Science and Politics…..With A Lesson from Psychiatry

 

I started reading this week’s edition of Science and was surprised to find several editorials about the relationship between science and politics. In addition to the editorials, news items like “Will Trump upend public health?” and “Trump picks lawyer for EPA.” Were no less alarming.

Marcia McNutt, President of the National Academy of Sciences wrote the first essay (3).  She correctly discusses science as a rational neutral process that by its very nature is apolitical.  She describes the peril of citizens ignoring scientific reality by quoting a 26% increased mortality rate in areas of the US where political leaders dismissed the importance of the COVID-19 vaccine.  She makes the point that science must define the body of information that policy should be based on - but it should not actually dictate policy.  She advocates for a role of listening to the affected people and fighting the disinformation that affects them.  Unfortunately, the process of active listening will not do anything toward fighting misinformation – especially when things get to the wide dissemination and meme stage. 

H. Holden Thorp, Editor-in-Chief of Science journals wrote the second essay (4) and it was more specific to the current political situation.  After commenting on the win for Trump he provides the following qualifier:

“Although his success stems partly from a willingness to tap into xenophobia, racism, transphobia, nationalism, and disregard for the truth, his message resonates with a large part of the American populace who feel alienated from America’s governmental, social, and economic institutions.”

The first clause in this sentence is accurate – but there are problems with the second.  Are xenophobia, racism, transphobia, nationalism, and dishonesty really symptoms of an underlying problem or do they represent the real problem of an opportunistic politician successfully scapegoating a portion of the population to gain the support of the electorate with these biases?  That has immediate relevance for the author’s proposed solutions of decreasing scientific misconduct to enhance public trust.  He points out that an animated defense on X/Twitter by scientists was not successful (how could it be based on the platform’s structure, biases and conflicts of interest?). He ends by correctly predicting that the attacks on science and scientists will go on unabated into the future and would like to see a response by the scientific community that makes them less successful.

The essay by Jaffrey Mervis (2) highlights concerns that research advocates have for the Trump agenda that is described at one point as defunding research to reduce taxes.  Any analysis of the tax plan shows that the savings are disproportionately awarded to the top 1% of wage earners.  A research physicist points out that there is no good news for science in the Trump agenda and that also translates to no good news to the tech industry that depends on government funded research for innovation.  Three areas from the Biden administration that may suffer are the Chips and Science Act, climate change, and research collaboration with China. 

The essay by Jocelyn Kaiser (1) focuses on the possible impact on the National Institutes of Health (NIH).  In this essay there is clear focus on Robert F. Kennedy, Jr. as a danger to the NIH and health related basic science research.  That danger on the one hand describes him with the euphemism “vaccine skeptic” and on the other quotes former NIH Director Harold Varmus as saying: ”enormous risks especially if [Trump] placed someone as unhinged as [Kennedy] into a position of responsibility.”  There is a lot of room between skeptic and unhinged.  Trying to present an even-handed description in this case is a clear error when responding to RFK’s rhetoric. It is not a stretch to say that his rhetoric may replace science as the guiding principle behind the NIH.  That is a problem regarding the role of science advising policy makers and a boundary problem on the part of rhetoricians.  Simply put – if you are an administrator with no science background and you are making science up – stay in your lane.

Another clear example of potential problems with a Republican Congress is still based on the COVID-19 pandemic and insistence that the bat coronavirus research was the source of the pandemic virus.  This has reached meme status in the MAGA community fueled by rhetoric from both Trump and members of Congress who have directly attacked NIH scientists.  In some cases those verbal attacks have resulted in threats of violence to those same scientists. All of that happening even though the origins of SARS-CoV-2 are not settled science - but most recent reports suggest origins in the wild like practically all pandemic viruses. Some politicians want to reform the NIH and that is typically a code word for changing an institution to something more like the one they want.  In the case of the Trump administration that can include banning fetal tissue research and I would expect other issues related to women’s reproductive health that the religious right objects to.

The final essay by Rachel Vogel (5) is focused primarily on the implications of Trump’s threat to leave the World Health Organization (WHO). The author reminds us that Trump started this process in July 2020 based on the false claim that “WHO had helped China cover up the spread of the virus in the early days of the pandemic.”  The Biden administration came in and stopped that process.  WHO member states are bracing for a second withdrawal or a reduction in funding to key programs that many think would be catastrophic.  Cuts could also be made to the US Agency for International Development (USAID) that administers many of these programs and other agencies funded to research and treat tuberculosis, malaria, and AIDS.  Political and religious ideology may also be a factor.  A program for AIDS relief started by George W. Bush is a possible target for indirect support of abortions and the use of language that right wing religious groups consider offensive including “transgender people” and “sex workers”.  It is likely that a “gag rule” on the dissemination of abortion information will be reinstated and the penalty will be withdrawal of funding.  Like aspects of the other essays, the author is hopeful that there will be ways to compensate for the Trump worst case scenario. Reform of the NIH has been talked about in the past.  Europe and other countries could compensate for the lack of US support.  Competitive funding sources like the BRICS group (Brazil, Russia, India, China, and South Africa) could also come to the forefront.  The amount of funding available from BRICS and what those countries would require in return is speculation at this point.    

The 5 essays highlight real problems and given Trump’s current nominations for the Director of HHS and NIH probably minimize them.  Suggested solutions to the problem seem to be the time-honored stay out of politics, present the data, and take the high road.  This is really an inadequate plan.  How do I know this?  The valuable lesson is that this is what psychiatry has done for decades.  Ever since Thomas Szasz began his repetitive rhetoric that there was no such thing as mental illness, or that psychiatric diagnoses were like drapetomania (later modified to drapetomania was somehow a psychiatric diagnosis) we have had to tolerate nonsensical criticism while major physician and psychiatric groups were silent.  The many leaders in the field who did respond and had excellent responses were eventually ignored as the neo-Szaszians continue to repeat this nonsense decades later.  An experiment by Rosenhan that was exposed as fraudulent continues to serve as an anchor point for antipsychiatrists – even though what happened clearly did not impact the field (deinstitutionalization had already started and the neo-Kraepelinians were already at work on reliable and valid diagnostic criteria).  The result of this rhetoric is significant hangover on the field. It is difficult to make a direct connection but common sense dictates that psychiatric resources probably takes a hit from all the repetitive negative rhetoric. That is the risk to all of medicine, public health, and scientific research with the current MAGA rhetoric.

Science typically considers itself above rhetoric and politics at least until the competition for grant funding heats up.  The editorials all fail to comment on this.  Instead, they suggest that leading by example, being available for consultation, and generally taking the higher ground will somehow correct corrosive politics.  That is both a naïve and losing strategy.  We currently have a party that has lied and misinformed the public repeatedly and at record levels.  It is supported by a large mainstream media organization with the same goals providing a constant diet of misinformation. It is funded by billionaires. The effects of all those dynamics are easily observed in attitudes toward real science and scientists.  Experts on autocracy and authoritarianism point out that the effect of constant lies on any group of citizens is that eventually they don’t believe anything – even if it happens to be the truth.  A standard authoritarian tactic is to attack expertise and pretend that it does not exist.   

At no recent point in history have legitimate scientists, physicians, and public health officials been threatened with violence by people who have no clear idea of what they do.  In many cases these professionals have been responsible for saving thousands of lives. That situation should be intolerable to any scientist or modern citizen who can evaluate the effects of science.  Furthermore, it should not be supported at any level by the government, but it currently is.  The same party that that supports lies also supports threats and violence at various levels up to an including an attempt to overthrow the US government. With the current election there is the expectation that attempt will be whitewashed as a protest further eroding the rule of law.

The curious aspect of this process is that it is right out there in the open. The repetitive lies are picked up by social media.  Proxies of that ideology begin to amplify them to the point that they become memes rapidly assimilated by true believers in the same ideology.  At that point they become part of that culture and resistant to change from rational arguments and additional information. There is no evidence that I am aware of that change is possible at that point and the most recent Presidential election is solid evidence.     

There is a semi rational basis to politics at best.  The current election illustrates this at many levels.  Major questions of character, intellect, and policy were ignored. The fact checking mode of the fourth estate was minimized.  Some media outlets were mere propaganda arms and provided no information for voters to make an informed decision. 

The only rational course is to continuously counter the repetitive propaganda being put out in social media.  There is no comprehensive strategy for doing this but it must be done.  It will take more than a few editors from Science journals.  A starting point may be a coalition of editors of science and medical journals with their own website dedicated to refuting misinformation and posting the real science. The time has come to stand up for what is science and what it not and protect people under attack for doing the right thing.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Kaiser J. Trump won. Is NIH in for a major shake-up? Science. 2024 Nov 15;386(6723):713-714. doi: 10.1126/science.adu5821. Epub 2024 Nov 14. PMID: 39541475.

2:  Mervis J. Research advocates see 'no good news for science'. Science. 2024 Nov 15;386(6723):712-713. doi: 10.1126/science.adu5820. Epub 2024 Nov 14. PMID: 39541473.

3:  McNutt M. Science is neither red nor blue. Science. 2024 Nov 15;386(6723):707. doi: 10.1126/science.adu4907. Epub 2024 Nov 14. PMID: 39541446.

4:  Thorp HH. Time to take stock. Science. 2024 Nov 15;386(6723):709. doi: 10.1126/science.adu4331. Epub 2024 Nov 7. PMID: 39508752.

5:  Vogel G. 'America first' could affect health worldwide. Science. 2024 Nov 15;386(6723):715. doi: 10.1126/science.adu5822. Epub 2024 Nov 14. PMID: 39541476.

There Is No Joy In Medicine

At least not nearly as much as there used to be.

I read a comment by a medical student recently who said that he found nothing in medical school - none  of the clinical rotations to be enjoyable at all.  As I looked back on it, at the interpersonal level there is a lot of subjectivity.  Although it was never stated personalities could make or break a rotation.  There was none of the anonymity of sitting is a large lecture hall and passing three or four tests.  As a medical  student, most of the teams I was on consisted of me, an intern, a resident and occasionally a more senior resident and one or more attending physicians.  Just as in real life, it was common to find people who really did not want to be on those teams.  They were fulfilling some sort of obligation.  As in real life, it was fairly common to be on a team where someone did not like you and if they were personality disordered could make your life a living hell.  But that was relatively rare.  As a medical student, the job was to keep your head down, not make any waves and absorb as much information as possible.

And some of those rotations were a dream.  A perfect combination of senior staff who knew they were there to teach, did a great job of it, and went the extra mile to be as cordial as possible to everyone in the process.  I have written about the last team I was on in medical school as an example.  The Renal Medicine team of of Milwaukee County Medical Center and Froedert Hospital in Milwaukee.  In those days there were three senior attendings who were also Professors in the medical school.  They ran an inpatient unit, outpatient clinic, and hypertension clinic. They also covered all of the inpatient consults. There was an associated group that took care of transplant and dialysis patients and all of the complications.  As a medical student my job was to do the initial patient interviews on the consults and present it to the team and round with the team on all of the inpatients.

It was an inspiring team to be a part of. One of the senior Internal Medicine residents was a guy who I had worked with before.  He was bright and had an incredible sense of humor. The most senior attending would give us all a hard time, but you could tell he was joking.  I never saw him lose his temper.  We were typically putting in 10-12 hour days with both patient care and didactics.  There was scheduled teaching time every day and plenty of teaching on the case presentations. Everyone was interested in the work and flexible. On my absolute last day of medical school the Internal Medicine resident told me they were swamped with admissions.  It was 6 PM and he knew I was graduating the next day.  He let me know that and then asked me if I could see 2 consults that needed to be staffed.  I did and felt good about it.  I lived about 1/2 mile away across the golf course sized county grounds and was ecstatic that night for completing medical school and that rotation.

Enjoyable rotations were not limited to medicine specialties.  I had plenty of contact with neurosurgeons in the same hospital.  The Neurosurgery residents had a grueling schedule starting as second year residents where they were basically on call every night.  They were in surgery in the morning and had to assess and treat acute emergencies in a very hectic emergency department.  The also ran a neurosurgery ICU.  On that service we rounded every morning and tried to get all of the work done on hospitalized patients by  11 AM.  The rest of the day was typically spent dealing with one emergency after another. The head of neurosurgery did not say much and appeared to be brusque, but he was an outstanding surgeon and teacher in the operating room.  We also had Radiology rounds every Saturday morning where he would review all of the imaging studies done on our patients in the previous week. That was a two month rotation for me and very enjoyable.

When I think of the common elements in those rotations that made them implicitly joyous - a few things stand out:

1.  They were intellectually rigorous:

There was no dispute that the teachers and professors knew the field inside and out and were interested in discussing it.  My only regret is that as a medical student - you really don't know enough to ask the best possible questions - at least I didn't.  My standard procedure was to study the problems that were being addressed in detail and in retrospect it might have been easier to ask a lot of questions.  Teaching occurred in detail and at length every day.  It was routine.

2.  They managed their own services:

These days practically all hospitalized patients are managed by hospitalists. Hospitalists will call in specialists as needed, but they basically assess the patient and leave a note in the chart.  People will say this is more efficient and have that same argument about primary care physicians not seeing their own patients in the hospital - but a lot is lost in the process.  Teaching is an obvious casualty. Are you going to learn more about a patient who is on your service 24/7 or one who you drop by and leave a note for the hospitalist team?  I have seen medical students following consultants around and they often look bewildered.  As a team, there is a sense of belonging and typically a place to hang your hat and discuss the work every day.

3.  There was no outside interference by the business world:  

The hospital landscape has become bizarre relative to the hospitals I trained in. Instead of morning rounds - you might see a team of physicians in a "huddle" in the morning.  That huddle may contain non-medical staff and administrators who have no role in patient care. There are really there to manage physicians. Some might tell physicians when to discharge patients.  Others are just there to report what physicians are doing to senior management.  Let me clarify that these are not multidisciplinary treatment teams. I had 20 years of those teams meetings that were clinically focused and then one day there was a case manager in that group and she was reporting what I was doing to a hostile medical director who threatened to override my decisions. At a team level there was an equally malignant administrator trying to undermine the relationship between medical and nursing staff.  It is clear from my medical school experience that none of the managers were necessary and they made the clinical situation much worse. Add utilization review and prior authorization done by companies with an obvious conflict of interest and the hospital landscape suddenly becomes a complete nightmare.  I found myself in the position of needing to go though 2 hours of prior authorization time in order to discharge patients on the same medications that they came in on. In other words the medications were already authorized but I had to do it again.

4: Physicians weren't treated like criminals:  

Physicians tend to not be very good with politics and have a short memory but I don't.  In the 1990s, a billing and coding system was introduced that was supposed to capture physician work and provide commensurate reimbursement.  Unfortunately the inventors of this system did not realize that it was totally subjective and far too detailed. In the only study ever done on the validity of the system, the chance that any two coders could agree on the same billing code was a coin toss. In the meantime, at some point during that decade my hospital colleagues and I were cloistered in a lecture hall and told that any mistakes on our documents were a crime and if a billing statement went out based on that crime - we could be prosecuted under federal racketeering charges. In the meantime, the FBI was raiding doctors offices and trying to make documentation errors into a federal crime.  Eventually the federal government must have seen this was a bit heavy handed and they turned enforcement over to compliance monitors in organizations.  I was awarded the "best documentation" one year by a compliance officer and the next year it was the worst. Over that year, I had made no changes to my documentation. Today there is a mountain of worthless documentation that takes each physician about 3-4 extra hours per day to produce that is the direct result of this initiative. If I was back on my neurosurgery rotation - the document would have been 3-4 handwritten lines.

5: Everybody was an expert - not pretending to be one:

Fake medical news is common across all social media.  Journalists commonly print the story that they want rather than reality.  A common story on this blog is is how physicians were bought off by (often trivial) gifts and this led to inappropriate prescribing and massive drug company profits. It was a good story while it lasted and some media is still trying to push it but when gifts to physicians were eliminated, the USA still has by far the most expensive pharmaceuticals in the world.  There are even more provocative headlines out there that don't pass the smell test.  It is in the best interest of click-bait journalists and business administrators to make it seem like knowledge in medicine is relative and anyone can possess it.

6:  Clinical care was cohesive and not fragmented: 

Business innovations in medicine leave a lot to be desired.  When the field is structured around the ideas of business managers and some of these problematic ideas are published as commentaries in prestigious medical journals - adequate care becomes an increasingly remote possibility.  On the services I mentioned patients were triaged to receive the state of the art care of the day.  They did not end up seeing a series of physicians or providers who had no clue about how to address the problem and hoping to see the appropriate specialist.  In fact one of the most embarrassing developments of managed care was the idea that they were going to put specialists out of business or install a gatekeeper to see who gets referred to a specialist.  There are ample examples on this blog of the importance of seeing the appropriate specialist without having to deal with any administrator erected obstruction.  The main fracture in medicine at this point has been the destruction of the psychiatric infrastructure and the incarceration of the mentally ill.

Just a few obvious reasons why my most joyous experience in medicine happened in medical school over 30 years ago.  I think it could all be distilled down to the basic truths of autonomy, professionalism, a singular patient focus, an intellectual approach to the field, and doing the right thing. That is when you have hard working physicians who enjoy the work and are not burned out.  Medicine is currently creaking under the weight of bad ideas from politicians and bureaucrats and all of the associated rationalizations.

It is no wonder that I often find myself thinking about my old renal medicine and neurosurgery teams and whether future physicians will ever be able to capture that joy again.

It is no wonder that when Grace Slick sings with conviction over my Bluetooth player that I am focused on those first 4 lines.......



George Dawson, MD, DFAPA




Graphics Credit:

Photo licensed directly from Gijsbert Hanekroot Fotografie. Title below:

Jefferson Airplane Perfornm Live At Kralingen Festival
ROTTERDAM, NETHERLANDS - JUNE 26: Grace Slick and Jorma Kaukonen from Jefferson Airplane perform live at Kralingen Festival in Rotterdam, Holland on June 26 1970 (Photo by Gijsbert Hanekroot/Redferns)


Lyrics:

From the song Somebody To Love performed by Jefferson Airplane.  Words and music by Darby Slick.


Supplementary:

Interested in Grace Slick photos from around the time of the release of this song. Contact me if interested.