Scaffolds

It’s exciting to realize that, despite my age, there are so many things that I have not stopped to think about: the seemingly random encounters with anonymous people in the course of a visit to a store or waiting for a bus downtown; inconsequential interactions with strangers on a sidewalk waiting for the light to change; overheard conversations at the next table in a Food Court in an otherwise unimportant mall. They are mostly forgettable, I suppose -background noise- and yet in retrospect, they ultimately form the invisible scaffolds of our lives.

Of course, I guess it’s tempting to dismiss most of these encounters -and anyway, there are far too many of them to remember, and they are far too numerous to catalogue let alone ponder the significance of each. I would feel overwhelmed if I had to remember the details of everything that happened to me in a day; I feel blessed that no one asks; it is not a requirement for old age.

And yet, I sometimes wonder if those forgotten contacts with the world form the hidden webs that bind me to reality: Occurro ergo sum, as it were. They have obviously decreased in our pandemic lockdowns and social distancing of late, but they are all around, if you watch for them. I still have trivial conversations with those lining up the requisite three feet away in the grocery store; I still feel a compulsion to interact with flowers in the woods and I continue to follow mysterious and partially hidden trails to see where they lead. I still attempt to understand the yawp of crows scattered in the forest as they try to stay in contact with their flock; and if our eyes engage, I still smile -masked or not- when I pass a person I don’t recognize on the sidewalk to show them I also am a member of their flock. How else to honour an otherwise forgettable stranger? How else to make sense of my life?

*

An elderly man (I try not to look for comparisons with my own misuse of years) apologized to me for coughing as I sat beside him on a bus a few weeks ago. He was wearing a mask above which, by chance rather than intent I suspect, his nose was almost entirely visible. He clearly had not entirely mastered the art of masking, because one ear also stuck out like Mickey Mouse from the pressure of the straps, and there was a rhythmic indentation of the fabric with each of his laboured inhalations.

“Damned thing keeps making me cough,” he ventured, as he apologized with his eyes and re-buried his nose. “But I’m double-vaccinated,” he hastened to assure me in the same muffled tone as his apology.

And that was that. Two streets later, he got off after stroking me with his eyes as he left -for tolerating him, I suppose.

*

A woman passed me carrying her tray to the drop-off box in the mall’s Food court to which I’d been travelling on the bus. I was sitting, unmasked, at a socially distanced table eating a bagel and lingering over my coffee, when she accidentally bumped into me, dropping a napkin onto my arm as she tried to avoid stepping on her little boy. Her eyes immediately registered horror -partially at the incursion into my space of course, but mainly for the fomitic napkin that had landed on my arm. I imagine the fact that she had also forgotten to don her mask after finishing her meal suddenly occurred to her as an added and unforgivable crime as well.

Ordinarily, I suppose this would have elicited no more than an embarrassed apology, but in this pandemic age, it seemed to her to have been an egregious trespass. “Oh my God, sir,” she muttered sotto voce, so as not to incur the antagonism of the otherwise uninterested patrons. “I’m so sorry!”

I smiled at her as a sign of forgiveness, and merely blew the napkin off my arm and onto the floor. I hoped she would see this as yet another sign of absolution, but she merely blushed, picked up the napkin and hurried off, while looking around the room to make sure no one else had noticed.

*

Much later, I was about to enter a popular pathway leading to the trail around a local lake when a dog rounded the corner. I like dogs -no, actually I love them and stop to pet every dog who will let me, leashed or not. I walk the trail several times a week, so by now, I suspect I know every dog I pass -or is it the other way around? At any rate, the dog I met that day was one I didn’t recognize, and it was attached to an ownerless leash. It was a black Labrador, I think, and as is the custom of every lab I’ve ever met, it started wagging its tail furiously and trotted up to me to say hello.

There’s something incredibly endearing about the look in their eyes as they poke their noses into strangers as if they were long lost relatives; it’s impossible not to recognize that there is something intelligent and curious staring out at you and requesting a pat.

I, of course, can never resist, but before I could reach out and touch its head, the owner came puffing around the corner and screamed at me. “Don’t you pet that dog,” she yelled, her eyes not at all as welcoming as her dog’s.

“He came up to me wagging his tail,” I explained, not a little put off by her attitude. I didn’t recognize the wrinkles I could see on her face above her mask, either; she was obviously not a local.

Her eyes narrowed and her forehead rumpled at my explanation as she grasped the leash firmly in two hands and pulled the dog away. “Dogs can catch human diseases, you know,” she added, shaking her head irritably.

The dog glanced at her and then back at me; I could swear his eyes apologized to me for his master’s rudeness and I could almost see him shrug, as he trotted reluctantly away realizing he had no choice in the matter.

I can only hope he realized that I was left without a choice as well…

Pelvic Exams

Medicine has been my life, and over the years I have seen my specialty of obstetrics and gynaecology break free of many of the traditions that shackled it to the past. Obstetrics was once a superstition-clad field -a world unto itself; gynaecology was mired in taboo and cultural sensitivities that often precluded open-minded and unbiased research and therapy.

To a variable extent, both managed to disentangle themselves from the constraining mesh of gendered folklore and even sexual politics by embracing a non-discriminatory and objective multidisciplinary approach to the problems surrounding each domain: what a pregnant woman had in common with her non-pregnant counterpart, for example. A recognition that gestational diabetes, say, could be engendered by the stresses of pregnancy and that its diagnosis and management had much in common with type 2 diabetes in both sexes. That not only did conditions -diseases, anomalies, medical and surgical abnormalities- have an effect on pregnancy, but that pregnancy had an effect on them as well. Treatment had to be contextualized. Tailored.

An awareness that one of the most common and devastating cancers of women had preliminary and treatable forms that could be detected by scraping the surface cells of the uterine cervix led to the development by Papanicolau of his eponymous pap smear in the early part of the last century. This mainstay of Women’s Health required some education, of course: although readily accessible physically, the cervix occupied an understandably personal and intimate region hitherto guarded by powerful societal norms -not to mention feminine propriety.

And yet, despite the obvious progress and benefits accruing to this approach, there remain other elements equally important to success. To ignore these, is to forget that there is more to personhood than meets the eye. We are more than the sum total of our parts.

I can’t help but feel that Medicine has sometimes capitulated to the Scientific Method -surrendered its mandate. Forgotten its purpose: to help and reassure. Even my own specialty, despite its undeniable progress, occasionally mistakes a valuable stand of trees for a forest and seems to be in a hurry to log them all to ground level -to the bottom, if you’ll pardon the mixed metaphor- in its haste to discover what might be hidden. There are tides of change that buffet us all, but are they sweeping baby, bathwater and flotsam out to some nebulous Sargasso place beyond the horizon? A place unreachable by the rest of us. Unusable. Unauditable. In our dash to embrace what has been called evidence-based care, have we thrown reality-based care overboard to lighten the load? The bureaucratic equivalent of jetsam: cargo thrown overboard to save the ship -a word derived from jettison.

We must be sensitive to changing times and evidence, of course; new data require new approaches. We must be aware of public opinion and evolving mores because sensibilities wander, expectations mutate. We are not the same people we were even a decade ago. We are an ever-simmering melange as new customs merge with established ones, and religions stir several pots at once.

So there is no one center around which things revolve; we are many circles, each overlapping. We are a stochastic society: a kaleidoscopic stew of boiling colours and tastes.

But just because there are many variables that resist easy classification, this does not necessitate ill-considered solutions. Some things in Medicine are important -worth preserving even if they require more work than in the past. More patience. More understanding.

Think, for example, of vaccinations. Who would have thought there would be any resistance to these life-saving measures a generation ago when polio, smallpox, diphtheria, tetanus –even measles- were reeking havoc across the world? Nowadays it’s not the doctors who are suspicious, but the public: ‘Why vaccinate my child and subject her to risks of side effects for something that nobody gets anymore?’

I hear this occasionally from my pregnant patients. So, I have to make the time to counsel them and attempt to answer their pre-printed Google inquiries. And by and large they understand. What they have been seeking is not so much a detailed data-ridden explication with appended references, but an empathetic hearing and discussion of their concerns. People are sensible, by and large. They simply want what’s best for themselves and their families. They want to be participants in health related issues –and why not?

But to come to the point of this essay: http://annals.org/article.aspx?articleid=1884537

Some patients have readily discoverable problems -an enlarging mole on their skin that worries them, say. But some areas are hidden –both from the world and the person herself. The vagina was not designed as a shop window, and what hides at its end in the pelvis –like the uterus, ovaries, Fallopian tubes, for example- are not subject to casual interrogation. Tests like ultrasounds or CT scans are only done when symptoms arise –and like everything else, that is often too late. This is a worry.

Most women are resigned to interval pap smears (and soon, no doubt, to interval HPV testing from the same area). It seems to be accepted by most people in the community that pap smears can detect abnormal cells arising on the surface of the cervix long before –years before- any noticeable symptoms appear. And the fact that the rest of the pelvis can be assessed at the same time as the pap smear is reassuring to most women. Expected, actually -especially since their doctor is already focussed on the area. In the neighbourhood, as it were.

So it came as a surprise to me that a recent guideline from the American College of Physicians suggested that a pelvic exam should not be done routinely with pap smears. Only if symptoms arise that are suggestive of pelvic pathology could one justify its performance… Where’s the reassurance in that?

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

There are harms associated with it apparently. Evaluated harms ‘included fear, anxiety, embarrassment, pain, and discomfort. Physical harms may include urinary tract infections, and symptoms such as dysuria, and frequent urination.’ Wow! I wonder who is doing the pelvic exams for their studies.

And I wonder if any of the examiners actually discussed the examination with the patient beforehand. Or, more importantly, asked her permission. Her arrival at the office for the pap smear was voluntary (one hopes) and so she must be an active and willing participant in any medical investigations performed on her –including a pelvic examination, obviously. If possible, she should be able to choose her examiner –a female doctor, for example, or someone she trusts and with whom she feels at ease. As for my part, if she should choose not to be examined at the time of the pap, I certainly do not object; but I always ask.

Sometimes, there are cultural differences where the patient would feel awkward being examined by a male and if I suspect that is the case, I do not insist or make her feel uncomfortable about having to make a choice. I also offer to have another woman (her friend, my secretary, or her husband if she so chooses) to be present in the examination room.

Examination is as much for her reassurance as to discover something. The choice is hers, not mine. But there is usually an expectation that it will be done –or at least offered. I don’t think that we should make a big production about it. I don’t enjoy going to the dentist –childhood memories of pain and discomfort, I suppose- but when I do go, I expect her to check more in my mouth than just my teeth. Even if it is just my regular dental checkup I am willing to have my tongue palpated and my gums poked and prodded… especially if it is just a check up. I want to prevent problems as well as solve them. And the more thorough the examination, the more reassured I feel when it is normal. Am I alone in this?

Let’s face it, there are some things that, like it or not, we need to do for our own benefit. In the long march of Time, they might not amount to much, but nonetheless we may put them off in anticipation of discomfort or embarrassment. Autonomy –choice- is paramount.

But let me paraphrase (para-sex) Shakespeare:

She that outlives this day, and comes safe home,                                                                         

Will stand a’ tiptoe when this day is named.

Kind of makes one proud to have participated, don’t you think..?