As the tPA debate reaches a fever pitch, EPs must remember how to separate fact from belief, and do so with a healthy dose of skepticism.
I admit it, I’m a skeptic and proud of it. Like Harry Truman, I’m afflicted by Missouri’s “Show me” philosophy. But as a human, I’m also aware that I come equipped with a belief structure and as with all humans, beliefs carry the day. I seek plausible explanations for the beliefs I hold and therefore, like so many, fall victim to conformation bias. But my brain is the ultimate belief engine and is exceedingly good at finding ways to justify those beliefs. Why else would I have believed at 16 that I could ask the most beautiful girl in the school to the prom and expect a positive response? Reality testing can be painful for a high school sophomore. The 2009 Harris Poll found that 82 percent of Americans believe in God, 60 percent believe in the devil and 23 percent believe in witches, even though there is the same amount of hard evidence to scientifically prove the existence of any of them. (As an aside, I will take as scientific fact the aforementioned beauty queen who turned me down for the prom stands as proof that witches do exist!)
I wrote recently about the ACEP Council being spanked for its tPA policy. (As you probably know by now, the ACEP Council voted to “reconsider” the ACP Clinical Policy on tPA and open the published statement up for public comment.) If you need proof that belief systems are powerful, pervasive and enduring entities, you need to look no further. Rational thinking on this issue, like our thinking on most issues, is complicated.
Skepticism is the rigorous application of the principles of science and reason to test the validity of all claims in the realm of provable entities and experiences. When you see a neon sign in a New York City hole-in-the-wall restaurant proclaiming “world’s best coffee,” you realize you have run into a twilight zone of belief, not fact. All scientific conclusions need to be tempered by the phrase: “at this moment, at this time.”
The requirement of the true skeptic, however, is the willingness to change his or her mind when presented with contrary scientific evidence. Skeptics do believe in things. But they seek to keep an open mind by honestly keeping the stream of information coming for rational analysis. The true balance of a skeptic is between orthodoxy and heresy, which are not easy to obtain since we function with our own human beliefs.
I believe in tectonic plates and the Big Bang theory. I don’t believe in alien crop circles or holocaust revisionism. Most people I hear expounding on these topics are more skilled at rhetoric and sophistry than meaningful scientific proofs. Conspiratorial theories of how Bush orchestrated 9-11 or how Obama was hoping for a Sandy Hook so he could push gun control drive me crazy. These are the theories of lunatics. But in a free society – and I use the term carefully – you just can’t tell these folks to put up or shut up. Free speech is a bitch. Most Americans (70 percent, apparently) do not understand the scientific process. Ninety percent could not explain the difference between inductive and deductive reasoning. And less than one percent even knew who Francis Bacon was. The world comes to us through distorted filters and lenses. Theories and hunches and weird hypotheses are given credence in proportion to their airtime in the mass media.
I therefore ask, as our debate on tPA for stroke goes forward, that we remember and consider the interplay of fact and belief. I think that the Spinoza dictum should prevail. Baruch Spinoza, the 17th century Dutch master/philosopher said: “I have made a ceaseless effort not to ridicule, not to bewail, not to scorn human actions but to understand them.” Ideological immunity is the built-in intellectual escape hatch in the scientific process. History eventually rewards those who are right. Copernicus replaced 1,800 years of Ptolemaic thought. Evolution replaced the immutability of species. And so on it goes. There is no reason to sacrifice our civility in the pursuit of these conversations.
Along with Spinoza, we should remember Hume’s maxim, which states: “A wise man proportions his belief to the evidence.” The Nobel Laureate physicist Richard Feynman, a smart man if there ever was one, wrote about his own prejudices and weaknesses to see truth when he commented: “The first principle is that you must not fool yourself. And what you should realize is you are the easiest person to fool.”
Remember as we seek truth those making extraordinary claims have the burden to produce supported data. But all politicians know that humans hate data. They want anecdotes and stories. Anecdotes are powerful belief engines which we need to approach with trepidation.
Cognitive heuristics – thinking shortcuts to help us make decisions in uncertainty – is how we live as emergency physicians in our everyday lives. A 16-year-old boy with right lower quadrant rebound tenderness has appendicitis for our purposes until proven otherwise. But such thinking, although great as rules-of-thumb, cannot be used in the long view for more difficult scientific processes, such as stroke. We are under constant pressure to have a solution where currently there is no answer. God, give us something so we just don’t have to sit there and watch lives being ruined by a vascular process! But what if the therapy is equivocal? What if the treatment is worse than the disease? We all remember Nesiritide. A good theory destroyed by inconvenient facts. Damn.
I propose some rules of engagement for not only the continuation of this debate on tPA, but for all contentious issues that approach us in the future:
Number one: We are all human. We all make mistakes. We’re all more controlled by our testosterone than our intelligence. Have a sense of humor. We are all going to die eventually.
Number two. Understand projection bias. The tendency to assume that others share the same or similar beliefs and attitudes must be recognized, admitted and abandoned. No, they don’t think the same. They may have a different set of priorities. That’s okay. You’re allowed to do that in this country.
Number three. Stop with the blind spot bias. This is the tendency to recognize the power of cognitive biases in other people while ignoring our own. Failing to recognize our own faults is killing the conversation. It leads to ad hominem attacks, which have done our profession genuine harm. A cease and desist order should now be in effect for such discussions.
Number four. Stop glorifying the “good old days.” A sense of “rosy retrospection” causes some to remember past events – and old scientific literature – as more positive than it actually was. It’s always wise to remember that the good old days are times more often remembered than experienced. No, the literature was not that convincing.
Number five. Finally, it’s not about us. It’s about the patients. No matter how much we apply both inductive and deductive reasoning to the tPA problem, this is not a high school debate. There is a patient, a family sitting there lost in a sea of bewilderment. They have heard of the magic medicine that reverses the insufferable outcomes of stroke. To watch someone you love and have grown old with now moving only half their body, drooling and unable to even utter words, let alone sentences, must be a moment of incalculable grief and despair. What we tell people at this moment in time is the true test of our courage and decision making. If you give the truth in this decision making process, what truth do you give? Is it just the facts that agree with your bias? Do you give them hope?
I got to watch these ends of the world collide in the courtroom not long ago. The doctor I was defending represented the greatest tragedy of all. He was bitter about the process. He was angry that he’d taken the time to get the real information as to when the patient’s stroke began, which as all of you know is not always easy to do. He was hurt, offended, incensed that he had been beaten and battered for four years even though he felt he did nothing wrong. He hates the emergency doctor who testified against him, smugly proclaiming that any doctor who did not give tPA was incompetent at least and potentially criminal in his actions. Emergency medicine functions under the tyranny of the immediate. Every pressure is forcing you to make a decision on an incomplete data set and apply therapies which may not be valid.
In all fairness, we won. But the final words of my defendant doctor to me illustrated the depth to which this discussion has sunk:
“Fuck them. Fuck them all. From now on, they’re all going to get the damn drug. It’s no skin off my butt.” I felt incredibly sad as the physician walked away.
The end of all lawsuits is not rejoice but relief. Thank god it’s over. But in truth, it’s never over. The next day we go back to work in the same emergency departments to confront the same uncertainties as before. To have our own professional society supporting unjustified policies adds insult to injury. The conversation goes on.
Argumentum ad captandum
7 Comments
After 56 yrs of medicine and 40 yrs of ER, I am still equivocal, but to keep my job, I will give the patients whatever they want. They don’t come to the ER to be educated. They come for a quick preconceived fix. My real dilemma is would I use tPA on my family. I don’t know.
Amen!!! Particularly enjoyed the “at this moment, at this time” comment. I address it a little differently in that you have to be willing to get off the train as fast as you got on it. Thanks for the article.
Greg, you reflect your philosophical training in every column you write, bringing to the fore years, nay centuries, of wisdom from the greats of the past, and illuminate current problems, and the flaws in our thinking. Bravo on another well-written and thoughtful discussion of a topic near and dear to us.
Another example of the system scrwing people and our colleagues patting us on the back, with ACEP continuing its’ blind process of appearing to do something without actually making a difference.
But Dr. Henry, of late, has been, shall we say, wandering away from his previously clear opinions and musings. This, and the last, column desperately needed editing.
As usual, spot-on and brilliant. Thank you, Dr Henry.
Thanks Greg for your insightful editorial. Having previously experienced the rigors of legal combat first hand, I feel for the Doc you defended. It’s hard to try to practice what we think is the best scientific brand of care, when you get sued for doing it. (I won too).
As for tPA, I have been in medicine long enough to see today’s Gospel become tomorrow’s Heresy. It is my opinion that we probably do not have enough scientific trials to confirm the benefits of this therapy. Additionally, I would like to see studies of real-world benefits, such as levels of function improvement allowing meaningful lifestyles in the survivors of stroke, not simply improvement in and artificially constructed scoring system.
I must admit I tend to approach this particular treatment with some skepticism.
Love these Greg Henry “Oh, Henry” columns.
But this one was even More Brilliant Than Usual (March – The Rules of Engagement) !
Hard to disagree with the logic, and hard to believe his amazing insights!
And hard to believe that it’s all in a monthly that gets sent to me. It is that Brilliant!
Thanks Greg!
Ben Roesch