Hide and Seek

I guess the hunt is never over. Just when you think you’re winning, a sleeper cell surfaces, one you hadn’t even suspected, and closets itself somewhere you’d never think to look –an endless game of hide and seek. A Samsara of possibilities.

An yet, what would be the thrill of exploration if you knew all of the findings beforehand? We all need quests -adventures that uncover the hitherto unexpected, don’t you think? It’s what gets us out of bed in the morning. Me, anyway.

Questions and answers, for example… Let me play the devil’s advocate for a moment. We tend to assume that answers are the result of questions –we ask a question and then search for a correct -or at least appropriate– answer. But are we actually falling into a post hoc fallacy? ‘Post hoc, ergo propter hoc’ –because something occurred right after, or seems to be a response, we assume the initial thing caused the second. That’s just one way to look at it, of course. What if we assume there are answers lying around everywhere, and that the game is to find the appropriate question –the one that fits? A kind of ante hoc approach, I suppose, in which the answers come first.

Okay, try this. Answer: There are significant numbers of bacteria living under, and protected by, the fingernails. Question: Why doesn’t persistent scrubbing eliminate bacteria on the hands? I know this approach is merely a capricious inversion, but sometimes transpositions help us gain an interesting, if not useful, perspective. An article from BBC brought it to mind: http://www.bbc.com/future/story/20160622-what-lives-under-your-fingernails

I’m a surgeon, and early in my career it occurred to me that the water I was using at the scrub sink before an operation was itself not sterile. After a fastidious and lengthy hand and arm scrub with whatever cleansing soap was in vogue, I would then rinse off the soap with what amounted to tap water… And then, yes, I would observe ‘operating room technique’ and don sterile gloves for the procedure, but, apart from perhaps reducing the amount of whatever had been on my hands, what had all that scrubbing accomplished? Was it just a theoretical conjecture that it actually made a difference? A sop to sterile tradition? And if I were required to wear sterile gloves anyway why not just, I don’t know, use the same soap I used in the shower? It would certainly be cheaper. Questions! Questions swirling around hunting desperately for answers…

Had we posed the answer first, though… (Can you pose an answer?) Maybe the answer: ‘there are significant numbers of bacteria in the subungual compartment’ is a perfect fit for the question: why ‘is this hand region […] relatively inaccessible to antimicrobial agents during normal hand-washing procedures’?

Think about it for moment. Isn’t this the classic conundrum of basic science –science that is done for its own sake, science that has no existing practical applications? It consists of a whole platoon of answers to questions that have not yet been framed –or at least questions that were not anticipated at the time, or maybe just not the questions that were asked. A classic example of an answer (observation) looking for the right question was that of the findings of Penzias and Wilson –two physicists working on a new type of antenna at Bell Labs in New Jersey. In the early 1960ies they found a source of noise (the answer) in the atmosphere that they couldn’t explain. Finally, after eliminating other questions, they realized it was the cosmic microwave background (CMB) left over from the Big Bang. They received the 1978 Nobel Prize in physics for finding the proper question: ‘Is there any evidence of the Big Bang still around?’

And how about another answer: DNA is a large double helical molecule containing patterns of paired nucleotides and is found in cell nuclei for some reason. Question: why is it there? Or even: Could it be related to reproduction? Or heredity…?

Okay, I know this is a bit of a cart-before-the-horse stretch, but I think it does make us less complacent and maybe more appreciative of raw data. Details. Complexity. I’m not suggesting that Inductive logic is somehow flawed –it’s one of the fundamental tenets of the Scientific Method which posits using observation (answers) to derive general principles (more answers).

It’s not that confusing, really –it’s actually how things work in Science. The questions often arise because of the observations –after them, in other words- and so require experiments (questions) to see if the observations were indeed the answers…

So, isn’t the world a wonderful place? I ask that question -just one of many- after observing all the answers lying around unquestioned –unbothered, really- on the grass and among the flowers growing outside my window, all the unchallenged clouds in the sky above, and all the sunlight glinting off my polished floor.

I wonder, sometimes, whether the King James translation of the apostle Paul’s letter to the Corinthians was unwittingly prescient: ‘For now we see through a glass, darkly.’ And only when we recognize the importance of the observation, are we encouraged to ask why is that?


Plus ca Change?

You know if you wait long enough, what was old becomes new again. Old fashions become retro and are seriously nouveau. I don’t wear ties or cuffed pants, but I’m sure if I hunted around in the closet I could find something that would make a teenager’s eyes water.

Theories are sometimes like that, although when they return, they somehow look different: different words, different rationalizations, different paradigms into which they have been conveniently slotted. Sometimes they return because of the Law of Unexpected Consequences: the current wisdom has led to an undesirable product. And that’s totally acceptable and indeed what is admirable in science as I discussed in my last blog. It is appropriate that we continually monitor the results of thinking a certain way, re-evaluate even established wisdom when it seems to be leading us astray.

Our problem is that change is often slow. We adapt. We accept that which is only marginally different from what we have come to expect. It is only by stepping back from time to time that we realize how great that change has become and decide whether or not it still meets our needs. Whether, in other words, it is still acceptable.

Okay, plus ca change… There is an article in the March issue of Obstetrics and Gynecology that suggests that it is okay to let a woman labour longer. Not only that, but they should be allowed to push longer in the second stage as long as the baby is not showing any signs of distress. The lead author is a member of the American College of Obstetrics and Gynecology (ACOG) Committee on Obstetric Practice, so it’s imprimatur does carry some weight.

ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries

The impetus for this reassessment, dare I say, is the number of Caesarian Sections that are being done. In itself,  a surgical intervention would not seem to be a necessarily bad thing if it saves the life or the future health of a baby or its mother. There can be downstream consequences to Caesarian Sections that are seldom given much press, though. Caesarians are not a pancea, and not without complications –all surgeries carry their own risks. But in the case of obstetrics, it is often not simply a one-time risk. The mother may desire another pregnancy, and because of the problems she encountered in her first labour, may opt for yet another Caesarian. Or, complications from the first one such as infection or wound problems may necessitate a second Caesarian. The concern doesn’t just stop with the delivery of the first baby…

The question at issue, however, is whether it was actually necessary to intervene in the first place, or whether other factors were at play. Judgement, of course, is a multiverse, subject to all the biases of current wisdom, past experience, and not least, the way it was taught in medical school or the residency program. We seem to be creatures of the algorithm; we feel happiest when we can plot things on graphs. The Friedman curve of cervical dilatation was one of the basics we were taught as medical students: if progress begins to deviate from the nice sensible curve, then do something. All well and good: start some medication to enhance the mother’s contractions, maybe, and then observe. And reassess… The temptation, of course, is to set some arbitrary time limit to the observation and then intervene if progress has not occurred. The study is suggesting that we lengthen that time limit… or perhaps even question  the need for one at all. Patience can be a virtue.

But we need patterns to help us; it has no doubt been to the advantage of our species, to categorize: to identify the growl in the woods, then slot it into a judgment. A reaction. A pattern. So if we don’t immediately see a pattern, we look for one. Or we create one. Of course, the patterns are often arbitrary; we just feel better when one is there.

And we love to measure things in that search –measure and then analyse. But in a sense, we’ve again arbitrized a tiny section of the whole and generalized from it. Think of putting a grid over a window overlooking, say, a street –but only concentrating on one tiny section of it –ignoring the rest. In square 1C there is are 106 green things that look like leaves, and they sometimes move randomly. And since that’s all we can see, we conclude that we’re dealing with a forest, and that there might be an animal in the tree making it move. Or maybe wind… We convince ourselves we have discovered something profound. Well, maybe we have, but it seems to me that what would  be far more profound would be to take away the grid and realize we were only measuring a small segment of a far larger, far more diverse whole.

Sometimes we do that, but more often we get caught up in minutiae –especially if they fit into the current paradigm. Or we can make them fit. We need to step back every now and then. Clear our minds. Look at the whole… Why did we think we should set limits on labour? Why did we feel we should give up in the second stage after pushing for a certain length of time? Did this ever make sense if mom and baby were okay? Is this one of the reasons women are feeling more comfortable with midwives, or electing non-hospital births?

Even as an obstetrician with a rather lengthy career, I hesitate to say I told you so, but it’s the wide tie coming back into fashion again… or are they already back? The caveat for all of these recommendations is –of course- that there are no other impediments to continuing the labour, or the pushing. Mothers get exhausted. So do babies… So do doctors. And it’s this latter category that we have to be careful about. There may be no reason for intervention in the labour other than frustration.

Lack of progress is a highly charged observation in labour, and even more so after an hour or two of pushing without seeing much success. It can lead to decisions that, in less emotionally and physically exhausting circumstances, might be made differently. And that is where the nurse, midwife, or doctor has to step back from the drama. Has to try to divorce herself from the fray and consider what is truly in both the baby’s and mother’s best interest. Has to try not to succumb to the frustration thickening the air. A word of encouragement from a trusted caregiver goes a long way to diffusing tension. Sparking renewed determination. Inspiring hope…

But I thought we all knew this.

Affairs of State?

What is it about les affaires d’amour that seem to capture our interest? Wave for our attention?  I am reassured by the activity in the world’s blogs -not to mention its press- that I was not alone in noticing the recent fuss around the alleged affair of the president of France. Adam Gopnik’s piece in the BBC News is, I think, one of the best reports:


It suggests, at the very least, that I was not born with an unusual amount of prurience -if one can think of it as a personal quality akin to, say, courage, or agape. But is it just curiosity that attracts my attention to activities I have hitherto been unwilling to perform -and, now that I am not in a relationship, perhaps even definitionally unable- or something more basic? Primal? Contemptible?

It has been argued that sexual affairs mainly pique the interest of those who have not yet had the chance to indulge in them -those whose consciences are clear not because it is beyond their pale, but more beyond their skill. Or opportunity… Being somewhat virginal in this respect -or perhaps naïve would be a better term- I imagine I can be allowed to comment on them, albeit from a position of ignorance… and yet I don’t suppose there are any rules, are there? It seems to me that only someone with an absolute and unquestioned possession of what is right and wrong should be qualified to judge. We usually assign this role to a deity. None of my friends fit into this rather narrow slot; no one in political office for sure…

For that matter, are there any absolutes when it comes to morality? Apart from such obvious things as murder or child molestation -I’m only short-listing things, not closing the door- why do there seem to be so many societal discrepancies? Is it simply a ‘Well they’re not like us, so don’t listen to them?’ or something more profound?

‘When in Rome, do as the Romans.’ I grew up with this aphorism, for some reason. It was certainly not geography -Winnipeg and the vast Canadian prairies were my childhood homes- and yet what I interpreted it to mean was that if you were living in a place where they did things differently, try to fit in even if you didn’t understand. Even if you didn’t agree. They likely had a reason to which you were not -yet- privy. Hollande -being French- has been variously caricatured as ‘typical’, ‘selfish’, or even ‘amoral’. But it is as if the Romans -read the French- always behaved a certain way. Or worse, being told by a non-Roman that Romans behave a particular way. And even worse: being informed by a non-Roman who has never even been to Rome (but has read about it)… I don’t know, it’s too much ‘third-cousin-twice-removed’ information for me.

I think we have to divide the Media’s interest into two parts. First, is it acceptable to cheat on someone; and second, should people in authority be somehow exempt from such intimate and personal scrutiny? Is this merely -I used the word before- prurience? The answer to the first question seems self-evident: no. There may be circumstances where cheating is easier, circumstances where it just ‘happens’, even circumstances where it might be possible to keep it secret, but I’m struggling to think of circumstances where it is the correct thing to do. Full disclosure: I’m an avowed, life-long ethical relativist, and yet even my relativism sees a problem with this. For that matter, even a liberal interpretation of Kant’s Categorical Imperative (an action is correct only if you could accept everybody doing it) suggests that sexual affairs might be problematic. And I have to come down somewhere, don’t I..?  Or is it permissible to obfuscate? Delay until the subject is forgotten.. or at least until something else is front and center?

How about the need to examine those in power more carefully than their flock? Well, not more carefully –as carefully. We are, none of us, above criticism; none above personal scrutiny -not because of who we are so much as that we are. Whether a public figure should be judged for things outside of the public realm is not the issue. If whatever doesn’t effect performance or obligations, then it must be assessed separately. Judged separately. But like it or not, agree with it or not, it will be analyzed. We do not live in a vacuum and we all cast shadows that follow us around as long as there is light; it is in darkness where ambiguity proliferates and context is muddled. Mistakes are made in the dark… and rumours lie like fields of mud. Waiting.

And then there is the rather insulting question of whether the French are somehow… different. Do the French really have a societal acceptance of ‘affairs’? Are they somehow less titillating there than elsewhere? It seems to me more appropriate to ask the questions differently. All of us that are not French ask them from the framework of our own belief systems, our own closets. No matter their answers, we will interpret them as members of different Magisteria where words, not to mention values, imbue them with different colours, different shades of relevance. We all see the world through different parents, and tempered backgrounds. We braid our opinions with fragments of ‘other’ to be sure, but in the final analysis we are seldom them, as much as us… Our judgements can rarely be extracted from the warp and weft of where we live and how those around us think.

Most of us are still, sadly, prisoners in Plato’s Cave. Have the French alone escaped? Would we know?

The Wandering Womb

The science that brought you heart transplants, kidney transplants, and even lung transplants, is at it again -with a vengeance. Well, maybe I shouldn’t word it that strongly -I’m sure the folks that thought this one up assumed they were doing some good. And maybe they are… I mean, Science is good, right?

I’ve always believed that the world is filled with answers just waiting for the right questions. If there’s a problem, grab an answer, then look around for the appropriate question; you might get lucky. That’s how it used to be done… Too random? Well then create a problem nobody’s thought of. Then solve it. I can think of several transplant problems one might want to create and then solve. It might make sense to attempt to transplant bowels, for example -you never know when a new set might come in handy. Or how about eyes? They’re useful… And then there is always somebody looking for a new pair of ovaries. For that matter, limbs would be big -entire limbs, not just their parts.  Tongues..? The list goes on. But a uterus? http://www.bbc.co.uk/news/health-25716446

I have to admit I am conflicted on this issue. On the one hand, it would seem natural for a woman without one to want one -a uterus does all sorts of important stuff: carrying babies springs immediately to mind. But hold on. A uterus placed in someone else’s body is in a foreign country. It is a stranger at a family party and after being roundly embarrassed and then exposed as someone they don’t know, it is immediately rejected and shown the door. Explanations just don’t work under those circumstances without drugging the entire family into submission. And don’t forget, the uterus doesn’t merely show up because it got the wrong address; it was likely recruited for a specific and important job. No one orders a new one just to re-create the painful periods of their youth, nor in order to keep a ready supply of fibroids on hand.

No. Odds on, it will be recruited as a biological isolette. An incubator. But fetuses are notoriously sensitive to chemicals as they are developing and so what keeps the incubator alive and well, had better have a similar effect on the incubee. And the only way to keep the body from destroying the transplanted uterus is with anti-rejection drugs -immune-suppressors- which are toxic. Swords of Damocles.

Obviously a similar situation obtains with a transplanted kidney going through pregnancy -it needs immune suppression, too. But although the demands on kidney function change with the constantly moving target of pregnancy requirements, one might argue that there are some fundamental differences that separate kidney function from uterine function in a pregnancy.

First, there is the obvious need for a fertilized egg to actually implant itself in the wall of the stranger -this is the bond that ultimately creates the placenta which in turn nourishes the developing fetus. I can’t imagine this is easy at the best of times. So, the uterine muscle must have a smoothly functioning mechanism to allow an attachment that is not impeded by any inflammatory response from the immune system, or inhibitory effect by the drugs. It has to be a strong and functional union because that union will have to allow for the growth and changing metabolic and nourishment needs dictated by it’s totally dependent passenger for the entire pregnancy: a Gordian knot…

That uterus will also have to grow as the baby grows inside it. Grow -not merely stretch. Too much stretching without concomitant growth might irritate the muscle fibers and cause them to do what muscles all over the world have been taught to do under the circumstances: contract. In obstetrical terms, this is sometimes known as labour… Admittedly, hormones from the placenta and who knows where else will normally have a role to play in keeping the uterus relaxed and quiet -coordinating things. But a transplanted uterus, already confused by its new digs and having to contend with a whole bagful of noxious chemicals may well react differently: like an already rebellious teenager in a new and (maybe) abusive foster-home… (Uhmm, okay that metaphor was probably a bit of a stretch as well…)

And if the pregnancy actually succeeded and made it to an acceptable state of viability for the baby, a Caesarian section would be necessary -I can’t see the uterus cooperating sufficiently to agree to any kind of productive and efficient labour. That’s fine, of course: under the circumstances a Caesarian delivery would likely be the safer option. Perhaps even a Caesarian hysterectomy, because I suspect the uterus would only be a single use entity after what it would have been through and so require removal anyway.

So, what am I saying? I suppose the first thing is that I congratulate the surgical teams for their success in many of the transplants so far and I wish them and the recipients the best of luck. It was inevitable that someone would try it some time, I guess. But remember, successful transplant does not necessarily imply successful function. I have to admit that it is a procedure I will watch with much interest, but from the corner of the room. If all goes well, it will surely be a boon for those women who have lost their uteri through surgery or disease, or even in the genetic lottery that occasionally intervenes so tragically in some lives. Until now, I suppose, adoption would have been the only option, but I understand the wish to gestate one’s own baby with one’s own eggs and in one’s own body.

Maybe, someday, uterine transplants will be viewed much like heart transplants… and yet they are not. Let us not forget that unlike hearts or kidneys, unlike lungs or livers that are transplanted only in extremis and when all other less drastic options have failed, with uterine transplants, survival of the recipient without the organ is not at stake; survival of the baby in utero is, however. And it’s not just survival, we’re aiming for either… It’s the healthy survival of an initially normal fetus that has developed and grown in an abnormal environment. Heaven only knows, enough can go wrong in a normal uterus -even with the best of care- let alone one stitched in place and clothed in chemical soup.

Perhaps I’m viewing this as an elder who has seen many promising ideas go badly wrong -think, for example of thalidomide and the developmental anomalies it produced in fetuses. Or DES for threatened miscarriages that resulted, among other things, in clear cell carcinoma of the vagina. So my advice is one of caution. Just because we can do it, doesn’t mandate that it must be done… Should be done. Ideas come and go -that’s what they’re for after all; it’s how we make progress. Improve things… But in this case, the results may influence -even malign- future generations; the results may be future generations. Let’s get it right -we’re not just dealing with kidneys here.

The Night of the Undead -Condom, that is… (female condom, I mean)

They’re back! Well, sort of… My somewhat sketchy memories of them -professional, you understand- are that they resembled the plastic bags you get at a supermarket… not female condoms (FC1s). They didn’t look at all like condoms! In fact, I still remember the jokes about needing Walmart greeters on entry and theft alarms on exit -this from the women themselves. No one seemed particularly enamoured of the concept: they were apparently made of polyurethane and quite apart from the distracting noise they made during use, they were ungainly not to mention unsightly. To use one at all required unprecedented devotion to the product and a fair amount of lead time…

Ahh, but they’re back; this time with fresh clothes: the new and apparently improved FC2 is made of non-rustling synthetic latex (as reported in the BBC News magazine : http://www.bbc.co.uk/news/magazine-25348410 ). I mean, the concept is a good one: empower the person who would suffer most from a pregnancy -the woman. And the article cites other advantages of the device as well: ‘They can be inserted hours before sex, meaning that there is no distraction at the crucial moment, and they don’t need to be removed immediately afterwards. For women, there is better protection from sexually transmitted infections, since the vulva is partially covered by an outer ring that keeps the device in place.’ All well and good; hard to argue with that… I guess.

Perhaps I am being overly critical, but I begin to sense a car salesman approach to a more professional selection in an article recently published in Lancet Global Health about three new models of the female condom: ‘The Cupid is available in India, South Africa and Brazil. It is vanilla scented and comes in pink or natural colours. It is currently the only model besides the FC2 to have been qualified by the World Health Organization (WHO) for public-sector purchase. A smaller version aimed at the Asian market is in trial.’ I suppose anything you can do to spruce up a classic is worthwhile if it makes it more desirable…

Innovation is what drives industry and no doubt adding variations to something I hadn’t even thought about for years, will appeal to a new and younger audience. A different audience. Several models -or at least their names- tweaked my interest. One, called the Air Condom -apparently available in Columbia- has a little pocket of air somewhere in it to make it easier to insert. And then there’s the Panty Condom (gotta love the name) that ‘is packaged with a special pair of knickers’ to keep it in place. Wow. That’s gotta appeal, eh?

But is merely sprucing up an old idea enough? I can’t help but wonder why the female condom never achieved much success in the first place. Is making a re-usable product -as some have suggested for poor countries- the answer? Or even an answer? I mean, would you hang it on the line to dry..? There must be something vaguely anathema about it -something subtle, perhaps embarrassing: something unsettling in the background. Or maybe it comes from the male partner and his unwillingness to countenance it. Who knows..? It might be as simple and intuitive as the idea that it’s better to Saran-wrap the outside of a stick than the inside of a glass. Anybody’s guess, I suppose.

And yet, whether the female condom ever takes off (no pun intended) I think that all is fair in family planning. Anything that adds a little spice to it, or makes people realize they have options is good. There’s an article in the Huffington Post with an interesting variation on this theme: ‘To Promote Family Planning, Let’s Have More Controversy’ ( http://www.huffingtonpost.com/christopher-purdy/to-promote-family-planning_b_4174943.html ) In other words, if people are talking about it -whether positively or critically- they’re thinking about it. Discussing it …and publically! Even condemnation provokes worthwhile response.

A good example of this is another mention in the Huffington Post of the Gates Foundation awarding grants for ‘Condoms of the Future’: http://www.huffingtonpost.com/2013/11/20/gates-foundation-condom_n_4312699.html Make male condoms interesting; make them exciting; make them up front and used above all. So if men aren’t happy with female condoms, make them happy with the testosterone version. Let men think they’re the ones leading the fashion parade. Let them think they’re in control… As long as family planning is out there and -dare I say- sexy in the community at large, everybody wins. Maybe even a souped up multicoloured twenty-first century retro model like the female condom. Personally, I’d change the name…

The Concept of Sober Second Thought in Medicine

Perhaps it is the vain attempt of Age to maintain its relevance in a time of incessant, dizzying innovation, but it seems to me there is something to be said for reflection before action.

We have here in Canada, a now much-derided political institution called the Senate whose members are appointed, not elected, and whose purpose is supposedly more to reflect regional differences than voter preferences (as in the other institution, the House of Commons). Approval of both institutions is required for legislation, although the Senate rarely rejects Bills passed by the more powerful and voter-elected House. Its purpose, at least according to Canadian myth, is to be a chamber of ‘sober second thought’, unsullied as it were by recent fads or the evanescence of events that might unwisely sway popular opinion.

While in practice, there is much to criticize about the Senate as an institution, the concept of ‘second thought’ is worthwhile.  And I see this as nowhere more important than in Health Care.

Our concept of health has evolved over the years as have our expectations. We no longer tolerate the intolerable with the equanimity of a century ago; at least in more affluent nations, we don’t expect children to succumb to infectious diseases, or women to die in childbirth. We assume there will be ever more sophisticated approaches to diabetes, treatments for autism, preventative strategies against heart disease… Knowledge conquers all.

But sometimes in our headlong rush to cure, we engender unrealistic -even unnecessary- goals. We unwittingly foster an assumption that living through life’s vagaries needs to be asymptomatic -or at least should be. And while I’m sure most of us understand the need for priorities in health care, its boundaries are, at best, often vague, and usually personal. This is to be expected: we enter the world of medicine only when there is a need, a worry -a symptom.

Symptoms are puzzles waiting to be solved, questions as yet unanswered. They do not always bespeak disease, of course; many point to an underlying concern, an anxiety that needs as much exploration as the condition feared. But the solution -the diagnosis and subsequent management- is not always as straightforward as it might seem. Not all symptoms require intensive investigation; not all conditions require treatment. And while all symptoms require explanation, most conditions also require options -and that is different.

The rush to cure leads down different roads, and not all of them pleasant -not all of them even necessary. An example from my specialty, gynaecology, might be illustrative. Let’s say a 48 year old woman is discovered to have fibroids (benign overgrowths of muscle tissue in the wall of the uterus) during a routine physical examination when she has her pap smear. She didn’t know she had them, had no symptoms that concerned her, and would no doubt have carried on her with life blissfully unaware of what lurked so silently just underneath her skin… But she is told she has some uterine tumours by her well-meaning family doctor. She is then told she needs an ultrasound -just to be sure they are fibroids- and is referred to a specialist for management.

The woman is understandably concerned about the ‘tumours’ growing inside her, and has probably talked to those of her friends who have had problems with fibroids, researched the issue online, and then arrived at the office primed for treatment. And there are many treatments -or at least, many variations on the theme of the need to treat. The usual approach has traditionally been a surgical one -with all the usual permutations and combinations that depend on the prevailing wisdom of the medical center or the research project currently underway. And then, of course, there are the medical and other non-operative methods -some new and sparkled with hope, some castigated online for the side-effects. As I have said, the need for cure can be all-pervasive, all consuming. And perhaps an imperative: anything less is a disappointment -a failure.

And yet the problem -at least in the case I have outlined- is not so much the fibroids, as the attitude attending them. They were, after all, aymptomatic, aproblematic, and indeed a concern that needn’t have been. Most will shrink after the menopause when there are no longer any stimulating hormones -and at 48, that time is not likely to be in the too distant future. Doing nothing, in other words, is acceptable; a ‘cure’ is unnecessary…

Yes, they could be treated -and heaven only knows they often are- but in her case, why? She needs an explanation, reassurance, and a promise of follow-up should any new questions or issues arise. You might think I have chosen a special case, an anomaly whose rarity shouldn’t really affect our exciting and ever-evolving management strategies. And it shouldn’t -there is much to learn, much to improve. We need cures for cancer, better and more effective vaccines, more inclusive and affordable Health Care… And yet sometimes we need to step back and decide what is truly worth pursuing and to what end; decide whether our goals have blinded us to the value of perspective. Knowledge without perspective is not wisdom; it is detail… It is Hope unsummoned.

The Senate may have something to teach us after all… despite itself.

Taking arms against a sea of troubles

A quasi-existential question: what do you do if you are a doctor dealing with a patient you don’t like? More importantly, however, what if you are a patient, forced by necessity or circumstance to see a doctor you don’t like? This is a question that is often framed in terms of racial, socioeconomic or cultural biases, but it may be something even harder to define, impossible to predict: a  clash of personalities or communication expectations. It should come as no surprise that no matter who we are or what our roles require, we simply do not get along with everybody. None of us.

I realize this can present major problems in emergency situations where choice and time may be severely constrained; hospitals often cover these exigencies with policy statements -directives as to how to proceed. The classic example in my specialty is the issue of a patient in labour whose baby goes into distress and requires some form of timely emergency intervention. It is three in the morning and the obstetrician on call is a male; the patient -perhaps because of culture or previous experience- will accept only a female obstetrician. While every effort is expended to accede to her request, it is sometimes simply not possible. Under such exceptional circumstances and in the interests of the baby in distress, the hospital policy can direct and delegate the emergency care of the woman to the available personnel. Most parents ultimately accept this and are grateful to have a healthy and uncompromised infant from the experience. It’s not a perfect solution, obviously, but under the circumstances, it is an understandable compromise.

There are other situations however, where a middle ground is perhaps more difficult to define and sometimes even more awkward and embarrassing to accept. Let us say, for example, you are referred to a doctor by your GP for a non-life threatening but nonetheless serious and important condition. It is difficult to get an appointment with any specialist, but your doctor assures you the wait is both necessary and worthwhile and sends in a referral. You investigate the doctor online and realize your GP has made a good choice, so you wait the two or three months to see him. But it is apparent within the first few minutes that you don’t like him; you don’t get along; he isn’t what you expected -or wanted- in a specialist. Now what?

Now consider the other side of the equation. You are a doctor seeing patient after patient; most seem appreciative, or at least pretend to be, and this is a balm to your fatigue. And then you notice that the next person, a new patient, is sitting on the other side of the desk staring at you suspiciously, avoiding eye contact when you attempt it, answering questions reluctantly or incompletely. It is clear she doesn’t like you, and yet she has been referred for ongoing care and management.

Both parties are embarrassed, or at least constrained in their response to the situation. To be fair, for the doctor, it’s an easier thing to probe gently at the relationship and try to uncover why there is hostility. Is she merely anxious about her condition, or concerned about its management? Are there questions that need answering? Options that need exploring? Is she not feeling heard for some reason? Is there something that is bothering her that you might be able to address? These are ways that are not unique to medicine to be sure. But if you cannot establish a rapport, if you cannot narrow the gap, would it be wise to continue the consultation? Would either of you benefit? Would whatever treatment suggested even have a chance of success if she was unhappy with you providing it? And what if it didn’t? Would she accept your explanations? Would she seek legal redress?

Of course, the interaction is one of unequal distribution of power no matter how it is disguised. The patient (I dislike the word client) needs something from the doctor and has probably waited a long time for the opportunity; it is important for her not to antagonize. And yet she doesn’t like him. Doesn’t trust him… So how much should she tell him? The information he requests is deeply personal, and confiding in him is out of the question. Does she merely terminate the interview and walk out? What is her GP going to think? Will she have to wait an even longer time to see another specialist? And suppose she doesn’t like that one either…

The problem is a multi-headed Hydra admitting of no easy resolution for either party.  One solution for the doctor, once he has recognized the difficulty, might be to suggest a second opinion -another colleague that she might find more acceptable. But even that is fraught with difficulties if they are all as fully booked as himself and the condition is one that would benefit from a more immediate response.  For the patient, however, there is probably an even greater dilemma if the doctor does not recognize -or care- that there is a problem. How does she let him know that she is not comfortable with him if he seems unaware? Or insensitive..?

Personal interactions are complex; even when overt power is not a factor, influence and authority are often covertly present. We are creatures of strata: higher status in one thing, lower in another; a sorting out of levels is inherent in all communication, all encounters. Medicine seems to engender a dependency that it needn’t: sometimes even a simple statement of concern would initiate a search for a solution.  However, it may be difficult for some people to be assertive -neither aggressive nor overly passive- in negotiating a need that is not being addressed. We are not all capable of that -even doctors…

Recognizing that I do not have a Nobel Prize-winning solution to a problem that has bedeviled mankind since its inception, and understanding that casting about blindly in the dark shadows of mistrust is unlikely to resolve the issue either, I have forsaken the twisted road for the simplest way out of the labyrinth:  I suggest the patient bring a friend or a partner to the consultation -someone who is at least privy to the issues and whom she could trust to mediate on her behalf. She may choose to have him stay in the waiting room, but he is nevertheless close at hand and readily available if needed. The extra -and trusted- surveillance might serve to identify her discomfort and extricate her from her seemingly untenable position. It’s what friends are for: to knit the raveled sleeve of care… Or at least spot the ravel.

A Canadian stem cell bank account?

There is method in the madness, the desperate rush for ontogeny. Cells huff and puff, some listening for instructions, others heading off in all directions like missionaries to new and just-discovered worlds. It is a busy place, the initial blastocyst turning into a multicelled embryo, as ontogeny recapitulates phylogeny, organs materialize out of apparent chaos, and form supersedes scaffold. Supervising all this, becoming all this, the Stem Cell quietly goes about its business of transformation: idea to blueprint to structure. Each starts off undifferentiated -uncommitted yet full of potential, a virtual library of plans; it then turns itself into whatever specialized cells the developing organism requires. It’s more complicated than that, of course, but a building usually is: walls hide a plethora of complexity, not to mention mystery.

And that these pluripotential cells, these nascent republics, hide in open view in the umbilical blood of every newborn baby -probably every newborn organism- should be grist for the just-so tales told to those same children years hence. It is truly a once-upon-a-time event that should thrill not only the wide-eyed child in the bed, but even the more sceptical adult storyteller. The Stem Cell is not just a progenitor, it is a gift almost too good to be true -an Aladdin’s lamp not to be ignored, nor, for that matter, to be trifled with. More -much more- needs to be learned before we rub it the wrong way, rub it roughly and are disappointed. Expectations too often outstrip reality. Much is promised, and no doubt much will be forthcoming. Currently, stem cells offer ‘promising treatments for leukemia, lymphoma, sickle cell disease and other blood, bone, immune and metabolic disorders’. But the path is unpredictable, tortuous, and meanders into the labyrinthine forest…

Stem cells were first discovered in the mid 1960ies in a type of cancer -a teratocarcinoma- that arose, not surprisingly, from cells that would ordinarily have formed gametes (germ cells). And the concept, the dream of pluripotentiality took off from there -more helpfully when a rich source of stem cells was found in umbilical cord blood. This eventually led to cord banks that would contract with parents to store the umbilical cord blood from their babies for their own future use -a relatively costly arrangement that charged more for potential than actual use. And anyway, not everybody could afford to store their baby’s blood. http://www.theglobeandmail.com/life/health-and-fitness/why-banking-on-cord-blood-isnt-necessarily-a-good-idea/article4209835/?utm_source=Shared+Article+Sent+to+User&utm_medium=E-mail:+Newsletters+/+E-Blasts+/+etc.&utm_campaign=Shared+Web+Article+Links  In other words, in Canada at least, a parent may pay as much as $1000.00 to start the process and then a premium each year to keep it stored in case it might be needed. And how often might it be needed? Well, apparently not very often at all. A 2007 American Academy of Pediatric policy statement on cord blood banking estimated that the use frequency was only one in a thousand to one in two hundred thousand! Other estimates have suggested higher usage rates since that statement was issued, but the point is that for an individual child, it is a substantial investment with a minimal yield.

So it has always seemed more appropriate to me that there be a national cord blood bank -one from which all in Canada could draw as the need arose. Other countries have done this… But until this year, only for-profit private banks were available in Canada. Now, at last, there is a national cord blood bank opening -albeit with limited branches at first: http://www.ottawacitizen.com/health/canada+first+national+cord+blood+bank+opened+doors+monday/8979216/story.html

Like adult blood donations in this country, cord blood should be donated free of charge. I don’t think profit should have any role in humanitarian projects. Health should not be something you have to purchase. Of course there is nothing stopping a parent from paying to store their infant’s cord blood for its own exclusive -or the family’s- use, although the above-linked 2012 article from the Toronto Globe and Mail, suggests that it is sometimes difficult to ensure a match for a family member even with that genetic kinship.

A national cord blood bank also offers a ready source of material for ongoing research. The ethics of using privately banked -reserved- blood for research is at the very least questionable, and unless agreed upon at the start, probably a breach of contract. And since the yield from any one umbilical cord is variable, but not excessive, if the parent is paying to store that limited quantity, it is cheeky to suggest they should not get all they’re paying for…

No, I applaud the new and national resource and wish them a speedy growth. And like the cells they guard, may the centers offering banks bloom like violets in the sun.

Take my milk for gall

Come to my woman’s breasts and take my milk for gall. Even Lady Macbeth was not without an opinion on the uses of a woman’s breast… And so it continues to this day; almost everybody has an opinion on breast feeding. This runs the full gamut from the harangue of Elisabeth Badinter in her March 2012 article in Harper’s Magazine: The Tyranny of Breast Feeding to the quasi-religious sermons published by the La Leche League that engender parent-like guilt for even considering alternatives.

It is, as they say, a Motherhood Issue: something valued in principle, honored for its obvious benefit to baby, and yet often abandoned in the frustrating weeks and months after birth when the glow has faded along with sleep and patience. There are data from various national surveys which show that on average although around 90% of Canadian mothers start out with good intentions and exclusively breast feed their baby -i.e. offering only breast milk (plus or minus vitamins, medicines, etc.) and no supplementation with other liquids, (formula, juices, etc.)- less than 25% continue with it. The World Health Organization recommends exclusive breast feeding each infant for the first six months of its life. Yes, the benefits to baby are that important!

Interesting though, despite the obvious benefits, there are various impediments to the practice: Culture -or is it country and its customs?- for one. The WHO has a global data bank on breastfeeding and some of the figures reveal startling differences by country alone -and not all related to social disparities in health, education or economics.

But admittedly, there are Canadian studies that suggest that breast feeding is chosen less often among single mothers, women with less education, or lower incomes. Some may not even choose to start breast feeding, let alone abandon it early. And when it is chosen, almost 50% of the ones who choose not to continue, stop within the first six weeks… So given this finding, is there anything that might help support, or lend itself to intervention in that critical window of time?

There is an article in the Canadian Medical Association Open Access Journal in January of this year (cmajo january 16 2013 vol.1 no. 1 E9-E17) that looked at just that, in 2 regions in the province of Nova Scotia between 2006 and 2009. Their exclusive and dropout breastfeeding figures were different from the Canadian average, but even so, they did identify “four potentially modifiable risk factors: prepregnancy obesity, smoking during pregnancy, no intention to breast feed, and no early breast contact by the infant.”

It’s that latter factor -the “no early breast contact by the infant” (read skin-to-skin contact, I would imagine) that intrigues me, though: that such a simple thing -placing the baby on the mother’s skin near her breast after delivery- could create so much difference! This is a policy I would have thought would be universal by now: we even encourage it after extraction of the baby during a Caesarian section in our hospital if the baby is healthy. Its what almost every woman craves -and baby as well- so why not?

And yes, the other modifiable risk factors loom large as potential targets -especially the ‘no intention to breast feed’ decision. One wonders whether frequently bringing up the topic in a respectful and sensitive manner as the pregnancy progresses (and her trust and bond with the health-care provider increases) might be helpful.

The other interesting thing I learned from the paper was that “educational interventions are more effective if focused on improving maternal self-efficacy than on enhancing knowledge.” Most women nowadays know why they should breast feed; it’s how to breast feed, especially with difficult infants and problems latching once they’ve left the hospital, that frustrates them and causes them to stop trying after a few weeks -or even days… Small communities seem particularly at increased risk, often because of a scarcity of easily accessible resources. Recognizing that continued support is very important in the early days after delivery is obviously an important key. So postpartum enthusiasm for breastfeeding on the part of the nurses and staff before the woman even leaves the hospital is the first step. Ideally, a 24 hour breast feeding hot line (perhaps utilizing the existing hospital maternity ward) would be helpful -night time is when the woman is tired and irritable and more prone to frustration. Lactation consultants -maybe also recruited from maternity nurses in the local hospital- would be another important resource. Of course, a knowledgeable and empathetic family doctor or midwife -and an understanding and patient partner- complete the readily accessible communal facilities… Support and understanding are what a community can supply with very little extra resources: the ounce of prevention strategy, I suppose.

But preemptive encouragement is even cheaper; so is motivation -prenatal motivation especially. It doesn’t take much time for the doctor or midwife to inquire about it, and often merely the willingness to listen to her concerns about breast feeding -or her doubts about her abilities- is enough to get the woman thinking.

No… I suspect that breast feeding is not for every new mother… but who knows, maybe it could be.

Health Care Provisos

I think one’s occupation tends to encourage a tightly focussed view of only one lane on the road, and a trust that it and it alone will lead to the intended destination. In my hitherto tunnelled vision, it had always been the Medical Model that dominated -to the exclusion of any rival Magisterium. But as time matures, I have come to realize that what makes you well has less to do with Medicine than life style, apportioned genes, good luck… The doctor plays only a minor and maybe incidental role in the spectrum that is a healthy life. Health care, then, is not only ‘doctor’ care, or ‘nurse’ care, or even hospital care -it is Society care.

Is our currently extended life expectancy the result of doctors and technology? Partly, no doubt, and yet of all the six billion or so people now extant, how many have been saved by organ transplants throughout the world? How many by dialysis? How many spend time in an ICU? It is an insignificantly small fraction of humanity and yet in many -most- countries we are living longer. I would submit that this is a result of better sanitation, better hygiene and better nutrition -as well as better doctors…

It’s interesting to me that one could correctly attribute several causes to, say, tuberculosis. There is the one we doctors seem to prioritize: the tubercle bacillus. And yet although it may qualify as a necessary cause -a sine qua non for the disease we label TB- is it a sufficient cause? If I have a positive skin test for TB but do not have the disease, and yet the poor homeless woman begging on the corner with the same positive test does, why is that? One could be forgiven for wondering if TB is caused by malnutrition, overcrowding, or poor hygiene -poverty, in other words.

For health ministers, QALYs (Quality Adjusted Life Years) have been in and out of vogue for a while now.  I do not pretend to understand all the intricacies of their assignment, but the concept does seem a bit too heavy on John Stuart Mill’s Utilitarianism for me. Let’s say, for example, you give a person in a wheel chair only 0.5 QALYs because of her limited mobility -compared to a ‘normal’ individual (who gets 1). Doing a renal transplant on her would still not result in the same number of QALYs for that treatment that you would get if you transplanted a kidney into an otherwise ‘normal’ woman because no matter the new kidney, she would still be in the wheelchair… So if you were trying to utilize those scarce resources to maximize QALYs, who would you pick? And would that be fair?

On the other hand, there is the theoretical ‘black hole’ phenomenon that political bioethical philosopher Jonathan Wolff describes: if you were to spend all the health care dollars on the worst off or the most needy, it would not much benefit the rest of that society who also have needs -and it would consume the entire budget as well… The compromise, of course, is to prioritize the most needy and yet acknowledge others in the resource allocation… And consider additional needs that at first glance, might seem peripheral to wellness.

What am I getting at? Well, it has been suggested that an alternative to throwing all the limited resources even a rich society has available for health care at the ill (traditional health care provision, medicines, new and expensive technologies) would be to spend some of it on improving housing and opportunities for the poor -the proverbial ounce of prevention… The ultimate cost of preventing illness would be less than having to treat it. So: affordable housing; education; the provision of contraception for women in situations where they might wish or require it; new vaccines instead of (or at least in addition to) new medicines to treat the diseases they might have prevented; affordable daycares to allow single mothers to work, decent minimal wages; provision of breakfasts and lunches at inner city schools for disadvantaged children… The list is even longer of course, and yet it is cheaper than the alternative in the long run.

We have to get away from the idea that Health Care is just treating illness, visiting clinics, or getting tests. It is an attitude of caring and providing sustenance for those in difficult circumstances; it is anticipatory intervention long before the overt manifestations of sickness or disease. It is the recognition that illness can arise as much in the situation, the milieu, as in the body. John Steinbeck summarized it well, I think: A sad soul can kill you quicker than a germ.