Monthly Archives: July 2015

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Forget it?

Memories are tricky things. Sometimes they’re not around when you want them, only to arrive later, when you don’t; sometimes they surround you, pester you, like wasps at a picnic. And other times you can’t find them at all no matter where you look. But the really tricky ones are those that never happened and yet they stand up and wave at you from the crowd as if they’ve known you for years. Sometimes they convince you…

The idea of false memories –or let’s be kind… mistaken memories- is not a new one, but several well-publicized instances recently have brought it to public attention. In the age of social media, of course, the cases are instant hits. Take the hyper-publicized example of Brian Williams, the popular NBC news anchor who claimed he remembered being shot down in a helicopter in Iraq 12 years ago. When this was disputed by veterans at the scene, he was forced to step down from his job. http://www.bbc.com/news/world-us-canada-31220600

Because most of feel we can rely on our own memories, the feeling was that he had obviously lied –perhaps to enhance his own role and bravery in the combat, or because of the notorious ‘fog of war’ –that state of confusion that arises in states of extreme stress and chaos on a battlefield.

So which was it? Fog, or lie? Or maybe post traumatic stress disorder (PTSD)? Well, the matter is more complicated than it might seem on the surface. There has been a lot of work done on ‘false memories’ of late –how and why they form. For example: https://blogs.brown.edu/recoveredmemory/files/2015/05/Loftus_Pickrell_PA_95.pdf  Memories, as one of the psychologists explained, are not like videos recorded on a DVD –the same pictures, the same information each time you play them. They are more like the material on Wikipedia –able to be modified or even changed completely depending on the need or as a result of any new information that might come along. They are, in a word, mutable. Unreliable.

And yet, unconfronted, the memories seem infallible and in most of our experience it seems counterintuitive that they would be otherwise. After all, why have memories if we can’t rely on them? I suppose the simplest explanation is that if we remembered everything that happened throughout the average day –let alone a lifetime- there would be insufficient storage to say the least. Our brains must pick and choose relevance, perhaps adding or subtracting things for efficiency or continuity as information and situations change… It used to be termed ‘retrospective falsification of memory’. Or, as the authors of the above mentioned paper describe it: ‘Relatively modern research on interference theory has focussed primarily on retroactive interference effects. After receipt of new information that is misleading in some ways, people make errors when they report what they saw. The new post-event information often becomes incorporated into the recollection, supplementing or altering it, sometimes in dramatic ways. New information invades us, like a Trojan horse, precisely because we do not detect its influence.’

This type of situation is certainly not unknown in the medicolegal kingdom. In the course of frightening and unexpected events, there is sometimes a variation of perception –especially if the event is associated with injury or seems to be the result of negligence or incompetance. Totally understandable, obviously, and yet there are often variations of what actually occurred that are remembered.

But the issues are not always of putative malfeasance. Sometimes they have a more personal tone.

I hadn’t seen Joanna for several years, the computer said. I have to admit that nothing about her was familiar. I had no record of seeing her for the pregnancy, but apparently I’d delivered her baby so I must have been on call for consultations that day for my colleagues. She’d not come back for a post partum check, so I assumed she had simply gone back to her regular doctor or midwife. And now, six or seven years later, she was sitting in the waiting room staring at the wall. She didn’t look at all happy to be there. The referral letter said she just wished to talk about a problem. Referral letters are not always helpful…

I smiled at her as I crossed the carpet to where she was sitting and extended my hand. The one that reached out to me was sweating, limp, and tentative –as if, given a choice and not witnessed by the others in the room, it would have stayed rooted in her pocket. Joanna was a small woman with short, tightly curled black hair, held in place by a yellow ribbon so tightly wound around her forehead that the skin in the immediate vicinity seemed blotched and ill. I wondered for a moment if that was why she didn’t return my smile –she couldn’t. It only let her frown.

In the office, she sat in the uncomfortable captain’s chair across from me like a post with knots for eyes. They didn’t move, but instead seemed fixated on something half way across the desk. I tried to put her at ease by asking her how she was but was met with a wooden silence; not so much as a splinter moved. I let the silence lie fallow for what seemed an eternity and then, feeling her anger, asked her as gently as I could, why she’d come back to see me after all these years.

The knots on her face moved upwards a few degrees, and the post shivered. “This is not easy for me, doctor. I didn’t want to come, but my family doctor said I should talk about it with you…”

I leaned my forearms on the desk to show I was listening, and asked her what she wanted to talk about.

She sighed and shifted uneasily in her chair. Suddenly the knots became eyes and they stared at me like the barrels of two guns. Her face tightened and her jaw clenched for a moment. “The delivery!”

I waited, but she remained silent. I wasn’t sure what she wanted me to say. I couldn’t remember it at all, although my secretary had been able to get the delivery note I’d dictated. I skimmed through it quickly, but apart from a ten pound baby and a vaginal tear as she apparently pushed it out before I could control it, I could find nothing else. “Was there something about the delivery you wanted to ask me?” I said when it was clear she was waiting for me to comment on it.

Her eyes grew larger and angrier. “The forceps! I told you I didn’t want forceps! My first baby was large and I didn’t need them for her…” She was almost shouting and little strands of saliva escaped with every word. “I told you..! And then because of the forceps, I got that tear in my vagina that took weeks to heal. We couldn’t have sex for almost 2 months!” Suddenly, tears appeared and ran down her cheeks. “I told you I didn’t want you to use forceps! I told you… But you wouldn’t listen. You kept telling me the baby’s heart was too low and she had to be delivered right away.”

I could see her clenching and unclenching her fists as she talked. “My secretary has managed to find the report I dictated on the delivery. I’m sorry I don’t remember more, but let me read it again…”

“I’ll bet you don’t remember it!” she said between clenched teeth. “The nurses told me about you before my midwife consulted you. Apparently you like forceps and are pretty good at it…” She shook her head sadly and looked at her lap for a moment. “But I told you I didn’t want forceps and yet you went ahead and used them on me!”

I pulled up the delivery report and read it carefully. I’d been exceptionally detailed in my dictation that night, so perhaps I had been concerned that the baby’s condition might have warranted it. I’d been called by her midwife in the middle of the night because she had been pushing for three and a half hours without much progress. The head was not coming down the vaginal canal and the baby’s heart rate was beginning to show signs of distress. I had examined her, explained the situation, and then told her the options: continue to push, although I didn’t recommend this because she hadn’t made any progress after all that time, and the baby’s heart rate was beginning to show decelerations indicative of distress; caesarian section; or trial of forceps (a concept meaning if the forceps weren’t successful after a reasonable try, that caesarian section would be the fall-back option.) She hadn’t wanted a Caesarian, so I’d asked the nurse to get the forceps ready –just in case. Then, when the nurse had entered the room with the forceps, Joanna had become angry and said she would not accept forceps for delivery.

There followed a sudden, profound, and prolonged fetal heart rate deceleration and something had to be done to help the baby right away. The situation demanded an immediate judgment call, and that meant the forceps. But just as I was reaching for them, she gave a mighty push and delivered the baby. Unfortunately I’d been unable to control the head on such unexpectedly short notice, so she’d sustained a vaginal tear. It hadn’t been terribly large, and I’d been able repair it without much difficulty. Baby seemed fine, and there were smiles all around.

As I was finishing reading the report, I could hear her voice repeating again and again “Why did you use the forceps, doctor. I told you not to use them…”

I forced a smile. “I didn’t, Joanna. The baby was in trouble and I needed to get her out quickly, but I didn’t get a chance to use them. You pushed her out as I was turning to get them ready.”

“But I heard them! I heard them clanking…”

Forceps are metal and as the two sides are assembled they often make a metallic clanking noise. (They superficially resemble salad tongs, although unlike tongs, they don’t actually squeeze the head in anything like the same way. They fit more like a helmet over the head and guide it down the vaginal canal like a dilating wedge in front.) I shrugged politely. “It was an emergency for the baby. She needed to be delivered right away, so I was probably getting them ready when you had that really strong push.” I chuckled at something and she stared at me. “Sometimes I think that just the threat of using them is as good as using them. Nothing motivates stronger pushing than clanking the forceps!”

First I saw her teeth and then a smile worked its way slowly into the space around them. “But I distinctly remember you putting them on… I think…” Her eyes wandered to the window behind me for a moment. “Can I see your report?”

I smiled as much in relief as at the dissolution of the tension in the room. “Of course.” I punched a couple of keys and the report chugged its way out of the printer. I handed it to her and sat back while she read it. Actually, she must have read it several times, each time shaking her head in steadily diminishing disbelief. Finally she folded it up and put it in her purse. “All this time…” Her eyes sought mine and I could see they had softened from birds of prey, to… the prey itself. “But I remembered it so differently…”

“Would you like me to see if I can get a hold of the nurses reports as well?”

A large, genuine grin spread across her head dividing her eyes from her chin as she shook her head a final time. “I’m so sorry, doctor… All this time…” Suddenly a thought occurred to her. “Tell me one thing, though.” She tore her eyes away mischievously and they flitted briefly about the room. “Were you wearing an earring that night?”

I must admit I blushed at the question and nodded my head. “It was a phase,” I added quietly.

She giggled and reached for my hand. “Well at least my memory didn’t screw everything up…”

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Recycling the Old

For everything there is a season, and a time for every matter under heaven…

Really? It made sense when I was young, I suppose -when all of Time was ahead. When I needed to think there was some order to things. That past and future meant old and new. But as the years slip past, I find myself wondering about disparate things. Opposites. Like what, really, is the difference between new and old? Is it merely a temporal distinction? A nudge along a spectrum? Or a more fundamental change -a conceptual shift? I suspect it can be any of these, of course, but it still begs the question: does any change, any difference qualify? What if there is no change in form at all, but rather a change in function? In Purpose? Would that be new, or merely a rose with another name?

The concept of recycling has been with us from the dawn of time. When materials were scarce or unavailable things were used again, either in their original roles, or repurposed for something else their makers had not anticipated -a new situation, a new need. And so the old rises from its ashes like a Phoenix, but this time in a different play as another, unfamiliar actor.

The tradition of respecting the wisdom of elders and retelling their stories is also an honoured tradition. But as stories do, they alter over time and are often interpreted in new and unexpected ways. The knowledge is not lost, it’s just explained in different words. Understood in a new context. Reconstituted. Society has learned that there is often a benefit that accrues to re-examining the old and looking at it from an altered perspective. So has Science: http://www.bbc.com/news/health-33635575 Bisphosphonates have been around for a while as treatments for osteoporosis, a condition in which there is decreased bone mass. They help to prevent bone loss and so strengthen the bones themselves. It is most frequently used in the post menopausal woman when she no longer produces bone-protective hormones from her ovaries.

Bone is a common site for breast cancer cells to travel to (metastasize) however, and they can lie dormant there for years after the primary tumour has been removed from the breast. And yet, interestingly, those women who were already being treated with the bisphosphonates in the menopause and later developed breast cancer, showed a 28% reduction in cancers developing in their bones. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60908-4/fulltext And because the patents on bisphosphonates have expired in many jurisdictions, the cost of these bisphosphonates is minimal when compared to other ‘new’ treatments on the market.

But there’s more. A medication originally designed for diabetes –glitazone- has been found to decrease the likelihood of developing Parkinson’s disease. http://www.bbc.com/news/health-33608725 Of course this is just a comet in an otherwise cloud-filled night because glitazone is not without its own serious side effects –bladder and heart problems, to name just two- but it is a promise whispered emphatically, albeit quietly, to anyone working in the field. A starting point for future research…

So I suppose we should keep poking about in the ashes. Stirring embers to see if there is a Phoenix hiding somewhere in the cinders, fast asleep and dreaming of another job. We affix labels to things –categorize, then name them for all time. It’s a way of keeping track. Knowing what to expect. The problem, of course, is that things change. Evolve. Mutate. And as Jiddu Krishnamurti, a philosopher, once said of the disadvantage of naming god, it constrains the concept. Limits it. Doesn’t allow for growth and development. I think it is sort of like naming and classifying something when it is only a seed and we are still unaware of its potential. Maybe old is something like that. Where there is life there is always a seed and its age is beside the point. Meaningless.

I’m beginning to see age as a definitional issue, and not in the currently favoured framework of chronological versus biological –or even psychological- age so condescendingly mouthed by those too young to have experienced the ill-disguised discrimination it entails. There is useful wisdom that accretes with years and experience of course. But age is an oven that cooks whatever has been put inside –changes it into something else. Sometimes something entirely new.

I opened with a quote from Ecclesiastes, so let me close with one from the Talmud: ‘For the unlearned, old age is winter; for the learned, it is the season of the harvest.‘

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A Gift of Age

Is philosophy a reward of age, or is age itself a gift that metaphysics merely opens: Weltanschauung? Is it just that there is a time when thoughts flow along different and unaccustomed neurons? Or are they maybe shunted to the diminishing residua of nerve cells that are still firing? I ask myself these questions sometimes when night closes in and stimuli flee. At times like this, I wonder if the weight of years are more hindrance than benefit. Less a present, more a penalty.

When viewed from outside the prevailing ethos, age –especially its accumulation- is a gift. A bonus on the journey from which only the very young think they are exempt. And despite the mounting detritus of discarded cells and greying hair, it is a book whose pages, although well-thumbed and sometimes soiled with regret and torn by mistakes, are nevertheless extant, and readable. They are stories told without a plot and written, often, for the author with little hope or even desire for publication.

And yet, congratulations are sometimes lip-serviced  -the words mere decoys to disguise a different meaning: better you than me. In underestimating the years attained, the truth is seldom spoken except casually, as a joke –retractable, and yet echoing uneasily in the room long after it is uttered. Age is a gift, and yet shoddily packaged, the ribbon askew and poorly tied, the paper faded and rumpled with constant handling. Still, it is something at least… A recognition if nothing else.

But I’m making aging sound like night thoughts: a punishment rather than the achievement that it is.

We were talking about this, a patient and I, when she came in for a renewal of a hormonal therapy that helped her cope with one of the gendered ravages of her wealth of years.

“The young just don’t seem very thankful for what we’ve done for them, do they?” she said with a maudlin sigh when the subject came up.

I sat back as well as I could in my creaking chair, and smiled that gently exasperated smile that old folks are allowed. “But we look back; they look forward, don’t you think? Retrospective analysis is the domain of the experienced. Why do you think we have memories?”

“I suppose,” she said shrugging her shoulders in polite acknowledgement of a point with which she was evidently not in complete agreement. “We always seem to criticize generations other than our own when they do things differently, don’t we?”

I nodded. “But if each generation didn’t change a little, we’d probably still be chipping away with stone axes…”

A tiny smile crept onto her lips in spite of her attempt to remain pessimistic. “Speaking of the youth looking forward, I remember thinking of that when I had my first child. You probably don’t remember, but I had a rough pregnancy –high blood pressure, gestational diabetes, and then Melissa not growing as fast as she should in the womb…”

I actually did remember. “She was born prematurely – I induced labour about 34 weeks gestation or so, didn’t I? I recall being rather worried…”

Her face lit up with the shared experience, but her eyes stared far off into the past. “I remember thinking that she should be so thankful she was born. So thankful she was healthy.” I nodded again. “Anyway, a friend who came to see me while I was still in the hospital said that as well as getting presents on her own birthday, Melissa should give me a gift each time. A celebration of how lucky she was.”

I sat up straighter on my chair. “What a great idea, Melanie. And..?”

Her eyes twinkled at me. “Yup –all three of my kids. It’s a sort of family tradition now. Some of their friends are trying it as well, they tell me.”

The idea struck me as terribly innovative. Maybe others had done it, but I hadn’t heard about it. “Think it’ll catch on?”

She shrugged. “It’d be sort of like an accessory nipple in a way don’t you think?  I mean, I suppose that’s what Mother’s Day is for…”

I thought about it for a minute. “Mother’s Day is a bit generic, though. A child’s birthday is unique -an acknowledgement of its own presence in the world… and all because of its mother. It’s not a national day, it’s a personal day. And that’s what makes it so special.”

She stared at her hands she’d folded in her lap and was silent for a moment. We were both quiet. “Why do we think about these things more as we get older?” she said finally, breaking the silence almost reluctantly. “Or is it just me?”

I shook my head slowly. Absently. I was also lost in my own questions. She was right; it did seem to matter more nowadays that we poked around in the past, stirring the embers. But why? Did we really need the fire? The heat? The light? Were we awakening memories, or searching for something else? Looking, perhaps, for ourselves..? As if in the ashes of the dying fire there were patterns. Clues which, if properly mixed, could tell us where we, the lighters of the fire, had gone.

I could feel Melanie staring at me. “I can see you rummaging around in there, doctor,” her voice said, rustling through the room and bursting past the opaque curtain my eyes had drawn across it. “Come out again. I still need you…”

I had forgotten to write her the prescription for more hormones, yet somehow I only heard the words ‘I still need you’. But they were enough. I suddenly realized that the most satisfying gift of all, the most welcome treasure of age, was presence, not presents. And despite anything else that might go amiss, I was needed. Isn’t this what we all work for? When all is said and done, does anything else really matter?

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Treemail?

Treemail? You’ve got to be kidding… Or is this simply a natural progression from Emailing your fridge, or telling the front door of your house to lock when you’re at work -something that in four or five years will be so banal and unsurprising that pointing it out as interesting will ensure that you are similarly categorized?

http://www.bbc.com/news/magazine-33560182 is the BBC News article that first brought this intriguing idea to my attention.

The original idea was to help preserve the trees in Melbourne, 40% of which were either struggling or dying in the regional drought. The authorities mapped all the trees and gave each one a specific ID. Then they decided that if they put these online, people could Email the city if they noticed any problems with a particular tree. Great idea: digitize something and it you’ve reified it; make it accessible and voila: an individual accorded all of the rights and privileges of anything else with which you can communicate.

Individuation, the process of distinguishing one thing from another thing -how, in other words we know that an individual is one thing and not someone or something else- is a fascinating subject. There are several fields that have adopted the idea. Jung, for example used the concept to describe how an individual becomes a unique subjective entity out of all the potential that existed subconsciously before he or she did so. And of course, social media long ago tapped into it to customize news to match the preferences of the reader (for example, see my essay https://musingsonwomenshealth.wordpress.com/2015/05/15/the-polarization-bias/ ).

But I have to say that, for me, the most thought provoking aspect of the notion is the philosophical one. If I can delve into some rather abstruse background, it may help to explain what I mean. In medieval philosophy, one could ask what something was –what group it belonged to and what it shared with others of its kind (plant or animal, for example) and this was known as quiddity –Latin for ‘what it is’. This grouping into categories, as it were, was contrasted with the uniqueness of a particular thing in that group –the thisness of an individual. In other words, that which caused it to be this particular thing, and nothing else. This concept goes by the name –stay with me for just a moment- Haecceity, from the Latin haecceitas, meaning thisness.

If nothing else, you have to love the words…

So the distinction would be something akin to the difference between the concept of a woman -quiddity- and the concept of Indira Gandhi (a specific woman) –haecceity.

What makes something unique, though? Surely not simply a name. There were apparently around 77,000 presumably unnamed trees in Melbourne when they decided to individuate them. Few of them were previously noticed as individuals, unless perhaps they exhibited some feature that stood out from the rest. Most were probably beautiful in their own ways, and each was certainly, on closer inspection at any rate, unique. But they were still trees –quiddities: background, shadows in the larger Gestalt, by and large- until they were granted numbers. Identifiers. First names, if you will.

And why is that so exciting? Because each has suddenly become real. Each emerged like a crystal precipitating from a previously undifferentiated matrix. Each is now recognizable, like a friend in a crowd -someone you know. And in a world of faceless, anonymous strangers it is nice to be able to smile at something familiar –the climate-friendly helper you’ve finally met. As Polonius says to Laertes in Shakespeare’s Hamlet: ‘Those friends thou hast, and their adoption tried, Grapple them unto thy soul with hoops of steel’

Haecceit them, I guess…

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A Slim Chance?

‘They are as sick that surfeit with too much as they are that starve with nothing’

Although the word ‘obesity’ was not used until the beginning of the 17th century, the suspicion that there was something distinctly unhealthy about it has been with us for millenia –certainly long before Shakespeare’s The Merchant of Venice was written. There was a time, of course, when food was scarce and so its acquisition and display was considered a sign of wealth and power. Only the more extreme examples of over indulgence seemed to stand out as unhealthy and undesireable. But it’s true that our standard of acceptance has varied over the centuries; our idea of what is normal is very much influenced by what we see around us (as I have commented in a previous essay: https://musingsonwomenshealth.wordpress.com/2015/04/02/nudging-childhood-obesity/)

There seems little question as to the adverse health problems associated with obesity, but I suppose the most worrisome aspect of its increasing prevalence is what is to be done about it. There have been those who have felt that to condemn it is to discriminate unfairly –unjustly attributing fault (and guilt) where there should be none. The International Size Acceptance Association (ISAA) for example was founded in the USA in 1997 to promote acceptance of excessive weight and end weight-based prejudice. But, by and large, there has been a general realization that unless something is done about it, the burden of obesity will result in a parallel but undue burden not only on health itself but also the facilities necessary to deal with its consequences.

So the challenge is staying abreast of the problem: treating it, or better yet, preventing it. There was an interesting article in a July 2015 BBC report about some of the problems with our approaches to the issue so far: http://www.bbc.com/news/health-33551498 Using UK data, ‘The research tracked the weight of 278,982 men and women between 2004 and 2014 using electronic health records.’ And the findings from this huge data base were disappointing: ‘For obese people (with a Body Mass Index of 30 or more), the annual probability of slimming down was one in 210 for men and one in 124 for women.

This increased to one in 1,290 for men and one in 677 for women with morbid obesity (BMI 40 to 45)’. In other words, ‘Current strategies that focus on cutting calories and boosting physical activity aren’t working for most patients to achieve weight loss and maintain that.’ http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2015.302773

There are, of course, other strategies –bariatric surgery probably the most successful of these. This is an approach that attempts either to restrict the amount of food that can access an adequate amount of bowel to be processed, or conversely to restrict the amount of processing (absorption of nutrients): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470459/

Quite apart from the fact that it is a surgical –ie invasive- approach, and requires both facilities and trained surgeons to perform, is expensive, and would not be scalable to the requirements of a large and increasingly needful population, it is not without problems. Depending on the study, there are complications in as many as 17% of cases, and even a need for re-operation in 7-10%. New data will emerge as methodologies improve, no doubt, but even if complications dropped to zero –an almost naïve fantasy- it would still not serve the needs of the vast majority of obese people.

No, it seems to me that the only viable option is that of primary prevention –establishing a culture of healthy eating, and an expectation of a more healthy weight spectrum. But even to say that, courts another naivete, namely that wishing it were so –knowing that it makes sense- is a view held by everyone. Were it not for the stigma of weight, how many would realize there was even a need for change? And is the stigma itself more of an impediment than an incentive to weight reduction? I found another study, this one with more of an emphasis on social justice than answers: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009.159491 And as the authors suggest in their abstract –again in the American Journal of Public Health: ‘On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.’

So, clearly the solutions must come from within –much as you have to want, say, to quit smoking before you will even hear the message. Maybe Shakespeare again, hinted at this when, in his play Julius Caesar, he has Cassius say to Brutus:

And since you know you cannot see yourself
So well as by reflection, I, your glass,
Will modestly discover to yourself
That of yourself which you yet know not of.

It’s a thought, anyway…

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The Body’s Clock

Scientists –well, all of us- have been suspicious about the health risks of shift work for a long time now. Perhaps there is a reason buried somewhere in our genes that suggests night is for sleeping and daytime for working. Originally, no doubt, it was because it was difficult to see things in the dark and lighting, even when it became available, wasn’t very good.

But there is another reason: the Circadian Rhythm (from the Latin circa –around, and dies –day) which is often defined as physical, mental and behavioral changes that follow a roughly 24-hour cycle, responding primarily to light and darkness in an organism’s environment. The body clock, in other words. And there’s the clue: light and darkness. These are not just elements in our environment that we have come to expect, they actually have a biological meaning for us although this is, to a certain extent, entrainable. Malleable. As Wikipedia (sorry!) puts it: The rhythm can be reset by exposure to external stimuli (such as light and heat), a process called entrainment. The external stimulus used to entrain a rhythm is called the Zeitgeber, or “time giver”. But it can take a while to adjust –think of jetlag, or sleep disturbance after starting a new shift at a different time.

The body can adapt to many things, no doubt; the problems seem to arise when the pattern keeps changing. As folk wisdom attests, we are inherently creatures of habit –acquired behaviour patterns that are repeated so frequently they can become almost involuntary. As no less an observer of folkways than Samuel Johnson once said: “The chains of habit are too weak to be felt until they are too strong to be broken.” So one might ask why we –and many other animals- seem prone to develop these routines, these almost unconscious ceremonies. Is it simply a need for predictability? Or is it something deeper, something tied to our evolutionary past..?

In our evolutionary development we obviously experienced disruption of light/dark cycles –they occur as we travel through the seasons- but these are gradual and steadily progressive; shift work –especially rotational shift work- is not. And only recently has it become more obvious that there may be a price to pay. There have been several studies that have looked at this in various ways, but ‘Although epidemiological studies in shift workers and flight attendants have associated chronic circadian rhythm disturbance (CRD) with increased breast cancer risk, causal evidence for this association is lacking’ as the abstract of a paper published in Current Biology noted. I saw this in a July 2015 article in BBC News reporting on a study co-authored by Dr. Kirsten Van Dycke which suggested that the chronic need to re-entrain the circadian rhythm because of changing light/dark cycles can increase the risk for both obesity and breast cancer! http://www.bbc.com/news/health-33569161 Now, admittedly, the study was done on mice who were prone to develop breast cancers anyway, but when the light/dark cycles were switched over a long period of time (‘Mice prone to developing breast cancer had their body clock delayed by 12 hours every week for a year’) they developed them sooner.

Humans are obviously not mice, but it is difficult to control for possible contributing factors in the average human study: ‘Several scenarios have been proposed to contribute to the shift work-cancer connection: (1) internal desynchronization, (2) light at night (resulting in melatonin suppression), (3) sleep disruption, (4) lifestyle disturbances, and (5) decreased vitamin D levels due to lack of sunlight. The confounders inherent in human field studies are less problematic in animal studies, which are therefore a good approach to assess the causal relation between circadian disturbance and cancer.’ http://www.cell.com/current-biology/abstract/S0960-9822(15)00677-6

And the conclusion from this study? ‘Animals exposed to the weekly LD [light/dark] inversions showed a decrease in tumor suppression. In addition, these animals showed an increase in body weight. Importantly, this study provides the first experimental proof that CRD [Circadian Rhythm Disturbance] increases breast cancer development. Finally, our data suggest internal desynchronization and sleep disturbance as mechanisms linking shift work with cancer development and obesity’.

This is worrisome, to say the least. One could certainly argue that a woman with an increased risk for breast cancer –say a heditarily aquired BRCA1/2 mutation- would be best to avoid jobs involving chronic irregular body clock disturbance such as flight attendants, commercial pilots, and so on. But I’m not sure the risk is confined to that population. What about others –especially if they have additional life-style risks such as smoking, diabetes, alcohol issues?

And what about men? If –as the study suggests- a chronic body clock disruption may cause a decrease in tumour suppression, would that not suggest a similarly increased risk? The disruption also seems to have an additional risk for increased weight gain –obesity. Is the risk for type 2 diabetes therefore also increased? Clearly this is an area requiring much more research -further elucidation of the mechanisms involved and mitigation strategies at the very least. Sleep is so important –regular sleeping patterns…

I can’t help but remember the words of Shakespeare’s Macbeth talking to his wife after he has killed Duncan, the king:

Methought I heard a voice cry, “Sleep no more!

Macbeth does murder sleep”—the innocent sleep,

Sleep that knits up the raveled sleave of care,

The death of each day’s life, sore labor’s bath,

Balm of hurt minds, great nature’s second course,

Chief nourisher in life’s feast.

Art, once again, anticipating Science…

by

Time Enough

Time, the faceless tyrant that rules our lives like an absentee landlord, is so abstract, so opaque, it is difficult to grasp. It is seeing through a glass, darkly if at all. Enslaving everything within its reach it is an impartial despot. Dispassionate in its all-embracing realm, we are each of us imprisoned and there is nothing outside the bars.

Time is an aloof conqueror with no interest in our supplications, no ear for our protests, and no concern with how we define it, measure it, embrace it. It simply is, whether or not we choose to acknowledge its existence.

And yet the question of its perception has always intrigued me. Is Time truly an owner and we, powerless and abused, its hapless chattel? Or are we merely imprisoned by perspective -glasses half empty? But as we continue to drain the glass, there is an increasingly vexing thought: what is it we have drunk?

*

The patient population that are sent to see me seems to have aged over the years I’ve been in practice -or, more likely, the referring physicians have aged as well, and the phone number of my office surfaces easily in their heads, like habits, traditions -Canon law instituted in a more insecure epoch in their careers. But the accretion of age around me is instructive: I am more aware than ever of the differences in our apprehension of Time. Our repudiation or acceptance of its influence in our lives.

Nora was an interesting example of time-obsession. I say ‘was’, because I saw and treated her a few years ago and she has never returned to see me; I like to think it’s because she had no further need, but I fear the worst. A silver haired woman in her late eighties, she sat solid as a post in the waiting room, absorbed, it seemed at first, with inner thoughts. And yet, as I stood behind the front desk attending to another task, I noticed her eyes darting about the room like bees investigating a busy field –alighting first on a child crawling on the floor then moving on to a bright but enigmatic picture hanging near the door. A woman busily turning pages of a magazine near the window was next, and then the little boy playing noisily and impatiently with a smartphone waiting for his pregnant mother to return from the washroom down the hall –little escaped Nora’s scrutiny, and yet she was a statue. Nothing else about her moved. Her black, floor-length dress might have been painted on, the golden bracelet around one of the wrists that rested in her lap was still and as yet ungleaming. Even her face was a calm mask revealing nothing –the only hint of serenity in the busy room. A place of refuge in the roiling world.

She was no different in the office at first. She sat quietly in the chair across from my desk and unleashed her eyes again to explore the room, the furniture, and then, almost as an after thought, me. “The terracotta lady in the corner…” She turned her whole body to stare at the sculpture as if her head and neck were welded to her shoulders as a unit. “…It has some coins scattered around it.” She turned once again to look at me, this time disapprovingly. “Am I supposed to feed it?”

It was an effigy of a woman with a begging bowl that someone had given me and it was beginning to accumulate coins for some reason. I smiled and shook my head. “I meant it as an ornament for an otherwise boring corner but…” I shrugged to indicate the coins were merely accidents.

“Guilt is something I outgrew years ago, doctor,” she said with obvious concern that the the terracotta lady and her bowl were put there to supplement my income.

I wasn’t sure if I was supposed to reply, but her eyes seemed intent on interrogating my face. “Time smoothes things out, doesn’t it?” It was a trite comment and I’m not sure why I even said it, but her expression changed immediately.

“After all my years, do you think it cares how I feel?” This time I decided to say nothing; she seemed angry about something. “We are its slaves, after all…”

“Slaves?” I thought maybe allowing her to vent would enable me to ask her why she thought she’d been sent to me. I’d read the referral letter, of course, but patients often understand things differently from their doctors.

She stared at me as if I were a little slow. “You wouldn’t understand, doctor. A woman is a slave to many things, and Time is no exception.” Her eyes continued to crawl along my face looking for a reason to continue their search. Finally, they returned to their home and she shrugged, as if the territory they had explored was not a threat. “Think about it,” she started carefully, the words slowly assembling inside her mouth. “Most of our lives we are calendars, ticking the months off from period to period, our hopes and fears captive to whether or not it arrives on time, our lives inextricably entwined with its schedule.”

I have to say, that the obvious is sometimes invisible –or at least disguised and camouflaged in the background. I hadn’t thought of the exigencies of Time on a woman being recorded like that.

“Males,” she continued, “are not subject to the same calendar. Time passes, for sure, but there is usually no need for it to be regimented in little orderly blocks. It is a different animal for you…” Her face softened and her eyes stopped moving. “Still a demon, perhaps, still unkind, but less constantly in your face.” She sighed, but visibly. Audibly. “It is a different Time.”

I wasn’t certain what to make of her idea –wasn’t certain how to turn the conversation towards the reason she had been sent to see me- but I was fascinated all the same. Maybe how we perceive the allotment, the measuring stick, changes something. She had been sent to me for the investigation of vaginal bleeding –abnormal and unexpected bleeding, to be sure, but nonetheless it was a calendar waved in her face once more. Something she had thought was long destroyed, was back to plague her yet again. As Hawthorne said, ‘Time flies over us, but leaves its shadow behind.’

Well, I suppose it does… but I am rather more drawn to the view of Rabindranath Tagore: ‘The butterfly counts not months but moments, and has time enough.’

I hope that Nora did, as well.

by

Age Prejudice

I suppose I should have seen it coming. I suppose I should have laid down firmer tracks, taken a more trodden path. I suppose I shouldn’t have been so influenced by Robert Frost’s poem, the Road Not Taken. But I was… ‘Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference.’ Well, at least I think I did -I didn’t mean to, or anything; it’s just something that, as I look back through the years, turned out that way.

All our paths are unique, to be sure, and it is likely the conceit of many of us to think that we, alone, have chosen singularities for ourselves –things, if not incomparable, then at least extraordinary: signatures for which only we could have been responsible.

So it is with some dismay that I came across a BBC News article describing a paper by William von Hippel, a professor of Psychology at the University of Queensland, in Australia in which he suggests that ‘although many people remain unprejudiced throughout their lives, older adults have a tendency to be more prejudiced than their younger counterparts.’ http://www.bbc.com/news/magazine-33523313

Older folks? Now wait a minute… As someone who did not suspect his way of life had ‘fall’n into the sere, the yellow leaf’, I feel almost blind-sided. Of course I didn’t see Harper Lee’s Go Set A Watchman coming either. I have been a life-long admirer of Atticus Finch –someone whose name I even bestowed upon a cat I once had- and Lee’s previous book To Kill A Mockingbird was always a beacon in troubled waters for me. Something that let me believe that we were more than our fists. That we could, if we chose, rise above the curses and anger that so frequently filled our streets. But even her older Atticus slipped beneath those waves it seems…

So is this how the path to maturity -the grinding road to wisdom- ends? An abnegation of all the tolerance that we have learned to espouse? An abrogation of all those principles we fought so hard to enshrine in law? A foretaste of the dark night of the soul that lurks, still hidden, behind the shadowed corners of our ever-increasing ages?

In fairness, if you read the original article in Psychological Science https://www2.psy.uq.edu.au/~uqwvonhi/S.vH.R.PS.09.pdf it attempts to frame the problem as a sort of neurologic deficit, suggesting –that age differences in implicit racial prejudice may be due to age-related deficits in inhibitory ability- perhaps absolving us elders of ultimate responsibility. As in dementia, it’s not our fault. Certainly not our wish… Some things, like grey hair or wrinkles, are merely part of the geography of age the trail runs through. But is increasing prejudice a town along the way, or a detour we didn’t have to take? A ghost town, sporting a few boarded up stores and nobody we recognize on the streets? A place we visited years ago, then left because we didn’t feel at home despite the friends we made?

The BBC report neatly summarizes von Hippel’s neurological hypothesis: The frontal lobes are the last part of the brain to develop as we progress through childhood and adolescence, and the first part of the brain to atrophy as we age. Atrophy of the frontal lobes does not diminish intelligence, but it degrades brain areas responsible for inhibiting irrelevant or inappropriate thoughts. Research suggests that this is why older adults have greater difficulty finding the word they’re looking for – and why there is a greater likelihood of them voicing ideas they would have previously suppressed.

Whoaa! I’m not sure I like that… I’ve always had irrelevant and probably inappropriate thoughts. I’ve always been a loose cannon. And now, I suppose, I should be worried that there is a threshold I might some day cross in which my age would shift me from being considered merely eccentric to a diagnosis of mild dementia –frontal lobe atrophy, no less- by default. Or maybe I should have worried about those mysterious frontal lobes all along –maybe I got a damaged pair from the outset.

Hmm, and I always figured it was the result of getting lost on that less-travelled road. It was, after all, ‘grassy and wanted wear’…

by

Why do we Know something?

Knowledge is interesting. But what is it, exactly? What does it mean to say you know something? Plato defined it as being justified true belief, but is it? Take Bertrand Russel’s famous thought experiment: the ‘stopped clock case’, for example. Alice looks at a clock and says it is two o’clock. Well, because the clock does indeed confirm that it is two o’clock, it seems justified; and because it is, in reality, two o’clock, it also seems a true belief. She could therefore be said to know that it is two o’clock… But, unknown to Alice, the clock had actually stopped working exactly 12 hours previously, so did she know that it was two o’clock? Or was it a fortuitous guess and not knowledge?

All this is a little out of my comfort zone to say the least, so I’m not even going to attempt straying into such philosophical realms as the ‘Gettier Problem’ (whether something that happens to be true but is believed, as with Alice, for incorrect or flawed reasons should be counted as knowledge). It is truly thought-provoking, though, isn’t it?

But Knowledge is not just a list of facts that happen to be true –whatever truth is- nor a compilation of disparate evidentiary items. It is not only an encyclopedia, it is a diary as well: the story of why it exists. There is often a purpose to it –or at least in its acquisition there may have been a reason, even if you stumbled upon it by accident.

In other words, there is another way of approaching the concept of knowledge other than how we know something to be true –the Scientific Method, for example- and that is why we know it. And I don’t mean to stir the lid of Pandora’s box with the ‘why question’, nor to intimate some sort of heterodox Creationist linkage, but merely to introduce something that I learned from a patient a few years back -a professor of philosophy at one of the local universities.

Nancy was a thin, forty-seven year old woman who had been sent to me for a recent episode of irregular menstrual bleeding. She was otherwise healthy and somewhat embarrassed at having to see me for something her mother and aunt had managed to work through without having to seek medical advice. Her family doctor had ordered an ultrasound of the pelvis and it had not revealed anything suspicious. In fact it had stated that no abnormalities had been seen to explain the bleeding.

I suggested it would be a good idea to sample the uterine cells with an office endometrial biopsy as a final reassurance that nothing had been missed. But I could see that she was uncomfortable with the idea.

“What are you hoping an endometrial biopsy will find, doctor?” she said suspiciously.

“Actually, I’m hoping to find nothing,” I said in my best, confident voice. “The ultrasound didn’t see anything to worry about…”

An eyebrow slowly crawled up one side of her forehead. “I realize that; my GP showed me the result.” The other eyebrow shot up to join its sister. “So… Why would you want to do a biopsy?”

I get asked this a lot. “Well, the ultrasound is not a microscope. It can’t tell anything about the type of cells that are in there.” She still looked unconvinced, I have to say, so I pulled out another of my usual analogies. “I suppose it’s something like trying to make a diagnosis from a shadow. You can guess a person’s height and perhaps her weight from her shadow, but even if you could tell she had long hair, you would have no idea of its colour. Nor would you know anything about her heart.”

Nancy was quiet for a moment, obviously thinking it through. I could tell from her face that she thought it was a rather clumsy explanation -not well conceived, and not terribly illustrative of her problem. “So,” she finally said, looking up at the ceiling for help, “The ultrasound is normal, the blood tests my GP did suggest I’m in the menopausal transition now, the abnormal bleeding only occurred in one menstrual cycle a few months ago, and I’ve been doing well since then…” She dropped her eyes onto my face and left them hovering there for a moment as she shook her head. “Tell me again why you think a biopsy would be a good idea.”

I have to admit that when she put it like that I had second thoughts, but nevertheless I pushed on, regardless. Was I just trying to save face, or was there truly a principle at stake? “Well… clearly there are different ways of approaching your bleeding… But if we do the biopsy, and it is normal, then at the very least we will have a baseline that reassures us that if it happens again in the near future, we can probably assume the cells are still normal…”

Nancy was good; she could read the hesitation in my voice. She smiled gracefully, but it was a polite smile. “Wouldn’t it make equally good sense to wait and see if it starts to happen more frequently and then do the biopsy?”

She had me. “Yes, I suppose that is an equally acceptable option.”

She sat back in her chair, crossed her legs, folded her arms across her chest and stared at me –not unkindly, not aggressively, but curiously, like a mother might watch a mischievous child. “I won’t ask you how you came to that conclusion, or how you know that a biopsy might be justified. Those are all fairly standard medical teachings, as I understand…” Her face wrinkled in concern. “But I’d be curious as to why you know that.”

I returned her stare. Why I knew that? Why does anybody know something? Because they read it, or were taught it, or figured it out… Why indeed?

“We all have options in our learning,” she continued. “There are many opinions to which we are exposed, rival paradigms, competing theories. And they all promise success; they all answer the questions differently. Like a hundred people crossing a single bridge, it’s not the same bridge for any of them. It’s a hundred bridges…”

Her face softened, like a teacher that realizes she has confused her pupil. “From all that reality has to offer, we have to decide what to privilege. There are just too many routes to the truth to take them all. We have to choose…

“But why do we choose one view, one approach instead of another? That’s what I’m asking.” She sighed, as if even the question, let alone the answer to it, was hopeless. “Why do you know one thing and not something else?”

Her question still troubles me. I had no answer for her then; nor do I now. I still wallow in the permutations and combinations of perpectives I confront daily and wonder how I manage to choose my direction without getting lost. Maybe it’s a confirmation bias: I have come to believe in the correctness of a particular viewpoint over the years and so only consider the evidence that confirms it. The diagnosis that points that way. And if the results don’t justify the approach? Well, there’s always rationalization to light the path I’ve chosen.

But do I really know why I know what I do, believe what I believe, think what I think? No, not so far… and yet the fact that I’m even aware of the discrepancy, and see the signs to other roads, is a good start isn’t it? As Marcel Proust wrote: The real voyage of discovery consists not in seeking new lands but seeing with new eyes.

by

Risk Perception

Risk is something we all need to assess from time to time. The problem lies in how we do it. If there are factors we fail to take into account that affect our risk perception then our evaluation may as likely be wildly unrealistic, as appropriate. Emotion tends to skew things in one direction or other, as does as the degree of perceived asymmetry between the benefits and dangers –if we really desire or enjoy something, we might be less risk averse than if we were not keen on it in the first place. The status or acceptance acquired from smoking for a teenager, say, might counterbalance the long-term dangers; it might not be seen that way by an older, more confident adult. And immediately experienced risk –driving a car with faulty brakes- may be more influential than future risk such as lifestyle changes for cardiac disease prevention. And then, of course, there are cognitive biases –our own subjective mythologies, expectations and intuitions- not to mention cultural biases, all contributing to the overall assessment of the acceptability or not of the risk.

But I suspect that a major obstacle in risk perception lies in its probabilistic nature. People have enough difficulty in understanding the simple Bell Curve distribution of likelihood let alone the mathematical Baye’s theorem which ‘describes the probability of an event based on conditions that might be related to the event.’ Our estimates are more intuitively driven than statistically. Understandable, to be sure, but unreliable in most appraisals. Misleading. Dangerous, even.

It’s hard to grasp the concept that even doubling a risk when it is almost imperceptably low already, still leaves it almost imperceptable. So, at what stage does it become unacceptable, if it wasn’t really perceived to be that in the first place? Is any risk acceptable if we know about it, no matter how small and unlikely? What about the background risks that are inherent in most things –be they visible and published or not? Riding a bicycle, for example, or running on a treadmill, walking to work… At what point do we merely turn off and get on with life?

The problem is certainly manifest in Medicine. Most of us invest health –especially our own- with an appropriately significant amount of concern. But it is more of an emotional than intellectual process, and we tend to interpret the concept ‘improbable’ as the much more personal ‘but possible’. Shadows, despite their insubstantiality, hide ‘what-ifs’ –or worse still, unrealistic fears that favourable probability cannot disguise.

Martha was one of those. I would never have guessed it to look at her, though. She sat relaxed and confident in the waiting room, surveying her adopted realm like a tall queen. Crowned with long brown hair, the curls danced from her shoulders as she stooped to pick up a child’s toy, then returned it to him with a smile that would have melted an older stranger. Fifty-ish and surprisingly thin, she was dressed in loose, faded jeans, orange sneakers and a light blue designer tee shirt that said ‘Dare Me, eh?’ She was in control of all she surveyed: monarch of the room.

She stood when she saw me approaching and extended her hand before I was half way across the floor. “I’m so glad to meet you, doctor,” she said loud enough for all to hear, and squeezed my hand like she was doing an exercise in the gym. A full head taller than me, I had to look up to see her face. For a moment, I felt like that little boy whose toy she had rescued, and as I led her back down the corridor to my office I had the distinct impression that, despite her being behind me, nonetheless it was me being taken for a walk like a small dog on a leash.

She sat down on the chair opposite my desk and waited for me to settle into mine before starting the interview. That’s how it felt: she was interviewing me like a reporter hot on a story.

“I’m here,” she said without the usual preliminary pleasantries, “because of a disagreement with my family doctor…” She left her thought unfinished so she could study my face for its reaction, and when she saw nothing but curiosity written on it, continued. “She seemed to feel that my worries about hormone replacement therapies were unfounded.”

She immediately folded her arms across her chest to -as her tee shirt invited me to do- dare her to defend herself. I wondered if she’d chosen it specifically for the visit. I smiled to diffuse her arms, but her body had hardened into place; everything remained on guard, and her eyes perched on her face like a pair of eagles watching me from their aerie in a tree.

I thought I’d keep it simple. Basic. “She felt you needed hormones?” A regal, no-nonsense nod. “And why was that?”

“Hot flushes.”

I duly typed this on my laptop, although I sensed it might be only the tip of a rather unpredictable iceburg. So I waited.

I could sense she was testing me, and the eagles shifted impatiently on their branches. “I don’t need hormones, doctor. I was just going in for my pap smear and she asked me about hot flushes.” A smile passed across her face like a shadow crossing a stage. “I think she just wanted to compare notes with me…”

I tried to concentrate on her mouth, her eyebrows, hair –anything but those unnerving eyes that seemed constantly on the verge of attack. “So you’re not bothered by them?”

She shrugged, but if I hadn’t been staring at her, I might have missed it. I sat back in my chair, wondering where the thread-bare conversation was taking us.

She could see my confusion, although I had tried to hide it behind an Oslerian mask of Aequanamitas. I sometimes find it doesn’t quite cover everything, no matter how I wear it. “Look, she’s a nice woman and I think she was just trying to be kind.” She hooded the eagles and looked over my shoulder at something for a moment. “It was a girl thing, I suspect –you know, an attempt at empathy, wearing my shoes, or something.” One of my eyebrows started to move before I could rein it in and she noticed it and grinned sheepishly. “After I left her office, it dawned on me that she’s probably on hormones herself. An example of the play within the play of Hamlet: The lady doth protest too much, methinks.”

Martha was obviously not your average patient –she even put the ‘methinks’ at the end, where its supposed to be. I was impressed. “You think she was trying to convince herself that hormones were safe?” Might as well cut right to the chase.

She nodded. “I made the mistake of arguing with her and it rolled downhill from there. I shouldn’t have been so righteous, but from my reading, I felt she was mistaken.”

I could tell being a referee in a contest where one party has done extensive research on the subject, and the other was speaking to the contrary out of vested interests would not be easy. Martha had probably read more Shakespeare than me as well. I approached the issue carefully. “What did you find troubling about her opinion?”

She smiled; her trap was laid. “Well,” she started equally carefully, “for a start, the risk of phlebitis is increased by about three hundred per cent on hormone replacement therapy…”

I inclined my head slightly –it was meant to acknowledge the number, but not succumb to it. “Well, in fact the exact incidence of DVT” –I used the acronym for deep vein thrombophlebitis, to show her I had some trifling knowledge of the subject- “is unknown because of the inaccuracy of clinical diagnosis, but if you want to look at another way, its incidence is up to six hundred per cent higher in the first year of use…”

Her smile broadened –she’d been validated. She had been right to worry.

“But,” I added when her smile looked as if it was going to split her face in two, “Six hundred per cent of what?” I let it sink in; I didn’t expect an answer.

“Well, six hundred per cent higher than in non-users…” Her eyes were hunters again –hawks this time, I think. The tone of her voice said that it was obvious. “Six hundred per cent higher, doctor! Six hundred…”

I briefly flirted with some sort of aerial fight, our eyes meeting each other somewhere over the desk in a dominance combat . But I’m not like that. “So, six hundred per cent higher than in non-users in the first year? Otherwise, -what did you quote, three hundred per cent higher?- after the first year of use, I guess you mean?” She nodded impatiently, as if she was being patronized. “And the rate in non-users?”

This time I did expect and answer… Or did I? Three times anything seems like an awful lot more. And six times…? She shrugged as if it were not that important. The relative increase was what mattered. “Well, given that I said that the exact incidence was hard to determine, the figure in many studies has been estimated at around 80 cases…” -I stretched it out for effect- “ 80 cases per 100,000 people. Give or take.” I paused for a moment again. “So, even six times that is –what?- 480 people per one hundred thousand. That’s…uhmm… 0.48 cases per hundred people per year?” It sounded about right… But I have trouble with decimals sometimes.

“Whether I’ve got the numbers exactly right is not the issue, really. The point is more that six times very little, is still very little.”

I could see her mulling it over in her head; doubt lingered on her face, but at least she’d put the hawks away for the day. “An interesting way of looking at it, I have to say… but certainly not intuitive at all, is it?”

I allowed myself a smile that I hoped was non patronizing. “Probability –statistics- is not very intuitive.” Her face stayed neutral. “If I told you I had a way of increasing your chances of winning the lottery by 100% would you be interested?” She nodded, as I knew she would. “It’s simple, really…” She rolled her eyes –no eagles there anymore. “Just buy two tickets.”

She sat back, but I couldn’t tell from her expression whether or not I’d convinced her –or even held her interest. “So tell me, doctor, if I were your sister, would you suggest I go on hormone replacement?”

I sighed; she’d asked for honesty, not medical rhetoric. I locked eyes with her. “If you were my sister?” She nodded –earnestly, I think. “No.”

She seemed surprised after my attempt at explaining probability and risk. “Why not?”

“You’d argue with me every time we met…”