Friday, March 9, 2018

The Spider Bias

Image result for charlottes webPoor Itsy Bitsy.
Poor Charlotte.
Poor Miss Spider.

All Itsy Bitsy did was climb up the water spout.

Charlotte saved Wilbur's life.

And Miss Spider-- remember her from Roald Dahl's James and the Giant Peach?--she was a kind and gentle soul to poor little James. Miss Spider says it best: "I am not loved at all. . .And yet I do nothing but good. All day long I catch flies and mosquitoes in my webs. I am a decent person. .  It's very unfair the way we spiders are treated."

Human beings' blame game with spiders is one of the strangest and most pervasive cultural biases I have discovered in my role as a family physician. Without evidence. Without a trial. Without a second thought. We believe spiders bite us. All the time. We see them around, we assume they are evil, and we blame them for strange otherwise inexplicable skin eruptions that have nothing to do with them.

The story goes something like this: 

Mr. human wakes in the morning with a sore red spot on his body. It may even have some pus. It hurts. He has no idea how it got there. He wants to know. There must be a reason, an identifiable cause. Incidentally, there are spiders in the world. In fact, the human saw one in the last week in his very house. Spiders are known to be evil. They bite. That's it! The spider did it. Case closed. 

This bias is surprisingly widespread. So much so that on any given day in any given emergency room, urgent care, or outpatient clinic in America, you will find someone reaching out for care for a "spider bite" caused by a spider they never saw. 

31 year old, spider bite, R arm (see photo)  

7 year old, spider bite, abdomen (see photo)
56 year old, spider bite L thigh (see photo)
2 year old, spider bite, leg (see photo)

Image result for mrsa abdomenImage result for mrsa infection
Image result for mrsa cellulitisImage result for mrsa furuncle

Sometimes the 31-year-old is a drug addict, but he could be a veterinarian. The 7-year-old might have a dog or perhaps a bearded dragon. Sometimes the 56-year-old has had one of these bites before. Out of curiosity and playfulness, my first question for such patients is always "Did you see the spider?" The answer is always no. Did you catch that? No one has ever seen the spider. Occasionally, the "no" is followed by an "Ahem, well, a few weeks ago I did see one. I saw a spider."

Now, put yourself in the place of a spider, just for a second; what it must feel like to be blamed when you weren't even seen in the building since last week? What it must be like to be assumed at fault by an entire nation? This is a classic case of guilty until proven innocent-- and a cultural belief so strongly held that a review of the case (much less a trial) is deemed unnecessary.

Poor spiders!

In my ten years as a  family physician in Northern California, I can definitively tell you that while I have seen plenty of patients who believed they had a spider bite, I have never actually seen a spider bite. Not once. Not a single time. One study in Southern California found that of 144 people seeking care for a spider bite, only 3 had an actual bite (that's a whopping 2%) . 

In my (albeit anecdotal) experience, 100% of presumed spider bites have turned out to be either small pustules or larger abscesses from a cutaneous bacterial infection (i.e. a skin infection). These infections are famously caused by staph aureus, and most often a newer antimicrobial resistant strain called methicillin-resistant staph aureus (aka MRSA). Turns out somewhere upwards of 25-30% of humans have staph aureus living on their skin (sorry if you didn't want to know that), and about 2% of us have MRSA. 

Our skin is our major defense mechanism; it protects us from burns, cuts, and infections. And yet, the barrier is constantly being challenged in both major and minor ways. With relative frequency, we nick ourselves on a piece of paper or with a sharp object and know exactly when it happened, but much more often, we have micro-perforations of our skin barrier-- little nicks that are so small we don't even realize they happened. These micro-perforations make us vulnerable to our own commensal skin flora hanging out on our skin,  thereby turning a mutually neutral existence into a bad relationship. 

Usually, our remarkable skin spontaneously heals itself after such a perforation, and we go along our merry way. But occasionally, when the conditions are right, skin disruption meets staph aureus (or even worse, MRSA), and infection ensues. That means occasionally someone actually did have a bug bite that got infected or a preexisting scratch that turned into an abscess, but more often than not, there was no obvious initiating factor. 

Such infections are no fun-- I have had a few and treated many. They are painful and embarrassing and can make you quite ill. Often, they need antibiotics or drainage (think: scalpel). Recently a perfectly healthy young friend of mine was hospitalized for just such an infection. 

My husband once wisely said to me that people blame spiders for skin infections because it's less scary than knowing the truth-- that is, that our own friendly bacteria are capable of creating what could become a serious infection-- and that it could happen to anyone at any time. It's freaky, he said, to imagine that there isn't something (or someone) else to blame.  Spiders are an easy target. 

What can you do to prevent abscesses and skin infections? Take good care of your skin. Wear gloves when indicated. Wash your hands. Don't scratch. Don't pick. Keep your fingernails short. Keep your skin well hydrated (with a good lotion or cream) and pay attention to any particularly dirty cut or scrape as soon as it happens. Even so, occasionally things will get infected. Soak them (in a basin or with a hot compress) and talk to your doctor if the redness or swelling is worsening.

What else can you do?

An even harder undertaking is to stop blaming the spiders, to start questioning our own biased assumptions, and to practice tolerance. 

As we stumble through this complicated life, overwhelmed with fake news and social media-driven hyperbole, we should reserve blame-- for blame often enough will lead us to be more fearful and less curious.  

Image result for charlottes web quotesWe should also continuously ask ourselves if our primary assumption is true.  In fact, it turns out that only about a dozen of the more than 40,000 species of spiders worldwide can actually cause harm to humans; and even the ones we know are bad (e.g. the black widow and the brown recluse) cause less harm than we might think. Just like Miss Spider said, spiders are mostly beneficial to humans by eating many insects that either infest our foods, are disease vectors, or are just plain annoying.

And we should practice tolerance. For being intolerant of spiders does nothing to decrease one's risk of a skin infection but does increase one's anxiety. Practicing tolerance allows us to peacefully coexist with other living creatures-- which sure sounds more pleasant than living in fear. Plus, you never know when you might be grateful to have a spider around. Right, Wilbur?

Roald Dahl's James and the Giant Peach
EB White's Charlotte's Web

Friday, January 12, 2018

Lying naked on the bed

A few weeks ago, my husband went in to have a vasectomy.  I am proud of him-- for being brave (only about 10% of US men get vasectomies); for announcing his reason for missing work to his all-male engineering team (imagine the uncomfortable squirms when he brought up the topic at their weekly debrief); and for taking ultimate responsibility for our family's family planning.

Image result for all juice no seedAnd so ends a two-decades long birth control chapter in this woman's life. Woohoo!

In his defense, he did way less milking of the situation than I had anticipated. I had envisioned him reclining dramatically on the couch with an ice pack on his crotch avoiding normal household duties and requesting room service and an endless supply of cereal and Game of Thrones episodes.  Instead, he came home with a smile on his face, exclaimed, "It wasn't really much more pain than a shot of Novocaine at the dentist", and went about helping out with the day-to-day madness that is having three young children. For the next few days, he took it a little easy, occasionally winced in discomfort, and his only recurring complaint was the itchiness.

All in all, it was a success. And a relief-- for both of us.

All said, I cannot help but ruminate on the one remark he made that I find particularly fascinating and somehow shocking: the totally new and "strange feeling of lying naked in the room waiting for the procedure to begin." He repeated a few times, "I've never been in that position. . . just lying there naked."

Lying naked on the bed.
Waiting for a procedure to begin.
Lying naked on the bed.
Lying naked on the bed.
Lying naked on the bed.
Lying naked on the bed.

How long have I been lying naked on a bed waiting for someone to come in?

Twenty-two years.

Since age 18, upon deciding I was going to have sex for the first time, and I dutifully made an appointment for my very first pack of birth control pills and my very my first pap smear. We don't do this, by the way, anymore. We don't pap 18-year-olds. Pap smears in the US start now at age 21, and in some countries in Europe cervical cancer screening doesn't start until age 30. We also don't tie birth control to the requirement you get a pap smear. Turns out that was a dumb idea. In fact, the only thing that birth control and pap smears have in common is that they kind of sort of both involve your private parts.

Again a year later, when I had another pap.

And again, when I had my first vaginal infection.

And again at age 21, when the Peace Corps required I have a rectal exam in addition to a bimanual  exam to be "cleared for service" (WTF?!?). The bimanual exam-- by the way-- is the "two hand" exam-- you know the one-- one hand inside your vagina, one hand outside on your belly, the one that doesn't feel very good and yet somehow seems important. It turns out that physicians don't really know what they are looking for when they do a screening bimanual exam-- our ability to detect cancers or other badness with our two hands is about the same as flipping a coin. In one study of women with known ovarian tumors, physicians were only able to "find" the tumor by examining with their hands 50% of the time. So this type of exam should only be done with forethought-- when your provider suspects you may have a uterine infection or some lesion that could be helped by examining you. 

And again, when I finished my Peace Corps service.
And again, and again and again.
When I got pregnant. And delivered. And got pregnant. And miscarried. And couldn't get pregnant. And had a test. And then another. And then another.
When I had surgery. And then intrauterine insemination. And then IVF.
When I got pregnant again. And delivered.
When the doctor yelled at me for not being undressed and "ready for him" at my postpartum visit with my fussy 6 week old baby who didn't want to be put down.

And again when I was pregnant with my third child and went in for my intake appointment. I was asked to undress completely, as the physician needed to examine my breasts and do a bimanual exam. The funny thing is-- I let her do it-- despite the fact that I know better. That there was no particular reason she should do such an exam at all. Her time (and mine) would have been better spent probing the safety of my relationship, my fears about my advanced maternal age, or heck, just getting to know me.

And yet, there I was, lying naked on the table.

This post is for you, women. For all of you who have laid naked on the table, wrapped in a generic cloth gown that gapes open no matter how you tie it-- or worse, a paper gown that literally rips into shreds as you attempt to preserve your modesty. And then wait for 3 or 5 or 25 minutes for that fateful knock on the door.  To have your very most private parts examined.

Being naked is scary. It's vulnerable. It's raw.  And, unfortunately, it's part of being a woman-- a woman who has sex, a woman whose parts are tucked up inside of her, a woman whose body is both capable and vulnerable-- to being pregnant, to contract disease, to have all the crazy shit that can happen to our amazing parts (everything from vaginal discharge to pelvic discomfort to herpes to a saggy post menopausal bladder).

This is also a post for you, doctors. The scariest part of being a doctor is being vulnerable to forgetting-- forgetting that every single body we have the privilege to see and touch and examine is that one person's only body. It is their most precious and private part. And they are entrusting me and you to acknowledge the power, recognize the specialness, and do what we need to do to care for them with utmost love and respect.

This is also a post for you, men, who may have less opportunity to lie naked on a table at the doctor's office. But your time, too, will come. You will get a hernia or a weird lump in your testicle, or maybe you will be one of the 10% of US men to sign yourself up for a vasectomy.  (It's not so bad, after all). In the meantime, please do us all a favor, and treat every body you come across (particularly those who are lying naked in front of you) with love and respect.

And some day, when you are scared or sick-- may your body be treated the same.