careful. And tactful. “I agree with you about probiotics, Loretta.” She smiled and nodded her head at my unexpected response. “The idea, of course, is to adjust the biota –the bacterial flora of whatever organ- to be able to suppress other unwanted organisms. But you can’t just use off-the-health-food-shelf probiotics –one type doesn’t do all jobs, just like one antibiotic doesn’t fit every occasion.” I glanced at her face to see if she was listening or playing with her phone again. She was listening. Staring at me in disbelief, actually. But in this Google age, I knew I had to be careful -I could only remember one article I’d read and that might already be outdated. For that matter, I couldn’t even recall where or when I’d seen it –the Canadian Medical Association Journal, maybe. But then again, she probably didn’t really have a yeast infection anyway…

“And the other thing is that good studies in this field are hard to find.” I hesitated a moment for effect -timing is everything. “I seem to remember there are a couple of probiotic regimes that have undergone scientific investigations. They were published a few years ago in…Ahh, the Canadian Medical Association Journal. You can look it up, I imagine.” The long-winded, but welcome news had forced her back into the chair, her phone into her pack, and the pack onto the floor. Then a look of concern replaced the incredulous rictus. “But how are the new bacteria going to be able to compete with all that toxic stuff in the area now? It might poison them, or overwhelm them before they even get a chance to set up a new colony.”

It was my turn to look concerned –well, at least curious. I’ve never understood the toxin theory promulgated by many of the alternative medicine practitioners. “How do you know there are toxins, or whatever, in the area, Loretta?” I sat back in my chair, convincing myself I had her.

Her eyes rolled as her hands reached into the pack at her feet in response to a muffled text. I assumed she was reacting to the disturbance, but suddenly realized it was me they couldn’t believe. She closed them slowly, patiently, in a slow motion blink and then opened them again, this time filled with all the sure and certain knowledge of youth. Her body texted me before any words left her mouth. “How do I know there’s still stuff living there now after months of using my colonic ‘strategies’ as you put it? Ever had a retention enema, doctor?”