Jul 01 2011
What does it take to become a doctor? Endurance and perseverance help. It is a long haul from college to practice. But the skill that is most beneficial is the ability to consume prodigious amounts of information, remember it, and recall it as needed. Although I often relied on ‘B’ to get me through some of the exams.
Thinking, specifically critical thinking, is not high on the list of abilities that are needed to become or be a doctor. Day to day, doctors need to think clinically, not critically. Clinical thinking consists of synthesizing the history, the physical and the diagnostic studies and deciding upon a diagnosis and a treatment plan. It is not as simple as you might think. When medical students start their clinical rotations and you read their notes, you realize they have what amounts to an advanced degree at Google U. They know a huge amount of information, but have no idea how the information interrelates and how to apply the that information to a specific clinical scenario. With time and experience, and it takes at least a decade, students become clinicians and master how think clinically, but rarely the need to think critically.
The volume of data combined with time constraints ensures that we need to rely on the medical hierarchy to help manage the information overload required to apply science and evidence based therapy. There is just to much data for one tiny brain to consume. Other doctors rely on me for the diagnosis and treatment of odd infections. In turn, I rely on the published knowledge and experience of my colleagues who have devoted a career to one aspect of infectious diseases. There is little time for most doctors to read all the medical literature carefully, and usually little need. We have people and institutions we use as surrogates.
Not only is critical thinking usually not required to be a good physician, but medical practice can conspire to give physicians a false sense of their own abilities. Really. Some doctors have an inflated sense of self worth. Who would have thought it? Spend time with some doctors and listen to them pontificate on politics or economics with the same (false) assurance that have in their true field of expertise, and you will run screaming from the room.
Medicine is rife with confirmation error. In practice there is rarely negative feedback for making a wrong diagnosis, since everyone is wrong all the time. The good doctors are nimble, changing course quickly rather than sticking to a wrong diagnosis. And there is no lack of positive feedback from good results. There is the potential for unbalanced positive feedback to engorge the susceptible ego. Last week I was walking downtown and was stopped by a lady, daughter of a patient, who introduced me to her friends as “the doctor who saved my mothers life.” Not really true given that medicine is a team effort, and while I made the diagnosis others had missed, I know if it I had not made the diagnosis, some other ID doctor would have. Talk about a chance for egoboo. On the other hand, I must admit to great irritation when the hard work of the ICU team pulls someones bacon out of the fire and the credit goes to god. I want to yell it was not god that saved your father, it was the doctors and nurses and respiratory therapists and the rest of the hard working, highly experienced ICU staff. And just why did god make him so ill in the first place? I do want at least partial credit and remain grateful that mind reading is not a reality.
The other weird thing that happens in medicine is the explicit knowledge we learn in medical school and residency over time becomes implicit. I have discussed before how sometimes I can come to the correct diagnosis with minimal information, almost intuition, and then explain after the fact how I came to the diagnosis. It almost feels like the answer bubbles up from below awareness. It is most peculiar how much of my medical reasoning occurs below my consciousness. If one is not careful that seeming quasi-omniscience could lead to a certain arrogance about your own abilities. And if part of your job is to hold peoples living hearts in your hand? It amazes me that the heart surgeons I work with are such nice, self-effacing people.
Add the lack of training in critical thinking to the weird combination of the Peter Principle and Dunning-Kruger Effect and you have a SCAM proponent in the making. The first says that people rise to their level of incompetence, and if someone masters an area of expertise, they become incompetent in another field. The latter suggests that “people make poor decisions and reach erroneous conclusions, but their incompetence denies them the metacognitive ability to appreciate their mistakes.” When good docs go SCAM.
Starting with the basic sciences as a premed and working your way through the Brobdingnagian quantities of information to understand the workings of the human body in health and disease results in knowledge, but not necessarily wisdom; learning not how to think, but what to think. You have to trust that those up and down the line of experience know, at least in part, what they are doing: intern to resident to chief resident to attending to subspecialist. I variously use team sport and hive intelligence to describe the practice of hospital medicine, although the Borg may be a better metaphor. That being said, there is, at least in my small neck of the woods, little dogmatism. Skeptics, die hard and otherwise, are often portrayed as close-minded and dogmatic, but in the teaching hospitals I practice in, explanations of the medical literature are often filled with qualifications and caveats as we teach the residents. How much of the great grey uncertainty that is medicine is passed on to patients is always an interesting question, and different clinicians will react differently to that clinical challenge.
I rarely see the caveats and uncertainty in the SCAM world that is common in medicine. Often my answer to a consult is that the patient does not have an infection, or if they do, I have no specific therapy and you have to let the disease run its course. I wonder, in passing, if anyone has ever gone to a SCAM provider and been told: Nope. Sorry. Can’t help you. —Insert magic here— has no benefit for —insert disease here—. I bet almost never.
Patients use SCAMs for a variety of reasons, and I do not pretend to understand why people prefer magic over reality. And, sounding like the arrogant tool of the medical industrial complex that I am, I wonder if part of the reason is they don’t know any better, and, really, most people have no reason to. The average person has little motive or inclination to become immersed in the background required to understand why SCAMs are nonsense. They have better things to do.
But MD’s? You would think a doctor would know better. Astronomers do not flock to astrology. Physicist do not push perpetual motion machines in large numbers. Geologists do not become young Earth creationists in droves. It flabbers my gaster that, after learning all the information required to put MD after your name, anyone could find any validity in any SCAM. Yet many do, too many. Part of my assumption is that the Oz’s and Chopra’s and Weil’s of the world do not process information about the world in the same way the Gorski’s and Novella’s and Atwood’s do. Either they never learned, or cannot learn, critical thinking, or, most importantly, applying the concepts to themselves.
I was originally dragging my feet writing this essay, as the topic was going to be Dr. Oz, who consistently demonstrates all the cognitive flaws and biases mentioned above. The first thing I did when I received my medical school acceptance letter, besides checking the name to make sure it was really addressed to me and not a mistake, was sell my electric typewriter, thinking I would never have to type again. The thought of transcribing his shows filled me with dread, as my typing skills are barely up to the task to transcribing the thoughts in my head, much less the words that flow from Dr. Oz. Imagine my delight when I came across an editorial in JAMA, Medicine’s Great Divide—The View from the Alternative Side, by Dr. Chopra, which has the same odd world view and odd thinking with none of the transcription issues. Cut and paste is so much easier.
The world of Dr. Chopra is radically different from the world in which I live and practice medicine. My professional world view is equal parts an understanding of objective science and an understanding of the almost too numerous to count human intellectual and physical frailties and short comings that make applying science to patient care difficult and prone to error. And that doesn’t even include just how hard it is to figure out what is going on in patients. Of course, people never see themselves as other see them. When I read Chopra’s account, I also have to ask myself, is my professional world view correct. Or am I just this guy, you know? But my Beeblebrox-like internal monologue reassuringly responds no. Let us go todash.
Conventional medicine is offended that alternative medicine even exists. For the average physician, to hear that an allergy patient is taking extract of nettle to treat his symptoms or that a breast cancer patient is being treated with coffee enemas and a macrobiotic diet arouses scorn. Over a decade ago, when the New England Journal of Medicine reported that Americans pay more visits annually to alternative practitioners than to MDs, the attitude of the editorial writer was barely disguised dismay and disbelief. It was as if the whole country had turned its back on jet travel to return to the horse and buggy.
I do not speak for conventional medicine, or as I like to call it, medicine, only for myself, but I do have a sense of dismay when doctors use and promote SCAMs. Other people? Not so much. Dr. Chopra evidently feels that relying on the irrational magics of earlier ages to be a reasonable way to approach health and disease. It is worse than horse and buggy, which will at least get you to your destination. SCAMs are the intellectual equivalent of returning to demon exorcism, cupping, bleeding and purging to treat and prevent illness. It is applying the principles of Harry Potter in a world where disease and death are real. In my world view, a bad idea. On the other hand, in the entire essay, he never once mentions a specific wackaloon SCAM as worthy for use in patient care, preferring to focus on the shortcomings of medicine.
Yet at bottom no one could really object to the aims of alternative medicine, which are to bring relief to the whole patient.
What is that old road to hell paved with? I can’t recall. Object to the aims? No. Everyone thinks they are acting in a beneficent manner he writes resisting the urge to be accused of Godwins Law. The methods? Well, yeah, I object to the methods, The objections with SCAMs have nothing to do with aims, Dr. Strawman. It is with how those aims are accomplished. I have trouble trusting peoples health and well being with interventions that have no basis in my understanding of reality.
He spends the rest of the paragraph dwelling on the pathologies of modern medicine: the lack of time and the unpleasant environments of modern hospitals, with the usual implied argument that since medicine has issues, SCAMs must be valid and the solution.
In other words, the other party in the divorce—those who have lost faith in conventional medicine—has its own valid reasons.
Because I am fat, therefore you are thin. It gets tiresome seeing the same flawed arguments. Has Dr. Chopra never bothered to peruse the cognitive error or logical fallacies pages on the Wikipedia to at least casually educate himself on the bare minimum of critical thinking? SCAMs of all stripe have to have to stand or fall on their own merits, not on the perceived and real failings of medicine. The response of my hospitals to the problems with medicine has not been to abandon medical science in favor of nonsense, but to rigorously apply the results improve on what we have, with remarkable results. We have made the airplane fly better, safer and more comfortably, not abandoned the airplane in favor of levitation. Italics mine:
The two camps are not as opposed as they once were. Twenty-five years ago the possible efficacy of traditional healing modalities, herbs, Eastern therapies like acupuncture, and even mind-body medicine was so foreign as to be entirely alien. Today there are still die-hard skeptics (ie people with a consistent understanding of reality who understand that the shortcomings of human cognition apply to themselves as much as to others), of course. But in a mood of expanded tolerance (read easy money), an MD can look at the research on neurotransmitters, cell membrane receptors, and brain physiology, which has made enormous strides in recent decades. Taken as a whole, this research describes the body as an integrated system that exchanges information continuously between the mind, via the brain, and every cell in the body.
What? Huh? Say what? I can’t see how the first part of the paragraph relates to the second half of the paragraph. I have to admit, with a child in middle-school, I have been reading my sons five-paragraph essays, with their emphasis on logical flow and coherence, so perhaps I am out of practice with reading essays written by adults and miss the subtle connections between alien modalities and modern neurophysiology.
One aspect of SCAM proponents I note is they like to take obvious conclusions, what should be almost banal statements, and make them seem like they are profound insights into the human condition available only to SCAM proponents, “the body as an integrated system that exchanges information continuously between the mind, via the brain, and every cell in the body.” Well, duh.
I guess Dr. Chopra hasn’t spent time on rounds in the hospital for a while, where the endless permutations of physiologic interactions and complexity are discussed, observed and modified. Understanding these interactions is part of what makes the practice of medicine, real medicine, so damn hard. It must be so much easier to do some quantum mind-body hand waving and not have to actually fret about the application of practical physiology.
With real-time scans from functional MRIs staring them in the face, MD’s have no reason to look upon the placebo effect, for example, as “not real medicine.” When patients feel relief from chronic pain by being given a sugar pill, the body’s endorphins are filling the same receptor sites in the brain that externally administered opiates fill.
Placebo has always been real medicine, the question is whether using a placebo is ethical (it is not, since lying to a patient is not ethical) and how effective placebo is (for pain, barely efficacious, for any other disease placebo has no effect). In my world view placebo is wrong, because lying to patients is wrong, its effects are marginal (especially for infections) and I have yet to find a way to use placebo without lying to a patient.
But SCAM practitioners have a key insight that only they have access to: the importance of diet. Of course he transitions into the old trope that diet is alternative. Alternative to starving I suppose. As my son would say to me, how edgy. Changing diet can improve cardiovascular disease. <sarcasm>WTF. No one ever told my ever in the last 25 years that diet was important for cardiovascular and other diseases. I want a refund from OHSU.</sarcasm>. It is important for SCAM practitioners to pretend that diet is somehow alternative, and then by extension, validating real nonsense in fields like reiki or acupuncture or homeopathy. SOS DD.
Seriously, what offends me is not alternative medicine, but sloppy, inaccurate, lazy thinking, be it in SCAMs, politics or literary criticism. And so much of SCAM is sloppy thinking, sometimes from educated people who I think should know better. But I remain of the opinion that sloppy thinkers make sloppy doctors. Dr. Chopra is a board-certified endocrinologist, and he is trying to imply with a straight face that lifestyle changes, diet and exercise, are not at the core of the approach to type 2 diabetes and cardiovascular disease? Ground rounds this week was an update on hypertension. The first part of the lecture? Diet and exercise. It is the old truth that if you repeat a lie often enough, people will come to think it true.
One sign of growing reconciliation comes in the form of softened terminology. Instead of calling it alternative or holistic medicine, as I’ve been doing, the more acceptable term is complementary and alternative medicine (CAM), which sends the signal, “See? I am not your foe. We can cooperate. We’re complementary.” Which is true.
It reads like Jake Chambers final essay. You have to watch CAM all the time, CAM is a pain and that is the truth. Really? You can add nothing to something and increase its value? If the integrative medical centers ever go under, they may have a job on Wall Street. 1 plus 0 is not 2, except in the world of SCAM. See. I am your foe. You offer nothing of value. Which is true.
Then he shifts to reality mixed with BS. Italics mine:
The problem is that an MD’s practice is badly set up to promote prevention (often true). Visits are too short (yep). Aren’t adequately trained beyond their specializations (BS). Their habits are focused almost entirely on drugs and surgery as treatment modalities (BS). Prevention is considered too “soft,” (BS) and yet, if you shift the burden of prevention to the patient (lets call it empowerment when the SCAMsters do it) (which most MDs are more than happy to do (lets call it a partnership when the SCAMsters do it)), there is enormous resistance (BS). The public has been given countless warnings about smoking, poor diet, and lack of exercise, yet we have by no means eradicated lung cancer, obesity, coronary artery disease, and type II diabetes (true). Lifestyle disorders prove intractable when people cling to bad lifestyle habits and resist adopting good ones (true, but whose ‘fault’ is that?). We remain a nation of sedentary overeaters, paying pious lip service to prevention while doing less than enough about it (true, but is the solution in SCAM?).
This is where CAM makes significant inroads, because one of its main themes is the return of power to the patient.
See, I told you where this was going. Doctors dump, CAM returns power to the patient. I love the language of BS. The lessons of Animal Farm and 1984 remain relevant in 2011, and probably for the life of the human species. I imagine that those who seek SCAMs are motivated to see a benefit from a particular SCAM. SCAM providers see a self-selected population who want to have results from what ever modality they are using. I would wonder how effective any SCAM based therapy would work if tested on a population of CFI or JREF members. So much potential for confirmation bias in the assertion that SCAMs have a unique ability to alter peoples behavior by empowering the patient.
MDs should welcome the whole trend to self-treatment instead of taking the scornful attitude that nothing works but the modalities taught in medical school.
So when is shifting the burden magically transformed into a trend to self treatment? When it is offered by a SCAM practitioner. Most MDs are aware that medical school is the beginning, not the end, of learning, and also recognize that it is as important to know what isn’t effective is as important as knowing what is effective. It is why medicine evolves and SCAMS are intellectually stagnant. Dr. Chopra seems to invent a world that does not exist, at least in Portland, and then rail against it. Trying to engage the patient is their care has been a goal in medicine for decades.
The real mystery—one that deeply intrigued me 25 years ago—is that so many therapies that totally disagree with one another manage to bring results. Ayurveda isn’t qigong; yoga isn’t Reiki; none of them is a placebo. Yet somehow healing exists, and the channel it takes can be quite unexpected and inexplicable.
The real mystery is that so many forms of astrology totally disagree with another manage to bring results. No mystery if you live in a reality-based environment. The real answer, the rational answer, is that none of them do diddley. People often get better and always have and the ability for people to fool themselves and others is endless. That paragraph, more than any other in the essay, sums up the difference I see between SCAM proponents and SBM: a complete lack of insight and critical thinking that allows people to not recognize their own limitations in understanding the world. Yet I am the closed minded arrogant tool. Sheesh.
Continuing in a vein separate from the world I work in,
The inconvenient truth that “you can heal yourself” has always been the foundation of medicine. The body is the locus of the healing system; physicians assist this complex, little-understood system. They do not actually do the healing. If this feels threatening to MDs, there is much more room for pride to take a fall.
Dude, its not inconvenient at all. We all know that. No one is threatened. So many Stuffy Guys, I worry about a tremendous conflagration should nonsense arguements become flammable. What’s next? We in SCAM understand that water is wet and fire is hot? Only SCAM practitioners seem to make it a virtue to trumpet the obvious as if it were some profound truth. Little understood? What, you give up reading the literature? Understanding of healing is not complete, but it is broad and deep.
Conventional medicine also faces the mysterious “decline effect”—established medications steadily lose their effectiveness over time, as if the newer generation of patients has different, less receptive physiologies.
Is this willful ignorance? Massive confirmation bias? Mysterious? Really? Doesn’t he read and think about these topics? Dr. Steven Novella:
…it is no surprise that effect science in preliminary studies tend to be positive. This can be explained on the basis of experimenter bias — scientists want to find positive results, and initial experiments are often flawed or less than rigorous. It takes time to figure out how to rigorously study a question, and so early studies will tend not to control for all the necessary variables. There is further publication bias in which positive studies tend to be published more than negative studies.
Further, some preliminary research may be based upon chance observations — a false pattern based upon a quirky cluster of events. If these initial observations are used in the preliminary studies, then the statistical fluke will be carried forward. Later studies are then likely to exhibit a regression to the mean, or a return to more statistically likely results (which is exactly why you shouldn’t use initial data when replicating a result, but should use entirely fresh data – a mistake for which astrologers are infamous).
Are SCAMs immune from the decline effect? Probably, since you can’t decline past zero. Any further decline in the effects of homeopathy or acupuncture or energy therapy would soon cross into increasing the symptoms they are attempting to treat.
For me, the most distressing aspect of the decline effect is how widely it is being ignored.
Come on rounds, Dr. Chopra. Listen to our Intensivists discuss the use of steroids in sepsis or the Cardiologist discuss the approach to acute coronary events with the residents. The history of the literature, why the approach has evolved as the studies have refined and extended our understanding. The decline effect is an integral part of the teaching of medicine, it is an integral part of the history of science and the evolution medicine. Just like the complexity and the integrated systems of the body, it is part of the foundation of the practice of medicine, although, like much of the foundations of medicine, rarely explicitly stated, except as a source of pseudo-profundity.
More distressing appears to be the inability to apply the same worry to SCAMs, where the history demonstrated increasingly better studies of SCAMs resulting in decreasing efficacy until well designed, bias free studies show no efficacy. Not a decline effect, but a crash, burn and explode effect, always ignored by the SCAM proponents. Oh well, a foolish inconsistency is adored by SCAM minds and its philosophizers. If you think medicine has issues, read the CAM literature. It is nice how artfully Dr Chopra fails to note that the literature in the SCAM world is several logs worse and almost no intervention has any physical or biological plausibility.
My purpose isn’t to justify the vast universe of healing modalities that exist outside Harvard Medical School (Besides the Palin-esque stab at populist anti-intellectualism, I note that Harvard is long past it’s prime as a medical arbitrator, what with the Osher Clinical Center and all. Harvard has consumed the Kool-aid). I look instead toward the next phase of this reverse marriage, which is shy courtship. If both sides stopped being defensive, they would see that they share core values: treating the whole patient, reducing suffering, closing the gap between healer and healed, and doing the least harm while bringing the greatest good.
Whoops. Forgot a core value: trusting patients lives and fortunes to therapies that have efficacy based on reality and that are effective. Small thing, I know, but I am old school and feel obligated to treat patients with therapies that are effective beyond the self delusions and biases of the practitioner.
With that in mind, I have little desire to debate with skeptics and scientists who disdain CAM and falsely claim that only their side is valid and evidence-based. The mystery of healing remains unsolved.
Whew. I guess he will not be responding in the comments and prefers to live in his own world. Like people who only watch Fox news. This week I helped cure/heal two heart valve infections, a relapsing fever, a malaria and a handful of pneumonias and skin infections. No mystery there for me. Do I understand all parts of healing? Nope. Does that invalidate the parts I do understand? Nope. Would any SCAM have ‘complemented’ any part of my patients course? Nope. I do agree that SCAMs are evidence-based, it is just that the science and evidence demonstrates they do nothing and that science and evidence has validated their worthlessness.
The next step will be to remodel medical school curricula so that future physicians are not wandering in the dark as my generation did, totally ignorant, if not blind, about treatments outside our narrow band of knowledge. Expanded medicine is the answer, I am sure of that.
Just as I am sure the world will not be improved by SCAMs modalities. For fun, let us make a list on the advances in human health made in the last 100 years, in the US or elsewhere, due to application of any SCAM:
My wife likes to say if you want to predict the future, look at the past.
I do not practice in the world of Dr. Chopra or understand its allure. His medical world is divorced from the one I work in, and his approach to understanding medicine could be used as a textbook examples on logical fallacies, cognitive errors, and disingenuous argument. I am less than impressed. As Dr. Feynman said, “The first principle is that you must not fool yourself, and you are the easiest person to fool.” Unless you think the future is expanded medicine.
SOS DD: same old stuff, different Doc. It has other meanings.
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