Tag Archives: inductive reasoning

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Sometimes the Twain Should Meet

That we are, each of us, different is a given; that societies and the cultures they produce are different, is also self-evident. But that any one individual picked at random should be representative of that difference is another matter. We humans tend to be bicameral when and if it suits us. For example: my Asian friend is clever and devious, so most Asians are probably clever and devious (inductive reasoning); but at other times: everybody knows the French are rude, so perhaps I should not hire that French person (deductive reasoning).

How much credence can we put in either type of reasoning when it comes to judging world views of different cultures? There was an interesting article in BBC News about this a while ago: http://www.bbc.com/future/story/20170118-how-east-and-west-think-in-profoundly-different-ways  And as you can imagine, the issue is complex: ‘From the broad differences between East and West, to subtle variation between U.S. states, it is becoming increasingly clear that history, geography and culture can change how we all think, in subtle and surprising ways – right down to our visual perception. Our thinking may even have been shaped by the kinds of crops our ancestors used to farm, and a single river may mark the boundaries between two different cognitive styles.’

‘[…] our “social orientation” appears to spill over into more fundamental aspects of reasoning. People in more collectivist societies tend to be more ‘holistic’ in the way they think about problems, focusing more on the relationships and the context of the situation at hand, while people in individualistic societies tend to focus on separate elements, and to consider situations as fixed and unchanging.’

For example: ‘An eye-tracking study by Richard Nisbett at the University of Michigan found that participants from East Asia tend to spend more time looking around the background of an image – working out the context – whereas people in America tended to spend more time concentrating on the main focus of the picture.’ So, ‘[…] this narrow or diverse focus directly determines what we remember of a scene at a later date.’ But because things like these seem to be so widely dispersed in a population, is it a genetic difference, or merely a learned, culturally favoured response? ‘Alex Mesoudi at the University of Exeter recently profiled the thinking styles of British Bangladeshi families in East London. He found that within one generation, the children of immigrants had started to adopt some elements of the more individualistic outlook, and less holistic cognitive styles. Media use, in particular, tended to be the biggest predictor of the shift. “It tended to be more important than schooling in explaining that shift.”’

The article goes on to suggest several theories as to why the so-called East-West differences arose in the first place -everything from epidemics, to types of crops grown by different populations, but the problem still remains: the differences lie on a spectrum –‘broad trends across vast numbers of people’. And yet even so, especially in small interpersonal discussions –dare I say ‘arguments’?- we are very likely to use whatever generalization makes our point.

But, for many of us, that tends to preclude any semblance of critical analysis. It’s far easier to succumb to the prevailing opinion without questioning the reasons for its presence, let alone its validity. And it’s not just the so-called East/West divide –the potential seems to arise whenever any culture examines another. Perhaps an example that stands out clearly in contemporary life, is that of the hijab –the headscarf. Sometimes the objections are couched in religiosecular terms of course, but they often boil down to simple perspective –Weltanschauung.

Aaisha, a Muslim friend of mine recently decided to wear the hijab, and although there were no prohibitive policies or objections from her bosses at work, she encountered resistance from a source she had not anticipated –her co-workers.

Some of it was just petty –“Why would you want to cover your hair?” one woman said to her, adding “It’s so beautiful” no doubt to take the sting out of her rudeness. But the woman had never complimented her hair before, so it rang hollow to Aaisha.

And then she told me about another, a man who had just joined the company a few months before and who seemed quite uncomfortable with hijab and glared at her whenever he passed her desk. Finally, she decided to talk to him about it.

“You keep staring at me, Jeffrey,” she said, smiling confidently as she walked up to his desk. “I get the impression you’re unhappy about something.”

He acted surprised at first, and then his scowl returned and he pointed at her head. “You didn’t used to wear that scarf, Aaisha,” he said, trying to keep his tone friendly.

Her smile broadened and she pointed to his tie. “I don’t remember you wearing that tie before, either, Jeffrey.”

He blinked uncomprehendingly. “It’s just a tie. I wear different ties all the time…”

She didn’t skip a beat. “It’s just a hijab,” she said, obviously proud of the word and pointing to her head.. “And you may have noticed, I also wear different ones all the time…”

His eyes narrowed and his forehead wrinkled. “A tie is different, Aaisha…”

She waited for him to continue, but he seemed to think his answer was complete –and for him, it probably was. Finally, she decided to ask the obvious question. “Oh…?  And how is it different?”

He actually rolled his eyes at the stupidity of the question. “It’s what men are expected to wear to work.”

The smile never left her face and she pointed to another man at the next desk. “John never wears a tie…”

Jeffrey shrugged. “We’re different, that’s all… And anyway, I’m my own person.”

Aaisha stood there, for a moment, and then blinked. “And so am I, I guess…”

Jeffrey seemed surprised at her answer, then shook his head. “Nobody makes me wear the tie…”

At this point, Aaisha laughed. “And nobody makes me wear a hijab, Jeffrey.”

He didn’t seem to know how to react. “But… Well, how about your husband?”

She shook her head, still smiling. “I’m not married… And my father and brothers are still back in England -just in case you want to involve them,” she added with a laugh.

Jeffrey began to sense he was losing the argument. “It’s a family tradition -and also a society thing- Aaisha. My father always wore a tie to work –and his father before him…” But his voice was less confident.

Aisha sighed. “Should I tell you about my mother, and her sisters? They all wore the hijab back in London –and not because they were forced to, they’d be quick to tell you. They just felt more a part of the community wearing hijab, so it, too, was a society-thing as you called it…”

He blinked, but slowly. “Your society, Aaisha, not ours!”

The smile returned, and she nodded her head towards John again. “And what about John? Does he belong to another society, as well? We’re all immigrants, Jeff; we’re all other if you go back a generation or two. And thank god we don’t all have to dress the same,” she said, touching the sleeve of his fraying shirt with her hand and winking coyly at him.

And for the first time, he smiled at her.

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Scientific Gynaecology

Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

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Staying in Touch

In the endless dark of night, belief that there will be a morning is sometimes all that sustains us. Hope springs eternal in the human breast, as Alexander Pope declared in one of his essays -and that is occasionally all there is. When Medicine fails, the understandable temptation is to turn to alternatives; when inductive reasoning seems insufficient (compilation and collation of observations to arrive at a tentative conclusion) then perhaps the converse might be helpful: deductive reasoning (start with a conclusion and then look around for supporting evidence). The Scientific Method tends to use more of the former than the latter to test hypotheses, although to be honest, it is often a melange. But to start with a conclusion and then to attempt to prove it can be a recipe for failure –or worse, deceit.

Alternative Medicine appears to be guilty of the latter -although whether by intent or naivete can be argued, I suppose- but it does seem to attract a certain edge of the population. I, for one, am not a believer, but to set the stage, perhaps a definition of alternative medicine would be helpful. The description in Wikepedia (sorry!) is as good as any I’ve seen: ‘Alternative medicine is any practice that is perceived by its users to have the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science. It consists of a wide range of healthcare practices, products and therapies, ranging from being biologically plausible but not well tested, to being directly contradicted by evidence and science, or even harmful or toxic.’

In this essay, I don’t intend to debate the merits or harms of alternative strategies for health, but merely to illustrate the pitfalls that can result when they are espoused too vigorously -when hope triumphs over experience. When, to paraphrase Macbeth, Physic is thrown to the dogs.

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I really liked Loretta; I could tell that as soon as I saw her in the waiting room chatting to her neighbours. A slender young woman barely grazing her twenties, she had short brown hair and was dressed in jeans and a yellow tank-top. Her face was all smile –or, rather, all teeth and tongue, with large, brown eyes occasionally mobilized to emphasize some point or other. The whole room seemed alive with laughter and focussed on her every word, her every gesture –and there were a lot of those. Her body was in constant motion, sometimes pointing with a ring-laden hand, then gesticulating with her arms as her bracelets clinked and ran up and down her forearms like beads on an abacus; even her legs were integral as she swung them back and forth to illustrate a point with her dainty sandal-clad feet – an actress playing to an adoring audience. I almost felt embarrassed as I crossed the room to lead her offstage. She actually waved to them as she left; I half expected her to blow kisses.

She sat on the edge of her chair in my office clutching a backpack in one hand and a phone in the other as if to relax was anathema to her. “You seemed quite popular out there,” I said, nodding towards the corridor that led to the waiting room.

Her smile broadened at the compliment. “I like to stay in touch with everybody… and everything,” she added, as if it were a necessary addendum, then filled the time between our words with safaris into the uncharted depths of her pack. “I’ve come here for a pap smear,” she said as she saw me scrolling on the computer. “That’s what my GP says, but it’s really because he doesn’t know what to do with me…” She let the sentence dribble to a close without a firm indication she was finished with it. Like it was still a work in progress. So I waited. A text arrived on her phone and she blinked at me and proceeded to thumb a rapid, practiced reply almost as if she was scratching her leg without thinking about it.

Still she said nothing, but instead inspected the room, starting with the pictures on the wall and then progressing to the the plants on my desk, inspecting them one by one, perhaps thinking I was going to quiz her about the office. “What is it that concerns your GP, Loretta?” I felt I had to say something.

She shrugged goodnaturedly and her eyes migrated to my face. “I suspect she thinks I’m too self aware…” She giggled at the thought, then noticed the puzzled expression that I had tried to disguise. “I like to be on top of things…” She immediately blushed and corrected herself. “You know, like my health and stuff.”

I smiled to encourage her to explain.

“Like, you have to be careful about what you put in your body. I mean they’re putting additives in everything. Bodies need help getting rid of all the toxins that build up: detox regimes.” I grimaced inwardly, but maybe she saw the shadows. “My GP said that was nonsense, too, but I know I feel better after a cleanse,” she said, momentarily dropping the smile and folding her arms across her chest with the bracelets following close behind for emphasis.

I tried to disguise a deep breath. “I see…” –but actually I didn’t– “Is there any reason he felt that a gynaecologist could be of some help?”

“Help?” she said with a sharp intake of breath, as if I had really not understood a word of what she’d been telling me.

“You know,” I quickly added, “Help with something that you’ve been unable to deal with using your…” I hurriedly rummaged around in my head for an appropriate word –one that wouldn’t seem to insult her, yet wouldn’t suggest acquiescence either. “…Your strategies.” I thought that sounded neutral and not overly critical. I wanted to keep her on my side to see if there really was anything I could do to help. She could sort out the knowledge base for herself later.

Before she could respond, another text arrived, prompting yet another seemingly mindless flurry of thumbs to resolve the issue. She didn’t apologize and I realized that this was just part of the background in her life -like traffic noise, or maybe someone bumping into her in a crowd. She found time to shrug at me again, but whether to acknowledge the text she had just answered or as a way of answering my question was hard to tell. “I’ve been getting a lot of yeast infections lately, so I tried another cleanse.”

Her eyes jumped onto mine to see if I needed any clarification, and rested there when my face didn’t light up sufficiently with comprehension. We live in different worlds they said.

“Toxins,” she added, like she was talking about the elephant in the room. “The bowel walls get encrusted with stuff and overgrowth of candida is one of the crusts.” She smiled innocently, almost as if she was going to admit to sneaking a cookie between meals. “I tried dietary modifications for months: fruit fasts, fiber-only diets… but no matter, I still got itching down there. So I tried a coffee enema once a week for a month. Then a probiotic one for almost three months.” She jangled her bracelets again as she thrust her arms upwards to suggest what else could she do. “Nothing worked, so finally I tried an enema using an antifungal solution that my girlfriend told me about. Jeez, try to keep one of those puppies inside for 15 minutes! I only managed 8…” She noticed the horrified expression that I’d tried desperately, but unsuccessfully to camouflage. “Eight minutes, doctor –not eight enemas!” She shrugged again –it was another form of speech for her, evidently. A sort of body text, I suppose. “But when I told my GP about it, he got really mad. “Of course there’s yeast in the bowel; we all have yeast in our bowels, he said… No he yelled that at me,” she added after thinking about it for a second.

“So I told him about the enemas they’re using nowadays for –I forget the infection…”

“Clostridium difficile,” I added helpfully, and also to show that I was still listening.

“Those are special fecal enemas, he yelled back at me, and only for a special problem!  Anyway, you can’t get rid of vaginal yeast with those silly health-product enemas, he added. Not even the probiotic ones. He said ‘probiotic’ more softly, though, as if maybe he wasn’t so sure about that one.” Her face perked up again as the indignation faded and the verbal catharsis revived her spirits. “The yeast down below isn’t so bad right now –it seems to come and go. But no thanks to him -none of his prescriptions helped…” She shrugged a text at me. “That’s why I tried colonics dead last. I mean I believe in probiotics, and I hate enemas.” She studied my face for a moment. “Hey, I was desperate.” Another jingle from her arms. “There’s gotta be another way to go. Despite what all my friends say, I still think enemas are unnatural, don’t you?”|

I have to say it was hard not to roll my eyes. I realized I had a chance to convert her to our side of the fence if I was careful. And tactful. “I agree with you about probiotics, Loretta.” She smiled and nodded her head at my unexpected response. “The idea, of course, is to adjust the biota –the bacterial flora of whatever organ- to be able to suppress other unwanted organisms. But you can’t just use off-the-health-food-shelf probiotics –one type doesn’t do all jobs, just like one antibiotic doesn’t fit every occasion.” I glanced at her face to see if she was listening or playing with her phone again. She was listening. Staring at me in disbelief, actually. But in this Google age, I knew I had to be careful -I could only remember one article I’d read and that might already be outdated. For that matter, I couldn’t even recall where or when I’d seen it –the Canadian Medical Association Journal, maybe. But then again, she probably didn’t really have a yeast infection anyway…

“And the other thing is that good studies in this field are hard to find.” I hesitated a moment for effect -timing is everything. “I seem to remember there are a couple of probiotic regimes that have undergone scientific investigations. They were published a few years ago in…Ahh, the Canadian Medical Association Journal. You can look it up, I imagine.” The long-winded, but welcome news had forced her back into the chair, her phone into her pack, and the pack onto the floor. Then a look of concern replaced the incredulous rictus. “But how are the new bacteria going to be able to compete with all that toxic stuff in the area now? It might poison them, or overwhelm them before they even get a chance to set up a new colony.”

It was my turn to look concerned –well, at least curious. I’ve never understood the toxin theory promulgated by many of the alternative medicine practitioners. “How do you know there are toxins, or whatever, in the area, Loretta?” I sat back in my chair, convincing myself I had her.

Her eyes rolled as her hands reached into the pack at her feet in response to a muffled text. I assumed she was reacting to the disturbance, but suddenly realized it was me they couldn’t believe. She closed them slowly, patiently, in a slow motion blink and then opened them again, this time filled with all the sure and certain knowledge of youth. Her body texted me before any words left her mouth. “How do I know there’s still stuff living there now after months of using my colonic ‘strategies’ as you put it? Ever had a retention enema, doctor?”

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The Empathy of Age

I am intrigued by the concept of empathy. Variously defined as caring, psychological identification, or even sharing another person’s feelings, it is nevertheless a quality incumbent upon those of us in the health profession in whatever capacity.

Empathy is a word that has, in some minds, become synonymous with other altruistic traits such as sympathy, compassion, or even pity, but it is broader than those -and perhaps that is what makes it so valuable -so unique as a descriptor. Sympathy, for example, is more restricted in emphasis: more of a feeling of concern for another who is in need; compassion, on the other hand is what we may feel when another requires our help –a motivator.

Empathy encompasses these, and more. I like the definition in Wikipedia: Empathy is the capacity to understand or feel what another person is experiencing from within the other person’s frame of reference.

But is empathy something like a genetic gift? Something that pushes those who possess it to self-select into the helping professions? Or is it more like courage: you don’t know if you have it until it becomes necessary?

No, apparently it can be taught –although I must say I must have missed that lecture in medical school because, along with things like ethics and cultural safety, it was an assumed quantity. If you were going to be a doctor, that meant you had it… But, like St. Thomas Aquinas’ understanding of Time, it was an entity that was only definable when you didn’t try -or the philosopher Krishnamurti’s objection to naming God, because it confined the concept…

Over the years, though, I have tried to confine it –or at least experience its various manifestations. And although these are no doubt legion, I am still thirsty. Readers of these essays have perhaps already had their fill of my insatiable insistence on the art of listening before speaking (For example: https://musingsonwomenshealth.wordpress.com/2015/06/30/when-silence-is-golden/ ) But I’m afraid there was yet another news article that caught my eye: http://www.bbc.co.uk/news/magazine-33287727  and I thought I’d try it out at the first opportunity. I’m always looking for new tricks.

Radical listening –that sounded easy. And familiar: “…be present to what’s really going on within – to the unique feelings and needs a person is experiencing at that very moment” and, in practice, “Let people have their say, hold back from interrupting and even reflect back what they’ve told you so they knew you were really listening.” Perhaps that’s what I have been doing all along, but not consciously aware of it, though. Or maybe not –maybe all doctors think they listen, but possibly what we are actually listening to is ourselves –our prepared judgements, our sure and certain feeling that we have the answers. Or, at least an answer… Science uses inductive methods: start with the data and then establish a theory that seems to fit. But maybe, despite our protestations to the contrary, we sometimes resort to a type of deductive reasoning: start with a theory and then make the data fit -or at least search around until we find some that do. Because if we don’t have an answer… what good are we?

Time for awareness. I thought I’d start with someone with a relatively common problem –a non-gendered one so I could more easily slip into their shoes, as it were. I scanned my list of patients for the day but none seemed suitable. I simply could not easily cohabit a mind filled with fibroids or endometriosis.

Loren was different. A woman with persisting hot flushes seemed initially excludable from my naïvely chosen criteria, and yet it soon became apparent that the hot flushes were a sort of proxy. She was a young looking 62 with barely a wrinkle on her face. Fashionably thin and elegantly dressed, she seemed to have ignored the years that have exiled so many others -stranded them, as it were, on a foreign, uninviting coast. No, Loren was a professor at one of the universities here in the city, and much in demand both for her human rights advocacy and her several books on the subject that seemed to be quoted whenever federal immigration policies were in the news.

“I get these hot feelings in the most unfortunate circumstances, doctor. They usually occur when I’m in a social situation where my reaction to them would be noticeable –giving a lecture, for example. Or an interview. I’ve never embarrassed easily, but if some commentator manages it, I find myself almost overwhelmed by a need to wipe my forhead –not a sign of strength.”

She paused, no doubt waiting to judge my reaction as to whether that was a common feature. Mentally rubbing my hands and determined to try my new tricks, I smiled reassuringly. “So these hot flushes occur in social situations where to acknowledge them would be awkward..?”

She nodded, and then as if she’d been given permission to speak again: “I’m worried, frankly. I never used to be like this.” She considered it briefly, and her eyes turned inward for a moment. “I’m beginning to see it as a type of physiological dementia –a sort of bodily facsimile… an early protoype of things to come…”

The thought seemed to bother her and she studied my face for a refutation. “I can see you’re worried, Loren,” I replied slowly. “I’ve never heard hot flushes described as a type of nascent dementia, though.” Good; I was proud of that succinct encapsulation of her thoughts and looked at her contentedly. This wasn’t so hard.

She sighed, but I wasn’t sure whether it was out of satisfaction at finally being heard, or frustration. “And words don’t come as easily as they used to any more. I’ve been blaming it on the hot flushes because the two seem… coeval.” She glanced at me, her eyes frightened birds huddling in their cages. “Like just now –I couldn’t think of another word that meant ‘at the same time’ quickly enough, so I substituted ‘coeval’…”

Another long pause; I wondered whether this was the time to reiterate –the word ‘regurgitate’ entered my head and I almost smiled, but her face looked so anguished I decided to go for it. “Words don’t come easily anymore –and you blame it on your hot flushes… I like the word ‘coeval’ I have to say.” I blushed at my amateurish attempt at precis this time…

She didn’t sigh this time, but I could tell her eyes were about to leave their nest. “I suppose all of us experience this after a certain age…” She diverted her attention to the picture of a peasant woman leading a horse that hung on the opposite wall. “But words have been my world, and their loss –or at least their current drying up to a trickle- terrifies me.” She continued to stare at the picture, as if the answer lay in the coloured sketch, its almost random lines a reminder of her words. Suddenly she turned to stare at me. No, to study my reaction. I could sense her dividing me into grids, mathematically precise areas for analysis. “Hormones didn’t help before… Do you think it would help to go back on them?”

It was a plea, begging for an answer. A solution. Anything to give her hope. It was going to be hard to stick with my radical listening approach… Or had I already done it? I tried to smile intelligently at her, tried to find some words to help, but like her, I was struggling. “Words…” I started hesitantly, aware that I was blushing at my sudden blank. It was like my head was an empty screen. “…don’t come easily to you anymore…” The look of frustration at my repeated attempts to incorporate her own words into my response was becoming glaringly obvious, and I could almost feel her anger. I sighed and abandoned my tactics. “Words don’t come easily to any of us after a certain age, and its not only embarrassing, it’s frightening. They are my world as well –they’ve been what have defined me not only as an explicator of the arcane, but also as a person. Words are friends I’ve called on whenever the need arose. They’re still there, but as with you, the words that arrive in response are often friends of friends. Acquaintances from books I’ve read and long since forgotten. Clumsy words. Opaque words with only approximate relevance that people merely skip over when they hear them, thinking I’m just being clever. Metaphorical.

“And then the words, like branches floating past in a slowly moving river, make way for others –more familiar, perhaps, but moving all the same. And the conversation continues with probably only me who noticed all the substitutions…”

Loren sat back in her chair with a look of satisfaction on her face. Her eyes, caged once again, sat twinkling at me from their lairs. “You know,” she said, apparently finding her words with ease, “I should go to doctors more frequently.” And with that, she reached across the desk and squeezed my hand. “That’s all I needed to…” -a slight pause, almost unnoticeable- “assimilate…”

We looked at each other and smiled. We were of an age.

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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.

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Critical Thinking and Bullying

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They deserve the chance…