Friday, March 23, 2012

Hospitals Should Learn From Hotels

Theresa Brown, an oncology, nurse wrote an op-ed piece in the New York Times on March 15, 2012 titled Hospitals Aren’t Hotels. In it she questioned the wisdom of using patient satisfaction survey results to determine hospital reimbursement.

A lot of what we do in medicine, and especially in modern hospital care, adheres to this same formulation. We hurt people because it’s the only way we know to make them better. This is the nature of our work, which is why the growing focus on measuring ‘patient satisfaction’ as a way to judge the quality of a hospital’s care is worrisomely off the mark.”

I worry that Brown’s line of thinking will only reinforce hospitals’ and doctors’ smug and arrogant attitude that our industry is special and cannot learn from less important sectors of the economy like hospitality. Bill Joy famously observed, "No matter what business you're in, most of the smart people work for someone else." There should be a corollary that states, "No matter what industry you're in, you can learn a lot from people in other fields." http://www.hospitalimpact.org/index.php/2011/11/16/title_33

Don Tapscott and Anthony D. Williams in "Wikinomics" (New York: Penguin, 2008) describe how cutting-edge companies outside of healthcare are benefiting from mass collaboration made possible by disruptive technologies and new digital tools.

Procter & Gamble has made "proudly found elsewhere" a way for the consumer products company to find 50 percent of its new products and service ideas from sources outside the company. Successful P&G products such as Olay Regenerist, Swiffer Dusters, and Crest Spin-Brush were developed by collaborating with scientists and engineers who do not work for P&G.

When HHS tried to implement a “mystery shopper” program to improve the patient experience for Medicare patients, the backlash from physicians was strong; CMS abandoned the program shortly after announcing it. And yet this well accepted retail tool has been reported to lead to better patient flow and improved wait times, extension of office hours, improved telephone etiquette, better physician communication with patients, and more time with patients answering questions about surgery. http://thehealthcareblog.com/blog/2011/06/28/are-mystery-shoppers-such-a-bad-idea-for-health-care-quality-improvement/

Elizabeth Bailey reminds Brown in a letter to the editor that Sir William Osler said,

“’Listen to your patient. He is telling you the diagnosis.’ Sadly, this simple message – to listen to the patient, carefully – is often swept aside in our fragmented, procedure- and data-driven medical system.” http://www.nytimes.com/2012/03/23/opinion/using-patient-surveys-to-rate-hospitals.html

Robert H. Schaffer points out that patients are able to accurately assess many aspects of being hospitalized that can make a difference in clinical outcomes:

“Maybe patients cannot assess the efficacy of many treatments, but they surely can tell whether they have rung the buzzer for a nurse and had to wait 20 minutes for a response; whether they have been wheeled someplace on a gurney and left alone in a hallway for what seemed like hours… whether a bewildering cast of medical characters came and went without explaining who they are and their functions.” http://www.nytimes.com/2012/03/23/opinion/using-patient-surveys-to-rate-hospitals.html

The developers of the Hospital Consumer Assessments of Healthcare Providers and Systems survey that Brown critiqued write that she repeated two common misconceptions about the survey.

“One is that there are necessarily tradeoffs between good patient experiences and good clinical care. The preponderance of the evidence (at least four recent studies) suggests the opposite: hospitals that perform better on the survey tend to do better on clinical measures, have fewer readmissions within 30 days and have lower risk-adjusted mortality.

A second misconception is that the survey is primarily a measure of satisfaction, and that high scores are achieved by catering to patients’ desires for unwarranted treatment. In fact, the survey focuses on important aspects of care such as whether new medications and post-discharge care instructions were explained clearly, which can be measured only by asking the patient. Evidence suggests that patients want clear communication, not unnecessary care.” http://www.nytimes.com/2012/03/23/opinion/using-patient-surveys-to-rate-hospitals.html

For the American health care system to deliver evidence-based, low cost, and high quality medical care will require that all of us change the way we do things. Health care providers like Theresa Brown need to acknowledge that the patient experience is included in the triple aim because it is vitally important. Dr. Day F. Hills defends Brown by writing, “Because patients are seldom the best judges of their medical care, that care cannot be measured accurately by such surveys.” http://www.nytimes.com/2012/03/23/opinion/using-patient-surveys-to-rate-hospitals.html This statement and Brown’s op-ed indicate to me that we have a lot more work to do to change the culture of American medicine. Dr. Day and Nurse Brown just don’t get it. The patient is the only one who can judge their medical care.

Wednesday, March 21, 2012

Hospitals Must Choose the Right Innovation at the Right Time

http://www.hospitalimpact.org/index.php/2012/03/21/hospital_leaders_must_choose_the_right_i

The Law Always Lags Technology: Implications for Digital Medicine

Three recent developments have highlighted how difficult it is to predict when and if disruptive technologies will transform clinical medicine in the United States. That we are undergoing an avalanche of new information and new technology is hardly newsworthy. From the dawn of civilization to 2003, human beings created 1 billion gigabytes of new information. In 2012, Google says they catalog 2 billion gigabytes of information every two days.

One of the confounding factors on how this new knowledge and technology is adopted by an industry like health care is the law. Henry Perritt, Jr. describes two ways to think about the relationship between the law and technology. Technological change is “a major source of human problems that the law must address.” The law also always lags technology because the common law tradition requires “that the legal system should not predetermine the course of technological application and product development.” http://jolt.law.harvard.edu/articles/pdf/v10/10HarvJLTech689.pdf

The first example of this concept of the law lagging technology involves American citizen Ellie Lavi who underwent in vitro fertilization and the subsequent birth of twins in Israel. When she went to the American Embassy, she was told that her children would not be American citizens unless she could prove that either the egg or sperm used in her case came from an American citizen. “The problem is that the law hasn’t kept up with the advances in reproductive technology,” states Lawyer Melissa Brissman. http://www.usatoday.com/news/world/story/2012-03-19/in-vitro-citizenship/53656616/1

Recently the Supreme Court heard arguments in another case, which illustrates how the laws lag technology. Karen Capato gave birth to twins 18 months after her husband died of esophageal cancer by using his sperm that had been frozen and banked before his death. The federal government denied her twins’ claim for Social Security survivor benefits, and she appealed to the Supreme Court. The justices really grappled with the problems of trying to figure out how to rule based on a 1930s federal law that never anticipated such technological advances. “You want us to sort of apply this old law to new technology,” observed Justice Stephen Breyer. Many of the justices worried about all sorts of scenarios: the wife remarrying, the complexity of state laws with different rules on benefits, and others. They have yet to decide this case.

http://www.federalnewsradio.com/?nid=615&sid=2792153

Yesterday, the Supreme Court ruled in favor of the Mayo Clinic and against patent protection for a biotechnology company named Prometheus Laboratories who had patented a test to calibrate drug doses of thiopurine to treat Crohn’s Disease and ulcerative colitis. http://online.wsj.com/article/SB10001424052702304724404577293390828369720.html Writing for the court, Justice Breyer “said natural laws may not be patented standing alone or in connection with processes that involve ‘well-understood, routine, conventional activity.’” This ruling may delay the implementation of personalized medicine, which touts being able to individualize the doses of drugs based on the patient’s genetics. Just before oral arguments at the Supreme Court, Prometheus was sold to Nestle, and Justice Breyer’s wife owned stock in that company. She sold the stock on the morning of the hearing so that Breyer would not have to recuse himself from the case. http://www.nytimes.com/2012/03/21/business/justices-reject-patents-for-medical-tests-relying-on-drug-dosages.html

These three examples that I read about in less than a month’s time highlight how the law always lags behind technology. Pundits, myself included, who write about how personalized medicine and digital technologies will transform medicine, must take into account the inability of the common law to rapidly adjust to new situations. We usually underestimate the eventual effect of disruptive technologies and overestimate how fast they will be adopted.

Saturday, March 17, 2012

Human Understanding, Randomness, Free Will, and Delusion Part V

I am just as tired of this five-part blog post as you are. That is assuming anyone has bothered to read all five parts (one of my twitter followers nicely tweeted that he liked my posts, but enough already with this particular post that seems to be going on forever). I am happy to announce that this is the final installment. I am unhappy to announce that the seventeen really smart people whose writings I have read for Parts I through IV really have not been able to answer my simple question, “What is going on in the world of Kent Bottles.” The seventeen experts who have accompanied me on this journey so far are: Tom and Ray Magliozzi, Nikoli Tesla, Misha Angrist, Ricki Lewis, Jackie Fenn, Mike Gazzaniga, Kurt Godel, Edmund Gettier, John Barrow, Karl Popper, Francis Crick, Raymond Tallis, Terrence Dean, Benjamin Libet, Tim Crane, and Robert Laughlin.

In Part V of our exploration, we have to deal with one more really smart person and one really dumb person.

The really smart person, whose views I do not always agree with, is Donald Rumsfeld, the youngest and oldest person in the history of the United States to hold the position of Secretary of Defense. Rumsfeld is famous for many things, but I want to focus on his classification of knowledge: known knowns (things we know to be true), known unknowns (things we know we don’t know), and unknown unknowns (things we are unaware that we don’t know). (http://www.youtube.com/watch?v=GiPe1OiKQuk)

Slavoj Zizek, the controversial Slovenian philosopher and cultural critic, observed that Rumsfeld left out the fourth possibility: “what we don’t know we know.” I interpret this to mean our collective unconsciousness. For an amusing and intriguing video discussing Rumsfeld and Zizek go to Jason J. Campbell’s Epistemic Modal Logic talk at (http://www.youtube.com/watch?v=p6aPBMAT5xM&feature=fvsr).

The really dumb person is McArthur Wheeler who was surprised when he was caught after robbing a bank in Pittsburg because he thought that rubbing lemon juice on his face would make him invisible to the security cameras. As Errol Morris writes in a fascinating and highly recommended blog The Anosognosic’s Dilemma (http://opinionator.blogs.nytimes.com/2010/06/20/the-anosognosics-dilemma-1/), Wheeler was “too stupid to know he was too stupid to be a bank robber.”

Wheeler’s arrest inspired David Dunning and Justin Kruger to write Unskilled and Unaware of It: How Difficulties of Recognizing One’s Own Incompetence Leads to Inflated Self Assessment. They write, “When people are incompetent in the strategies they adopt to achieve success and satisfaction, they suffer a dual burden: Not only do they reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the ability to realize it. Instead, like Mr. Wheeler, they are left with the erroneous impression they are doing just fine.”

Morris shares a conversation he had with Dunning where Dunning said:

“If I were given carte blanche to write about any topic I could, it would be about how much our ignorance, in general, shapes our lives in ways we do not know about. Put simply, people tend to do what they know and fail to do that which they have no conception of. In that way, ignorance profoundly channels the course we take in life. And unknown unknowns constitute a grand swath of everybody’s field of ignorance.”

And Morris concludes his five-part essay with the following:

“I have to admit my fondness for the Dunning-Kruger Effect. But is it a metaphor for existence? For the human condition? That we’re all dumb and delusional? So dumb and delusional that we can never grasp that fact? It’s so profoundly depressing and disturbing. Even sad. Dunning gives us no hope. The McArthur Wheelers of this world will never understand their limitations. But aren’t we all McArthur Wheelers?”

I doubt that the philosopher Colin McGinn knows much about McArthur Wheeler, but Morris’ entire blog made me think about the new mysterian school of consciousness studies. The key paper was written by McGinn and is available here http://art-mind.org/review/IMG/pdf/McGinn_1989_Mind-body-problem_M.pdf McGinn is interviewed in a ten minute video that provides a good overview of all theories of consciousness (http://www.youtube.com/watch?v=CLFtGb9RKPo). In a nutshell, McGinn argues that consciousness is a concept that the human mind is incapable of understanding and that the material world contains things that physics will never, even in the future, totally understand.

But maybe it is okay if we cannot understand everything about the world we live in. Maybe we should just accept the fact that our homo sapiens brains were not designed to understand everything. Even though Gazzaniga has taught us that our brains will confabulate an answer even when there is no answer to understand.

Perhaps we should leave the last words to a physicist and a novelist.

Freeman Dyson in reviewing a book by a deterministic scientist named Weinberg wrote:

“Our ape-brains and tool-making hands were marvelously effective for solving a limited class of puzzles. Weinberg expects the same brains and hands to illuminate far broader areas of nature with the same clarity. I would be disappointed if nature could be so easily tamed. I find the idea of a Final Theory repugnant because it diminishes both the richness of nature and the richness of human destiny. I prefer to live in a universe full of inexhaustible mysteries, and to belong to a species

destined for inexhaustible intellectual growth.” (Freeman Dyson, “What Price Glory? A review of Steven Weinberg’s Lake Views, The World and the Universe,” New York Review of Books, June 10, 2010.)

The novelist Siri Hustvedt in What I Loved wrote about science:

“It’s a language I’ve come to hate, because it admits no mystery and ambiguity into its smug vocabulary, which arrogantly suggests that everything can be known’”

Friday, March 16, 2012

Human Understanding, Randomness, Free Will, and Delusion Part IV

In many ways this long and meandering four-part blog post is entirely Michael S. Gazzaniga’s and Benjamin Libet’s fault. We have already met Gazzaniga and his left-brain interpreter theory that resulted from studying split-brain patients who underwent surgery to treat epilepsy. Gazzaniga has explored what these studies mean in several books, all of which are written in a way that the layperson can understand. David Wolman has recently published in Nature a nice overview article that would be a good place to start for someone just starting to grapple with their brain’s inherent need to explain things, even when the brain does not have a clue as to what is really going on (http://www.nature.com/news/the-split-brain-a-tale-of-two-halves-1.10213)

As shocking as my brain’s need to confabulate to make sense of a world that increasingly makes no sense is the work of Benjamin Libet of UCSF who stimulated the brain of an awake patient undergoing surgery; he discovered a time lapse between stimulating the cortex that represents the hand and when the patient signaled they were conscious of sensation in the hand. In more recent studies, John-Dylan Haynes showed that the outcomes of an inclination can be encoded in brain activity up to 10 seconds before the patient is conscious of it. Chung Siong Soon also expanded Libet’s work when he showed that regions in the cortex associated with voluntary movement lit up on fMRI scans five seconds before the subject was aware of making a choice. Song concluded that a network of control areas in the brain “begins to prepare an upcoming decision long before it enters awareness.” This phenomenon has been labeled Bereitschaftspotential, which I cannot pronounce, or readiness potential, which is easier for me to say. Gazzaniga summarizes the staggering implications of these experiments:

“If actions are initiated unconsciously, before we are aware of any desire to perform them, then the casual role of consciousness in volition is out of the loop. Conscious volition, the idea that you are willing an action to happen is an illusion.” (Who’s In Charge? 2011)

Libet has written:

“If the ‘act now’ process is initiated unconsciously, then the conscious free will is not doing it.” (Journal of Consciousness Studies 8 (2001)

This idea that my brain makes decisions to act before I am conscious of them confuses me because I have a hard time accepting that my decisions are not mine own. I experience that I have free will. Patrick Haggard shared my dismay when he wrote that Libet’s original experiment in the 1980’s was “one of the most philosophically challenging…in modern scientific psychology.”

Raymond Tallis, who we met in Part III criticizing fMRI studies in his book Aping Mankind, has offered a different interpretation of these readiness potential studies:

“We need not only to look at the action Libet’s subjects were asked to perform but also to fill in some of the context in which they performed it. The action was the simplest imaginable: a flexing of the wrist…That movement was itself only a minute part of a long sequence of movements amounting to a large-scale action that could be described as ‘taking part in Dr. Libet’s experiment.’ This large-scale action began at least as far back as getting up in the morning to visit Libet’s lab…; involved consenting to take part in an experiment whose nature and purpose and safety was fully understood; and required…listening to and understanding and agreeing to the instructions that were received – and then deciding to flex the wrist. In other words, the immediate prior intention, the psychological event timed by Libet, was not the whole story of the action but only a tiny part of it.”

The philosopher Tim Crane has influenced Tallis’ interpretation by pointing out that “our actions are interconnected, as are intentions, decisions, and plans. The fact that the decisions in the Libet experiment seem to follow the actions is also irrelevant, Crane argues, because our actions unfold without there being explicit decisions…at every node. When I am walking to the pub to meet you, there isn’t a separate decision corresponding to every one of the hundred steps I take to get there.”

Gazzaniga has also helped me think through this problem. He writes that the hard determinists in neuroscience make the following causal chain claim:

“(1) The brain enables the mind and the brain is a physical entity; (2) The physical world is determined, so our brains must also be determined; (3) If our brains are determined, and if the brain is the necessary and sufficient organ that enables the mind, then we are left with the belief that the thoughts that arise from our mind are also determined; (4) Thus, free will is an illusion, and we must revise our concepts of what it means to be personally responsible for our actions.”

Claim two is the weak link in the above argument; the physical world may not be predictably determined because “the nonlinear mathematics of complex systems does not allow exact predictions of future states.”

The “aha” moment for me was when Gazzaniga, like Tallis, claims that looking for free will in individual brains makes no sense if these human capacities are emergent properties found in the “group interactions of many brains.” Nobel prize winner Robert Laughlin in A Different Universe describes the importance of the concept of emergence:

‘What we are seeing is a transformation of worldview in which the objective of understanding nature by breaking it down into ever smaller parts is supplanted by the objective of understanding how nature organizes itself.”

Gazzaniga wryly drives this point about different levels of organization, each of which require a different set of laws, when he comments that one cannot predict the freeway will be full of traffic during rush hour by examining a cam shaft of an automobile.

Tallis calls the level of organization where we have free will “the human world.” He describes “the human world” as “a new kind of space, an arena we humans have collectively created, which is the theatre of our freedom, to which our selves relate: the place in which we live our lives as persons rather than as organisms.”

I think we are finally getting somewhere, and I hope to be able to complete this blog in Part V, which will appear shortly.

Monday, March 12, 2012

Human Understanding, Randomness, Free Will, and Delusion Part III

In this exercise I am trying to understand what is going on in my world. Car Talk with the Magliozzi brothers is popular with 4 million listeners because they attempt to fix real world problems that callers have with their cars. Genomics, proteomics, and gene therapy have captured the attention of the public and science journalists because they attempt, so far with limited success, to move us from diagnose and treat to predict and prevent which should help us lead longer and more satisfying lives. In Part I and Part II, we saw that even experts like Ray and Tom Magliozzi sometimes are stumped and that science does not always deliver what I desperately need and want: a clear and truthful understanding of what is going on in my world.

Neuroscience and evolutionary psychology are fascinating subjects to read and claim to provide a framework to give me what I want. The natural sciences claim to give an explanation for everything in my world, including me as a human being. However, the explanation the scientists offer clashes with my understanding that I am a conscious person who has a coherent and unified self that is capable of exercising free will. I am a little worried that my left-brain interpreter is making up this story, but that is how I feel.

Most scientists believe we live in a completely determined universe that is governed by physical laws. Since human beings are part of the physical world the physical laws must explain our behavior and even our consciousness. Although it is troubling to disagree with Spinoza and Einstein who accepted this theory, it just does not seem right to me. The neuroscientists tell me that my mind or my soul is just my brain at work.

Here is Francis Crick, who switched over to neuroscience after discovering DNA, in his book The Astonishing Hypothesis: The Scientific Search for the Soul:

“You, your joys and sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules.”

One wonders if Crick was familiar with Hippocrates’ writings on epilepsy where he opined:

“Men ought to know that from the brain, and from the brain only, arises our pleasures, joys, laughter and jests, as well as our sorrows, pains, griefs and tears. Through it, in particular, we think, see, hear, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant.”

And here’s what neuroscientists SR Quartz and TJ Sejnowski have to say about human character:

If you think that there is an inviolable core within you that dictates how you behave despite any context – something called character– a growing mound of psychological and historical evidence suggests that you may simply have never been exposed to an extreme context in which to test yourself. Character may be an essential –but largely baseless– story we tell ourselves.”

The evolutionary psychologists reinterpret human psychology within a Darwinian framework. Raymond Tallis in Aping Mankind: Neuromania, Darwinitis and the Misrepresentation of Humanity summarizes the basic tenets of evolutionary psychology:

· The brain is a computer designed by natural selection to extract information from the environment.

· Individual brain behavior is generated by this evolved computer in response to information it extracts from the environment.

· The cognitive programs of the human brain are adaptations. They exist because they produce behaviors in our ancestors that enabled them to survive and reproduce.

· The cognitive programs of the human brain, which were adaptive in ancestral environments, may not be adaptive now.

· Describing the evolved computational architecture of our brains allows a systematic understanding of cultural and social phenomena. This architecture consists of a myriad of modules, such as cheat-detection modules, snake-fear-detection modules, and waist-to-hip-ratio-detection modules.

Why am I so troubled by the dominant orthodoxy of neuroscience and evolutionary psychology? If all our actions were predetermined at the time of the Big Bang, then why should we be bothered with trying to help our fellow human beings or lead an ethical life? If all our actions are so predetermined, then it makes no sense to hold criminals responsible for the most heinous crimes. Their brains over which they have no control made them do it. Learning about meliorism by reading William James and John Dewey at the University of California saved me from having to choose between pessimism, which seemed hopeless and optimism, which seemed na├»ve. I am afraid that if we accept the orthodoxy of determinism we will “abandon” all those who Tallis notes “are still denied long life, good health, security, and pleasure, living short lives of unbearable suffering.”

While I still have not arrived at my preferred destination (a clear and truthful understanding of what is going on in my world), three books have convinced me that I am not the only one who is troubled by the current natural science orthodoxy. Raymond Tallis, a former Professor of Geriatric Medicine at the University of Manchester, writes in Aping Mankind a combative, sarcastic, and devastating critique of the current state of neuroscience and evolutionary psychology. Michael S. Gazzaniga, director of the SAGE Center for the Study of the Mind at University of California, Santa Barbara, in Who’s In Charge? Free Will and the Science of the Brain offers a defense of holding individuals accountable for their actions in a determined universe. Terrence Deacon, professor of neuroscience and anthropology at the University of California, Berkeley, in Incomplete Nature disputes the popular notion that the mind is the software of the brain in a dense and hard to penetrate volume that attempts to explain how the mind emerges from the brain.

These three books crystallized my reservations about the avalanche of studies in both peer-reviewed and popular journals that claim to locate the place in the brain where love or God or criminal behavior originates. It is comforting to discover authorities like M. B. Crawford who observes that these studies are “often accompanied by a picture of a brain scan, that fast-acting solvent of critical faculties (www.thenewatlantis.com/publications/the-limits-of-neuro-talk). It is also depressing to encounter Scott Vrecko who catalogs neuroscience studies of altruism, borderline personality disorder, criminal behavior, decision making, empathy, fear, gut feelings, hope, impulsivity, judgment, love, motivation, neuroticism, problem gambling, racial bias, suicide, trust, violence, wisdom, and religious zeal.

Tallis provides examples of the most questionable studies and then proceeds to explain why they don’t deliver what they claim. Tallis takes Mario Beauregard to task for “The Neural Basis of Unconditional Love” fMRI study where home care workers looked at pictures of people with intellectual disabilities first neutrally and then with feelings of unconditional love:

“By subtracting the brain activity seen in the first situation from that seen in the second, the authors pinned down the neural network housing unconditional love. It was distinct from that which had previously been identified for romantic love and maternal love – although there was some overlap – and it included parts of the brain’s ‘reward’ system. This Beauregard has argued, may be the link between reward and strong emotional links which (guess what?) ‘may contribute to the survival of the human species.’”

In a sarcastic footnote, Tallis says he would be surprised “if the ideal of unconditional love would survive the removal of the salary as a condition of caring.”

Tallis gleefully and with great relish criticizes these studies for the following reasons:

· fMRI measures brain activity indirectly by documenting increases in blood flow that may be supplying more than one set of neuronal discharges

· The simple design of the experiment does not reflect the complexity of unconditional love as experienced in real life

· There are serious problems with the localization observed in such studies

· One prominent experimental psychologist in a paper title “Voodoo Correlations in Social Neuroscience” noted that “a disturbingly large and quite prominent segment of fMRI scan research on emotion, personality and social cognition is using seriously defective research methods and producing a profusion of numbers that should not be believed.”

· A review concluded that “the reliability of fMRI scanning is not high compared to other scientific measures.”

· fMRI scanning, according to David Dobbs, “overlooks the networked or distributed nature of the brain’s workings, emphasizing localized activity when it is communication among regions that is most critical to mental function.”

· fMRI scanning studies confuse correlation, causation, and identity.

fMRI scanning studies are interesting, but one has to suspect that the profusion of articles may be a reflection of tenure committees being more able to count number of publications than to understand whether good science is being performed by their assistant professors up for promotion to associate professor. The profusion of fMRI scanning reminds me of all of the articles that are being published that link a gene to a chronic disease in such a way that does not affect at all what the clinician taking care of the patient does in the clinic.

Part IV will continue to explore how critical thinking is essential to understand the world we all live in.

Saturday, March 10, 2012

Human Understanding, Randomness, Free Will, and Delusion Part II

In Part I we explored how human beings jump to conclusions when they think they understand reality. This usually occurs when the explanation makes sense, and all of us tend to generate reasons why things are the way they are. It makes sense that understanding our genome would allow us to predict what diseases we are predisposed to developing and to try to do something to avoid getting the disease. Predict and prevent make sense. It makes sense that gene therapy should work because it is so logical and understandable. If you replace the defective gene with the correct gene you should cure the disease.

Why do we humans assume we have the capacity to understand reality?

“This what our brain does all day long. It takes input from other areas of our brain and from the environment and synthesizes it into a story.”

I still remember how excited and bewildered I was the first time I learned about split-brain patients and Michael S. Gazzaniga’s left-brain interpreter. Gazzaniga early in his career studied patients who underwent surgical severing of the corpus callosum in order to treat their intractable epilepsy. The operation cut off all communication between the left and right brain hemispheres.

"We showed a split-brain patient two pictures: A chicken claw was shown to his right visual field, so the left hemisphere only saw the claw picture, and a snow scene was shown to the left visual field, so the right hemisphere only saw that. He was then asked to choose a picture from an array of pictures placed in full view in front of him, which both hemispheres could see. The left hand pointed to a shovel (which was the most appropriate answer for the snow scene) and the right hand pointed to a chicken (the most appropriate answer the chicken claw). Then we asked why he chose those items. His left hemisphere speech center replied, “Oh, that’s simple. The chicken claw goes with the chicken,” easily explaining what it knew. It had seen the chicken claw. Then, looking down at his left hand pointing to the shovel, without missing a beat, he said, “And you need a shovel to clean out the chicken shed.” Immediately, the left-brain, observing the left hand’s response without knowledge of why it had picked that item, put it into a context that would explain it. It interpreted the response in a context consistent with what it knew, and all it knew was: chicken claw. It knew nothing about the snow scene, but it had to explain the shovel in his left hand. Well, chickens do make a mess, and you have to clean it up. Ah, that’s it! Makes sense. What was interesting was that the left hemisphere did not say, “I don’t know,” which truly was the correct answer. It made up a post hoc answer that fit the situation. It confabulated…We called this left-hemisphere process the interpreter.” (Who’s In Charge? Free Will and the Science of the Brain, New York: HarperCollins, 2011)

Does it bother you as much as it does me that when my brain cannot truly understand what is going on, it decides to make up a story? Does it bother you that we are hardwired to confabulate? How can I be sure that the story I am telling myself is consistent with the truth? How can I be sure I know what is going on?

Science must be able to help me out here. After all science searches for what we can establish as justifiably true. Physicist James Cushing has written that science “requires at a minimum that our scientific theories are to be taken as giving us literally true descriptions of the world.” (Philosophical Consequences of Quantum Theory, Notre Dame, Indiana: University of Notre Dame Press, 1989) Ten out of 11 physicists “claimed that what they were describing with their symbols and equations was objective reality,” according to mathematician John Casti. (Paradigms Lost, New York: William Morrow and Company, 1989) I am feeling like I am on a little firmer ground here.

That is, until I remember Kurt Godel and Edmund Gettier. Godel proved that mathematics powerful enough to do arithmetic could not be both consistent and complete when he wrote a correct equation that said this statement cannot be proven. Gettier confused me when he showed one can have a justified, true belief and still have no idea what is going on. Gettier’s thought experiment was to imagine a man who believes there is a sheep in a field because he mistakes the dog he sees for a sheep. However, behind a large rock there is indeed a sheep that the man cannot see. Even though the three criteria for knowledge (belief, justification, and truth) are met, it is hard to say this man knows what is going on. After all, what he knows is based on his mistaking a dog for a sheep.

(Steve Hagen, How the World Can Be the Way It Is: An Inquiry for the New Millennium into Science, Philosophy, and Perception, Wheaton, Illinois: Quest Books, 1995)

The astronomer John Barrow notes “the practice of science…rests upon a number of presuppositions about the nature of reality.” He identifies nine such presuppositions:

· The external world is external to our minds and is the source of our sensations.

· The external world is rational

· The world be analyzed locally without destroying its structure

· The elementary entities do not possess free will.

· The separation of events from our perception of them is a harmless simplification

· Nature possess regularities which are predictable

· Space and time exist

· The world can be described by mathematics

· These presuppositions hold in an identical fashion everywhere and everywhen. (The World Within the World, New York: Oxford University Press, 1988).

Lys Ann Shore and Karl Popper add to my doubts that science will tell me what is really going on. Shore has written, “The quest for absolute certainty must be recognized as alien to the scientific attitude, since scientific knowledge is fallible, tentative, and open to revision and modification.” (Hagen, 1995) I would guess that Shore, like Nassim Nicholas Taleb, has been influenced by Karl Raimund Popper’s ideas about the philosophy of science.

The Stanford Encyclopedia of Philosophy summarizes Popper’s philosophy of science (http://plato.stanford.edu/entries/popper/):

“Scientific theories, for him, are not inductively inferred from experience, nor is scientific experimentation carried out with a view to verifying or finally establishing the truth of theories; rather, all knowledge is provisional, conjectural, hypothetical—we can never finally prove our scientific theories, we can merely (provisionally) confirm or (conclusively) refute them; hence at any given time we have to choose between the potentially infinite number of theories which will explain the set of phenomena under investigation. Faced with this choice, we can only eliminate those theories which are demonstrably false, and rationally choose between the remaining, unfalsified theories. Hence Popper's emphasis on the importance of the critical spirit to science—for him critical thinking is the very essence of rationality. For it is only by critical thought that we can eliminate false theories, and determine which of the remaining theories is the best available one.”

Popper thought there are only two kinds of scientific theories: those that have been proven to be wrong and those that have yet to be proven wrong.

Part III will continue to explore how we can understand what is going on in the world.

Human Understanding, Randomness, Free Will, and Delusion Part I

Just because something makes sense does not mean it explains reality. And yet we are always trying to make sense of a world that scientists increasingly believe is totally random. And if the world is totally random, why do I think I have free will?

I usually do not listen to Car Talk, but I did happen to be driving in Gladwynne when Sally of North Salem, New York proclaimed, “I stumped the Car Talk guys.” Their immediate response is important. One brother said, “No, we do not have any experience with it. We haven’t given you an answer, but we will.” The other brother chimed in, “It doesn’t mean we don’t have an answer.”

What baffled the Magliozzi brothers was Sally’s driving under power lines in Waccabuc, New York and hearing a loud sound “like an electric charge” and seeing a bright light envelope the entire car. She was calling trying to figure out what happened.

One automotive expert’s answer was, “You saw something that wasn’t there or you are nuts.” His sidekick opined that Sally nodded off, was startled by interference from her car radio, and she woke up with the sun in her eyes. Tom and Ray Magliozzi are both MIT graduates, and they realized they did not really know what to tell Sally. They decided to ask their 4 million listeners to make sense of Sally’s experience and labeled the discussion board on their website as Weirdness in Waccabuc. (http://www.cartalk.com/content/weirdness-waccabuc)

The responses demonstrate that humans are never at a loss for an explanation, even when they have no idea what they are talking about:

“She was hit by a random lightning bolt.”

“I’m a pilot. Occasionally when the atmospheric conditions are right, we get a thing called precipitation static building up on the windshield. When it eventually discharges it can create quite a bright flash or sometimes ‘dancing lights’ called St. Elmo’s Fire.”

“Sally had a seizure.”

“It’s obvious, and I’m stunned that you were not aware that she had been scanned by the MOTHERSHIP and more than likely transported to the MOTHERSHIP examined and returned in a flash of light.”

“What appears to be a flash of light can be a symptom of a serious retinal (eye) problem, and you should call her and urge her to see an ophthalmologist as soon as possible.”

“Did anyone consider she might have had a slight stroke? It’s called a TIA and this might explain things, as there was nothing wrong with the car. Maybe she should go to the doctor.”

“I wonder if this experience could be symptoms of a brain disorder, i.e., a brain tumor or seizure or even an aura of a migraine…. She should probably see a doctor.”

“Waccabuc is also rich in Indian history…. Some people claim that they’ve seen Indian spirits lighting the ovens, especially at night. Most of those who claim to have seen the lights have viewed them from their cars.”

“You need Nikoli Tesla. Sally experienced what is called “Ball Lightning.” The bright flash and cackle are typical. It’s a harmless but often terrifying ionization of air caused by a large static charge…. Her tires built up static on the dry pavement. She passed under the power lines at exactly the right moment, and the field she passed through triggered the ionization, just like the trigger capacitor and transformer trigger a camera flash.

My money is on the last explanation, and I am even surer that I truly understand what happened to Sally after consulting my books on Tesla, an eccentric genius who has always fascinated me. But are there some things that cannot be readily explained? And why is it so hard to accept the truth once it has been revealed? And why do we humans have to try to understand everything anyway?

We humans get ourselves into trouble all the time by thinking we understand things when we really don’t. A good story that makes sense is enough for many of us to jump to conclusions that reinforce our view of the world.

I am reminded of this problem by two books I recently read: Misha Angrist’s Here Is a Human Being at the Dawn of Personal Genomics and Ricki Lewis’ The Forever Fix. Angrist is uniquely qualified to explore the many issues surrounding those who want to understand themselves by sending off their spit specimens to 23andMe or Navigenics. Angrist has trained as a genetic counselor, received a PhD in genetics from Case Western Reserve, teaches at the Duke University Institute for Genome Sciences and Policy, and was the fourth subject in Harvard’s George Church’s famous Personal Genome Project. His book describes how the blogosphere warmly embraces the “Saliva Diviners” who truly believe that knowing one’s genome will allow one to progress from traditional medicine’s diagnose and treat to digital medicine’s predict and prevent. He also gives equal time to physicians and scientists who emphasize that knowing one’s genome does not really tell you how to prevent most diseases in 2012; there is not much actionable that one cannot get from a much less expensive detailed family genetic history. Referring to the CEO of Navigenics, one scientist told Angrist, “Dietrich is a nice guy. The 23andMe people are nice ladies. But I don’t know what this is going to do for anybody. It’s a waste of time and money.”

Angrist concludes his book by stating: “I had come and seen my genome…But of course I ignored most of their contents. Not because they were toxic, but because in the end, this journey of self-exploration had turned out to be more of a speculative intellectual exercise than a life-changing clinical one. I had arrived at the theater early enough to grab a good seat, but the carpenters were still building the set.”

Truly understanding genomics keeps getting harder and harder because nature is really complicated and complex. For example, an allele can predispose a patient to type 2 diabetes when inherited from the father, but the same allele can protect against type 2 diabetes when inherited from the mother. Epigenetics is the emerging study of how histone proteins and methyl groups attached to DNA control when individual genes are turned off and on during a human lifetime; their discovery has complicated the easily understood metaphor that genes are the software of our body. This week’s New England of Journal of Medicine had disturbing news for those of us who want to believe that personalized medicine means we can genotype malignant tumors to guide targeted therapy against the specific defective biochemical pathway caused by mutations in the tumor DNA. Genotyping of 4 renal cell carcinomas revealed that only one third of the 128 mutations were present in all sites sampled and that mutations were different in primary and metastatic tumors. (http://www.nejm.org/doi/full/10.1056/NEJMoa1113205?query=featured_home#.T1jNegH6pWY)

During the 1990’s I thought I understood how gene therapy was going to revolutionize clinical medicine in short order. It seemed straightforward to identify the genes responsible for a particular disease; it seemed logical to fix the defective gene and load it into viruses to get the therapy into the affected cells. Many experts agreed with the director of Stanford’s Gene Therapy Technology Program who predicted in Business Week, “Within the next decade, there will be an exponential increase in the use of gene therapy.” Shortly after the publication of that optimistic prediction, Jesse Gelsinger died after undergoing gene therapy at the University of Pennsylvania for a genetic metabolic disease. Lewis’ book The Forever Fix brilliantly examines why gene therapy has not yet lived up to the promise many of us saw in the late 20th century.

Carl Zimmer in a book review of Lewis’ book applied Jackie Fenn’s Hype Cycle graph to grapple with why we get so excited about scientific breakthroughs that we think we truly understand.

“Again and again, she had seen new advances burst on the scene and generate ridiculous excitement. Eventually they would reach what she dubbed the Peak of Inflated Expectations. Unable to satisfy their promise fast enough, many of them plunged into the Trough of Disillusionment. Their fall didn’t necessarily mean that these technologies were failures. The successful ones slowly emerged again and climbed the Slope of Enlightenment.” (http://online.wsj.com/article/SB10001424052970203753704577255170103122382.html?mod=googlenews_wsj)

Part II will continue our exploration into human understanding and delusion.