Sometimes an idea comes along that sticks in the mind like it belongs there – like there was already a space patiently awaiting its arrival. After that, it might fade or seem to disappear into a cloud of other ideas and thoughts, but then it reappears with the unexpected familiarity of an old friend who just happens to be in the neighborhood and gives you a call. Later visits never reproduce the wonder of the first encounter, but they bring a calm that approximates the meaning of the word wisdom.
For me, such ideas are usually personified – Einstein, Joshu, Eliot, Freud, Mandelbrot. They seem oddly connected in that they poked holes in how I’d been thinking, and offered me another perspective that I didn’t quite know was there. A few years back, I added another luminary to the cloud. I had been asked to give a short graduation address by the graduates of our Psychoanalytic Institute [short, because the speaker at the previous graduation had exceeded our endurance by leagues]. It was an honor, but I was skeptical that I could come up with a short topic that would rise to the occasion.
I knew what I wanted to say. I wanted to attack the dogmatic way many analysts have approached this whole business of theories of mental life and psychotherapy in general. On the other hand, I wanted to say something about what our graduates had learned along the way. Then I remembered something an old iconoclastic mentor, a Pathologist, had said when I was a Fellow in Immunology in a previous life. He was talking about the difficulty of giving talks to peers. The gist of what he said went like this: "Talking to peers is a pain. Either they taught you what you know, or you’ve already taught them what you’ve learned – so you have to come up with some new angle. But since there’s nothing new under the sun, I always look for something old that we’ve all forgotten. And it really helps to find an old Greek." I hadn’t thought about what he said for years.
But armed with the triad of words and phrases [skeptical, dogmatic, and old Greek], I did the modern thing and hit the Internet. Within a short period of time, the talk wrote itself as Pyrrho of Elis clicked into the space in my mind that had long been waiting for him. In fact, I got there immediately – I googled skepticism, looked at the Wikipedia entry, and there was Pyrrho. Here’s the short version.
Pyrrho was from Elis, a suburb of Athens. He started life as a painter, but gravitated to Philosophy. He became one of the Philosophers that traveled with Alexander the Great on his campaigns of conquest and he was influenced by the Philosophers in the East that he met on those travels. When he returned to Greece, the dominant school of Philosophy was Dogmatism. We know a jaded version of Dogmatism, largely from the excesses of the Catholic Church centuries later. At the time of Pyrrho, Dogmatism was something lofty, like the "search for absolute truth." Pyrrho taught that there was no absolute truth, and his teachings became known as Skepticism. What we know of Pyrrho outside later writings about his philosophy are stories that we know aren’t true. They’re the jokes the Dogmatists made about him – parodies of his indecisiveness. They told the story that Pyrrho was walking down the road and saw a man fall face down in the mud. While Pyrrho pondered, the man died from asphyxiation. Or a story that his students followed him everywhere to make sure that he decided to eat [those old Greeks weren’t so great with jokes].Since there were no absolute truths, Pyrrho taught that we had to accept relative truth, always maintaining a questioning attitude, vigilant for things that might cause us to revise our former approximations. We call it healthy skepticism these days, and it’s the essence of the scientific method. Pyrrho was perfect for my talk. Psychoanalysis at its best is a benevolent skepticism about the anachronistic meanings that our patients live by as if they were true, even when they cause havoc in living. And Freud was a grand skeptic, skeptical of his own ideas as well as others, constantly revising his theories even as he defended them. Pyrrho’s story offered a way to talk about paradigm ascension and exhaustion – and about the perils of dogma in general. Pyrrho was a welcome comrade in my pantheon of personified ideas…
In my first medical specialty, rheumatology, many of the diseases were of unknown etiology [still are]. Unlike psychiatry, there were plenty of visible signs and symptoms, laboratory abnormalities galore, but causes remain elusive. There were treatments – some empiric, some based on known mechanisms of disease – but most were toxic in one way or another, and often dangerous: high doses of Aspirin, Corticosteroids, Gold injections, antimalarial drugs, chemotherapeutic agents, biologicals. And both the toxicity and the efficacy varied widely from patient to patient. The principle is that every treatment in every patient is a therapeutic trial. There is often too much variability within a group of patients with the same disease to make individual predictions, so it was a medication trial in every patient. I understand that’s still somewhat true in rheumatology even with the newer agents [just listen to the mumbled ending to the t.v. ads for these drugs].
That principle must’ve followed me into psychiatry, because I still feel that way. I didn’t come to psychiatry to be a medication maven, but when using our drugs, I still see it as an individual therapeutic trial – the efficacy and safety data gathering starts anew with every case. In practice, it was easy because I saw people frequently. In the clinic where I now work some, it’s harder because I see people more frequently than most. But I guess I’d rather be a schedule clogger-upper than too casual with medications. That’s just healthy skepticism in my book – the lesson of old Pyrrho of Elis.
The Empire of Humbug: Not So Bad Pharma – current
Brand Fascism and Witty A: Report to the President
My version above is simpler. Randomized Placebo-Controlled Clinical Trials and Evidence-Based Medicine have been treated as dogma, absolute truth. But even the most honest of trials [rare in psychiatry] can dull the single most important thing physicians bring to the individual patient – their healthy skepticism.
“Evidence Based Medicine has become synonymous with randomized placebo-controlled clinical trials even though such trials invariably fail to tell the physician what he or she wants to know which is which drug is best for Mr Jones or Ms Smith – not what happens to a non-existent average person”.