Noceboes? How Cute.

I have always been fascinated by neologisms –new words that substitute for more commonly used ones. They can be clever, rude, or just plain silly, but often their point is to get noticed –or perhaps draw attention to their inventors. There was a time –before social media, at least- when we used to applaud people like Shakespeare for turning nouns into verbs, or adjectives into more active participants. And it was a time when elders, if they forgot the word for which they were searching, would simply come up with a new one. Of course, they still do, but it is often  lost in the ebb and flow of media utterage (pardon the neologism). I have written about this before in another context, but the subject continues to intrigue me: https://musingsonretirementblog.com/2016/05/22/what-did-you-say/

This time, however, I was more interested in the clever contrast of nocebo with the word it was replacing, placebo, that was reported in an article in the CBC health news: http://www.cbc.ca/news/health/nocebo-effect-greater-expensive-drugs-1.4358664

I suspect we’re all acquainted with the placebo effect: the ability of a harmless, inactive substitute to have a beneficial effect if it is believed to be the treatment. Again, I have covered this in a previous essay: https://musingsonwomenshealth.com/2016/04/20/rethinking-placebos/

But there seems to be no end to our ability to fool ourselves, and the concept of ‘noceboes’ is yet another illustration. ‘The opposite of the placebo effect — perceived improvement when no active medicine is given — nocebo is the perception of negative side-effects from a benign “medication” in a blind trial.’

The article reports on a study published in the journal Science, which suggests that ‘Expensive medicines can seem to create worse side-effects than cheaper alternatives.’ This particular investigation ‘focused on the pain perceptions of patients who were treated with creams they believed had anti-itch properties but actually contained no active ingredients.’ And, as one could no doubt predict from the title of their publication, Nocebo effects can make you feel pain, ‘Though the scientists ensured the temperatures applied to the two creams were consistent, those who received the expensive cream rated their pain as nearly twice as intense as those who received the cheaper cream. The study suggested that patient expectations related to price can trigger brain responses resulting in higher perception of pain, said Alexandra Tinnermann, a co-author of the study and neuroscientist at University Medical Center Hamburg-Eppendorf.

‘Tinnermann’s team used a functional MRI scanner to identify areas along the spinal cord that were activated during participants’ experience of side-effects. They also pinpointed two brain regions that were more stimulated among participants who believed they received the expensive drug.’

The ethics of using placebos –tricks- is one thing, but what about those of choosing between several recognized and approved medications where the only difference is the price? On the surface, it might seem to be a saving for all concerned. If the data hold up in further studies, why prescribe new and probably higher cost medications, if they’re more likely to have side effects?

Unfortunately the very ethics that require medical practitioners to discuss the possible side effects of any medication, are also known to influence the experience. Knowledgeable patients report more side effects than those who, for whatever reasons, are blissfully unaware of what to expect. Perhaps it’s more a question of which of Pandora’s boxes the practitioner should open -a zero sum game, no matter.

I was sitting on a park bench in the shade of a tree one sunny summer day, trying to finish a book a friend had loaned to me. It wasn’t very interesting, despite her recommendations, and although I was determined to discover what she had liked about it, I found my mind looking for excuses to put it down. My ears soon found a distraction. Two little boys had abandoned their bikes on the  grass nearby and were engaging themselves in scaling the leafy tower of what I had assumed was my own special shade tree. Hidden by several bouquets of leaves fluttering gently in the afternoon breeze, I suppose they thought they were invisible in their private redoubt.

“Thought you were sick, Jay,” one of them said, as if he wondered if he was in danger of catching whatever Jay had.

“I’m on antibiotics, Jordan,” the other answered defensively.

They were silent for a few moments, although I could hear them grunting as they climbed ever higher.

“My mother doesn’t believe in them,” a voice, probably Jordan’s, said very firmly.

“Why?” was Jay’s surprised reply.

Jordan was silent for a moment, clearly trying to remember. “She says they can make you sick.” Even from my position far beneath them, I could almost feel Jordan’s italics.

“How?”

Another, grunt-filled silence as they switched branches. “She says they can make your skin go red…” He hesitated for a minute while he combed through his memory. “And give you… make you wanna throw up.”

Jay seemed to hesitate before answering. “Well, I’m not red or anything, but… uhmm, sometimes I do feel a little like throwing up, I guess. Anyway I have to go to the toilet a lot, so it’s hard to tell.”

“She says that’s what happens with them too, Jay. It’s why I just take vitamin pills.”

“My mother says those don’t usually work… People only think they do.” Jay felt a need to defend his antibiotics. “Mom says we imagine things sometimes…”

“Like what?” Jordan sounded sceptical. For a while, I could only hear the leaves rustling, so I wasn’t sure if they’d already climbed too high to hear.

“Like… Like that vitamins can keep us from getting sick.” I could hear one of them shifting somewhere above as a branch cracked. “And she says some people won’t take antibiotics because they’re afraid of, uhmm…” He hesitated, while he searched for the right word. “…the side-stuff.”

“You mean ‘side-defects’?” Jordan pronounced the words carefully, condescension fairly dripping from his words.

“Yeah. She says if they hear about the defects, they figure they’ll get them.”

“Well my mom says doctors have to tell people about them, though, Jay… It’s the law.” He added smugly.

Jay seemed to think about it for a second. “Then no wonder, eh?” he said, as if he finally understood.

“No wonder what?”

“No wonder people get ‘em,” Jay answered, triumphantly.

From the mouths of babes.

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Trippingly on the Tongue

I’ve always liked the poetry of metaphor with its imagery revealing nuances hiding shyly in the background. Words alone sometimes convey their meanings too narrowly, whereas metaphors allow imagination to roam more freely, only loosely tethered to definitions. After all, depending on the context of its use, meaning is often reliant on Weltanschauung. Such is communication; language is only the messenger.

Usually one can imprison meaning, of course -confine it in a cramped little box from which, should it ever escape, it would cease to be useful. Indeed, it would be a Pandora’s box from which it escaped. And yet, even there, what remained inside after all the mischief and malevolence had escaped, was Hope. Maybe that’s what metaphors are: unexpected colours leaking from behind the bars… Liberations.

Of course, metaphor is value-laden as well as culture-dependent. One society’s metaphors do not always translate into that of another -hence the difficulty of truly understanding and appreciating the poetry of another nation, especially if it must be converted into a different language. It made me wonder whether there may be similar disparities with gendered interpretations of metaphor.

There was an interesting article in BBC Future a while ago that caught my eye: http://www.bbc.com/future/story/20170718-the-metaphors-that-shape-womens-lives It made me realize that there are many ways the genders differ. Of course, it may be that when we hear an unusual expression for the first time, we (either sex) cling too firmly to denotative -definitional- aspects of the words for interpretational safety, when the more imaginative and unexpected connotative sense is what was intended all along. And it’s in the connotation -the metaphoric significance- where we differ…

For example, what is a ‘glass ceiling’? ‘Originally popularised by Gay Bryant at the height of the feminist movement in the 1980s, it’s a widely used term today that describes an invisible barrier that keeps women from occupying executive positions. The metaphor suggests that women should aspire to ‘break through’ the ceiling – but the problem is that it describes only the women reaching up, rather than, say, the men that are peering down from the top. This arguably places unfair responsibility on women to smash the ceiling, rather than focusing on the role of men in creating and maintaining it.’

There are other metaphors in use of course, often involving glass -presumably to convey the idea of invisible barriers to movement for women. So, the ‘glass cliff’ which depicts the idea of  ‘how senior women are often hired for risky and precarious roles at times of crises’ and therefore making them look bad if they fail to succeed. Or, the non-glass example of the ‘sticky floor’, which describes how women often feel stuck in low-wage jobs where career ascension is unlikely.’ 

But, handy as they are in explaining often complex topics, metaphors -in these contexts anyway- tend to oversimplify the problems ‘offering only a specific angle or viewpoint that isn’t the full picture.’ They confine us to viewing the world through a narrow aperture -a spotlight that illuminates only one small part of the stage. ‘“Women are the effect to be explained,” says Michelle Ryan, a psychology professor at the University of Exeter. “We never talk about men being overconfident, we always talk about women being underconfident. And we never talk about men having privilege or finding it easy; we always talk about women finding it difficult.” Ryan believes that the metaphors we’re using to describe women at work reflect the world’s androcentricism [sic] – our insistence that, even in 2017, we consider the male experience as “the norm”’

The issue is not entirely one-gendered, though. There is the concept of the ‘glass escalator’, a term occasionally applied to men in female-dominated industries that ascend to upper ranks more quickly than women. And yet, as Caren Goldberg of Bowie State University in Maryland points out, metaphors are employed when there is an “exception” to the rule or gender stereotype.’ So in the example she cites, it was applied to a male nurse (in a predominantly female dominated profession at the time) and implied that he probably chose nursing because he wasn’t able to get in to medical school.

‘The obvious upside of any these metaphors, however, is that they highlight social phenomena that might otherwise remain invisible and therefore impossible to resolve. But in order to address the circumstances that lead to women being held back, and men rising seamlessly, it shouldn’t be forgotten that metaphors simplify complexity.’

In an admittedly convoluted way, it reminds me of a woman I met the other day at a bus stop. I suppose I only met her by default, really -nobody would stand beside her because she was exhibiting a rather odd behaviour -probably Tourette’s syndrome, I’d thought at the time. She would be standing quietly at the curb, and then suddenly bend forward and seem to be vigorously cleaning and polishing something above her. This would last for a few seconds, often becoming more and more frantic, and then subside, leaving her once again peaceful, although by the look on her face, perhaps not content.

She was in her thirties, I would guess, and dressed quite respectably in a blue pant-suit, with a spotless white blouse and short stubby earrings that would be unlikely to achieve any unwanted momentum during her seemingly randomly timed tics. Her auburn hair was sensibly short and her makeup intact as far as I could tell. Apart from her odd movements, she seemed like a typical business woman on her way home from work.

And, when she moved beside me in the now-disrupted line up, she smiled apologetically. “I’m sorry, sir,” she said -hurriedly, I thought, in order to explain herself before she was once again overcome by the movement. “It’s just my latest tic…”

At that point and without any obvious warning, she launched into another bout of scrubbing something invisible over her head. I tried to pretend I didn’t notice, but she wasn’t fooled.

“I think stuff at work must have kicked this one off,” she said and then blushed.

“What do you mean?” I asked, genuinely interested.

She stared at me for a moment, perhaps wondering if it was something appropriate to confess to a stranger at a bus stop. Then her smile returned briefly before the tic arrived again.

“They’re all used to me at work,” she explained when she was able to. “But the boss isn’t.” She risked a sigh to indicate her frustration. “I mostly just repeat words to myself so they’re not as disruptive. But occasionally a movement takes over, and that’s what he doesn’t understand… Or like. I think he wonders if I’m actually mentally handicapped, or something.

“Anyway, even though I’ve been working there as an accountant for almost ten years, he’s never promoted me. I’m well regarded by my colleagues, and they’re almost all men…but…”

I could see a sudden change in her face as she leaned over the curb and the tic began again.

“But my friend Amrita thinks it’s just the glass ceiling that’s holding me back,” she said, once again in temporary control. “And yet, I’m not certain that reassures me…”

Her bus pulled up suddenly, and she stepped onto it like any other passenger, and was gone. I saw her smile at me through the window when she found a seat though, and I nodded in a friendly recognition of what she’d shared with me. But, like her, I’m not sure her friend was right -ceilings are not the only battles.

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.