She wears her faith but as the fashion of her phone.

Everything is a matter of time, isn’t it? Everything changes. Like the apocryphal monkeys typing away infinitely, everything will be written. Everything will be transmogrified somewhere. Some time. Somehow. I suppose that should be a comfort, but I can’t escape the nagging feeling that there is something unrequited in all that: an imbalance between now and then -no bridge to mediate between what is, and what some nebulous future may unfurl for our children’s children.

And yet, an article I found offers some hope that I might have missed the entr’acte, missed a vital link in the ever lengthening chain of progress –or at least underestimated its importance. I’m talking about the smartphone. I grow old… I grow old… I shall wear the bottoms of my trousers rolled, as T.S. Eliot wrote –that, at least, may be a suitable mea culpa for my inattentiveness, perhaps.

I should have seen that with all of the changes occasioned by the phone, other subtle philosophical alterations might well hide within its shadow. ‘He wears his faith but as the fashion of his hat; it ever changes with the next block’, as Beatrice says in Shakespeare’s Much Ado About Nothing. Who would have thought that religion itself might live the same fate? http://www.bbc.com/future/story/20170222-how-smartphones-and-social-media-are-changing-religion The mobile phone Bible seems to be replacing the book Bible –at least with many of the younger religious crowd. And the result may have been a loss of context –no thumbing through the pages looking for something, just an arrival at whatever nugget was requested –like looking it up in Wikipedia. In other words, an information Christianity, a virtual religion. ‘“A new kind of mutated Christianity for a digital age is appearing,” says Phillips [director of the Codec Research Centre for Digital Theology at Durham University in the UK]. “One that follows many of the ethics of the secular world.” Known as moralistic therapeutic deism, this form of belief is focused more on the charitable and moral side of the Bible – the underlying tenets of religion, rather than the notion that the Universe was created by an all-seeing, all-powerful leader.’

Although I hold neither religious affiliation, nor any particular interest in the Bible, I have to say I am intrigued by the philosophical machinations the smartphone seems to be engendering –the moralistic therapeutic deism, as it is increasingly being referred to. The results of interviews with three thousand teenagers were summarized in (sorry) Wikipedia, and seem to establish the tenets of this theism. First of all, ‘A god exists who created and ordered the world and watches over human life on earth.’ And ‘God wants people to be good, nice, and fair to each other, as taught in the Bible and by most world religions. The central goal of life is to be happy and to feel good about oneself.’ But what I found particularly interesting was the idea that ‘God does not need to be particularly involved in one’s life except when God is needed to resolve a problem.’

And why do I find this  so-called ‘moralistic therapeutic deism’ so interesting? It seems to me it may be the early phases of an evolution of religious thought engendered by the way we are beginning to assimilate information. Or perhaps I should say they are –the millennials. I suspect that we elders –or should I say just ‘olders’- still adhere to the belief that data does not necessarily spell knowledge.

But, as the article points out, ‘[…]a separate strand of Christian practice is booming, buoyed by the spread of social media and the decentralisation of religious activity. For many, it’s no longer necessary to set foot in a church. In the US, one in five people who identify as Catholics and one in four Protestants seldom or never attend organised services, according to a survey conducted by the Pew Research Centre. Apps and social media accounts tweeting out Bible verses allow a private expression of faith that takes place between a person and their phone screen. And the ability to pick and choose means they can avoid doctrine that does not appeal. A lot of people who consider themselves to be active Christians may not strictly even believe in God or Jesus or the acts described in the Bible.’

I doubt that this phenomenon is exclusive to Christianity, either. Any religious doctrine which has a credo that can be digitized, is susceptible -nuggetable into bite-sized digestible portions. Wikipediable.

I think that is what two girls were talking about at the bus stop a few days ago. Both wearing delightfully colourful hijabs, they were huddled around their smartphones giggling.

“Where did you find that?” the taller of the two said shaking her head. She was dressed just like any other teenager –running shoes, jeans, and a bright orange leather jacket- but a dark blue hijab seemed almost tossed onto her head and barely draped over her shoulders. Perhaps it was the wind, but the almost-studied disarray was charming.

The other girl, stouter and wearing a long black coat, also sported a red, hijab-like scarf that barely covered half her head despite her constant readjustments. “It’s Al-Quran [an app, I later discovered],” she answered as if that should have been obvious.

The taller girl tapped on her screen for a moment and then nodded her head. “But, you know that’s not what Abbad said…”

The other girl just shrugged. “He always thinks he knows everything, Lamiya.”

“Well…” I could see Lamiya sigh, even though I was trying not to watch them. “He usually gets it right, Nadirah… I mean, don’t you think…?”

I couldn’t help but smile when Nadirah rolled her eyes. “He only gets it right when you don’t know! If you don’t check on it…”

Lamiya seemed to pout. “I just, like, took his word for it…”

“You can’t do that blindly, Lami… Not anymore.” She made another attempt to readjust her hijab in the biting wind. “Not when you can look it up!” She shivered deeper into her coat and I could see her breath whenever the wind died down. “Things just aren’t what they used to be for our parents… We can actually, like, check,” she said as their bus pulled up and they got on, leaving me still informationless in the cold.

 

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Grapple them unto thy soul with hoops of steel.

What is a friend? I think I could parallel St. Augustine’s answer about Time: ‘What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.’ Friendship is such a universal concept, such an acknowledged need, I’m not sure why it is difficult to define. Perhaps it is so much a part of our Umwelt that the only aspect of it that becomes consciously discernible is its absence. It is our air…

But of late, it seems to me that its meaning has been further eroded, further diluted, by its use in social media. It is now a verb as well as a noun –all well and good if we are willing to enrol people as friends much as we might solicit them to join a political party, or consider anybody that smiles at us as worthy of the designation.

Obviously, friendship is a spectrum and simply because we use the same word to designate the entire range does not reveal much about the meaning or the importance of its constituents to us. In a sense, if used generically and without a more descriptive adjective, the word is an empty shell –‘Full of sound and fury, signifying nothing’ as Macbeth said of Life. And that life is actually not so full of friends -‘Which the poor heart would fain deny and dare not.’ to quote Macbeth out of context once again. We do not have as many friends as we think –nor is it even possible to sustain the emotional effort necessary to acquire and succour more than five, or so, close friends. http://nyti.ms/2baJQPL

So, I suspect we should be careful how we use the term and in what context –for what purpose. The number of ‘friends’ we think we have are akin to the denominator of a fraction. It’s the numerator –the number of close friends- that determine the size. The value… I would have thought this was so obvious as to be almost trite. Uninteresting. But maybe the idea that a friend is someone requiring at the very least, an ongoing personal, non-virtual, interaction is a generational thing. Am I just having a semantic argument with myself; am I merely a Cassandra unable to understand that it is only my opinion that is being contested, and that its tenets have already been superseded? Food for thought…

And yet, there are consequences. Sometimes it is best to check in the rear-view mirror from time to time.

*

I’ve always liked Jennifer. She is a twenty-something year old woman I have known for several years now. I first met her because of a minor abnormality of her pap smear, and have seen her every year or so since then. I think she sits in the same place in the waiting room each time, too; I always associate her with the seat in the corner by the window –the one partially hidden by the Areca palm. She’s a small person, and her never-varying outfit of jeans and sweatshirt seem to blend beautifully with the green of the plant. Even her dark, shoulder-length hair sometimes resembles the type of shadow I imagine the plant would cast if it could… I don’t know why I think that; maybe because they’re both quiet. Both still. Both background.

The other day when I saw her in her usual spot, she was typing away furiously on her cell phone. She looked on edge, and the troubled expression did not disappear even when she saw me smile and walk across the carpet to greet her.

There’s often an easy-to-spot anxiety in some patients –the kind I usually can’t hide when the dentist ushers me into his chair- but I knew Jennifer, and the referral note just said she was back for a repeat pap smear.

“You look worried today, Jennifer,” I said when we were both seated in my office. “Are you concerned about the pap smear?”

She’d put the phone in her pocket and was staring absently at a terra cotta woman sitting on an oak stand with her begging bowl. I’d had it there for years, so Jennifer had certainly seen it before. She shook her head, but left her eyes gently stroking its contours. “She always makes me relax… I’m glad she’s still here.” I could see her trying to disguise a sigh. “It’s nice that some things stay the same…” She was quiet for a moment as she thought about it. “…Stay the way they’re supposed to be,” she added to herself as she moved her eyes slowly over to my desk like sleeping birds and left them lying there. They didn’t see me, I don’t think.

I waited for her to continue, but she merely repositioned her attention onto her lap. “What do you mean?” I asked, when it became clear that she needed to talk about it.

Up flew the eyes to the box of tissues on the desk and she grabbed a handful to wipe away some tears. “It’s nothing about my pap smears,” she said in a hoarse voice. “I don’t need to take up your time…”

“The pap smear talk can wait for a bit, Jennifer. Tell me what’s upsetting you.” I smiled reassuringly, but her eyes never reached my face.

She took a deep and stertorous breath and then decided to send them on a reconnaissance flight in my direction. “Oh, it’s just my ‘friends’,” she said, making sure I understood that there were quote marks around the word. “I invited all 147 of them to like a business website that I’m starting…”

I have to admit that I was a bit confused. “Like? As in Facebook ‘like’ you mean?” I had no idea what message that sent. A friend had once asked me to ‘like’ her barbershop on Facebook and I had duly complied –it seemed simple enough… and if it made her feel good, what the heck, eh?

She nodded, although I could tell by her face that perhaps I shouldn’t have needed to clarify such an obvious point.

“And…?”

She took a deep breath and shrugged. “And, well I guess I don’t really have 147 friends.”

I didn’t ask her how she knew -I figured that was probably obvious, too. But I must have looked surprised, because she giggled at the notion. “I mean I didn’t really think they’d all like the page, but…”

I had to chuckle –I couldn’t help myself. “I don’t even know that many people, Jennifer. I mean not counting patients…” I quickly corrected, as her face interrogated me in disbelief.

“How many friends do you have on Facebook, doctor?”

I shrugged. “I don’t know… I mean, counting my kids and a few close friends… twenty, maybe…?”

She thought about that for a few seconds. “I don’t know how I got so many.” She glanced at the statue again. “Sort of like collecting tee shirts, I guess. They look so nice in the store, but I hardly ever wear them.”

A thought suddenly occurred to me. “Do you know how many ‘liked’ your… uhmm, page?” I tried to sound knowledgeable about the words, but to tell the truth, I was on slippery ground and I think it showed.

She caught her eyes, before they completed a roll and managed to salvage a serviceable smile out of what I’m sure was headed for a smirk. Then her eyes twinkled without her planning on it, and she giggled with delight at my expression. “Only seven, so far…”

It was my turn to nod, and I sat back in my chair as I did so. “Well maybe you come out the winner, then…”

She tilted her head, as cute as a button, and I could see the adult stirring behind the mirror of her eyes.

“Now you know what ‘friend’ really means…” I said, smiling.

Her eyes hovered around my face for a moment before they returned to their owner, and I think she blushed.

Time Enough

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

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

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

*

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

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

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

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

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

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

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

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

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

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

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

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

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

I hope that Nora did, as well.

Trust

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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