The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’

Advertisements

Why do we Know something?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

Resistant Organisms

I’m not sure that patients are any smarter than they used to be, but they certainly come pre-loaded with more facts. Sometimes these are relevant, often they are contextually unrelated to the reason for their visit. Contiguous, perhaps, yet only distantly attached –second cousins once-removed. Sometimes they seem to be variations on a word, a disease, or a belief; Google’s explanation for one symptom drawn from a bouquet of  complaints  –helpful maybe, but only in the setting of an accurate diagnosis of the cause: the condition responsible.

This is not to admonish the patient for trying to help, nor to disparage the often disparate droplets of assistance, but merely to acknowledge that it is possible to drown in a wading pool. Quantity does not equate to quality when it comes to facts. Nor does it equate to knowledge, unfortunately. If not intelligently –knowledgeably- selected, only some of them are flowers worth looking at; most are weeds.

But weeds are often what grow the fastest, and once they’ve taken hold, they are hard to get rid of.

“My doctor told me I have yeasts,” said Janice, the tiny woman sitting across the desk from me. She had seemed pleasant enough at first, and had even smiled at me as I shook her hand in the waiting room and led her down the corridor to my office. But once  the door was closed and she was settled in a chair, her face hardened and she glared at me as if she were going to attack. She was dressed in an ankle length patterned skirt with a white blouse. It was fraying at the cuffs, but she wore it so ostentatiously that maybe it was supposed to look like that. Her brown, pony-tailed hair was pulled so tightly across the top of her head from her forehead, I wondered at first if her facial expression was because her skin was hurting.  Actually, it was anger.

I had a peek at the referral letter to soften the interrogation her face was attempting. ‘Recurrent yeast infection’ it said. ‘Nothing works’. Great: an offload.

Before I could say anything, I felt the desk move as she leaned against it to sigh. “I’ve been on at least six forums about yeast, and I’m convinced I don’t have yeasts in ‘there’. She said the word ‘there’ softly, warily, so as not to shock me. “So I didn’t take any of the medications she prescribed.” Janice studied my face carefully for a reaction. I think she was disappointed I didn’t react to the dropped gauntlet.

But it was meant as a challenge. An audit. I was being screened.

I tried my best to take a history from her, but it was like trying to pry water out of a box. She knew what she had and anything else about her that didn’t directly address it she deemed irrelevant. I could understand why her family doctor had referred her. She only admitted to feeling itchy ‘down there’, and immediately closed her eyes as if she’d given away a secret. “But there’s nothing else, doctor,” she added quickly, lest I suspect some lack of regional care on her part.

I glanced at the the referral information again, but it was running a close second to Janice in disclosures. “Ahh… well, did your family doctor send off any swabs from the area?” I thought I’d better not use anatomical terms, because she hadn’t.

She eyed me suspiciously, no doubt wondering whether I was trying to prove her wrong. Then, after a long, contemplative pause, she nodded. “Only grew normal flowers…” She considered it for a moment, “I’m sure she said ‘flowers’ but I think she used the wrong word,” she said, obviously contemptuous of anybody who would do that.

Flora, she meant,” I suggested as humbly as I could manage without laughing out loud. “The normal kinds of bacteria that grow in the region,” I added, to assuage her skeptically tight brow.

“But not yeasts,” Janice added to hammer home her point. “I’m very particular about cleaning myself, so there’s no way stuff like that could have crawled in.”

I tried not to react, and when the horror had receded from her face, I suggested I would like to see if I could resolve the issue for her, once and for all.

Another suspicious glance, a moment of closed-eyed silence, and then a nod. “But I want your nurse in with us,” she managed to whisper through gritted teeth and lips that looked as though they’d been sewn shut. I readily agreed; I was going to suggest it myself.

As it turned out, I was unable to find any evidence of a yeast infection when I looked at samples from the vagina under the microscope. Just some areas that appeared white, like a thin veneer on the skin near the vagina. She was so elated at the vindication and the wisdom of those online forums that she even agreed to let me do some cultures and a couple of biopsies.

A different Janice walked through the door a week later to discuss the results. Her face was relaxed, and so was the hair that now hung loosely and in curls to her shoulders. No more frayed blouse, no ankle length skirt –just jeans and a grey, baggy sweat shirt. Maybe it was the real her.

“Well, doc, what’s the news?”

“No yeast,” I answered, scanning the reports. “And no STIs,” I added with a grin, that was magnified by a chuckle on her part. “No cancer…”

She sighed loudly and a bit theatrically. “I didn’t come back here to discuss what I don’t have, doctor.” But she said it with a twinkle in her eyes. ‘At least we don’t have yeasts,’ they whispered to each other almost conspiratorially, as only eyes can do.

“The biopsies showed a skin condition called lichen sclerosus,” I explained. “It’s a thinning of the skin, probably caused by the immune system…”

“Not an infection?” She was immediately suspicious again.

I shook my head.

“So what’s the treatment?” Wariness once more surfaced on her face, hardening it into little wrinkles.

I smiled to diffuse the tension. “A steroid ointment you have to apply daily to the area for a few weeks. It turns off the immune response causing the skin problem.” I had to tread a bit carefully with this; to tell the truth I wasn’t sure this was the entire mechanism.

“Does it affect yeasts?” her face knotted up even further. “Because you have to be careful about that, you know.”

I raised an eyebrow as a form of silent question –one that I hoped would encourage her to expand on her concern.

“You know what we’re doing to bacteria..?” I wasn’t sure whether she wanted me to answer, but fortunately she resolved the question by answering it herself. “We use so many antibiotics we’re encouraging resistant germs: Superbugs!” She said the last word with such horror, it was as if she had just mentioned the Devil. I almost expected her to cross herself as a protection. “It’s all you read about nowadays. And we’re running out of effective antibiotics!” She stared at me with needle eyes, daring me to contradict the wisdom of her forums.

I scuffled around inside my head for the proper expression to wear. I finally settled on a serious, yet hopeful demeanor. Then I decided to draw her out. “Yeast are not bacteria, Janice… And anyway, they’re not your problem.”

“Doesn’t the immune system keep yeasts in check?”

“Well, in the vagina, lactobacilli help a lot…”

“What about people who get AIDS? Don’t they get overwhelming yeast infections?” She crossed her arms, certain she’d scored a point. “And don’t they have a turned-down immune system?” she added as a finishing coup.

I sat back in my chair, wondering where she was going with this. “And what is it you are concerned about, Janice?” I said when she seemed satisfied she had bested me.

Superyeasts!” she answered defiantly. I could almost feel the italicization.

I had to chuckle; I couldn’t help myself. “You mean a yeast infection that is resistant to every known treatment?” I knew I was going to need to look that concept up later.

She nodded, satisfaction written across her body in bold letters. “Can you imagine a life lived with a permanent itch? Where scratching doesn’t work?” She had finally made her point –and, she hoped, maybe another convert. She knew she had to spread the word. Save the world from resistant stuff…

http://www.ncbi.nlm.nih.gov/pubmed/17906120 Candida drug resistance

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC105901/  Candida resistance in HIV