Saturday, March 31, 2012

A questioning frame of mind

As I wrote in Our Truman Show, it is not easy to ask why medical curricula include some diseases but not others. This is a short followup.

It will be more or less obvious, but it fits with future, more detailed posts.

Textbooks

Few ever question medical textbooks (or diagnostic classifications or practically anything else). It feels out of reach and out of place and not safe.

For one thing, textbooks are a given. Are you going to question the air you breathe too? Textbooks are just there. It is not easy to question ordinary things.

Know your place

Furthermore, like Truman, we are not supposed to question them. That would be questioning authority. They have our best interests at heart — don't you know your place?

The world has already been explored. Time to turn back, Truman.

Textbooks have origins, and are made by man

We can trace the contents of medical textbooks to specific policy decisions made by specific individuals at specific times, but we assume there is no value in it.

We don't stop to think about conflict of interest.

Not true of everything

Interestingly, that isn't true of everything. Questions feel more comfortable with old books or TV shows.

For example:

Q: Why was the author so flowery in that old book?
A: To flatter his patron.

Q: Why did her shirt get pulled all the way off when she dropped through the ceiling panel in that TV show? Isn't that hard to do by accident?
A: That was for the ratings.1

Do you see what I mean? We are used to questioning things that are safe to think about. Going meta is standard.

Old books feel man-made. We feel justified, and not absurd, asking why they are the way they are. It feels natural, and not seditious, to consider motives.

Yet billion-dollar medical deals do not raise questions about motives.

Money and people

The contents of textbooks are always the result of money and people being placed in certain places and not others, but we don't question them.

We question things that don't matter. We don't question things that do matter. That's the part that interests me.

Status report

A moment in a TV episode raises questions, but the complete absence of certain serious AIDS-like multisystem neuroimmune diseases from medical textbooks does not raise questions.

Conclusion

That is the frame of mind I am challenging.

It all seems ordinary. It is all banal. People are dying.

I think sometimes it is worth just making an observation out loud. Even an obvious one.

Samuel

Footnotes:

1 It feels safe to question the reasons for including this scene:

Note: this citation was certified to be entirely scholarly by a panel of unbiased experts.

9 comments :

  1. Hi Samuel, there is another side to questioning textbooks. I found a glaring error in a commonly used textbook on biochemisty by Lehninger. I took it to the lecturer very early in the course. He looked at me like I was crazy, he didn't believe me, he wanted corroborating evidence (which I provided) and then probably never followed up. I certainly never heard about it again. Bye, Alex

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  2. Indeed. Thank you, Samuel. (And as always, thank you for the Star Trek segue!)

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  3. Bravo, Samuel. And that you, as always, for the Star Trek segue!

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  4. Good questions, excellent conclusions, but one factor to consider is that more people look at movies and tv than at medical textbooks.

    My conclusion: medical textbooks must be made more entertaining so that more people will read and question them.

    But that idea only raises further questions:

    Aren't there enough naked bodies in medical textbooks to make them sufficiently entertaining?

    Or are we just tired of losing our shirts for Medicine?

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  5. An important topic, as ever, Samuel. Evidence-based medicine started out more than 20 years ago, with the 'clinical expert' textbook model firmly in its sights:

    When Antman et al. compared the evidence accumulating from randomized trials and systematic reviews of treatments for myocardial infarction with recommendations from contemporaneous textbooks, they found that most texts were failing to recommend thrombolytic therapy, even for specific indications, six years after the first meta-analysis showed it to be efficacious. Moreover, these same texts and reviews were persisting in recommending routine lignocaine prophylaxis for ventricular fibrillation, despite ever-stronger evidence that it was likely to be useless in lowering case-fatality.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295384/pdf/jrsocmed00064-0020.pdf

    Although textbooks of internal medicine and surgery have improved since then, ME-CFS is still owned by prescientific psychiatry, so no change there.

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  6. I have former colleagues who write textbooks in their fields (not medicine, but it's the same in history, sociology, psych). They do the best they can to cover what they consider the major issues. This reflects what they learned from their teachers was important as well as new things learned in the last 15-20 years of their teaching and research careers. When you realize that most of the people writing textbooks are over 40, as were the textbook writers they learned this stuff from, you can see how many generations it takes for things to change. Thank God for internet freedom. We don't have to wait for the textbooks, do we?

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  7. Hi Alex, yes, I think people have a hard time believing that textbooks are fallible. Your story is familiar.

    Hi Khaly, thanks :).

    Hi Creek, my take is that our democracies need to be more questioning and there need to be significantly more checks and balances.

    Hi wisden, so non-sham evidence-based medicine means using studies instead of clinical experts' opinions? From a political perspective, which is easier for industry to control and influence? Seems some only need to call something "evidence". But I imagine clinicians can be bought off too.

    That is really sobering, Janis. The trick seems to be getting people to realize how deadly the problem is. It's as if institutions are running people instead of people running institutions.

    ===

    Thanks everybody for great comments as always.

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  8. When I try to talk to a doctor, and question his or her knowledge of ME/CFIDS, the normal response is the surprised raising of eyebrows coupled with the wtf? look. The wtf? look is aimed directly at my rapidly deflating pride in knowing something of other about the history of my illness and the medical community's complete lack of interest in it. It would be funny if it wasn't my life.

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