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Guiding Lights

This is, I admit, a content free post. July and August are the sunny days here in the great Pacific Northwest, and rather than spend time in front of the computer, I am outside with the kids. To compound matters, I was on call the labor day weekend (I usually write the first draft the weekend before the posts are due) and was very busy. I am finishing this early on Thursday on an airplane to Vegas. My wife and I are taking our first non-child containing vacation in 19 years while my youngest is on a 4 day school trip. Wander the strip, see a show and enjoy the desert heat as a couple and not a family.

I have not had the time to spend researching a topic, so instead I thought I would ramble on about 2.5 topics that have been on my mind. Writing helps to focus my thoughts. Even though I often have residents on service, I still write daily notes as the act of putting thoughts into words is the best way to clarity thoughts. Next week the kids are back at school and I am sure the rains will start up and I will again have time to go into full research mode. In the meantime feel free to ignore this post.

There is nothing to see here. Move along.

As a third year resident I came across the notes I had written on a patient when I was an intern and I thought, man, What a maroon, what an ignoranimus. I was amazed what I had learned during the prior three years. Somewhat of the same process has occurred in my time at SBM. Not only have I learned a ton about various SCAMs, but more importantly I have refined and extended how and why I think.

There were two events recently that started my unusual attempt at introspection. Socrates I am not, preferring to keep the demons at bay by keeping my mind busy with external stimuli rather than examine my own life. The first was the entry on the central dogma of SCAM by David Gorski. The second was a video from TAM, where Jamie Ian Swiss talked in part about the criteria for being a skeptic*. It lead me to thinking about the criteria I use to assess medicine and the medical literature. What are the standards I mostly try to follow? They are not dogma so much as the first or guiding principles I use. I write here only for myself, my colleagues are free to disallow any knowledge of my actions.

There is a reality independent of human existence

It is a truth I hold to be self evident. If all humans were to vanish in a puff of CO2 and H2O, reality would go on without us. Long after the sun has gone nova Voyager will continue its trajectory through space following the laws on motion and gravity. Unless it returns as V’Ger.

Reality is defined by the basic sciences

At the human scale, classical physics, anatomy, chemistry, physiology, biochemistry etc. provide a reasonably complete framework for understanding medicine and reality. If there is, as someone more fluent in English than I suggested, more things under heaven and earth than are drempt of in my philosophy, then it needs to be demonstrated as either an extension of what we know or as radical new physical phenomena. In my scant 30 years in medicine all the breakthroughs have come from extensions of what we know. The demonstration of energies, physiologies and anatomies that are the underlying mechanism by which the various SCAMs are purported to have their effect are a Godot yet to arrive.

Plausibility within the context of known reality is important in evaluating the truthiness of new medical phenomena

I have practiced medicine for almost 30 years and while there has been much that has been learned or discovered, there is nothing that has not been within the framework of the basic sciences. In contrast, much of SCAM is not just implausible but impossible given the accumulated knowledge of the last 500 years. There is unlikely to be medical discoveries the equivalent to the dark matter and dark energy. The dreams of Oz et al for a new medicine are illusory.

The default mode of the brain is not rational/critical thinking

Not only is it difficult to think rationally and avoid the numerous logical fallacies to which we are prone, I wonder if it is impossible for some.

Most human characteristics fall into a bell shaped distribution, with some having more or less than others. Variability is the norm, although within often narrow parameters. If there is a spiritual module in the brain, I do not have it. Whether I was raised that way or born that way, I cannot say, but it seems to be X-linked in my family. I have always been unable to comprehend spiritual concepts, and it was not for a lack of trying in younger days. All I ever developed from meditating in a Zen temple were numb legs from sitting cross legged. I have friends and family who seem to commune with a god or spirits I can neither understand or comprehend. It is, I suppose, like color to a deaf person or music to the blind^.

Similarly, I really wonder if a rational/critical thinking module is missing or rudimentary for some people. How else can someone read about homeopathy or reiki and not laugh? Or maybe it is me. I lack the necessary neurologic module that can see the truth.

The first principle is that you must not fool yourself, and you are the easiest person to fool. ~ Richard Feynman

Combined with the Dunning-Kruger effect, this makes for a potent combination for researchers, patients and physicians to completely misinterpret information. My time in the world of SCAM has reinforced the notion that we think poorly, do not realize that we think poorly and are unable to realize that we can’t realize that we think poorly. Convoluted? I will not go another level into the Inception. N-Rays remains my archetype example of how easily it is for honest and intelligent researchers to fool themselves and others. So much of the SCAM literature is measurement N-Rays emitted from the tooth fairy. I think Harriet is unaware that tooth fairies are the primary source of N-Rays.

We are prone to a plethora of logical fallacies that keep us convinced that unreality is real and those same fallacies keep us from recognizing our errors. Perhaps that is why I do not like to examine my own life; the enormity of the mistakes could cause me to explode like Mr. Creosote.

Most medical research is of poor quality and the results either overstated or wrong

Although there is a great deal of enjoyment in dissecting a SCAM paper, most being of remarkably poor quality, I have come to realize how much of what is published in medical literature is suboptimal. Quality medical research is extremely difficult to do and that is certainly reflected in the SCAM literature, where it is rare to find an article that doesn’t have all the criteria that make the conclusions suspect.

It is sobering that simultaneously we know so much and so little about the treatment of common diseases. The nice thing about infectious diseases is I have the luxury of knowing that if I can kill a bug in the test tube, I can usually kill it in the patient. It makes treatment decisions easier when there are a lack of well controlled clinical trials for unusual diseases.

The plural of anecdote is anecdotes, not data

Anecdotes are powerful. People respond to stories of cures more viscerally than knowing the results of a study. And there has never been a good answer when a believer tells me an anecdote where their friends aunt had pain relief from acupuncture or a cancer cured by colloidal silver, just what do you have to say to that, Mr. Skeptic? Nothing, of course, that doesn’t make me look like an out of touch, bloviating, old naysayer, droning on about bias and placebo.

We do need to be better with anecdotes and stories. Not as proof of a concept, but as illustrative of a concept. In medicine lectures are often started with a case to personalize the disease or treatment to be discussed.

In. My. Experience.

They remain the three most dangerous words in medicine, at least as a criteria for choosing a treatment. A physician who uses the words ‘strong’, ‘big gun’ or ‘powerful’ to describe antibiotics has demonstrated with almost 100% sensitivity and specificity they know nothing about antibiotics and should be ignored. Similarly, avoid the physician who chooses therapies from experience. Simultaneously, experience has made me an infinitely better diagnostician, but I would wager that most health care workers conflate the two .

Like anecdotes, however, ‘in my experience’ is the proverbial two edged sword. Patients want to know that you have experience and success with whatever treatment you are suggesting, and are less interested in what the studies show. I often try and mention both options: the studies demonstrate that I am prescribing the best therapy and it has worked in my hands. Most of the time they are more reassured that I have experience than the fact I am up to date on the literature. Every now and then I will treat a disease for the first time, such as a tropical parasite. No one in Portland has extensive experience with, say Leshmania. Patients never look comfortable when I say this is my first case, but the data suggests the treatment will work. Physician and patient never think about the nuances of both anecdote or experience.

Understanding is always tentative and subject to change

Everything is subject to change, although the requirements for changing an opinion are proportional to the amount of prior information to support a conclusion. It would take an compelling study to have me change my mind that beta-lactams are the best antibiotic for the treatment of S. aureus endocarditis, or that evolution is false or that acupuncture effect is anything besides patient and physician reporting bias.

We are now on our descent into the Las Vegas airport. That’s all folks.  .Those were all of my opinions. Thank you for reading them.

*Digression.

I came across an interesting quote by way of Skepchick in the Humanist. As a side note in an article on women in the secular movement, Susan Jacoby make an interesting comment:

In the Center for Inquiry, the organization with which I’m most familiar, this often expresses itself as a division between “humanists” and people who call themselves “skeptics.” There is a lot of overlap between these two groups but, in my experience, the skeptics tend to be more conservative…

My first thought was Hm. Is that the case? That is not the distinction I would have made. Conservatives, to paint with a broad brush, are reality and data adverse. I tend to self label as a skeptic, and although I agree with most humanist positions, I never think of myself as a humanist.

What I know of both groups is more from their publications than from hands on experience. I usually find the Skeptic Inquirer interesting and informative and I usually find Free Inquiry to be uninteresting. The difference to my mind is that the former is more about facts, the way the reality may or may not function. The latter is more about opinion, the arbitrary laws, rules, habits and regulations that make a society more or less tolerable. What interests me is knowing how the natural world works. While I have strong opinions on the issues raised by Free Inquiry, the opinions are based at their root on nothing, and as such are not that interesting.

When we were playing golf last week my son double hit the ball. He wondered why it counted as two strokes and a swing and a miss also counted as a stroke. What, he asked, is a golf stroke? The swing or the contact with the ball? I told him both, it is one of the many arbitrary and often inconsistent and irrational rules that govern life. A humanist would worry about those rules, a skeptic about how to measure a double hit or a miss. While I agree with the humanist philosophy, I suppose I am more of a Shruggie when it comes to their application.

It would be an interesting sociology/psychology study to compare and contrast the two groups.

^ not a mistake.

Posted in: Science and Medicine

Leave a Comment (27) ↓

27 thoughts on “Guiding Lights

  1. fxh says:

    “The ball is neither in nor out until I call it”

  2. William M. London says:

    Anecdotes have problems as evidence in medicine that tend not to be fully appreciated. Several SBM bloggers have illuminated problems with anecdotes, especially in comparison to various types of studies that control for confounding factors. But I’m afraid that the slogan “The plural of anecdote is not data” is problematic as well. I hope to eventually write up a detailed explanation, but the bottom line is the evidentiary value of specific anecdotes depends on the nature of the anecdotes and the context in which they are offered. Hint: A good example of what I’m talking about comes from the history of infectious disease medicine.

  3. Janet Camp says:

    I very much enjoyed your musings, but I cannot for the life of me understand anyone choosing Vegas over the Oregon Coast–okay, maybe the show, if you really love Wayne Newton that much. :-)

  4. Cymbe says:

    A skeptic is supposed to look at everything skeptically. A humanist is just someone who rejects religion – or something like that, I am not entirely sure. You can reject religion and be (relatively) gullible in other respects – look at Bill Maher, who doesn’t believe in the germ theory of disease. Since in the United States, political religion is aligned with the right, it makes sense that humanists be more left-leaning. There is no inconsistency between being a humanist and participating in the near-hysteria over fracking, but a good skeptic would demand solid evidence before condemning the practice.

  5. NYUDDS says:

    With apologies to Richard Feynman, my father, years and years ago, used the same aphorism, but in coarser language: “Try never to BS anyone, but above all, never BS yourself.”

  6. FYI: Our sun will never go nova unless it aquires a binary companion at some point in the future. The fate of our sun is an expansion to red giant stage (wiping out whatever life remains on Earth at the time), followed by a white dwarf stage when fusion has ceased.

  7. mousethatroared says:

    “My time in the world of SCAM has reinforced the notion that we think poorly, do not realize that we think poorly and are unable to realize that we can’t realize that we think poorly. Convoluted? I will not go another level into the ?”

    Sometimes I see someone who is clearly fooling themselves, you see errors in status building (fashion, professional decisions), socializing, lifestyle or science…the mistake often appears obvious to those around the person, but that individual is oblivious.

    When I see this, I am seldom struck by the thought “Oh look, isn’t that person’s foolish!” Instead, I instantly think “OMG, I am almost certainly doing the same thing somewhere in my life and there is no f@$king way I’ll be able to protect against all the possible errors that are obvious to others” Clearly looking for errors that endanger life and limb SHOULD take precedent, but I suspect our instincts often lead many of us to prioritize looking for social and status (fashion, professional) errors over science and health.

    Is that weird or completely wrong? Don’t know.

    Regarding “conservative” being reality and data adverse. There is the other non-political meaning of conservative. Meaning to be change adverse or using the minimal response needed, as in ‘the conservative treatment would be…” I would find that description to describe many skeptics. Not sure if the context of the quote implies one meaning over the other.

  8. Scott says:

    It’s also notable that many conservatives are utterly revolted by the modern Republican party, so you can’t even equate those two groups.

  9. Harriet Hall says:

    Kudos! This is a cogent statement of my principles, and I think it represents the principles that guide all the writers on this blog.

  10. qetzal says:

    Not only is it difficult to think rationally and avoid the numerous logical fallacies to which we are prone, I wonder if it is impossible for some.

    I’d say it’s impossible for us all. To paraphrase someone or other, we can avoid some of the fallacies all of the time, and all of the fallacies some of the time, but none of us can avoid all of the fallacies all of the time.

  11. windriven says:

    “Conservatives, to paint with a broad brush, are reality and data adverse.”

    Some conservatives are. Some liberals too. As it happens the skeptics of my acquaintance (read: in my experience ) tend toward conservative economics and liberal social values. To quote some blogger I read from time to time, “Most human characteristics fall into a bell shaped distribution, with some having more or less than others. Variability is the norm…”

    Any who let their labels do their thinking for them are the ones who are reality and data averse.

  12. DugganSC says:

    I’ll admit that I too object to the labeling of Conservatives as being data-averse. I suppose that if one went with a literal interpretation of the word, people who resist change could be said to be data averse since they don’t want to learn anything that might change their mind. On the other hand, that’d be the same as painting Liberals as wanting to move ahead before they have data on-hand, the other side of being data-averse.

    Personally, I think that a balance of conservatism and liberalism is necessary in any stable construct whether it’s politics, religion, or film production. Someone needs to be pushing for things to improve and someone needs to be pushing back to be sure the baby isn’t thrown out with the bathwater or funds thrown after projects that aren’t going to go anywhere.

  13. rork says:

    “Reality is defined by the basic sciences”.
    What got said under this topic I mostly liked, but this sentence makes me want to do missionary work, cause
    the word defined is being abused by doctors very very often. Maybe they don’t have any real use for the word so they do whatever with it. I see stuff like “we will define the downstream targets of transcription factor x” in grants. Docs are saying it when they actually mean things like measure, study, investigate, and to someone like me, they sound like an idiot when they do this. Don’t let it be you.
    There are many other abused words, often trying to sound professorial or educated. It may even work on some people. Don’t say ablate for shRNA knockdown for example. Simple and clear is good. It’s a damn knockdown.

  14. MS, MT(ASCP) says:

    I commented elsewhere on the web the importance of anecdotes and scientific inquiry. While I maintain that anecdotes do not make data in any way, they can serve the important function of the starting point for legitimate inquiry. Expanding on that, anecdotes are stories to remind us why we perform studies, and what the ultimate goal of the information we generate should be: to help someone in need, distress or who is suffering. They have no place in directing inquiry or interpreting results because that is not how they function. Instead, they provide the emotional drive and commitment to doing good, solving problems and to ethical application of knowledge.

  15. Badly Shaved Monkey says:

    I hope this will not be seen as a grammar nitpick, but “truthiness” is not a synonym of truthfulness or truth. The dictionary embedded in my iPhone gives it as;

    “The quality of seeming or felt to be true even if not necessarily true”

    “Truthiness” embodies a useful and important concept different from truth or truthfulness and I wish strongly to assert the truth of this not its truthiness.

  16. Badly Shaved Monkey says:

    Oh, I may have to backtrack a bit and clarify that it started as a synonym but has been made distinct more recently, but I still contend the current coinage is useful.

    [Yeah, great job blowing the impact of a punchline, Monkey.]

    [[Nothing to see here?]]

  17. Badly Shaved Monkey says:

    On the utility of anecdotes, I’m happy to dismiss positive anecdotes as near-worthless, but I think ‘negative’ anecdotes have a greater value, though I’m not sure how to quantify it. 

    I think it’s known here I’m a vet. If I give out a licensed painkiller, X, to an animal owner and they tell me their arthritic Labrador is less lame the next week, my ingrained pedantry forces me on many occasions to try to set that improvement in context and make proper allowance for spontaneous amelioration and all the other confounders that are at play. 

    However, if I am given a new licensed NSAID, Y, by the drug company that is “better” than the previous drug, but I have client after client telling me they’ve seen no improvement, I feel somewhat justified in giving more weight to that negative evidence than I would to its positive opposite.

    Given all the positive biases working in favour of Drug Y, for the client to have the confidence to report a negative outcome feels like something of greater evidential weight (That statement has truthiness for me :) )

    Is there a formal sense in which confirming anecdotes and disconfirming anecdotes are not simply mirror images and equal in magnitude?

    I hope I have conveyed the sense of the issue adequately. 

  18. BillyJoe says:

    “If all humans were to vanish in a puff of CO2 and H2O, reality would go on without us”

    I prefer to think of it this way:
    From my point of view, if it were not for the fact that I am here then there may as well be nothing at all. Therefore the fact that everything is here is important only because I am here.
    Not sure if that makes sense to anyone else.

  19. BillyJoe says:

    “Reality is defined by the basic sciences”

    Some say that the outcome of experiments in quantum physics is incompatable with an objective reality.
    I tell then to put their theory into practice by jumping out of a ten storey window and see if the path below might restore a respect for concrete reality.

  20. @BJ, seems like a take on the “anthropic principle” – “We see things the way we do because we exist.” Ie, it’s easy to look back at all things that had to be “just right” for life to exist on Earth (planet formation, distance from the sun, atmosphere, evolution, at some point a sabre tooth tiger didn’t kill our evolutionary “Eve”, etc.) However, had things not gone that way, we wouldn’t be sitting here questioning our existence – we simply wouldn’t exist. In other words, I agree. :)

  21. BillyJoe says:

    “a believer tells me an anecdote where their friends aunt had pain relief from acupuncture”

    Or they ask you if you have tried it. A most satisfying answer is…
    You cannot decide if something works by trying it, you have to do a clinical trial.

  22. Cymbe says:

    BillyJoe: Or they ask you if you have tried it. A most satisfying answer is…
    You cannot decide if something works by trying it, you have to do a clinical trial.

    And the answer to that will be: what’s a clinical trial? When you’re dealing with such a person, it’s either a clueless dupe, or a conscious charlatan.

  23. DugganSC says:

    @Cymbe:
    Or they start arguing that either it doesn’t work on everyone or something about the clinical setting creates invalid results The latter is very often cited for studies on psychic results because it’s common knowledge in such circles that skeptics block psychic abilities. However, it does sometimes have some bearing, especially if results depend on emotional state. The classic case was the psychology study involving having kids watch violent videos and then leave them with the clown doll to see if they’d attack it with results that the kids who watched the violent videos were more likely to attack the clown. Last I heard, they found that the effect is negligible if you remove the factor of said kids being isolated in a cold lab away from any comfort before setting them in front of the clown.

    There was a recent post here about eliminating factors in the testing to be sure you’re only testing your hypohesis. If the CAM types had any interest in the scientific method, they’d be trying to eliminate such variables in the testing that might bias against their methods. Or, alternately, they’d be trying to remove extraneous factors to find the core of how their cure works. Of course, they have no interest in shining a bright light in their shadowy corners…

  24. Geekoid says:

    William M. London – Anecdotes aren’t data. Never have been. They are stories about someone perception of something they experienced with their bias firmly attached. Or worse, a repeat of someone else’s story.

    In some circumstances they can warrant and investigation FOR data, but they themselves are not data.

  25. Scott says:

    @ Geekoid:

    In some cases they can be, depending on the nature of the claim for which they are advanced. For the claim “tigers sometimes attack people,” an anecdote of a person attacked by a tiger is adequate data to accept the claim. Whereas for a claim which would need good statistics to evaluate, anecdotes are pointless.

    Certainly there are large swathes of subjects where the saying is reasonably accurate (including the bulk of the topics discussed on this blog). It’s probably fair to say, MOST subjects of scientific interest. That doesn’t make it universal.

    After all, everyone knows that blanket statements are always wrong.

  26. mousethatroared says:

    DagganSC – ” the kids who watched the violent videos were more likely to attack the clown.”

    And that was considered a BAD thing?

  27. William M. London says:

    Geekoid, the subjective anecdotes you describe are testimonials. I agree they don’t qualify as data. But testimonials are not the only anecdotes we encounter. Case reports and case series are anecdotes that are useful to consider as data (and evidence) because they include documentation of events. As long as we recognize their limitations (and why they are low on the hierarchy of evidence in evidence-based medicine), case reports and case series should be recognized as data.

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