The Stealing Steps of Age

Elderspeak. We’ve all heard it: baby-talk for seniors, an almost unconscious reaction to those we deem cognitively impaired, or hopelessly out of date. It’s a kind of pretend-communication with those who seem unreceptive, or beyond the pale of verbal comprehension.

Although the term is aptly descriptive and eerily evocative of rows of beds with wrinkled heads whose staring eyes peek out from where their bodies are tucked, I have to admit I had not heard the word before seeing an article in the CBC News. It described a study published in The Gerontologist about the way a group of nuns cared for their elderly colleagues from their convent: http://www.cbc.ca/news/health/nuns-elderly-1.4039508

‘The sisters caring for cognitively impaired elderly nuns in a Midwestern convent spoke to their care recipients in a way that sounded strikingly different to linguistic anthropologist Anna Corwin. The nuns rarely used “elderspeak” — a loud, slow, simple, patronizing and common form of baby talk for seniors. Instead, Corwin reports, they told jokes, stories and blessed the sick nuns, all the while speaking to them like they were completely capable, even though their ability to communicate was significantly diminished.’

‘The nuns in the infirmary suffered from dementia, Alzheimer’s disease, aphasia, stroke and neurological deterioration, and all had limited or impaired communication abilities. Sometimes the caregiver nuns held the sick nuns’ hands, and sometimes they massaged their legs, Corwin said.’

It all sounds so… sensible. So empathetic. And yet, so often we are frustrated by our apparent inability to effectively communicate that elderspeak becomes a sort of default –almost as if those to whom we are speaking are not really listening, or, depending on their condition, are minimally aware of our presence. And this can be especially prevalent among overworked care providers in geriatric wards.

‘Kristine Williams, a professor at the University of Kansas School of Nursing in Kansas City, trains nursing home providers to use less elderspeak. Her studies found that communication training can reduce the number of diminutives, terms of endearments and collective pronouns senior caregivers use.’ But training to do what?

The nuns offer an interesting option. ‘The caregiver nuns had long-established deep relationships with their elder charges, Williams noted. “They are in almost a family-like relationship, as opposed to someone who’s a nursing assistant in a home,” she said.’ And what they offered, was not condescension or inadvertent humiliation. Not patronage or mere toleration. ‘”They see these older adults, even when they’re lying in bed moaning and can’t move, as not being reduced by these chronic conditions but still as whole individuals.”’

The study was an interesting one, and yet its findings should not surprise us. ‘Beauty doth varnish age, as if newborn, and gives the crutch the cradle’s infancy’ as Shakespeare said. In other words, finding beauty in old age can transform it and make it bearable –in this case both for the aged as well as the caregiver.

Now that I think about it, I suspect I learned that years ago when I was a beginning medical student and visiting my aunt Shirley who was hospitalized after a stroke. She was stored –that’s the only word to describe it- in an older part of an already-old hospital on a ward –a large room, really- lined on both walls with beds like a dormitory. And for the most part, as I described above, all one could see looking down the rows were heads peeking out from neatly tucked bedsheets, white hair splayed across the pillows or stuck to the scalp with sweat. Some had eyes that moved, but mostly it was a room of mouths –none speaking, all busy with just the chore of breathing.

Shirley was one of the exceptions, propped as she was by a series of pillows and a cloth bib whose tethers kept her from tipping over the bed railings and onto the floor. Her voice was slurred and indistinct, so I had trouble hearing what she had to say, but I could tell she was getting better because she was complaining about the woman in the bed next to hers.

“There’s nothing there,” she kept saying, her eyes pointed at the head beside her that was staring, unblinking, at the ceiling. “They’ve put me in an empty room, dear, and I don’t like it.”

My aunt had always been gregarious, some might even say nosy, so to be confined to a room where she couldn’t extract vital gossip and life histories, was a type of exile for her. A punishment.

“You seem to have improved each time I come here,” I said, trying to cheer her up. For my part, the ward depressed me. “They’re obviously treating you well,” I added, quickly running out of small talk.

Part of her mouth smiled, but most of her face seemed still asleep. Not at all happy.

“Your aunt is improving, sir,” a soft voice said from behind me.

I turned and saw a short, smiling, grey-haired nurse dressed in white trousers and a white shirt buttoned up to his neck. His eyes were twinkling, and he was gazing at my aunt as if he, too, was proud of what she’d accomplished. There weren’t very many male nurses then, so I was surprised. “I expect they’ll be transferring you to another ward, soon, Shirl,” he added locking her eyes in his and ignoring me for a moment. “So quit complaining, eh?” He chuckled when he saw her smile broaden and the rest of her face follow suit. He reached out and squeezed her toe through the sheet and wandered off to check on the next bed. Shirley giggled, obviously pleased.

I could hear the nurse talking to that unresponsive woman in the next bed, although he spoke quietly. First, he tilted his head to stare at the ceiling above her bed. Then, he smiled. “You know, Liz, I figure you must have much better eyes than me…” He liberated a skeletal arm whose flesh hung from it like curtains on a window and held it tenderly. “…Because no matter how often I look, I still can’t see whatever it is that you find so interesting up there.” He gently squeezed her hand. “We’re gonna have to discuss this over a beer someday, eh?”

Her face didn’t change, but her breathing seemed a little less laboured. A little slower. More even. “Anyway, is there anything you need me to help you with today?” he said as he ever so gently massaged her arm then flexed and relaxed her fingers. When he’d finished with that arm, he tucked it under the sheets again and repeated the exercise on the other. “I’m going to come back and move you into a different position in a few minutes, Liz, so don’t get too comfortable like that, eh?” He loosened the sheets around her and raised the railings around the bed again that guarded her from falling. “And I’m going to make sure that physiotherapist you like comes with me to massage your legs.” He winked at her flirtatiously and gave her leg a squeeze through the sheet.

“He might as well be talking to the pillow,” Shirley whispered, as he busied himself with the railing. “All she does is stare at the ceiling. She doesn’t seem to notice when I talk to her…”

“So wait for me, Liz. I don’t want to have to go looking all over the ward for you again,” he said, laughing, and wandered off to yet another bed.

“I do like Bill,” Shirley said when he was out of earshot. “He treats us all like family –like we matter.” She was silent for a moment and then, just when I was about to leave, she managed to snag me with her good hand. “But I don’t know how he stays so cheerful here. I think half of the patients don’t even know he’s talking to them.” And her eyes wandered over to the woman in the next bed again. “It must be terribly discouraging for him, don’t you think?”

I glanced at the woman, and for a moment, I thought I saw her eyes flicker as if they were searching for something. Someone. And then, a tear? But maybe it was just a trick of the light, because, as her face relaxed a tiny bit, they closed and she began to snore. Not loudly, not as if she couldn’t breathe –but quietly, comfortably, and slipped from the waking dream, into yet another more peaceful one further inside.

 

 

 

 

 

 

 

The Primrose Path

Age is sometimes mysterious, isn’t it? Despite the experience and occasional brush with wisdom I have encountered, I am still a child in many ways. Naïve -not so much about things I have encountered in my drive through life, but more about those on streets I have not visited. Addresses in the shadows.

I suppose there will always be issues that will never spring to mind in our normal passage through the years and yet, in retrospect, one wonders how they were missed. Or why. What, for example, happens to different populations as they age? And who do we get to care for those who have chosen -or been forced- to walk the darker paths, then fallen neglected and forgotten by the wayside, too old to re-offend? Should we care for those who flout our laws and reject the duty to conform? Are we a family, or just a collection of intolerant strangers easily offended and quick to turn away?

Imponderables, to be sure, and yet, like it or not, there are needs that must be met… by someone anyway. I was intrigued by an article in the BBC News about aging prostitutes in Mexico City: http://www.bbc.com/news/magazine-38677679  One of their members opened a retirement facility for them.

I must admit, that the plight of aging sex workers had never really occurred to me. I’m not sure what I thought would happen as they got old, although, as a gynaecologist, I was certainly aware of their life style risks; their need for consultation in the Emergency Department was a regular and frequent occurrence whenever I was on call. For some reason, I’m reminded of that quote of Queen Katharine buried deep in Shakespeare’s Henry VIII: ‘Like the lily, that once was mistress of the field and flourish’d, I’ll hang my head and perish.’ Is that how they end their days…? I hope not.

But a retirement home –how perfect! The social safety net in Mexico is likely not as comprehensive as that in Canada, and yet even here, I’m not aware of any such facility. Indeed, the oldest profession has undergone other, more callous impediments as I noted in a 2014 blog on prostitution laws: https://musingsonwomenshealth.com/2014/06/12/prostitution-laws/  So perhaps it might be asking too much to wonder if such a facility might be in the offing -if not governmentally sponsored, then perhaps privately funded. Or better still, a legal adoption of  something like the New Zealand model might discourage exploitation and even offer salaries and, who knows, pensions…? Comfort for their end of days?

*

I do not ordinarily sit in malls; I do not ordinarily go to malls, for that matter, but sometimes circumstances foster unexpected opportunities. I was tired that day –tired of fighting through Friday crowds in search of things I probably didn’t need, or at least could likely find with a little effort somewhere else. I had just decided to look for a place to rest and collect my thoughts, when I saw a woman check her watch and stand to leave an uncomfortable-looking wooden seat near where the tide of people was sweeping me. I immediately swam over and moored before the woman right behind me could claim it for herself.

The seat was one of four that served as a kind of breakwater for the waves of people flowing down the shop-lined banks in confused eddies. Bolted to the floor, they were arranged in a little circle, presumably to facilitate conversation, but only two of the occupants seemed to know each other. They were deep in conversation so even an exchange of pleasantries seemed inappropriate, but just before I closed my eyes, I managed to catch their attention and smile at them. In the seat beside me was an old man who also smiled, but seemed more preoccupied with his watch than anything else.

The women were quite old and both looked as if they’d seen better days. Although their clothes were clean and obviously worn with an attempt at style, I could see fraying at the hems, and areas where the patterns were disrupted by attempts at repair. Both their faces were wrinkled, as much by life as age, I suspected, and the one directly across from where I sat, seemed hollow around her cheeks and gummed her words through sparsely distributed teeth. Short and gaunt, she sat proud and straight in her chair, however, her long, greying hair swept back in an elegant ponytail that danced each time she talked. She had dressed that day in a green, fading sweater and black jeans that seemed a bit too large, so the cuffs were carefully rolled to matching folds.

The other was a larger woman with short, ash-white hair that she had scrunched under a blue baseball cap that had some sort of a truck logo on its front. She was dressed in a red and white flower print dress which seemed to hang shapelessly below a tattered and faded nylon jacket that had probably once been totally black. At her feet was a big, stained cloth shopping bag that bulged oddly in places with items too irregular to be just clothes.

Friendly strangers, they both smiled back at me before resuming their conversation.

I closed my eyes and tried to relax into the wooden slats, but their words kept floating over to me during lulls in the storm of voices and accidental elbows hurrying past me. I could tell it was an unsafe anchorage at best.

“Haven’t seen you for a while. You still working, Ethel?” It must have been the pony-tailed woman, because her words seemed strangely distorted and her lips smacked together a little as she spoke.

A gaggle of children passed nearby so I missed some of the response. “… men anymore, Rita…”

“Yeah, I guess, eh?” But I didn’t think Rita sounded very sure. “You still on the…” A demonic laugh surfaced in the crowd for a moment then faded along with Rita’s words.

“Yeah,” Ethel replied. “Hard to get off though, eh?”

I opened my eyes to get a little more comfortable on my seat, and saw Rita nodding in agreement. “Hang out in the same place?”

Ethel shrugged as I closed my eyes again. “They know me there,” she answered.

I imagined Rita nodding in agreement. “Mmmh,” I heard.

School must have ended for lunch, because a group of noisy teenagers rambled past, joking and poking each other. “What shelter you going to nowadays?” Ethel’s words caught my attention, even amidst the confusion of teenage jests and I opened my eyes, pretending to adjust my position again.

I could see the indecision on Rita’s face, and her lips moved as she considered her answer. “Used to go to the one on Main…”

“Yeah, me too,” Ethel agreed, glancing at her. “Got assaulted there, though, so I sometimes try the Sally Ann…”

“Mmmh.”

“What about now, Rita?” She adjusted her baseball cap as she spoke. “Where you headed tonight…?” She sounded suspicious. They were clearly not good friends –just acquaintances, perhaps, who’d found themselves in adjoining seats to shelter from the weather for a while.

Rita stared at Ethel for a moment, obviously uncertain how to answer. Then she ordered her eyes to scan the passing crowd. “Found a new place. Some of the girls got together…” But it wasn’t the noise of passing voices that ended her words.

Ethel tried to find out more, but Rita suddenly stood and waved, as if she recognized someone in the crowd, and dived into a particularly noisy wave and disappeared.

Ethel sighed and then gathered up her things and melted into a similar eddy going another direction. Despite her weight, she seemed frail and aged. Her movements were no longer fluid, her gait was unbalanced and she hobbled with a decided limp. But as she disappeared, her eyes brushed mine -by mistake, I thought at first, but when I remembered it later, I wondered if it had just been habit. A desperate plea for another friend –however temporary.

 

 

 

 

Time Out, eh?

Time-outs to wring behavioural change from naughty children are all the rage nowadays. Everywhere you go there seem to be men sitting near their tantrum-laden little boys in the parking lots of stores, or women standing outside of cars fastidiously ignoring the screams of alternately pounding and pouting children confined within. Perhaps this has been going on for years, but only recently have I begun to notice the ritual. In fact, it seems so ubiquitous, that I am beginning to suspect a flaw in my own upbringing. I don’t remember being an easy child; maybe I just had easy parents. Or maybe the Encyclopedia Britannica of the age didn’t cover that aspect of childrearing.

It might be investigating the obvious, but I had to look it up at any rate. Time-outs are more acceptable attempts at behaviour modification than corporal punishment –spanking comes to mind- especially in public, where the difference between remonstration and child abuse is uncomfortably opaque. The idea of social exclusion was likely popularized in a paper by a Dr. Montrose Wolf at the University of Washington in the mid 60ies, drawing on the work by his mentor, Dr. Arthur Staats (who called it ‘time-out’).

But, unless you grew up in Winnipeg in the 1950ies, you might now regard time-outs as such an intuitively obvious way of treating both the child’s misbehaviour and the resultant parental frustration, that you would be forgiven for assuming it had been hard-wired in our DNA. Perhaps it was, but with variable penetrance, and probable mid-prairie epigenetic modification –anyway, there seem to be some issues with its application: http://www.cbc.ca/news/health/time-outs-study-parenting-1.3888166

By default, I suppose I’m an educationally impoverished repository of doctrinal wisdom when it comes to children. As an obstetrician, for years -until my own arrived, at least- my responsibilities ended with handing the freshly-liberated, and usually screaming newborn to the mother, tidying things up, and then congratulating the smiling, emotionally overcome parents before I left the room. I didn’t expect to be confronted with any of their subsequent behavioural peccadillos. But, as Shakespeare’s Cleopatra remarked, those were ‘my salad days, when I was green in judgment’.

Usually, I enjoy seeing children in the waiting room –they lend a kind of friendly family air to the office. Sometimes, however, there are things I need to discuss with the mother, procedures I need to perform, or even examinations that might alarm the child, so my enjoyment is often that of seeing the child stay in the waiting room. It’s not called that for nothing.

Clara was already a harried teenage mother of a two year old when I first met her several years ago, and I delivered three more for her in the following years. Now in her late twenties and recently divorced, she had been sent to see me for permanent birth control.

I heard the excited screaming even before I reached the front desk, and I have to admit that I hid behind a wall to assess the situation more fully before I ventured into the open. The first of the children I delivered -Edward, now around five- was stirring the pot by running around the room clutching a toy to his chest so the dauphin, despite the obvious entitlement of age, could not get it.

Clara’s long auburn hair, now partially liberated from whatever restraints she’d attempted at home, was hanging forlornly around her shoulders, while her eyes followed the action around the room like a hockey game. A large lady now, she sat uncomfortably on the edge of her seat, no doubt hoping to catch Edward and the toy if he was so unwise as to come anywhere near grabbing range. The youngest, still breast feeding, was the only one over whom she exercised even temporary dominion.

I glanced nervously around the room from the shelter of the alcove, hoping she had brought a friend or older family member with her, but Clara was the last patient of the day and the room was otherwise empty.

“Clara,” I said, face prepared, and hoping she hadn’t noticed me behind the wall. “Nice to see you again.”

The children immediately stopped running and flocked to my side to tug on my clothes. Jamie, the oldest, grabbed the toy from Edward, who was now too busy trying to reach my stethoscope to notice.

“I… I saw you… watching from the alcove, doctor,” Clara said, blushing a deep crimson because she almost said ‘hiding’. “I tried to get my sister to take care of the kids, but she had to work today…” She shrugged and reached out with lightning speed to grab Jamie’s arm before he could swat his brother. “You behave yourself, Jamie, or you’re gonna do a Time-out, eh?”

Jamie immediately akimboed his arms and made a face at his brother. “He grabbed my car…!”

Clara glared at him and frowned, but from the defiant face with which Jamie greeted the threat, I could see the battle lines hardening.

I glanced at my secretary sitting behind the front desk, but she was on the phone and I realized that I was on my own. “Let’s go into my office,” I said, with a worried look at the boys, and the little girl, Janice, who by now had decided that the way to recapture some attention was to stick her tongue out at Jamie. Only the baby seemed compliant, but that was probably because Clara was still nursing her.

My office, unfortunately, was not designed for children –there are simply too many things that could tip over or break if handled indelicately. On the way down the hall to the office, I even thought of getting my secretary to fake a call from the hospital requiring my immediate assistance, but she was still on the phone and merely winked at me as I passed. I got the impression she was just holding the receiver for show.

As soon as the troupe entered the office they began to explore, and Jamie, who had probably never seen pennies before, made a quick exploratory lunge for the penny bowl that sat in front of a terra cotta statue of a begging lady precariously balanced on a little oak table. Edward, on the other hand, was reaching for the carved wooden statue of a woman holding a child that I had put behind a plant on my desk, and Janice was trying to extract the contents of the shelf where I keep my medical journals. It was a multi-pronged attack worthy of an Alexander.

“I’m not sure this is going to work, doctor,” Clara said, trying unsuccessfully to reposition the baby onto a breast while glaring at all three of her children now crawling along the floor scooping pennies into their pockets.

I called my receptionist to come in with us. “Laura,” I said as she opened the door a crack and peeked in. “Please put the phone on hold, or something…  I need your help.” Actually, I needed a time-out.

I could feel Laura’s eyes rolling behind the door. She was the mother of three young children, so she knew what I was going to ask.

“I want you to take the kids and… occupy them for a few minutes while I talk to Clara.”

She shrugged, but I could tell from her face that she thought it might be an interesting challenge as she gathered the tribe -minus the now sleeping baby- and led it out of the door. The office felt so peaceful suddenly that Clara and I just looked at each other for a moment. I managed to gather a more complete history and when I opened the door to lead her across the hall to the examining room I could only hear quiet giggles.

Finally, after Clara and I had discussed her needs, we both tiptoed down the corridor to the waiting room. But it, too, was quiet except for Laura’s voice telling a story as the children sat around her in a little circle on the floor.

Each of them had a plastic speculum with a sticker face stuck on the top and when Laura asked a question, one of the children would make the speculum talk. They were loving it and didn’t even look up when we crossed the rug. But Laura did, her eyes glistening from quiet laughter.

Clara just stared at them, unable to speak.

Laura chuckled and then shrugged. “I gave each of them a choice of those little funny face stickers we always give to the kids and showed them how to attach them to the top of the speculum.” A contented sigh escaped as she watched them all talking quietly to each other through the specula. “From then on, it was just role playing…”

“How did you ever think of that, Laura?” I asked when they’d all left.

She shrugged again. “The specula have always reminded me of quidnuncs… you know, snoops -those who insist on sticking their noses in other people’s business.”

I had to sigh in admiration -Laura has a name for everything. I just hope she doesn’t expect me to name the specula now… But I looked up quidnunc just in case.

 

 

 

 

 

The Serpent’s Egg

We all see the world through our own experiences, paint it with our own colours, fly our own flags. They seem real to us –unique and even necessary to our identities. As if it’s enough to be simply what we wear; as if we are only what we’ve been taught to show. But sometimes we need distance to understand that there are other equally compelling ways of defining ourselves. Other less travelled roads.

I say this, of course, as an unwitting member of a large club in which I was enrolled without being required to read the rules. But I guess most of us say that, don’t we? Male privilege –it’s something that’s hard to see if it’s all you’ve known. Easy to deny –and certainly easier to excuse- if you’re the privileged one. Especially if you can’t even understand the claim; to a sock, everything is a foot. It’s why we have them…

I worry that it is a learned attitude, however –like assuming all girls want to play with dolls, and all boys want to play with cars. A self-fulfilling prophecy if it’s taught early enough –valid only because we know it’s how it should be. Harmless, perhaps, if it does not disadvantage either side, but untenable unless dispassionately assessed. Unfortunately, we all tend to bring our own agendas to the analysis. Our own talking-points. Our own pasts…

A state in Australia is making a brave attempt to bring some historical context to the issue, and create some early awareness of the challenges of gender perspective and gender stereotypes: http://www.bbc.com/news/world-australia-37640353 ‘Students will explore issues around social inequality, gender-based violence and male privilege.’ This is not to suggest that Australia is any different in its treatment of women, but it is a welcome departure from many countries that don’t even acknowledge the problem. ‘Primary school students will be exposed to images of both boys and girls doing household chores, playing sport and working as firefighters and receptionists. The material includes statements including “girls can play football, can be doctors and can be strong” and “boys can cry when they are hurt, can be gentle, can be nurses and can mind babies”.’ And it doesn’t stop with primary school education. ‘A guide for the Year 7 and 8 curriculum states: “Being born a male, you have advantages – such as being overly represented in the public sphere – and this will be true whether you personally approve or think you are entitled to this privilege.” It describes privilege as “automatic, unearned benefits bestowed upon dominant groups” based on “gender, sexuality, race or socio-economic class”.’ Good on them!

But I think we have to be careful to walk the middle path. Accusations are seldom neutral; they often engender anger and even retaliation from those accused. So, perhaps predictably, in Australia ‘a report on a 2015 pilot trial accused it of presenting all men as “bad” and all women as “victims”.’ It’s one thing to illuminate the entire stage for a play, but still another to spotlight only one particular area. Decontextualize it…

*

Jeannette seemed like a fairly typical young woman as she sat relaxed in her seat and talking to several other women in the waiting room. Her long auburn hair danced lightly on her shoulders when she laughed, and her eyes sparkled as she leaned over to accept a toy from a little boy who had toddled over to her on a whim. Dressed in a loose grey sweatshirt and faded jeans, she wore a fresh, newly-pregnant smile that every woman in the room could see. And even the older ones followed her with their eyes –memories of bygone years. Her joy, theirs to enjoy -if only vicariously, and for too brief a time.

But her smile faded as soon as she sat across the desk from me in my office. Her eyes were predators shackled for the moment, the cage doors open nonetheless.

“I understand congratulations are in order, Jeanette,” I said, looking at my computer screen, and missing the change in her face. “Your family doctor says this is your first pregnancy…”

“The father doesn’t want me to keep the pregnancy,” she said tersely, her lips thin and tight, and as I looked up, she sent her eyes to savage my smile, and her forehead seemed to pucker as they left.

I had never met Jeannette before, although I had apparently seen her mother as a patient several years ago. That was all the GP said  -maybe it was why he had sent her to me for her pregnancy. I took a deep breath and leaned forward in my chair. These are always difficult conversations. “And how do you feel about that, Jeannette…?”

I could see her face relax a bit, as if my response had caught her by surprise. “I… I don’t think it’s fair!” She searched in her pockets for something, and then grabbed a tissue from my desk and dabbed her cheek. “I mean he’s blaming me for getting pregnant…” She took a deep, stertorous breath and sat back on her chair. “He refused to wear a condom –he said it would show I didn’t trust him…” I could see her squeezing her hands. “I didn’t, actually… I mean we’d never slept together before, but we were good friends… and…” Her eyes had softened with tears so she dropped them onto her lap and grabbed a handful of tissues. “Well, we were both drinking –he kept filling up my wine glass and…”

I remained silent and waited for her to continue.

“And he doesn’t even believe it’s his anyway… I was too easy he said!” Her face hardened again and her eyes dared me to agree. “I got really angry. ‘You were pretty easy, yourself’, I told him. And that’s when he punched me in the stomach and left…”

I have to admit that my mouth fell open. “Did you report him, Jeannette?”

She looked at me with a puzzled expression on her face. “He’d just deny hitting me, doctor!” she said through gritted teeth as if it were obvious. “And he’s already telling my friends it was consensual sex…”

I took a deep breath and tried to keep my expression neutral. “Did you tell your GP all this?”

She shook her head. “He wouldn’t understand. I just said I was pregnant…”

I sat quietly for a moment, wondering how to proceed, when she suddenly smiled warmly at me. “Can I ask you something, doctor?”

I nodded with a smile –sometimes it’s all you can do.

“If I were your daughter, what would you say to me?”

I thought about it for a bit, then looked at her and sighed. “When you do dance, I wish you
a wave o’ th’ sea, that you might ever do nothing but that.”

Her face brightened even more and her eyes sparkled in the sunlight from the window behind me. “That’s from Shakespeare’s ‘Winter’s Tale’ isn’t it?”

I nodded, surprised both that I quoted that line of all things, but also that she knew what I meant.

“Better start filling in that antenatal form on your screen, don’t you think?” she said, barely able to contain her face.

And we both laughed. Sometimes poetry has the privilege, I realized –not gender…

 

 

Digital Naivete

I suppose it was inevitable; I suppose I should have guessed… When you are charged with consulting on a generation that seeks its information online, there are issues that are only apparent in that venue. And treatment algorithms which don’t take that into consideration are woefully naïve. Doomed to fail.

There are smartphone apps for everything I guess, but in an Ob/Gyne practice like mine, there are only two that my patients seem willing to share with me: obstetrical dating apps that disclose the expected date of baby’s arrival, and period tracking apps. In an age of constant immersion in information sharing and with an understandable need for inclusion in any decision making, I think that both of these programs -especially the menstrual tracker- would be considered especially useful to any women at risk of pregnancy, particularly so if they also suffered from irregular periods. A natural extension of that, then, might be to extend its use. To adapt it for another purpose for which it was not originally intended -a technological exaptation.

But an article a while ago in the BBC news (also an app, by the way) looked at some of the pros and cons of menstrual tracking apps: http://www.bbc.com/news/health-37013217 that raise some serious concerns.

The idea of being able to follow one’s periods without the need to carry a marked calendar around is appealing, to say the least. It might also allow the recognition of a pattern in an otherwise seemingly random sequence. And even with a predictable cycle, other discernibly helpful patterns may become obvious. As one English singer put it: “When you are starting your period or you’re pre-menstrual, the hormones that rush around your body affect your larynx in ways that are detrimental to your singing voice. I use the app to avoid auditions, premieres or really important performances on those days if I can.” And, ‘The app also helps her identify connections with changes in her emotions, eating habits and headaches’.

So far, so good. As that English singer put it: “Being able to chart what happens to you and how you uniquely respond to your cycle is a great way of taking ownership of something that really sucks – but is completely necessary.” Perhaps the more you know about how unique you are (or aren’t) the more likely you are to feel in control –not simply a table of random numbers, a caster of dice… But there is a danger in relying too heavily on a reading and analysis of an app that merely calendarizes a menstrual cycle –especially an irregular one.

Yes, it is generally true that one usually ovulates about two weeks (or so) before the period starts, but each cycle has been exposed to a different set of conditions –stress, exercise, illness, and so on- so the rule is not reliable. Especially for contraception. The time period before ovulation (the follicular phase) while the egg is being readied in the follicle can be quite variable. If not using serial blood tests, or the like, one needs at least temperature charting and/or mucous testing to discover more reliably when ovulation has occurred… and then, of course, it’s probably too late to take precautions to avoid pregnancy.

The phase after ovulation (secretory phase) is also variable –although often less so- for a variety of reasons, so it won’t reliably predict the exact timing of an oncoming and expected period either.

The whole tracker app thing can be thought of as a digital rhythm method. And if you subscribe to that philosophy, a period tracker app may help you to remember when your last period started, so you can practice periodic abstinence. The Mayo Clinic suggests that with dedicated and consistent observance of this method, one might expect a failure rate of perhaps 13%. Although we all must decide what risk is acceptable given our circumstances, it does seem high in comparison with most other forms of contraception. And, ‘[…] the Royal College of Obstetricians and Gynaecologists has warned they [period tracking apps] should not be used as a form of contraception.’

Another thing that worries me about many of these apps –especially the downloadable free ones- is security of the information that you need to submit. As a privacy campaigner for medConfidential –a British privacy advocacy group- points out: ‘[…] if an app is free, consider whether you are paying for it in effect by giving away your data – and investigate where it might be going.’

With the blooming crop of digital savants, I suppose the posting of a cautionary list is merely an annoying Jeremiad from an older, and more naïve generation. And yet, there is more than a tittle of necessity to the reminders. Sometimes even the young need to step back and critically examine what they have come to believe is commonly accepted and practiced amongst their peers. The wisdom of the crowd differs markedly from the wisdom of the individual and although we may wish something to be so, as Plato observed: ‘Real knowledge is to know the extent of one’s ignorance.’

Or, put another way, with all due deference to the digital generation, Shakespeare’s immortal line in Julius Caesar: ‘Your wisdom is consumed in confidence’. Don’t let it be so…

 

 

 

 

 

 

The Grief that does not Speak

How weary, stale, flat, and unprofitable seem to me all the uses of this world!

Like Hamlet, we all recognize this mood: the black dog lying in the noonday sun, the cloud that even hides the moon. It is the tear that defeats the wavering smile –and yet… And yet, there is often something more behind the grief, something that is hidden beneath the first impression. Shakespeare, again, understood this over four hundred years ago: ‘Give sorrow words. The grief that does not speak whispers the o’erfraught heart and bids it break.’

I suppose we all impose our own reality; we all see the world through our own experience. But, sometimes we see through that glass darkly. Things are not always what they seem.

Alethea looked calm and happy as she sat in my waiting room. In fact, she was smiling and talking with a little child who’d toddled over to her in his diapers with a toy. She was bending over in her seat, her long black hair almost reaching the little boy, as she tried to make him laugh. Her full-length black, cotton skirt and her blue silk blouse contrasted sharply with his bulky white diapers –a chiaroscuro worthy of a picture, but he waddled off to another woman as quickly as he’d arrived. The waiting room is like that here: a work in progress; an evanescent scene of fleeting beauty.

Alethea smiled again when I greeted her, and examined me with friendly eyes. I had anticipated avoidance, or at least timidity from a woman referred to me with recalcitrant depression. A woman, according to a rather extensive explanatory note, who seemed refractory to multiple attempts at treatment. But I’m a gynaecologist, and although we’re sometimes involved on the edges of depressive illnesses, most of us lay no claim to the territory. We’re adjuncts –often last-minute guests- invited to the therapy just in case; we’re seldom primaries.

But in my office, she seemed less at ease, her eyes flitting from the plants in their pots to the eclectic pictures hanging on the walls. They spent some time inspecting a terra cotta sculpture of a woman begging with a bowl that I’d positioned on a little oak table.

“You certainly have wide-ranging tastes, doctor.” I don’t think she meant it as a criticism, so I took it as the long missing compliment I have yet to hear from my staff.

I smiled, and opened up the computer.

“I’m afraid my GP wrote a rather long note justifying the referral to you; she seems quite worried –or maybe frustrated with me.” Alethea rested her eyes on me for a few seconds. “I asked to see you rather than a psychiatrist.” And then she chuckled. “She was not happy about that, I’m afraid.”

I pushed the computer to one side and sat back in my chair. “Do you mind if I hear your version, first?” I asked.

“Thought you’d never ask,” she said as she made herself more comfortable in the sturdy, old wooden captain’s chair that I insisted on keeping across from my desk, her eyes twinkling with amusement at my suggestion, but still cautious.

“Well,” she started, obviously trying to place the events in their proper order, “A few months ago, I went to see my GP because of some problems I was having –you know, coping stuff,” she added when I wrinkled my forehead. “Anyway, I was in tears when I sat down in her office and had trouble even talking to her without crying.

“She got very clinical and I could tell she was trying to remain an objective observer.” Alethea rolled her eyes and sighed. “She does that sometimes when all I need is a hug or something.” She risked a quick glance at my expression. “But I realize that’s not what doctors are supposed to do…

“Anyway, she asked me all the usual questions about my work, and my home life…” Alethea blinked and looked away. “I think she felt a bit uncomfortable with that part because my partner also used to go to her.” Suddenly she stared at me and I could feel the anger in her eyes. “I really don’t know why that would matter…”

She quickly snatched a tissue from my desk and wiped her eyes. “I’m sorry, doctor, I guess my GP is not the only one who gets frustrated.” She took a long, deep breath and exhaled it slowly. “She said she’d never seen me like that before, and that whatever might be going on, I was seeing it through the lens of depression.” She glared at the begging lady statue for a moment. “She actually said ‘lens of depression’ for god’s sake! Like no matter what I said, or experienced, it was somehow misinterpreted through that bloody lens, or whatever.”

Alethea seemed uncomfortable and kept readjusting her body on the hard chair so I pointed to a more comfortable one nearby. That got her smiling again, but I could tell she was still angry.

“She insisted I go on one of those new antidepressant medications –you know, the ones that aren’t supposed to make you tired. The ‘no side-effects pill’ she called it. ‘Just try It for a few weeks and let me know if it helps,’ she said and escorted me to the door, all buddy-buddy.”

She brought the comfortable chair close to the desk and helped herself to a handful of tissues. “But it only made things… worse.”

I leaned forward on my chair, detecting something she was implying in the way she said that word. “How do you mean, Alethea?”

A tear rolled down her cheek and she dabbed it with the tissue. “I didn’t feel at all like sex, when I was taking it and…” She hesitated for a moment. “And that really made her mad.”

I was confused. “Made who mad?”

She was staring at her lap, but her eyes wandered up to my face for a brief look before she called them back. “My partner.” She sighed again. “So I decided to go off the antidepressants after a while and went back to the GP. She seemed upset that I had only given them a month, and said I was still acting depressed. At that point she said I needed to see a psychiatrist, but I refused. ‘You have a chemical imbalance,’ she almost screamed at me, and implied that if I didn’t get help soon, there might be dire consequences.” Alethea glanced at me again. “I suppose she thought I might try to off myself or something.” She giggled at the thought and when I looked puzzled, she smiled and continued. “Maybe it’s your birth control pill, Alethea. I don’t know why you insist on taking them anyway.’” Alethea’s face turned mischievous and her eyes twinkled like when she first came in. “Because I’m Bi, you stupid woman!” she said and laughed. “Well, I didn’t actually say that to her, but I felt like it…

“Anyway, I convinced my GP to send me to you.”

I squirmed a little uncomfortably in my own, soft chair. “Why me?”

A playful smile emerged. “My aunt and cousin see you… They said maybe you’d listen.”

I think I blushed. “And what about your partner? Did she think you were… depressed?” I hesitated before using that word. “Did she listen?”

Alethea’s face suddenly tensed. “She was abusive,” she said between gritted teeth, and sent her eyes to scout my face again. “She used to scream at me and throw things around. I hated going home after work.”

“Did you tell that to your GP?”

She shrugged. “I told you, she felt uncomfortable about it. And anyway, she had a diagnosis –and a treatment,” she added, with a wry smile. “That’s what medicine is about nowadays, isn’t it?” The smile disappeared, to be replaced by a sweet grin. “And once you have a treatment, it’s… Next!” she said, rolling her eyes, and we both laughed.

“And so what’s happening now? Are you still with your partner?”

Her face beamed and her eyes sparkled. “Now, I’m back with my old boyfriend -it takes a long time to get in to see you,” she explained with a chuckle. “We’re even planning to have a child soon, maybe.” Her eyes hovered under the ceiling for a second or two. “I guess I wasted your time, doctor, but my aunt was right -it does help to talk about it… And I thought I should meet you anyway,” she added, and decided to make eye contact again. “You delivered my cousin last year…” The twinkle returned. “Care to see me again –in a while?”

I think my smile told her I’d love to see her again.

And as she left, I couldn’t help but think of that wonderful metaphor of Khalil Gibran: ‘Sadness’, he said, ‘is but a wall between two gardens.’

It certainly is.

Is Beauty really skin deep?

Although love looks not with the eyes but with the mind, as Shakespeare reminds us, there is a redness of the cheek that is not as kind as a simple blush. So may the outward shows be least themselves, he also says. The world is still deceived with ornament.

Acne arrives at the wrong time of life; it usually declares itself around the same time a teenager is trying to establish her identity; trying to acquire independence; experimenting with relationships outside the family. It is a time of uncertainty when self-esteem and confidence may be suspended, like the Sword of Damocles, on that single hair of outward appearance.

Acne is nothing new; it has probably been around as long as there has been skin with hair follicles to get blocked. Oil from glands is one of the culprits and these are more common on the face and upper body. The hormonal changes of puberty may result in changes in activity of these glands -that, plus genetics, and excessive growth of the bacterium Propionibacterium acnes, all contribute to the unfortunate timing.

An article last summer in the BBC News reminded me of the consequences that affected a patient I once saw in my office for gynaecological consultation.  http://www.bbc.co.uk/newsbeat/article/36712810/doctors-warn-acne-could-become-resistant-to-antibiotics

The waiting room was full that day and I saw Janice sitting quietly in the corner, her face almost buried in a magazine. She was a tall, thin, sixteen-year-old wearing tight designer jeans with a cream-coloured baggy sweater and beautiful deep blue hijab that she wore sufficiently loosely around her head that, even when she looked up, seemed to cover most of her face.

At first I wasn’t sure what to make of this. I wondered if it might be a cultural, or religious requirement for seeing a male gynaecologist -or merely a teenage affectation. But apart from her continuing reluctance to expose her face, she seemed more at ease once she was seated in my office.

The consultation note from her GP was one word: Contraception!! -with two exclamation marks. I took that as a sign.

“So, what can I do for you, Janice?” I usually like to let the patient tell me why they were referred; it’s sometimes different than what the family doctor thinks.

She shrugged. “Birth control, I guess…” But she seemed rather unsure.

I smiled and tried to make eye contact, but she continued to look away, first to a painting on the wall beside her, and then to the other wall where I had placed a terra cotta statue of begging woman on an oak stand. Janice seemed to favour the statue.

“Is that for tips?” she said, indicating the bowl the woman was holding in front of her. It was filled to overflowing with coins.

I laughed and shook my head. Everybody seems to ask the same question, and then puts a coin on the pile. “I’m not sure why some people do that, but I empty it from time to time and give it to real people begging on the street. I like to think that’s what my patients want me to do with it.”

She turned her head to look at me and I could see a smile peeking from the shadows inside the hijab. “I didn’t bring any change…”

My smile broadened. “That’s okay, I’ll put a coin in the bowl later for you if you like.”

The hijab nodded.

I settled back in my chair. “So you want to discuss contraception, Janice?” Another nod. “What have you been using so far?”

She shrugged. “Condoms at first…” She hesitated and then sighed. “Then when we got to know each other better, I went on the pill.”

“Is that what you’re on now?”

She shook her head. “They didn’t work. Well…” She lowered her head, so all I could see was the top of her hijab. “Actually, I kept forgetting to start them again after my period…” Two eyes peeked timidly from the shadows on her face. “So I had a couple of… accidents.”

She said the last word in a whisper I could hardly hear as she lowered her head to look at her lap. Suddenly, her head jerked upwards to face me and she pulled the hijab back so I could finally see her face. Both her cheeks were rough and jagged seas of red nodules, some weeping and moist, some merely little cysts about to burst. I could understand why she had chosen to wear her hijab as she did.

“My GP tried me on several kinds of treatments for the condition, but none of them helped. In fact, it was getting worse, so she sent me to a dermatologist. And she just put me back on higher doses of some antibiotic I’d already been on: mino-something.

“Minocycline?”

She nodded, and her eyes filled with tears, so I handed her a tissue from the desk. “But she said it was dangerous for a developing baby, so I had to stay on the birth control pill.” She looked up at the ceiling for a moment, shaking her head. “I told her I kept forgetting to take them, but the doctor just shrugged and told me to write little notes for myself… Stupid woman!

“After the second abortion, my boyfriend and I decided the birth control pills didn’t work so I stopped them. When I told my GP about it, she took me off the antibiotics, too… I guess because she thought I might get pregnant again…” She wiped her eyes and grabbed another tissue from the box I kept on the desk. “And now look at me!”

Her eyes flitted around my face for a moment, and then she summoned them back. “They wanted to put an IUD in me at the time of the second… procedure, but I wouldn’t let them.” Her eyes found mine again. “They recommended the hormonal one.” She seemed on the verge of tears again. “But they told me it might worsen the acne.”

All of a sudden, she leaned over the desk towards me –as if she wanted me to really see what she had to deal with. “I can’t stand my face like this!” She sat back in her seat again. “My boyfriend has already left me; my friends whisper behind my back. Everybody is afraid to look me in the face…” She grabbed a handful of tissues this time and dabbed her cheeks when she’d dried her eyes. “I’m really confused, doctor. Nobody seems to know what they’re doing; they keep changing their minds…

“I can’t go on like this! I can’t…” She took a deep ragged breath. “I need somebody to tell me what to do before I fall off the edge… Or jump,” I heard her whisper into the folds of her hijab.

And then her eyes almost bored into my skull. “Can you help me, doctor?”

Her expression worried me; she was desperate and clearly in crisis -obviously at that edge. I had to do something.

“Tell me, Janice, when you were on both the pill and the antibiotics that last time, was your acne improving?”

She nodded vigorously. “The doctor told me the hormones in the pill sometimes help.”

I smiled in agreement, although I didn’t feel comfortable dealing with acne; I suspected she needed to go back on the antibiotics and her GP was right, she needed absolute protection against pregnancy while she was on them. Minocycline is a class D drug –meaning there is positive evidence of human fetal risk.

And then something occurred to me. “Was it only when you were restarting the birth control pill after your period finished that you forgot to take them?”

She nodded, obviously embarrassed. “There was a lot going on in those days…”

“But you were happy with the pill? I mean it wasn’t giving you any problems?”

“No… except for the pregnancies.”

“So, if you didn’t have to stop the pill for a period, would that work for you?” I watched her closely. “I mean, do you think you would remember to take them?”

She nodded carefully, and stared at me. “Yes… But you mean I wouldn’t have any periods?”

I nodded. “You can take the birth control pill every day for three or four months at time –or even more- then stop and have a period.” Sometimes the simplest solutions work the best.

She thought about it for a moment. “Uhmm… But if I didn’t get my period, how would I know I wasn’t pregnant?”

A good question. I smiled what I hoped was a reassuring smile. “Well, it’s true that Minocycline can interfere with the absorption of the pill, but the risk of pregnancy is still low. And you should supplement the pill with a condom.” I waited till she made eye contact again. “In fact, if you’re starting a new relationship, wouldn’t condoms be a reasonable precaution anyway?”

The acne made way for a face-swallowing smile. “I’ve sworn off sex… Well, at least until I get my face back.” I could tell she was blushing, even under the hijab. Even under the acne.

But I could finally hear some hope in her voice, and I was reminded of another verse from Shakespeare: ‘I will go wash; and when my face is fair, you shall perceive whether I blush or no.’ It seemed fitting, somehow…