Archive for September, 2008

Vanity, thy name is “expert”

Posted on September 29, 2008. Filed under: Everything you wanted to know about doctors, Layman's AI, Personal philosophy, Self-deception |

As my medical school years drew to a close, each of us faced the choice of residency that would determine how we spent our professional lives. A close friend and member of AOA, the medical honor society comparable to Phi Beta Kappa or Law Review, declared that he had chosen OB/GYN. He and I had shared what I felt was a miserable experience as “acting interns” on the obstetrics service our senior year, so his choice astounded me.

“Why?”

His answer was seminal: “Have you noticed the size of the textbook?” Indeed, the OB/GYN text was far smaller than that of any other subject we studied. “I think it’s possible to learn everything there is to know about OB/GYN. I can be an expert.” Perhaps he was citing the mental comfort associated with mastery of a skill, and the unlikelihood that he would find himself in a situation beyond his capabilities, akin to a world-class martial arts expert walking alone at night. I suspect the knowledge that one’s work was done as well as could be done would provide substantial comfort, especially if one were well-paid, and the importance of that work were protected and promoted by a guild system. [NOTE: in those days, there was little concept of medical malpractice, a scourge which subsequently would hit the OB/GYN specialty harder than any other.]

Yet, I think his answer (and his career choice) may have been more instinctive, and perhaps outside his conscious awareness: the possibility of being an expert may have been subsumed by the possibility of being recognized as an expert. Dr. Robin Hanson, on the Overcoming Bias blog, initiated a discussion of a similar concept, referring to “expert at” versus “expert on, in which the former could perform successfully and the latter could talk about it successfully. I’m referring to a third entity: an expert on a topic who also is an expert at that topic. He is an expert by all practical considerations, and he is well-remunerated. Is that enough? Perhaps not.

I have observed a distinct change in attitude when the expert-aspirant is exposed to his peers. In my own field, I wanted to be, planned to be, and worked to be the best in the world. In my own mind, I achieved that (male surgical sexual medicine is a very small pond for any size frog), and I was compensated financially in adequate fashion. I want to be satisfied with the knowledge that my work was of superior technical and ethical quality. But it’s a self-edited summary; often (not always) at the highest levels of anything, self-satisfaction seems overrated, and inadequate. At a conference of IPP (inflatable penile prosthesis) technical experts, early in my career, I was seated at dinner next to a surgeon who was prolific in numbers of successful operations. In fact, studying his methods had caused me to take a number of steps that benefitted both my technical skills and my practice success. Because of his influence, and my subsequent personal experience, he and I both used the same brand of IPP in our patients. Neither of us was in academics, so our “fame” came only from our patients and from the recognition of the manufacturer. He mentioned that he had performed “3- or 4-hundred” procedures that year. Unlike some areas of surgery, the number of IPP surgeons who ever perform more than 100 procedures in a year can be counted on two hands. My pride was piqued, and I replied, “I did 201, and Mr. X (the manufacturer CEO) told me that was tops in the world.” When I was just starting, this same surgeon had asked me to join his practice; after the dinner encounter, he was never friendly to me again. It was vanity versus vanity. Of note, I am very unpopular with the “experts on” in my field, those I call the “thought leaders”, none of whom are “experts at”. It’s the recognition, stupid.

Lest you think that the self-satisfied expert at/expert on doctor is immune to this vanity, give him a chance for recognition. Pharmaceutical and device manufacturers have caught on to this weakness in spades. The opportunity to be the star at doctor-to-peer lectures and presentations has changed the attitude of many a current physician, and strongly influenced his practice habits. Even when one has reached the pinnacle of both actual and recognized expertise, the vanity drive remains strong. Dr. Michael DeBakey gave the AOA visiting professor lecture during my junior year. I don’t remember much of what he said, but one quote has stayed with me: “I could make a career simply correcting the mistakes of other vascular surgeons.” Probably a true statement, especially at the time, but of what value was this knowledge to junior medical students? Could there be any doubt that recognition was the driving force?

Recently on Overcoming Bias, the smartest of the smart have shown not only are they are not immune to the vanity of the experts, they actually are as pedestrian as the rest of us when it comes to this human frailty. In the posts and discussions here, here, and here, it’s all about who is the smartest, who is the best qualified, and who is the leading expert. One would think pride in one’s intelligence is severely misplaced. As one of the main posters, Eliezer Yudkowsky, has said, “We are the cards we are dealt, and intelligence is the unfairest of all those cards.” Yet note the ego-involvement. One would think that accomplishment was a far better source of pride. And if that accomplishment has not yet occurred? Such encounters as this are the result. I choose Mr. Yudknowsky as an example only because he is a dedicated student of the human thought process, and one of two main writers on a blog dedicated to eradicating bias. If it can happen to such as him, perhaps it’s innate.

*Pro tip*:The ultimate goal is not only that I succeed, but also that you fail.

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The truth will set you free… but first, it will piss you off.

Posted on September 25, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Personal philosophy, Self-deception |

David J. Balan, on Overcoming Bias, writes about the difficulty of responding honestly when people say, “Give it to me straight.” Generally, it’s such a bad idea that the Cajuns in my neighborhood have a story to illustrate:

Boudreaux was a widower whose most valued possession was his cat, Felix. Boudreaux won a trip to Europe, and he asked his friend Thibodeaux to look after the cat in his absence. “Thib,” he said, “I’ll call you from England to check on Felix.” Three days into the trip, Boudreaux indeed called Thibodeaux and asked, “How’s my cat doin’?” Thibodeaux replied, “Mai, Boudreaux, your cat died.” Boudreaux was beside himself, first with grief, then with anger. “Thib,” he wailed, “You don’t just tell somebody flat out that their cat died. You got no sensitivity. You should ease into it. Like, you should say, ‘Boudreaux, your cat’s on the roof, but I’m pretty sure we can get him down.’ Then when I call the next day, you say, ‘We got your cat down, but he caught pneumonia. The vet’s pretty sure he’ll be OK.’ Then on the next call, you say, ‘The cat took a turn for the worse, but the vet’s giving him some powerful medicine.’ Then the next day, you finally say,’Boudreaux, we did all we could, but your cat passed on.’ That’s the way you handle bad news like this.”

Thibodeaux expressed his remorse for his insensitivity and vowed to be more thoughtful. Two days later, Boudreaux called again. “Thib, how’s my mother?” Thibodeaux replied in his kindest voice, “Boudreaux, your mother’s on the roof.” (more…)

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Medicine as a guild

Posted on September 18, 2008. Filed under: Everything you wanted to know about doctors |

Only recently, with the reflection time provided by the onset of disability retirement, and with the prodding of Robin Hanson’s posts on Overcoming Bias, I realized that the practice of medicine is not a science. It’s closer to a “guild”.

The art of medicine is a well-known cliche, apparently referring to the use of one’s “clinical judgment”. Such judgment, to a great degree, is anecdotal, based both on individual experiences and that of our mentors. These mentors, or their peers, hold the power to determine the student’s eligibility for guild membership, and as one would expect, their customs and belief systems are parroted back to them. Yet our medical dean told us as freshmen: “In order of increasing unreliability, there are lies, damn lies, statistics, and anecdotes.” The practice of medicine involves a lot of science, but at best, it’s a hybrid. Its guild characteristics are undeniable (it’s my blog: with possession comes privilege), with exclusive selection requirements, rights of membership, and extensive turf-protection mechanisms. I touched on this in the maiden post for this blog. (more…)

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The sooner the better?

Posted on September 16, 2008. Filed under: Sexual issues |

When does a normal function become a medical disorder? When it’s premature ejaculation. There are a myriad of things one could discuss about this phenomenon, most of them controversial, and frequently gender-biased. Just the definition is confusing. Premature? For who? 

The mammalian activity of relatively rapid ejaculation (within one to several thrusts) when mating had been selected for its advantage long before Homo sapiens arrived on the scene. There are a number of imaginable reasons that success went to the quick; among them: not getting killed while having sex. While it is said that all men pay for it one way or another, that price is too high. To my mind, I see no reason to imagine that early hunter-gatherer humans had long bouts of lovemaking, just as modern non-human primates do not, as a rule. I have commented earlier about the lack of evidence for a reproductive role of the female orgasm, and I doubt that Alley Oop brought flowers and practiced foreplay. Actually, I doubt he asked permission. I feel certain that the desire of males to increase ejaculatory latency voluntarily is a relatively recent development, and a social one, that goes against genetic tendencies. In other words, the condition we now call “premature ejaculation” is biologically normal. But this is one area in which almost every man I know prefers to be “abnormal”. At least since Casanova, men have recognized that this is a race in which they are better off not to finish first.

I have some thoughts about this, as you may have anticipated. Consider this: (more…)

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Penile undermarketing

Posted on September 6, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Sexual issues |

Alert blog-reader Moshe has asked the question: “If these penile implants you’ve talked about are so wonderful, how come I haven’t heard much about them?” You know, Moshe, I’ve been asking that same question since 1975, when I scrubbed in for my first inflatable penile prosthesis (IPP) operation. The result was so impressive that the female scrub nurse (unmarried) remarked, “Can you get me a list of men who have these things?” She wasn’t referring to size; the finished product was no bigger than the original. What she saw was control: comes up when you want it to (no matter how drunk the guy, nor how ugly the girl), stays up ’til everybody’s happy (or at least finished). The most urgently anxious patient I ever had was a widower in his 70’s who had just married a similar-aged widow. “Doc,” he begged, “I just got to get me one of those transplants (sic) right away: I just found out her late husband had one!” Ah yes, tough competition there. (more…)

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Rise and shine!

Posted on September 5, 2008. Filed under: Medical marketing, Sexual issues |

MIT computer scientist Dr. Scott Aaronson, in a post at Overcoming Bias, asked: Why do we, as a society, provide food stamps for the hungry but not sex stamps for the celibate?

Exhibiting a version of Godwin’s Law, the reader comments eventually deteriorated into a discussion of rape. Two anonymous commenters, the first an (I would guess) outraged feminist calling herself “Noir”, and the second a male chauvinist pig (as they were called in my day) using the clever nom de plume of “Anon”, argued over the plausibility of female-on-male rape. Anon’s eloquent pronouncement was: A woman forcing a man into sex is nigh-on physically impossible. She could of course violate him in various ways, but these mostly don’t even resemble sex. Retired urologist happened to be passing, and his shock at such ignorant effrontery caused him to wade in with the last comment in the thread. Alas, he was casting pearls before swine, as the readers showed no interest in his erudite remarks. Hence, the necessity for this fascinating post.   (more…)

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You’re going to stick what into my what?!!

Posted on September 3, 2008. Filed under: Sexual issues |

In this post, I promised to give it to you “straight” about some treatment options for ED, and the inside (a little more ED humor there) info that goes along. Yesterday, we talked about the pills your ol’ pappy wished he’d had when his “best friend, Mr. Happy” died before he did. Today, we’ll feature the self-administration of  intra-penile injections for the purpose of showing “condition wood”. The operative word is “showing”, as this account of the legendary first public demonstration of the ability of injected vasoactive drugs to produce erections recalls: “The introduction of the penile prosthesis paled in comparison to British physiologist Giles Brindley’s dramatic demonstration at the 1983 Annual Meeting of the AUA. Brindley closed his lecture by dropping his pants to reveal a perfectly erect phenoxybenzamine-induced erection.”   Now that’s science! Medical conventions are just not what they used to be (nor is ol’ Giles).  (more…)

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.

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