The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.

 

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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.

A Patient Named Cindy

I enjoyed Cindy (not her real name); how could I not? Short, plump, with uncertain hair of indescribable colour that was tossed on her head like a salad begging for dressing, she captured my interest the first time I saw her in the waiting room.

She was pretending to look at a magazine, all the while sneaking amused glances at the more staid and nervous patients waiting for their turns on the obstetrical pedestal. Her heavily made-up eyes whispered fashion but her dress screamed Walmart. I could see others in the room look away in embarrassment –confusion, more likely- but Cindy just smiled: a queen supremely aware of the distance between her and her court. Regally bemused at their furtive glances, she would sometimes confront the faces hiding behind their own pretended reading, inadequately camouflaged with turning pages, or pointing out a picture to a curious child.

Something about her made them uneasy. Maybe it was the hem of her sequined dress that she wore distressingly close to the edge of her more brightly coloured panties. Or the tattoos on her legs that stretched ever upwards even beyond the hem. But I suspect it was that she knew they were looking and didn’t care. Relished the attention, actually…

And yet the attention her clothes seemed to invite was as unimportant to her as the screen in a movie theater: you needed to stare at it, but it wasn’t really the center of your attention. It was the vehicle necessary for you to appreciate the show. And Cindy knew she was the show.

It was hard to be formal with her –she was so… out there. She did not invite –she would not permit– the usual power pyramid so rampant in a medical office: she was Cindy, and I was the doctor –with a small ‘d’. She needed advice, and I was its purveyor. Period. If she needed shoes, or a dress, she would have gone somewhere else. I was merely the seller of medical suggestions; she could pick and choose from the assortment offered.

When she sat in the chair by my desk that first time –provocatively again, over-revealingly again- she stared at me for a moment, probably wondering if I would react. But I only smiled, kept my eyes riveted on her eyes, and asked her why she had been referred.

A hint of a smile touched her face briefly and then immediately exploded into a delightful and disarming laugh. “Guys never know where to look when I sit like this,” she said, adjusting her posture to a more socially acceptable form and sliding her hem back down over her knees. “You can judge a man by where he puts his eyes, don’t you think?”

“And..?”

“And I suppose I can trust you,” she said with an expression that seemed older and wiser than her twenty-three years.

“Well,” I said, carefully avoiding the mine-fields she had already sprinkled around the conversation, “what can I do for you?” I thought it was the most direct way to elicit a usable response.

A smile so large it nearly split her face in two suddenly materialized. “You know, doc, your question almost makes me dizzy… It’s usually my question. The one I  have to start with as well.” I have to admit that I shifted uncomfortably in my seat. She noticed it, of course. Cindy would. She straightened politely in her chair and dropped her smile to a category B and shrugged. “Sorry. Everybody says I’m a bit direct. I think it goes with the job.”

“Which is?” I asked when I recovered a bit of my usual equanimity.

The smile turned wicked. Naughty. “I’m a hooker.” She thought about the word for the briefest of moments and then added: “Well, actually I usually use the word ‘escort’ but I figured you’d see through that right away. Most men don’t –or at least pretend they don’t. Guys are like that –they like to pretend that you’re not doing it just for the money.” She stared at me for a moment, as if waiting for me to respond. Then she shrugged dramatically. Theatrically.

I casually picked up my pen as if I were going to write it all down and, as with everything I did, she noticed. It was almost as if she felt she could control me with her words. She did, I suppose…

“You want me to stop wasting your time and tell you why I’m here,” she said with a loud sigh and leaned forward across my desk. Normally I feel a need to protect the space on my desk –over the years it has become an extension of my authority, my personal space- but she did it so naturally, it caught me off guard. Anyway, before I could react she said “I want to have a child,” and sat back, retreating into neutral territory.

I must have looked puzzled –You couldn’t hide anything from Cindy, because she answered my expression before I had even framed a question. “Even strumpets want babies, doc.” Then she smiled at my apparent amusement with her vocabulary. “We also read sometimes…”

“Anyway, I came more just to size you up today…” She tittered at her unintended trade-talk pun. She was silent for a moment –something I came to realize was an uncommon jewel with Cindy – and then her eyes twinkled and her whole body smiled. “I think you’ll do, doc. I think I like you.” Praise indeed.

I never succeeded in helping Cindy with her infertility issues, but all the same, she became a regular distraction in the waiting room. She modified her clothes and hair styles, of course, but I had the impression they were all for the same effect. She found ‘regular’ people banal, uninteresting, and so she teased them. Goaded them, really. She seemed to relish harsh looks, and her body language spoke novels about the seating arrangements she usually provoked. She was the only relaxed one in the room, and she knew it. Loved it. Craved it, maybe.

One day, when I peeked around the corner to see if a particularly obnoxious patient had arrived, I noticed Cindy sitting in the corner seat with a heavy looking briefcase. She had placed it between her lewdly open legs, almost daring anyone to try for it. And she had an oddly satisfied look on her face.

When her turn finally came to be invited into the office, she started talking –as usual- before I could open the chart. Not that I needed a chart for her. After preliminary investigations had suggested that the reason for her failure to conceive was that her Fallopian tubes were no longer open –blocked, perhaps, by one of the many episodes of infection she had encountered in her life on the street- I had tried to refer her to an infertility clinic. She hadn’t liked their attitude after one visit, so she kept coming back to see me.

“Got something for you, doc,” she said, positively beaming. “I wrote a novel,” she said, anticipating my question. “I thought you might like to read it before it’s published,” she continued. My eyebrows must have twitched, because she immediately continued. “Yeah, one of my…friends is a publisher; we did a trade.” I didn’t ask.

But I did read it when I got home that night. It was short –fifteen chapters and more of a novella- but amazingly well-written. It didn’t surprise me – Cindy was obviously bright and a shrewd observer of mankind (I use the word advisedly). What did surprise me, however, was the subject matter: the medical system in general and me –disguised, of course- in particular.

It was a story of the life she knew best: she and her friends in the business –the violence of the street, the drugs, the john-encounters, but more poignantly the unsuccessful attempts of the women to be taken seriously. To be treated as needful humans, not occasionally-moving receptacles. Her words were street-harsh, but no less effective. Certainly no less persuasive. It was a book written from the heart, not from the mind, and this made it all the more compelling to me.

The story was one of suspicion of life outside her world. How it disappointed and disparaged the protagonist and her friends; how they mistrusted outsiders by necessity –survival was knit by acquiescence and tribe. Even in illness and need, they felt themselves alone, bereft of help from a mistrustful and unkind society whose judgments were cruel and who forced impoverished expectations of treatment on them.

Then the woman decides her need for a child is so great, and her attempts to become pregnant so unsuccessful, she needs some outside help. So she visits various clinics where the doctors don’t take her seriously. Her friends just shrug and shake their heads. Of course there’s no help out there for people like her –people like them.

But she persists and manages to get a referral to a specialist –a male specialist is all she could get, but she decides to visit him anyway. The waiting room she finds herself in is middle class and she thinks the women sitting there are so intense she is amused. Not a good sign, she figures, but she has gone this far so she is determined to persist.

When the doctor finally leads her into his office she is struck by one thing: a tall carved wooden statue of a thin native woman holding a baby. It is sitting on his desk and there is a plant beside it through which it peeks with curious eyes. And it is smiling. The carving seems to talk to her about refuge. Safety. And it comforts her. This is the man who can help her, she decides. He’d put the carving on his desk beside a beautiful plant for a reason.

And the story ends with her feeling hopeful. No, he can’t help her, although he tries. But that is the point for her: he tries. And that’s what really matters. Not the result, not the abnormal tests, not even the fact that she probably can’t have a baby. Somebody heard her cry of desperation; somebody listened. And maybe that’s what she really wanted all these years: someone who cared.

I have to admit I cried. My god, is taking notice of someone that important? Is what some of us are searching for merely to be heard? Noticed? To be distinguishable from the background?

You know she never returned to the office after that. Maybe she was too embarrassed, or maybe she had no further need, but I really hope her novel was published. And I hope the man who had promised her a voice, became one and not just another moveable shadow in her life.

Harm Reduction

I have always been suspicious of zero-tolerance; it implies intolerance as much as anything else. A thousand people crossing a bridge, are a thousand people crossing a thousand bridges… We are simply not all the same, nor are our worlds, our needs, our perspectives. And even if some issue could be proven beyond a reasonable doubt, there would always be those for whom it was still not acceptable -or even relevant. Our views are just not theirs.

Many of us see things through cultural and socioeconomic lenses, parental filters, and with confirmational biases in full bloom, assume that we have good and verifiable evidence: what we accept is universally applicable, validated and therefore reasonable.

This leads to various problems, both ethical and legal however. Take smoking as an example. If we accept -as most of us do- that smoking is a major health hazard, what should we do about it? What can we do about it? Well, at least two options suggest themselves. We could ban cigarettes outright, make them illegal -zero-tolerance- much as we do for other undesirable drugs.  Or, in Canada (or any other country with universal health benefits), we could sell the cigarettes (and profit from the sales) but deny tax generated health benefits to smokers with conditions caused by the cigarettes… Even if the smokers are themselves contributing to those taxes.

Perhaps a better and more useful, more benevolent approach might be to change societal attitudes towards the problem: make it unfashionable, undesirable, say, to smoke. This is widely seen as the answer nowadays -albeit a plodding and often unpredictable approach. The results are slow in coming, and often different from what we had originally intended. And there is the ever-present danger of intolerance and prejudice -a new, self-righteous view of the way things should be…

I see this in obstetrics. Alcohol, which in other circumstances is acceptable -even the norm- is very much stigmatized in pregnancy. There are certainly many good and evidence-based reasons for concern -the Foetal Alcohol Spectrum Disorder (FASD) among the most serious of them. And the fact that there is no unequivocal evidence of a threshold for alcohol intake below which it is safe in pregnancy adds to the worry of both doctor and public alike -to say nothing of the mother. Clearly, it would be safest for mother and foetus not to consume alcohol at any level.

But how realistic is this? I advise my pregnant patients not to drink, and yet I try to do it in a non-judgemental fashion; the last thing I want to do is make it difficult for them to talk to me about it. Many are reluctant -even ashamed- to admit their alcohol consumption for fear of criticism or censure. And in hospital, they are even afraid of their baby being apprehended if their behaviour were detected and judged by someone in authority.

One way to approach the problem is routine screening of all patients for alcohol consumption -letting them know that this is standard practice, not a judgment. This is helpful in many ways: promoting awareness of the problems sometimes seen in pregnancy with alcohol, and dealing with what might be termed ‘problem drinking’ early so that a reasonable plan can be formulated.

The standard brief intervention -and endorsed by the SOGC (Society of Obstetricians and Gynaecologists of Canada)-is simple, brief, and helpful: Assess, Advise, and Assist -quite self-explanatory, really. But it does not equate to zero-tolerance of alcohol in pregnancy -that would alienate, not assist. Those that had an alcohol problem would simply not admit it for fear of censure or the other ramifications that attend suspected, or potential foetal abuse…

No, we must aim for harm reduction, and set realistic and achievable goals if we truly want to help. Yes, it’s a compromise, but one that will likely keep the woman in antenatal care. The important thing is trust; if she feels she can talk to me about things and that I won’t judge her unfairly if she admits to issues that usually engender societal censure, she is more likely to be amenable to suggestions, maybe even motivated to change or modify her behaviour.

At least this is what sustains me in those hours between dusk and dawn when, sleep denied, I try to convince myself that anything is possible… That someone is actually listening.

Ignorance is the curse of God; knowledge is the wing wherewith we fly to heaven.

I can only hope.