Information versus Wisdom

I saw this post on another blog today and thought it was a good title.  I end up pondering this idea almost every day.  In medicine these days we are inundated by data scientists on the one hand and administrators on the other.  The data scientists tell us how they are going to revolutionize medicine through their analysis of large data sets.  The theory is that there are patterns in the data that can be detected only with advanced computational methods.  Having gone through the spreadsheet era and seen how easy it is to prove almost any theory with a large spreadsheet, I am very skeptical of Big Data.  Just dredging through the data, looking for patterns and writing it up does not seem very rigorous to me.  It strikes me more like one of the popular TV shows where the agents are in the field but solidly connected to the computer whiz back at headquarters who is capable of pulling up any document, any floor plan, and hacking into any closed circuit TV system in order to get the information that is needed.  I don't think that science works that way.

On the administrative side, it is the worst of times.  The statistical efforts of administrators are frequently laughable attempts to legitimize the next genius idea to come down the pike.  Their mistakes in healthcare are legendary ranging from the promise of the electronic health record to the RVU based management of physicians as widget producers, all exhaustively documented with numbers.  I sat in a meeting one day that showed 95% of the physicians in the department were not "producing" enough to cover their salary.  The problem was that nobody had done the multiplication on "work RVUs".  When the appropriate multiplier was added it was a different story.  Administrators also tend to collect a lot of numbers that they think will be useful for an analysis, without thinking ahead to the data analysis and statistics.  They seem to have no idea about basic statistical analysis much less more advanced analysis like how to legitimately analyze data over time to detect real differences.  There is no better example than the state of Minnesota collecting PHQ-9 scores over time from anyone trying to treat depression in the state.  They seem to think that unconnected collections of those numbers at different points in time will have some kind of meaning. Administrators also have the habit of creating studies that confirm their vision of the world and when those studies are complete - that is all of the "proof" that is necessary.  The entire concept of managed care rests on many of those studies.

On the wisdom side of things I can think of no better example than a colleague who I said goodbye to today.  He worked with me for the past 2 1/2 years.  He is an Internist who is also an Addictionologist and is ABAM (American Board of Addiction Medicine) certified.  He has been a physician since the early days of the HIV/AIDS epidemic and treating those patients was a significant part of his early practice.  He has an encyclopedic knowledge of the care of those patients and how it has evolved as well as being an excellent Internist.  He is interested in psychiatry and can talk in psychoanalytic terms.  He is also an expert in LGBT issues and can speak with authority on that subject.  I certainly did not want to see him go, but for the purposes of this post, I can think of no better example of wisdom that comes with medical practice.  He could be consulted on any number of complex problems in his areas of expertise and provide a very well thought out answer based not so much on information, but on what works and what the potential complications are.  Any physician can tell you that these are the folks you want to work with.  When I think about data mining approaches toward these areas of knowledge, I think about the 31 page document that is available online that looks at the issue of medication interactions of psychotropic and HIV medications.  It is a compulsively great document, but lacks the wisdom to help you pick the best therapy for a manic patient on tenofovir.

Granted my position is a thoroughly biased one.   I make no apologies for wanting to work with physicians who have the greatest technical expertise and know how to apply it.  I don't mean people who can recite facts or even algorithms.  I mean the people who know all of that and can look at the patient with the most complicated medical situation and still come up with a plan of action and how that patient must be closely monitored.  They also know when it is better to do nothing at all and that is a difficult skill to acquire.  Practically everyone leaves medical school and residency with a strong treatment bias.  You are taught to be "aggressive" and that most of the treatments that you do will do some good even if there is not cure.  In clinical practice, that is far from the truth.  In psychiatry for example, you have to recognize that there are certain biological predispositions, clinical patterns, boundaries, and personalities that are the warning signs of disaster with certain treatments.

When I first started in medicine in the 1980s, the wisdom based model was still the predominate model in most clinical settings.  Now it is much less frequent and there are departments that are just looking for people to fill in the gaps.  They don't necessarily want to retain you they just want to "keep the numbers up."  They also don't want you spending a lot of time on complex cases, because the payment rates rapidly decline if you are not shuffling people in and out the door.    When the administrators start recruiting bodies based on their revenue models and Hollywood accounting,  I hope that I will always end up on the side with the wisdom, rather than a heap of useless information.

There is a lot of that going around these days.  



George Dawson, MD, DFAPA      



Supplementary 1:  I was going to jam in a section to comment on emotional and moral reasoning in view of the expected backlash to the Rosenbaum articles in the NEJM, but decided to add it here instead.  It would have strained the above essay.  It has been an interesting (and fully expected) exercise in political rhetoric.  Predictably the critical articles mischaracterize her position and ironically are at least as guilty of the fallacies that they accuse her of using.  In one case, a new fallacy is pretty much invented.  I think it is instructive to note that in these matters, logic goes out the window.  There is no pathway to a sound judgment.  It basically involves rallying the troops to see who can shout the loudest.  My self proclaimed bias above is part of the reason I am firmly on her side (but will refrain from the shouting).  For anyone who thinks like me, there is no convincing me that the appearance of conflict of interest is the same as actual conflict of interest.  There is no convincing me that free pizza and donuts will cause me to blindly prescribe a medication - probably because I have not eaten Big Pharma food since the early 1990s.  In fact, if I think of a more plausible thought experiment about how much cold hard cash it would take to pay me off to prescribe a drug, I can't come up with a figure but it would have to be absolutely stratospheric compared with the usual speaker fees that people are listed in the Sunshine Act database for.  All of that is based on the fact that I work for a living and treat real patients.  I am accountable to those patients.  If a medication does not produce real results or it causes too many side effects (like my early experience with paroxetine) it is off the Dawson formulary and I don't prescribe it again.

This is of course like arguing with Democrats and Republicans.  I know that some pro-appearance of COI=COI will strongly dislike my experience and the way my thoughts on this matter are anchored in the way I practice medicine.  That is the nature of arguing about emotional and moral reasoning in what the Institute of Medicine (IOM) describes as an ethical vacuum.  The recent editorials certainly don't prove a thing.

The usual focus of these debates also leaves out the big picture that many entire University departments (math, science, engineering) actively collaborate with industries and in many cases actively invite industry participation in order to advance those fields.  The notion that physicians are not able to do that because they have a sacred trust to patients and would be somehow compromised remains implausible to me, particularly when nearly all of the major decisions that physicians make in this country have been seriously tampered with if not controlled by managed care companies and pharmaceutical benefit managers for nearly 30 years.

That is a massive conflict of interest that nobody talks about and it affects 80% of all of the healthcare in this country.

Supplementary 2: The graphic at the top of the post is from Shutterstock.

Interviewing 101

Interviewing seminars are a big part of the first year of psychiatric training.  I am not sure how it goes these days, but I can recall having to record interviews and being critiqued by the instructor and all of my peers in seminars.  I can remember not always agreeing with the critiques.  Every psychiatrist goes on to develop their own interview style around the basics.  Just about every interview is unique because it also depends on the person you are talking with.  The flow of information in the interview has always been fascinating to me.  At times you can cover all of the essential elements in 30 minutes.  At other time you can talk for 90 minutes and end up with 25% of the information.  Facilitating and directing that flow of information is one of the key elements of interviewing.  Against that backdrop I found this commentary on an interview of Robert Downey, Jr. somewhat interesting.  It seems surprisingly linear.  It reminded me of some of my media interview experiences where the predominate advice seemed to be: "No dead air.  Either I am talking over you or you are talking over me.  Got it?".  This clip has been widely broadcast for the past several days.  In it, the interview takes a bad turn and Downey politely gets up and walks out.  The discussion near the end of this brief clip suggests that there were probably just a few minutes left.







In the critique of this interview, Kathleen Kelley Reardon focuses on what is described as the human chemistry between the participants and how that potentially involves features like attractiveness, mood, timing and other features.  Reardon speculates that Downey may not have been up for the interview and the transition to personal questions may have been premature. She sees it as an excellent case study in what can go wrong with interviews.  I think that there are some good examples of what might go wrong but there are also some unknowns.  From my vantage point as a psychiatrist I have a few other observations and I have never had to worry about the tone of the interview, but then again I am never working on an interview as an infomercial.

1.  The introduction is very important, but we may have missed it.  Even though this is supposed to be the entire interview, it begins with Downey speaking.  This is an old Oral Boards style point - if you don't introduce yourself and set the context of the interview - come back and try it again next year because you have just failed the exam this year.  The interviewer could have saved himself a lot of problems by discussing the interview context ahead of time and setting ground rules for what the actor is or is not willing to discuss.  You don't have time to discover that in an 8 minute interview.

2.  Too many people in the room is never a good thing.  Because I am teacher, I still have people observing my interviews for teaching purposes and I never like it.  I have to be completely focused on the other person and how they are affecting me.  I did not see Downey as distracted or disinterested; I saw him look to his advisor several times until it got to the point he was overtly looking for advice.  I saw him make a clear announcement at one point: "Are we promoting a movie?" where he was clearly dissatisfied in the direction things were headed and that comment was directed to other people in the room.  The best way to maintain focus is to make sure that there are only two people in the room.

3.  What is the purpose of the interview?  There has to be a focus on that point and the interviewer needs to be aware of it.  In a psychiatric or medical interview the overriding agenda is that there is a mutual focus on a problem that needs to be solved for the patient.  Everything is as confidential as possible.  I heard a prominent psychiatrist and researcher say at a psychotherapy conference that some of the primary goals are: "Be nice to the patient and say something useful to them."  In a celebrity interview there are really dual agendas - publicity for both the interviewee and the interviewer.  Being a celebrity interviewer can lead to celebrity status on its own.  The interviewer is probably aware of how they want to come across to the viewers.  Where do they want to be along the famously provocative to famously uncontroversial spectrum?  Do they aspire to be a celebrity interviewer?  How focused are they on entertainment versus journalism?  I personally cannot think of a greater intrusion into the interview process.

4.  Contrary to the author's point, I don't think that the reporter (Krishnan Guru-Murthy) had a problem with transitioning or failing to read the cues of Downey. He seemed anxious to me. Downey came across as authoritative when talking about American cultural influences but then somewhat oppositional and defensive when talking about a past opinion that he gave during an embarrassing period in his life. He was aggressive when commenting on the interviewer's motor behavior and suggesting that he was running out of time to ask (what was probably going to be) a controversial question.  This would have been an entirely different interview if the focus had been maintained on superhero culture and the actors theories of where the film fits into that genre. He had a pretty good interpretation of some of the Stan Lee origins in Vietnam era America.  Just the time line of those developments and the further implications for the film would have filled the time.

5.  Sometimes the person being interviewed drops a gift at your feet and you have to go with it. As an example, if I am interviewing a person who has been incarcerated I rarely go directly after that information.  I can probably get the historical details elsewhere and it is a threat to the interview process.  I don't want the interviewee to develop the "cop transference" and start to experience it as a police interrogation.  And I usually have an hour compared to this less than 10 minutes session.  The  interviewer needs to be aware of the fact that he is not doing psychoanalysis and that all of those Barbara Walters interviews where there was a key emotional disclosure occurred after hours of interviewing and heavy editing.  In this case Downey talks about how he portrays the character and how his interpretation of the character had changed over time.  That leaves him talking to a small part of the audience for this interview - the people interested in art and acting but that would have ended a lot better.

6.  As I watched the interview, I had the question about whether there were any journalistic biases operating.  It becomes clear that Guru-Murthy wants Downey to answer questions that have nothing to do with the movie and were from a very difficult time in the actor's career.  It is clear that the reporter's anxiety level is building as he tries to force those questions.  And, it is clear that he is trying to force them into the smallest possible window in this interview - the final minutes.  It was anxiety provoking for me to watch that section of the interview.

7.  There is often a lot of focus on the process aspects of the interview.  It seems that the emphasis on the communication aspects of the interview are very linear - pick up this cue and make this intervention.  Interviews (at least the way I see them) are non-linear,  There are a lot of parallel processes going on and interviewers tend to elicit much different information based on their biases and techniques.   There may be times where I slow the interview way down to get at specifics and at other times I am looking for global markers and whether they are present or not.  

8.  Based on my past experience,  I also had to wonder if the gotcha dynamic was operative.  I have been called in for media interviews where the reporter has some preconceived notion of how the world works.  A good example is the fallacy that the Christmas Holiday season is the peak time of the year for suicides.  After I had spent some time explaining to the reporter over the phone that this is really not true, during the interview I was pummeled with comments and anecdotes about how people naturally get depressed and kill themselves more often during Christmas.  This has happened to me more than once and it is a good reason to avoid reporters.

The way this interview ended seemed quite civil to me.  It is not surprising to me that the media is making a big deal of it in spite of the fact that really catastrophic interview endings tend to occur with people who are accusatory, demanding, threatening and/or aggressive.  In an interview with an actor that is not likely to happen.

Despite all of our focus on interviewing in psychiatry, we seem to be loathe to look into the science of it all.  For the past 30 years we have been operating under the illusion that in order to make a DSM diagnosis, all it takes is getting the answers to the right questions.  Those questions were typically structured interviews using DSM or the precursor RDC criteria.  It gave way to the Diagnostic Interview Schedule (DIS) for early epidemiological work followed by the Schedule for Affective Disorders and Schizophrenia (SADS).  This work seems to have led to brief diagnostic checklists based on  the DSM criteria.   I read an article in the Journal of Clinical Psychiatry once that suggested if all of the clinicians in a clinic used the SADS as their diagnostic interview they would have better outcomes.  The idea that a structured interview or checklist elicits better or more useful information than an experienced psychiatrist interviewing the patient is another great fallacy in the field.  I would actually put that at the top of the list and rate it higher than needing a head to head comparison of antipsychotics based on time to discontinuation or whatever the Cochrane Collaboration has to say about "limitations of methodology / need more study" for practically any drug trial.  The evidence that I am right is replicated tens of thousands of times every day by psychiatrists out there doing the same work.  If you interview the same patient twice it is very unlikely that they will give  you the same history.  I have a standard flashcard that lists about 100 medications of all classes and they will not consistently endorse the same medications on this list.  We interview people about their subjective experience and that experience is always plastic.  That is much more interesting than storing the encyclopedia on computer chips.

In some cases we might put a metric like test-retest reliability on an interview metric or the global result of a structured interview.  Given that we are measuring something that reflects the functioning of a highly plastic organ, I don't know why we would expect reliability to be high.

That brings me back to this interview.  Our interview technology is a holdover from the 1950s.  We have evolved subtle modifications over the years but currently we are constrained to a small fraction of the conscious state and we do not know how to optimize the flow of relevant information.  This is a major limitation.  There have been some theorists who have looked at mapping diagrams of the interview process but none have gained any widespread acceptance.

The only good news for psychiatrists now is that we are not operating at the level of reporters.


George Dawson, MD, DFAPA

Lies, Damn Lies, And Normal Brain Function

I have listened to the past 48 hours of constant criticism and speculation about the implications of what is generally described as a "lie".  News anchor Brian Williams made a statement about remembering that he was shot at in a helicopter in Iraq and forced down after it was hit by a rocket powered grenade.  That statement occurred on an interview with David Letterman and several other venues over the past 12 years.   The actual section of the video is from the 2:50-7:20 of the 18:14 clip.  In the interview he was entertaining, self effacing and talks about himself as being an "accidental tourist".  He rejects Dave's suggestion that he be looked at in a different light because of this incident and praises the volunteer troops and emphasizes that he hopes the troops get what they need when they return home.    The statement and previous clips (3) have been scrutinized by various sources.  Today there are also a number of places looking closely at other statements for similar errors or possible "lies".  Conspiracy theorists always want to prove that there is a pattern.  The formal press and the blogosphere generally wants to see successful people fail in some way.  There are many stories suggesting that this has implications for Williams credibility as a journalist.

Notice how I slipped the word "error" in there.  One of the preconditions for classifying a statement as a "lie" is that it is a conscious effort to mislead.  Mistakes are not technically lies although I have been in settings in medical training where trainees were punished for mistakes and treated as if those mistakes were lies or at least the product of a significant character flaw. A little context is always relevant.  Williams typically reads the news every night for the past 11 years.  He has read more information during those broadcasts than most people will every speak to their colleagues and coworkers in a lifetime.  All of that information is probably vetted by another editor and the person entering the text.  He has presented that information in a way that has led him to have the reputation as being a very reliable source of news.  Secondly, he is under a great amount of scrutiny, much more scrutiny than an average person would expect because he is constantly recorded and easily recognized as a celebrity.  Finally, what can he be expected to gain from intentionally telling a misleading story.  What is his possible motivation?  He clearly dismissed Letterman's attempt to make it a big deal and immediately made it a story about the volunteer forces and returning veterans.  All of these factors seem to be ignored in the typical analysis of the statement and his apology.    

Mistakes like this are commonplace.  In the past month, I have had two very bright young colleagues recall my unusual eating habits from dinners that recently occurred.  One of them recalled me eating a large piece of prime rib, the other frog legs.  I have not eaten beef in 30 years and have never eaten an amphibian.  In those events my colleagues did not recall a feature of the event and there was a misattribution based on that lack of recall.  In many situations, my usually excellent memory does not match up with the recall of others from the same situation.  In 1975 (or so) I was in the Hotel Jacaranda in Nairobi, Kenya with a few of my Peace Corps friends.  We were all seated around a large rectangular table getting ready to order dinner.  I was particularly jumpy that night and when a waiter bumped into my elbow, I reflexively dumped a cup of cocoa on a friend sitting immediately to my right.  When I say dumped, I mean about 16 ounces of warm liquid poured right on top of his head and over his glasses.  I was very embarrassed at the time, but the incident was apparently forgotten by the other 5 friends sitting at that table.  I tried to revisit that event with my friend a few years ago and according to him - it never happened.  Whose recollection of the incident is likely correct, a person who has an associated memory of being embarrassed about it or the person who would just as soon forget about it?

None of my anecdotes matches one that is probably self aggrandizing to some extent but their are similiar examples in the literature.  Eye witness testimony comes to mind.  You are a star witness in the case and the fate of the defendant hinges on your testimony.  Psychologist Daniel Schacter points out in his book (1) that more than 75,000 criminal trials are decided each year on the basis of eyewitness testimony.  A recent analysis comparing eyewitness testimony to DNA evidence suggested that eyewitness testimony was mistaken in 90% of cases.  A more recent review (2) suggests that the number may be closer to one in three.  I have testified myself in courtroom situations where I was told by attorneys that I would not have to speculate on a specific question.  I was asked that question anyway, but with enough experience I knew the correct response was to say that I could not answer the question.  I have always wondered about what happens when people are witnesses in important cases and they have the expectation that they need to come up with an answer to every question whether they have an answer or not.  I am sure that I have seen this happen in real courtroom testimony.  That stress in combination with imperfect human memory has the potential to create a new story or at the minimum information that creates more noise than signal.

The second aspect of the Williams scenario involves the binding of certain events in the correct order across a number of situations.  Watching the NYTimes montage in reference 3 illustrates what I am  talking about.  Earlier footage clearly illustrates that he was on the ground with helicopters that had taken small arms fire when he landed in a helicopter that was probably doing what he described in the  Letterman clip.  Is it possible that this was binding failure?  Schacter's definition of which would be "the gluing of the various components of an experience into a whole.  When individual parts of an experience are retained but memory binding fails, the stage is set for all kinds of source misattributions....".   It is easier to recall actions and scenes presented together but significantly more difficult to recall which action occurs in which scene (4).  That experimental finding is interpreted to mean that information about scenes and information about actions are stored in different parts of the visual memory system (4).  Further binding is adversely affected by age (5) and other sources of interference (6) with both the features of a scene and the bindings.  Psychiatrists who keep detailed notes on their patient encounters will easily observe these binding failures and different histories being given at different points in time.  It is also likely that the longer you live, the more you will encounter this phenomenon in your own life.

People lie and people forget - so what?  In the final analysis, very few observers have access to all of the information necessary to determine what is a lie and what is not a lie.  By definition the only discriminating factor is a conscious awareness on the part of the liar.  I have no access to information more than anyone else and no conflict of interest when it comes to Mr. Williams or NBC.  The current situation requires some reflection on why it has the appearance of being so important.  Is it possible that this is a case of faulty recall and misattribution?  I think it is and most of the analyses to the contrary are not based on how human memory works.  There are a number of questions that can be asked about these analyses.  Why is there an opinion based on very scant information?  Is it possible that emotional bias is involved in the complex decision-making of the author?  Is the author denying the fact that these kinds of experiences have happened to them?  Or is jumping to conclusions an aspect of the author's character that they would just as soon not look at?  Is it really that surprising that thousands of journalists and bloggers want to add their own sensational spin to this story?

Those may be much more relevant questions than the one being asked today.



George Dawson, MD, DFAPA


References:


1:  Daniel L. Schacter.  The Seven Sins of Memory.  Houghton Mifflin Company; Boston, 2001, 272 pp.

2: Wise RA, Sartori G, Magnussen S, Safer MA.  An examination of the causes and solutions to eyewitness error.  Front Psychiatry. 2014 Aug 13;5:102. doi: 10.3389/fpsyt.2014.00102. eCollection 2014. Review. PubMed PMID: 25165459

3:  Jonathan Mahler, Ravi Somayia, Emily Steele.   With an Apology, Brian Williams Digs Himself Deeper in Copter Tale.  New York Times February 5, 2015.

4: Urgolites ZJ, Wood JN.  Binding actions and scenes in visual long-term memory.  Psychon Bull Rev. 2013 Dec;20(6):1246-52. doi: 10.3758/s13423-013-0440-1. PubMed PMID: 23653419.

5: Pertzov Y, Heider M, Liang Y, Husain M.  Effects of healthy ageing on precision and binding of object location in visual short term memory.  Psychol Aging.  2014 Dec 22.  [Epub ahead of print] PubMed PMID: 25528066.

6: Ueno T, Allen RJ, Baddeley AD, Hitch GJ, Saito S. Disruption of visual feature binding in working memory.  Mem Cognit 2011 Jan;39(1):12-23. doi: 10.3758/s13421-010-0013-8.  PubMed PMID: 21264628.


Supplementary 1:  

It  turns out that I was able to think of a better anecdote after I penned the above post.  On Tuesday September 11, 2001 I was doing what I did every morning as an inpatient psychiatrist for 23 years.  I was sitting in a team meeting with all of the representative disciplines including social work, occupational therapy and nursing.  At about 8:15 a nurse came in to give us a report and she happened to mention:  "We just heard that a plane hit one of the Twin Towers in New York City.  It's on the news right now."  When she said that my recollection was that I said: "If I was there right now I would be trying to get as far away as possible.  That was a terrorist attack and there may have been something else on that plane."  The rest is history, but for the purpose of this post did I really make that statement?  I had just tried to run an early Internet campaign for US Senate and one of my overriding concerns was terrorism.  My campaign could be best described as an abysmal failure.  I seemed to be one of the few people in the state interested in terrorism.  Almost everyone else had been concerned with spending the imaginary federal surplus, something I considered to be the product of capital gains taxes on the Internet stock bubble.  For that matter, do I really remember all of the people in the room at the time?  I am pretty sure I do, but it would not surprise me at all if I struck up a conversation with somebody who I thought was there only to learn that they were not.  Nobody who I thought was in the room ever approached me after the incident and asked me about my statement.  I took that as pretty good evidence that I should keep my mouth shut.  I also remembered something I read about Harry Stack Sullivan.  He was a psychiatrist who specialized in the interpersonal psychotherapy of people with schizophrenia.  He had a number of therapy experiences that he wrote about that were very striking and unique.  In his writing at one point he said that he realized that he just needed to stop writing and talking about those experiences because he could not say for  sure what had actually happened versus what was embellished.  I always remembered that cautionary note as well as the slang term "power story" from my youth in the North.  A power story was assumed to be an embellished story to make one look good.  A typical response might be (in a mildly sarcastic tone): "OK Paul Bunyan - where is Babe the Blue Ox?"  It is probably not a good thing to be remembered as the psychiatrist who tells power stories unless you are retired and sitting in a bar in northern Wisconsin.