In my recent review of Peter Palmieri’s book Suffer the Children I said I would later try to cover some of the many other important issues he brings up. One of the themes in the book is the process of critical thinking and the various cognitive traps doctors fall into. I will address some of them here. This is not meant to be systematic or comprehensive, but rather a miscellany of things to think about. Some of these overlap.
Everything is attributed to a pet diagnosis. Palmieri gives the example of a colleague of his who thinks everything from septic shock to behavior disorders are due to low levels of HDL, which he treats with high doses of niacin. There is a tendency to widen the criteria so that any collection of symptoms can be seen as evidence of the condition. If the hole is big enough, pegs of any shape will fit through. Some doctors attribute everything to food allergies, depression, environmental sensitivities, hormone imbalances, and other favorite diagnoses. CAM is notorious for claiming to have found the one true cause of all disease (subluxations, an imbalance of qi, etc.).
One of his partners put dozens of infants on Cisapride to treat the spitting up that most normal babies do. Even after the manufacturer sent out a warning letter about babies who had died from irregular heart rhythms, she continued using it. Eventually the drug was recalled.
Another colleague prescribed cholestyramine for every patient with diarrhea: not only ineffective but highly illogical.
When I was an intern on the Internal Medicine rotation, the attending physician noticed one day that every single patient on our service was getting guaifenesin. We thought we had ordered it for valid reasons, but I doubt whether everyone benefited from it. Read more »
*This blog post was originally published at Science-Based Medicine*
Just when I’ve lost hope that mainstream media will stop perpetuating the myth the more medicine equals better care, the Associated Press came up with this excellent piece. The article states, rightly, that “anywhere from one-fifth to nearly one-third of the tests and treatments we get are estimated to be unnecessary,” and that, “it may lead to dangerous side effects.”
Regular readers of this blog should be familiar with those concepts. I wrote recently that patients often reject evidence-based medicine. One reason is that there aren’t enough clinical guidelines available for patients to make an informed decision. Read more »
*This blog post was originally published at KevinMD.com*
An audience member at a recent NYC Skeptics meeting asked me how I handled conflict surrounding strongly held beliefs that are not supported by conclusive evidence. As a dentist, he argued, he often witnessed professionals touting procedure A over procedure B as the “best way” to do X, when in reality there are no controlled clinical trials comparing A and B. “How am I to know what’s right in these circumstances?” He asked.
And this is more-or-less what I said:
The truth is, you probably can’t know which procedure is better. At least, not at this point in history. The beauty of science is that it’s evolving. We are constantly learning more about our bodies and our environment, so that we are getting an ever-clearer degree of resolution on what we see and experience.
It’s like having a blurry camera lens at a farm. At first we can only perceive that there are living things moving around on the other side of the lens – but as we begin to focus the camera, we begin to make out that the animals are in the horse or cattle family. With further focus we might be able to differentiate a horse from a cow… and eventually we’ll be able to tell if the horse has a saddle on it, and maybe one day we’ll be able to see what brand of saddle it is. Each scientific conundrum that we approach is often quite blurry at the onset. People get very invested in their theories of the presence or absence of cows, and whether or not the moving objects could in fact be horses. Others say that those looking through the camera contradict one another too much to be trusted – that they must be offering false ideas or willfully misleading people about the picture they’re describing.
In fact, we just have different degrees of clarity on issues at any given point in time. This is not cause for alarm, nor is it a reason to abandon our cameras. No, it just gives us more reason to continue to review, analyze, and revise our understanding of the picture at hand. We should try not to make more out of photo than we can at a given resolution – and understand that contradicting opinions are more likely to be evidence of insufficient information than a fundamental flaw of the scientific method.
I have noticed that impatient photo-gazers have a propensity to demand answers before accurate ones are available. And this leads to all manner of passionately held, but misguided beliefs both in the scientific community and beyond. We must somehow find a way to make peace with limited information, eagerly seeking more, without being dogmatic about premature conclusions. My dentist colleague should not feel pressured into choosing sides on an issue that cannot be fully evaluated yet – and will have to wrestle with ambivalence as he waits patiently for more data.
But far more worrisome than living with ambivalence is living with stagnation. I would argue that one of the greatest red flags in the scientific world is an unwillingness to learn – an unyielding commitment to a set of beliefs, despite increasing evidence that they are not accurate. I think of homeopathy and acupuncture as good examples of this phenomenon – since they have not evolved significantly since their inception, their proponents therefore must admit that they have learned almost nothing new since the dawn of their use. The lack of refinement of treatment protocol is evidence of the system’s belief-based (or placebo-based) nature. As John Cage, US composer of avant-garde music, once said,
“I can’t understand why people are frightened of new ideas. I’m frightened of the old ones.”
As I mulled over my fuzzy image analogy, an even better one came to mind: the game of 20 questions. For those of you who didn’t play this game growing up, its rules are simple: one person must think of a person, place, or thing and the other(s) have 20 questions that they can ask in order to guess who/what the first person had in mind. The challenge is that the questions have to be asked so that the response is either yes or no. If the questioners can’t devine the name of the person, place or thing within 20 questions, the respondent wins. If the questioners guess the identity of the object within 20 questions they win.
Science is a little bit like 20 questions (of course we have unlimited questions that we can ask) in that we constrain our research to answer a very specific question under a very specific set of circumstances (formulating a “yes” or “no” type question). No one question or answer is likely to unlock the solution to the larger puzzle – it’s the collection of questions, taken in context of one another, that leads to meaningful understanding. When we don’t understand the best path forward, it’s likely that we are early on in the game of 20 questions, with little information to guide us. Occasionally we get lucky and ask the right question early – but more often than not we’re left to scratch our heads and ponder yet another question to help unlock the “mysteries” that face us.
That is the beauty and the pain of science – it’s slow, it’s methodical, it leaves the honest participant in a state of ambivalence with some degree of frequency, but in the end it yields real answers if we wait for the clarity that can come from careful analysis. Without it we are left with magical beliefs and misguided explanations… we’re left with Jenny McCarthyism.
*This blog post was originally published at Science-Based Medicine*
Regular readers of my blog will know that health fraud, misleading product and treatment claims, and deception of vulnerable populations (snake oil for cancer patients, for example) really get under my skin. For this reason, I’ve teamed up with a group of scientists and physicians to create a blog devoted to medical accuracy, transparency, and integrity in health reporting. It’s called Science Based Medicine, and we offer daily exposés of misleading health claims and practices. It’s a great way to learn about how to think critically – and to apply a scientific approach (rather than subjective and anecdotal) to discerning truth from error.
My contribution to the blogging team is to highlight online health fraud, scams, deception and misguided attempts to help consumers “live healthier lives.” I post once a week, every Thursday morning. Please head on over and check it out. It’s a great team of bloggers – and they’re looking out for you!
Here is a list of my recent posts:
A Shruggie Awakening: One Physician’s Journey Toward Scientific Enlightenment
Disintegrating Integrative Medicine: Lessons From Baking
When Further Research Is Not Warranted: The Wisdom of Crowds Fallacy
Knowledge Vs. Expertise: The View From Consumer Land