Sunday, October 4, 2009

How to Get Into Medical School

Once in a while, I interview pre-med applicants to my school. While the medical students' evaluations are probably influential as only a low-NPV serial-killer screening test, I still very much enjoy doing them. This is because, if the applicants are eventually admitted, I get profuse thank-yous and friendly hellos for the entire subsequent year. Other than this experience, I have no knowledge whatever on the inner workings of the admissions chambers, so my insights are based on some post-call Gladwellian blinks.

Please note that Numbers 1 and 4 should not actually be followed by anyone, and are akin to obtaining a Golden Ticket by serially eating thousands of candy bars, or harassing hundreds of factory employees to unwrap them. It's just not worth it.

1) Take Physics for Poets.
And Literature for Actuaries. PE for Hobbits. Enroll in the easiest courses that fulfill pre-med requirements, and for which you almost certainly can earn an A- or above. The caveat here would be that you'd have to choose a somewhat traditional-sounding major, so it cannot be Fashion Merchandising, Liberal Studies, or Communications. Slightly newer, but still well-respected (and sometimes difficult, depending on your school- be careful!) majors, such as Women's Studies, as well as many interdisciplinary majors (i.e. Latin-American Studies) are considered fine.

My reasoning here is that, when it comes to course-work, admissions committees care mostly (though not exclusively) about Overall and Science GPAs, as well as a notable absence of Cs. A B- in "Physics for Future Nobel Laureates" is worth less than an A- in your standard Calc-based Mechanics course. Don't take any high-stakes gambles.

(For those now tuning in: Do NOT actually follow this advice. Take 4 years of Russian, a Combinatorics class, and a seminar on James Joyce. Keep your life joyous and a bit irrationally exuberant.)

2) Do your Undergrad at State School.
State school makes sense in general, and especially so if you are pre-med. It's generally easier to get an A in the science classes there. I know this statement may draw some contrarian personal testimonies from people who attended The University of Somewhere. The thing is, I know that many of the kids there are just as smart as the ones in Someone University, and that the teacher quality is likely the exact same. But the same student can often be in the top 10% of his Orgo class in a public school (also improving his chances for getting an excellent recommendation), rather than in the middling middle of an equivalent Ivy course.

3)Sign up for at least one test prep program, but not for any live classes.
Study by simply doing as many sample test questions as possible, starting on day one. Then go over the explanations and the reading material for anything you get wrong. You may get many or most questions wrong in the beginning. Still, do not waste time reading through the review books before you start taking practice tests. Take your MCATs in April, not August. Try to get at least a 30, unless you funded your school's infectious diseases institute (Treating Burmese children suffering from infectious diseases is not an acceptable substitute).

4) If Short on Time, Don't Dedicate a Huge Amount of Time to Clinical Experiences
While you should have some shadowing or hospital volunteering experiences, you do not actually need much of it. An EMT who has transported five patients looks roughly the same on an application as an EMT who has worked since age 16, has delivered a hundred babies, and can already interpret EKGs. The AMCAS does ask you how many hours per week you spend on each activity, but 5 hours vs. 10 hours per week probably doesn't get noticed. If stressed and cynical, think of marginal benefits.

(Repeated disclaimer: This advice is about what gets you into medical school, not about what you should do. To become a good doctor, take advantage of every opportunity you can to gain clinical experience. Some people cut corners without any one else ever noticing, but don't allow your values and ambitions to conform to this strategy).

5)Be Specific in your Essays.
When answering questions for your secondary applications, do not write "I am passionate about..." Have a strong, unique opening, even for those one paragraph answers. When addressing why you want to attend a particular school, refer to specific professors or programs. Don't use generic phrases like "Exceptional academics," "Excellent location," or "Outstanding research." Instead, say that you've always admired the [Insert Name] Free Clinic that Dr. [Insert Name] started, and you would like to volunteer there because he sees a lot of patients with [Insert medical condition], which is a disease you may want to specialize in.

(Don't lie. No one will ever know whether or not you are truly interested in that clinic, but to maintain your dignity, try to identify specific features of a school that you do actually care about.)

I know my take on medical school admissions is a bit cynical. However, even the most caring and mission-minded committee members must focus one eye on the US News rankings. The subsequent diplopia means that the theoretically best choices for pre-meds are not necessarily those that insure a successful application. If you find yourself sacrificing too many opportunities, I'd recommend dropping pre-med, enrolling in PA school, keeping your specialty of choice, and becoming a happy, dedicated, and productive clinician.

Wednesday, September 30, 2009

Psych Consult

Mr. A is a 40-year old male. After checking in his items with the clerk, and obtaining a full evaluation from the ER doc, the psychiatrist and students begin the interview.

Mr. A: You have to check me into the psychiatric unit. Otherwise, I'm going to hurt somebody! And I'm going to kill myself!

Student: Mr. A., Which do you plan to do first, hurt someone else or kill yourself? [Yes, I know it's a weird question, but we use it to assess the viability of the plan. Some patients take the bait].

Mr. A: Hurt someone else first!

Student: Who do want to hurt?

Mr. A: Anyone who pisses me off! I was already going to hurt at least 5 people today, before I checked in.

Student: How do you plan to harm someone else?

Mr. A.: I'm gonna stab them with a fork!

[After full assessment]

Physician: Mr. A, we're going to admit you into the psychiatric unit of the hospital... students can you please bring over Mr. A's belongings?

Student: Clerk, can you tell us which one's Mr. A's locker?

Clerk: Yeah, it's over here. But he only brought one item with him. I think it was a fork.

Sunday, August 30, 2009

The Epistemology of Paranoid Schizophrenia

Note: All details, including names, ages, and specific descriptions of conversations with staff or patients have been considerably changed. Sorry, I know that reality blogging is more fun than fake medical encounters. Additionally, the discussion exclusively concerns people with relatively mild or well-controlled schizophrenic symptoms, with whom I can easily engage in conversation.

When the psychiatry resident asked for an update on Tracy, I glibly responded, "Still very delusional. Thinks the CIA is after her."

"She's not delusional!" the doctor corrected. "The CIA or the FBI or whatever agency really is after her. Tracy used to threaten killing former President Bush numerous times. During her last hospitalization, I had to argue with the authorities for hours, to convince them that she's safe for discharge." Thus, my near-designation on my patient's record as possessing this delusion, or a "fixed, false belief," that is not "widely held within the context of the individual's cultural or religious group" was in error. Tracy's paranoia was based on truth.

The interesting part, however, of working with schizophrenic patients is generally not figuring out what is false; Patients have spoken of receiving commands from their televisions to overthrow the "vitamin pill industry," and of obtaining classified information that their true parents are Liza Minnelli and Bobby Fisher. Many patients insist that a doctor or nurse can gain remote access to the contents of their brains, via some transhumanistic, genetic link-protocol of sorts. False belief, check.

Determining what falls under cultural norms can be a bit trickier. One patient, David, believes that he and fellow schizophrenics have powers in the "sixth dimension," on an "etherical, astral, plane," a belief that I'd brand as delusional, if I 1) Knew what it meant, curvilinear coordinates not being my forte and 2) The International Headquarters of the Theosophy Society weren't right in my hometown, flagging this as a possible local cultural or religious belief.

The main challenge in assessing delusions, however, lies mainly in determining which are considered "fixed," or intransigent to reason and the passage of time. A binary "yes" or "no" to describe the "fixedness" of a belief is inadequate. Many patients come to the hospital voluntarily, desperate to rid themselves of fearsome beliefs or voices that they know, at least in part, aren't true. Thus, they demand anti-psychotics that deny the pleasure of dopamine, and beg for mood-stabilizing drugs that inhibit norepinephrine-fueled arousal. And those are just some of the intended effects. Side effects include dystonia, neuroepileptic malignant syndrome, the frog-tongued gestures of tardive dyskinesia, and the rabbit-mouthed oscillations of EPS. Patients are often desperate to "unlearn" their beliefs, and hope to foster distrust of the voices in their head, which so distrust everyone around them.

Tom, one of my fellow medical students, asks patients an interesting question: "What do you think is the percent probability that your belief is true, and what is the percent probability that it isn't true?" Lillian, who's convinced that President Obama promised her $1 million, so long as she refrains from eating, (the Cult of the Presidency is the only thing both alive and well in the psych ward) said "About 5% of me thinks it's true, and 95% of me thinks it's not true." Five percent is not terribly much. I'm sure there are plenty of beliefs I maintain with a similar level of certainty that would confer me with at least an Axis II diagnosis, if someone could scan my brain for the latest Bayesian updates. Which leads me to wonder if percentages and predictions can adequately capture the credos that serve as the foundation for diagnosing paranoid schizophrenia.

For those of us with homo economicus pretensions, such stated probabilities may even persuade us that schizophrenic biases are simply standard deviants from very irrational mean population thought content. Indeed, critics of psychiatry often insist that people are deemed psychotic, simply because their delusions don't conform to what all the cool kids are fabricating this season. In this view, once norms change (like they did when the medical professions stopped labeling homosexuality as a disease), many schizophrenics will be considered as peers among the unhinged masses, with all our opioidic (agonistic and antagonistic both), nonsensical beliefs unleashed.

Perhaps we can focus on a more qualitative approach to evaluating "fixedness." After all, numbers don't seem to work with a patient named Mark, who contemplates (at least after he's taken his meds) of the instructions he "receives" from the devil via rap songs on the radio, "they're sometimes real...I don't know... it's so hard to separate in my head." Perhaps, we can ask an Isaac Levi-inspired series of questions, checking off what David considers "serious possibilities," out of a "potential corpora of knowledge and evidence." I can ask David, "Do you think that it's physically possible for you to hear the devil speaking to you, and only you, from the radio? Logically possible? Technologically possible? Psychologically possible?

Defenders of psychiatric designations counter their critics by noting that virtually every DSM-IV diagnosis, including schizophrenia, must involve significant impairment in occupational or social functioning. Apparently, in 2003, 20% of Americans affirmed to pollsters that an HIV vaccine already exists, but is being kept a secret. And yet, I don't see many people staging the proper revolt that such a conspiracy, if actually true, would merit. Aberrant thought content alone is not the rate-limiting-step to being diagnosed as schizophrenic. Many people have negative thoughts about the vitamin pill industry, but only Sally (who has Schizoaffective Disorder, Bipolar Type) embraced her mission by roaming in the streets, "recruiting" fellow revolutionaries (i.e. passing cars), and propelling Los Angelenos into traffic-induced hysterics.

So for paranoid schizophrenics who maintain only 5% certainty about their delusions, perhaps they simply act upon this glimmer of confidence more often than others, like the "Deal or No Deal" folks who, knowing basic math, still reject the banker's actuarially outlandish offer, because, what if the million is in my box? According to polls, many Americans claim that our current president is a foreigner, and is thus ineligible for his elected position, according to our country's most sacred national document. Then we go off to do our laundry and water our lawns. However, there are always those few that can't eat, sleep, or tweet, while harboring such persistent ideations of conspiracy.

A behaviorist might say that, Bayesian self-reports not-withstanding, patients' actions exclusively measure their convictions. Skinnerians will believe our stated fidelity to untruth when they see it! All the rest perhaps just falls under the purview of "symbolic belief." In other words, you may take pride in widely professing that Obama is an alien, but watch your shame when a behaviorist calls you out on your pretense! My humble suggestion: To stay out of the psych ward, you're better off holding certain beliefs as insincerely as possible.

Wednesday, May 6, 2009

Palliative Care Grand Rounds is Up!

Thaddeus Pope at the Medical Futility blog does a beautiful job hosting the latest Palliative Care Grand Rounds. For my contribution, I describe an experience working with the family of a 28-year-old patient who died of breast cancer.

Tuesday, April 21, 2009

Med-staffing Coachella

Coachella is like a giant exhibition of Roomba vacuum cleaners, where restless young beings motor along toward one end of the giant field, bump into someone or something at the other end, and then head in a different direction, continuously for three days straight. Occasionally, one might stop to check out a band, buy a tofu naan sandwich, or take a puff of something. But mostly you just kind of amble around, smiling with kinship at each person whom you passed by a couple of hours earlier.

This seemingly underwhelming activity is actually quite joyful, and I do plan to one day attend as an actual ticket-holder. This year, I served as a med-student-helper-outer-to-the-EMTs, (but not officially as an EMT, as my license expired a few years back). The Company (not HIPAA) forbids us from speaking even generally about the cases we saw, but I'd say that the biggest progress made involved my riding of an awesome John Deere Gator everywhere. Thus, the lingering childhood resentment over my lack of Power Wheels (Miskeena!) is now officially resolved, sans therapy.

Thursday, April 16, 2009

Grand Rounds is Up Again!

Brought to you by Dr. Guzmán at Pharmamotion. My submission addresses the pressing issue of med student apparel.
Guzmán has a very Canadian post about Gp IIa/IIIb inhibitors (a class of anti-platelet function drugs) over here. I mention this because tonight is the magical night where the fairy godmother comes and I transform into a Canadian at the stroke of midnight. So I'm channeling all my Kafkaesque energies into becoming the pharm video narrator with the pleasant voice, rather than this guy.

Sunday, April 12, 2009

Weird Medical Etymology of the Day

Fornication comes from the word fornix, which means "arch." In Roman times, customers used to identify the brothels by a prominent archway at the entrance. (Coincidentally, we refer to the anterior, posterior, and lateral fornices as components of the uterus, but we also have a fornix in the brain, so interpret that as you will).

HT: My Gross Anatomy Prof

Disclaimer: I take no responsibility for the possibility that this is all urban legend.

Friday, April 10, 2009

Doctors and Speeding

“The officer proceeded to pull out his gun, point it at my face, and told me to lay face down on the ground, which I did. At this point, my ID card dropped on the floor and I remember him stepping on me, probably putting his knee on my back, and then cuffed me.”

This is how a Dr. Ziworitin of UMC describes his encounter with a cop, after the physician was stopped for speeding, while rushing to hospital for an emergency.
Radley Balko writes, "Even if the cop doubted this guy was a doctor, the cuffs, gunpoint, and a boot in the back all seem more than a little excessive, no?"

The shear theater and spectacle of the violent assertion of power certainly makes ones bristle. However, the outrage over this incident, as well as the outcome of the DPD PR disaster, both make me a bit uncomfortable. Certainly, cops ought to exhibit some common sense. However, people should know that one's emergency does not confer an implicit right to put other people's lives in danger. If we express only populist outrage, (which is distinct from genuine sympathy for the driver's misfortune), we may forget to communicate that it is perfectly reasonable for a cop to stop a car, and tell the driver to slow down (pulling out the gun is...unnecessary).

I don't know how things work here in the U.S., but when I worked as an EMT for the Red Star of David in Israel, we were explicitly forbidden from going beyond a particular speed, even if the patient was in cardiac arrest. So if people facing tragedy deserve to not be harassed and threatened by the cops, the police, in turn, deserve increased public awareness that sensible traffic rules aren't conditional to one's personal, or even tragic, circumstances.

Medical Research Fraud

Because of "Scrotumgate,", my favorite medical resource, The Thackery T Lambshead Pocket Guide to Eccentric & Discredited Diseases, requires an update.
HT: My Pharm Prof

Tuesday, April 7, 2009

Grand Rounds is Up!

Leslie at "Getting Closer to Myself" did a fantastic job of organizing all the posts submitted by a motley crew of medical bloggers. The theme is "Reflections on the way life used to be."
And I got a star next to my name! If I still got stars for doing good work, I'd be on dean's list.

In other world wide web-related news, I have a post up about medical licensure at the "Students for Liberty" blog. It features a sweet parking spot (these things matter to L.A. girls).

Monday, March 30, 2009

The Banality of Marijuana in Medical Education

In one of our GI lectures, among the interminable pharmacology powerpoint slides that address anti-emetic drugs, the following information appeared:
If an alien guest to our planet perused a pocket pharmacopeia, and had to guess which drug would be "fetishized" over all others, I doubt he'd pick marijuana. Mind you, I'm not convinced that there are many positive benefits for healthy people to take marijuana (and smoking a combustion product is more carcinogenic than using a vaporizer). Yet cannaboids strike me as just another class of drugs with certain indications and side effects, some known, some perhaps unknown. Another anti-vomiting drug, metoclopramide, can lead to tardive dyskinesia (Parkinsonism). Scopalamine, yet another, features a whole slew of anti-cholinergic (antagonistic to the parasympathetic nervous system) effects, and can cause delirium in overdose.

However, when patients with cancer obtain the latter two drugs, we praise modern medicine's ability to provide some alleviation to the horrible side effects of chemotherapy. When patients happen to select the former, we convict their state-law-compliant medical dispensers of crimes punishable by up to 100 years in prison.

Monday, March 23, 2009

Taleb and Pre-test Probabilities

Arnold Kling comments about Russ Roberts' conversation with economist Nassim Taleb:

I was most interested in the latter third of the conversation, where Taleb talks about his radical empiricism. For example, he argues that medicine makes more progress with trial-and-error than with knowledge of biological processes.

Trial and error would require taking a drug already known to be ineffective, adding a methyl group, testing the new molecule on a statistically significant number of patients, and then methylating again, until we've tested infinite permutations of "little-value-added" functional groups. We'd be bored sick.

One of the reasons why many empiricists object to all the funding that goes into certain alternative medicine projects, such as magnet therapy or reiki, is that, based on our understanding of physiological or biochemical principles, the pre-test probability of such treatments being effective is pretty low. An extreme Popperian would object, insisting that we can't truly know if anything works, before testing it, (and once experiment concludes, we still couldn't be sure). Such agents of uncertainty would be technically correct.

However, science does not mean claiming omniscience nor capitulating to any smidgen of doubt. Science involves taking the information that lies before us, determining what phenomenon is most likely, and using these findings to develop a testable hypothesis. We are occasionally lucky enough to discover a drug whose mechanism of action we do not fully understand (such as in the case of Topirimate for epilepsy, or the prevalent use of beta-blockers of hypertension, long before we knew how it worked). Yet relying on lucky breaks, or "trial and error," rather than "hot on the trail" paths gleaned from discoveries in biology, is like searching for a bank robber by starting with the As in the phone book. Or like seeking out a black swan, by beginning the expedition at a local Los Angeles lake.

Thursday, March 19, 2009

Med Students Lobby Congress for Tuition Breaks

People, I know that we aspiring physicians are all in major debt, but some Americans can't afford the rent for their trailer homes. Let's leave the welfare-for-the-well-to-do-groveling to the AIG execs.

Ross Douthat is Trying to Murder Michael Kinsley! (Or Some other Distortion of Douthat's Views)

Brad Delong links to "The Daily Beast" and writes:
Michael Kinsley confronts the fact that Ross Douthat doesn't care more than a smidgeon about whether Kinsley lives or dies from Parkinson's disease.

If Kinsley were facing imminent death, and the only guaranteed antidote was a destroyed embryonic stem cell, I'm sure Douthat would fly over in a crimson-colored-cape and perform the destruction necessary to save the day. The fact that Douthat opposes federal funding for promising basic science research, that may one day be used treat PD, is far removed from the notion that Douthat doesn't care whether Kinsley lives or dies. If all of us were certain that could automatically save a life by sponsoring a certain magnitude of stem cell research, most of us would wire donations overnight. We don't do this, and thus admit that Kinsley's life is not immediately and urgently dependent on it. Reducing the situation to two variables (Kinsley's life versus stem cell funding), as well as admitting no degree of uncertainty about the potential effects of both the research and its related public policies, is innacurately simplistic.

Ok, I stood up for the social conservative.

Now, let's get the pluripotent blastocyst-derived inner cell mass differentiation party started!

Update: Before writing this post, I had written the first paragraph, as a comment in Brad Delong's blog (it did not include the more bellicose title of this post). It was taken down, after a few hours. Brad Delong has the right to do whatever he wants on his blog. However, I am disappointed by an academic who is unwilling to tolerate reasonably polite critique.

Wednesday, March 18, 2009

Who Lives?

Mr. Smith is a 58-year-old African-American male, who appears at least a decade older than his stated age. He is about 6’0, slim, and features a neatly-trimmed mustache. He sits stooped forward, and relies on a cane to get around. Mr. Smith has a pleasant affect, and even offers to get me a cup of water. His legs show moderate edema, and his eyes feature notable scleral icterus. Mr. Smith is on the list.
Mr. Smith inquires to whether I’m “also on dialysis,” and if I voted for Obama. I told him that I’m attending as a medical student, and that I don’t share my political views in public. Mr. Smith believes that Obama will bring us “back to nature” and will stop “sending jobs overseas.” I smile and tell Mr. Smith that I hope the president helps solve the economic crisis. This is no occasion for pessimism.

Mr. Smith expounds on his dating woes. His last girlfriend was “too needy,” and wanted something more permanent than Mr. Smith was able to provide. Mr. Smith implies that his misgivings were more due to his lack of emotional readiness, rather than the fact that his remaining days are contingent on a fluctuating number on a table, and that, like many of the 101,236 current Americans waiting for an organ, he may die before receiving a much-needed kidney transplant.

I met Mr. Smith, because I happened to sit next to him this past Sunday in a downtown Los Angeles theater, to view “Who Lives?,” a play Sponsored by the Renal Support Network. The production takes place in early 1960s Seattle, and explores the moral anguish afflicting a committee dedicated to choosing the lucky few who will test a curious, but experimentally promising machine, which “removes your blood, cleans it out, and then returns it to your body.”

The panel consists of a devout priest (“God has chosen us for this very important purpose”), an overwhelmed homemaker (“Father, there isn’t anything spiritual about this!”), a blue-collar craftsman (“The workers are always getting a raw deal, so what’s so wrong…”), a pedantic, neophyte doctor (“Disease is just the gross exaggeration of aging”), a pushy Jewish lawyer (“F-ck doctors”), a beautiful, liberated grad student, and some un-endearing blonde guy, who instinctually rejects Black applicants, and focuses the rest of his attention on seducing the grad-student. The group’s task involves ranking people, not merely based on medical criteria, but also each applicant’s presumed “value” to society. Thus, the committee debates the relative "significance" of musicians versus businessmen. The wealthy versus the poor versus the “rags to riches” success stories. Women versus men. Women with children versus men. Fertile women versus infertile women versus men. Blacks versus whites.

Today, such technocratic management of life and death strikes one as pretty abhorrent. Unfortunately, however, I find no solace in our contemporary method of organ allocation. Indeed, while we, as a society, have come to recognize the human infallibility inherent in prioritizing human lives, we now do something far worse, by creating an artificial shortage of life-saving organs, and banning individuals, charities, and the government from paying people for their kidneys.

We invoke all kinds of moral arguments to dissect messy commerce and greed from the prim and genteel art of uprooting a meat-sized slab of tissue, hitching it to various tubes and plumbing out a urine stream. To defend the volunteer-only status of organ donation, liberals and conservatives alike manufacture arguments that they would never entertain, when concerning other topics: “The poor will be the first to give up their organs, and this is harmful!!” (Cs: Should we prevent the needy from obtaining payday loans or eating at McDonald’s? Ls: Ought we to restrict women from obtaining abortion or birth control, even if it posed her some risk?) “It will be racist!” (Check out the demographic makeup of the waiting list.) “It will cheapen the ideal of giving from the goodness of one’s heart! “ (Ls: Do you ascribe the same logic to food stamps? More ceremoniously- “Would you like to sign up today and volunteer to save a life?! Low risk and high 'goodness of heart' satisfaction! No? I, shamefully, haven't signed up either...”) “Legalization will increase violence and coercion!” (Organ prohibition, meet drug prohibition), “Only rich people will be able afford them!” (Rich medical tourists and insurance-holders are generally the only ones who can afford obtaining organ transplants. If legalized, there may still be a disparity between the rich and poor in organ procurement, just as there is in all aspects of medicine, but this does not call for a ban on all medical procedures. However, we can legalize organ sales, and then- depending on whether you favor Heritage or TAP- accept a certain degree of inequality, or fiddle with our health care system, so that the poor can afford organs, as well).

My feeling is that most people oppose economic exchange of organs simply because the whole idea seems very, very unpleasant (yes, to me, too!). But good public policy is not constructed to convenience such a persnickety relic of natural selection as our sense of disgust. We ought to focus solely on whether we are actually helping people like Mr. Smith, who needs additional time to find the fellow freewheeling partner of his dreams.

In “Who Lives?,” while the committee pores over endless piles of pallid folders, the delicate housewife cries out, “We shouldn’t even have the power to make this decision!” However, she and her colleagues at least brave the clearly-understood ramifications of crafting countless letters featuring the dreaded words, “We regret to inform you...” Today, meanwhile, we largely avoid such formalities, by revering our high-minded legal dictates, and remaining casually inattentive to the tragic reality of thousands of end-stage kidneys.

Friday, March 13, 2009

Judging Others

At Overcoming Bias, Robin Hanson states:

When evaluating someone intellectually, I tend to downplay their degrees, publications, affiliations, etc. and focus on how they handle themselves in intellectual conversation. But most academics have more prudish norms, and consider it rude to challenge prestigious visitors to thoughtfully discuss topics beyond their prepared speech. Thank goodness my favorite lunch partners share my imprudish tastes. :)

I wonder if his method of evaluating intellectual ability may introduce more bias than does checking out the speaker's degrees.

If someone has a fancy education or job, she demonstrates that she was at least able to accomplish something minimally substantial over time (except in rare cases). If you judge someone based on a single conversation, well- What if he was nervous? Sick that day? Expresses himself better through writing than via speech?

I'm still working out my general approach to judging others. Which is the most fair (and possible) strategy: Matthew 7:1 , Pirkei Avot 1:6, or regularly scheduled Bayesian Updates?

Wednesday, March 11, 2009

Show Your (Well, Other People's) Work!

Olivia Judson's fabulous blog for the New York Times leads me to wonder:
Why aren't all journalists required to cite their references?

Monday, March 9, 2009

Just Deserts

I just viewed a Bloggingheads video, which featured Will Wilkinson, of the Cato Institute, and Lew Daly, scholar at Demos, and author of the book, "Unjust Deserts." Daly asserts that, because, capitalism's winners' can attribute much of their success to the intellectual contributions of past innovators, the wealthy Johnny-come-latelies owe some sort of "royalties," to the rest of society.

Robert Nozick once made a similar, "Hey, Those rich guys weren't all that back then," argument, but only to armchair-psychoanalyze the jealousies of the anti-free market intellectual class. He believed their views stem from the sudden weaning of these approval-junky scholars from their teachers' sweet, selective praise:

"Schooled in the lesson that they were most valuable, the most deserving of reward, the most entitled to reward, how could the intellectuals, by and large, fail to resent the capitalist society which deprived them of the just deserts to which their superiority "entitled" them?"

I'm having technical issues using the bloggingheads site (image only appears in the corner), so I will embed my next queued video over here:

Moore's Paradox

In second grade, I received a poor evaluation on a particular homework assignment. We were given a worksheet, which featured sentences such as:

A) It is raining outside
B) "I like chocolate."
C) "That girl is beautiful."

The teacher told us to ignore whether or not the statements were true, but to focus on whether or not each fell into the purview of fact or opinion. I sincerely believed that A and B were facts, and that C was an opinion. (B was apparently an opinion).

I'm still a bit stubborn about that answer. Can't a lie detector determine, within a certain margin of error, whether or not the anonymous kid indeed enjoys chocolate cake? I suppose this semantic confusion can be avoided with clearer instructions about which aspect of the sentence to evaluate, or with a less hopelessly literal third grader (The girl in the sentence is stating her opinion. Get over it, kid).

In his new communal blog, Less Wrong, Eliezer Yudkowsky mulls over Moore's paradox, Wittgenstein's favorite reflection on assertion versus belief: "It's raining outside but I don't believe that it is." Yudkowsky expounds on this contradiction to differentiate between belief and endorsement. He says,
"It's not as if people are trained to recognize when they believe something. It's not like they're ever taught in high school: "What it feels like to actually believe something - to have that statement in your belief pool - is that it just seems like the way the world is. You should recognize this feeling, which is actual (unquoted) belief, and distinguish it from having good feelings about a belief that you recognize as a belief (which means that it's in quote marks)."

I think that the mix-up largely stems from failing to juxtapose the concepts of truth/falsehood with fact (be it true or false)/opinion . Beauty is neither truth nor falsehood. It's just opinion- until we are given a more specific, working definition (i.e. "Beauty is the democratic consensus").

As Yudkowsky mentions, we use the word "believe" to express a lot of different concepts. For example, we say,

1) "I believe she is beautiful"- If we ignore the fussiness of my third-grade self, we'll call this an opinion, neither true nor false. Perhaps in need of clearer criteria, but certainly not irrational.

2) "I believe it is raining" -A statement concerning fact, which can be proven as true or false", and

3) "I believe in life after death"- A statement concerning fact, which cannot, however, be reasonably proved or disproved.

We also use the word "believe" ways that are difficult to categorize- say, "I believe in liberal/conservative political policy."
Is this statement purely an endorsement that requires no need for evidence (Example 1)?, Or, given clear-cut, agreed-upon goals, can evidence show that one ideology is likely superior (Example 2)? Or is this divide, with its necessary "whole world as laboratory" scientific design so hopelessly flawed and impossible that it is akin to attempting to prove "life after death."(Example 3)?
2 plus? 3 minus?

Is the term "belief" better used to make assertions regarding facts, or is the word better spared for expressions of mere opinion? My problem is that, despite having passed third grade, I'm still not always sure about the category in which my pronouncements belong.

Sunday, March 8, 2009

Hal Incandenza on Doctors

It will start in the E.R., at the intake desk . . . or in the green-tiled room after the room with the invasive-digital machines; or, given this special M.D.-supplied ambulance, maybe on the ride itself: some blue-jawed M.D. scrubbed to an antiseptic glow with his name sewn in cursive on his white coat’s breast pocket and a quality desk-set pen, wanting gurneyside Q&A, etiology and diagnosis by Socratic method, ordered and point-by-point. There are, by the O.E.D. VI’s count, nineteen nonarchaic synonyms for unresponsive, of which nine are Latinate and four Saxonic. . . . It will be someone blue-collar and unlicensed, though, inevitably—a nurse’s aide with quick-bit nails, a hospital security guy, a tired Cuban orderly who addresses me as jou—who will, looking down in the middle of some kind of bustled task, catch what he sees as my eye and ask So yo then man what’s your story?

Thursday, March 5, 2009

Random Stuff From This Week

Last weekend, I attended the California GOP Convention, where I mostly hung out with the Log Cabins (luau themed party with free piña coladas!). Yes, I know I've just outed myself as a Republican, but I consider this choice as largely strategic. My political passions constitute a giant matrix, but, given a de facto two party system, a tiny vector, once political polarity is superimposed. I work for this group.

I went on a mini-hike in Eaton Canyon with the husband (That's me above, taking a break). Roots sweatshirt- yeah, I'm half Canadian. Every year, I pit stop to visit my bubbe (yoy!)in Toronto (eh!), before heading to New York (bitch). Pictures of all the Eaton Canyon waterfalls are trapped my husband's camera at lab, so they'll be up later.

Today, I took the practice boards at my school. I'm kinda screwed- unless the Kaplan Fairy leaves, like $10,000 under my pillow.

I have a 5:45 a.m. AA meeting to attend, as part of my Clinical Medicine course, so I've made a searching and fearless moral inventory of myself, and decided that I'm justified in spending the night blogging and watching the entire season of Top Chef (although some spoiler already told me that the bald yid wins).

Sunday, March 1, 2009

Narrative Medicine

Ms. Smith is a Caucasian 68-year-old morbidly obese (400+ pounds) woman being treated for congestive heart failure. She takes short, labored breaths, and has symmetrical pitting edema in her legs.

Ms. Smith cannot get up to move herself to sit on the bedside commode, so the petite Chinese nurse leaves to request additional help. As the nurse exits the room, Ms. Smith turns to me and says, "She can't do this by herself? What are they paying her for?"

Ms. Smith's father was an abusive alcohol addict. Ms. Smith divorced her husband about 30 years ago, after she discovered that he had cheated on her, the first clue being the gyn's diagnosis of chlamydia and gonorrhea. She had had a hysterectomy at age 28, due to a prolapsed uterus, following birth of twins. When she announced her intentions to divorce her husband, he said, "I wasn't going to stay with you, anyway. I wanted more kids, and you can't have any." Ms. Smith's ex-husband recently died of a stroke, following surgery for prostate cancer. Ms. Smith says "I am glad that G-d let me see him in such pain in my lifetime, the bastard deserved it."

Ms. Smith never leaves her house, but a kind neighbor drops off some groceries about twice a month. She has no relationship with her children or grandchildren, for reasons she did not specify. She has no plans to improve her life (her one pleasure is "spraying her sheets with perfume," which reminds her of the way her mom smelled, and provides an "aromatherapy" feeling). However, she does faithfully take her 13 medications every day.

I asked Ms. Smith what she had to lose by sending her grandkids Christmas or birthday cards. If she didn't have a relationship with them, the worst thing that can happen is that the situation remains the same. Ms. Smith, bitter during most of the conversation,lightened up during my blunt challenge. "Yes. That is true. What do I have to lose?" Then her smile faded. "I just don't think I'd be able to deal with the rejection."

In many ways, I'm privileged to work in a hospital; For better or worse, I get to witness and learn from other people's life mistakes. This is a woman who spends the overwhelming majority of her day watching TV in her bed. It would seem to an objective observer that a genuine attempt to live in any different way ought to be wholeheartedly embraced. Ms. B is not afraid of death ("I'm just waiting for God to take me, when he wants to take me"), but is utterly panicked about sending a Christmas card.

When I see situations like this, I realize just how irrational it is to be nervous about contacting an old friend or putting up an inarticulate blog post or do anything else, for which I might be judged. I see the ultimate futility of caring too much about what other people think.

I suggested an alternative for Ms. Smith- perhaps she can keep journals, which her granchildren could one day read. Ms. Smith started to ramble excitedly, "Yes. It could by my legacy to them. Something for them to know me by...It won't get my voice inflections...but I could still give them advice..make sure they don't make the same mistakes. I can tell them to always stay celibate. That is the only way to stay safe."
I've recently read about "Narrative Medicine," a movement pioneered by Rita Charon, in which patients, even (especially?) those in palliative care, write and reflect about their illnesses. To me, the narrative medicine is particularly seductive, as it provides opportunities for doctors to inculcate values in which they're often criticized for being remiss- empathy, consideration of the "whole" patient, and integration of other fields- all without sacrificing a commitment to evidence-based medicine.

The evidents suggests that narrative medicine may help mitigate pain, or even increase survivorship and longevity. Promoting science-based medicine is not in conflict with recognizing the bio-social-psychological model of medicine, nor realizing that the effects of, say, loneliness can discernible physiological consequences.

I had no major suggestions that were acceptable for Ms. Smith, on how she could perhaps improve her life (Therapy? No Nutrition Counseling? No). She will likely remain alone for the rest of her life. However, she might punctuate her TV-viewing with journal keeping. So, maybe I've my part to ensure Ms. Smith's lasting legacy.
I wonder when I'll start recommending to all the lonely seniors that they ought to start blogs.

Wednesday, February 18, 2009

Do Not Mess With Dana Stevens

A few days ago, I wrote a post admiring the writing skills of Dana Stevens, the culture critic at Slate. I then stumbled upon the following review of Stevens, which included such tidbits as,

"The result in Stevens has been some of the most comically overwrought prose this side of an undergraduate civics paper. Two posts by her in, and the Movie Club is the worse for wear....[after quoting Stevens] It’s January 3rd, folks, yet that may be the most inept attempt at a meaningful sentence I digest all year."

I will try (and often fail) to avoid forging ad hominem attacks. However, I am a big believer in defending people, even phantoms whom I've never met, the ones who live in copper wires and fiber optic cables. Thus, I do not draw my own "civility line" at presenting harsh critics in their own words. Therefore, here is more from Freddie DeBoer:
Title of Blog Post from last week:
"The Continuing Fraud of Mickey Kaus"

On Martin Peretz:
"His blog is linked to by mainstream blogs and online magazines. He is a firmly establishment figure. He is also a vulgar and hateful man....he's become a clownish figure..."

And then there are almost 400 earlier blog posts that I don't have the energy to wade through. This all may seem like trying to remove the whips from the sex shop; after all, the civility norms of the internet differ from the general tone of face-to-face conversation or academic journal critique.

However, what irks me is that the following is posted on Freddie De Boer's personal wikipedia page:
"I believe that the irrational anger, out of hand rejection, and defensive zeal with which people on Wikipedia reject postmodernism reveals the degree to which that rejection is the product of doubt and fear...I think nothing can be accomplished without an attempt at genuine dialogue, founded on mutual respect and a good faith understanding of the opponent's viewpoint [words bolded in original]."

As much as I try, I will not always write in a respectful tone. Please call me out on it, as this is something I try to avoid. We all have our bad days. However, if someone mocks people whom I admire, he will be called out on that, as well. We are left with differences of opinion concerning what is respectfully-conducted discourse, and upon whom forceful language is legitimitely proclaimed. Therefore, it's a good thing Freddie's a self-described "post-modernist."

Tuesday, February 17, 2009

What is Bill Maher's Religion?

Larry King interviews Bill Maher, February 14, 2009:

KING: From our blog, Chris writes, "Bill, what is your silver bullet for health care?"

MAHER: Well, eat right would be a good start. Stop eating that crap in the supermarket. I think most health problems are from lifestyle choices. This is something no politician ever talks about, because no politician is going to say, get off the couch; you're fat; you know, ask the doctor if getting off your ass is right for you. But that really is the key to it. People don't catch a cold, they hatch a cold by things they put in their body. We have way too much toxicity and too few nutrients.

KING: Do you get a flu shot?

MAHER: Never. Never.

KING: It's a vaccine against the flu?

MAHER: First of all, that's a huge scam. Even if it worked, and I don't believe it does, by the time the actual flu came around, it would have mutated from whatever they shot into you. That is a good example of the corruption --

KING: You eat nothing in a box or in a can?

MAHER: Things that are in boxes or cans generally are not good. But have some peanut butter tonight if you like, Larry.

Here Bill Maher manages to deny the pathogenic cause of disease, as well as blame victims for acquired viral infections, stating that people "hatch a cold." Does Maher feel the the same way about Dengue Fever? Polio?

This is an example of hyperbole gone wild. Is Maher correct that people with suppressed immune systems are more susceptible to suffer an illness? Yes. Do people develop weaker immune systems by eating unhealthy foods? Perhaps. But Bill Maher's misleading statements imply that dietary intake is the primary cause, or at least an extraordinarily significant cause, of developing viral rhinopharyngitis.

In fact, the extensive National Health and Nutrition Examination Survey suggests that, while obesity is responsible for numerous pathological phenomena, overweight and obesity seem to be protective from death via infections1. (The researchers used a COX model to account for the fact that the obese tend to die earlier from other diseases, before getting a "chance" to die from infections). While one randomized controlled trial (RCT) in mice showed that genetically ob/ob obese rodents were more likely to die from influenza virus than "slim" rodents2, another RCT demonstrated that ob/ob obese mice were more resistant to death from the malarian parasite, Plasmodium berghei3. Thus, the research relating to the link between obesity and infectious disease is insufficient to be considered conclusive, and additional studies should be performed on this topic. However, Maher's conjecture that acute coryza (common cold), or other infectious diseases, are largely "hatched" from dietary choices, is invalid.

Even if we were to discover a causal link between eating habits and symptomatic coryza infection,4how does Maher know that "toxins" are the culprits, rather than excess fat? Which specific toxins are responsible? Additionally, on what basis does Maher believe that "nutrients" inoculate people from the common cold?

Indeed, many Americans ought to lose weight for other reasons, so at least this embellishment likely has mild consequences.

But then Maher moves on to vaccines.

An estimated 20,000 Americans die from influenza every year. So, if Maher convinces people to avoid a efficacious inoculant, he is behaving very irresponsibly.

Several randomized controlled trials demonstrate the effectiveness of the flu vaccine in children and non-elderly adults, and no scientific study seems to have refuted this. For example, according to the CDC:

A 4-year randomized, placebo-controlled trial of children aged 1-15 years found vaccine effectiveness ranging from 77% to 91%, following only one dose of vaccine given to previously unvaccinated children3."

There is a bit of controversy regarding the efficacy of the flu vaccine in the elderly population. While most well-designed cohort studies have shown that the flu vaccines reduce incidence of influenza infection and death for this demographic 4, these data has been contested in a few other studies 5. However, let's say we did discontinue vaccination of the elderly. We should then employ even greater care to vaccinate children, in order to decrease the probability of elderly exposure to the virus. (The authors of the Canadian study that challenges the usefulness of vaccination for the elderly, indeed noted, "Placebo-controlled randomised trials show influenza vaccine is effective in younger adults.")

Even if Maher, for some wacky reason, does not recognize the validity of such studies, why does he believe that the findings published in these journals amount to a "huge scam," a fabrication intended to hoodwink the public, and an example of "corruption"? These articles all seem to me like the expected process that takes place to advance scientific knowledge, rather than some large conspiracy. In order to save lives, we rely on the best evidence we have, concerning the costs and benefits of every preventative measure and treatment.

We already know that Maher views religious people unfavorably, and that he maintains staunch views on a whole gamut of topics. However, if Maher distrusts both theological doctrine and scientific research, which Higher Authority does he rely on as his arbiter of truth?

1. Katherine M. Flegal and Barry Graubard, et. al. "Cause-Specific Excess Deaths Associated With Underweight, Overweight, and Obesity" JAMA. 2007;298(17):2028-2037.

2.Alexia Smith, Patricia Sheridan, et. al. "Diet-Induced Obese Mice Have Increased Mortality and Altered Immune Responses When Infected with Influenza Virus." Nutritional Immunology137:1236-1243, May 2007

3. Vincent Robert, Catherine Bourgouin, et. al. "Malaria and obesity: obese mice are resistant to cerebral malaria" Malaria Journal 2008, 7:81

4. Please note that infection with the Influenza virus is always the primary etiology. By "causal link" I mean that dietary habits might lead to increased rate of clinical disease from infection, or decreased ability to kill off the virus.

5. Kathleen Neuzil and William Dupont, et. al. "Efficacy of inactivated and cold-adapted vaccines against influenza A infection, 1985 to 1990: The Pediatric Experience." The Pediatric Infectious Disease Journal:Volume 20(8)August 2001pp 733-740
CDC link that review some of the evidence about flu vaccines is at

6. Most of the research in this area seems to have been

Peter A. Gross, Alicia W. Hermogenes, et. al. "The Efficacy of Influenza Vaccine in Elderly Persons: A Meta-Analysis and Review of the Literature." Annals of Internal Medicine. Volume 123 (7) October 1995 pp. 518-527

See also a randomized controlled trial at

One study involved a Swedish cohort study of 260,000 age 65 or older. The researchers state, "The relative risks of mortality among vaccinated versus unvaccinated individuals were estimated using Cox's proportional hazards regression adjusted for, and stratified by, demographic factors and comorbid conditions." They found that they needed to vaccinate 297 in 1998/1999, 158 in 1999/2000 and 743 in 2001/2002 (the vaccine was not so great that year) in order to prevent one vaccine related death among the group, let alone prevent incidence of developing an influenza infection.
a. Ortqvist, F. Granath. "Influenza vaccination and mortality: prospective cohort study of the elderly in a large geographical area." Eur Respir J. 2007 Sep;30(3):407-8.

7. Lone Simonsen, Roberty Taylor, et. al. "Mortality benefits of influenza vaccination in elderly people: an ongoing controversy."
The Lancet Infectious Diseases, Volume 7, Issue 10, Pages 658 - 666, October 2007.

Saturday, February 14, 2009

Confessions of a Cinemaholic

On days following a horrific exam, I often lounge and loaf and consider a career in frittering and tweeting my time or otherwise "writing stuff on the internet." Then, I occasionally come across something like this,which manages to construct such exemplary commentary on a movie that seems so painfully stupid. I am actually curious about what Dana Stevens has to say about "Gigli" and "Glitter." I am not worthy. Good thing I really enjoy medicine.


Each Friday, my school sends a delegation of medical students out to Juvenile Hall, where we split up in twos, and instruct the kids on rotating topics, such as Decision Making, Dating Violence, Sexually Transmitted Diseases, and Contraception. The teens are aware that, while misbehaving during math class might earn some class cred, acting out during Sex Ed means that one's not man/woman enough to handle the topic. Thus, we enjoy their rapt attention (other than that one fluke pencil-stabbing incident), as we point to Netter illustrations of vas deferens and cervical ora, and pass around examples of dental dams, condoms, and diaphragms.

We thought that we were being all educationally innovative with our "Guess which STD?" Jeopardy game, featuring fun-filled images of condylomata lata and genital warts. However, it seems that we are totally outdone by Derek the Abstinence Clown, with his fun-filled juggling shtick. It is unclear to me what juggling has to do with safe sex (tossing pins leads to tossing machetes leads to, I don't know, neurosyphylis?). Derek has Austin the Seventh Grader balance a phallic symbol cane in one hand, which represents "doing whatever feels right like now." The cane begins to tumble, upon which Austin is summarily chastised.

On Austin's second attempt, Derek asks Austin to focus on his hopes and dreams. He also finally moves out of Austin's way, allowing the kid room to adjust his arm, so that the bottom of the cane can continuously counteract the torque of the top. Newton's Laws and Austin's Hope-Focusing conspire to ensure the cane's successful stability. From this analogy, the junior-high kids learn the imperative of avoiding drugs, alcohol, cigarettes, and especially, pre-marital sex.

Heeeeeere's Derik!!:

Tuesday, February 10, 2009

Don't Look At Me, I Just Work Here

Like Kerry Howley, I believe that when it comes to government regulation of in-vitro fertilization gone wild, the bureaucratic cure could be worse than the infertility cure.

However, Kerry sees a doctor who performs IVF as a morally neutral agent, working like an employee at the One-Hour-Photo Shop, shrugging his shoulders as he develops mementos of adultery and scandal, separating his own duties from his clients' sins.

We ought to distinguish crusades of government, as well as the passive observation of moral indiscretions already committed, from the actions of clinicians who potentially cause significant harm. Carrying octuplets to term would almost certainly lead to low gestational birth ages and weights (the California woman's offspring averaged about 2.5 pounds), as well as a dramatically increased risk of abruptio placenta, congenital malformations, eclampsia, or other events that could lead to long-term adverse effects for the products of this Guinness Book adventure. Indeed, someone might find it precious to ensure the birth of a child with Huntington's Disease, so Junior could be "just like mom," but I would decline the request to preferentially pluck such favored follicles.

Of course, we risk committing "IVF refusal ad absurdam"; We begin with objections to embryos with HD, and end with the dismissal of embryos cursed with my characteristic attached earlobes. Additionally, dramatically increased risk does not equal a guarantee of harm. Thus, I understand why conscientious clinicians might not yet object to the implantation of eight embryos. However, I reject the overall notion that a doctor ought to shove fingers in her ears, ignoring the loud protestations of her ventromedial prefrontal cortex, as it shouts that something is not quite right.

Upon public outbursts, such as "How could doctors let her bring so many babies to term?," Kerry counters with
"If there is a problem here, I’m pretty sure it is not that doctors are insufficiently judgmental in matters of female reproduction. Fertility specialists are medical service providers, not religious counselors, not ethicists. I would no more ask a GP whether it is ethical to bring 8 babies to term than I would ask her to hold forth on the existence of souls."
The problem is, the critic does not necessarily esteem the doctor an expert on ethical matters, but merely objects to the doctor's violation of said critic's own ethical views. I'm not concerned with the accountant's opinions on the ethics of tax fraud. But I will denounce him when he unscrupulously helps people cheat.

Friday, February 6, 2009

Some of These Things Are Not Like the Others

Some statements to start off your Sunday:

1) "The theory of evolution is a myth."
2) "The government should not fund stem cell research."
3) "Vaccinations cause autism."
4) "Funding for the NSF does not belong in a stimulus bill."
5) "We should repeal the Clean Air Act."
6) "Climate Change is a hoax."

Let's start with the easy question: What is similar about all of these statements?

Answer: They are beliefs commonly touted by many conservatives, and are mocked, in turn, by liberals- (although some liberals also agree with statement "3").

Ok, now what is a major difference among these statements?

Answer: Statements 1, 3, and 6 (Group A) are all contradicted by scientific evidence and are not factual. People who believe in them, either don't know or don't care about the empirical findings of scientific research. Statements 2, 4, and 5 (Group B), however, are merely political arguments. There is perhaps a strong correlation between belief in 1, 3, and 6 AND advocacy for 2, 4, and 5, but this does not mean that the two categories are equivalent.

And I believe that this distinction is essential.

If you've read the "Republican War on Science" or many of the posts on Scienceblogs, people will blithely cite, within the same post or sentence, statements from both categories A and B as evidence of the shear philistinism of conservatives or Republicans.

The problem is, people who understand both the possibilities and limitations of science should know better than to conflate these two categories. A true empiricist ought to realize that a fellow empiricist, no matter how seemingly unsuitable his political beliefs, can, at least theoretically, reject Group A while accepting Group B. For example, one might oppose government funding of stem cell research on moral grounds. Or he may not be morally opposed to stem cell research, but believes that public policy should defer to the opinions those who oppose such research. Or perhaps such funding simply conflicts with his views about the proper role of government. The notion that "Legitimate human life morally starts only starts after 'such and such' time," is non-falsifiable, as "legitimate human life" is personally, rather than scientifically, defined. Thus, there is no reason to believe that someone's opinions about the ethics of abortion, stem cell research, and arguably even birth control has anything to do with science, so long as one does not justify such beliefs with unscientific claims.

Some people, for whatever reason, might not believe that the Clean Air Act was a good law. I am reluctant to list such reasons, for one, because I know nothing about the law, but, more importantly, because heated counter-arguments would obfuscate my main point, which is: One's political beliefs, no matter how objectionable, are not necessarily related to one's recognition of the value of the scientific method, empirically-derived knowledge, Reason, or objective standards of evidence. Information derived from Science might help inform our opinions about morality or politics, but our conclusions are ultimately based on personally-formulated ethical "first principles" (i.e. "Do no harm," "Government is a good/bad tool for solving social problems" etc.).

So eager are some scientists to denounce their ideological foes, such scientists betray the public by implying that "science says" that certain legislation ought to be passed, or that certain moral opinions ought to be espoused by all defenders of Reason. They do a disservice to their readers, making it seem as if non-falsifiable statements fall under the purview of science. Thus, the public's understanding of the way science works diminishes. "Politicizing" science can exist on both sides of the aisle.

I can think of one circumstance for which the political is inextricably linked to the scientific, in which case the liberal scientist politicos have a legitimate argument. This involves the issue of advancing false statements within the public sphere to gain a preferred political resolution. In this case, the only moral first principle is "Do not lie"- a principle so nearly equivalent to "Embrace science," that I would concede liberal scientists' stances in applicable cases. Such a situation might include advocacy of the teaching of creationism in biology class, within the public schools. Additionally, while there is nothing "unscientific" about opposing a cap-and-trade policy, if one advertises against such a policy by using bogus data to "show" that "climate change doesn't exist," he would be making unscientific, non-factual statements. The same principle applies to someone who conjures up false epidemiological data to "prove" a purported link between abortion and breast cancer. As a "social liberal," I would usually agree with the liberal scientists, in these cases. However, my opinion is that the relationship between scientific reality and political expediency is, nevertheless, quite messy. When otherwise-empirically-sound scientists leave academia and enter think tank headquarters, they occasionally "skew" or "pick and choose" facts and figures, perhaps out of a political or moral belief that the "ends justify the means," or simply due to plain, old cognitive dissonance. In other words, in politics, much more than in science, (nearly) "everybody lies."

The bottom line is- If someone espouses counterfactual information, call him anti-science. However, if he simply opposes your science-related political opinions, call him something else.

Monday, February 2, 2009

Should Medical Students Make Fools of Themselves on the Internet?

Researchers at the University of Florida don't think so. They believe that physicians in training ought to remove those keg party snapshots from Facebook, and instead use social networking sites "to enhance their professional identities." The co-authors deplore the fact that medical students reveal their political preferences, relationship status fluctuations, and unsavory interests (they mention "Texas Chainsaw Massacre") for future patients to see.

The problem is, when virtually every professional-in-training has already gone "1 million strong for Obama/McCain/Barr/Nader/Pigasus" or, (for the more brazen), "I would never sleep with a [insert political party here]," then the definition of "professional" has already been, de facto, redefined. Why get rid of (or clean up) Facebook accounts, utilized by 64% of medical students, when it is so much easier to invite the other 36% to join along?

The article states,
"There is some evidence that students do begin to understand the impact of Facebook as they approach graduation. The study found that while 64 percent of medical students had public Facebook accounts, only 12 percent of resident physicians did."
To me, these statistics don't indicate any panicked account closures en masse, but speak to the flood of Mark Zuckerberg's contemporaries who have recently entered medical school, and collectively just say "meh."

One of the researchers argues that
“Doctors are held to a higher standard...There are stated codes of behavior that are pretty straightforward, and those standards encourage the development of a professional persona.”

If someone simply enjoys doing colonoscopies, and also singing karaoke, must he be a man at home, and a doctor in the street? Should we hold doctors to a "higher standard" when it comes to non-medical matters? Does this concept simply re-enforce the old-fashioned notion that doctors are "different from you and me?"

Granted, there are some things doctors could publicize that would convince me to avoid sitting next to him on a bus, let alone let him perform my cardiac surgery. If some-one joined a fictitious "I Hate My Patients Club" or some other ridiculous group, it might be sensible to choose a different doctor. However, by announcing his opinions on Facebook, rather than simply confiding in his poker buddies, the doctor does me the favor, as now I can cross him off my PPO list.

However, with 21st century snark and sarcasm, we can't interpret the significance of someone's membership in even the most unsavory of medical student groups- such as,“Physicians looking for Trophy Wives in Training” (it is unclear to me this is a dangling modifier, or if the medical students emphasize the "training" of the "trophies" more than their own). In this post-modern generation, we don't know if the students actually aspire to this vision of their futures, or if they're actually mocking a largely passé Dr. 90210 attitude, in which marrying boring women1 is considered desirable.

I suppose that, no matter the intentions, it is still perhaps inappropriate to advertise activities or opinions that would cause offense. But once the details of our lives are inevitably strewn across the internet, someone is going to find something objectionable (My doctor is President of the Barry Manilow Fan Club???) Where would we draw the line? The answer to this might be obvious to some boomers out there, but I can safely say that many of us young folk haven't a clue.

We tend to wistfully look back at those old-fashioned physicians of yore (or at least those of 1960s television)- caring, nurturing, and kind. However, today's doctors can still achieve these qualities without dulling our personas- even "Marcus Welby M.D." opens with Dr. Kiley riding his badass motorcycle.

1. The doc's wife may be intelligent. I've never seen the show.

Thursday, January 29, 2009

Quick Overview of My Intro to Urology Clinic

The first clue about the maturity level of your typical urologist, can be gained from seeing, on the door of the doctors' lounge, a labelled picture of the handsome animal featured above. These urologists strike me as the future incarnations of Kumar, the guy from that White Castle movie.

In contrast to the bawdy behavior of the urologists, one of our patients, Mr. Smith, was the quintessential "gentleman." He thanked us for taking the time to see him. Whenever he referred to any portion of the male anatomy, he said "Sorry, to the ladies, I don't mean to be impolite talking about these things." He was fully aware of his prior condition, and had followed his previous doctors' advice. The juxtaposition becomes especially absurd, however, when you notice the patient's right leg that is cuffed to the bed, and the two police officers sitting in the corner, mindlessly surfing the web, Berreta 92s intimidating from their holsters. The patient has scars on his back and legs, all from multiple previous gun shot wounds. Based on the manners of most of the patients who head over from County Jail, I can only assume that Cotillion is scheduled between recreation and lockdown.

No kid grows up dreaming of becoming a urologist. Even medical students tend to not think of it (I want to work with urine!) The thing is, however, unlike the "stereotypical" image of a surgeon, who might be seen angry and annoyed, the urologists love to make jokes, have fun, and really get along with their patients, all the while doing a cool fusion of medicine and surgery. The two attendings whom my group assisted today are volunteers, who spend one day a week away from their private clinics, just to teach us lowly Second-Year-Know-Nothing-Medical Students. They showed us the procedures for inserting a Foley catheter, doing sonogram assisted prostate biopsies, and performing a cystoscopy. They were all so eager and excited to teach us whatever they could, and we were all having a blast. It's kind of like an old boy's club, but one where young boys and all girls are invited, too.

Response to Comments on My Last Post (Yikes This Can Go on Forever!)

Hello “Schwartz,”

Thanks for your comments. I’m going to try to quickly respond. Sorry that the sources are messily scattered throughout. I'm aiming to get this done before 6 a.m. Urology clinic.

Adina,Your method of debate is a refreshing change from the usual vitriol. Thank you.I have a couple of initial questions I'll get out of the way first:
“1) Do have experience in statistical analysis or epidemiology?”

I freely admit that I am not nearly an expert in the subjects of statistical analysis or study design. However, when discussing these topics, I hope you will focus on the content of my arguments, rather than on my degrees or qualifications (please note that I do believe degrees are important for some things). In other words, I don’t care if you graduated from clown college. If you make good points, I will afford them the same respect that I would to those of a statistician. As an aside, I have taken non-graduate-level courses in biostatistics, epidemiology, economics, and math. Additionally, I worked for a clinical research study (for only one year).

Did you read the details or any critical reviews of the epidemiology you broadly reference?”

I made sure to read the major components of every paper I referenced. In terms of critiques of the study design, I have read many thorough (unconvincing) rebuttals to a number of the studies I presented at and

There are some much better-reasoned review articles available, which address the drawbacks of various studies. For example, this article compares a number of epidemiological studies, addressing the purported link between autism and vaccination. They find that Heron’s study fulfills 5/8 epidemiological criteria, and the research of both Hviid and Verstraeten each fulfill 6/8 criteria. In other words, they are strong, but not flawless studies (there are extraordinarily few epidemiological studies about anything that would fulfill all 8/8 criteria). The Geiers’ study, the only one that found a link between vaccination and autism, fulfilled 0/10 criteria. The methodology used in this article review article appears quite sound.

(Parenthetically the third world application of Rota vaccine is relevant but so is the fact that it is currently recommended as a childhood vaccine in the US. The US recommendation is justified as a reduction in cost due to reduced hospitalization, not death. This is far more relevant to your readers when considering the risks.)

CDC: “The number of intussusception cases reported to date after RotaTeq administration does not exceed the number expected based on background rates of 18-43 per 100,000 per year for an unvaccinated population of children ages 6 to 35 weeks.”

"However, these claims have been investigated (Ten studies to show MMR doesn't cause autism. Six that show thimerosal doesn't cause autism, etc.)"
In order to support the notion that the claims of damage have been vaccinated, you would have to produce case studies or at least detailed follow-up for the affected group OR at least you have to illustrate that enough study of children with similar risk profiles were studied en masse. Neither you or Dr. Offit have provided them so right off the bat, the definitive statement that the topic has been studied is not justified in my opinion. In general, you will find that in the cases of vaccine damage very little documentation is available and there certainly is no large cumulative study of affected children. That alone should raise red flags in a system that mandates a medical intervention.

I’m not sure what you mean by similar risk profiles. Do you mean studying patients in a case-controlled study, rather than the current practice of conducting longitudinal cohort studies? (In other words, finding kids who are already known to have autism, and then finding out about their exposures, rather than recruiting kids with known exposures, and then following them to determine if they were later diagnosed with autism).

I’m not 100% sure what kind of study you’re referring to, but if it is a case-controlled study, then I feel that such a study would have little value. A case-controlled study, in this situation, is susceptible to information bias (Differential reporting of past exposure information based on disease status), Selection Bias (Controls and/or cases chosen in such a way that they are systematically more (or less) likely to be exposed than the population from which they were drawn), Confounding. (Failure to measure and adjust for all potentially confounding factors can lead to invalid associations), and Temporal Relationship Problems. (Can’t be certain the exposure preceded the onset of the disease). (Sources of bias copied from Epidemiology Lecture notes created by Dr. Christopher Haiman).

It shouldn't be a surprise that Hannah Poling's case was actually investigated in detail likely only because her father was a neurologist with both the power and wherewithal to ensure her case was studied in detail"In terms of the Vaccine Court, the fact that those girls got money from the Vaccine Compensation Fund is not particularly relevant, because the cases are not judged based on scientific evidence" “

I might have missed it, but I don't see anywhere they state that the decisions are not based on scientific evidence. Medical records and expert assessment were provided in this case, and certainly expert assessment qualifies as scientific evidence. Your definitive statement here is not justified.”

I’m having trouble with this argument. Do you think that if we went to court to resolve a dispute about evolution vs. creationism, then the findings of the court would be scientifically relevant, so long as the judges heard the testimony of experts? I am not sure if you are saying that courts ought to be recognized as legitimate arbiters of a scientific debate, but if so, I must disagree. Courts might invite scientists to testify about their research, but the court itself has no meaningful role in determining of the scientific merit of such testimonies. Because courts must make legal decisions, the public hopes that the courts will do their best to be objective and weigh already discovered evidence appropriately, as well as figure out which witnesses are most credible. Ultimately, however, the legitimate value of scientific findings is determined by the scientific community through the scholarly writing and peer review.

Additionally, I am pretty confident the percentage of “experts” who testified that vaccines cause autism was dramatically larger than the percentage of scientists, in the general population, who agree with that notion. Court cases are misleading, because disproportionate representation leads to an assumption that there is widespread debate about a given issue, when opposition might actually exist among only a small fringe group.

"A team of lawyers (called "special masters") with no medical background, rather than a judge, jury, scientists, or medical professionals, preside over the cases." The Poling case was conceded after a review by the HHS scientists. It never went to a hearing before the Special Masters. The HHS scientists examined the scientific evidence presented and determined that a hearing was not required, as they concluded the act of vaccination contributed to her brain damage (encephalitus) leading ultimately to a diagnosis of Autism. Your own statements don't match the facts and display the bias of Dr. Offit's opinion pieces (where it is difficult to evaluate the level of bias).

The only document relating the Poling case that is provided on the Vaccine Court's website is at
It states,
“The undersigned [special masters] directed respondent to file a status report after reviewing Dr. Zimmerman’s expert report that addressed respondent’s position regarding petitioners’ claim that Hannah’s seizure disorder was vaccine-related. Petitioners filed the expert report from Dr. Zimmerman after the status conference. Respondent’s review of Dr. Zimmerman’s expert report…On February 21, 2008, respondent filed a Supplemental Rule 4 Report addressing. The respondent stated that “[h]aving reviewed this additional evidence, medical personnel at the Division of Vaccine Injury Compensation, Department of Health and Human Services (DVIC)] now recommend compensation for Hannah’s seizure disorder as sequela of her vaccine-injury in accordance with 42 U.S.C. § 300aa-11(c)(1)(C)(ii).” Id. at 2. Based on respondent’s concession, a damages determination is now underway in this case.”

Please note that the report states that a single respondent, rather than a team of DHHS experts, was asked to review the case (using the files provided by Hannah’s doctor0. The document does not mention the identity of this respondent. He or she could be a member of ARI or Generation Rescue, for all I know. Then the special masters made the final decision. Your account of what happens does not correspond to the account written in the document (See page 2). However, there may additional documents that I cannot locate, so I will look at those, if you know of any.

You seem to make more factual errors about the case of Andrew Wakefield: "Many of Wakefield's co-writers testified in court that he had falsified data, and 10/13 authors retracted their names from portions of Wakefield's most significant study, stating "We wish to make it clear that in this paper no causal link was established between the MMR vaccine and autism, as the data were insufficient.""I am interested in which trial of Dr. Wakefield anyone testified that data was falsified? I suspect you're incorrectly referring to the Omnibus hearing (which you yourself stated was unscientific) which did not involve Dr. Wakefield at all. Allegations against him were made despite the fact he was not a participant in the hearing, and thus he had no opportunity to rebutt the accusations. It would be good for you to clear up this allegation of yours, because as it stands, your statement does not match the facts that I am aware of. Given the diligence of most of your post, you seem to be making quite a few errors around the legal and personal aspects. I can only assume that you have been swayed by the many biased writings of these events without actually understanding the details of the events that unfolded. Wakefield is currently undergoing a GMC fitness hearing in the UK but no transcripts have been published and no verdict delivered so your conclusions appear a bit premature.

You are correct. I apologize for the error, and have placed a correction it in my previous post. Chadwick had testified at the Omnibus Hearing, not at a trial related to Andrew Wakefield. (I confused this case with the hearing for professional misconduct that Wakefield is currently undergoing at the General Medical Council in the U.K.) The extraordinarily detailed testimony against Wakefield, by the primary researcher who had carried out the experiments is quite damning, nonetheless. Please see part of the transcript at
There were other testimonies of many major problems in Wakefield’s research. For example, according to the testimony of Dr. Stephen Bustin, the now defunct diagnostic center that Wakefield used, Unigenetics, claimed to have “detected measles gene using a type of PCR that could detect only DNA." (Offit 171)” The measles virus doesn’t contain DNA, only RNA. Please read about the findings of the 2004 investigation of Wakefield’s laboratory at

You also make two further misleading statements: First, your wording infers that the retraction was significant despite the fact they only retracted the interpretation not for scientific reasons, but public relational ones as they noted in the section of their statement that you ommited. Second, you infer that the lack of a causal finding between MMR and autism was a new revelation, when it was already explicitly stated in the original paper (discussion section page 641). Your selective quoting makes a big deal out of very little just like the misleading press releases on the topic.

Wakefield was very smart in trying to have it both ways: Always saying that nothing can be known for sure (so that no one can pin anything on him), but then making frightening statements about vaccines to the public. Wakefield et. al. were careful to write “We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described. Virological studies are underway that may help to resolve this issue… We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunization. Further investigations are needed to examine this syndrome and its possible relation to this vaccine.”

Every researcher is aware that no medical study can “prove” anything, so it is silly to write “we did not prove,” in a paper. They seem to imply that they have significant evidence, but that this evidence just doesn’t qualify as “proof.” If you believe this argument is just a petty focus on semantics, then please note that Wakefield used every public opportunity, following the article’s publication, to imply that his findings were indeed significant. In an interview following publication of the article, Wakefield says:

“It is our suspicion that there may well be [a link between MMR and what he refers to as “this syndrome”] but that is far from being a causal association that is proven beyond doubt… Again, this was very contentious and you would not get consensus from all members of the group on this, but that is my feeling, that the, the risk of this particular syndrome developing is related to the combined vaccine, the MMR, rather than the single vaccines…. Again, this was very contentious and you would not get consensus from all members of the group on this, but that is my feeling, that the, the risk of this particular syndrome developing is related to the combined vaccine, the MMR, rather than the single vaccines…Well, the interesting thing is that the damage, the behavioural or developmental change tends to occur quite soon after administration, and this is where, why parents or GPs or paediatricians have been able to make the link, the association with MMR.”

These sound like pretty ominous warnings for an article whose authors are extraordinarily cautious and humble about the significance of their findings. Wakefield even held a press conference about this issue, which prompted segments of the British public into mass hysteria. Vaccination rates fell dramatically, and the incidence of deaths from measles rose.

We may disagree about the significance of the retraction. There were multiple flaws in the study, with or without the retraction. Because you feel that I was omitting information, here is the portion of the paper, to which you refer:
“We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. However, the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent.”

"However, these claims have been investigated (Ten studies to show MMR doesn't cause autism. Six that show thimerosal doesn't cause autism, etc.)"
Going back to this quote, I want to continue driving into the studies you reference through Dr. Offit. First, I'm surprised at your use of such a definitive statement (doesn't cause autism) that really can't be supported by any scientific studies of epidemiology. The conclusion that doesn't cause Autism isn't even that interesting really. We want to know if it contributes to damage including autism (or other problems). The case of Hannah Poling is a great illustration that vaccination alone did not cause the damage, but it certainly appears to have triggered and exacerbated it.

I only addressed the autism issue. If you feel that autism is only of many disorders caused by vaccination, and that autism is the least “interesting” among them, then I guess it’s the anti-vaccinationists' lucky day, because I have no energy to refute the link between vaccines and dozens of different disorders. Yes, you are correct. The studies did not (and cannot) conclude “thimerosal doesn’t cause autism.” I intended to say that we have an extremely low level of uncertainty that vaccines do not cause autism. Please read my last post, in which I spoke about how one can never reject a proposed null hypothesis. See my Xenu example.

This is particularly pertinent with Thimerosal and this leads to my original questions at the top. If you read the details of these studies, you'll find that the two founding components are data on the prevalence of Autism and the estimated cumulative exposure of Thimerosal during infancy. I hope you've read critical reviews of the studies quoted by Offit, and the data they're based on. If you aren't aware, there is wide disagreement on the reliability of the Prevalence data, and there are significant known issues with the Danish Registry, the UK's GPRD, and the US databases over the period of time studied. I recommend at least finding and reading some of the statistical arguments against the use of prevalance numbers in these studies. As you should know, the role (and bias') of the statistician is critical in influencing the outcome because numerous assumptions and adjustments must be made in these studies which are already subject to a high risk of false positives and negatives. When working with difficult, inconsistent, or incomplete data (sometimes withheld from independent public analysis) the knowledge of conflict of interest is quite important.

Yes, I read the critical review on the Danish study of 500,000 children (see links above). Just yesterday, Italy released a study stating that there was no link between autism and vaccination. I don’t believe that the statisticians in all of the different countries, for in all of the different studies are part of some vast conspiracy. Of course, in any discipline (perhaps excepting math), there can be biases introduced in a study. However, these studies generally feature good epidemiological study design. I don’t understand how people who oppose vaccination can be so demanding about the standards of these studies, when they rely primarily on case reports or research from faulty databases (Such as the Geiers’ use of the VAERS database) There is no flawless epidemiological study that shows smoking causes lung cancer. However, I’m sure we can agree that the epidemiological data from around the world have added up to demonstrate clearly that smoking causes lung cancer. Now all of the studies are adding up, and they refute a vaccination/autism link.

The other issue is that these studies only look at the cumulative exposure over a long period of time. We know that the timing toxic exposure to virus' (CRS is a great example) or toxins in fetus' or infants can be quite significant in determine the outcome of damage. We also know that very low levels of heavy metal exposure can also have a significant effect neurological outcomes (ex. lead: None of these factors are even remotely considered in these studies, yet you and others including Offit make definitive statements like "doesn't cause Autism". They only studied cumulative dose to be the defining factor, an assumption that does not hold up all the time on it's own. Another aspect that is often ignored (and Contrary to Dr. Offit's published opinion in peer-reviewed journals) the concomitant application of vaccines (MMR and Thimerosal containing) are not actually required study for pre-regulatory approval and generally remain unstudied from a safety perspective. (

No matter when the vaccination occurs, if vaccinations indeed caused autism, we would find a difference between the vaccinated group and the control group. Even if we miss a lot of diagnoses by failing to follow everyone to late adulthood, the cases missed should be equal in both groups (or perhaps even greater in the control group- parents of kids who have vaccines are more hypervigilant, due to their concerns, and would likely notice autism symptoms earlier), so this wouldn't skew the results toward the null.

Thus, I don't think that following vaccinated people for a very long time is necessary, unless you believe that vaccines are only responsible for autism diagnoses that become apparent after childhood. In that case, we would see a difference in autism rates, only if we followed children all the way to adulthood. Sounds far-fetched.

Or perhaps you're implying that, even if mercury doesn't cause autism, it does cause neurological disorders that are only apparent adulthood? These new claims about non-autism related neurological disorders are a whole different topic. I don't know why there is a new idea about vaccines every day! Anyway, the absence of a link between vaccination and (non-autism) neurological disorders have been addressed in at least three studies (see Offit 247)or H. Frankel. "Report finds no link between thimerosal and neurodevelopmental disorders." The Lancet, Volume 358, Issue 9288, Pages 1163-1163

In reference to the notion that metals and other hazards are all around us, I don’t see how that would influence the results. Both vaccinated and unvaccinated kids would be exposed to such metals, so we would still need to see an increased incidence of autism for vaccinated kids. Your premise would require that vaccinated kids are subject to fewer “heavy metals” in their daily lives, and that this is the reason why the incidence of autism is equal in the vaccinated and non-vaccinated groups (i.e. the non-vaccinated group got all of their “heavy metal poisoning” from the environment, but vaccinated kids got their's from vaccines, so now the incidence is equal). This sounds farfetched, and is practically irrelevant, because it doesn't matter what would "cause" one's autism, if the chances of "acquring it" are the same, no matter the ubiquitous exposure.

Honestly, I wasn’t aware of the brand new suspicion (i.e. it’s not MMR that causes autism, nor thimerosal that causes autism, but only using the two of them together). After a claim is debunked, it doesn’t follow that a study must be made to investigate an “updated” conjecture. As I said in my last post, whenever new evidence comes along, the proposed causes always seem to keep change.

In terms of environmental exposure, data from the Minamata Bay mercury disaster show that no increased number of children developed autism, which even Aposhian was forced to admit at the omnibous hearing. (He then said that this is because mercury toxicity isn’t dose dependent, and that “This is an ancient form of quotation that until recently we taught in medical schools…we no longer believe that the dose makes the poison”) See Offit 166 and

From my perspective that type of language is unsubstantiated by the reality of the limitations of the studies. The fact that Dr. Offit regularly makes public statements of this type (in addition with factual error that require correction) significantly hurts his credibility and I argue exposes his bias. Overstating the conclusions of scientific study, especially ones based on weak data is a reccuring issue. As for MMR, I suggest you read the Cochrane systematic review of MMR studies from 2005/2006:
After reviewing an extensive list of "definitive" MMR studies performed over several decades, they concluded that the study of both efficacy and safety was inadequate. If you read the details, (I suspect you'll find several of Dr. Offit's references in there) you'll see findings of serious methodological issues with seemingly "credible" study also heralded historically by regulatory bodies as "definitive". From this perspective you might understand why I remain skeptical of definitive claims issued by the likes of Dr. Offit.

You are correct that none of the 139 articles fulfilled all of Cochrane’s inclusion criteria. I don’t know how you think a better epidemiological study could be designed, which would adequately fulfill the exacting criteria. No study that is currently being proposed by anti-vaccinationists could possibly suffice, so we would be wasting money if conforming the Cochrane standards was their primary goal. Epidemiological studies have a lot of disadvantages, in comparison to controlled environments with drosophila insects or rats. The Cochrane study does recommend vaccination and says, “Exposure to MMR was unlikely to be associated with Crohn's disease, ulcerative colitis, autism or aseptic meningitis (mumps) (Jeryl-Lynn strain-containing MMR). We could not identify studies assessing the effectiveness of MMR that fulfilled our inclusion criteria even though the impact of mass immunization on the elimination of the diseases has been largely demonstrated… No credible evidence of an involvement of MMR with either autism or Crohn's disease was found.”

Overall, I think there is plenty of justification of continued study. None of these studies you referenced ever examined the long term effects of either MMR or Thimerosal exposure in any RCTs (or as close as we can get given ethical limitations). We know from recent history (HRT being a prime example) that large long term studies often reveal unexpected negative outcomes in treatments assumed and shown to be safe by previous regulatory studies.

There are lots of claims we haven’t studied. In a world of unlimited abundance, I'd say, sure let’s have continuous studies about everything. A million studies. Regardless, NIH-funded studies are currently underway to examine this issue, and many more are planned, so it is a mute point.

"As I wrote on my other post, learning about the experiences of my patients and their families will be crucial for my providing good care, but is not relevant to science-based medicine (excepting in the use of case studies, which have limited value, and which are generally only used to develop hypotheses)."
This is an interesting opinion which I would like to examine outside of the vaccine discussion. Expert opinion still plays a role in evidence based medicine (which is what I assume you meant when using the term "science based medicine"). Cumulative clinical experience forms the heart of expertise. I am concerned that you also dismiss the value of clinical experience in detecting problems. It is exactly the detection of patterns of anecdote that usually lead to further study of issues. The other important factor is that repeated follow-up into similar individual cases may reveal biological mechanisms which can (and should) also be used to form a hypothesis. The fact that disease reporting is mandated by law, yet pharmaceutical adverse event follow-up outside of research settings is voluntary are rife with error is a sad reflection on our priorities in my opinion.

You are incorrect that I dismiss the value of clinical experience in detecting problems. Gaining clinical skills in how to recognize signs and symptoms, in order to form a diagnosis is quite different than assuming to know the etiology of an insufficiently studied disease. A good doctor might develop the clinical skills to recognize autism, but this does not mean he has any knowledge what caused it. Recognizing this requires some humility on the part of the clinician. Yes, I’ve mentioned that case studies, or any other observations, can be used to form a hypothesis.

Again, thank you for bringing a refreshingly politeness to the discussion. I wish you success in your studies. My only suggestion is to drill into the details of the assumptions underlying the evidence you use to justify closing the door on further research. Given the significant challenges facing our newer generation of doctors, I think you should drill into the well documented issues (plenty of peer review studies on this topic) with industry funded peer-review studies, and into the details of the impact that bias can have on statistical analysis. You might find (like I did) that the conclusions you're quoting are based on a lot more assumptions and questionable source data than you would like. (the latter not the fault of the authors, but on the lack of interest/diligence by medical regulatory authorities).
Potential Bias: I have two healthy NT children, one partially vaccinated (older), one unvaccinated (younger)

Thank you “Schwartz.” If you respond to this, I’m going to have to let you have the last word. My adventures in autism blogging are putting a cramp my non-school-related life.

Take Care,