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!”’

Time Enough

Time, the faceless tyrant that rules our lives like an absentee landlord, is so abstract, so opaque, it is difficult to grasp. It is seeing through a glass, darkly if at all. Enslaving everything within its reach it is an impartial despot. Dispassionate in its all-embracing realm, we are each of us imprisoned and there is nothing outside the bars.

Time is an aloof conqueror with no interest in our supplications, no ear for our protests, and no concern with how we define it, measure it, embrace it. It simply is, whether or not we choose to acknowledge its existence.

And yet the question of its perception has always intrigued me. Is Time truly an owner and we, powerless and abused, its hapless chattel? Or are we merely imprisoned by perspective -glasses half empty? But as we continue to drain the glass, there is an increasingly vexing thought: what is it we have drunk?

*

The patient population that are sent to see me seems to have aged over the years I’ve been in practice -or, more likely, the referring physicians have aged as well, and the phone number of my office surfaces easily in their heads, like habits, traditions -Canon law instituted in a more insecure epoch in their careers. But the accretion of age around me is instructive: I am more aware than ever of the differences in our apprehension of Time. Our repudiation or acceptance of its influence in our lives.

Nora was an interesting example of time-obsession. I say ‘was’, because I saw and treated her a few years ago and she has never returned to see me; I like to think it’s because she had no further need, but I fear the worst. A silver haired woman in her late eighties, she sat solid as a post in the waiting room, absorbed, it seemed at first, with inner thoughts. And yet, as I stood behind the front desk attending to another task, I noticed her eyes darting about the room like bees investigating a busy field –alighting first on a child crawling on the floor then moving on to a bright but enigmatic picture hanging near the door. A woman busily turning pages of a magazine near the window was next, and then the little boy playing noisily and impatiently with a smartphone waiting for his pregnant mother to return from the washroom down the hall –little escaped Nora’s scrutiny, and yet she was a statue. Nothing else about her moved. Her black, floor-length dress might have been painted on, the golden bracelet around one of the wrists that rested in her lap was still and as yet ungleaming. Even her face was a calm mask revealing nothing –the only hint of serenity in the busy room. A place of refuge in the roiling world.

She was no different in the office at first. She sat quietly in the chair across from my desk and unleashed her eyes again to explore the room, the furniture, and then, almost as an after thought, me. “The terracotta lady in the corner…” She turned her whole body to stare at the sculpture as if her head and neck were welded to her shoulders as a unit. “…It has some coins scattered around it.” She turned once again to look at me, this time disapprovingly. “Am I supposed to feed it?”

It was an effigy of a woman with a begging bowl that someone had given me and it was beginning to accumulate coins for some reason. I smiled and shook my head. “I meant it as an ornament for an otherwise boring corner but…” I shrugged to indicate the coins were merely accidents.

“Guilt is something I outgrew years ago, doctor,” she said with obvious concern that the the terracotta lady and her bowl were put there to supplement my income.

I wasn’t sure if I was supposed to reply, but her eyes seemed intent on interrogating my face. “Time smoothes things out, doesn’t it?” It was a trite comment and I’m not sure why I even said it, but her expression changed immediately.

“After all my years, do you think it cares how I feel?” This time I decided to say nothing; she seemed angry about something. “We are its slaves, after all…”

“Slaves?” I thought maybe allowing her to vent would enable me to ask her why she thought she’d been sent to me. I’d read the referral letter, of course, but patients often understand things differently from their doctors.

She stared at me as if I were a little slow. “You wouldn’t understand, doctor. A woman is a slave to many things, and Time is no exception.” Her eyes continued to crawl along my face looking for a reason to continue their search. Finally, they returned to their home and she shrugged, as if the territory they had explored was not a threat. “Think about it,” she started carefully, the words slowly assembling inside her mouth. “Most of our lives we are calendars, ticking the months off from period to period, our hopes and fears captive to whether or not it arrives on time, our lives inextricably entwined with its schedule.”

I have to say, that the obvious is sometimes invisible –or at least disguised and camouflaged in the background. I hadn’t thought of the exigencies of Time on a woman being recorded like that.

“Males,” she continued, “are not subject to the same calendar. Time passes, for sure, but there is usually no need for it to be regimented in little orderly blocks. It is a different animal for you…” Her face softened and her eyes stopped moving. “Still a demon, perhaps, still unkind, but less constantly in your face.” She sighed, but visibly. Audibly. “It is a different Time.”

I wasn’t certain what to make of her idea –wasn’t certain how to turn the conversation towards the reason she had been sent to see me- but I was fascinated all the same. Maybe how we perceive the allotment, the measuring stick, changes something. She had been sent to me for the investigation of vaginal bleeding –abnormal and unexpected bleeding, to be sure, but nonetheless it was a calendar waved in her face once more. Something she had thought was long destroyed, was back to plague her yet again. As Hawthorne said, ‘Time flies over us, but leaves its shadow behind.’

Well, I suppose it does… but I am rather more drawn to the view of Rabindranath Tagore: ‘The butterfly counts not months but moments, and has time enough.’

I hope that Nora did, as well.

Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.