Such Sweet Sorrow

I kind of figured sugar would sneak back. It always does! Just when you think it should be terminally ashamed of the stuff it’s done, it shows up as somebody else and fools everybody. I mean, forget trying to pretend that you don’t recognize it in a crowd, that you can’t see under its mask. Sugar is, well, sugar, eh? No matter how it tries to sweet-talk its way around you, it is what it does. Period.

But what is that? Apart from fuelling our atavistic requirements for easily assimilable energy, and therefore surviving early Darwinian whittling, I’ve often wondered if there’s more to sugar than meets the tongue. It has too large a presence in our world to be confined to pleasure alone. Almost every organism seems drawn to it. Should this be telling us something?

Every once in a while my overweening, but naïve hunches are rewarded with information that addresses much the same issues but in ways I hadn’t considered: http://www.bbc.com/future/story/20180328-how-sugar-could-help-heal-wounds?

Moses Murandu is a man who grew up in the rural Easter Highlands of Zimbabwe, and later moved to England to work in its National Health System. ‘A senior lecturer in adult nursing at the University of Wolverhampton, Murandu completed an initial pilot study focussed on sugar’s applications in wound healing and won an award from the Journal of Wound Care in March 2018 for his work. […] To treat a wound with sugar, all you do, Murandu says, is pour the sugar on the wound and apply a bandage on top. The granules soak up any moisture that allows bacteria to thrive. Without the bacteria, the wound heals more quickly.

‘In some parts of the world, this procedure could be key because people cannot afford antibiotics. But there is interest in the UK, too, since once a wound is infected, it sometimes won’t respond to antibiotics. […] And a growing collection of case studies from around the world has supported Murandu’s findings, including examples of successful sugar treatments on wounds containing bacteria resistant to antibiotics.’

Well, it’s safe to say that I don’t know how much sugars will contribute to our health and well-being, but they do serve as a reminder that western science is not the sole guardian of knowledge. Or wisdom. Answers are not rare -they are lying around everywhere just waiting for the right questions to discover them. The right curiosity. And we run a risk dismissing traditional enlightenment -folk wisdom- out of hand.

The problem, as I see it, is one of attribution. The credibility we assign each source should be determined by the results of testing its hypothesis, finding the appropriate question to interrogate whatever is proposed as an answer. Finding the key that fits the lock… And the thesis investigated does not have to be of mind-bending importance; science is not the exclusive purview of people in white coats. Nor those of a certain age…

I recently happened upon a Tim Horton’s café in close approximation to a message from my stomach that it needed both a coffee and a bagel. Not being in the mood to argue, I decided to accede, although my loyalties normally lie with Starbucks. I had been wrestling with the question of habit on my walk –my strange unwillingness to explore new ground, consider new sources. Tim’s could be the answer waiting for the question.

Science, if it be considered from the inductive perspective, I reasoned, required the inference of laws from particular instances -answers from the right questions. In other words, Propose, Test, and then validate or refute. It isn’t enough to simply assume…

I had chosen a busy time unfortunately, and I was lucky to find a single table in a corner by the window. It was squeezed between a group of elderly women crowded around a larger table busy consuming their donuts and politely slurping their coffees, and a small table like mine occupied by a harried looking mother trying to bottle-feed a squirming, unhappy baby in her arms and a young boy busily kicking the legs of his chair.

The elders were surprisingly quiet, but not the little boy, so my ears naturally focussed on him.

“Why can’t we go, Mommy?” he kept asking.

I could tell his mother had almost reached the end of her tether, and she stared at him crossly, determined not to interrupt the feeding. “Because I’m still feeding Janny, Tim,” she replied, tensely. “She’s really hungry.”

The boy tilted his head curiously. “She’s squiggling around; she’s not even sucking…”

At that point the baby began to cry even louder-scream, actually- so the mother put the bottle on the table and positioned the baby on her shoulder to burp it.

But Tim still looked puzzled. “But she doesn’t like the bottle, Mommy,” he said, as if his mother should have noticed by now.

His mother shrugged, almost in tears. “I know, Timmy, but you were hungry too, remember? That’s why we came in here instead of going back to the car.”

Tim sat back in his chair for a moment to process the problem. “Well, why don’t you let Janny suck your breasts?” he said, in the rather loud voice of a four year old.

I could see his mother blush as soon as he said it, but Timmy had merely proposed a tentative hypothesis that could easily by tested to see if he had asked the right question, and his face was as innocent as a new nappy.

His mother leaned over the table with Janny so she could show Tim that they could talk quietly about it. “I would if we were sitting in the car…” she said, but he continued to stare at her, still puzzled. “And the car is still a long way away, Timmy.”

Tim leaned over the table like his mother. “Why can’t you breast her here?” he asked innocently.

She smiled and glanced around the room, embarrassed. “Some people don’t like to see mothers breast feed their babies in public.” She tried to whisper but Janny was really screaming now. She glanced at the washroom, no doubt wondering if she could feed her baby in there, but it must have been a small room, because there was already a line of needy hopefuls that had formed at the door

Tim smiled as if he knew how to solve the problem with his initial hypothesis, and he leaned towards me on his chair. “Hey mister,” he said in his best, grown-up voice, “Do you mind if Mommy breasts Janny in here?”

His mother was now beet red, and she glared at her little son and then attempted to smile at me. “I… I’m sorry…I…” But she was too embarrassed to continue.

“I don’t mind at all,” I said, trying to reassure her with a reciprocal smile. “You can use my jacket to cover yourself, if that would help…” I said, beginning to take off my jacket.

One of the elderly women at the next table leaned over and gave a thumbs-up to the frazzled mother. “We’ve all been there, dear,” she said and winked before she turned back to inspect her plate for donut remnants.

I handed the mother my jacket and the baby settled into the welcoming breast somewhere underneath. Propose, test, validate…

I added some extra sugar to my coffee, and settled back in my chair to celebrate the triumph of citizen science that even a child could perform. It’s just a matter of finding the right question, after all…

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Hide and Seek

I guess the hunt is never over. Just when you think you’re winning, a sleeper cell surfaces, one you hadn’t even suspected, and closets itself somewhere you’d never think to look –an endless game of hide and seek. A Samsara of possibilities.

An yet, what would be the thrill of exploration if you knew all of the findings beforehand? We all need quests -adventures that uncover the hitherto unexpected, don’t you think? It’s what gets us out of bed in the morning. Me, anyway.

Questions and answers, for example… Let me play the devil’s advocate for a moment. We tend to assume that answers are the result of questions –we ask a question and then search for a correct -or at least appropriate– answer. But are we actually falling into a post hoc fallacy? ‘Post hoc, ergo propter hoc’ –because something occurred right after, or seems to be a response, we assume the initial thing caused the second. That’s just one way to look at it, of course. What if we assume there are answers lying around everywhere, and that the game is to find the appropriate question –the one that fits? A kind of ante hoc approach, I suppose, in which the answers come first.

Okay, try this. Answer: There are significant numbers of bacteria living under, and protected by, the fingernails. Question: Why doesn’t persistent scrubbing eliminate bacteria on the hands? I know this approach is merely a capricious inversion, but sometimes transpositions help us gain an interesting, if not useful, perspective. An article from BBC brought it to mind: http://www.bbc.com/future/story/20160622-what-lives-under-your-fingernails

I’m a surgeon, and early in my career it occurred to me that the water I was using at the scrub sink before an operation was itself not sterile. After a fastidious and lengthy hand and arm scrub with whatever cleansing soap was in vogue, I would then rinse off the soap with what amounted to tap water… And then, yes, I would observe ‘operating room technique’ and don sterile gloves for the procedure, but, apart from perhaps reducing the amount of whatever had been on my hands, what had all that scrubbing accomplished? Was it just a theoretical conjecture that it actually made a difference? A sop to sterile tradition? And if I were required to wear sterile gloves anyway why not just, I don’t know, use the same soap I used in the shower? It would certainly be cheaper. Questions! Questions swirling around hunting desperately for answers…

Had we posed the answer first, though… (Can you pose an answer?) Maybe the answer: ‘there are significant numbers of bacteria in the subungual compartment’ is a perfect fit for the question: why ‘is this hand region […] relatively inaccessible to antimicrobial agents during normal hand-washing procedures’?

Think about it for moment. Isn’t this the classic conundrum of basic science –science that is done for its own sake, science that has no existing practical applications? It consists of a whole platoon of answers to questions that have not yet been framed –or at least questions that were not anticipated at the time, or maybe just not the questions that were asked. A classic example of an answer (observation) looking for the right question was that of the findings of Penzias and Wilson –two physicists working on a new type of antenna at Bell Labs in New Jersey. In the early 1960ies they found a source of noise (the answer) in the atmosphere that they couldn’t explain. Finally, after eliminating other questions, they realized it was the cosmic microwave background (CMB) left over from the Big Bang. They received the 1978 Nobel Prize in physics for finding the proper question: ‘Is there any evidence of the Big Bang still around?’

And how about another answer: DNA is a large double helical molecule containing patterns of paired nucleotides and is found in cell nuclei for some reason. Question: why is it there? Or even: Could it be related to reproduction? Or heredity…?

Okay, I know this is a bit of a cart-before-the-horse stretch, but I think it does make us less complacent and maybe more appreciative of raw data. Details. Complexity. I’m not suggesting that Inductive logic is somehow flawed –it’s one of the fundamental tenets of the Scientific Method which posits using observation (answers) to derive general principles (more answers).

It’s not that confusing, really –it’s actually how things work in Science. The questions often arise because of the observations –after them, in other words- and so require experiments (questions) to see if the observations were indeed the answers…

So, isn’t the world a wonderful place? I ask that question -just one of many- after observing all the answers lying around unquestioned –unbothered, really- on the grass and among the flowers growing outside my window, all the unchallenged clouds in the sky above, and all the sunlight glinting off my polished floor.

I wonder, sometimes, whether the King James translation of the apostle Paul’s letter to the Corinthians was unwittingly prescient: ‘For now we see through a glass, darkly.’ And only when we recognize the importance of the observation, are we encouraged to ask why is that?

 

Scientific Fraud

Science –whose Latin etymology denotes knowledge- started off as a branch of philosophy and gradually morphed into its present form. Recently, however, it seems to be resting on a progressively unstable foundation with the general public. By its very nature, Science accumulates its knowledge by induction: observations elicit explanations which suggest experiments designed to test these. The results are always contingent –a classic example might be that of swans: if all we see are white swans, it might be reasonable to conclude that all swans are white –until, that is, we find a black swan. So knowledge is couched in probabilities –everything is potentially refutable and our statements about it must reflect how likely it is to be a continuing truth. This is fine unless we crave certainty.

In an increasingly uncertain world one can understand the appeal of religions, if for no other reason than the assurance that the mainstream variants project. But historically, even the supposedly eternal truths revealed by religions have been contingent upon success in battle, or survival in times of environmental or social disasters. Certainty is a horizon that shifts and recedes whenever it is approached. However close we may feel we are, it is, like the rainbow, forever out of reach.

Of course, many do not agree with this; many feel that certainty is attainable and harbour a lingering suspicion of any system that cannot provide it. Why should faith be piled onto something that accepts that it is open to being refuted -welcomes it, in fact?

There are enough confusing and seemingly contradictory studies published to challenge the Public’s trust in Science. At times, its credibility seems to be balancing on a knife’s edge; the slightest puff of scandal could well be enough to destabilize the already tenuous confidence. For some people, it is already gossamer thin.

It is with this in mind that my fears often migrate to the subject of fraud in science. For me, it is not only a question of how it could happen, but rather, why it would. I was intrigued by an article in an article in the Canadian Medical Association Journal from last year entitled: ‘Scientific misconduct or criminal offence?’  (http://www.cmaj.ca/content/187/17/1273.full) The article examines whether we should be treating scientific fraud as merely naughty ill-advised behaviour, incompetence, or criminally punishable conduct. The standard of proof needed to successfully achieve a legal conviction is apparently quite stringent and so, often in the interests of limited financial resources and depending upon the seriousness of the case, lesser sanctions are frequently used. In Canada there is a Secretariat on Responsible Conduct of Research. ‘The Secretariat is a government agency responsible for implementing the Tri-Agency Framework on Responsible Conduct of Research on behalf of Canada’s major federal government granting agencies… A researcher who breeches the framework may receive letters of education or admonishment. More serious cases could merit sanctions, including withdrawal of funding or even the ability to apply for funding.’ And each year, says Susan Zimmerman, the current executive director, ‘there are about 90 breeches of the framework, but very few, perhaps three or four, would be considered serious. Even fewer would constitute a criminal offence. And if one did, the Secretariat is already obligated to notify the authorities. Instead of trying to ferret out the rare egregious bad apple, the Secretariat, as stewards of public money, focuses on reducing unacceptable results. The agency considers that approach to be a more productive use of limited resources than trying to determine if a researcher made an honest mistake or acted in bad faith.’

All fine and good, I suppose, but I still wonder about the already suspicious Public Opinion about science in general. ‘In a 2014 BMJ article, Bhutta, who has a strong interest in research ethics, argued that scientific fraud can have huge consequences on public health and clinical practice, citing the damage to global vaccination coverage caused by the “fraudulent and discredited” research of Dr. Andrew Wakefield that linked vaccines to autism. There is little risk to committing research fraud, beyond damage to reputation, and the research community is doing an inadequate job of policing itself, according to Bhutta, who wrote that “additional deterrence through punitive measures such as criminal proceedings should be added to the repertoire of measures available.”’

If the results of a study were indeed woven out of whole cloth, the lack of legal consequences would feed the worst fears of an admittedly small segment of society which mistrusted western medicine’s perceived mantle of omniscience to start with. If it were fraudulent, they would wonder, then why wasn’t the doctor prosecuted? Was it because there was some uncomfortable truth to his findings that an embarrassed Medical establishment, which had been pushing the safety of vaccines for years, was trying to cover up? How many other studies are fraudulent that either haven’t come to light, or have been quietly hidden under the covers?

The point is not so much that infractions are few and often inconsequential, nor that the naysayers and critics are few in number, but that the the condemnations are loud and insistent. Without a visible and concerted effort to rebut their arguments, allay their suspicions, and demonstrate that there are consequences for deception, their doubts will only grow larger, and their trust in the scientific approach further diminish. Already we have seen the effects of an underlying mistrust in the uncertainties of science manifesting itself in the climate change deniers.

Add fraud to the inherent uncertainties embedded in the scientific method, and we can begin to worry about the punishment of Sisyphus condemned forever to roll a massive boulder up a hill then watch it roll back down again. Consequences must suit the action. Justice delayed is justice denied.

 

 

 

 

 

 

 

 

 

 

Scientific Gynaecology

Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

Staying in Touch

In the endless dark of night, belief that there will be a morning is sometimes all that sustains us. Hope springs eternal in the human breast, as Alexander Pope declared in one of his essays -and that is occasionally all there is. When Medicine fails, the understandable temptation is to turn to alternatives; when inductive reasoning seems insufficient (compilation and collation of observations to arrive at a tentative conclusion) then perhaps the converse might be helpful: deductive reasoning (start with a conclusion and then look around for supporting evidence). The Scientific Method tends to use more of the former than the latter to test hypotheses, although to be honest, it is often a melange. But to start with a conclusion and then to attempt to prove it can be a recipe for failure –or worse, deceit.

Alternative Medicine appears to be guilty of the latter -although whether by intent or naivete can be argued, I suppose- but it does seem to attract a certain edge of the population. I, for one, am not a believer, but to set the stage, perhaps a definition of alternative medicine would be helpful. The description in Wikepedia (sorry!) is as good as any I’ve seen: ‘Alternative medicine is any practice that is perceived by its users to have the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science. It consists of a wide range of healthcare practices, products and therapies, ranging from being biologically plausible but not well tested, to being directly contradicted by evidence and science, or even harmful or toxic.’

In this essay, I don’t intend to debate the merits or harms of alternative strategies for health, but merely to illustrate the pitfalls that can result when they are espoused too vigorously -when hope triumphs over experience. When, to paraphrase Macbeth, Physic is thrown to the dogs.

*

I really liked Loretta; I could tell that as soon as I saw her in the waiting room chatting to her neighbours. A slender young woman barely grazing her twenties, she had short brown hair and was dressed in jeans and a yellow tank-top. Her face was all smile –or, rather, all teeth and tongue, with large, brown eyes occasionally mobilized to emphasize some point or other. The whole room seemed alive with laughter and focussed on her every word, her every gesture –and there were a lot of those. Her body was in constant motion, sometimes pointing with a ring-laden hand, then gesticulating with her arms as her bracelets clinked and ran up and down her forearms like beads on an abacus; even her legs were integral as she swung them back and forth to illustrate a point with her dainty sandal-clad feet – an actress playing to an adoring audience. I almost felt embarrassed as I crossed the room to lead her offstage. She actually waved to them as she left; I half expected her to blow kisses.

She sat on the edge of her chair in my office clutching a backpack in one hand and a phone in the other as if to relax was anathema to her. “You seemed quite popular out there,” I said, nodding towards the corridor that led to the waiting room.

Her smile broadened at the compliment. “I like to stay in touch with everybody… and everything,” she added, as if it were a necessary addendum, then filled the time between our words with safaris into the uncharted depths of her pack. “I’ve come here for a pap smear,” she said as she saw me scrolling on the computer. “That’s what my GP says, but it’s really because he doesn’t know what to do with me…” She let the sentence dribble to a close without a firm indication she was finished with it. Like it was still a work in progress. So I waited. A text arrived on her phone and she blinked at me and proceeded to thumb a rapid, practiced reply almost as if she was scratching her leg without thinking about it.

Still she said nothing, but instead inspected the room, starting with the pictures on the wall and then progressing to the the plants on my desk, inspecting them one by one, perhaps thinking I was going to quiz her about the office. “What is it that concerns your GP, Loretta?” I felt I had to say something.

She shrugged goodnaturedly and her eyes migrated to my face. “I suspect she thinks I’m too self aware…” She giggled at the thought, then noticed the puzzled expression that I had tried to disguise. “I like to be on top of things…” She immediately blushed and corrected herself. “You know, like my health and stuff.”

I smiled to encourage her to explain.

“Like, you have to be careful about what you put in your body. I mean they’re putting additives in everything. Bodies need help getting rid of all the toxins that build up: detox regimes.” I grimaced inwardly, but maybe she saw the shadows. “My GP said that was nonsense, too, but I know I feel better after a cleanse,” she said, momentarily dropping the smile and folding her arms across her chest with the bracelets following close behind for emphasis.

I tried to disguise a deep breath. “I see…” –but actually I didn’t– “Is there any reason he felt that a gynaecologist could be of some help?”

“Help?” she said with a sharp intake of breath, as if I had really not understood a word of what she’d been telling me.

“You know,” I quickly added, “Help with something that you’ve been unable to deal with using your…” I hurriedly rummaged around in my head for an appropriate word –one that wouldn’t seem to insult her, yet wouldn’t suggest acquiescence either. “…Your strategies.” I thought that sounded neutral and not overly critical. I wanted to keep her on my side to see if there really was anything I could do to help. She could sort out the knowledge base for herself later.

Before she could respond, another text arrived, prompting yet another seemingly mindless flurry of thumbs to resolve the issue. She didn’t apologize and I realized that this was just part of the background in her life -like traffic noise, or maybe someone bumping into her in a crowd. She found time to shrug at me again, but whether to acknowledge the text she had just answered or as a way of answering my question was hard to tell. “I’ve been getting a lot of yeast infections lately, so I tried another cleanse.”

Her eyes jumped onto mine to see if I needed any clarification, and rested there when my face didn’t light up sufficiently with comprehension. We live in different worlds they said.

Toxins,” she added, like she was talking about the elephant in the room. “The bowel walls get encrusted with stuff and overgrowth of candida is one of the crusts.” She smiled innocently, almost as if she was going to admit to sneaking a cookie between meals. “I tried dietary modifications for months: fruit fasts, fiber-only diets… but no matter, I still got itching down there. So I tried a coffee enema once a week for a month. Then a probiotic one for almost three months.” She jangled her bracelets again as she thrust her arms upwards to suggest what else could she do. “Nothing worked, so finally I tried an enema using an antifungal solution that my girlfriend told me about. Jeez, try to keep one of those puppies inside for 15 minutes! I only managed 8…” She noticed the horrified expression that I’d tried desperately, but unsuccessfully to camouflage. “Eight minutes, doctor –not eight enemas!” She shrugged again –it was another form of speech for her, evidently. A sort of body text, I suppose. “But when I told my GP about it, he got really mad. “Of course there’s yeast in the bowel; we all have yeast in our bowels, he said… No he yelled that at me,” she added after thinking about it for a second.

“So I told him about the enemas they’re using nowadays for –I forget the infection…”

Clostridium difficile,” I added helpfully, and also to show that I was still listening.

“Those are special fecal enemas, he yelled back at me, and only for a special problem!  Anyway, you can’t get rid of vaginal yeast with those silly health-product enemas, he added. Not even the probiotic ones. He said ‘probiotic’ more softly, though, as if maybe he wasn’t so sure about that one.” Her face perked up again as the indignation faded and the verbal catharsis revived her spirits. “The yeast down below isn’t so bad right now –it seems to come and go. But no thanks to him -none of his prescriptions helped…” She shrugged a text at me. “That’s why I tried colonics dead last. I mean I believe in probiotics, and I hate enemas.” She studied my face for a moment. “Hey, I was desperate.” Another jingle from her arms. “There’s gotta be another way to go. Despite what all my friends say, I still think enemas are unnatural, don’t you?”|

I have to say it was hard not to roll my eyes. I realized I had a chance to convert her to our side of the fence if I was careful. And tactful. “I agree with you about probiotics, Loretta.” She smiled and nodded her head at my unexpected response. “The idea, of course, is to adjust the biota –the bacterial flora of whatever organ- to be able to suppress other unwanted organisms. But you can’t just use off-the-health-food-shelf probiotics –one type doesn’t do all jobs, just like one antibiotic doesn’t fit every occasion.” I glanced at her face to see if she was listening or playing with her phone again. She was listening. Staring at me in disbelief, actually. But in this Google age, I knew I had to be careful -I could only remember one article I’d read and that might already be outdated. For that matter, I couldn’t even recall where or when I’d seen it –the Canadian Medical Association Journal, maybe. But then again, she probably didn’t really have a yeast infection anyway…

“And the other thing is that good studies in this field are hard to find.” I hesitated a moment for effect -timing is everything. “I seem to remember there are a couple of probiotic regimes that have undergone scientific investigations. They were published a few years ago in…Ahh, the Canadian Medical Association Journal. You can look it up, I imagine.” The long-winded, but welcome news had forced her back into the chair, her phone into her pack, and the pack onto the floor. Then a look of concern replaced the incredulous rictus. “But how are the new bacteria going to be able to compete with all that toxic stuff in the area now? It might poison them, or overwhelm them before they even get a chance to set up a new colony.”

It was my turn to look concerned –well, at least curious. I’ve never understood the toxin theory promulgated by many of the alternative medicine practitioners. “How do you know there are toxins, or whatever, in the area, Loretta?” I sat back in my chair, convincing myself I had her.

Her eyes rolled as her hands reached into the pack at her feet in response to a muffled text. I assumed she was reacting to the disturbance, but suddenly realized it was me they couldn’t believe. She closed them slowly, patiently, in a slow motion blink and then opened them again, this time filled with all the sure and certain knowledge of youth. Her body texted me before any words left her mouth. “How do I know there’s still stuff living there now after months of using my colonic ‘strategies’ as you put it? Ever had a retention enema, doctor?”

Critical Thinking and Bullying

A few weeks ago, a young woman came in to see me to have her first Pap smear. While I was taking a routine sexual history, she admitted she had recently been bullied online. I’m not even sure how the topic came up, but she didn’t seem very upset, so I asked her about it.

“The guy was a real dick,” she said. And when I asked her how she reacted, she merely shrugged. “Everything he said was false and all my friends should know that… So I ignored him.”

“And did he try it again?” I admired her reaction, but I have to admit I was curious.

She liberated a beautiful smile and shrugged mischievously. “Yeah, once… But then I guess he gave up.” She allowed her eyes to roll upwards comically. “My mother always told me to ignore stuff that wasn’t true.”

It got me thinking about why some people are able to withstand that kind of thing, while others succumb. I don’t pretend to know what motivates bullying, but I do suspect my patient was taught an effective remedy from an early age.

Critical thinking is a way of examining a statement or assertion in order to understand the background and motivating factors for its existence. Its credentials, in other words. It is a way of distancing oneself from the message and analysing everything that went into making it before either accepting or rejecting its content. Also, it is a way of avoiding confirmation bias –reading or assessing only those issues with which one already agrees, rather than sampling a variety of views and thinking of them as interesting, but as yet unproven assertions.

In important ways, this is what Science does: everything is open to checking and possible refutation. Nothing is spared re-examination. Carl Popper, the philosopher of science, suggested that an assertion, a theory, must be worded in such a way that it is testable, otherwise it can not be generalized -or as he would put it, it can only be considered scientifically valid if it is falsifiable- ie checkable. Anything else is merely an opinion -as, for example, the statement ‘Red is the most beautiful colour’. It is not testable, and therefore certainly neither provable nor undeniably valid. This is the first simple rule of thumb we can teach: we must help children to parse input.

Young children tend to question everything- it is how they learn. But in the very young –under, say, six or seven years of age- they often use magical thinking: cause and effect are not necessarily demonstrable either by reason, or even observation. Past that age, however, they begin to understand agency. Causal chains. It is a good time to introduce the concept of validity: was something really a result of an action, or was the action merely associated in time or location so as to seem to have influenced it? And although this is a good first start it is nonetheless one that is not necessarily intuitive. For example it would be tempting to assume that a boy running past a crying girl had done something to her -it might fit with a previous experience. But maybe he was running to catch a bus and it was a coincidence that the two were in the same area at the time she was crying… It requires more proof. More examination.

The habit of questioning things before accepting them can be taught. It can be made into a reflex before reacting. But it needs to be developed early, before the temptation to interpret hastily, or even reciprocate mindlessly, has become entrenched.

The basic elements of simple logic can be taught. For example with inductive reasoning, one attempts to generalize from observations. So if all the crows you have ever seen were black, then you might conclude that all crows are black… Until somebody sees a white crow that is… It is falsifiable, in other words. Most taunts are of that variety -and with practice, easily refuted.

Or even with deductive reasoning which works the other way -from the general to the particular: All men are mortal; Socrates is a man; therefore Socrates is mortal -the classical example. But it only works if the premise is valid (ie. that all men are mortal). And it may only be somebody’s opinion that it is valid…Once again, is it like that example of red being the most beautiful colour? We can all be taught to analyse things like this. We can all be taught to be wary of unsubstantiated statements. Rumours. Gossip. Taunts…

And the critical thinking approach can even apply to actions as well as assertions. A simple example: a young girl is hit by a snowball and another child, a boy, is standing nearby in a group of boys and staring at her. Was he to blame? Did he throw it? Maybe, but without further analysis, further investigation, there’s no proof. No reason to jump to a conclusion. Why did she think it was him? Is her reason based on anger, or is it justified..? This is the basis for the idea that a person is innocent until proven guilty… It is an important concept to inculcate in the growing mind. It is a way of distancing oneself from the action, no matter how provocative, and setting it aside until it has been analysed further. We all judge input, we all react to issues we encounter. And some things do require an immediate response. But it’s how we come to the judgement, how we analyse the data –how we react- that is critical.

You can see where this is leading I suspect: bullying. Bullying -whether on the playground or online, whether by deed or word- has the advantage of unfair leverage only if the process is unexamined. Only if the person being assailed is not used to subjecting taunts to the same questioning. Stepping back, if only momentarily, and processing the information. Checking it. Falsifying it. Refuting it -like my patient was able to do.

A difficult thing to do in the moment, for sure. But without any experience in dissecting assertions –deconstructing them, as PhD candidates are fond of saying- there are only reactive emotions. Victimization. Loss of self esteem that could and should withstand the storm. Self esteem, after all, is partly based on one’s ability to see oneself as in control.

As in mathematics and science, critical thinking is a valuable tool for assessing what we experience in the world. It helps us to parse what we read, what we’re told, what we think… It brings perspective to the unexpected, the hostile and the just plain annoying. It can and should be taught from grade school onwards, building on the simpler examples from year to year –class to class. Younger children may not understand the complexities of the Scientific Method, nor what Popper was on about, but with patience and persistence they will.

They deserve the chance…