Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

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: http://annals.org/article.aspx?articleid=1884537

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?

http://www.2minutemedicine.com/new-acp-guidelines-recommend-against-regular-pelvic-exams/

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..?