Whether ’tis Nobler in the Mind

I may have inadvertently stumbled upon something important. I may have found a boundary marker that potentially distinguishes New Age from Old Age. Of course, definitionally I could be way out of my league –New Age being construed as anything that happened after I left university- but considered as a panoply, I think it works, if only conceptually.

I happened upon an article in the CBC news app while scrolling through my phone, that struck me as interesting: http://www.cbc.ca/1.4302866 -perhaps because I had never thought about technology in those terms, and perhaps because I felt embarrassed that I had been caught doing just that.

The premise was that we seem to turn to various apps on our devices for problem solving of many sorts. Everything from comparing shopping prices to trends in fashion to the latest news. And, as we are increasingly discovering, these digital peregrinations revisit us in the form of directed advertisements hoping to cash in on our whimsical journeys. Nothing is thrown away in the digital world –even our whims are stored, categorized, and pragmatically redistributed. And if notions, then it seems a small step to include moods. Emotions –positive, or otherwise- should be equally trackable.

In fact, I learned that ‘Google announced it now offers mental-health screenings when users in the U.S. search for “depression” or “clinical depression” on their smartphones. Depending on what you type, the search engine will actually offer you a test. […] And Facebook is working on an artificial intelligence that could help detect people who are posting or talking about suicide or self-harm.’

Perhaps this is where I feel the shadow of a boundary issue. There seems little question that mood disorders transcend age and gender; what is more problematic, however, is whether there may be a generational divide in confiding those emotions digitally, or even believing that solace could lie therein. The problem is not so much in putting these issues in writing –diaries, and correspondence, after all, have long been a rich retrospective source for biographers. The difference, it seems to me though, is the intent of the disclosure –diaries have traditionally been personal, and usually, not meant as a way of communication, but rather a way of sorting out thoughts. Private thoughts. Letters, as well, were directed to particular individuals –often trusted confidants- and not meant for publication outside that circle. Have the older generation –Generation R, for example (Retirement, to attach a label)- been sufficiently swept up in the digital river, to feel comfortable in clinging to its flotsam like their children?

I’m certainly not gainsaying the efforts of the internet giants to expand into the mental health realm –it seems a natural progression, so perhaps this is a start… and yet it’s one thing to key in on various words like ‘depression’ and have the algorithm kick in with a screening test, but another to sift through the context to determine the appropriateness of offering the test. I suppose random screening like that may be helpful for some, but as Dr. John Torous, the co-director of the digital psychiatry program at Harvard Medical School and chair of the American Psychiatric Association’s workgroup on smartphone apps, observes, ‘”One of the trickiest things is that language is complex … and there’s a lot of different ways that people can phrase that they’re in distress or need help.”’ Amen to that.

Quite apart from translational difficulties and the more abstract and culturally-fraught issues with their changing metaphors and societal expectations, there are other language problems –even in the dominant language of whatever country: changing vocabularies, local argot, and misspellings, to name only a few.

To state that human culture is complex, is a trope, and to believe that artificial intelligence will be able to keep up with its multifaceted, ever-changing face, anytime soon is probably naïve. And, as the article points out, privacy –no matter the promises of the internet provider, or the app-producer- is another weak link in the chain. Quite apart from malicious hacking, or innocent and trusting confidence in the potential for help, ‘Our phones already collect a tremendous amount of personal data. They know where we are and who we’re speaking and texting with, as well as our voice, passwords, and internet browsing activities. “If on top of that, we’re using mental-health services through the phone, we may actually be giving up a lot more data than people realize,” Torous says. He also cautions that many of the mental-health services currently available in app stores aren’t protected under federal privacy laws [at least in the United States], so you’re not afforded the same privacy protections as when you talk to a doctor.’

In a very real –if mainly age-related- sense, I am relieved I did not grow up in the digital age. I am fortunate that Orwell’s prescient ‘1984’ was available, not as a quaint attempt at predicting the future, but as a warning about a creeping surveillance that seemed so malevolently unrealistic when it was written –it was first published in 1949, remember. And when I read it, the date was still sufficiently far in the future that it seemed more science fiction than predictive. Yet, as the years wore on, and society changed in unexpected ways, the horrors of the theme, for me at least, became more and more uncomfortable. More and more possible, despite the reassuring smoke blown in our eyes by those eager for progress, and mesmerized by the possibilities.

I mention this, not to suggest that I was unique in this discomfort –I was obviously not- nor to imply that what we are now experiencing is evil, or even threatening, but merely to explain the hesitation of many of those my age in accepting, unreservedly, the digitally-wrapped gifts so readily proffered. It is not a venue to which I would likely turn for health issues, or emotional sustenance.

For me, there is something more reassuring about an eye-to-eye encounter with another member of the same species, able to understand the vagaries of language, and compare the nuanced phrasing of my words with the expression on my face. Perhaps, I’ll change -perhaps I’ll have to- and yet… and yet I’d still feel better dealing with an entity –a person– able to experience the heart-ache and the thousand natural shocks that flesh is heir to. And yes, someone who has read and understood what Shakespeare meant.

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The Black Sewing Box

I love mysteries, and if they involve finding buried treasure, so much the better. Thoughts of treasure chests used to conjure up maps and pirates hiding valuable things in faraway and largely inaccessible places. I suppose that shows my age, because nowadays, the more likely proxy for a treasure chest in the popular imagination is a flight data recorder –a black box- submerged beneath thousands of meters of ocean or buried under rocks on the side of a faraway mountain. Hidden wealth for sure.

The myth of faraway, or at least elusive, treasure is an ancient one; think of the Greek myth of Jason in quest of the Golden Fleece -the golden wool of a ram which symbolized authority. There is something enticing about that which we do not have, but might obtain with sufficient diligence. And information seems to be the treasure most prized in the modern era. Information is Power. Information is Knowledge.

And yet, despite the cache of data contained in the almost magically endowed black box, and despite its reputation as the only solution to an otherwise insoluble problem, we forget its other, earlier, and less forthcoming incarnation –its perhaps even more obscure aspect. In computational and engineering models, a black box is something we can use, but don’t understand. For every input, there is an output, but like a magician’s sleeve, we don’t know why. The brain is still a black box. You and I are, for all intents and purposes, black boxes. And that is what is so appealing to me: that none of us are completely knowable. Predictable. We are all magician’s hats…

A short article in an August 2015 Canadian Medical Association Journal stirred the coals of my easily invoked imagination: http://www.cmaj.ca/content/187/11/794.full  It likens the measured parameters in an aviation ‘black box’ to a research project involving operating rooms at a Toronto hospital. ‘The technology involves several cameras and microphones, along with sensors to document physiological data and key aspects of the environment, such as temperature.’ But this foray into the sacred chambers of the OR is not merely another frivolous time-and-motion study, so beloved of factories and corporations everywhere. No, as the article puts it: ‘The intent of the new technology is to enhance health team performance, pinpoint errors and missteps (human and otherwise), and subsequently identify ways to prevent and address those issues.’

Having spent a good part of my career as a surgeon in the OR, I appreciate the need to improve performance and prevent mistakes. In a teaching hospital, much of our time in surgery goes to passing on our skills and honing the competence and judgement of the resident doctors in the program. We become the monitors. But, as hinted in the old fable of mice deciding that the best way to detect the approach of a cat would be to hang a bell around its neck, who will bell the cat? In other words, how do we know that the surgeon –or whoever- is not passing along bad habits? Faulty techniques in need of improvement?

One way tried in recent times, has involved having another surgeon in the OR as an observer. A later meeting to debrief and discuss opportunities to modify identified issues then helps to improve performance. Unfortunately not all of us are open to suggestions about our skill-sets, and other opinions are sometimes seen as criticisms. Ego and the fear of loss of reputation likely figure prominently in the equation even though the findings are kept private. Only if this practice of observation and subsequent discussion were made universal would it have a chance of thriving as a learning tool, however.

Another, although for some, equally uncomfortable method of improving performance in the OR, would be the practice of having a more junior surgeon, say, scrubbing with another more experienced colleague as part of a mandated hospital policy for quality assurance -much as hospitals now require yearly performance and outcome reviews for hospital reappointment. Personally, I like this approach. It is an easy way to learn and see new techniques in a less stressful environment than if I were in charge of the case. And I think we can also learn from the residents we are teaching who have studied in other hospitals and with other surgeons. There are many ways to improve our skills if we don’t allow ourselves to become encased in habit and focussed only on our own clothes. As Isaac Newton might have put it, ‘If I have been able to see as far as others, it is by standing on the shoulders of colleagues.’ Well, okay, perhaps he said it better, but our options to improve seem to be either carrot or stick.

There is a trend creeping into public media of assessing and rating doctors on their outcomes. How many patients benefitted from the surgery? How many had complications? How many surgeries has the doctor performed? What about her colleagues? The publication of these data sets may seem reasonable, but unfortunately they leave many contributing factors in the shadows –or even unreported. Unconsidered. For example, perhaps the surgeon in question has a high complication rate because, as the most experienced, she gets the most difficult cases -maybe the ones that have failed other treatments.

All things considered, perhaps the black box approach has more compelling merit than first meets the eyes. If the public were assured that procedures were monitored and recorded this might go a long way to assuaging their suspicion of incompetence or malpractice. And as the article suggests, ‘Data recorded by the black box system could well speak for patients unable to speak for themselves because they were under anaesthesia or unfamiliar with hospital procedures and protocol.’ Let’s face it, ‘black box’ monitoring certainly helps to instill a level of confidence in airplanes: just knowing that after a difficult or problematic flight, experts could discover what actually happened and correct it for the future.

There is a problem with the black box method, however –an obvious one for surgeons: ‘the data in an operating room black box could be used as evidence in medical malpractice suits unless precluded by legislation — in much the same way morbidity and mortality assessments made by hospitals and staff for the purpose of quality assurance and improvements are exempt from being used in court.’ We all learn from our mistakes –and from the mistakes of others. We must, otherwise the errors will be repeated. And most of these issues are not the result of malpractice or incompetence. They are potentially teachable moments, if you will.

In fact, one lawyer commenting on the black box idea, felt that ‘the data could also help surgeons who are being sued. “With the black box, critical procedures and techniques could be objectively assessed by peer surgeons when a poor outcome occurs. From the surgeon’s point of view, the data would be confirmation that all was done right but the poor outcome was beyond their control.”

So, in a way, it’s prudent to swallow unsweetened medicine now to ward off disease down the road. In the words of Tolkien, ‘It will not do to leave a live dragon out of your plans, if you live near one.’