Essay: If Only All We Wanted Was Expert Advice

Several plumbers have come over to examine my situation. They listen to my story and hear my explanation, an account that to me, a nonplumber, makes perfect sense. Then they look at me like I am crazy — not a little crazy but completely nuts — and tell me to either buy a new dishwasher (tried it already: didn’t work) or else wash my dishes more thoroughly before loading the dishwasher (vide above: done, no luck). Then they tighten something or loosen something, nod sympathetically to my wife, and head for the door — fast — leaving me with flecks on the glasses and mounting disappointment. But, hey, what do they know?

During the latest round, I realized how similar these exchanges are to those I sometimes have with patients. Patient concerns obviously are of a scope and scale completely different from those of my appliances; yet the patients too have a problem, a problem that is clearly defined to them, a problem they have spent hours, days, weeks, perhaps years mulling over. They understand their situation exactly and unflinchingly. Most have tried this and that to assess its impact on their condition: they eat less or differently; they exercise more or change sports; they sleep in the other room for a week or two; they try their child’s medicine given years ago for something possibly similar. They are little Pasteurs pursuing a solution in the lab of their own body, adhering to the scientific method with admirable rigor.

And yet often I dismiss their ideas with the same careless flick of the wrist I have come to expect from the latest in my long line of plumbers and dishwasher subspecialists. Like the plumber, I’ve heard that one before, whatever the complaint; I’ve previously spent time and wasted patient hope chasing the same false lead down a dead-end path. I hope I have learned from my missteps, gained in wisdom, tempered my own eagerness to order test after test. I am the one with more experience at this, right? Isn’t that the point?

Many patients sense my reluctance to consider their theories. One recently asked me to evaluate him because of a sense of deepening fatigue without fever or weight loss; might it be an infection? I explained that I had tried many times through the years to diagnose infection in patients with his specific set of complaints but had never turned up an answer. In my judgment, the “million dollar work-up” was a waste of his time and money. After I finished, we stared at each other in awkward silence. I had broken his heart a little, and I too was demoralized. It is not enjoyable to trample hope.

It seems to me that what we have here is a basic problem with our attitude toward experts. The calculation ought to be simple: we all seek people who know more about a situation than we do exactly because they know more than we do. Of course, we always want experts. And when we find them, we ought to trust them, right? Instead, however, we dismiss them when they aren’t whistling our tune. We suddenly become more expert at the very thing we thought they were expert at. After all, patients come to see me in a major research hospital, the ultimate house of science, a temple to the rational mind built on a foundation of countless sharp-edged logical observations made by experts from Hippocrates right up to the doctors and researchers published in this week’s New England Journal of Medicine. I am the somber keeper of this great tradition, the translator of the randomized double-blinded placebo-controlled studies conducted by thousands of researchers on hundreds of thousands of patients. I have the facts.

Ah, but there’s the rub. When matters of personal health (or home appliances) are at stake, we want a lot more than expertise from our experts. The rational world suddenly loses its appeal; dull, steady scientific observation seems only dull and steady. We want some pixie dust, a little magic, an eccentric genius who can see through the usual mumbo-jumbo to the core of the problem (paging Dr. House).

But until our prince comes, we are left with the most basic, bare-bones determination: do we trust this guy or not? And this decision, rather than following along a perfectly manicured line of reasoning and evidence, relies on that least scientific of all human inclinations — the simple leap of faith.

Dr. Kent A. Sepkowitz is vice chairman of medicine at Memorial Sloan-Kettering Cancer Center.

 

Essay: If Only All We Wanted Was Expert Advice

 

Several plumbers have come over to examine my situation. They listen to my story and hear my explanation, an account that to me, a nonplumber, makes perfect sense. Then they look at me like I am crazy — not a little crazy but completely nuts — and tell me to either buy a new dishwasher (tried it already: didn’t work) or else wash my dishes more thoroughly before loading the dishwasher (vide above: done, no luck). Then they tighten something or loosen something, nod sympathetically to my wife, and head for the door — fast — leaving me with flecks on the glasses and mounting disappointment. But, hey, what do they know?

During the latest round, I realized how similar these exchanges are to those I sometimes have with patients. Patient concerns obviously are of a scope and scale completely different from those of my appliances; yet the patients too have a problem, a problem that is clearly defined to them, a problem they have spent hours, days, weeks, perhaps years mulling over. They understand their situation exactly and unflinchingly. Most have tried this and that to assess its impact on their condition: they eat less or differently; they exercise more or change sports; they sleep in the other room for a week or two; they try their child’s medicine given years ago for something possibly similar. They are little Pasteurs pursuing a solution in the lab of their own body, adhering to the scientific method with admirable rigor.

And yet often I dismiss their ideas with the same careless flick of the wrist I have come to expect from the latest in my long line of plumbers and dishwasher subspecialists. Like the plumber, I’ve heard that one before, whatever the complaint; I’ve previously spent time and wasted patient hope chasing the same false lead down a dead-end path. I hope I have learned from my missteps, gained in wisdom, tempered my own eagerness to order test after test. I am the one with more experience at this, right? Isn’t that the point?

Many patients sense my reluctance to consider their theories. One recently asked me to evaluate him because of a sense of deepening fatigue without fever or weight loss; might it be an infection? I explained that I had tried many times through the years to diagnose infection in patients with his specific set of complaints but had never turned up an answer. In my judgment, the “million dollar work-up” was a waste of his time and money. After I finished, we stared at each other in awkward silence. I had broken his heart a little, and I too was demoralized. It is not enjoyable to trample hope.

It seems to me that what we have here is a basic problem with our attitude toward experts. The calculation ought to be simple: we all seek people who know more about a situation than we do exactly because they know more than we do. Of course, we always want experts. And when we find them, we ought to trust them, right? Instead, however, we dismiss them when they aren’t whistling our tune. We suddenly become more expert at the very thing we thought they were expert at. After all, patients come to see me in a major research hospital, the ultimate house of science, a temple to the rational mind built on a foundation of countless sharp-edged logical observations made by experts from Hippocrates right up to the doctors and researchers published in this week’s New England Journal of Medicine. I am the somber keeper of this great tradition, the translator of the randomized double-blinded placebo-controlled studies conducted by thousands of researchers on hundreds of thousands of patients. I have the facts.

Ah, but there’s the rub. When matters of personal health (or home appliances) are at stake, we want a lot more than expertise from our experts. The rational world suddenly loses its appeal; dull, steady scientific observation seems only dull and steady. We want some pixie dust, a little magic, an eccentric genius who can see through the usual mumbo-jumbo to the core of the problem (paging Dr. House).

But until our prince comes, we are left with the most basic, bare-bones determination: do we trust this guy or not? And this decision, rather than following along a perfectly manicured line of reasoning and evidence, relies on that least scientific of all human inclinations — the simple leap of faith.

Dr. Kent A. Sepkowitz is vice chairman of medicine at Memorial Sloan-Kettering Cancer Center.

 

Michael C. Latham, Expert on Nutrition in Developing World, Dies at 82

The cause was pneumonia, his son Mark said.

Dr. Latham, who directed the Program in International Nutrition at Cornell University for 25 years, first encountered the problems of nutrition in the developing world while practicing medicine as a young doctor for the British colonial service in Tanganyika (now Tanzania).

After the country had gained its independence, he stayed on and was appointed the director of the nutrition unit of the public health ministry. He became alarmed at efforts by Western companies to expand their marketing of infant formula to underdeveloped countries, where high birth rates promised a growing consumer base, and he became one of the first and most forceful public health scientists to sound a warning.

In many poor countries, he pointed out, mothers mixed powdered baby formula with contaminated water, leading to diarrheal diseases. To make the formula last longer, they often used too little of the powder, depriving their babies of vital nutrients.

Bottle feeding was “incredibly difficult and extremely bad,” Dr. Latham wrote in a 1976 report with Ted Greiner, but “the media onslaught is terrific, the messages are powerful and the profits are high.”

“High also is the resultant human suffering,” they wrote.

Dr. Latham’s cause, taken up by several health groups, led the World Health Organization in 1981 to develop a set of guidelines, the International Code of Marketing of Breast-milk Substitutes, which was intended to govern the behavior of private companies. He was a prominent figure in the boycott of Nestlé, a leading manufacturer of infant formula, which agreed in 1984 to abide by the marketing code.

The ideal food for infants, Dr. Latham argued, was breast milk. Its benefits, he wrote, were not limited to improved physical and mental development. It could also potentially curb population growth, he argued, since parents who were confident that their children would thrive would be more likely to have smaller families. In 1991, he helped found the World Alliance for Breastfeeding Action to explain and promote the benefits of breastfeeding around the world.

Michael Charles Latham was born on May 6, 1928, in Kilosa, Tanganyika, where his father was a doctor in the British colonial service. After earning a medical degree from Trinity College, Dublin, in 1952, he worked in hospitals in Britain and the United States before returning to Tanganyika to practice medicine in rural areas. During intermittent leaves, he earned a diploma in tropical public health from the London School of Hygiene and Tropical Medicine in 1958.

After leaving Tanzania in 1964, he taught nutrition at Harvard, where he received a degree in public health in 1965. In 1968 he was recruited by Cornell as a professor of international nutrition. He turned the university’s small Program in International Nutrition into one of the world’s largest training centers for nutritionists, many of whom went on to work in international agencies and public health departments around the world.

His research led to improved programs on infant nutrition, the control of parasitic diseases in humans, and the supply of micronutrients to poor populations.

Dr. Latham often did consulting work in Africa, Asia and South America for organizations like the World Health Organization, the United Nations Food and Agriculture Organization, Unicef and the World Bank.

In addition to his son Mark, of Somerville, Mass., he is survived by his second wife, Dr. Lani Stephenson, and another son, Miles, of Trumansburg, N.Y.

He was the author of two important books on international nutrition, “Human Nutrition in Tropical Africa” (1965) and “Human Nutrition in the Developing World” (1997), as well as a family memoir, “Kilimanjaro Tales: The Saga of a Medical Family in Africa” (1995), which drew on the journals kept by his mother, Gwynneth Latham.