Why Ask Why?

Humans are wired to constantly search for causes for (and solutions to) every problem. This is probably our most useful adaptation, but it can lead to certain difficulties, especially for doctors.

Take flu shots, for example. It has been shown conclusively that flu shots do not give you the flu. (They couldn’t give you the flu due to the way they’re designed, but people went and did studies on it anyway.) Yet there are many people out there who swear that flu shots give you the flu. Why?

Flu shots are given during cold and flu season. A certain number of people will come down with an upper respiratory infection in any given week. If one of those people happened to get their flu shot that week, it’s easy to see why they would assume that the shot was to blame. Forever after, they will attest that flu shots give you the flu—and will probably convince a few other people of the same. Trying to argue against this is nearly futile. I attempt a preemptive strike with every flu shot I give, telling them that the shot won’t fully protect them for about two weeks, so they could still catch the flu in that time, but I’m not sure how well this works.

Trying to bring on labor is another example. Studies have shown that NOTHING works to bring on labor, with the exception of the drugs used for formal induction in the medical setting. Castor oil? Doesn’t work. Having lots of sex? Doesn’t work. Scrubbing the floor on hands and knees? Doesn’t work. Nipple stimulation? Doesn’t work. Acupuncture? Doesn’t work. Ankle massage? Doesn’t work. Walking/jumping? Doesn’t work. Stripping the membranes? Doesn’t work. Primrose oil? Doesn’t work. Raspberry tea? Doesn’t work. And so on and so forth.

But wait! I can hear a lot of you (probably most of you) thinking. My doctor recommended having sex, and it worked for me! My best friend used castor oil, and it worked for her! My midwife swears that several of her patients have gone into labor after drinking raspberry tea! I know these things work!

But think about it. No matter what, every pregnant woman eventually goes into labor. And whatever thing she did just beforehand will always be credited with doing the trick. Therefore of course all of these things have “worked” for some people. But when they’ve been formally studied—having fifty pregnant women do nothing while another fifty twiddle their nipples, for instance—the rate at which they go into labor is exactly the same.*

Birth defects are yet another example. I was talking with a pregnant friend recently about how nutty everybody gets about pregnant women doing anything—taking medications, drinking coffee, having a little alcohol, lying on their backs. This hysteria seems to be getting worse and worse. Partly this is just part of the whole trend toward fetishizing pregnancy, I believe, but partly it’s because of the way birth defects occur. There are only a few things that are known to cause terrible birth defects—thalidomide, oral isotretinoin, and a couple other uncommon things—but even if you don’t have exposure to one of those, there is a 2-3% risk of major birth defects. And when one of these spontaneous defects happens, of course everyone starts wondering what caused it, and remembering every cold tablet and cup of coffee and hot bath they took during pregnancy. If you do a retrospective study looking at birth defects, the mothers of babies with defects always remember more exposures to everything than the mothers of healthy infants. But if you do a prospective study, following people through their pregnancies and documenting exposures, there’s no difference between those in which defects occur and those in which they don’t.

If something happens often enough—a colicky baby being fussy, for instance—it’s easier to figure out (by trying a lot of things that don’t consistently work) that nothing you do causes it or cures it, and it just needs to be waited out. Relatively rare things that can occur randomly (getting pregnant, birth defects, most cancers) or that inevitably end with time (pregnancy, a chest cold) are the things that really lend themselves to myth-making about causes and solutions.

The belief that every phenomenon can be explained and every problem solved is a wonderful thing much of the time. It’s great when someone with diabetes understands that eating carbohydrates causes their blood sugar to rise or that taking their medicine brings it under control. But it’s frustrating when someone can’t accept that doctors don’t have the solutions to everything. (The doctors who can’t accept that—and there are many—are even more frustrating.)

I wish I had a better way of explaining this to patients. Sometimes when people ask me “Why did I get this disease?” I’ll answer, “Just bad luck,” and they look at me like I’m crazy. I suppose if I were religious, I could answer, “Only God knows the reason,” but 1) I’m not, 2) my patients might not be either, and 3) even if they are, it could be an annoying thing to hear (“I’m sure God has a reason for why you had this miscarriage!”).

How do you deal with things that can’t be explained?

*UPDATE: OK, I should know better than to use an inflammatory example such as this. I say the following in a comment below, but I’ll add it here too: the induction of labor example was meant mostly as an example of a perfect setup for fallacious beliefs to take hold. Yes, there are studies here and there that suggest that a couple of these things might increase the odds a little bit of delivering earlier (though several of those studies were actually done in conjunction with oxytocin, so I’m not sure that you can count them). But having looked at the evidence, I’m standing by my assertion that none of those things is worth having anyone put themselves out in any way to do, because if they work at all, the effect is teeny-tiny. Remember, negative studies mostly don’t get published, so if there are a few weakly positive studies—or positive weak studies—chances are very good that there are at least a few unpublished negative studies.

I’m not saying that everyone should be induced medically by any means; I think too many people get induced as it is, and if we just waited until babies were done gestating we’d have fewer c-sections. I also think childbirth has been overmedicalized in general—I even think that the evidence supports the superiority of (supervised) homebirth in multiparous women. But the things that I see heavily pregnant women doing to try and bring on labor just seem miserable, and the amount of advice they get about it could give anyone a headache. (Which doesn’t help bring on labor either.)

And yes, I’m having a wretched day, and week for that matter.