Frailty -Thy Name is Woman?

There seems to be no end in the struggle to differentiate men from women. You’d have thought that by now, we would have settled the boundary disputes, agreed on who owns what, and set up market stalls on anything remaining. It’s all shared territory anyway. Of course, maybe that’s naive. Maybe there are fundamental discrepancies that admit to only superficial comparisons. Relativities…We are, when all is said and done, different from each other not in terms of value, or worth, or intelligence -or anything like that- but physiologically. And there’s the wonder.

That we complement each other seems so adaptive, so perfect… And yet, do others that interact with us -microorganisms, for example- see it the same way? Are infections as unbiased, fair and equal as we are striving for in our societal evolution? Human laws be damned -do they see us as the same, or do their rules change depending on our sex? Do they discriminate?

We’ve all sniggered about the unequal fury of ‘man colds’ and the like, but whatever evidence supported or rejected this contention has always been subject to the confirmation bias of those studying it. An article in the BBC News seems to have uncovered yet another layer of the Matryoshka doll: http://www.bbc.com/news/health-38304071

They have reported on a 2016 article in Nature Communications by Ubeda and Jansen which suggests that ‘Viruses can evolve to become more aggressive in men than in women’. This has usually been attributed to hormonal differences, and the effects these might have on the immune response, and no doubt this does play an important role. But suppose one were to examine this from a different perspective?

‘Viruses have ways of spreading that are unique to women – such as to a child in the womb, during birth or breastfeeding.’ From the invading organism’s point of view, this is important. ‘Scientists at Royal Holloway University in London used mathematics to model whether this altered the way viruses behaved. Their findings suggest there may be an advantage to infections being less aggressive in women as reducing the risk of killing the mother increases the chance of infecting the child.’

They’re not meaning to suggest some form of microbial intelligence of course -other than that those who happen upon a better way to survive and more successfully propagate their kind will be able to continue passing on their genes. ‘”Viruses may be evolving to be less dangerous to women, looking to preserve the female population, the virus wants to be passed from mother to child, either through breastfeeding, or just through giving birth.”’ The Selfish Gene kind of thing -survival of the most adaptive.

All this is very interesting, but for me, it also raises the question of the nature of intelligence, and whether we have truly cornered the market. Without becoming unduly tautologically entangled, how should we define intelligence -and therefore decide who, or what, possesses it?

I suspect it is no longer sufficient to equate mentality (to use an obviously autological word) with brain size, and neuronal density… Or maybe even neurons –trees, for example, have interconnecting root systems, often associated with fungal networks, that are able to communicate after a fashion. Trees and plants are also often able to signal to each other about threatening insect infestations, allowing the production of defensive chemicals. But they live in a different Magisterium almost -they cannot run or hide, so another mechanism was required for survival in an ever-changing environment.

Humans, with our recently evolved Weltanschauung, tend to frame the capacity of other organisms in terms of our own, and their intelligence by what we judge they have accomplished in their own environment. The fact that they have been successful at survival has often been seen as irrelevant to the discussion. Whether an organism can reason –if we can ever peel away the inbuilt hubris implied by the word- is surely another way of saying, ‘learns from its mistakes and adapts appropriately’ -even if that is only in terms of the next generation enabled by the survivor. We have adjusted in our fashion, and they in theirs.

Still, I don’t mean to attribute our characteristics to microorganisms who could care less what we think. Sometimes, it is enough to survive and create the next generation; sometimes adaptation-whether over time and generations, or in one lifetime- can be seen as a goal achieved. So, is it too much to believe that there may be an effective strategy that is gender-modifiable? And is it too much to call it a strategy? Is this such stuff as dreams are made on…?

However much we hesitate to anthropomorphize an issue, a change of perspective is often heuristic. It may well lead to a new understanding and hence a novel approach to a hitherto unsolvable problem. Although this is purely speculative at this stage, the researchers in that article suggest ‘that eventually it may be possible to use drugs to trick viruses into thinking they were infecting women in order to make them less aggressive.’

What an exciting prospect that we may no longer feel a need to completely ignore gender in our dealings with the world -that we may finally be able to shed the guilt of being unable to meld the two into a seamless fabric, and feel embarrassed that, like a poorly executed pentimento, traces of the discrepancy continue to persist.

Recognition and concession of difference does not imply censure or stigmatization -rather, it invites a celebration of the unique patterns each can offer. A realization that a recipe with only one ingredient is uninteresting and bland. And, given the conjecture in the Nature and Communication paper, it’s an awareness of something suspected since antiquity: that our remedies oft in ourselves do lie.

Sometimes, like Robert Frost we just have to take the road not taken:

I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.

How Ethical is Ethical Compromise?

What to do with a minefield? Once it is there, is it sufficient to avoid it while we investigate and map it –mark it off as terra incognita- or must we act immediately to attempt to remove all mines even if we do not fully understand their distribution or destructive capabilities? Even if we may miss some and our initial enthusiasm was deemed naïve?

This is an admittedly inadequate metaphor when applied to ethics, to be sure, but in many ways is illustrative of the pitfalls of being too quick to judge; or, alternatively, of assuming there is only one approach –and that the one chosen is perforce the correct and appropriate one.

Unfortunately, majority opinion often quietly assumes the mantle of indisputability in a culture, no matter its importance or suitability elsewhere. And even to question the legitimacy of the assertion is to question the legitimacy of the social norms to which its members unconsciously adhere. It may not necessarily intend to negate them, or overtly dispute them, but by subjecting them to investigation, it may seem to disparage their sanctity.

It is difficult to step out of our societally condoned patterns of thought and our long-hallowed mores; it is troubling to observe customs that seem to violate what to us are ingrained standards of morality. It is difficult indeed, to accept that we may not be in sole possession of moral rectitude –that there may be alternate truths, alternate moralities, even alternate equally valid perspectives.

I raise this with regard to the increasing awareness and condemnation of female genital mutilation (FGM). To be clear from the start, I do not condone FGM nor feel that it should be perpetuated; indeed I have to confess that I have great difficulty viewing it as anything other than a culturally-imposed abomination -misogyny writ large. I was, however, intrigued by a paper published in the Journal of Medical Ethics that sought to assess the issue in a more critically constructive fashion than I have seen before: http://jme.bmj.com/content/early/2016/02/21/medethics-2014-102375.full  It is really a very thoughtful and enlightening paper and I would strongly suggest that it is worth reading –if only to learn more about FGM and its cultural significance stripped of any pre-loaded societal baggage.

I was impressed by several things in fact. They sought to classify the procedures in terms of degree, medical issues, the ethical underpinnings of FGM, cultural sensitivity, and whether or not any form of the procedure would constitute gender discrimination or the violation of human rights. I will let the reader judge how thoroughly these fields were covered, but caution against our usually self-imposed wall of confirmation-bias that often precludes a dispassionate consideration of views that don’t fully accord with what we ‘know’ to be the correct ones… http://www.cbc.ca/news/health/female-genital-mutilation-legal-1.3459379 -this brief article from the CBC is perhaps a more assimilable and balanced –albeit nuanced- summary of the arguments.

I suppose the issue is not so much whether the practice should ever be acceptable –although neonatal male circumcision seems to have made it through the gate- as whether by outlawing it, the procedure will be driven underground as seems to be happening currently. If it is so important to a culture –whether justified by mores, or religion- that there seems to be an imperative to have it performed to allow an individual’s acceptability to be confirmed in the community, then wouldn’t it be better to acknowledge this, but mitigate the harm?

The authors have attempted a classification of FGM into 5 categories, the first two of which are thought to have minimal if any permanent effects on the girl -no effects on sexual pleasure, functioning, or reproduction. And, of course, if accepted, could be done under an anaesthetic, rather than by test of courage. Its acceptance could serve to assuage the cultural imperatives while essentially eliminating the greater severity and mutilating effects of the more complicated forms of the practice. It would be an intermediate –and hopefully temporary- step on the road to complete elimination of the procedure.

To be sure, the objection raised is often the one of argumentum ad temperantiam –the fallacy of assuming that the truth –the resolution- can be found in the middle ground between the two conflicting opinions. The problem, of course, lies in the validity of the opposing claims. Should one really be looking for the middle ground between information and mis (or dis) information? Sometimes the distinction is easy, but sometimes it is the minefield I discussed above. Primum non nocere –first of all do no harm- is the guide. As the authors state: ‘… analysis of issues in medical ethics generally regards principles as being prima facie in nature, rather than absolute. Therefore, important emotional and social considerations can trump minor medical considerations.’ In fact, because of the extreme and negative connotations of the term female genital mutilation, the authors even propose an alternative, less pejorative name: FGA (female genital alteration).

Without trying to push the concept and its acceptance too strongly, let me quote the summary of their intent: ‘Since progress in reducing FGA procedures has been limited in states where they are endemic and the commitment of people from these cultures to these procedures has led to their persistence [even in] in states where they are legally discouraged, alternative approaches should be considered. To accommodate cultural beliefs while protecting the physical health of girls, we propose a compromise solution in which liberal states would legally permit de minimis [a level of risk too small to be of concern] FGA in recognition of its fulfilment of cultural and religious obligations, but would proscribe those forms of FGA that are dangerous or that produce significant sexual or reproductive dysfunction.’

Compromises are always difficult; no one gets all they want, and yet each gets something. I raise the issue of female genital mutilation/alteration mainly for information but also for discussion. Sometimes, we need to know something about what we oppose. Always, in fact…

Statistics and Gender

Statistics, the collation, analysis and ultimately, the interpretation of data, have never been easy – at least for me. They have never reached the level of intuitive and, indeed, have barely climbed past manipulative in my head. And I readily admit to occasional cognitive dissonance even when they are used to support what I already believe. Or, rather, want to believe… I wonder if the sources from which I have accessed the numbers might be those that already pander to my own biases. In the cloud of assertions that cover me, everything is obscure and up for grabs.

I suppose it’s like that for us all, though –we hear what seems important to us and sift clumsily through the rest, filing most of it somewhere else, if at all. Especially if what has been measured is not crystal clear –or at least what has been reported is not. A classic example was that of a survey of shared parental leave in the UK. It was initially reported that only 1% of men were opting for this –much less than the rest of Europe. In fact, however, the figure reported was 1% of all men, not 1% of men who had just had a baby.

We have to examine what we read before we arrive at our conclusions; most of us don’t. Most of us have neither the interest, nor the tools to know if what is presented to us is reasonable, or at least free of bias – especially our own confirmation biases. A lot slips through the net.

A good example of this are the statistics on women and girls: http://www.bbc.com/news/magazine-36314061

‘There is a black hole in our knowledge of women and girls around the world. They are often missing from official statistics, and areas of their lives are ignored completely.’ For example, a record of their participation in the labour force in various countries. The data are often biased towards employment in the formal sector, which in those countries, is where men work. ‘Buvinic [an expert from the Center for Global Development, a think tank] argues that many women get missed out because they consider themselves primarily as housewives, when in reality they work on farms, do part-time jobs and seasonal work or run their own businesses.’

‘There are other problems too, Buvinic says. Not all countries collect statistics on other aspects of women’s lives, such as domestic violence or maternal mortality rates, and when they do collect this data they often do it in different ways, making international comparisons difficult.’ And, ‘There are many statistics that are collected without being broken down by sex, which makes it hard to tell when women are not being treated equally.’ For example, “Until recently, very few banks disaggregated their customer data by sex, leading to difficulties in understanding reasons behind the persistent gender gap in access to and use of financial services,” says Megan O’Donnell, one of Buvinic’s colleagues at the Center for Global Development.’

That I find all of this surprising speaks to my naïveté, I suppose, and yet I have my doubts that many of us would take the time from our busy lives to consider what this neglect might mean. David McNair – Director of Transparency at the One Campaign, a group that fights poverty- even uses the weighted ‘sexist’ epithet and summarizes the problem succinctly: “The reason why it is sexist is that women and girls are disproportionately left out of data collection. They are uncounted, therefore they don’t matter.”

Roughly half the population on the planet doesn’t matter? And it’s the half that has gestated and succoured that other half -the only half that is counted? Even if I try my best not to be an historical revisionist, it does not make sense to me.  Perhaps McNair, again, had the best explanation: “If you have robust data then you can be held to account for your decisions. There are people who have a vested interest in not having that information in the public domain.”

But I suppose we have to look for any encouraging little cracks in the imposing male edifice: ‘Recently the UN’s International Labour Organisation (or ILO) held a conference, where labour statisticians agreed how to start collecting data on unpaid and domestic work, for example time spent cleaning your house. Ten countries have volunteered to take part in a pilot to use this new framework to measure unpaid work.’

Whoa, ten countries have decided to put their toes in the water…? Or rather, their statisticians in the water? How brave. Maybe Macbeth was on to something when he said that ‘tomorrow creeps in this petty pace from day to day.’ It’s the end of his soliloquy that has me worried though: ‘It is a tale told by an idiot, full of sound and fury, signifying nothing.’

Oh, I hope not…

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Probiosis

Bacteria, by and large, have received a bum rap (pardon the pun). Ever since they were discovered, there was a sense they were up to no good. Why were they always hanging around sick people, it was asked? And why did foul smelling things –the miasma (you gotta love these words)- always have bacteria skulking about in the background? There must have been some reason why -since the beginning of time, we have instinctively avoided rotting meat or putrescent items… Could it be the bacteria?

Of course, this eventually caused people –okay, Scientists– to wonder why our intestines are full of these malevolent creatures –and therefore why we weren’t all dead, or at least always ill on their account. The further paradox was when it became murkily clear that if this same intestinal effluvium were mixed with drinking water, we would be –very ill, that is.

So, how can you have your cake and eat it, too? Could it be that there was some sort of balance of good guys and bad guys in our guts that kind of neutralized each other in there? And maybe the balance wasn’t the same in the water near the sewage pipe?

And for that matter, because there were so many of them inside us, maybe it was for a reason? Even thinking like that seemed anathema to doctors –and companies- who had made their fortunes out of fighting them. And then, slowly, as the moon slipped quietly behind some clouds on the horizon, came the dawn. The paradigm shifted and it became acceptable to speculate that at least some bacteria might be on our side in Tennyson’s ‘Nature, red in tooth and claw’. Helpful bacteria living in secret bowel-caves, like traitors imbedded behind the enemy lines, were diligently hunted. And myriad uses were ascribed to their families. I even wrote about this a couple of years ago:

https://musingsonwomenshealth.wordpress.com/2014/05/15/the-human-microbiome/

So it was only a matter of time until those who had hitherto persecuted all microbes, were persuaded to alliances -marriages of mutual convenience. Helpers of helpers were proffered: probiotics.

Probiotic –even the word has come to inspire hope. And its etymology: pro –on behalf of- and bios –life, nails it, don’t you think? I’ve touched on the subject before in my essays, as well:

https://musingsonwomenshealth.wordpress.com/2015/09/27/miasmatics/

But I’m not trying to reinvent the wheel here, nor seduce you into re-reading my old essays. I am, however, still interested in the subject and was therefore somewhat disappointed in an article in the BBC News that seemed, at first, to denigrate the concept of probiosis: https://www.theguardian.com/science/2016/may/10/probiotic-goods-a-waste-of-money-for-healthy-adults-research-suggests There is a link in the article to the original meta-analysis paper in Genome Medicine.

I suppose it captured my attention the way any attack on my Confirmation Bias might: once I have been converted to a point of view, I take umbrage at any attempts to desecrate it… No, actually, that’s not true –I pay attention to the detail of the contention and see whether it could be refuted -what Carl Popper believed must be an essential component of all good Science.

This paper –a review of seven randomized, controlled trials (admittedly small numbers in each) of probiotics in healthy adults- concluded that there was ‘a lack of evidence for an impact of probiotics on fecal microbiota composition in healthy adults’. Fair enough, but contrary to the headline that might have attracted people to the article (Probiotic Goods a ‘waste of money’ for healthy adults, research suggests), buried near the end of the piece is the admission that ‘the real impact of the probiotics may have been masked by small sample sizes and the use of different strains of bacteria and variations in participants’ diets, among other factors’.

And the author of the Danish study, Oluf Pedersen, admitted: ‘“To explore the potential of probiotics to contribute to disease prevention in healthy people there is a major need for much larger, carefully designed and carefully conducted clinical trials.

“These should include ideal composition and dosage of known and newly developed probiotics combined with specified dietary advice, optimal trial duration and relevant monitoring of host health status.”’

So I think the final word on probiotics is still to come. It would make sense that one might not notice much of a change in fecal microbiota composition in those who are healthy and presumably already in possession of what Goldilocks described as ‘Just right baby bear’ stuff. But whether it could be further improved is the point at issue. There seems to be some evidence that it can be improved in those who need improvement –but at this stage, even that claim is contentious.

But it’s early yet, and as Robert Frost observed when he stopped by woods on a snowy evening: The woods are lovely, dark and deep, But I have promises to keep, And miles to go before I sleep… And so do we.

 

 

 

Prove it!

If there’s one thing that a long life has taught me, it is that most of us seldom stray far from the path. Once launched, our trajectory is largely predictable. I suppose this is necessary for co-existence –that there are societal norms is, after all, what binds us together as a group. Knowing what people want –what they are comfortable with- makes it possible to plan ahead with a reasonable expectation of success.

And yet, what if circumstances change? Even Science admits it runs on statistical probabilities. Nothing is forever the same, despite our expectations; despite the hopes of even the most enlightened that it will not deviate too much from that to which we have become accustomed. But progress depends on change, depends at least on altered perspective. That someone can look at the same data and interpret it differently –see different patterns in it, perhaps, or even apply it to something entirely different- is what we have come to expect of our modern world.

But there is often an inter regnum, that can be confusing -a time before the paradigm shift is complete; when wisdom, -no, expectations– demand that we judge the results of whatever investigations we have done, in the light of what the past, or experience, has taught us. And as a consequence, not only do we limit our inquiries to those things that seem to prop up those views, but we discard, or criticize data that fail to validate them. Same information, different eyes. It’s often called the Confirmation Bias and I’ve written about this in one form or another before: https://musingsonwomenshealth.com/2015/05/15/the-polarization-bias/

The problem is that it seems to be a Mobius strip, and the same data are used to prove opposite contentions. There are rules that can be applied, of course –methodologies that help to sort out interpretive biases:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126323/  but it’s all too easy to fall back on what seems natural to us: to assume that what has been found either substantiates what we believe it should, or to criticize it for its presumed deficiencies or mistakes if it does not.

There seems to be no end to the variations on that all too familiar theme. It’s certainly not unknown in Medicine, and a recent example springs to mind.

I remember Jerra -partly because of her unusual name, I suppose. When I saw it on the office day sheet, I assumed it was a typo and thought I would correct it as I introduced myself to her in the waiting room. She was the first patient booked for the day and none of the few other early-risers in the room looked anywhere near 62.

“Jerri,” I said with a smile, walking directly over to a thin, grey-haired woman sitting bolt upright in the only chair by the window. Her first reaction was to assess me from head to toe with hostile green eyes that, had they not been restrained, might have attacked me as I approached.

“It’s Jerra,” she said, ice congealing on the words as they approached my ears.

I blushed. “I’m sorry, Jerra,” I stammered, embarrassed at my rash decision to modify it.

“And it’s Mrs. Tandill…” she added haughtily, refusing –or perhaps not deigning– to shake my extended hand.

The waiting room went quiet, all eyes on us, as she followed me reluctantly across what now seemed a long hike over the floor and down the corridor to my office.

Once inside, she glanced quickly at the sculptures, and plants, and repositioned the chair further from my desk. She did not want to be here, and was letting me know in the bluntest possible way.

“You seem uncomfortable, Mrs. Tandill,” I said when she seemed settled in her seat. “I’m sorry we got off to a rather rough start…”

“So am I, doctor,” she said, still glancing around disapprovingly at the art work hanging on the walls. “I am only here at the behest of my GP, you understand.”

I smiled, hoping to diffuse the tension, but her face didn’t change. She was an attractive, if severe looking woman. Dressed in a loose black silk dress that brushed the tops of her shoes when she walked, tiny silver hoops in her ears, and a matching silver brocaded scarf that hid her neck, she carried herself like royalty. Even her short, greying hair sat regally on her head like a tight-fitting crown, not a curl out of place.

And me? I was still dressed in my OR scrubs –albeit freshly changed- after an unscheduled 8 AM Caesarian section that made me late for the office. The stark contrast with her apparel and the thwarted expectations of how a new specialist should present himself may have stoked her anxiety with the visit.

“My GP says I need a hysterectomy,” she said, suddenly glaring at me like a vexed mother with her child.

I checked the very thorough history her GP had sent with the consultation note. Jerra had presented to her with postmenopausal bleeding, years after her periods had finished. She had sent her for an ultrasound which had confirmed that there was a thickened lining in the uterine cavity, and had even done a biopsy of the tissue. The pathology report of the biopsy did not find cancer, but rather an overgrowth –hyperplasia- that can be a precursor to cancer.

Jerra was still staring at me when I looked up from the computer screen. “Dr. Hannah gave me a copy of the pathology report, doctor,” she said, sternly. “And I researched it further.”

“And what did you find, Mrs. Tandill?” I needed to know what she had read before I could put the results into some sort of context for her.

Her body seemed to relax at being given an opportunity to discuss it, but I could see her face was still wary. On guard. “First of all, that there are several types of hyperplasia” –she pronounced the word very carefully- “… and that some types are further along the spectrum towards cancer.”

I nodded slowly, not wanting to challenge her interpretations unless warranted.

“The type that seems most predictive of cancer, is the abnormal hyperplasia…”

Atypical,” I interjected, just so she’d know I was listening carefully, I suppose.

She managed a rigid, if fleeting smile. “Atypical. Thank you.” She referred to some notes she’d folded into her purse. “That word was not mentioned in the report, and I even showed it to a friend of mine -who is a nurse- and she agreed.” When I didn’t object, she lashed out at her GP. “I’ve been going to Dr. Hannah for several years now, and I usually trust her judgement, but I think she’s made a mistake here… I’ve never been on hormones,” she added as a kind of preemptive rebuttal of an accusation she expected to hear. “She says the biopsy may have missed a more… atypical area and so to be safe, I should have my uterus removed. You doctors always seem to want to remove things.” She settled back in her chair having made her case, and prepared to fend off the denial.

I took a deep breath while I decided how to approach the problem. I agreed with the concerns of her GP -at her age, there shouldn’t be much of a lining in the uterus at all, let alone one that was sufficiently thick to bleed. Something must have caused the hyperplasia. And yet, I could also understand Jerra’s anxiety. “I suppose our problem in cases like this is one of certainty, isn’t it? On the one hand, the pathology results as they stand could explain the bleeding and the ultrasound, but not with complete certainty. There could be some even more abnormal tissue hiding in a corner of the uterus that was not sampled with the endometrial biopsy…” I’m sure her GP had already gone over this with her, but it needed to be repeated. “And if that were the case, and we left the abnormal cells in place, we might all regret the decision later.”

She sat straight up in her chair shaking her head the whole time I was speaking. “Dr. Hannah kept saying the same things, doctor.” She sighed and stirred restlessly on the chair. I could see her clasping and unclasping her hands on her lap. “Let me be clear -as far as the pathology report is concerned, there is no cancer. I have…” she referred to a copy of the report in the bundle of papers again carefully folded in her purse. “… I have ‘simple hyperplasia’ –which, as I understand it, is far removed from the cancer end of the spectrum. I find it reassuring, and I fail to understand why you do not.” At this point she actually crossed her arms tightly across her chest and nailed me to my chair with an angry glare. “You’re looking at the same data as I am, and yet you are interpreting it totally differently,” she added, as if she were paraphrasing something she’d read online.

I smiled, again, but it did nothing to diffuse those eyes that searched for a permanent foothold on my face. “I suppose I’m just being careful, Mrs. Tandill. Experience teaches me that…”

Medical schools teach you, doctor!” she interrupted angrily. “Mentors that have been through the same system instruct you how to think about these things.”

I sighed, and I’m afraid I was not very successful at disguising it from her. “Have you had any more bleeding –since the biopsy, I mean?” She shook her head dismissively, and I sat back a little on my chair, all too aware I had also been revealing my discomfort at her anger. “Would you feel better if I did another biopsy…? To confirm the first one?” I added this in hopes of walking the middle road between her wishful thinking that the biopsy was indeed reassuring, and at least not denying the possibility that it may have missed something worse.

At that point she got to her feet, still scratching at my cheeks with her eyes. “No, I would not feel better! You would probably continue to recommend biopsies until you found the result you anticipate, doctor, and I will simply not play that game with you.”

And with an angry shake of her head she turned and walked out the door.

But maybe she was on the right track; maybe compromise -the middle ground- only re-routes the problem and detracts from whatever the data purport to demonstrate. No matter the number of repetitions, an interpretation of the results is still required. And if the data warrant it, a stand on one side or the other must be taken and we must live with the consequences. I think there comes a time when we must disagree with Macbeth when he says to MacDuff ‘Damned be him that first cries, “Hold, enough!”’

The Most Unkindest Cut of All

It was the best of times, it was the worst of times

I’m a surgeon, so for me, the operating room has always been a haven of sorts. It’s one of the few places where I feel safe from interference from out there. Where, for a brief but immeasurable time, there is no outside –no politics, no traffic jams, no rainy days- just the task at hand. It is a magic place where we all work as a team –all interdependent, all focussed on our mission, all oblivious to anything else. A world unto itself, it exists briefly -like Brigadoon- then vanishes as suddenly leaving only remnants glimpsed through a door: soiled sheets being secreted away into plastic bags, or paper drapes being crumpled into even noisier containers by relative strangers -a different team- busy with wiping and washing… And then the room is empty, barren of meaning –its sacred purpose subdued by the evanescently profane. A sanctuary no more.

I say ‘no more’, but that is hyperbole because it always begins again: samsara. It is an organism that cannot be fully assessed from outside the doors. In the room it is measured in the steady pulse of a beating heart, the razor thin stroke of a piece of steel, the strength and tightness of a length of string.

There are, of course, distractions inside, but they are like traffic noises in the night and soon forgotten, hidden in blood or quickly acclimatized as more urgent problems –often unexpected- surface in the morass of organs vying for attention. It is a stormy sea, the opened body, and to navigate requires immersion in the troubled waters.

But absorption, however deep, demands surfacing from time to time to take stock, to breathe deeply –to assess and plan. And it is then, when the spirit needs whatever succour it can find, when distractions finally disturb -bewilder. It is then when the team finds solace in music.

Ay, and there’s the rub. http://www.bbc.com/news/health-33771022

There are as many tastes in music and what soothes, as there are people in the room -as there are people in the world, probably. So what knits up the raveled sleave of care for one, is definitely not the nourisher of life’s feast for another (Sorry, Macbeth). The article I’ve linked is from the BBC News and suggests that music in the operating room may be counterproductive.

But it is more of a ‘Just right, baby bear’ story I think -obvious stuff that seems almost too obvious to study: if the music is too loud, people can’t communicate with each other; dance music with drums or whatever, definitely distract, although they didn’t elaborate. But the BBC report partially retracted the condemnation towards the end of the article and suggested a compromise approach that fits more closely with my own Confirmation Bias: a link to a 2011 study reported in The Journal of Anaesthesiology and Clinical Pharmacology: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161461/ This was a prospective, questionnaire-based cross-sectional study -a survey- that tried to pin down elements of music that might be acceptable both to those who were standing or sitting in the operating room as well as the silent one who wasn’t.

For example, ‘…62% thought that music helped in reducing anxiety of patients before anesthesia’ – or to completely obfuscate the observation and clothe it in scientific attire: ‘According to the gate control theory which is based on the fact that pain is an integrated sensory, affective, motivational system that modulates noxious input and attenuates the perception of nociceptive inputs, it has been suggested that pain and auditory pathways inhibit each other. Perhaps the activation of auditory pathway by music during surgery inhibited the central transmission of nociceptive stimuli.’

And also: ‘Our study revealed that 59% of the respondents thought that music helped in reducing their autonomic reactivity in stressful surgeries thus calming them down and allowing them to approach their surgeries in a more thoughtful and relaxed manner.’

It goes on to suggest (with references) that: ‘Music has been used to achieve a wide range of outcomes not only in the hospital, but also in the community and residential care settings. It minimised anxiety levels of patients during hospitalisation and during unpleasant or invasive procedures. It helped people relax. Its effect has been measured in terms of its impact on the person’s heart rate, blood pressure and respiratory rate. It reduced the severity of pain and the need for analgesia in people with acute or chronic pain. It was found to improve cognitive function in terms of behavior, eating and minimised the need for physical restraint for people with dementia. The effect of noisy environment produced by medical equipments in OTs [Operating Theatres- or ORs] and critical care units on patients was also found to be minimal, when music was played in such settings. Patients and hospital visitors were more satisfied with the care provided. It improved mood and feeling of well being for a range of different patient groups. It enhances tolerance level of people to unpleasant or invasive procedures, such as insertion of intravascular lines, surgical interventions, burns dressings and chemotherapy.’

Then there was an attempt to prescribe tempo: ‘Tempo of music around 60-80 beats per minute was found to be the best for creating relaxation. A higher tempo acted like a “driving input”, which resulted in increased heart rate, blood pressure and respiratory rate.’ So, since I prefer the classical music I usually bring to be played in the OR, this meets with my approval, and as long as the team doesn’t nod off during the more lugubrious passages I think I satisfy those criteria.

But of course, volume is the elephant in the room. As the authors of the study put it: ‘The volume of the music played also had a tremendous effect on the mood of the OT staff. Of the total study population 59% of the respondents preferred medium volume while 41% preferred low volume of music in the OT. It was evident that the staff would not let music compromise or interfere with the technical aspects of patient care or competence.’

Although I think it’s hard to turn a symphony up too loud in an OR, I’ve found that violin or even -dare I admit it- piano passages tend to elicit angry, but accidental, elbows in my ribs if played other than sotto voce. I tried out opera once as well, only to discover that the musical device I used was missing for the next case… So I hesitate to draw any firm conclusions… Except that it kept the team awake, I guess -I mean you have to be alert to plan where to hide an iPod.

But I will leave the final words to Shakespeare again –this time from Henry IV: ‘Let there be no noise made, my gentle friends; Unless some dull and favourable hand Will whisper music to my weary spirit.’ A simple request -but this time from a king. They outrank even surgeons.

Dealing with Women

“The sky is falling! The sky is falling!” cried Chicken Little running around frantically when confronted with an unexpected knock on her head. There are any number of versions of the story but all, seemingly, involving females who misinterpreted some benign event as being catastrophic. Fearful. Outside of their comfort zones. In other words, acted inappropriately given the circumstances. Worse, they acted hysterically. The message as I read it being twofold: the obvious and more polite one is that sometimes we overestimate a danger and panic; but the covert, unstated, and more troubling one, is that it never seems to be the rooster that is panicking.

It is interesting that we seldom notice this; the observation seems trivial because of the folk tale’s obvious purpose of decrying overreaction. And yet that is the point: it seems trivial because we are distracted by the message; the messenger is merely the vehicle for its dissemination: a believable advocate for jumping to unwarranted conclusions, reacting with alarm, not intellect. Bewilderment, not analysis… And looked at through this lens, I see stereotyping –undeclared, of course, and easily ignored, and yet like a persistent but faint shadow, visible when pointed out.

We still live in a barely camouflaged misogynous culture where unattractive attitudes are often left unbathed and then dressed in cleaner clothes. Things unsaid are still implied; it is a kingdom of the once-removed. The wry smile. The innuendo. Of course it’s a thin line that separates description from interpretation and I don’t wish to be accused of usurping Chicken Little as a twenty-first century Rooster Little, but I think it is becoming increasingly obvious that roles –as well as expectations- are ripe for change. The old allusions are wandering from the mark and ring hollow, even when they hit. It’s hard to understand why it has taken so long to notice -or am I, too, overreacting? Seeing things I am convinced exist -a flagrant example of Confirmation Bias? Perhaps, but every once in a while, even in quiet corners, I sense a change in attitude -and  I hope, like a row of dominoes, once one male bastion falls, the rest will follow, however slowly. However reluctantly…

And yet, it is not the weakness in the castle walls that surprises me so much as the attitude of its inhabitants. Behind those ramparts, cultural beliefs and self-serving, unquestioned suppositions, are guarded like Samson’s hair, because to modify them, even in the slightest way, courts a potential diminution of power. A waning of privilege. A loss of control. Or maybe, worst of all, a loss of quality.

Stuff and nonsense! Too long have we been satisfied with the low-hanging fruit while the tree, unconcerned with gender all along, has been offering so much more. And yet for some reason it still seems to come as a surprise that females, given the opportunity, can be the equals of males. A good example, I think, was the recent nuclear talks with Iran.

I was drawn to an article in BBC News that felt it had to point out that there was a significant and necessary role played by women in the negotiations: http://www.bbc.com/news/world-us-canada-33728879 I loved the fact that somebody noticed the role they played, but I have to confess I was a little disconcerted by the fact that it had to be pointed out at all –as if to say ‘Look what they can do if we let them…’ As if negotiations –serious negotiations, important negotiations- were the sole prerogative of men. A male-only club.

In fairness, however, I suppose there were other constraints to the active involvement of women in these particular negotiations that are obvious only on closer inspection –those of religion and the customs both it and its culture impose. For example: ‘When an agreement is struck among parties, it is standard practice to “shake on it” in order to seal the deal. But when a historic nuclear accord was reached in Vienna, Austria, on 14 July between Iran and the P5+1, the Iranian negotiators could not shake the hands of their female interlocutors due to the country’s strict religious customs.’

When compared to the historic accord that was reached, these are minor things, however. As Wendy Sherman said (‘She was one of the chief architects of the Clinton administration’s North Korea nuclear policy and had taken the lead on the US team’s nuclear talks with Iran since 2011’): “I grew up in Baltimore where there’s a large Orthodox Jewish community where the same is true, but I think we all understood how to speak to each other without shaking hands and understanding each other to the extent that we got an agreement.”

Bravo! The excuses for excluding women were always a house of cards. Let’s hope that not only do the cards fall, but to paraphrase Macbeth’s tortured description of the by-then-dead Duncan: that ‘After their life’s fitful fever they sleep well’. And this time, there should be no guilt. Only hope and celebration.

Kegel Exercises in Pregnancy

Okay, okay, I was wrong! It happens. Sometimes the brain gets in the way of scientific studies –prejudges them. Alters them in little ways so they do not conflict with its own opinions. Or, worse still, is influenced by a confirmation bias that precludes even the perusal of any information that makes it uncomfortable. The brain can be its own editor, redacting reams of otherwise useful knowledge, recusing itself inappropriately. None of us readily admit guilt in this respect, of course. In a sense, we are blind to it… or want to be.

I’m a gynaecologist as well as an obstetrician, so I have long been aware of the value of strengthening the pelvic floor muscles to prevent urinary incontinence amongst other things. There are a set of muscles –the levator ani muscles- that act as a kind of pelvic platform and help support the various organs that transit through the area, notably the bladder, uterus, and rectum. Exercising them was proposed by a Dr. Kegel in 1952, albeit to strengthen their ability to narrow the vagina and hence the ease of orgasm. I think a more frequently admitted use, is to reduce urinary incontinence, however. Indeed, to discover  the correct muscle for training, the woman need only attempt to stop her urinary stream and she has identified the correct one.

Prominent among the levator ani muscles is the pubococcygeus muscle. (The name merely describes where the muscle starts –the pubic bone, and where it ends- the coccyx, or tail-bone. On its journey, it wraps around, first the urethra –the tube that empties the bladder-  and then the vagina, and finally the rectum, like a series of hammocks). The fact that strengthening it can constrict the vaginal diameter when contracted, has always been a kind of two-edged sword for those of us who deliver babies. On the one hand, there is some fairly longstanding and convincing evidence that it can indeed help to prevent the involuntary loss of urine (urinary incontinence). But remember that it not only helps support the bladder and its opening, it is also a hammock that supports and constricts the vaginal canal. Well, that’s what the baby has to squeeze through… So, does the one benefit become a detriment to the other? Are you robbing Petra to pay Paula?

I have to admit that I was one of the exercise skeptics; it made sense to me that the stronger the muscles that surround the vagina -the greater their bulk- the narrower and more difficult the passageway for the baby to pass through at delivery. At the very least, I reasoned, it would take a greater effort on the part of the mother to force her baby through. And all this at a time when she is already exhausted from her labour. Maybe it would make more sense to work on strengthening those muscles in the weeks and months after delivery. Everything in the area was stretched or torn from the effort of actually pushing the baby’s head out, so perhaps the benefits would accrue if those muscles were strengthen then –a sort of postpartum rehabilitation.

In other words, would strong pelvic floor muscles increase complications in either labour or birth? Would there be a higher incidence of Caesarian Sections, for example? Or the need for episiotomy (cutting the skin at the opening of the vagina) to allow more room for the baby’s head to descend? Would there be a greater need for so-called operative delivery (forceps or vacuum extraction)?

Well, here’s where the information from large studies are more helpful than personal experience. Each of us carries a bias –acknowledged, or buried deep within our own reminiscences of similar situations. If I, for example, believe that the Kegel exercises are a hindrance to normal delivery, I am more likely to remember any episodes in my career where that might indeed have played a role –unaware, or maybe conveniently forgetting  (or not even asking about) times when it didn’t. Confirmation bias again. Limited, or selective, observations are not necessarily a valid reflection of the collective reality. They amount to opinions, not proof, and carry only as much weight as the prestige of the propounder allows. In my case, it was never very much…

The benefit of Kegel exercises in pregnancy remained somewhat controversial in the obstetrical community –at least amongst us iconoclasts- until some Norwegian researchers, notably Kari Bo at the Norwegian School of Sport Sciences, decided to investigate it in a large group of women (18,865 primiparous women) who practiced Kegel exercises at various frequencies per week during pregnancy. The group then looked at the outcome and complications of their labours and deliveries. http://www.ncbi.nlm.gov/pubmed/19461423 There was no difference in outcomes between those who did Kegels religiously in pregnancy, and those who did not. Presumably, the pelvic floor muscles –as strong (and bulky?) as they had become- were able to relax enough to allow normal passage of the baby.

I learned a lot from that paper –and a lot about the way my beliefs interpret my experience. A lot, too, about the way many of us travel through our lives, influenced as we are by only limited familiarity or exposure to events, and drawing perhaps unwarranted –or at least unproven- conclusions from them. And although it is inductive reasoning with all of its inherent uncertainty, deriving conclusions that are reliable and from sufficient observations can be a problem. Generalizing, in other words: probabilistic forecasting from limited available data. An example sometimes given is: all the swans I’ve ever seen have been white, so therefore it would seem reasonable to conclude that all swans must be white… until, that is I see a black swan. Obviously, any one person’s experience must be limited, so any conclusions derived from them, must also be limited.

All generalizations are false, including this one, as Mark Twain famously observed. I’m not sure I’d go that far, though. I think George Bernard Shaw was closer to what I have learned about depending on one’s own experience to the exclusion of competing views: Beware of false knowledge; it is more dangerous than ignorance.

The Polarization Bias

Okay, I have to admit to living an unbeknownst lie –unbeknownst to me, at any rate. Sometimes it is easy to coast, to accept help where it is offered and feel almost foolishly grateful for suggestions that foster the dependence. Advice is seductive, guidance addictive. But more importantly, it is insidious. Critical thinking -critical analysis- suggests that we process whatever information we are offered by considering its validity when compared with other sources, other viewpoints, other contexts. It is what we should do; it is not what we usually do. Time constraints, biases, laziness –they all conspire to let us float on the tide. Drift.

I suppose my awareness of the current may have started when I was casting about for a book to read. Like many of us, I have a passion for reading that is naively open to recommendations. The online Amazon book store is an almost limitless cornucopia of books. And when you click on one, a section appears just beneath your choice that says: Customers who viewed this item also viewed… And a list of similar books on similar subjects is just a click away: a topic-specific, yet unrequested bounty spilling onto the screen. And all with seemingly different approaches but eerily similar viewpoints to the book you’ve chosen. A coincidence? Or a recognition that you have a particular worldview whose advocates you are more likely to read? And buy.

At first, I was both pleased and amazed that Amazon could find so many different authors and topics that I found compelling and place them before me like a waiter with a dessert tray. So easy to choose from only what is offered –too easy… What I initially thought of as a diverse array of well-considered opinions, I began to realize was an artfully arrayed selection that fostered my already-held biases. A compass that always pointed north, no matter the coordinates.

I suspect that most of us, even offered the choice, would find no compelling reasons to change allegiance, or flirt with opinions we have been taught to mistrust. We feel uncomfortable accepting that the opposition feels the way it does on grounds that are equally persuasive for it. Rather than being open even to thought-provoking alternative ideas, we rust into positions that further restrict our ability to move.

But what if the news we so avidly ingest nowadays could be similarly sorted to our tastes and presented to us as a fair representation of what is really happening? How would we know of the manipulation? How could we become aware of the slanted viewpoint when it so closely agrees with our own –when it is what we want to hear? Confirmation bias is difficult to resist even at the best of times.

http://www.huffingtonpost.com/2015/05/12/facebook-study-polarization_n_7245192.html?utm_hp_ref=world&ir=World

I hadn’t realized that many people actually read those snippets on Facebook that purport to inform. I had thought most of them were not terribly well disguised ‘infomercials’, but perhaps that is my bias -the boreal plain to which I am unwittingly confined. But that our serving of news should be chosen for us according to our likes and dislikes is anathema. And that our meal of information should be expurgated and mashed into a small, more easily digestible aliquot of words smacks of propaganda. Control. Handling… I would like to digest unchewed information in my own way, thank you. I can deal with heartburn; I’m not good with starvation.

http://www.bbc.com/news/technology-32707014

The dilution of mainstream media and its as-yet relatively unfettered ability to pretend to present both sides of an argument is worrisome. Similarly, the accretion of our sources of information into a few huge monolithic blocks with their own interests to serve is dangerous. Especially when they presume to know what opinions will keep us quiet.

“Let every eye negotiate for itself and trust no agent,” says Claudio, in Shakespeare’s Much Ado About Nothing. Bravo!

Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.