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Science And The Game Of 20 Questions

An audience member at a recent NYC Skeptics meeting asked me how I handled conflict surrounding strongly held beliefs that are not supported by conclusive evidence. As a dentist, he argued, he often witnessed professionals touting procedure A over procedure B as the “best way” to do X, when in reality there are no controlled clinical trials comparing A and B. “How am I to know what’s right in these circumstances?” He asked.

And this is more-or-less what I said:

The truth is, you probably can’t know which procedure is better. At least, not at this point in history. The beauty of science is that it’s evolving. We are constantly learning more about our bodies and our environment, so that we are getting an ever-clearer degree of resolution on what we see and experience.

It’s like having a blurry camera lens at a farm.  At first we can only perceive that there are living things moving around on the other side of the lens – but as we begin to focus the camera, we begin to make out that the animals are in the horse or cattle family. With further focus we might be able to differentiate a horse from a cow… and eventually we’ll be able to tell if the horse has a saddle on it, and maybe one day we’ll be able to see what brand of saddle it is. Each scientific conundrum that we approach is often quite blurry at the onset. People get very invested in their theories of the presence or absence of cows, and whether or not the moving objects could in fact be horses. Others say that those looking through the camera contradict one another too much to be trusted – that they must be offering false ideas or willfully misleading people about the picture they’re describing.

In fact, we just have different degrees of clarity on issues at any given point in time. This is not cause for alarm, nor is it a reason to abandon our cameras. No, it just gives us more reason to continue to review, analyze, and revise our understanding of the picture at hand. We should try not to make more out of photo than we can at a given resolution – and understand that contradicting opinions are more likely to be evidence of insufficient information than a fundamental flaw of the scientific method.

***

I have noticed that impatient photo-gazers have a propensity to demand answers before accurate ones are available. And this leads to all manner of passionately held, but misguided beliefs both in the scientific community and beyond. We must somehow find a way to make peace with limited information, eagerly seeking more, without being dogmatic about premature conclusions. My dentist colleague should not feel pressured into choosing sides on an issue that cannot be fully evaluated yet – and will have to wrestle with ambivalence as he waits patiently for more data.

But far more worrisome than living with ambivalence is living with stagnation. I would argue that one of the greatest red flags in the scientific world is an unwillingness to learn – an unyielding commitment to a set of beliefs, despite increasing evidence that they are not accurate. I think of homeopathy and acupuncture as good examples of this phenomenon – since they have not evolved significantly since their inception, their proponents therefore must admit that they have learned almost nothing new since the dawn of their use. The lack of refinement of treatment protocol is evidence of the system’s belief-based (or placebo-based) nature. As John Cage, US composer of avant-garde music, once said,

“I can’t understand why people are frightened of new ideas. I’m frightened of the old ones.”

***

As I mulled over my fuzzy image analogy, an even better one came to mind: the game of 20 questions. For those of you who didn’t play this game growing up, its rules are simple: one person must think of a person, place, or thing and the other(s) have 20 questions that they can ask in order to guess who/what the first person had in mind. The challenge is that the questions have to be asked so that the response is either yes or no. If the questioners can’t devine the name of the person, place or thing within 20 questions, the respondent wins. If the questioners guess the identity of the object within 20 questions they win.

Science is a little bit like 20 questions (of course we have unlimited questions that we can ask) in that we constrain our research to answer a very specific question under a very specific set of circumstances (formulating a “yes” or “no” type question). No one question or answer is likely to unlock the solution to the larger puzzle – it’s the collection of questions, taken in context of one another, that leads to meaningful understanding. When we don’t understand the best path forward, it’s likely that we are early on in the game of 20 questions, with little information to guide us.  Occasionally we get lucky and ask the right question early – but more often than not we’re left to scratch our heads and ponder yet another question to help unlock the “mysteries” that face us.

That is the beauty and the pain of science – it’s slow, it’s methodical, it leaves the honest participant in a state of ambivalence with some degree of frequency, but in the end it yields real answers if we wait for the clarity that can come from careful analysis. Without it we are left with magical beliefs and misguided explanations… we’re left with Jenny McCarthyism.


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*This blog post was originally published at Science-Based Medicine*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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