The Physician’s War
The Story of the Hidden Battle between Physicians and a Science Based on Pathological Consensus
This is my first post about the book “The Physician's War: The Story of the Hidden Battle between Physicians and a Science Based on Pathological Consensus" available at Amazon.
In the book, I joined Dr Lawrence Lynn to discuss critical care science. The book is unique in scope, ambition, and content. We don't present the top-down patronizing approach you are used to receiving from critical care scientists. Instead, we dig into the history of critical care and find what went wrong and how errors were perpetuated as dogma.
The tipping point was at the bedside when you and I realized most COVID-19 patients were not responding to PEEP tables and “protective” ventilation was actually dangerous. What was wrong with ARDS protocols? It is much deeper than it seems.
I transcribed an excerpt from a Datamethods discussion titled “The End of the Syndrome in Critical Care” where Dr Lynn and I discussed why we decided to present our ideas in a book.
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(Dr Lynn) "My view is that we talk endlessly about these things but that’s not productive except perhaps as a catalyst for the young. My goal is more ambitious. I hope to induce or precipitate the deep debate and dialog required in critical care science. This was the reason for the book coauthored with @Rafael_Leite and David Lynn.
So far the leaders will not debate at a deep level. This is the reason we wrote the book for the lay public and the non critical care scientists because lumping scientists are not going to read it. The term “lumping scientists” is not disparaging, this is fundamental to the method by which they modify Hill’s technique.
There is always the theoretical “common driver” argument, which was the basis for the lumping in the 1960s, but a common driver of which diseases in which mix of the diseases under test?
Are not RCTs hard enough when diligently following the single disease model of Hill?
Yet no one will talk about this. It seems that the option of moving from the synthetic syndrome lumping model and going to the single disease model and then combining the diseases later for which a common response to treatment is identified, should, at least, be debated.
We should, at least debate whether the Petty/Bone RCT shortcut (lumping by threshold) modification of Hill’s method is valid and if so what are the parameters rendering the Petty/Bone RCT method valid? To my knowledge no statistician ever investigated the Petty/Bone RCT method Petty/Bone was presented to them as a single disease equivalent (I.e. Hill’s method). In other words, statisticians think they are using the RCT method of Hill and Fisher, not Petty& Bone.
Yet the standard in critical care is the Petty/Bone RCT method. No one questions it. Perhaps no one even thinks to question this decades-old standard method. Furthermore, I don’t think any of the statisticians are aware.
This is not something that the syndrome science thought leaders can consider or perhaps even comprehend. They have been indoctrinated in the Petty/Bone RCT method and they think randomization allows the modification.
So action by leaders of the overarching philosophical and mathematical dimensions of science are required at a deeper thinking level than the thought leaders are capable of, within the constraints of their bias in their own clinical RCT realm. Specifically, this requires those from outside the discipline at a higher academic level that the “realm leaders” cannot ignore.
Critical care syndrome science will aggressively debate vaccines, masking, the need for a 30cc/kg mandate for sepsis, and almost anything. It goes on in Twitter all the time. However, they will not debate, for one minute, the “science of their own science”. That, they will not discuss. You will never see them here and I have often invited them.
So they cannot do it. They are too weak as a function of their bias. This also is not disparaging. Who is not intellectually weakened by their own bias? Therefore, the appeal now is to the public and to the scientists and philosophers of science itself. They are the only hope to get introspection and debate which is required to maintain the validity of any science.
Open debate and open minds are the two ingredients required to produce the almost magical self-correction feature which is characteristic of real science. We need that now for the world’s health."
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I have subscribers from 70+ countries. I think many will identify with what goes next.
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(Dr Leite) "Unfortunately, the critical care community is not prepared nor willing to pivot away from “lumped by threshold” syndromes like ARDS and sepsis.
After decades of replacing disease definitions with arbitrary thresholds, critical care has normalized the mistake and enthroned it as a dogma. As I said elsewhere, try to convince a physician that pneumonia is not pneumonia until the patient is hypoxic or crosses any other arbitrary threshold. Threshold definitions are not disease definitions. They won’t generate a treatment because they don’t point to a treatable cause.
Notably, it is easy to see what is wrong in this distorted form of science. Nevertheless, the field is paralyzed, testing interventions without a disease model.
In the book, we discuss how the field is stuck in such mistakes. To begin with, consensus threshold definitions are the NIH standard for funding. Instead of sparking innovation, the agency now acts to prevent innovation in the field of critical care.
Moreover, there is a move that may run unnoticed in America. American influence was the vehicle to spread the apical mistake made by Petty and Bone everywhere in the world. There is no place in the world for questioning the dogma. We described it as a form of intellectual colonization.
We shouldn’t expect critical care researchers to change the course anywhere in the world. They will keep publishing and receiving grants inside the dogma.
Critical care is trapped in this conundrum and won’t fix itself from inside out. We bet on data scientists, scientists from other areas, and the lay public to call for change.
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We are calling for a worldwide discussion of critical care science. Join us!
For those so comfortably placed inside the box, there is no incentive to think outside of it, or to let anyone else do it.