White Coat Underground

Put a fork in it?

Posted by PalMD on September 15, 2009
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A recent piece of mine caused a bit of a “blogwar”, if you will. It lead to a “rebuttal” on Dr. Bremner’s blog, and an additional response from Dr. David Gorski. The discussion has been interesting (no, not Doug’s incoherent response, but the comments and emails of others). One letter in particular helps sum up the ideologic rift between science-based medicine and “everything else”.

The following was written by a physician:

I would ask Drs Gorski and Lipson if an iconoclast like Dr Bremner might be serving a valuable role as gadfly to an entrenched failing status quo in bio-medicine who have made the mistake of deifying science? I would posit that the very essence of science is always and incessantly asking the question- “is it possible that I may be wrong?”. And I strongly support the return of narrative- the patient’s individual story- to the practice of medicine. The incomparable Sir William Osler, one of my heros in medicine, knew that well.

I believe that of all the determinants of successful US bio-medicine medicine going forward that a strong dose of humility is in very tall order.

To make progress our egos must die first- a basic psychiatric principle. It is much better and much more important to be tolerant and kind than to be right.

I support Dr Doug Bremner’s role as a colorful and passionate iconoclast. We need more like him.

This deserves a thorough fisking, given that it is rife with logical fallacies. Let’s take the first (run on) sentence:

I would ask Drs Gorski and Lipson if an iconoclast like Dr Bremner might be serving a valuable role as gadfly to an entrenched failing status quo in bio-medicine who have made the mistake of deifying science?

First, being an “iconoclast” and “gadfly” is not necessarily a good thing. Taking a stand against the “status quo” is only valuable if: 1) the status quo is a problem, and 2) you present a valid critique and valuable alternative. What Bremner offers is a blunderbuss. He takes what would otherwise be useful critiques of the corruption of science by industry and spews pseudoskeptical grapeshot at anything he feels is tainted by Big Pharma.

I would posit that the very essence of science is always and incessantly asking the question- “is it possible that I may be wrong?”. And I strongly support the return of narrative- the patient’s individual story- to the practice of medicine. The incomparable Sir William Osler, one of my heros in medicine, knew that well.

Well, I don’t think any practicing physician would agree that we have lost “the narrative”—medicine would be impossible without it. I certainly do agree that being willing to accept that one is wrong is the essence of science. It is a rare event indeed that the alternative medicine community embraces the truth of negative results.

I believe that of all the determinants of successful US bio-medicine medicine going forward that a strong dose of humility is in very tall order.

To make progress our egos must die first- a basic psychiatric principle. It is much better and much more important to be tolerant and kind than to be right.

No. No, no, no, NO! It is not better in science to be tolerant and kind than to be right. I can be as tolerant and kind as I wish, but if I smile, purr, and wave my hands but fail to understand the etiology and evidence-based treatment of coronary artery disease, my patient my die happy but prematurely. One should strive to be kind and tolerant, but being right does not exclude these values. If we fail to deliver proper care to a patient, all the tolerance in the world won’t console her family.

This defense is no defense at all. What is the goal? To simply be involved in a boring internet imbroglio? Or to advance the science and practice of medicine?

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Comments

  1. #1 qetzal
    September 15, 2009

    Good job pointing out the false dichotomy – MDs should strive to be tolerant, kind, AND right. And even if we accept the either/or premise, the letter writer has it backwards. For most MDs in most situations, being right is much more important than being tolerant and kind.

    Seriously, can anyone offer a situation where it’s better to be tolerant, kind, and wrong? Note that situations where there is no right or wrong don’t qualify.

  2. #2 Denice Walter
    September 15, 2009

    re:your commenter’s “run on sentence”(also the “Dr”,”Drs”).Is he a Brit or Irish? My Irish friend is astounded by our very liberal use of punctuation, “You use so many commas.”

  3. #3 SrrAB
    September 15, 2009

    …Because nobody ever sues doctors for medical malpractice when they really screw up, as long as they’re tolerant and kind…amirite?

  4. #4 titmouse
    September 15, 2009

    Doctors who say, “don’t get vaccinated,” when the facts support vaccination, are not kind to their patients.

  5. #5 Orac
    September 15, 2009

    A counterexample: David Irving is an “iconoclast” and a “gadfly.” Being an iconoclast or gadfly is not necessarily a good thing.

  6. #6 Donna B.
    September 15, 2009

    I think the problem here is calling a nutcase an iconoclast.

    As a patient, I think there’s quite a bit about the practice of medicine that can be called into question. Yes, some of the “traditions” need to be questioned and probably put out to pasture.

    One thing that is affecting my medical care at the moment is a lack of access to specialty care because of a shortage of doctors. A 3 to 4 month wait to see a neurologist really isn’t acceptable when some symptoms are getting worse and I have already been diagnosed with a brain tumor.

    A similar wait for an appointment with a psychiatrist for a person who has just been released from a psychiatric hospital with only 30 days of meds isn’t reasonable either.

    This person (for whom I serve as SS payee) also can’t get his PCP to renew the prescriptions up to the date of his psychiatry appointment. How does this help?

    So… what I see as needing reform is not only the method of paying for health care, but also a reform in the way it’s delivered. This is not meant to be disrespectful to doctors, as I been a patient of only one in my near 60 years that I absolutely hated going to.

    Even then, I ended up feeling sorry for him. I witnessed him put forth his best effort at having a bedside manner. It hurt to watch this. The treatments he offered didn’t do me much good (a few days of pain relief wasn’t enough to justify waiting two months before I could get another brief period of relief.)

    I realized that his offering of these (for me) not worthwhile treatments funded his true calling — treating arthritis in children. While waiting to pay or waiting for lab tests, I saw the way he interacted with his young patients and their parents.

    My question is why should this man not have a practice solely directed to youthful rheumatoid arthritis patients? If it were not for the general shortage of rheumatologists in this area, I think he would limit his practice, increase his impact, and be a much happier doctor.

    I’m not so sure that there is a shortage of primary care physicians that could not be filled by physician’s assistants and nurse practitioners. Where I think there’s a shortage is in diagnosticians. I’m not likely to fall for the woo of a “holistic” quack selling me vitamins, but I’d truly love to sit down with a doctor and try to figure out which of my symptoms are caused by which diagnosis and to ask the question — are they related and how?

    In my most idealistic moments, I think health care should be completely unrelated to the way it’s paid for. Relating the two has led to fee for service, which, in practice really does lead to treating symptoms rather than people.

    First, let us separate the two and then reform them individually.

  7. #7 Jimbo Jones
    September 16, 2009

    I disagree that you need to provide an alternative. Pointing out the faults in the status quo is good enough when you’re trying to say that the status quo is faulty. Of course, coming up with an alternative that addresses these faults is helpful, but unnecessary.

    That said, I agree completely with everything else you’ve said here. To the point where, if forced into a dichotomy regarding tolerance and rightness, I’ll pick rightness every time. Qetzal, #1, is right on the money.