Medicine and Evolution, part 4a: Physicians seduced by "intelligent design" creationism (revisited briefly)

You know, I've been waiting for your post on this ever since you first hinted about writing it. It is fantastic, and the second part is an important addition. I am assuming/hoping that thie two-part post will appear in next editions of Skeptic's Circle, Tangled Bank, Grand Rounds and Teaching Carnival.

Speaking as both a physician and a scientist, I concur that the term "technician" is not appropriate. I view physicians as the engineers of biology. Applied scientists, who have different outcomes (one could even say more practical outcomes) in mind.

I am sad to say that my sister-in-law though perhaps not a hard core creationist, is "somewhat skeptical of the theory of evolution". She also thinks that God speaks to her directly. She has an American Indian medicine wheel at home on which she "prays and meditates". Worst of all, she is quite open to "eastern medicine" and other "alternative treatments" like acupuncture etc.

Prior to medical school my wife and her were very close. They are identical twins, and were best friends. After medical school she came back a changed person. Her arrogance quotient went through the roof. Her tolerance quotient fell through the floor. She became easily distracted in social situations and used friends and family as pawns to accomplish things for her, rather than actually caring about them.

I didn't go to medical school so I am just guessing, but it appears to me that conventional teaching and indoctrination techniques of medical students is a very harsh metamorphic process. Any character flaws a person may have going in to medical school, become amplified in a defense against the bombardment of personal and professional attacks perpetrated by the medical school system. As a result, real caring gets morphed into "professional detachment" and doubt into confidence. In the case of my sister-in-law, "professional detachment" is now how she approaches all personal relationships.

I realize that to a certain extent the end justify the means. No one wants a week willed or wishy washy doctor, but it seems that the medical education system needs to take a broader perspective on our future doctors, and mental health and critical thinking are aspects that need to be stressed more. Of course, that would require society as a whole, valuing those same ideals and I don't see that happening anytime soon.

I don't know if the place is the medical school curriculum but the pre-med curriculum. If in both human anatomy and physiology course there is no discussion or mention of evolution's role, it's a logical presumption that evolution does not apply to medicine or to humans.

Mike

Great posts.

Lorraine Day is also a Holocaust denier. That alone says nothing about her medical quackery, naturally, but it is a warning signal. It's interesting how quacks often become quacks across the entire board, rather than restricting themselves to one particular field. Maybe it indicates inherent dishonesty, ineptitude, a deficiency of critical thinking, or all three.

Our brains are the best machine ever developed for pattern recognition. We can do that at many scale, both spatial and temporal, plus we can integrate those scales seamlessly.
Indignous cultures can identify patterns of weather, productivity, phenology, etc. Furhtermore, they have no problem identifying patterns of disease. They also have no problem identifying patterns of healing by the use of medinical plants and treatment therapies. On the other hand, the underlying processes that produce those patterns are basically unknown to those cultures. Thus, they generate myths, stories, etc, to explain them.

Science is the search for patterns in nature and the causes of those patterns. In general, a physician needs to be capable of identifying patterns, and need not to concern him/herself with the processes. I have known a few physicians over the years and I'm constantly amaze about how little they know on issues like how diseases emerge, how are maintained in populations, the evolution of resistance, etc.

We have tons of pre-meda in our Department. They all have to go through four core courses in the beginning. The first is Animal Diversity, whcih is evolution. The second in molecular, cellular and developmental biology, which is not taught very exlicitely in an evolutionary context. The third is Animal Anatomy and Physiology which is taught as a lower-level version of Evolutionary Physiology. The instructor is an evolutionary biologist. The honors section reads Nesse & Williams. The fourth course is Behavior, Ecology and Evolution where they get evolution in full force. In the latter two course they also do independent research projects, the first in the lab, the second in the field. I TAd the course #4 twice and, for their final paper describing the findings from their project, I demanded a portion of the Discussion be devoted to the evolutionary context of their research. This forced many of them to, from the get-go, choose projects that directly test adaptive function of particular physiological processes in various animals.

After the four core course they can pick and choose, and many prre-meds go on and take Human Anatomy, Human Physiology and Neurobiology - three courses that do not place too much emphasis (though some) on evolution. If they think they are really smart, they may try to take our two-semester graduate course in General Physiology which is taught at the medical school level and is regarded as the toughest course on all campus (from Engligh, through engineering to the vet school). Everything else is evolutionary: Comparative anatomy, histology and embryology, Principles of Development, Comparative Physiology, Comparative Endocrinology, Animal Behavior, Behavioral Endocrinology, Biological Clocks, Evolutionary Biology and many, many ecology and conservation biology courses. They cannot help but get slamed with evolution on every turn, in every semester.

Errata - I TAd the course #3 twice.

Orac,

I am curious how one would integrate evolution into a medical school curriculum, most notably for the first years (doing gross anatomy). Some schools now run "themes" for four to eight weeks wholy focused on a particular organ system. Would it be good to slide in a few lectures over the course of the year on evolutionary biology (with respect to each system) or to offer it as, like you say, as an elective sometime in third year?

I ask this since my girlfriend is a first year med student, and remarks occasionally on how certain professors and students are baffled about the spread of ID. I think a better approach is to get those med students before they even get into medical school, by especially tightening up the biology degree and pre-med requirements to include a well structured class in evolutionary biology. Too often one can get through biology programs without even one class in evolution (explicitly).

Wonderful post
from an interested physics undergrad

I missed that point Flex made in the other comments. He sums it up perfectly. I shudder to think our med schools could be encouraging a new generation of docs like these. From your links, I was pretty shocked to find this list of med schools, including the best out there, with complimentary/integrative/alternative (or any other adjective synonymous with pseudoscientific) med departments. I'll take hope and prayer from my loved ones; from my doctor I expect skepticism, critical thinking, knowledge and use of proven techniques, shrewd evaluation of research, and the ability to solve complex problems based on evidence. This requires a solid comprehension of science; at the very least this should include an understanding of the foundation of biology! A belief in young earth creationism is such an intellectual cop-out, I am persuaded to think it puts everything one accepts as fact into question (or at least it puts one's ability to evaluate scientific evidence into question). The arrogance required to state unequivocally that one knows the mind of God (which is essentially what one is saying when one claims evidence of 'intelligent design' in nature, or that one simply knows how life was created) is as undesirable a trait in a physician as willful ignorance.

I missed that point Flex made in the other comments. He sums it up perfectly. I shudder to think our med schools could be encouraging a new generation of docs like these. From your links, I was pretty shocked to find this list of med schools, including the best out there, with complimentary/integrative/alternative (or any other adjective synonymous with pseudoscientific) med departments. I'll take hope and prayer from my loved ones; from my doctor I expect skepticism, critical thinking, knowledge and use of proven techniques, shrewd evaluation of research, and the ability to solve complex problems based on evidence. This requires a solid comprehension of science; at the very least this should include an understanding of the foundation of biology! A belief in young earth creationism is such an intellectual cop-out, I am persuaded to think it puts everything one accepts as fact into question (or at least it puts one's ability to evaluate scientific evidence into question). The arrogance required to state unequivocally that one knows the mind of God (which is essentially what one is saying when one claims evidence of 'intelligent design' in nature, or that one simply knows how life was created) is as undesirable a trait in a physician as willful ignorance.

(Apologies if this gets doubl-posted. It didn't show up, but may just be in the spam queue.)

Whereas evolution, as a particular course, need not be part of med school curriculum, scientific method certainly ought to be. It's hard to imagine a person being accepted to med school without already having firm grounding in science, but the home-schooled Alice tells us otherwise. Any physician will be in the position of having to evaluate new information, as well as needing the ability to separate his/her "feelings" about what works from proof of same. It's reassuring that, at this late date, "evidence-based medicine" is becoming the new watchword.

A couple of other random comments. I trained at the same time and in the same place as Lorraine Day. In addition to being strikingly beautiful to an overworked and under, uh, relieved intern/resident, she was indeed a highly competent orthopod. Having visited her website not too long ago, I was shocked to see what's become of her. Mystifying on the one hand; evidence of the fallibility of the human mind under duress on the other. Which further confirmation of the need for doctors to know science.

An anesthesiologist with whom I often work, and who is a quite brilliant man, deeply versed in his craft and in the science behind it, has a naturopath wife. I tred softly when discussing it, but my curiosity is strong: what does he really think of it? Best I can tell, he's open-minded where there is room for it, amused where there isn't, and glad she's happy.

The overlapping of religious and "scientific" credulity is puzzling as much as it is frightening. I can accept the need for humans to hold certain beliefs, as they pertain to meaning of life/death and afterlife issues. It beats, at least for some, lying awake at night. And I can see that many people are able to segregate, and even openly acknowledge the conflict, such beliefs from reality. I know a man who lost his daughter tragically, and it nearly ruined him. Having not been religious before, the thought of seeing her again in some sort of afterlife gave him solace. He said, "Given the choice, I choose to believe." Who can argue with that? Yet maintaining such belief does not, for him, require rejection of things that are known: the age of the earth, evolution, etc. Perfect. And he's an attorney. I could not have as a physician a young-earth creationist. Maybe a lawyer. But medicine is too much based on science for me to feel comfortable with a person who can bend her/his mind to such an extent, in a field which would directly impact my health. This would be true even if I weren't a physician.

Penultimately, I suppose someone ought at some point to consider all of this in the context of home-schooling. Once again we come up against complex issues: freedom of speech, expression, parental rights, etc -- vs the needs of society. To what extent is there potential damage from indoctrination of false ideas? How many people like Alice would it take before a society stops advancing? Is there a minimum number of brilliant inquisitive and well-educated people a society needs to keep going? I'd think we need way fewer brilliant innovators than worker-bees, and as such I can rationalize the slow descent into dumbness that our society seems to be riding. One Orac, in other words, can cancel dozens of Alices, I'd guess. But it's a worry.

Finally, in trying to promote my book in the other thread on this subject, I nearly did the opposite, worming a Darwin reference as a way of legitimizing mention of the book. So now I make things worse by ranting on a subject not really even in the book (I did make very subtle and anonymous reference to Lorraine Day in it, since it's a memoir of my training). I'll try further to undo the damage by suggesting looking at "A chance to cut is a chance to cure" blog, which is listed in the Orac blogroll, and which has a nice review of the book.

Just for the record, I'm not wedded to my terminology.

I simply wanted to point out that a lack of understanding of the principles behind a specific design or procedure does not necessarily make the person performing the procedure incompetant.

I used the terms technician and engineer because in my experiance technician level work can be performed by someone with rote knowledge while true engineering work requires a deeper level of understanding.

For what it's worth, I probably would classify about 40% of the time spent on my job as unnecessary paperwork, 40% in technician level work (mainly conformance testing), 10% on necessary paperwork, 5% in training others, 4% wasting time, and less than 1% on work requiring an engineer's level of knowledge.

Finally, I did not mean to imply that a physician just dispenses pills. When I wrote "selecting the treatment option which makes to most sense", I was thinking of all the additional things you mentioned even if I didn't explicitly state them. Again, my apologies if anyone thought I was making light of the work of a physician.

So far as I can tell, practising medicine is far more difficult than any engineering I've ever encountered.

Cheers,

-Flex

I wonder if the mental disconnect needed to believe in a 6000 year old earth is akin to what scientists in Stalinist Russia had to cope with, when Mendelaian genetics was proclaimed anti-worker, and all biology had to conform to Lamarkian evolution? How do you do meaningful work when needed thoughts are verbotten?

"Speaking as both a physician and a scientist, I concur that the term "technician" is not appropriate. I view physicians as the engineers of biology."

Not a bad analogy, although engineering doesn't require the same encyclopedic knowledge as medicine - grasp the concept, turn the handle on the math, and you're done.

But I think that the applied aspect of medicine and engineering are the same reason why you see a lot of creationist engineers as well as physicians - ther's a focus on solving a 'problem', rather than the pure exploration of knowledge, plus an engineer or physician are sufficiently technically educated that they can pick out issues out of context and weave it into a narrative that's convincing to a poorly-informed lay person.

And, given they earn their living from a craft unconnected from their reputation as honest-seekers-of-knowledge, they don't have to worry about their reputation in the say way a scientist does.

The problem might be lack of critical thinking in courses, both in medical school and undergrad. I only have an outsider's perspective on medical school, but it does seem like it emphasizes memorization and process over scientific reasoning, which probably makes a lot of sense for clinical work. More like engineering than science, something I remarked on in pharyngula and something orac also said here.

I'm more familiar with pre-meds, since I've taught them intro physics and MCAT classes in physics and organic chem. My experience with these students (juniors, on average) is that most of them have never been taught how to reason about things. They often hate physics because you can't just memorize your way through - you have to understand it to do well in the course. (You'd have to understand it to pass if grade inflation weren't so prevalent.) The MCAT classes were easier because they were more about memorization and tricks to do well on the test.

So I don't think the solution is to present more evolution in the pre-med curriculum. We should require more reasoning in their classes, even at the expense of knowledge. A tough decision maybe, when medical school admissions depend on MCAT scores and 4.0s.

I have to say, I really appreciate everyone's desire to eradicate creationists from the medical community. Do we now have heresy and orthodoxy in science? Are certain religious beliefs not permitted among physicians? With all due modesty: I aced my premed classes, the MCAT, my preclinical courses, and Step 1, and my attendings and residents find me at least competent. I understand disease processes and drug mechanisms, and can diagnose as many common illnesses as my colleagues. None of this is affected by my creationist beliefs. Please think again before you proclaim so intolerantly that the screening process has failed if creationists become doctors. (If evolution is really true, creationism will eventually go the way of geocentrism. Don't sweat it. )

The problem might be lack of critical thinking in courses, both in medical school and undergrad.

Precisely. However, more reasoning and critical thinking doesn't have to come at the expense of knowledge. The courses that most challenged my critical thinking ability in college were literature-based humanities courses. One professor in particular consistently argued for better critical thinking skills, to the point where he announced it should be the major purpose of an undergraduate education. I tend to agree. These types of courses may be a good requirement to start adding to the pre-med curriculum. But I don't think they have a place in med school; at that point, you should have proven you have the capacity for critical thinking, that you are ready for training to be a physician. Like Orac said, that is the purpose of med school.

Alice, above, posted:

(If evolution is really true, creationism will eventually go the way of geocentrism. Don't sweat it. )

No one IS sweating it, except creationists. As Lewis Black so eloquently put it, "We have the fossils, you don't." And more all the time, including those transitional-form ones that seem so important to creationists. The noise ID'ers and their ilk seem to be making lately is really a death rattle. Going the way of Geocentrism, indeed. And Soon.

I'm not certain if one can relate the ways physicians and engineers go about their work as being similar, based mainly on the fact that both rely on applications of science to do their jobs. From interacting with the chemical engineers that I've worked with, their work relies so heavily on math, statistics, computer modeling and physics as well as all the advances in engineering, to aid them in making their professional decisions, that it's not that meaningful to compare this to the ways physicians do their jobs, particularly those who primarily take care of patients.

Perhaps a more apt comparison in terms of applied science would be to consider what doctors do relative to what industrial chemists do. The latter, one of whom is myself, do have to apply scientific knowledge from a variety of chemical fields to perform our jobs. We are expected to do useful things that results in practical applications of chemistry. Although I can be somewhat creative, all my work is done within the constraints of budgets, company policies, marketing objectives and timetables, government regulations and manufacturing capabilities. Doctors work under numerous constraints as well. However, I do have one luxury that physicians don't. I can run experiments to test whether the chemicals I choose to use are beneficial in the products that I'm responsible for. I don't have to rely on our suppliers marketing glitz or what's on their websites for the majority of my information. For a variety of reasons, physicians can't do this when they prescribe treatments or drugs. One would hope that they rely more on their own or their collegues' experiences, what is in the PDR or on the FDA websites, or what is in medical journals, rather than what is promoted in slick marketing campaigns from drug and medical device companies.

One thing that has struck be as odd, when I've read about how doctors are trained, is how they are purposely and publically humiliated during their training if they don't know the answers to questions. Little of this goes on in the chemical world, particularly that of an industrial chemist. In fact, the opposite is true, we're expected to ask a lot of questions, and seek out the advice of more experienced chemists. It's not seen as a sign of weakness to ask for advice. As one of my bosses said to me, "Learn from what others already know." Another one once told me that the sign of a good chemist is a person who is not afraid to say they don't know something. And you have to recognize that you don't know something, to say you don't know something. We're not beaten down for doing these things.

One thing that has struck be as odd, when I've read about how doctors are trained, is how they are purposely and publically humiliated during their training if they don't know the answers to questions.

Of course, in general people don't die if chemical engineers don't know the answer to a question. Doctors are sometimes called upon to deal with life-and-death situations where seconds literally count (trauma, cardiac arrest, fetal distress, for example). In these situations, indecisiveness, not knowing what to do, or choosing the wrong treatment can and does kill. A doctor getting flustered under pressure can and does kill, because a doctor who freezes or spazzes out when a patient crashes endangers the patient. Some of this abuse is part of a general toughening up process designed to train the students to be able to think on their feet, not get flustered even under pressure, and know what to do in emergency situations. You can argue that maybe it goes too far or maybe this isn't the best way to train students to know what to do in these situations, but the abuse (known in medical school as "pimping") is not without its reasons.

It's also not usually seen as a sign of weakness to ask for advice, unless it's obvious that you haven't tried to think the situation through for yourself (nonemergency situations, of course, where saving the patient trumps all such considerations). And if you haven't at least tried to think the situation through yourself and are too quick to ask for advice for problems that should be within your realm of expertise, well, in a doctor is it so unreasonable to view that as a sign of weakness?

True, most doctors don't have to deal with such emergency situations very often, and many never at all after they finish their residency. However, the purpose of medical school is to produce an undifferentiated physician who can handle general medical problems and is prepared to go on to further postgraduate training in a specialty. Medical schools are generalist in nature. They at least have to begin to lay the groundwork to prepare medical students to deal with emergencies.

Regarding the discussion of the similarities/differences between medicine and engineering, it's noteworthy that engineers also seem to be more susceptible to creationism than would be expected from people with a scientific background. I have a hunch that part of the reason for this is that the main difference between "applied sciences" and "pure sciences" is that the former disciplines involve imposing value judgments on states of nature; in medicine certain states of nature are "pathological" and to be avoided; in engineering, certain states of nature represent a system that "doesn't work." In other words, these disciplines include a mix of the normative, "what should be," and the empirical, "what is." And their goal is to transform, through human effort, less-desirable empirically-observable states of nature into more-desirable ones.

The problem is that humans are lazy and there can be a strong temptation to skip over the "through human effort" part and fall into the trap of trying to transform the state of nature through belief alone. Most people, unless they're truly delusional, don't try to do this when it comes to the immediate problems their profession deals with; no competent professional acts as if he can wish a patient into health or a bridge into stability. But when it comes to matters in which the professional doesn't have a direct stake, it's easy to magically slide from "this is how I think this natural process should work" to "this is how I think this natural process does work." To use a somewhat strained grammatical analogy, medicine and engineering are "imperative" disciplines whereas biology and physics are "interrogative" disciplines. It's easy for people to lose the distinction between the prescriptive and the descriptive.

I have to say, I really appreciate everyone's desire to eradicate creationists from the medical community.

Alice, that's the logical fallacy known as the straw man argument. I never said that I wanted to "eradicate" creationists from the medical community (read this for my views on young earth creationists). What I did say is that a belief in creationism (particularly young earth creationism) is an indication that one's critical thinking skills and grasp of science are not up to snuff, leaving one prone to other pseudosciences. In physicians, it doesn't worry me if the credulity that produces creationist beliefs leads one to believe, for instance, in cold fusion. It does, on the other hand, concern me if that same credulity leads to an inability to recognize quackery when one sees it or to harmful pseudoscience like denying that HIV causes AIDS. And it is a valid point. People who lack critical thinking skills in one area tend to be susceptible to logical fallacies in another.

That was my point. That is why I worry when I see a medical student or physician who is a creationist, particularly a young earth creationist.

Congratulations on doing well in medical school. However, medical school is often largely too much a matter of memorization rather than understanding. I've often said that you don't have to be particularly intelligent to get through medical school. Above average intelligence will do. However, you do have to have an enormous ability to work and memorize. You will probably do just fine as long as you stay in a specialty or situation where cutting edge medicine is not necessary. Hopefully, you will be able to compartmentalize and your credulity However, be wary. Genomic medicine depends heavily on evolutionary principles, biology, and molecular genetics to make any sense at all. It's going to be harder and harder for you to avoid it.

Please think again before you proclaim so intolerantly that the screening process has failed if creationists become doctors. (If evolution is really true, creationism will eventually go the way of geocentrism. Don't sweat it. )

Another straw man argument (plus the ad hominem of accusing me of "intolerance"). I never said that. I merely expressed concern that physicians are not grounded enough in science and critical thinking, and pointed to evidence indicating their level of acceptance of creationism as an example. You may think your critical thinking skills are adequate, and probably in medicine thus far they are. But young earth creationist beliefs are a marker of a bigger problem in critical thinking skills. I sincerely hope that you remain able to compartmentalize as you have been able to thus far. That you will remain able in the future is not a given, once you are out on your own and away from the environment of your medical school or residency, where you will no longer have professors and colleagues around to reinforce your medical teaching. That's why it's so critical to develop such skills early.

As for creationism going the way of geocentrism, I have no doubt that that will eventually happen. Ever since Darwin first reported his theory, the evidence supporting evolution has only gotten stronger and been reinforced my numerous interlocking lines of evidence supporting the concept of common descent. Remember, though, that it took centuries for geocentrism fade away. Darwin only reported his work 150 years or so ago. It could easily take as long for creationism to disappear as it did for geocentrism, in which case neither you nor I (or anyone alive today) is likely to see that happen in our lifetimes, and neither are our children or grandchildren.

Lorraine Day is also a Holocaust denier. That alone says nothing about her medical quackery, naturally, but it is a warning signal.

I am not sure if Lorraine Day truly is a Holocaust denier, although she did testify for the Holocaust denial Ernst Zundel, specifically that he had cancer and needed to be released from prison. True, she did sign a petition calling for his release, but it's not clear if it was because she supports Zundel's Holocaust denial, because she was a friend, or because she didn't know that he wasn't in jail awaiting proceedings to deport him to Germany from Canada because he was a Holocaust denier but because of his ties with radical right wing organizations. She could have seen his imprisonment as a freedom of speech issue, even though it was not.

Zundel, however, is an excellent example of my thesis. He's a full blown Holocaust denier and a full-fledged altie. His wife claimed that he "cured" himself of lung cancer, and he's into all sorts of woo-related treatments. His credulity when it comes to Holocaust denial clearly is a marker for his tendency to believe all sorts of dubious altie claims and a variety of conspiracy theories.

If by creationist alice simply means a belief in some sort of creator, well, that in itself is not necessarily inconsistent with critical thinking. Intelligent design ups the ante into denial. And any way you look at it, one has to accept existence without creation: either the universe, or the creator. If you can accept the concept of a creator existing without having been created, why then not the universe? Why have a belief system whose leap requires rejecting of what can be known?

And as to the "pimping" issue. I wouldn't argue that it's all in bounds. However, the most important thing a physician needs to know is when she/he doesn't know what she/he's doing. Hammering deep into one's psyche a feeling of alarm bells when one is outside of a comfort zone -- and making sure the perceived comfort zone is reality-based -- may be the most indispensible thing one learns in the medical school/residency process. Moreso in residency. Especially so, in my experience, in a surgical residency. (There was a time when some other specialties, unnamed herein, seemed to inculcate the opposite: a few weeks rotating through this or that specialty was enough to create a general physician quite capable of being a so-called gatekeeper, deciding when a specialist was needed and even what the specialist ought to be allowed to do.) For a gritty and witty and very informative look at a surgical residency, click (hoping this is HTML enabled) here

In an amusing little irony, my school's main teaching hospital is named after the guy who invented homeopathy. Yet we don't have any electives or research centers based on alternative or complementary therapies.

We do have electives in humanities, usually short courses interspersed with our regular studies that focus on the human side of medicine, some through analysis of art. We also have had a lot of lectures that try to keep us focused on the patient's perspectives in health care, in an attempt to minimize the number of us that turn into what LBBP described above.

I think it's important to keep in perspective that doctors and medical students are a diverse group of people. Some get jaded and become distant from other people. Others maintain a saintlike compassion. Some get set off track and divulge in alternative theories of health, others roll up their sleeves and march into laboratories to push for new treatments... At any rate, there's strength in diversity - a good medical community takes all types.

Medical school is a strange machine, that takes in bright and compassionate people and tries to turn them into seasoned professionals through a lot of strenuous study. It's not perfect, and I'm sure some people come out of the machine mangled and disillusioned. But the great strength of medicine is that it has largely protected itself from larger social and political trends that would try to shape medical curriculum. So a few creationist doctors or MDs who venture off into non-empirical land can be tolerated, as long as they don't try to sieze control of the machine. I dunno. I don't think there's any impending threat of medicine being taken over by people who reject scientific theory, but it's good to remind ourselves every now and then that ultimately what we do is grounded in solid science. So I think it's healthy (bad pun?) to run the creationists and Lorraine Days over the coals every now and then.

Sid,

I didn't mind your plugging your book the first time. I didn't even mind when you did it a second time. Heck, I even checked out Dr. Bard Parker's review on A Chance To Cut Is A Chance To Cure (one of my favorite medblogs, given that it's written by a busy practicing surgeon). Given his endorsement, I even thought the book might be worth checking out sometime, and I still might check it out after my grant writing frenzy dies down after the deadlines at the end of May.

However, with your latest mention of your book, I really have to tell you that the shamelessness of your book plugging is starting to get on my nerves. I imagine that it may be getting on the nerves of my readers as well.

As a physician who lives his life burdened with rational thought and evolutionism, I have to agree. Enough book plugging. And speaking of book plugging, I write about that and much more in.....

I think Alice would get along great with the group of med students I encountered last year who had to be reprimanded several times for praying over patients against their wishes. Pretty tolerant of them I thought. If someone doesn't agree just force it on them right? I work on occasion with a PICU fellow who is a young earth creationist and it never ceases to amaze me how much science he uses on a day to day basis while rejecting so much science at the same time.

I admit I don't know all the requirements for premed, as that is not my concentration, but one of the most useful classes I've taken in school (and I'm graduating in three weeks) is Research Methods in psychology. It's required of all psych majors (in addition to statistics) and has given me a firm grounding in how to critically read research articles (of all types) and understand if the statistics are being misreported (especially in more pop science media outlets). This skill has been helpful in every other science or research-based class I've taken. Just checking up on the degree requirements for chemistry and biology majors at my school, there is no such requirement on a research methods class.

It appears that, as others have suggested, the push for critical thinking -- especially in the understanding of the scientific method and how to tell good science from bad -- needs to start at the undergraduate level. And interesting that us "soft science" psychologists are already doing it!

Yeah, atltarheel, I had a research methods class for my psych major too. It was boring as hell, but I have to admit, it gave me a real leg up on the bio majors, who for some reason didn't have much in the way of stats or experimental design. And we actually had a course our first year of med school on principles of medical research, which involved the same stuff - how to interpet statistics, read peer-reviewed articles, random assignment, controls, all that good stuff. It didn't exactly cover the philosophy of the scientific method, but it was a pretty good start. Oh yeah, and psychology isn't a soft science. I got into many a debate over that in undergrad...

And Dr. Bartram, maybe I'm just a cynical bastard, but the image of a group of med students praying over a patient just strikes me as very funny. A little worrisome to be sure, but amusing nonetheless. I know medical students in general are pretty incompetent on the wards, but they don't have to wear their incompetence on their sleeves by resorting to prayer!

A few comments:

First, about engineers and creationism. It's not necessarily the numbers of people involved; it could well be that having a technical background makes them trickier. For example, Joe Schmoe creationist doesn't have powerful tools to argue with, but Dembski can BS much better, due to his math background.

To Alice - creationism is dead, intellectually and scientifically. It's been reduced to a zombie, incapable of producing new results. The impact today is *not* scientific or intellectual, it's political.

I imagine that it may be getting on the nerves of my readers as well.

You imagine correctly. It was such a good comment up until then, too.

I think Alice would get along great with the group of med students I encountered last year who had to be reprimanded several times for praying over patients against their wishes.

OK, I just had to pop my eyes back into my head. I never would have thought I might encounter peers like that in med school. And to have to be reprimanded more than once? The mind boggles...

I apologize, Orac. I've gone a bit over the top; it's new to me on several levels. I hereby desist.

"""Not a bad analogy, although engineering doesn't require the same encyclopedic knowledge as medicine - grasp the concept, turn the handle on the math, and you're done"""

Not so much- an engineer has to know where the problem is, why there is a problem, how to fix the problem and do it in a VERY short window of time so as to cause no shut down time, or worse, injury, death and explosions. My relative is taking their engineer course exam- the government one, and has 2500 specs/situations/formulas to memorize and apply.

Kind of like a doctors job.

My really big question is why do we allow pseudoscience into medicine. I asked on PZ Meyers blog if doctors were science based a few weeks back and people said it was an art. Maybe that explains the art course? Really- if there is no scientific basis for science, or it is optional to practice medicine without one after you have graduated, then WTF??? Maybe we should all just go to a healing artist like the ones found in the backs of free papers, and save the government a hell of a lot of money. I am incensed by the attitude that it is an art. Maybe bedside manner is an art, but not the actual diagnosis. And maybe people should suck it up and either leave doctors who don't have an effective bedside manner or freak on them AND write a letter to their governing body rather than whine about how conventional medicine has let them down so they are taking their toys to the whoo hoo playground. There are incompetent and rude idiots EVERYWHERE in life, and it seems like no-one actually tells these people what the problem is- they just leave. I will tell you from experience that when you do the Chicken Louie on a doctors head because he has just dismissed you as a fool or a mere peon, it gets their attention. Especially when you look them in the eye and tell him you are not there to waste your time and money or his- you are here because it is necessary and he better figure it out. Not exactly pleeasant, but at least I was as brutally honest as he was nasty.

People are not even being failed by doctors per se in the American system. With HMO's calling the shots, your average person has no better access to care and treatment than what I receive here in Canada. You are limited to who you see and what you spend- thankfully I am not. My complaint is with access to technology. Not a good thing to worry about- waiting for an MRI can be excruciating. I can get one without the government hassle.

As for med schools and CAM medicine- I just found out one of our hospitals has a freaking homeopathic provider in our old fols hospital. She writes about miasma as a problem- it blocks energy or some such nonsense. This is crazy. We have a HOPE FOUNDATION OF ALBERTA at our University, and it has government funding. Why? To study the effects of HOPE on illness trajectory and outcome. Pure and utter crap and whoo hoo but if I wasn't angry about this and listening to public radio- I would have never known about it. 2 million in funding when we need nurses and doctors and equipment. Nice.

Whatever- keep posting and know that if we continue on this path we will be screwed and an American Dark Age in the sciences will begin and there will be no hope for American ingenuity and inventiveness and curiousity- because everyone will just believe in their very own faith healer. What fun that will be.

This is interesting re: med school and memorizing. I'm an undergrad in physiology and was fascinated by physiology, anatomy, etc. I thought I would get all of that in med school, so I went and applied to take the MCAT (which is this Saturday). Then I went and took and MCAT class. I ended up hating the class. I could reason and critical think fine, but I cannot stand rote memorization and regurgitation. I can work through equations conceptually, play with multiple equations, and understand how it(they) works, but I cannot just memorize equations. The letters and numbers in equations just slip out of my head.

Everyone else in that class really liked to memorize. I was the opposite: I hated just being told something, I had to know why. So now, I'm way behind in the class but I really know why an equation is the way it is. Everyone else just memorized it.

I've decided to go to grad school instead, and just go with it on the MCAT.

I am incensed by the attitude that it is an art. Maybe bedside manner is an art, but not the actual diagnosis.

You shouldn't be

For example, there is a phrase in medicine that says, "The patient looks sick." What does that mean? It's not always something that you can put your finger on. It can be a combination of factors, each of which may not trigger any alarms but together tell the experienced clinician that a patient is in trouble, even if he looks outwardly stable and not too bad to the less experienced clinician or to the lay person. Some physicians can make a diagnosis with very little information and just looking at the patient because they've seen it so many times before. That and many other things comprise the "art" of medicine, along with, as you point out, all the patient interactions. In surgery, the "art" shows up, for example, in knowing exactly when to make what move to avoid trouble or in constructing a very pretty anastomosis, even though a less pretty one would be just as functional and the patient never sees it anyway. Knowing when to operate on a patient with an acute abdomen and when it is safe to observe the patient can be guided by science, but a lot of it still boils down to experience and judgment. We can try to design clinical trials to guide us, but in the end the results may be ambiguous, particularly in surgery. (Woo-hoo, this topic could be more blog fodder for the near future!)

Yes, medicine should be science-based primarily. It should be evidence-based. But it is still both a science and an art, and the art will probably remain even as medicine becomes more scientific. The art comes in when the science is less certain, for example in diseases for which there is little Level I data available or for diseases for which there are several acceptable treatments and the treatment must be tailored to the individual patient.

Along those lines: I've always found that, no matter how much I've been told in advance of seeing a patient, it never comes together for me until I'm at the bedside, seeing and touching that person. I may not find out more than the data already collected, but it's not until seeing the patient that I feel fully informed and ready to draw conclusions. And it's nearly always true that one must sift through lots of data, often contradictory. The "science" of medicine does not always lead to clear results: the uncertainty principle squared. When one takes measure of a human, the results are not always reproducible. Most of us, I'd say, have seen physicians who possess brilliant minds and who can enumerate an impressive list of possiblities, but who can't make the final synthesis needed to provide care...

Orac, I agree with your comments about knowing a sick patient. I feel that a significant part of my pediatric residency was learning to identify a sick child. I have seen countless children in my 10 years of practice who were quite ill and very experienced parents failed to recognize it. Anyone who has been through medical school and residency can remember the colleague who may have been technically at the top of the class and who knew all the facts but failed in this critically important area which involves overall pattern recognition.

Concerning the teaching of the scientific method and critical thinking: This represents not a failure of medical school or undergraduate education but a failure of elementary education. My eight year old understands the scientific method, which is the underpinning of our modern society, from teaching at home. Science in the school setting for her is already mostly rote memorization. Sadly enough, I think most elementary school teachers don't understand the rise of the scientific method as the foundation of our growth in knowledge over just the past 300 years. We shouldn't expect medical schools to teach what should have been taught as the basics of a science oriented education. In addition, the theory of evolution should be held up as one of the prime examples of the success of the scientific method.

Doctors are indeed the "engineers' of medical science, but there are two points to consider. First, an engineer who's out of his depth, or just gets lazy, starts to act like a technician....

The other point is that doctors aren't just medical engineers; They also have a human/social job, which is at least as important in the real world. This is what I've sometimes called their "priestly role", and it's not something you can separate from the kind of person who wants to become a doctor. Unfortunately, the two jobs each require a different set of skills! Not everyone can manage both, and more to the point, not enough people can manage both. The need to balance these two aspects leads to some difficult decisions as far as who gets to become a doctor....

I posted my comment in part 4 instead of 4a. Because I'm an idiot. I said a lot of the same stuff Orac said in this post

RPM said:

Secondly, don't most premeds engage in some research as undergrads? It was my impression that the competitive nature of med school application requires a resume with some research experience. Given that most research at an undergraduate institution is not of the clinical variety, shouldn't they at least have some understanding of how basic research is done?

'research' seems to consist of pipetting. At the undergrad level at least. THe questions they're asking/answering are simply too small, too simple, and too insignificant for it to have any real effect on the way these students think.

Obviously present company excepted, but one thing a lot of people don't realize about med students is that never in their educational process is critical thinking encouraged. As one of the commenters mentioned, a lot of med students/doctors basically become technicians. There's a big difference between learning about science and learning how to do science. One thing I'm fortunate for is that I was able to get at least some training in how to do science (masters in bioanthropology) before medicine sucked me in. And the one thing that hits me day after day is that med school (at least the first two years) is like first year undergrad all over again. 'learn this', 'memorize that'.

To those who say there's no room for more evolution education, *snort*.

I'm almost done with my first year of med school, and it's amazing how much of this stuff I'm told by recent graduates and long-time practitioners I will never see/use again (except for USMLE Step 1 next summer). Instead of useless classes, why not spend more time on evolution? After all, as Dhobzansky said, "nothing in biology makes sense except in the light of evolution"

One last point, biology/evolution education at the high school and introductory undergrad level needs to be drastically revamped to something more like physics. Instead of being a massive population genetics/mathematical equations borefest, we ned to introduce people to the theory and the whole of the theory. And not only that but introduce them to the evidence. I took AP biology in HS, took at least 5 evolutionary bio courses in undergrad, and got a master's in human evolution, and amongst all that coursework, not once did the professors treat it as their responsibility to cover why evolution is fact

Alice, you know why it bothers me that creationists are becoming doctors? Because to believe in creation despite all of the empirical proof out there means that one is intensely dogmatic. Med school can teach you to be dogmatic as well. The combination of personal dogma and educational dogma scares the pants off me.

Let me tell you from personal experience that there is nothing worse than dogmatic doctors. Nothing. That's when you get the 'well he has 3 out of the 4 cardinal symptoms, but he's missing the 4th, so we can rule that out.' Or, my personal favorite (and the one that kept me from getting my VERY screwed up back from getting looked at properly for nearly 10 years), 'He's too strong to have nerve damage and muscle imbalances'.

It's also dogma that leads doctors to warn a 210lb athlete with a 32" waist about his 'weight problem', while failing to warn that athlete's father of 'normal BMI' (but very overweight) of the danger's to his health.

Creationists have already proven themselves to make an a priori decision and then make the facts fit what they want them to.

Not a good recipe for the very messy real world.

I'm not saying they can't make good diagnosticians (because I've known a few who were), just saying that they have the deck stacked against them.

"Of course, in general people don't die if chemical engineers don't know the answer to a question. Doctors are sometimes called upon to deal with life-and-death situations where seconds literally count (trauma, cardiac arrest, fetal distress, for example). In these situations, indecisiveness, not knowing what to do, or choosing the wrong treatment can and does kill. A doctor getting flustered under pressure can and does kill, because a doctor who freezes or spazzes out when a patient crashes endangers the patient. Some of this abuse is part of a general toughening up process designed to train the students to be able to think on their feet, not get flustered even under pressure, and know what to do in emergency situations."

Point taken. Given the above stressful conditions, it's critical that person be able to quickly think and act on their feet.

But what about when a doctor is seeing a patient in their office? Is there a method to teach medical students and/or residents, given that they've memorized so much information, how to apply all that knowledge in a skillful way, so they can draw reasonable conclusions about what's wrong with a patient? From my own experiences, about half the doctors I've seen, all in their offices, appear to be able to be able to draw upon what they've learned or practiced, and whatever information is in front of them. The other half seem to get befuddled, unless there's a CT scan or an MRI or lab test that unequivacably shows what's wrong.

"Of course, in general people don't die if chemical engineers don't know the answer to a question."

That's true. But there are important ways that a variety of engineers make contributions that have a positive impact on peoples' health. Right now, for fun, I'm reading a book called 'Treatise on Controlled Drug Delivery'. It's edited by a chemical engineer. It's 550 pages of engineering equations and graphs (It's slowly frying my brain). Even I, a chemist, had no idea how much engineering goes into making a controlled release drug or transdermal patch.

Another role that engineering has played is in the development of CT scanning. The two people who won the Nobel prize in medicine for this are Allan Cormack, a physicist, and Godgrey Nounsfield, an electrical engineer. A B.S. in electrical engineering, that's all. Somebody had to work out the initial practical problems of this imaging technique, to the benefit of us all.

There are a lot of individual engineers and other scientists who quietly work behind-the-scenes contributing to advances in medicine. Their work isn't as dramatic or immediate as a surgeon doing an emergency operation. Which is why there are TV shows like 'ER' and 'Grey's Anatomy', but not ones called 'An Electrical Engineer and his Computer Models' or 'Chemical Engineer: Fickian Diffusion or Not!'

Dear Orac

I woke up this morning and thought of you. Well, not exactly, but when my radio went off I heard some nonsense about a Pediatric CAM organization in our Stollery Children's Hospital at the U Of Alberta.
Here is one link.
http://www.pedcam.ca/

http://www.care.ualberta.ca/scientists.htm

Here is a really interesting link on WHY kids are Cammed in the hospitals- their parents are asking for it because they don't like /have faith in REAL medicine......

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1297505

In an age where health care dollars are tight enough are we really to believe that this is an effective use of dollars and resources and PEOPLE???

I would love to know what you make of this as I am absolutely sick and shocked and angry. Is the anger worth it any more?

I still am upset. I know of what you speak- the patient LOOKING sick. As a parent I have had to convince people my children were sick because me knowing my kids was not enough. One time was pneumonia another an ear infection. Both times ended up with hopsital stays after the initial pat on the head by two older male docs who patronized me. That may not be indicative of everyone's experience, but as a mom who looked a lot younger than her years, it was a real, ongoing experience. And rather harrowing. I finally got to the point where I go to a medi-centre where I know the doc and just wait- because he trusts my instincts, does follow up and knows that I HATE being there for hours waiting so I probably am not there for sh*ts and giggles.

So is there bad art in medicine? Im my tiny corner of the universe I would say resoundingly YES. There are doctors who still make stick figures, and prescribe inappropriately and do not advance medicine in any way. There are doctors who can draw at an intermediate level- they know form and function and can do their job well- with no real newness but enough competence that people go by and say what a nice person. There are people in medicine who are Renoirs and Picasso's- they have magnificent ability and can see beyond the norm to create and maintain practices that are people centred and results centred and are second to none in their use of science and reason.

Probably a pretty bad analogy, but I do think that a doctor as an artist just does not fit. Maybe because too many docs stay on the art side and do not explore the science enough. When as a layperson I read more about how to read papers, synthesize information and how to figure out if a drug really is indicated for a certain condition than a medical person-----fact not fiction here AND only anecdotal I know----------- that is disturbing. For example, one drug was being peddled for a bunch of un-related conditions. It was a wonder drug. It would do A B and C at a dose big enough to take out two of me. It worked on certain receptors in the brain. It would help.

Dutifully, a loved one went through this treatment regimen. Somnolence, dizziness, weight gain, and irritability ensued. No relief from the original condition. Well, up the dose. Did that. Not so much luck. Exacerbation of symptoms. Quit the drug after several thousand had been spent, because it was interfering with the ability to be cogent.

I decided to investigate. This drug was actually approved for ONLY two conditions, the drug had no affinity for the receptors that had been told to us, and the side effects reported were absolutely on par with what others taking it had experienced. That the drug had made it past thousands of doctors to treat many conditions was not based on science at all. I will leave you to fill in the blanks as to why it was handed out like candy.

Two years later- the same condition- the same group of medical people. THE SAME ADVICE. Go on this drug. It is a great drug. Luckily, my loved one was able to contact me to come down and deal with this. I was able to persuade them to back down after showing medical records that showed this drug had not previously had efficacy, and educate them on the dearth of clinically valid information regarding this drug. A second drug was posited, but then rejected when I pointed out that it clearly was a CNS danger when mixed with their client's other drugs. I am just a person. These are people in a position of trust. They ought to know more than I do. They ought to know that when some organizations do a retrospective study on drugs that that is not the same as a double blind placebo study. They ought to know that no such study exists for the condition they are purporting to treat.

Science is a frame of mind. It is an ability to ask questions and look up information, separate the wheat from the chaff and synthesize what you are seeing or reading. It is a curiousity about the world and your particular place in that world. It is a bullsh*t detector- when A B and C do not happen, or happen so inconsistently as to be meaningless, then there should be a small voice asking why doesn't it work? Especially in a healing profession.

Every day I cook. It too is seen as an art and a science. There are principles in cooking. Too much heat- burnt. Too little - it is going to take forever to see results. Certain additions to a food can break it down, or keep it from sticking or make it fluffy. It is science. My food tastes no different if I am in a pissy mood or in a good mood. It tastes no different if it is on a blue plate or a white bowl. It tastes no different if I am in a hurry or not on a hurry while eating. The scientific principles behind cooking outweigh the presentation. It is still nutrition. Again maybe not a good analogy, but a fair one.

I guess I just think too many doctors are hung up on the art of doctoring, rather than the hearing of their patients and the science of their fields. I am not going to get better because a doctor is reassuring or comforting - I am going to if the doctor goes and does his tests. If there is no hope for what ails me, jollying me along with a false reassurance or bogus treatment will not be helpful. If I am fortunate to get a doctor who can put patterns together when my child is ill and come up with a diagnoses of lower lobe pneumonia- YAY for me and mine!!! And thankfully it is not CF or anything more drastic.

Thank you! I do hope you write more about this. I would like to know if evidence based medicine is effective at cutting costs, or if it stifles innovation, or are the drug companies going to have a reaction to it. I ahve a million questions at ten thirty here on a Saturday.

At the risk of sounding repetitive, I have to stick my oar in once again and defend my comparison.

It may surprise some people, but engineering is also a mixture of art and science. I suspect that you have to be in the specific engineering field to see it, but there times in engineering where experiance is more important than data.

The most obvious spot is when, like doctors, a device doesn't function properly. Sometimes the fault is easy to spot. At other times, the problem is deeply hidden. The art of engineering, at that point, is in deciding which tests to run to expose the point of failure. There are hundreds of various tests, but only a few make sense in any situation. In some cases it's obvious which tests to run. In other cases the only determining factor is the judgement of the engineer. Some engineers want to run all the possible tests, and I think there are physicians who do the same. Other engineers form a judgement without doing tests (or test strictly for positive results), and prescribe a change to the device rapidly. Other engineers suggest a number of changes to make without testing, we call that shot-gunning and those of us who prefer to think of our field as scientific abhor that approach. Shot-gunning is often preferred by our management, however, because they think it gives the best chance of a quick fix (and it looks impressive to a customer, all the little machines going 'beep').

As another example; molding plastic parts. The analysis of how plastics flow in molds has come a long way in the last couple of decades, but deciding what the shape of the plastic part needs to be to mold it without defects is still more of an art than a science.

There ARE vast differences between engineering and medicine. For one thing, today's physicians have to learn a lot more than any undergraduate engineer. For another, engineers often have more time available to make a judgement and test it. But there is more art to engineering than is usually credited.

There are also times when lives are at stake. At one point in my career I was working on air-bag controllers. If you have a fault in your air-bag controller, the air-bag can go off at the wrong time, setting off that pipe-bomb on your steering wheel. Nowadays I work on headlamp switches, another safety critical device. It's not as critically immediate as a individual in an ER. But my engineering experiance has been integral to the safety of the drivers of about 30 million vehicles.

I'm not knocking physicians here. I still think that as a class doctors are better trained, have a harder job, and work on more ornery devices than engineers. I'm just pointing out that like doctors, there are a broad range of functions that an engineer may be doing, and some of those tasks are closer to art than science.

Now back to studying for my final in the finance course I'm taking. It's always a fun break dropping in here.

Cheers,

-Flex