Tag Archives: patterns

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Let Every Eye Negotiate for Itself

We are very attuned to patterns, aren’t we? We see them even when they aren’t there, filling in the lines, reading the shadows to complete the image. But does the face we see in the play of light on forest leaves, or the finger in the sinuous beckoning of the windblown grass really fool a mind that can do mathematics in its head? Or is it just a brief dalliance, a foray into a theatre for a moment or two? A titillating fantasy that fades when the eye moves on to other, more important, things?

A stereotype is a pattern too, but more deeply etched, and coloured so convincingly it is mistaken for the thing itself. Not recognized as a simulacrum, it is treated as archetypal, requiring few, if any, revisions –so self-evident it is almost a causa sui. And yet, hic sunt dracones, to continue the Latin –here be dragons- for stereotypes are, by default, fancifully-charted territories. Like incomplete maps filled in with imagined beasts, they are not reliable guides. They do not help.

And yet they are so prevalent, it is often difficult to recognize them, let alone extract them from the gestalt. So they persist, and like a Where’s Waldo face, only emerge from the background if we make a concerted effort to find them. But usually, there has to be a motivation to look –something that shakes us from our apathy. Our indifference.

It’s so easy to slip into somnolence, isn’t it? So easy to let things pass us by unexamined as long as they don’t threaten to disrupt our day. And yet, to escape the pastel hues in which our waking hours are often painted, it is sometimes an adventure to search for the chiaroscuro hiding in plain sight.

There was a delightful article I noticed a while back that managed to open my eyes again: http://www.bbc.com/news/world-latin-america-38132503

It recounts the story of a a 19-year-old woman from Guatemala who designs clothes for people with Down’s syndrome. The thing is, ‘Before she was an internationally-recognised designer, Isabella Springmuhl says she was rejected by two fashion schools in her native Guatemala because she has Down syndrome. “They said I would not be able to cope,” recalls the 19-year-old. But that rejection was exactly what Isabella needed to turn her life around […].’

So, instead, her mother took her to a sewing academy that would accept her. ‘While learning how to sew, Isabella was asked to design outfits for worry dolls – traditionally hand-made dolls originating from Guatemalan and Mexican folk traditions. The tiny dolls are usually put under children’s pillows in the hope that they will take away their sorrows while they sleep.

‘Isabella took a different approach.

‘”Isabella didn’t want to design clothes for… finger-sized dolls,” says Mrs Tejada [her mother]. “She created life-sized dolls and dressed them in the colourful embroidered jackets and ponchos that she’s now famous for.”

‘Isabella moved from designing for dolls to people, and soon enough produced a collection that gained the attention of the fashion world. Earlier this year, she became the first designer with Down’s syndrome to take part in London Fashion Week.’

But it didn’t stop there. Isabella points out that her main inspiration for designing arose after a struggle to find well-fitting clothing for her body type.

“It was difficult for me to get clothes,” Isabella says. “We have a different body constitution; we are shorter, wider, or very thin. My mother always had to fix the clothes she bought for me. So I decided to design clothes that fit people with Down’s syndrome, plus I really love Guatemalan textiles and the diversity of colours and textures they represent.”’

Wow! I get a shiver down my spine when I think of the odds that Isabella was willing to tackle. But, I wonder if she ever thought of them as odds, or merely as challenges that needed extra effort each time they arrived. Not only are there rivers to ford as a young person hoping to succeed in a highly competitive field, but the water sweeps all but the most determined, the most talented, downstream with barely a ripple.

But what am I? asks Tennyson, An infant crying in the night, An infant crying for the light, And with no language but a cry. I doubt that Isabella ever thought of herself like that. From time to time, there arise those exceptional people who do not understand the concept of failure. Who do not doubt or lose their way. Who are so confident in themselves, no matter the circumstance, that they press on and build on what they know they have, and are ingenious about what they don’t.

Stereotypes fail these individuals, as they do anything unique. How can you epitomize a Caesar, or cage a Churchill? How can you oversimplify a courageous person? How to paint the journey of a cloud? Tennyson, again from In Memoriam A.H.H:

The hills are shadows, and they flow

From form to form, and nothing stands;

They melt like mist, the solid lands,

Like clouds they shape themselves and go.

And so, how to stereotype a syndrome? In Down syndrome, or trisomy 21, there is an extra (part or whole) chromosome 21, which causes an assemblage of physical and intellectual features, including a characteristic, recognizable, but variable facial dysmorphia. It is the latter that may prejudice unthinking employers into feeling that they couldn’t cope, that the individual could never fit in, or perform like the rest of their employees –or other students, in Isabella’s case. But they were wrong.

Creativity knows no boundaries; we all fit somewhere on a spectrum –individuals with Down syndrome included. And imagination, like courage, does not stop at the edge of a chromosome.

Let every eye negotiate for itself, says Shakespeare’s Claudio in Much Ado About Nothing, And trust no agent, for beauty is a witch against whose charms faith melteth into blood.

I think Isabella is a beautiful person, don’t you…? And how do you stereotype that?

 

 

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Prove it!

If there’s one thing that a long life has taught me, it is that most of us seldom stray far from the path. Once launched, our trajectory is largely predictable. I suppose this is necessary for co-existence –that there are societal norms is, after all, what binds us together as a group. Knowing what people want –what they are comfortable with- makes it possible to plan ahead with a reasonable expectation of success.

And yet, what if circumstances change? Even Science admits it runs on statistical probabilities. Nothing is forever the same, despite our expectations; despite the hopes of even the most enlightened that it will not deviate too much from that to which we have become accustomed. But progress depends on change, depends at least on altered perspective. That someone can look at the same data and interpret it differently –see different patterns in it, perhaps, or even apply it to something entirely different- is what we have come to expect of our modern world.

But there is often an inter regnum, that can be confusing -a time before the paradigm shift is complete; when wisdom, -no, expectations– demand that we judge the results of whatever investigations we have done, in the light of what the past, or experience, has taught us. And as a consequence, not only do we limit our inquiries to those things that seem to prop up those views, but we discard, or criticize data that fail to validate them. Same information, different eyes. It’s often called the Confirmation Bias and I’ve written about this in one form or another before: https://musingsonwomenshealth.com/2015/05/15/the-polarization-bias/

The problem is that it seems to be a Mobius strip, and the same data are used to prove opposite contentions. There are rules that can be applied, of course –methodologies that help to sort out interpretive biases:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126323/  but it’s all too easy to fall back on what seems natural to us: to assume that what has been found either substantiates what we believe it should, or to criticize it for its presumed deficiencies or mistakes if it does not.

There seems to be no end to the variations on that all too familiar theme. It’s certainly not unknown in Medicine, and a recent example springs to mind.

I remember Jerra -partly because of her unusual name, I suppose. When I saw it on the office day sheet, I assumed it was a typo and thought I would correct it as I introduced myself to her in the waiting room. She was the first patient booked for the day and none of the few other early-risers in the room looked anywhere near 62.

“Jerri,” I said with a smile, walking directly over to a thin, grey-haired woman sitting bolt upright in the only chair by the window. Her first reaction was to assess me from head to toe with hostile green eyes that, had they not been restrained, might have attacked me as I approached.

“It’s Jerra,” she said, ice congealing on the words as they approached my ears.

I blushed. “I’m sorry, Jerra,” I stammered, embarrassed at my rash decision to modify it.

“And it’s Mrs. Tandill…” she added haughtily, refusing –or perhaps not deigning– to shake my extended hand.

The waiting room went quiet, all eyes on us, as she followed me reluctantly across what now seemed a long hike over the floor and down the corridor to my office.

Once inside, she glanced quickly at the sculptures, and plants, and repositioned the chair further from my desk. She did not want to be here, and was letting me know in the bluntest possible way.

“You seem uncomfortable, Mrs. Tandill,” I said when she seemed settled in her seat. “I’m sorry we got off to a rather rough start…”

“So am I, doctor,” she said, still glancing around disapprovingly at the art work hanging on the walls. “I am only here at the behest of my GP, you understand.”

I smiled, hoping to diffuse the tension, but her face didn’t change. She was an attractive, if severe looking woman. Dressed in a loose black silk dress that brushed the tops of her shoes when she walked, tiny silver hoops in her ears, and a matching silver brocaded scarf that hid her neck, she carried herself like royalty. Even her short, greying hair sat regally on her head like a tight-fitting crown, not a curl out of place.

And me? I was still dressed in my OR scrubs –albeit freshly changed- after an unscheduled 8 AM Caesarian section that made me late for the office. The stark contrast with her apparel and the thwarted expectations of how a new specialist should present himself may have stoked her anxiety with the visit.

“My GP says I need a hysterectomy,” she said, suddenly glaring at me like a vexed mother with her child.

I checked the very thorough history her GP had sent with the consultation note. Jerra had presented to her with postmenopausal bleeding, years after her periods had finished. She had sent her for an ultrasound which had confirmed that there was a thickened lining in the uterine cavity, and had even done a biopsy of the tissue. The pathology report of the biopsy did not find cancer, but rather an overgrowth –hyperplasia- that can be a precursor to cancer.

Jerra was still staring at me when I looked up from the computer screen. “Dr. Hannah gave me a copy of the pathology report, doctor,” she said, sternly. “And I researched it further.”

“And what did you find, Mrs. Tandill?” I needed to know what she had read before I could put the results into some sort of context for her.

Her body seemed to relax at being given an opportunity to discuss it, but I could see her face was still wary. On guard. “First of all, that there are several types of hyperplasia” –she pronounced the word very carefully- “… and that some types are further along the spectrum towards cancer.”

I nodded slowly, not wanting to challenge her interpretations unless warranted.

“The type that seems most predictive of cancer, is the abnormal hyperplasia…”

“Atypical,” I interjected, just so she’d know I was listening carefully, I suppose.

She managed a rigid, if fleeting smile. “Atypical. Thank you.” She referred to some notes she’d folded into her purse. “That word was not mentioned in the report, and I even showed it to a friend of mine -who is a nurse- and she agreed.” When I didn’t object, she lashed out at her GP. “I’ve been going to Dr. Hannah for several years now, and I usually trust her judgement, but I think she’s made a mistake here… I’ve never been on hormones,” she added as a kind of preemptive rebuttal of an accusation she expected to hear. “She says the biopsy may have missed a more… atypical area and so to be safe, I should have my uterus removed. You doctors always seem to want to remove things.” She settled back in her chair having made her case, and prepared to fend off the denial.

I took a deep breath while I decided how to approach the problem. I agreed with the concerns of her GP -at her age, there shouldn’t be much of a lining in the uterus at all, let alone one that was sufficiently thick to bleed. Something must have caused the hyperplasia. And yet, I could also understand Jerra’s anxiety. “I suppose our problem in cases like this is one of certainty, isn’t it? On the one hand, the pathology results as they stand could explain the bleeding and the ultrasound, but not with complete certainty. There could be some even more abnormal tissue hiding in a corner of the uterus that was not sampled with the endometrial biopsy…” I’m sure her GP had already gone over this with her, but it needed to be repeated. “And if that were the case, and we left the abnormal cells in place, we might all regret the decision later.”

She sat straight up in her chair shaking her head the whole time I was speaking. “Dr. Hannah kept saying the same things, doctor.” She sighed and stirred restlessly on the chair. I could see her clasping and unclasping her hands on her lap. “Let me be clear -as far as the pathology report is concerned, there is no cancer. I have…” she referred to a copy of the report in the bundle of papers again carefully folded in her purse. “… I have ‘simple hyperplasia’ –which, as I understand it, is far removed from the cancer end of the spectrum. I find it reassuring, and I fail to understand why you do not.” At this point she actually crossed her arms tightly across her chest and nailed me to my chair with an angry glare. “You’re looking at the same data as I am, and yet you are interpreting it totally differently,” she added, as if she were paraphrasing something she’d read online.

I smiled, again, but it did nothing to diffuse those eyes that searched for a permanent foothold on my face. “I suppose I’m just being careful, Mrs. Tandill. Experience teaches me that…”

“Medical schools teach you, doctor!” she interrupted angrily. “Mentors that have been through the same system instruct you how to think about these things.”

I sighed, and I’m afraid I was not very successful at disguising it from her. “Have you had any more bleeding –since the biopsy, I mean?” She shook her head dismissively, and I sat back a little on my chair, all too aware I had also been revealing my discomfort at her anger. “Would you feel better if I did another biopsy…? To confirm the first one?” I added this in hopes of walking the middle road between her wishful thinking that the biopsy was indeed reassuring, and at least not denying the possibility that it may have missed something worse.

At that point she got to her feet, still scratching at my cheeks with her eyes. “No, I would not feel better! You would probably continue to recommend biopsies until you found the result you anticipate, doctor, and I will simply not play that game with you.”

And with an angry shake of her head she turned and walked out the door.

But maybe she was on the right track; maybe compromise -the middle ground- only re-routes the problem and detracts from whatever the data purport to demonstrate. No matter the number of repetitions, an interpretation of the results is still required. And if the data warrant it, a stand on one side or the other must be taken and we must live with the consequences. I think there comes a time when we must disagree with Macbeth when he says to MacDuff ‘Damned be him that first cries, “Hold, enough!”’