Reflections on the Bell Curve

We -many of us in the Western world at any rate- live our lives on a Bell Curve, thinking -hoping- we occupy a place near an out-lying position: the 5% area that presumes we are not just normal,  but rather, exceptional… And given the population numbers, there is time spent worrying that we are inadvertently drifting towards the center -the average- and hoping that we are somehow firmly anchored on an edge where interesting things happen. We seem to aspire to live in interesting times, despite the doom that these times apprehend in the apocryphal Chinese curse.

It is a mild conceit, perhaps, but one that is not without ramifications: to discover that one is, in fact, quite average is inevitable as one travels through an otherwise eventful life, but to realize it too soon, may be to hold an imperfect mirror up to what had hitherto been seen as important and to distort an otherwise perceptible, measurable -believable- reality. It may denigrate the path, impute the incentives that had determined the choice.  Purpose maligned is purpose denied. We are, to an extent, our choices and we choose what we hope -or expect… 

Or do we? My interest was stirred by an otherwise banal finding in a study reported in the Huffington Post: that ‘dreading pain may be more unpleasant than the pain itself’.( http://www.huffingtonpost.com/2013/11/24/dreading-pain_n_4318114.html ) Uhmm, okay… I mean, how new is this? Let me quote from a 16th century poem (Sir Philip Sidney) that already recognized that: Fear is more pain than is the pain it fears. Plus ca change, eh? But it made me think that how we perceive things is highly conditioned by our expectations of them. Or dread of them.

Think of an impending biopsy, for example, where the result -not volition- may determine the direction of the road ahead. It is when the Bell Curve becomes an albatross, and not a presumption. Although pain and the anticipation thereof was what was examined, it seems to me not a large step to posit that the study would also suggest that we often see ourselves on the wrong end of the 5% -the wrong side of the curve- and the pain varies according to how anxious we are about the result of the test. Even though the likelihood is one of benignity and we have been reassured to that effect, that is not how we feel it beforehand.

Or consider childbirth, with all its attendant myths and worries -pain not being the least of these, of course. That it is a process which has been enacted countless times without incident, or that -hopefully- it will be supervised with expertise and thoughtful care seems of little import until it has happened.  One’s Bell Curve position, in other words, is only of value in retrospect and seems not at all meaningful until it is history.  As a result, we may enact the expected pain or imagined problems over and over in our heads until it clouds our judgement,  or engenders choices that might otherwise have lain fallow.  I’m thinking here of the woman opting for an elective primary caesarian section for the delivery of her first baby, for example -chosen largely through fear of the unknown, fear of the unexperienced, fear generated by the uncontextualized tales of friends. Or even the decision to forego an attempt at a trial of labour after a previous caesarian section because of an anticipated repeat of similar circumstances.

And yet, is this telling us anything new? Well, probably not, except that much of our anticipated discomfort may be misplaced, or at least magnified more than necessary. Of course some of it stems from nescience -a rather obtuse, but kinder term for ignorance -a state that a doctor, say, might hope to ameliorate through patient explanation and reassurance and an exploration of the person’s reason for the anxiety. Spending time with them, in other words…

But sometimes -often, in fact- the anodyne seems to be in getting on with whatever needs to be done -and sooner rather than later, according to the study. Of course this is not always possible -and not even usually possible in obstetrics- but the concept, where feasible, still seems both appropriate and preferable: scheduling the surgery or other treatment at the earliest opportunity, putting the person on a cancellation list to expedite the procedure if there is not a more proximate possibility, triaging operative timing to take into account other factors than merely when they were first examined in the office. Even to be seen to be trying to take her worries into consideration may be anxiolytic… Although I am not overly hopeful; we are who we are: There was never yet philosopher that could endure the toothache patiently -an observation from an earlier but likely more widely read study: Shakespeare’s Much Ado About Nothing...

Advertisements

An exploration of Menopause as a Boundary Phenomenon.

For years now, and especially as I age, I have been compelled by the idea of edges. Boundaries. Something different obtains there, something that differentiates them from whatever they demarcate. They are privileged areas, faerie-tale areas. Think, for example of silhouettes -treetops, say, against an evening sky; they are nothing but edges: intricately crocheted patterns, filaments of black against the dying pale blue background, they are trees and yet, strangely, they are not quite…

Edges are unique. They are where whatever was, is no more, but has not yet become other. It is a magic zone where the last remnant of something is defined, a demarcation that is at the same time inside and outside and yet really neither. Skin, which both contains what we are, and yet joins us to a place that we are not is a boundary; at what point, however does it cease to belong to the body? The surface -an area whose microscopic crevasses are deeply probed, caressed, and profoundly affected by molecules of outside? Or should there be a thin, arbitrary neutral zone where we allow that the skin has jurisdiction, though not strictly speaking, contiguity? A skin by virtue of proximity, not conquest; clothes whose owner is beyond dispute because they are being worn.

So boundaries are special: areas where ownership is not so much in dispute as definitionally obscure; where distal examination on either side is uncontested, and yet what constitutes the actual delineation of one or the other, nominally problematic. And functionally ambiguous, as well… Light, temperature, texture, authority -all are idiosyncratic, recalcitrant in the immediate vicinity.

We are constantly traveling through edges, aren’t we? Journeying from day into night, sleep to wakefulness, wondering to comprehending -these are some of the more obvious ones. Short term edges, if you will. But there are others less apparent as margins, that evolve more slowly, and whose fringes are so spread out we even categorize them differently: infancy, childhood, adulthood, old age… And yet, although their edges are also ill defined, they are equally magical and puzzling.

Take Menopause, as an example. It is a special edge: a junction -a phase-change, even. It is a bookmark between two Magisteria as different from each other as water and ice… But , menopause is a process rather than a boundary, it could be argued. A transition. There are no definitive edges to be contested, no uncontentiously delimitable state that precedes it, no clearly identifiable, and universally unique one that follows… no post hoc ergo propter hoc… Hence the vague, exculpatory and all inclusive concept of the Perimenopause –a concept that doesn’t so much explain, as encompass anything in the vicinity. Ambiguous. Nebulous, even. Ahh, but could this be an Edge description where the aforementioned boundary conditions obtain? A not-so-magic interregnum?

And yet, is that fair? Is any attempt to describe it thus, merely academic dissimulation?  Like a useless PhD thesis that is ultimately filed in the dark recesses of some seldom-visited library after its initial defence? Well, to start with, it seems to me that even if considered as an experiential phenomenon alone, examining the Menopause as if it were a boundary phenomenon has validity. And profit. The transition is palpable, the remembered state -that solidity away from the edge- different from the soon-to-come conditions temporally distal to the margin… So there is a vague and ill-defined border area that is clearly, if only subjectively differentiable from the rest: the pre and post menopause…

But, so what? Is there some relevance to describing the menopausal transition as an edge? Is there a believable and important justification for such equivocation? Remember that a boundary is a unique and special area, a marker as necessary for successful progression as a stop sign at a busy intersection. It is a biological divide that signals the need for reallocation of available resources. Unlike the almost imperceptible passage from childhood into adulthood, recognizable only in retrospect, and perhaps only by others, Menopause is a state, whose margins, although blurred, are acknowledgeable. Discernible. And borders that are distinguishable, even unwelcome, prompt reassessment. Reflection -albeit as if through a glass darkly.

As much as we may wish to deny it, we all change over time. It creeps up on us; the reflection in a mirror only revises the face of others, seldom our own. And yet the acknowledgement of Time and its passage is fundamental to growth -our own and theirs. Successful adaptation requires preparation, thoughtful anticipation. It is prudent to hesitate and plan the route before entering a forest.  And although from a distance it seems obvious where to stop, on nearing the trees, the boundary (again a border) seems less clear. Fortunately, unlike men, for women at least, there is a sign. An advantage: an Edge…

The Miracle (part 2): a woman’s story in 2 parts

“Emily.” It was the doctor’s voice, and he was leading her into a seat in his office as if she were an old lady. “Emily, it’s good to see you again…” his voice trailed off as he inspected her. “But you were supposed to have come back to see me a month or so ago, remember?”

Why was everybody always asking her if she remembered something or other? She was here wasn’t she? And besides, he knew she couldn’t keep running back to him with every little complaint until she was sure.

“Now remember last time you were in, you said you were having some…ah…” He referred to a folder that lay open on his desk. Couldn’t he remember, she wondered? It hadn’t been that long ago. “You were having some trouble with your bowels,” he continued as if he hadn’t really forgotten. “Constipated, bloated, vague discomfort in your pelvis…”

‘Vague discomfort’? Had she really said that? She became aware that he was drumming his fingers on the desk. It was all very funny, really. He was obviously expecting her to say something but all he would do was look at her quizzically over the bridge of his glasses. His straight, mouse-brown hair was too long for his thin body, she thought. And he was wearing the same creased grey suit as last time. What kind of a doctor only owned one suit?

Finally he ventured to speak again. “What’s been happening lately?” But she only smiled. “Bill told me you’ve been quite sick…” Again the look, and again she refused to be manipulated. “He said you’ve had some more pain and have started to vomit.”

She shrugged. Damn that Bill! This was all supposed to be so different. Why did Bill care anyway? He was never around much and even when he was, he was merely there. But so was she -trees in a meadow: untouching, indifferent, one or the other always in the shade.

Doctor Brock looked annoyed and was having trouble disguising it. “Bill said you wanted to see me Emily.”

She stared at the open file in front of him filled with writing in blues and blacks. Why would he use different colours, she wondered? And some things looked as if they had been underlined; this puzzled her as well. She didn’t think she’d ever told him enough to underline. She blinked, trying to resolve whether or not the line went through or under a sentence. Even doctors made mistakes. The chart was too far away to see clearly, however, so she leaned forward slightly, and as she did he cleared his throat.

“What did you want to see me about Emily? You’re still feeling unwell, aren’t you?”

There he goes again, she thought -just like Bill: he hadn’t asked, he’d stated -accused, actually. As if feeling unwell was wrong -no… expected. She was amazed at the stupidity of the man. How could she confide in someone who couldn’t understand how she felt about it all? She should have gone to a woman.

He sat back in his comfortable leather chair, determined to wait her out. Why was he so stupid? No, obtuse; she knew he wasn’t stupid exactly, just unable to relate to a woman’s needs at a time like this. She stared at him, confronting him silently with her unblinking accusation. She needed someone else; she was sure of it.

He coughed at her quiet threat, as if the noise might dissipate it -make her blink first, maybe. But she was determined. “I’m sorry doctor, you just don’t seem to understand.”

The sudden flurry of words made him jerk forward awkwardly in his chair. She got up to leave. “But you haven’t even told me what’s wrong, Emily. How can you expect..?” She was through the door before he could finish.

“It’s a woman doctor I need,” she told Bill in the car. He may have heard, but he didn’t turn his head or even shrug; it didn’t really matter anymore.

*

Dr. Heath was very young -something the Yellow Pages didn’t mention. But at least her door had the usual trappings of confidence: a sedate, cream-on-plastic plate with the requisite number of letters after her name -a few extra, even, as if to invite entry.

As soon as she got inside, though, Emily realized she had made a mistake. It was cheery enough, with heavily carpeted floors and a large double-glazed window with a view of the city; the plants were nice, if a trifle under-watered; and there were pictures on the walls of babies: babies with hats, babies in diapers, babies at breasts… It wasn’t the office that bothered her. It was the age of the patients that seemed strewn about like clothes: teenagers -all of them. Some pregnant, some with skirts up around their waists -a rogue’s gallery of young people, all staring impudently at her as she crossed self-consciously in front of them to the front desk.

The receptionist couldn’t have been much older, and as Emily gave her name she thought she caught a fleeting smirk that never quite surfaced. “You’ll have to fill in this form for the doctor, Emily. And I’m afraid she’s running a bit late today.” It wasn’t an apology, simply a statement. Take it or leave it.

The form was simple enough: allergies, major illnesses, medications and the like. Nothing too personal -she liked that. The doctor, however, was.

Dr. Heath was a pleasant little thing of about twenty-five, blond, smartly dressed and with eyes that seemed to hunt like spotlights when they hit. She fastened them on Emily. “My nurse mentioned something about you being late for your period, Emily,” she said noncommittally.

Late? That was a laugh. But Emily nodded. “It’s been four or five months now.”

The doctor didn’t seem surprised -or at least her eyes were calm. “Were they regular before?”

Emily closed her eyes impatiently. Of course they were regular. What was she getting at? She took a deep breath. “Yes.” And then she opened her eyes and stared out the window.

“I see,” said the doctor. But Emily didn’t believe her. Her eyes were too steady to be real; nobody was that calm. Dr.Heath wrote something in the chart then looked up again. “Any other symptoms?” She actually smiled when she said that, but Emily was not taken in.

“Maybe you should just examine me, doctor.” It was a simple statement, made calmly, quietly, but the doctor’s expression immediately changed.

“I’m afraid I’ll need to know a few more things about you before we get to that.”

“I’ve filled in the form, so it should all be in there, doctor,” she said confidently. You had to get control of these things early.

Dr. Heath stared at her intensely for a moment, obviously deciding what to do, then shrugged and pointed to a narrow door that Emily had not noticed when she entered. The doctor looked smaller now -pale even. “You’ll find a gown on the table in there. Please undress from the waist down. I’ll be there in a moment.”

It was long moment and Emily could hear voices through the door, but not clearly enough to understand. The doctor’s though, sounded excited, agitated. Had she made the doctor uncomfortable? Emily thought about it for a moment and then rejected the notion: she’d been civil. They were both adults.

The examining room was cold but she stripped to her underwear and sat on the examining table huddled under the flimsy gown. Soon it would be over. Should she tell Bill? He would eventually find out, she realized, but could she count on his support? She chuckled at the thought.

Dr. Heath suddenly appeared at the door, smiled wanly, and asked her to  lie back. “Where does it hurt, Emily?” she said softly.

Emily lifted her head. “Hurt? Who said it hurt?”

The doctor straightened her shoulders a little. “I’ve talked to Dr. Brock.”

“You had no right…” she started, tears forming in her eyes. “What I told him was… just between us.” But she realized how silly that sounded and looked down at her feet.

“Emily, Dr. Brock was concerned. I’m concerned.”

“You had no right,” she repeated, fighting back a sob. “I suppose my husband talked to you as well…” The doctor nodded. “You’re all trying to make it all so… so abnormal,” she said grabbing for her clothes. “Can’t any of you accept it for what it is?” Her cheeks were wet now.

Dr. Heath didn’t move. “What is it Emily?” she said in a soft, sad voice. Emily glared at her and finished dressing. “What is it?” she repeated and grasped her shoulders.

Emily broke free and forced her way past the doctor. “A miracle,” she said between sobs.

“Emily!” There was no mistaking the tone this time. “Emily I’ve talked with your doctor…”

She was through the door but she stopped by the window, near the doctor’s cluttered desk. The cars had their lights on now and it was raining; the sky barely cleared the tops of the buildings. Why was it always like that, she wondered.

“Emily, please listen to me…”

But she just shook her head. Tears rolled gently down her cheeks and she made no effort to wipe them away. Why should she listen? She was living with the proof right here in her abdomen. Her hand reached involuntarily for the palpable swelling growing quietly inside. There. It moved again; she was certain it did. Nothing they could say or do would convince her otherwise. Perhaps another doctor… Yes, that was it, another doctor -an older, more experienced one this time.