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  • Winter 2022 Editorial: Half Empty

    Is the glass half empty? Betteridge's law of headlines states: "Any headline that ends in a question mark can be answered by the word ‘no.’ ”

    This is not just a joke. It’s one of several reasons we tend to think things are much worse than they really are. Journalists are taught to scare us and get our attention. So, they pose questions, without good evidence, that in our minds, suggests a horrible alternative. But we remain suckers for this and other journalist scams. We regularly forget that their agenda is to first get us to read, watch or click and then to entertain us. Information and understanding are low priorities.

    You remember the lesson in high school. Newspapers learned that the headline, “Dog bites man” works, not the other way around. We get that. But if Martians came down to visit for a while, they would read our newspapers and assume that humans are the biters and dogs their bitten victims. The bias towards shocking us means that we, as well as the Martians, will usually get the wrong and dreadful impression.

    Unfortunately, this gives most of us anxiety that things are going very wrong. Certainly, we’ve been acutely aware of many bad things lately including COVID, dysfunction in Washington D.C., the partisan divide, economic threats locally and globally, international saber rattling, the rise of authoritarian governments, etc.

    The Brookings Institution reports that almost half of all Americans anticipate that there will be another Civil War (presumably with fewer cavalry charges) in the next decade. Don’t believe that. Don’t lose sleep over these silly surveys. I saw a patient last week with positive visual phenomena as a symptom related to extreme sleep deprivation. She said she hadn’t slept well since April 2020. Her extreme state of constant alertness had actually changed her brain chemistry. All I could suggest was going cold turkey from TV news, cable, and internet. I’m pretty sure she won’t take my advice. Our overblown fears are the manifestation that the news presents an extreme version of “ascertainment’ bias. Even if what we hear is true, it is not representative of the real world.

    Unfortunately, that really feeds right into human nature, which was designed by evolution to examine the routine and daily world we each live in and be on the lookout for anything amiss or dangerous. It’s a little like squirrels who must live their lives glancing over their shoulders, ready to race up the nearest tree whenever they see a moving shadow.

    A second scientific explanation for our tendency to overreact to the bad news is that it is presented without numeracy. That is, either the numbers aren’t given, or a pseudo-number is provided. The message from the media is: 1) Here’s an alarming anecdote; then 2) It happened again! So, it must be a new trend; then 3) It’s a crisis. Often, there’s nothing new or critical about the crises.

    In the 1970s we were told that fatal shark attacks were a new and terrible danger for Americans visiting beaches. In fact, the numbers were small (averaging about one per year in the U.S.) and, seen over a global and long-term view, not any higher than before. But a lot of cheap papers were sold, movies made and unfortunately, a lot of families changed their plans to surf and play at the water’s edge. The much greater risk would have been their car drive to the beach.

    The lack of numeracy is further pushed by news media, cable and the internet, when they don’t give us numbers to issues that should require them. Yet, we are usually offered qualitative answers to quantitative questions in an effort to alarm or persuade us. “There is arsenic in my tap water!” I saw this on an ad on TV for bottled water. Of course, there is arsenic in your tap water. A few molecules of arsenic are in all sources of water (even bottled). How much is okay? The Environmental Protection Agency says 10 micrograms/ml is the tolerable limit. That still means 10 parts per million. I might prefer a filter that reduces that to 0.01 parts per million, which still translates to over 10,000,000,000,000,000 molecules of arsenic per glass. I’d be happy to drink that water. As the toxicologists say, “It’s not the poison, stupid, it’s the dose.” In other words, if it’s to be informative, then the answer to a quantitative question can’t be qualitative. It requires numbers.

    Remember the Fukushima nuclear reactor disaster? Remember all the early reports of radiation leakage? First, the newspapers said that the accident caused an exposure of about 10 Sieverts (Sv)/hr. to civilians living nearby. Later editions published the number of 0.1 Sv/hr. That means the first report was a hundredfold mistake! So, I kept checking newspapers and magazine articles on the subject. When the scientific papers finally got published, the true figure turned out to be only .000001Sv/hr. The first number is lethal, the last hardly worth noting.

    What the news articles didn’t tell us was that you get about .001 Sv/yr. just from inhabiting the surface of our planet. Or that you get an extra 0.000035 Sv of cosmic radiation each time you fly across the United States. But don’t worry; it’s not the poison, it’s the dose! By the way, how many people died from radiation at Fukushima? Many people I ask, guess in the range of hundreds to thousands. Any death is too much, but the answer is, probably one. That’s important to know if you are going to argue against future nuclear power plants as too dangerous. And how does that mortality rate compare to all the accidents associated with oil drilling, refineries, storage, transport, etc.? Nuclear reactors are probably one of the safest energy technologies around. Arguing such things without numbers is just ignorance.

    But it’s worse. When the news-cable-internet media do give us numbers, they often are just giving us the numerator of a fraction, without regards to the denominator. Of course, if you don’t have the denominator, you don’t have the real number. In the early days of COVID, I was telling my wife that COVID tended to kill old people (like me). She disagreed and then showed me a newspaper article making her point and describing three deaths in people aged less than 30. And she was right in that the point of the article was that the young were dying a lot. But the three were out of how many? In the city, the state, the whole country? Over what period of time? And how does that rate compare to COVID deaths in older people?  It didn’t say. The newspaper article was making the point with anecdotes, not data, and their conclusion was mostly wrong, but very alarming, which was exactly their intention.

    Unfortunately, the transition from a dramatic case to a trend, and then a crisis, happens all the time and people use this drumbeat to become even more convinced that reality is terrible. Yet, put into correct numbers and context, it often turns out that things are better now than before (for example, fewer violent civilian deaths, fewer cases of people dying from terrorism and fewer deaths from military actions in the last few decades). Steven Pinker’s “Enlightenment Now,” makes these and similar points.

    Pinker shows that the rates of murder (homicide), have come down in every society precipitously in the last few centuries. Even the well-known increase in Mexico in about 2005 was a local high preceded and followed by much lower numbers. I also found it interesting that for over 200 years, it was much higher in Southwest U.S. than in New England.

    Pinker also shows that deaths in war have until 2015 been getting much lower as well. He shows how much safer airplane flights are now even compared to the 1970s and 1980s. The combination of ascertainment bias caused by news-cable-internet media wanting to shock us, together with innumeracy, leads us to the false conclusion that things are getting much worse, when the contrary is the case.

    There is another form of innumeracy that we, as physicians, should be more familiar with. My patient says to me, “I have a new blood test, and it says I have a rare disease.” The blood test is 99% sensitive and 99% specific. So, it must be right? I have to tell him, no. Especially if there wasn’t a good enough reason to have taken the test in the first place. Medical scientists know about Bayesian analysis, but most MDs and almost all patients don’t.

    Bayes’ theorem was that you multiply the pretest probability by the test probability. But if the pretest probability is very low, the positive screening test tells you very little. These tests were designed to be used in high-risk settings. I am often referred patients who had no symptoms but harbored great concerns, shared by their referring physician, due to positive lab tests. Most often, I explain to them that I’m convinced that they really don’t have the disease that worries them. In fact, they should never have been even tested. We’ve learned the hard way that PSA tests for prostate cancer, mammograms for breast cancer and even chest CTs have to be done selectively. Even pathology specimens, which are generally very accurate, aren’t perfect. If you do a temporal artery biopsy on a 90-year-old with symptoms of giant cell arteritis (GCA), and it comes back positive, it probably is GCA. But if you blindly did the same biopsy on a 12-year-old without symptoms, notwithstanding the positive pathology report, it probably is not GCA. You shouldn’t have done the test, and having done it, the results do not have the same meaning. Bayes understood.

    In a related vein, sometimes, I hear a few of my patients tell me that they have decided on their own medical management, having already “done my research.” I hate that phrase as it actually signifies an ignorant rejection of authority, education, experience, and credentialing. People have the right to read anything and to decide their own course of treatment, of course. But has the democratic spirit of equality devolved to where someone’s ignorance trumps the expertise of an authority? When it comes to just self-determination, fine. I’m offended, and my patient ends up suffering. But when many do it, it becomes a social phenomenon, and it detracts from our social zeitgeist that depends on expertise and leadership to respond to general calamities. 

    So why are we still losing sleep? I’ve stopped watching all TV news stations. The world has gotten extremely good at spreading bad news; journalism seems to have lost its North Star, the internet and social media are influencing people more than institutions and experts can. So, it may become necessary for us to take personal responsibility for what news we believe and how we let it affect us. We should worry less. The sky is not really falling, it’s just that it seems that every reporter is now a “Chicken Little” who just doesn’t want to write that the sky is blue and still up. Unfortunately, there are too many who watch too much TV news, or worse yet, cable, or worst of all, internet news and social media, who may really think that the sky is falling.

    I am not a Pollyanna. Indeed, there are several new threats that deserve our attention. But maybe we should also take some moments to celebrate the many things that have gotten incrementally better but don’t make the News.