May 25 2012

Understanding Evolution and Being a Good Doctor

I need to dip into the topic suggestions more often. Here is a good recent question:

Hi Dr. Novella,

Over at Why Evolution is True Jerry Coyne wrote about Ben Carson, the creationists doctor at Johns Hopkins, saying some bizarre stuff about evolution. In the comments a couple people have made the point that they don’t think understanding evolution is directly relevant to being a doctor (especially a surgeon, ENT, or oncologists). One commenter even said he thought oncologists “have precisely and exactly zero need to understand evolutionary theory.”

I tried to argue that understanding the foundational principle of biology was directly relevant to physicians, in a variety of areas. I am very interesting in your views on the subject. Does understanding evolution help a doctor be better as her/his job? Is understanding evolution going above and beyond as a doctor, or something that should be expected of physicians?

Here’s the link to the main comment I had in mind (#30) and a couple responses, including mine:
http://whyevolutionistrue.wordpress.com/2012/05/16/creationist-sugeon-to-give-commencement-address-at-emory-university/#comment-219290

Thanks!

In my opinion there are two basic questions here: how relevant is evolution to the science of medicine, and how does understanding the science of medicine impact the practice of medicine?

Evolution in Medicine

The topic of evolution in medicine has been discussed many times before, mainly the context of a creationist challenge to the relevance of evolutionary principles in medicine. Their argument is that evolution is of no practical use, because it’s wrong. Legitimate science, they argue, always has a practical use. While I think there is a kernel of legitimacy to this premise – that valid science has utility – it is not always true and it is not a litmus test for legitimate science. There does not need to be an immediate practical application of dark matter, for example, in order to consider the evidence for dark matter compelling. A claim, however, that has an obvious practical application, like ESP, does raise skepticism when it cannot be used for the purpose to which it is so obviously suited (if it existed). Creationists, therefore, are misapplying this notion, or perhaps overapplying it. Evolution can be completely true without having direct application to the science of medicine.

Their other premise, however – that evolution is of no practical use to medicine, is also false. (Here is a website dedicated to the issue.) Evolutionary principles are important in understanding antibiotic resistance, genetic illness, and the natural history and response of cancers to treatment, to name the most obvious examples. It is also critical to understanding any animal model of biology or human disease. A great deal of the basic science on which science-based-medicine depends requires an evolutionary perspective in order to interpret it properly.

The creationist claim, therefore, is based upon two false premises.

Evolution and the Practice of Medicine

The second question is whether or not an individual doctor needs to understand evolutionary principles in order to be a competent physician. This is really part of a broader question – do doctors need to understand scientific principles in order to be a competent physician?  I think the answer is yes, but with a significant caveat.

Within medicine there is a standard of care that is developed by the medical community, but mostly driven by the recognized experts in their field synthesizing available evidence and experience. For the average physician in private practice, in order to be minimally competent they need to understand clinical decision-making and the current standard of care as it applies to their specialty. For procedure-based specialties, like surgeons, they also need to be technically competent. None of this requires an understanding of the science behind medicine.

Physicians who practice in this manner are essentially behaving like technicians, not scientists. They have the requisite fund of knowledge and know what practices are required in given situations. The more procedure-based a practice is, the more a physician can get away with this level of practice, as their technical skills comprise a larger portion of their daily practice.

However, while I think you can get to a level of minimal competence practicing in this fashion (cook-book style, following standards of care without necessarily understanding how they came about), this level of practice results in a mediocre clinician. This is because it is essential to understand scientific principles in order to be a fully functional clinician. Again I will break this down into two areas.

The first reason that understanding the science of medicine is important to the practice of medicine is making sense of the science itself. While there are many practice guidelines and published standards available, they are not comprehensive, and cannot account for every unique patient situation. Further, science is always rapidly changing and practice guidelines take time to put together so there is always a lag. Practitioners therefore often have to rely upon their reading of the latest published evidence.

It is also not uncommon for there to be controversies within the standard of care. You may remember the controversy that arose over the new guidelines for screening mammography in women. Different groups disagreed on what those guidelines should be. There was recently a similar controversy over the use of PSA in screening for prostate cancer. There are also emerging therapies, like the liberation procedure for alleged CCSVI in multiple sclerosis. The MS community claims that CCSVI and its treatment are far fetched and not legitimate, but there is a vocal minority claiming significant results and demanding research. What should a physician say when asked about this procedure by their patient?

It is increasingly common, in fact, for patients to ask their physicians to help them make sense of the scientific evidence with regard to a specific disease or treatment. There may not be a published guideline available, or the evidence may all be preliminary and ambiguous. There are also increasingly treatments that are on the fringe of science, and some that are outright fraudulent, and a good clinicians needs to be able to navigate all this scientific complexity with and for their patients.

The second reason that understanding scientific principles is helpful to being a good clinician is that they are directly applicable to clinical decision making. Understanding the nature of placebo effects, confirmation bias, the limitations of human memory, and other cognitive biases is critical to making sense of a patient’s history, their diagnosis, and their response to treatment. Each interaction with a patient is a mini-scientific investigation, and thinking scientifically (and skeptically) is critical to doing that well.

Understanding evolution is therefore important to clinical practice to the same degree that it is important to the science of medicine, as I briefly outlined above.

The final question is this – what implication does being a creationist have on the ability to think scientifically in general. I have serious concerns about the scientific literacy of anyone who can deny the science of evolution. On the other hand, however, people do have the ability to compartmentalize. It is reasonable to argue that denial of evolution requires a certain lack of critical thinking skills and/or factual information about biology and the evidence for evolution, but people seem to be able to function scientifically in one area, but then function completely irrationally in another area that has special ideological significance. They may not even see the conflict between the two, or they find some way to rationalize them away.

Conclusion

In summary, I think that the science of evolution has very clear implications for the science of medicine. The ability to think critically and scientifically is very important to being a competent clinician. However, individuals can get by following published standards and compartmentalizing their personal unscientific beliefs.

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51 responses so far

51 Responses to “Understanding Evolution and Being a Good Doctor”

  1. bluedevilRAon 25 May 2012 at 9:47 am

    One trend that I find particularly disturbing is that among young doctors and medical students (young people as a whole, even) there is a tendency to dismiss the scientific consensus because of a mistrust of the scientific process. The joke that people often make is “you can find a study to support anything.” Okay, fine. But being able to interpret those studies and weigh them appropriately is where med students and physicians really need help.

    I watched a talk by Paul Offit recently and he said that recently trained med students and physicians are less likely than their older colleagues to understand the importance of vaccines. He attributes it to the fact that most of the young docs/students have never seen a lot of these diseases. I do not doubt that is true, but I think it extends beyond that. I would like to see a study that investigates med students and residents’ beliefs regarding vaccines. How many get vaccinated, how many recommend vaccines to their families, friends and patients, how safe are vaccines, do vaccines cause autism, etc. I am curious but also afraid about what the results might show.

  2. mlegoweron 25 May 2012 at 10:03 am

    “Physicians who practice in this manner are essentially behaving like technicians, not scientists. They have the requisite fund of knowledge and know what practices are required in given situations. The more procedure-based a practice is, the more a physician can get away with this level of practice, as their technical skills comprise a larger portion of their daily practice.

    However, while I think you can get to a level of minimal competence practicing in this fashion (cook-book style, following standards of care without necessarily understanding how they came about), this level of practice results in a mediocre clinician.”

    This got me thinking about something I occasionally turn over in my head in regards to health care expenditures and the health care economy in general. I have always felt that there is a market for intensely specialized medical technicians, who can rely mainly on technical training to diagnose and treat one particular thing— say a broken bone— and who don’t require the length of training or education or degree of licensure than a medical doctor currently requires. Obviously, there will always be a need for fully trained physicians. But the more of these primarily technical procedures can be performed by what are essentially very skilled technicians (instead of highly educated scientists), the more it would bring down the costs of those procedures by introducing more competition, right? While I agree that this would likely lead to “mediocre clinician[s]“, it seems to me that there are cases where mediocrity would suffice, and would be substantially cheaper.

  3. daedalus2uon 25 May 2012 at 11:07 am

    mlegower, the problem is that highly specialized training does not give one the expertise to understand when one is beyond their expertise.

    I am reminded of a story that a clinician in the UK told of a man who was having a dissection of the aorta (not sure if I am getting the term right). The clinician called the ambulance service and told them to get the man to the emergency room ASAP. The ambulance driver had been trained to treat heart attack victims a certain way (and this was not it), so he stopped along the way and did the diagnostic protocol he had been trained to do. The man died because he didn’t get to the hospital quickly enough where what he did have could be managed.

  4. Bronze Dogon 25 May 2012 at 11:19 am

    But the more of these primarily technical procedures can be performed by what are essentially very skilled technicians (instead of highly educated scientists), the more it would bring down the costs of those procedures by introducing more competition, right? While I agree that this would likely lead to “mediocre clinician[s]“, it seems to me that there are cases where mediocrity would suffice, and would be substantially cheaper.

    I agree to some extent. There are plenty of relatively mundane ailments and routine procedures that don’t require much skill, but I have some worry that some proportion of seemingly simple cases might have some hidden abnormality you’d need a skilled doctor to notice.

    One thing that immediately comes to mind is that I’ve heard some really nasty diseases described as having “flu-like symptoms” as the first sign of infection. I’d hate to find out that someone didn’t get proper help in time because he caught one of those and only got flu treatment because a technician-type didn’t recognize it. Hoof beats usually signal horses, but you need a good doctor to identify the occasional zebra.

  5. mlegoweron 25 May 2012 at 11:29 am

    daedalus-

    Sure, I can see that: when all you have is a hammer, everything looks like a nail. But the question is— and this may be a callous approach, but forgive me— is success in these cases worth the additional expense? Or put another way, how far do we take the precautionary principle approach? I don’t know the answer, because it involves knowing how common these types of errors would be as well as how much we could expect costs to go down if this type of system were implemented. Obviously if many lives would be lost due to insufficient expertise by these technicians and the cost savings would be in the millions, then it’s probably not worth it. But if only a handful of lives would be lost due to technician error, and the cost savings would be billions of dollars… At what point do the benefits outweigh the costs?

    This isn’t a totally apt analogy, but sometimes you have a flat tire, you are relatively certain you have a flat tire, and all you want is someone to confirm that and change your tire. Or your oil filter needs to be changed, you are relatively certain your oil filter needs to be changed, and all you want is someone to confirm that and change your oil filter. You don’t want to have to pay a highly skilled mechanic for their time just to do that, which is why Jiffy Lube exists. Even if the guy at Jiffy Lube might miss a transmission problem, you would rather pay the $30 and be screwed the 1 time in 100 you end up missing a big problem than pay $100 every time and be sure you catch it.

  6. nybgruson 25 May 2012 at 12:17 pm

    mlegower:

    I would actually argue that at a certain point, which is not as nicely positioned as we’d like, the cost savings and outcomes trends would reverse drastically.

    The problem is that you need someone to manage them. It has been shown that mid level practitioners does lower costs of care and improve outcomes. But these are always physician/mid-level teams. And that all makes sense.

    But I would argue that training mid-level style practioners to be primary caregivers is a recipe for disaster as well as having too low of a physician:mid-level ratio. I think there is room for additional mid-level practioners and I think it is a great model when implemented properly. But to have, as you suggest, purely mechanic type physicians who are skilled at (say) only doing knee replacements or a few surgeries would be counter productive. Someone still needs to make the decision when (and when not) to do surgery and manage the patient afterwards. That cannot be done by mechanics, IMO.

    Furthermore, a properly trained physician can grow and adapt to changing guidelines, new techniques and technologies, new drugs, etc with minimal difficulty. A specifically trained mechanic physician would need significantly more re-training to stay up to date and viable since the basic understanding of why things are done is lacking. Dr. Novella pointed this out in his post above, and we can see it in doctors we currently consider mediocre or “bad” (and even old codgers who refuse to take on new data and keep thinking the “old way” is still good enough).

  7. daedalus2uon 25 May 2012 at 12:40 pm

    If you want to improve health care from a public health perspective and lower costs from a public health perspective, using technicians with a reduced degree of training and skill is not how I would approach it. I think it would be a lousy way to try and improve care. I don’t think it would improve care, and I don’t think it would save much (if any) money.

    The major cost in health care is insurance company administration and profit. Eliminate that and costs go down ~20% across the board. More because insurance companies add to the administrative costs of health care providers.

    Diverting patients to low skill practitioners first would be something insurance companies would like because it is another impediment to receiving care, it is another hurdle patients have to jump over, another excuse to deny payment.

  8. SARAon 25 May 2012 at 1:35 pm

    Surely the nurse practitioner and the physician asst represent the mid level. In some cases they represent specialized tech as well.

    If you wish to cut down the cost of training an MD, you could modify the process and skip the prerequisite of 4 year under grad and add in the necessary science courses in medical school. I imagine that would cut 2 years out of the process.

  9. mnestison 25 May 2012 at 1:56 pm

    I think Steve’s differentiation regarding technicians and scientists is an important one. In neuroscience thinking and conceptualizing about the brain and how it has adapted over time to different environmental demands has greatly enriched how we’ve come to think. This can be seen in recent work with the cerebellum and basal ganglia, as we are now understanding and thinking about cognition as extensions and outgrowths of older motor systems. The cerebellum in humans for example contains a much larger posterior hemisphere that we are finding has implications for cognition; we knew it modulated and refined motor control and lesions resulted in ataxic symptoms for example, but we’re finding that certain posterior lesions might also modulate certain aects of cognition too – some patients with cerebellar lesions expeierience almost a type of emotional dysmetria for example. Getting a bit tangential – I’m trying to type this on a tablet – but the point is that thinking in terms of how bodily systems were built to adapt has huge implications in furthering our understanding going forward no matter what system we’re talking about.

  10. Rayon 25 May 2012 at 2:27 pm

    Very nice explanation. Thanks Steve! I was a creationist until after I completed a residency and I agree that believing nonsense produces thought patterns that easily give rise to believing, and possibly practicing, more nonsense. For example, in my experience a lot of CAM people are creationists. Just my experience – no studies. As an anesthesiology resident I was competent (despite what some of my former attendings might say :) ) but lacked exactly what Steve addressed above. When I came out of the creationist fog, a lot of things in science and medicine made sense and IMO I became a better physician in general and specialist.
    Regarding the second theme here, CRNAs can adequately handle many if not most routine cases in the OR, especially with a anesthesiologist available. Again this is based on my experience – no studies. It is also my understanding that an anesthesia team consisting of CRNAs along with an anesthesiologist can offer quality care for reduced cost. This seems to be true in principle at least if not always in practice.
    A final caveat. The two most talented surgeons I ever worked with were technicians pure and simple. Their were dangerous when they actually tried to practice medicine. But in the OR, I would gladly have them as my surgeon. IMO, there is a place for MDs that are actually technicians.

  11. mlegoweron 25 May 2012 at 2:51 pm

    I did not mean to take over the comments with the economics question. While I do think it’s an interesting topic, it is sort of a digression from the main point of Steve’s article.

    It seems obvious to me that evolutionary science is important to medical science, and insofar as knowing the science is important to medical practice, it would seem important to medical practice as well.

  12. Wholly Fatheron 25 May 2012 at 3:18 pm

    I knew people in medical school who were very good at remembering facts. They used mneumonics, and all sorts of tricks to memorize vast quantities of information. Those sorts of people may do very well on multiple choice type tests, but are not necessarily good problem solvers.

    Good problem solvers are people who can apply principles across various specific facts. Understanding the anatomy, physiology, and pathology of the liver is much more useful than being able to recite a list dubiously dozens of things that can cause jaundice. If one understands the principles, one can generate the same list logically, but the converse is not true.

    The most important unifying principle that underlies all of biology, and therefore all of medicine is evolution. I am not saying that someone who does not believe in evolution cannot be a good doctor. I am sure there are many who are. But, by disregarding evolution, their toolbox lacks one of the most useful tools for weaving otherwise disparate pieces of information into a coherent understanding of medicine.

  13. _rand15_on 25 May 2012 at 7:46 pm

    It’s interesting to turn the issue around and ask if there were any good doctors before the theory of evolution was published or at least widely available. True, the state of medical knowledge was much less than now. But if we could find a way to determine that some given doctor from back then was indeed a good doctor, this would argue against the need to understand or accept evolution as a prerequisite. Ignaz Philipp Semmelweis, perhaps?

  14. daedalus2uon 25 May 2012 at 8:35 pm

    randl5, I don’t think there were any good doctors before evolution. There might have been healers, who could help people via placebo effect and maybe there were some treatments that were effective through trial and error. Wounds had to be bound up but pre-evolution was also pre-germ theory.

    An analogy that I think is appropriate is that the theory of evolution is to medicine what calculus is to physics. You can sort-of do physics if you memorize equations that someone else has derived and understands, but you are not really doing physics unless you understand the derivations.
    .
    If you don’t understand evolution, then medicine is just magic tricks. You give this pill and people get better.

    Wholly Father is correct. There is only one scientific schema that biology and hence medicine fits into. If you understand how it is put together, you can interpolate and extrapolate in ways you can’t if it is just a collection of facts.

    It is like the saying that science is built from facts but is no more a pile of facts than a house is a pile of stones.

  15. Rikki-Tikki-Tavion 25 May 2012 at 8:53 pm

    From a German perspective, and this may also be true for America, I see the problem with young doctors mostly with their GPA requirements.

    In my experience, people with near-perfect GPAs are often very bad problem solvers. I have two theories why that would be, if it is in deed true:
    a) Solving problems requires creativity, which is in some ways the opposite of ability to concentrate. School asks almost exclusively for concentration and not creativity.
    b) People at a certain level of intelligence quickly think they understand things well, because they don’t see the whole depth. Smarter people wonder about apparent contradictions in incomplete knowledge and waste time to resolve them, that could be used to gather a shallow understanding of more topics. Such a shallow understanding is all one needs to ace test papers.

    Your thoughts?

  16. BillyJoe7on 26 May 2012 at 1:18 am

    Politicians in Australia love de-skilling the workforce. It’s much cheaper on the public purse. Doctor’s work gets done by nurses, nurse’s work gets done by nurse assistants, and nurse assistant’s work gets done by anyone who wants to do it. However, it doesn’t work in the long run. In time, nurses demand pay equality with doctors and nurse assistants demand pay equality with nurses and alll they end up with is an overpaid, underskilled workforce.

  17. ccbowerson 26 May 2012 at 9:41 am

    “In my experience, people with near-perfect GPAs are often very bad problem solvers.”

    Rikki- I doubt that this is true, but I do think that grades only weakly correlate with ability to problem solve. I think that your conclusion is due to this weak correlation being somewhat surprising.

    The ability to do well in terms of GPA and ability to problem solve are 2 different, but somewhat related, things. GPA requires some baseline aptitude, but is largely a product of effort on the part of the student to remember facts for examinations. Effort is usually the more important factor since students have already been selected by an admissions process which should narrow the range of aptitudes to some degree. In many cases a high GPA can be obtained by memorizing facts for examinations. Good problem solving requires a broader understanding of the interrelatedness of those facts, but still require a high level of knowledge. A person with a high GPA may or may not have put some effort into learning the interrelatedness of the memorized facts

  18. ccbowerson 26 May 2012 at 10:05 am

    Although I understand that many people have a remarkable ability to compartmentalize, I do not think I could stay with a physician that was an evolution denier. That would be sufficient evidence for me that the physician was incapable of thinking clearly (at least in some circumstances), and lacked certain critical thinking skills.

  19. _rand15_on 26 May 2012 at 10:16 am

    @daedalus2u:
    “Wounds had to be bound up but pre-evolution was also pre-germ theory.”

    There are many different kinds of understanding. Semmelweis made his discovery before Darwin published his work on evolution, for example. And the rise of knowledge of the existance and role of germs in disease was separate from understanding of evolution.

    “An analogy that I think is appropriate is that the theory of evolution is to medicine what calculus is to physics. You can sort-of do physics if you memorize equations that someone else has derived and understands, but you are not really doing physics unless you understand the derivations.”

    You think that Galileo didn’t understand physics? Or Kepler (who somehow developed a marvelous intuitive understanding of orbital forces and numbers while at the same time having a completely bogus metaphysics)? Or Boyle (of Boyle’s law)?

    “If you don’t understand evolution, then medicine is just magic tricks. You give this pill and people get better.”

    It’s not that much different today, really. Penicillin, do you think that Fleming knew anything about the evolution of the gunk in his petri dishes when he realized he had something special? Many if not most medications work for reasons that are not well understood or verified.

    “There is only one scientific schema that biology and hence medicine fits into. If you understand how it is put together, you can interpolate and extrapolate in ways you can’t if it is just a collection of facts. ”

    If a skilled clinician has a good understanding of human biology, and a good intuition about human health and disease, I claim that that person has a great foundation for being a good doctor, evolutionary knowledge or no. I think that some *researchers* need a deeper understanding, but here we’re talking about doctors and medical care.

    What both doctors and researchers should have is a good understanding of scientific ways of thinking (as Steve has written), but that has nothing to do with evolution per se.

  20. nybgruson 26 May 2012 at 10:20 am

    I agree with daedalus – there was no such thing as a “good doctor” prior to evolutionary theory (i.e. pre-Darwin). Not by any metric that would make a useful comparison to answer the question anyways.

    Also, I fully agree that understanding science and the method and applications of it are extremely useful. I have colleagues who will undoubtedly be highly trained mechanics. Simple unifying concepts – which often do hinge on basic premises of evolutionary theory – are unknown to them. Thus, they toil endlessly memorizing factoid after (seemingly unrelated) factoid. I spend significantly less time studying than they do (and even have time to haunt the commentaries of this blog as well as SBM) and consistently receive significantly higher marks than they do on school assessment and on the USMLE. One of my undergrad degrees was in evolutionary biology. And I also did not memorize physics formulas (save a few of the very basic ones like the force of friction equation) – re-derived them every exam (and was always amongst the first finished and I once got an A- because I was not quite so strong in acoustics). I also did not memorize organic chemistry reactions – I learned the principles behind them. Which is why the professor pulled me aside once and commented that out of a class of almost 400 I was one of 8 that got a particular question right – he had made a question where it appeared to fit the standard reaction pattern but changed a couple of subtle parameters which made the outcome completely different. Those who had just rote memorized the various classic reactions missed the question with the same wrong answer.

    The point is that many of my colleagues, and many doctors in existence today, will become highly trained mechanics. The danger though is that they don’t realize that they are just highly trained mechanics – they feel as if this extremely arduous and expensive education has given them the analytical skill and understanding of a scientist. And thence you get the Oz’s and Weil’s and Guarnieri’s of the medical world.

    Yes, not just knowing but actively understanding evolutionary theory is both directly and indirectly useful for generating a highly skilled and competent physician. I can give many more specific examples, but the broad overview – as you may imagine – is that it primarily lays in the molecular world. The cellular interactions with each other as well as with drugs, the changes that happen in certain disease states and why, and how to reverse or otherwise alter them fundamentally lays in understanding the interconnectedness of protein families and signalling cascades. This is indeed evolution leading the way and showing us that life is really a poorly slapped together patchwork of what works rather than the elegant design creationists love to think it is. The miracle of life is truly that we haven’t fallen apart at the seams ;-)

  21. nybgruson 26 May 2012 at 10:26 am

    @ccbowers:

    Although I understand that many people have a remarkable ability to compartmentalize, I do not think I could stay with a physician that was an evolution denier. That would be sufficient evidence for me that the physician was incapable of thinking clearly (at least in some circumstances), and lacked certain critical thinking skills.

    I agree. I’ve argued this many times before and many often miss the point – if someone can compartmentalize like that then it is invariably because of ideology, because of deeply held belief (aka faith). If they can do that for something like evolution where they are so obviously wrong, especially in a field where a basic understanding of the necessary principles is indeed necessary, then one simply cannot predict where another strongly held belief will arise that allows them to contradict reality. It may be in something important to you.

  22. nybgruson 26 May 2012 at 10:57 am

    @rand:

    There are many different kinds of understanding.

    aka “different ways of knowing.” This is incorrect and a logical fallacy.

    Semmelweiss also was not the originator of germ theory. He was the one that originated hand washing (sort of – his story is typically quite romanticized) but not germ theory itself. His observations are indeed part of what spurred further interest, but it was primarily Pasteur credited with it. His work was from 1860-64. It was later Koch that established the postulates for determining if the germ caused the disease in 1890. And of course John Snow and the pump handle of 1854 round out the big players of germ theory. But we can see the progression of Semmelweiss/Snow to Pasteur/Koch was one of demonstrating that something was contagious and causing disease, to that “something” likely being germs, to a way of establishing it was indeed germs causing it.

    You think that Galileo didn’t understand physics?

    No. Not the way we do now. He laid a solid foundation by making astute observations. But the Maya also tracked celestial movement and made extremely precise predictions based on that. But if you limit yourself to understanding physics without calculus, then you are indeed very limited to understanding big things on small scales. Galileo with all his knowledge would never have been able to build a jetliner, for example. Your attempts here are almost straw men. The understanding is a continuum with occasional small leaps (in evolution we would call that punctuated equilibrium). So yes, the maximum Galileo would have been able to understand physics is signifcantly less than say, myself, or most definitely daedalus.

    Or Kepler (who somehow developed a marvelous intuitive understanding of orbital forces and numbers while at the same time having a completely bogus metaphysics)?

    That is an example of the compartmentalization that ccbowers was speaking of and not relevant to the discussion at hand.

    It’s not that much different today, really.

    Yes, it is. And where it isn’t is where you find the ability for woo like Reiki, acupuncture, and homeopathy to exist.

    Penicillin, do you think that Fleming knew anything about the evolution of the gunk in his petri dishes when he realized he had something special?

    No, of course not. He observed a phenomenon. Do you think that if we had not understood the principles of evolution we would have been able to design the dozen plus succesors to penicillin to be able to thwart the bacterial resistance?

    As daedalus said – if you just go with the basic memorization of the Sandford guide then it is hardly more than magic pills to you. You will not be able to understand when to apply a different tack since all you have are a set of rigid guidelines with no way to be able to deduce when and how to alter them to a new situation.

    Many if not most medications work for reasons that are not well understood or verified

    This is incorrect. Most medications have a complete or mostly complete mechanism. But the fact that many do not – yet – does not mean that you can eschew an understanding of evolution and still be a highly competent physician. There is a mechanism and how it works undoubtedly lays in some foundational principle of our evolution.

    If a skilled clinician has a good understanding of human biology,

    You cannot have a good understanding of human biology without a good understanding of evolutionary principles. That is the point we have been trying to make. Otherwise you are learning a bunch of facts which consist of seemingly random strings of letters without understanding the interconnectdness of it. That is an understanding of biology, but certainly not a good one.

    and a good intuition about human health and disease

    Intuition is always a bad way to go. That is why we use science to guide our understanding and decisions.

    I claim that that person has a great foundation for being a good doctor, evolutionary knowledge or no.

    I unequivocally refute your claim. As I said above you need an understanding of evolution to have the good understanding of biology you yourself claim is necessary. Beyond that, using evolution as a foundational point of understanding will allow you to learn and understand much more than you ever possibly could just memorizing facts. And of course, “intuition” has repeatedly proved itself a very bad way to try and do science, but also specifically medicine as well.

    We could argue whether you could be a good enough doctor without evolutionary knowledge. I would still say no, since you would only be good enough in simple and easy cases and the outliers and strange cases coming your way you would completely flub. It would comprise a small percentage of your total practice however since, as we know, common things are common. But relying on getting all the “easy ones” right and flubbing all the “hard ones” does not a good doctor make.

    What both doctors and researchers should have is a good understanding of scientific ways of thinking (as Steve has written), but that has nothing to do with evolution per se.

    It does, as you cannot have a solid grasp of the biology and physiology without utilizing evolution as a starting point to organize the necessary knowedge in your head.

  23. PhysiPhileon 26 May 2012 at 10:58 am

    “I do not doubt that is true, but I think it extends beyond that. I would like to see a study that investigates med students and residents’ beliefs regarding vaccines. How many get vaccinated, how many recommend vaccines to their families, friends and patients, how safe are vaccines, do vaccines cause autism, etc. I am curious but also afraid about what the results might show.”

    I’m guessing it would have good results. I’m in medical school smack in the middle of the bible belt (only Oklahoma MD program). Professors crack jokes about antivaxers, and we are taught about the benefits and the dangerous reactions associated with certain vaccines.

    I went into medical school because I was interested in medical science and Steve got me interested in neurology. So I came with a very anti-CAM/anti-antivaxer/anti-woo mind set and I’m definitely still really believe in all those things but when I causally bring it into conversations with classmates there responses seem to be underwhelmed.

    I think that being in the skeptical movement has made me hypersensitive to topics like this one -so I apply stronger relationships between pseudoscience or something that isn’t scientifically based with some other factor. The relationship between a physician and their knowledge of evolution just doesn’t seem to be that strong. Can someone provide an example of how a physician can have the medical knowledge of diagnosis/treatment but do to there lack of understanding of evolution, they provide bad treatment?

  24. ccbowerson 26 May 2012 at 11:34 am

    “Can someone provide an example of how a physician can have the medical knowledge of diagnosis/treatment but do to there lack of understanding of evolution, they provide bad treatment?”

    This has already been discussed to some degree in regards to it being a reflection of (a lack of) critical thinking skills, but in addition- it shows a combination of (unwarranted) intellectual hubris and (at least some) disregard for science in general when the science conflicts with an ideological commitment.

    If a physician can disregard something like evolution, which has overwhelming evidence from many distinct areas of science, how will that physician approach areas of medicine? No area of medicine has the evidence that evolution does, so if that physician disagrees with certain guidelines/standard of care what is to stop him/her from disregarding the evidence in that case?

  25. ccbowerson 26 May 2012 at 11:41 am

    Woops. Now that I reread the “do [sic] to there lack of understanding of evolution.”

    The things that I wrote really don’t apply to a mere lack of understanding, which could be a more passive thing (e.g. accept evolution as a valid theory, but have a limited understanding). Is this what you meant?

  26. nybgruson 26 May 2012 at 12:39 pm

    I think that is what physi was going for (the latter post ccbowers).

    I have been thinking about it and I think that a direct and accurate answer to his question would be “very few if any.”

    The reason being that if there is a confirmed diagnosis and an established best treatment protocol, then you are done. But if that’s what medicine was, then we could have monkey and iPhones doing medicine.

    The direct and active understanding of evolution is necessary to be able to understand the principles of why that diagnosis is correct and the treatment is what it is. Without that understanding, you would not be able to adequately apply that knowledge of diagnosis and treatment to a patient that doesn’t exactly fit the study parameters. In other words it would be truly cookbook medicine.

    Quite frankly in many cases simple mechanic style cookbook medicine is good enough. Smart enough people have figured out enough to reduce the complexity down to “Tests A+B = Diagnosis D = Treatment E” for the vast majority of cases. Hence the utility of mid-level providers.

    The easiest example to most directly answer physi’s question however is oncology and infectious disease. If you don’t actively utilize and think of the evolutionary principles involved you may get the answer right initially but be unable to change your tack as the tumor/bacteria evolve.

    I agree that detailed knowledge of epigenetics and proteomic interactions of genetic expression are rarely used directly in clinical care – that is more of a research and cutting edge care sort of thing. But having a basic understanding of the simple foundational principles of evolution indeed do come into play regularly when making antibiotic choices or even chemotherapeutic choices.

    And, as I argued above, you can’t begin to have the solid foundation of knowledge to be a great doctor without employing evolutionary principles in your understanding of the basic sciences portion of medical school.

  27. JLTon 26 May 2012 at 2:14 pm

    Isn’t it so that e.g. chemotherapeutical treatment of cancers is designed to minimise the risk of “making” the cancer resistant (by killing of the susceptible cancer cells, leaving the potentially resistant cells)? This isn’t my field and it’s been a few years back, but I remember reading an article that discussed different strategies (which are basically build on evolutionary theory) to achieve that.

    The search for a vaccine for HIV involves evolutionary theory. There’s been a very recent article that described that HIV inside one patient can be much more diverse than the originally infecting HIV particles between different patients, indicating that there are constraints to what elements of the virus genome can mutate while staying infectious – this might aid in the development of vaccines. To built evolutionary trees of HIV could help identifying those elements.

    To understand the immune system an understanding of basic principles of evolution is important. E.g. the whole mess of antigen receptor generation in lymphocytes (i.e. our immune cells) makes only sense if you understand basic principles of evolution. Our immune system can react to a whole lot of antigens (e.g. pathogens) even if it has never “seen” it before, even completely new ones. This is possible because during the maturation of lymphocytes the receptor genes are rearranged. Each lymphocyte gets a random set of gene segments, knit together by a few more random bits, so that each lymphocyte gets a unique receptor. This is the only way our immune system can work in a world were the pathogens constantly evolve and change. If we had only a static set of receptors, we would have almost no defense against a whole lot of pathogens that would evade detection through mutation.
    But this comes with a price – some of these newly assembled receptors will recognise parts of ourself as the “enemy”, so each maturing lymphocyte goes through a process that removes these self-reacting cells (called clonal deletion). This is equivalent to negative selection. If this process fails, autoimmunity is the result.
    If a mature T cell detects an antigen, it starts proliferating, making more T cells with the same receptor; if it doesn’t detect anything, the T cell dies after a while – this is positive selection.

    This part of the immune system (cell-based) is the evolutionary younger part of our immunity, the older part is the so-called innate immunity. Understanding that the cellular part came later helps in understanding some more intricacies of our immune system. And understanding the immune system is important to develop effective treatments for a whole range of illnesses, e.g. autoimmune diseases and cancers (which are at least in part the result of a failure of the immune system to clear mutated cells).

    Understanding the genetic diversity in humans that is a result of our evolutionary history can also be of importance for medicine. E.g. people with African ancestry are much more genetically diverse than say people of European or Asian ancestry. A lot of drug testing/clinical trials are done with mainly Caucasians. These might result in treatments that are safe for the majority of Caucasians but not safe for some people with African heritage because they have gene variants or combinations of gene variants that just don’t exist in Caucasians.

    Sorry for the long, jargon-filled rant. I hope at least some of you can make some sense of it.

  28. ccbowerson 26 May 2012 at 2:20 pm

    “The easiest example to most directly answer physi’s question however is oncology and infectious disease”

    Yeah, I guess the obvious example is treating an infection. If choosing an antibiotic for an infection, you should not choose one that was just prescribed a few weeks ago. In addition to it being a sign that the organism may not have been suceptible to that antibiotic to begin with (in cases of treatment failure with no suceptibilities), the use of that particular antibiotic is also a selective pressure which can increase the likelihood that the infection (even if new) is being caused by organisms with increased resistance to that antibiotic.

    In all honesty, it doesn’t take much understanding of evolution to figure that one out, but that mistake is surpringly still done too often

  29. daedalus2uon 26 May 2012 at 2:24 pm

    Someone cannot have good intuition about biology or medicine unless they allow their intuition to change based on new data.

    If someone allows their intuition or fact based knowledge to change based on new data, they would accept evolution as the unifying structure of biology and medicine.

    You really can’t be a good science based practitioner of anything, unless your dominant ideology is that you accept fact based ideas and change those ideas as new facts are developed.

  30. nybgruson 26 May 2012 at 3:18 pm

    JLT made some goods points as well regarding the utility of evolution in medicine.

    I suppose (perhaps?) an apt anology would be a car mechanic at a Jiffy Lube vs a mechanical engineer at Ford. I’d be willing to bet that the Ford engineer would be able to fix a wider range auto problems much more efficiently and effectively than the Jiffy Lube mechanic. Yet, in most day-to-day cases Jiffy Lube is all you need and Steve over at Jiffy Lube will do a fantastic job.

    I see the difference between a physician who weaves evolutionary understanding (and the principles behind that understanding) into learning and practicing medicine and one who doesn’t even consider it at all to be analagous. And obviously the creationist physician is a whole different – and worse – kettle of fish.

  31. nybgruson 26 May 2012 at 3:22 pm

    In all honesty, it doesn’t take much understanding of evolution to figure that one out, but that mistake is surpringly still done too often

    I agree. And that is why I find it funny because creationist physicians still employ evolutionary principles in their medical practice without admitting or realizing that they are doing so for that very reason.

    I suppose I would have to say though that the majority of utility in understanding evolution in medicine is to aid in learning it in the first place and to offer a basis for reality checks in interpreting the literature, rather than directly in daily patient care. Obviously some fields of medicine would be more heavily reliant (genetics, oncology, infectious disease) than others (surgery, family practice, interventional radiology). And some (internal medicine) would rest in the middle. IMHO, anyways.

  32. Ericon 26 May 2012 at 3:28 pm

    I am a physician (MD) and a scientist (PhD) and so I’ve been able to witness what each field thinks of the other first hand. Unfortunately, physicians are in a large part NOT scientists. I’m constantly amazed at how many people confuse a doctor (physician) for a doctor (scientist). Yes, they use science. Yes, they try to understand the scientific method. And yes, some publish in peer reviewed journals. But, no, they do not have to use the scientific method when treating patients — even if they understand science, it isn’t always a help in treating actual living, breathing patients. Medicine is based largely on tradition, teaching, and (lastly) on science.

    For many, if not most, diseases and illnesses, it would be unethical, malpractice, and far too costly to perform a well controlled trial. The vast majority of medical studies are under-powered, overstate the results, or have (usually minor) methodological problems. This doesn’t mean that they aren’t helpful or invalid. It just means that physicians have to on a daily basis balance what they’ve been taught, what they have had work for them in the past, and what the current literature is stating. With four years of medical school, two to seven years of residency, possibly a fellowship, and then many years of practice, teaching and experience is the driving force. Working 40-80 hours a week studying and then taking care of patients, increasing costs of medicine, and rising patient volumes, you learn to do what is best for your patients in an efficient manner. Unless you’re treating something novel or strange (which does happen for most specialities in perhaps 1% of patients), you can base your diagnosis and treatment on what has worked before and what current practice guidelines recommend. It is the novel situations that require actually researching what to do which usually means finding an up-to-date practice guideline, a recent review article, phoning a colleague, or consulting another physician. Of these, consulting another physician is safest for the patient and most timely.

    Practice guidelines that are developed by physicians, scientists, and experts together, are the BEST way to incorporate current scientific information into the clinical practice. Hopefully they use the latest primary literature, the best and most experienced clinicians, and can weigh the different factors including risks, benefits, and alternatives. Unfortunately, these are only available where they would have the most impact — the common or dangerous conditions. The less common the condition or less severe the outcome, the less likely there will be a practice guideline or even published review article.

    As a concrete example, yesterday I saw a patient who was referred from the emergency department for a foreign body sensation in his eye after wood working. Close examination revealed a tick in next to the eye between the two eye lids. How would you remove it? We had one medical student, two residents, and an experienced ophthalmologist all brainstorming how to treat this rare problem. The main two points of concern are that first ALL parts of the tick need to be removed otherwise the immune reaction would not diminish and there could be a need to go to the operating room (yes, for a tick), and second he needed to be tested and/or treated for tick-borne illnesses. How to remove the tick isn’t going to be in any text book, there are no practice guidelines, and there are maybe only one or two review articles on the topic (never-mind that they are behind journal pay-walls). The primary literature are case reports and opinions — not exactly rigorous science. Some advocated taking the patient to the operating room to remove a section of the lid and thus the entire tick. Others recommended using blunt tipped forceps in the office. When there is no good “science” for what is best, you end up being careful and picking the one that is most efficient in terms of resources (time, money, risk).

    I am a firm believer in the value of vaccinations, the fact of evolution, and the existence of dark matter. I would say that any physician worth their salt is a believer in vaccinations — I would probably drop a clinician immediately if they did not since that would indicate a fantasy world on their part. Unless you’re a clinical geneticist or infectious disease specialist, evolution does not have much impact on the daily practice of medicine. Yes, it does impact the emergence of antibiotic-resistant bacteria; but on a single patient scale its unlikely to be relevant. For the antibiotic resistance scenario, clinicians should limit the use of antibiotics to necessary cases not only for resistance concerns but also cost and side-effects; thus, an understanding of selection and evolution is not strictly necessary.

    Evolution is less important to practising medicine. Personally, I’d question the ability of an internal medicine doc who doesn’t believe in evolution. But it wouldn’t matter for a radiologist to be excellent. Just like I don’t care what a model or actor believes about vaccines, it doesn’t matter to me what a radiologist believes about evolution — I’d question their rationality but that doesn’t mean that they couldn’t be an expert radiologist. Finally, I’d love for a physician to have a curiosity about dark matter or quantum tunnelling or nucleogenesis, but those topics that I find interesting aren’t needed for medicine (or most of medical science).

    In summary, there is a continuum for scientific knowledge and literacy, and its a fallacy in my mind to consider all physicians as scientists. A physician (MD/DO) better believe in the benefits of vaccinations. I’d question the rationality and basic science knowledge of any “creationist” physician or “alternative medicine” practitioner. Likewise, a trained scientist (masters or PhD) better believe in evolution or I’d question most that they say.

  33. JLTon 26 May 2012 at 3:48 pm

    “I suppose I would have to say though that the majority of utility in understanding evolution in medicine is to aid in learning it in the first place and to offer a basis for reality checks in interpreting the literature, rather than directly in daily patient care. ”

    In addition to that, understanding evolution is often important for the development of new treatments and directing basic medical research. So your Ford engineer can design completely new cars, while Mr. Steve can only drive them.

  34. Danon 26 May 2012 at 5:08 pm

    Another example of where understanding evolution might be helpful to a physician is in understanding motivation (especially in considering evolutionary explanations over pop psychology). For example, a couple days ago I was driving back from the gym and scanning the radio and heard Dr. Drew on Love Line say that most (or maybe he said many) people who overeat and are very overweight are trying to wall themselves off from the world to deal with psychological problems. Understanding about the environment of evolutionary adaptiveness and why we have such a strong desire for sweet and fatty foods that isn’t optimal in our culture of plentiful junk food could help a physician understand poor diet habits better than relying on Freud and pop psychology (and Dr. Drew is an “addiction specialist” making those assumptions, I’ve heard other physicians make similar claims about diet that don’t even seem to consider environmental mismatch).

    I was a psychology minor in undergrad, and the evolutionary psych class is just about the only psychology class I’ve thought was relevant to my first year in med school. I know that a lot of evolutionary psychology is just-so stories, but at least it is based on evolutionary science, and might at least make a physician skeptical of simplistic understandings of addiction, psychological development, and motivations. It seems to me that at least considering that pathological behaviors might be in part explained by our current environment being a lot different than the environment that a lot of human evolution occurred in is germane to understanding patients.

  35. Danon 26 May 2012 at 5:34 pm

    Oh, and thank you for answering my question Dr. Novella. This blog, the SGU, and Science-based Medicine are a few of the limited non-required things I made time to enjoy during my first year of medical school. Keep up the good work!

  36. tdizzle05on 26 May 2012 at 9:40 pm

    With regards to Steve’s comments about compartmentalization, I’ve seen that happen often with some creationists from other walks of life (for example, with some engineering colleagues of mine). No matter how brilliant their critical thinking is on the job and how much they understand how their field has develop scientifically, as soon as evolution comes up those skills fly out the window. At least in my work environment, if they employed the same fallacious thinking directly to their job they would fail miserably. It boggles my mind how this phenomenon could happen, but I suppose it’s somehow rooted in our psychology to be susceptible to it.

  37. BillyJoe7on 27 May 2012 at 6:14 am

    JLT,

    The response of the immune system to invading organisms that you have outlined is often given as evidence for “adaptive mutation”. I see you have given the “Darwinian” explanation.

  38. sepanjh1@gmail.comon 28 May 2012 at 8:15 am

    I agree that people can compartmentalize quite well in general. Some commenters seem to imply that they would ask a doctor is whether he/she is a creationist before making an appointment. Hmmm… being a skeptic of evolution doesn’t imply not understanding it.

  39. ccbowerson 29 May 2012 at 10:28 am

    “Hmmm… being a skeptic of evolution doesn’t imply not understanding it.”

    It applies either not understanding it or intellectual dishonesty, neither of which I would like in a physician. (I guess both is also an option, but thats not good either) Why would I go to such a physician when there are clear thinking ones out there?

  40. BillyJoe7on 30 May 2012 at 6:17 am

    “Some commenters seem to imply that they would ask a doctor is whether he/she is a creationist before making an appointment. Hmmm… being a skeptic of evolution doesn’t imply not understanding it.”

    But being a creationist does imply not understanding evolution.

  41. daedalus2uon 30 May 2012 at 6:32 am

    sepanjh1@gmail.com, being skeptical of evolution not only implies not understanding evolution it pretty much proves it.

    If someone knows and understands the facts and theory behind evolution, the only reason they could have for remaining skeptical that evolution is the best tentative explanation would be if they had a better one. So where is this explanation that is better than evolution?

    An explanation that is better than evolution would be a guaranteed ticket to Stockholm, if it was correct.

  42. BillyJoe7on 30 May 2012 at 5:24 pm

    daedalus,

    You should always have a sceptical attitude towards everything.
    Did you mean evolution denier?
    (ie climate change sceptics are actually climate change deniers)

  43. daedalus2uon 30 May 2012 at 7:51 pm

    BillyJoe, evolution being the scientific theory which has the most supporting evidence by far, in every field, by many orders of magnitude, someone who tries to boost their “skeptic” cred by claiming to be so skeptical that they are even skeptical of evolution, doesn’t know the meaning of the term “skeptical”.; They are a denier.

  44. Alastair F. Paisleyon 31 May 2012 at 1:34 am

    @ Steven Novella

    > There does not need to be an immediate practical application of dark matter, for example, in order to consider the evidence for dark matter compelling. A claim, however, that has an obvious practical application, like ESP, does raise skepticism when it cannot be used for the purpose to which it is so obviously suited (if it existed). <

    This is just another example where you want to have it both ways: "There does not need to be an immediate practical application for some discipline in order to make it a legitimate science, unless, of course it is parapsychology.”

    There’s experimental evidence for psi phenomena. And parapsychology is recognized as a legitimate science (whether you approve of it or not) by the AAAS (American Association for the Advancement of Science).

  45. bluedevilRAon 31 May 2012 at 11:06 am

    Arguing that because the Parapsychology Association (PA) is a member of the AAAS makes it a legitimate science is not a very good argument. I could just as easily argue that neither the PA nor the Rhine Research Center are scientific organizations due to the fact that Duke University severed all ties with the two organizations in the 1980s. Rather than arguing scientific legitimacy based on an organization’s ties, I think it’s much more relevant to simply say that Rhine’s experiments, while interesting, were never successfully duplicated.

  46. BillyJoe7on 31 May 2012 at 5:25 pm

    daedalus,

    I think we do have a different defintion for sceptic and denier.
    Whilst not denying the evidence no matter howm convincing, I have a sceptical outlook on everything.

  47. BillyJoe7on 31 May 2012 at 5:37 pm

    Alistair,

    Your restatement of Steven Novella’s paragraph is a straw man.

    Parapsychology, by it’s very nature, should have practical application if it were true. There is no evidence, for example, that ESP works, therefore this brings parapsycology into question.
    Dark Matter, by it’s very nature, does not have practical application. However, it would, if it existed, explain why galaxies hold together given their angular momentum, something which does not seem to have any other explanation. Therefore it is worth studying.

  48. PhysiPhileon 01 Jun 2012 at 12:22 pm

    Dan,

    “Understanding about the environment of evolutionary adaptiveness and why we have such a strong desire for sweet and fatty foods that isn’t optimal in our culture of plentiful junk food could help a physician understand poor diet habits better than relying on Freud and pop psychology”

    But understanding why one has a desire, especially if you say it evolved, has little practical value. It’s just a means to memorize facts of biology and not a very efficient one since initialisms like “PPFG – Pathway Produces Fresh Glucose” for the irreversible enzymes in gluconeogensis can accomplish basically the same thing in much shorter amount of time.

    My main point from my post a few days ago was that we skeptics seem to over emphasize the value of understanding certain scientific topics like evolution when from a practical – input vs output – Turing type of way – it’s superfluous for the goal at hand (e.g. diagnosis, treatment)

  49. Danon 02 Jun 2012 at 12:54 am

    I’m confused by your post PhysiPhile, the initialism PPFG has just about nothing to do with understanding motivation or why people overeat. I gave a specific example of Dr. Drew relying on pop psychology to make bad assumptions about overeating and basing his medical advice on those faulty assumptions, presumably because he didn’t consider evolutionary explanations, so I don’t know how you could say understanding motivations has little practical value.

    I think understanding motivations of patients has value much beyond just memorizing basic facts like irreversible enzymes. I’d encourage you to read some articles or books on evolutionary medicine to see why it is valuable to physicians. If you can get Oxford’s Principles of Evolutionary Medicine from your library that would be a good place to start, also I pointed to some other resources in reply to the comment at Why Evolution is True which is linked in my question in Dr. Novella’s post.

  50. PhysiPhileon 02 Jun 2012 at 3:09 am

    “so I don’t know how you could say understanding motivations has little practical value.”

    It’s not the understanding of motivations that I have issues with – its the idea that understanding the evolution of those motivations will someone alter them that I have a problem with.

    Can you give me a theoretical case where an obese patient comes in and you are able to reduce his weight by conferring an understanding of the evolutionary causes of his excessive weight? Seems kinda silly to me. Personally I would just criticize their behavior and not worry them about evolution.

  51. Danon 02 Jun 2012 at 5:42 am

    PhysiPhile, the story of the doctor who just cares about the disease and doesn’t care about why the patient got that way is a straw man that CAM proponents use to criticize real medicine, I’m surprised that you actually seem to back that idea. Just criticizing behavior and sending them on their way isn’t enough for many patients, they need help understanding why they behave that way so they can make useful changes (just look at the research on cognitive-behavioral therapy outcomes).

    I did give you an example of how understanding the evolution of the motivation to overeat is useful in talking to patients. I’ll repeat it again, Dr. Drew is an addiction specialist who is still using pop psychology to explain overeating and basing medical recommendations on that pop psychology. Understanding the evolutionary drive to overeat due to environmental mismatch leads to drastically different treatment recommendations, someone who explains most chronic overeating via pop psychology might try to help people boost their self-esteem or send them to non-scientifically verified forms of talk therapy, while someone who understands environmental mismatch is going to be able to explain why they are having problems and help patients understand why lifestyle and environmental changes are so important. I never said you’d necessarily worry the patient with details of evolution, the whole debate is about whether understanding evolution is useful for doctors. Please take a look at the references I mentioned, I think you’ll change your mind about how important understanding the foundational principle of biology is to being a good doctor.

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