Remembering Forgetting

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.”

You Got Me Pregnant!

Some things seem to go unappreciated don’t they? They’re background noise. Shadows in the moonlight. You might think that this doesn’t apply to medicine, but it does. Much of what we do is taken for granted –or at least taken for expected… appreciated, but for a variety of reasons, not publically acknowledged. And that’s fine with me; I’m certainly publically humble. Shy. I seek shadows not spotlight. I’m not certain I would know what to do on a pedestal.

Besides, I don’t do what I do for accolades –I embarrass easily. And I’m content with smiles, or even a face that signals thanks; I probably should have gone into Pathology, or some other solitary field where the propensity to blush is not a handicap. They didn’t teach us how to accept praise in Medical School; they didn’t even mention blushing –or maybe I just missed that class.

But, not to diminish the appreciation I do receive –I’m an obstetrician, and in the fullness of  l’accouchement  there are congratulations all round. Thanks in spades. It is enough -it is their moment after all, not mine.

And anyway, I forget things –forget people, for example. I may have seen them every month for a year, and yet on the street, they are sometimes just faces that smile at me when I pass, and like most faces, vaguely familiar… Maybe. Some eyes seem to ask for more than just a fleeting nod but these are requests to which I dare not accede lest I be required to remember something of their past… I don’t do pasts the justice they deserve sometimes. Pasts matter; they are what knit the fabric we wear and to ignore them is to ignore the coloured  patterns that make the present so vibrant. The future so hopeful.

Memory was a given in Medical School –it was what you had to have to get there in the first place. It was not so much educere –a Latin word suggesting drawing out or eliciting something already there- as inducere –putting something in that they wanted you to have… But I digress.

I have carried this neural handicap with me my whole career: my memory seems selective at times.  I am prone to remember things I don’t need –a hair style on an elderly lady, a lilting way of speaking, the eyes of a woman looking at her newborn baby… Interesting things that help to flavor the roiling stew of facts and numbers I’ve stored behind the eyes I try so hard to keep neutral in the office. Things that disguise the otherwise unadorned potpourri of diseases and anatomical discrepancies hidden beneath the words that stagger so reluctantly from my patient’s lips. Things –flowers- so precious in the world of suffering my job is wont to assess.

I need to escape sometimes: long walks along the beach, a movie, dinner with friends… or dinner alone. They’re all tricks to dampen down the past. Too much past, and you’re condemned to live there –or at least visit uncomfortably often. And for me, dinner in a nice, crowded little restaurant at table along the wall is the perfect anodyne. Like a bodhisattva, I am of the world, but comfortably without as I sit, hidden in the corner, sipping casually on a glass of wine, watching others do the same. I am peacefully alone in the crowd, digesting my thoughts in joyful anticipation of the ritual of food.

I was at one such place a few months ago. The room was crowded, and quietly boisterous  as I was shown to a table by a window overlooking… Well, it was so dark outside, it overlooked the reflection of the room –a double room, in effect -perfect for inspecting plates on other tables and who was sitting in front of them. Everybody was dressed as if they knew others would be watching them: the woman nearby in the designer jeans, so tight she looked unable to move, with only  a salad in front of her; and her partner, casually elegant, tucking into some sort of pastivorous mixture that steamed as he forked it. They were quietly avoiding something –communication, likely. Others nearby were toasting each other with sloppy, uncertain gestures, waving napkins at one another as each attempted to prevent the inevitable spills. Everyone seemed engaged in something; everyone was alive and enjoying it.

My eyes were drawn to the aisle where I’d entered. The room was full to overflowing –nobody was leaving- but I could see one of the servers staring at me. She was a tall young woman with her blond hair pinned back into an attractive bun, and as usual there was something familiar about her face. She was talking excitedly to a man behind the bar and nodding in my direction. At first I was flattered; I thought perhaps she had noticed that my wine glass was almost empty. Great place, this, I thought and smiled back at her. She returned the smile with an expression I’d seen before. Then a puzzled look attacked her face, as if my smile had confirmed something. She bowed her head for a moment, as if thinking it through, and suddenly her eyes opened wide and I could see her take a deep breath.

Then, as luck would have it, there was one of those stochastic diminutions of sound that seem to occur in restaurants from time to time as people decide to pursue their dinner for a moment rather than their conversations.

“You got me pregnant!” the server screamed in her excitement, pointing at me and walking towards my table with an intense but unreadable look on her face. I couldn’t tell if she was angry or bent on revenge. Me? I just hoped she was mistaken.

The restaurant was muted when she said it. Completely silent when she’d finished. Everyone turned to stare at me, the accused, as if I’d abandoned her after a night of debauchery. I could see the look of disapproval on the woman in the designer jeans. Perhaps she was regretting her choice of partner for the evening but I couldn’t tell because she was staring at me with a malevolence I’ve only seen in movies. People began to whisper to each other and I could sense, as much as hear, guffaws and sniggers. Caught, I could hear them think. Serves him right!

I could tell they were all waiting to see what the server would do once she reached my table. There was a palpable silence when she did. They were preparing themselves for a battle. Deciding what to do. How to react. What is the appropriate protocol to be followed in such a raw and unusual circumstance anyway? Grab me and pin me down? Call 911? Take a video of me with their cell phones and post it on YouTube? I thought about all this as she approached, but my social skills had never been stretched that far before.

In the eternity of those last few steps before she reached me, I could feel my face redden, and my mind racing like it is said to do in the moments before an impending and inevitable accident. I scoured mental relationship files and flipped through the disappointing ones in the blink of an eye, desperately searching for some mistake I’d made. An indiscretion, perhaps. A date I’d forgotten –or blocked from conscious memory. Anything. But, for some inexplicable reason, there was nothing to exculpate. In terms of the reaction I was provoking, my life was undeserving. Banal, if not entirely flawless.

Suddenly she was there, standing excitedly in front of me in the tomb-like silence of a room full of frowns. Their eyes, their expressions, their postures –all were balancing on a knife’s edge. Hoping for a resolution of the tension and yet dreading, what was to come.

She stared at me for a moment, teetering on the edge of a conflicting internal debate on what she should do now that she had an unanticipated and, no doubt, unwanted audience. Then her eyes twinkled and her face dissolved into a smile so large it hardly left room for ears; so genuine, I thought she might faint with ecstasy; and so intense I had to stand to acknowledge it. She grabbed my hand and squeezed it until it hurt. And then, putting her arm around me, turned to the crowd and said, “Sorry folks. I didn’t mean to disturb your dinners. It’s just that I never did thank my doctor for solving my infertility problem!” She pulled me close and kissed me on the cheek and then promptly blushed when the room erupted into applause. “I’m so impulsive sometimes,” she said and backed away, still holding my hand.

The room slowly settled back into its usual rhythm after that, and she walked quickly back to the bar to see if her next order was in. Later, when I was simply a mildly diverting memory in the drunken crowd, my own server –fortunately one with an unfamiliar face- presented me with a bill with a smiley-face drawn on it, and a big zero where the charges should have been. But the vaguely familiar-faced owner accosted me as I left.

“I’m sorry about that, doctor,” he said, looking embarrassed as he shook my hand. “My wife gets so excited about things now that she’s a mother… Never rests any more -even here. She’s always finding something to do.” He looked at me for a moment as if he wanted to tell me something else and then smiled and turned away. As I reached the door, however, he spoke again. “Can you get us a boy next time, though, doc..? The girl we got never seems to sleep.”

On Remembering Faces

Faces are important; they are like little signs we wear to allow others to recognize us. Unlike, say, fish they are distinctive and carry verbal labels further enabling meaningful categorization. A face without a name begs inquiry; a name without a face, recollection or even retrospection…

In a way, remembering faces is a sign of respect: you have had dealings with them; they had temporal significance for you; they were and remain important. And in standing out from the crowd –egregious in its original sense of standing out from the herd- there is a bond, however tenuous. I passed a smile in a hospital corridor the other day and I mistook it for agape: that look we donate to total strangers that we pass like ships. And I saw the look of disappointment and saw her whisper something to her partner who glanced at me as well. She stopped and turned a few steps past me and addressed me by name. And even when she explained that I’d operated on her mother a few years ago, my recollection of the event remained wrapped in cloud. Overcast.

Some people have the eidetic skill of instant recognition and with that identification the story of the paths they shared, along with the appropriate assignation of adventures encountered along the way. It immediately sets both parties at ease; there is no awkward pause, no need for hasty explanations of how each was once significant to the other.

But recognition is a blessing not equally bestowed. There are times for many of us when a chance encounter contains as much information as leaves on a tree, and an individual is as anonymous as a fallen twig. I cast no aspersions, but memory has a way of defocussing details, melding them into a delicious stew of once-tasted dinners. Or am I making the mistake of assuming I am representative of the average other? A mental excuse: an inadvertent equivalent of psychological projection?

I have been in medical practice for many years now; I have encountered myriad people along the way, delivered uncounted thousands of babies -maybe I do have an excuse… And yet to forget a face that greets me on the street -a face with which I have had a nine month relationship, perhaps- still seems rude. Insensitive. The fact that it may have been ten years ago -or more- has not dimmed their memory of the relationship and its consequences. The child at their side refusing eye contact with me is an integral part of their life -one they shared with me long ago. They live the memory; I claw desperately at the door of a cupboard where I have stored the files.

Some faces I remember, of course: some people have a way of welding their identity onto the shelf -forever distinct, immutably present and on display. They are the caffeine of memory, but like dessert, uncommon at most meals.

Now I have to admit that most people are interesting, and all are distinctive -or seem so- at the time. Even the most obnoxious patient sows her seeds; recollection depends not so much on the quantity as the quality of the experience. And it may not be a two-way street. We all walk at different speeds, and touch with different skin. We may hold our expectations in common -there are some universals that seem self-evident- but our perceptions are uniquely our own. We, alone, wear them, feel them, live them… They are why we take home different messages -patient and doctor. They are what individuate us. Separate us…

But I would still love to return the unsolicited smile of remembrance with a look of wide-eyed honesty.  I need a book somewhere inside with a specially marked page that I could read and interpret quickly enough to make it seem that her face was never stored in the bottom of some pile; that she, at least, was special. Unforgettable.

But my guilt shines through each time I pass; I hope they understand I don’t mean to forget. But oh, it presses to my memory, Like damnèd guilty deeds to sinners’ minds –Shakespeare understood, I think… Even if I’ve forgotten the context.