A Picture is worth…

Communication -explanation- in Medicine is so important that one might even consider it paramount. Except in circumstances where the patient receives a treatment of which she is unaware because of an accident or the severity of the illness, her understanding of the reasons for the therapy and the side effects it may engender often determines whether or not the prescribed regime will be followed – and sometimes whether or not it will even have the desired effect. A cure is not necessarily the same as the elimination of all symptoms: think of eliminating a headache only to be left with a fuzziness in the head, a feeling of fatigue, a ringing in the ears… In order to adjust her expectations appropriately and help her to understand what the concept of ‘cure’ might entail -in order to understand what it is not, in other words- there must be an explanation she can understand -especially if there is a process or mechanism she can visualize. An anatomical correlate with which she can identify. An algorithm, even. In many instances, this necessitates the use of diagrams.

The Diagram has always fascinated me; its etymology (loosely rendered as ‘explanation by lines’) less so: there is a magic in its enlightening power that transcends mere lines, outstrips even the most eloquent vocabulary. It is the Word Incarnate, as it were. And yet there are problems: we each see the world through different eyes. The past influences the present; so does fear… And although diagrams are often drawn to allay anxiety, sometimes they merely distract. Whatever I’ve drawn is open to interpretation and confusion if it is not both clear and commensurate with her own notion of what her internal organs look like. And most people have no idea… I sometimes show my post-op patients  pictures taken during their operation -the ovarian cyst that I have removed, for example, or the spot of endometriosis I have coagulated. Unfortunately I suspect that for most, it is a ‘Where’s Waldo’ puzzle -everything is strange but similar and mixed together randomly; for some, an ovary is merely a white meatball in a bowl of extra large fettuccine noodles. Or sausages, maybe. We see what we are used to.

The  idea that my diagrams may not be adding to someone’s understanding of their condition is uncomfortable for me, though. Anathema, maybe. I mean, my uterus looks really similar to the pictures I’ve studied, and I can draw a fairly recognizable Fallopian tube. But if the patient has never seen an ovary, or maybe even thought about a fibroid, the drawing may be totally devoid of meaning for her. She might nod politely as I doodle on about how the end of the Fallopian tube grasps the ovary like little fingers picking up a ball, and hear me explain that it’s why they call them fimbria: Latin for ‘fingers’… but if she wasn’t linguistically inclined -or was simply nervous- the words might still be meaningless. Unhelpful. Perhaps all she was really seeing were two wiggly lines becoming ragged and imaginatively bankrupt at what might be a ball, or a poorly drawn circle. And since she would know that an ovary should contain eggs she might be wondering why I didn’t draw them as well. Two people crossing a bridge and each seeing a different bridge. Two worlds, two paradigms… one diagram.

I was reminded of this the other day when a patient that I had not seen for some time, immediately smiled when she saw some of the photocopied diagrams I keep on my desk for immediate explanatory reference. The one most visible is of a uterus with its two Fallopian tubes arching conveniently far from its side like arms from shoulders. Of all my reference diagrams, I have always been attracted to its simplicity. That it is unmistakably a uterus with Fallopian tubes I thought was obvious; it is so utterly characteristic and self-explanatory there is nothing else it could be mistaken for.

“I see you still have the drawing of the cow,” she said matter-of-factly, and smiled again.

“Pardon me?”

“The cow,” she said, rolling her eyes as if I’d have to be blind not to see it. She sat back in her chair for a moment, to give me time to follow her words, but when I didn’t say anything, she leaned forward again to study it more closely. “Well, I suppose it could be a goat, or something, but…”

She tried, unsuccessfully, to disguise a sigh but when she saw me staring at her, she shrugged and pointed to the uterus. “The head,” she said slowly and carefully, so I could follow her finger on the diagrammatic womb. “And here are the horns.” She enunciated clearly, like a teacher explaining a difficult concept. “See? The tubes are like long, skinny horns sticking out of the top of the head…” She smiled, obviously proud of her explanation.

Two different bridges, I suppose. But the converse can also obtain: the bridge sometimes determines who crosses it. Another patient I hadn’t seen for a while -not the same one, I don’t think- brought in a beautiful black-and-white photo she’d taken of a mountain range. She seemed quite excited about it and immediately plopped it on my desk as she sat down.

I looked at it and smiled. “Beautiful picture,” I said, somewhat taken aback by the irrelevance of its arrival on my desk. I even tried my best to look grateful, in case it was a present. “Did you take it?”

She smiled, but I couldn’t help but notice that behind the smile was a hint of disappointment.

“Can you see them?” she asked, hope creeping into her voice. As if maybe I could redeem myself.

“Uhmm, well I really like the shadows of the trees… Sort of like an Ansel Adams photograph,” I added lamely. “Incredible detail.” I was staring intensely at the picture, not sure what more I could add.

“But what do you see?”

I felt like a child on a school tour of an art gallery. Evidently there was more to the picture than the trees and the mountains. I’d been really proud of my mention of the shadows, but I’d obviously missed the mark.

“Breasts!” she said finally, exasperation evident in the tone of her voice. She pointed to a couple of peaks in adjacent mountains, and waited for any sign of recognition in my face. I suspect what she wanted was a show of admiration for the perspicacity required for her to spot the resemblance.

She was, I knew, a visual artist and becoming quite well known. I tried to pretend I saw the breasts, but the trees kept bringing me back to earth. And for some reason, all I could think of was my cow diagram.  In a feeble attempt at humour I told her I saw a cow -a feeble attempt to diffuse the situation, really.

“A cow?” Her eyes widened in admiration. “Really..? Where?”

I sort of randomly moved my finger around the photo, pausing on a tree after skimming over a rather angular mountain.

She sat back, clearly impressed. “You know it’s really amazing how we all see different things, eh?”

Nature versus Princess Nurture

I’ve often wondered how much of a role acculturation plays in modelling who we are. Am I a gynaecologist because my mother restricted my prairie play-things to a rather effeminate teddy bear named Girl and a doctor’s bag that probably wasn’t? Or did I choose to play with them -as opposed to, say, waving tree branches around like weapons- because there was something in my genetic code and in the epigenetic functioning of the methyl groups which switch genes on and off that whispered “Ob/Gyn” in my still-young ears? I mean, there does seem to be something to the long held suspicions that males and females are wired differently ( http://www.theguardian.com/science/2013/dec/02/men-women-brains-wired-differently ) but I’m sure there’s more to it than that: Medicine is -hopefully- genderless. A wire-free zone, I like to think…  And yet, can the equation be boiled down to the overly simplistic apothegm of ‘Nature versus Nurture’? Perhaps. But if so I suspect it’s less ‘either-or’ than this pithy assertion suggests. Like nouns, each component has many adjectives that alter the meaning, change the hue, modify the intent. It seems to me that an explanation that offers only black or white answers is always suspect.

I suppose that is why the idea of gendered toys has always puzzled me; and why I find the Goldieblox variation on that theme so intriguing. A Stanford educated engineer, Debbie Sterling, thought she should challenge the Pink Aisle concept of toy stores -you know: one side of the store is for boys and the other (the pink side)  is for girls. She thought that maybe she could interest more girls in engineering by changing what they play with: construction toys as well as (instead of?) Princess glitterati and the like -hence Goldieblox. http://www.huffingtonpost.co.uk/2013/11/20/goldieblox-inspire-little-girls-to-become-engineers_n_4308556.html ). The thrust to this end has hitherto been later -in high school; this just starts the process earlier. Great. It’s a start, anyway.

There are, of course, skeptics.  Some argue that Goldieblox is just a clever market ploy to sell new toys to girls -remember the pink Lionel Trains of a few years ago? (Probably not -they hardly sold). In other words, it’s just a way of moving the Princess paraphernalia further down the shelf to make room for Goldieblox -on the same pink aisle, of course. Others observe that their daughters already play with boy’s toys ( http://www.huffingtonpost.com/sandra-shpilberg/goldieblox-girls-education_b_4340094.html ). All well and good, but why should the toys be marketed like that in the first place? Is it the only way that retailers can sell them to parents wanting to please their choosy offspring? Or…to parents wanting to mold their children..?

It has been suggested that preschool children are less concerned -more confused- about gender and gender roles than older children. Perhaps it’s part of the malleability of early neurodevelopment, or maybe it’s because at that age it really doesn’t matter. The pattern of wiring is likely still multimodal -more flexible, at least, than it will be. It strikes me that we as parents should be rejoicing at that window of opportunity to widen their horizons, enlarge their choices. What will be may well be what will be, but perhaps without as many stipulations.

Maybe it’s a Societal Issue: maintain the stereotypes and stabilize the Culture. Well, but does it? And even if it did, is that what we want? What we need? Nowadays, there are very few homogeneous countries, very few places untouched by other cultures, new ideas, fresh approaches.  Paradigms shift; innovations arise; people change -and so do norms. We don’t think the same way as our ancestors; we even modify what we learned from our parents and adapt it to the current reality. It’s how we grow -how a society grows. Evolution isn’t simply a biological mechanism for acclimatization, it’s a process of learning from the past and readjusting to the present. ( http://www.huffingtonpost.com/lauren-berninger/why-girls-dont-want-to-be_b_4324255.html  ). And so we must prepare for a future that will see roles change; a future that will probably see gender in a very different light. A future, maybe, that will not so much be colour-coded into pinks and blues as opportunity-rich… equal opportunity laden, one would expect. And even though Shakespeare was poetically realistic: If you can look into the seeds of time, and say which grain will grow and which will not, speak then unto me, I am perhaps a little more hopeful. A little more directive. I will speak, albeit softly.

Midwifery… Deja vu all over again?

Well, I see that midwifery is back in the news again, so I thought I’d revisit the issue -my last look at it  was in November, 2012. Its not that I’ve changed my opinions -I haven’t; nor that I have since discovered something new and compelling about the role of midwives in pregnancy -I continue to support them as I always have. Its more that I am surprised that there should still be any lingering doubt as to their value; that we should still be treating midwifery as if it were an Alternative Medicine -you know, like Huckleberry leaves for indigestion, or something. Midwives have proven their worth over millennia; their extensive and practical experience has helped countless women over the centuries -especially those who couldn’t afford, or even access doctors with their often unhelpful and sometimes misguided medical beliefs and practices -some dating back to Aristotle… It occurs to me that perhaps I am  being too harsh, too revisionist -too reductive- in my recollection of Medical History, but until quite recently there didn’t seem to be much advantage accruing to the involvement of a doctor in the care of a woman in labour.

A predictably Canadian stimulus -the CBC News- got me thinking about midwives again. They reported on a recent issue of the Cochrane Database of Systemic Reviews which looked at 13 studies that included more than 16,000 women comparing various models of obstetrical care with midwife-led care. This model is different from what has traditionally been known as the Medical Model in which a doctor is in charge and a midwife is (maybe) part of the team, but not the leader. In it, she was a useful accessory perhaps, but really just a doctor’s helper: someone who could see the simple and uncomplicated cases and therefore ease the doctor’s burden. I almost said ‘was allowed to see’ these, but I caught myself.

So the meta-analysis tried to put midwife-led care into perspective: was it as good as doctor-led care? Was it merely a niche product serving women with unusual needs and attitudes, or more mainstream in its goals and aspirations? Were they just two Majesteria staring at each other from afar, as incapable of comparison as the proverbial apple and orange?  Well it turns out that one can compare them, and after allowing for the more complex and sicker women that are more likely to find themselves assigned to the medical camp, it seems that there are definite benefits to seeing a midwife… Surprise!

Of course one could argue about some of the touted advantages of midwife-led care mentioned in the article: the use of fewer epidurals for pain relief in labour, for example. I’m not sure I understand why a procedure that truly does relieve pain -and which, if used in a timely and appropriate fashion, has minimal effects on the outcome of labour – can not be judged to have a positive effect on the experience. Labour doesn’t need to equate to running a gauntlet; there are no prizes for enduring the most punishment; no moral or societal penalties for actually enjoying it -in other words, being open to pain relief without a sense of guilt or failure. Or at least cherishing the opportunity to choose. Epidurals aren’t for everyone, but its nice when they’re available. Options are good. Maybe its the man in me wondering what all the fuss is about natural labours; can any labour that results in the birth of a baby -perhaps apart from circumventing it entirely with a Caesarian Section- really be unnatural? Unplanned, maybe; not living up to expectations or desires, perhaps; requiring interventions one would rather have avoided, possibly -things happen… All of us -doctors included- would like to see events unfurling as the mother had hoped, and honestly try our best to achieve this. But above all, we want a satisfying, but safe delivery of a healthy infant.

Fewer episiotomies is another benefit to midwife-led care apparently… Uhmm, I’m trying to remember the last time I -or my colleagues- had to resort to one of these! But I understand the point: there are some things doctors may do that could be construed as unnecessary intervention.  I take exception to a comment the CBC reported from a Guelph, Ontario midwife, though. She apparently felt that the fewer midwife interventions noted in the studies made sense “given how midwives view birth as normal.”  [italics are mine]. However, she does go on to say that “There’s more time in the visit to really address their concerns, so my expectation is we would really care for the whole person, address problems early, refer problems early and that allows women to be healthy.”  No Us and Them in that follow-up statement;  no aspersions cast there. Indeed, she’s managed to encapsulate just why I feel so comfortable with midwives. But I would like to suggest that even doctors are capable of considering the whole continuum of conception-pregnancy-birth as normal, too.

Choice in pregnancy care is the important issue, I think. Midwives, like general practitioners, refer to specialists when there is a need. Some pregnancies are known to be at higher risk than others right from the start -an older woman with hypertension, or diabetes, for example- but even there, as long as the midwife, mother, and specialist are comfortable with each other and with the probability of more intensive and perhaps more frequent testing, shared care between them is still an option if the patient wishes to continue with the midwife. Its a beautiful compromise that dips a toe in both rivers without being swept away by either.

Postpartum Depression -Just words?

Postpartum depression -I know these are only words, medical words, I suppose: descriptors. Language. But for all we’ve done with these particular words, what little attention we seem to have paid to them, they are still only words. And yet they describe a condition that has dogged us for millennia: the darkness that follows pregnancies like a silent shadow.  Creeping quietly in the background, it bides its time, stalks its prey. Camouflaged, it is visible only if you look carefully along the trail, study the  subtle indentations where it hides, part the branches of its lair. It’s always there. Lurking. Waiting.  And given the opportunity -a gift of circumstance perhaps, a melange of genes, a naivety of observation-  as the brilliant light of birth is slowly extinguished, it rises suddenly from the shade and pounces like a hungry cat.

It bothers me that we pay it so little heed until it strikes; that we read the cover of its book so well and then, seduced by the play of colours on the top, miss the message written clearly not so deep within. We act as if it were a surprise that things are not always as they seem; that we all have shadows if we dare to look behind.

There are quite a few tools -questionnaires, by and large- that have been designed to help doctors and midwives anticipate most perinatal problems long in advance. The problem, of course, is in according depression sufficient importance. We are too often focused on measurements in pregnancy: weight, blood pressure, the amount of protein in the urine sample, fetal heart rate, growth of fetus, position of baby –real things, objective things. Important things to be sure. Most of us feel more comfortable in writing numbers and words in their proper columns and following the trend; understanding and charting the ongoing fetal development: Ontogeny recapitulates Phylogeny as they taught us in medical school. There’s a certain comfort in the dispassionate assessment of what we take to be an objective, measurable reality. There are rules.

Emotions on the other hand are mysterious; we hardly understand ourselves, let alone the vagaries and vicissitudes of the moods, coping mechanisms, or even guiltily-expressed thoughts of our patients -their words on exhibit, but weeks apart on consecutive visits. On some of those occasions they’ve had a hard time at work, or have argued -are maybe even arguing in the office- with their partners; they’re polite, but only on the surface. Other times they’re all smiles -or all questions… Sometimes they never even get a chance to speak- just the partner. But I think that these are clues to an observant midwife, or doctor -even if the various screening strategies (such as the Edinburgh Postnatal Depression Scale, for example) have not been utilized. They are certainly helpful in gauging the amount of anxiety the woman is feeling, the attitude she has to her partner -or vice versa- and the amount of support she is receiving at home… all contributors to possible future problems.

Some of the clues -the postpartum ones at any rate- are revealed by simply asking the mother if she has been feeling down, depressed or hopeless of late, or if she has been finding that she is losing interest or pleasure in doing things. If she answers yes to either, then does she want or need help in dealing with it? The questions are asked sensitively, casually, and with no hint of prejudice or blame. They are not traps to assign the stigma of mental illness, nor to criticize her ability as a mother.

I am fortunate in my center to have a Reproductive Psychiatry program that is interested in assessing pregnant women and their risks for developing adverse postpartum mental health issues. They come up with strategies -not necessarily medication- to help, apprise her of facilities available in the community and ensure that the mother is in the system should there be problems. The woman knows where to go for help if she needs it.

I try to identify the risks both from history, observation, and direct questions as to whether they feel they might benefit from someone as well as me to talk to. I usually stress that it is better to be prepared beforehand than caught unawares. I try help them to understand that it is as much for the baby’s well-being as their own. Once the patient realizes that the referral does not mean that I think they already have mental problems, and that they won’t be pressured into taking antidepressant medications with their possible -yet controversial- effects on the fetus, they usually accede to my concerns. Caring for a person, means more than entering their data in a chart… Words, even in the correct columns, only go so far.

Words are signs, signals in the void that separates us all: little lights… and sometimes they’re really all we have. They’re among the few things that touch us deeper than skin; they often tell us more than we can take in with our eyes. But only if we listen.

Words

Are more than billboard signs,

Lined up

Along the road;

More than pictures

Hanging

On a wall.

Although

They can be pretty

As a group,

Perhaps

It is an accident of birth

That any one of them

Alone

Has more than a passing flair.

But

Each one

Is a suitcase,

Opening…

The Wrong Idols

I guess we’ve always needed idols: things beyond our ken or ability to achieve; things for which we strive but are just out of reach. They’re more than goals; they’re so desirable we almost worship them. They are what we are not -or at least not any more- but because they are so prized, they assume a disproportionate worth.

And the surprising thing about these idols is that they are more subjective than objective, more evanescent than real. They are often societally engendered, and culturally perpetuated. And there are temporal (and maybe geographic) boundaries beyond which they lose their meaning. Fashion is perhaps the most obvious and pervasive of these: despite its obvious, albeit transient importance, time strips it of significance fairly quickly. We all know this, expect this, accept this.

We are fickle and easily besotted creatures and our tastes are subject to random currents that tangle us together and carry us en masse to ever changing shores. You’d think we’d learn -or at least step back occasionally to wonder where we’re going. Or why. Insight is a gift that most of us leave unwrapped.

Beauty, like fashion, is built on shifting sands. Things that even a moment’s reflection would forever embed in the camp of the sacred are sometimes ignored, seldom mentioned -or worse: denigrated. I’ve always felt that the post partum abdomen is one of these. So I was pleasantly surprised to find an article about it in the BBC News in an article entitled Are Women’s Bodies Still Beautiful After Pregnancy?  http://www.bbc.co.uk/news/magazine-23276432

The idea that stretch marks are more like wrinkles than merit badges has always rankled me. The very notion of a need to hide them rather than celebrate them is anathema. Counterintuitive. They are earned credits to be displayed proudly.

Perhaps what may be distressing is the thought that the changes herald a phase-shift; that the abdomen will forevermore advertise a loss of innocence, a recognition for all (maybe) to  see that the bearer is no longer inter regnum in society. A different stratum has been enjoined.

Change is fraught with anxiety and inlaid with traps for the unwary. It is a new dress that looked good in the store, but in a later mirror, arouses doubts as to how or when to wear it -whether it was even a good choice. But a moment’s breath, and the beauty surfaces again. And again. There is nothing that unfolds from that recognition but awe; I suspect that little stays the same in life that is truly worthwhile. We are not the creatures even we remember…

I wrote a poem about this once -it captures some of what I mean in metaphor:

There was a time,

I think,

When colours splashed me

As I walked along the street-

Not playfully

But in earnest

As colours are when they dance among the leaves

Flirting lightly with the wind.

I thought

I heard some whispers from the grass

Where dark things stretched

And shopped for light

Like tiny bathers on a cloudy beach.

I even listened to the summer waves

Breaking,

Falling exhausted on the shore

With messages from somewhere

That wished them well on every tide.

I suppose it once made sense

To worship everything that moved-

Or might-

And find divinity in a tree;

Those were days when people laughed

Not once

But often in the night

With no one near.

It doesn’t matter any more,

Of course:

The world was different

Then

And so was I,

I guess.

But sometimes

When the shadow of a cloud

Consumes the footsteps that I follow,

I wonder

Where do all the colours go

When I close my eyes?

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.

The Miracle (part 1): A woman’s story in 2 parts

It was still there, no doubt about it. She patted her stomach warily, as if she were afraid it would go away with too critical an examination. But it was real -or as real as any present could be inside a box- hidden away, untouchable: Schrödinger’s cat…  Some things required faith; not everything in life was a punishment.

Up till now it had been a draw. Meaning, purpose, goal -whatever one called it- was a childhood memory, or maybe a fantasy. The fabric of her life, like an often-mended blouse, was intact but barely recognizeable. Even Bill, who had promised so much at first, had not so much the power of a colored thread in any dream she wove. Nothing distinguished him from a thousand others. He was like a picture that had hung above the bed for years: describable in an instant, but noticed only when missing. He added nothing to her life, subtracted nothing. Were other men the same, she wondered, looking vacantly around the room?

She was sitting in the front room – the back room, actually, since it looked out over an ill-kept back yard of aging trees and spotty grass. It was raining as usual and the rotting boards of the patio seemed to stare blankly at the clouds like old men waiting in their beds to die. The furniture was the same, she thought, itemizing it one by one as if she were still a stock clerk after all these years. A china cabinet made of some cheap wood by her grandfather a century or so before, stood at fragile attention across the room, arthritic and brittle with age. She ticked it off mentally with a sigh, noticing the lack of dishes on its shelves. Like her, it merely occupied space.

A lot of the furniture was like that, though -the couch on which she sat, for example. Even looking at it, she was hard-pressed to name the colour. Its utter banality saved her from the need to classify it as to style or pattern. It merely was; it existed, and was allowed to, simply because it was there. No other reason. Nor did the coffee table distinguish itself, except that it was not the floor, nor was it the same color or texture as the blue-green rug. The room was an occupied space; it was not the kitchen, it was not the bedroom… The room and what it contained -including herself- could best be characterized by what they were not; some inscrutable pique of nature had defined them all by inference only.

Maybe that’s why her life had never changed: Nothing is difficult to rearrange. Until now, that is. She allowed herself a little smile and glanced at her unseen present, her secret. For a moment in her mind, it seemed to glow, the colors expanding and wavering with her breath. What did they call those color-filled boxes you held up to the light and turned? Kaleidoscopes? In the grey, unpolished world she now had a kaleidoscope of her very own.

A brief pain lanced though her lower back, followed by a burning sensation in her groin. Not yet, she thought, clenching her fists tightly against the jolt. But this wasn’t the first time she’d felt its complaint. There was also the pressure -the constant, dragging pressure that made her feel as if all her pelvic organs were going to drop out- and the bloating, to the point of nausea. All to be expected however, and she smiled again, embarrassed by her sudden wealth.

It had been a couple of months since she’d begun to feel different. At first, only the pressure and discomfort after eating -nothing major, and really only noticed because she had nothing else to notice in her life. Well, that wasn’t quite true: Bill had seemed more attentive to her. He said she was losing weight, not eating -that she was changing on him. Bill didn’t like people to change because then he never knew what to expect. But what did it matter what he thought? She could see where she was gaining weight… She was different, and that was that.

Bill seldom confronted her with the change, but she could tell he was concerned. Communication was not something he entered lightly and he often changed his mind on the brink of a sentence. Recently he had been trying to fathom the problem from a distance with inquisitive glances and a puzzled look on his face -attempts, in other words, to make her admit there was something wrong. Admit? What he really wanted was a confession. As if she had done something wrong by not being the routine, predictable Emily. She shrugged and sighed inwardly. Maybe if he just talked about it… Or about something: the weather, the supper, her hair, the time of day -anything. Maybe then it would be alright… Or a least better… But of course in a grey and toneless world, words are just passing clouds, indistinguishable after a while from everything else.

She was interrupted in her reverie by Bill -not the man (he seldom came into this room), but the voice… the command, rather. Ever since she had known him, even his questions had been commands garnished over. Then, at least he had tried to disguise them; now he seldom bothered.

“Emily, what are you doing? You’ll be late for the doctor.”

“In a minute, Bill.” Oh how she hated him sometimes. Hated? Was that true, or was it just painful when he surfaced abruptly from the background where he lived? Possibly where they both lived. Until recently she couldn’t have said where she lived, but of course all that was different now.

She rose slowly to her feet, dizziness stirring the room like pudding -but it didn’t last: things like that are not designed to last. Markers -that’s what she called them- events that rimmed a change of state: up, down, standing or sitting… She did not dwell on the thought, and the dizziness passed as quietly as it had arrived.

She ventured a few tentative steps across the carpet but towards the window and not the door as she had intended. A movement outside had caught her eye and she was captured by the damp, leaf-strewn lawn. A four o’clock wind was mindlessly poking at the balding trees that stood like a living fence around the yard. They, too, were brown, but not what had attracted her. There was also the patio, rambling and broken, where a chair leg had teased the ancient boards apart. It was brown as well. And so was the grass under the rhododendron bush that squatted like a disheveled toad in the middle of the yard, untidy, unadorned… But it was the lawn’s problem, not hers.

She sighed and looked away. But not soon enough; there, almost hidden under a yellowed leaf beside the railing of the decaying deck, she saw it. Only the tail was visible now, but a smeared, red line marked its erratic trail. While she watched, the tail twitched once. A cat, brick-still on the rail above, studied the movement for a moment, then pounced. Emily quickly shut her eyes as a wave of nausea rolled over her.

“Emily! What’s keeping you, woman?” This time it was the man who entered the room. Balding and short, he kept fingering a caterpillar-like moustache on his marshmallow face. He looked out of place in the room -like some waxen, glistening beetle that hadn’t yet scuttled out of sight. His head was perspiring and the dim light from the yard speckled it with tiny shadows. “Emily, I thought I asked you to hurry up!”

She looked at him -or rather, through him- like she had the window. “What? Oh, the doctor… I’d forgotten,” she lied.

He stared at her with unreadable insect eyes. “Forgotten?” he hissed, “You asked me to make the damned appointment in the first place. Christ woman..!” He stomped his foot in anger, but to her the gesture and the words were empty. “I can’t understand you,” he sputtered, choking on his saliva. “For a month you’re sick, and when you finally decide to do something about it besides complain, you forget.”

“I’ve never complained,” she interrupted softly.

His face grew red, and he paused long enough from fingering his moustache to wipe his forehead with his sleeve. It was a sloppy habit, she thought, and blinked twice.

“No, you never complain!” he continued. “Not you. Not in words, anyway; words I could handle. No it’s all the other things: the sighs, the groaning at night… No, you don’t complain, you torment.”

It was meant to be cruel she realized, but it had no effect. The words just disappeared into the cracks of the floor hitting nothing: water sucked down a drain.

He turned abruptly and left the room. “I’ll be in the car,” he shouted at the hallway, then vanished as if he’d never been. She could hear him fussing around by the front door, banging things or dropping them in frustration, but he might as well have been outside for all it mattered to her.

The tail was gone now, she noticed; so was the cat. She shuddered at the hidden, unfair struggle going on somewhere outside, but even as she did, it occurred to her that it probably wasn’t like that at all. Life and death likely snuck past her each day unseen… Like her life.

A sudden spasm of pain shot through her pelvis leaving her nauseated. And a horn somewhere continued its insistent complaint. She smiled as the pain eased slowly from her back. Unseen could be a wonderful thing: it was a gift not yet unwrapped.

On Remembering Faces

Faces are important; they are like little signs we wear to allow others to recognize us. Unlike, say, fish they are distinctive and carry verbal labels further enabling meaningful categorization. A face without a name begs inquiry; a name without a face, recollection or even retrospection…

In a way, remembering faces is a sign of respect: you have had dealings with them; they had temporal significance for you; they were and remain important. And in standing out from the crowd –egregious in its original sense of standing out from the herd- there is a bond, however tenuous. I passed a smile in a hospital corridor the other day and I mistook it for agape: that look we donate to total strangers that we pass like ships. And I saw the look of disappointment and saw her whisper something to her partner who glanced at me as well. She stopped and turned a few steps past me and addressed me by name. And even when she explained that I’d operated on her mother a few years ago, my recollection of the event remained wrapped in cloud. Overcast.

Some people have the eidetic skill of instant recognition and with that identification the story of the paths they shared, along with the appropriate assignation of adventures encountered along the way. It immediately sets both parties at ease; there is no awkward pause, no need for hasty explanations of how each was once significant to the other.

But recognition is a blessing not equally bestowed. There are times for many of us when a chance encounter contains as much information as leaves on a tree, and an individual is as anonymous as a fallen twig. I cast no aspersions, but memory has a way of defocussing details, melding them into a delicious stew of once-tasted dinners. Or am I making the mistake of assuming I am representative of the average other? A mental excuse: an inadvertent equivalent of psychological projection?

I have been in medical practice for many years now; I have encountered myriad people along the way, delivered uncounted thousands of babies -maybe I do have an excuse… And yet to forget a face that greets me on the street -a face with which I have had a nine month relationship, perhaps- still seems rude. Insensitive. The fact that it may have been ten years ago -or more- has not dimmed their memory of the relationship and its consequences. The child at their side refusing eye contact with me is an integral part of their life -one they shared with me long ago. They live the memory; I claw desperately at the door of a cupboard where I have stored the files.

Some faces I remember, of course: some people have a way of welding their identity onto the shelf -forever distinct, immutably present and on display. They are the caffeine of memory, but like dessert, uncommon at most meals.

Now I have to admit that most people are interesting, and all are distinctive -or seem so- at the time. Even the most obnoxious patient sows her seeds; recollection depends not so much on the quantity as the quality of the experience. And it may not be a two-way street. We all walk at different speeds, and touch with different skin. We may hold our expectations in common -there are some universals that seem self-evident- but our perceptions are uniquely our own. We, alone, wear them, feel them, live them… They are why we take home different messages -patient and doctor. They are what individuate us. Separate us…

But I would still love to return the unsolicited smile of remembrance with a look of wide-eyed honesty.  I need a book somewhere inside with a specially marked page that I could read and interpret quickly enough to make it seem that her face was never stored in the bottom of some pile; that she, at least, was special. Unforgettable.

But my guilt shines through each time I pass; I hope they understand I don’t mean to forget. But oh, it presses to my memory, Like damnèd guilty deeds to sinners’ minds –Shakespeare understood, I think… Even if I’ve forgotten the context.

Questions and Answers in Medicine

Questions, questions, questions… They are the scaffolding that surrounds any medical encounter. One could almost phrase it semi-mathematically: patient/doctor = question/answer. And the success of the relationship -at least at the start- is largely dependent on the answer part of the equation. Patients usually come armed with both a problem and questions about it. That is natural, but sometimes the latter are as thickly layered as bees around a hive and actually obscure the issue to be addressed. Not all questions have answers; not all problems have solutions -not at first, anyway and sometimes not at all. This seems all too often the case in obstetrics.

Many questions arise out of what seems at first to be mild, symptom-related curiosity: vague, and only occasionally experienced sensations in pregnancy such as, say, leg cramps, fatigue, or maybe even shortness of breath. Most are relatively common complaints, the causes of which are not well characterized and don’t admit of a detailed, scientifically validated explanation. Indeed the answers need sometimes to be experientially based and may therefore vary from patient to patient, and even doctor to doctor -a point readily noted by the more concerned couples who have often consulted friends with similar symptoms.

I have to admit that I sometimes feel evasive, or even fraudulent answering some questions as if I was in possession of the one correct answer: there may not be one. But I know that behind each question is a concern, a fear only thinly disguised with a smile, that there is something wrong with the pregnancy. And of course, sometimes there is, so each question has to be considered in the context of a reasonable differential diagnosis. The leg cramps could herald a phlebitis, the shortness of breath an infection, or even a pulmonary embolus. And nowadays the patient often knows this and seeks reassurance.

And of course, not everything is pregnancy-related: nausea and vomiting could be signs of a viral hepatitis, increased frequency of urination could be a bladder infection… Questions -problems- can be Hydra-headed; to view them in monochrome may be a mistake. There is a balance required: not every headache is a sign of pregnancy induced hypertension, nor every dizzy spell an anemia. Not every symptom is pathological, and as I am fond of telling my patients, pregnancy is not a disease.

Still… To miss something serious is unacceptable -incompetent, even- but to alarm unnecessarily has its consequences as well. There is a middle road, even with complex and alarming questions: it is to listen carefully and compassionately and to consider each query in context. Often the patient doesn’t want a detailed academic answer, just a thoughtful reassurance mindful of her own particular situation. The fact that a concerned stranger on the bus said that she looked a little pale, or perhaps puffy in the face calls for a different level answer than a question about newly acquired cramps early in the pregnancy. That much is fairly obvious.

But what may be less appreciated especially on a busy day in the office is that even trivial questions are asked for a reason. She may, in fact, already know -or intuit- the answer and feel silly bringing it up. But she needed to ask -just in case… And her concern deserves attention, not merely a quick, reflexive reassurance that might seem to her both insufficiently analysed and dismissive. Even pausing briefly before answering suggests a more detailed and therefore considered analysis of her worry.

Answering questions is a skill and one which benefits and matures with experience; one has to be mindful of the reason for the question, as well as the depth of the answer expected. It is an art; it should not be artful -we have politicians for that.

The Feminine Perspective?

“Men and women think differently, doctor,” a patient said to me recently, shaking her head in response to some requested advice from me. “You of all people should know that.” It was stated with a look of smug authority, as if  to disagree would have been tantamount to an admission of professional incompetence. And while I don’t concede the point that to disagree with what seems to be a societal dictum necessitates a conclusion of medical bankruptcy, it got me thinking…

I suppose the first thing that occurred to me was to question the assumption that my specialty somehow enabled entrance into the heavily guarded sanctum sanctorum of my patients –female patients at that. It kind of invokes the Theory of Mind, doesn’t it: the early discovery by a child that others also have things going on in their heads, and that they may differ from her own thoughts or perceptions. It’s an important step in eventual integration into society; it’s also a recognition that because it’s different, we can never really know what someone else is thinking.

So, in that sense, no: I (a male) can’t know what my patient (a female) is thinking -any more than I could if that person were another male. I can suspect that it might differ from what is going on in my head, but given a common purpose -the solving of a medical need, say- I can intuit that we can communicate something meaningful about that.

“Ahh, but it’s not just that we live in different bodies, doctor,” -I could almost hear her response to my thoughts- “It’s more the way we approach the problem.” Really? Are the goals actually dissimilar, or is it more a difference in perspective -a choice of route? And is the perspective culturally assigned, or does it reflect a basic underlying gender difference in physiology and wiring? Is it just that we are supposed to think a certain way -an assumption- or that we, in fact, do -an innate, genetically driven imperative?

Are the perceived psychological differences in the sexes superficial and societally contrived, or are they more like two Magisteria -the approach Gould chose to describe the difference between religious and scientific knowledge and authority? It’s a difficult question obviously, but I sometimes think it has degenerated into more of a media-driven competition -each side trying to enlist support from an otherwise disinterested and unaffected Public.

I sat back in my chair and smiled inquisitively at my interlocutor. “And how would you approach this problem?” I asked, hoping to learn something from the encounter.

“Well, for one thing, I would offer more choices.”  She sat up straighter and crossed her arms defiantly, daring me to disagree.

Fair enough; I suspect we would all like more of a say in how we deal with a problem. I nodded my head in agreement. In medicine, even if there are no other viable therapeutic choices, there is always the option of doing nothing -seeing what will happen over the coming days or weeks. But I suspect that the choice of that option transcends gender, transcends the assignation in the genetic lottery…

But maybe I was missing something; maybe she was operating with a world-view that necessitated a different assimilation of Reality. For that matter, maybe there was a different reality for her -one that I could never hope to experience. Maybe what she experienced as Red, for example, I experienced as Blue and yet we both named it with the same word. How could I ever know? A troublesome thought indeed.

And yet, ever the pragmatist, even if we both meant something different by that word, but arrived at the same destination, wouldn’t the communication have been successful? The goal achieved?

She wasn’t finished with me. “And I think you were assuming I should just accept your opinion, doctor.” She obviously hadn’t liked any of my solutions, although I had offered her several. She had probably only heard the word ‘hysterectomy’ among them.

It occurred to me that although we both wanted to solve the same problem, her condition had a different meaning for her altogether. And it didn’t hinge on her sex as much as on the way she envisioned herself as a person, as the protagonist inside a personal history: her story.  She possessed an identity tied to what she currently was, and whose very existence was contingent on whom she might inadvertently become.

But we’re all like that: we are who we have been; the past drags behind us like a shadow. It’s company for us on our long trip; it’s our suitcase full of memories… So that alone cannot be what she was alluding to.

That we all see the world from our own perspective, and that it is different for each of us, is merely stating the obvious. That we each come to a problem with a different history is equally obvious. We have all been entangled in cultural webs that have conditioned the way we respond to issues. In the beginning, perhaps it was all engendered by biological constraints, but I think most of us now realize the artifice in that.

What, then, accounts for the difference, other than milieu?

Bertrand Russell, a philosopher mathematician of the last century had some small influence on my early development; I make no claim either to have read all of what he has written, or for that matter to have understood more than a small part of what he had to say, but I have always remembered one passage -one pearl- that made sense to me. Perhaps it was the only thing I could understand:  For my part, I distrust all generalizations about women, favorable and unfavorable, masculine and feminine, ancient and modern; all alike, I should say, result from paucity of experience.

Maybe I should have read more of him; there are many perspectives…