Super Jewish Historical Prediction Game: Female Modern Orthodox Clergy Edition

I. circa 1980

Cathy Conservative: Women can be rabbis!
Joe Modern Orthodox: Pshaw!

II. 2009

Joe Modern Orthodox: Women can...umm...kinda be rabbis!

III. 2025

Joe M.O.: ___________ (fill in the blank)

Evidence based medicine: pragmatic, objective, or authoritarian?

In the spring issue of Perspectives in Biology and Medicine, Maya Goldenberg dissects the contradictions of evidence-based medicine (EBM). (I found the article through philpapers.org, which I didn't know about before.) On the one hand, EBM's commitments to pragmatism

are readily apparent in EBM’s clear allegiance to experimental methods of inquiry that set aside past habitual thinking in favor of purely empirical investigation. Indeed, EBM’s promise of “the application of the best research evidence to medical decision-making” (EBMWG 1992) could have been achieved by strictly pragmatic scientific methodology.

On the other hand, EBM lays claim to the marble statuary of objectivism, which is problematic.

[The] objectivist ontology,where the evidence “speaks” and reliable knowledge follows, presents an occupational hazard to (actual) medical practice. Subjective content muddies up even the most rigorous evidence-based practice by the inescapable layers of interpretation and sociocultural influence that enter in the setting of research agendas (including what projects get funded and why), the production of evidence in primary research, and the selection of which evidence is chosen to inform policy and practice.

But EBM's hierarchy of evidence, with the randomized controlled trial (RCT) at the top, rests on shaky grounds itself:

From a pragmatist perspective, the problem is not so much that the gold standard status is tenuous, but that the RCT’s placement of at the top of the hierarchy is so insistently maintained. It is largely in the interest of avoiding dogmatic theoretical commitments that pragmatists endorse a bottom-up approach to theory construction, where localized beliefs must pass the test of experience in order to be elevated to generalizable knowledge claims.There are numerous experimental scenarios in health research where the RCT would not be the methodology of choice,which suggests that the hierarchy of evidence would not pass the rigors of the bottom-up approach to theory building.

EBM's certainty in its own objectivism leads to a blindness: "[t]he hierarchy of evidence is the point at which evidence-based methodology can be charged with authoritarianism." There are some juicy accusations in this article, which I didn't know before, about the financial relationship between EBM "producers" and the editorial boards of certain journals, e.g., BMJ.

However, in her conclusions, Goldenberg is fittingly pragmatic:

In the interest of better science, I propose that EBM’s pragmatic features are worth keeping. By this, I mean that the open-ended critical inquiry should be encouraged, as should comparative clinical research and problem-specific methodology (which may include uncontrolled methods and even reliance on clinical judgment).The rigid hierarchy of evidence, as we have seen, leads to considerable problems for EBM and should be dismantled.The EBM critics,writing from the post-positivist philosophy of science tradition, have amply demonstrated these problems. But the constructive project of revisioning or perhaps recasting the evidence-based approach to medicine requires that the worthwhile aspects of EBM not be discarded along with its flawed features.

Chasidic Yiddish blogger Katle Kanye on the swine flu

Original here. Translation mine.

The truth is that we Chasidim haven't been so impressed by the swine flu from the beginning. Yes, it's gotten to South America, Europe, and even Israel. But that sort of thing usually doesn't interest a Chasid too much, and a "God have mercy"or a "it shouldn't happen to us!" can take care of it. So folks in New York have gotten it too? I assume you're familiar with the verse "and all the children of Israel had light in their dwellings"! And which cheder pupil doesn't know about the plague of blood when the Egyptians bought water from the Jews - so what's the difference here? ...They said about AIDS that it would eat up the whole world, but like the lice in Egypt it stopped at the Chasidic zip codes. Just like the miracle of the shemittah farmers who clearly see their blessings compared to their neighbors, all the maladies I visited upon Egypt are not seen or found among those who are meticulous in their observance of commandments both major and minor. So much the more so in this case because we don't eat the flesh of pigs - their hoof is cloven but the cud they do not chew - and we're in the month of Iyar, which stands for I, God, am your healer.

The catastrophe is though that - whether it's really true or they're just saying it - two yeshiva students from Mir got it. Oh my teachers and rabbis, death has risen to our windows, come to our palaces and the Angel of Death is attracted to white shirts and black hats too. Now it's a tragedy. I know the experts say that it's easier to get infected on the train than it is from a Chasid's achoo on the other side of the Mediterranean, but what do the experts know? They say the world's getting warm but the kutchme sellers aren't yelling for a bailout. When Chasidic young men get it it's a whole other story. It's our concern now, so we need to get in touch with the Chasidic doctors and move mountains.

Nevertheless, as they say, in all labor there is profit, or as the goyim say, every cloud has a silver lining. A truly God-fearing Jew feels a spiritual satisfaction, a feeling that we're not left out, we're on the guest list too. Leave it to the Jews: if there's something to pick up in the world you can bet that we won't be left behind. We might look different but there's nothing we don't have. We'll get there. We won't just get there, we'll make the whole business our own by giving it a name. Make a mishebeirach, change pig to Mexico, and confuse the devil just like we do on the eve of Rosh Hashanah... from a swine's flu you can make a silk purse, or a shtreimel.

What are we to learn at the bedside? A re-examination of Verghese's essay "Culture Shock"

Abraham Verghese's essay "Culture Shock" (pdf) made a lasting impression when I came upon it last night during a quiet period at work. He writes beautifully about the real patient, with all his spots and signs - as opposed to what Verghese calls the "iPatient," the simulacrum found inside the electronic medical record but nowhere else.

I do realize that we residents, no matter where we train, hone our skills on the iPatient's indices ("The iPatient's blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed") while getting ever farther away from the bedside physical exam done on the real patient. This article makes as powerful a case as any I've read for the re-centering and re-honing of my skills, and it comes at just the right time, when I have the chance to make a transition to be the kind of doctor I want to be. 

But Verghese is confused in his defense of the physical exam - he doesn't know what rationale he wants to focus on, or how he feels about physical diagnosis as justified (or questioned) by evidence-based medicine. Here he is in one place:

If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.

This is the argument from efficiency, or maybe from diagnostic rigor - exceeded somewhat by Verghese's clear affection for the physical exam as a pedagogic and maybe, even, an esthetic, cultural, and moral tool. But it's not clear whether Verghese believes that the physical exam does improve diagnosis or efficiency. Just paragraphs later, Verghese takes another turn:

Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a larg pleural effusion is worthwhile in and of itself.

The physical exam's actual use in diagnosis is again feinted toward, but without making a real case one way or the other ("we need continued study in this area," the academic physician's classic copout that I know I use at the end of every article I write).

Near the end of the essay, and most confusingly, Verghese takes yet another tack when describing with understandable pride the teaching of the bedside physical exam he coordinates with his chief residents:

We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart.

But this comparison is double-edged. If a finding on the physical exam is like a biomarker, then it is like any other diagnostic test, which can be ignored, re-interpreted, or even not tested at all based on the prior probabilities the physician approaches the patient with. Perhaps - given the patient - I might prefer the information given by X-ray to my own physical exam. Or maybe, given the vagaries of varying echocardiography reads, I might privilege my own cardiac exam.

This is why I find Verghese's essay, though moving and personally challenging to my own too-ingrained love of EHRs, to be ultimately unsatisfying. If medicine is a culture, it changes. If the physical exam is to be a practical part of the diagnostic art, and not a relic, it too must change. Let's find out which parts of the diagnostic exam work, and why. We know that no physician does the "head-to-toe exam" for more than a fraction of his or her patients, so which parts should be done when? When is it useful to look for Roth's spots as a diagnostic adjunct rather than as a fascinating bedside pedagogical tool of limited clinical import? (Probably rarely.) Given our limited time with patients, should we not build rapport and understanding by asking more detailed histories at the bedside, rather than indulging in percussion of parts which have no diagnosis to yield up? 

I take Verghese's wisdom and his eloquence but I look for rigor elsewhere, trying to spend my time with the patient in ways that build our therapeutic relationship and find a true diagnosis efficiently.

Activism and Jewish Science

The folks at 36 Under 36 are an accomplished bunch, but The Jewish Week is laboring within a limited definition of Jewish activism: viz., stuff which yields a creative product or institution immediately appreciable by the Jewish lay public. But (with the exceptions of Ethan Tucker and Adam Kirsch) what this definition leaves out is the intellectual effort of Jewish academia, which never got anyone to make aliyah or become a mikvah habitué but - for all that - is of value. I wonder if the assumption might be that activists Act, while pure intellectuals don't. But that would be wrong.

Swine flu on one trotter

1. Even now no one knows how bad it could get. Or even (given that we don't know the real denominator of all cases) whether it's worse than regular old seasonal flu at all.

2. The limits of genetics: you can download sequences of many varieties of influenza A H1N1, but that tells you nothing about transmission and an unknown amount about virulence.

3. A prime example here of how people think of risks: the flu crisis is immediate and scary and thus available to them in a way that less immediate risks are not (car accidents, malaria).