Jul 31 2008

Doctor Bashing

The essence of bigotry is making assumptions about an individual or treating them based upon a group to which they belong. This is not limited to race and ethnicity, and can also include profession. There is a difference in that people are not born into their profession; there is a sorting process (both self-selection and societal), and so statistical observations about those who enter a profession are legitimate. Never-the-less, simple-minded statements to the effect that all lawyers are crooks, all doctors are arrogant, and all priests are pedophiles, is bigotry plain and simple.

It seems that people are most sensitive to bigotry aimed at groups of which they are members, and so when people try to tell me how doctors are (sometimes not knowing at the time that I am a doctor) I admit that gets my attention more than if they chose to insult oceanographers as a group.

Doctors are a popular target of bigotry these days for various reasons, some earned but mostly unfair. Historically physicians enjoyed a place of privilege in society. A generation or two ago nurses would stand when a doctor entered the nursing station, and no one questioned the paternalistic style that was typical of the doctor-patient relationship. Believe me – those days are long gone, but culture has inertia and that quaint image of the physician persists to some degree, although only in the negative sense it seems. Because doctors are seen as privileged many people think that they are a fair target for unfair criticism – that bigotry against doctors is OK.

Don’t get me wrong – there is much to criticize about the medical profession and many individual doctors. Criticism is good and healthy. In fact one of the aspects of my own profession that I think is the core of its strength is its self-criticism. But when criticism goes far beyond being constructive and factually based, and becomes an end to itself for the purpose of tearing a group down, that is bashing.

And that, in my opinion, is exactly what PhysioProf was engaged in when writing this post. He was reacting to a news story about an orthopedic surgeon who was placing, without consent, temporary tattoos on his patients while they were under anesthesia, including a tattoo of a rose placed beneath the panty line of one female patient. PhysioProf used the incident as an opportunity to gratuitously bash the medical profession. I also think he missed the point about this case.

I don’t think the actions of this surgeon result from the arrogance of the medical profession. He justified the action by saying that he wanted to give his patients something to smile about – a little post-operative surprise that would elevate their mood. This was not about arrogance, but rather about a misguided and utterly failed attempt at good bed-side manner. The surgeon wanted to be soft and cuddly, to concern himself with his patient’s feelings. This, of course, is a good thing, but should never be placed before professional ethics. We cannot lie to patients to make them feel good, we should not cross personal barriers that threaten our professional judgment, and we should not place temporary tattoos on unconscious patients. This was a well-intentioned but incredible lapse of professional judgment.

I will also point out that physician bloggers, especially surgeons, were the first to criticize this bone-headed move.

Here is PhysioProf’s take on the incident:

As someone who spends a substantial portion of his professional time teaching medical students, I can tell you that this kind of attitude–that physicians are gods, not mere mortals, and wield power over other human beings that no one dare question–is inculcated in them from the very beginning of medical training. It is an ugly secret of our medical training system. And the more prestigious the institutions where physicians receive their training, the more overweening is this attitude.

Apparently PhysioProf is living in the 1950′s (which perhaps is even unfair to doctors from the 1950′s). It is difficult for me to comment on PhysioProf’s experience, because he blogs anonymously. I do not know what institution he works at, in what capacity, and for how long. My guess is that he teaches physiology in the first-year pre-clinical classroom course. I don’t know, but I guess that he is not a doctor but a PhD physiologist, or perhaps he is an MD/PhD but does research and does not practice clinically. I had such instructors in medical school.

What I do know is that PhysioProf’s statement bears no resemblance to my personal experience with medical training or medical practice. For me, medical school was a deeply humbling process. It takes years to get over the constant sense that you are overwhelmed by your own ignorance. Respect for patients as individuals was the rule, not the exception. In fact I remember an incident on my surgical rotation when a fellow student referred to a patient as a case – by the type of surgery that was performed. The senior resident spent a good time pointedly telling him that we refer to patients by their names and that we are expected to know as much as possible about our patients – not just their surgery.

Of course, physicians, like any other group, are greatly variable. There are doctors who are jerks, those who are full of themselves, those who are simply incompetent yet are confident in their own infallibility, those who are intellectually lazy, and those who are fatally gullible. There are also doctors who are brilliant, insightful, sensitive, caring, and diligent. I have personally witnessed the full spectrum.

In my experience academics, those who teach medical students, tend to be more thoughtful than the average physician, take their duties seriously, and if anything go out of their way to teach proper respect for patients and an appropriate professional attitude. There are exceptions – there always are – but PhysioProf was not talking about individuals – he was talking about a systemic character of medical training. He was using his pseudo-anonymous authority to bolster his opinions, but I think if you solicited a broader base of opinion and experience you will find his views to be extreme and not representative.

Confirmation Bias

I cannot talk about bashing and bigotry without talking about confirmation bias, which, in my opinion, is the greatest intellectual pitfall that contributes to bigotry. People will tend to remember those bits of information that support their bigotry, while ignoring, forgetting, or explaining away those that contradict it. If you read the comments section of PhysioProf’s entry you will see a lot of confirmation bias. For example, Anna wrote:

My fav was listening to doctors standing around smoking (right near the entrance of the no-smoking hospital, which meant everyone had to go through their damned smoke) complaining loudly about how SOME patients just coudn’t be convinced to give up their bad habits for their health.

Strangely, I hear this a lot. It’s practically an urban legend that many doctors smoke. A more complete view is that in the US only about 3% of doctors smoke, compared to the general population which is about 20%. I don’t know any doctors personally who smoke – if they do, they hide it. Within medical culture today smoking is practically taboo.

Jessi wrote:

after reading these stories i feel so lucky. ive had 15 kidney surgeries all with the same doctor and hes been amazing in every way. he has cried with my mother while discussing my health.

my shrink is amazing too as is my GP. my dentist is so great i dont even mind getting dental work done.

A key component of confirmation bias (and superstitious thinking) is the dismissal of counter examples as exceptions. Jessi feels that her personal experience with good doctors makes her lucky, rather than calling into question the negative stereotypes being promoted. Many friends and family have told me about how bad other people’s doctors are, but their doctor is great. Everyone thinks they are the exception.

People do not instinctively think this way, but all examples, good and bad, are data. Counter examples are just as much real data as confirming examples, but we do not treat them that way. We tend to formulate our assessment of the data as – all doctors are arrogant jerks with a god-complex, except for those exceptions who aren’t. Whereas a more rational view of the data would be – some doctors and jerks and some aren’t.

I see this personally on a regular basis. After telling me how doctors behave, I often inform people how I behave, which is usually in stark contrast to their caricature. The near universal reaction is – well, you’re the exception. I may follow with the observation that most of my colleagues behave this way as well. To which the common response is – that may be the way things are up at Yale, but not everywhere else. What about my colleagues at other academic institutions? Well, then maybe at academic centers, but not in private practice. But I have friend and colleagues in private practice who behave the way I do. There doesn’t seem to be any number of counter examples I can give that will shake them from their pre-existing conclusions.

Confirmation bias is a powerful straitjacket.

Those Darn Physicists

While I’m talking about doctor bashing, it is always disturbing for me to encounter it within the skeptical community itself. I have now been to several skeptical meetings where a non-physician skeptic gratuitously bashed the medical profession and received enthusiastic applause from the audience. This may be a coincidence, but in every case it was a physicist doing the bashing.

Most recently at TAM6, Neil deGrasse Tyson gave an excellent skeptical lecture. Neil is an astrophysicist, the director of the Hayden Planetarium, and a wonderful science popularizer. He also seems to be an all-around great guy. But for some reason he doesn’t seem to like the medical profession very much.

Years ago I was at another skeptical meeting on science and medicine, and Neil, who was just in the audience at that meeting, asked a question that amounted to – what’s all this fuss about alternative medicine? Isn’t this just doctors defending their turf? He was rebuffed by a speaker who asked how he would respond as the director of the Hayden Planetarium if the board forced him to carve out a substantial portion of the planetarium to promote astrology. He acquiesced the point.

During his keynote at TAM6 he told the following hypothetical tale. A patient sees three doctors, the first tells them they have a terminal illness with 6 months to live, the second that they have 7 months to live, and the third that they have 5 months to live. Taking the average, the patient concludes they have 6 months to live, and yet they survive for years. Neil wondered why they would think this was a miracle rather than just conclude that they saw “three idiot doctors.” He further argued that the agreement in their prognostications was due to similarities in their indoctrination. These statements were met with enthusiastic applause from a room of skeptics, and a few skeptical doctors quietly shaking their heads (myself included).

First, I have never told a patient they have X amount of time to live – and I diagnose patients with incurable terminal illnesses on a regular basis. We just don’t express the situation in that way. Rather we give statistical information – 50% of patients survive for about two years, but some survive longer, even up to 10 years, and there are rare cases of remission. I understand that patients will often walk away thinking – I have two years to live – but that is not what doctors actually say.

Second, it is incredible that a scientist would dismiss medical science as indoctrination, as if it is not evidence-based. Perhaps different doctors may give a similar prognosis to the same patient because they are reading the same published scientific data.

What such a tale, hypothetical as it is, really teaches us is the challenge of communicating statistics, such as survival curves, to patients – especially during an overwhelming emotional situation. A patient who survives to the tail end of a survival curve is not miraculous, not because their doctor is an idiot but because some people survive to the tale of the curve – otherwise the tail would not be there.

The tragedy is that such attitudes do great harm to the skeptical cause. Believing that physics is more of a “hard” science (a misleading term in itself) than medicine, sociology, or evolutionary biology obscures the real line between science and pseudoscience. That is what we are trying to teach the public – how to tell the difference between fake science and the real thing. The fact that physicists can have precision to many digits to the right of the decimal place does not make their data more scientific. What matters is the process.

Such attitudes also blur the line between legitimate medicine and fraudulent medicine. Medicine is – or at least should be – science-based. That is what matters. Dismissing all medicine as soft and based upon culture, rather than evidence, serves to level the field between magical-thinking charlatans and science-based professionals.

Conclusion

Well, that’s the end of my rant. I admit I may be a little defensive on this topic. Take my opinions for what they are worth. I only ask that you do not dismiss them as an exception. I am a doctor too, I am part of the data.

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51 responses so far

51 Responses to “Doctor Bashing”

  1. sjames1958on 31 Jul 2008 at 12:55 pm

    Rant away boss.
    I think you meant tail of the curve. The tale is in the tail, so to speak.

  2. SidBhatton 31 Jul 2008 at 1:43 pm

    I guess there’s also a cultural aspect to it. The “quaint image of the physician” you described is largely still true in India. My dad (a radiologist) was telling me about an argument he had with some guy over some real-estate transaction. My dad said, “The guy insulted me to my face! Me, a doctor! Can you believe it?” As if he deserves respect in *all* aspects of life. Made me cringe. I would hate to make a generalisation, but most doctors I saw in India seemed to have that kind of attitude. Here in the U.S., they seem more down-to-earth.

  3. Roy Nileson 31 Jul 2008 at 1:51 pm

    Those physicists are just being protective of their hard earned place in the pecking order.

  4. JustinWilsonon 31 Jul 2008 at 2:25 pm

    I understand what Tyson was trying to say. But, it’s easy to reinforce the negative stereotype doctors seem to have and there is always anecdotal evidence to validate the stereotype.

    However, I can’t imagine the majority of people would hold that stereotype.

    PhysioProf seems to be a person, I’m sorry to say, a little like myself. I’m a software developer and I complain about the sloppy development practices of those I have worked with and continue to run into. I rarely take a moment, aside from now, to think about the ratio of good-practiced programmers and bad-practiced programmers. Thinking about it now, I would have to say 1:1. That doesn’t stop me from saying “Developers are getting sloppy.” I haven’t even met enough programmers or had enough time to justify that opinion. It’s just one of those things that happens when you are emotionally involved. I imagine PhysioProf was emotionally involved.

    I can truly appreciate your perspective on this subject, Dr. Novella. And, I appreciate your rant on the topic. As always, thanks for getting my mind moving.

  5. arbitrary.markson 31 Jul 2008 at 2:45 pm

    I checked out PhysioProf’s series of posts at Feministe and my brain hurts from all the vitriol and unnecessary cursing. His (I think he’s a male) farewell post reads:

    “For those “f*ing whiny-a* t*ty bab[ies]” (as Lauren so aptly put it) who petulantly refused to engage the content of my posts, and whose comments boiled down to nothing more than ““Where’s your argument; where’s your evidence; you’re not convincing; waah, waah, waah”, please read this brilliant f*g post by Ilyka at Off Our Pedestals.

    That post basically says “Talking about privilege requires you to name, define, and analyze patterns” but then offers no real insight into how to do any of that, except one’s unadulterated experience. Strange that someone who teaches basic science at a university doesn’t realize that we have biases we’re unaware of and that we can’t always rely upon our interpretation of patterns. That’s why other kinds of corroborating evidence is needed. How this person can’t see that asking for evidence and arguments is engaging content, I don’t know.

    And on the situation with MDs, I can say as well (being married to a neurologist) that I personally have also seen the spectrum. My theory is that confirmation bias about jerks is going to go into overdrive when you’re in a vulnerable situation. Generally that’s when people are seeing doctors. Of course, there’s also some anti-science and anti-authority stuff in our culture that I think could be unpacked, too, as you point out, helping to understand why patients hear one thing when doctors say another.

    All in all, great post.

  6. mattdickon 31 Jul 2008 at 2:45 pm

    I love your description of doctors as people. As an example of what drives me crazy:

    My father was a colonel in the US Army. His father was a 3-star General, his uncle a 1-star, my variety of cousins and uncles are similarly high-ranking military officers. I hear *often* about how “well the generals aren’t down there taking bullets” or “the brass just has no idea”. Jokes (like those about doctors) abound about the bumbling or ignorant or evil high-officer.

    Well those people are my father and grandfather. They raised me. They got up, went to work, and came home to people they loved and wanted to protect. My grandfather *was* in the trenches, he *did* take fire, he was as aware of the toll of human life war takes as anyone who has ever lived. And he did his job with that knowledge always at the top of his mind, with every sympathy and empathy for the soldiers, sailors and airmen he commanded. But the stereotype persists.

    And on the messaging front, my father was just diagnosed with a glioma, and I was in the room with my mother and him when the doctor communicated his chances. He did exactly what you say you do, he said, and I will likely never forget his words, “20% of patients live two years.”

    Well the stress of that moment is like nothing else my father and mother have ever gone through. As we left the hospital, his reaction was, “Well, he said two years, let’s go out and live well for two years.” He is the wisest man I’ve ever know, and he’s also very intelligent as well. But he heard “two years” and didn’t (at first) delve into that it was 20% and that he’d go down hill before then, etc, etc, etc. He’s more than capable of understanding all that, and I’m sure by now he’s worked through all of it, but at that moment, almost no one is capable of taking that data without a heavy filter.

    And the doctor was great, and helpful, and understanding and caring and so is my aunt, my best friend from college, two other close friends of mine, my GP, my wife’s OB/Gyn, and every other doctor I’ve known personally. I’m sure the great warmth and affection I have for the medical profession is due to my close connection with so many doctors and nurses, so perhaps I’m as biased in the other direction.

    Great post, sorry about the length.

  7. clgoodon 31 Jul 2008 at 2:54 pm

    Excellent post, Dr. Novella, as usual. And an understandable rant.

    I’m afraid that part of medicine’s wounds are self-inflicted. Recently Robert Sutton, author of No Asshole Rule, spoke here at work. He’s found that there is some correlation between career and abuse of inferiors. Interestingly, surgeons were among the worst offenders, with many of them proud of and bragging about the way they treat nurses. I suspect that it may be a holdover from the old paternalism you mention.

    On the other hand, a friend of mine once said he’d never met an OBGYN who wasn’t mellow and happy. In my limited experience (confirmation bias alert!) I’d have to agree.

    Generalizations – though occasionally useful – can rapidly turn into bigotry, and I think all your points are valid and well-taken.

    One thing for sure: I’m not letting a physicist near me with a scalpel.

  8. IdanH14on 31 Jul 2008 at 3:14 pm

    I must adit, I was convinced before I even read this post. My experiences with doctors were mostly good. I had a few jerky doctors, but even then I didn’t changed my general opinion – which is exactly what you wrote in this article.
    Thanks for a great post,
    Ido

  9. jonny_ehon 31 Jul 2008 at 4:01 pm

    I remember Tyson’s comments during his keynote, and I remember thinking “Hmm, I wonder what Dr. Novella has to say about that”. It took a while, but patience paid off. I can’t remember if I clapped or not (if I did, I was just ‘following’), but I do remember thinking that there was ‘something’ quite wrong with what he said.

    One other point in TAM gave me some pause about the skeptics in attendance. During Penn & Teller’s Q&A, Penn blurts out that they should do away with public schools. I was shocked by the number of people that applauded that one. I consider myself libertarian in nature, but even that seemed extreme to me.

    When I first saw the subject of this blog post, I assumed you were going to address the doctor/medical establishment bashing from the CAM crowd. I especially despise the whole “doctors are the 2nd leading cause of death in America” bullshit. But Harriet Hall already addressed that a while ago on sciencebasedmedicine.com

  10. DevilsAdvocateon 31 Jul 2008 at 4:23 pm

    In no way can a well thought out and honest addressment of an issue be a ‘rant’. Excellent entry.

    My field and my peers involve Ph.D ‘doctors’ for the most part, psychologists mostly. Unfortunately, it is a field where many attributes thought stereotypical are probably truer than we’d like to admit, that is, it’s proved in my experience and in my location to be a woo-intensive, asshole-rich environment, where clinical decisions are often influenced by, and sometimes based on, political considerations of all things, and those of the faddish, pop culture type. As for woo, here’s an actual tx planning quote: “Well, I read an article in People Magazine where a team in Oregon is getting excellent results with their depressives by using the therapeutic touch therapy one of their RNs taught them…..”

    That’s bad enough, but when the Ph.D psychologist nods and orders it up… ay yi yi. Oh, the battles a skeptic can get into in the outpatient mental health and substance abuse treatment milieu……..

    In most circles -social, political, etc. – I’m considered a centrist, a middle of the road, common sensical guy, but in this field I’m considered rock rigid and closedminded, a throw back, the Jesse Helms of therapy.

  11. Niels Kjaeron 31 Jul 2008 at 4:38 pm

    I am willing to bash any -ists who asks me a question and does not show any sign of listening to my answer.

    That is why I consider myself the ultimate bigot: I believe in myself but trust others.

    To verify is more in the eye of the beholder than holding the eye.

  12. deciuson 31 Jul 2008 at 5:29 pm

    Tyson’s attitude is surprising, to say the least.

  13. DevilsAdvocateon 31 Jul 2008 at 6:31 pm

    Ditto: decius, re: Tyson, but especially surprising given the thinness of its premises.

  14. PalMDon 31 Jul 2008 at 7:27 pm

    This led to a rather heated discussion in my corner of the blogosphere. There does appear to be a somewhat insurmountable barrier to communication in some cases, with one side insisting that docs are not arrogant pricks, and the other saying, “yes they are, where’s your data”.

    There is a tremendous inconsistency in the reasoning.

  15. Intrepydon 31 Jul 2008 at 7:37 pm

    It’s frustrating, and it’s true. Doctors get a bad rap. I think the economics and politics of medicine isn’t helping. The need to see a certain volume of patients to remain viable, or the need to satisfy third party payers, drives a wedge between doctors and patients. Doctors a human beings, and some become disillusioned. Most, like Steve argues, are true to the profession.

    I encounter a different kind of prejudice. As a resident in radiology, I’ve found that this particular medical specialty gets a bad rap — from other doctors! As a medical student, I was advised by my Internal Medicine clerkship director to pick a specialty that wouldn’t “put your communication skills to waste.” Another time, I overheard a respected oncologist cursing my medical school class for gravitating towards “easy” specialties. In reality, the specialty is extremely challenging intellectually with its encyclopedic knowledge base and rapidly evolving scope, and it’s particularly demanding of polite and effective communication with other clinicians and, yes, compassionate communication with patients.

    I suppose it’s a symptom of the human condition. Besides confirmation bias, I would guess that negative interactions are more indelible than positive ones. Flashbulb memory.

  16. mat alfordon 31 Jul 2008 at 8:38 pm

    To be clear from the outset, I’m an optometrist, not an MD…

    Give the guys a break! Being a practicing doctor can be just so monumentally difficult! In addition to being an evidence based scientist, an MD needs to have the communicative skills to relay often complex information to a (largely) scientifically illiterate audience.

    The pressure and stress involved in consistently making the correct decisions can be immense.

    Mix in a dollop of social worker, lawyer, therapist etc, etc. it is no wonder doctors are become targets when they don’t perform to to a particular patient’s pre-conceived standard.

    I would have spent a bit longer on this but I’ve a patient waiting to see me…!

    Oh to be a showbiz physicist…!

  17. Diane Henryon 31 Jul 2008 at 10:56 pm

    I’m not sure that this is limited to doctors: I’d call it “other bashing.” How often has a friend told you about the morons at work, or the idiots on the other team? How about: Attorneys are snakes, mechanics are dumb, contractors will screw you and do a lousy job to boot, scientists are dogmatic materialists stuck within their limited worldview, pick your negative stereotype. (I’m using these as examples of broad stereotypes; these are not my actual beliefs!)

    It seems to me that whenever we don’t know very many people of a certain group it’s easy/common to paint the group with very general negative strokes, most of which come down to: my group good, other groups bad.

  18. DevilsAdvocateon 31 Jul 2008 at 11:04 pm

    “Hell is other people.” ~Jean-Paul Sartre

  19. mat alfordon 01 Aug 2008 at 12:31 am

    Pithy quote as ever, DA….

    Diane, I get what you’re saying, but why would Neil deGrasse Tyson be indulging in “other-bashing”?

    It seems to me he may be the type to try ‘poisoning the well’ of others to embiggen his own position. I notice he tried something similar with Richard Dawkins a couple of years ago:

    http://sandwalk.blogspot.com/2006/11/neil-degrasse-tyson-and-richard-dawkins.html

    Would it be unfair to bring up Neil’s previous dancing career?(source: wikipedia)

  20. [...] From Around The Blogosphere 7.31.08 Doctor Bashing -Another great post from Steven Novella. Here, he discusses anti-doctor sentiments that seem to be [...]

  21. mat alfordon 01 Aug 2008 at 6:01 am

    I get what you’re saying Diane, but why would Neil deGrasse Tyson indulge in “other bashing”? Perhaps he feels it embiggens his own position?

    Perhaps most critical thinkers are already aware of this exchange between Neil deGrasse Tyson and Richard Dawkins, if not it’s definitely worth a look:

    http://sandwalk.blogspot.com/2006/11/neil-degrasse-tyson-and-richard-dawkins.html

  22. Nitpickingon 01 Aug 2008 at 9:06 am

    Steve, why didn’t you bring this up when interviewing Tyson for the Skeptic’s Guide? Did he give that speech after the interview?

  23. Oracon 01 Aug 2008 at 9:30 am

    Steve,

    Did you mention your concerns to Neil? If I knew him, I would have, and I would have been pretty strong about it.

  24. Diane Henryon 01 Aug 2008 at 10:43 am

    Thanks Mat, good point.
    Maybe it’s not “other-bashing” but maybe its mindlessly repeating easy stereotypes? Having not been at TAM, I can’t really say, but could Tyson have just as easily made a negative comparision using ambulance-chasers (not necessarily a one-to-one substitution, but as a general point)?

    In my experience, doctors are just one of many groups that get bashed. Living in Washington State, I do of course know many anti-Big Pharma people, but, they’ll just as quickly bash other groups as doctors (though, curiously, never alt med folk).

  25. Steven Novellaon 01 Aug 2008 at 10:53 am

    I think there is a general tendency, as others have pointed out, to think of groups of people with whom we are not personally familiar as abstract entities – not real people.

    Regarding Neil – I met him for the first time at TAM. I would love to discuss this with him, but did not have the opportunity. We did interview him for the SGU, but had a strict time limit and I made the decision not to use it on this topic.

    He is clearly a very thoughtful person and seems like a genuinely nice guy. I can only speculate as to the origins of his apparent attitude, and again would love to discuss it with him sometime. (I have e-mailed him since TAM, but he has not replied – probably lost in the flood.)

  26. Fifion 01 Aug 2008 at 11:20 am

    In the context of a meeting of skeptics, it is strange to find interdisciplinary discrimination when everyone supposedly has the same objective. It sounds like there was more cynicism at work than actual skepticism.

    What makes it even more odd is that (misunderstandings about) quantum physics is what a lot of new agers use to justify their ideas about energy healing and the mind creating objective reality. You’d think a physicist would be aware of that and actually be interested in joining science-based doctors in clarifying these misperceptions. It would be interesting to understand where his cynicism comes from, if he would be willing to discuss it. Is it because Deepak Chopra is a doctor and there are a few MDs who exploit woo to make a quick buck? Has he had a bad personal experience with a doctor? Does he just not understand the complexities of practicing medicine and holds some of the same magical beliefs and expectations about medicine that much of the general public does? Does he expect doctors to be infallible? You might uncover why some other intelligent people hold a similar cynicism. Or do you think it stems from the fact that a lot of quantum woo is channeled (pun intended) though healers and CAM types? (Though I find it strange that he’d buy into CAM when he speaks out about quantum woo in physics! Perhaps you should ask him what kind of treatment he seeks when he needs medical treatment?)

    On another front, let’s not forget that there’s inter-specialty doctor bashing that goes on too. Tribalism, which is essentially what’s being talked about, is pretty natural if one identifies primarily as being part of a group (and bases part of one’s self worth and social value in belonging to a certain group). It’s why it seems useful to me to have human at the top of one’s list (or even animal/mammal/ape) of who/what one is if one wants to enlarge one’s identity to be more inclusive.

  27. Oracon 01 Aug 2008 at 12:34 pm

    That post basically says “Talking about privilege requires you to name, define, and analyze patterns” but then offers no real insight into how to do any of that, except one’s unadulterated experience. Strange that someone who teaches basic science at a university doesn’t realize that we have biases we’re unaware of and that we can’t always rely upon our interpretation of patterns. That’s why other kinds of corroborating evidence is needed. How this person can’t see that asking for evidence and arguments is engaging content, I don’t know.

    Yeah, that’s PP to a tee. He’s self-righteous to the point of being a foul-mouthed pompous ass about that issue. And if you don’t agree with him it’s always because you’re part of the power structure and can’t recognize your inherent “privilege,” which makes it impossible for you to recognize that you have privilege and others don’t. To some extent, there is a point there, but PP takes it far beyond reason and uses it as a cudgel to attack anyone who disagrees with him. But, hey, as a middle-aged white male doctor I’m part of the “privileged” class, so what do I know?

    Of course, PP is a white professor at a prestigious university (unlike Steve, I do know who he is; it was harder than it is to figure out who I really am, but not that much). He apparently can “understand” the whole privilege thing. Odd that he can’t seem to admit that others of his same general ilk might also understand it.

  28. Annieon 01 Aug 2008 at 1:14 pm

    Excellent analysis of “other” bashing. I’d also add that physicians deal with issues cirtically important to people, and that, the physician/patient relationship is always personal. Perhaps that’s a primary source of the tendency to make widespread generalizations and why it bears some relationship to the intensity of reactions.

    I come at this from a different perspective – that of being affiliated with a profession that is widely portrayed by negative stereotype, is ignored by most people from other professions and which garners little respect in general – professional nursing.

    Even in the comment thread here, there is reference to an RN which implies profession-wide scientific ignorance, sub-legitimacy, and woo.

    It’s pretty difficult to be taken seriously, and the evidence thus far from my blogging efforts is that nursing isn’t viewed by the public, the science and medical communities as having much legitimacy, worth and scientific value, although the actual application of nursing research demonstrates lower patient M&M rates, higher patient self-reported and demonstrable quality of life, increased compliance with health prescriptions and higher satisfaction with health care.

    But who will know?

    Professional nursing isn’t included in the vast majority of health reportage. Nurses aren’t used as expert sources. Nursing research isn’t generally cited. Even in the blogosphere, I can count on the fingers of one hand the number of nurse bloggers who write about professional issues, research and application to patients.

    That’s not much of a narrative, is it?

  29. neiltysonon 01 Aug 2008 at 1:16 pm

    I feel compelled to clarify and correct two points made by Dr Novella:

    1) My statement about alternative medicine was misremembered by you. Allow me to clarify what I actually said, while, as a communicator, share some of the blame for being mis-interpreted in the first place.
    In response to a conference session spent bashing alternative medicine for its potential and real dangers to the public I simply said that one could hold another session, with equal intensity, on all the ways medical malpractice has harmed the public. And so if you want to keep people from turning away from modern medicine then you need to be sensitive to this fact and somehow fold it into your analysis of, and solutions to why these people are disillusioned.

    2) About my “idiot” doctors comment. The word is harsher than I had indended. i should have said “incompetent” instead. It was a poor choice for which I apologize. But I maintain the larger truth of the point. What I actually said was hat if three doctors diagnose you with 5, 6 and 7 months to live, and you go home and pray to God, and get others to pray for you and you, live for years beyond these predictions, this person is more likely to credit the intervention of God than to suppose that the three doctors are incompetent. This fact **astonishes me** and points to the power the medical profession can have over a person’s self awareness of his or her prognosis.

    A further, more important point that I did not explicitly make, is that if the survival distribution for a diagnosis says something like what Dr. Novella gives above: e.g. 50% survive 6 months. 10 % survive 10 years, the medical profession is more likely to declare these data as “the” survival profile of the disease rather than as the consequence of deep ignorance to what is actually going on with a disease from one person to the next. Because if you actually understood the causes and effects of a disease as it interacts with different people, you would then be able to tell each person with precision when he or she will die. But you are not there yet. Provide the data (as you do) but then admit the ignorance rather than sweep it into the probability distribution of survival.

    In just the same way weather forecasters say, “50% chance of rain tomorrow,” This of course means they have no clue at all whether it will rain, because if they did, the chance of rain would approach 0% or 100% and not sit anywhere in between.

    In short, I seek candor in scientific ignorance. Anything else is a charade.

    Neil deGrasse Tyson
    Astrophysicist
    New York City

  30. Calli Arcaleon 01 Aug 2008 at 1:42 pm

    Very nice article. One thing about doctor bashing is that it’s a lot like lawyer bashing. It’s a group who (justifiably or not) are perceived to wield a lot of power, make lots of money, hear some very private information from their clients, and are paid basically for helping someone who is desperate. There is some truth to the stereotype, because certainly a doctor or lawyer could seriously exploit their clients. This is why things like medical boards and the Hippocratic Oath exist. This is why medical ethics is so important.

    But of course the reality is that the majority of doctors and lawyers, just like any group, are good people. I know a lot of doctors. They vary, like any group, but the vast majority are fine medical professionals. (On the other hand, what you don’t know about a person can be shocking. One notable exception from this group has always been well-liked by his patients, and regarded as maintaining a high degree of professionalism. It seems that this was not true with all of his patients, as he recently had his license suspended indefinitely for abusing his position of authority.)

    Many groups get singled out for unfair stereotyping, generally ones who enjoy special levels of respect in social settings: doctors, lawyers, professors, clergy, politicians, royalty, corporate executives, military officers, etc. It is human nature. That said, it’s distressing to see skeptics fall prey to it, especially in a fashion which elevates “alternative” medicine to a higher standard than it really deserves.

    If it feels better, though, I know one physicist who has a high regard for doctors. My brother has a PhD in physics and works as a research scientist for the Cleveland Clinic. ;-)

  31. overshooton 01 Aug 2008 at 1:45 pm

    This led to a rather heated discussion in my corner of the blogosphere. There does appear to be a somewhat insurmountable barrier to communication in some cases, with one side insisting that docs are not arrogant pricks, and the other saying, “yes they are, where’s your data”.

    Well, that’s the problem now isn’t it? There is no data available to the general public. My orthopod seems to have done a credible job on a leg repair, but all I really know is that he’s OK to talk to, I didn’t end up losing the leg or with a nasty postop infection, etc. My brother’s experience with a series of orthopods and shoulder repairs going back decades has been uniformly negative, but for all I know they didn’t have much to work with — and neither does he.

    People form their opinions on insufficient or unreliable data because that’s all they have. With all the will in the world, there is simply no way I can pick an organic mechanic on any basis better than word of mouth, unreliable as that may be. At that point all of the problems with human perception, bias, etc. start another round.

  32. Steven Novellaon 01 Aug 2008 at 3:36 pm

    Neil,

    Thanks for taking the time to clarify your statements. Of course, I absolutely may not be remembering the incident at the science meets alt med conference accurately – it was several years ago. Also perhaps I misunderstood your point at the time. I was certainly left with the notion that you thought our criticisms of CAM were heavy handed. The astrology analogy seemed apt at the time, and you accepted it (at least that’s my memory).

    My problem with your comments at TAM were the two that I emphasized – the likely explanation is that the doctors were “idiots” (the term “incompetent” is less inflammatory but makes the same point), and their agreement in prognosis due to common education. I think the more likely explanations for such a scenario (especially given that your premise was three doctors) is that the patient misinterpreted the survival statistics that were explained to them, and second that the agreement was due to basing their opinions on the same available published data.

    Your point about admitting the limitations of our knowledge is absolutely correct. However, I wonder why you think that it is not standard of care and common practice to do so.

    I personally tell patients – we cannot predict the future, we cannot say what will happen to an individual patient. All we can do is estimate what is likely to happen based upon studying people who have had the same disease – and here’s the data.

    I have no reason to think that I am an anomaly. This is how I was trained, it is what I have witnessed in my teachers and colleagues, it is not only good practice, it is common practice.

    Yes – there are many mediocre, poor, even incompetent doctors, just like with any profession. But they do not determine or compromise the standard of care or common practice.

    My feedback for your talks in the future – by using three doctors in your example you seemed to be saying – this is not an isolated mistake or a random incompetent doctor, but a systemic problem in the medical profession that is part of their training. I do not know what that is based on and it does not accord with my own experience as a physician and teacher.

    Thanks again for visiting my blog. I would love to discuss this further with you, as I think those of us promoting science education benefit greatly from cross-fertilization from other specialties.

    (And you talk at TAM was fantastic. :) )

  33. Oracon 01 Aug 2008 at 3:42 pm

    Because if you actually understood the causes and effects of a disease as it interacts with different people, you would then be able to tell each person with precision when he or she will die.

    That’s a questionable assertion at best, I’m afraid, given the great variability in biological systems. At best we could perhaps narrow down error bars around the predicted time somewhat, but it’s highly unlikely that we’re ever going to approach anything even somewhat close to physics-like precision in predicting a biological variable like life expectancy in a patient with a terminal disease. The inherent variability and noise in the system are too high, and that’s one of the things that makes medicine and biology so hard.

    Besides, Medicine is not a pure science anyway, but rather an applied science, and this is where the human element of medicine comes in. I’m not sure that it would necessarily be an altogether good thing to be able to make such predictions with that high a level of precision. One of the tasks of a physician is to try to allow a patient with a serious or terminal illness some hope. Letting the patient hope that he may fortunate enough be one of the few, the 10%, who lives 10 years, to use Dr. Novella’s example, has value in keeping the patients’ spirits up. I’m not saying to lie, to excessively sugarcoat the situation, or in any way to give false hope. If a patient has metastatic pancreatic cancer and thus as a 50-50 chance of lasting 6 months and less than a 15% chance of lasting a year, the patient should be told that. But the hope for being among the 15% is not a bad thing most of the time.

  34. jonny_ehon 01 Aug 2008 at 3:49 pm

    neiltyson said:

    In response to a conference session spent bashing alternative medicine for its potential and real dangers to the public I simply said that one could hold another session, with equal intensity, on all the ways medical malpractice has harmed the public. And so if you want to keep people from turning away from modern medicine then you need to be sensitive to this fact and somehow fold it into your analysis of, and solutions to why these people are disillusioned.

    Why assume that people choose alt. med. because they are disillusioned with scientific medicine? Some people may be attracted to it because it makes big promises, a comforting illusion. Do people choose to believe in other forms of non-sense because they’re disillusioned with reality? People probably come to strange beliefs for different reasons.

    But even so, what’s your point? Should the doctors not be speaking out against alt med? There are plenty of doctors working to improve scientific medicine from within, I think it’s ok to have some doctors encourage people to abandon unscientific medicine or at least reexamine their beliefs.

    This reminds me of your “before telling people that religious belief is silly, convince the 7% of believers in the National Academy first” argument. Again, I don’t see how this is relevant. I’m not a genius scientist, yet I went from believer to non-believer. And strangely, when that happened I became extremely interested in science, which led me to buying Death by Black Hole (great book BTW). You should be thanking Dawkins for that sale.

    What I actually said was hat if three doctors diagnose you with 5, 6 and 7 months to live, and you go home and pray to God…

    I agree with you that if a doctor tells a patient that they have ‘six months to live’, yet don’t explain the uncertainty in the prognosis, they are incompetent. But you also have to consider that patients remember things differently than what doctors say. A doctor might say that 90% don’t make it past six months, but the patient then reports six months later that the doctor said “you only have six months to live”. Give the doctors some credit!

    Provide the data (as you do) but then admit the ignorance rather than sweep it into the probability distribution of survival.

    But isn’t presenting the probability distribution a way of exposing our current ignorance?

    BTW, I really enjoyed your keynote (highlight of the event), and keep up the fantastic work on NOVA Science Now.

  35. overshooton 01 Aug 2008 at 4:22 pm

    but it’s highly unlikely that we’re ever going to approach anything even somewhat close to physics-like precision

    Please don’t overstate the precision of physics. WAAAAY too much of what we do is purely random, and we only get away with it by averaging more instances than you have available. For instance, my idea of a “tiny” charge is about 20 electrons, and they really are all alike. How long do you have to keep looking to find 20 breast cancer patients who are even similar, much less identical?

  36. Oracon 01 Aug 2008 at 4:33 pm

    Well, that is another reason other than the inherent variability of biological systems that Dr. Tyson’s assertion strikes me as medically very naive.

  37. halincohon 01 Aug 2008 at 11:00 pm

    As a fellow physician and regular listener to the SGU and reader of the associated blogs I have been fascinated by the apparent aggressiveness by many in the skeptical community towards those outside of the community. While I, in no way, shape, or form believe in a micromanaging “God,” I don’t think I’m a true atheist either. I guess I’m closer to being in the deist camp , like Jefferson and possibly Einstein. Though I don’t think that a supreme entity is necessary ( ok, so I’m a deist lite ), I don’t have a problem with those who do. Religion-wise, I simply have a problem with those who think that if there is a God that he plays dice on a daily basis on every street corner, war venue, or ball field in the world. Sometimes though, because I’m not a hardened atheist, I feel outside of the skeptical community. With this in mind, Dr Tyson’s mild attack on our profession and your response intrigued me.

    So a highly respected member of the scientific world dissed us in the context of alternative medicine, well … to a degree, he has a point. Because of the volume of patients we have in traditional medicine ( as compared to alternative ) and because any “medication” that has a true physiologic effect, in turn, has a potentional side effect, we of course will do UNINTENTIONAL harm much more frequently than those who practice alternative care. Also, if a practioner is careless (even ONE time) or just plain dangerous idiotic ( religious zealots can practice medicine ) malpractice can occur. However, sometimes, paraphrasing the docs on the TV show ER, despite our best efforts ( no malpractice )bad things simply can happen.

    The important point though is risk vs benefit. A homeopathic’s benefit is totally due to the placebo effect, accupuncture’s best benefit is possible pain relief ( though the data is mixed, at least it’s not the hogwash of extreme practioners of the ancient art ), and osteopathic medicine ( I am a D.O. ) is at it’s most reliable for musculoskeletal pain ( again, extremists may make strange claims ). I LOVE the placebo effect. I embrace it. The mere act of coming to a doc for some is a placebo. Traditional medicine’s strength, however, is that it aggressively investigates the risks of treatment as well as any benefit. Also, the root cause of both disease and well being are constantly being questioned, upgraded and re-evaluated. Alternative medicine … not so much. And that is one of it’s dangers.

    Dr Tyson is right, often we do not know with 100% accuracy why a medication works or what the pathophysiology of a disease is, but we do know a lot and we do seek the truth. Most of us do not idiotically feel we know everything; we simply use what we know as best as we can and hopefully we can effectively communicate this to our patients. Furthermore, truth takes time. I used to be frustrated by how relatively inadequate and slow our research seemed to be ( restrictions by ethics sure can limit experimentation ) at times. Even animal studies are limited in this day and age. Recently, however I’ve been reading subjects much closer to the expertise of Dr Tyson. In the Trouble with Physics by Lee Smolin I was surprised to discover that medicine doesn’t seem so slow and backwards afterall. Hundreds of physicists follow string theory as if it were a religion, without evidence, without definitive proof. They have done so for over twenty years! In his book he also discussed the pros and cons of loop quantum gravity. He finally suggests that a new generation must generate research outside of the present box.

    On page 354 he states

    ” To my fellow theoretical physicists … We constitute a scientific elite only because the larger society we are a part of cares deeply about the truth. If string theory is wrong but continues to dominate our field, the consequences could be severe – for us personally as well as our profession. It’s up to us to open doors and allow the alternatives in, and generally raise the standards of argument.”

    Physicians also constitute a scientific elite ( Smolin differentiates craftsman from visionaries ) and most clinicians are craftsman, but that doesn’t lessen the importance of being a GOOD craftsman.

    But all of us, whether we are a physician, a physicist, or a skeptic must not belittle, shut out, or ignore that which is out of our specific community for one never knows where the next visionary will come from. If a practioner of alternative medicine, by utilizing the tenants of the scientific method, discovers a cure for cancer, then WONDERFUL! If a non string theorist, one day in the future does discover a unifying theory of physics, then WONDERFUL! And if they believe in God, who cares!

    If we ( skeptics )become too close minded, are we any better than the followers of Jenny MCCarthy?

    Ok, we’d still be better … but you get my drift.

    Inspiration can come out of left field sometimes and as long as the left fielder practices the scientific method, I’m good with that.

  38. mat alfordon 02 Aug 2008 at 4:12 am

    Some excellent exchanges here – just re-enforcing this as one of the best blogs out there….

    Can we just all agree to bash real estate agents?

  39. Joeon 02 Aug 2008 at 6:03 pm

    Steve,

    You mentioned annoyance at the phrase “hard science.” You probably understand, but other readers may not, that the term “hard” does nor refer to “difficulty.” Rather, “hard” refers to the ability to make solid predictions. For example, if I have an insulated bucket of warm water and I add a known amount of ice at a certain temperature, I can confidently compute the final temperature of the system. On the other hand, If I have high blood pressure and you prescribe a dose of a drug, it is only an educated guess what my medicated BP will be (and that is not for lack of understanding).

    Put another way, physics is less complex than biology because it is easier to control all the variables. Biology (medicine) is more complex, and more difficult to to study and apply, since controlled experiments are harder to perform.

    If you think of the scientists who have rocked the world in the last two centuries, you will probably find that Darwin and Einstein come out on top.

    So, the various sciences do vary in rigor; but rigor varies inversely with respect to difficulty.

  40. neiltysonon 02 Aug 2008 at 6:57 pm

    “# Oracon 01 Aug 2008 at 4:33 pm”

    “Well, that is another reason other than the inherent variability of biological systems that Dr. Tyson’s assertion strikes me as medically very naive.”

    I maintain that a phrase such as “inherent variability in biological systems” is code for “we do not yet understand biology well enough to predict with accuracy the causes and effects of important diseases that we diagnose.” Most things in nature look complex, variable, and hard to predict, until they are fully understood. That’s the very nature of scientific discovery. Admit the ignorance. Quantify it as best you can. And work hard to reduce it to zero.

    Yes, in the end, its all about the error bars.

    And yes, string theory borders on religion. But notice that its strongest critics are other physicists (e.g. Lee Smolin, Lawrence Krauss)

    Lastly, I have no fundamental issues with Dr. Novella’s follow-on comments to my post. And I thank those of you on this Blog who did attend TAM06 for your kind remarks about my keynote there.

    I must move on. The Universe beckons.

    Neil deGrasse Tyson

  41. overshooton 02 Aug 2008 at 8:23 pm

    I maintain that a phrase such as “inherent variability in biological systems” is code for “we do not yet understand biology well enough to predict with accuracy the causes and effects of important diseases that we diagnose.”

    That, or it’s a code phrase for “complex nonlinear systems which are influenced by quantum effects.” In other words, chaos rules — or at least has a sizable voting bloc.

    Despite our best efforts, thermal noise (quantum mechanics in your face) plays a dominant role in quite a few areas of electronics now, and solid-state electronics are orders of magnitude less complex (in the chaos theory sense) than biological systems.

    Bottom line: it’s not an excuse, it’s part of the physics. Learn what we will, there inherent limits to predictability of biological systems and although we’re not up against them, we can see them with a good set of binoculars.

  42. Steven Novellaon 02 Aug 2008 at 9:53 pm

    I think it’s both, actually. Certainly we have tons more to learn and as we do the error bars will decrease. For example, we are likely on the verge of using personal genetic analysis to better predict response to drugs. Quick and cost effective genetic analysis will dramatically reduce the error bars.

    But, overshoot is also correct, there are limits. People are not electrons. Just like we cannot predict the weather (inherently, not because of limited knowledge, but due to chaos) there will always be limits to our ability to predict interactions in a complex biological system. Imagine, for example, the possible number of permutations of 5 drugs (a conservative number for the geriatric population). Predict the interactions with every possible combination. Now throw in every possible combination of genetic variation.

    Yes, the error bars will decrease inversely with our knowledge – but no matter what treatment will always have a component of trial and error.

    There will also always be error bars on prognosis because you cannot predict random events. I just had a patient with a neuromuscular disease, whose life expectancy was still 20 years, die of pneumonia as a complication of his disorder. That was a random unpredictable event. That aside, prognosis involves every permutation of coexisting diseases and conditions and measures of health, as well as response to treatment. Chaos.

  43. halincohon 02 Aug 2008 at 10:08 pm

    “And yes, string theory borders on religion. But notice that its strongest critics are other physicists (e.g. Lee Smolin, Lawrence Krauss)”

    All the sciences deserve to be scrutinized over and over again ( tis the strength of science – and yes, the questions and concerns can come from all members of society ) , but with all due respect that a much accomplished man such as you deserves, medicine’s strongest critics should come from within the field as well – and it does. We debate, we research, we debate again – we evolve. Yes, it is much more difficult to control variables during human experimentation, but equating not knowing everything about a given system, such as a disease state, as “scientific ignorance” is dismissive and suggests naivety regarding the research within the science of medicine itself.

    Medicine is a clinically applied science based primarily upon physiology, anatomy, biochemisty, and pharmacokinetics; psychiatry, less so, yet the field relies heavily on neurochemistry and neuroanatomy in this day and age – again, it has evolved! And yes, some diseases such as fibromyalgia, remain in it’s infancy of understanding, but others such as diabetes is deeply understood, even though debate in the field of diabetes ( such as how tightly should glucose be regulated: the recent ACCORD trial, ADVANCE trial, and STENO-2 trial ) remains hot and heavy. Again, debate is good!

    Before I became a physician I was a grad student in Experimental Psychology with my primary emphasis on the physiological basis of behavior. The most important thing that I learned was general experimental design, methodology, and statistical analysis. Though I’m frustated that medical research’s variables cannot be more tightly controlled , I understand the limitations because of ethical considerations. But well done, peer reviewed, medical research is satisfactory research. Yes, this research will not yield the same depth of detail of a Hadron collider, but at least our research won’t destroy the Earth. What’s that? I sound naive? I meant to, sir. What’s your excuse Dr. Tyson?

  44. Oracon 02 Aug 2008 at 10:52 pm

    I maintain that a phrase such as “inherent variability in biological systems” is code for “we do not yet understand biology well enough to predict with accuracy the causes and effects of important diseases that we diagnose.”

    I’m sorry, Dr. deGrasse Tyson, but that’s just more of exactly the medical naivete I was talking about in the first place. Such thinking may take one far in physics, but it’s a lot more problematic in biology. Steve nailed many of the reasons why.

    Of course, to some extent you have a point. No doubt we will “narrow those error bars,” maybe even considerably, but the level of precision in predicting prognosis that you implied is highly unlikely ever to be achieved. The reason is that the biology of, for example, cancer (my specialty) doesn’t just appear highly variable. It is highly variable. In fact, cancers of the same histological type often behave very differently. To some extent gene expression signatures are telling us a bit about the biological differences that account for that, but even tumors with similar genetic signatures can behave differently. It’s a stochastic and chaotic system. Moreover, you will never have the sheer number of “events” to observe that physicists do to hone highly “tight” statistics.

    But it’s worse than that.

    Even different populations of cells in the same cancer can exhibit very different behaviors. Moreover, these cells interact in numerous complex ways with the tumor microenvironment and other tumor cells, each acting on the other, and in the meantime they are evolving under selective pressures unique to the microenvironment in which the tumor arises–changing the very behavior of the tumor as an “organ system” in difficult to predict ways. Add to that the interaction with the patient as a whole and the patient’s various comorbidities, and there’s another level of complexity.

    Finally, because of its unique nature as applied biology on humans, there are ethical and psychological aspects of medicine that further limit just how far we can go to narrow those error bars.

  45. halincohon 03 Aug 2008 at 9:51 am

    Excellent point about CHAOS in biological systems, Steven. And if it were only limited to the biology it would make our lives as clinicians that much more simple. Throw in the stresses of everyday living – psychology, sociology, economy, etc etc – and the chaos effect wrecks havoc with predictions in medicine and the lives of our patients. I hope I am still in practice when the knowledge of our genome ( in my opinion, the most underrated discovery in our lifetime, if not beyond ) becomes an everyday clinical tool. It won’t eliminate the chaotic battle of the living, breathing , working human, but it will allow us a better predictive tool in choosing our weapons for the clinicalfight.

    Dr Tyson reminded us that the universe awaits … and I await his peers amazing discoveries.

    But our smaller “universes” await, within all of us, and this medical universe is just as fascinating … and just as wonderfully frustrating.

  46. Niels Kjaeron 03 Aug 2008 at 10:13 am

    “Of course, to some extent you have a point. No doubt we will “narrow those error bars,” maybe even considerably, but the level of precision in predicting prognosis that you implied is highly unlikely ever to be achieved. The reason is that the biology of, for example, cancer (my specialty) doesn’t just appear highly variable. It is highly variable. In fact, cancers of the same histological type often behave very differently. To some extent gene expression signatures are telling us a bit about the biological differences that account for that, but even tumors with similar genetic signatures can behave differently. It’s a stochastic and chaotic system. Moreover, you will never have the sheer number of “events” to observe that physicists do to hone highly “tight” statistics.”

    Being a experimental physicist heavily involved in precision measurements of the standard model I can only say: Spot on!
    In my (less and less humble) opinion, good physicists don’t forget to use the term “standard”.

    How do I most easily convince my own GP that I am not standard? All the standard tests my GP has put me through “failed”, but still my GP does not seem to say anything else than: you look like a standard human being. I can “change my GP” but that is also tricky, because then I will find a new GP who sends me to a specialist whom I do understand, and therefore might find a problem which is imaginary.

    Before we have a universal language for what being ill means, we should be afraid that we cannot solve this dilemma.

    The standard candle can after my opinion only be to:
    (measure, treat, measure)
    What is to measure?
    What is to treat?
    What is to measure really?
    “Patient dies in the middle of the night” could be a “small” and “reasonable” start on an interesting journey. 100,000,000 human deaths a year is quite a few.

  47. Roy Nileson 03 Aug 2008 at 5:30 pm

    So much for the present state of artificial intelligence.

  48. Groovydocon 04 Aug 2008 at 8:37 pm

    First time poster here, and this is a bit of sore topic for me, as a practicing MD. I personally am not sure why so many people engage in doctor bashing in my presence, both personally and professionally. Usually it goes something along the lines of ” I went through eight docs and none of them could figure it out.” In fact, if I was ruled by anecdote, I’d have to assume at least 80% of all practicing physicians should retire or be brought up before their respective medical boards.

    Thankfully, my practice environment is full of competant, compassionate health care professionals (docs, nurses, midlevels), so I can keep perspective. But those assertions seem to be filling some basic need that I’m not sure I’ve fully grasped (other than promoting my need for a vacation.)

    Oh, and an additional thought in regards to Dr. Tyson’s thoughts and the replies regarding medical predictions:

    Don’t forget other HUGE variables not mentioned….
    Patient beliefs and behavior are also capable of having huge impacts on their disease process. What treatment options will they choose? Will they procrastinate, take their meds, stop drinking or smoking, look both ways crossing the street? Good luck narrowing down life expectancy too much based on “individualizing.” If there’s anything I’ve learned, getting to know someone that well is likely to take far more time than will ever be available in a realistic practice , and still subject to extreme variablility.

    Ooops, sorry, this wasn’t supposed to be “my rant.”

    Stay Groovy

  49. halincohon 05 Aug 2008 at 10:51 pm

    Hi Groovydoc,

    This was my first time posting in Neurologica as well. When an esteemed professional such as Dr Tyson makes comments as above, we physicians, in the same blogosphere, must put in our two cents worth.

    As a companion piece to your comments, Viagra has taught me a lot about how important it is to assess how deeply a patient is attached to his or her given therapy. The more they own it, the more they are emotionally committed to it, the more they want the treatment to work and the more they tolerate in terms of side effects.

    Heartburn and flushing can occur with both Niacin and Viagra, and yes the frequency is MUCH higher with niacin, but why have only 50% of my patients tolerated the side effect with Niacin whereas as NO ONE who suffers the side effects with Viagra ever says I won’t take this anymore?

    People can insert their own joke as a punchline.

  50. weingon 18 Aug 2008 at 12:36 pm

    neiltyson,
    “Because if you actually understood the causes and effects of a disease as it interacts with different people, you would then be able to tell each person with precision when he or she will die. But you are not there yet.”

    That is true in physics as well. If you actually understood the laws of physics and how they interact, you would be able to make 2 identical snowflakes. But you are not there yet.

  51. Sagacious Sycophanton 23 Aug 2008 at 12:49 am

    Thank you very much for this post. I think I internalised my mother’s mistrust of doctors without ever realising it. (She shopped around till she found a doctor that wouldn’t chide her for not vaccinating her children etc etc)
    Most of the doctors I’ve seen in my life have been excellent, yet I always feel so nervous when I have to see a new one. And I am relieved and surprised when they are professional, friendly and competent, and have never questioned this reaction.

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