Marie Curie, Geiger counters and mass hysteria: more in common than meets the eye

What do Marie Curie, a Geiger counter and mass hysteria have in common? Well, to answer this question we need to go Sir Arthur Eddington, who was a British astrophysicist and philosopher of science at the turn of the 20th century. He came up with what is frequently referred to as the Eddington parable, which has nothing to do with the stars specifically and everything to do with how we make scientific progress. Here it is for your reading enjoyment, as told in this editorial (available by subscriptionby Diamond and Kaul, two highly respected clinician-researchers:

Let us suppose that an ichthyologist is exploring the life of the ocean. He casts a net into the water and brings up a fishy assortment. Surveying his catch, he [concludes that no] sea-creature is less than two inches long. An onlooker may object that the generalization is wrong. "There are plenty of sea-creatures under two inches long, only your net is not adapted to catch them." The ichthyologist dismisses this objection contemptuously: "Anything uncatchable by my net is ipso facto outside the scope of ichthyological knowledge, and is not part of the kingdom of fishes which has been defined as the theme of ichthyological knowledge. In short, what my net can't catch isn't fish”.

Suppose that a more tactful onlooker makes a rather different suggestion: "I realize that you are right in refusing our friend's hypothesis of uncatchable fish, which cannot be verified by any tests you and I would consider valid. By keeping to your own method of study, you have reached a generalization of the highest importance—to fishmongers, who would not be interested in generalizations about uncatchable fish. Since these generalizations are so important, I would like to help you. You arrived at your generalization in the traditional way by examining the fish. May I point out that you could have arrived more easily at the same generalization by examining the net and the method of using it?"

So,you see my point? Tools determine knowledge. Period.

  

In praise of not knowing

Recently I had the occasion to tell my 10-year old an old secret: until I was into my forties, I had a strong belief that the rest of the people in the world knew something I did not know. I don't mean just about stuff I do not know, but about everything! It was unnerving, anxiety-provoking and self-defeating. Until one day I had the epiphany that most humans feel this way, not just me. So, be humbled by not knowing and move on.

Yet even more recently this line of self-examination has led me to the conclusion that I end up saying "I don't know" a lot. I read a definitive tweet from someone I respect, and I say to myself "I don't know"; I read a new paper in a journal and say, "Gee, I don't know", I hear a political speech, and I walk away saying, "I just don't know." Is it that I am an idiot, or intellectually lazy? Perhaps. But what is occurring to me more and more lately is that what we are convinced of today will be much less certain and obvious tomorrow, barring some truly sacred cows. This is called growth, and as far as I can tell is a desirable development.

On the other hand, saying "I don't know" sometimes means that it just does not make sense to take sides. I know that we have to apply current knowledge and not wait for perfect information, but I still do not see getting all polar about stuff. Most of the time we act like there are only two possibilities, and they are diametrically opposed to one another. Well these are false dichotomies promoted by our educational system, which drills into us the idea that there are only two answers to any question: the right one and the wrong one. What if this is untrue? What if we change the way we think about the world, and instead of seeing only the black and the white, the left and the right, the correct and the incorrect, we start really seeing the entire continuum of possibilities? What a fantastic variety of solutions we might stumble upon to our perennial questions!

A nice mind game could be trying to think about stuff without using words. Can we do that? It is thoroughly difficult, yet it is language that seems to bracket our conceptual understanding of the world within and around us. Take the word "race" or "gender", for example. These are human-made and defined terms, which are meant to distinguish rather than merge. Yet just think how uncomfortable we can be made by a person with an ambiguous gender identity, say. Why? Because he/she does not fit into our preconceived dichotomy? Uncertainty is uncomfortable, and dichotomies cure uncertainty. But I am not sure that nature is all that into dichotomies.

The human brain is wired for "belonging." I believe it is for this reason we gravitate to our respective extreme corners of thinking and being, instead of meeting somewhere in the isle. The isle is an uncomfortable place, yet that is where we must aim to be. All the borders we have created are imaginary separations. Instead we can reposition them as the glue that unifies that which lies to either side.

Here is to not knowing more!

Why easy is not always good

My mother-in-law is a typesetter. She will not read a book unless it is not only appealing in its content, but also pleasing to the eye. When I was in medical school, she did quite a bit of work for medical textbook publishers. Comparing books typeset by her to what I was grinding through on a daily (and nightly basis) incensed her: unwieldy tables appearing three pages away from the corresponding text, small letters crammed to capacity onto oversized pages, few illustrations -- all baffling, annoying (and easily fixable) transgressions against readability. Yet, like all budding docs of all generations, I plowed through these morasses of knowledge without giving its readability much thought -- this was just what you did to get to your goal.

Yesterday I was listening to a program where the author Amy Chua was interviewed about her (ahem) embattled autobiography Battle Hymn of the Tiger Mother. Ms. Chua, though evenly humored throughout the interview, was on the defensive nearly the entire time, explaining how the intent of her opus has been grossly misunderstood by the public, thanks to attacks by critics on her parenting style. And granted, looking at the book as a parenting manual through the prism of our Western parenting norms is a bit disturbing. Yet putting its events in a culturally appropriate context, as well as looking at the content as a narrative rather than a guide, leads to completely different conclusions.

Why am I bringing up Amy Chua's interview after talking about my conquest of the unreadable? Well, it seems that ease is what we have come to expect from everything. What I mean by this is that not only do we expect easily readable texts, but we also expect people to present themselves in such a way as to make it easy for us to like them. Why else change your appearance through life-threatening eating disorders and grueling surgeries, get coached on how to make friends and influence people, and comment on how unlikable some of our female politicians are? Is this not a triumph of form over substance?

Amy Chua clearly bucks this trend in her book and is paying the price. But what worries me is that we are all paying a price. By creating another false dichotomy of "she is nice" or "he is nasty", we have eschewed a more realistic view of our human foibles. We are all nice sometimes and nasty at others. Yet this dichotomy has proven supremely fruitful to our political discourse, where for 30 years this new reality has been taking root. And it has born fruit, so that now people who do not hold similar opinions to ours are summarily dismissed as "nasty" or idiotic, and we are satisfied to surround ourselves with "nice" like-minded sycophants. How primitive it renders our political and social interactions!

Ms. Chua's immigrant parents' philosophy resonated with my upbringing. Coming from lands of uncertainty and deprivation, as immigrants, our parents subscribed to Maslow's pyramid and taught us that economic security trumped everything else. This is why only certain career choices were acceptable, while others were relegated to the back burner of a hobby. These choices were not about ease, but about doing what we were taught was the right thing. As John Adams said:

I must study Politicks and War that my sons may have liberty to study Mathematicks and Philosophy. My sons ought to study Mathematicks and Philosophy, Geography, natural History, Naval Architecture, navigation, Commerce, and Agriculture, in order to give their Children a right to study Painting, Poetry, Musick, Architecture, Statuary, Tapestry, and Porcelaine.

We all set priorities, and some of them may not be easy. I myself still read books even if they are not all that well presented; my priorities are content and writing style, though, to be sure, I do not frown upon the beauty of the visual form. I even enjoy characters who in, their multidimensionality, are a challenge to like. And I have learned in the rest of my life to enjoy people who do not necessarily hold easy or quick appeal for me, yet in the long run prove to add unimaginable richness to my life. Nietzsche coined the famous quote "What does not break you will make you stronger." In all aspects of our lives, while, based on Nietzsche's statement, adversity is a sufficient but not necessary road to strength, pushing ourselves a little bit out of our stuporous ease may prove to be one timely remedy.

Guest post: How our brains are wired to advance science

We have a treat today. Today I am featuring a guest post from my brilliant 17-year-old niece Katherine Dana. She is currently applying to colleges, and this is one of her brief essays. Kathy is interested in animal communication specifically, but, as you can see, also spends a lot of time thinking about science in general. And oddly, she seems to be contemplating similar themes to the ones we address here. 
While it is hard for me to stop waxing poetic about how proud I am of her, I will now cut myself short, so that you can enjoy her lucid commentary.

By Katherine E. Dana

Marcel Proust once wrote, "The real voyage of discovery consists not in seeking new landscapes, but in having new eyes." Thus goes the song of science, humanity's great unifier. Science is not merely the means for collecting random information—it is the means through which we make sense of our world. It is messier than mathematics, less exact. And yet in some ways, it is this very inexactitude that gives science its potency, and allows it to cut to the very heart of nature's chaotic randomness. It works by taking the givens of nature and churning out elegant guesses, which predict as effectively as they describe.

One quality that distinguishes mind from machine is that leap of thought that psychologists term "heuristics"—mental shortcuts, expressly designed to help us connect the dots without having to consciously traverse the spaces between. This is our organic advantage.

While today's machines, no matter how complex, are restricted to lengthy algorithms, we may leap from branch to branch. Nowhere in human endeavors is this cognitive edge more apparent than in the combined efforts of humans seeking to find new truth. For before we can know, we must question; and this is where insight is most crucial. It is not enough to investigate the familiar. We must find the courage to ask uncomfortable questions, and be willing to uproot even our most cherished beliefs, all in the name of a deeper understanding.

Paternalism of "science-based" medicine

This is a post I did originally for BMJ's doc2doc site. I am cross-posting it here for your convenience.

Lately I find myself getting more and more incensed with colleagues who seem to preach science-based medicine as the be-all and end-all in the truth about everything. I have blogged about this many times, and some of the references I make below are expanded upon in some of my recent posts. 

The argument goes like this: We who practice science-based medicine are the only ones that are correct in our approach because everything we do comes from a scientifically derived pool of evidence. Anything else is quackery, also referred to as "woo", which includes all modalities that do not fall in line with this EBM paradigm. They rail equally against healing crystal charlatanism, acupuncture, Reiki, and "anti-vaxers", lumping them all into the ignorant masses that dare go against what we "know" at their own and societal peril. They maintain that there is not room for anything in healthcare other than the "proven" scientific interventions.

So, if they advocate for science as the prevailing force in medicine, why should I, a firm believer in evidence as the backbone of healthcare, object? Well, here are some of my reasons, and let's see where you stand.

First of all, it is my belief that all interventions should be approached with equanimity, if not equipoise. Although I am quite dubious that either healing crystals or Reiki can produce actual results, I do not want to confuse the absence of any evidence to this effect with the evidence of absence of the effect. Although I am not that interested in allocating resources to studying these fields, it would be paternalistic of me to bar their further investigation. So the society can decide what it wants to do with them, and in the meantime every individual can make her/his own choice whether to spend their money on them. Interventions in the broad area of traditional Chinese medicine (TCM), including herbs and acupuncture, elicit less visceral aversion in me, and may be shown down the road to have desired health effects, though their study may not be amenable to our current methodologies. Again, at this time, if an individual wants to try them out, they should be keenly aware of how little we explicitly understand about them, including both their risks and potential benefits. 

The vaccine debate is yet another completely different issue altogether. In our privileged society the specter of infectious epidemics is for the most part but a distant memory, yet our concerns for the safety of our children combined with a rampant, albeit not altogether unjustified, distrust of the pharmaceutical industry and the government, have colluded to promote a biased yet durable suite of misinformation about the risk-benefit profile of vaccinations. Some of this prevailing sentiment may be because, in my opinion, we have focused on the wrong outcomes (e.g., the economics rather than morbidity associated with chicken pox), or that we have overstated what we really know and understand, at the risk of sounding too confident and therefore not trustworthy partners in this important area of public health. But these are just my own speculations. What is more important is what we do know about "science-based" medicine.

The uncomfortable truth about clinical science is that by its nature it is inexact. If it were precise, we would be able to describe it through simple mathematics without resorting to statistics, where the wild card is probability of an event. Relying on statistics is wise to understand what happens in large groups of subjects; it is altogether a mistake to take this information for God's own truth for any individual. As I have explained before, statistics are akin to that joke about assuming a spherical cow in order to help a farmer with his milk production quandary. The assumptions of normality, the dark art of log transformations, the cramming of a binary individual into a continuous distribution of population probabilities are all part and parcel of how we develop our understanding in the clinical sciences. No wonder when we bring this knowledge to the bedside a lot of the time it does not seem to apply to the specimen before us, and we are faced with having to use our judgment much more than the science-based medicine mavens are willing to admit. I often wonder how a 2-week prolongation in median survival in a cancer population, even if statistically distinguishable from the much-maligned placebo effect, is in practical terms all that useful. Yet these are effect sizes that we often see in science-based medicine.

My intent is not to belittle what clinical science has and continues to bring to the society. After all, thanks to it, we have a much better understanding of many illnesses now, and we can even take credit for effecting better outcomes for many a sick individual. At the same time we really need to sow humbleness in place of arrogance in all the places where the latter runs rampant. Philosophers of science have understood for decades that there really is no universal truth, and everything we think we know we understand through the prism of our collective human and individual experience. So, instead of wasting time on throwing boulders at our competition, why not take a closer look at the material that our house is made of. Dropping our inveterate paternalism in favor of being truthful about the degree of our uncertainty may make us look more human and fallible, yes. At the same time, it may show our patients and the public at large that we are on the same side. Though this is a risk, it is a necessary one to repair our rapidly crumbling therapeutic relationship. Admitting to not knowing is not only not a weakness, it is the only way to scientific progress.