Mostly it is pretty easy for me to think of things I want to
write about in the area of medicine and social justice; there is so much awful
stuff going on there. But today it was harder; I want to write about the
bravery of Christine Blasey Ford, and how powerful the calm, collected
testimony that she gave was, especially given the fact that she had nothing to
gain except harassment for herself and her family, and even death threats that
required her to go into hiding.
I want to write about the atrocious behavior of Brett
Kavanaugh, who has a lot to gain -- a lifetime appointment to the Supreme Court
of the United States – but chose to take the low road, not just denying the
charges but displaying aggrieved entitlement, snarling and attacking and
refusing to give straight answers to straight questions. Right out of the
Donald Trump playbook. And absolutely not the behavior we want on the Supreme
Court, or even that we heard about his control in his current Appeals Court
job. Much more, in fact, like the 17-year old Kavanaugh that Dr. Blasey Ford
described.
I want to write about the tone-deaf but mission-focused
hubris of the 11 white men who formed the majority on the Judiciary Committee. Ten
of them having made up their minds in advance, they were not going to be
derailed by anything, certainly not the testimony of the witnesses. Led by
their chair, Sen. Grassley, who never made eye contact with Dr. Blasey Ford but
kept his eyes on the paper he was reading from, and their attack dogs (Lindsey
Graham, harsh, and John Cornyn, snide) they had a woman prosecutor question the
female witness so as not to look like they were who, in fact, they were. That
the format never allowed Rachel Mitchell to pursue a line of questioning was
irrelevant, since it was all a charade for them. It is a shame that they made
old men look so dumb and evil; remember that Grassley (85) and Hatch (84) were
arrogant misogynists when they were younger, and that those (like Crapo and
Cruz and Sasse) still in the 40s already are the same.
But this is a blog about medicine and social justice, and
while there are certainly social justice lessons to be learned (in the
negative) from the disingenuous cavorting of racist, sexist, we’ll-do-this-because-we-can
behavior of white men in the hearing room, it has little to do with medicine or
public health. Except, of course, to the extent that this entitled behavior is so
frequently seen in those fields.
I recently wrote about an example of entitled corruption in
José Balsega, the former Chief Medical Officer of Memorial Sloan-Kettering
Medical Center (“Baselga,
graft and corruption in medical research: why should we tolerate it?”,
September 16, 2018), and we just learned that their
vice president in charge of corporate relations has been required to pay them
back the $1.4M he made from, essentially, insider trading.
I have also written about other corrupt executives, mainly
in the pharmaceutical industry (e.g., “Epi-Pen®
and Predatory Pricing: You thought our health system was designed for people’s
health?”, September 3, 2016). These “Masters of the Universe” (h/t
Tom Robbins) think they deserve everything they can get, and the rest of us be
damned. Thanks to women like Heather Bresch of Mylan (Epi-Pen®) and criminal mastermind Elizabeth Holmes of
Theranos, they are not all men. But mostly they are, and even these women had
the protection of old men; Bresch’s father is Sen. Joe Manchin (D-WV) and
Holmes attracted rich old white guys like Riley Bechtel of Bechtel, George
Schultz, former Secretary of State and Bechtel CEO, and William Foege, former
head of the CDC and hero of the anti-smallpox crusade, in a real-life parody of
a bad thriller femme fatale.
Bad behavior is rife
in the medical and public health communities, motivated, like that in the
pharmaceutical sector and politics, by self-interest, a desire for money and
power. Aaron Carroll, in “The
Upshot” in the New York Times on
September 24, 2018, writes about the many forms of bias in scientific and
medical publication. He takes off from an article in Psychological Medicine, “The
cumulative effect of reporting and citation biases on the apparent efficacy of
treatments: the case of depression”, but he points out the many forms of
bias affect research and research papers in general. These include publication bias, which means journals
are more likely to publish papers with positive results (our study showed this
new treatment worked!) rather than negative (well, we thought this would work
but it didn’t, 😞); outcome
reporting bias where only the positive outcomes are published and the
negatives are left out; spin where,
when unable to avoid reporting results that are negative, you use language to
make them seem more positive; and citation bias, whereby other authors are
much more like to refer to (“cite”) papers with positive results than those
with negative, thus increasing their visibility. He does not specifically
discuss confirmation bias, in which
researchers are much more likely to notice and report on findings that confirm
their prior ideas and dismiss those that contradict them, but this is also very
insidious.
Sometimes the
stakes, seen by the really rich and powerful, are minor – status and reputation
in the academic scientific community (recalling the old adage “competition in
academics is so vicious because the stakes are so low”). However, it is not
just the researchers who are at fault. Journal editors and publishers are
motivated by their own metrics of success, such as the “impact factor” based
upon how often articles in their journals are cited by others. And, of course,
our old “friends”, the pharmaceutical companies, are behind much of this bias,
suppressing negative results for the drugs they make and emphasizing secondary
outcomes (unethical!). For them, the stakes are financial and very high.
Carroll does a masterful
job, supported by research published in a number of journals. He ends by
discussing the ways in which these practices hurt we, the people, by getting
false or misleading information out to other physicians and scientists. This
can lead to us receiving treatments that don’t actually work, or work as well
as they are portrayed as doing, or may even be more likely to harm us than help
us. He emphasizes the important fact that not all, or even most, published
scientific research is not to be trusted, but that these scurrilous articles
are out there, and depend upon not only reporters and the public, but doctors
not reading them carefully. Sadly, many medical (and other) professionals often
hear only the reports of research in the popular press or, if they read the
study, read only the Summary, or the Discussion section (most easy to “spin”)
instead of carefully looking at the reported Methods and Results and drawing
their own conclusions. Carroll makes a series of suggestions as to how the
discipline might change this culture of bias; they are good and should be
pursued.
I am not sure where
the blame originates, whether from our leaders like our politicians and
businessmen who see truth as an option which can be disregarded in the pursuit
of money and power, or our scientists who take these illegitimate roads to further
their own careers, or the public which has become agnostic about truth and
searches only for confirmation of their own preconceived notions (or biases).
But I am sure that, at all these levels, it is a bad thing and corrosive of the
progress that should come from new knowledge.
Most of us will never
get the chance to publicly put ourselves out there on the line like Dr. Blasey
Ford, and very likely wouldn’t if we could. We can, however, stand for the idea
that truth is not “revealed” but emerges from continuing work, from confirmation
by replication of studies, from more work that further elucidates the truth. And
that the enemy of truth is the kinds of biases that Dr. Carroll discusses.
In talking about his
suggestions for correcting them, Carroll writes “These actions might make for more boring news and more tempered
enthusiasm. But they might also lead to more accurate science.” And that
would be good for us all.
