“Luckily, medicine is a practice that ignores the requirements of science in favor of patient care.”

1 Comment

Javier Benitez writes:

This is a paragraph from Kathryn Montgomery’s book, How Doctors Think:

If medicine were practiced as if it were a science, even a probabilistic science, my daughter’s breast cancer might never have been diagnosed in time. At 28, she was quite literally off the charts, far too young, an unlikely patient who might have eluded the attention of anyone reasoning “scientifically” from general principles to her improbable case. Luckily, medicine is a practice that ignores the requirements of science in favor of patient care.

I [Benitez] am not sure I agree with her assessment. I have been doing some reading on history and philosophy of science, there’s not much on philosophy of medicine, and this is a tough question to answer, at least for me.

I would think that science, done right, should help, not hinder, the cause of cancer decision making. (Incidentally, the relevant science here would necessarily be probabilistic, so I wouldn’t speak of “even” a probabilistic science as if it were worth considering any deterministic science of cancer diagnosis.)

So how to think about the above quote? I have a few directions, in no particular order:

1. Good science should help, but bad science could hurt. It’s possible that there’s enough bad published work in the field of cancer diagnosis that a savvy doctor is better off ignoring a lot of it, performing his or her own meta-analysis, as it were, partially pooling the noisy and biased findings toward some more reasonable theory-based model.

2. I haven’t read the book where this quote comes from, but the natural question is, How did the doctor diagnose the cancer in that case? Presumably the information used by the doctor could be folded into a scientific diagnostic procedure.

3. There’s also the much-discussed cost-benefit angle. Early diagnosis can save lives but it can also has costs in dollars and health when there is misdiagnosis.

To the extend that I have a synthesis of all these ideas, it’s through the familiar idea of anomalies. Science (that is, probability theory plus data plus models of data plus empirical review and feedback) is supposed to be the optimal way to make decisions under uncertainty. So if doctors have a better way of doing it, this suggests that the science they’re using is incomplete, and they should be able to do better.

The idea here is to think of the “science” of cancer diagnosis not as a static body of facts or even as a method of inquiry, but as a continuously-developing network of conjectures and models and data.

To put it another way, it can make sense to “ignore the requirements of science.” And when you make that decision, you should explain why you’re doing it—what information you have that moves you away from what would be the “science-based” decision.

Benitez adds some more background:

As I’m sure you already know, what and how science is practiced means different things to different people. Although pretty significant this is just one quote from her book:) I may be wrong but I think she is a literary scholar interested in epistemology of medicine. Here’s a few links to give you more context on the book:

  1. This book argues that medicine is not itself a science but rather an interpretive practice that relies on clinical reasoning.
  2. She makes it clear that medicine is not a science, but a science-using practice with a collection of well-honed skills involving a special familiarity with death.
  3. Here Montgomery shows, with example after example, just why we should see medicine, not so much as a science but rather as situational reasoning serving a practical end; an endeavour based upon, but distinct from, medical science
  4. She suggests that “science is a tool, rather than the soul of medicine” and that medicine “is neither a science nor an art. It is a distinctive, practical endeavor whose particular way of knowing . . . qualifies it to be that impossible thing, a science of individuals”.
You probably already know we memorize lots of facts, get very little training in statistics and philosophy, so asking a doctor if the practice of medicine is a science is a challenging question. I also think it’s a very important question and addressing it would benefit the field.

This all raises interesting questions. I agree that it would be a mistake to call medicine a science. As is often the case, I like the Wikipedia definition (“Science is a systematic enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the universe”). Medicine uses a lot of science, and there is a science of medicine (the systematic study of what is done in medicine and what are the outcomes of medical decisions), but the practice of medicine proceeds case by case.

It’s similar with the practice of education, or for that matter the practice of scientific research, or the practice of nursing, or the practice of truck driving, or any job: it uses science, and it can be the subject of scientific inquiry, but it is not itself a science.

The post “Luckily, medicine is a practice that ignores the requirements of science in favor of patient care.” appeared first on Statistical Modeling, Causal Inference, and Social Science.

Read the whole story
ProbablyWrong
2 days ago
reply
There is scientific medicine, and there is non-scientific medicine.

The limits of scientific medicine include: the limits of data, research, access to data and research, etc.

Medical practitioners cannot stop practicing when they reach the boundaries of science and venture into non-scientific medicine.

But the virtue of the practice of non-scientific medicine is a virtue of necessity, and a hope that a mind rigorously trained on scientific principles continues to follow those principles when formal knowledge is insufficient for the problem at hand.

Share this story
Delete

Being President Is Hard

1 Comment

For the time being President Trump is having a hard time governing so far, having accomplished very little so far except pulling down his own popularity.  For now he is assuaging his fans by say “I inherited a mess”, but even his fans will only buy this excuse for so long. He promised to do things, and even if things are “a mess” he’ll have to deliver eventually with some actual things. One possible result of this would be a very healthy development: Trump tells convinces his fans that being President and governing in general are hard to do. 

There is a myth on both the left and right that I think is very unhealthy: the only thing stopping the country from being a lot better in a variety of ways is crooked and ineffective politicians. This is a popular view among Trump voters as well as Bernie voters. If only we can get someone in who is not a crooked politician, then we’ll finally get the great policies and outcomes we deserve.

Unfortunately, the reality is a lot messier than this. Crooked and bureaucratic politicians aren’t what’s stopping manufacturing jobs or the rust belt from being saved. Watching Trump struggle to make any headway on passing tax reform that favors domestic production is the first piece of evidence. It’s hard to say what side of the border tax debate would even be the one “corrupt politicians” would support. Figuring out what the economic effects of the border tax will be is generating a lot of debate among experts, and whether it would be WTO compliant is another issue. Then you have to wonder whether other countries will retaliate. Then of course there is the issue of this being far from sufficient to bring back many manufacturing jobs. When it comes to saving the rust belt and manufacturers, corrupt politicians are the low on the list of problems here.

Crooked politicians beholden to industry donations aren’t the only thing standing between Bernie fans and single-payer: the health insurance industry employs 350,000 workers. In contrast, there are only like 50,000 coal jobs and there were 80,000 back in 2010. Those very few coal jobs being lost are creating a lot of noise, how would it look if 350,000 health insurance jobs went away? And remember how far Obama had to go out of his way to promise everyone who likes their healthcare could keep it? So to get single payer you have to deal with all the people who don’t want to lose their health insurance, all the workers who don’t want to lose their jobs, and all the taxpayers who are going to face a higher tax bill. “Crooked politicians” don’t even make the list of the top 10 biggest things standing in the way of single payer.

Being President is hard. Governing is hard. Coalition building is hard. Legislating is hard. Many good policies are unpopular, and even popular policies will often harm lots of people who will get very loud, upset, and oppositional about it. Trump is going to figure this out, and hopefully he will tell his fans.

 

 

Read the whole story
ProbablyWrong
2 days ago
reply
"the health insurance industry employs 350,000 workers. In contrast, there are only like 50,000 coal jobs and there were 80,000 back in 2010. Those very few coal jobs being lost are creating a lot of noise, how would it look if 350,000 health insurance jobs went away?"

As one of those 350k, I support single payer, knowing it will cost me my job. Checking my privilege, however, I can expect a softer landing than typical coal miner.

But that is also why I am happy to pay taxes that fund the safety net.
Share this story
Delete

Save the frogs !

1 Share

Amphibian survival can be a natural biomarker for subtle environmental changes.  A poster promoting a frog exhibit at the Vancouver Aquarium reminds everyone why frogs are important.
Read the whole story
ProbablyWrong
2 days ago
reply
Share this story
Delete

NY Times Concern Trolls with False-Equivalency Piece about Liberal "Identity Politics" Driving Moderate Republicans to Trump: Twitter Responds

1 Share


The New York Times today published one of its false-equivalency, concern-trolling pieces (it's linked above by Ian Milhiser) about how liberals, with their "identity politics," are ostensibly driving mythic moderate Republicans into the arms of Donald Trump. Twitter is having none of it. Twitter is eating the concern trolling alive. Here's a string of tweets in response to the Times piece:



























Read the whole story
ProbablyWrong
2 days ago
reply
Share this story
Delete

New York Post thinks Beyoncé should cover up and Adele shut up. They are so wrong.

1 Share

screen-shot-2017-02-19-at-4-06-23-pm

 

An Op-Ed in the New York Post has lots to say about the motherhood on display at the Grammys. The author criticizes Beyoncé for her “tush-wiggling” and “pagan fertility worship” and finds Adele’s words about her struggles with motherhood “self indulgent.” I think the take home message from the column is supposed to be if you are so famous that everyone knows you by your first name keep your belly at home because no one should see that shit except your husband (apparently the NY Post parenting style guide is very 1950s) and if you have money talking about your health is a bore. Oh, and both Adele and Beyoncé are “fetishizing” motherhood and damaging feminism. Or something.

I have some thoughts that I would like to share.

 

I will admit my bias up front. I do not believe in miracles, I know when something unexplained happens science has simply not caught up to offer a biologically plausible explanation. Even if I believed in miracles I would never believe that pregnancy is one because we wouldn’t have stillborns or amniotic fluid embolisms and women wouldn’t be beaten for having a third girl or for the inconvenience of not wanting to have sex at 36 weeks.

 

As an OB/GYN I know that thousands upon thousands of women die from pregnancy in third world countries. That they walk, sometimes for days, with ruptured membranes to seek care only to die from sepsis on arrival. The lucky ones survive with fistulas. I also know that thousands of women worldwide die from illegal abortion. Some die wanting to be mothers and others die because they don’t want to be mothers. It all seems very non miraculous to me.

 

Pregnancy was not a miracle for me personally either, it was the result of an expensive medical intervention that erroneously produced triplets. One son died at birth and my surviving two were born extremely prematurely and 13 years later one still suffers serious ramifications of prematurity.

 

However, none of my medical education, years of delivering babies, my belief system about miracles, knowing how maternity care or safe abortion is not available to hundreds of thousands of women, or my personal bad experience with pregnancy makes me want to judge Beyoncé or Adele and the idea that they are “fetishizing” motherhood is idiotic.

 

If someone believes their pregnancy or labor was or is a miracle, who am I to judge? It is pretty cool to have a human come out of your body. If someone wants to believe they are a Goddess because they are pregnant or have that belief inform their art or their baby shower how does that hurt me? If someone thinks their IVF pregnancy was a miracle, then for them it was. Some people think that rain is a miracle or that being in love is a miracle or that Jesus performed a miracle for turning water into wine. It’s all good. Maybe their definition of miracle is different than mine or maybe they believe a Spirit or Mother Earth intervened. As long as we are not making health care policy based on a personal belief system of miracles then I’m cool. Believe away.

 

If Beyoncé wants to celebrate and express art with her body, that’s great. I would never expect her to stop because of her pregnancy. Should pregnant celebrities wear tents and only be seen from the neck up or from behind bags of groceries like in 1960s television? If so maybe the New York Post should be writing about Lawrence Welk and I Love Lucy reruns and not the Grammys.

 

Goddess stuff usually goes over my head so what I got from Beyoncé’s performance was how strong and confident someone can be during pregnancy and thank goodness that chair didn’t fall. But that’s the thing about art, it means different things to different people. Naomi Schaefer Riley of the New York Post seems to have forgotten that art can also makes people uncomfortable. On purpose.

 

When I heard Adele talking about the struggles of motherhood I didn’t hear privilege, I heard a woman saying motherhood was hard for her and I guess that makes me think if it could be hard for someone who seems to have so much then it might help someone else feel okay about their own struggles. I just hosted an evening with the author Ayelet Waldman who wrote A Really Good Day, a very personal account of her struggles with her mood disorder. I saw an audience full of people who felt less broken because someone who looks like she has it all dared to say she was suffering. Knowing you are not alone is some of the most powerful medicine. I suspect some people might call it miraculous.

 

Still dismissive of celebrities? One of the most helpful things in my life came from Nicole Kidman. I am not being trite. I had recently delivered and had the ashes of one son in a jar and the other two were struggling to live and I heard her speak about the pain of her divorce from Tom Cruise on a talk show. She spoke about how her father said to her, “It is what it is. It’s not what it was meant to be, but it is what it is.” An Op-Ed writer might sneer and think a rich, stunningly attractive movie star’s pain was self indulgent, after all what could she know of a “real person’s” pain? I am not lying when I say Nicole Kidman’s words changed my life. It was as if a light switch were flipped and all of a sudden I was able to reframe everything. I went from the depths of depression to I’ve-fucking-got-this. Some might even call the change miraculous. If I ever meet Nicole Kidman I will probably burst into tears that is how much she helped me. If Adele’s words had that impact for just one women then someone might be right to call the change for that woman miraculous.

 

If you choose to believe your pregnancy is a miracle, that’s cool. If you want to believe you are a Goddess for having kids, that’s cool too. If you are Jane Doe and you want your pregnancy to be a theatrical event, well, it’s your pregnancy. In fact, if you want to be a Goddess whether you have a uterus or not doesn’t matter. The only requirement to be a Goddess is the belief that you are one.

 

Some people want to celebrate their reproduction and others don’t. They may celebrate it in ways I can’t understand, but choice is choice is choice you know?

 

If a woman wants to display her body whether she is pregnant or not is irrelevant. A pregnant Beyoncé performing in a sexy gold outfit does not disrespect any single woman’s pregnancy experience nor detract from the work it takes to be a mother or father and if Adele talking about her struggles bothers you and you can’t see how it might help someone then empathy and the human experience aren’t your strong suit.

 

 

 

 






Read the whole story
ProbablyWrong
2 days ago
reply
Share this story
Delete

Portrait of a Personality Disorder, Part 3: Cognitive Distortions in Cluster B Personalities

1 Share
We all distort things in our heads.  If you're honest with yourself, you know you do.  We all have distorted memories of relationships and disagreements.  We all have distorted ideas about ourselves.  We all have distorted ideas about other people and other people's motives.

But here's the thing . . .  Some people distort more frequently and to a greater degree than others.  Some people cannot or do not acknowledge their distortions and do not even seem aware they might be distorting.  Like all disorders, Cluster B personality disorders are identified, not by unique traits or behaviors, but the frequency, severity and impact of certain traits and behaviors.  The cognitive distortions seen in Cluster B personalities have a direct impact on how an individual relates to other people.

Human relationships are, by and large, reciprocal phenomena.  There is give and take.  And, there is a feedback loop.  I say something nice to you, you say something nice to me, and we both feel good.  Or, I say something mean to you, you return the favor, and we both feel bad.


With Cluster B personalities, the feedback loop is broken.  The short circuit is a defense mechanism in which the individual unconsciously or semi-consciously edits their awareness of their own behavior in such a way to protect their perception of themselves.  The result is an individual who sees themselves as always the victim (as in Borderline Personality) or always the better person (as in Narcissistic Personality).  Perception of other people are not anchored in objective observation, but instead are wildly changeable based on how the other person makes the personality disordered individual feel at any given time.

Lucy's distorted perception of the same interaction?
Lucy of Peanuts provides us a nice illustration of the principle of distortion and the effect it has on relationships.  Now, how about we look at a real life example, say, a recent example?  Here is an excerpt from Thursday's presidential news conference:
QUESTION: . . . You said that the leaks are real, but the news is fake. I guess I don't understand. It seems that there's a disconnect there. If the information coming from those leaks is real, then how can the stories be fake? 
TRUMP: The reporting is fake. Look, look . . .And I'll tell you what else I see. I see tone. You know the word "tone." The tone is such hatred. I'm really not a bad person, by the way. No, but the tone is such -- I do get good ratings, you have to admit that -- the tone is such hatred. . . .But the tone, Jim. If you look -- the hatred. The, I mean, sometimes -- sometimes somebody gets...Well, you look at your show that goes on at 10 o'clock in the evening. You just take a look at that show. That is a constant hit. The panel is almost always exclusive anti-Trump. The good news is he doesn't have good ratings. But the panel is almost exclusive anti-Trump. And the hatred and venom coming from his mouth; the hatred coming from other people on your network. . . I -- I think you would do much better by being different. But you just take a look. Take a look at some of your shows in the morning and the evening. If a guest comes out and says something positive about me, it's -- it's brutal. . . .Tomorrow, they will say, "Donald Trump rants and raves at the press." I'm not ranting and raving. I'm just telling you. You know, you're dishonest people. But -- but I'm not ranting and raving. I love this. I'm having a good time doing it.But tomorrow, the headlines are going to be, "Donald Trump rants and raves." I'm not ranting and raving.Go ahead. . . . 
QUESTION: Just because of the attack of fake news and attacking our network, I just want to ask you, sir... 
TRUMP: I'm changing it from fake news, though. 
QUESTION: Doesn't that under... 
TRUMP: Very fake news. 
QUESTION: ... I know, but aren't you...(LAUGHTER) 
TRUMP: Go ahead. 
QUESTION: Real news, Mr. President, real news.. . . But aren't you -- aren't you concerned, sir, that you are undermining the people's faith in the First Amendment, freedom of the press, the press in this country, when you call stories you don't like "fake news"? Why not just say it's a story I don't like. 
TRUMP: I do that. 
QUESTION: When you call it "fake news," you're undermining confidence in our news media (inaudible) important. 
TRUMP: No, no. I do that. Here's the thing. OK. I understand what you're -- and you're right about that, except this. See, I know when I should get good and when I should get bad. And sometimes I'll say, "Wow, that's going to be a great story." And I'll get killed.I know what's good and bad. I'd be a pretty good reporter, not as good as you. But I know what's good. I know what's bad. And when they change it and make it really bad, something that should be positive -- sometimes something that should be very positive, they'll make OK. They'll even make it negative.. . . as an example, you're CNN, I mean it's story after story after story is bad. I won. I won.
Here, like Lucy, we have an individual who sees himself as a victim and simultaneously, better than, a clear sign of a narcissist (more on that later). And, like Lucy, he is seemingly oblivious to his part in any negative behavior or bad outcome. You can see the distortions all serve to bolster, not just the image of the man, but more specifically, his self-image.

This is a clear and beautiful example of a neurotic process expressed publicly and recorded by worldwide news outlets.  It is less an argument, than the man's internal process, expressed outwardly, for he is not attempting to convince his audience of his greatness and their badness, so much as his argumentation serves to reinforce his internal beliefs.  By stating his distortions externally, they become more real for him internally.

And, this is exactly what is so challenging about relating to and attempting to have a reason-based conversation with someone with a Cluster B personality type.  There is no real give and take.  The disordered individual is simply having an argument with himself or herself, and, while you may be the target, you cannot meaningfully take part in the manner you are used to if you are expecting a reciprocal give-and-take relationship.
Read the whole story
ProbablyWrong
3 days ago
reply
Share this story
Delete
Next Page of Stories