The Trigger Warning

Call me naive, if you will, or maybe even uninformed, but not insensitive. Not indifferent; I am neither.  Unaware, perhaps comes closest. And, until recently, the concept of trigger warning was not one that I thought would have arisen in the day to day world of office gynaecology. But I was wrong.

A trigger warning, I have since discovered, is an alert to the audience (or patient) that what you are going to say might inadvertently offend or upset them –especially if they had experienced a related trauma. Theoretically, at least, it gives them an opportunity to prepare themselves beforehand, or inform you that they would rather not hear that part of your discussion. Many university lecturers have taken to issuing these warnings in their preparatory notes, or at least at the beginning of their lectures, I understand.

And at first glance, it seems the reasonable thing to do. If something in the lecture might offend or distress some students, then they should have the opportunity to opt out of that particular lecture without punitive consequences. On the other hand, to withhold some of the contents from the entire class in case it offends someone, seems like censorship. So I think that a prophylactic warning beforehand is in everybody’s best interest.

I suppose it could get out of hand, however.

Jennifer was a patient that I had seen for the first time in the hospital colposcopy clinic for  a rather long history of abnormal pap smears. I had looked at her cervix through a colposcope (a microscope with a long focal length so it can visualize the cervix even high up in the vagina) and biopsied an area that was likely responsible for the pap smear change; she had come to the office to discuss the findings.

A young woman in her late twenties, she seemed quite self assured as she sat quietly in the busy waiting room reading a magazine oblivious to the noise around her. Dressed in black designer jeans and a baggy yellow sweat shirt that said ‘Really?’ in bold blue letters, she looked capable of weathering any disturbance. But, as absorbed in the intricacies of the magazine article as she seemed, her eyes immediately locked on mine when I appeared in the room. Brown, curious eyes, as I recall; eyes that, once engaged, held their target until it turned away –or responded as I did, with a proffered hand.

When we were settled in my office, and she had inspected the room, a sudden and unexpected smile appeared on her face. It was, I suspect, an attempt to force me to give her good news about the biopsy. “So what did you find, doctor?” she said, with a lilt in her voice.

It’s often difficult to discuss an abnormality with someone who seems sure that nothing is wrong. Obviously her GP had chosen not to. “Well, you remember that the pap smear that brought you to the colposcopy clinic in the first place was abnormal…”

“Yes,” she interrupted, “but it was only mildly abnormal…”

I smiled in what I hoped was a reassuring fashion and nodded. “Pap smears are an early part of a screening system that helps us to decide whether or not to investigate further. They’re just cells that we collect by scraping the surface of the cervix after all.”

Her expression immediately changed and her previously cheerful face tightened. “What are you trying to tell me, doctor?” she said, and straightened in her chair. She stared at me for a moment, but before I could formulate an answer, words tumbled from her mouth. “Do I have cancer? Is that why you brought me in today instead of letting my GP tell me?”

I kept my eyes calm, and shook my head. “No, far from it.” Once someone has used the C word, I often find it’s important to disavow them of it immediately or it festers in the background. “You have a moderate abnormality on the biopsy I took.” I avoided using the Bethesda system’s alternate label of ‘high grade’ to help her to process the news. “It’s definitely not cancer, but if you left it for a while, it might certainly take that route…”

“Left it how long?” she asked, trying, unsuccessfully, to keep the panic out of her voice.

I shrugged, to show her that I wasn’t particularly worried. “Years, likely… but we usually treat it soon after we diagnose it… Just in case.” I added thoughtfully.

Her eyes were dinner plates and her mouth was trembling; I thought she might burst into tears, so I handed her a tissue.

“And… How do you treat it?” She managed to look out the window behind my back for a moment. “Surgery?”

I nodded reassuringly. I was about to describe a small five or ten-minute operation we do in the outpatient’s department under local anaesthetic when she exploded in tears.

“I will not let you take my uterus out, doctor!” she said between sobs. “We’re trying to get pregnant!”

“I won’t let me take your uterus out either, Jennifer,” I said, trying to lighten her mood, I guess. But it backfired.

“You seem to be taking this whole thing rather lightly, doctor. I would have hoped you would be more sensitive…”

My face fell. “I’m sorry, Jennifer. I was just trying to reassure you that removing your uterus was not the kind of surgery I had in mind. It was a rather clumsy attempt, though. I’m sorry…”

Her forehead softened and she grabbed another tissue and relaxed a little on her chair. “Remember, we want to get pregnant soon,” she said, her words tentative now. “We’ve already lost one… I had a miscarriage last year,” she added hastily for fear I might not understand. She stared at me for a moment. “Could I wait till after I’ve had a baby and then do the surgery?

I looked at the findings from the colposcopy once again. She had a rather large lesion and the pathology report suggested that some areas of the biopsy might be more severe -not cancer, but certainly meriting treatment. “You always have a choice, Jennifer…”

“But…”

I realized she probably felt there might be different opinions for management so I sat back in my chair to show her I was willing to listen, but she just continued to stare at me with a mixture of anger and disbelief on her face. “Would you like me to ask your GP to send you to another gynaecologist for a second opinion?”

She didn’t say anything, so I decided to describe the operation I usually perform for her abnormality: a LEEP (Loop Electrosurgical Excision Procedure). It involves taking the abnormal cells off the cervix by removing a thin disk of tissue. I drew on a diagram of the cervix and uterus as I was describing it so she could understand it a little better. I even gave her the diagram to take home with her.

As I was finishing, she looked up from the paper and locked eyes with me again. “And the complications?  Am I going to be able to have children?”

I smiled at her again. I had been about to discuss possible complications with her. “Well, hopefully it won’t interfere with that, but if you look it up online, you’ll see a few complications listed. In my experience they’re not very common, though.”

My attempt to put the complications into some kind of perspective for her obviously didn’t reassure Jennifer. “What are they?” She said, rather harshly I thought.

“Well, in pregnancy, the cervix has to remain strong enough to hold the baby inside until it’s ready. If too much of it is taken away with the surgery, then it might open prematurely –incompetent cervix it’s called- and the pregnancy might be lost…” Her mouth fell open and her eyes narrowed. “But,” I continued before she could say anything, “nowadays that first ultrasound you get in pregnancy can look at the cervix and pretty reliably reassure us that it’s not likely to happen.” I kept my face as neutral as I could in an attempt to disarm her growing distress. “And if it seemed likely that the cervix was shortening, or if we discovered a problem later in the pregnancy –the baby’s a lot bigger then, remember, and so it exerts more pressure on the cervix- we could put a stitch called a ‘cerclage’ around the cervix to keep it closed. Then, near the end of pregnancy when the baby is old enough to be born safely, we untie it…”

She could barely speak, she was so angry. She glared at me through predatory eyes and then, with clenched teeth and a barely open mouth, she managed to say something. “You know, I’m really disappointed in you doctor! With all your experience and with all I’ve heard about you, I’m really disappointed.”

I suppose my expression changed to one of puzzlement –astonishment, really- because she immediately began to put on the coat she’d kept on her lap.

“You knew I’d had a miscarriage –it’s on that form I filled out in the hospital for that clinic. And I told you here in the office just a minute ago. You could see I was worried, and yet you still kept talking as if it was simply business as usual…!” She grabbed another tissue and dabbed both eyes again. “I had a hard time recovering from the pregnancy I lost… But you didn’t care!”

“I’m sorry… I…” But she wasn’t listening.

“Any doctor who was sensitive to their patients –anybody for that matter- would have known to give a trigger warning…” she said and stood to leave. “I’m going to ask my GP to send me to someone more empathetic,” she said and turned on her heel and stomped angrily out of the office.

I felt terrible too; I felt I’d failed her -even though there’s no easy way to tell people things they don’t want to hear. Thinking back on it, I suppose I was insensitive to her needs. And yet…

It’s hard to be anything but humble in this field…

 

 

Autism and Obstetrics

I’m an obstetrician caring for worried mothers. They’re worried about things that might put their developing foetuses at risk for a whole range of issues and ask me for advice. Obviously I’m neither a paediatrician nor a child psychologist, so questions about autism leave me alone in troubled waters. There are so many rumours of risk, so many studies that seem to implicate everything from diet to anaerobic exercise in pregnancy, vaccinations to mercury in calcium supplements.

I wish I knew more about autism; I wish I knew anything indisputable about it… Well, that’s probably a bit harsh. I know that it’s now referred to as ASD (Autism Spectrum Disorder) and that it’s a neurodevelopmental disorder with problems in at least two areas: social impairments –things like communication and interaction- and behaviour abnormalities like repetitive patterns of  activities and that sort of thing. But it all seems rather vague. Especially the social components. At the severe end of the spectrum it’s an unmistakable impairment, and yet at the milder end…

http://www.ninds.nih.gov/disorders/autism/detail_autism.htm#268283082

It may be a sensitive set of criteria that bundles all the right things in it, and yet it’s rather spotty on the specificity. An example might help. Let’s say you’re a fisher and you want to improve your ability to catch salmon so you’ve designed a special net. You pull it up and there are a hundred fish in it, so it works –it catches lots of fish, but only one salmon. But, it did catch a salmon so it’s sensitive for salmon, but not very specific for them.

I also know the DSM-5 criteria of ASD –I’ll quote them from a more readable source: the 2014 UpToDate data base we have in our hospital. ‘ASD is characterized by 1. persistent deficits in social communication and interaction (eg. deficits in social reciprocity; nonverbal communicative behaviors; and skills in developing, maintaining, and understanding relationships) and 2. restricted, repetitive patterns of behavior, interests, or activities.’ They also say that the symptoms must be present early in childhood development, but may not become manifest until social demands exceed limited capacities. And there are three levels of severity rated separately for social and behavioral characteristics.

Okay, I understand those criteria –sort of- but coming from a medical specialty that is used to more concrete, objectively provable, and investigatable symptoms, they still seem rather vague. And there remain the difficulties that I have with including the milder, vaguer, less impaired end of that Bell curve distribution of characteristics –the end that may include variations of normal, idiosyncratic behaviors which may represent other issues –parental, social, even poverty-related stresses that might impinge on the child’s behavior.

I suppose it’s the boundaries that trouble me. There seems to be a wide variability of the reported prevalence of ASD and some indication that it is increasing of late, perhaps related to changes in definition as well as increased awareness. But how valid is that?

I’m all for increased awareness of ASD, just as long as we can be sure it is ASD that we’re aware of. This is important for interpreting the studies that purport to assess various causes of autism. For example, a BBC article reported a study from the Harvard School of Public Health which implicated air pollution as yet another cause. But, as the article suggests: ‘Experts said pregnant women should minimize their exposure, although the link had still to be proven.’

http://www.bbc.com/news/health-30521255

Good advice, I’m sure –pollution likely has many adverse effects on a developing foetus. One more wouldn’t be much of a surprise. Avoid pollution when you are pregnant by all means. But place that in the context of a pregnant woman who lives in a city where she cannot avoid it, and then add the additional worry of a possible link to autism in her unborn baby and you have sewn the seeds of an intractable anxiety. Helplessness. Despair. The fact that it is as yet unproven gets buried in the message; the statement that it is biologically possible does not.

As the aforementioned UpToDate 2014 data concludes: ‘The pathogenesis for ASD is incompletely understood. The general consensus is that ASD has a genetic etiology, which leads to altered brain development, resulting in the neurobehavioral genotype. Epidemiologic studies indicate that environmental factors account for few cases.’

I realize that there is a fine line between informing the public, and frightening them unnecessarily (or inadvertently), and I recognize and accept that we should all have the right to know what is being said in scientific circles about topics that affect us. Clearly it is difficult to balance whether or not to publicize information that is still in the process of being assessed and integrated into a coherent and testable theory, versus information that has been collated into a more accepted and validated model, but I think it would be a sensible, albeit challenging, step. It is a serpent’s egg, and reminds me of the warning of Brutus in Shakespeare’s Julius Caesar: ‘a serpent’s egg, which, hatch’d, would as his kind grow mischievous.

I’m certainly not advocating censorship –maybe just awareness. Prudence… Judgment.

On Remembering Faces

Faces are important; they are like little signs we wear to allow others to recognize us. Unlike, say, fish they are distinctive and carry verbal labels further enabling meaningful categorization. A face without a name begs inquiry; a name without a face, recollection or even retrospection…

In a way, remembering faces is a sign of respect: you have had dealings with them; they had temporal significance for you; they were and remain important. And in standing out from the crowd –egregious in its original sense of standing out from the herd- there is a bond, however tenuous. I passed a smile in a hospital corridor the other day and I mistook it for agape: that look we donate to total strangers that we pass like ships. And I saw the look of disappointment and saw her whisper something to her partner who glanced at me as well. She stopped and turned a few steps past me and addressed me by name. And even when she explained that I’d operated on her mother a few years ago, my recollection of the event remained wrapped in cloud. Overcast.

Some people have the eidetic skill of instant recognition and with that identification the story of the paths they shared, along with the appropriate assignation of adventures encountered along the way. It immediately sets both parties at ease; there is no awkward pause, no need for hasty explanations of how each was once significant to the other.

But recognition is a blessing not equally bestowed. There are times for many of us when a chance encounter contains as much information as leaves on a tree, and an individual is as anonymous as a fallen twig. I cast no aspersions, but memory has a way of defocussing details, melding them into a delicious stew of once-tasted dinners. Or am I making the mistake of assuming I am representative of the average other? A mental excuse: an inadvertent equivalent of psychological projection?

I have been in medical practice for many years now; I have encountered myriad people along the way, delivered uncounted thousands of babies -maybe I do have an excuse… And yet to forget a face that greets me on the street -a face with which I have had a nine month relationship, perhaps- still seems rude. Insensitive. The fact that it may have been ten years ago -or more- has not dimmed their memory of the relationship and its consequences. The child at their side refusing eye contact with me is an integral part of their life -one they shared with me long ago. They live the memory; I claw desperately at the door of a cupboard where I have stored the files.

Some faces I remember, of course: some people have a way of welding their identity onto the shelf -forever distinct, immutably present and on display. They are the caffeine of memory, but like dessert, uncommon at most meals.

Now I have to admit that most people are interesting, and all are distinctive -or seem so- at the time. Even the most obnoxious patient sows her seeds; recollection depends not so much on the quantity as the quality of the experience. And it may not be a two-way street. We all walk at different speeds, and touch with different skin. We may hold our expectations in common -there are some universals that seem self-evident- but our perceptions are uniquely our own. We, alone, wear them, feel them, live them… They are why we take home different messages -patient and doctor. They are what individuate us. Separate us…

But I would still love to return the unsolicited smile of remembrance with a look of wide-eyed honesty.  I need a book somewhere inside with a specially marked page that I could read and interpret quickly enough to make it seem that her face was never stored in the bottom of some pile; that she, at least, was special. Unforgettable.

But my guilt shines through each time I pass; I hope they understand I don’t mean to forget. But oh, it presses to my memory, Like damnèd guilty deeds to sinners’ minds –Shakespeare understood, I think… Even if I’ve forgotten the context.

Baby Boxes

Baby Box. The term itself is innocuous enough -cute, even- but the controversy it has engendered is far from benign. The concept is a simple one: instead of abandoning an unwanted baby, it is possible to leave it safely and anonymously in an incubator, often associated with a hospital, and usually inconspicuously accessible via a little door outside. At my hospital, when that outside door opens an alarm rings at the nurses desk, but it is delayed for 3o seconds or so, to allow the mother to leave and remain anonymous. The UN Committee on the Rights of the Child is asking for them to be banned, at least in Europe (where they are legal in many countries and available in many others), ostensibly because they violate children’s rights to identify their parents.

A German pastor, Gabriele Stangl, seems to have come up with the idea of the box in 1999 in response to the killing of a baby by the distraught mother. I find it hard to argue against the concept of such a refuge but because of the UN concern, perhaps it merits further analysis.

The argument that a child has the right to know its parent is a reasonable one, and yet it assumes that the child in question survives to ask the question. One implication therefore is that the problem lies not so much with the Baby Boxes, as with the need to abandon the baby in the first place. Unplanned pregnancies with the attendant need for contraception, health care programs available for all and social policies that care for people unable to survive otherwise… These, rather than the embarrassing Box that exposes the issues for all to see, are the real problems, so I suspect that the thrust of their argument rests on the need for psychologic, social and medical support for the community in general -and the mother in particular. But these services must not only be available but also accessible to all who require them -in other words, in a culturally and socioeconomically acceptable format that will not threaten those so marginalized that they have dropped out of other well-intentioned public and community programs. Sensitive, in other words, to their needs, however disparate from the norm.

And this is a tough sell to people who have learned not to trust the System with all its bureaucratic and legal constraints. They have realized there is usually a price to pay, whether in pride or criticism of a way of life they had not intended. The prejudice runs deep and subtle and often unnoticed by everyone except the people it purports to help. Having a program in place is one thing; making it effective and useful is another. Canada prides itself on its public health care system, its inclusivity, it’s universality, and yet there are many women who do not avail themselves of it except in dire emergencies, if then. It is not so much the availability of a service, in other words, but more its acceptability, and until we find a way to make it more sensitive to the needs of a population which lives on the edges of an otherwise oblivious society, there will be tragedies.

A wiser government -a wiser UN- would recognize the dissonance and, for the time being at least, prepare for those who, through no assignable fault of their own, do not choose the room it has prepared. The Baby Box is just another room, just another choice. There is no coercion in this, no implied change of policy abrogating the responsibility of a society to care for its less fortunate or less motivated members; it does not mean condoning the abandonment of unwanted babies. It does suggest a pragmatic approach, however: one that recognizes there will always be those who either do not want to be under the umbrella, or maybe cannot even find it. I remember a poem by Emily Dickinson: The soul selects her own society, then shuts the door; on her divine majority obtrude no more. It is a plea for the right of all of us -any of us- to have a choice. And it is a plea for the rest to recognize that there is a choice.

It’s not the choices we must work to change, but the reasons we make them.