Scientific Gynaecology

Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

The Art of Medicine

The purpose of art is washing the dust of daily life off our souls’, as Picasso said. I suppose he was on to something there, but I rather fancy Francis Bacon’s take on it: ‘The job of the artist is always to deepen the mystery’. The reproductions that hang on the walls of my office have certainly deepened mine –well, to be accurate, more the patients who comment on them.

Of course not all of my visitors even look at the walls; they’re often too fixated on describing their symptoms, and watching for my reaction. Trust is awarded or subtracted in the first few moments of an interview of course, but once the merit badges have been allotted, and rank assigned, their eyes often wander to more interesting things. For some reason, I can’t seem to monopolize their attention once they have decided to relax. But, of course, art is therapeutic as well -although perhaps less helpful for most gynaecologic conditions than some more hopeful alternative practitioners might wish.

And yet it does provide a certain continuity that my more regular customers seem to appreciate. Some of them have developed unusual affinities for, say, a certain painting hanging on a particular wall. Or the smile of a character in a photograph… I’d like to think that it is actually a recognition of my taste in art, my ability to select soothing yet interesting subjects that reflect my own philosophy of life. In fact, I think Janet, one of my more perceptive patients, described it best. She was biding her time as I struggled to fill out some laboratory forms for her. And to stay awake I suppose, she began to look around the office. I glanced up once, after trying unsuccessfully to correct an egregious mistake on the screen, and saw a puzzled expression writing itself on her face. When she noticed my attention, she immediately erased any traces of concern and replaced them with those of a frustrated teacher.

And then, when she saw my eyebrows raised inquisitively, she blushed as if caught in some secret and embarrassing act. “You certainly have a…” There was a moment’s hesitation as she rummaged desperately for a more neutral word than she was about to utter. “…An eclectic taste in art…” Her eyes inadvertently strayed back to a reproduction that I’d hung on one wall. It depicted two young girls standing side by side looking in opposite directions while only partially covered by some sort of blanket or quilt. Their faces were beautiful, although one looked a bit worried about something. I saw it as, I don’t know, youthful hope, or maybe the puzzle of growing up.

“I was just thinking of an art gallery,” she said, trying to smile -and yet I could almost see the ‘buts’ slinking in the shadows behind her eyes. I sat back, hoping for a compliment. Redemption. “But, you know…” Her eyes darted from one picture to the next like sparrows looking for a roost. “…They don’t seem to illustrate any particular theme. Nothing connects one to another…” She focused her attention on a large photograph of a man holding a baby and indicated her target with a nod of her head. “I mean, you have a man with a baby in this one –nice photograph, I suppose- but then, on the wall behind me, there’s the coloured line drawing of a peasant woman leading a horse…”

I’d never experienced a critique of my art before and I didn’t know whether to feel honoured, amused, or embarrassed. I chose embarrassed. “I…ahh… Well, they just seem to accumulate over the years. I mean, I didn’t choose them to illustrate a particular theme, or anything…”

Her face believed me, and her smile tried to plaster over any unpleasant criticism. It tried to exculpate me from my tasteless choices. Her eyes, however, no longer sparrows, were birds of prey and I could see her fighting with her need to be honest and yet not cast aspersions on me. On my world. On my ability to be her doctor.

“Maybe move the Woman with the Horse to the examining room and the…” She suddenly had second thoughts. “No, I don’t think the IUD picture would be suitable in here…” She closed her eyes for a moment, trying to reconfigure things in her head. “I like the smiling woman –it’s a Rosamund isn’t it?”

The drawing was on a far wall and I had to squint to see the signature. I couldn’t quite make it out, so I was forced to shrug. I mean, who looks at signatures?

“What about that green apple picture hanging in the hall..?” It was amazing how much she’d noticed. “No, actually it adds a light touch to the corridor –sets a mood, as it were.” Her eyes alighted briefly on one of my diplomas, flitted to me, then on to her lap when she saw me watching. I could see her trying to disguise a sigh. She was not successful.

She’d told me she’d come for a consultation on the menopause and yet she was aggressively adamant that she was coping perfectly well with The Change  -and she continued to insist this even under what I thought was careful questioning. Apart from a recent and bitter divorce, things were completely under control -better than they’d ever been, in fact. I glanced at my computer screen again, and then accidentally refreshed it, for some reason. There was now a note that my secretary had just added to the referral letter section -her doctor had faxed the information to me a few minutes before before. Janet had requested a second opinion when her GP had suggested she might need to go on hormone replacement therapy for her menopausal symptoms. She’d become enraged at his lack of judgement and his inability to keep up with the current medical literature. She wanted –no, demanded– to see someone who wouldn’t judge her on insufficient evidence and wouldn’t assume that her every foible was attributable to insufficient hormones. Apparently she’d suggested that he needed them more than she did. And he’d assumed she would neither give me an accurate history nor deliver the note he’d written.

She saw me scrutinizing the screen as I started scrolling through it, and a mischievous smile captured her immediately. “Still can’t find his referral letter?” she asked, with what was another uncamouflaged smirk after one more quick look around the room. “He gave me a hand-written letter in a sealed envelope for you…” I studied her expectantly when she decided to prolong the suspense; she was not a happy woman and I fully expected her to unleash the eyes again. “I don’t think he has a computer; and anyway I threw the letter away,” she added in answer to my unspoken question. “I read it, of course, but it was all nonsense.” Her lips parted slightly in what was either a broken grin, or more likely, a sneer. I could see her hands tighten into fists in her lap. “Never trusted the man,” she said, looking again at the two little girls in the picture. “No taste.” She turned to look at the Woman and the Horse on the wall behind her and then sighed loudly.Theatrically -no attempt at a disguise…“Unlike you…”

We both laughed, but I’m not sure at what. Or at whom…

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”

 

Why do we Know something?

Knowledge is interesting. But what is it, exactly? What does it mean to say you know something? Plato defined it as being justified true belief, but is it? Take Bertrand Russel’s famous thought experiment: the ‘stopped clock case’, for example. Alice looks at a clock and says it is two o’clock. Well, because the clock does indeed confirm that it is two o’clock, it seems justified; and because it is, in reality, two o’clock, it also seems a true belief. She could therefore be said to know that it is two o’clock… But, unknown to Alice, the clock had actually stopped working exactly 12 hours previously, so did she know that it was two o’clock? Or was it a fortuitous guess and not knowledge?

All this is a little out of my comfort zone to say the least, so I’m not even going to attempt straying into such philosophical realms as the ‘Gettier Problem’ (whether something that happens to be true but is believed, as with Alice, for incorrect or flawed reasons should be counted as knowledge). It is truly thought-provoking, though, isn’t it?

But Knowledge is not just a list of facts that happen to be true –whatever truth is- nor a compilation of disparate evidentiary items. It is not only an encyclopedia, it is a diary as well: the story of why it exists. There is often a purpose to it –or at least in its acquisition there may have been a reason, even if you stumbled upon it by accident.

In other words, there is another way of approaching the concept of knowledge other than how we know something to be true –the Scientific Method, for example- and that is why we know it. And I don’t mean to stir the lid of Pandora’s box with the ‘why question’, nor to intimate some sort of heterodox Creationist linkage, but merely to introduce something that I learned from a patient a few years back -a professor of philosophy at one of the local universities.

Nancy was a thin, forty-seven year old woman who had been sent to me for a recent episode of irregular menstrual bleeding. She was otherwise healthy and somewhat embarrassed at having to see me for something her mother and aunt had managed to work through without having to seek medical advice. Her family doctor had ordered an ultrasound of the pelvis and it had not revealed anything suspicious. In fact it had stated that no abnormalities had been seen to explain the bleeding.

I suggested it would be a good idea to sample the uterine cells with an office endometrial biopsy as a final reassurance that nothing had been missed. But I could see that she was uncomfortable with the idea.

“What are you hoping an endometrial biopsy will find, doctor?” she said suspiciously.

“Actually, I’m hoping to find nothing,” I said in my best, confident voice. “The ultrasound didn’t see anything to worry about…”

An eyebrow slowly crawled up one side of her forehead. “I realize that; my GP showed me the result.” The other eyebrow shot up to join its sister. “So… Why would you want to do a biopsy?”

I get asked this a lot. “Well, the ultrasound is not a microscope. It can’t tell anything about the type of cells that are in there.” She still looked unconvinced, I have to say, so I pulled out another of my usual analogies. “I suppose it’s something like trying to make a diagnosis from a shadow. You can guess a person’s height and perhaps her weight from her shadow, but even if you could tell she had long hair, you would have no idea of its colour. Nor would you know anything about her heart.”

Nancy was quiet for a moment, obviously thinking it through. I could tell from her face that she thought it was a rather clumsy explanation -not well conceived, and not terribly illustrative of her problem. “So,” she finally said, looking up at the ceiling for help, “The ultrasound is normal, the blood tests my GP did suggest I’m in the menopausal transition now, the abnormal bleeding only occurred in one menstrual cycle a few months ago, and I’ve been doing well since then…” She dropped her eyes onto my face and left them hovering there for a moment as she shook her head. “Tell me again why you think a biopsy would be a good idea.”

I have to admit that when she put it like that I had second thoughts, but nevertheless I pushed on, regardless. Was I just trying to save face, or was there truly a principle at stake? “Well… clearly there are different ways of approaching your bleeding… But if we do the biopsy, and it is normal, then at the very least we will have a baseline that reassures us that if it happens again in the near future, we can probably assume the cells are still normal…”

Nancy was good; she could read the hesitation in my voice. She smiled gracefully, but it was a polite smile. “Wouldn’t it make equally good sense to wait and see if it starts to happen more frequently and then do the biopsy?”

She had me. “Yes, I suppose that is an equally acceptable option.”

She sat back in her chair, crossed her legs, folded her arms across her chest and stared at me –not unkindly, not aggressively, but curiously, like a mother might watch a mischievous child. “I won’t ask you how you came to that conclusion, or how you know that a biopsy might be justified. Those are all fairly standard medical teachings, as I understand…” Her face wrinkled in concern. “But I’d be curious as to why you know that.”

I returned her stare. Why I knew that? Why does anybody know something? Because they read it, or were taught it, or figured it out… Why indeed?

“We all have options in our learning,” she continued. “There are many opinions to which we are exposed, rival paradigms, competing theories. And they all promise success; they all answer the questions differently. Like a hundred people crossing a single bridge, it’s not the same bridge for any of them. It’s a hundred bridges…”

Her face softened, like a teacher that realizes she has confused her pupil. “From all that reality has to offer, we have to decide what to privilege. There are just too many routes to the truth to take them all. We have to choose…

“But why do we choose one view, one approach instead of another? That’s what I’m asking.” She sighed, as if even the question, let alone the answer to it, was hopeless. “Why do you know one thing and not something else?”

Her question still troubles me. I had no answer for her then; nor do I now. I still wallow in the permutations and combinations of perpectives I confront daily and wonder how I manage to choose my direction without getting lost. Maybe it’s a confirmation bias: I have come to believe in the correctness of a particular viewpoint over the years and so only consider the evidence that confirms it. The diagnosis that points that way. And if the results don’t justify the approach? Well, there’s always rationalization to light the path I’ve chosen.

But do I really know why I know what I do, believe what I believe, think what I think? No, not so far… and yet the fact that I’m even aware of the discrepancy, and see the signs to other roads, is a good start isn’t it? As Marcel Proust wrote: The real voyage of discovery consists not in seeking new lands but seeing with new eyes.

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.

The Tail and the Dog: Cause and Effect in Medicine

Does the tail ever wag the dog? Is an issue ever so compelling that cause and effect are reversed? Or at least suspended..? Sorry, I wonder about such things.

I remember reading a book many years ago by the British philospher A.J. Ayer called The Problem of Knowledge. In it he discusses a religious sect that believed its members were either born to go to heaven or born to go to hell. They spend their lives assuming and acting as if they were in the Heaven group, no doubt hoping to influence how they were born -the future influencing the past when you think about it. Effect influencing Cause. The very idea intrigued my teenage brain but I was unable to replicate the switch no matter how I tried. No matter the subterfuge, no matter the wording of the premise, I still ended up with a faulty syllogism.

But my misgivings have decreased in the intervening years and although I’ve never met a member of that sect, I believe I have encountered situations with eerie similarities. Disturbing parallels.

*

“I don’t think you’re really listening to me, doctor,” said the thin, immaculately coifed woman sitting across the desk from me. She’d been talking without interruption for five minutes or so. Sixty-five, and well into her menopause, she had short, greying hair, and a severe, noticeably-wrinkled face. She stared at me as if I had just insulted her and I could see her pale bony hands forming fists and silently massaging her lap as she spoke.

I’d just met her and was trying to understand why she’d been referred to me. “I’m sorry,” I said with a smile. “I was just trying to get a more complete history…”

“I’ve told you the relevent history doctor,” she interrupted impatiently. “You have to learn to listen!” I could tell she was deliberately italicizing words. The sigh that I tried to disguise did not go unnoticed, however, and her eyes sharpened like knife blades and attacked my face. “My doctor assured me you would listen to me.” She sounded almost petulant.

“Well perhaps I was too focussed on background details,” I said to mollify her, then sat back in my chair to indicate that I was, indeed, listening now.

“I have cancer, doctor. Nobody can find it, but I know its there as surely as I know this desk is hard.”

I kept my expression neutral and nodded for her to go on and explain things yet again.

“My sister died from squamous cancer of the cervix and my mother died of adenocarcinoma of the stomach,” she said, the terms obviously well-rehearsed. “And my uncle had some other kind of cancer that nobody could find until he died…”

That was certainly a lot of cancers I had to admit, but I couldn’t think of any obvious connecting factors. Stomach and skin derive from different tissues embryologically but the cervix cancer was almost certainly related to HPV –a sexually transmitted virus. And she didn’t know what type of cancer had killed her uncle.

Apparently satisfied that she had made her point, she straightened up in her chair and folded her arms tightly across her chest.

I nodded my head to encourage her to continue, but she merely slashed at me with her eyes, the skin of her face now tied so tightly I wondered if it would tear. I could see she was challenging me to contradict her. I managed a little smile but I didn’t really feel like it. “What makes you so certain you have cancer, Emily?” I thought maybe using her name might soften her face. “Is it the family history of so many cancers, or some symptoms you are experiencing?”

That seemed to catch her off guard and she unlocked her arms so her hands could wander back onto her lap. “It’s more of a feeling, doctor; it’s hard to explain.”

I sighed audibly and studied her face. It had gradually lost its anger and the skin seemed looser, older. She looked fragile now. Frightened. “Let me see what tests your doctor has done so far…”

“They’re all normal,” she said softly before I could even look at the referral letter. “I’ve been pestering my doctor for several years about my concern…” Emily looked almost embarrassed. “She did both abdominal and pelvic ultrasounds because I told her I was having pain. Then she did a whole bunch of blood tests to check my liver and kidney function but nothing showed up.” She stared at her hands for a moment. “I even convinced her to do a CAT scan of my head…” She looked up at me with a shy little smile hovering about her lips. “Headaches,” she said to ward off a question she could tell I was about to ask. And then she buried her eyes in her lap again. I could almost see her trying to think of something to convince me to keep searching.

“I’m tired all the time and I’ve been losing weight…” But even she didn’t seem convinced. Sad, burrowing eyes peeked out at me from behind deep ridges of skin that had come out of hiding as her anger dissolved. She chuckled half-heartedly. “I’m becoming so neurotic about this that sometimes I wonder if I’m creating a lot of these things out of whole cloth…” Her face brightened at the idiom.

Then she shook her head slowly. “You know, my cancer is almost like a religion: you have to take some of the tenets on faith alone. They don’t make sense, and you’d rather just ignore them, but something makes you go on. You still believe, because there’s something to it, something you suspect is true, even if you don’t understand why.”

I’d never thought of undiagnosed illness like that. I looked through the test results I’d been sent, but found nothing suspicious. No clues. Nothing that even suggested a direction for further investigations. Her pap smears were up to date and all normal; she’d  had a colonoscopy and had somehow convinced a gastroenterologist to investigate her stomach and esophagus. And a dermatologist had done some biopsies a couple of years ago because she had a few moles on her arms and legs. “Would you mind if I examined you?” I thought I’d better ask.

She shrugged and shifted in her chair. “You won’t find anything, but yes. You’re my last hope.”

Given the history, I have to say she had no more hope than I did of finding something. Anything. But I did a thorough examination –I took her blood pressure, I listened to her chest and checked her breasts for lumps. I palpated her abdomen for masses and pain. Lymph nodes filter out infections, but sometimes also tumor cells in the process of spreading, so I even felt for the lymph nodes in her groin to see if they were enlarged. People who run frequently have the occasional small lumps in their groins from incidental cuts on their toes, but she had some that were really quite large and painless, and on one side only.

Curious, I asked if she did a lot of running, or if she’d injured her foot or leg recently. She shook her head. “Do I look like a runner, doctor?” She had a point.

I was puzzled by the lumps, so I redoubled my search for an explanation. What had caused them? The only thing I could find, after doing the usual gynaecological examination, was a multicoloured, dark mole hidden in a labial fold near her vagina. It was on the same side as the lumps.

I finished my examination and asked her to come into the other room when she’d dressed.

“Did anybody mention they’d seen a mole near your vagina?” I asked, when she returned.

She shook her head. “I have moles everywhere,” she said, rolling a sleeve of her sweater past her elbow and showing me her arm. “I think everybody has been more focussed on my cervix because of my sister.” She couldn’t help smiling. “Even my GP just whips a speculum in whenever she’s in the area.”

“What about the dermatologist you saw?”

She chuckled. “He wouldn’t go anywhere near there.” Suddenly she stopped talking and looked at me. “Why? Is there a problem? The other moles were just benign nevi…” She had obviously been reading about her diagnoses.

“It’s an unusual place for a mole,” I said, somewhat hesitantly. “I think it should be removed.”

She studied me for a moment, nodded her head slowly, purposely, while the skin on her face tightened and then relaxed. Her eyes softened and she reached across the desk to grasp my hand.

“Thank you, doctor.”

I must have looked puzzled, because the smile on her face broadened in response.

“All these years…” she said, slowly, softly, and almost to herself. “I knew there was something; I just didn’t know where.”

“But…” I hadn’t even mentioned my concern about malignancy in the mole. If anything, I hoped I’d underplayed it so she wouldn’t panic.

She squeezed my hand. “I’d rather be on a path –any path- than wander around, lost.” She sat back in her chair, almost satisfied at the turn of events. “Our remedies oft in ourselves do lie, which we ascribe to Heaven.”

Wow: All’s Well That Ends Well. I wonder if she’d memorized that for just such an occasion. Perhaps she felt that discovery was tantamount to remedy for her… Vindication. Validation. I also wonder if Ayer would have understood.

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.”