Facing up to the Medicine

There is something magical about a face. It is at the same time familiar and yet mysterious. And although it contains many parts with disparate functions, these are somehow secondary. We see the face as a unit, then judge the components; it is a face first, and only subsequently an aggregation of details. It is the whole which imparts meaning, stirs emotion, engenders response. Only then do the ingredients surface. As St. Jerome said: ‘The face is the mirror of the mind, and [the] eyes without speaking confess the secrets of the heart.’ So I suppose it should come as no surprise that development of reliable facial recognition technology is considered so important. http://www.bbc.com/news/technology-33199275

But there are other domains in which it matters, too. Less technical perhaps, and yet more intriguing. Sometimes it’s not just the perpetuation of facial patterns enabling recognition from encounter to encounter that garner attention so much as a metamorphosis of something far more elusive, far more difficult: the ravages of age. There is something about a face that transcends Time itself. We are recognizably who we are despite the years: My comfort is that old age, that ill layer-up of beauty, can do no more spoil upon my face, as Shakespeare has King Henry V say.

Of course we all suspect we have escaped; daily visits to the mirror cannot see the change any more than frequent glances at a clock can spot the hour hand’s slow progress. Whatever we suppose Time to be, and however we conceive of its passage, barring the before and after of catastrophic events, its gait is not fixed, nor its effects on us often noted from day to day. We mostly live our lives in relative time, and adjust our expectations so gradually they are only apparent to others who happen upon us after long and unexpected intervals. And even then, unless confronted, go unspoken by and large -undescribed, unless in favorable terms.

*

The woman on the other side of my desk looked familiar -in the way some new patients seem to do; I could almost place her. Almost… I see a lot of people –some more frequently than others, to be sure- and yet after a few months or years of absence, even those with whom I’ve had extended exposure tend to generify. Recognition often requires initiation on their part. Prodding. Reminiscing… The encounter often ends with embarrassment or pretense on my part, disappointment on theirs, degenerating into an inadvertent charade for both of us. I don’t wish it so, but alas, I have not been blessed with an eidetic memory of faces past.

Of course, it’s easier to recall some people. They adopt a position on a chair that begs for remembrance, or a way of holding their head that is unique. With Sally -the name on my computer daysheet- it was her face. I tried to analyse what made it so memorable, as I sorted through some papers on my desk. Her eyes? They were brown and calm –they did not seem hunters at the moment, nor imprisoned behind long lashes; not deep set in shadows, not  hiding behind thick distorting lenses. In fact they were far from striking or even distinctive. Her nose was neither large nor mishapen, and her mouth seemed to sit comfortably in its alloted place and smiled only when appropriate, if infrequently.

She noticed me sneaking glances at her as I pretended to play with the keys on my computer, and sighed. “You’re trying to remember, aren’t you, doctor?”

Her voice, too, was familiar, and yet only vaguely so. She was like some book I’d read years ago, whose style and mood, were immediately recognizable, and yet the story, and the ending, were obscure. Tantalizingly close, but so far irretrievable.

“You haven’t changed at all from the first time I met you,” she said, painting my face with her eyes. “Hardly any grey in those curls, still no wrinkles, and that unmistakable look of innocent puzzlement whenever the focus is deflected back onto you.”

Why would anybody remember that? I smiled to diffuse my discomfort.

“Same smile, too,” she whispered, sitting back in her chair triumphant in her recollections. I was evidently who she expected to find -the one she had remembered. Her memory had served her well so far and her face was celebrating.

Who was this anyway?

She straightened up in her chair and sat forward slowly. Deliberately. “I know I’m just here for a pap smear, and you’re a busy man, doctor, but given our history, would you mind if I asked you a personal question?”

I hate it when somebody says that. A polite request usually demands a courteous acquiescence -especially when an unrecalled ‘history’ is offered as a reference.

I nodded, but tried to indicate by my expression that I was only doing it to be –what?- polite. My forehead, I’m sure, made my point.

She noticed, and a tiny smile escaped, ran across her lips, and disappeared on the other side. I could see her amending her question on the fly. “I’m sorry, I didn’t mean to embarrass you. It’s just that you look so much the same as I remember from that first time… It’s uncanny, really.” She leashed her eyes for a moment to study my reaction. I could feel them trying to peel information off my face as they sat, hooded and dangerous on the edge of her thoughts. “I’ve been trying to figure out what it is.”

“Probably the scrubs I always wear,” I said, trying to be funny I suppose.

She shook her head and tried out another smile. “No… I don’t think so.”

Something about the varying texture of her smiles and how they each pulled differently at her eyes, caught my attention and a memory –a shadow, really- flitted like a ghost just out of reach.

A new smile, thin and toothless –an unasked question smile- appeared like a figure glimpsed through a thick gauze curtain, only to disappear again before adequate identification. She was beginning to unnerve me. But suddenly, like opening a gate, everything rushed out.

She took a deep breath and straightened herself on the chair as if she were about to answer a question in class. “I… I asked to see you for a reason, doctor. The pap smear was just an excuse…” She looked past me to stare out the window for a moment, obviously uncomfortable. Embarrassed.

“My midwife sent me to you for an urgent consultation twenty-two years ago. It was my first pregnancy and I wanted so much for everything to go smoothly –you know, home delivery, no pain killers… Anyway, one day Maryanne told me I had to see a specialist. I wanted to see a female, but for some reason I ended up with you.” She glanced at me to see how I was reacting, and then, reassured, continued. “I remember you were very nice, but you said there was not enough fluid around the baby and that it wasn’t growing so you wanted to induce labour right away. You asked me if I had any questions, but I was only thirty-two weeks along in my pregnancy then so I panicked and ran out of the office. I phoned the midwife and she assured me you had a great reputation but I didn’t believe her. I couldn’t. I was sure you were a fake, so I drove back to Surrey where I used to live. I wanted to think it over. But that night I went into premature labour and they had to deliver Melissa there by Caesarian section.

“She was quite sick when she was born –she spent more than two weeks in their nursery,” she said, wringing her hands as if it had all happened yesterday. “And you know, for some reason I blamed you. Like, if you’d decided my midwife was wrong, everything would have been okay…” She sighed and wiped away a tear. “Weird, eh? Hormones, I guess, because then they had to hospitalize me for depression. I was so paranoid I couldn’t think straight for months…”

She took a deep breath and another, different, expression surfaced. “Have you read any Oscar Wilde, doctor?” She asked, her eyes suddenly cold.

I nodded –but carefully. I had the uncomfortable feeling I was being led into a trap. “The Portrait of Dorian Gray?” she asked, her voice now soft and apologetic.

I steeled myself. It was the story of a hedonistic and dissolute man who remains handsome and young while his portrait –stored in the attic- ages and reveals all the evil he has committed.

“At the time, I thought of you as Dorian Gray,” she said, now inspecting her hands tightly kneading her lap. “All show, pretending to be kind, but all the while not caring what I really wanted… Really needed.” She shook her head slowly –maybe she did that when I saw her that time so very long ago. I don’t remember. “I apparently phoned all my friends and told them to stay away from your office… I hated you when I was sick… I tried to spread rumors…”

Well, at least it was Dorian Gray and not Jekyll and Hyde she’d read… Small comfort, I suppose.

Suddenly she sat up and leaned across the desk to grasp my hand. “But it was my portrait that was up in the attic, wasn’t it? It was me all along that was the fake.

“You know I’ve waited all these years to tell you about it -to apologize… but I was afraid.”

I squeezed her hand as a tangible acceptance of her apology and sat back trying to think of something to say to diffuse the mood. “And Melissa? How’s she doing now?”

Yet another smile surfaced briefly, changed its mind for a moment, and then re-emerged as a gigantic grin. “You delivered her baby a couple of  years ago, doctor. I was sitting in the far corner of the delivery room in the shadows for most of it, afraid you’d recognize me. I remember you kept looking over at me –wondering why I wasn’t standing beside my daughter. I didn’t quite know what to do. I kept trying to smile, but I was so ashamed, the smile kept disappearing…” She looked at me quizzically for a moment. “Did you recognize me?” Her face knotted up. “I have to know…”

It was my turn to smile this time. “No…” I said slowly, unable to suppress a blush at my failing memory. I hope that made her feel a little better. And yet, although I hadn’t recognized her then, I realized what had puzzled me about her today: she was wearing the face of a woman I’d come to know quite well; she was her daughter but through a glass darklyThe time is out of joint- O cursed spite, that ever I was born to set it right!” said Hamlet. It felt like that…

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Another Advantage of Breast Feeding?

As Mark Twain observed: What a good thing Adam had- when he said a good thing, he knew nobody had said it before. I don’t know about you, but I am getting tired of the media reporting on studies that contain nothing new and passing them off as fresh and enlightening. Even more upsetting is the fact that we often don’t even notice -or care… Studies that say nothing fresh or merely recycle what we already know, do not contain information so much as noise.

Time, then, to ask a more searching question: why is it important that we study this? And this is not to denigrate pure science, nor to suggest that investigations that are not directly goal-oriented are worthless. There is much value in answering the question by asserting that we were simply curious how it worked. Or why. Or under what circumstances -all of which are adding to our understanding of the world. Curiosity, after all, is merely a yet-unaswered question. A piece of the knowledge jigsaw puzzle. And its answer may well be worthy of reportage…

But to investigate the wheel and then conclude that it likely works by rolling, does nothing to inform. Indeed, publication of the results does little even to entertain, let alone educate… Or perhaps it does entertain -like those endless cat videos on Youtube, maybe there is value to a mindless occupation of the time that stretches between otherwise meaningful events. But the whole endeavour smacks more of playing cards until someone turns out the lights…

What is it that has me so vexed? So frustrated at banality uncleverly disguised as news? Well, I happened upon an article in the BBC ‘News’ about breast feeding and how it decreased the risk of depression.  http://www.bbc.com/news/health-28851441   It seemed a reasonable hypothesis; almost 14,000 mothers were studied and the results published in the online journal Maternal and Child Health (Aug. 21/14).

It’s a rather complicated statistical paper, but in summary it suggests that the risk of depression after delivery decreases considerably  if the mother was healthy to start with, intended to breast feed and found that she could. Okay, I could have predicted that. But, if she had been healthy, intended to breast feed, but found she couldn’t for some reason, her risk of depression more than doubled. Oh yes, and they found that  “the beneficial effects of breast feeding were strongest at 8 weeks after birth and that the association was weaker at  8 months and onwards.”  Uhmm… am I missing something here? Has something hitherto unsuspected slipped past me? Something, at least, that would change attitudes to breast feeding, or management plans for pregnancy?

Post partum depression is a serious problem in our society, with up to 10% (or more) of women at risk. That’s why we screen women during early and mid pregnancy to anticipate that risk and attempt to set up support systems for those who we judge are on that path. Anything that might ameliorate the danger is therefore a valuable addition to our management strategies. I’m not sure this study has even re-invented the wheel, however. It seems to demonstrate that if a mother’s plans work out, she is happy, if they don’t, she isn’t… Is it helpful to know this? Perhaps -but does it change anything? I suspect we will all continue to encourage mothers to breast feed and regard the oxytocin it engenders -the bonding hormone- a plus. But not an unanticipated one. Nothing has changed…

But then again, maybe constant reiteration –permananent recycling- is what we want. What we deserve…Maybe a society that tolerates laugh-tracks on comedy programs to help them to know what is funny, and that thinks apparently spontaneous applause in a talk show demonstrates the merit of the discussion, needs to be apprised of the obvious.

Am I being too cynical? Too arrogant? Well, perhaps. And yet…

It was early Thursday evening, and I was sitting in the OR lounge waiting to do an emergency operation. A surgeon and her resident were sitting nearby, their faces glued to the ever-changing TV images in front of them. I thought at first it was a talk show but they were staring at the screen as if it were a parental avatar, their expressions religious, their attention rapt.

I had been too preoccupied until that point to notice, but they seemed so intense I suspected something of profound significance was being discussed so I turned to watch. It was actually a cooking show and some celebrity that I didn’t recognize was being shown the basics of barbecuing a hamburger. “First, you want to get the grill good and hot,” the serious looking man in the chef’s hat was saying, pointing at the thermometer on the hood. “Then, you carefully place the patty on the grill –use a spatula with a long handle so you don’t burn yourself- and sear one side just enough to keep the juices sealed in…” He said this in a hushed and reverent tone as if it were one of the Ten Commandments. The studio audience clapped in delight at this little pearl of wisdom, and I noticed the surgeon restraining herself from doing the same. Her resident, ever mindful of imitative protocol, actually did manage a clap after glancing furtively at her mentor.

The surgeon suddenly became aware of my presence in the room and smiled with an expression I used to see in church after a sermon. She seemed surprised at my composure in the face of the Revelation. Or maybe annoyed that I hadn’t understood. Actually, I was disappointed; I felt as if I’d just been told the earth was round.

And it wasn’t even the vapidity of the program that made me remember the incident –maybe some people don’t know how to barbecue hamburgers, so maybe the show deserved prime time. Maybe the information it contained truly was important and not just another example of mildly entertaining celebrity fluff. Not having watched what went before, perhaps it was just an inter regnum… But no, it was more the reaction to it. The surgeon and her acolyte seemed overly awed by its significance -as if they wouldn’t have been at all surprised if it were the subject of a research paper in a prestigious journal.

I suppose the depressing reality is that it is me who is so far off-kilter that I cannot appreciate something of value. That I mistake the important for the banal. Knowledge for noise. But I can’t help wondering who decided that a celebrity learning how to cook a hamburger should occupy prime time. Or wondering why a study showing that people may get depressed if things don’t work out as they planned surprises anyone.

We all need a time out, for sure: a time when we just unbutton the brain and let it sit on the couch beside us eating popcorn. But surely we also need a time in. I’m with Shakespeare on this: We know what we are, but know not what we may be.

 

 

Postpartum Depression -Just words?

Postpartum depression -I know these are only words, medical words, I suppose: descriptors. Language. But for all we’ve done with these particular words, what little attention we seem to have paid to them, they are still only words. And yet they describe a condition that has dogged us for millennia: the darkness that follows pregnancies like a silent shadow.  Creeping quietly in the background, it bides its time, stalks its prey. Camouflaged, it is visible only if you look carefully along the trail, study the  subtle indentations where it hides, part the branches of its lair. It’s always there. Lurking. Waiting.  And given the opportunity -a gift of circumstance perhaps, a melange of genes, a naivety of observation-  as the brilliant light of birth is slowly extinguished, it rises suddenly from the shade and pounces like a hungry cat.

It bothers me that we pay it so little heed until it strikes; that we read the cover of its book so well and then, seduced by the play of colours on the top, miss the message written clearly not so deep within. We act as if it were a surprise that things are not always as they seem; that we all have shadows if we dare to look behind.

There are quite a few tools -questionnaires, by and large- that have been designed to help doctors and midwives anticipate most perinatal problems long in advance. The problem, of course, is in according depression sufficient importance. We are too often focused on measurements in pregnancy: weight, blood pressure, the amount of protein in the urine sample, fetal heart rate, growth of fetus, position of baby –real things, objective things. Important things to be sure. Most of us feel more comfortable in writing numbers and words in their proper columns and following the trend; understanding and charting the ongoing fetal development: Ontogeny recapitulates Phylogeny as they taught us in medical school. There’s a certain comfort in the dispassionate assessment of what we take to be an objective, measurable reality. There are rules.

Emotions on the other hand are mysterious; we hardly understand ourselves, let alone the vagaries and vicissitudes of the moods, coping mechanisms, or even guiltily-expressed thoughts of our patients -their words on exhibit, but weeks apart on consecutive visits. On some of those occasions they’ve had a hard time at work, or have argued -are maybe even arguing in the office- with their partners; they’re polite, but only on the surface. Other times they’re all smiles -or all questions… Sometimes they never even get a chance to speak- just the partner. But I think that these are clues to an observant midwife, or doctor -even if the various screening strategies (such as the Edinburgh Postnatal Depression Scale, for example) have not been utilized. They are certainly helpful in gauging the amount of anxiety the woman is feeling, the attitude she has to her partner -or vice versa- and the amount of support she is receiving at home… all contributors to possible future problems.

Some of the clues -the postpartum ones at any rate- are revealed by simply asking the mother if she has been feeling down, depressed or hopeless of late, or if she has been finding that she is losing interest or pleasure in doing things. If she answers yes to either, then does she want or need help in dealing with it? The questions are asked sensitively, casually, and with no hint of prejudice or blame. They are not traps to assign the stigma of mental illness, nor to criticize her ability as a mother.

I am fortunate in my center to have a Reproductive Psychiatry program that is interested in assessing pregnant women and their risks for developing adverse postpartum mental health issues. They come up with strategies -not necessarily medication- to help, apprise her of facilities available in the community and ensure that the mother is in the system should there be problems. The woman knows where to go for help if she needs it.

I try to identify the risks both from history, observation, and direct questions as to whether they feel they might benefit from someone as well as me to talk to. I usually stress that it is better to be prepared beforehand than caught unawares. I try help them to understand that it is as much for the baby’s well-being as their own. Once the patient realizes that the referral does not mean that I think they already have mental problems, and that they won’t be pressured into taking antidepressant medications with their possible -yet controversial- effects on the fetus, they usually accede to my concerns. Caring for a person, means more than entering their data in a chart… Words, even in the correct columns, only go so far.

Words are signs, signals in the void that separates us all: little lights… and sometimes they’re really all we have. They’re among the few things that touch us deeper than skin; they often tell us more than we can take in with our eyes. But only if we listen.

Words

Are more than billboard signs,

Lined up

Along the road;

More than pictures

Hanging

On a wall.

Although

They can be pretty

As a group,

Perhaps

It is an accident of birth

That any one of them

Alone

Has more than a passing flair.

But

Each one

Is a suitcase,

Opening…