Monthly Archives: October 2014

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Uterine Transplants

I just knew it was going to happen; I could feel it in the air: a live and healthy baby delivered from a transplanted uterus.

It was the womb’s turn. After all, people have been trying to transplant stuff since anatomy began. Unfortunately, before the concepts of physiology, infection and immune rejection were appreciated, they all failed. Miserably.

There were exceptions, of course, such as the successful kidney transplant between identical twins in 1954 -where their immune systems were obviously identical as well- but until the ability to avoid the toxicity of anti-rejection drugs was improved, organ exchanges were limited to the desperate or the foolhardy.

A few solitary successes occurred late in the 19th century with skin grafting, but until good immune suppressors like cyclosporin (1970) were developed, most organs –that is to say, most patients– didn’t survive for more than two or three weeks.

And then it took off. Kidney transplants are now routine; heart transplants -while more dramatic because of the need for a healthy organ from an individual who is unfortunately unable to use it any more- no longer garner headlines like Dr. Christian Barnard’s first success in 1967.

And the list of organs being transplanted is beginning to read like an anatomy textbook. Everything from pancreas to lung, combo packs like heart/lung, and even an entire face in 2013. If you can name it, somebody somewhere is trying to transplant it. So it was surprising that the poor uterus was left sitting in the shadows for so long.

In fairness, though, it had been attempted several times before in various medical centers, with little success –ie  ability to do what the uterus was designed to do: incubate and deliver a  live, healthy baby. Not until the 2013 transplant in Gothenburg Sweden, with Dr. Brannstrom’s surgical team was a live baby born from a uterus a year after it was installed. Everything seemed to work –the recipient began to menstruate regularly- so one year after the transplant, having cryopreserved an embryo beforehand, it was placed into the uterus and followed closely as it developed.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61728-1/abstract

The baby was born prematurely (at 31 weeks and 5 days, rather than at the average 40 weeks) because, although blood supply to the uterus was apparently normal, the patient developed pre-eclampsia (pregnancy-related high blood pressure) and there were some problems with the baby’s heart rate that apparently mandated delivery.

Were these complications the result of the transplanted organ (the donor was an unrelated 61 year old post-menopausal woman), the immosuppressants (she was on a triple therapy consisting of tacrolimus, azathioprine, and corticosteroids), or just bad luck? And would such a transplant be able to function normally –like a transplanted heart, say- and contract efficiently enough to enable labour and vaginal delivery? Or would a caesarian section be required in all cases? It’s probably too early to say.

So congratulations to the parents and the transplant team. Fortunately, the need for uterine transplantation is uncommon, and adoption, or even surrogacy remain as other less drastic options. But it seems to me there are issues that, despite the success, have yet to be adequately addressed.

Ethical issues, for one thing. Unlike, say heart or kidney transplants where death may ensue if transplantation is not available in a timely fashion, the uterus is not essential for the continuation of life. And the procedure entails sophisticated, difficult and risky surgery that is frought with possible life-theatening complications in and of itself –including, of course, rejection of the organ despite the immunosuppressants. The surgery, by the way, is far more arduous and byzantine than the routine hysterectomies that are over-performed around the globe –extra tissue has to be obtained along with additional dissection to be able to reconnect the arteries and veins efficiently. So both donor and recipient are at increased risks…

But what troubles me the most I suppose, are the possible long term effects of the immunosuppressants on the developing foetus growing inside the transplanted organ. Azathioprine, for example. It interferes with DNA synthesis, and inhibits the proliferation of quickly growing cells… That seems a lot like what needs to happen in a rapidly growing foetus, doesn’t it? Azathioprine is a pregnancy Category D substance: to be used in life-threatening emergencies only when no safer drug is available. And there is positive evidence of human foetal risk. Even tacrolimus doesn’t have a lot of available human studies in pregnancy.

No doubt safer and more predictable immunosuppressants will be found, but for now I remain concerned that we may be trading something away. Just because we can do something, doesn’t mean we should. Unlike other organ transplants where the risk is assumed by the recipient alone, uterine transplants for reproduction share the risks with a rapidly developing and vulnerable foetus which might not manifest any problems until years in the future.

I realize I may be dismissed as a male Cassandra, a person who cannot see dawn through the warp and weft of the cobwebs of his past, but sometimes we have to stand back for a moment. Sit down and think things through. Decide whether we’ve gained more than we’ve lost, and whether it will be too late to change our minds if and when some damage is revealed.

In this case, one would be well to think of Mabeth’s dilemma:

I have no spur to prick the sides of my intent, but only Vaulting ambition, which o’erleaps itself

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FHR: Fetal Heart Rap

When I was a child, I was fascinated with noise. Well, perhaps sounds would better describe what interested me. What were they –I mean really? And what happened to them after I heard them? When I was finished listening and if there was nobody else around to use them, what occurred then? Sounds told us stuff –information- and I didn’t think Nature would just throw them away. So were they like the wind and simply moved on after touching my ears, or did the data get stored somewhere? Collected and saved –someplace chock-a-block with noise bouncing off every wall, or stacked neatly in little, labelled piles? Maybe there was a sound library somewhere. And when I discovered echoes, I thought I was getting close: recycled sound. It was like taking a book out of that library.

As I grew older –I was going to say matured, but that never really happens, does it?- the riddle of the information contained in sound only intensified for me. I mean, where is it? I even wrote a novel to explore my fascination with it (Sound Bites) that’s published somewhere Googleable online, but that didn’t quell the itch… I began to wonder if I was haunted by something –an idée fixe.

When we are enchanted by something, does that make it more likely we will find it? Or just more likely that we will look for it..? Seek, and ye shall find. But even more mysteriously, does it find us?

 

FHR. Every obstetrician –every nascent parent- knows what that stands for: Fetal Heart Rate. Along with uterine contractions, it’s what we measure on our monitors in delivery rooms around the world. More importantly, it’s the sound that connects us to that inner intrauterine environment. The hidden world. It’s the baby talking to us, giving us a weather report directly from that moist, warm space where we all once lived.

And it’s not a one-off either. Midwives, doctors -and increasingly, parents- are regularly tapping into it for news. Information. Meaning. It’s a sound fraught with emotion and expectation –the unopened present.

But I recently got to unwrap the present in an unexpected venue, in an unforeseen medium: music.

 

“Would it be okay if my uncle came to one of my appointments?” Cynthia was a tiny little woman from the Caribbean that was seeing me for her first pregnancy. She spoke with a delightful accent and every sentence was embedded in an almost musical rhythm. It was as if she was singing to me… She was certainly one of my favourite patients and I looked forward to her visits.

With the notable exception of her husband –another small person who usually sat quietly at her side with an embarrassed smile on his face- I hadn’t met any of her family. “Of course he can come with you, Cynthia,” I said. “Your aunt, too, if you want…”

She shook her head, and ringlets of rich, shiny hair escaped from her headband like children at recess. “No, my aunt is no longer with us…” She blinked and then a huge smile invaded her face and her eyes twinkled like crumpled foil in the overhead lights. “Uncle Ed raised me pretty well by himself…” She seemed to hesitate for a moment before continuing. “But now he says he’s curious.”

“Curious?” Now I was curious.

She nodded her head, and her hair came out to play again. “About the sound.”

“The sound? I don’t…”

“You know, doctor. The sound!”

My face must have galvanized her husband because he realized he finally had a role to play: the interpreter. “She means the sound you play from the baby each time we come, doctor.”

“The baby’s heart rate?” I tried not to make it sound like a question. More like an acknowledgment of a point made. They both nodded their heads in a sort of random unity, and smiled. The doctor had understood.

“Well, I’ll try to put on a good show for him, then.”

Cynthia glanced at her husband and a surprised expression flitted briefly over her face; she suppressed it as she turned back to look at me. “Do you know my uncle?” she said, this time unable to disguise her curiosity at my seeming prescience.

I shrugged politely and smiled. “I don’t think so… Should I?”

They exchanged looks again; secrets crept from eye to eye. “Well…” –her husband started to say something, but Cythia reached out and squeezed his hand.

“It’ll be a surpise… Okay?” she said, the last word asking for my permission.

“Okay. I’ll look forward to meeting him.” I really was looking forward to it.

She was fairly far along in her pregnancy so I saw her again in a couple of weeks. It was, however, just long enough for me to forget the surprise. An office is busy, even chaotic at times. There are many surprises…

Cynthia was already in the examination room when I walked in and I noticed the uncle immediately. A tall, thin man with a patchy white beard, sat comfortably beside her –lounged might describe it more accurately. He looked entirely at ease in his rumpled brown fedora and clean but wrinkled blue suit, and his face lit up and immediately cracked into a thousand crevices when he noticed me and smiled. He stood up and extended his hand. “Thanks for letting me come,” he said, his voice sonorous with a hint of gravel. “Cynthia’s been bragging about you for some time now,” he added, and his eyes locked on me like talons from under the brim of his hat.

He glanced at an expensive looking recording device he’d placed on the table by the sink and his smile widened. “Thought I’d record the baby –if that’s okay with you…” He was asking permission, but his eyes knew my answer and relaxed their grip, caressing my face briefly as they returned to the recorder.

“Of course, of course,” I found myself repeating, strangely nervous that my performance might not be up to the machine –or the uncle’s- standards. Cynthia got onto the table and I proceeded to take her blood pressure and assess the size of the baby in her abdomen with my measuring tape. It was an old tape, the numbers worn thin by the years of use, and for some reason I felt embarrassed with it. Like I should have used the new one I had in another room…

And then came the time to listen to the heart. I positioned the doptone over the region of her abdomen I hoped would give the best sound and turned it on. Nervously again. With stage fright, almost. I got the area right and the sounds pounded out in their usual steady cadence –fast at first (I had disturbed the baby by measuring the abdomen) and then settled down into a steady, industrial rhythm. A horse galloping. One hundred and forty hooves per minute -I almost said that, I was so anxious.

Uncle Ed, for his part was entranced, and his eyes were focussed elsewhere –inside his head, if I had to guess. Then he closed them -closed the private door- and his whole body began to sway in sync with the beating heart. Even his feet began to tap. I almost thought he was going to get up and dance…

Finally he raised his head and opened his eyes, sated. Exhilarated. Then, like an orchestral conductor he nodded for me to stop the sounds as he reached for the machine to turn it off in tandem. The performance was over; I almost expected applause, but except for the delight, bordering on exaltation I could feel around me, that was it.

He shook my hand warmly, gathered up his instrument, and sidled out of the room as relaxed and in control as ever. He left Cynthia beaming and her husband wide-eyed. But she winked at me as she left –a show of silent appreciation of the concert.

The whole episode left me puzzled however. Why had I felt so nervous? It was like I’d been onstage the whole visit. I walked down the short corridor that led to the reception desk and discovered both my secretaries huddled together and whispering loudly. They both looked up in unison when I turned the corner, their eyes sparkling, their expressions, well, rapt I suppose. Another puzzle.

“Interesting chap that uncle, eh?” I said, to break the spell.

“Interesting?” one of them managed to gasp as they saw my entirely benign expression.

I felt naïve, for some reason. “Yeah, he was really into the fetal heart stuff. He even recorded it,” I said, trying not to expose how strangely anxious his taping of it had made me, but I must have said it too loudly.

A patient I didn’t recognize was sitting nearby in the waiting room and she rolled her eyes when she heard me. “Well, I guess so, eh?” she said, and exchanged glances with one of my secretaries. They both laughed.

“Do you even know who that was?” the patient said.

I shook my head slowly. But just then, my colleague, the other doctor in the office, called for the patient, and she disappeared through a door after winking at my secretaries with an enigmatic smile on her face.

“Well,” I said to the now empty waiting room, trying to pretend I wasn’t as curious as I must have looked. “Who was the uncle..?”

Another set of eye-rolls –this time from behind the counter. “Come on,” one of them said when she finally found the strength to close her mouth. “Don’t you ever listen to rap?” She pronounced it like an accusation, but I know she didn’t mean it like that.

I am appreciated in the office –admired, maybe- but not for my musical insight. I am loved for other things… I hope.

 

 

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Medicine and Ideology

Some things are more definitive than others –less ambiguous, more predictable. Reliable, in other words. They lend themselves to yes-no answers, right-wrong judgements, good-bad characteristics. And some people prefer to see the world in black and white like this. Uncertainty is uncomfortable for them; they crave cognitive closure in the opinion of Arie Kruglanski, a professor of psychology at the University of Maryland.

It would seem that there are times in a life –usually inter regna, times of transition- when this eschewal of indeterminacy is more powerful: adolescence, retirement, divorce, and so on. And at those times, when everything seems unstable and unfamiliar, shelter from the maelstrom under any unmoving roof seems prudent. Rules and unequivocal, unchanging answers are tempting accessories. That something is either right or wrong can be comforting in times of stress.

One problem with this bichromatic need however, is that things are rarely static. They are continually modified by circumstance and context; the questions that need to be asked, and especially their answers, expand and mutate. They evolve over time, in other words. So, for example, that someone is, or is not pregnant, may be unambiguous and beyond dispute. But whether that pregnancy continues or miscarries, is healthy or complicated is not. Things change, are unpredictable, and answers –facts?- obtained at one stage may not obtain later. Life is flux -an ever moving current.

And, of course, context is almost as relevant as substance. Nothing is separate from its surroundings. A pregnant woman, say, is a member of a group –however tenuous- or at the very least, a member of a society. A culture. There are obligations and expectations unique to her milieu that may not be immediately apparent –especially to someone not a member of that group. And these conditions do not often lend themselves to a one-time appraisal, a permanent and unbending judgement, or a right/wrong approach. A rigid doctrine -established on whatever principles- does not always work. In fact it imprisons; it imposes an unchanging view on a constantly unfolding reality. It is dogma.

So it was with some concern that I read an article in the Sept.16/14 Canadian Medical Association Journal –in the news section- entitled ‘US politics and ideology enter exam rooms’. In it was outlined some of the requirements in certain states that seem to impose political or moral ideologies on both patients seeking assistance, and medical staff trying to provide it –an arena that one would expect to be free of bias and coercion.

There are some American states, apparently, that require a woman seeking a pregnancy termination to be shown –not just offered-  a view of the ultrasound of her fetus. In my opinion, this is just cruel –a punishment thinly disguised as help. Disclosure. An admonition clothed in the scarily garish colours of useful information. That there may have been extenuating circumstances –whether personal or social- that led to her decision to terminate would seem to be irrelevant. The choice the woman has to make is a painful one –it is seldom capricious, rarely if ever carelessly taken. That someone should be available to help her with her decision and counsel her before and after if she wishes is a given. But it should not be an impediment.

As the article observes, ‘In such cases, it’s not just the doctor and the patient in the room. In effect, it’s the state government, too.’  This is the not-so-thin edge of a wedge that seeks to modify behaviour –even behaviour condoned in law- by mandating seemingly reasonable adjuncts to the process. ‘What could be wrong with offering to show the woman her fetus on an ultrasound?’ one can almost hear them pontificate mellifluously with fists all the while clenched tightly behind their backs. But the operative word here is ‘offer’. The term suggests choice.  Not coercion. Bullying. Threat.

I recognize that I’ve chosen a contentious issue –pregnancy termination- to illustrate a much more fundamental point: the relational autonomy that should be a cornerstone in our dealings with others. And yet it forms –must form- an essential foundation if we are to reach out to those who, constrained by their own beliefs or cultures –their own experiences- are reluctant to seek our help. It seems to me that it is only humane to enable them -actively encourage them- to access whatever aid we are able to provide. It is not merely magnanimity on our part. Not generosity. Not accommodation. It is empathy; a recognition that despite our differences, we are all struggling. All seeking some path through the chaos of one transition or another. And the cognitive closure need not be punitive. Nor dogmatic.

In fact, it can be instructive. Insightful. As Shakespeare observed, It is not in the stars to hold our destiny, but in ourselves. And we must help others to see this. We must enable them, and so enable ourselves.

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The Crown Jewel

 

Ahh, those were the days! The days when naivete reigned. The once-upon-a-times when my practice was young and everyone around me seemed old. They spoke a language I had not anticipated in my training; they seem to have subscribed to different dictionaries, or the words were smudged so they did their best with what they could make out. I began to wonder if my background in the prairies had hidden me from modern descriptive English. Cloaked me in innocence. After all, it was the place where I was assured by a teacher in grade three that Winnipeg was the only place in the world where we did not speak with an accent.

Of course, since then I have lived in many places, and my vocabulary has expanded accordingly -but it is the jargon of common things by and large: words we might use with a person in the office, or a friend at a coffee shop. Every day things… Doctors generally do not unwrap their esoteria in public, and their user-unfriendly descriptives for particular bodily parts or conditions go largely untranslated. Unappreciated in the main. And anyway, most people have their own names for the stuff.

But when you’re first starting and building a practice, the world is freshly scrubbed and terminology an adventure. I quickly discovered that patients are wont to try new doctors in a never ending quest for clarity –someone whose explanations they can understand. Someone who doesn’t have to resort to pointing at the area in question. We are all under somebody’s microscope.

*

It was only my second month in practice, and I wasn’t very busy.

“Doctor, I hope you can help me,” the olive-skinned woman said as soon as she sat down. Her long black hair was carefully pinned on her head, but as she gestured, little strands would escape and cross her eyes like windshield wiper blades. Far from annoying her, she hurried the transit in a trained fluid sweep of her head as if it was an integral part of her everyday speech.

She was a heavy woman, but dressed in a stunning green blouse and black jeans, she wore her weight, like her height, as a gift. The most striking feature about her, though, was her eyes. Intense and brown, they prowled the room in search of prey, then fastened upon me like a cat, and once engaged, stapled me to my chair.

I struggled to disengage and tried to focus on her chart for a moment. Usually there is an explanatory referral letter, but there were only three words scrawled in pencil –hurriedly, I think, because they were almost undecipherable.

My face must have fallen, because she unlatched her eyes, scanned the upside-down letters, and said, “Dr. Edwards is a man of few words, eh?”

I looked up, embarrassed at my inability to decipher the letters, and turned the page so she could read it. “Any idea what it says?”

She studied my face to see if I was kidding. “He was kind of puzzled by my stuff, so he told me to explain it to you… Anyway, it says ‘something quadrant pain’ –whatever that means.” A mischievous look snuck onto her face and her body shivered ever so slightly, the movement slowly descending like a wave. “I’ve got pain in my parts… My private parts,” she added quickly, concerned that fancy might draw me to more public venues.

“And when do you get pain… there?” I asked, hoping for more clarity.

She thought about it for a moment. “Well, mostly during my monthlies I suppose, but occasionally during his act.” I must have looked blank, because her eyes dropped briefly as she searched for a more apt description. “You know,when he… walks through the door,” she said, and sat back in her chair convinced she had simplified the term.

She struggled through her history with a litany of words I had never heard before. Things like ‘tweenie-legs’ and ‘bloaty-stuff’ surfaced briefly, then sank just as quickly after I’d made a stab at translating them into something I could dictate to her doctor.

But when we’d plodded through the symptoms and I’d had a chance to examine her, it seemed likely that she had endometriosis –a painful condition where some of the endometrial cells that normally line the uterus and are expelled during menstruation, are forced back through the Fallopian tubes into the abdominal cavity where they can grow.

The condition is usually diagnosed and treated with a laparoscope –a telescope inserted through the belly button under an anaesthetic. Pretty standard stuff. But this seemed to worry her more than the condition itself. “I’m kinda worried about my crown jewel,” she said, her brown eyes watering.

I smiled and assured her that I would not be taking anything out of her. I had heard the expression ‘crown jewels’ before but always in the plural, and never referring to women. But, summoning up a vague memory of trash talk in the YMCA locker room, I assumed it was a code for ovary and not wanting to become entrapped in another of her semantic vortices, I left it at that.

*

The last thing she said to me in the OR before the anaesthesiologist put her to sleep was “Careful of the crown jewel, eh, doc?” I touched her shoulder reassuringly and watched her close her eyes as the medication took hold.

“What was that about?” the scrub nurse said as she was prepping her adomen.

I shrugged. “I was hoping I was the only one who didn’t understand…”

Belly buttons are interesting areas, I have come to realize. They exist in all sizes and shapes. Their contours run the gamut from vertical alignment to transverse and since the laparoscope has to be inserted through it, the incision has to be similarly tailored so it is inapparent after it heals. Hers was distorted, however, so I found I had to be creative. I ended up cutting a short horizontal line about as long as my little finger nail on its lower edge much to the surprise of the resident doctor who was assisting me.

“I’ve only seen it cut vertically,” she said with some hesitation evident in her voice. It wasn’t exactly a criticism –residents don’t usually criticize their staff- but I could hear the implied judgement in the tone. I smiled beneath my mask, and said something to justify my decision. But it was a bluff; I recognized my heresy all too clearly. If it healed with a ridge, or a scar, there might be complaints. It made me all the more determined to leave her ovaries unharmed.

And then, after dealing with the endometriosis, and dictating the operative report, I promptly forgot about the navel issue. Until, that is, she returned to see me several weeks later.

*

She sat down opposite me as she had that first time, but her eyes were so intense I could barely see her face. “What did you do, doctor?” she said in an accusatory tone before I could even open her chart.

“Do you still have the pain?” I asked carefully –almost shyly, given the spotlight of her eyes. I felt naked in their allegation. Like I had done something wrong.

She turned down the wattage and I could finally see the smile that had been in possession of her face all the while. “No, of course not…”

‘Of course not’? I took a deep breath as the memory of her umbilical incision rose slowly and painfully into my chest; my resident had been right.

“How did you do it?” she said a little too loudly, her eyes firmly grasping my head. “My friends all noticed; everybody’s been commenting.”

“I’m sorry,” I managed to mumble, my cheeks no doubt red with the effort. “I don’t underst…”

“The belly button!” She interrupted and then almost jumped across the desk in her frenzy. As it was, she leaned so far she was almost touching me. Then she relented and retreated slowly into her chair. “You know what I do, don’t you?”

Actually, I didn’t –in those days I rarely noticed if a profession was written on the chart- but I could hear the word ‘lawyer’ humming softly in the background.

“I dance professionally,” she said. “I specialize in the danse du ventre, to use my favorite description.” I think I must have accidently raised an eyebrow, because she rolled her eyes impatiently and added “A belly dance!”

“I still don’t…”

“My crown jewel,” she said, carefully enunciating each word as if speaking to a slow child. “I wear a ruby in my belly button as part of my act.” My face stayed blank. “It always falls out unless I glue it in. Those kittens are heavy, you know. Especially when you’re moving everything around.”

“So..?” I didn’t know where she was going with this, so I tried to stay neutral. Sensitive.

“So whatever you did worked… Sits in there like a baby in a blanket now.”

I allowed myself a smile.

“The girls in the troupe are all impressed,” she said, positively beaming. “I told them to pretend they had pain in their parts so they could get to see you.”

Well, I guess it’s a start, eh?

 

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Critical Thinking and Bullying

A few weeks ago, a young woman came in to see me to have her first Pap smear. While I was taking a routine sexual history, she admitted she had recently been bullied online. I’m not even sure how the topic came up, but she didn’t seem very upset, so I asked her about it.

“The guy was a real dick,” she said. And when I asked her how she reacted, she merely shrugged. “Everything he said was false and all my friends should know that… So I ignored him.”

“And did he try it again?” I admired her reaction, but I have to admit I was curious.

She liberated a beautiful smile and shrugged mischievously. “Yeah, once… But then I guess he gave up.” She allowed her eyes to roll upwards comically. “My mother always told me to ignore stuff that wasn’t true.”

It got me thinking about why some people are able to withstand that kind of thing, while others succumb. I don’t pretend to know what motivates bullying, but I do suspect my patient was taught an effective remedy from an early age.

Critical thinking is a way of examining a statement or assertion in order to understand the background and motivating factors for its existence. Its credentials, in other words. It is a way of distancing oneself from the message and analysing everything that went into making it before either accepting or rejecting its content. Also, it is a way of avoiding confirmation bias –reading or assessing only those issues with which one already agrees, rather than sampling a variety of views and thinking of them as interesting, but as yet unproven assertions.

In important ways, this is what Science does: everything is open to checking and possible refutation. Nothing is spared re-examination. Carl Popper, the philosopher of science, suggested that an assertion, a theory, must be worded in such a way that it is testable, otherwise it can not be generalized -or as he would put it, it can only be considered scientifically valid if it is falsifiable- ie checkable. Anything else is merely an opinion -as, for example, the statement ‘Red is the most beautiful colour’. It is not testable, and therefore certainly neither provable nor undeniably valid. This is the first simple rule of thumb we can teach: we must help children to parse input.

Young children tend to question everything- it is how they learn. But in the very young –under, say, six or seven years of age- they often use magical thinking: cause and effect are not necessarily demonstrable either by reason, or even observation. Past that age, however, they begin to understand agency. Causal chains. It is a good time to introduce the concept of validity: was something really a result of an action, or was the action merely associated in time or location so as to seem to have influenced it? And although this is a good first start it is nonetheless one that is not necessarily intuitive. For example it would be tempting to assume that a boy running past a crying girl had done something to her -it might fit with a previous experience. But maybe he was running to catch a bus and it was a coincidence that the two were in the same area at the time she was crying… It requires more proof. More examination.

The habit of questioning things before accepting them can be taught. It can be made into a reflex before reacting. But it needs to be developed early, before the temptation to interpret hastily, or even reciprocate mindlessly, has become entrenched.

The basic elements of simple logic can be taught. For example with inductive reasoning, one attempts to generalize from observations. So if all the crows you have ever seen were black, then you might conclude that all crows are black… Until somebody sees a white crow that is… It is falsifiable, in other words. Most taunts are of that variety -and with practice, easily refuted.

Or even with deductive reasoning which works the other way -from the general to the particular: All men are mortal; Socrates is a man; therefore Socrates is mortal -the classical example. But it only works if the premise is valid (ie. that all men are mortal). And it may only be somebody’s opinion that it is valid…Once again, is it like that example of red being the most beautiful colour? We can all be taught to analyse things like this. We can all be taught to be wary of unsubstantiated statements. Rumours. Gossip. Taunts…

And the critical thinking approach can even apply to actions as well as assertions. A simple example: a young girl is hit by a snowball and another child, a boy, is standing nearby in a group of boys and staring at her. Was he to blame? Did he throw it? Maybe, but without further analysis, further investigation, there’s no proof. No reason to jump to a conclusion. Why did she think it was him? Is her reason based on anger, or is it justified..? This is the basis for the idea that a person is innocent until proven guilty… It is an important concept to inculcate in the growing mind. It is a way of distancing oneself from the action, no matter how provocative, and setting it aside until it has been analysed further. We all judge input, we all react to issues we encounter. And some things do require an immediate response. But it’s how we come to the judgement, how we analyse the data –how we react- that is critical.

You can see where this is leading I suspect: bullying. Bullying -whether on the playground or online, whether by deed or word- has the advantage of unfair leverage only if the process is unexamined. Only if the person being assailed is not used to subjecting taunts to the same questioning. Stepping back, if only momentarily, and processing the information. Checking it. Falsifying it. Refuting it -like my patient was able to do.

A difficult thing to do in the moment, for sure. But without any experience in dissecting assertions –deconstructing them, as PhD candidates are fond of saying- there are only reactive emotions. Victimization. Loss of self esteem that could and should withstand the storm. Self esteem, after all, is partly based on one’s ability to see oneself as in control.

As in mathematics and science, critical thinking is a valuable tool for assessing what we experience in the world. It helps us to parse what we read, what we’re told, what we think… It brings perspective to the unexpected, the hostile and the just plain annoying. It can and should be taught from grade school onwards, building on the simpler examples from year to year –class to class. Younger children may not understand the complexities of the Scientific Method, nor what Popper was on about, but with patience and persistence they will.

They deserve the chance…