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Perhaps We Don’t Know Crap…
Rudolf Virchow is one of my few heroes. He was born in what is now Poland in 1821, and died 80 years later after a remarkable career in medicine (which he chose, because he viewed his voice as too weak to be a pastor). He was the first to describe such diseases as leukemia, embolism, spina bifida, and many others. He was one of the few academics of his era who was openly critical of Charles Darwin and the resulting eugenics, describing Darwin as an “ignoramus.” Lacking modern scientific techniques of electrophoresis and isoelectric focusing, he pioneered modern techniques of autopsy. He is widely credited with making the science of medicine less wizardly and more scientific. He was always a step ahead of his colleagues, regardless of the consequences of his outspoken criticisms of his contemporaries. He was widely criticized in his day, although many of his theories have proven to be more valid as we learn more about biochemistry, genetics, and so on.
In 1856 Dr. Virchow said, “Inflammation is the cause of atherosclerosis”. How he figured this out with the tools he had available, I’m not sure. But there is significant evidence available today that suggests that he might be right. The “pleotrophic benefits” of statins refer to their ability to reduce risk of heart attack even in those in whom they don’t change their cholesterol numbers. Statins are potent anti-inflammatories. Is that how they work? Maybe. Maybe Dr. Virchow had a point. We’re still not sure. So now, after more than 150 years, we have a name for his description of atherosclerotic disease, if not an understanding.
There are a few hundred different coronaviruses out there. Why is COVID-19 so deadly? I’m not sure. Why is the delta variant so problematic? I’m not sure. How did Virchow figure out what inflammation is? I’m not sure. But I know this: We don’t know crap. About crap. And I’ve decided that Dr. Virchow knew a lot of crap. About crap. Perhaps I could teach him a few things, given my understanding of modern science. Or perhaps I couldn’t. Perhaps I should temper my modern arrogance. Or perhaps I shouldn’t. I’m not sure.
Why do some of my patients die of pneumonia, while others get a sinus infection? I’m not sure. Why do some people have a stroke with a BP of 135/84, while others smoke cigarettes and die of old age at 102? I’m not sure. Why did my mother die young of some random cancer while complete losers live to be 100 despite years of self-abuse? I’m not sure.
Although I’m not sure it matters. I went into medicine hoping to understand all this stuff. And the better I get at my job, the more it’s clear that I don’t know crap about crap. So I read more Virchow. And I drink bourbon.
It helps. I guess. Although I suspect Dr. Virchow is chuckling somewhere. I suppose. I’m not sure.
Dr. Virchow said, “Medicine is a social science, and politics is nothing else but medicine on a large scale.” I have often wondered why leftists try so hard to gain governmental control of medicine. Perhaps Virchow understood. Perhaps he understood a lot. I’m not sure.
The more I study any field, the more it becomes obvious that I don’t understand. The less I know about any field, the more arrogant I become in my conclusions about that field. This seems odd to me. Although not, perhaps, to Dr. Virchow.
I have my own opinions about masks, vaccines, statins, ACE inhibitors, aspirin, infectious disease, leukemias, organ transplants, auto-immune diseases, bipolar disease, atherosclerotic disease, aneurysms, valvular disease, chronic sinusitis, and so on and so forth. And I’m sure I’m right. I presume that doctors 200 years from now will be referring to me as an accepted source, even long after I’m gone.
But perhaps they won’t.
Perhaps I lack the insight of a primitive doctor born well before my time. Or perhaps not. I’m not sure.
I am forced to decide. On each patient that walks into my office. I do the very best I can. And surely I’m right.
Right?
As we’re faced with difficult decisions, perhaps we would be well-advised to maintain a certain degree of humility. A degree of humility that does not come naturally to people in general. And not to politicians. And certainly not to doctors, specifically.
We do the best we can. And we hope that others do the best they can. And we hope that we all learn from the process.
Arrogance is not necessarily wrong. But lack of humility is wrong. Or, at least, it is dangerous.
Dr. Virchow understood this. He viewed strong centralized power structures as inherently dangerous: “Medicine is a social science, and politics is nothing else but medicine on a large scale.”
We do the best we can. But we must remain perpetually vigilant to the limits of our own hubris.
Politicians, and doctors, and humans in general – we struggle with such things.
But we keep trying. Those who came before us lacked our perspective, and our virtue. So we know better, right?
Right.
Unless we don’t know crap. About crap.
That is a possibility which we ought to consider.
Perhaps limited government makes sense. Perhaps we should seek to reduce the impact of harmful thinking by reducing the power of our government to enforce compliance to current theories. Whatever they are. Perhaps it is the amplification of bad ideas that is more dangerous than the bad ideas themselves. Perhaps we should worship modesty more than arrogance. Perhaps we should respect the ideas of others as much as we respect ourselves. Perhaps we should remember that we may not be as smart as we think we are.
Just perhaps…
Published in General
Could you please explain your beef with Darwin. The racism that came from his later fans was obviously horrific. But I have never heard of any decent refutation of his claims.
That’s a big topic that I’ve been avoiding.
I refute his claims, in many ways. I apologize for not listing my views here.
I’ll do so soon. But summarize to say, I think that many of Darwin’s hypotheses have been proven wrong over the years.
I’ll get to this soon. Sorry about that…
The older I get, the more I learn, the less I know…
I tried to make a similar point a couple of days ago (here, comment #2), but, as usual, you are much more clear, concise, and eloquent. There is a great deal of opining on topics where people show complete certainty with no actual training in the field in which they opine. With all of my years of education and experience, I can always point to someone–often many people–who know more than I do, even in my areas of expertise. The only place I claim absolute authority is in recipes I made up myself (pretty small beer, as the saying goes). Outside of that…
As someone whose BP is officially 136/86 (just mailed the supporting info to the FAA this afternoon and I sure hope they let me have at least a 3rd-class medical certificate), I’d like to know some crap myself!
I was going to respond to another physician’s post but I think here is a better place. That post got me thinking about meta-analyses, stopping points, and statistical meditations in general, but thanks to this post, I’ve formed a firmer idea: guys like Dr. Virchow didn’t suffer from statistics. The field barely existed during his career, although it certainly got started. Glossing over the arithmetic, I did think and perhaps Dr. Virchow would have thought that if you have test or control groups where there are zero incidences of some misfortune, there’s no information to process. And where these groups have tiny incidences, you still can’t say anything decisive. In a medical setting; a legal setting is another matter. In a medical setting, you’ve got to go back to your…microscope, which may have been all Virchow had. And study crap closer!
Doc didn’t say he had a beef with Darwin. He said Virchow did.
Another fine post.
Oh, so it was his fault.
Can we go back to wizardry now?
You’re not sure which, but you made your choice, and I think it was the right one.
Try philosophy. We can make whole careers out of admitting that we don’t know.
Good point. But I have lots of beefs with Darwin. I’ll go over that at another time…
I done said this crap one time.
Maybe someday I’ll say more.
So much here.
We are living in an epistemological nightmare.
Any true scientist must first stipulate that he has no way of actually knowing anything. It is only findings, indications, pointers . We are never there. We are feeling our way through a black labyrinth with with a few sacred books as guides. No light, sound, maybe a fragrance, other vague and disputable hints.
Sometimes very wrong. But thanks to the scientific method, they are proven wrong eventually, but can do damage for decades.
We always think we know and we don’t.
This quote comes to mind:
Jiddu Krishnamurti And when researching this , same guy
I don’t think that we will agree. But that’s OK. G-d through no merit of our own has made us Americans so we can disagree and not fight.
Indeed.
This made me smile because it reminded me of Mr. She’s remarking that he believed the history of medicine could largely be boiled down to a series of very bright men who studied disease and, one at a time, figured out how to move the causes of each from the column headed “Evil Spirits” over into the column headed “Bugs.”
Yes, we do have good arguments. :-)
And . . . back to the “Evil Spirits” column.
Specialists see things in eccentric ways. I thought everyone knew politics is a requirements analysis problem.
The idea I get from the Tower of Babel story is that God separates the nations to protect them. If one nation makes foul choices, the other nations are protected from the consequences.
Its an argument for freedom, that allowing each person to make their own choice, it is supposed to insulate others from those choices.
Effectively, if I’m going to suffer for any negative consequences of a decision, I should be in charge of that decision – not someone else.
There’s limits here, but certainly, at national vs global level, the evidence should be clear – forcing all people the world over to engage in the same exact thing makes all of us susceptible to the same negative consequences.
That’s funny. This is what Linus Pauling said, too.
I’ve been thinking about this and I believe that “knowing” and “science” is definitionally misunderstood. People try to fit it into a “rational” binary conceptual framework (either absolutely true or absolutely false) when it is actually analog. Every child is born with the innate drive to inductively form patterns and to simultaneously deductively make decisions so as to alter the future. (This explains how toddlers can come to rule their parents.) And to deny children the experiences that they are hard-wired to use to form inductive “knowledge” causes them to die, literally.
Knowing is an 80% truth that is true nearly 100% of the time. Two things added to two other things always produces a count of four. We call this pattern a tautology, but it is not. It is inductively derived pattern that always leads to a deducible result. And any child can do it. This is human knowledge.
No. People are superstitious and not logical.
That’s an intriguing statement, but it seems to need context. Did Dr. Virchow provide any examples?
Seems like a variation on “medicine is as much art as science.”
The elaboration is the post. You can think you know what causes something and then be stymied when, in a great many cases, things turn out just fine even in the presence of confounding factors. Redux: smoking kills. Except for when it doesn’t.
There’s so many minute variables that we haven’t even begun to understand in this huge, complex system that rivals the known universe and is known as the human body. And where dozens of tiny variables exist, there’s chaos to the eye that has not learned to see those variables or how their tiny effects ripple through the system. Like currents shaping the patterns of our skin in our mother’s womb, leaving us with complex patterning that can’t be replicated in any human being, not even your identical twin.
Social science suffers from the same complexity which makes it really hard to pinpoint triggers. These events turned this person into a psychopath, but that person is perfectly fine even with similar events. There are unseen factors, interactions, currents that are poorly understood that confound all attempts to explanation and perfect predictability.
In a nutshell, it is chaos theory to our imperfect eye.
But don’t worry about climate science. We totally know how to predict what will happen over 20 years of interaction between trillions of gas molecules in constant motion with trillions of unmeasured water molecules in constant motion. Extinction-level warming, that’s what!
Engineers like me often compute solutions to our problems to three or four significant digits. A building’s floor strength might work out to 127.2 pounds per square foot. And we know enough about structures and strengths of materials and rebar performance and numerous other confounding factors that the floor almost certainly will hold 127 pounds per square foot.
But any sane engineer is going to declare that floor will hold 100, not 127.2. Or maybe only 75. Because “almost certainly” is not the same as “certainly”. “Engineering margin” exists to deal with the unknown unknowns. Medicine is not the only field with angst over the unknown. (One of the reasons I chose to not be a Civil engineer.)
Socrates discusses this in the Apology. He went to different kinds of people “reputed to be wise”, like poets and craftsmen, and discovered that they did know many things, but also suffered from thinking they knew things that they actually didn’t. Socrates thought he was in the better position of not knowing the things they did, but also free of the deception that he knew many things he actually didn’t.
It’s easy to get puffed up with a little bit of knowledge and start thinking of yourself as a generally smart guy whose opinions are inherently reliable. Knowledge of a particular science, for instance, doesn’t protect one from spouting uninformed opinions on matters unrelated to that science, but it seems to be a temptation hard to resist.
I’m always troubled by the logic of these statements. If someone stipulates that they have no way of actually knowing anything, then one thing they can’t know is whether they can’t know anything. Maybe this is why it is “stipulated” rather than stated as a matter of fact. But if we don’t know it as a matter of fact, then why stipulate it? To channel G.K. Chesterton, starting with the principle that I can’t know anything isn’t a spur to move me forward, but a nail pinning me to the spot I am in.
Returning to Socrates again, I understand the claim that I know nothing as of now, but whether I might know something in the future, or that there might be someone out there who knows how to know, are things I can’t deny on pain on self-contradiction.
And winning a well-deserved Nobel prize for discoveries in the field of infectious disease doesn’t keep one from being a crackpot on other infectious disease issues.
Well done, @drbastiat – an excellent piece of of writing. The opening two paragraphs by themselves are worthy of being promoted to the Main Feed.
Ungh. Are you agreeing with me or agreeing against me? :)
Knowledge is like a clock with a minute hand: I never know exactly what time it is, but I can be darned close, to the fifth of a minute, but the reading is never really exactly correct. Then they went to the digital clock and I can now tell time to the second. But nobody’s clock is set to the precise time so we think we can know the time with more accurately when we really don’t. We look to the precision of the clock rather than the accuracy of the time it tells.
I think thinking is like that: analog thinking is pretty darn close. But with the digital (absolute and precise) use of the laws of logic, we can can be much more precise, but then we think the increased precision of our thinking makes the result more accurate. We rely on the precision of the logic rather than the accuracy of our presuppositions and the scope of our facts.
I find it strange sort of. The older I get the more I realize how little I know and, based on my limited knowledge, how much I don’t understand things. And the strange part is that I find some comfort at looking at things and saying “hmmm, well, that’s beyond my understanding”.
Someone once told me that all certainty falls in the face of one question: “why?”. Take anything that you know for sure to be true and ask “why is this true?”. If you do service to the question you’ll soon realize understanding why something is true is every bit as complicated as arriving at the fact in the first place. I guess as I get older I’m more inclined now to accept something as being “just so” without understanding “why is it just so?”.