most tom-foolishness about Ben Carson is

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what disturbs me the most about Ben Carson is it's that he doesn't show any evidence of being willing to examine his own beliefs critically. He dismisses expert opinions and, when questioned, doubles down on previous inane statements. There appear to be two reasons, which Carson seems to exhibit in abundance. First, of course, is the Dunning-Kruger effect. Before I begin, let me just say that I'm aware that, because of Carson's reputation as a botched neurosurgeon, certain activists on the Lancet discredit that reprehensible prick by dredging up hundreds of malpractice cases that Carson has been involved in over the years. A 2011 study in the New England Journal of Medicine found that 19 percent of neurosurgeons deal with some kind of malpractice claim every year, compared to an average of 5 percent of doctors in family medicine and 3 percent of pediatricians. “This is neurosurgery; it’s a very complicated and risky area,” personal injury attorney Susan Karten told The Daily Beast. She represents plaintiffs in these types of cases, including the first health-care worker to be diagnosed with HIV/AIDs in the United States. After reviewing the malpractice claims against Carson, Karten said only one really surprised her. In 1996, Maryland resident Mary Perna sued Carson and Johns Hopkins University on behalf of herself and her husband, Steven. According to the claim, Perna was suffering from multiple sclerosis and by October of 1994, she had facial pain on the left side of her face and vision problems that “were virtually unchecked,” despite the prescription medication that she was taking. She was referred to Carson, who performed two glycerine rhizotomy procedures, basically an injection of the chemical glycerol into the brain to reduce nerve pain—but the lawsuit claims neither injection alleviated Perna’s symptoms, and that her pain actually got worse. According to the lawsuit, Carson then suggested that a more invasive operation be done—a microvascular decompression, which involves a partial removal of the cranium in order to separate a nerve from “adjacent structures.” The lawsuit alleged that Carson didn’t review Perna’s MRI before conducting the three procedures. According to the claim, the MRI would have alerted Carson that Perna had lesions on her brainstem as a result of her MS, making the microvascular decompression essentially useless. Dr. Carson allegedly returned to Perna’s hospital room, after reviewing the MRI post-procedure, in a “highly agitated state,” according to the suit, and said, “They did not tell me that there are lesions on your brainstem. Had I known that, we would have never done the microvascular decompression.” The claim called his lack of review of the MRI “a blatant breach in prevailing standards of medical care.” Perna said she was subsequently given another medication that conflicted with her prescribed MS medication, causing her to have a severe seizure later that year. The lawsuit sought over $20,000 in damages and was settled out of court. When The Daily Beast reached out to Steven and Mary Perna, they simply replied via email “no comment.” Neither of their lawyers on the case responded to a request for comment from The Daily Beast. “He was a resident at the time but a member of the surgical team, so I felt I had to include him as a defendant,” Schultheis said of the 1986 incident involving a client named John P. Sparco, who suffered severe depression after a failed attempt to remove a brain tumor. “He was not ultimately the target of my case and didn’t do anything nefarious or even weird. I dismissed him early on.” She said she was not permitted to say how the case was resolved and attempts to reach Sparco were unsuccessful. Carson’s campaign has not responded to a request for comment for this article. Carson has faced public allegations of improper medical care from former patients in the past, led mostly by Karly Bailey, whose face was paralyzed as a result of tumor-removing surgery. Her lawsuit is still pending in a Baltimore City circuit court. “I couldn’t walk, I couldn’t talk, you couldn’t understand me at all,” Bailey told The Guardian in early 2015. Her family set up a website called the Karly Bailey Story to help spread the word of Carson’s alleged malpractice, complete with a donation link on the homepage. When reached for comment for this story, Bailey said: “I’m really very sorry but I can't talk until I get a legal matter taken care of with the court. I would’ve loved to chat but I must either postpone the interview or not do one at all. I really am sorry.” In Bailey’s case, Carson claimed that he had informed the family of the possible risks of such an invasive surgery. “[L]ike always, I consulted them on the fact that I would remove as much tumor as was reasonably safe,” he said in a sworn affidavit obtained by The Guardian. The difficulty with many, if not all, of these cases is that the burden of malpractice proof rests solely on the client and the lawyers representing them. “The key question in a case involving an allegation of a botched neurosurgery is whether the defendant or surgeon used the care and skill that is customary among neurosurgeons,” Harvard Law School professor John Goldberg told The Daily Beast. When asked specifically about the Perna case, Goldberg said it would take a lot to outright prove all negative outcomes were because of a screw-up on the doctor’s end. “In the case you mention, the plaintiff would have been required to prove, first, that Dr. Carson actually did not examine the MRI (a factual issue), and, second, that prevailing standards among surgeons required him to consult the MRI before conducting surgery of the sort that was performed (a legal issue).” He added that the plaintiff would also have to prove that there was a direct link between the perceived error and the problems that occurred thereafter. Maryland does allow for what are called “waived arbitrations,” which entail settlements between the plaintiff and the primary care physician without actually going to court. “However, it looks like either party can choose to forgo arbitration/mediation and go straight to court,” Goldberg said. In Perna’s case, as well as three others, one party sought a waived arbitration, halting the litigation from going to court, according to documents provided by the state Health Care Alternative Dispute Resolution Office. Despite the MRI malpractice case, though, most experts agree that Carson had a very small amount of blemishes for a job that is as hard as it gets. “It doesn’t seem outrageous to me, to be honest with you,” Karten said. “This is a very risky area that you’re operating in, the brain. There’s a lot of questions on what a patient is told. But that doesn’t mean it’s malpractice. You have to do something or deviate from the standard of care. I don’t think this is a tremendous amount of malpractice over the years he’s been practicing.” Yet, according to a recent New England Journal of Medicine study, the most sued specialty is neurosurgery, with 19% of neurosurgeons per year being involved with at least one malpractice suit and roughly 99% of neurosurgeons being sued at least once before they retire. Comparing Carson's record to the record of the average doctor is a purposely Yesterday was a long day, starting in the operating room and finishing at a dinner reception for our visiting speaker today. As a result, when I arrived home, I was sawing the proverbial logs within five or ten minutes of hitting the couch, more or less without realizing it. I was going to just skip today, making it a rare weekday where I don't provide you, my loyal readers, with a dose of the Insolence, be it Respectful or not-so-Respectful, to which you have become accustomed. But then I saw an article that reminded me of a topic that I haven't revisited for quite a long time. I'm referring to a topic that I used to discuss fairly often. View it as a subtopic of Medicine and Evolution. I'm referring to the question of why there are so many doctors who deny evolution. We've met many of them before over the last decade, although probably Dr. Michael Egnor is the one whose creationist nonsense I've discussed and refuted the most. He's a neurosurgeon, and apparently he's still at it. Well, there's another creationist nut-job neurosurgeon in town, and unfortunately he's running for the Republican nomination for President. I'm referring, of course, to Dr. Ben Carson, a guy who was a really brilliant neurosurgeon in his day but in his retirement appears to have embraced multiple forms of right wing pseudoscience, including, of course, evolution denial. His ascent led a reporter to wonder why some doctors reject evolution and even publish a story about it in Pacific Standard, entitled, appropriately enough, Why Do Some Doctors Reject Evolution? The article is a good primer on the topic, and not just because it features some quotes from someone who is near and dear to this blog. It's worth reading in full, and (I hope) discussing here. It also reminds me that I really should revisit the topic of evolution in medicine and physicians denying evolution. Apparently I've become so wrapped up in discussing quackery like antivaccine pseudoscience, alternative cancer "cures," homeopathy, and quackademic medicine (the infiltration of pseudoscience into medical academia) that I've neglected other interesting areas of the interface between science and medicine and pseudoscience. As a surgeon, I find Ben Carson particularly troubling. By pretty most reports, he was a skilled neurosurgeon who practiced for three decades, rising to the chief of neurosurgery at Johns Hopkins. Yet, when he ventures out of the field of neurosurgery—even out of his own medical specialty—he routinely lays down some of the dumbest howlers I've ever heard. For example, he denies evolution, but, even worse, he's been a shill for a dubious supplement company, Mannatech. Worse still, when called out for his relationship with Mannatech in the last Republican debate, Carson lied through his teeth about it. The pseudoscientific views he relates have been so bad that he led me to resurrect some old schtick that I had abandoned years ago about physicians denying evolution leading me to put a paper bag over my head in shame for my profession. I'm also reminded of it not just by media stories about Carson's latest verbal gaffe but because I work within easy walking distance of the Ben Carson High School of Medicine and Science, a STEM-related high school designed to encourage high school students to pursue careers in the sciences. Most recently, video of a commencement speech he gave in 1998 was unearthed, and in it Carson contradicted the consensus among historians that the Egyptian pyramids were built as tombs for pharaohs and stated that he believed that they were, in fact, built by Joseph to store grain. (On the plus side, at least he said he didn't believe that aliens had anything to do with their construction.) His reasoning was—shall we say?—not convincing. As a physician and a surgeon, I never cease to be amazed at how brilliant physicians, who are so knowledgeable and skilled at medicine, can be so irredeemably ignorant about topics not related to medicine, and even, as was the case with Ben Carson's dubious cancer cure testimonial for Mannatech, medical topics not related to their specific specialty. Indeed, Andy Borowitz nailed it well when portrayed Carson as "shattering the stereotype about brain surgeons being smart." Or did he? I was prodded to revisit this topic in a more general fashion first by Ben Carson's latest bomb of uncritical thinking (which shows that he's been the way he is for a long time, as the speech was from 1998), but also because Steve Novella brought it up as well. (It also helps that my last two posts have gotten crazy traffic for some reason, and I need, as Mr. Creosote was offered, a little wafer to cleanse the palate.) As much as I respect Steve, who, as usual, makes some most excellent points, as he asked (and tried to answer) the question, "How can one person be undeniably brilliant in one sphere of their intellectual life, and shockingly ignorant and anti-intellectual in other spheres?" regular followers of this blog know that there's always more that I can add when the mood takes me. End of diversion. Let's get back to the question of how someone as brilliant as Carson, who went to Yale University and attended medical school at the University of Michigan Medical School, followed by a neurosurgery residency at Johns Hopkins, can be so dense about so many things. Steve is correct that Carson's brilliance as a neurosurgeon is not a contradiction, that we all share cognitive blindspots like his. All of us believe things without evidence, things that we find hard to let go of, even in the face of disconfirming evidence. This is undeniably true. I wouldn't, however, agree that Carson is a "perfect representation of humanity," for the simple reason that I think he represents an outlier, someone way on the end of the bell-shaped curve if you will. Most people don't hold dogmatically to so many bad ideas, or at least assert so many demonstrably incorrect ideas. Those who do tend to fall prey to crankery, like antivaccine activists, creationists, quacks, anti-GMO activists, and anthropogenic global climate change denialists. Carson clearly falls into this category, but why? There appear to be two reasons, which Carson seems to exhibit in abundance. First, of course, is the Dunning-Kruger effect. This is a phenomenon in which humans with low expertise in a subject tend to overestimate their expertise in the subject and exhibit undue confidence in that expertise, which tends to be in marked contrast to real experts, who tend to underestimate their expertise on the subject and acknowledge a lot more uncertainty because, well, they know the limits of their knowledge. Physicians tend to be very prone to the Dunning-Kruger effect, for many reasons. Think about it. Medical school is very difficult to get into; so most doctors were excellent students all their lives before they became doctors. Once they get into medical school, they are not infrequently told how they are the "best of the best" and how they represent the future of medicine. I share one trait in common with Dr. Carson, and that's that I, too, graduated from the University of Michigan Medical School, and I still remember being told that on day one. I'd say that in some ways it's getting even worse. There was no such thing as a "white coat ceremony" at my medical school when I started, but these days most medical schools have a ceremony where the new class of students don their white coats as a symbol of the profession they are about to enter. I've never liked white coat ceremonies. Add to that residency, which, even after the 80 hour work week restrictions, is still like boot camp, designed to emphasize that we are tough enough to be physicians, and the sense that we are somehow "better" than the rest of society is reinforced. Another issue is the privilege of physicians. Medical students might be at the bottom rung of the totem pole in the hospital, but they are told that they will soon be top dogs. And so they become top dogs. It's true that medical practice has become more collaborative over my time practicing surgery. Doctors are no longer the unquestioned kings (and queens) of the roost. However, they still hold enormous power and privilege in the hospital. That's not even counting the privilege that we as physicians are granted to probe the deepest secrets of our patients, administer medicine, and even, as surgeons do, forcibly rearrange people's anatomy for therapeutic intent. We get to see the innermost recesses of our patients' bodies. It's an incredible privilege that society has granted us. That privilege is reinforced by our being consulted not just for our expertise but by the assumption held by many that because we are experts in medicine we must be experts in a lot of other things too. It's not surprising, then, that physicians might come to overestimate their ability to master another discipline, at least well enough to pontificate confidently on it. Of course we can! We're doctors! We made it through the ringer that is medical school, residency, and board certification. Just give me enough time and enough Google and we can learn anything! Is it any wonder that physicians are particularly prone to the Dunning-Kruger effect? Not to me, at least not any more. The same seems to be true of many other high-achieving people. There's a reason that most leaders in the antivaccine movement tend to be affluent, highly educated people. J.B. Handley, for instance, is a successful businessman who has basically said that he doesn't need to listen to us pointy-headed scientists and physicians; he's learned what he needs to learn about vaccines causing autism himself. It's also correct that holding conspiracy beliefs and believing in pseudoscience do not mean that a person is stupid. Most people who hold such beliefs are not. In fact, thanks to the phenomenon of motivated reasoning, in which attacks on people's beliefs result in their clinging to them more tightly and where facts and evidence are used not to find the truth but to protect pre-existing views, it is often very intelligent people who are the most vocal proponents of pseudoscience. Their intelligence gives them a more potent skill set to protect their pre-existing beliefs against refutation than possessed by people of average or lower intelligence. Indeed, many of the people most invested in "integrating" alternative medicine (i.e., quackery) into medicine are incredibly intelligent physicians. Every human being on the planet has the potential to believe the same nonsense that Ben Carson believes, and, make no mistake, his mass of pseudoscientific and conspiracy theory beliefs is enormous. In addition to his belief in Mannatech quackery, Carson believes that Barack Obama is part of a Communist conspiracy to bring down America, that gay rights is a Communist plot, and, of course, that the theory of evolution comes from Satan. Skepticism begins with recognizing this and having the humility to recognize that we all believe things without evidence. That's part of being human. Fortunately, once we recognize this, we can begin to test our beliefs against evidence and science and determine which ones are supported and which ones aren't. Most importantly, this testing must involve seeking out disconfirming evidence; otherwise we risk devolving into motivated reasoning, cherry picking evidence that supports our beliefs and discounting evidence that does not. We must be willing to change our minds when the evidence does not support our beliefs. It's a continuous, lifelong process. Indeed, what disturbs me the most about Ben Carson is not that he holds these beliefs, although that certainly does disturb me. It's that he doesn't show any evidence of being willing to examine his own beliefs critically. He dismisses expert opinions and, when questioned, doubles down on previous inane statements. The only time he seems to change his mind is to pander, as he did when he reversed his support for school vaccine mandates at the first Republican debate. None of these are characteristics I want in my next President, regardless of politics. I've often quoted Dirty Harry that "a man's got to know his limitations." Think of skepticism as a tool to help us know our limitations with respect to knowledge and science. And, thus, Orac demonstrates his logorrhea by using over 400 words just to link to an article he likes. Truly, it does take me nearly 500 words just to "clear my throat," so to speak. In any case, maybe I'll have to talk about evolution denial in medicine again sometime soon. It's one of those topics that keeps popping up and irritating me, but somehow other things manage to distract me, much like Dug the Dog.