“The fall of a prominent behavioral scientist tells of a system where research is judged not on merit, but on the attention it gets.”
“…remember that science is about asking questions, not pursuing answers.”
-James Hamblin, MD
The Atlantic: A Credibility Crisis in Food Science
“Earthlings is a 2005 American documentary film about humankind’s total dependence on animals for economic purposes. Presented in five chapters (pets, food, clothing, entertainment and scientific research) the film is narrated by Joaquin Phoenix, featuring music by Moby, and was written, produced and directed by Shaun Monson.”
How Not to Die describes the numerous health benefits of eating a plant-based diet. After reading through half the book, I watched Earthlings to see arguments from the animal rights activists for eliminating animal products from the dinner table. Personal health has always been my primary interest for minimizing meat consumption. But the message in this documentary is just as difficult to ignore as it is to watch.
There are some valid counter arguments to abandoning meat, which are listed in this reddit thread. The most compelling was that from an Indian man who argues he will not stop eating meat nor stop providing it for his family because he has genuine concern that his children my not survive due to malnutrition. Perhaps citizens of the more developed nations are the primary audience for this documentary.
I have watched a handful of anti-meat documentaries, and often they appeal to emotions such as shame, guilt, or anger. Earthlings takes a more objective role, showing film of industrial animal manufacturing in the United States. It was refreshing to be treated as a neutral observer, instead of being reprimanded. There are definite appeals to emotion, but the dialogue in the documentary is more calm than any I’ve seen before.
Earthlings has made me reconsider my current relationship with meat and animal products. I imagine I have grown up with more livestock experience than many of my neighbors. I learned from my family to slaughter fish, chickens, turkeys, and rabbits for food. I attempted a pescatarian diet for several years in my twenties, but only for personal health reasons. This is the most cognizant I have been of my indirect participation in the massive consumption of animals, and what that actually means.
Three Stages of Truth
- Violent Opposition
Attributed to German Philosopher Arthur Schopenhauer (1788–1860)
- Nation Earth: Earthlings 10th Anniverary Edition
- Michael Greger, MD: How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease
- Reddit: People who didn’t after watching ‘Earthlings’ – why not?
- Reddit: Indian man’s comment
- University of Waterloo: Science, Pseudoscience, and The Three Stages of Truth by Jeffrey Shallit
“As much as 30% of the entire world’s stored data is generated in the health care industry. A single patient typically generates close to 80 megabytes each year in imaging and electronic medical record (EMR) data. This trove of data has obvious clinical, financial, and operational value for the health care industry, and the new value pathways that such data could enable have been estimated by McKinsey to be worth more than $300 billion annually in reduced costs alone…Read More”
NEJM Catalyst: Using It or Losing It? The Case for Data Scientists Inside Health Care by Marco D. Huesch, MBBS, PhD & Timothy J. Mosher, MD
Cigarettes contain many chemicals that increase the risk of cancer. Polycyclic hydrocarbons and tobacco-specific N-nitrosamines are some of the more well-known carcinogens in this class.
But now, e-cigarettes appear to be isolating nicotine, and leaving behind many of the old toxins from cigarettes. This sounds like e-cigarettes may be “better” for the modern smoker. Are smokers of e-cigarettes increasing their chances of cancer later in their lives? If so, what is the risk of cancer from smoking pure nicotine?
For the sake of discussion, let’s ignore the possibility for novel cancer-inducing chemicals introduced from the various oils and heating mechanisms in e-cigarettes. Let’s assume it is possible to have a method of smoking that only exposes the smoker to nicotine and nothing else. Would this method of smoking still cause cancer?
This review of the literature on Nicotine from 2015 suggests the answer is “yes”. Nicotine alone still increases the risk of cancer for the smoker of pure nicotine.
“Several lines of evidence indicate that nicotine may contribute to the development of cancer.
“Evidence from experimental in vitro studies on cell cultures, in vivo studies on rodents as well as studies on humans inclusive of epidemiological studies indicate that nicotine itself, independent of other tobacco constituents, may stimulate a number of effects of importance in cancer development (5, 6).”
Prolific child neurologist and author, Dr. Siegel uses a variety of images to explain what he thinks should be taught to children in America.
He uses his hand to provide a concrete visual model of the brain.
He also summarizes his “mindsight” model as a combination of brain, mind, and relationships. He expounds on the over emphasis of brain, or somatic, focus in mainstream culture and medical school. He argues we neglect the education of mind and relationships after children graduate kindergarten.
TEDx: The Power of Mindsight by Daniel J. Siegel, M.D. – 10/18/09
A Practical Introduction to Factor Analysis: Exploratory Factor Analysis
Survey questions or “items” (e.g., on a scale from 1 to 5, how strongly do you agree with the following statement…) may be repeated measures of certain underlying “factors”. Where factors are a true underlying construct that a survey attempts to measure. For example, a factor a survey may attempt to measure might be the anxiety caused by learning statistical analysis (using SPSS software). Factor analysis looks at understanding what is really being measured by multiple questions in a survey.
There are a ton of new concepts in this class, but online resources are often a more simple and clear way to learn.
Before forecasting its future, there is likely merit in explaining what physiatry is.
What is Physiatry/PM&R?
“Physiatry, also known as pain management and rehabilitation (PM&R) is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.”
Medicine tends to be sterile. When the end goal is reduced to keeping the patient alive, or moving a lab value within its appropriate range, doctors can forget to be human. Resources are stretched thin in a county hospital in a large metropolitan area. Providers are only attending to biological issues because they are prioritizing scarce resources. They are not trained to deal with the more pressing, social issues. What is the point in treating a patient’s asthma, discharging them back to the streets, waiting for another exacerbation, and then rounding on them next week after they’ve been admitted once again from the ER? Patients like these need social work and preventive public health measures. Instead they get expensive medications once every few months. Medical care can feel calloused and at times even cruel.
On the other end of the spectrum, there are fields based entirely in human connection, but they lack teeth. Naturopathy and alternative medicines have either been shown to have no efficacy, or there is no incentive to research them because they are assumed to be entirely based on the placebo effect. Sometimes people need to be heard and feel connected with their provider. These fields take advantage of this, and patients may be happier, albeit less healthy.
PM&R is western medicine that focuses on the patient’s function and quality of life. Chronic pain patients have sifted through the medical system, frustrated by the lack of resolution to their pain. They’ve stumped doctors who cannot do anything for them because all of their lab values are correct and they seem healthy enough by the protocol standards. Surgeons will happily perform surgery, but it seems a drastic move exposing patients to serious risks, which can be minimized or ignored during the pre-op. Surgery may be the best option for some, but certainly not all of these patients. Physiatry can offer medical treatment, alongside physical therapy for a multidisciplinary approach to increasing patient health and quality of life.
But it turns out, not many procedures used by physiatrists have been supported by clinical evidence.
Dr. Braddom Predicts the Future of PM&R
Dr. Randall Braddom is a clinical professor of physiatry. While at Rutgers Medical School in 2014, he gave a 100-Slide PowerPoint presentation that concisely summarizes the field of PM&R and it’s future direction from his perspective. Dr. Braddom acknowledges how worthless predictions of the future often are, but an experienced physician creating a deep portrayal of their specialty is worth far more than SDN forums.
According to Dr. Braddom, the field of physiatry is placing more value on research. One of the reasons is that physiatric procedures have not been validated in randomized clinical trials, and insurance companies are eliminating reimbursements for procedures without scientific evidence supporting their efficacy. The large proportion of physiatrist in clinical practice may see large reductions in their financial reimbursement for some of their procedures, such as sacroiliac and Z-joint (zygapophysial) injections. A whole field of doctors potentially not getting paid for their work may be a powerful force. It seems that clinical research opportunities in PM&R will likely thrive in the near future.
Below are select few slides from Dr. Braddom’s presentation.
PM&R Research will Boom Soon
Trend to Evidence Based Medicine
Evidence Basis of PM&R is Significantly limited due to:
- Limited research
- Distance from molecular biology
- Clinical studies lack analytical rigor
Research is Critical for PM&R Practice
- Outcome Studies are key to practice survival
- Randomized controlled trials (RCT’s)
- Almost no other kind of research is taken seriously
- Uncontrolled research is only a pilot study, at best
- Laboratory moving closer to the bedside
- New emphasis on Evidence Based Medicine in Health Care Reform
Few Physiatrists Have Become High Quality Researchers
- Length of training required
- Debt level problem
- Perceived decrease in research funding
- Instability in research funding
- Monetary rewards of clinical practice
- Physiatric personality: people oriented rather than rat oriented
“It has also been generally agreed that Rehabilitation research has not done well in fulfilling its objective of providing a foundation of knowledge for rehabilitation practice.”
AAPMR LNA: 2004 Physiatric Effort Report
- Outpatient 50%
- Inpatient 23%
- Administration 10%
- Teaching/CME 4%
- Research 3%
- Miscellaneous 10%
What to Do After Residency
2014 ABPMR Subspecialty Exams for Physiatrists
- Sports Medicine
- Neuromuscular Medicine
- Pain Medicine
- Hospice and Palliative Medicine
- Pediatric Rehabilitation Medicine
- Spinal Cord Injury Medicine
- Brain Injury Medicine
What Percentage of Residents Join Orthopedic Groups?
- Range from 10-40%
On residents joining Orthopedic groups:
“This is a sin against humanity!”
– PM&R Chair
From reading forums, it sounds like being a physiatrists working in an orthopedic practice may be a horrible experience. Surgeons with large personalities shunt all their conservative preventive care to one physiatrist on the team because it is a waste of their time to do injections when there are more challenging surgeries to be performed.
I personally would not want to spend so much time in training to be looked down upon or taken advantage of financially during my day to day practice. I don’t see the allure to working in orthopedic groups that the 22% of survey respondents said they are doing.
PM&R is a Great Field
- Patients appreciate what we do
- Not limited by an organ
- Jobs of all types available
- Population demographics favor us
- Good balance of procedure/E&M
- Many academic opportunities
- Good physiatric profile/nice people
- Small (10,000)
PM&R is focused on patient outcomes and quality of life. There are a wide variety of procedures, subspecialties, and practice styles within physiatry. Dr. Braddom presented many trends in the field as of 2014, and where he expects it to head in the future. He underscores the growing research opportunities in PM&R, the breadth of fellowships for sub-specialization, and that working in an orthopedic group may be less than ideal. Regardless of his prophecies, as of now physiatry looks like a promising career path.
The Atlantic: The Problem With Satisfied Patients
Doctor Voices: What is PM&R?
Doximity: Randall L. Braddom, M.D., M.S.
The California Society of Physical Medicine and Rehabilitation: The Future of PM&R From a PGY-46
“The series of reviews commissioned by SPPE over the past year shed important insights on the current state of psychiatric epidemiology [1-5]. Our reading of this series has led us into discussions of the scope and goals of our discipline, and how, within a historical context, it is expanding in both predicted and unforeseen ways. In this editorial we first reflect on the history of our field, and how the wealth of information in these reviews provides insight into newly emerging directions of inquiry. Then we discuss major advances and remaining challenges in the field not covered in the series. Finally, we consider the overall scope and future directions of psychiatric epidemiologic inquiry in the years to come.”