Should doctors be more than medical technicians?

I’ve thought of this question several times in the last few years, most recently in connection with two emergency room visits for my mother. She complained of (among other things) a very bad headache. Early on, one doctor ordered a ct scan of her head to see if there was maybe a tumor or something to explain the headache. The ct scan showed nothing out of the ordinary.

Here’s the bit that made me start wondering about doctor education, or intelligence or something: When the ct scan came back clean, the doctors then proceeded to completely ignore the headache. It was as if, when the test showed nothing, the problem simply ceased to exist.

This is the way not-very-skilled technicians operate. People who, in the IT field (my field) would be level 1 help desk and who would probably never progress beyond that level. Example (a real one):

Me: “I have a problem with my internet connection.”
Tech support: “I’ll test the line.” (pause) “The line is fine.”
Me: “Okay but I keep losing my connection.”
Tech support: “Restart your modem and check that it’s plugged in correctly.”
Me: “I did that. The modem is fine. There’s something wrong with the connection.”
Tech support: “I’m sorry sir but the line is clean. You need to check your modem.”
Me: “Aaaaaaaaauuuugggggghhhh!”

After a couple of days of arguing I got them to escalate to level 3 support, a real live engineer, who took about 5 seconds to discover that my connection was flapping. He sent out a technician who found that the physical line leading to the house was loose.

The trouble is, there’s no way to tell an emergency room doctor to “escalate my case to the next level.” And then there’s the not so small problem that if the level 1 doctor-technician doesn’t figure out that he needs to escalate, someone could die. Even if he does eventually figure it out, someone suffers while he fails to solve the problem.

Let’s go back to the analyzing this in the IT context. A user calls and says his screen is frozen. The mouse doesn’t move. A brand new help desk employee looks behind the computer, says, “The mouse is plugged in” and then walks away. If I ran the department, the IT worker who behaved that way would be given intensive schooling in how to troubleshoot a problem. This would include the most basic step of checking to see if a solution worked before giving up on the problem. If the schooling didn’t take, he would be unemployed.

It seems to me that the standard for doctors should be at least as high as for IT workers. Am I being unreasonable?

The problem may not be the standard for medical troubleshooters. Inexperience is another possibility. Several of the doctors looked young to me. Then again, I’m old enough that lots of people look young to me, even after I find out they have teenage children. Anyway, I would expect inexperienced people to be more obsessive about troubleshooting than more experienced people. Someone with more experience, after all, is better (or thinks they are) at knowing when something isn’t really a problem.

It seemed almost as if what we were seeing was some kind of cognitive deficit. When the test showed nothing, the doctors’ brains stopped processing the problem. It seemed as if they had become so dependent on the technology that when it failed to provide an answer, they simply stopped processing the problem. It was as if in their minds, the tech COULD NOT FAIL. If it showed nothing, there must be nothing to show.

As it turns out, other doctors were able to determine that there were other tests that could be run and treatments that could be tried even before seeing the test results. Hallelujah! Somebody did some thinking. The doctors who figured out what to do (we hope – the jury is still out on whether or not they succeed) were specialists and this too may be part of the problem. The specialists had expertise that allowed them to recognize signs that those outside their field did not.

Funny. In the TV show House, all the doctors always know everything about every field. The dwarven plastic surgeon knows all about rare genetic disorders. The arrogant neurologist with the inferiority complex can recite arcane details of the effects of poisoning by rare earth metals or almost unheard of kinds of cancer. The aggressively nice allergist knows how to run every piece of medical equipment and perform every medical test ever thought of, and interpret the results correctly. In real life, when we asked a surgeon what was wrong, he said, “I don’t know but whatever it is, it doesn’t need surgery.” (Seriously. He really said that. And this one even looked old enough to need to shave once in a while.)

Still, segmentation of skills can’t be too big a part of the problem we saw. After all, even a lowly help desk tech who doesn’t know what to do after seeing the mouse is plugged in, usually can figure out who to ask. This seems like a basic skill that anyone in a complicated field should have not to mention a direct consequence of basic human curiosity.

But what do I know? If I had any brains, I’d be a doctor.

One of the things that makes being a fan of science fiction a little difficult is the traditional absence of creativity in Hollywood products. That is, even on the rare occasions when Hollywood tries to do science fiction, they don’t generally try very hard to make it good or interesting. An even worse problem is the traditional ignorance of science in Hollywood and journalism. But that’s not what I want to talk about today. What I want to talk about is that staple of TV science fiction: The Genius.

Notice that the word is capitalized. Not mere genius but more like Super Genius. The person with an intellect so enormous that he (usually, though sometimes a she, as characters Amanda Tapping played very well in Stargate: SG1 and much less convincingly in the deeply inferior Sanctuary) is a master of every science and all technology. Often these people are so brilliant they not only understand everything, they go far beyond what the rest of the world knows, inventing whole new sciences and extending existing ones to unimagined new heights.

In stories, these people have two functions. Those are to explain what is going on to the audience (and incidentally to the folks around them) and to come up with the one great idea that can save the day, or save the world, or at least save the story from a depressing ending.

The third, often unintended function, is to annoy the living hell out of the audience, especially those of us who know that that’s just not the way things work.

The Genius is an easy gimmick that dates back at least to the golden age of science fiction when Doc Savage was still a new character and John W. Campbell was writing his stories of over-the-top heroism in the face of universe-sized threats. For the last 4 decades or so, the quintessential Genius has been the comic book character Reed Richards, a.k.a. Mr. Fantastic of the Fantastic Four. This is a guy who can develop a portal to open up a portal to parallel universe before lunch, then reprogram an alien robot to turn on its creators (who, except for their easily hacked robotics, are much more technologically advanced than Earth people), thus saving the world by dinner.

Famously, these geniuses who can do anything are often insane and horribly evil. Dr. Moriarty, the Napoleon of Crime comes to mind. And, of course, Dr. Doom.

It’s always amazing how very much these lone geniuses accomplish that involves more than just thinking. Dr. Doom invented a time machine. Currently, there is no working theory of how one of those would be made. Time, so far as we know is one-directional (it may have to do with quantum forgetting| ). But even if we had a good theory of time travel, someone who has spent decades learning the math and physics to develop the theory has not also spent decades learning how to build the equipment, or earning the money to buy the parts (and the electricity!)

Often what these geniuses do involves other genius things first. Building an android sounds simple on paper:

1. Build robot
2. Make robot look and act human
3. Send robot to conquer the world, Pinky!

But in reality, there are dozens of lesser problems involved in building a robot, and making it look human, and making it act human. Computers that can interpret pictures well enough to be considered able to see do not yet exist, despite some brilliant people working for years to develop them. It turns out, vision is a hard problem.

Thinking is a hard problem too (for robots I mean. It doesn’t take a genius to figure out I walked into that one. Just let it go). So is walking. Just ask any 8-month-old.

Talking is a problem. Sure, robots can repeat noises like any myna bird but connecting complex ideas (like “kill the master” or “Build me a girlfriend”) to complete sentences is really hard. Just ask any College English professor how many students have mastered this. Then drink heavily to counteract the depression.

Even if you could figure out how to build an android, it would take one person years to type out the software to solve all the attendant problems!

That’s one of my main points. That even for geniuses, turning an idea into reality is hard. Teams of brilliant people worked together for years to come up with technological advances like the microwave oven or the TV or the personal computer. These things don’t spring full grown from one person’s brain. They take work!

But TV, movie and comic book geniuses always skip past such difficulties without even noticing them. Then, more often than not, they get in trouble because it never occurred to them to check and see if the bad guy was still breathing after the monster robot stepped on him. Somehow, that force field that saved his life last week never comes to mind when wondering what’s going to happen this week.

And this is one of the serious problems with having supposed geniuses being written by people of average (or, judging from the quality of most of television, far below average) intelligence. Fictional entertainment is overpopulated with idiots of near infinite intelligence who can create technological wonders beyond the wildest dreams of Asimov, Clarke or Heinlein but still only survive because the equally brilliant nemesis forgot to lock the door, or some such idiocy.

The other day I found a funny and sickening blog post that explained part of this problem. Basically, on some allegedly science fiction shows, the writers simply insert place holders for high technology and let someone else fill in the details. “We’ve built a [fill in technological words here] to beat the aliens!” The genius problem in reverse: People who’ve spent years learning to write for TV haven’t learned enough about technology to write even bad techno-gibberish – which is about all they usually end up with anyway  (It’s a very funny and informative post. Read it here).

The new show StarGate: Universe has a slightly unusual approach to the genius problem. In recognition that no one genius can solve all the problems there are (or more likely because they thought the character mix needed a likable computer geek), they have two. There’s the older, grouchy and sinister genius and the young, innocent, kind of dorky but friendly and likable genius who is probably smarter than the old guy but is too naive and inexperienced to know it. If this sounds like Dr. Smith and Will Robinson, it’s a pure coincidence. They’re on a ship they can’t control, careening around a universe they don’t understand, but they aren’t lost in space. They’re just misplaced. And they don’t have a robot (yet).

The older genius solves all the simple problems like how to stay alive. The younger one finds and miraculously understands the alien technology that just happens to be what they need right now. More importantly (from the point of view of the writers), the younger one will almost certainly act as the older one’s conscience, since it’s so hard for the Great One to relate to mere humans.

The blog post I referred to above laments the use of technology as a sort of substitute for divine intervention, to be called up to get them out of problems and otherwise ignored. In most stories, genius is pretty much the same. It’s a magic wand to call up miracles when needed and otherwise hide away, affecting nothing. It has no consequences of its own, has no influence on the characters (no, being obsessive about working in the lab or uncomfortable with members of the opposite sex are not consequences of genius. Those are just stereotypes). It means nothing.

Where genius is concerned, sloppy, uncaring writing is the norm. It’s no surprise then if the rest of the show seems a bit lost in stereotypes too.

At my job we encourage people to use Test Driven Development (TDD). The short explanation of that is that before you write a line of program code, write a test for what it is supposed to do. I confess I don’t always adhere to this. For me the rule would be more like, test early and test often. Testing is a skill and it can be hard. Testing first is also a skill. Like any skill it takes time to learn (and I’m getting better at it all the time!).

For years now, though, I’ve found that even my sloppy and less-than-perfectly skilled approach to testing seems to be too much effort for some people. At a previous job I routinely heard other people complaining that some system/server/software was broken when, in fact, their own code (or configuration or approach or whatever) was really broken. My colleagues and I would say something like, “Did you try it from a different computer?” And, as often as not, when tried on a different computer it worked fine. Reboot and try again. Don’t place blame before you’ve gathered the relevant information. Thank you kindly, call again soon.

See? It’s not just programming. Programming is just an environment where testing is measurable and has well developed tools.

There’s another idea behind testing that shows clearly when you write automated (therefore repeatable) tests for your code. It forces you to figure out your assumptions ahead of time. Often, you quickly realize you should consider other possibilities. What if the incoming number is 0 (zero, null, nothing, empty set) instead of what you expect? Dividing by it would be bad. That’s the fun thing about tests (at least if you have a mind like mine); I often write 3 or 4 tests for a function – 1 or 2 for the way it’s supposed to work, and a couple more to see if I can break it. You see, end users rarely understand the difference between good data and bad data. And even if they do, sometimes a cat walks on the keyboard (go away Kilroy! – that’s my cat) and inputs something you didn’t intend. So you have to anticipate these things.

But, as I said, testing applies to a lot more than just programming, as my “reboot” example above should show. I’ve been known to bring the philosophy of testing everything to areas that have nothing to do with computers. Think about it: You hear about a new TV show (let’s call it Dollplace just as a hypothetical example). You know the history of some of the people involved and you believe it will probably be a good show. But do you immediately start a fan club? No! You watch the show for a while first (and see an okay but dull pilot followed by a better episode that hints at improvements but still isn’t up to the level you want to see from such talented people).

In other words, you test the show.

Rumors are something people rarely test and should. Heard a rumor that your old friend (hypothetically) Eliza has been in training to be a ninja? Well, she has done martial arts before. It’s plausible. But there’s no need to decide right away if you believe it or not. Why not call her on the phone and ask? You might find out that it’s just for a (so far, mediocre) TV show and has nothing to do with actually being a ninja.

I also believe in testing whether the dog will like a particular brand of food, whether the car will get better mileage with a new kind of gas and even whether or not a politician supports policies he says he supports, even if he sounds sincere when he says it (Voting records are much more reliable indicators of belief than talking points). And all sorts of other things. Maybe that’s why I took to TDD in the first place. The logic seems a natural fit to me.

Testing is how we know, as opposed to just thinking we do. When someone tells you the network is down, you don’t instantly rush off and call Al Gore to complain. There are many possible points of failure for an internet connection. It could be your computer’s network card. It could be your router. It could be your computer isn’t even turned on. It could be a bad cable. So first, you run a test. Go to a different computer and see if you can get to the Internet. Can’t? Check your router. And so on. TEST possible causes before making a decision.

We don’t know how to test everything. If I suspect I have some rare tropical disease (apparently one that causes its victims to type maniacally), I call the doctor. And the doctor runs tests. Why would he do that when the web site raretropicaldiseasesyoumighthave.com says I have it? Because he wants to know, not just accept a rumor. Is that such a hard concept?

There were several things that inspired today’s testing rant. One was a workplace discussion with someone who is incredibly smart but who isn’t an extremely experienced programmer. I was singing the virtues of Test Driven Development – even if I’m not the greatest at it, promoting it is part of my job – and she was resisting. Basically, to someone who does not have the habit of thinking in terms of tests, the idea of testing code before it’s even written seemed silly. Like many programmers (not just beginners), she believed that running the code once in a while to see what it turned out would be test enough.

Maybe she doesn’t own a cat. I’ll have to ask.

(Note: She was not against using automated tests and I was able to get her to see that you should test small blocks of code as you write them, so as to catch errors before they get hidden in miles of spaghetti. It was the test FIRST thing she never quite got. I take progress where I can get it. My own testing has a way to go too.)

Another one of today’s inspirations was this video: Luke Francl Explains Why Testing Is Overrated.

He says, in essence, testing is only part of the equation and we shouldn’t rely too heavily on it, especially not to the exclusion of other important tools for ensuring code quality. He even concedes that there may be more than one way to write good code, so his views should not be taken as gospel (for more on his views, check out his blog post on the subject here: Maybe there’s more than one way to develop good software?). Every word is completely true. But I get the feeling that it’s been a long time since he’s had to convince someone that testing at all would be a great improvement. Note that in that last sentence by “testing” I mean writing test code that you can run repeatedly and, if the code still works, always get the same result. I don’t mean opening a web page up in your browser and saying, “Yup. Looks good to me.”

“Looks good to me” worked great for the developer of the Edsel, didn’t it? I mean the car. I’m not talking about some program that used that for its name (Because there probably is one. All the good names get recycled. )

Another part of the inspiration for ranting about testing was that I was working on my wife’s website (I do that once in a while, really I do) and needed a little information about a minor point of syntax. So I googled for it and quickly found what I needed. But here’s the thing: Out of maybe a half dozen blog posts I looked at that claimed to be tutorials NOT ONE showed how to test the technique being taught. I’ve found that’s the norm. Sometimes there’s a little blurb that says something like, “Of course in real production code, you would have tests, too.”

How would you like to see that in a tutorial on driving a car, or gardening? “Of course, in a production garden you would use water.” Really? How much? How often? Does it matter if it’s a little bit yellow?

How about doing your taxes? “In a real tax form you would also fill out schedule C for your home business.” Thanks. That’s good to know. Now how do I do it? And does it matter if I leave it out because there were no instructions? I’m sure the IRS will understand. It’s not like the numbers need to add up or anything.

How about a hydroelectric dam? In a real dam, you would use strength numbers from the actual materials used and calculate stresses for a range of volumes of water since, you know, it might rain someday. But explaining how to do that is beyond the scope of this blog post.

Testing. I’d say it’s not just for programmers – if I could get more programmers to do it.

Never mind me. I’m just ranting.

Maybe it’s some kind of law of nature that immediately after I write a blog post about a subject, the next day there will be new stories related to the same subject. Last week I wrote something about critical thinking and, shortly thereafter, there was an interesting story in Science Daily claiming that tests show that college freshman majoring in science have terrible reasoning skills whether they were educated in the U.S. or in China.

My first reaction was, “Duh!” Young people in general have terrible reasoning skills. That’s why those of us who are older call them idiots. At this point it would be polite of me to explain that I’m just kidding but, in fact, I’m not much. Face it, how many people look back on their younger selves and think, “Wow! I was sure smart then! I wish I was that smart now!”? I have my glasses on and I still can’t see any raised hands. But, believe it or not, this is not intended to trash the thinking capacity of young people. I was trashing a study about them, actually.

The article about the study mentioned that Chinese students knew many more facts than American students (but please don’t get me started on the state of science education in America!) but performed just as poorly on tests of scientific reasoning. That is, even the ones who knew many scientific facts were unable to solve many of the problems they were given.

From this, the researchers (Or maybe it was the reporters. It’s so hard to tell sometimes. But don’t get me started on the state of science journalism in America either!) concluded “that educators must go beyond teaching science facts if they hope to boost students’ reasoning ability.” I found this to be a very poorly reasoned conclusion based, as it was, on the strange assumption that it’s even possible to teach reasoning or that it’s possible to teach it to children. Talk about a triumph of optimism over experience!

To illustrate the point, let’s go to another study [reported in The Shortsightedness Of Youth], that used a popular test of deferred gratification to find out …. (No drum roll is necessary but feel free to provide one anyway) that young teenagers don’t like to defer gratification. Interestingly, rather than relating this to education, television or bad parenting (all of which are popular scapegoats for children’s problems), they related it to physical brain development. “The study found that teens are shortsighted more due to immaturity in the brain systems that govern sensation seeking than to immaturity in the brain systems responsible for self-control.”

This is perfectly reasonable. It means that young people think differently because the organ of thought is not yet fully developed.

It is not a big stretch to see that this same developmental issue may apply to critical thinking and scientific reasoning. It is possible that critical thinking takes time to learn, and new college freshman haven’t had minds capable of learning it long enough to have become very proficient at it. Far be it for me to let teachers off the hook for poor educational outcomes (but I swear I won’t say anything about science education in this country) but incomplete brain development is a better explanation for the similarity of outcome for otherwise completely dissimilar student groups than the theory that all science teachers in both the U.S. and China are failures.

The really interesting thing here is the poor scientific reasoning in the conclusion that both countries need to learn better methods of teaching scientific reasoning. It seems that whoever formed that conclusion did so because it was the conclusion they expected or wanted, rather than actually applying their gray matter to find a really good explanation. And if adults (I presume they are adults. Few school kids get enough funding to perform these kinds of studies) have that much trouble with scientific reasoning, why would they expect anyone else to be good at it?

Maybe good reasoning skills can’t be taught at all. Maybe it’s a genetic thing, like being smart or tall or extremely loquacious (look it up. It means this post has gone on too long). Someone should study that.

An odd coincidence of things I saw in the news lead me to think about critical thinking. A recent study claimed that the rise of electronic has improved certain visual skills but has also reduced the prevalence of critical thinking, especially among the young. [See Is technology producing a decline in critical thinking and analysis?]. It’s hard to argue with that. People don’t read very much these days (if they ever did). Watching TV is passive and not very critical. I seem to recall that there was proof of this twice when TV writers went on strike and people just kept watching the repeats that were aired in place of new shows.

It’s hard to be much less critical than re-watching the same stuff that bored us on the idiot box (as my father has been known to call it) the first time. But does watching TV (or playing video games, or chatting via SMS or IM) really engage the brain that much less than other traditional human activities like gathering nuts and berries, or walking behind a plow? I’m not so sure. I’m also unsure that reading, alone, has much to do with critical thinking. It depends on both the quality of material being read and the quality of thinking the reader does about it. Experience shows that cramming for a test does not foster serious thought. Mostly, it just gives me a headache. (I hope that’s not just me!)But there’s more. I also ran across an interesting story that seemed to show a problem with critical thinking. The story is about an unexpected increase in the population of mountain gorillas during a time when the park where they lived was occupied by an army at war (the Congo Civil War). [See Mountain gorilla population increases despite war] There are two serious flaws in this story. First, the population only increased from 72 to 81 in a little over a year. It’s a significant percentage but not a big absolute number. A relatively small variation in the birth rate or in the survival rate of infants or even in the death rate of adults could account for this and have nothing to do with any trends in the outside world.

On the other hand, having an army nearby is something few animals or people are able to ignore, so it probably had something to do with the change. The question is, why was it a surprise that the gorilla population increased? Why would anyone expect it to decrease? Are gorillas prone to attacking large groups of people, provoking the people to shoot and kill them? That seems unlikely. Most animals avoid large groups of people, except for things like rats that can scavenge off the garbage that accumulates around humans. Gorillas aren’t rats.  They eat things that would likely be in short supply around large groups of people, especially people who cut down brush and trees in order to make camp. So that seems to argue that the gorillas would stay away from people.

Well then, are gorillas such good eating that a group of humans, finding them near by would naturally hunt them down for dinner? I hit Google for the answer to that and was surprised to find out that gorillas may (might, maybe) be killed for meat to be exported. [see Gorillas] But the key to this was that the market for that meat was in the West, not in Africa itself. Apparently, the people who live near gorillas have not developed a taste for them.

The biggest human threat to gorillas is apparently poachers (who want to export the meat), not soldiers. And this is where we get back to the idea of critical thinking. Poachers are far less likely to be active in the area of a large armed force, that may kill them just to be sure they aren’t spies, than in an area without any such force. In other words, having an army around may actually be good for the gorillas, as long as the gorillas don’t go attacking anybody or making nuisances of themselves.

There! Was that such hard logic to follow? [Note: This is an example of real critical thinking, though it could be argued to be incomplete. It is critical because it examined premises, considered multiple scenarios and even used research to resolve uncertainty, rather than simply picking what would support a given conclusion and using that.]

Now I’m going to contradict myself. The problem with the article, which presumed that gorillas were threatened by any human contact, was NOT lack of critical thinking. It was lack of good critical thinking. Even before television, smart phones and computer games, there was not much good critical thinking in the world. Even avid readers and skillful writers have been known to be idiots (I could name a few but that’s an argument for another post). One very cynical way to look at the alleged damage to critical thinking done by modern media, would be to count it as a good thing, because it also removes from so many the opportunity to pretend that being well read equates to being smart.

Maybe a better way to look at it would be to consider that reducing something that was not there in the first place does no harm in the grand scheme, and might even provide opportunities to teach real critical thinking.Remember that the argument goes that electronic media have improved people’s visual skills at the expense of thought. But visual skills can be used to teach critical thinking too. Whatever became of the Classic Comics of the good old days?