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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

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