A Blog Around The Clock

Last couple of weeks months were awfully busy, on many fronts, not least finalizing the ScienceOnline2010 program, herding cats almost 100 moderators/presenters to do various stuff (e.g., respond to my e-mails) in a timely manner, and making sure that registration goes smoothly. This is also the time of year when activation energy for doing anything except going to bed to hide under the covers is very high for people suffering from SAD. Thus, you did not see many ‘original’ posts here lately, I know.

But, it’s not that I have been totally idle. Apart from teaching my BIO101 lab again, I also went to several science-related events in the Triangle over the past two months. I feel like I should blog about each one of them separately, at length and with nuance, as this hangs over my neck like the Sword of Damocles – I feel I should not blog about anything else until all of these event reports are out of the way.

So, in a compromise solution, instead of a bunch of long separate posts, I will collect all the brief reports from all the events here, in a single post, get that over with and mentally free myself to blog about other stuff soon.

Lisa Sanders at UNC

Lisa Sanders is a physician and a professor of medicine, but you probably heard of her in a different context: Lisa writes the Diagnosis column in The New York Times, has recently published a book Every Patient Tells a Story, and has inspired and acts as the medical adviser to the TV show House (of which I heard, not being a TV watcher, at the beginning of her talk).

Lisa Sanders came to the Triangle last month and gave talks at Duke and UNC. Bride of Coturnix and I went to the UNC talk which filled a large auditorium. Her book is being read by all the UNC medical students who will then discuss the book in smaller groups.

The process of diagnosis has three steps: interview, physical exam and laboratory tests.

Laboratory tests have become more and more dominant as the preferred part of the diagnosis process, for a number of (cultural) reasons:

First, they are the quickest, thus save the physician time (others do the work).

Second, unlike interviews that seem subjective, or physical exams that look medieval, lab tests look like ScienceTM! – there are numbers there. And you can’t argue against numbers, can you? This works great on the background of lack of statistical sophistication (or outright innumeracy) on the part of both physicians and patients. No arguing. No second opinions. The process moves on smoothly for everyone. Except, the numbers cannot be trusted as much they usually are.

Third, a number is not an opinion, thus it is a safeguard against lawsuits. It saves physician’s asses in such cases.

Both the frenzy and the (perceived) lack of time and the fear of lawsuits would be diminished if we had a real healthcare reform (not the compromise of a compromise of a compromise bill that is brewing in the US Senate right now, but an actual reform) in which the physicians could get their authority and trust back and be able to practice their art and craft and science with some degree of freedom. In a system in which insurance companies determine how care is done, physicians are just technicians and cannot earn authority and trust.

So, with everyone jumping onto lab tests, the art of interview and the art of physical examination are slowly dying out. They are not even taught in some medical schools any more. Where they are taught, as soon as newly minted physicans are on their own they join the medical culture that frowns upon these two steps of the diagnostic process.

Yet, Dr.Sanders showed data from two studies (done in different countries by different people in different years), both providing almost exactly the same results. In about 75-80% of the cases (physician encountering a new patient for the first time), the physician comes up with a correct diagnosis after the interview. In about 10-12% of the cases, the doctor has to correct her/himself after the physical exam in order to arrive at the correct diagnosis. And in only the remaining 10-12% or so cases did the lab tests provide information that forced the physician to change one’s mind and come up with the correct diagnosis. In 8 out of 10 cases, the interview was sufficient!

When asked why they are shunning the interviews, physicians respond that they have no time – the system is forcing them to see too many patients per day. A study shows that physicians interrupt patients’ stories abruptly, very soon, sometimes as early as 3 seconds into the interview. Yet, in another study, when doctors were asked specifically not to interrupt, the interviews lasted only one minute longer. Just one minute! Thus interruption does not really save any time – it’s an illusion.

But what is more important is that the interruption itself means something. First, it means that the physician is not really listening. Second, it tells the patient that the doctor is not listening. By relaxing for that extra minute and actively listening to the patient, not just fishing for diagnostically important information in the account but also listening to hear how the patient perceives him/herself, and how that perception is altered by the illness, the physician gains a better understanding of the patient, can probably come up with a better diagnosis and, most importantly, gains trust with the patient. That trust is very important later, when the physician needs to rely on the patients to be disciplined about the treatment. The interruption loses that trust, something that smooth-talking medical quacks are quick to jump on, offering to listen even if their treatments are completely bogus.

What a patient does during the interview is story-telling. A physician needs to be trained to listen to and understand such stories – to glean how the change in health status affects the self-confidence, self-view and self-worth of the patient, how it changes one’s life-plans and ambitions, what fears it brings, what difficult adjustments in lifestyle it requires. To see the patient as a person, not just a disease.

And then, the story-telling does not end with the interview. The physicians and nurses need to communicate with each other about the patient and that also entails, when done right, story-telling (which need not be spoken, it can be in the chart). Finally, the healthcare providers need to know how to tell the story back to the patient, both to convey the diagnosis and to gain the trust needed for the patient to accept and follow through with the treatment. Quick recitatiton of code-numbers and Latin words just won’t do.

So Lisa Sanders, with her book, her column, her advising of House MD and her speaking tour, tries to teach the importance of the interview and the physical exam, the art of listening and storytelling. I am glad that UNC is taking her seriously.

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The next day, a bunch of us met with Dr.Sanders at the West End Wine Bar in Durham. It was great fun to talk to her in an informal setting and to ask questions that I did not dare ask at the public talk in front of hundreds of med school professors and students and something like the entire nursing school of UNC. After all, my only perspective on medicine is from the position of a patient (and a reader of some med-blogs) so I learned a lot, yet was aware how little I actually know about medical training and practice. Anton organized that meet-up with the local science communicators and wrote his summary of the week’s events on his blog:

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Steven Churchill at Sigma Xi

Steven Churchill is a professor of Evolutionary Anthropology at Duke University. His focus is on the role of projectile weapons in the evolution of humans. Dr.Churchill gave a talk at Sigma Xi as a part of their Pizza Lunch monthly series.

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What is a projectile weapon? It is something that can be thrown far away – more than just a couple of meters – and with sufficient power to seriously injure or kill a large animal. A non-projectile weapon, even if it can be thrown with force to a shorter distance of a couple of meters, requires either ambush hunting or chasing the prey into a corner or a bog where it can be approached and stabbed from a close distance. A projectile weapon allows hunters to hunt out in the open, perhaps just hiding in the tall grass. Thus two types of weaponry target different kinds of prey.

But inventing projectile weapons requires refinement in technical skills of making them, technical skills in throwing them, and changes in anatomy to make projectile weapons effective. And once invented, projectile weapons have novel ecological impacts, including impacts on further cultural evolution of humans.

This is what Dr.Churchill is studying. He is focusing on Europe, the invention of projectile weapons by modern (“Cro-Magnon”) humans and lack of such invention in Neanderthals, how that impacted the ecological relationship between the two species, and how that contributed to Neanderthal extinction as well as extinction (through competitive exclusion, as well as direct competition by killing) of all the large European carnivores except wolves.

In the talk, Dr.Churchill surveyed several different aspects of his research. He is approaching the question from several different angles. One is the study of spear tips in the archaeological record – their shape and size, the weight, the aerodynamics of the shape, etc. all tell something about their use as either close-contact or projectile weapons. Some (rare) spear handles and spear-throwers tell their own stories.

Then there is the fossil record of humans, Neanderthals and other large carnivores that show numbers and geographical distributions, migrations and dates of extinctions.

Next, there are anatomical cues – skeleton is malleable during development and bones in the upper arm develop differently in cultures that use contact weapons versus those that use projectile weapons as the stabbing technique is different from the throwing technique – throwers have different torsion angles in the humerus and also the humerus of one arm gets thicker than that of the other arm – this pattern is found in humans, but not in Neanderthals.

Finally, the general shape of Neanderthals would make them strong stabbers but poor throwers, so even if they tried throwing (perhaps by seeing the spears used that way by modern humans) they would not have been effective hunters with that technique.

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Then, there are wounds in the bones of some fossil humans and Neanderthals. By conducting an experiment – throwing spears into pig carcasses at various speeds, powers and distances (yes, throwing done by a machine) and analyzing the effects on bones – Churchill and his students could conclude that the wounds in the fossil bones were indeed the result of projectile weapons thrown from a distance.

The talk was, as is usually the case on these occasions, a quick survey of various studies. I did not read all the papers by him or his competitors, so I cannot write anything from a position of my own expertise. But my feeling is this:

Each piece of evidence he showed is weak on its own, but put together they make a strong case. And the strength is not purely additive, i.e., in the sense that more data is stronger than fewer data. The strength comes from consilience. Let me try to explain how that works.

Let’s call his preferred hypothesis ‘Hypothesis A’. One piece of evidence he shows is consistent with Hypothesis A, and weakens (or eliminates) an alternative Hypothesis B, but is also strongly vulnerable to alternative Hypothesis C. Another piece of evidence is consistent with his Hypothesis A, and weakens an alternative Hypothesis C, but is also strongly vulnerable to alternative Hypothesis D. Yet another piece of evidence is consistent with his Hypothesis A, and weakens an alternative Hypothesis D, but is also strongly vulnerable to alternative Hypothesis B. When you look at all of his evidence together, all of it is consistent with Hypothesis A and all alternatives look weak. Thus with all pieces being individually weak, the whole edifice still looks very powerful.

Now, to make clear, Dr.Churchill pointed out several times that the research he focuses on, his Hypothesis A, is not the one and only explanation for the extinction of Neanderthals (and other large predators). He just asserts that it is an important component of the process that led to this result and perhaps a more important component than some other people in the field are ready to admit. Of course, that’s how science works: different people focus on different aspects of a problem, and the strength of each person’s data will determine how the whole picture is built in the end.

This was definitely an interesting talk on a topic I never thought about before. DeLene was also there and wrote her thoughts about the lecture on her blog Wild Muse as well as on the Science In The Triangle blog.

RTI Fellows Symposium: Integrating Basic and Applied Research

This was a two-day event at the University of North Carolina’s Friday Center in Chapel Hill. This was also the first time I saw the Friday Center from within and I was looking at it with the eyes of a conference organizer. It has a Goldilocks quality to it: not so pleasant, intimate and science-themed as Sigma Xi, and not as big, cold and corporate as the Raleigh Convention Center. Just the right size and feel. But expensive as hell – Sigma Xi has been good to us over the years, not sure if we could negotiate a similar deal with Friday…..though we have definitely grown and a 420-seat main conference room at Friday Center looks good.

I could attend only the Monday morning portion of the meeting, but Sabine Vollmer was at the Symposium for the whole thing and wrote two blogs posts about the rest of the program here and here with a lot of details.

There were four broad themes entertained by the symposium: Personalized Medicine, Behavioral Neuroscience of Alcoholism, Global Climate Change and Education Opportunity and Achievement. Each of the themes had its own breakout session later, but Monday morning was reserved for Keynote Speakers, one on each of the four topics, each of interest to me in one way or another.

Let me first dispose of the things I did not like about the conference before I get into things I liked.

Over the past few years, most of the conferences I go to are informal, unconference or unconference-like events: from Scifoo in Mountain View, to Science FEST in Trieste, to ConvergeSouth in Greensboro, to our own ScienceOnline meetings. Even the ‘real’ science meeting I like to go to, the SRBR meeting, is very relaxed and informal – shorts-and-Hawaiian-shirt-clad scientists giving funny and entertaining talks about their new findings in my own field, with internal jokes, calling out friends in the audience and occasional hackling joke from the room (OK, OK, I overstate – folks are mostly nice and polite, especially when the talk is given by someone younger, e.g, a properly dressed graduate student, waiting in attentive silence until the end and then asking proper questions afterwards, but still, the general atmosphere is friendly and relaxed).

I realize of course that different conferences require different setup and different levels of formality. Not everything is a Bar Camp. While I was personally uncomfortable wearing my suit-and-tie costume at the IASP meeting, I understood that this was a business meeting in a business venue with businessmen (and a handful of businesswomen) in business attire talking about business.

But this one, I think, was a mismatch. All (or almost all) speakers were scientists talking about science. Almost everyone in the audience were scientists. For this kind of meeting, the organization was far too formal. And not just in pomp and ceremony and dress-code. For example, if you look at the abstracts, they don’t really say anything about the topic of the talk – they go in great detail about the speaker, including all the past and present appointments, awards and honorary degrees. This indicates that the organizers were more interested in the power hierarchy (i.e., ‘look at VIPs we managed to get here to talk’) instead of the substance of what they are saying. It felt more like a big corporate show-off than a conference meant for an exchange of ideas.

Then, there was no time designated for Question & Answer periods after the talks. I wanted to ask questions, but there was just no mechanism for doing so. I understand there were panels afterwards, but even those were built strangely – with panelists, after each gave a separate talk, sitting at a table on a podium above the audience, physically looking down at the audience, thus psychologically inhibiting all but the bravest from actually speaking up. I do not know how it went, but I doubt it was a free-wheeling discussion.

Then, the talks. Two speakers actually read their talks. Arrrgh! Yawn (and I was FULL of caffeine).

Others were much better. Howard McLeod gave a good, clear introduction into personal genomics and personal medicine, its pros and cons. Robert Jackson from Duke provided a good summary of the current state of science of climate change.

Ronald Dahl talked about adolescent brain development (something I am very interested in, both professionally and as a father of two adolescents), especially the lengthening of the period between onset of puberty which arrives earlier and earlier (the timing of which is not matched by an earlier development of other brain functions, including self-control) and the delay of societally approved age for onset of sexual activity (including marriage). Thus the duration of the period during which adolescents are sexually mature (but not entirely emotionally mature) but discouraged from sexual activity is getting longer and longer – which is an obvious problem. Couple that with the tendency of adolescents to be unable to resist, despite personal fear, engaging in risky behaviors, problems like teen alcoholism and traffic accidents are on the rise.

Lunch Keynote Speaker, Ralph Tarter, was the biggest dissapointment. His talk about bridging the Two Cultures and lessons from Hollywood was surprising for its naivete easily detectable by anyone who’s been reading science blogs for more than a year or so (including Framing Wars, response to Sizzle and response to Unscientific America, along with bloggers who routinely write about history of science). It was infused with nostalgia for good old days when scientists and poets drank wine and talked together (ehm, scientists and poets at the time were the one and the same people – that was Victorian era when gentlemen of means could afford to indulge themselves in such pastimes as philosophy, natural history and poetry and meeting their like-minded buddies at the pub). Science today is a very different business, specialized, expensive, profesionalized and rightly so. That’s progress.

The worst part was the lunch talk was the last point – a very erroneous analogy between peer-review of grants and movie reviews. First error: grants are reviewed before they are funded – movies are reviewed after they are funded. Second, as much as the grant review is prone to error, it is still done by well-meaning teams of scientists who are at least trying to evaluate the proposals according to their merits. Yes, outlandish proposals have a harder time than bandwagon stuff or conservative approaches, but it is at least attempted to be done fairly. Which movie gets funded is totally up to whims of movie moguls and producers. I bet even smaller percentage of submitted movie scripts gets actually made into movies than a proportion of grant proposals that gets funded. And while grant reviewers may look at the past publishing records of the grant submitters, the movie magnates are not in any way swayed by the statistics of positive or negative views of particular actors by movie critics in the media.

The highlight of the day was the talk by James Evans. I know Jim well, but I have never seen him speak before. And he blew me away. He knew that all the other speakers on the Personalized Medicine topics will be over-optimistic, so he took it on himself to provide a counter-view, a summary of cautionary notes backed up by data and a nice dose of humor. It was a very energetic and fun talk that explained very clearly what claims by personal genomics companies really mean, why they are so seductive if you don’t stop to think about them, and how they stack up against reality.

NESCent panel on intersection of public policy, economics, & evolution

NESCent Catalysis Meeting, coorganized by the Evolution Institute was on November 13-15, 2009 and several of the participants remained another day and came to NESCent on the 16th to report on the meeting in a form of a panel. The meeting and the panel were organized by David Sloan Wilson, professor of evolution at Binghamton University and one of my newest SciBlings. The other panelists were Dennis Embry, John Gowdy, Douglas Kenrick, Joel Peck, Harvey Whitehouse and Peter Turchin.

The main idea of the meeting is that evolutionary theory has something to offer in the realm of understanding human societies and thus shaping policies governing aspects of human activity. In the domain of economics, for example, it appears that the classical economics (i.e., the Chicago School) is unbeatable in the corridors of power. Yet, it is essentially faulty and this has been shown many times, including by numerous Nobel Prize winners in Economics. The idea that humans are rational (and perfectly informed) economic players is just plain wrong. Yet our economic policy is built upon that error. Perhaps developing and using models from evolutionary theory can finally bring the well-past-due overturn of the faulty economics and become the basis for smart, modern economic policies. The work is just beginning.

Perhaps the insights from the study of social and eusocial animals, mainly insects, can inform the discussion about social behavior of humans. How do simple rules for simple brains result in complex behaviors of, for example, bee swarms? Perhaps if we used such simple rules, instead of relying on every individual human being highly intelligent, impartial and rational, we can devise policies that will actually work, in various domains of human activity.

Taking into account multi-level selection models of evolution one can start understanding the differences between small-group societies (e.g, in rural areas) and large-group societies (e.g., in large cities), why those result in diefferent behaviors of individual humans living there, and why the differences between the two types of groups often lead to civil wars (often wars we usually do not see or describe as civil wars due to our own myopia, not realizing that a war between two adjacent regions may, in fact, be a war between the city and the country “mentality” – something quite obviously applicable to the US red vs. blue states, really small-town conservatism vs. big-city liberalism). Why imposing large-group organization (i.e., a President and a Parliament, i.e., a ‘centralized government’ of a unified country) may not work in a country like Afghanistan in which the society was always organized via local kin-and-friend networks – evolutionary theory can open our eyes on such questions.

This group of people, coming from a variety of backgrounds including history, anthropology, ecology, economics, psychology, political science, ethology and evolutionary biology, will try to tackle these and similar questions over the years to come.

Interestingly, the meeting was apparently an Unconference (though they have never heard of the term before), with discussions starting some months before the event (I presume online), leading to the choices of topics actually discussed in sessions which were free-style discussions, not speeches. One of the panelists noted that interdisciplinary meetings are usually excercises in misunderstanding, as each participant brings in different language and different axioms, but not this meeting – people actually made an effort, in advance, to study and learn other people’s perspectives before encountering them in the sessions in real life. This made the meeting, judging from the enthusiasm of all panelists, a resounding success.

This was the first time I ever visited NESCent (though I was excited when I first heard about its founding five years ago) and it was really nice to see Craig McClain and Robin Ann Smith again, as well as to meet, for the first time in real life, John Logsdon who blogs on Sex, Genes and Evolution and has come to NESCent for a nine-year sabbatical.

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Solid Waste Management Vendor Fair at the RTP Headquarters

I got to see this almost by accident. I was going to the RTP headquarters to talk to them about their new blog and, for the price of free pizza, wondered around the exhibit and saw a brief talk about the ways North Carolina is doing recycling solid waste, why that is a good thing, and what are the prospect for the future. But I will let Cara Rousseau give you more details, in a post on the new RTP blog.

SCONC celebration of the Origin of Species 150-year anniversary at NESCent

Just a couple of days after my first ever visit to NESCent, I found myself there again. The occasion, the anniversary of the publication of the Origin Of Species (though officially today), was a good excuse for SCONC to have its monthly meeting at NESCent.

Robin Smith welcomed us all with a piece of great news – the funding for NESCent was extended for another five years! Then, while we were enjoying some delicious food, we were treated to three interesting presentations by current NESCent post-docs: Julie Meachen-Samuels talking about Smilodon, how it hunted differently than modern Big Cats and what it means for our understanding of palaeo-ecology and evolution, Trina Roberts about the diversity and biogeography of tree shrews (and how to get DNA from museum skeletal specimens!), and Eric Schuettpelz about the way ferns radiated into many species with the appearance of forests of (flowering) trees by occupying a new niche – living on the tree trunks as epiphytes, in the shade.

I found myself thinking about parallels between the Smilodon presentation and the one on projectile weapons I heard a couple of weeks before. Neanderthals uses stabbing close-contact weapons (and are now extinct) while modern humans used projectile weapons, thus being able to hunt different kinds of prey (and are now extant). Similarly, most Big Cats today hunt by giving chase to their prey and then killing it with their long canine teeth, often having to hold the teeth clenched in the trachea for several minutes until the victim dies. But Smilodons (the saber-tooth cats) had to hunt differently – from an ambush, presumably in thick forests and not out in the open country. They overpowered their prey using the weight and strength of their forelimbs and only at the end finished the completely immobilized victim with a quick slice with their canines. If they tried to keep their teeth inside still struggling large animals for more than a moment, their long but thin canines would break. In some ways, the Smilodon hunting technique is analogous to using close-quarters weapons, while the techniques of modern Big Cats is more analogous to hunting with projectile weapons (with themselves being “projectiles”). With such a massive body, with hindquarters so much smaller than the front half of the animal, and with no tail they could use for balance, saber-tooth cats could not run fast enough and long enough to be “projectiles”. Perhaps that’s why they, like Neanderthals, are now all dead.

And yes, we had a Darwin birthday cake – Russ Campbell has the pictures.

Comments

  1. #1 Arunn
    November 24, 2009

    1) On Lisa Sanders at UNC: Although I live now in a metro, the concept of a family physician is still in vogue here and in our home. Half the cure for most ailments is in the mental. When my physician listens to me for a while and THEN assures me there is a cure etc., I already feel half cured before taking the prescribed medication. So much so our family visit the ‘family physician’ (or he does when prompted) even for an ordinary fever for which we know the remedy a priori.

    This listening part of diagnosis or the art of the interview, as Dr. Lisa Sanders points out, is declining amongst the newly minted physicians. Two years back, I had the bad experience of being rudely intruded exactly within 30 seconds while trying to explain how laser-cauterizing a pimple didn’t work (which, she did earlier!). I walked out of the clinic never to return.

    Wanting to earn more (time is money) could be a motive for such quick-check-cure. Treating patients as “subjects” in the neo-medical curriculum could be another reason.

    2) On Steven Churchill at Sigma Xi: Your (Bora) explanation for consilience is nice.

    I wonder whether there is a niche for poison-tipped projectile weapons in the evolution of humans.

    Cheers,
    Arunn

  2. #2 Stephanie Z
    November 24, 2009

    I love your idea of brief, Bora. :)

    You’ve written in praise of amateur and citizen science, and here you’re lauding the professionalization of science. Have you written anywhere about how you see the two working together?

  3. #3 Coturnix
    November 24, 2009

    It looked brief in my notes ;-) But then I had to add this and add that…. I suffer from Orac Disease!

    In a perfect world everyone is a scientist, though some are better trained and thus paid professionals while others are amateur citizen scientists. But this is not a perfect world. I guess I need to think through and write a post about the relationship between professional scientists (and yes, years in school and lab count for something) and the democratization of science via various Citizen Science projects, etc. In this post, I was really just trying to say that today’s science is advanced to the point that specialization is necessary and it is not possible for all, or most, or many scientists to be just like the old Victorian scholars. That time is now long gone, and using old Ebglish gentlemen as figures to aspire to in the 21st century science is silly nostalgia at best, anti-science at worst.

  4. #4 Catharine
    November 24, 2009

    Wow! Nice post, Bora. On Lisa Saunder’s talk at UNC: This is a real problem that goes beyond poor quality office visits. Now that everything in the ICU is computerized, docs often don’t bother to come in and have a look at the patient and write orders from the physicians’ “work” room, where they look at online flow sheets and labs. This is wrong (and dangerous) for so many reasons. More and more frequently when I have a situation that seems important enough to “bother” the resident about, he’ll come in, look at the monitor, look at me and shrug his shoulders and say “so? what’s the problem?” It is left to me to tell him (in a nice and subservient way) to LOOK AT THE FUCKING PATIENT. Who, at a glance, looks like she is about to die and it doesn’t take four years of medical school to figure that out. I understand and respect the fact that doctors are way overburdened (as are nurses). But the it seems to me to be a matter of basic competency to examine the actual patient (and hopefully before treatment decisions are made).

    I am so jealous that I didn’t get to go to the conference at the Friday Center with you. Jim Evans is absolutely brilliant (look up his work) and a decent person on top of that. At the ASBH conference, I had a similar experience of despair when people would *read* their papers. The result it that you are listening for form — word choice, grammar, structure, etc. and miss out on the *content* entirely. What a shame, what a waste of time. I’m not saying that every paper needs to be a performance, but at least talk in such a way that I am able to listen. Shit, I can read.

    I don’t really have anything to say about projectile weapons, except maybe in general, one would do well to avoid them.

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