Tag: medicine

The World’s Top Scientists and Doctors

On By Christopher LansdownIn Philosophy, UncategorizedLeave a comment

There’s a cartoon going around which shows a man pointing at his computer and calling out, “Honey, come look! I’ve found some information all the world’s top scientists and doctors missed!” It’s been roundly and deservedly criticized, but I’d like to focus on a few points I haven’t been touched on.

The first point is the level of generality that is used (“all the world’s”) when “top” scientists and doctors are all specialists. If the guy may have discovered some information about whether dietary fructose causes insulin resistance, what does it matter whether the world’s greatest geologists don’t know this? Who cares whether the best heart surgeons know it? Would anyone be surprised if the world’s greatest ophthalmologist knows nothing about it? The cartoon makes it sound like tens of thousands of brilliant people have all been studying the exact question the guy has been researching, but the reality of specialization is that the number of people who are actively studying whatever exactly the guy may have found may well number less than a dozen. There’s no guarantee that this small handful of people are among the best and the brightest, except in the narrow sense that someone who took bronze in a competition with only three people in his division is the best in the world who showed up at that meet.

This, of course, is even assuming that anyone is actively studying the field. The inclusion of “doctors” suggests that what the man has found relates to health, and the number of things being studied in health is absolutely dwarfed by the things that there are to study. It’s entirely possible that there are no experts in the specific subject that the guy believes he’s found information in because no one has funded research into it in the last twenty years. And even if they had, it’s entirely possible to be an expert in only one aspect of a subject; a scientist who conducted the world’s greatest trial on the effect of aspirin in reducing heart attack incidence may be completely ignorant as to whether it’s effective for treating lower back pain.

Then we come to the thorny problem that many people are not courageous enough to consider: who has declared these people to be the world’s top scientists and doctors? Was it themselves? In theory, there is no one more qualified to identify the best in a field than the best in the field. But, of course, a man saying that he’s the greatest is worthless. So is it the world’s average doctors and scientists? But how do they know that these other people are better than they are? How did they even form this opinion? Where would a heart surgeon get the information necessary to know how good another heart surgeon is? Do they, in their copious free time, watch each other perform surgery? And what of researchers? Are we to suppose that scientists drop in and conduct audits of each other’s labs to see how well they’re actually conducting their research? Or does this all come from people who are not experts at all, observing? That might be valid for doctors like heart surgeons for whom we can collect easily evaluated data such as “how often was the surgery successful” and “how often did the patient die on the table”. Though even there, any system which relies on measurement can be gamed. A surgeon can look fabulous by only accepting the healthiest patients compared to one who takes on the riskiest patients. And most fields in science and medicine do not admit of even this kind of measurement. No one expects everyone with chronic back pain to become pain free, and the only reliable way to judge a doctor’s nutritional advice is to wait until all his patients die and see how old they were, and what their qualify of life was over the years. Since they may well outlive the doctor, this is useless.

So suppose you find a doctor who says that fructose induces insulin resistance and you need to limit your sugar intake, while a government-sponsored doctor says that you should eat as much fructose as you want but limit your fat intake. How do you know that the government-sponsored doctor is the top doctor and not merely the doctor with the best political connections? How do you know that the doctor with the plain office is not, in fact, the top doctor, in terms of ability?

People really want infallible oracles that they can query for whatever knowledge they want, but it’s just not available.

And, truth to tell, even if they found it, most people would reject it because they wouldn’t like the answers that it gives.

The Development of Psycho-Analysis Makes Sense if you Assume it Doesn’t Work

On By Christopher LansdownIn Philosophy, UncategorizedLeave a comment

I recently read the transcript of Freud’s lectures explaining to a Clark University audience what Psycho-Analysis is (Five Lectures on Psycho-Analysis). One of the things that struck me was that the development of Psycho-Analysis that he outlined makes sense if you assume that Psycho-Analysis doesn’t work.

The background we need was provided by Freud in the first lecture: a description of hysteria, which was the condition he was trying to treat. Basically, it’s a catch-all for severe ideopathic symptoms in a female. That is, if there’s something really wrong in a woman and doctors can find no physical cause, that’s then called hysteria. This isn’t trivial stuff—one example Freud gave was a woman who suffered paralysis in part of her body for extended periods. But, here’s the background we need: according to Freud, instead of despairing, doctors tended to give a good, if indefinite, prognosis. That is, the symptoms often went away on their own, though on their own time frame and not a predictable one.

So before we look at Psycho-Analysis, let’s look at the properties that a scheme of treatment which doesn’t work needs to have in order for the person developing it to be able to convince himself that it works, if it’s applied to conditions which tend to eventually get better on an unpredictable time frame.

The first and most obvious property it needs to have is that it can’t be supposed to work immediately. If it was supposed to work immediately, it would be obvious that it doesn’t work. Any such scheme of treatment must, therefore, be a process. However, it cannot be a definite process, because the patient might get better before the process is finished (which would not be a disaster because it could be credited to the process working extra well, somehow, though it would sew seeds of doubt) or else they might still be ill when the definite process has finished. It must, therefore, be an indefinite process.

What sort of properties would an indefinite process need to have, given that it’s not actually doing anything? Well, it will be tremendously helpful if it consists of a series of steps, each of which does have a definite conclusion, since that will give a feeling of accomplishment. If the indefinite process were just endless repetition of the same thing (e.g. identical breathing exercises), most people will get bored. By breaking the process up into steps, the feeling of completion of each step will give a sense of accomplishment, even if the total number of steps are not known. There will be a feeling that something has happened.

It would also be helpful if at least parts of this process are enjoyable or fulfill some other human need such as companionship, sympathy, etc. People will be a lot more inclined to believe that a process is doing what they want if it’s at least doing something that they want. This one you nearly get for free, though, since it’s hard to have a human being who sees you on a recurring basis and not have this feel like some amount of companionship. As long as the process doesn’t feel entirely adversarial, most any process that involves regularly meeting another human being will check this box.

The indefinite process also needs to be able to be explained as completed whenever the patient gets better. If you were supposed to keep doing something forever and the patient gets better, that creates a big credibility problem. And remember that we’re not talking about credibility to the patient, but credibility to the practitioner. A patient can just think he got lucky and who wants to question being well too soon? But a practitioner can only get lucky so many times before he starts to think that there’s something wrong with his theory.

If the indefinite process consists of some kind of peeling back of layers, that will do a pretty good job with this, so long as there’s no way to tell how many layers there are before you hit the last layer. Each layer being peeled back will feel like an accomplishment, and whenever the patient gets better anyway, you can declare that the layer you most recently peeled back was the last layer and this explains why the patient is cured.

Another requirement for the indefinite process is that the steps involved need to be something that everyone can do. You can only remove a splinter from the skin of someone who has a splinter, but you can massage anyone who has a body. If the process is a peeling back of layers, the process needs to be something where anyone can think that they have those layers.

OK, so, given all of that, what do we see in Psycho-Analysis?

The basic premise is that the patients’ symptoms are caused by unresolved conflicts from the past which they have purposely forgotten in order to not have to deal with them (“repressed”). These must be dealt with in reverse chronological order, that is, you have to resolve the most recent first. There are various techniques for uncovering the memories so that the patient can deal with the repressed conflict but one of the chief ones is doing free association with dreams, guided by the therapist.

So, how does this correspond to what we’d expect to see in a treatment that doesn’t work for a condition which will eventually get better on its own?

Perfectly.

We have an indefinite process with distinct steps—the uncovering of each individual repressed conflict (and its resolution, though that’s often easy once it’s faced directly). This allows a feeling of accomplishment with each step. We also check the box of fulfilling some other need—regularly spending time with someone who is interested in us usually feels good. Indeed, a noted feature of psychotherapy is “transference,” which is the patient feeling for the therapist feelings that they “actually” have for someone else. Often this is sexual attraction, but it can be anything—friendship, a parent-child relationship, etc. Of course, another interpretation of this is that the patient, who is lonely in some way, is starting to believe that the therapist is meeting this need. That will certainly provide the reason to keep coming back.

We also have a peeling back of layers. Each repressed conflict must be dealt with before the next one, starting from the most recent to the oldest. This can be terminated at any time—once the symptoms stop, you conclude that you’ve finally uncovered the original repressed conflict. We also have the feature that anyone can do the work. One of the main techniques is to free associate on the substance of one’s dreams. We all dream, and anyone can say whatever comes into one’s head when thinking of some part of the dream. The analyst’s chief job in this free association is to direct it. The analyst picks up on the key parts and asks for more free association on that, as well as asking questions about the subject. Whenever that stops working, there are always more dreams and more free associations to be made. Truly, anyone can do it.

In short, I could not have predicted Psycho-Analysis merely by the assumption that it doesn’t work at treating conditions which tend to get better on their own, but nothing about it surprised me at all.

Well, that’s not quite true. I didn’t expect Freud to redefine “sexual”to mean “sensory.” Which means that a lot of his theories about things like the oedipal complex aren’t nearly as whackadoodle as they sound when you first hear them. I’m dubious that they’re true, but they’re not “had your brains surgically replaced with rat droppings” insane.