Preparing for an Election

Now and again I am reminded of classics of literature, classics that I’m afraid too few folks know these days.  They bring us phrases and images that we have used to illuminate our speaking and writing; but without knowing the sources folks don’t really understand the images.  The Bible comes to mind, as do the works of Shakespeare. 

However, this evening I’m thinking of the fables of Aesop.  How many know they are the source of the phrase “don’t be a dog in the manger?”  That’s not related to the manger we know best – the one Jesus was born in – but to a story about a dog in comfort who prevented an ox’s dinner.  How many know the fables are the source of the phrase “sour grapes?”

Tonight, though, I’m thinking of the frogs who wanted a king.  You can read that fable here.  Go ahead – it will only take a minute or two.

Now that you’ve read it, you’ll understand the question of whether one would prefer King Log or King Stork.  Sure, King Log seems ineffective, even inert; but he won’t consume you like King Stork.  King Stork has an energetic, even aggressive program; but King Log will leave your life pretty much as he found it.

In these political times some might assume the civil government brought this to mind.  However, I’m thinking about something smaller and more singular.  Very soon now I will participate in the election of the next bishop of my diocese – the election of my bishop!  It’s not the same.  Oh, we vote, and there have been efforts to inform the voters – in this case, the diocesan convention – as well as those the voters will represent in one sense or another.  But, it’s not the same.  There aren’t campaigns, or at least nothing on the same sort of scale.  (I suppose there may have been some “campaigning,” but I’m not in the right circles to know.)  There haven’t been “campaign promises” (or, again, I’m not in the right circles).

But the most important way in which it’s different is that we’re praying to be guided by the Spirit.  We decide by voting, but we are praying that our voting will conform to God’s intent, and that instead of us deciding who our next bishop will be, the Spirit is using us to express God’s decision.

But, as I often say with patients, it would be much easier if God were better at conversation.  I have heard a voice that I thought was God, and circumstances seemed to confirm it; but I haven’t heard a voice about this Episcopal election.  Even if I had, I couldn’t be sure anyone else had heard that voice. 

So, each of us going to have to think about several questions: what do I want in a bishop?  What are the gifts and skills I think a bishop should have for the good of the diocese?  I’m not going to answer that definitively on this blog, much less in this blog post.  At the moment I’m just conscious of being betwixt and between.

How do I balance my own wishes and the good of the diocese – to the extent I’m able to separate the two?  How do I apply in the best Anglican tradition Scripture, Tradition, and Reason?  How do I decide among the candidates?  Each brings gifts and limitations, and none would be perfect; for, don’t we observe at each such election that Jesus couldn’t get elected as a bishop?  So, how do I choose among them, trying to figure out whose specific balance of gifts and limitations best fit whatever needs I focus on? 

And so, I find myself wondering whether I would be better off with King Log or King Stork.  And of course it isn’t really that straightforward, because none of the candidates is as passive as King Log, nor as destructive as King Stork (or at least we pray not).  How do I decide?  How?  How?

So, remember us in your prayers.  I’m trying to hear God, and I believe the other clergy and lay delegates are as well.  Remember us, and pray that we might hear clearly for our souls’ health, the health of the diocese, and the health of the Episcopal Church.

Reviewing the Evidence

I know I’ve complained more than once (say, here or here) about problems with how medical research is conducted and paid for. The problems I’ve occasionally pointed to are known, if not always discussed. The consequences could be quite serious. You have to wonder who’s paying attention.

One answer is John Ioannidis and those who study with him. Dr. Ioannidis of the University of Ioannina in his native Greece is a meta-researcher, a researcher whose expertise and interest is in critiquing the work of other researchers. He is profiled by David Freedman in the latest Atlantic Magazine, as one of their "Brave Thinkers," and the article is well worth reading.

Dr. Ioannidis has combined his expertise in medicine with a talent for math to look closely at what some of his peers have presented and gotten published. When he looked, he had legitimate concerns about what he found. In one review published in JAMA, the Journal of the American Medical Association, he reviewed 49 well regarded studies, 45 of which stated that they had demonstrated effective therapies. He then discovered that 34 of those 45 studies were replicated, and of those 34, 14 were either “wrong or significantly exaggerated.”

While the standard concerns about funding for research biasing the questions, and therefore the results, Dr. Ioannidis suggests another. As Freedman describes it,

Imagine, though, that five different research teams test an interesting theory that’s making the rounds, and four of the groups correctly prove the idea false, while the one less cautious group incorrectly “proves” it true through some combination of error, fluke, and clever selection of data. Guess whose findings your doctor ends up reading about in the journal, and you end up hearing about on the evening news? Researchers can sometimes win attention by refuting a prominent finding, which can help to at least raise doubts about results, but in general it is far more rewarding to add a new insight or exciting-sounding twist to existing research than to retest its basic premises—after all, simply re-proving someone else’s results is unlikely to get you published, and attempting to undermine the work of respected colleagues can have ugly professional repercussions.

We might consider this the “headline bias:” as is commonly said in the news business, “if it bleeds, it leads,” and the sensational is more likely to get attention, even apparently in peer-reviewed journals. Caught between pressure to publish on the one hand, and the general need to fit in with one’s professional peers, both researcher and reviewer can get caught up in highlighting the new and different, even if there’s better information in the replication of earlier studies, whether to affirm or refute them.

The profile of Dr. Ioannidis is an interesting article, and it highlights explicitly the importance of this meta-research. We claim early and often that we want to make our decisions based on evidence. The assumption, of course, is that the information we have is accurate and dependable – that is it, in fact, evidence. If we find it isn’t – when we find it isn’t – we need to take one of those most difficult steps in human experience: we need to take a step back and think again.

A (Bizarre) Window Into an Important Process

I have mentioned before that I participate in the process in my hospital of overseeing the credentialing of physicians.  That is, I’m part of a committee that looks over the shoulders (in our case, literally in the same room to watch the work) of the physicians who decide whether physicians have the training, licensure, certification, and practice history to qualify for privileges at my hospital.  It can be an interesting process, and I’m quite appreciative at how hard the physicians on the credentialing committee work and how seriously they take this.

So, it certainly caught my attention that the California Board of Medical Examiners has begun hearings before and administrative law judge on the practice of Dr. Michael Kamrava, the fertility specialist who implanted and cared for Nadya Suleman, mother of fourteen including the octuplets for which she was labeled “Octomom.”  The Board is raising the questions of whether this was in Ms. Suleman’s best interests, in the best interest of children, and in accord with the standards of care of physicians providing this specialized care.

That phrase, “standard of care,” is important in medical practice.  It carries connotations of professional standards, clinical competence, and benefit to the patient.  In any given specialty establishing the “standard of care” involves knowledge of current research, often expressed by statements from professional societies.

And there are standards of care in fertility medicine.  As a result of his practice, exemplified perhaps in his care of Ms. Suleman, Dr. Kamrava has been expelled by the American Society for Reproductive Medicine.  That does not affect his medical license, but it is a damaging critique of his practice.  By itself, his expulsion doesn’t affect his ability to maintain his practice, but it may well affect his privileges with hospitals around him.

There are certainly many issues around fertility medicine, and especially around the production of numbers of embryos to be maintained in frozen storage until – and unless – desired.  At the poles, there are those who consider them “products of conception” that can be discarded unless offered for some use, such as development of human stem cell lines for research and/or therapy; and those who, committed to the belief that these are persons held in abeyance, want to see them offered for adoption by implantation.  It raises issues of whether children are blessings and miracles of God, that for medical reasons some may never receive; or objects (even if of affection) to which we have “a right.”

However, those issues will not be at the forefront in this review.  They won’t necessarily be irrelevant, but they won’t be primary to the discussion of “standard of care.”  This review will not question premises underlying this medical specialty, but will focus on practice within it.

It is worth noting that this is a process that rarely gets this level of attention.  That is, physicians are challenged all the time, whether in court or before a state board, but it is rarely of more than local interest.  It gets into local papers, and goes into state registries, but doesn’t get national attention, or even hold the local attention for long.  There is a National Provider Data Bank maintained by the Department of Health and Human Services to which states can submit adverse actions against physicians.  The purpose of the Data Bank is

intended to improve the quality of health care by encouraging State licensing boards, hospitals, professional societies, and other health care organizations to identify and discipline those who engage in unprofessional behavior; to report medical malpractice payments; and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from State to State without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, clinical privileges, professional society membership, and exclusions from Medicare and Medicaid.

But, the information is really intended for hospitals and other institutions, and not the general public.  That is in its own way problematic.  It’s not unheard of for a physician to move enough so as to change jurisdictions ahead of consequences, and the public hears little about it.  This will give an opportunity for most of us to observe a review that is commonly out of sight.

Testimony has begun, and even after testimony a decision may take the California Board a while to issue a decision.  One way or another, it will be interesting to watch, and hopefully enlightening. 

Political Thought for October 15, 2010

Why is it only "class warfare" when those at the bottom make demands of those at the top, and never when those at the top make demands of those at the bottom?

Some Reflections on the New Atheists

They speak of matters that only they and their followers perceive.
They speak of matters both vast and infinite, and intimate and infinitesimal; but they assert that these matters directly affect our lives and our futures, as individuals and as a species.
They describe these matters in a highly technical language known well only to a small specialist caste.
They establish institutions to sustain their studies, educate their followers, and promulgate their teachings.
They gather to share their minutiae and publish their works.
They do their best to share their ideas with the public, but have difficulty getting across anything but the broadest ideas, which almost always get distorted.
Some of them are determined, and even militant, about defending the truth of their understanding of the nature of things against other understandings.

Who might I be talking about? How about, for example, Richard Dawkins and Stephen Hawking? I’m talking about the material determinists preaching (yes, preaching) under the heading of the “new atheists.”

Lets’ try this again.

They speak of matters that only they and their followers perceive.

• Have you ever actually seen a quark, much less been able to tell which is top or bottom, which is charm or strange?

They speak of matters both vast and infinite, and intimate and infinitesimal; but they assert that these matters directly affect our lives and our futures, as individuals and as a species.

• For example, quantum mechanics and astrophysics; or genes and ecosystems.

They describe these matters in a highly technical language known well only to a small specialist caste.

• Specifically, higher mathematics. It is the language – indeed, for much of their work the only language – in which these concepts can be described with precision.

They establish institutions to sustain their studies, educate their followers, and promulgate their teachings.

• How about MIT or Cal Poly; or, for that matter, the departments of Physics, Astronomy, or Engineering of any major university.

They gather to share their minutiae and publish their works.

• Well, there’s the American Nuclear Society, or the American Physical Society.

They do their best to share their ideas with the public, but have difficulty getting across anything but the broadest ideas, which almost always get distorted.

• Think about reports of scientific discoveries in the public press, especially in the areas of nuclear research or medicine.

Some of them are determined, and even militant, about defending the truth of their understanding of the nature of things against other understandings.

• Again, think of Richard Dawkins, or Victor Stenger.

They speak with certainty, or at least with conviction, of matters which are based in fact on assumptions.

• This takes a bit more reflection, but it’s clear. Take, for example, the pursuit of a Grand Unified Field Theory. The idea has long prevailed that there must be one theory (in fact, one equation) that will account for electromagnetism, gravity, and the strong and weak forces within the atom; and indeed that the theory must be elegantly simple. That idea is an assumption. It can be argued for and against, but it’s an article of faith.
• Or, again, take quarks. No one has seen one. They are predicted in the math, and in the results of high energy physics experiments at CERN and elsewhere spots and lines show up in the film that seem to match the math; but the math is part of a specific model, a mathematical construct. Suppose one of the premises of the model is wrong.

Now, let me first acknowledge that this also applies to religion, right down the line. In fact the language of theology, at least of academic theology, is awfully technical and obscure. That’s part of the reason that in fact stories of religion in the public press are so dependably partial.

Second, I’m happy to acknowledge that the scientific community is in fact quite diverse. I have observed before that I grew up surrounded by folks with PhD’s in the hard sciences, including my father, who were also active in faith communities. Folks like Dawkins and Stenger are extremists to the point of becoming stereotypes, and not really representative. (And I’ll admit I’m not sure about Hawking and Christopher Hitchins. Hawking spoke of God as “unnecessary,” but I haven’t heard much anti-religious commentary from him. Hitchins is a journalist and not a scientist per se; and while he’s clear on his position, lately he’s been much less, well, obnoxious in his rhetoric. And I respect his recent statements that his diagnosis of cancer will not change his beliefs.)

But, only the extremists in the religious traditions deny that these are matters of faith, and not provable. By the same token, its the extremists among the material determinists who deny their underlying assumptions and feel they must be militant about the exclusive reality of their world view.

This has gotten a lot of ink and pixels lately, including among some of my colleagues. To some extent, I think that’s because, whether we realize it or not, they are behaving just like us. What I think is interesting and ironic is realize that they are behaving just like us; and they’re absolutely blind to it.

Opportunities to Hear From Military Chaplains

I received an interesting email from Marcia Colgar, owner of the website onlinechristiancolleges.org. She has a blog on her website, and she wanted to inform me of her post, Top 25 Chaplain Bloggers. And I do find it interesting. All of these bloggers are military chaplains; and while I have spent my career in health care chaplaincy, I have great respect for my colleagues in military chaplaincy. I did also note that right now one of them is in health care chaplaincy. Specifically, he’s just begun a CPE Residency in a military hospital.

I am not making comments pro or con regarding online education. I’ve known graduates from Ivy League schools who appeared to have come away with all the right connections, and virtually nothing else of value; and I’ve known folks who really had learned an awful lot simply in being well read. I will say that the blog is interesting, including in addition to the list of military chaplain blogs, the (very respectful!) post 50 Best Blogs for Wiccans. So, take a look at least at the Top 25 Chaplain Bloggers, and remember the important ministries of our colleagues in military chaplaincy.

"Evidence-based" Needs Good Evidence

I’ve written before about evidence-based medicine.  As a general principle, I believe in it.  I certainly think we ought to be reviewing, studying, and evaluating our health care interventions and discarding those that don’t work or, worse, actually do harm.

So, I was certainly interested when my Best Beloved directed me to Huffington Post and this article by Mark Hyman, MD.  Dr. Hyman lays out serious problems with some of the evidence on which our recent medicine has been based.  And he’s not simply expressing an individual opinion, however informed.  Instead, he points to recent reviews of research in JAMA, the Journal of the American Medical Association; the Archives of Internal Medicine; and the New England Journal of Medicine.  So, there’s evidence that the evidence has been distorted on which some important medicine has been based.

Much of this has long been a concern.  Research has been directed by those pay for it.  Now, it can be a small issue in choosing the direction of research.  People choose to research what funders will pay for.  One result is that practical, potentially profitable research gets funded, and basic research – fundamental research that may stimulate something potentially profitable, or may not - doesn’t.

It’s a much more serious issue when the interests of the funders drive the results of the research, or the way the results are reported.  There has long been a complaint that when pharmaceutical research shows a study drug doesn’t work, or doesn’t work better than competitor drugs, the results don’t get reported, or get distorted.  Now there are reviews like those Dr. Hyman points to that say document instances of this.

And then there are the issues of drugs sold and prescribed “off market” – that is, to treat conditions for which the drugs haven’t been tested.  Granted, sometimes those “off market” applications can appear to offer benefit; but that benefit hasn’t been documented, or documented well, and the risks specific to the “off market” use haven’t been determined.  That’s why it’s illegal for pharmaceutical companies to market drugs for the “off market” use.  Unfortunately, as Dr. Hyman documents, the costs of those violations in terms of fines are nothing compared to the profits.

I will also note that Dr. Hyman shares my feelings about reports of research in the news media.  He notes that often reporters focus on headlines that misrepresent the study results, or amplify a study’s importance all out of proportion.  If on top of that the research has been badly done, and/or the reports in the peer-reviewed sources are distorted, it becomes not only more difficult but perhaps outright hazardous to trust a news report on any given study.

Dr. Hyman has seven steps we can take, and I think they bear repeating.

How to Protect Yourself From the Spin Doctors

1. Follow the money: Be a detective and look up the articles mentioned in the news. Find the study, see who wrote it, and determine what financial conflicts of interest they have. Also check who funded the research.

2. Do your homework: Be suspicious of media reports of scientific findings. Does the finding make sense in the context of other studies and is it the best possible approach. Educate yourself by learning to use PUBMED (the National Library of Medicine) and reviewing different perspectives.

3. Does it pass the "sniff test": Is the treatment suggested just a "me too" drug that has not been proven to be any better than existing treatments? Does it make sense to you or does something smell rotten? Trust your intuition.

4. Advocate for an arm's length relationship between industry and academia. Write your Senators and Congressmen to develop new regulations and legislation that will build a fire-wall to protect us. Grants are fine, but Pharma should have no participation in study design and should not be allowed to interpret or publish results.

5. Demand a no revolving door policy between industry and government regulators. Former drug company executives should not be on FDA committees or involved in regulation or legislation.

6. Advocate for comparative effectiveness research. Preventing this research allows Pharma not to play fair.

7. Campaign for finance reform: If done effectively, can limit the influence of industry on government.

I think these are all steps well worth taking as individuals, and worth requiring of both those who provide our health care and those who pay for it.

So, take the time to read Dr. Hyman’s article.  It will give you pause.  But, if we can press researchers, health care practitioners, payers, and community leaders to change, work like his can also give us all better health care.