Awakenings

I have taken a break over the past months while doing some more formal writing and (partially) recovering from illness. I ended up missing a whole lot of deadlines. The picture of Sisyphus sleeping is reproduced with kind permission of artist Michael Bergt.

I also spent some time thinking about the way we discuss malfunctioning systems in medicine.

During my break, I received some interesting documents about various cases I have been exploring. I received two amazing documents about UK medical regulators. These tell a story of corrupt organizations that are more interested in a surreal brand of public relations and self-protection than in any form of honesty. I received a few documents about myself.

Some of these documents made me angry. I have been wondering whether there is a type of discussion that is not legitimate. The internet is a scary place. Is it reasonable to embarrass individuals in positions of authority when those individuals have not (by any reasonable standards) behaved appropriately? I have generally tried to avoid embarrassing individuals, even though I have had ample reason and opportunity to do so.

Some of the documents I have are about other scandals that have already been ignored for many years. In many of these cases, both perpetrators and accusers have already suffered greatly. These are not individuals who are now in positions of any great authority.

The Bruce Hall affair

One such case is that involving Professor Bruce Hall in Australia. The scandal involving Hall resulted in the destruction of several careers. It has never been properly and openly addressed or discussed. The lessons have not been learned. Almost two years ago, I attempted to find out what happened. I began communicating with three very angry complainants, a journalist, several onlookers and Professor Hall himself. My questioning precipitated a trail of events which conveyed more about what might have happened than was conveyed by any of the conflicting reports. I was left with an immense feeling of sadness, not only for the students and staff who had raised problems, but also for Professor Hall himself.

Those students and staff wanted accountability, honesty and transparency. There was nothing that suggested to me that this was the intent of any of those in charge. Professor Hall was tired and apparently ill. He wanted to get on with doing good science. The real villains, it seemed to me, were not Hall or his wife, but rather the University of New South Wales and two medical journals who had behaved abominably. I ended up not discussing it at the time.

A document about myself

I also received a document about myself. This was an item of correspondence between two rather powerful individuals. It seems that my own refusal to go along quietly with attempts to manipulate the scientific method and the scientific record might imply that I am mentally ill. This kind of assertion is unfortunately a regular feature in many similar scandals. The person who wrote that letter should have known better. He failed to ask any of the obvious questions. He failed to stand up for what was right. He was someone I respected as a scientist. Indeed, he was someone who respected me (until I started asking the wrong type of question about the activities of his friends). I found this letter far more depressing than any of the futile and damning attempts by various authorities to cover-up what happened.

Is it worth discussing these things?

I think it probably is.

But it is hard to find a voice that conveys an attempt to learn (and teach) about malfunctioning systems - without also appearing to have a vindictive wish to inflict damage.

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My fortune cookie

I just returned from a great sociology/philosophy meeting near Paris. My fortune cookie at dinner had this rather nice message:

and in French


See previous posts on decorum in science here:

1. On decorum in medicine
2. On swearing versus thuggery

"What I lack in decorum, I make up for with an absence of tact."
- Don Williams, Jr. (American Novelist and Poet, b.1968)

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On swearing versus thuggery: a statistical analysis

A few bloggers commented on the (referenced) use of a bad word (F***) in my previous post (1, 2), and a few more commented below the post itself. I received a large number of comments by E-mail. The post was about suppression of data from Zetia or ezetimibe clinical trials, and the harm to both science and patients that results from such actions. I hypothesized that I would get some very negative responses to the linguistics, but that was not the case (n=13, all either positive or neutral). Sadly, for purposes of this discussion, it was therefore not possible to disprove the null hypothesis of no-offence.

I thought I would use this to discuss two rather different topics of relevance to medicine in general.

1. The statistical relevance of non-occurrence of an event
2. The problem of decorum versus thuggery

The statistical relevance of non-occurrence of an event

In this case there were no negative responses amongst 13 events. This problem has general relevance in medicine. Commonly, in clinical studies there are no observed events in a large number of patients. Forgetting for the moment that study patients might not reflect real-world patients, and that results of studies are often manipulated, it is interesting to examine the statistical meaning of non-occurrence. For example, if there are no deaths following liver biopsy in 200 consecutive patients in a particular hospital, how confident can we be about the mortality rate? If no patients (of 13) die in a Phase I study of an experimental drug, what does this mean? If the public relations officer of a bisphosphonate manufacturer claims that there were no cases of Osteonecrosis of the Jaw (ONJ) in formal clinical trials (n=3000) what are the confidence limits for the rate of ONJ within the population (assuming no-cheating, proper followup, and real-world similarity of trial patients)?

If the true rate of occurrence of an event in the population is R, then the probability P of non-occurrence in n consecutive patients is:

P = (1 - R)ⁿ

We can solve this for n as follows:

n = (log P)/log(1 - R)

This enables calculation of the number of consecutive non-occurrences needed to infer a low rate of occurrence R at a chosen P value. To the naive, the resulting numbers may seem surprising. If there are no deaths in 13 patients in a Phase I trial, then all we can say is that the likely death rate is less than 20% (at P=0.05). To infer a death rate in our Phase I study of not more than 1% we need to observe 299 cases with no death. I wonder whether patients in Phase II trials are provided with such information, either numerically or in spirit?

On the problem of decorum and swearing

I was interested in some of the responses I received. In the words of David Kern:

When you're in an argument with a thug, there are things much more important than civility. I do not like incivility. Yet, I like thugs even less.

My feeling is that our profession cares a great deal more about decorum and a sort of "pseudo-politeness" than we do about actions that are truly immoral, anti-science, and damaging to patients. Patients seem to care rather more about scientific honesty than we imagine. I have written previously of the quotation by the Irish priest Steve Gilhooley about the relation between decorum and thuggery. The quotation was delivered as part of a sermon on El Salvador. Gilhooley spoke passionately from the pulpit:

"I said to them, '70,000 people have been butchered and none of you gave a shit.'"

There was silence. A priest had sworn in the pulpit.

"And the reason I know none of you gave a shit," he continued, "was because none of you fell off your seat when I said '70,000 had been butchered', but nearly all of you fell off your seats when I said 'shit'."

Much of Gilhooley's feelings about the church would apply to the current sad state of medicine. Says Gilhooley [of the church]

"There are those who would rather hide the truth. Those whose priorities have become so skewed that they would protect [sexually] abusive priests before they would protect those who fight for justice and transparency. These are the people who are really in control in the Church. Well, let them get on with it. Let them bury it in the ground, and then we'll all start something else."

The offense caused by words depends on the priority we ascribe to various things. According to the "Hitchhiker's Guide to the Galaxy," the most offensive word in the universe is "Belgium." A journalist in the Melbourne Sunday Age (29.6.2003) provided an eloquent example of the significance of words following Greg Rusedski's Wimbledon soliloquy during his tennis match with Andy Roddick:

"As this is a family paper, both major and minor obscenities have been replaced by the names of birds. The result should be informative and educational."

"I can't do anything if the crowd albatross calls it. Absolutely vulture ridiculous. At least replay the point. Robin ridiculous, falcon ridiculous, budgie ridiculous. Some lesser-crested grebe in the crowd changes the whole match and you allow it to happen. Well done, well done, well done. Absolutely muttonbird..."

Here are some varied educational links:

1. Stupendous BBC/Advertising Standards Authority report on swearing - an impact analysis listing all the bad words (complete with graphs and statistical analysis)
2. Great piece on the evolution of swearing by a Geoffrey Nunberg (a linguist at UC Berkeley)
3. Why we curse. What the F***? by Steven Pinker, Harvard (fantastic, a must read).
4. Clin Psych blog on the Pinker article
5. How stuff works: Swearing
6. Swearing in other languages
7. West Side woman faces jail time for swearing at toilet: Pennsylvania Times-Tribune. Dawn Herb was facing jail for swearing at her overflowing toilet in her own home. She was overheard by an off duty police officer who heard her yell: "Are you f***ing retarded? Get me the f***ing mop." Patrolman Gilman said he then yelled, "Watch your mouth", to which the person replied: "F*** off.". She was later acquitted.
8. College Teacher fired for saying F___ in class: Inside Higher Education
9. Devil's Kitchen: On swearblogging (an excellent, intelligent UK political blog which includes a great deal of swearing).
10. Ben Goldacre: Sweary Mary

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