Tag Archives: patient expectations

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The Feminine Perspective?

“Men and women think differently, doctor,” a patient said to me recently, shaking her head in response to some requested advice from me. “You of all people should know that.” It was stated with a look of smug authority, as if  to disagree would have been tantamount to an admission of professional incompetence. And while I don’t concede the point that to disagree with what seems to be a societal dictum necessitates a conclusion of medical bankruptcy, it got me thinking…

I suppose the first thing that occurred to me was to question the assumption that my specialty somehow enabled entrance into the heavily guarded sanctum sanctorum of my patients –female patients at that. It kind of invokes the Theory of Mind, doesn’t it: the early discovery by a child that others also have things going on in their heads, and that they may differ from her own thoughts or perceptions. It’s an important step in eventual integration into society; it’s also a recognition that because it’s different, we can never really know what someone else is thinking.

So, in that sense, no: I (a male) can’t know what my patient (a female) is thinking -any more than I could if that person were another male. I can suspect that it might differ from what is going on in my head, but given a common purpose -the solving of a medical need, say- I can intuit that we can communicate something meaningful about that.

“Ahh, but it’s not just that we live in different bodies, doctor,” -I could almost hear her response to my thoughts- “It’s more the way we approach the problem.” Really? Are the goals actually dissimilar, or is it more a difference in perspective -a choice of route? And is the perspective culturally assigned, or does it reflect a basic underlying gender difference in physiology and wiring? Is it just that we are supposed to think a certain way -an assumption- or that we, in fact, do -an innate, genetically driven imperative?

Are the perceived psychological differences in the sexes superficial and societally contrived, or are they more like two Magisteria -the approach Gould chose to describe the difference between religious and scientific knowledge and authority? It’s a difficult question obviously, but I sometimes think it has degenerated into more of a media-driven competition -each side trying to enlist support from an otherwise disinterested and unaffected Public.

I sat back in my chair and smiled inquisitively at my interlocutor. “And how would you approach this problem?” I asked, hoping to learn something from the encounter.

“Well, for one thing, I would offer more choices.”  She sat up straighter and crossed her arms defiantly, daring me to disagree.

Fair enough; I suspect we would all like more of a say in how we deal with a problem. I nodded my head in agreement. In medicine, even if there are no other viable therapeutic choices, there is always the option of doing nothing -seeing what will happen over the coming days or weeks. But I suspect that the choice of that option transcends gender, transcends the assignation in the genetic lottery…

But maybe I was missing something; maybe she was operating with a world-view that necessitated a different assimilation of Reality. For that matter, maybe there was a different reality for her -one that I could never hope to experience. Maybe what she experienced as Red, for example, I experienced as Blue and yet we both named it with the same word. How could I ever know? A troublesome thought indeed.

And yet, ever the pragmatist, even if we both meant something different by that word, but arrived at the same destination, wouldn’t the communication have been successful? The goal achieved?

She wasn’t finished with me. “And I think you were assuming I should just accept your opinion, doctor.” She obviously hadn’t liked any of my solutions, although I had offered her several. She had probably only heard the word ‘hysterectomy’ among them.

It occurred to me that although we both wanted to solve the same problem, her condition had a different meaning for her altogether. And it didn’t hinge on her sex as much as on the way she envisioned herself as a person, as the protagonist inside a personal history: her story.  She possessed an identity tied to what she currently was, and whose very existence was contingent on whom she might inadvertently become.

But we’re all like that: we are who we have been; the past drags behind us like a shadow. It’s company for us on our long trip; it’s our suitcase full of memories… So that alone cannot be what she was alluding to.

That we all see the world from our own perspective, and that it is different for each of us, is merely stating the obvious. That we each come to a problem with a different history is equally obvious. We have all been entangled in cultural webs that have conditioned the way we respond to issues. In the beginning, perhaps it was all engendered by biological constraints, but I think most of us now realize the artifice in that.

What, then, accounts for the difference, other than milieu?

Bertrand Russell, a philosopher mathematician of the last century had some small influence on my early development; I make no claim either to have read all of what he has written, or for that matter to have understood more than a small part of what he had to say, but I have always remembered one passage -one pearl- that made sense to me. Perhaps it was the only thing I could understand:  For my part, I distrust all generalizations about women, favorable and unfavorable, masculine and feminine, ancient and modern; all alike, I should say, result from paucity of experience.

Maybe I should have read more of him; there are many perspectives…

Aside by

It’s never easy to be a doctor -especially an obstetrician. Accouchement is just too unpredictable; babies are just too vulnerable, too fragile. Too many things can go wrong. Quickly. Unexpectedly. Too many people are affected -the doctor included.

Most of us travel through our days in the naïve hope that we will somehow escape unscathed; that bad things only happen to others; that there are probably no slings and arrows of outrageous fortune -not really. We will be, by and large, protected either by good fortune or statistics -we and our children. We rightly assume that with due diligence, and a good doctor, complications can be predicted and bad outcomes prevented. Otherwise why attend clinics? Why arm ourselves with knowledge, gird ourselves with expectations? Hope does indeed spring eternal.

But circumstances sometimes conspire to frustrate even the best intentions; the most thorough preparations are occasionally inadequate. In Life, nothing is certain; the unforeseen is just that, and only after the event is it predictable. Only after the tragedy is there a possibility of some elucidation, and even then, only a possibility of instruction. Of a lesson learned. Even after endless review -and it is always reviewed- it so often remains random and unfair.

Surely at this stage of our progress in Medicine, these things should not happen -not today, not in hospital.  Anticipation. Prevention. Avoidance. Isn’t that what we always preach? That if we think hard enough, monitor long enough, and analyse well enough, most things are either preventable or at the very least, avoidable? The key word, though, is ‘most’. Some things can and do slip through the fine net of surveillance no matter how hard we watch. Some situations arrive at the door unannounced and we have to do our best to deal with them before they enter -or at least minimize the damage if they manage to knock us down as they elbow past…

But while it’s never easy for anybody involved, it is the parents for whom I grieve. They have waited so long in joyous anticipation of a life with their child. That its arrival should be traumatic after all those months and all that excitement, that all that promise need be put on hold, or stored on some high shelf as Hope, is almost unbearable.

And yet, endure it we must, until the path emerges once more from the forest and we can see again. Thank god its a route I have seldom travelled, and yet each time, as if it were the first, I am lost. We are all connected; when one suffers we all suffer. And this is how it should be: the link is strong. It’s what makes us human, binds us together as a society: we care. God forbid that it could ever be different.

And even in the darkest place, there is still hope. I remember Helena trying to explain to the King how she can help in All’s Well That Ends Well:

“Oft expectation fails, and most oft there
Where most it promises; and oft it hits
Where hope is coldest, and despair most fits.”

We all need a hint of light, no matter how dim it seems when it first approaches.

Intimations of Mortality

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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?