In choice, we are so oft beguiled

It’s interesting just how important categories are in our lives, isn’t it? I mean, let’s face it, often they’re just adjectives –subordinate to their nouns. Add-ons. And yet, they can frame context, colour perception, and even determine value. Some, like, say, texture or odour may be interesting but trivial; some –size, or cost, for example- may be more important although optional in a description. There are, however, categories that seem to thrust themselves upon an object and are deemed essential to its description, essential to placing it in some sort of usable context. To understanding its Gestalt. These often spring to mind as questions so quickly they are almost automatic. Gender is one such category, age, perhaps another. And depending, I suppose on the situation, the society, or even the category to which the listener belongs, there may be several others that are deemed necessary to frame the issue appropriately.

The automaticity of a category is critical, however. If the category is felt to be of such consuming importance that it needs to be established before any further consideration can be given to the object, then that object’s worth –or at least its ranking- is contingent. It is no longer being evaluated neutrally, objectively. It comes replete with those characteristics attendant upon its category –intended or not. Age, for example, wears certain qualities, incites certain expectations that might prejudice acceptance of its behaviour. Gender, too, is another category that seems to colour assumptions about behaviour. So, with the assignation of category, comes opinion and its accompanying attitude.

One might well argue about the importance of these categories, and perhaps even strategize ways of neutralizing their influence on reactions, or subsequent treatment. The problem is much more difficult if knowledge of the category is so necessary it is intuitively provided as part of what is necessary to know about, for example, a person.

I suspect that in my naïveté, I had assumed that foreknowledge of many of these categories was merely curiosity-driven. Politeness oriented. Important, perhaps, so that I wouldn’t be surprised -wouldn’t embarrass the person at our initial encounter. But I am a doctor, and maybe see the world from a different perspective. A piece in the BBC, however, made me realize just how problematic this automaticity had become. How instinctive. http://www.bbc.com/future/story/20130423-is-race-perception-automatic?ocid

The article dealt mainly with its effects on racism, and the difficulties of countering it if we accept, as some evolutionary psychologists seem to believe, that it is basically intuitive. Evolved for a reason. Wired-in. ‘[…] if perceiving race is automatic then it lays a foundation for racism, and appears to put a limit on efforts to educate people to be “colourblind”, or put aside prejudices in other ways.’ But, as Tom Stafford, the author of the BBC article puts it, ‘Often, scientific racists claim to base their views on some jumbled version of evolutionary psychology (scientific racism is racism dressed up as science, not racisms based on science […]). So it was a delightful surprise when researchers from one of the world centres for evolutionary psychology intervened in the debate on social categorisation, by conducting an experiment they claimed showed that labelling people by race was far less automatic and inevitable than all previous research seemed to show.

‘The research used something called a “memory confusion protocol” […] When participants’ memories are tested, the errors they make reveal something about how they judged the pictures of individuals. […] If a participant more often confuses a black-haired man with a blond-haired man, it suggests that the category of hair colour is less important than the category of gender (and similarly, if people rarely confuse a man for a woman, that also shows that gender is the stronger category). Using this protocol, the researchers tested the strength of categorisation by race, something all previous efforts had shown was automatic. The twist they added was to throw in another powerful psychological force – group membership. People had to remember individuals who wore either yellow or grey basketball shirts. […] Without the shirts, the pattern of errors were clear: participants automatically categorised the individuals by their race (in this case: African American or Euro American). But with the coloured shirts, this automatic categorisation didn’t happen: people’s errors revealed that team membership had become the dominant category, not the race of the players. […] The explanation, according to the researchers, is that race is only important when it might indicate coalitional information – that is, whose team you are on. In situations where race isn’t correlated with coalition, it ceases to be important.’

I don’t know… To me, this type of experiment seems so desperate to appear to be wearing a scientific mantle, that it comes across as contrived –kludged, if you’ll permit an equally non-scientific term. But I take their point. If there is some way of diffusing the automaticity of our categorizations –or at least deflecting them into more malleable descriptors –teams, in this case- perhaps they could be used as exemplars –wedges to mitigate otherwise uncomfortable feelings. Placeboes –to put the concept into more familiar language for me.

Stopgaps, to be sure, and not permanent solutions. But sometimes, we have to ease into things less obtrusively. Less confrontationally. A still-evolving example -at least here in Canada- might be gender bias in hockey. Most Canadians have grown up exposed to hockey, and might be reasonably assumed to have an opinion on the conduct of games, players, and even rules. And yet, until relatively recently, the assumption was that hockey players –good ones, at least- were male. For us older folks, it was automatic. No thought required; no need to ask about gender. But no longer is that the case. For a variety of reasons, there is still no parity, and yet it is changing –slowly, perhaps, but not conflictually. And so, despite any initial challenges, is likely to succeed.

Am I really conflating success in the changing mores of hockey with gender equality? Or basketball teams and how we view their members, with racial equality? Am I assuming that diminishing discrimination in some fields leads to wider societal effects? Yes, I suppose I am. A blotter doesn’t care about the kind, or the colour, of the ink it absorbs; it’s just what it does. What it is. And, in the end, isn’t that what we all are, however vehemently we may protest? However much we may resist the similarities that bind us in relationship for fear of losing our own identities?

But if we step back a little, we may come to appreciate that the correlation need not be like that of a blotter -need not involve a team, or a marriage… I am reminded of the advice from one of my favourite writers, the poet, Kahlil Gibran: Love one another, but make not a bond of love: let it rather be a moving sea between the shores of your souls.

It’s the way I prefer to see the world, anyway…

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The Bicameral Mind

Time to unwrap the Jeremiad again, I’m afraid; I’m getting tired of this. Really tired. I know it’s an American thing, but stop it will you? Or can you? Every time there’s a bicameral shift it tears the fabric a little more and unravels what I want to believe about your country. Yes, I’m Canadian and watching with unvetted eyes I guess, and yet sometimes it is good to hear from the other side of the mirror. To listen to the indrawn breath and pause to look around. Sometimes acumen travels in disguise: the dusty traveller leaning on the fence, the unwashed face of Vishnu. Wisdom does not always wear a flag.

One of the things I’m referring to, of course, is the perpetually probationary status in the United States of both family planning and pregnancy termination. Women’s rights seem contingent upon the prevailing ideology, their status as stable as the government in power -guaranteed only conditionally, and as changeable as the pen that underwrites them.

As a non-combatant, I suppose I should only listen with firmly closed lips; perhaps the border should be a closed curtain so I cannot see through. And maybe I should apologize for being so critical, but when is this vacillation going to stop? I accept that there are valid differences of opinion, and that any decision is inevitably temporally adjudicated. Times change, and so do populations and their ethnic and cultural compositions. It’s happening to us all. But surely the answer isn’t to retreat behind the doors and barricade the walls.

And defunding organizations that seek to address the issues of involuntary overpopulation would seem unduly parochial and even internationally misunderstood. It is the special duty of an enlightened nation to accept that there are many roads and many destinations. It has, it seems to me, the burden of reasonable neutrality, grounded observation, and judicious guidance.

The issue, I think, should be one of choice not fiat. Conscience, not doctrine. To offer alternatives is not to coerce, nor to prejudice the selection; it is surely to achieve the goal for which the options were offered in the first place. Not all things are equally acceptable; not all choices are politically or culturally permissible, to be sure. So a variety of solutions might have a greater likelihood of admissibility. A greater possibility of success.

Several years ago, I travelled to the States to attend a gynaecological convention and discovered that not only was pregnancy termination still an inflammable topic for many delegates, but even the provision of Family Planning counselling for whoever requested it. I found this hard to understand, especially at a meeting of specialists in the field.

I remember questioning one of the doctors I met there and she rolled her eyes at my Canadian naïveté. “Do you remember that fable of Aesop called ‘the Belly and the Members’?” Now I felt really naïve because I had to shake my head.

She seemed surprised. “Well,” she said, after interrogating my face for a moment to make sure I wasn’t kidding her. “The version my daddy told me when I was young went something like this. One day, after carrying the body through a long day of heavy work, the feet complained that they seemed to be the only ones in the body who had to work. Of course the hands argued with them that they were the ones who should complain -the feet may have carried the body, but they had to carry and even balance the load. The only thing they could agree on, after a long argument, was that although the four of them worked all day, in the end it was the stomach who got all the food.

“So, they devised a plan. The feet refused to walk to the stove, and the hands refused to pick up any food.”  The doctor smiled at this point and pierced me with her eyes. “And you can guess what happened after a while… They all got weak and finally had to agree to work together. Only the stomach could give them the strength they needed.”

She giggled at the end and touched my arm playfully. “I can’t believe you didn’t know that one, doctor.”

I hate it when a colleague calls me ‘doctor’, but I let it pass. “And I take it the fable is telling us that we all have to work together, no matter that we’re different? And that we can all have different opinions?”

Her expression changed and a puzzled look crept onto her face. “Never thought of that, actually… My daddy said it meant that we all have our jobs, but need someone –something- watching over us to give us strength and direction… Reminding us of what we should do. He said the Stomach was our Conscience… But I think he really meant the President… Or maybe the Lord…” She shook her head in apparent disbelief at my interpretation. I blinked, because it didn’t make sense to me. I wondered if she’d remembered it wrong.

“You must have similar fables even up there in Canada…” I could tell she was trying to understand my confusion. Transcend boundaries.

“Well,” I started, just like she had, “I do remember one about chopsticks…” She smiled at my multiracial example –so Canadian. “It was something one of my Chinese patients told me after giving me a little gift for delivering her baby. She said her father had told her this when she was a child.

“’There was an old man,’ she said, ‘who was close to death, and worried about what would happen after he died. He decided to ask the wise village elder if he knew what it would be like in Hell. The elder smiled and told him to imagine a large room filled with people. ‘They are all thin and hungry,’ he said ‘even though there is food everywhere.’

“’Then why are they so thin,’ the old man asked?

“’Because their chopsticks are each ten feet long,’ was the answer.

“The old man thought about it for a minute. ‘And Heaven,’ he asked, ‘What’s it like in Heaven, then?’

“The elder laughed. ‘Imagine another large room. There is food everywhere, but the people are fat and happy in spite of their ten foot long chopsticks…’

“The old man was puzzled. ‘But… I don’t understand.’

“The elder smiled and put his arm around the old man. ‘In Heaven, they feed each other…’”

Perhaps, I thought, after watching my colleague’s reaction, perhaps there is something more profoundly different about our two countries than simply the colour of our mailboxes…

The Polarization Bias

Okay, I have to admit to living an unbeknownst lie –unbeknownst to me, at any rate. Sometimes it is easy to coast, to accept help where it is offered and feel almost foolishly grateful for suggestions that foster the dependence. Advice is seductive, guidance addictive. But more importantly, it is insidious. Critical thinking -critical analysis- suggests that we process whatever information we are offered by considering its validity when compared with other sources, other viewpoints, other contexts. It is what we should do; it is not what we usually do. Time constraints, biases, laziness –they all conspire to let us float on the tide. Drift.

I suppose my awareness of the current may have started when I was casting about for a book to read. Like many of us, I have a passion for reading that is naively open to recommendations. The online Amazon book store is an almost limitless cornucopia of books. And when you click on one, a section appears just beneath your choice that says: Customers who viewed this item also viewed… And a list of similar books on similar subjects is just a click away: a topic-specific, yet unrequested bounty spilling onto the screen. And all with seemingly different approaches but eerily similar viewpoints to the book you’ve chosen. A coincidence? Or a recognition that you have a particular worldview whose advocates you are more likely to read? And buy.

At first, I was both pleased and amazed that Amazon could find so many different authors and topics that I found compelling and place them before me like a waiter with a dessert tray. So easy to choose from only what is offered –too easy… What I initially thought of as a diverse array of well-considered opinions, I began to realize was an artfully arrayed selection that fostered my already-held biases. A compass that always pointed north, no matter the coordinates.

I suspect that most of us, even offered the choice, would find no compelling reasons to change allegiance, or flirt with opinions we have been taught to mistrust. We feel uncomfortable accepting that the opposition feels the way it does on grounds that are equally persuasive for it. Rather than being open even to thought-provoking alternative ideas, we rust into positions that further restrict our ability to move.

But what if the news we so avidly ingest nowadays could be similarly sorted to our tastes and presented to us as a fair representation of what is really happening? How would we know of the manipulation? How could we become aware of the slanted viewpoint when it so closely agrees with our own –when it is what we want to hear? Confirmation bias is difficult to resist even at the best of times.

http://www.huffingtonpost.com/2015/05/12/facebook-study-polarization_n_7245192.html?utm_hp_ref=world&ir=World

I hadn’t realized that many people actually read those snippets on Facebook that purport to inform. I had thought most of them were not terribly well disguised ‘infomercials’, but perhaps that is my bias -the boreal plain to which I am unwittingly confined. But that our serving of news should be chosen for us according to our likes and dislikes is anathema. And that our meal of information should be expurgated and mashed into a small, more easily digestible aliquot of words smacks of propaganda. Control. Handling… I would like to digest unchewed information in my own way, thank you. I can deal with heartburn; I’m not good with starvation.

http://www.bbc.com/news/technology-32707014

The dilution of mainstream media and its as-yet relatively unfettered ability to pretend to present both sides of an argument is worrisome. Similarly, the accretion of our sources of information into a few huge monolithic blocks with their own interests to serve is dangerous. Especially when they presume to know what opinions will keep us quiet.

“Let every eye negotiate for itself and trust no agent,” says Claudio, in Shakespeare’s Much Ado About Nothing. Bravo!

The Tampon Tax

I have to admit that I am sometimes puzzled. Not, you understand, to suggest that I am omniscient at other times, but merely that I, too, am apt to get lost in the various back alleys of our government. They seldom come with maps; they are not meant for untroubled navigation. In fact, I suspect they are purposely labyrinthine –not to encourage questions, but so you can be misdirected more effectively.

I recognize that to run a bureaucracy, decisions have to be made that may not be popular with some, and that for the sake of continuity and efficiency these should not be subject to change on a whim. But sometimes their perusal in daylight reveals egregious errors in judgement, wisdom and even fairness. I also realize that in a caring society, those less fortunate than the majority, those with unmet needs, and those who are unable to access the ears of government should be folded into its bosom. For example, items necessary for health or daily living are usually exempt from extra taxation –value-added taxes (Goods and Services Tax –GST in Canada). It is an assurance that those with special needs –incontinence products, for example- will not be unduly penalized. Admittedly, it is only a small concession, but at least it is an acknowledgement that we are all part of a community, an affirmation that we are all noticed and our differences accepted, if not totally underwritten. There are benefits accruing to membership in Society.

Of course in a democracy the majority will derive the most benefits, if only because it has chosen the government. As long as the minority is not oppressed, ignored, or denied the benefits offered to the rest, I think this is reasonable –or at least the most ethical compromise short of requiring them to abrogate their identity, or leave the country if this is not possible. No, Canada is a multicultural mosaic as we are fond of saying; we cherish difference and relish the weft and woof of our societal fabric.

And yet it seems a discrepant appreciation -an arbitrary one still rooted in attitudes so deeply ingrained that they are visible to those in power only through a public outcry when it threatens their incumbency.

I have long wondered about society’s attitude to menstruation: https://musingsonwomenshealth.wordpress.com/2014/11/26/menstrual-taboos/

Admittedly, we in the West have come a fair way already. The topic is no longer taboo in our public media and, except for the more provocative advertisements for menstrual products, barely provokes an eyebrow. Necessity is the Mother of conversation. And yet the Canadian Government –and the governments in several other countries as well, it would seem- has yet to hear it. If, as I have said, items necessary for health or daily living are granted a tax exemption, then what has it been thinking all this time? Or do Governments think?

http://www.huffingtonpost.ca/2015/02/18/no-tax-on-tampons_n_6705022.html

Why menstrual products should be ignored as necessities is beyond me. It can’t be that the issue is a minority one that can be conveniently hidden, or assuaged by a few photo-ops like those assuring a small northern community that the government is indeed looking into building a skating rink for them; this is a 50% issue. Nor could it be construed as a definitional discrepancy: if contact lenses are covered by the dikat, then there’s certainly no argument to exclude menstrual products. Except…

Well, except that those taxes are probably a rich revenue source, for one thing. But, more troubling, is it a remnant of a long-buried attitude towards women and their place in our society? The previously ignored tip of a huge iceburg? A sleeping tiger that government would rather step around –ignore but not arouse?

There are braver souls, however. Individual colours that have managed to disengage themselves from the wallpaper we all wear. Patterns previously unappreciated as they slept undisturbed and unprovoked in the background:  http://www.cbc.ca/news/canada/british-columbia/tampon-tax-petition-collects-more-than-50-000-signatures-1.2974155

It would be well for those in charge to walk carefully. The tiger is huge. Feed it. Nourish it. Befriend it.

Opinions

I am sometimes bewildered; I live in an ever-changing sample of opinions -often at odds with my own. In many circumstances I would welcome, even encourage this potpourri, but usually the people holding these often colourful bouquets have come to me for answers, not more flowers. But what is it that differentiates an answer from an opinion?

In the Great Age of Internet what are we to do with the information the patient brings with her problem: the carefully harvested compendium of facts that seem to apply -if only peripherally- to her condition, the assortment of variations inherent in any garnered explanation, the pastiche of expertise purporting to supply if not the answer, then at least the diagnosis? It sometimes presents as much of a challenge as the condition for which my opinion was originally sought.

I suppose I should be grateful for any help I can get. We are all unique, and diseases -conditions- manifest themselves idiosyncratically on occasion. But it is often the patient’s attachment to their research that presents the difficulty. I suppose we are all wedded to our autonomy and our ability to process and analyse any unusual facets of reality that confront us -it is why we still exist as a species, after all. And there is value in the ability to assume control of a situation, not to be overwhelmed by it -victimized by it. Characterization, classification and enumeration of symptoms are a shared responsibility after all. As a specialist, I rely on it.

But perhaps there is a threshold phenomenon at work here: it is not so much the amount of data, as its quality and relevance that obtains. The fact that a fishing net contains a hundred sundry fish, including the one salmon that I need to solve a puzzle does not necessarily increase the value of the catch. And I might even miss the seeing the very thing I want in all the bounty. Abundance is not always a luxury; it is sometimes an encumbrance, a millstone. It often carries with it the obligation to follow it even further into a morass of inapplicable detail -misleading detail, beguiling detail.

And even if there is no misdirection, no distraction, there lurks the danger of the proposed solution. While it may be obvious that there are often many ways to resolve an issue, it may be less so that not all paths are equal -either equally effective, or equally safe. Solutions are contingent on many things, one of which is the quality of evidence upon which they are based. Solutions are often multifaceted, requiring a blended approach, even a multidisciplinary one. The sheer number of permutations and combinations does not lend itself to a superficial or naïve analysis. Dragons lie that way.

So, one of the more worrisome effects of the extensively researched and therefore convincing self-diagnosis is the proposed treatment regimen. Even assuming an appropriate interpretation of symptoms and an arrival at the gates of a congruous synthesis, the suggested solution can be problematic. Where it merely involves a class of medications, I can usually suggest more readily available alternatives: safer or less expensive drugs -although even here, brand names often accompany an optimal resolution in whatever research to which the patient has been privy. I don’t necessarily mean to suggest conflicts of interest of the researchers so much as difficulty for the untrained and -in that respect- unsophisticated patient in separating wheat from chafe.

It is even more difficult to explain why a particular procedure, or diagnostic modality may not be available to them. Or why I do not possess the skills to perform a surgery only recently described in another country or even another region. Worse, from their perspective, perhaps I have not even heard of it.

All of this is certainly not to denigrate patient participation in their own care, or involvement in seeking a solution. It is perhaps to highlight an evolving process in which we are all partners in health care, each having contributions to make and suggestions to offer. The extent -and value- of the contribution from each party has yet to be established however, and I suspect it will be an ever-moving target for some time.

But is the era of the expert -the doctor- running its course? Will it ever be sufficient to feed one’s symptoms into a computer program (presumably one already acquainted with other unique and personal biometric and physiologic attributes) and await the diagnosis and treatment? There are programs right now that purport to facilitate such things for doctors; is it just a matter of time before they escape into a more public domain?

Or is there truly something more important and distinctive about the doctor-patient encounter: the listening, the body language, the obvious empathy? Is it only the doctor’s opinion that is so important, or is it something else as well? Of course the opinion must be rooted in fertile and appropriate soil; of course it must embody a well-considered analysis of the data presented. But if that were all, would it suffice for most of us? Or do we want -no, require- more than that? To be heard by another..?