Mind Trips

Does your mind ever behave as if you weren’t getting enough fibre in your diet? Does it ever seem to plug up with loge -or whatever the noun form of logy is? Mine does that whenever it doesn’t get sufficient exercise, I find -not enough thinking perhaps. On the other hand, even when I think of something to think, keeping it on track is more like trying to keep a cat on a trail: every time something passes by or rustles in the bushes, it’s off. I love the adventure, mind you, and yet I can’t help but wonder if it’s supposed to wander like that. I mean, is it a design flaw, or a sign of trouble in the pipes somewhere -a detour around a badly maintained section of road? Frankly I’m tired of trying to balance loge with rogue.

Of course, although it’s sometimes a problem in the dead of night when my eyes are unable to distract it, by and large it doesn’t care what’s going on around it, or in what direction it was originally pointed. My mind has a mind of its own.

But maybe all minds are like that; maybe we all have a naughty homunculus (or perhaps, a gynuncula) that sits at the steering wheel somewhere inside and veers from road to road with merry abandon. An insightful essay by Jamie Kreiner, from the University of Georgia, pointed out that the problem was also common amongst medieval monks: https://aeon.co/ideas/how-to-reduce-digital-distractions-advice-from-medieval-monks Who would have guessed?

‘They complained about being overloaded with information, and about how, even once you finally settled on something to read, it was easy to get bored and turn to something else… Their job, more than anything else, was to focus on divine communication: to read, to pray and sing, and to work to understand God, in order to improve the health of their souls and the souls of the people who supported them… The ideal was a mens intentus, a mind that was always and actively reaching out to its target.’

Of course, even with the best intent, their minds strayed; something had to be done about it. ‘When the mind wanders, the monastic theorists observed, it usually veers off into recent events. Cut back your commitments to serious stuff, and you’ll have fewer thoughts competing for your attention… Most Christians agreed that the body was a needy creature whose bottomless appetite for food, sex and comfort held back the mind from what mattered most.’ You can see where they’re going with this.

But there is a limit to the extent to which you can deprive a body, and so, ever mindful of the goal, they decided to turn the problems into solutions -well, sort of… ‘Part of monastic education involved learning how to form cartoonish cognitive figures, to help sharpen one’s mnemonic and meditative skills. The mind loves stimuli such as colour, gore, sex, violence, noise and wild gesticulations.’ So, ‘if a nun wanted to really learn something she’d read or heard, she would do this work herself, by rendering the material as a series of bizarre animations in her mind. The weirder the mnemonic devices the better – strangeness would make them easier to retrieve.’

The act of producing these memory aides was supposed to enable concentration and avoid distracting thoughts. Of course, as Kreiner points out, ‘caveat cogitator: the problem of concentration is recursive. Any strategy for sidestepping distraction calls for strategies on sidestepping distraction.’ I used to hate cleaning my teeth when I was a child, so my mother, no doubt fearful of the dental bills she would have to pay, asked me to try not to think of a puppy while I was brushing them. The idea was so bizarre, I’d end up inadvertently finishing the trip around my mouth while trying desperately to forget about the puppy… Uhmm, well maybe the medieval monks were not supposed to use distractions to fight distractions, but then again, my mother wasn’t running a religious institution, just a bathroom.

Anyway, as Kreiner also describes, ‘A more advanced method for concentrating was to build elaborate mental structures in the course of reading and thinking. Nuns, monks, preachers and the people they educated were always encouraged to visualise the material they were processing. A branchy tree or a finely feathered angel…  The point wasn’t to paint these pictures on parchment. It was to give the mind something to draw, to indulge its appetite for aesthetically interesting forms while sorting its ideas into some logical structure.’

Kreiner even teaches these medieval cognitive techniques to her students. She thinks that ‘Constructing complex mental apparatuses gives them a way to organise – and, in the process, analyse – material they need to learn for other classes. The process also keeps their minds occupied with something that feels palpable and riveting. Concentration and critical thinking, in this mode, feel less like a slog and more like a game.’

So, I thought I’d give it a try. I’m currently trying to learn coding -computer programming- and my mind, not understanding a thing about what I’m reading, tends to wander off. The whole thing seems so alien to an older person like me who was brought up on the words and metaphor of poetry that I despaired of ever being able to create stick-figures in it, let alone finely feathered angels -even from the Coding for Kids book I eventually digressed into.

There is, however, an ever-repeating figure that sticks with me from the book. The code I’m learning is called Python and helpfully, the figure that keeps greeting me is a smiley snake wearing a baseball cap. Just thinking about the smile and the cap, helps me to relax -makes me smile- even though if I saw it slithering across the table, my concentration would likely refocus on my legs, not its cap. But safely confined to the book, I find it centers me. It holds my attention like that puppy I had to try to forget. And when it’s hiding somewhere, I can hardly wait for it to reappear, because you never know with snakes, eh?

As for helping me focus on the code, well I can remember it’s called Python, at least… I mean, that’s something, right?

Learned without Opinion…

Sometimes we are almost too confident, aren’t we? Encouraged by something we’ve just read, and recognizing it as being already on file in our internal library, we congratulate ourselves on the depth and breadth of our scope. Perhaps it’s the title of an abstruse article, and even the picture at the top of the page that helped identify it. Or… was it something online, whose excellent graphics made it memorable? And, of course, what does it matter where you saw it? You’ve remembered it; it’s yours. Anyway, you know where to find it if the details are a bit fuzzy.

So, does that mean you know it -have thought it through? Analyzed it? Understood it…? Unfortunately, the answer is too often no. It’s merely filed somewhere, should the need arise. But knowledge, and especially the wisdom that might be expected to accompany it, is often lacking.

This was brought -worrisomely- to my attention in an article in Aeon. https://aeon.co/ideas/overvaluing-confidence-we-ve-forgotten-the-power-of-humility

Drawing, in part, on an essay by the psychologist Tania Lombrozo of the University of California –https://www.edge.org/response-detail/23731– Jacob Burak, the founder of Alaxon, a digital magazine about culture, art and popular science, writes ‘The internet and digital media have created the impression of limitless knowledge at our fingertips. But, by making us lazy, they have opened up a space that ignorance can fill.’ They both argue that ‘technology enhances our illusions of wisdom. She [Lombrozo] argues that the way we access information about an issue is critical to our understanding – and the more easily we can recall an image, word or statement, the more likely we’ll think we’ve successfully learned it, and so refrain from effortful cognitive processing.’

As Lombrozo writes, ‘people rely on a variety of cues in assessing their own understanding. Many of these cues involve the way in which information is accessed. For example, if you can easily (“fluently”) call an image, word, or statement to mind, you’re more likely to think that you’ve successfully learned it and to refrain from effortful cognitive processing. Fluency is sometimes a reliable guide to understanding, but it’s also easy to fool. Just presenting a problem in a font that’s harder to read can decrease fluency and trigger more effortful processing… It seems to follow that smarter and more efficient information retrieval on the part of machines could foster dumber and less effective information processing on the part of human minds.’ And furthermore, ‘educational psychologist Marcia Linn and her collaborators have studied the “deceptive clarity” that can result from complex scientific visualizations of the kind that technology in the classroom and on-line education are making ever more readily available. Such clarity can be deceptive because the transparency and memorability of the visualization is mistaken for genuine understanding.’

I don’t know about you, but I find all of this disturbing. Humbling, even. Not that I have ever been intellectually arrogant -that requires far more than I have ever had to offer- but it does make me pause to reflect on my own knowledge base, and the reliability of the conclusions derived from it.

So, ‘Are technological advances and illusions of understanding inevitably intertwined? Fortunately not. If a change in font or a delay in access can attenuate fluency, then a host of other minor tweaks to the way information is accessed and presented can surely do the same. In educational contexts, deceptive clarity can partially be overcome by introducing what psychologist Robert Bjork calls “desirable difficulties,” such as varying the conditions under which information is presented, delaying feedback, or engaging learners in generation and critique, which help disrupt a false sense of comprehension.’

To be honest, I’m not sure I know what to think of this. Presentation seems a key factor in memory for me -I remember books by the colours or patterns of their covers, for example. Seeing a book on a shelf often helps me remember, if not its exact contents, then at least how I felt about reading it. But I suppose the point of the article is that remembering is not necessarily understanding.

And yet, the book I see on the shelf may, in some fashion, have been incorporated into my thinking -changed something inside me. I’ve read quite a few books over the years, and been surprised, on re-reading them -or later, reading about them- that what I had learned from them was something totally different from what I suppose the author had likely intended.

A good example is Nobel Prize laureate Hermann Hesse’s Magister Ludi (the Glass Bead Game), which I read in the early 1960ies. I completely misremembered the plot (and no doubt the intention of the narrative) and for some reason was convinced that the whole purpose of this story was to suggest that a young student, Knecht, who had devoted his entire life to mastering the Game, comes to realize that his ambition was meaningless in the grand scheme of things -and near the end of the rather long novel, drowns himself as a result. Anybody who has actually read Magister Ludi, blinks in disbelief if I tell them what I remember of the story: I hadn’t really understood what Hesse had been trying to say, they tell me…

But, nonetheless, the novel had quite an effect on me. Because I remembered it the way I did, I began to realize how we come to rank our beliefs -prioritize our choices compared to those around us. So, was it worthwhile to train for years, dedicate his life, and eventually succeed in becoming the Master of a Glass Bead Game, for goodness sakes? And if he did, so what? Would that really make a difference anywhere, and to anybody?

For that matter, are there other choices that might have mattered more? How would you know? Maybe any choice is essentially the same: of equal value. I thought Hesse’s point terribly profound at the time -and still do, for that matter, despite the fact he probably didn’t intend my interpretation…

Perhaps you see what I am getting at: ‘understanding’ is multifaceted. I learned something important, despite my memory distorting the actual contents of what I read. I incorporated what I remembered as deeply meaningful, somehow. Was what I learned, however unintended, useful? Was it not a type of understanding of what might have been written between the lines? And even if not, the message I obtained was an epiphany. Can that be bad?

I’m certainly not arguing with Lombrozo, or Burak -their points are definitely intriguing and thought-provoking; I just worry that they are not all-encompassing -perhaps they overlook the side-effects. The unintended consequences. Maybe knowledge -and understanding- is less about what facts we retain, and more about what we glean from the exposure.

So, did I understand the novel? Perhaps not, but what I learned from it is now a part of me -and that’s just as valuable… What author, what teacher, could hope for more?

Remembering Forgetting

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Digiphilia

My computer seems to be constantly doing things behind my back, or under my fingers. One minute it’s performing some sort of update, the next, applying a patch or pretending to, at any rate. I have to trust that whoever makes the little signs that pop up is honest and doing things in my best interests. But how would I know -until it’s too late? There’s a lot of hope that goes into owning a computer nowadays -but sometimes it seems more like a Mafial protection racket and I do what it says so I don’t get hurt. So my data doesn’t leak out onto Facebook. Doesn’t de-encrypt on its way to the Cloud.  Of course, that’s what I pay it to do, but nonetheless it always seems busy. Like me.

Sometimes I wonder what that means, though -being busy. Is it like my computer -being occupied with a thousand thankless tasks whose relevance is probable, but unprovable and invisible? Or is busy actually more like what it does for me when I ask it to print something, or search for a particular file and display it? Something I can use, in other words.

The questions are not as odd as they seem. A patient of mine seemed to be confronted with a similarly existential angst one day as she was fiddling with an app on her smartphone trying to find the date of her last period. I’d seen Jenny a few times in the past for heavy and irregular periods, but they’d sort themselves out and I wouldn’t hear from her until the next time her family doctor became concerned. A young-looking woman in her mid-forties, she always seemed busy with something in her purse or in the depths of one of the voluminous pockets of the coat she always chose to wear. Then, like a magician extracting a rabbit from one or the other, she’d hold up a scrap of paper like it was a Dead Sea Scroll and wave it at me in triumph. “I knew I’d written it down,” she would explain, her face red with the effort. “It’s the best way.”

It was different this time, however. I hadn’t seen her for a while and her hair was longer, greyer, and piled on top of her head like she’d done it in a hurry in the dark. Her face had changed as well -more lined. More flustered. She was wearing a dark blue woolen sweater with no pockets, and her purse wouldn’t have held much more than a phone. But as agitated as she looked, she greeted me with a warm smile of recognition.

My first question, after the usual reminiscing banter seemed the obvious one. “Your doctor says that your periods are heavy and irregular again,” I began, glancing at his letter on the screen of my laptop. “When did the last one start?” This initiated a confident dip into the little purse and a rather smug look on her face. She pulled out a standard issue smart phone and started to punch in the password to unlock the screen. I could tell from her expression that it hadn’t worked. “I decided on a simple one, so I’d remember the password,” she explained with a blush. “But I think I entered it backwards…” She smiled to herself and re-entered it with much the same result. “Damn! Maybe I’m using the one for my debit card -the PIN thing…” she added for clarification. “Or could it be the..?” She punched in a few more numbers, this time angrily, then sighed noisily. She blushed again, but her cheeks were already flushed with irritation. “New phone,” she added, but more to herself than me. “Actually, my first smart phone…”

She put it on the desk for a moment while she decided what to do.

“Just tell me the approximate date your last period started,” I said to calm her down a little. “It doesn’t have to be exact…”

But I could see an idea flash across her eyes. “I wrote it down just in case,” she said and stood up to reach into a pocket in her jeans. My fingers hovered over the keyboard in anticipation. “Here it is,” she said, pulling out a crumpled piece of brightly coloured paper the size of a small post-it reminder like I used to stick on my charts to alert my secretary to do some task or other. Jenny had her backup systems.

But it wasn’t the date of her period, it was the password for the phone.  I rolled my eyes when she wasn’t looking, and smiled patiently: my backup system…

Soon she was deep in the inner mysteries of her phone hunting for an app, scrolling randomly it seemed to my watchful gaze. I glanced at my watch -eighteen minutes so far of no progress in solving the problem she had waited so long to see me for.

“I used to just remember things like this,” she said with an embarrassed shrug. “Then, when my periods became irregular, I would write the dates down…”

I couldn’t see her face as she said this -her long, greying hair had come unravelled from its original wrappings and was hanging over her nose and eyes as she stared at the tiny screen, head bowed as if in prayer, frantically scrolling through some app or other with her fingernail.

“My girlfriend convinced me to get one of these,” she said, perhaps pointing at the phone that was hidden in her lap behind the desk. She looked up briefly and smiled at me. “You remember Lara?”

It was a statement really, not a question despite the obvious verbal question mark. I decided I did not have to respond and just smiled in return. I had no idea who Lara was.

“You delivered her little girl a few years ago,” she continued almost as an aside, trying to multitask as she whacked at the screen. “Anyway she said she’d given up pencils for good and was happy about it. No more scraps of paper in her pocket, or sounding the depths of her purse for a reminder she’d forgotten she’d put in there.” She surfaced again for air, and then just as unexpectedly disappeared behind her hair. “No more worrying about where things are; everything’s in the same place…” Her hair quivered for a moment, then the moment passed and the scratching sound resumed. “You can even set an alarm on some of the apps… Not this one, though,” she added, as if to excuse her absence.

“Anyway, Lara says to say hello.” And then a whispered curse, as if her friend had joined her behind the wall of hair.

“Any word about your period?” I  asked, pretending it was a joke.

Jenny giggled nervously and waggled her hair again. “I should have written that down somewhere for you… Well, I mean I did, but I can’t find it.” Two eyes peeked timidly through the hair like children hiding in a bush. Then suddenly, her head bobbed up and the hair parted as a curtain might with a gust of wind. “Wait a minute,” she said, excitedly, “I did write it down!”  She jumped to her feet and managed to cram some fingers in another pocket in her jeans. “Hah!” she shouted excitedly. “Here it is! You always have to have a backup plan, don’t you?” She pulled out another post-it note and placed it triumphantly on my desk.

I smoothed it out and tried to read the now-smudged writing on it as she watched my every move with ill-disguised pride. When I seemed to be having difficulty she gently retrieved the tiny document from my grasp and translated it. But slowly, like a teacher trying to help an unexpectedly slow pupil. “It says nine days ago, doctor. It started nine days ago -well, probably nine and a half, because they often seem to start the night before…”

I have to say she was very patient with me. More patient than I felt. “Nine days ago Jenny?”

“Nine and a half,” she corrected me.

“But couldn’t you just have told me that in the first place? I thought maybe it might have been a few weeks ago, or perhaps a very long time ago…”

She shrugged noncommittally. “That’s why I wrote it down,” she said as if I was still being a bit slow. “I didn’t want to give you the wrong information, after all…”

“But…”

She looked at me, obviously annoyed that I was not being more understanding. “I lead a busy life, doctor. I can’t be expected to remember everything.” She softened her expression like a mother, concerned she might have been a bit hard on her child. “So I write everything down where I can find it when I need it.”

I stared at her phone for a moment and shook my head with a knowing smile. I don’t think she saw that, though, because she was obviously  pleased with her methods and was carefully folding up the password on that first piece of paper and getting ready to put it back in her pocket again. “When you’re busy, you have to have a plan,” she said proudly. “And a backup…” she added wisely, in case I hadn’t seen the wisdom in it all.

The Gyne Phone

The iconoclasts were people who destroyed religious icons for various reasons. It’s a practice that began thousands of years ago. And somebody’s messing with the icons again -but this time, it’s the  iconoplasts

The icon has ancient roots and the word derives from the Greek word eikon meaning ‘likeness’ or ‘image’. Originally, it was usually a religious depiction of a god, or saint, but destruction of icons (iconoclasm –clasm deriving from the Greek word Klan, meaning to break) gradually morphed into destructive acts against the status quo. However, given the ubiquity of the computer, icons today usually refer to representative symbols on the screen of different options or programs.

Before written traditions gained a foothold, the dissemination of information or tribal history depended on oral transmission –i.e. on memory. But this presented some problems in terms of the sheer volume and accuracy of what needed to be passed along. Addressing this issue, Wikipedia (sorry!) notes: “Without the use of writing systems to transmit information through time, oral cultures employ various strategies that serve similar purposes to writing. For example, heavily rhythmic speech filled with mnemonic devices enhances memory and recall. A few useful mnemonic devices include alliteration, repetition, assonance, and proverbial sayings. These strategies help facilitate transmission of information from individual to individual without a written intermediate…”

Then, with the advent of written transmission of information, one can imagine a gradually increasing dependence on this and perhaps a decline in the need for the enhanced memory techniques so necessary before:  http://www.historyofinformation.com/narrative/oral-to-written-culture.php  At the time, I suspect this phase would have been fraught with objections from those traditionalists concerned about the atrophication of memory itself. Change is worrisome; it can have unintended consequences…

Well, the Phoenix has once again been aroused: http://www.bbc.com/news/education-34454264  It seems that since most of us carry instantly –and ubiquitously- available information around with us in the form of smart phones or tablets, there is little need to memorize phone numbers or even addresses. And even less incentive, since we might remember them incorrectly. Egad!

I’ve noticed the transition over the years in my practice. At first, the patients would come in with lists –questions written on usually irretrievable little pieces of paper stuffed into their purses. Of course if they couldn’t find the lists, some of them then made desultory attempts to remember what they had written, but often to no avail. I became quite skilled at offering clues as to what they might want to ask, but alas, that too atrophied as time and computing advanced. It’s a two-way street, I guess. Use it or lose it.

But my younger patients (of course) appear to have taken it to extremes –or at least, so it seems to me… Judin was the most recent example, I think. She was a twenty-something woman of Persian extraction and she had come to me because of abnormal pap smears. Otherwise healthy, she sat proud and unmoving like a marble goddess in the chair opposite my desk. Her eyes tiptoed to my face and sat there like curious birds. She was dressed casually in a pale blue sweat shirt and white jeans, and as she moved her head from time to time, her earrings tinkled like little bells hiding inside her long, dark gleaming hair. Her phone lay dormant on her lab, but I could see her right hand clutching it like another equally precious jewel.

I commented on how beautiful and unusual I found her name and she smiled serenely, tossing her hair nonchalantly back and over her shoulders. “It’s the name of a village in Iran where my cousin was from. She came to live with my parents but died before I was born.”

“A village near Tehran?” I have to admit I was approaching the limits of my knowledge about Iran –my knowledge of its geography, at any rate.

She shook her head and the tinkling started again. “No, it’s in a very dry and poor region of the Sistan and Baluchistan province in the south east corner of my country -by the Gulf of Oman and the Arabian Sea,” she added helpfully, but she could read the confusion on my face. “Tehran is quite far north near the Caspian Sea.” She stopped for a moment to smile. “Judin is in the middle of nowhere.” Her eyes twinkled this time instead of her earrings. “Honestly!”

Judin –the woman- was obviously well versed in geography and family history, and I would have loved to pursue it further, but I realized, as did Robert Frost, that ‘I have miles to go before I sleep’… I had to press on with the consultation.

Some of the questions were background issues –housekeeping data that I needed to acquire to ensure I would not miss any other information that might be relevant to her abnormal pap smears. “When did your last period start?” I asked, assuming this would be a good place to start.

She smiled, and called her eyes back to roost while she lifted her phone from her lap like a religious icon. She tapped at it for a moment. “Just a minute,” she said sweetly enough. “Gotta find the app…” I could see her scrolling through the screen, her face intense, her body rigid. “Oh, here it is,” she said and glanced at me. “What was the question?”

“When did it start?” I prompted, fascinated by the effort she was making in her search.

I lost her eyes for a moment as they disappeared behind her lashes and then her lashes behind her hair as it fell forward when she lowered her head. “Well…” I could tell she was into it now: her voice seemed strained and I could see she was really concentrating. “…I’m having it now, and they only last 3 or 4 days since I started on the birth control pill…” Suddenly her face surfaced before she could restart a smile. “I don’t actually know… I guess I forgot to enter it.” She blushed and her smile disappeared. “Sorry,” she said, and looked at her phone again. “I’m going to say ‘yesterday’…” She thought about it for a moment. “No, it must have been the day before, or I probably would have remembered it.” She assumed the goddess pose again. “Yes,” she said, but more firmly now –more assertively. “Yes, it was two days ago!” She looked at me with an almost smug expression on her face that seemed to say “Isn’t technology wonderful?”

I nodded and entered the date in my computer –my substitute for her smart phone, I suppose. “And were your periods regular when you were not on the pill?” She looked at me strangely. “You know, once a month…?” I added.

She hoisted the phone once more and scrolled through it looking for the app again. It seemed to be taking a long time, so I pretended to bang my mouse against my coffee cup accidentally. “Yes,” she said hesitantly and without looking up. “But, you know I wish all months had the same number of days. Eyeballing the calendar to see if it’s the same would be so much easier.” She glanced at me, and then submerged her face in the phone again. “It’s easier to count the days I bleed than the ones I don’t.” Another glance to see if I was following her. “Fewer squares to count,” she added to make sure I understood.

“Maybe you should suggest that to the app-people,” I said, wondering if I’d used the correct word.

“You mean the IT people? The software engineers?” She smiled at me like a mother might to correct her young child. “What a great idea!” she said, when the idea struck home.

But I’d been skipping about in taking her history, and I thought I’d make sure I’d obtained the entire historical data before moving on to more pertinent issues. The age of menarche -or first period- can sometimes be helpful gynaecological information. “Do you remember how old you were when you first began to menstruate?” I could see a puzzled expression taking control of her face. I thought maybe English might be her second language and ‘menstruate’ might not be a word she would hear around the house. “When did you start your periods?”

The puzzled look disappeared, and a different one –an almost irritable one- replaced it. “Two days ago…” She cocked her head as if I hadn’t heard her the first time. But she was willing to forgive it, I could tell.

“No…” I paused for a moment, in order to figure out how to phrase it more clearly for her. “I mean you probably started to have your periods when you were quite young… Do you remember what grade you were in, or where you were living when you had that very first one?”

She nodded her head and stared at something on the wall behind me as if she was thinking about it. “I was young alright, but…”

I waited, for a moment or two and was just about to tell her to forget about it so we could move on when she suddenly fixed me with another puzzled stare. I could feel the weight of her eyes sitting on my glasses like two passenger pigeons that had already delivered their message.

“I can’t answer that question, doctor,” she said and sat back in her chair. My eyebrows must have moved because I could see her sigh in disbelief at my ignorance. “I didn’t have a phone then…” she said and shrugged. It was so obvious!

The Manopause

The menopause can be a mysterious time, although the mechanism is easily enough defined: the cessation of menses because of the lack of estrogen production by the ovary. The concept may be simple, but the ramifications and folklore that surround it less so. It has always worn its myths like a hood, obscuring the face beneath, confusing the experience like shadows on a rainy day.

Descriptions are legion, but ultimately unhelpful in dissipating the fog the definition drags with it: hot flushes, sleep disorders, irritability, worries about cognition and memory, regrets about the loss of fertility, and concerns about sexual function and desires… And although some symptoms may cross the gender divide, many -if not most- are unique to women. Unique to ovaries.

And the response to the change can be unique as well.

I hadn’t seen Elizabeth for a long time –in fact I couldn’t remember ever seeing her. Memory deficits are not the sole prerogative of the estrogen deficient –although in fairness, when I tried to look it up, it must been well over ten years since her last visit because the chart had been destroyed. The legal limit that we are required to keep records had obviously been exceeded.

She treated it as if it had only been a month or two, and greeted me with a smile usually reserved for someone who is supposed to go over some frequently-repeated test results. Someone she’d seen in the mall last week, and at a restaurant the week before. But there was a hint of suspicion in her smile.

“Elizabeth,” I said, extending my hand when I greeted her in the waiting room. “Nice to see you again,” I continued as I led her down the corridor to my office. She looked at me politely and sat down in a chair by the window across from my desk, perhaps waiting for me to reminisce.

The referral letter said only that I had seen her before and that she seemed angry about something. She was 55 years old, was on no medications, and she had some questions about the menopause.  “So, what can I do for you, Elizabeth?” A rather predictable opening, I suppose, but it didn’t commit me to anything –in other words it didn’t disclose the fact that I couldn’t remember a thing about her.

She probed me with her eyes for a moment, suspecting, I think, that I didn’t recognize her. But if she was disappointed, she didn’t betray it with her face. The ghost of a smile reappeared, and her eyes relaxed enough to twinkle through her glasses.

She didn’t look the merry type, I decided. Her hair was greying and pulled back tightly in a bun. Her outfit was severe: a black, loosely hanging dress that covered her ankles but not her jewelleryless arms. She was a thin, tall woman and sat as straight as a pole in the chair, her white skin even more pallid where it met the dress.

“How will I know when I’m in the menopause?” she said suddenly, as I glanced at the computer screen searching for more clues.

I met her eyes half way, and smiled reassuringly. I hadn’t had a chance to take a history, so I had to be careful with my answer. “Well, in many women, the symptoms can be very subtle, but generally speaking, the usual tip-off is an irregularity of menstruation and eventually its cessation. And, of course, there are often hot flushes, irritability and…

Her face turned smug and her smile condescending. “But I haven’t had a period for years, doctor…” She sat back in the chair and regarded me with some ill-disguised amusement. I must have looked confused, because she sighed both audibly as well as visually –performance art. “You took my uterus out fifteen years ago…”

I did my best to retain a modicum of Aequanimitas: I tried not to blush.

“Big fibroids,” she continued, to add to my discomfort. “You said one of them was the size of a basketball… I thought you’d remember.” I was blushing now, and about to apologize, so she backed off. “It has been a long time, I suppose.”

I attempted a smile, but I think it came out as rather forced and weak. I decided I’d better take a more detailed history before I addressed her concerns. “I’m sorry, but unfortunately I no longer have your records so I’m going to have to ask you a few questions… First, are you having any symptoms of the menopause?”

She frowned a look of concern unrolled onto her face. “Why don’t you have my records? You did my surgery…” Her eyes suddenly tied me to my seat. “Suppose I developed complications?”

I started to feel defensive. “The law requires us to keep the files for only 10 years unless there is an ongoing  attendance,” I said, rounding off the numbers for her. “I haven’t seen you for longer than that, and you haven’t declared any complications in that fifteen years that I know of…”

She lengthened herself to the full length of her spine and glared at me. “My complication may be the menopause, doctor!”

I tried to stay neutral. Professional. “I’m sorry, Elizabeth, why do you think that?”

Her face crinkled into a little wrinkled ball, like a piece of paper someone had crumpled before throwing it away. “You took my uterus out!” She almost spit the words at me, as if I should have known that was the problem.

I sighed in an unsuccessful attempt to duplicate her previous performance. “Did I remove your ovaries as well?” At forty, I wouldn’t have.

She stared at me wordlessly for a moment. “You did a total hysterectomy you said, doctor.” She said the last word as an insult, not as a descriptive, or an honorific title.

I smiled and realized she had not really understood what I had done. “A total hysterectomy merely refers to the act of removal of the whole uterus –the total uterus. A partial hysterectomy, on the other hand, means I’ve only taken part of it out –left the cervix, usually…” Her expression didn’t change. “I wouldn’t have taken your ovaries out at that age, because… Well, first of all because they would still have been working and producing hormones, and secondly there would have been no need to do so.”

I hoped that would mollify her, but if anything, her face crinkled into an even smaller bun. Then why haven’t I had any hot flushes, or irritability?” She could see one of my eyebrows start to raise –it’s really hard to control that- and hissed audibly at me. I think it was a hiss, but maybe she was  just breathing through her teeth.

I tried to relax my expression –a Mindfulness technique. “Whether or not your uterus is present, the ovaries don’t last forever. They eventually stop producing hormones.” I realized I shouldn’t have used the word ‘last’ as soon as I said it; it just sort of slipped out.

She shook her head slowly in her anger. “You men are so insensitive about the ovaries! You just don’t know what they mean to us, do you?” I suppose it was a rhetorical question, because she continued the rant without stopping for a reply. “And I’m surprised to hear that attitude from a doctor!” She stopped talking for a moment and looked at me. “You weren’t like that back then…” The scowl returned. “And to tell you the truth, doctor, I don’t remember you like this at all…” She glanced around the office. “Not even the office.”

I was about to say something reassuring to her –like that I’d probably changed a few things in here over the years- when she suddenly stood up and wrinkled her nose. It was hard to spot in her overall expression, but I noticed it immediately. Her eyes closed briefly as if she could somehow block out everything that she didn’t like about where she found herself. And then, gathering herself up to her full six foot height, she thanked me for my time and stomped out.

You know, I still can’t remember operating on her… and I don’t think she does, either.

Elder Gynaecology

I love old people. Sounds a bit patronizing I suppose but I’m becoming one of them, so I have vested interests. And anyway, even the most reticent among them have had a unique, personal view of history. A well tested perspective of Time and its evolutionary ravages. They have grown an almost uncanny ability to step outside and look at their lives as one might their house from the sidewalk.

Talking with them is an adventure, a journey. A long journey. I have travelled part way along the collective path –the common trail from which each has wandered looking for their the way -their destination- but I am ever fascinated with their routes. Never bored, yet usually intrigued by the roundabout ways they have found to describe it. Camouflage it, really. It is seldom a direct road –more frequently a series of detours that require patience to navigate.

As the family doctors who refer to me get older, I sometimes think they have my name written down on some old Rolodex in the top drawer of their desks, so it’s readily at hand when an elderly patient whose baby I may have delivered asks them if I’m still in practice –or at least, still alive. I may not remember them, but for some reason they remember me. It’s nice to be remembered, but it usually comes with an expectation of reciprocity. No one, especially of advanced years, wants to walk down a one-way street. We all crave familiarity. Recognition. Memories we can share.

Unfortunately, charts are not kept forever and computerized records are relatively new kids on the medical block. So when I see them, it’s frequently with a blank slate -a tabula rasa  as it were. But when I think more clearly about their reactions to this cognitive gap, I have to admit that most of them are not at all nonplussed. They merely tell me all about it; they fill me in about the intervening years. I love it; it’s like going to a history tutorial.

Emma. The name rang no bells, sounded no alarms; I had no idea if I’d ever seen her before, in fact. I glanced at the referral letter before I went to meet her in the waiting room: Please see this delightful, loquacious lady for a gynaecologic check. You saw her 10 or 15 years ago apparently. Well, no clue there. No old chart. No information about why or exactly when I’d seen her before. I have to admit I cheat before I greet them in the waiting room –I look at their old records and try to pretend I remember some of the details about why I once saw them. I’m sure they all know I do that, but it’s an acceptable crib, I expect. No one calls me on it. They pretend that they have a special place in my practice. My memory. Everybody wants to pretend that there is a statue of them somewhere. A commemoration. But there was nothing on Emma. I would have to plead unwilling and embarrassed ignorance.

“Doctor,” she said in a strong, loud voice as soon as she saw me. “Dr. Stegal was sure I saw you before…” she said, all the while hoping he was wrong. I could hear it in her voice.

She was a thin woman with tightly coiffed, short white hair that she wore almost like a toque over her ears. Quite becoming, I thought: it enclosed her face like one of those little ornate frames you see sitting on desks all over the world. I have to admit I didn’t recognize it, but wrinkles are a good disguise. Like one of those Russian dolls, her eyes were set within wrinkles within yet more and deeper grooves on her skin when she smiled. She never stopped smiling.

I led her into the consultation room and sat her down opposite my desk. As soon as she settled in the assigned seat, and adjusted the bright red dress she’d worn for the occasion, her face lit up with the expectation of a good talk with an old friend. She couldn’t help looking around the room for a moment, no doubt comparing it with scraps of memory. Her smile waxed and waned in concert with fragmented recollections; her eyes would focus on a picture and recede within to riffle through her files then emerge, satisfied she had classified it correctly, then fly to another branch, another picture, another piece of my aging, chipped furniture. Her eyes said she was beginning to remember the old visit, but her face told me she didn’t know what it had been for.

“I see you still have that old metal desk, doctor.” This was clearly an opener. A gambit to facilitate my entrance into her world. I smiled lamely; what could I say? I liked the desk. “My daughter reminded me of the desk, and those little magnetic signs you had on one side. Fridge magnets she called them.” She shifted on her chair and craned her neck to look at the side near to the door. “Yes, I see they’re still there.”

I shrugged good-naturedly. “I’d forgotten about them…”

“But you certainly have a beautiful office, doctor,” she added as if I hadn’t spoken. “I remember that picture behind you. The woman only partially drawn?” she said as if I’d forgotten that as well. “Do they still make those?”

I wasn’t sure if it was a real question, or merely an observation that I hadn’t much changed things over the years. I turned around to look. It gave me time to consider how I was going to lead her into telling my why she’d come to see me.

“I saw one just like it in Kresge’s a while back…” she said to soothe things over. It must have been a while back because I think the store chain changed its name to Kmart before my daughter was born.

“Well, it’s good to see you again, doctor,” she said tentatively, getting comfortable in her chair again. “My daughter says to say hello…” She didn’t really finish the sentence, but did temporarily immobilize me with a stare that dared me to ask her who her daughter was.

“Oh, that’s nice of her,” I responded, proud of my quick, noncommittal answer. “Please say hello to her for me.” It was lame, but I was trapped by her eyes. I had to say something.

Emma’s face changed from happy to wicked. “Do you remember her?” I shrugged. “I told her you wouldn’t, but she wouldn’t believe me. ‘After all the problems I had, he’ll remember, mom,’ she said.”

I could  see the hint of a smile trying to force its way through her wrinkles. It looked like work.

She shrugged resignedly, as if her shoulders had felt the weight of the world before and this one more disappointment was not going to do her any harm. “Judy was always a drama queen-always worried about something. Always thinking she was sick, ” she said, sighing loudly. I assumed Judy was her daughter, but it opened no doors. I mean how many Judys are there in an average gynaecologic practice? “I remember when she was a little girl, Henry made her a tiny doll house to distract her, and she’d lie on the floor for hours and play with it. Henry was good with his hands. He could fix anything. We never called a plumber, you know. Didn’t have to… Well there was that time something got stuck in a drain and we had to call one because he had one of those metal snakes, but he was way too expensive. And it was just hair that was blocking it.” She stared at me again briefly and only let go when I smiled in submission. “It wasn’t Henry’s hair, though; Henry was bald as a table…”

I smiled again and picked up the referral letter and examined it. Maybe that would work. “Dr. Stegal says…”

“Well, he shouldn’t really say anything. I never really saw him for more than two minutes before he suggested I go to see you…”

I sensed a perfect, but rare opportunity. “And what did you want to see him about?”

She sat up straighter on the chair and crossed her arms. “I didn’t want to see him, doctor…”

“My mistake. Why did you go to see him, then?”

She settled back into the chair; she was looking entirely too comfortable. “Well Judy came over a couple of weeks ago…” She considered this for a moment. “It was just after the anniversary of Henry’s… departure. So I guess that would be three Saturdays ago…”

It seemed important to fix the date, so I waited patiently. I stole a glance at my watch; my secretary would be panicking if I didn’t surface pretty soon. I prodded her gently. “Why did Judy come over to see you?” A stupid question, I suddenly realized. I could hear the answer before she even opened her mouth.

“We were going to go to the cemetery and then stop at his favorite restaurant for lunch.” She focussed her attention on my face, so I couldn’t interrupt her train of  thought. “Have you ever eaten at the MacDonald’s on Fourth?” When I didn’t reply –didn’t even try to reply- she finished her thought. “Well, we both ordered the chicken nuggets and we started talking about the Menopause.” I could hear her capitalize it. “She asked me what mine was like. Well, I said, it was a long time ago… ‘And did you have any problems  with it then?’ No, I said, but then I remembered –I’d had a bit of bleeding three or four years after my monthlies had stopped. That really seemed to alarm her. ‘Did you go to see the doctor?’ For some reason, I couldn’t remember if I had, so she immediately made a phone call to Dr. Stegal. ‘You can’t let these things go,’ she said. So, I saw Stegal –but hardly long enough for him to open my chart.

Now we were getting somewhere!

“But now that I’m here, guess what..?” Her expression had changed.

I hate it when people do that. I’m supposed to be asking the questions.

“When I saw the office today, it began to come back to me.” I put a purposefully puzzled expression on my face and left it there. “I’d seen you for the bleeding. You did a biopsy and cleared me. ‘Don’t worry about it’, you said. ‘Get on with your life’ –I remember you said that, and I thought it was so nice. So sensitive. After all the pain of that biopsy, it was the right thing to say. Almost an apology…”

She was about to continue when I interrupted as gently, but as quickly as I could. While she was taking a breath. “So is that why Dr. Stegal sent you to see me today?”

“I think so. The only person he really spoke to was Judy…” She looked around the room nostalgically for a moment and then at me again. This time with some concern on her face. “We don’t have to do another biopsy do we? Judy thought we would.”

I graced her with my most benevolent smile. “Have you had any more bleeding, Emma?”

She shook her head solemnly. “None since I saw you and that was probably twenty years ago.”

“Then I think we can just watch things for now. I closed her empty chart and got up from the desk –but slowly, so she wouldn’t think I was rushing her.

Her face turned sly. “But Judy has. Now she wants to come and talk to you.” She stopped when she saw my expression change. “Oh not now! No, she has an appointment for next month.” She got up from her seat and walked toward the door. Suddenly she stopped. I hoped she hadn’t changed her mind about leaving.  But her face, when she turned to look at me, was beaming. “You look worried, doctor,” she said with obvious concern. “Don’t worry,  I’ll come with her and help to explain things.”