Digital Naivete

I suppose it was inevitable; I suppose I should have guessed… When you are charged with consulting on a generation that seeks its information online, there are issues that are only apparent in that venue. And treatment algorithms which don’t take that into consideration are woefully naïve. Doomed to fail.

There are smartphone apps for everything I guess, but in an Ob/Gyne practice like mine, there are only two that my patients seem willing to share with me: obstetrical dating apps that disclose the expected date of baby’s arrival, and period tracking apps. In an age of constant immersion in information sharing and with an understandable need for inclusion in any decision making, I think that both of these programs -especially the menstrual tracker- would be considered especially useful to any women at risk of pregnancy, particularly so if they also suffered from irregular periods. A natural extension of that, then, might be to extend its use. To adapt it for another purpose for which it was not originally intended -a technological exaptation.

But an article a while ago in the BBC news (also an app, by the way) looked at some of the pros and cons of menstrual tracking apps: that raise some serious concerns.

The idea of being able to follow one’s periods without the need to carry a marked calendar around is appealing, to say the least. It might also allow the recognition of a pattern in an otherwise seemingly random sequence. And even with a predictable cycle, other discernibly helpful patterns may become obvious. As one English singer put it: “When you are starting your period or you’re pre-menstrual, the hormones that rush around your body affect your larynx in ways that are detrimental to your singing voice. I use the app to avoid auditions, premieres or really important performances on those days if I can.” And, ‘The app also helps her identify connections with changes in her emotions, eating habits and headaches’.

So far, so good. As that English singer put it: “Being able to chart what happens to you and how you uniquely respond to your cycle is a great way of taking ownership of something that really sucks – but is completely necessary.” Perhaps the more you know about how unique you are (or aren’t) the more likely you are to feel in control –not simply a table of random numbers, a caster of dice… But there is a danger in relying too heavily on a reading and analysis of an app that merely calendarizes a menstrual cycle –especially an irregular one.

Yes, it is generally true that one usually ovulates about two weeks (or so) before the period starts, but each cycle has been exposed to a different set of conditions –stress, exercise, illness, and so on- so the rule is not reliable. Especially for contraception. The time period before ovulation (the follicular phase) while the egg is being readied in the follicle can be quite variable. If not using serial blood tests, or the like, one needs at least temperature charting and/or mucous testing to discover more reliably when ovulation has occurred… and then, of course, it’s probably too late to take precautions to avoid pregnancy.

The phase after ovulation (secretory phase) is also variable –although often less so- for a variety of reasons, so it won’t reliably predict the exact timing of an oncoming and expected period either.

The whole tracker app thing can be thought of as a digital rhythm method. And if you subscribe to that philosophy, a period tracker app may help you to remember when your last period started, so you can practice periodic abstinence. The Mayo Clinic suggests that with dedicated and consistent observance of this method, one might expect a failure rate of perhaps 13%. Although we all must decide what risk is acceptable given our circumstances, it does seem high in comparison with most other forms of contraception. And, ‘[…] the Royal College of Obstetricians and Gynaecologists has warned they [period tracking apps] should not be used as a form of contraception.’

Another thing that worries me about many of these apps –especially the downloadable free ones- is security of the information that you need to submit. As a privacy campaigner for medConfidential –a British privacy advocacy group- points out: ‘[…] if an app is free, consider whether you are paying for it in effect by giving away your data – and investigate where it might be going.’

With the blooming crop of digital savants, I suppose the posting of a cautionary list is merely an annoying Jeremiad from an older, and more naïve generation. And yet, there is more than a tittle of necessity to the reminders. Sometimes even the young need to step back and critically examine what they have come to believe is commonly accepted and practiced amongst their peers. The wisdom of the crowd differs markedly from the wisdom of the individual and although we may wish something to be so, as Plato observed: ‘Real knowledge is to know the extent of one’s ignorance.’

Or, put another way, with all due deference to the digital generation, Shakespeare’s immortal line in Julius Caesar: ‘Your wisdom is consumed in confidence’. Don’t let it be so…








Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.


The Caesarian Path

The Caesarian section has a fascinating, if largely apocryphal history. In all likelihood it was probably a procedure of last resort to save the unborn child when its mother was already dead or near death. That the famous Julius Caesar –like Shakespeare’s MacDuff- was ‘from his mother’s womb untimely ripped’ seems unlikely, however appealing the etymology. In fact, the name may well derive from the Latin verb ‘caedere’ –to cut- and hence the cognomen (originally a nickname). Pliny the Elder, according to Wikipedia, ‘refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, “cut from the womb” giving this as an explanation for the cognomen “Caesar” which was then carried by his descendants.’

At any rate, before the days of appropriate antisepsis let alone adequate analgesia, the survival rate for both the mother and baby would have been dismally low. And despite isolated reports of its use throughout recorded history in such diverse countries as India, China, and even Babylon, it was always a procedure of desperation. A triumph, as Samuel Johnson once wrote in another context, ‘of hope over experience.’

Unfortunately it has now become merely a triumph of experience -a default position assumed at what seems to be the slightest provocation. The fact that it is an operation that can be booked in advance under some circumstances, and therefore superimpose a degree of predictability on the scaffolding of the anticipated chaos of labor, has been seen as desirable in some quarters. And in fairness, there are those for whom labor carries undue risks for either mother or baby and its avoidance would be prudent if not lifesaving. The issue, I think, is in the interpretation of risk.

The other, perhaps more problematic concern, is that of choice. At least in a system of limited resources, or one in which the public purse is providing medical coverage, one could ask whether an elective Caesarian section for no other compelling obstetrical reason than patient choice, is a sustainable option. Or even a desirable one.

So, what about in a user-pay system? Is it merely a matter of supply and demand: build more hospitals to accommodate the needs and whims of those who can afford them? Is that an efficient use of their resources? Is it even an ethically defensible position? The matter has finally prompted the Brazilian government to wade in, as an article in the July 7/15 BBC news reports:

Of course, there are many reasons for elective Caesarian sections –some of which are the result of previous and unsuccessful attempts at vaginal delivery that necessitated Caesarian deliveries at that time. The desire to avoid a similar and frustrating trial of vaginal delivery is certainly understandable –if not always necessary- under those circumstances. These are the so-called elective repeat Caesarians. Others, as I indicated, are obstetrically mandated because of developing or pre-existing risk factors –once again, hard to argue against. There is an interesting and informative article that attempts to put the Canadian experience (2007-2011) into perspective –a classification system (the Robson Classification System) that can be used to make international comparisons in Caesarian section rates:

But getting back to the situation in Brazil. As the BBC article suggests, ‘Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%’. And the new government rules ‘…oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. Doctors will also have to justify why a caesarean was necessary. They will have to fill in a complete record of how the labour and birth developed and explain their actions.’ That they may not have been doing this routinely before is troubling, to say the least.

Also, ‘Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors.’ I would have thought this practice would have been universal and intuitive -without the need for a government fiat.

But, as worrisome as all of this seems, there is another, perhaps more subtle pressure on the woman to opt for a Caesarian delivery in Brazil: ‘Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed.’ And as Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brazil last year, “The best way to guarantee yourself a bed in a good hospital is to book a caesarean.”

Of course the blame does not wholly fall on the medical profession there –nor even, perhaps, on their preferred management strategies in pregnancy. ‘Researchers say many women also see caesareans as more civilized and modern, and natural birth as primitive, ugly and inconvenient. In Brazil’s body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive.’

It is always dangerous to judge another country and another culture by our own standards. Our own sensibilities. And yet the risks are transnational and universal. They do not disappear simply because of a differing national mythos. Surgery is surgery; complications are inevitable co-travellers with it in spite of all precautions, and good intentions -the hidden, unwanted occupants of every operating theatre. And while we may never be able to stem the tide of primary elective Caesarians –even education on the subject has challenges overcoming fear or fashion- we may be able to convince women that their choice does not come without baggage. Unintended risks. To journey through a new geography, it helps to have thought about it first; planned the route to avoid unnecessary problems; consulted a knowledgeable guide –someone who will travel along with you. And remember what Seneca wrote: ‘Be wary of the man who urges an action in which he himself incurs no risk’.

Speak up, eh?

In the often dull Gestalt of Canadian politics, it is sometimes difficult to distinguish background from foreground, but every so often a light goes on and shadows spring to life. Shadows we would fain deny, yet dare not, to paraphrase Macbeth as he waits for battle. It is, perhaps, an apt example given that it is the military that so recently stepped into the media’s blazing sun. Soon to retire as the Chief of the Canadian Defense Staff, General Tom Lawson, in a widely watched television interview, said “Sexual harassment is still an issue in the Canadian Forces because people are “biologically wired in a certain way.” And this set off a national forest fire that has yet to be extinguished.

This is not unexpected in light of a recent report on sexual misconduct in the Canadian Forces issued by former Supreme Court Justice, Marie Deschamps who suggested that sexual misconduct in the Canadian military was ‘endemic’.

And then, predictably, this was espoused by members of parliament –all, not unreasonably, wanting to reflect the mood of their constituents.

This is as it should be, of course. Neither sexual harassment nor sexual misconduct are tolerable –especially in a military setting where power inequities are inherent to its structure and therefore largely inescapable. The creation of an ‘independent centre for accountability for sexual assault and harassment outside of the CAF with the responsibility for receiving reports of inappropriate sexual conduct, as well as prevention, coordination and monitoring of training, victim support, monitoring of accountability, and research, and to act as a central authority for the collection of data’ as the third recommendation of the Report suggests, would be an important first step in addressing these inequalities. And for those who are not certain of whether to bring it to the attention of their superiors, another of the recommendations: ‘Allow members to report incidents of sexual harassment and sexual assault to the centre for accountability for sexual assault and harassment, or simply to request support services without the obligation to trigger a formal complaint process’. And if this seems inadequate, or difficult -perhaps because the offender was a superior officer-  another of the Report’s ten recommendations, no doubt for emphasis, also mirrors this: ‘Allow victims of sexual assault to request, with the support of the centre for accountability sexual assault and harassment, transfer of the complaint to civilian authorities; provide information explaining the reasons when transfer is not effected.‘ In other words, the ability to be heard. Noticed. Helped. It would be difficult, indeed, to find fault with any of the recommendations as they seek to change attitudes in what, for millennia, was an all-male club. -or for a more succinct listing of the recommendations:

And General Lawson did later apologize for this ‘awkward characterization’ as he termed it on a subsequent CBC interview: “I apologize for my awkward characterization, in today’s CBC interview, of the issue of sexual misconduct in the Canadian Armed Forces. Sexual misconduct in any form, in any situation is clearly unacceptable,” the statement said. “My reference to biological attraction being a factor in sexual misconduct was by no means intended to excuse anyone from responsibility for their actions.”

His original ‘biologically wired’ comment, in the cool light of retrospect, was bound to attract attention of course –especially given the sexual misconduct report and his position as chief of the defense staff. It was a poorly conceived and not terribly clever analogy -definitely not Pulitzer Prize material… But all the same, I worry about the reaction it engendered -the media seemed to focus only on the ‘biologically wired’ part. Context, it seems to me, was either lost or misconstrued -his message was interpreted as naïve at best, camouflage for inaction at worst. And yet, awkward or not, I would like to think the general was not attempting an excuse, but merely an explanation of something that, were we able to say it without fear of backlash, should be evident to everyone. Like it or not, there are biological differences between the sexes, and the military was perhaps the last remaining refuge for unadulterated testosterone -a place where actions truly spoke louder than words. We see some of those actions now as unacceptable -not only ill-considered, but even criminal. Fair enough; I certainly agree. But I also think it is reasonable that I expect, and am willing to tolerate, different behaviour from a soldier than, say, my doctor. I would not accept ethical or moral perfidy from either, and yet each protects me from different things in different ways -and presumably with different world views. Different sensitivities. Let’s face it, those people who decide on a career in which armed combat is a distinct possibility, are not likely to be averse to confrontational situations. But of course, judgement is required: aggression can be multidimensional. Hydra-headed -and inappropriate. It is, I suppose, why there are chains of command: the need to superimpose order on chaos. Training –or should I say taming– those primal instincts.

Of course it will not happen overnight just because we wish it so; not all of the report’s recommendations have been accepted outright… Yet. Perhaps it was felt that there was a fine line to balance, even now. So the report from Justice Deschamps is a recognition of the current reality –the one that requires a Center for Accountability. But to pretend that there is only one acceptable way to talk about the root cause of the problem -one way to name the Devil- is not helpful. There are many ways to acknowledge a truth. Many paths to the sea… And we are en route -but still walking, not running. Maybe senior officers should all be taught communication skills as well as battle tactics. Readings on rhetoric as well as studies of SunTzu might be useful parts of their preparedness strategies. Shakespeare hints at this in Julius Caesar:

There is a tide in the affairs of men. Which, taken at the flood, leads on to fortune; Omitted, all the voyage of their life Is bound in shallows and in miseries.

Autism and Obstetrics

I’m an obstetrician caring for worried mothers. They’re worried about things that might put their developing foetuses at risk for a whole range of issues and ask me for advice. Obviously I’m neither a paediatrician nor a child psychologist, so questions about autism leave me alone in troubled waters. There are so many rumours of risk, so many studies that seem to implicate everything from diet to anaerobic exercise in pregnancy, vaccinations to mercury in calcium supplements.

I wish I knew more about autism; I wish I knew anything indisputable about it… Well, that’s probably a bit harsh. I know that it’s now referred to as ASD (Autism Spectrum Disorder) and that it’s a neurodevelopmental disorder with problems in at least two areas: social impairments –things like communication and interaction- and behaviour abnormalities like repetitive patterns of  activities and that sort of thing. But it all seems rather vague. Especially the social components. At the severe end of the spectrum it’s an unmistakable impairment, and yet at the milder end…

It may be a sensitive set of criteria that bundles all the right things in it, and yet it’s rather spotty on the specificity. An example might help. Let’s say you’re a fisher and you want to improve your ability to catch salmon so you’ve designed a special net. You pull it up and there are a hundred fish in it, so it works –it catches lots of fish, but only one salmon. But, it did catch a salmon so it’s sensitive for salmon, but not very specific for them.

I also know the DSM-5 criteria of ASD –I’ll quote them from a more readable source: the 2014 UpToDate data base we have in our hospital. ‘ASD is characterized by 1. persistent deficits in social communication and interaction (eg. deficits in social reciprocity; nonverbal communicative behaviors; and skills in developing, maintaining, and understanding relationships) and 2. restricted, repetitive patterns of behavior, interests, or activities.’ They also say that the symptoms must be present early in childhood development, but may not become manifest until social demands exceed limited capacities. And there are three levels of severity rated separately for social and behavioral characteristics.

Okay, I understand those criteria –sort of- but coming from a medical specialty that is used to more concrete, objectively provable, and investigatable symptoms, they still seem rather vague. And there remain the difficulties that I have with including the milder, vaguer, less impaired end of that Bell curve distribution of characteristics –the end that may include variations of normal, idiosyncratic behaviors which may represent other issues –parental, social, even poverty-related stresses that might impinge on the child’s behavior.

I suppose it’s the boundaries that trouble me. There seems to be a wide variability of the reported prevalence of ASD and some indication that it is increasing of late, perhaps related to changes in definition as well as increased awareness. But how valid is that?

I’m all for increased awareness of ASD, just as long as we can be sure it is ASD that we’re aware of. This is important for interpreting the studies that purport to assess various causes of autism. For example, a BBC article reported a study from the Harvard School of Public Health which implicated air pollution as yet another cause. But, as the article suggests: ‘Experts said pregnant women should minimize their exposure, although the link had still to be proven.’

Good advice, I’m sure –pollution likely has many adverse effects on a developing foetus. One more wouldn’t be much of a surprise. Avoid pollution when you are pregnant by all means. But place that in the context of a pregnant woman who lives in a city where she cannot avoid it, and then add the additional worry of a possible link to autism in her unborn baby and you have sewn the seeds of an intractable anxiety. Helplessness. Despair. The fact that it is as yet unproven gets buried in the message; the statement that it is biologically possible does not.

As the aforementioned UpToDate 2014 data concludes: ‘The pathogenesis for ASD is incompletely understood. The general consensus is that ASD has a genetic etiology, which leads to altered brain development, resulting in the neurobehavioral genotype. Epidemiologic studies indicate that environmental factors account for few cases.’

I realize that there is a fine line between informing the public, and frightening them unnecessarily (or inadvertently), and I recognize and accept that we should all have the right to know what is being said in scientific circles about topics that affect us. Clearly it is difficult to balance whether or not to publicize information that is still in the process of being assessed and integrated into a coherent and testable theory, versus information that has been collated into a more accepted and validated model, but I think it would be a sensible, albeit challenging, step. It is a serpent’s egg, and reminds me of the warning of Brutus in Shakespeare’s Julius Caesar: ‘a serpent’s egg, which, hatch’d, would as his kind grow mischievous.

I’m certainly not advocating censorship –maybe just awareness. Prudence… Judgment.