What’s Wrong, What’s Right?

In a New York Times op-ed piece on the healthcare legislation, The Fight Is Over, the Myths Remain, Brendan Nyhan states:

Studies have shown that people tend to seek out information that is consistent with their views; think of liberal fans of MSNBC and conservative devotees of Fox News. Liberals and conservatives also tend to process the information that they receive with a bias toward their pre-existing opinions, accepting claims that are consistent with their point of view and rejecting those that are not. As a result, information that contradicts their prior attitudes or beliefs is often disregarded, especially if those beliefs are strongly held.

Nyhan addresses the curious tendency we humans have to regard opinion as factual information—in his example, popular myths about the content of the recently passed healthcare bill, now signed into law.  In short, it all comes down to preconceived personal perspective.  Here the old axiom about drawing your curve and then plotting your points is apropos.  We tend to view the world through tinted lenses, all the while assuming that we are the only ones who see objectively.

I was intrigued to read about the former medical student Michael Burry who turned his economic insights into a popular financial blog.  Impressed with his knowledge, Wall Street gurus began to take regular notice of his predictions.  Indeed, many of the financial companies he endorsed turned out to be winners in the market.  Everyone, it seemed, was on the same financial page, until Burry noticed a disturbing trend.  Solid institutions that went on to fail shared one thing in common:  all had invested heavily in subprime mortgage securities.  Eventually, Burry convinced Wall Street to issue credit default swaps through which he bet against the popular tide—and subsequently won big.

This scenario demonstrates Nyhan’s premise:  when faced with the same set of factual data, observers generate wildly different interpretations.  As a consequence of acting on the basis of these observations, the risks are enormous:  you could win big (like Burry), or you could lose big as well.

Which brings me to the role of science in contemporary society.  Just how objective a discipline is science?  When confronted with the same set of facts, how is it that scientists formulate theories with markedly different import?

Global warming:  true or false?

Health care reform:  good or bad?

Wall Street reform:  desirable or undesirable?

In his new book Wrong, science journalist David H. Freedman wonders why scientific pronouncements often turn out to be misleading, exaggerated or entirely off the mark.  Part of the problem, he opines, is that many times scientists are forced to rely upon surrogate measurements, because they cannot get at the things they need to measure directly.  Thus, they have to make inferences from suboptimal data.

Economists, for example, rely on economic indicators extracted from bits of data to identify trends and forecast the economic outlook. Unfortunately, most research papers published in economic journals don’t conclusively prove anything one way or the other.  Freedman wonders:  “If tests of the exact same idea routinely generate differing, even opposite, results, then what are we supposed to believe?”

Freedman highlights the work of Dr. John Ioannidis, an M.D. with an undergraduate degree in mathematics, originally published in JAMA (John P.A. Ioannidis, “Contradicted and Initially Stronger Effects in Highly Cited Clinical Research,” Journal of the American Medical Association Vol. 294, No. 2 (2005): 218-28).

According to Ioannidis, “most medical treatment simply isn’t backed up by good, quantitative evidence.”

The whole point of carrying out a study is to rigorously examine a question using tools and techniques that would yield solid data, allowing a careful and conclusive analysis that would replace the conjecture, assumptions, and sloppy assessments that had preceded it. The data are supposed to be the path to truth. And yet these studies, and most types of studies Ioannidis looked at, were far more often than not driving to wrong answers.

Ioannidis felt he was confronting a mystery that spoke to the very foundation of medical wisdom. How can the research community claim to know what it’s doing, and to be making significant progress, if it can’t bring out studies in its top journals that correctly prove anything, or lead to better patient care?

The largest source of wrongness in scientific studies is publication bias.  Prestigious medical journals eagerly publish studies that demonstrate novel or unanticipated results.  Witness Andrew Wakefield’s bogus study published in the Lancet that purported to link the administration of the MMR vaccine to autism.  This problem is compounded further by the mainstream media, which is only too quick to disseminate such conclusions to the public at large.  Such misperceptions have a tendency to persist for years.

In his classic treatise on The Structure of Scientific Revolutions, Thomas Kuhn argued that “professionalization” leads to “an immense restriction of the scientist’s vision and to a considerable resistance to paradigm change.” He opines that scientists become captives to a paradigm “like the typical character of Orwell’s 1984, the victim of a history rewritten by the powers that be.”

Perhaps scientists themselves possess their own set of preconceived notions, which in turn dictate how they interpret the data they measure.  I suppose that it all depends on which side of the emotional aisle you happen to take your seat.

As Mr. Nyhan writes: “People seem to argue so vehemently against the corrective information that they end up strengthening the misperception in their own minds.”

Web and Flow

On the morning of the day prior to departing for Atlanta, where I was scheduled to give a formal presentation about a pig and a spider, I rolled out of bed early—it was my Saturday to cover the office.

While toweling off after my shower, I noticed a grey spider descending from the light above the bathroom sink. Her spinnerets formed a nearly invisible silken thread as she dropped down to hang motionless before the mirror. Shortly, she retreated up to the light and selected another point from which to begin a new descent. This time she dropped down to the shelf below the mirror and crawled behind my toothbrush. Gingerly, I nudged it to the side to reveal the spider resting by a tiny puddle of water.

She measured a centimeter in length, double that if you included her front legs. I could see the array of her black eyes and mouth-parts moving as she drank from the miniature pool.

I exited the bathroom to dress, and when I returned I found that the spider had struck out in a new direction, cantering across the wall to the shower stall, where she tucked herself in behind the aluminum molding.

Here is E.B. White’s description of Charlotte in Charlotte’s Web: “Stretched across the upper part of the doorway was a big spiderweb, and hanging from the top of the web, head down, was a large grey spider. She was about the size of a gumdrop.”

I’ve seen plenty of spiders around our place, but never a solid grey one like this one in the bathroom. Uncanny!

With the exception of a minor glitch in the sound system (thankfully, there was a savvy tech in the room to remedy the situation), the presentation at the Georgia World Conference Center in Atlanta, What Charlotte’s Web Can Teach Us about Caring for Critically Ill Children, came off well.

When I arrived at the lecture room 10 minutes before we were scheduled to start, I counted 8 tables with 10 chairs at each table, and no one to fill them. I needn’t have worried—within minutes the hall was packed to standing room only. One group actually huddled on foot at the back for small group discussion over the entire two hours. (I found out afterwards that we hosted 125 attendees.)

I told a story as part of the introduction, then proceeded to show the video clips from Charlotte’s Web, pausing intermittently for discussion and feedback.

Several folks gave us two thumbs up afterwards. One fellow who works in interventional cardiology asked me if I might be able to give the same presentation at the institution where he works—Children’s Hospital in Dallas.

I also met a fellow who, after he learned who I was, told me that he’s read every column I’ve written for the past two years. Now what are the odds of that happening?

When I returned home, after I unpacked my bag and stowed my paraphernalia in the proper places, I retired to the bathroom. As I stood outside the shower, reaching in to test the water temperature with one hand, once again I glimpsed the grey spider. She descended from the storage shelf by a single silken thread, hanging motionless for a moment in the air, before continuing down to light upon a purple plastic box lying on the floor.

I bent down to have a closer look and studied her carefully. I was certain she was the same spider that I had seen that day before departing for Atlanta. The color and body size were identical, right down to her tiny facial features. Then there was the fact that she inhabited the same small room as before.

But what clinched it for me was when she said, “So tell me: how did the presentation go?”

Humane Medicine — House calls, Homebodies

In my student days, I trained at an urban health clinic. Although we saw the gamut of general medical ailments, my most invaluable lessons came when the doctor and I ventured out into the local community to make house calls.

Interested readers can now access my latest Humane Medicine column, House calls, homebodies: Remembering that you came, recently published in the Journal of the American Academy of Physician Assistants.

The light within

People are like stained-glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.

                                                     — Elisabeth Kubler-Ross

 “Would you mind if I brought a friend along to our Saturday breakfast?” my friend Al asked.  “I’ll be chauffeuring him up to Vermont afterwards that morning.”

“Fine with me,” I said.  I recognized the name—someone I had met previously but didn’t know well.

Our guest ambled into the restaurant with a cane.  A big man, he sported a neatly trimmed white beard and moustache.  We had selected one of the large booths to accommodate everyone.  Our guest inched down along the padded bench until he settled directly opposite me.

He had bright blue eyes and a strong voice.  He stowed his cane on the seat and shook hands all round.

The waitress poured the coffee and took our orders.  We made small talk until the plates of food arrived.

Our guest told us he was born on Long Island three months before the 1938 hurricane.  “They never forgave me for it,” he chuckled.

“Who?” I asked him.

“The city of New York.  They figured the storm was all my fault.  We moved south shortly after that.  Then on to Michigan’s upper peninsula.  At that time the houses were built with a front porch on each story.  With an average annual snowfall of 25 feet, local residents would sit out on the lower porch in summer and the upper one in winter.”

“A story for each season,” I mused.

“Yes,” he laughed.  “Eventually, we ended up on the west coast.  I call San Francisco my home.  That’s where I fell in love with sailing.”

“I used to do some sailing myself,” I told him.  “Up in Boston, when I was stationed on a Coast Guard cutter.”

“A Coastie, yes?  I served in the auxiliary for years myself.”

“What did you do for a living?” I asked.

“Worked as a newspaper reporter on the San Francisco Call-Bulletin for a number of years before I matriculated in theology school.  Went to British Honduras for a spell; later got into prison ministry at the federal penitentiary in Tallahassee, Florida.”

He knew the folk music groups from the 60s:  Peter, Paul and Mary; the Kingston Trio; the New Christy Minstrels.  “That’s where John Denver got his start, you know,” he said.  “Of course, his name wasn’t ‘Denver’ back then—some long Polish name, never could pronounce it.”

Somehow the subject of Kubler-Ross’ stages of death and dying came up.  I told him that I had just returned from Atlanta, where I gave a presentation on caring for terminally ill children.

“I worked with Kubler-Ross when she was doing some studies on terminally ill children at Dallas Children’s Hospital,” he said.  “Some of her research was quite insightful:  doll play and creative art.  One kid drew a bird with a broken wing.  Another drew a bright yellow butterfly—I remember that one vividly.  Big, bright yellow.  He died shortly after that.”

We sat in silence for a moment.  An entire era flashed through my mind: the hurricane of 1938, the snows in upper Michigan, sailing on San Francisco bay, the civil rights movement, the Vietnam war and Woodstock, a boat in Belize, the Tallahassee penitentiary, death and dying in Dallas—somehow all coming together over a Saturday morning breakfast of bacon, eggs and homefries.

He was a big man with a white beard and moustache.  If you looked carefully at his bright blue eyes, you could sense the light shining from within.

An Evening of Promise

It was a little bit mixed sort of block, fairly solidly lower middle class, with one or two juts apiece on either side of that. The houses corresponded: middle-sized gracefully fretted wood houses built in the late nineties and early nineteen hundreds, with small front and side and more spacious back yards, and trees in the yards, and porches….Supper was at six and was over by half past. There was still daylight, shining softly and with a tarnish, like the lining of a shell; and the carbon lamps lifted at the corners were on in the light, and the locusts were started, and the fire flies were out, and a few frogs were flopping in the dewy grass, by the time the fathers and the children came out….And yet it is habitual to summer nights, and is of the great order of noises, like the noises of the sea and of the blood her precocious grandchild, which your realize you are hearing only when you catch yourself listening.   —James Agee in Knoxville: Summer 1915

Yesterday’s rains have driven the humidity away. After a day of clear blue skies, the coolness of the evening beckons me from the house. I won’t last forever, this weather whispers in the wind. After supper, spontaneously, I respond to the quiet invitation.

From the overhead wire along our street a sparrow pipes his courtship song. The dog strains at her leash, plowing her miniature muzzle through the cool grass. The evening sun bathes her white fur orange. For one brief moment she stands like a small fierce lioness on the savannah, sampling the air.

A bluejay screams from his perch in the oak that stands at the upper corner of the graveyard. The lavender asters have been felled by the workmen’s mowers. All the grass is now neatly trimmed at the base of the headstones.

We walk our traditional loop down the hill to the end of the cul-de-sac and back. The dog pauses periodically to sample each invisible odor with her nose. Off to the left the trunks of the maples glow in the sunlight as the wind rustles the leaves on their high branches.

Back at the top of the hill deep within a forsythia bush a catbird rehearses a scenario of bars she will never succeed in blending into a final symphony. Still she persists in her attempts to perfect each string of notes unrelated to the last.

The lawns on our street have been clipped, as close to manicures as any New England yard will ever get. As we ascend the driveway, I notice the yellow primroses have bowed their heads for vespers.

All is in readiness. Five days more, with the ripening of the strawberries, the granddaughter will arrive.

Memorial Day, 2010

At the northwest corner of the food court inside Atlanta’s CNN center, a small bronze plaque attests to the valor of First Lieutenant Gary C. Jones, United States Army, killed in action in the Republic of Vietnam, February 9, 1968. According to the inscription, Lieutenant Jones was awarded the Distinguished Service Cross posthumously.

At the base of the wall these words are carved in stone:

“To those who fight for it, Life has a flavor the protected never know.”

I had taken a plane to Atlanta over the Memorial Day weekend to attend a professional conference. As I waited in the departure lounge at the airport near my home, I noticed a number of military personnel sauntering down the concourse. They were dressed in camouflage Army fatigues and combat boots. All of them carried massive packs on their shoulders. Several walked hand in hand with significant others: wives or girlfriends, I supposed.

One military couple ambled more slowly than the rest. The man carried a small boy in his arms. Periodically, he would lift the child high into the air, then pretend to drop him down without letting go. The boy giggled in delight at each of these maneuvers. As they approached the gate, I could see that the boy, who looked to be about a year and a half old, was dressed in pajamas bearing colorful prints of lions, giraffes and bears. The mother walked along close by her husband’s shoulder.

They stood beside a bank of chairs. The mother offered the little boy some whipped cream from her coffee on the end of a drinking straw. He accepted it gladly, opening his mouth in anticipation of another treat.

Finally it was time to say goodbye. The couple hugged each other holding the boy between them. When the woman pulled away, I could see her red-rimmed eyes. She reached out for the boy, he fell easily into her arms, and she proceeded to walk back down the long corridor with the boy looking at his father over her shoulder. The man watched them go, and I watched the man watching them. Finally he turned away, seemingly unable to maintain his composure.

Later at the Atlanta airport, I saw this same man huddled with his comrades-at-arms, studying an electronic flight status board. Two commercial pilots strode by in uniform carrying overnight bags in their hands. As they passed by the servicemen, one of the pilots reached up to touch the brim of his own hat and said, “God bless you fellows in your service.” The soldiers looked at them and grunted an unintelligible reply.

On the wall at the northwest corner of Atlanta’s CNN building near the plaque commemorating the personal sacrifice of LT Gary C. Jones, a wooden frame houses these words:

“War drew us from our homeland in the sunlit springtime of our youth. Those who did not come back remain in perpetual springtime—forever young—and a part of them is with us always.”

“Notes from a Healer” — Mindless Medicine

Many times good doctoring entails more than just prescribing another pill.

My latest installment of Notes from a HealerMindless Medicine — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.