The Problem of Puberty

Puberty is alchemy, don’t you think? Like the chrysalis of a butterfly, the girl emerges from the pupal case of her childhood into an adolescent -an almost-woman- with hormones ablaze. It is a magic time of change, both in growth and physiology, but also in cognitive development. It is a time of evolving expectations, but more slowly developing judgement –the brain, too, is undergoing renovations. Hence our oft-aggrandized memories of the time –not deceptions, exactly, but distortions. To paraphrase Napoleon: history is the version of past events that I have decided to agree upon.

Many of the manifestations we see of puberty are the confusion of autonomies –the challenges to the boundaries that society imposes. I think Wikipedia has summarized the issues quite succinctly: ‘Psychologists have identified three main types of autonomy: emotional independence, behavioral autonomy, and cognitive autonomy. Emotional autonomy is defined in terms of an adolescent’s relationships with others, and often includes the development of more mature emotional connections with adults and peers. Behavioral autonomy encompasses an adolescent’s developing ability to regulate his or her own behavior, to act on personal decisions, and to self-govern. Cultural differences are especially visible in this category because it concerns issues of dating, social time with peers, and time-management decisions. Cognitive autonomy describes the capacity for an adolescent to partake in processes of independent reasoning and decision-making without excessive reliance on social validation.’ It is obviously a special and bewildering, albeit a magical  time. A time for planting the crop that is to come…

Because there are so many physiological processes involved, the actual start of puberty has always been approximate. Genes no doubt play a major role in its onset, but nutrition and general health are obviously involved as well because puberty is changing –it’s starting earlier. As an article from BBC news reports: The age of puberty is changing around the world. In the UK it is currently starting about one month earlier every decade. In China it is more than four months earlier every decade.

Of course, we have an almost obsessive need to analyze every change –to match every nuance with some overly reductionist, albeit plausible, explanation. Meat, for example. Yes, I’m serious:  Although it’s an older study, and Vegan-unreferenced, I have to wonder if they could have equally successfully used milk consumption, or perhaps eggs, or even Starbucks coffee… 

But whatever the causes of earlier puberty, that very change may have unexpected –and perhaps unwanted- ramifications as the MRC Epidemiology Unit  at the University of Cambridge recently published using the data of almost half a million people from the UK Biobank:

Doesn’t it seem strange that improving health and nutrition could have untoward, unintended consequences, although somewhat removed in time and maturity? Perhaps targetable with preventive interventions to be sure, as the authors point out in their abstract, but nonetheless ironic –the Red Queen needing to run faster and faster to stay in the same spot…

The most convincing evidence of the effect of an earlier puberty, apparently, is in its association with higher risks for type 2 diabetes and cardiovascular disease in women. A simple reasoned path to the type 2 diabetes (and its well known association with obesity) might be that: ‘early childhood rapid growth and overweight precede early puberty timing in both sexes, but in turn early puberty timing leads to subsequent rapid gains in weight and adiposity during adolescence and early adulthood’, but this may be an over-simplification of one of many factors that may be contributing –longer exposure to hormones, say, or life-style decisions altered by earlier maturation than peers: ‘environmental stressors may precede early puberty, but in turn early puberty leads to more risk taking behaviours and poor school performance.’ Intriguing, but speculative to say the least.

And on the more optimistic side of changing pubertal age? Well… there is a trend towards a lower risk for breast cancer in those with a later onset of puberty –although in fairness, this is likely related to a decreased time of exposure to hormones, so I’m not sure if it isn’t just a bit of trade-off… And anyway, trend is often what you call something that is not statistically significant (and yet perhaps lends credence to your hypothesis?).

But are we simply treading water in storm-tossed seas?  At risk of drowning in the details of semi-focused data swirling around us –most of which, at least in this case, was dependent on self reported medical histories and events that happened years before? Admittedly, the age of the first period is probably recalled with fair accuracy by most women –it is an event like few others- but aren’t researchers as seduced by this form of reasoning as the rest of us: the development of diabetes just begging for a scapegoat? So, choose the goat, widen the parameters, and voila…

An illustrative example of how easy it is to be led astray: many years ago, before we knew very much about the causal agent for cancer of the cervix (it is now known to be the human papilloma virus) but had pretty well decided it was something infectious –something sexually transmitted at any rate- the herpes virus came under scrutiny. It was infectious; many women exhibiting it also had abnormal pap smears suggesting precursor lesions for cervix cancer; and it was obvious –women who developed herpes were almost always aware of it. Herpes was easy to blame, because it was fairly straightforward to date the pap smear problem to some time after the event of acquisition. Everything fit –except it was not the cause. Not only did people who had never experienced herpes also develop abnormal pap smears, but similarly, not all people with herpes developed pap smear changes. The recall was an easy data point -something to blame- it’s just that it was the wrong thing.

My point is, it can be misleading to attribute cause merely based on recallable events. We all require explanations -something to blame. But, Post hoc ergo propter hoc? Well, the Latin may sound authoritative but not in Medicine. It is a logical fallacy…

This is all unfair to the study I know; I don’t mean to cast aspersions on either the researchers or their methodology, and yet I can’t help but worry about reports of this kind. Huge data bases are tempting geologies for data mining. But association is not necessarily causation.

As the humorist James Thurber once wrote: ‘Well, if I called the wrong number, why did you answer the phone?’ –just in case, I guess…


The Gyne Weed

I think most of us have a rather Schadenfreude relationship with weeds: on the one hand, they are undesirables, illegal aliens usurping land otherwise dedicated to something useful; but on the other, some of them are quite pretty -even beautiful. Especially in someone else’s garden. Of course it’s all a matter of context, isn’t it? It’s a weed here, but not there -a productive member of one society attempting, uninvited, to switch allegiance to another. In a way, you have to admire their resourcefulness and courage. It must take a lot of self-confidence to show up where you’re not wanted and then make a success of it.

Weeds, however, are not often seen as courageous –quite the opposite: they insinuate themselves into an unsuspecting and vulnerable population and spread dissent. They’re obvious targets for discrimination. Persecution. They are generally regarded as anathema everywhere they go. Period.

I am more ecumenical when it comes to weeds, however. As a male gynaecologist, I too am in foreign soil; I too am a weed. But the idea never occurred to me at the beginning of my career. I thought anybody was welcome to grow there.

And then I met Suzy. I liked her as soon as I saw her in my rather under-populated waiting room. She would have stood out even in a full one. With pig-tailed, red-brown hair, face done up in freckles and a toothy smile, I was immediately reminded of Anne of Green Gables. But she was rather short and plump and was wearing severe black clothes that belied her expression and said ‘Back off’.

And yet we’re all a study in contrasts aren’t we? At that time, I had a mop of long curly brown hair that barely covered the single earring in my left ear. Oh yes, and a reddish beard that fought with the hair for attention. Looking back those many years, I’m surprised the Department even hired me. Equal opportunity stuff, I guess. But I digress.

Suzy did not seem at all surprised when she saw me walking across the empty waiting room to greet her. In fact, she seemed almost relieved at being seen before her appointment time. Well, perhaps ‘curious’ describes it better.

When her eyes interrogated mine for the reason, I muttered something about the last patient not showing up. Actually, the last three had not showed up either, but I wasn’t going to admit that to her. Her eyes then toured my body and flitted back to rest in their little cages, twinkling at their efforts.

“These things happen, doctor,” she said to break the tension, but I could tell she understood.

“So why did you come to see me, Suzy?” I said as she settled down in an uncomfortable wooden chair across from the desk in my office.

This seemed to take her by surprise. It was if there were preliminaries that hadn’t been observed before settling in for business. Like the weather, I suppose –or maybe what she did for a living. “I’m an actress,” she said as if I’d asked the question. I nodded politely and put on a fresh smile to show her I found that interesting. She studied my reaction for a moment and then settled back into the chair as if she could make it more comfortable. “I try to take on roles that challenge me…Challenge Society…” She left the sentence dangling for some reason. “You know, gender stuff…” Another dangle.

“I see,” I said to show that I was listening, but I wasn’t sure why she was telling me this.

“I’m a lesbian,” she suddenly blurted out, and checked my face to see if she had shocked me. It was a time before people were as open and proud of it as they are today.

I have to say I blushed at her honesty, but I wasn’t shocked and she could tell. A huge grin exploded on her face and I could see her snuggle further into the chair. “So, I’ve never had sex with a man…” She stared at me in obvious defiance, and then relaxed into the the smile once more. “But my GP insists I have another pap smear.”

I sat back in my own more comfortable chair and put down my waiting pen. “Did you tell your GP you are a lesbian?”

Her eyebrows shot up. “You kidding?” I sat up straighter. “Our whole family goes to see her. She even delivered my younger brother. So, even though I’m twenty-four, I know she’d tell my parents.” She blinked as if she couldn’t believe my naïveté. My innocence. “We live in a small town, doctor. There’s religion bubbling up everywhere. Serious religion!” She smiled and looked out the window for a moment. “That’s why I asked to see someone in the city…” She thought about it for a minute or two, wondering whether or not to elaborate, I suppose.

Then she locked eyes with mine again. “I’m a weed, doctor. They don’t want anybody like me to take root there; I’d endanger their carefully cultivated crop of souls… Spread the seed…”

I hadn’t thought about gender preference like that before -or more accurately, I hadn’t thought much about it at all. I suppose it must have shown in my expression because she immediately smiled again. This time, mischievously. The twinkle was back in her eyes, and a dimple I hadn’t seen before suddenly appeared in one cheek. “We’re both weeds though, aren’t we doctor? We both crossed a line somewhere.” She sighed and straightened up. “I think I just needed to tell someone who’d understand.”

My expression must have reassured her she was right because she immediately started to button up her coat. “I agree there’s probably no rush to do a pap smear, Suzy…But what should I tell your GP?”

Suzy shrugged and stood up. “You’ll think of something, doctor. Weeds are nothing if not resourceful.” She hesitated before going through the door, looked over her shoulder, and winked at me conspiratorially. “Tell her I wouldn’t let you. Maybe I’ll get her to do it -after all, I’ve already sewn the seed…”

What’s in a Word?

Alexithymia. Ever heard of it? Me neither. It sounds like one of those words you’d get in a national spelling bee when they’re trying to off you. Fortunately it has a rather pedestrian etymology: ‘a’ meaning ‘without’; ‘lexis’ –speech, or words; and ‘thymos’ – soul, or emotions. In other words: no words for feelings. Hmm… Who would have thought it was a condition? Mind you, since there’s one called anhedonia, the gloves are off.

I’m fairly certain that its shadow would never have darkened my office door, had not a patient pulled it deliberately from her purse while reaching for her phone. Pandora comes immediately to mind, but this lady’s name was Alexis – or, rather, Alexisse as she quickly corrected me- with the accent on the last syllable would you believe? She seemed innocent enough sitting in the waiting room, but in retrospect, she was more a pier in the currents of a hectic room than a middle aged lady. The usual waves of noise and confusion seemed to break over and around her with as little effect as a storm on a breakwater. Throughout the maelstrom, she maintained a smile on her face, but she later admitted to me that it was a well-practiced artifice –a mask that she would always carry with her to help her to blend in.

Her clothes certainly helped as well –a grey skirt worn just below the knees, white blouse buttoned tight around her neck, but loose at the wrist, and black shoes with just a hint of a raised heel. Her light brown hair was short and tidy and her nails long and uncoloured. An average height, she would have melted into any crowd without a trace. Indeed, she followed behind me to my office like a shadow.

I’m describing her like this in the full light of retrospect, however. We always tend to remember things in ways that make sense to us I suspect, although at the time, only the word stood out. She presented as a model patient, and was not at all upset that I was running behind time and was almost an hour late before I was able to see her. “These things happen,” she said with the same smile she’d worn through the whirlwind out front. “I carried a book with me, just in case.”

I brought up her file on the computer as she sat contentedly across the desk inspecting the art work on the walls. I’d not seen her before, but the only thing the family doctor had sent me was the result of a pap smear she’d done recently. Alexisse was a new patient for her as well, and apparently had not had a pap done for over ten years. But worse, the smear was read as showing some malignant cells.

“Did you find the pap smear results?” she suddenly asked, the smile still on her face.

I nodded and looked at her for a moment before speaking. She didn’t seem at all upset so I assumed her GP hadn’t discussed the results with her. Of course the diagnosis was unlikely to be firm until a biopsy of her cervix had been done, so perhaps she had decided to wait until I did that before discussing it with Alexisse.

“Dr. Mandel said you’d be able to confirm the diagnosis with a biopsy.”

The smile never left her face but I was drawn instead to her eyes –they were totally neutral. Cool, if anything. “What did Dr. Mandel say about the pap smear?”

Alexisse shrugged. “Well, for a start, she tried to downplay everything. She said that pap smears are only screening tests and so sometimes they are mistaken…” She stopped for a moment and stared at me with an unchanged expression. “But even when somebody goes to great lengths to paint a black paper white, you know it still ends up looking grey.” Her eyes sought mine to see if I understood.

I approached the topic carefully. “So… What do you think she was trying to tell you?”

Another shrug. “That I have cancer of the cervix.” She said it as if I had asked her about her last period.

I was speechless for a moment. There was no sign that she was upset. No tears. No tightening of her facial muscles. Just the smile –the mask. “You don’t seem very upset. Your family doctor must have done a good job of discussing it with you.”

Alexisse shook her head. “She seemed a little confused about what to say. She asked me if I had any questions, and when I didn’t, said she’d send me to see you.” She stared at me for a while and when she saw that I looked puzzled as well, sat back in her chair.

“I have alexithymia,” she said as she reached nonchalantly into her purse to turn off a phone that was ringing. I must have cocked my head, because her expression intensified. “It’s a condition that makes it difficult to feel emotions –even identify them as such. I’ve learned to put a smile on my face along with my makeup in the morning.”

I started to ask if it was a type of autism, but she saw the word forming in my mouth and waved it away. “Only half of us with the condition are autistic, if that’s what you’re going to ask…” She took a deep breath and let it out slowly. “I’m sure it’s a spectrum disorder –worse in some, less in others.” The smile appeared again. “And the next question you’re going to ask is about my name. Isn’t it a little suspicious that my name is almost the same as the condition? I mean I can almost see everybody thinking it. Go online and you’ll see the community calls its members ‘Alexes’. It’s why I’ve started pronouncing my first name differently…” She sighed briefly. “I don’t think the condition is even accepted by mainstream psychiatrists yet. It wasn’t in the DSM IV at any rate… But I have to admit I haven’t looked lately.”


She crossed her arms and stared out the window. “I’ve always wondered about why everybody except me seemed to get excited about things. I can’t remember ever being angry, or crying at a movie. People thought I was weird.” She shifted her position on the chair. “Anyway, I looked up the etymology of Alexis –which is how my parents spelled the name- and realized it came from the Greek for ‘without speech’. It didn’t take Dr. Google very long after that to introduce me to alexithymia.

“And no, I haven’t had a formal diagnosis. Dr. Mandel asked me about that.”

I sat back slightly on my chair to get the computer screen out of the way. “Well, frankly I’m more concerned with doing a biopsy as soon as possible than with any personality disorder you might have…” I wanted her to know that the most important thing to think about at that moment was her health. I meant well, but her facial expression changed immediately. She looked almost angry –hurt, at the very least.

“Personality disorder? And that I might have?” Her whole body tensed at the perceived insult. “I think you’re being entirely too insensitive, doctor!” She shook her head slowly. “Just like my family doctor. Now you see why I don’t go to doctors very often.” She started to get up from her seat. “Your secretary can let me know when you’re going to do the biopsy,” she said, still shaking her head in disbelief. “You all seem to ignore who I am for what I have…” She fixed me with a glare that almost pinned me to my seat then left the room with a toss of her head… Anger?

She never showed up for any of the biopsy appointments despite multiple phone calls from both our office and her family doctor’s. I can only hope she sought help from someone who listened to her pleas for understanding. I don’t know whether she actually had alexithymia or some other mental issue such as schizophrenia, but it clearly seemed to interfere with her ability to process information appropriately. I’ve since learned that alexithymia is often associated with other psychiatric disorders, so perhaps she had decided to fixate on a more acceptable but obscure variation. Maybe she’d been wearing another mask -one that even she had not suspected. Or one that she found too difficult to acknowledge…

I also Googled the word and discovered that the BBC had an article on it that was dated a month or so prior to her visit: I remain open to convincing, but I keep remembering what Iago said in Shakespeare’s Othello: ‘I will wear my heart upon my sleeve for daws to peck at. I am not what I am.

The Myth of Medicine

The concept of the myth has always intrigued me. Not, as it is historically characterized – the fabulous stories of gods and heroes- or the more populist idea of an untruth or counterfactual, but rather as a metaphor. Myth as a way of explaining something that is difficult to put into words, that defies rational explanation: the meaning behind the meaning. Like those Russian nesting dolls, they are multilayered, with understanding hiding within significance which is in turn hiding under context hiding behind appearance… A myth is the meaning of a flower. It is a poem.

And yet it need not be so abstract, so elusive. All of us have myths: they are our stories –who we are, or at least how we have come to understand ourselves. As the famous Swiss psychiatrist Carl Jung said in his autobiography: Thus it is that I have now undertaken, in my eighty-third year, to tell my personal myth. I suppose the challenge, however, is to disentangle the reality from the fantasy… Or does it really matter? And are they both merely different colours of the same myth? Joseph Campbell, the author of many books about mythology, said: “…the only way you can describe a human being truly, is by describing his imperfections. The perfect human being is uninteresing… Aren’t children lovable because they’re falling down all the time and have little bodies with heads too big?”

We are, for all intents, our mistakes. Our foibles. Our myths. And that which we appear to be, we are not –or at least that may not be how we see ourselves. So, for the doctor, which is the more important –because to treat the person, we have to find them first?

I am reminded of a patient I saw  long ago when I was a freshly washed gynaecologist just setting up my practice in an era of militant feminism. Ms Debrashen –that was her title, she insisted, just like mine was ‘doctor’- was a frail-looking eighty year old but dressed in jeans and a sweat shirt that had I’m Talking to You written in Gothic script on the front. I suppose I should have been intimidated, but her smile was so disarming, I couldn’t help but return it as I greeted her in the waiting room. She extended a bony hand to shake before I could even free my own from her chart, and would have led me  down the hallway to my office if I hadn’t stepped in front of her to make sure she went through the correct door.

“So what can I do for you Mrs. Debrashen?” I said, still smiling, as she plonked herself down on a chair beside my desk.

Ms Debrashen,” she corrected me, but not unkindly. “I want you to do a pap smear. I haven’t had one in years, and my family doctor refuses to do one on me.” As she said this, she replaced her smile with a flinty stare that brooked no nonsense. I will be obeyed, it said for a moment, and then relaxed into a more Canadian, please. “I don’t know what got into him; I’ve gone to him for years, but he just climbed up onto his doctor horse and said I was too old.” She sighed theatrically and shrugged angrily. “Too old? Too old to be screened for cancer..?” She shook her head in disbelief. “Does he think I’ve lived long enough already?”

I took a carefully disguised deep breath and let it out slowly. Quietly. I decided to start with a thorough history in case there were some extenuating circumstances. Most cancer agencies throughout the world, and certainly the one in my own province here in British Columbia, have said that there is no indication for continuing to do pap smear screening after the age of sixty-nine. Only if there were recent abnormalities in the pap or as a followup to recent treatment for abnormal cells would it be justified. And of course, then it wouldn’t be screening, per se, but followup.

I took what I felt was a complete history and then, as a tactical decision, asked about her pap smear history at the very end. But no, all of her past pap smears were normal, she insisted.

She sat back in her chair, folded her arms across her chest and stared at me with a rather smug but expectant expression on her barely-wrinkled face.

“The Cancer Agency in British Columbia usually recommends not doing any more pap smears after you turn seventy,” I said, rounding it off for simplicity.

A curiously satisfied smile captured her face –as if she were laying a trap for me, but had to be careful not to give it away. “And why is that, doctor?”

“Well…” I started, not totally comfortable explaining to a woman of her age about the increasing belief in those early years of virology, that the abnormalities of the cells of the cervix registered by the pap smears were in fact the result of some sexually transmitted agent.

Her smile turned into a chuckle when she noticed my obvious embarrassment. “We are not always as we appear,” she said, the merriment evident on her face. “We write our own myths, then wear them, you know… Doctors no less than their patients.” I suppose I must have looked puzzled, because she sat back in her chair as if she were settling in to tell me a story. “Both you and I are Matryoshka dolls, and we only unveil the deeper ones when and if it serves our purposes.” She softened the severity of her latest array of smiles. “You are only looking at one of the dolls –the one you expect to see.”

I smiled the tolerant doctor-patient smile, and started to say something, but she waived it away with a flick of her hand.

“You didn’t ask me much about my sexual history, did you?” I think I blushed and she immediately seized upon it. “Too embarrassing, right? And yet had I been twenty or so, you would have jumped on it immediately when I told you I wanted a pap smear.” I didn’t have to answer –she had me. “But despite my age, and my failing eyesight, I can still read…” She pretended to look out of the window behind my desk to ease my discomfort, but I could tell she was actually watching me out of the corner of her eyes. “The current thinking is that abnormal pap smears are the result of sexual transmission, I understand. Like a disease.” She risked at direct glance at my face and when she could see the astonishment on it, she left her eyes resting there. “So, how would you get a new sexual disease, I wonder?” She let her words dangle for a moment to tease me. “I suspect there are only two mechanisms –either my partner is dallying in another realm, or I myself have strayed into a new kingdom.”

I tried to keep my mouth from falling open -I loved her words.

“But suppose I knew all this, but was unwilling, or afraid to share that aspect of my story with you because it didn’t conform to what I have always wanted to believe about who I am? And what you wanted to believe…” She stared at me for a while with innocent cow-eyes. “Or, on your side of the curtain, suppose you didn’t want to risk offending me because it would be like talking back to your grandmother. Belittling her. Disrespecting her…” She straightened herself in the chair as if she were about to get up. “So you see we are both trapped in our stories.” A huge smile spread from ear to ear as she rose to her feet. “But we’re only trapped as long as we don’t recognize them as surfaces. Clothes…”

She pointed at the examining room. “Let’s do the pap smear, now. I’m going to be late for my friends,” she said, and then started for the door, as I still sat immobilized in my chair.

“I was a Social Anthropologist in my previous life,” she said, looking back over her shoulder and winking. “Just thought you’d like to meet one of my deeper dolls…”


I’ve never forgotten Ms Debrashen over the years. She taught me to question assumptions. Interrogate them. But it made me wonder just how much I can know about anybody. Some of those deeper layers are inaccessable even to the person from whom I’m trying to obtain a history. So overlayered with hope and retrospectively altered memories, some are forever hidden in the myths they have become. Perhaps for clearly displayed symptoms and signs, my medicine can work. I can treat a prolapsed uterus, or an elevated blood pressure, but in a way, that is almost like mending a sweater, or washing a shirt. It is hard to see the skin they hide beneath. And I am at a disadvantage peering through the murky water in which they stand to find something they’ve dropped or hidden. …

She made me appreciate the words of Hamlet when he repudiates his mother for insinuating he is pretending grief merely to get attention:

Seems, madam? nay, it is, I know not “seems.” ‘Tis not alone my inky cloak, good mother, Nor customary suits of solemn black, Nor windy suspiration of forc’d breath, No, nor the fruitful river in the eye, Nor the dejected havior of the visage, Together with all forms, moods, shapes of grief, That can denote me truly. These indeed seem, For they are actions that a man might play; But I have that within which passes show, These but the trappings and the suits of woe.

Pelvic Exams

Medicine has been my life, and over the years I have seen my specialty of obstetrics and gynaecology break free of many of the traditions that shackled it to the past. Obstetrics was once a superstition-clad field -a world unto itself; gynaecology was mired in taboo and cultural sensitivities that often precluded open-minded and unbiased research and therapy.

To a variable extent, both managed to disentangle themselves from the constraining mesh of gendered folklore and even sexual politics by embracing a non-discriminatory and objective multidisciplinary approach to the problems surrounding each domain: what a pregnant woman had in common with her non-pregnant counterpart, for example. A recognition that gestational diabetes, say, could be engendered by the stresses of pregnancy and that its diagnosis and management had much in common with type 2 diabetes in both sexes. That not only did conditions -diseases, anomalies, medical and surgical abnormalities- have an effect on pregnancy, but that pregnancy had an effect on them as well. Treatment had to be contextualized. Tailored.

An awareness that one of the most common and devastating cancers of women had preliminary and treatable forms that could be detected by scraping the surface cells of the uterine cervix led to the development by Papanicolau of his eponymous pap smear in the early part of the last century. This mainstay of Women’s Health required some education, of course: although readily accessible physically, the cervix occupied an understandably personal and intimate region hitherto guarded by powerful societal norms -not to mention feminine propriety.

And yet, despite the obvious progress and benefits accruing to this approach, there remain other elements equally important to success. To ignore these, is to forget that there is more to personhood than meets the eye. We are more than the sum total of our parts.

I can’t help but feel that Medicine has sometimes capitulated to the Scientific Method -surrendered its mandate. Forgotten its purpose: to help and reassure. Even my own specialty, despite its undeniable progress, occasionally mistakes a valuable stand of trees for a forest and seems to be in a hurry to log them all to ground level -to the bottom, if you’ll pardon the mixed metaphor- in its haste to discover what might be hidden. There are tides of change that buffet us all, but are they sweeping baby, bathwater and flotsam out to some nebulous Sargasso place beyond the horizon? A place unreachable by the rest of us. Unusable. Unauditable. In our dash to embrace what has been called evidence-based care, have we thrown reality-based care overboard to lighten the load? The bureaucratic equivalent of jetsam: cargo thrown overboard to save the ship -a word derived from jettison.

We must be sensitive to changing times and evidence, of course; new data require new approaches. We must be aware of public opinion and evolving mores because sensibilities wander, expectations mutate. We are not the same people we were even a decade ago. We are an ever-simmering melange as new customs merge with established ones, and religions stir several pots at once.

So there is no one center around which things revolve; we are many circles, each overlapping. We are a stochastic society: a kaleidoscopic stew of boiling colours and tastes.

But just because there are many variables that resist easy classification, this does not necessitate ill-considered solutions. Some things in Medicine are important -worth preserving even if they require more work than in the past. More patience. More understanding.

Think, for example, of vaccinations. Who would have thought there would be any resistance to these life-saving measures a generation ago when polio, smallpox, diphtheria, tetanus –even measles- were reeking havoc across the world? Nowadays it’s not the doctors who are suspicious, but the public: ‘Why vaccinate my child and subject her to risks of side effects for something that nobody gets anymore?’

I hear this occasionally from my pregnant patients. So, I have to make the time to counsel them and attempt to answer their pre-printed Google inquiries. And by and large they understand. What they have been seeking is not so much a detailed data-ridden explication with appended references, but an empathetic hearing and discussion of their concerns. People are sensible, by and large. They simply want what’s best for themselves and their families. They want to be participants in health related issues –and why not?

But to come to the point of this essay:

Some patients have readily discoverable problems -an enlarging mole on their skin that worries them, say. But some areas are hidden –both from the world and the person herself. The vagina was not designed as a shop window, and what hides at its end in the pelvis –like the uterus, ovaries, Fallopian tubes, for example- are not subject to casual interrogation. Tests like ultrasounds or CT scans are only done when symptoms arise –and like everything else, that is often too late. This is a worry.

Most women are resigned to interval pap smears (and soon, no doubt, to interval HPV testing from the same area). It seems to be accepted by most people in the community that pap smears can detect abnormal cells arising on the surface of the cervix long before –years before- any noticeable symptoms appear. And the fact that the rest of the pelvis can be assessed at the same time as the pap smear is reassuring to most women. Expected, actually -especially since their doctor is already focussed on the area. In the neighbourhood, as it were.

So it came as a surprise to me that a recent guideline from the American College of Physicians suggested that a pelvic exam should not be done routinely with pap smears. Only if symptoms arise that are suggestive of pelvic pathology could one justify its performance… Where’s the reassurance in that?

There are harms associated with it apparently. Evaluated harms ‘included fear, anxiety, embarrassment, pain, and discomfort. Physical harms may include urinary tract infections, and symptoms such as dysuria, and frequent urination.’ Wow! I wonder who is doing the pelvic exams for their studies.

And I wonder if any of the examiners actually discussed the examination with the patient beforehand. Or, more importantly, asked her permission. Her arrival at the office for the pap smear was voluntary (one hopes) and so she must be an active and willing participant in any medical investigations performed on her –including a pelvic examination, obviously. If possible, she should be able to choose her examiner –a female doctor, for example, or someone she trusts and with whom she feels at ease. As for my part, if she should choose not to be examined at the time of the pap, I certainly do not object; but I always ask.

Sometimes, there are cultural differences where the patient would feel awkward being examined by a male and if I suspect that is the case, I do not insist or make her feel uncomfortable about having to make a choice. I also offer to have another woman (her friend, my secretary, or her husband if she so chooses) to be present in the examination room.

Examination is as much for her reassurance as to discover something. The choice is hers, not mine. But there is usually an expectation that it will be done –or at least offered. I don’t think that we should make a big production about it. I don’t enjoy going to the dentist –childhood memories of pain and discomfort, I suppose- but when I do go, I expect her to check more in my mouth than just my teeth. Even if it is just my regular dental checkup I am willing to have my tongue palpated and my gums poked and prodded… especially if it is just a check up. I want to prevent problems as well as solve them. And the more thorough the examination, the more reassured I feel when it is normal. Am I alone in this?

Let’s face it, there are some things that, like it or not, we need to do for our own benefit. In the long march of Time, they might not amount to much, but nonetheless we may put them off in anticipation of discomfort or embarrassment. Autonomy –choice- is paramount.

But let me paraphrase (para-sex) Shakespeare:

She that outlives this day, and comes safe home,                                                                         

Will stand a’ tiptoe when this day is named.

Kind of makes one proud to have participated, don’t you think..?


Cancer of the uterine cervix is a sexually transmitted disease; it is the second most common cancer of women in the world and it is spread sexually. Who would have guessed? The clues were there all along, of course: it was more common in sex workers, and women who had become sexually active at an early age; it was rare in nuns… But it took a while to connect the dots -and for technology to catch up with suspicions: viruses couldn’t even be visualized until the invention of the electron microscope, although their existence was suspected much earlier using filters with holes too small for bacteria to pass through. And then their DNA had to be identified in cervical cancer cells… and classified. It was a long journey all right.

But sexual transmission? The jump from abnormal Pap smear to the bedroom was -and is- a hard sell.  The fact that more than 80% of sexually active humans have been exposed to the virus was hard enough, but add to that the knowledge that the vast majority of teenage infections will clear on their own because of the vigorous immune response at that age, and you have a recipe for confusion. Or complacency.

Cancer of the cervix is rare before the age of 25 -the virus has a long prodromal developmental period- so after telling women how important Pap smears were in preventing, or at least detecting, this infectious cancer, raising the age of the initial Pap smear from the time of first sexual activity to age 21 in North America, did little to foster understanding. And then playing with the frequency and mode of surveillance for the rest of the age groups… Well, it was almost a breach of trust; changing the rules after years of teaching was just not on.

I mention this only to put the contemporary problems of counselling young women into some perspective. Especially now that vaccination against some of the more common and troublesome varieties of Human Papilloma Virus is possible. Vaccination has always had its opponents, and HPV is no different. But for my practice, there seem to be two major questions that arise: the need for continuing screening after vaccination, and the need for vaccination if a woman has already had a pre-cancerous condition treated.

These are confusing, if not vexing questions. There are at least 15 types of HPV that cause cancer but only two major varieties that account for the vast majority of cases in the community: types 16 and 18 (they’re numbered, rather than given cutesy names). These are the strains that are incorporated into the current vaccines. So if a woman has already had dysplasia -the pre-cancerous condition caused by the virus- it will have been caused by only one of those types and she is still vulnerable to the other. And therefore she still needs to be vaccinated. I get asked this every day, I think. Fortunately the schools in my province have incorporated the HPV vaccination into the early grades at school -hopefully before sexual exposure- so the question may well be an anachronism in the foreseeable future.

But the need for continuing screening in a vaccinated population is more difficult to understand in an era brought up on the concept of herd immunity: the idea that the more people who are vaccinated, the less prevalent the virus, and hence the less chance of being exposed to it. What tends to get forgotten, however, is that there is never a completely protected group: we are a heterogeneous society with new, unprotected people entering it from outside; immunity may wane; less common strains or perhaps novel viruses might gain prevalence and not be incorporated into the contemporary vaccine products. No, there are many reasons not to let down the guard of vigilant surveillance.

But a problem still persists: HPV doesn’t behave at all like a sexually transmitted infection in the minds of most people. We have come to expect cause and effect to be temporally accountable: the unprotected sexual encounter last week results in identifiable symptoms this week. Blame is assignable; lessons are learned. But with HPV, cause and effect are often separated by uncharted and imponderable years of time. There are seldom symptoms, seldom acquired wisdom. No one -or everyone- seems culpable: a difficult take-home message indeed. As I have already suggested, the voyage from Pap to Prevention is a stormy one.

But maybe this is just a generational thing: what we find difficult to assimilate today, will be greeted with a knowledgeable shrug tomorrow. We are creatures of more than structural evolution; more than linear accrual. As Shakespeare says: We know what we are, but know not what we may be. Or even better: Lord, what fools these mortals be!

Screening Systems

Science, or at least the scientific method, can disappoint can’t it? We are informed -assured- that something is correct, the right thing to believe, and then with the passage of time and the arrival of new data must suddenly disavow that ‘Truth’ and start all over again. The comforting feeling that we have at last apprehended the underlying essence of something is torn away, leaving us with yet another useless fragment: a wide tie in a narrow-tie world… And the change, not fully understood, is apt to leave us bewildered and suspicious that nobody really understood it in the first place -not even those in charge. We are short-term creatures and our lives are brief; certainty is a luxury we long to indulge. A longer view of things is usually difficult and often opaque so a whole generation will espouse one thing, but the next another.

Medicine is not exempt. We spent a lot of time educating people -and governments- that a yearly health check-up was a good investment of time and resources: it would diagnose conditions at an earlier stage when treatment would likely be more successful and less expensive. It would save lives, save dollars; it was, and is, intuitively appealing. After all, a car needs periodic oil changes and during the process the mechanic might notice a tire that is abnormally worn, or a pipe that is almost rusted through; why would we be any different?

It’s a good question, and one with which I have struggled as well. And yet studies have suggested that although the occasional asymptomatic condition may be detected for which treatment, or at least counselling with follow-up would be indicated -things like hypertension, diabetes, cervical cell abnormalities detected by Pap smears or breast lumps with mammography come to mind- the inevitability of falsely positive tests often lead to far more extensive -and expensive- investigations that go nowhere. The yearly checkup, in other words, is being repudiated, despite its visceral appeal.

I remember when I was an intern and a new process was introduced that allowed multiple tests to be performed on a single sample of blood. One ordered, say, a hemoglobin to investigate a patient suspected of having anemia but as well as getting the hemoglobin, several other parameters were also reported. Statistically, there was a good chance that one of them would be abnormal -not necessarily the one being investigated, but merely a random error produced perhaps by medicine the patient was taking or food she had eaten, maybe even the time of month or hormone status. But it couldn’t be ignored, so further investigations would be undertaken -usually unnecessarily. The hospital continued to use the systemic multiple analysis on the blood tests, but soon realized that it made more sense to report only the entity requested. False positives can be a problem.

People become accustomed to certain screening systems, too; the programs become self-evidently appropriate, and any change to them is resisted as being either mean-spirited, or short-sighted. Prostate Specific Antigen testing, Mammography, and even Pap smear screening have all come under scrutiny of late. False positives, and even false negatives have been implicated as problems associated with undo reliance on them.

Take Pap smears, for example. Recommendations have varied over the years and jurisdictions, but the idea was that since cervical cancer was once so prevalent and deadly, it made sense to try to detect abnormal cells as soon as possible in a woman’s life. Suspicions that it was somehow associated with sex lead to the suggestion that Pap smears be started soon after she was sexually active -often within three years. Then how often? Well the recommendation in my center -assuming the first Pap was normal- was to repeat them once a year for three years and then every two years thereafter if they stayed normal. It seemed an entirely appropriate and reasonable approach at the time, so the public was educated accordingly. It became a widely accepted and normative routine and embedded itself within the public psyche: a woman needed regular Pap smears, and to wait too long between tests courted disaster. Hard to argue against that.

Until, of course, it was realized that certain subtypes of the Human Papilloma Virus (HPV) were responsible for cervical cancers and that young people often seemed to be able to mount an immune response to them without the need for treatment. So it became apparent that Pap smear testing too early in a woman’s life might lead to unnecessary interventions and the possibility of complications, not to mention the ever-attendant anxiety. Therefore the recommendations were amended (in some centers anyway): Pap smear screening might best be commenced at 21 years of age, and not shortly after sexual activity began. Many women did not feel comfortable with this approach, either for their daughters, or themselves, for that matter. More frequent was better, even if it led to further investigations such as microscopic examination and biopsies of the cervix (Colposcopy) that might prove negative. We need handles to grasp, doors that open; we need something we can trust. And they had been assured they could trust a regular regime of Pap smears. After all, it had certainly reduced the incidence of cervical cancer in the population. Once again hard to argue.

And now, yet again, it changes. If HPV is required to cause cervical cells to become abnormal, and the usual time for this to occur can be measured in years after the infection, wouldn’t it make sense to lengthen the interval for screening to take this into account -every five years, say? Maybe co-test with a Pap smear at the same time to make sure that abnormal cells hadn’t been brewing there for a while and then apply an algorithm to account for discrepant results? Or perhaps give the nervous public a choice: Pap smears every three years, or HPV and Pap every five? But because transient HPV infections are statistically more likely to occur in younger women (immune differences or amount of sexual activity, possibly?) don’t offer HPV testing to women under 30 because that might lead to unnecessary investigations… Confusing? Scientifically justified, but emotionally difficult to swallow?

I raise these issues because, well, my patients do. It’s not a little thing to change a habit, especially one inculcated by the profession and then rescinded or at least amended after widespread acceptance –generational acceptance. It requires not a little humility to reveal that we have not yet arrived. But, Wisely and slow, they stumble who run fast: Shakespeare again seemed to understand. But, do we?