The Cleanse

Sometimes, if I have the chance, I like to review the list of referral letters before I see any patients for the day. It tells me what to expect; how to allocate the time for the consultations; whether any of them might be particularly interesting. Surprises happen. The other day, one letter about a patient caught my attention. It was short and to the point: Chronic yeast infection. Tried everything. Nothing worked!

Great. I noticed she was booked for the end of the day so there was always the chance that she wouldn’t show up. The thought sustained me all that morning.

But of course, she did.

Quite an confident looking young woman in her early thirties walked into the office accompanied by her partner. Tight jeans and a bulky grey tee shirt announced her presence on the chair, a too-loud voice from an un-makeupped face made it echo around the room.

“I’ve just done a cleanse, but I thought I’d keep the appointment anyway,” she shouted defiantly. I suppose it wasn’t technically a shout, but it made my ears vibrate nonetheless. She glanced at her partner to underline the proof of the assertion, and then they both glared at me, in case I dared to disagree.

I’d never actually knowingly talked with anybody who’d confessed to a cleanse, and to tell the truth, I was a little vague on what it entailed. I thought I’d ignore the gap, and ran my eyes over the referral paper to make sure I had the correct patient. “So…” I said, noisily unfolding the referral letter on my desk -I often start this way, to demonstrate beyond a doubt that I am in possession of their doctor’s opinion- “Your doctor tells me you’ve had a yeast inf…”

Both their eyebrows shot up in unified derision of whatever it was that the letter contained. “Oh, don’t listen to her!” the partner interrupted in a softer, angrier voice. “She had no idea what was going on with Marcie…”

“Was..?” There was hope in my tone.

“I told you I did a cleanse!” Marcie said, almost reverently. And slowly, as if she were spelling the word out in her head.

I must have looked puzzled, because she produced an overly-tolerant look on her face, and smiled at me, the only slow one in the room.

“Cleanse!” She said it so slowly she seemed to caress the sound on the way through her lips. “It’s a way of ridding your body of its built-up toxins.” When my expression didn’t change, she continued after a maudlin sigh that her partner obediantly repeated. “The colon contains all sorts of toxins that build up over the years and stop the body from fighting off things like yeasts…” She rolled her eyes at the need to explain it to a specialist like me.

“So it worked?” I had meant it as a tentative acceptance of her information at first, but by the time the sound made it out of my mouth it had turned upwards into a question.

Her partner, Grace, seemed offended. “Of course it worked!” she said indignantly. “We both tried it,” she added proudly and smiled broadly at Marcie.

“The theory makes sense, when you think about it,” Marcie bellowed at the picture on the wall behind me. I could almost feel it rattle.

“Oh? Why’s that?” I was trying to be polite –there’s absolutely no evidence for its benefit in the standard medical literature. In fact the fecal microbiome is important for proper immune functioning- but I’m afraid that, once again, my words came out suggesting I was doubtful at best.

Her eyes narrowed and her face tightened –both faces tightened, actually- and she straightened her tee shirt as shocked as if I had sworn in church.

“There’s evidence,” she said and crossed her arms defiantly, satisfied that she had bested me.

I tried to look neutral –neither judging, nor rejecting her statement. “I…” It was all I could get out before she launched into a tirade.

“You doctors,” she roared, somehow managing to make ‘doctors’ sound like a disease. “You restrict your information to narrow little unreadable journals. You never read anything that disagrees with what you already think you know… Or, if you happen on it, you never read the whole thing…” I used the opportunity between her breaths to think about that one. Maybe she had something there… Confirmation bias is something we all struggle with.

She quickly turned to Grace who nodded in support. “There was a website I saw just last week that proves it…” She hesitated momentarily when I picked up a pen to write it down. In fact, she lowered her voice to encourage me.  It’s  http://www.tylervigen.com/

And then she laboriously spelled out each letter, including the forward slashes -in case I got them backwards, I suppose. “I just looked at a couple of them, but they were stuff you’d never find in your medical journals –and all statistically proven.”

I must have raised my eyebrows, because she quoted an example. “Did you know, for example, that the per capita consumption of chicken in the USA is correlated with the total USA crude oil imports? Don’t you find that strange? I mean stuff like that is proven, but they don’t want us to know about it.” She crossed her arms again.

I just concentrated on keeping my expression neutral, all the while trying to figure out how oil imports had anything to do with cleansing.

“And what about the margarine one, Marcie?” Grace added to overwhelm me with evidence.

Marcie nodded, somewhat annoyed she had chosen the chicken example, I thought. “Anyway, I’m betting it’s the same with colon toxins!”

And with that, they both rose in unison and thanked me for listening, all the while glancing furtively at each other. “We’ll come back if it doesn’t work out, though,” Marcie added as a sop to my dignity as she left the room.

As for my part, I felt disappointment at my inability to defend myself. Sometimes naivete is attractive, but usually it is just annoying. Incapacitating…

Out of curiosity, I looked up the website that night. Marcie must have skipped over the title, though -it was called Spurious Correlations. Or maybe she read it as ‘Curious’ Correlations… Anyway, I managed to find an article on it in the BBC News Magazine  http://www.bbc.co.uk/news/magazine-27537142

Somehow, I think they both missed the point of the website -written by a student at Harvard- that correlation does not equal causation. But maybe it wouldn’t have mattered: I didn’t read the whole thing…

 

 

 

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The Concept of Sober Second Thought in Medicine

Perhaps it is the vain attempt of Age to maintain its relevance in a time of incessant, dizzying innovation, but it seems to me there is something to be said for reflection before action.

We have here in Canada, a now much-derided political institution called the Senate whose members are appointed, not elected, and whose purpose is supposedly more to reflect regional differences than voter preferences (as in the other institution, the House of Commons). Approval of both institutions is required for legislation, although the Senate rarely rejects Bills passed by the more powerful and voter-elected House. Its purpose, at least according to Canadian myth, is to be a chamber of ‘sober second thought’, unsullied as it were by recent fads or the evanescence of events that might unwisely sway popular opinion.

While in practice, there is much to criticize about the Senate as an institution, the concept of ‘second thought’ is worthwhile.  And I see this as nowhere more important than in Health Care.

Our concept of health has evolved over the years as have our expectations. We no longer tolerate the intolerable with the equanimity of a century ago; at least in more affluent nations, we don’t expect children to succumb to infectious diseases, or women to die in childbirth. We assume there will be ever more sophisticated approaches to diabetes, treatments for autism, preventative strategies against heart disease… Knowledge conquers all.

But sometimes in our headlong rush to cure, we engender unrealistic -even unnecessary- goals. We unwittingly foster an assumption that living through life’s vagaries needs to be asymptomatic -or at least should be. And while I’m sure most of us understand the need for priorities in health care, its boundaries are, at best, often vague, and usually personal. This is to be expected: we enter the world of medicine only when there is a need, a worry -a symptom.

Symptoms are puzzles waiting to be solved, questions as yet unanswered. They do not always bespeak disease, of course; many point to an underlying concern, an anxiety that needs as much exploration as the condition feared. But the solution -the diagnosis and subsequent management- is not always as straightforward as it might seem. Not all symptoms require intensive investigation; not all conditions require treatment. And while all symptoms require explanation, most conditions also require options -and that is different.

The rush to cure leads down different roads, and not all of them pleasant -not all of them even necessary. An example from my specialty, gynaecology, might be illustrative. Let’s say a 48 year old woman is discovered to have fibroids (benign overgrowths of muscle tissue in the wall of the uterus) during a routine physical examination when she has her pap smear. She didn’t know she had them, had no symptoms that concerned her, and would no doubt have carried on her with life blissfully unaware of what lurked so silently just underneath her skin… But she is told she has some uterine tumours by her well-meaning family doctor. She is then told she needs an ultrasound -just to be sure they are fibroids- and is referred to a specialist for management.

The woman is understandably concerned about the ‘tumours’ growing inside her, and has probably talked to those of her friends who have had problems with fibroids, researched the issue online, and then arrived at the office primed for treatment. And there are many treatments -or at least, many variations on the theme of the need to treat. The usual approach has traditionally been a surgical one -with all the usual permutations and combinations that depend on the prevailing wisdom of the medical center or the research project currently underway. And then, of course, there are the medical and other non-operative methods -some new and sparkled with hope, some castigated online for the side-effects. As I have said, the need for cure can be all-pervasive, all consuming. And perhaps an imperative: anything less is a disappointment -a failure.

And yet the problem -at least in the case I have outlined- is not so much the fibroids, as the attitude attending them. They were, after all, aymptomatic, aproblematic, and indeed a concern that needn’t have been. Most will shrink after the menopause when there are no longer any stimulating hormones -and at 48, that time is not likely to be in the too distant future. Doing nothing, in other words, is acceptable; a ‘cure’ is unnecessary…

Yes, they could be treated -and heaven only knows they often are- but in her case, why? She needs an explanation, reassurance, and a promise of follow-up should any new questions or issues arise. You might think I have chosen a special case, an anomaly whose rarity shouldn’t really affect our exciting and ever-evolving management strategies. And it shouldn’t -there is much to learn, much to improve. We need cures for cancer, better and more effective vaccines, more inclusive and affordable Health Care… And yet sometimes we need to step back and decide what is truly worth pursuing and to what end; decide whether our goals have blinded us to the value of perspective. Knowledge without perspective is not wisdom; it is detail… It is Hope unsummoned.

The Senate may have something to teach us after all… despite itself.