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Neurological and Cultural Underpinnings of Being Plugged

Posted on September 8, 2009
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First, an apology to my readers. I’ve let trivia overwhelm me. That combined with a few other things have prevented me from updating my blog more promptly. I hope to rectify the situation this week.

Part 1: The Hardware (or Biology)

A day or two after I posted my article on the madness of speed in the modern culture, I read an entry on Frontal Cortex that shed some more neurological light on our pathological condition. I wrote a little about this in my earlier article, but this hopefully provides a more complete picture. I was indulging in speculation then, but it looks like I wasn’t that far off.

Back in 1954, a psychologist at McGill University in Canada, James Olds, and his team accidentally discovered that if a probe is inserted into the lateral hypothalamus of a rat and the rat was allowed to stimulate its own probe, the rat would stimulate itself till it collapsed. This was hailed as the discovery of the brain’s pleasure center. But neuroscientists were unhappy with this term. They found that far from producing pleasure, people who were stimulated in this area were more crazed than happy. Two researchers, Jaak Panskepp and Kent Berridge, independently concluded that this area was more concerned with seeking or searching than pleasure. Berridge concludes that mammals have two separate systems, one for seeking and the other for liking, which is the brain’s real pleasure center. Emily Yoffe, the author of the Slate article that inspired the entry on Frontal Cortex, writes:

“But our brains are designed to more easily be stimulated than satisfied. “The brain seems to be more stingy with mechanisms for pleasure than for desire,” Berridge has said. This makes evolutionary sense. Creatures that lack motivation, that find it easy to slip into oblivious rapture, are likely to lead short (if happy) lives. So nature imbued us with an unquenchable drive to discover, to explore. Stanford University neuroscientist Brian Knutson has been putting people in MRI scanners and looking inside their brains as they play an investing game. He has consistently found that the pictures inside our skulls show that the possibility of a payoff is much more stimulating than actually getting one.”

Dopamine, the well known neurotransmitter associated with the euphoric feeling and consistently tagged as being the reward drug, apparently has more effect in motivating us than in satisfying us. Rats that had their dopamine producing neurons destroyed, starved to death even when the food was right in front of them because they had lost the desire to reach for it. Berridge says that dopamine does not have satiety built into it. Rats who had dopamine flood their brains were quicker in navigating a maze to reach food than ordinary rats, but they were not any more satisfied than the ordinary rats once they found the food. Dopamine is also thought to be responsible for maintaining an internal sense of time. So, when an hour has gone by whilst surfing the web, you have dopamine to thank again. The neurotransmitter not only drives the seeking system in our brains, it also makes us lose time as we constantly stimulate ourselves following one hyperlink after the next. Novelty fuels dopamine and the next email has all the potential of being novel (it just might be the response from that gorgeous girl from the cafe agreeing to meet for dinner). Berridge says that like Pavlov’s dogs, we salivate at the ding announcing new mail.

Jonah Lehrer adds an interesting twist to this. This endless desire for curiosity doesn’t make us want to read Feynman’s Lectures on Physics or learn a new language or a skill. He says: “..we don’t treat all information equally. My salient fact is your irrelevant bit; your necessary detail is my triviality. Here’s the paradox of curiosity: I only want to know more about that which I already know about.” So, there we have it, a neurological explanation for why we develop a tic if we’re unplugged even for an instant.

Part 2: Software (or Culture)

Driving back from the library yesterday, I heard a brief segment from a program called “The Cambridge Forum” on NPR. The speaker was Carl Honore, a leading evangelist of the so called “Slow Movement”. He said something that I thought provided the cultural impetus for our behavior. Western culture (and thereby much of modern culture just about everywhere) has always thought of time as linear, of a line moving towards progress and betterment. Economics is a fundamental bedrock of modern culture. Everything we do, the way we want to be, who we want to be, is driven in part by a model of wanting more, of the philosophy that as homo economicus ‘more is better, greed is good’ (as quoted memorably by Gordon Gekko, the Michael Douglas character in the movie Wall Street). With time being also a scarce quantity (limited by our lifetime), and the desire to make progress, we squeeze more and more into a given unit of time.

Carl Honore writes in his blog:
“…is unplugging now the ultimate luxury?

Of course, being online can be wonderful. We are hardwired to be curious and to connect and communicate. The problem is that in a world of limitless information and constant access to other people, we often don’t know when to stop.

Being “always on” is exhausting and superficial. It erodes our producitivity. It locks us into what one Microsoft research called a state of “continuous partial attention.”

Continuous partial attention. I found that a very apt description of how I find my state of mind, many times. The days I throw caution to the wind and just be completely with Maya, I feel invigorated. Her sense of wonder, her endless fascination with what we dismiss as ordinary, her complete lack of urgency (except when she’s hungry) and purposelessness make it much more refreshing if I don’t let trivia (sometimes work is trivia too) put me in a constant state of partial attention.

I ran into the slow movement via a book about Slow Food, the activity that unleashed the slow movement. I had nodded off reading the book (or so I remember) and didn’t pay any further attention to it. By visiting Carl Honore’s site and other sites associated with the Slow Movement, I see interesting insights and practices that maybe of benefit in helping fix this drug, the accelerating, unyielding desire for more.

“There is more to life than merely increasing its speed” – Mahatma Gandhi

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Frenetic Existence

Posted on July 20, 2009
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Wednesday, July 15.

Went to bed early last night, woke up early this morning, had a half hour of solitude before Maya woke up. fed her and put a new diaper when she woke up and she fell asleep immediately, had an undisturbed shower and shave, checked email and got the first meeting canceled as the agenda was not clear. Maya woke up for good. She was in great spirits as she was not hungry and had a good full 10 hours of sleep. This is going to be a beautiful day, I thought to myself. And then the wheels started coming off.

When we had moved to our friend’s house in Palo Alto, I offered Ginez a choice: to either come at 8:30 so that I could catch a bus to the train station or to come at 8:45 so that she could drop me at the station. She preferred to drop me off at the station as it gave her fifteen more minutes of sleep.

8:38. Ginez called to say that she was stuck in traffic. A car was on fire on the freeway and after getting off the highway, the internal expressway was also a giant parking lot. She was at least 15 minutes away. This set off a domino in my head. 15 minutes late meant that I’d probably not get to the train station on time which meant that I’d miss the company shuttle to work which meant taking the light rail. Taking the light rail meant changing trains to reach my office, which meant that I maybe at work only by 10:15 or so instead of 9:30. Was I glad that I had canceled my meeting at 9:30 ? Nay. I was a little anxious that I’d be late.

8:42: I called Ginez to ask her where she was. She had come up to Middlefield Road and said she’d take that exit to come home. I asked her to hurry.

8:47 I was getting a little nervous. I had no meeting till at least 11. Why was I in a tizzy ? I diapered Maya, picked up my backpack and went outside to wait for Ginez.

8:50. I called Ginez again. She was at Alma and Churchill. She said even these residential roads were choked. She asked if I could come to the corner of El Camino and Park Ave to make up for the lost time. I said yes and started hurriedly walking with Maya in my arms.

8:55 Got to the corner of El Camino and Park. No Ginez. Called her again. She said that she was getting onto El Camino and that she’d be there in a minute or so.

8:57 Ginez is at the light, waiting for the U turn. With no traffic on my side of the road, I hurry across the road, strap Maya in and get inside. Ginez is apologetic, saying that she starts early enough to avoid traffic delays, but that today was really bad. I tell her not to worry, that if I miss the train, I miss it, that it is not the end of the world.

8:58 The light changes and we hurry to Palo Alto Caltrain station. I’m quite confident now that I’ll miss the train. We’ve only 3 minutes left. I imagine jumping into the waiting train just as the door are about to close, without validating my ticket. What will I tell the conductor if they ask for tickets, I wonder.

9:02 As we pull into the station, I see the train on the platform with the doors shut. I think, OK, I’ve missed it. As I get out, I realize that it’s the northbound train. I leap for joy. I can still catch my train. I see the southbound train pulling in. I leap out, wish Ginez a good day, don’t even kiss Maya goodbye and start running. Time enough to validate the ticket, I think.

9:03 I get into the train along with a horde of others. I hear an announcement that the train will not stop till Santa Clara. I’m surprised, then relieved that maybe this is the earlier train. I get out along with others, some looking confused as they check their watches. I hurry up to the conductor, who doesn’t even look at me as he says “The Mountain View train is right behind”. I guess a lot of folks have already asked him the question.

9:05 I call Ginez and tell her that the trains are all delayed, that the commute is messed up everywhere today. I wonder if the company shuttle will wait for me as I pace the platform. I call a friend in India to say hello. They’re watching a thriller. I hang up. I notice that the northbound train hasn’t yet moved. I look down the tracks and see another train, up ahead, stopped. Stuck due to engine trouble, I think. I pity the northbound commuters.

9:10 No sign of the train that is “right behind”. People start pulling out their cell phones and start rescheduling their day.

9:20 A southbound train pulls in. I get in and seat myself. I hear an announcement that this train will stop at all stations between here and San Jose. I’m surprised. What train is this, I wonder. I hope that the company shuttle is still waiting for me. That the driver would’ve noticed the previous train zip by without stopping and realized that he had to wait some more. I hope their policy is to wait for the train, and not give up within a few minutes or so and depart.

9:30 I arrive at Mountain View station, am glad to see the company shuttle still waiting. Rush to it, get in, greet the driver and settle down, happy that I’ll be at work before 10.

Why did I have to rush about like a headless chicken, when I knew that I had no meeting till 11 ? Habit ? Just the pace of modern life ? My own personality ? As I was doing this mindless jiggle, a part of me was observing me doing it and telling me, rather gently, that I had no reason to act this way. But the part that seemed in control, went about anyway.

A growing chorus of voice say that modern psychology is looking for the problem in the wrong place or in the wrong person. They evince that psychology asks people to learn to cope with the existing system rather than realizing that the existing system is broken and that is the reason so many people need psychological help. It is a continuation of the Western philosophy that elevates the individual and free will above that of the society that the individual is a part of.

The modern world is in a sense, a world gone mad. When the founding fathers of the US spoke of everyone’s right to “life, liberty and the pursuit of happiness”, I think they emphasized happiness, not the pursuit. But pursuit is what we’ve decided we’re after, happiness be damned. Why do we indulge in such behavior ? It is as cliche as cliche can be that many on their deathbed say, “I wish I had spent more time with my family”. We watch movies such as the brilliant American Beauty and Revolutionary Road, but never succeed to apply the lessons to our life. The Revolutionary Road is as good a movie about the madness of the American Dream as any I’ve seen. Despite a chance to get out of the humdrum of existence, an existence so boring that it kills all joy, the male protagonist allows himself to be sucked back into the rat race with devastating consequences. As I watched the movie, I recognized that given the right circumstances, I could be that character played so well by Leonardo di Caprio (and Kate Winslet deserved an Oscar for her performance in this movie, not The Reader). Yes, we’ve somewhat out of the rat race today, having opted to work part time, for less money and to stay at home caring for Maya. But still in experiences like the one that started off this entry, I betray the deeply ingrained habit.

As I was sitting in the train, my mind also went back to a book that I had recently read, Alan Lightman’s “The Diagnosis”. Not highly recommended, but the initial chapter was a riveting description of the madness that is modern life. A man on his way to work on a beautiful summer morning loses his memory. His memory returns a few days later, but his entire body starts to go numb. He is sucked into the medical establishment with its plethora of tests to determine the cause of his numbness. A scene in the waiting room at his doctor’s room, I also consider brilliant. Almost the entire first chapter is available online at Random House’s website.

Why do we do this ? The reasons are probably many and complex. But one factor that I had not considered occurred to me when I ran across an interesting article over at Mind Hacks, another neuroscience blog that I track every now and then. The article talks about a recent experiment concerning the reward circuit in our brains. Dopamine is a neurotransmitter that is commonly associated with pleasure, and with reward. We’re animals seeking rewarding activities. Unlike the popular myth however, researchers are finding that as much dopamine is released on the expectation of a reward as on a real reward. The article described an experiment conducted on people involved in a gambling game. The study found that near misses (you almost hit jackpot) released about as much dopamine as real wins, but the overall experience was awful. In other words, dopamine was released even when the outcome was not pleasurable.

All this is fine, you say. What has this got to do with why we pursue modern life despite knowledge of its ills ? Let me quote directly from the article:

Interestingly, although near-misses were experienced as aversive they increased the desire to play the game but only when the person had some perception of control, by choosing what the ‘lucky’ picture would be.

Of course, like choosing ‘heads or tails’, it’s only an illusion of control because the outcome is random anyway.

But because of reward expectancy the dopamine system is most active when we think we can control the outcome and modify our strategy next time, even if that sense of control is completely false.

In other words, we run the treadmill because we think we can change the outcome. Something special, something unique about us, our situation, our spouses, our children, our work that will change the typical outcome .

In headaches and in worry
Vaguely life leaks away,
And Time will have his fancy
To-morrow or to-day. – W.H Auden

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Of New Years And Their Resolutions

Posted on January 2, 2009
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On new year’s day, I awoke to a gray dawn. A gray that continued well into the afternoon, a gray that seemed portentous of the future of the coming year, given the global economic morass. A gray, I hope, not of the coming presidency.

A few days back, on NPR’s Science Friday, Ira Flatow interviewed a clinical psychologist, Dr. John Norcross about the nature of new year resolutions. I was astonished by Dr. Norcross’s statement that between 40 and 46 percent of those who make resolutions, succeed in keeping their resolution beyond six months. I had expected a far smaller number. Sure enough, a brief search revealed a December 2007 article in the British paper, The Telegraph, that another professor, a Dr. Richard Wiseman found that only 12 percent of the people were successful in keeping their resolution. Dr. Wiseman tracked about 3000 people who participated via the Internet – some 60 percent in the UK and the rest in the US – for around a year to arrive at his conclusion. Are the British worse off than their American counterparts in keeping resolutions ? Further search revealed a study published by Dr. Norcross in which when success was measured over a longer period, 2 years, the success rate to be only 19 percent. Dr. Wiseman’s experiment, by the way, is still open and you can join here.

I was struck by one of Dr. Wiseman advice’s: women and men must pursue different strategies, if they’re to be successful in their resolutions. He said that women were more likely to succeed when they revealed their resolutions to their social circle and were encouraged to not give up in the face of minor setbacks; men were more likely to succeed when their goals were simple and specific, rather than vague. His observation was that men are unrealistic about their expectations and so benefit from setting simple, specific goals. His mantra for succeeding in setting goals were:

  • Make only one resolution
  • Plan the resolution ahead of time. Don’t wait till the new year’s eve to come up with a goal.
  • Make new resolutions, don’t repeat previous resolutions as this will set you up for frustration
  • Men, be specific about your goals and keep them simple. Women, tell others about your resolution.
  • Make the goal personal such as being attractive to women rather than just losing weight.

What about Dr. Norcross ? What words of wisdom did he have for those who made new year resolutions ? He recommends the same set as the one Dr. Wiseman, except that he doesn’t provide any gender-specific advice. He advices publicizing your goal, keeping it simple and specific to everyone, not just a specific gender. He also recommends to not let a slip get in the way of keeping at the resolution. He quotes a study that observed that 71 percent of successful resolvers said that they felt even stronger about pursuing their goal after their first stumble. Finally, he recommends changing environments to break old habits, to not go to the bakery if you want to avoid eating sweets. Another fascinating statistic that he provides is that of those who tried to change but didn’t make a resolution, only 4 percent were successful at the end of six months. So, the chance of success increases tenfold if one makes a resolution compared to not making one!

In an article published back in 1992, in the American Psychologist, Dr. Norcross, suggests that there are five stages to making a change (what’s with this preoccupation with five in the psychology community ? five stages of change, five stages of grief ?): pre-contemplation, contemplation, preparation, action and maintenance. Dr. Norcross suggests that those who make a resolution and make it public are well into the fourth stage of making a change and hence have a better chance of making a change compared to those who didn’t make a resolution. I suspect that for this to be true, people who make resolutions must be those who had them ready well before new year’s eve.

The brain physically changes when we learn new habits. The neurons in the prefrontal cortex and basal ganglia, two main actors in the learning process, show visible changes as new habits are acquired. The changes are so permanent, at least in the basal ganglia, that once acquired, they cannot be forgotten. They can lay dormant for a while, but when the right cues are provided, the old, long forgotten neuronal patterns fire again, and the prodigal son returns. Dr. Ann Graybiel and her team at MIT discovered this back in 2005. They also found that it was not possible to reverse the process i.e. to unlearn. The right cues caused the neurons that had changed in response to the learning to fire again. This explains why habits are so hard to break, why it is important to not recreate situations that cause the old habit to trigger again, to not go to the bakery if you to curb that sweet tooth.

The brain has two ways of processing inputs: a slow, conscious way and a fast, automatic way. As anyone who’s learnt a skill such as roller blading or downhill skiing knows, the initial motions are forced, slow and jerky while once the skill has been learned, the motion is smooth, fluid and automatic. Habit forming is slow, requires constant reinforcement in the form of rewards and constant attention. The prefrontal cortex is responsible for executive control, inhibiting a thought from conversion to action. But this requires self control or will power. An article published in April 2008 in the New York Times, says that willpower is like a muscle: there is only so much it can do before it fatigues. From the article:

The brain’s store of willpower is depleted when people control their thoughts, feelings or impulses, or when they modify their behavior in pursuit of goals. Psychologist Roy Baumeister and others have found that people who successfully accomplish one task requiring self-control are less persistent on a second, seemingly unrelated task.
…
For example, if you do not want to drink too much at a party, then on the way to the festivities, you should not deplete your willpower by window shopping for items you cannot afford. Taking an alternative route to avoid passing the store would be a better strategy.

This is one reason why new habits are so hard to form and why it is essential to keep the resolutions simple, specific and single. The good news of the same study, however, is that like muscles, willpower can be built up through exercise. A study speculates that even an exercise such as brushing your teeth with your other hand for two weeks can improve your willpower. And once willpower improves, it can be used to deal with more curbing other bad habits. The NYT article states that people who stuck to an exercise regimen for two months also reported reducing impulsive spending, alcohol and junk food consumption and smoking. While the reason for the increase in willpower with practice is not well understood, the article speculates:

Perhaps neurons in the frontal cortex, which is responsible for planning behavior, or in the anterior cingulate cortex, which is associated with cognitive control, use blood sugar more efficiently after repeated challenges. Or maybe one of the chemical messengers that neurons use to communicate with one another is produced in larger quantities after it has been used up repeatedly, thereby improving the brain’s willpower capacity.

I cannot remember if I ever practiced making new year’s resolutions. The Dalai Lama once said, “There is no world peace without inner peace”. Inner peace continues to be my every year’s resolution, every day’s resolution. I, for one, wish inner peace to all peoples in the coming year.

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How Doctors Think: A Review

Posted on October 30, 2008
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The sister of a friend of mine in India suffered from Crohn’s disease, a disease of the digestive system that is rare amongst Asians. Her condition was misdiagnosed for several years, causing her an immense amount of suffering. I have another friend who’s wife is suffering from something that has not been identified yet. Every doctor seems to think something else is wrong and she’s subject to a different treatment each time. Even temporary relief is rare.

Studies based on autopsies indicate that 10-15% of diagnosis are wrong. What are the causes of these failures of diagnosis ? Is it that the condition is really rare such as in the case of Crohn’s disease that it is difficult for the doctors to know or is it something else ? Come to think of it, how do doctors think their way to a diagnosis ? And why is it that many times, two different doctors disagree on the diagnosis ? What if I were a drunk or if I was obese ? Does my doctor emotionally react to my state (in disgust, for example) or don’t they ? If they do, how does that color their care ? What if they were positively affected by my condition, seeing me fit, in good condition, articulate and well mannered ? Does their positive thinking about me negatively affect my care ?

How Doctors Think by Dr. Jerome Kroopman is a book that addresses these questions. Dr. Kroopman, himself a physician and a professor at Harvard Medical School, has written a brilliant, lucid and engrossing book that addresses the very nature of how doctors think. That our thinking is fraught with myriad cognitive biases is well accepted now. This book illustrates how those errors are at the heart of incorrect diagnosis and the conditions that cause them.

Dr. Kroopman says that experts studying misdiagnosis that caused serious harm to patients attribute most errors to errors in thinking, not to lack of medical knowledge. He quotes one study that attributed 80% of misdiagnosis to cognitive errors, and another study that parceled inadequate medical knowledge to only 4% of the cases. About 15% of all diagnosis were incorrect says a 1995 report in which doctors provided a diagnosis based on written descriptions of the patient’s symptoms and examined actors simulating patients with various diseases. The average diagnostic error in interpreting medical images (such as XRays, CAT scans and MRI) is about 20-30%, an alarmingly large number. In a study assessing 100 radiologists on chest x-rays, they disagreed amongst themselves 20% of the time, when asked the same question a few days later after studying the same x-ray again, they disagreed with themselves 5-10% of the time. 60% of them failed to identify a missing clavicle. But cuing them saying that these x-rays were part of identifying cancer, 83% of them identified the missing clavicle, when told that it was part of an annual physical, 58% missed the finding.

Over the course of 320 pages and 10 chapters, Dr. Kroopman looks at different kinds of doctors from ER physicians to family practitioners to pediatricians to radiologists to specialists and brings a keen eye to the nuances of each profession, their difficulties and their practices and how cognitive errors enter the diagnostic process. In an era where doctors find themselves squeezed by money on either end, by big money pharma on one end and by the insurance industry at the other end, the book also addresses the kinds of cognitive errors that result, in part, by the the role of these two major ecosystem players.

The Cognitive Errors

Dr. Kroopman runs through the gamut of cognitive biases as he follows the minds of doctors during the course of their making a diagnosis. Many of these cognitive biases amplify each other resulting in a decision that seems rock solid to the physician but is not.

When a doctor sends a request to a radiologist asking for a check of the lungs for checking lung cancer, that question makes the radiologist think in a particular way, about lung cancer as opposed to say pneumonia. Or at other times, a doctor may send a patient to a specialist with a statement such as “I’m sending you a case of renal failure and diabetes”. Forcing doctors to think about particular outcomes makes them not think about certain others. This creates the framing error. A simple joke illustrates the framing error. Two friends go to a church for praying and one of them gets an urge to smoke. He decides to check with the priest before smoking. He asks the padre, “Father, is it OK to smoke while I pray” to which the father responds with utter horror and chastises him. When he reports the result to his friend, his friend says that he asked the wrong question and proceeds to ask, “Father, is it OK to pray while I smoke” to which the padre gushes, “My son, it is always OK to pray when you’re doing anything”. The first question activated the “smoking” frame and the second, the “praying” frame. The annual physical versus the cancer example quoted at the start of this article is a more pertinent and troubling example of the framing error.

A pediatrician seeing a stream of cranky children with fever who have the flu can easily overlook the one exception with meningitis. A doctor in India seeing a patient with diarrhea, vomiting and abdominal pain is more likely to consider irritable bowel syndrome rather than Crohn’s disease because that is the common case and Crohn’s is hardly seen. In other words, the brain arrives at a specific conclusion (or set of conclusions) based on the information that is easily available and we implicitly assume that “if we can think of it, it must be important”. This is called availability error. If I asked you if there are more number of words that start with the letter t compared to words which have t as the third letter, you’re more likely to think that it’s the former because of the ease with which you can come up with words that start with the letter t.

Once we’ve arrived at a conclusion, we tend to selectively look for data that confirm our conclusion and ignore or reinterpret the rest. This is called confirmation bias. Ego is a big factor here since we like to think of ourselves as more competent than we really are. Various studies show that the more incompetent we are, the more certain we tend to act (Sarah Palin effect ?). One example that Dr. Kroopman points to is a study comparing 100 radiologists in which the bottom twenty were more confident than the top twenty.

In another anecdote, a doctor looking for the cause of a persistent ache in the hand concludes that the cause are cysts in the hand when the problem was something else altogether. Search satisficing is caused by our stopping to look for causes once we’ve settled on one. For example, if you’re rushing to the airport and realize you’re missing your wallet, you start searching for it desperately; once you find it, elated, you rush out of the house, only to realize much later that you’ve forgotten the plane ticket inside. Having seen the cysts, the doctor stopped looking for other causes. Dr. Kroopman quotes a physician, “”Finding something maybe satisfactory, but not finding everything is suboptimal”.

Anchoring is another reason for search satisficing. In an experiment, participants were asked about the percentage of African nations that were members of the UN. They asked one group whether the percentage was more or less than 45% and they asked the other group if the percentage was more or less than 65%. Each group tended to anchor their answer around the number quoted to them, 45% or 65%. The doctor who arrived at the cysts as the answer, weighted his diagnosis by anchoring his decision on the importance of cysts.

Many of these errors are also caused by attribution error, especially if the patient is associated with negative stereotypes. Dr. Kroopman provides the anecodote of a patient who comes to a doctor after a decade of illness with labels of “anorexic” and “psychiatric” and how those labels helped many doctors give the patient a short shrift, arriving at a diagnosis rather quickly. Similarly, a doctor seeing a very personable, older patient may demur from subjecting him to a more invasive test that would really clear that little lingering uncertainty about the diagnosis.

Commission bias is caused because of the very nature of the medical profession (nay, the Western culture). It is the desire to act instead of observe. “Don’t just stand there, do something” is the Western mantra. Dr. Kroopman points to surgeons as examples of people with this bias.

The Conditions

All these cognitive biases are heuristics that we resort to when we’re in a hurry. Most of these biases can be overcome by pondering. But in an age where pediatricians and general practitioners attempt to remedy their lowering reimbursements from HMOs by seeing more patients, ponder is something they cannot do. And in places like ER, the very nature of what they do forces the physicians to work quickly. One ER physician is quoted as saying that he feels like a circus juggler, spinning plates on a stick; slowing down will cause everything to crash. Similarly, a primary care physician is quoted as saying that looking for the out of the ordinary gets very hard because she feels like someone looking for a face in a passing train; if the train goes faster and faster or if you get distracted, you can easily miss that face. Dr. Kroopman states that on the average, a radiologist views 150 CAT scans over a weekend and a CAT scan has dozens of images; new technologies such as MRI produce hundreds of images. Scanning them visually looking for errors takes time and time is always pressing (on the other hand, a radiologist who looks at an image for more than 38 seconds, risks seeing things that aren’t there).

Physicians also have to walk a balancing act between raising unnecessary fears and ignoring real problems. Learning how to communicate becomes a key factor. Dr. Kroopman says that there is a myth that a brilliant doctor is a poor communicator and a good communicator is a poor doctor. Both are essential, he says. A good doctor is one who communicates well, listens and speaks. The kinds of questions (s)he asks can result in a diagnosis arrived at through a stream of cognitive errors. Most of us are afraid and anxious when we visit a doctor, we also don’t want to appear stupid, as somebody wasting the doctor’s time. If we perceive the doctor is rushed or don’t get asked the right set of questions, we may not provide the information necessary to arrive at the right diagnosis. A study found that on average, a doctor interrupts a patient 18 seconds after the patient first starts telling their story.

Dr. Kroopman also says that much of what doctors practice is a result of where and under whom they studied. Shanthala tells me of procedures that were insisted on in her MD program that the hospital where she works don’t insist and instead do it slightly differently. “Playing God” is a familiar term used to describe doctors. Part of that allure is the mask of certainty that most doctors exude. Dr. Kroopman says that the orthodox and conservative medical establishment fosters such attitudes.

What Can We Do

Reading books like this can leave us wondering if there’s anything we can do. Fortunately, Dr. Kroopman offers lots of suggestions, questions that we can ask to jar the doctor out of their heuristics. For example, we can ask what organs are around where we’re having the problem forcing the doctor to consider other possibilities than gall stones. Or we could ask the doctor to compare the lingering pain post-surgery to having a tooth pulled to get more specific answers. He even helpfully summarizes all these questions in a single epilogue.

Dr. Kroopman addresses these and much more in a book filled with real life anecdotes, many from his own life, both as a doctor and as patient; most of the cases are real cliff hangers. He rarely casts a jaundiced eye on either the doctor, the system or the patient, though he does sound skeptical about the current health care system with insurance companies and big pharma calling the shots. Overall, a very knowledgable and pleasurable read. Highly recommended.
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Oh! Why Can’t She Remember

Posted on October 23, 2008
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Starting here, what do you want to remember ?
How sunlight creeps along a shining floor ?
What scent of old wood hovers, what softened
sound from the outside fills the air ? – William Stafford

I am four years old (or is it three ?), walking with my parents down a street in Coimbatore, a city in Southern India, where we lived at the time. All of a sudden, my parents start pointing to things on the opposite side of the street, hoping they can distract me. But, it’s too late. I’ve spotted the red bus in the display window of the toy store we’re passing and start demanding that they buy it for me. I kick up a ruckus in the street. My parents tell me that if I don’t stop, they’ll just abandon me in the street and go away. “Go ahead”, I said, like some miniature Clint Eastwood, “Leave me. I’ll just hop into an auto and tell them to take me to Tatabad and come home”.

This is among my first vivid memories of my life. Is it a real memory or one planted much later, made up after the countless repetitions of the event over the years ? I can recall playing with the maids who worked in the house at that time, a mother and daughter pair, a house on the second floor (first storey for the British versions) with a big balcony overlooking the street. I don’t recall any friends from that time nor any other details such as the school that I went to. I cannot recall anything earlier in my life.

As I played with Maya the other day, it struck me that she will not be able to recall the memory of that day and of all the days before that. The care, the love, the sleepless, exhausting nights and days will all be folklore, hand-me-downs from her parents. Yes, there will be the photos and the videos, but it’ll never be the same as remembering it herself. It seems like one of life’s ironies that we cannot recall those days, when we were so cared for, nursed to life when we were most vulnerable, how much we depended on parents and how selflessly they served us (though my father admits that when he wanted to sleep, he would rub a pain balm on my forehead that would burn, making me close my eyes and fall asleep). If we remembered those days and nights, would we be less angry at our parents as we get older ? Intelligent design ? Well, certainly ironic design.

Curious about everything associated with babies now, I wondered about this inability to remember our earliest times.

The condition is real. It goes by the name of infantile amnesia. The story of what causes it is a long one, it is the story of our attempts to understand the very fabric of ourselves, what makes me think of me as me, the story of memory. Saul Bellow famously wrote “Memory is life”. Several books, some of them bestsellers like Daniel Schacter’s “Searching for Memory”, are devoted to this subject. It is also an ongoing story because there is still much that we do not know. And sometimes new research throws out old, seemingly solid explanations. Here is my attempt to synthesize that story into something small enough to fit a blog post.

Memory is a many-splendored thing. There are many forms of it, many places in the brain where it is constructed and stored. For example, almost everybody is aware of short term memory and long term memory. Short term memory or working memory is how we experience the now, the immediately immediate past. It is where we store the telephone number long enough to dial the number. It is fairly limited in capacity, capable of storing about 7+/-2 items, be they telephone numbers or something else. Long term memory is the remainder of that immediate past, stored and retrieved many, many times, sometimes years later. Another kind of memory is what is called implicit or procedural memory. Even if an Maya can’t remember the details of these initial years, she is learning many things perfectly well, such as the ability to sit, crawl, walk, learning that a cry usually fetches one of us pretty quickly. Contrasting this implicit memory is explicit or declarative memory, the consciously recalled past. Explicit memory itself is made up of two kinds: episodic memory, an example of which is the story at the start of this entry and, semantic memory, which is our knowledge of how the world operates such as physics, maths, social roles and culture.

Like just about everything in neuroscience, or at least modern neuroscience, much of what we know is a gift from a host of unfortunate characters, people who’ve suffered some form of grievous injury to their brains, providing neuroscientists an opportunity to glimpse into the functioning of the brain. For memory, the main individual is known only by the initials H.M (or Henry M). Suffering from epilepsy from an early age, HM was referred to a surgeon, William Scoville, in Connecticut, USA. After localizing the cause of the seizures to his medial temporal lobe, Scoville surgically removed the structure in an attempt to stop the seizures. After the surgery, HM lost his memory, became an amensiac, suffering from severe anterograde amnesia i.e. he was unable to convert any short term memory into long term memory. However, he could still learn new motor skills, indicating that his procedural memory was intact, though he couldn’t remember learning the skills. Since HM had no amnesia before the surgery, the medial temporal lobe was held responsible in the functioning of memory.


Starting from that event in 1953, we arrive at today’s understanding of the parts of the brain that are associated with the functioning of memory. Based on the outcome of the surgery on HM, the hippocampus is generally credited with playing a key role in the creation of new explicit memories. What that role is remains uncertain. A recently published study on two people who both suffered damage only to the hippocampus shows that while one of them showed no deficiency in memory, the other had difficulty creating new memories. The researchers theorized that a very specific location within the hippocampus maybe responsible for creating new memories. Unfortunately, even the most sophisticated techniques seem confounded in pinpointing this kind of detail. Amygdala, considered the emotional center of the brain, is responsible for emotional memory. For example, we tend to react and remember emotionally charged words and events more than non-emotionally charged ones. Damage to the amygdala causes us to lose this difference. The prefrontal cortex is considered important in remembering the when and where of our memory, the context of the memory. Called source memory, it is what enables us to distinguish between an imagined event and a real event. To remember what we were doing on October 22, 2008 compared to the date of our wedding. Since this is one of the last parts of the brain to mature, it is suspected to be responsible for why children are notorious at not remembering where they learned something. Besides these structures, a neurotransmitter (chemicals that are used to relay, amplify and modulate signals between a neuron and another cell), acetylcholine is considered to be responsible for promoting the creation of new memory. Acetylecholine is primarily sourced in the basal forebrain and it is the degeneration of that part of the brain that results in the memory loss in that dreaded disease, Alzheimer’s.

Neuroscientists theorize that the brain encodes a memory by strengthening the connections between groups of neurons that participate in the storage of the experience. Many contend that there isn’t a single place in the brain that encodes the memory of an experience. For example, the brain uses different systems for retrieving written and spoken information. Using all the different places where the experience is encoded, the brain reconstructs the experience of that past experience. New research reveals that the very same neurons that fired when we originally experienced something, fire when we remember the experience. But because the brain does not encode every specific detail about an event, it manufactures our memory of that experience by filling in the details from other memories. So what we remember is never really accurate. Worse still, the more we remember an event, the stronger becomes the way we remember it, until eventually we’re only left with our recollection of it, not what really elapsed, the “Rashomon” effect.

A psychologist, Caroline Miles is credited as the first person to have formally studied infantile amnesia, back in 1893. Sigmund Freud proposed the first reason for childhood amnesia. He suggested that we deliberately repress the memories of those early years because of the trauma that we suffer as a consequence of our psychosecual development. This theory has been mostly rejected.

The reasons why we fail to remember those early events are divided into two main causes: that it is a problem of storage and that it is a problem of retrieval . Some contend that the memory never was stored due to a lack of maturation of the two main structures of memory, hippocampus and prefrontal cortexThe “problem with retrieval” camp proposes many different reasons for infantile amnesia, mostly related to context. For instance, it is postulated that since language doesn’t develop until much later and much of what we explicitly remember is verbalized, infants can’t remember those early years. Another theory is that since we develop a sense of self only around two years or so, we can’t remember earlier events because we don’t think of them as pertaining to us. Context is crucial in our ability to recall. So, another theory suggests that we have difficulty recalling those baby times because we are never again placed in the same position as an adult that we were in as infants, surrounded by giants, actions that were beyond our comprehension. As one blog puts it: “Rather than being completely forgotten, our earliest experiences may actually be mislabeled”.

Despite our early, seemingly immature, episodic memory, our implicit memory seems quite up and ready at birth, or even before. Infants learn a variety of motor skills as they grow. Much of new newborn research is based on what is called operant conditioning, the ability to associate our action with subsequent reward or punishment. Infants are known to suck at different rates to obtain a particular reward such as mother’s face or her milk. Another source of figuring out what goes on insider their baby minds is a baby’s preference for new items, the novel over the mundane. An infant will pay more attention to new events and objects compared to older ones. Studies using this technique have shown than newborns can remember a visual stimulus for only a few minutes while a five month old can remember it upto three months later. Novelty preference requires that infants can recognize, distinguish the old from the new. This is also a form of memory that is now called pre-explicit memory, because it uses the same circuitry that explicit memory uses.

Interestingly, it has been found that girls recall much more vividly, much earlier events compared to boys. Studies of infant monkeys have revealed the cause to be the hormone, testosterone. Some others point to culture as the reason for this difference, that we engage girls more than boys when they’re infants. Even more interestingly, Maori children have been known to recall events from a much earlier age as compared to European children and Asian children tend to recall events from an even later age than the Europeans.

I sometimes am glad that infants can’t recall as well as we’d like them to. Maya maybe appalled at how inexperienced we are as parents.

References:
- Wikipedia (the image is from there)
- Searching For Memory by Daniel Schacter
- What’s Going on In There by Lise Eliot
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