Tag Archives: Pap smear

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A Flicker of Hope

It’s interesting what catches our attention when we surf the apps on our smartphones nowadays. Some of the more provocative articles have dubious sources, of course, but with a little digging the original study can often be found and the claims checked. The problem, however, is that even these results need to be reproducible in case either the methodology or the results were unreliable –and also the conclusions drawn from them. That’s why it’s often unwise to believe everything you see reported –or, on the other side, to report everything you want to believe… Fear and Hope are wonderful incentives, and so the issues in the study need to be thoroughly researched and vetted for bias and innuendo and references to the original study need to be included.

Perhaps because I am now retired, any article about time-related changes catches my eye more easily. So I find myself particularly interested in studies that suggest progress is being made -not with respect to age itself, but more the evolving process of aging: the gerund. It was with considerable interest that I read the BBC news on the use of flashing light therapy for Alzheimer’s http://www.bbc.com/news/health-38220670

I also attempted to read the original paper from MIT (entitled Gamma frequency entrainment attenuates amyloid load and modifies microglia) published in the December 2016  issue, of the journal Nature should you wish to struggle though it, but I have to confess that for me, even the title was difficult…

At any rate, the article suggested that flashing light in the eyes of mice that were genetically engineered to have Alzheimer’s-type damage in their brain, ‘encouraged protective cells to gobble up the harmful proteins that accumulate in the brain in this type of dementia. The perfect rate of flashes was 40 per second – a barely perceptible flicker, four times as fast as a disco strobe.’ And ‘Build-up of beta amyloid protein is one of the earliest changes seen in the brain in Alzheimer’s disease. It clumps together to form sticky plaques and is thought to cause nerve cell death and memory loss.’ Research has focused on ways to prevent this plaque formation using drugs, but with limited success so far. If a non-invasive method like a flickering light can activate the immune system to do it by itself, so much the better. ‘The researchers say the light works by recruiting the help of resident immune cells called microglia. Microglia are scavengers. They eat and clear harmful or threatening pathogens -in this instance, beta amyloid. It is hoped that clearing beta amyloid and stopping more plaques from forming could halt Alzheimer’s and its symptoms.’ Fine with me.

I did, however, initially wonder about how bothersome the flickering would be –news reports on television usually caution their audience whenever even flash photography is found in the report, presumably because of the risk of triggering epileptic seizures. But, as the article discussed: ‘For the patient, it should be entirely painless and non-invasive “We can use a very low intensity, very ambient soft light. You can hardly see the flicker itself. The set-up is not offensive at all,” they said, stressing it should be safe and would not trigger epilepsy in people who were susceptible.’ Better and better! It’s just preliminary stuff, of course, but at least it opens up new pathways and ideas for further research.

As if even reading about the concept was in itself therapeutic, the article immediately triggered what, at first blush, would seem to be a non-sequitur memory of a patient I saw many years ago. The issue as I recall was not so much about mental aberration -although the patient herself was apparently suffering from paranoid schizophrenia- but more about her speculation on the possible effects of flickering light on mental function.

I was, I think, in my first year of residency training in the gynaecology program and was doing a rotation in one of the older teaching hospitals in the city. In those days, things were very busy on the wards and so our tasks were apportioned according to our seniority, the senior residents doing the lion’s share of new consultations, while we juniors were given those jobs that, while important, required less experience -pap smears, usually.

My senior’s name was Sara, I remember, and she decided I should be the one to go to the psychiatric ward to do a pap smear on one of their more ‘unusual patients’ as she said to tease me.

“What do you mean ‘unusual’?” I asked. Sara didn’t like to go onto that ward, for some reason, so she usually made some excuse.

She stared at me for a moment before answering, I remember. “Oh, you know, she has paranoid delusions and hallucinates, or something…” But it was clear that Sara really had no idea why our department had been asked to do the pap, nor had she any intention of doing it herself.

I was beginning to suspect this was merely another sluff. Sara fancied herself a consultant now and able to delegate things she didn’t want to do. “But if she’s paranoid and hallucinates, wouldn’t it be better if the doctor doing the pap smear was female?”

Her expression turned angry at that point, and I recall her almost attacking me with her eyes. “Oh for god’s sake, there’ll be a nurse there with you the whole time… Or maybe they said two…” she added, uncertainty softening her glare, but not her resolve to send me to that ward.

I showed up at the psychiatric area and was allowed in only after identifying myself via the phone just outside the door. Then I was led to the brightly lit nursing station, and a rather large matronly nurse handed me the chart of the woman needing the pap.

“She hasn’t had a pap smear in years,” the nurse said in a soft voice, so it couldn’t be heard in the corridor outside of the station. “And her voices told her she has cervix cancer…”

“Her voices?” I should have been more professional, but I was already feeling a bit apprehensive about being inside a locked ward. “I mean, shouldn’t we wait until she’s feeling a bit better before we…”

“We can’t seem to find any good medication for her yet,” the nurse interrupted. “The doctor thought that we could at least calm her by checking her cervix.”

Greta –I still remember her name- was already in the examination room, sitting in her gown on a little table that had a set of rickety old metal stirrups at one end. They’d apparently had to borrow everything from another ward for the job. As soon as I entered with the nurse, Greta examined me from top to bottom with suspicious eyes.

“You’re a man,” she said before we were even introduced.

The nurse, whose name I forget, walked over to Greta and held her hand. “You remember we talked about this, Greta,” she said in the same soft voice she’d used before. “And you said it was okay…”

Greta nodded, smiled and lay back to put her feet in the stirrups. “They said I should show you my cervix,” she said, the italics staring at me between her knees. “Not the one with cancer, though…  I’m supposed to keep that one hidden.”

“Her voices,” the nurse quickly whispered in my ear as I sat on a little stool they’d also borrowed for the occasion along with a light on a long, flexible metal pole. It looked as old as the stirrups.

I got the speculum and the pap smear paraphernalia ready as the nurse readied the light. The bulb kept flickering, though. I fiddled with the bulb to see if it was loose, but it seemed tight enough. And it was obviously plugged into the wall. On, off, on, off… the light was beginning to annoy me. I snapped the switch a few times, but still, it insisted on flickering. On, off, on, off…

“I’ve got a flashlight,” the nurse said, but when she turned it on, it was so weak, I knew I wouldn’t be able to see cervix high up in the vagina with it.

“Well, maybe I can do the pap smear with the flickering light,” I said and shrugged.

Suddenly Greta raised her head and stared at me again. “Sometimes the prongs don’t make good contact in the wall. Everything’s so old in this place,” she added, shaking her head. “Take the plug out and squeeze the prongs.”

By this time I had the speculum in my hand, so I nodded to the nurse to try Greta’s suggestion. Sure enough, squeezing the prongs stopped the flickering.

Greta was still staring at me through her legs. “I may be crazy, doctor, but I’m not stupid…”

I put the speculum down on the medical tray I had on my lap. I sensed Greta wanted to explain something. “It’s a signal, you know.” I didn’t think I should reply. “The light’s always trying to tell you something –sometimes it’s angry, but more often it’s just trying to help…” Her feet still in the stirrups, she raised herself onto one elbow and continued. “It gets right into the brain to help, you know. It doesn’t stay there long enough, though, and that’s why it has to keep going in and out, in and out… And each time it tries, it flickers…” Then she stopped talking for a moment and stared at the nurse with an amazed expression on her face. “That’s what the doctors should be trying –not all those horrible pills…”

Maybe that incident stands out because it was the first pap smear I’d ever done. I don’t remember the result in Greta’s case –I was near the end of my rotation in that hospital- but I do remember Sara asking me what I’d done with that patient.

“Why?” I asked, afraid Greta had accused me of doing something improper.

“The ward told me that your patient seemed much calmer after you left and she apparently kept telling everybody you’d come up with a new treatment, or something…” And then I remember Sara smiling condescendingly at me, as if to say that junior residents could never do anything of the sort.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The Slow Cooker

Dare I comment on the speculum?

It is a very underrated item, when you think about it – I mean, if you think about it… Uhmm, considering its job and everything… Ask any gynaecologist. Like shoes, one size does not fit all. In fact, continuing the analogy, there are many shapes and designs: long ones, short ones, wide ones, thin ones, metal ones, disposable plastic ones… And of course, uncomfortable ones that seek to transcend all categories.

Some doctors seem to specialize in one type or another, oblivious it would seem, to basic engineering mechanics, acolytes of the school where Function is a slave to Need –unchanged, some would say, from the glory days of Papanicolau where just seeing the cervix was deemed a success. Old habits die hard though, and so the equation is usually solved by asserting that benefits are worth two times more than discomforts. A handy, if unnecessary, deception if only because it is a justification rather than an explanation. A deafness -another barrier which does not encourage compliance except, as with some dentists, in extremis.

But I like to think that I have a specular selection from which I can choose the least uncomfortable member and am quick to point out that I have endeavoured to match Size to Need rather than the first item I happen upon in the drawer.

I long ago abandoned the disposable plastic speculum in favour of their autoclaveable metallic parents largely because of the greater selection of styles to minimize discomfort. True, never having had to endure what for some must be an unwelcome embarrassment, I nevertheless hope I am sensitive to the anticipatory dread that a gynaecological visit must engender. And I am a male; I would have nightmares…

But for all its putative advantages, there is one major downside to metal when compared to plastic: temperature. More specifically, temperature difference. I do not pretend to understand the physics of why they are always cold but personally, I suspect the First Law of Thermodynamics as defined by Wickipedia: The increase in internal energy of a closed system is equal to the heat supplied to the system minus work done by it. Think about it. The speculum is usually closed while it is in the drawer -and I must confess I do not heat my drawers- and of course its not doing any work in there either… An icicle just waiting for an opportunity.

So for years I have depended upon the hot water faucet in the sink to warm up my choice of speculum; unfortunately I am several floors distant from the boiler so running the water is usually interminable and makes us both uncomfortably aware of our respective bladders. No, the tap is not the answer. But I am a gynaecologist, not a plumber.

I used to joke about my inadequacies and I was getting quite good at innovative excuses. Too good: laughter may assuage anxieties and diffuse tensions, but it slowly and inevitably becomes too valuable an excuse to abandon. Especially when no other solution presents itself.

But although I may not be an engineer, nor a thermodynamicist, some of my patients are. Okay, one of them is.

One winter, when pipes were freezing everywhere in the city, a pregnant patient and I were forced to endure a spectacularly long faucet session. It was the beginning of her third pregnancy and I needed to do a Pap smear. Pregnancy, however, does not easily admit of prolonged personal water storage, and so after a few minutes she was becoming visibly agitated with the wait.

“For god’s sake, doctor, why don’t you just use a cold clamp and get on with it?”

I smiled and walked over to the drawer in the examination table and pulled out a speculum. “Here’s why,” I said, letting the ice cold device touch her leg. “And it’s called a speculum, not a clamp…”

“Should be called a specicle,” she said and giggled, careful not to attract the attention of her already disquieted bladder. Then she sat up suddenly and asked me to leave the room while she got dressed again.

After I went into my office and busied myself with paperwork, the roil of tap water suddenly stopped and I could hear doors opening and closing, and bare feet slapping hurriedly along the corridor leading to the waiting room. After a few minutes she reappeared and sat down across from my desk looking dishevelled, but relieved.

“You have to do something about this,” she said, her lips trying valiantly to smile through her blushing cheeks. “It was the same in the last pregnancy…” She considered it for a moment. “No, I think you were actually able to get the thing warm before I had to leave…”

“It was summer then,” I added after riffling around in her chart for a moment. “But you’re right,” I said trying to put on a professional face. “Maybe I should keep a kettle on the boil in there…”

Her eyes actually enlarged when I said that so I shrugged to diffuse the suggestion.

As a result, the large eyes rolled and the barest hint of teeth surfaced for a second. “What we’re aiming for is warmth, doctor. Tepidity. Not tea.”

Tepidity? I rather liked that word and vowed to try to slip it into a conversation some day. “Well, you’re a mechanical engineer aren’t you?” For some reason I had written this beside her name on the chart.

She nodded mischievously, the light from my desk lamp glinting in her now narrowed eyes. “You mean like I could apply the Second Law of Thermodynamics to your speculums?”

“I thought it was The First Law…”

“There’s a First Law?” she said and laughed so hard I thought she might have to leave again.

*

And then, as time passed, I forgot about specifics and reverted to humour to deal with the inevitable delays in warming the instruments. Forgot, that is, until almost a year later when she arrived for the first visit after her baby had arrived.

After the usual peek at the inconsolably crying baby her worried husband was carrying, the somewhat belated congratulations and then apologies for not being on call for the birth, and her assurance that all had gone exceptionally well, she sat back in her seat. Almost smugly, I thought.

I scanned her chart for a moment. “We never did do the…”

“The Pap smear,” she said, interrupting me as if she’d been waiting all along for me to bring up the subject.

Suddenly I remembered. “Do you want to visit the washroom now? Before I turn on the hot water, I mean?”

She shook her head and glanced at her husband. “I’m fine, thank you.” But her face lingered on him when he stayed sitting. The baby was quiet now, so I thought maybe she was just silently congratulating him. “I think Jennifer needs changing. Is it okay if we change her in the examination room, doctor? Now they were both smiling.

“Of course,” I replied. “Just let me know when you’re ready and I’ll come in.”

They disappeared into the other room wheeling the baby carriage with all their supplies, and closed the door. It is a rather thin structure, the door, and I could hear them whispering and giggling; the baby seemed to be sleeping through the procedure. Amazing.

“You can come in now,” she said after a few minutes in a too-loud voice -the voice of a child who has just hidden some cookie crumbs under the table.

I opened the door and saw her husband sitting quietly on the little chair I keep in the room. I could see the baby fast asleep in her stroller and the mother sitting on the edge of the examining table. There wasn’t much room in there at the best of times, and with the husband, the baby and the carriage, it was like being in a crowded elevator.

I smiled at her and headed for the sink to turn on the hot water.

But I had to thread my way past husband and stroller so before I could make it to the sink she said, “You know I was thinking about it after my little problem with that last Pap smear…” I stopped and turned to her. “I think it was the First Law after all…”

It took a moment for it to sink in. “Ahh, you mean the temperature of the speculums.” She nodded. “Well, it was just a guess,” I said modestly, and meaning it.

“So, I thought I’d correct that and actually apply the Second Law.”

“Uhmm…”

“Closed system,” she said and laughed, pointing to the sink.

Her husband leaned back so I could see more of the counter. And there, proud as Punch, was a Slow Cooker -a Crock Pot- plugged in and partially full of water. There was even a speculum in it.

“Water’s probably not at the correct body temperature yet…” she said and smiled. “But it’ll do for now.”

I walked over to the counter and dipped my finger into the water, speechless for a moment. And then it came to me: “Not quite the correct degree of tepidity, you mean?”

I could see her smiling; she knew it was her word. “I mean, I don’t want to see a kettle in here,” she said and settled back on the table.

 

 

 

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Critical Thinking and Bullying

A few weeks ago, a young woman came in to see me to have her first Pap smear. While I was taking a routine sexual history, she admitted she had recently been bullied online. I’m not even sure how the topic came up, but she didn’t seem very upset, so I asked her about it.

“The guy was a real dick,” she said. And when I asked her how she reacted, she merely shrugged. “Everything he said was false and all my friends should know that… So I ignored him.”

“And did he try it again?” I admired her reaction, but I have to admit I was curious.

She liberated a beautiful smile and shrugged mischievously. “Yeah, once… But then I guess he gave up.” She allowed her eyes to roll upwards comically. “My mother always told me to ignore stuff that wasn’t true.”

It got me thinking about why some people are able to withstand that kind of thing, while others succumb. I don’t pretend to know what motivates bullying, but I do suspect my patient was taught an effective remedy from an early age.

Critical thinking is a way of examining a statement or assertion in order to understand the background and motivating factors for its existence. Its credentials, in other words. It is a way of distancing oneself from the message and analysing everything that went into making it before either accepting or rejecting its content. Also, it is a way of avoiding confirmation bias –reading or assessing only those issues with which one already agrees, rather than sampling a variety of views and thinking of them as interesting, but as yet unproven assertions.

In important ways, this is what Science does: everything is open to checking and possible refutation. Nothing is spared re-examination. Carl Popper, the philosopher of science, suggested that an assertion, a theory, must be worded in such a way that it is testable, otherwise it can not be generalized -or as he would put it, it can only be considered scientifically valid if it is falsifiable- ie checkable. Anything else is merely an opinion -as, for example, the statement ‘Red is the most beautiful colour’. It is not testable, and therefore certainly neither provable nor undeniably valid. This is the first simple rule of thumb we can teach: we must help children to parse input.

Young children tend to question everything- it is how they learn. But in the very young –under, say, six or seven years of age- they often use magical thinking: cause and effect are not necessarily demonstrable either by reason, or even observation. Past that age, however, they begin to understand agency. Causal chains. It is a good time to introduce the concept of validity: was something really a result of an action, or was the action merely associated in time or location so as to seem to have influenced it? And although this is a good first start it is nonetheless one that is not necessarily intuitive. For example it would be tempting to assume that a boy running past a crying girl had done something to her -it might fit with a previous experience. But maybe he was running to catch a bus and it was a coincidence that the two were in the same area at the time she was crying… It requires more proof. More examination.

The habit of questioning things before accepting them can be taught. It can be made into a reflex before reacting. But it needs to be developed early, before the temptation to interpret hastily, or even reciprocate mindlessly, has become entrenched.

The basic elements of simple logic can be taught. For example with inductive reasoning, one attempts to generalize from observations. So if all the crows you have ever seen were black, then you might conclude that all crows are black… Until somebody sees a white crow that is… It is falsifiable, in other words. Most taunts are of that variety -and with practice, easily refuted.

Or even with deductive reasoning which works the other way -from the general to the particular: All men are mortal; Socrates is a man; therefore Socrates is mortal -the classical example. But it only works if the premise is valid (ie. that all men are mortal). And it may only be somebody’s opinion that it is valid…Once again, is it like that example of red being the most beautiful colour? We can all be taught to analyse things like this. We can all be taught to be wary of unsubstantiated statements. Rumours. Gossip. Taunts…

And the critical thinking approach can even apply to actions as well as assertions. A simple example: a young girl is hit by a snowball and another child, a boy, is standing nearby in a group of boys and staring at her. Was he to blame? Did he throw it? Maybe, but without further analysis, further investigation, there’s no proof. No reason to jump to a conclusion. Why did she think it was him? Is her reason based on anger, or is it justified..? This is the basis for the idea that a person is innocent until proven guilty… It is an important concept to inculcate in the growing mind. It is a way of distancing oneself from the action, no matter how provocative, and setting it aside until it has been analysed further. We all judge input, we all react to issues we encounter. And some things do require an immediate response. But it’s how we come to the judgement, how we analyse the data –how we react- that is critical.

You can see where this is leading I suspect: bullying. Bullying -whether on the playground or online, whether by deed or word- has the advantage of unfair leverage only if the process is unexamined. Only if the person being assailed is not used to subjecting taunts to the same questioning. Stepping back, if only momentarily, and processing the information. Checking it. Falsifying it. Refuting it -like my patient was able to do.

A difficult thing to do in the moment, for sure. But without any experience in dissecting assertions –deconstructing them, as PhD candidates are fond of saying- there are only reactive emotions. Victimization. Loss of self esteem that could and should withstand the storm. Self esteem, after all, is partly based on one’s ability to see oneself as in control.

As in mathematics and science, critical thinking is a valuable tool for assessing what we experience in the world. It helps us to parse what we read, what we’re told, what we think… It brings perspective to the unexpected, the hostile and the just plain annoying. It can and should be taught from grade school onwards, building on the simpler examples from year to year –class to class. Younger children may not understand the complexities of the Scientific Method, nor what Popper was on about, but with patience and persistence they will.

They deserve the chance…