I have always been somewhat of a science nerd and had what I consider to be a first rate science education at a liberal arts college. I had gone to this school on a football scholarship with the intention of becoming a phy ed teacher and a football coach, but the science education there was too compelling to ignore. I ended up being a biology and chemistry major and rapidly forgot about football. Brook's essay of what is science, what is the most compelling science and how that makes psychiatry as far from science as possible led me to think about memorable experiments from my undergrad days.
Experiment 1: The Limnology experiment: For a while in my undergrad career, I considered being a limnologist or fresh water biologist. My undergrad college was one of the first to emphasize the environment and ecology. A lot of the work involved doing population estimates of plankton and aquatic invertebrates. We spent hours classifying and counting thousands of organisms that are unknown to most people. We used various sampling techniques and statistics to determine populations of these organisms and whether they seemed to be influenced by any environmental variables. At one point I had equations from an journal article to calculate the probability that a specific species would be in contact with another one - called the "probability of inter species interaction." This is biological science.
Experiment 2: The PChem experiment: Physical Chemistry was the undergrad chemist's dream course when I was in college. You dreamed that you would be able to pass it. We had a text that was not very accessible, but a professor who was brilliant, very accessible and an excellent lecturer. I liked it a lot after we finished thermodynamics and moved on to other topics. Back in the 1970s we had very primitive computing power. Our lab had an old HP calculator that was as big as a current desktop with less computing power than a modern day scientific calculator. One of our tasks was to estimate electron densities around carbon atoms in aromatic hydrocarbons. In an afternoon in the lab we ran the numbers. This was the science of physical chemistry.
I have intentionally left out all of the details of the experiments because for the purpose of comparison with Brooks thesis they are unnecessary. From his essay we learn that biology and chemistry are real sciences with a "distinctive model of credibility". The examples I have given are from those fields. We learn that psychiatry is a "semi-science" because "the underlying reality they describe is just not as regularized as the underlying reality of say, a solar system". I will stop at that point because Brooks further examples rapidly degenerate. What do we have so far?
Looking at my experiments, #2 clearly has the regularity of a solar system. What could be more regular than the electron density for a specific molecule? It fits Brooks definition of science to a tee. What about experiment #1, the biological experiment? Here we have a number of organisms. Some have nervous systems and the others (eg. phytoplankton) do not. I did a series of calculations to look at the probability of one species encountering another. There were certain assumptions to those calculations about randomness to make the calculation much easier to do. But what if I wanted for a moment to be a "behavioral limnologist" and attempt to predict the behavior of a specific stoneflies in the sample? What if I wanted to determine the 5% of stoneflies that exhibited behavioral characteristics, that differentiated them from the other 95%? Suddenly we have a problem. The source of that problem is a nervous system. The underlying reality of most even slightly complicated nervous systems is that they will never have the regularity of a physical system. They have evolved not to. Regularity in a nervous system locking it into a physically predictable system is not in any way adaptive for any animal that needs to forage and reproduce. It is the kiss of death.
But is gets complicated at additional levels. The human brain is highly evolved to have significant processing power. At another level, there are theoretical concerns about whether it is possible to ever to map behaviors and psychiatric symptoms directly onto some neurobiological system. Unlike my experiment 1 above we are rarely interested in looking at only life or death as the outcome variable. The variables that will allow us to study different populations are going to be much more complex than grossly observed behaviors. There is a complicated nervous system between those behaviors and the environment.
Is psychiatry really not a science because it is complex and attempts to deal with the complicated phenomena associated with the human brain? Should we ever be concerned about 1:1 mappings of psychiatric disorders onto a specific genetic or neurobiological defect? Is it possible that a human nervous system is so complex that it is unrealistic to expect that this might happen?
Unlike Brook's theme nobody is a "Hero of Uncertainty". Uncertainty is the expected condition and one that every psychiatrist should be comfortable with. Psychiatry and the associated neurosciences will never be reduced to the predictable calculation of a physical system and that has nothing to do with one being a more prestigious science. It has to do with evolution and complexity. It has to do with what philosophers call the "demarcation problem" between what is and what is not science. More to come on that in the near future.
George Dawson, MD, DFAPA
Showing posts with label David Brooks. Show all posts
Showing posts with label David Brooks. Show all posts
Saturday, June 1, 2013
Thursday, May 30, 2013
Brooks on Psychiatrists As "Heroes of Uncertainty"
Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise. His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology". Psychiatry is certainly comparable to biology but not to physics. And what is it about psychiatry that is unscientific? The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme. It is probably why many authors seek to equate psychiatry with the DSM. The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry. The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.
Brooks characterization of the DSM shows a continued lack of understanding of this manual by every journalist who writes about it. There is practically no psychiatrist I know of who considers it to be authoritative. Very few psychiatrists actually go about their diagnostic business by reading through DSM criteria. That activity would be limited to novices and medical students. It is well known that only a fraction of the diagnoses listed are ever used in clinical practice. After familiarizing themselves with the major changes, few psychiatrists will every open it again. Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual. The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it. Despite all of the concern about the public impact - psychiatrists are the target audience here. Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it. I guess a lay person might be impressed, but I never met a psychiatrist who was.
Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems". That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist. That technical knowledge is contained in a vast literature, much of it written by psychiatrists. It is the reason that ongoing training and education of physicians is a career long commitment. In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.
There is the associated question about whether physicians are scientists or not. I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not. That is quite different from suggesting that physicians are unscientific. There are certainly not many physicians who are performing scientific experiments and publishing papers. I suppose that you have to do that to be a professional scientist. On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians.. I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year. Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise". There really is no art in medicine. The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns. They can apply that knowledge to patient care. In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.
This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine. My study of psychiatry finds it in neither of those locations. There is a reason that psychiatrists need to go to medical school. The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist. Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine. When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.
Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences. Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus. I will give Brooks partial credit when he writes about the DSM. Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible". When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel. But I also know that I am not rolling the dice or taking a leap of faith. I am doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.
George Dawson, MD. DFAPA
David Brooks. Heroes of Uncertainty. NYTimes May 27, 2013.
Brooks characterization of the DSM shows a continued lack of understanding of this manual by every journalist who writes about it. There is practically no psychiatrist I know of who considers it to be authoritative. Very few psychiatrists actually go about their diagnostic business by reading through DSM criteria. That activity would be limited to novices and medical students. It is well known that only a fraction of the diagnoses listed are ever used in clinical practice. After familiarizing themselves with the major changes, few psychiatrists will every open it again. Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual. The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it. Despite all of the concern about the public impact - psychiatrists are the target audience here. Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it. I guess a lay person might be impressed, but I never met a psychiatrist who was.
Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems". That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist. That technical knowledge is contained in a vast literature, much of it written by psychiatrists. It is the reason that ongoing training and education of physicians is a career long commitment. In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.
There is the associated question about whether physicians are scientists or not. I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not. That is quite different from suggesting that physicians are unscientific. There are certainly not many physicians who are performing scientific experiments and publishing papers. I suppose that you have to do that to be a professional scientist. On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians.. I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year. Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise". There really is no art in medicine. The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns. They can apply that knowledge to patient care. In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.
This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine. My study of psychiatry finds it in neither of those locations. There is a reason that psychiatrists need to go to medical school. The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist. Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine. When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.
Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences. Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus. I will give Brooks partial credit when he writes about the DSM. Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible". When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel. But I also know that I am not rolling the dice or taking a leap of faith. I am doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.
George Dawson, MD. DFAPA
David Brooks. Heroes of Uncertainty. NYTimes May 27, 2013.
Thursday, July 5, 2012
SCOTUS decision irrelevant for health care reform
The decision by the Supreme Court on June 28 regarding the Patient Protection and Affordable Care Act has generated a lot of speculation about the implications for health care reform, the politics of the Supreme Court, the health of Supreme Court justices, and the impact on two party politics. Very few people seem really focused on the issue of health care reform. Even the most positive spin on this decision misses the mark. This article by Brooks that seems to center on the ideology of the Court and how the decision is healing is illustrative with the following quote:
"People in both camps seem to agree: We’ve had a big argument about health care over the past several years, yet we haven’t tackled the big issues. We haven’t tackled the end-of-life issues. We haven’t fixed the medical malpractice system. We are only beginning to correct the antiquated administrative systems."
"People in both camps seem to agree: We’ve had a big argument about health care over the past several years, yet we haven’t tackled the big issues. We haven’t tackled the end-of-life issues. We haven’t fixed the medical malpractice system. We are only beginning to correct the antiquated administrative systems."
And:
"... we haven’t addressed the structural perversities that are driving the health care system to bankruptcy. ... American health care is still distorted by the fee-for-service system that rewards quantity over quality and creates a gigantic incentive for inefficiency and waste."
The observations like essentially all observations about the ACA ignore the basic fact that this IS managed care and in fact - managed care on steroids. Managed care has proven time and time again to not contain costs and introduce administrative inefficiency in over two decades of experience. Whether or not the Supreme Court allows it to go forward or it is politically defeated in the future is peripheral to the fact that managed care has not worked as a device to contain health care inflation and it certainly does not provide either quality care or innovation. It can make money for stockholders and CEOs. In fact, in an up or down economy I can't think of a better recipe for making money than being able to deny health care benefits to a group of health care plan subscribers or deny or reduce reimbursement to physicians.
The structural perversity in the system is that in the overwhelming number of cases, personal health care decisions are no longer made between a patient and a physician. Contrary to managed care hype, their decisions are not necessarily based on any legitimate evidence. They are based on what is good for business and in this case we don't have a business that needs to build a better product. We have a business that has to ration access to a service.
Until that is recognized - health care reform is basically continuously rearranging ways to shift money from the people providing the care and the people paying for care to business entities that are "managing" the care.
The outcome is as predictable as where the managed care systems have gotten us to at this point.
George Dawson, MD, DFAPA
"... we haven’t addressed the structural perversities that are driving the health care system to bankruptcy. ... American health care is still distorted by the fee-for-service system that rewards quantity over quality and creates a gigantic incentive for inefficiency and waste."
The observations like essentially all observations about the ACA ignore the basic fact that this IS managed care and in fact - managed care on steroids. Managed care has proven time and time again to not contain costs and introduce administrative inefficiency in over two decades of experience. Whether or not the Supreme Court allows it to go forward or it is politically defeated in the future is peripheral to the fact that managed care has not worked as a device to contain health care inflation and it certainly does not provide either quality care or innovation. It can make money for stockholders and CEOs. In fact, in an up or down economy I can't think of a better recipe for making money than being able to deny health care benefits to a group of health care plan subscribers or deny or reduce reimbursement to physicians.
The structural perversity in the system is that in the overwhelming number of cases, personal health care decisions are no longer made between a patient and a physician. Contrary to managed care hype, their decisions are not necessarily based on any legitimate evidence. They are based on what is good for business and in this case we don't have a business that needs to build a better product. We have a business that has to ration access to a service.
Until that is recognized - health care reform is basically continuously rearranging ways to shift money from the people providing the care and the people paying for care to business entities that are "managing" the care.
The outcome is as predictable as where the managed care systems have gotten us to at this point.
George Dawson, MD, DFAPA
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