D. Ur-Gosh. State University of New York College at Purchase.

Rather than acknowledging the selectivity of its process and the official necessity of demon- strating the right conclusion purchase 180 mg diltiazem with amex, and rather than admitting the complexity of the issue and the limits of its evidence purchase diltiazem 180mg, it invests both its process and its conclusions with a mantle of indubitability diltiazem 180 mg online. Third, and perhaps most importantly, whereas normal science deals with dissent on the basis of the quality of its evidence and argument and considers ad hominem argument as inappropriate in science, corrupt sci- ence seeks to create formidable institutional barriers to dis- sent through excluding dissenters from the process of review and contriving to silence dissent not by challenging its qual- 230 ity but by questioning its character and motivation. If it is to command academic respect it is crucial that this new epidemiology develops rigor- ous canons of scientific inference and applies scientific criti- cism remorselessly and unselectively even when the results do not please the investigators. The 20th century has already had enough of regimes which tolerate, even encourage, bad or fraudulent science in the name of the good of the nation or society. But not many school leavers have heard of Mill since providers of compulsory state education are careful not to allow his essay On Liberty to fall into the hands of their charges. Until the 18th century, the place of man in the universe and the rules of right conduct were defined by the Church. Right conduct, common decency and even good manners were to be replaced by lifestylism. Lifestyle experts came mainly from the disciplines of epidemiology and statistics. Those on the receiving end were never asked whether their idea of happiness had any resemblance to a correct lifestyle as set down in government publications. As de Jouvenel put it, The handling of public affairs gets entrusted to a class which stands in physical need of certitudes and takes dubi- ous truths to its bosom with the same fanaticism as did in other times the Hussites and Anabaptists. Like Leninism, healthism, with its wonderful promises, attracts dedicated altruists and otherwise intelligent people. Some of them may even acknowledge that people may get hurt in the process, but as Marxist-Leninist activists used to say, when you are clearing a wood, splinters fly around. The glorious visions of Health for All, or of the Smoke-free Planet by the Year 2000 can only be criticised by irresponsible lack- eys on the payroll of industries which thrive on making people sick, or by moral idiots. Their power is, in practice, uncontested because of the legitimacy they have spuriously borrowed from medicine and science and their concerned beneficence. A benign form of paternalism or a puri- tanical zeal to establish behavioral conformity? While the medical profession is not renowned for an exemplary puritanical lifestyle, the control of the lifestyle of others enhances their power. The power of the medical profession is jealously guarded and is vested in their moral, charismatic and scientific authority. The moral authority of doctors has rarely been questioned as doctors are on the side of the angels; they fight evil, suffering and death. The study of human behaviour is not a science in that it discovers no universal laws. It constructs moral stories, meaningful only for a particular society, time and place. This is not to imply that human behaviour is not an important and intriguing subject, but not everything interesting is a science. In medi- cine, blinks correspond to the objective signs of disease, but the concept of disease is in part a wink-construct, and the purpose of medicine is to give blinks meaning. More recently, the urge to normalise has been extended to the behaviour of healthy people, as part of the new policy of health promotion and disease prevention. According to one, the Senior Minister of State for Education announced a new government strategy to combat obesity among schoolchildren - they were to be given marks for their weight in their report books, so that their parents when checking on their academic progress 4 would also see their grade for health and fitness. The Straits Times quoted a cardiologist who called for a tax rebate for those who joined health clubs or purchased sports equip- 5 ment, such as treadmills or exercycles. Health propaganda is disseminated in English, Mandarin, Tamil, and Malay in order to reach as many Singaporeans as possible. Even chew- ing gum is banned in Singapore, though according to the Singapore Ministry of Health, only those who chew in places 6 of food consumption are to be prosecuted. This argument is difficult to refute if those who have power to coerce others to change their ways also have a monopoly of defining what is foolish, stupid or irresponsible. I love banquettes of quail eggs with hollandaise sauce, and clambakes with lobsters and crepes filled with cream. And if I am abbreviating my stay on this earth for an hour or so, I say only that I have no desire to be a Methuselah, a hundred or more years old and still alive, 7 grace be to something that plugs into an electric outlet. Health education should provide useful, factual infor- mation to enhance rational decision-making, that is, reasoned choice. One of the possible outcomes of such a decision is to ignore the health warning and to accept the risk. As Wikler pointed out, Health education may call for actual or deliberate misinfor- mation: directives may imply or even state that the scien- tific evidence in favour of a given health practice is unequivocal even when it is not. Similarly, from the economic point of view, the fairness principle does not apply, which, as Wikler pointed out, would require penalising non-smokers who by their extended living consume an unfair share of social security and pension payments. Some ethicists have tried to defend the paternalistic role of the State by arguing that only sensible measures are being adopted and that there is no danger that the State will turn into Big Brother. This is a specious distinction since paternalism untainted with moralism is an abstract entity with no real counterpart; lifestylism is moralistic paternalism par excellence.

In addition to pulse diagnosis cheap diltiazem 180mg otc, traditional Chinese medicine incorporated the five elements discount diltiazem 180 mg without prescription, five planets purchase diltiazem 180mg without a prescription, con- ditions of the weather, colors, and tones. Acupuncture as a healing art balanced yin and yang by insertion of needles into the energy channels at different points to manipulate the qi. For the A brief history of medicine and statistics 3 Chinese, the first systematic study of human anatomy didn’t occur until the mid eighteenth century and consisted of the inspection of children who had died of plague and had been torn apart by dogs. Medical theory included seven substances: blood, flesh, fat, bone, marrow, chyle, and semen. Diet and hygiene were crucial to curing in Indian medicine, and clin- ical diagnosis was highly developed, depending as much on the nature of the life of the patient as on his symptoms. Other remedies included herbal medications, surgery, and the “five procedures”: emetics, purgatives, water enemas, oil ene- mas, and sneezing powders. Anatomy was learned from bodies that were soaked in the river for a week and then pulled apart. Indian physicians knew a lot about bones, mus- cles, ligaments, and joints, but not much about nerves, blood vessels, or internal organs. The Greeks began to systematize medicine about the same time as the Nei Ching appeared in China. Although Hippocratic medical principles are now con- sidered archaic, his principles of the doctor–patient relationship are still followed today. The Greek medical environment consisted of the conflicting schools of the dogmatists, who believed in medical practice based on the theories of health and medicine, and the empiricists, who based their medical therapies on the obser- vation of the effects of their medicines. The dogmatists prevailed and provided the basis for future development of medical theory. In Rome, Galen created pop- ular, albeit incorrect, anatomical descriptions of the human body based primar- ily on the dissection of animals. Most people turned to folk medicine that was usually performed by village elders who healed using their experiences with local herbs. Other changes in the Middle Ages included the introduction of chemical medications, the study of chemistry, and more extensive surgery by those involved with Arabic medicine. Renaissance and industrial revolution The first medical school was started in Salerno, Italy, in the thirteenth century. In the fifteenth century, Vesalius repudiated Galen’s incorrect anatomical theories and Paracelsus advocated the use of chemical instead of herbal medicines. In the six- teenth century, the microscope was developed by Janssen and Galileo and pop- ularized by Leeuwenhoek and Hooke. In the seventeenth century, the theory of 4 Essential Evidence-Based Medicine the circulation of blood was proposed by Harvey and scientists learned about the actual functioning of the human body. The eighteenth century saw the devel- opment of modern medicines with the isolation of foxglove to make digitalis by Withering, the use of inoculation against smallpox by Jenner, and the postulation of the existence of vitamin C and antiscorbutic factor by Lind. During the eighteenth century, medical theories were undergoing rapid and chaotic change. In Scotland, Brown theorized that health represented the con- flict between strong and weak forces in the body. Cullen preached a strict following of the medical ortho- doxy of the time and recommended complex prescriptions to treat illness. Hah- nemann was disturbed by the use of strong chemicals to cure, and developed the theory of homeopathy. Based upon the theory that like cures like, he prescribed medications in doses that were so minute that current atomic analysis cannot find even one molecule of the original substance in the solution. Benjamin Rush, the foremost physician of the century, was a strong proponent of bloodletting, a popular therapy of the time. He has the distinction of being the first physician in America who was involved in a malpractice suit, which is a whole other story. This alluded to the probability of two events being the product of the probability of each, but without explic- itly using mathematical calculations. Among the ancients, the Greeks believed that the gods decided all life and, therefore, that probability did not enter into issues of daily life. The Greek creation myth involved a game of dice between Zeus, Poseidon, and Hades, but the Greeks themselves turned to oracles and the stars instead. This was probably the biggest step toward being able to manipulate probabilities and determine statistics. In 1202, the book of the aba- cus, Liber abaci by Leonardo Pisano (more commonly known as Fibonacci), first introduced the numbers discovered by Arabic cultures to European civilization. In 1494, Luca Paccioli defined basic principles of algebra and multiplication tables up to 60 × 60 in his book Summa de arithmetica, geometria, proportioni e proportionalita. He posed the first serious statistical problem of two men play- ing a game called balla, which is to end when one of them has won six rounds.

The first country in the world to have compulsory health warnings on alcoholic beverages was Colombia cheap diltiazem 180mg overnight delivery, where cocaine discount 180 mg diltiazem with visa, without a health warning buy generic diltiazem 60mg online, is freely available on the streets. However, there has been a hitch in the medical presen- tation of the case against alcohol. Numerous studies have uncovered an unexpected and strong negative correlation between alcohol consumption and coronary heart disease. Even increases in alcohol- related mortality from other diseases for an average drinker are not high enough to offset the dramatic protective effect of alcohol on coronary heart disease but they tried to keep it out of health education materials. What else was the press supposed to report when studies published in The Lancet and in the British Medical Journal reported a 40-60 per cent reduction in the risk of coronary heart disease in 178 drinkers of up to 40 to 60 drinks a week? Professor Gerald Shaper, one of the main opponents of the idea that alcohol is beneficial to health, stated that: The belief that light or moderate drinking is good for health in general and for the cardiovascular system in particular may be well documented and widely supported. It seems that in medicine two different sets of criteria apply for accepting or rejecting evidence. If there is the slightest hint that something pleasurable may do harm, such evidence is immediately accepted, inflated and disseminated. If, however, the same pleasurable activity is shown to be beneficial in any respect, such evidence must be suppressed, ridiculed, or dis- missed. The idea that alcoholism is a disease and alcohol its aetiological agent is again gaining ground. What the medical model misses com- pletely is the question of why some people eat more (or drink more) than is good for them. The medical model simply medicalises problems of living, of which drinking too much is a symptom. The most eloquent refutation of the concept of alcoholism 180 as a disease is provided by Thomas Szasz. While excessive drinking may cause disease, it does not follow that drinking itself is a disease. There is no doubt that pleasures carry risks, but it is equally true that where there is no risk there is no fun. At a meeting sponsored by the Committee of Smoking and Health of the Medical Society of the District of Columbia, an ethicist explained that smoking was inherently immoral since it violated at least three fundamental moral principles. Smoking is a complex behaviour, with little understood neurophysiological and psychological mechanisms. A smoker of 20 cigarettes a day for 50 years will smoke 365,000 ciga- rettes, which, if laid end to end, would stretch 30 kilometres. Assuming an average of 15 puffs per cigarette, the smoker inhales five million puffs. With the alleged 5,000 poisonous substances in smoke, he receives 25 billion doses. What is surprising is that many smokers survive this chronic poisoning relatively unscathed. The awesome intensity of the war against tobacco in all its forms cannot be accounted for simply by referring to certain epidemiological reports which have shown that smokers are more likely to die of lung cancer than of some other diseases. They pose new questions about the relationship between the state and the individual, about the right to privacy and about the legislation of morality. Where is the boundary between information and propaganda, between education and coercion? In 1988, according to a count in the British Medical Jour- nal, Australian newspapers alone carried 1,600 items about 185 smoking, of which 83 per cent disseminated fear. The British Health Education Authority raised objections to films which depicted smokers, even though most of them were portrayed as villains. Health educators regularly complain to news- papers which feature photographs of smokers. Einstein with a pipe will not do: the pipe should be skilfully retouched from the photograph so that young readers will not be cor- rupted. They used to do this with the images of Trotsky in historical photographs from the Soviet Union. The continuous barrage of anti-smoking propaganda uses the promise of better health as its ostensible aim. The cam- paign, however, has gradually degenerated into a single-issue fanaticism. As the majority of smokers now belong to low- income groups, the anti-smoking crusade of the new ruling class, who control media and education, has encountered little resistance among the middle classes, even when its rhet- oric changes from coercive altruism to plain abuse. The shift from medical aspects of smoking to moral exhortation only became possible when smoking declined among the middle classes (the upper classes have generally kept aloof and amused) and was further facilitated by the rise of neopuritanism. Samuel Butler in The Way of All Flesh commented on the absence of any Biblical injunction against smoking: It had not yet been discovered [but] it was possible that God knew Paul would have forbidden smoking, and had purposely arranged the discovery of tobacco for a period at which Paul should no longer be living. According to The Guardian a Harley Street doctor regret- ted warning a chain-smoking Saddam Hussein about the dan- gers of smoking: T honestly believe that without my advice Saddam would have died years ago. A debate periodically flares up in medical journals as to whether smokers should receive the same medical care as non-smokers, especially if they fail to give up their detestable habit. Geoffrey Wheatcroft recalled in The Daily Telegraph that when the historian Sir Raymond Carr had broken his arm while hunting, the attending surgeon confessed that if he had had any moral or legal choice he 122 Lifestylism would have left it untreated, since he hated hunting so 190 much.

Create files of clinical examples illustrating each bias with appropriate correcting strategies Limitations in feedback Identify speed and reliability of feedback as a major requirement in all clinical domains effective 180 mg diltiazem, both locally and systemically Biased evidence gathering Promote adoption of cognitive forcing strategies to take account of disconfirming evidence diltiazem 180mg visa, competing hypotheses buy generic diltiazem 60 mg on-line, and consider-the- opposite strategy Denial of uncertainty Specific training to overcome personal and cultural barriers against admission of uncertainty, and acknowledgement that certainty is not always possible. Encourage use of “not yet diagnosed” Base rate neglect Make readily available current incidence and prevalence data for common diseases for particular clinical groups in specific geographical area Context binding Promote awareness of the impact of context on the decision-making process; advance metacognitive training to detach from the immediate pull of the situation and decontextualize the clinical problem Limitations on transferability Illustrate how biases work in a variety of clinical contexts. Adopt universal debiasing approaches with applicability across multiple clinical domains Lack of critical thinking Introduce courses early in the undergraduate curriculum that cover the basic principles of critical thinking, with iteration at higher levels of training 38,39 pears lacking for System 1, the prevailing research emphasis noted earlier, several studies suggest that when the 51 52 in both medical and other domains has been on System 2. Overconfidence often occurs when determining a course of Prompt and reliable feedback about decision outcomes action and, accordingly, should be examined in the context appears to be a prerequisite for calibrating clinician perfor- of judgment and decision making. From the enced by a number of factors related to the individual as standpoint of clinical reasoning, it is disconcerting that well as the task, some of which interact with one another. It seems to be espe- cially dependent on the manner in which the individual enced clinicians, they are “less able to articulate what they gathers evidence to support a belief. In medical decision do than others who observe them,” or, if articulation were making, overconfidence frequently is manifest in the con- possible, it may amount to no more than a credible story 6 about what they believe they might have been thinking, and text of delayed and missed diagnoses, where it may exert its most harmful effects. But this is hardly surprising as it is sicians exhibit overconfidence in their judgment. It is rec- a natural consequence of the dominance of System 1 think- ognized as a common cognitive bias; additionally, it may be ing that emerges as one becomes an expert. As noted earlier, propagated as a component of a prevailing memeplex within conscious practice of System 2 strategies can get compiled the culture of medicine. A problem Numerous approaches may be taken to correct failures in once solved is not a problem; experts are expert in part 2 6 precisely because they have solved most problems before reasoning and decision making. Berner and Graber outline the major strategies; Table 3 expands on some of these and and need only recognize and recall a previous solution. Presently, no 1 strategy this means that much of expert thinking is, and will remain, has demonstrated superiority over another, although, as an invisible process. Often, the best we can do is make S28 The American Journal of Medicine, Vol 121 (5A), May 2008 inferences about what thinking might have occurred in the lectively lead to an overall improvement in decision making light of events that subsequently transpired. Halifax, Nova Scotia, Canada Seemingly, clinicians would benefit from an understand- ing of the 2 types of reasoning, providing a greater aware- Geoff Norman, PhD ness of the overall process and perhaps allowing them to Department of Clinical Epidemiology and Biostatistics explicate their decision making. Whereas System 1 thinking McMaster University is unavailable to introspection, it is available to observation Hamilton, Ontario, Canada and metacognition. The authors report the following conflicts of interest with Educational theorists in the critical thinking literature the sponsor of this supplement article or products discussed have expressed long-standing concerns about the need for in this article: introducing critical thinking skills into education. The implicit assumption is made that by the time students have References arrived at this tertiary level of education, they will have achieved appropriate levels of competence in critical think- 1. Evidence-based practice: logic and critical 1 ing skills, but this is not necessarily so. In: Mac- bly not, and there is a need for the general level of reasoning Kinnon N, Nguyen T, eds. Ottawa, Ontario: about detachment, overcoming belief bias effects, perspec- Canadian Pharmacists Association, 2007. Incidence of adverse events tive switching, decontextualizing, and a variety of other 55 and negligence in hospitalized patients: results of the Harvard Medical cognitive debiasing strategies. The epistemology of clinical reasoning: perspectives from philosophy, psychology, and neuroscience. Concise Encyclopedia of Information Processing in more than a brief session on cognitive debiasing. Individual differences in reasoning: implica- pertise with training, to date there is little evidence tions for the rationality debate? Psychopathological symptoms, social skills, and per- do clinical teachers need to guard against teaching pattern recognition sonality traits: a study with adolescents Spanish. Berner and Graber is analytic models of reasoning describe optimal diagnostic that the gaps in our knowledge far exceed the soundly process, i. If physicians are not established areas, particularly if we focus on empirical find- employing these analytic processes, the assertion is that ings based on real-world work by real physicians. How is it that our knowledge about diagno- situation, experts seldom engage in highly analytic modes sis—historically the most central aspect of clinical practice of decision making. Rather, under these conditions, experts and one that directs the trajectory of tests, procedures, are most likely to use fast and generally sufficient strategies. However, the lack of progress in ap- Most of the research performed regarding diagnosis in plying research findings to the messy world of clinical medical contexts has concerned static decision problems: practice suggests that we might benefit from examination only 1 decision needs to be made, the situation does not of an expanded set of questions. However, much of the work of medicine concerns dy- namic decision problems: (1) a series of interdependent Diagnostic Models decisions and/or actions is required to reach the goal; (2) A great deal of the work to date has assumed that diag- the situation changes over time, sometimes very rapidly; nostic thinking is best described by highly rationalized (3) goals shift or are redefined. In contrast to static problems, in dynamic little or no consideration of alternative approaches. There problems there is no theory or process element even close are some exceptions, including criticisms of this view 4,5 6 to being considered normative, either for approaching the (see Berg and colleagues and Toulmin ), Norman’s 7,8 problem or for establishing a particular sequence of de- research on clinical reasoning, and Patel and col- 9 cisions and/or actions as correct. Neverthe- Statement of Author Disclosures: Please see the Author Disclosures Problem Detection and Recognition section at the end of this article.