User talk:MastCell

You'll be missed. Bishonen | talk 00:39, 4 August 2010 (UTC).

MastCell ^Talk 22:49, 30 September 2010 (UTC)

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Don't try to worm your way out of this

Are you really a real doctor? Note for the humor-impaired: this is not a serious question. - 2/0 (cont.) 19:49, 21 May 2010 (UTC)

Hello central?. . . dave souza, talk 20:47, 21 May 2010 (UTC)

The definitive word on my qualifications can be found at Wikipedia:WikiProject Medicine/Participants, under my username. MastCell ^Talk 03:27, 22 May 2010 (UTC)

Looked at it. Putting two and two together in the accepted Wikipedia fashion, I have deduced that your real name is Robert Sean Leonard. Short Brigade Harvester Boris (talk) 03:32, 22 May 2010 (UTC)

Yeah. Looking at my picture from my Wikipedia biography, I can't help noticing that I've let myself go a bit since Dead Poets' Society. But then, you should see Robin. MastCell ^Talk 03:41, 22 May 2010 (UTC)

Speaking of, do you think House has jumped the shark? We used to watch it religiously but this year we found we weren't bothering to keep up. Short Brigade Harvester Boris (talk) 03:49, 22 May 2010 (UTC)

To be honest, I think it jumped the shark in the first season, but it's saved by the fact that it generally doesn't take itself too seriously, and because the character and acting are great. I have to admit I haven't seen much of this season. Community won me over, and this season of 30 Rock has been pretty great. So I've been watching those - I feel like I don't have time for an hour-long drama anymore. Life is too busy. And basically, every day of my life is exactly like an episode of House - they really nailed the realism... (just kidding). MastCell ^Talk 18:41, 22 May 2010 (UTC)

Hi MastCell, Speaking of one’s wikipedia-relevant life experience…have you ever done any basic research, of the kind geared toward ascertaining a physical fact about nature? I’m asking because my training is in that kind of science, and I’m finding there’s a bit of a culture gap between the top priorities of that kind of science and the kind of science that is most immediately useful in the daily practice of medicine.

I dearly hope this question isn’t offensive. I have great respect for medicine and don’t mean to suggest there’s anything “wrong” with that kind of science; merely that there are, necessarily, proximal social considerations in medicine that are more distal in the science of isolated cells and molecules. Best wishes, Postpostmod (talk) 13:18, 26 May 2010 (UTC)

I'm going to decline to go into detail about my personal history, because I value what's left of my pseudonymity here. I do agree with your observation; I think that clinical research is a very different endeavor from basic science. The two areas attract different kinds of people and have different approaches and criteria for measuring success. If I were to greviously oversimplify, I'd say that in basic science questions are pursued primarily because they're interesting, while practical applications are often a secondary consideration. In clinical research, practicality is a prime consideration; often the most interesting and important questions can't be feasibly answered because it would be insurmountably impractical to do so. The best-designed clinical trial on Earth is no use to anyone if it fails to accrue patients and can't achieve any statistical power.

More to the point, the kind of questions faced in the daily practice of medicine are difficult precisely because they often haven't been the subject of rigorous clinical research. It would be impossible to practice truly "evidence-based" medicine, because it would be impossible to acquire a suitable evidence base to face every conceivable (or even every common) clinical scenario. For conditions that are uncommon or clinically heterogeneous, it is impossible to conduct a suitably powered randomized controlled trial, or sometimes even a decent prospective observational cohort. If you focus too narrowly on specific clinical conditions and scenarios, then you'll never accrue enough patients to conduct a meaningful study - and even if you did, the results wouldn't necessarily be generalizable if your population was narrowly defined. On the other hand, if you cast a broader net, then your patient population becomes heterogeneous, limiting your ability to draw specific conclusions.

That's why I get annoyed when people compare medicine to aviation (usually in terms of the markedly superior safety record of commercial aviation). Sure, practicing medicine would be like flying a plane - if every time you took off you had no idea exactly where you were going, and you'd never flown that exact model of plane before, and an M.B.A. at air traffic control might decide to override your judgment about the best flight plan, and if the passengers were actually at the controls and were free to decide to ignore your recommendations about flying the plane because of something Dr. Oz said on Oprah, and if your navigational maps were accurate only to a p-value of 0.05 at best...

In terms of social considerations, I do feel for scientists who lose control of their work when it's in the public domain, and have it re- (mis-)interpreted by various political forces. In general, I don't think scientists are very well-equipped for the political arena, and to the extent that ignorance routinely triumphs over enlightenment, I think that disconnect is partially to blame (of course, the pathetically poor state of scientific literacy and education in the US is also part of the problem, as is the media's approach to scientific controversies).

Anyhow, I'm digressing again. Did you have a specific issue in mind, or was that a general question? MastCell ^Talk 16:39, 26 May 2010 (UTC)

Hello, thanks. Your second paragraph describes beautifully the issue I'm exploring. I offer you kudos for your writing skill.

It will take me a little while to craft an explanation of how this relates to our conversation about the diagnosis of Lyme disease. Frankly, I'm concerned about unintentionally offending. Obviously, it‘s both a complex, and a touchy, subject. I feel that extracting a “best guess” at the biological facts from the perhaps overly voluminous literature is quite challenging enough, without bringing emotional issues into the mix.

By the way, I love your aposematic moniker - thanks for the warning. I’ll create what I hope will be an adequately non-inflammatory explanation of my concerns and send it along here when it’s ready.Again, many thanks, and my compliments, for your elegantly phrased, substantive reply to my question. Best wishes, Postpostmod (talk) 15:16, 27 May 2010 (UTC)

I wouldn't worry too much about offending me. I (try to) have a pretty thick skin, at least as far as online discussion is concerned (arguably less so in real life, depending on whom you ask). I actually value a thought-provoking discussion over an excessive concern for politeness, although that preference doesn't translate well onto Wikipedia. By the way, I don't mean to minimize the human aspect of the issue. I think anyone who knows people debilitated by symptoms that cannot be readily explained has a sense for both the suffering and the vulnerability that result. Anyhow, thanks for the thought-provoking discussion, and take your time. MastCell ^Talk 17:44, 27 May 2010 (UTC)

Hello, I’m back, after having a houseguest for several days and then enjoying the incredible holiday weekend weather. Warblers have almost all passed through, but the locally breeding birds have lots of ugly-cute babies. It's endlessly amusing to watch their family life.

Thanks for your kind understanding of my issue around offending on a touchy subject. I think it takes a pretty thick skin to edit Wikipedia, and in fact to do anything that puts one out in public (including cyberpublic) on potentially contentious issues. I'm not blessed with that; I'm just wistfully hoping for WP:NAM, and hoping that if I treat peoople with respect, they'll treat me with respect. This strategy, of course, is famously useless in dealing with bullies of various sorts; I think it's best for delicate souls to ignore or avoid them whenever possible. They've got their reasons, and they've got their natural enemies who have the chops to deal with them.

The more general issue about offending is that it tends to drive a discussion away from facts and logic, and toward irrelevant emotional defenses. Nothing wrong with emotion, we all have it and need it. It's just that it muddies the waters of an investigation of the facts. So I'm hoping to avoid stirring up that unhelpful murk.

Having said that, I, as Murphy's law would dictate, now need to ask an indelicate question. May I ask if you're naturally inclined to notice breaks in logic? I think this is a separate skill from general intelligence, somewhat like a sensitivity to spelling and usage - some highly intelligent people are not naturally good spellers, and their skin doesn't crawl when someone mixes up there, their, and they're, or affect and effect. I happen to be a good speller, but I recognize that, useful and aesthetic as it is, it could fairly be regarded as a sort of idiot-savant skill, like being good at fast mental math. I'm asking, not because I personally doubt your personal skill at logic, but because I think, not to put too fine a point on it, that there are some whoppers (or, to put a fine point on it, some commonly stated assumptions of unsubtly dubious merit) there are some consequential discrepancies in the mainstream medical literature, that somehow don't get detected by either the experts or the rank and file. And when they're pointed out, the whole profession's eyes seem to glaze over (or the hapless messenger is indignantly censured for unseemly behavior). This must mean, unless you see an alternative explanation which I'd be grateful to consider, that in the culture of medicine there is no social pressure to recognize such gaps, and could even mean that there is social pressure against recognizing them.

So I guess I've raised two (potentially thorny, sorry about that) issues - are you sensitive, in general, to breaks in the chain of a logical argument? If not, then I won't bother discussing them, but will focus on other ways of understanding reality, of which there are many. And, if you are, and have consequently noticed some of the more obvious ones in the medical literature, what do you think culturally accounts for their going unremarked? I'll end here, as it seems that considering too many issues at once is counterproductive to a straightforward discussion, and if emotional issues arise, we'll be able to know what triggered them and how to backtrack to the place where rationality was last in effect.I hope, if I say something unnecessarily tactless, you will dispassionately explain where I've gone astray and help me improve my skills in respectful debate.

I congratulate you again on your writing skill. And I appreciate your mention of the suffering caused by debility that cannot be readily explained by current medical concepts. Perhaps we would both agree, in principle, that such suffering and debility should be related as carefully as possible to any physical evidence that sheds light on the case, in order to have the best chance of alleviating it. And finally, thanks for your appreciation of the inherent limits of clinical research, when compared to more easily manipulated fields of enquiry (or is it inquiry? ;-). I think that's a rare insight, and extremely valuable.

I hope you're getting good spring weather wherever you are. You'd be astounded at how many people I saw last weekend lounging directly on the grass in shorts and flip-flops, in this LD-endemic area. Good for the local tourist economy, bad for the public health. Best wishes, Postpostmod (talk) 15:12, 3 June 2010 (UTC),

Apology/Revision

Oops, I blew it. I just resumed listening to Jon Stewart's America on CD, and my chuckles died away as I realized I had let his sarcasm infect my tone in my very recent post to you, above. I gather it's not proper WP policy to edit it out, and I don't know how to use the strikeout method yet, so please, help me out and make the following changes in it, mentally if it can't be done physically:

Replace the portion between "whoppers" and "dubious merit" with "discrepancies". Ignore the entire following sentence.

Replace my references to "you" with references to a purely abstract, hypothetical member of WP:MED, with regard to following a train of logic. Maybe be could call him/her THD for The Hypothetical Doctor.

I'm very sorry, this caught me by surprise. It's amazing how contagious an impartial tone can be, especially if it includes the pleasure of humor. Anyway I just learned a valuable lesson, and I'll be careful never to read or listen to Jon Stewart or his ilk before talking to anyone who disagrees with me! Best wishes, a much subdued Postpostmod (talk) 17:43, 3 June 2010 (UTC)

Sorry for the delay. Don't worry so much about offending me; I didn't see anything in your initial post that was anything less than civil, although I appreciate your attention to tone.

Of course I think I'm capable of recognizing breaks in logic, but then people are notoriously bad at assessing their own capacity for introspection and critical thought. One has to be wary of the Dunning–Kruger effect - my lack of ability to think critically may actually impair my ability to recognize that lack. Sorry for being, er, post-modern about it. :P

In terms of specific logical gaps underlying common medical assumptions, that's a complex question. I think there is a tendency toward groupthink, or at least accepting something because X authority said so, inherent in any complicated and highly specialized field of knowledge. In some ways it's a useful heuristic - for example, I don't consider myself qualified to analyze the relative impact of various antiplatelet agents after myocardial infarction, so it's quite useful for me to accept the American College of Cardiology's take on the subject. The danger, of course, is that if their (undoubtedly human and fallible) expert panel missed something major, then I've also missed it by accepting their synthesis. Critical thinking is essential, but it's also impossible to apply universally - there just isn't enough time, especially for a working physician or researcher, to independently assess every assumption underlying standard medical practice.

On the other hand, I'm also deeply dubious of assertions that all of the expert bodies in a field have made some major, basic error of logic. At the extreme, it's like the AIDS denialists, who claim that every scientist who's done successful work with HIV has been duped into thinking it causes AIDS. At some point, it's just entirely implausible that such a basic error could have been carried forward so far. To a lesser extent, the climate-change "skeptics" are in the same boat, as if there were some magical set of assumptions that the National Academies of every large nation on Earth have overlooked. That's not to say it's impossible, and we shouldn't set up sacred cows that are beyond reasonable questioning or debate. The trick is to know when you've passed the "reasonable" threshold.

Without knowing which specific apparent breaks in logical thought you're referring to, it's hard for me to comment intelligently on your second question. I'm guessing that it has to do with the Lyme ELISA, but it would probably be easier to discuss if I had a more concrete sense of what you're referring to. Sorry for the non-answer... MastCell ^Talk 18:29, 7 June 2010 (UTC)

Hi MastCell. Thanks for your patience with my spilkes. I like your Sontag quote. I didn’t figure that out until I was in my mid-forties. ;-)

Lots of great early summer action in the wetlands. My area is blessed with numerous parks with wide paths along water. Some of the newbie bird (and newbie bird-parent) antics are hilarious. We saw a kingbird trying to feed a mulberry to the babies. S/he tried each of the three in turn, and each tried but failed to engulf it. Good idea that didn't work out. The moms and dads are overworked trying to feed everybody, but it doesn’t last long, and I’m sure it’s well-compensated by the sense of purpose and dignity they enjoy. At least that’s how I felt at the height of my scientific career. I don’t have kids - not enough faith in the benevolence of the universe, I guess.

Now, about the logical problems with using the ELISA for LD diagnosis. Here is one notable inconsistency in the officially stated policy, which raise questions about the reliability of the IDSA guidelines. I’m using your quotes on the subject, since I can be sure that you are both aware of, and willing to acknowledge, the presence of these statements in legitimate medical discourse. Of course, there is abundant verifiable evidence to back up these statements, which we could both cite if necessary.

“ELISA is an inadequate diagnostic tool when used in isolation. That's why no one in their right minds recommends using it in isolation; for instance, as you note, the CDC recommends that diagnoses be made clinically and laboratory testing used in an ancillary role.” MastCell[[1]]

“I think Lyme disease is almost certainly grossly underdiagnosed and underreported. A more useful screening test would be hugely important.” MastCell [[2]]

I agree with you, and more importantly, I think the preponderance of data agrees with both of us. But, the IDSA guidelines say:

"Clinical findings are sufficient for the diagnosis of erythema migrans, but clinical findings alone are not sufficient for diagnosis of extracutaneous manifestations of Lyme disease or for diagnosis of HGA or babesiosis. Diagnostic testing performed in laboratories with excellent quality-control procedures is required for confirmation of extracutaneous Lyme disease, HGA, and babesiosis.’ [emphasis in original]"[[3]]

See the problem? in the guidelines, and how it contributes to the gross underdiagnosis (and consequent undertreatment, delayed treatment, etc.) of LD? And see how it's therefore not a good idea, from a humanitarian standpoint, to defend the guidelines beyond what is reasonably required by WP:MEDRS?

Hope you're enjoying the summer, best wishes, Postpostmod (talk) 15:04, 17 June 2010 (UTC)

Hi, just a note to let you know I'm still interested. Hope all's well, Postpostmod (talk) 21:04, 30 June 2010 (UTC)

Sorry - I had gotten a bit preoccupied and missed your response until just recently. But continuing our discussion is now officially on my to-do list. :) MastCell ^Talk 21:06, 30 June 2010 (UTC)

Hello, just checking in. We've been having quite the heat wave, but it just thunderstormed and Yay! it's down to 70 (deg F). Hope you and yours are well, Postpostmod (talk) 20:35, 10 July 2010 (UTC)

Hi there, checking in again, so thread doesn't get accidentally archived. (If it does, I guess we can dig it out again if need be.) I see I'm still on your to-do list. Looking forward to hearing from you. New heat wave coming here, after a few days' relief, which gave the house a chance to cool down. Hope all's well, Postpostmod (talk) 14:49, 16 July 2010 (UTC)

Sorry, I've been spending most of my on-Wikipedia time elsewhere, as you can probably see... I don't like to get caught up, but those kinds of processes are usually time-sensitive. If you ignore them and then wish you'd said what you had to say, you can't go back. Anyhow, I just haven't had the time/mental energy to continue our conversation in the past week or two, although I do intend to. I don't have an automated archive system (I do it by hand), so this thread won't go anywhere. Thanks for your patience. MastCell ^Talk 16:40, 16 July 2010 (UTC)

Just caught your reply - it didn't show up on my watchlist for some reason - oh well. Thanks for communicating, looking forward to it. Best wishes, Postpostmod (talk) 00:00, 22 July 2010 (UTC)

Hello, more great summer weather here. We're in the middle of shorebird migration, and herons seem to be on the move. Two evenings ago saw a black-crowned night heron, a great egret, and two green-backed herons, in addition to the usual few great blue herons, just at our one local pond. I've been reading books about historical epidemics, and the threat of new ones (bird flu); pretty interesting. It had never occurred to me that all epidemics are political hot buttons, but now of course it seems obvious, as they can have huge economic effects. Nobody wants to be the first to admit their country (village, town, state, etc.) is infected, because people will then avoid the region, and the stigma and economic damage can be long lasting. Apparently epidemiology routinely has to deal with public relations, governmental actions, news control, etc., in addition to the purely biological issues.

Back to our subject, I just edited a couple of sentences of my comments - one that I had mentioned before that I thought was impolite, and one at the end of my post of 17 June, which you haven't answered yet. I thought maybe the second question, that I have withdrawn, was too difficult, and that was keeping you from responding. If that's not it, could you let me know what the problem might be, and maybe I can think of a way around it, so we can continue our discussion of Lyme disease testing? Thanks very much, hope all's well with you, Postpostmod (talk) 17:26, 28 July 2010 (UTC)

Hello, I'm still interested. Best wishes, Postpostmod (talk) 14:23, 4 August 2010 (UTC)

OK, I apologize for the delay, and let me see if I can help pick this up where we (I) left off. I think that the CDC guidelines are based on Bayesian probability - in other words, the utility of a diagnostic test varies depending on what the pre-test probability is. Erythema migrans is a relatively unusual skin lesion outside of tickborne disease, so if someone shows up in a Lyme-endemic area with EM, then the pre-test likelihood that they've been exposed to Lyme disease is very high - so high that additional diagnostic testing doesn't really add much. So it makes sense that in the case of EM in an endemic area, the clinical finding is sufficient for diagnosis.

On the other hand, the extracutaneous manifestations are a different kettle of fish. Even for widely agreed-upon manifestations like joint pain, fever, myalgias, etc, the differential diagnosis is much broader than just Lyme. For those manifestations, therefore, it makes sense to utilize a diagnostic test in addition to clinical findings, because the pre-test probability isn't as high and there are other competing entities in the differential diagnosis. This applies even more strongly to the disputed manifestations of "chronic" Lyme disease, which are protean and overlap with a wide range of other diseases and syndromes - in those cases, you need some sort of diagnostic testing, or you're really firing blindly.

The problem is that ELISAs are not the most specific tests in the world. You get false positives, which is why they're frequently used as screening tests but usually require some sort of independent confirmation (e.g. in HIV testing). If you take a test with a high false-positive rate, and you apply it to a population with a relatively low pre-test probability of disease (e.g. people with wide-ranging medically unexplained symptoms), you will end up with basically no predictive or diagnostic power whatsoever.

I'm not sure if I'm really addressing your question - I apologize, but because of the delay on my end, I lost the thread of our conversation a bit. Anyhow, if I'm off on a tangent, please feel free to refocus me on the aspects of testing that you wanted to discuss. MastCell ^Talk 21:15, 6 August 2010 (UTC)

Hi there, thanks for your friendly reply. I'm in the middle of a round of family visits, should be able to reply next week. Hope all's well, Postpostmod (talk) 00:54, 12 August 2010 (UTC)

Okay, I'm back. Whew. I'm glad I have such a nice family, but it takes a lot out of me to do the social stuff for long uninterrupted periods of time.

I wrote a long, logically structured reply, but then realized it is probably not suitable for a medium like the web that relies more on skipping and skimming than on uninterrupted critical reading. It seems it's best to focus on one simple question at a time.

So I wonder if I could just ask you to try to recall where you picked up the impressions I quoted from you above, which I'll repeat here so you won't have to scroll up:

“ELISA is an inadequate diagnostic tool when used in isolation. That's why no one in their right minds recommends using it in isolation; for instance, as you note, the CDC recommends that diagnoses be made clinically and laboratory testing used in an ancillary role.” MastCell[[4]]

“I think Lyme disease is almost certainly grossly underdiagnosed and underreported. A more useful screening test would be hugely important.” MastCell [[5]]

To summarize, please tell me where you got these impressions.

Thanks! I appreciate it! hope all's well with you and yours, Postpostmod (talk) 18:17, 20 August 2010 (UTC)

Oops, I made another blunder in tone. I had bolded the quotes from you in my post of 20 August 2010 (just above this one), but it looked like I was yelling. I don't think a strikeout would fix that, so I hope it's okay if I just remove the bold from the text and put in a note that I did so.

[Note to readers: Postpostmod had originally bolded the quoted diffs just above. Postpostmod is now removing the bolding to correct the tone of the post.]

Again, sorry to have been impolite. I think I had just been needled by someone else, and inadvertently adopted their tone. (An explanation, not a justification.) Best wishes, Postpostmod (talk) 13:09, 25 August 2010 (UTC)

Hello, I'm still interested. Best wishes, Postpostmod (talk) 16:33, 2 September 2010 (UTC)

Hi there, I'm still interested. Hope you and yours are well, Postpostmod (talk) 20:13, 17 September 2010 (UTC)

Hello, I'm still interested. Best wishes, Postpostmod (talk) 13:22, 23 September 2010 (UTC)

Hi, still interested. Best, Postpostmod (talk) 20:16, 13 October 2010 (UTC)

Hello, I'm still interested. Regards, Postpostmod (talk) 13:40, 27 October 2010 (UTC)

Hi, still waiting for your reply. You must be arguing with a bunch of people on a bunch of issues, to judge from your main page. The issue I've raised is relatively easy, though, because it's not very subtle, and it's all right there in the literature, no "conspiracy theory" required. ;-)

If you'll recall, the question was regarding the accuracy of Lyme disease testing: how do you reconcile the conflicting authoritative statements by IDSA (positive 2-tier test is required for diagnosis of all non-EM cases) versus the CDC (testing should only be used to support a clinical diagnosis)? To be useful, the reconciliation must be done in a way that doesn’t sacrifice patient well-being. In other words, the fact that it's more convenient (often glossed over as “more objective”) for doctors and insurers to depend on a lab test is irrelevant if the test is inaccurate. I've looked at the data in the literature and I think they don't support the IDSA position on this one. Half of the IDSA panel that reviewed the guidelines agreed with me on this, so it’s hardly a fringe position. I was hoping to engage your curiosity so you could figure out what's wrong with the testing dogma for yourself; it's kind of a fun eureka experience, to catch the big shots making rookie errors in print. But, I guess you're never going to do that. So I'll tell you what's wrong with that literature, just for due diligence’s sake. You kindly put a lot of words into explaining your view of medical culture to me, and I appreciate it, so here's a lot of words explaining what I find important and why.

The most obvious problem is that the studies that claim to show that the two-tier test is sensitive in late Lyme disease (LD) are invalid due to using a circular argument. See, as just one of many examples, Steere et al 2008, PMID18532885. When you read the methods you can see that the study requires a positive 2-tier test for a patient to be included as someone with late LD - then, after a few pages of tables, graphs, discussions of other issues, when they get to the conclusions, they say that their results show that greater than 99% of late LD patients have a positive 2-tier test. Read that sentence again. Well sure they do, since that's how you chose them. It’s 100%, guaranteed. I know, it's crazy, and I have no idea how something so obvious keeps getting past referees and into the high-profile literature, unless they just rubber-stamp it "accept", to save time, because it's from a big-name lab. This would be disastrous for the scientific enterprise if it were common, but of course experienced pillars of the scientific community like you and me, unlike those pesky fringe people, know that only rarely would respected medical researchers do something so obviously damaging to science, and to patients.

This is just an example. The literature on this disease is full of stuff just as ridiculous, repeated over and over. I think it's the repetition that allows it to pass as true.

And why am I bugging you about it? Because you keep chiming in on the LD talk page and article. You and Tim are the two people most responsible for maintaining the page in its current incarnation, which is far from exhibiting an impartial tone regarding the controversy.

I can see that it would be embarrassing for anyone in the current WP:MED group to acknowledge a situation in which respected medical authority figures are demonstrably not respectable. And I realize that WP doesn't have any easy policy fixes for a situation like this one. NPOV does direct editors to describe disputes, not to engage in disputes, but this distinction often is ignored in practice, probably because the ability to do it is rare, plus it's not as much fun as denouncing evil-doers. ;-)

I appreciate the valuable concept of due and undue weight. In fact, even if all mainstream knowledge was as tainted as this case, it would still be important to fully document the currently dominant view, in any article on any subject, because that's the view people have to deal with in the real world, whether it's right or wrong or somewhere in between. Sick people and their care-givers, however, also have to deal with the biological reality of the disease. They don't have the luxury of believing a plausible tale told by an authority but signifying nothing.

You must have noticed that sometimes the medical hierarchy gets itself into a self-reinforcing rut. It's not helpful to get indiscriminately angry at anyone who questions authority. Sometimes they just want to help push the truck out of the rut. I'm not asking you to join them in the mud, just to examine the science in addition to the mainstream dogma, and edit accordingly. ;-)

If you're sick of this, you can always take the 5th, say you won’t answer the question, and archive the thread. I'm not the type to get mad and yell about it, as you've probably noticed by now.

Guessing that that’s what you’ll do, let me reiterate that I greatly appreciate your sharing your insights about the culture of medicine, both clinical and academic. I printed them out for future reference. I’ve been reading a bunch of books about the topic, and they’ve been real eye-openers, but there’s no substitute for off-the-cuff riffing by a practitioner.

Best wishes, from your friendly and loyal opposition, Postpostmod (talk) 21:44, 8 November 2010 (UTC)

Sorry for being non-responsive. For whatever reason, the impetus to respond to people who are aggressively obstinate or ignorant is strong, while the impetus to respond to your commentary, which has been reasonable and civil, is lower. So I guess the moral of the story is that you should be more obnoxious? :) In any case, you may have noticed that I've wound down my participation here pretty substantially, so in part I just haven't been bothering with this place as much as I used to.

About Steere et al. (PMID 18532885), I think you probably have a point. And, as I'm sure you know, Raphael Stricker raised exactly the same point in a letter published in Clinical Infectious Diseases. Steere's response was sort of, well, non-responsive. I think the paper in general was not particularly well-written. The sensitivity is going to be 100%, as you note, although the specificity depends more on the false-positive rate in the control populations. Steere et al. did explicitly mention the circular nature of this reasoning in the lead-in to their discussion, but they should have been clearer about it. For a more robust description of the operating characteristics of two-tier testing, I guess you'd have to go back to Bacon et al. 2003 (PMID 12695997) or thereabouts... without the paper in front of me, I seem to recall that they examined the test in a population that was clinically (rather than serologically) diagnosed with late manifestations of Lyme.

I should emphasize that I'm not an expert on Lyme disease, by any means. I don't diagnose or treat Lyme. That said, I can tell you that my sympathies are always going to be with a group of scientists when they're subjected to abusive, politically motivated interrogations by people who are pandering for votes rather than taking an interest in the question at hand. That's true whether it's Richard Blumenthal or James Inhofe doing the interrogating. There is fraud, abuse, and ignorance in science, but the number of times that they have been effectively remedied by politicians ignorant of the underlying subject matter is... zero, as far as I know. But I digress.

Yeah, I've noticed that medical thought gets stuck in a rut sometimes. I've also noticed that some people suffer - and I mean really suffer - from symptoms that are entirely real but medically inexplicable. And I've noticed that when medicine can't find an etiology for such suffering, into the breach rush every manner of charlatan and snake-oil salesman. Think of all of the scams that have pushed to people with medically unexplained symptoms, from candidal overgrowth to somatids to "adrenal fatigue" to "Wilson's syndrome". I'm not saying that the ILADS people are in this group, but when someone tells people with medically unexplained symptoms that they've found The Answer That Their Doctors Missed, my default attitude is skeptical. And without getting into ad hominem stuff, the background of some ILADS figures isn't especially reassuring. But again, this is a digression.

I'll leave you with a book recommendation, although you may already have it on your reading list. Take a look at White Coat, Black Hat by Carl Elliott. It's a thought-provoking read; I don't disagree that he's identified real problems, but I do feel like he didn't make even a token effort to provide a balanced perspective or seek out data that might conflict with his preconceived hypotheses. Then again, I guess we all have our blind spots. :) Anyhow, I think you'd enjoy reading the book. MastCell ^Talk 05:34, 9 November 2010 (UTC)

Hello, thanks for responding, and for cracking the paper. I've got the Bacon paper around here somewhere and will take a good look at it (I'm old-fashioned, I like to get comfy on the couch with a red pen). I ordered "White Coat, Black Hat" from my local library system, but it may take awhile because all the copies have holds on it already - must be a hot topic.

By the way, the latest NEJM has a theme of medical errors and their prevention (I think it's mostly surgical). My favorite of all the books I've read so far on errors of thought, and how to avoid them, is Groopman's "How Doctors Think". Richard Smith's "The Trouble With Medical Journals" is an excellent discussion of publication issues, and he's witty, but it's not a pleasure to read because of the book design. Of course, I got a kick out of "The House of God", which you must have read. Regarding our topic of circular reasoning, the Leggo says, "Most people who have glomerulonephritis and spit blood have glomerulonephritis and spit blood."

I'll get back to you more substantively in a few days - gotta go look at ducks now. Gorgeous weather! Best wishes, Postpostmod (talk) 18:06, 13 November 2010 (UTC)

Yes, I saw the NEJM articles on medical errors. Interesting stuff. I have to admit, I'm not a huge fan of Groopman's medical writing - I prefer Atul Gawande, or Abraham Verghese, or even Richard Selzer - but I have been meaning to look at "How Doctors Think". Thanks for the reminder to request it from the library.

House of God is, of course, a classic. I remember visiting Beth Israel in Boston - I had considered (but decided against) doing part of my training there - and they seemed quite proud of being the model for the fictional House of God. It seemed like a somewhat ambiguous honor to me, but whatever. One final recommendation is Becoming a Doctor, by Melvin Konner. He's an anthropology professor who decided he wanted to become a physician. The book contains his observations - with an anthropologist's perspective - on the culture of medical education. They aren't particularly charitable. I'd like to think things have gotten better, but some of his descriptions still have a ring of absolute familiarity. Anyhow... MastCell ^Talk 20:20, 13 November 2010 (UTC)

Hi, quick update. I ordered "Becoming a Doctor", thanks for recommending. Located and re-read the ref you mentioned, Bacon et al. 2003 (PMID 12695997). I think it's not the one you want - it's another one of the circular ones. Disclaimers within the text, but not in the abstract, where it counts. I believe you, that there exists a paper where the authors say they ignored the previously established serological status of the patient, and still came up with the verdict "sensitive", but I think I'll focus my efforts on documenting the circular ones. ;-). Craven et al. PMID: 8903216 is instructive, as to what issues were considered while setting the standards for testing at the Dearborn meeting in 1994.

Great "ducking" Sat and Sun, 10 species on local ponds. And interesting behavior: the mallards were head-bobbing to each other as they do in spring, presumably in response to the slightly warmer weather. We also saw a group of them splashing each other with water like kids in a pool. No wonder they're so prolific, they don't miss a chance for fun or romance. ;-) Best wishes,Postpostmod (talk) 15:29, 15 November 2010 (UTC)

Barnrock of general admiration

		You ROCK!!!!
		Contrary to the caption, I think you might actually be as awesome as this. Now go wail on a guitar! WLU (t) (c) Wikipedia's rules:simple/complex 20:39, 16 June 2010 (UTC)

Greetings -- thought you may have an interest in this

Hi MastCell, as a relative newcomer here I've joined in on an article that I see you worked diligently on (ironing out a scenario of WP:SOCK, WP:NPOV and WP:COPYRIGHT it seems) nearly one year ago. To make a long story short, I wish to spend some time slowly but surely working with other editors to bring this article up to Wikipedia's own standards, and I've posted this introductory note (along with a proposed infobox) to get things headed in the right direction over there. Anyhow, I recognize that you are taking a breath of fresh air from the admin world for the time being; however I felt it important to extend a courtesy note to say Mahalo, hope all is well, and if you get a chance to weigh in on my approach, great. But if not, no worries. Kind regards, Carthan (talk) 17:08, 11 October 2010 (UTC)

Looking for direction

Hey, I know you've had a run-in with this editor before, so I was hoping you could advise me on how to proceed here. [6] My best efforts at being conciliatory have not been very fruitful. Thanks! Arbor832466 (talk) 23:00, 19 October 2010 (UTC)

Hey, I'm looking for direction also. I want to know why you went to my talk page and claimed that my edit was not supported. It was completely supported by three reliable sources. Also, it is not good form to wander around looking for other editors gang up on other editors. Just a reminder. Have a good day!--InaMaka (talk) 23:58, 19 October 2010 (UTC)

I think my concerns were spelled out clearly on your talk page. They have not been assuaged by your subsequent editing. Re: Arbor832566, I would suggest remaining civil, avoiding edit-warring, and pursuing dispute resolution as appropriate. That said, if the deeply inappropriate editing by InaMaka continues, then I will either address it or refer it to another admin, because it's an abuse of this site. MastCell ^Talk 03:49, 20 October 2010 (UTC)

Re: Block

Fair questions. For the record, I was not involved in a content dispute or edit warring with the editor in question. As an administrator I was attempting to restore some order and preserve a talk page from having recent content archived and placed "out of sight". I am happy to enlighten those who are curious as to exactly what happened and why this editor has been blocked for a short period of cooling off time. I happened upon the Juan Williams article last night and noticed that there was some edit warring going on. And in particular there were some attempts to archive current material from the talk page which is not appropriate conduct. One of the threads being put out of sight had responses from this month - indeed this past few days (though the section itself had been started a year back.) It discusses some sensitive matters. But the discussion was not of a tabloid nature, it quoted from and linked to the Washington Post - the employer of Williams at the time of the incidents discussed. And referred to matters for which Williams was investigated, disciplined and apologized. Matters that were very widely reported at the time. The sole area of contention was the exact nature of the incidents. And that is precisely why we have talk pages - for forthright, civil discussion between editors. There was other recent content that the editor was seeking to archive. Wearing my Administrator hat I stepped in civilly and restored the content. Not as an editor warring with an editor. But as an Administrator restoring a long-held protocol. And I requested that this recent material not be deleted or archived. The editor immediately reversed the restoration. It was then that I spent a little time looking through the recent histories of the editor's interactions with other editors and discovered that there were several complaints of bullying by this editor. I investigated and I regret to say that I did find numerous examples in just the preceding 24 hours of a very aggressive tone and threatening text towards other editors in both his messages and in his edit summaries. They are all there to be seen. By way of example he wrote to Veriss1 "I've set you right. Don't do it again". And "Anyone who continues to use Wikipedia to fight these battles will be taken to task". He wrote to Davidpatrick: "You either go with the sources or you don't edit." And "You either need to learn how to write biography articles on Wikipedia, or you need to stop writing. It's very simple." Those types of comments are not conducive to healthy discourse.

Being charitable and assuming that the editor is generally of good faith but perhaps being a hot head in the heat of edit warring, I decided to give him a clear warning that he could be blocked for his actions in removing article talk page material and uncivil interactions and inviting him to respond. By referring to the specific Wikipedia guidelines that he would be encouraged to review during such a suspension I truly hoped he would take a deep breath and realize that if several people (at least two editors and an Administrator) were all unhappy with his tone of discourse that perhaps he needed to cool down. But his immediate response was belligerent and to declare that I was "a meat puppet for Davidpatrick and Veriss1". Apart from the fact that this is patently false, it unfortunately confirmed the identical issue that the other editors have complained of. Namely a bullying aggressive tone that is counter-productive to civil discourse on Wikipedia. That is the reason for the block. I truly hope that the time off will help the editor to read Wikipedia:WikiBullying, Wikipedia:No angry mastodons, and WP:CIVIL and reflect on the merits of a calmer more friendly approach to fellow editors, even in the heat of disagreements. (PS. I'm sending this same reply to the other two individuals who responded, plus I'm posting this on my own talk page in case anyone else posts a similar query). 23skidoo (talk) 12:44, 27 October 2010 (UTC)

Now that this incident has blown over, I hope you're interested in sticking around to work on more potentially productive areas of the project. MastCell ^Talk 15:53, 5 November 2010 (UTC)

FYI

I feel you should know that I mention you here. I am very upset about this thread so I would appreciate any input you may have about what is going on there. Thanks, I'm stepping back for a few to calm down, --CrohnieGal^Talk 13:55, 30 October 2010 (UTC)

Drwilson48

I don't know if you noticed, but a couple of hours after you left a note for User:Drwilson48 about edit warring, User:Stevenson1425 took over the campaign to suppress criticism and promote favorable information at the IAHP article. WhatamIdoing (talk) 01:44, 5 November 2010 (UTC)

OK, thanks for the heads-up. I will look into it. MastCell ^Talk 02:06, 5 November 2010 (UTC)

Israel-Palestine editing

Hi MastCell, following the recent deterioration in editing of the Israel-Palestine set of articles, I've set up a page to discuss the problem and possible solutions at Wikipedia:WikiProject Arbitration Enforcement/Israel-Palestine articles. Your input would be appreciated. PhilKnight (talk) 15:15, 5 November 2010 (UTC)

I don't actively follow that set of articles, so I hadn't realized that the editing environment had deteriorated. I've tended to stay away from the area more recently, because I find the editorial dynamics depressing. I've recently become much more selective (or selfish, if you like) about how I spend my volunteer time here. In any case, I will take a look at the page you mention, but I can't promise anything in terms of input or follow-through. MastCell ^Talk 15:57, 5 November 2010 (UTC)

ANI thread regarding libel claims at National Council Against Health Fraud

I appreciated your attempt to improve the sourcing of this section, but the LIBEL claims needed to be addressed formally. I started an ANI thread in which I mentioned you here . --Ocaasi (talk) 21:08, 10 November 2010 (UTC)

MEDRS

What the heck is the agenda here? Wikipedia talk:Identifying reliable sources (medicine)#Policy.2FGuideline. Either I'm obtuse, or he's obtuse, or there's more to this than meets the eye. (Yes, I've seen the ANI thread, and I can't figure if this is just obtuseness, a misuuderstanding on my part, or polite POV pushing). SandyGeorgia (Talk) 23:22, 11 November 2010 (UTC)

Sandy, if I may chime in, QG and I have a brief but fairly involved history at Chiropractic where the article has been whipped into nearly textbook scientific form through QG and other's strident and strict application of WP:ASF (which is now kind of just WP:ASSERT) and WP:MEDRS which has given very strong weight to particular systematic reviews regarding the general safety of Chiropractic. So, I put MEDRS on my watchlist. I can explain more, but basically, that is the extent of the topic-specific background you need to know.

A few days ago I saw QG had removed text explaining the hierarchy which subordinates MEDRS to NPOV, for one, and after considering replacing it, finally did today (coincidentally or not, on an evening he suggested I might be breaching wp:libel). Anyway, the impetus may not have been entirely random, but I had it on my to-do or to-consider list for a few weeks, and I replaced it.

As you probably know, there's been a debate/battle for quite some time about NPOV vs. SPOV. MEDRS has been a big help for scientific sourcing, and I don't regret that a bit. I have more trouble with the way it has been imposed on alternative medicine articles, however, where some of the articles have imo, a nearly anti-alternative-medicine bias. That may be expected in certain instances where research has not matched up with alt.med practicioner's claims, but it also may be part of a broader and less neutral opposition. So, MEDRS is very much at the center of debates around Pseudoscience, and Chiropractic, Accupuncture, Alternative Medicine, etc. are all highly controversial articles, many of which have been to ArbCom and back.

All of that still, however, had nothing to do with my advocacy for SlimVirgin's addition. I've been working on unrelated policy issues for a few months, trying to do basic cleanup for consistency and simplicity. I thought the statement-in-question was a helpful pointer, and as a relatively new editor, always found a high level of confusion between policies and guidelines, especially RS (and implicitly MEDRS) which comes into play on virtually every article, and particularly so with contentious and explicitly medical issues.

After that, I just thought it was a matter of finishing the conversation where it started. I figured that if Colin objected to it being on MEDRS, that we might as well hash it out there rather than on the template page; if one content guideline objection can't be overcome I wasn't sure it was worth continuing more broadly. That's pretty much it.

Policy is a big mess and lots of people are trying to clean it up in a variety of well-intentioned though not particularly coordinated ways. At the same time, different snippets of policy portend to sway the balance in delicately stacked controversial articles. Sometimes small edits are not always small, or they can seem to be motivated by a broader agenda. As I said above, that may have been the nudge, but I was looking at these policies for quite some time relative to my brief tenure, and intended to work on those statements anyway. As the RfC now going on a wp:V suggests, this is a tip-of-the-iceberg issue regarding clarity and consistency of policies. Which brings the background up to date. Does that not cover anything? Ocaasi (talk) 01:48, 12 November 2010 (UTC)

I recall a fellow editor once equating the level of obtuseness with word count. Somebody then did something about it Shot info (talk) 02:10, 12 November 2010 (UTC)

And on an aside - where's Elonka and WP:TAGTEAM when you need it!!!!1one :-) Shot info (talk) 02:12, 12 November 2010 (UTC)

Shot, you made a pretty strong point that we should be focusing on issues not editors. I presume that word counts are included in the red-herring category. Would you mind dropping the haranguing. If you want the focus to be on the article rather than the miscellaneous side issues, please do so as well. Ocaasi (talk) 02:20, 12 November 2010 (UTC)

Sometimes the best thing to do is not to reply if you don't like how things are going for you. It's not my fault that this new editor "Ocaasi" has lit up my watchlist - probably the same as lots of other editors - as you have no doubt by now noticed and after much shopping at many noticeboards - found you are being ignored? Now I wonder why that is :-). BTW, "haranguing" - reframing the argument is something that is easily seen through here in WP. Also I reveal in the irony of having you asking me to focus on the article - rather than issues. Yet all over my watchlist there is "Ocaasi" focusing on many issues - mainly of his own creation. Who would have thought it :-) Shot info (talk) 03:00, 12 November 2010 (UTC)

Shot, I don't mind how things are going at the moment. I got more in-depth/detailed than I should have re QG on the NCAHF talk page, and have been working on the sources since. The only noticeboard was AN/I. MEDRS was only tangentially related, as is this. Haranguing was not about the article but about your following here to make a not-exactly-necessary comment on the length of my post. I asked you to focus on the issues, because you asked me to focus on the issues. If you're serious about it, good, then we can drop the unrelated stuff, and perhaps return to the article content. Ocaasi (talk) 03:16, 12 November 2010 (UTC)

I think you are confusing me with another editor who has asked me to focus on the issues - which is really not unusual as you haven't really being focusing on the issues at all, so to have other editors ask you this is quite honestly unsurprising. My point (sarcastic as if may be) is merely to help remind you that we are here to do something - although the way you are editing at the moment reminds me of something WP isn't supposed to be. Read those archieves yet? :-) Shot info (talk) 03:23, 12 November 2010 (UTC)

I think battlegrounds are best left elsewhere as well, but I can't quite figure out your mix of antagonism and advice. You don't want this to be a battleground and you don't think we should focus on editors, but you seem somewhat invested in the article and are making comments about an editor. I'm not seeing the 'let's make an article' at the bottom of it. As I said above, if you feel like dropping the comments and sarcasm and focusing back on the content, that would line up nicely with what you've suggested. If you prefer to keep it up, I'll just let you share this moment of peculiar revelry by yourself. Ocaasi (talk) 03:36, 12 November 2010 (UTC)

So no, archives not read yet? Pity. By doing so you will see and understand and perhaps comprehend why it appears that your edits are not being viewed in good faith. I can only point you in the direction - you however can (and probably will) continue to write reams about it... Shot info (talk) 04:21, 12 November 2010 (UTC)

• OK, guys. Let's take a break, or at least take it outside. To go back to the policy question, I feel pretty strongly that this site needs to provide high-quality, accurate, scholarly medical information. For all the BLP zealotry, well-founded as it is, I think the medical articles are far and away more important from both an ethical perspective and in their potential for real-life harm.

  WP:MEDRS (and the best practices codified in it) are meant to apply to all medical content on Wikipedia, including alt-med articles. Alternative medicine articles aren't a free-fire zone where we drop our sourcing requirements. We owe readers accurate, high-quality, encyclopedic information on alt-med topics just as much, if not more, as on more mainstream medical topics. It's harder to write good articles on alt-med topics, because there are proportionately fewer quality sources and exponentially more crappy sources, but we can do it if we work at it.

  The editing of policy pages raises a couple of concerns. One of them I codified here as point #5: I'm not a big fan of editing policy pages to influence a specific content dispute. That's a temptation to be avoided wherever possible. One of the reasons that policies and guidelines are such a bloated mess is that they're often edited to influence specific content disputes. Or else they're edited as part of a years-long crusade by individual editors who want policy to reflect their personal vision of Wikipedia. Both of these are the wrong approaches - policies should be altered to reflect what's working in practice. The medical articles work, in practice, for the most part - at least they're among the best content Wikipedia has to offer, and they're steadily improving. WP:MEDRS was an attempt to codify the practices that have led to success in this topic area.

  As to Sandy's question about more than meets the eye: I guess my cynical answer is that wherever SlimVirgin is involved, there's bound to be more than meets the eye. I don't think it's a secret that she has an agenda that she wants to see reflected in this site's content and sourcing policies. That agenda hasn't really attracted much support, but anyone experienced in the ways of this site realizes that you "win" disputes not by convincing people by force of reason, but by outlasting them. So we see these same tropes inserted into various policy pages every few months. A cynic would conclude that she's just waiting for the people who have opposed these changes to wither away or get tired and give up.

  To go back to Sandy's original question, I do think there's a bit of soup-spitting here. I doubt it's intentional or malicious, but a number of people (more patient than I) seem to be getting the feeling that they're going around in unproductive circles. MastCell ^Talk 04:56, 12 November 2010 (UTC)

• Thanks ... sorry you had to type so much to confirm that I'm not obtuse :) SandyGeorgia (Talk) 09:06, 12 November 2010 (UTC)

Thanks for the link to WP:SOUP. Never seen that before. Brilliant. Colin°^Talk 09:08, 12 November 2010 (UTC)

I'm not as dumb as I look, and polite TLDR posts don't obscure when a POV is being pushed by attempting to change policy. SandyGeorgia (Talk) 09:11, 12 November 2010 (UTC)

Sandy, I thought an explanation was what you were looking for, so I went into the details. Naming policies may seem like a distraction, but that was the language I found in use on alt.med articles, not an attempt to obscure things. As for a POV, I somewhat took on one side of the debate at Chiropractic, but I don't consider policy something that should be used to suit particular articles--something I was trying to avoid at MEDRS. I have tried to explain my subject-related involvement, which doesn't eliminate a potential bias, but it lets editors know some of the context... Ocaasi (talk) 12:20, 12 November 2010 (UTC)

Proposal to move Autism to Autistic disorder

Hi MastCell. Your expertise would be welcome at this proposal. Anthony (talk) 17:02, 13 November 2010 (UTC)

I felt like I was reading the book version of Minority Report

Might want to keep an eye on the Journal of Personality and Social Psychology for the next month or two. NW (Talk) 17:23, 18 November 2010 (UTC)

Why am I reminded of the opening scene of Ghostbusters? This might actually be a useful illustration when I give talks on introductory biostats, approaches to the medical literature, and Bayesian reasoning. Let's say the prior probability that psi phenomena exist is - what? - 5%, based on existing knowledge. And then you have a paper, or a series of papers, which find statistically significant evidence of psi phenomena with a p value of <0.05. What is the post-test likelihood that psi phenomena exist? What is the likelihood that the papers' findings are true, as opposed to false, positives?

Of course, the acknowledged authority on this sort of thing is John Ioannidis - his paper on "Why Most Published Research Findings Are False" gets my vote for most thought-provoking publication in the field, and clearly applies to the paper you mention. The studies hit almost all of Ioannidis' red flags - small sample size (for individual studies), small effect size, "flexible" design (for example, they spiced up the erotic images when they found men weren't responding to them as expected), etc. It's a good illustration of the dangers of science-by-p-value. MastCell ^Talk 19:05, 18 November 2010 (UTC)

Very interesting, I'll read more when I have a few spare moments (at this rate, sometime in January 2012...) However, I'll try to dig up a link passed on to me by a former colleague about the problems with peer review, and how difficult it is to get published when the reviewers don't like one's results, regardless of the quality of the study. Risker (talk) 19:18, 18 November 2010 (UTC)

I'm going to assign my class extra-credit of calculating the Bayesian likelihood for the results quoted in paper NW refers to. I wonder if the authors of this study were aware of Lindley's paradox. In fact, the Wikipedia article that I cite gives away the correct answer. Amazing. ScienceApologist (talk) 19:49, 18 November 2010 (UTC)