Did you say something?

There is often a lot more to conversation than meets the ear -hidden things, unstated things- but for some reason, we usually still understand the message. I’d never really thought about this, to tell you the truth, although I was an unwitting acquiescent, I suppose. It’s  easy enough to assume that everything is context driven… until it isn’t, that is. So, sometimes an explanation of the rules can be helpful.

How, or why I stumbled over an essay by the philosopher Maria Kasmirli from the University of Sheffield, I’m not certain, but I was fascinated by the subject: conversational implicature: https://aeon.co/ideas/what-we-say-vs-what-we-mean-what-is-conversational-implicature

Maybe it was the idea of implicating someone in something without their knowledge or consent that intrigued me, although to tell the truth I was just curious about the process rather than the crime. I really had no information on the nature of conversational implicature.

Kasmirli starts off with an example of a letter of reference that merely suggests that the applicant is a nice person. It does not say whether or not they would be suited to the job. The dilemma that this raises for the interviewer then, is whether the reference deliberately avoided mentioning whether the applicant was suitable (because he wasn’t), or whether, in fact, he was. The inference was, of course, that he wasn’t suitable; the meaning of this indirect message is an implicature.

This term was apparently coined by the British philosopher Paul Grice who ‘distinguished several forms of implicature, the most important being conversational implicature... [which] depends, not on the meaning of the words employed… but on the way that the words are used and interpreted… conversational implicatures arise because speakers are expected to be cooperative – to make contributions appropriate to the purpose of the conversation in which they are engaged. More specifically, they are expected to follow four conversational maxims: (1) give an appropriate amount of information; (2) give correct information; (3) give relevant information; and (4) give information clearly.’

‘According to Grice, a conversational implicature is generated when an utterance flouts one or more of these maxims, or would do so if the implicature weren’t present. In such cases, we can preserve the assumption that the speaker is being cooperative only by interpreting their utterance as conveying something other than, or additional to, its literal meaning, and this is its implicated meaning.’ That makes sense, I suppose…

So, in the example of the letter of reference, ‘the information she (the letter writer) gives is obviously insufficient, flouting the maxim of quantity. Hence, we infer that she is trying to convey something else, which she doesn’t wish to say directly, and the obvious conclusion is that what she’s trying to convey is that Smith [the applicant] is unsuitable for the job.’

Unfortunately it sometimes suggests something else, though: ‘sometimes an implicature arises in order to prevent a flouting. Suppose you need petrol and someone tells you: “There’s a garage around the corner”… If the speaker did not believe that the garage was open, then their reply would violate the maxim of relation, so to preserve the assumption that they are being cooperative we must assume that they do believe it is open.’ Context is everything, I suppose. And anyway, ‘conversational implications can always be cancelled by adding a further statement.’ Like, Smith is not only a nice person, but he is also well qualified for the job. There could also be some legal implications if you equivocate, or deliberately don’t mention something of course.

I imagine that most of us have an intuitive grasp of conversational implicature however, although I suspect that much of it is probably culturally driven. Grice’s approach is also much more complicated and disputed than was evident in Kasmirli’s essay, but nevertheless she simplified the concept enough that non philosophers (like me) could understand the basics.

The article was particularly relevant to me as I reminisce about the many letters of reference I was asked to write for my undergraduates over the years. I am a retired Ob/Gyn now, but looking back, I’m not entirely sure that I grasped the importance of all of Grice’s conversational maxims; I’m sure that I inadvertently flouted more than one of them on occasions. Of course, I always tried to respond truthfully, but as to clearly… Well, sometimes I felt it more appropriate to approximate my assessments of the candidate’s credentials, but gently, and carefully, so as not to negate them. Of course, neither did I wish to unleash someone on the public that the program would regret. Sometimes it’s a fine line…

I can still recall one inventive student in his final year of training who always seemed to be trying to find unusual ways of practicing the specialty in order to resolve some of the obvious difficulties inherent in a male having to understand, let alone solve, female issues. It caused no end of puzzled smiles whenever he entered a patient’s room as they wondered how he would try to ingratiate himself and his gender with them. These were harmless, if not actually humorous attempts, but the nurses, who were used to dealing with a new batch of trainees rotating through their wards every few weeks, were concerned that he would be misunderstood and complained to me. And yet the patients, when I saw them in my office after their discharge from hospital, were more sanguine about him -amused more often than not.

So, when he asked me for a letter of reference after successfully passing his exams a few months later, I was unsure what to write about him. His theory and OR credentials were satisfactory, but apart from his obvious enthusiasm, whether I could honestly recommend him, given his behaviour with patients, was more difficult. In my opinion he was competent to practice my specialty, and I saw no deficiencies in his knowledge -it was just… well, his interpersonal skills were unusual.

I decided to waffle -perhaps that’s why I still remember a lot about how I phrased the letter I wrote to his prospective hospital.

‘Dr. James [I have changed his name, for obvious reasons] has successfully completed his training from our program and in my dealings with him, I have found him to be knowledgeable and enthusiastic. You will realize, of course, that as is usual in Residency programs, I was his supervisor for only a limited time.

During the time I worked with him however, he proved to be very competent in the operating theatre, with a quick grasp of newer techniques he learned from my younger colleagues who were also responsible for his instruction. And if I seemed puzzled, he was quick to revert to my more traditional surgical approach without complaint.

And he was also quick to respond to any post-operative problems whenever they arose, and explain them to the patient with knowledgeable clarity and what seemed to be heart-felt empathy.

He was also able to adapt to changing moods and preferences in the birthing rooms, while continuing to adhere to strict best-practice guidelines. The case room can be an emotionally fraught region, but he usually managed to assuage most of the conflicts between the demands of what he felt was required in the circumstances and the birth plans of either mother or midwife.’

I remember that I was quite proud of the letter but not sure how to end it, so I just left it like that. Thinking about it now, it seems to me that I had more or less covered Grice’s four conversational maxims and I don’t think I flouted, but I’m not sure what the implicature was that I conveyed. I’ve not heard anything bad about my referenced candidate, or whether he actually got the job -but neither did I receive a thank you letter from him. Maybe that isn’t expected for conversational implicatures, though.

At any rate, he didn’t ask me to write another of those letters, so I have to assume the best.

A Flicker of Hope

It’s interesting what catches our attention when we surf the apps on our smartphones nowadays. Some of the more provocative articles have dubious sources, of course, but with a little digging the original study can often be found and the claims checked. The problem, however, is that even these results need to be reproducible in case either the methodology or the results were unreliable –and also the conclusions drawn from them. That’s why it’s often unwise to believe everything you see reported –or, on the other side, to report everything you want to believe… Fear and Hope are wonderful incentives, and so the issues in the study need to be thoroughly researched and vetted for bias and innuendo and references to the original study need to be included.

Perhaps because I am now retired, any article about time-related changes catches my eye more easily. So I find myself particularly interested in studies that suggest progress is being made -not with respect to age itself, but more the evolving process of aging: the gerund. It was with considerable interest that I read the BBC news on the use of flashing light therapy for Alzheimer’s http://www.bbc.com/news/health-38220670

I also attempted to read the original paper from MIT (entitled Gamma frequency entrainment attenuates amyloid load and modifies microglia) published in the December 2016  issue, of the journal Nature should you wish to struggle though it, but I have to confess that for me, even the title was difficult…

At any rate, the article suggested that flashing light in the eyes of mice that were genetically engineered to have Alzheimer’s-type damage in their brain, ‘encouraged protective cells to gobble up the harmful proteins that accumulate in the brain in this type of dementia. The perfect rate of flashes was 40 per second – a barely perceptible flicker, four times as fast as a disco strobe.’ And ‘Build-up of beta amyloid protein is one of the earliest changes seen in the brain in Alzheimer’s disease. It clumps together to form sticky plaques and is thought to cause nerve cell death and memory loss.’ Research has focused on ways to prevent this plaque formation using drugs, but with limited success so far. If a non-invasive method like a flickering light can activate the immune system to do it by itself, so much the better. ‘The researchers say the light works by recruiting the help of resident immune cells called microglia. Microglia are scavengers. They eat and clear harmful or threatening pathogens -in this instance, beta amyloid. It is hoped that clearing beta amyloid and stopping more plaques from forming could halt Alzheimer’s and its symptoms.’ Fine with me.

I did, however, initially wonder about how bothersome the flickering would be –news reports on television usually caution their audience whenever even flash photography is found in the report, presumably because of the risk of triggering epileptic seizures. But, as the article discussed: ‘For the patient, it should be entirely painless and non-invasive “We can use a very low intensity, very ambient soft light. You can hardly see the flicker itself. The set-up is not offensive at all,” they said, stressing it should be safe and would not trigger epilepsy in people who were susceptible.’ Better and better! It’s just preliminary stuff, of course, but at least it opens up new pathways and ideas for further research.

As if even reading about the concept was in itself therapeutic, the article immediately triggered what, at first blush, would seem to be a non-sequitur memory of a patient I saw many years ago. The issue as I recall was not so much about mental aberration -although the patient herself was apparently suffering from paranoid schizophrenia- but more about her speculation on the possible effects of flickering light on mental function.

I was, I think, in my first year of residency training in the gynaecology program and was doing a rotation in one of the older teaching hospitals in the city. In those days, things were very busy on the wards and so our tasks were apportioned according to our seniority, the senior residents doing the lion’s share of new consultations, while we juniors were given those jobs that, while important, required less experience -pap smears, usually.

My senior’s name was Sara, I remember, and she decided I should be the one to go to the psychiatric ward to do a pap smear on one of their more ‘unusual patients’ as she said to tease me.

“What do you mean ‘unusual’?” I asked. Sara didn’t like to go onto that ward, for some reason, so she usually made some excuse.

She stared at me for a moment before answering, I remember. “Oh, you know, she has paranoid delusions and hallucinates, or something…” But it was clear that Sara really had no idea why our department had been asked to do the pap, nor had she any intention of doing it herself.

I was beginning to suspect this was merely another sluff. Sara fancied herself a consultant now and able to delegate things she didn’t want to do. “But if she’s paranoid and hallucinates, wouldn’t it be better if the doctor doing the pap smear was female?”

Her expression turned angry at that point, and I recall her almost attacking me with her eyes. “Oh for god’s sake, there’ll be a nurse there with you the whole time… Or maybe they said two…” she added, uncertainty softening her glare, but not her resolve to send me to that ward.

I showed up at the psychiatric area and was allowed in only after identifying myself via the phone just outside the door. Then I was led to the brightly lit nursing station, and a rather large matronly nurse handed me the chart of the woman needing the pap.

“She hasn’t had a pap smear in years,” the nurse said in a soft voice, so it couldn’t be heard in the corridor outside of the station. “And her voices told her she has cervix cancer…”

“Her voices?” I should have been more professional, but I was already feeling a bit apprehensive about being inside a locked ward. “I mean, shouldn’t we wait until she’s feeling a bit better before we…”

“We can’t seem to find any good medication for her yet,” the nurse interrupted. “The doctor thought that we could at least calm her by checking her cervix.”

Greta –I still remember her name- was already in the examination room, sitting in her gown on a little table that had a set of rickety old metal stirrups at one end. They’d apparently had to borrow everything from another ward for the job. As soon as I entered with the nurse, Greta examined me from top to bottom with suspicious eyes.

“You’re a man,” she said before we were even introduced.

The nurse, whose name I forget, walked over to Greta and held her hand. “You remember we talked about this, Greta,” she said in the same soft voice she’d used before. “And you said it was okay…”

Greta nodded, smiled and lay back to put her feet in the stirrups. “They said I should show you my cervix,” she said, the italics staring at me between her knees. “Not the one with cancer, though…  I’m supposed to keep that one hidden.”

“Her voices,” the nurse quickly whispered in my ear as I sat on a little stool they’d also borrowed for the occasion along with a light on a long, flexible metal pole. It looked as old as the stirrups.

I got the speculum and the pap smear paraphernalia ready as the nurse readied the light. The bulb kept flickering, though. I fiddled with the bulb to see if it was loose, but it seemed tight enough. And it was obviously plugged into the wall. On, off, on, off… the light was beginning to annoy me. I snapped the switch a few times, but still, it insisted on flickering. On, off, on, off…

“I’ve got a flashlight,” the nurse said, but when she turned it on, it was so weak, I knew I wouldn’t be able to see cervix high up in the vagina with it.

“Well, maybe I can do the pap smear with the flickering light,” I said and shrugged.

Suddenly Greta raised her head and stared at me again. “Sometimes the prongs don’t make good contact in the wall. Everything’s so old in this place,” she added, shaking her head. “Take the plug out and squeeze the prongs.”

By this time I had the speculum in my hand, so I nodded to the nurse to try Greta’s suggestion. Sure enough, squeezing the prongs stopped the flickering.

Greta was still staring at me through her legs. “I may be crazy, doctor, but I’m not stupid…”

I put the speculum down on the medical tray I had on my lap. I sensed Greta wanted to explain something. “It’s a signal, you know.” I didn’t think I should reply. “The light’s always trying to tell you something –sometimes it’s angry, but more often it’s just trying to help…” Her feet still in the stirrups, she raised herself onto one elbow and continued. “It gets right into the brain to help, you know. It doesn’t stay there long enough, though, and that’s why it has to keep going in and out, in and out… And each time it tries, it flickers…” Then she stopped talking for a moment and stared at the nurse with an amazed expression on her face. “That’s what the doctors should be trying –not all those horrible pills…”

Maybe that incident stands out because it was the first pap smear I’d ever done. I don’t remember the result in Greta’s case –I was near the end of my rotation in that hospital- but I do remember Sara asking me what I’d done with that patient.

“Why?” I asked, afraid Greta had accused me of doing something improper.

“The ward told me that your patient seemed much calmer after you left and she apparently kept telling everybody you’d come up with a new treatment, or something…” And then I remember Sara smiling condescendingly at me, as if to say that junior residents could never do anything of the sort.