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!”’

Consequences: the Smacking Laws

Ahhh, spanking, the dreaded consequence of miscreance meted out in retrospective fairness by loving parents anxious to create an appropriate conscience in their child. Anxious to establish that there are consequences to behaviour that have not gone unnoticed. Will not go unnoticed. It is one end of a spectrum running between reward and dissuasion all in the name of, well, persuasion. Encouragement. Manipulation.

But words matter, don’t they? Depending on how I wished to portray it, I could easily have used more pejorative words, punitive, violent words such as, oh, coercion, intimidation, threats, or even assault. The devil is in the words. The message. The intent.

So it was with much curiosity that I was drawn to a BBC article on the Irish Smacking law that seems to have drawn the ire of the European Committee of Social Rights. http://www.bbc.com/news/world-europe-32887584 Well, in truth, it was a complaint from the UK’s own Association for the Protection of All Children in 2013 that launched it all. As the article points out: ‘Corporal punishment was banned in Irish schools in 1982 and, by 1996, it was a criminal offence to hit schoolchildren.’ but it apparently still allowed ‘reasonable chastisement’. So in a recent decision, ‘the European Committee of Social Rights said none of the Irish legislation referred to it expressly banned “all forms of corporal punishment of children that is likely to affect their physical integrity, dignity, development or psychological well-being”.’ As a result, the ‘Irish Minister for Children James Reilly told the state broadcaster, RTÉ, that ‘his department has started talks with the Department of Justice and Equality on removing the defence of reasonable chastisement from Irish law.

Well, that’s that, I suppose -another spoke in the wheel of human rights; another barrier to violent punishment… But hold on a moment. What just happened here? The UK association maintained that ‘[…] the existence, under Irish Common Law, of the defence of reasonable chastisement “allows parents and some other adults to assault children with impunity“.’ Fair enough criticism, perhaps. But failing the ability to spank, what are the other options that remain? Well, said the Minister, ‘in recent years, most parents have used other ways of disciplining their children’, but ‘he said he wanted to see the options available on abolishing the reasonable chastisement defence before considering any new legislation to ban parental smacking. The minister added that he has instructed his officials to prepare regulations that would explicitly ban corporal punishment of children in foster homes or in the care of the state.

Uhmmm. I think he should be worried about the content of the European denunciation that proscribed –as quoted above- punishment of children (in this case corporal) likely to affect their physical integrity, dignity, development or psychological well-being. So, is verbal abuse acceptable as an alternative to physical punishment? How about withdrawal of love or affection… or proper care? Would none of these affect development or psychological well-being?

I suppose there is always the option of ignoring the misbehaviour. But if the behaviour was a cry for help –a cry for attention- then looking the other way doesn’t seem appropriate, nor likely to change the behaviour. Nor would it, either, if it is a naïve attempt to find boundaries –or for that matter to have them delineated more clearly. More forcefully.

Transgression is fraught with penalties; order is sewn together by laws and consequences. I would be the last one to condone violence to a child –or anyone else, for that matter- but I am honestly at a loss to know how to deal effectively with recalcitrance. I am, to be sure, of an other era when the mere threat of retribution –spanking, or the ‘strap’- was enough to deter behaviour. So was withdrawal of privileges, I suppose -but that engineered manipulation rather than change: either ransoming the privilege, or misbehaving anyway as in Macbeth’s ‘Lay on, Macduff, and damned be him who first cries, “Hold, enough!” as he defies Macduff when Birnam Wood comes to Dunsinane.

Anyway, I’m not sure how one would police spanking. Physical violence, yes: bruises, fractures -or worse- on visits to the doctor’s office or the emergency department. But it would certainly be even more difficult to uncover –let alone gather enough evidence to prosecute- non physical violence, though. So, I wonder whether it is a terrible thing to retain ‘reasonable chastisement’ as a more benign response than what is left: a letting off of steam to prevent the otherwise impending explosion.

I don’t know that it is punishment that I condone, however –I think it is rather the consequences that should follow the act that would otherwise be disciplined. I would prefer to let my own opinion lie fallow while the dust settles on the Irish thing, and merely quote George Bernard Shaw’s observation of the wages of deceit: ‘The liar’s punishment is not in the least that he is not believed, but that he cannot believe anyone else.’ Consequences!