Journalism and the Scientific Method

Three years ago, I reviewed Seth Mnookin’s book The Panic Virus. In that review, I noted the importance of science reporting in assisting the public’s understanding of scientific research and science in general. Keeping this in mind, I want to highlight an article from the Ottawa Citizen by Elizabeth Payne, a Postmedia health reporter. The article addresses the question, “Could infections cause Alzheimer’s?”

In her article, Payne considers the controversy about the link between microbes and Alzheimer’s disease. She reports that those scientists who favour the microbe hypothesis have made a widespread plea that the public “embrace” their hypothesis.

Payne’s reporting is factual and clear. It leaves the reader with the opportunity to consider whether the microbe hypothesis research supporters or the plague hypothesis supporters are more credible. It calls upon us implicitly to consider both theories, but to remain open to the results of the ongoing research on Alzheimer’s disease. To be open to possibility, to be able to assess alternatives as revealed by rigorous study, is the essence of science. Through her reporting, which points out the conundrum of a controversy in scientific research, Ms. Payne makes it clear why the public should not, in fact, “embrace” a hypothesis until the research and much more consideration yield a clear result.

I am a clinician, not a researcher, but I work in a university teaching hospital affiliated with a research institute and so I have participated in clinical studies. When focused on one’s own research study, it is easy for a researcher to become attached to trends that one believes are emerging from one’s research. I have done enough research to realize how dangerous this is. I have learned that one must be faithful to the scientific method that has fostered the real breakthroughs.

The scientific method is systematic and allows for the modification of the hypothesis. Learning the scientific method is one of the first lessons in science class in elementary school. I remember having to devise experiments in Grade 3, not for a science fair project or research but to demonstrate that I understood the scientific method. That same lesson was repeated at the beginning of many grade school science classes for years to come. The scientific method is fundamental but, like all fundamentals, it is more easily expressed than understood. Ms. Payne’s excellent article reported some news from medical science and reminded us of how difficult it is to learn the scientific method.

(Note: The excellent graphic depicting the Scientific Method included here comes from the Science Buddies Website. Science Buddies is an award-winning, not-for-profit organization dedicated to building scientific literacy.)

DSM V and Thomas Szasz

Like many North American Psychiatrists, I have spent a good part of the past six months thinking about DSM V, The new Diagnostic and Statistical Manual of the American Psychiatric Association. Like DSM III and DSM IV before it, the new manual’s publication is giving rise to significant controversy that is likely going to set back the goal of decreasing the stigma surrounding psychiatric illnesses, their treatment, and mental health practitioners. Criticism against the manual is coming from such highly respected organizations as the British Psychological Society.

In reading through some of the negative opinion, I was taken back over thirty years to a time when Thomas Szasz’s The Myth of Mental Illness was causing a sensation among a number of mental health practitioners.  The Myth of Mental Illness was published in 1961 and Szasz was among those who were highly critical of the American Psychiatric Association’s manual:

“It is important to understand clearly that modern psychiatry – and the identification of new psychiatric diseases – began not by identifying such diseases by means of the established methods of pathology, but by creating a new criterion of what constitutes disease…Thus, whereas in modern medicine new diseases were discovered, in modern psychiatry they were invented.” (Italics are Szasz’s)

This is very similar to some of the concerns expressed regarding DSM V, and, behind the debate, one senses the same emotional response that many had to Szasz’s seminal work. At the time, those who included psychiatry as one of the medical sciences could be disturbed by reading Szasz’s work since he expressed so authoritatively exactly the opposite view.

With this in mind, consider this statement from the Open Letter to the DSM-5:

“We thus believe that a move towards biological theory directly contradicts evidence that psychopathology, unlike medical pathology, cannot be reduced to pathognomonic physiological signs or even multiple biomarkers.”

Reference: http://www.ipetitions.com/petition/dsm5/

When I have skimmed DSM V, and read the introduction, I was struck by the expressed strong desire of the authors to address psychiatric diagnosis scientifically. It seemed to me that the intent was that mental illnesses would be illnesses with as much validity as all other medical illnesses, leaving behind the credibility gap of the past, when mental illness, by virtue of being “less worthy” than physical illness, led to stigmatization.

It is a long time since I have thought about Thomas Szasz. To me, he was one of the forces that upheld stigma by emotionally focusing on those circumstances where there were uncertainties in an attempt to persuade that authoritarianism was more important in psychiatry than science. The visceral, emotional reactions to DSM V also seem tinged with belief more than science, if indeed science is an objective pursuit.  Read the Open Letter and then go to The Thomas S. Szasz, M.D. Cybercenter for Liberty and Responsibility ( http://www.szasz.com/) and see how they compare to you.

The Patient’s Medical Home and Me

Last week, after I posted my blog on my concerns regarding “Primary Care Pediatrics”, Shereen Miller responded thoughtfully, asking, “Who is the quarterback of each person’s health care?…Should someone be in charge, connecting all the dots…”

This question is immediately answered for me by the Patient’s Medical Home, as described by the College of Family Physicians of Canada in their position paper A Vision for Canada: Family Practice: The Patient’s Medical Home. (http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf)

This paper defines the Patient’s Medical Home as “a family practice defined by its patients as the place they feel most comfortable – most at home – to present and discuss their personal and family health and medical concerns. It is the central hub for the timely provision and coordination of a comprehensive menu of health and medical services patients need. ” Does this not sound exactly like the service Shereen is seeking, as a patient?

As a specialist physician providing mental health care, I also like the idea of a family physician trained to coordinate my patient’s personal health care so that my team can attend to mental health concerns. All too often, it is necessary for the multidisciplinary mental health team to attempt to piece together a patient’s health status ourselves, without the longitudinal view of a personal  family physician who has monitored someone’s health over many years.

While the introduction of primary care models in the past decade in Ontario has given more patients access to a hub for their primary care, there is not yet a system in place for specialists like me to easily plug into the central team. To some extent, this is because many specialists are in hospitals, physically and virtually disconnected from patients’ family physicians. I can see the value of better connections between specialists like me, who are experts with difficult to manage chronic illnesses, and family physicians and their teams. Right now in Ontario, many family physicians’ teams have the services of allied health professionals, e.g. social workers, pharmacists, nurses, directly on the team but this collaboration does not yet completely extend to specialist physicians such as psychiatrists, internists or pediatricians. Some of the large university family health teams do have these “shared care” services but, as far as I know, none of the community-based family physician groups have access to specialists as I have described above.

In my view, such a system offers tremendous advantages to patients. First of all, because of the ready access, collaboration regarding which patients’ conditions need a consultation versus therapy could be undertaken quickly, eliminating some of the time usually spent waiting. Another consideration mentioned by Shereen was the notion that the doctor is not always required in a patient’s assessment and diagnosis. Certainly psychiatrists are very used to working with allied health professionals – I have worked on multidisciplinary teams since my residency and, like all of my psychiatric colleagues, team-based care for patients with psychiatric conditions has the best outcomes. This system eliminates another layer of inefficiency, allowing patients better, quicker access to specialty care.

I have been sold on the idea of the Patient’s Medical Home since I first read about it and heard it described. To extend this care to include specialists requires some changes to our current funding models, but different funding and not more funding is required.

Having said this, I am sure there are disadvantages to the model I have begun to describe.   I would like to hear about them to see if they can be overcome. I am also taking the advice from my readers by examining some of the models in place in other countries to see how they would refine this concept of specialty care being a “room” in a Patient’s Medical Home.

It is important for all of us to consider how the developments in primary care can more fully exploited for every patient’s benefit. How would this work for you?