The campaign to end mandatory maintenance of certification is, as of yesterday, at 20,000 signatures. This is just shy of 10% of the people affected; what are the other 90+ percent thinking? Still, it was enough to make the professional societies pay attention.

Derek Lowe writes about a recent Cancer Cell paper pitting glioblastoma cells against each other in a mouse model:

A single clonal line that hit on high Myc expression could outcompete fifteen thousand others from a standing start!

As someone who’s treated patients with Burkitt lymphoma, the Myc-dependent cancer, I can absolutely believe this.

Aaron Goodman’s petition to eliminate Maintenance of Certification requirements for ABIM-certified physicians is on track to reach 20,000 signatures, which would be just terrific. But it was at 16,000 2 weeks ago, and the pace has certainly slowed down. Do the other 200,000+ certificate holders think mandatory MOC is a good idea, on top of the state-mandated Continuing Medical Education?

Jason Snell notes that the iMac’s strongest legacy was Apple itself:

The company was close to bankruptcy when Jobs returned, and the iMac gave the company a cash infusion that allowed it to complete work on Mac OS X, rebuild the rest of the Mac product line in the iMac’s image, open Apple Stores, make the iPod, and set the tone for the next twenty five years.

I’m currently reading The Dao of Capital, which is all about the Austrian school of economics and the roundaboutness of true entrepreneurs, and this made what Apple is doing even more salient. Can you name a more roundabout tech company than Apple? ⊕ To be clear, I suspect little of this was premeditated in the long term — i.e. no, Jobs and Ive probably did not have a Vision Pro in mind as the ultimate goal when they thought of the iMac — but the ethos of seeing everything as a potential intermediary and not commoditizing it fully à la Samsung is very much the Apple way. Using the iMac as the intermediate step towards the iPod, which was itself an intermediate step towards the iPhone, which was supposedly to be an intermediate step towards the iPad but turned into something much greater, though it also did end up being an intermediate step towards Apple silicone, all the while peppering these intermediary products with technology — LiDAR, ultra-wide lenses, spatial audio — that would become the key building blogs of Vision Pro, which is itself an intermediary towards who knows what. Very Austrian.

Thinking more closely to home, I can think of a few biotech companies that may be doing something like this — maybe, if you squint — but none come close. The addiction to immediate profits that the distorted American health care market provides is much too great.(↬Daring Fireball)

Jake Seliger is a writer with an aggressive, incurable cancer, a wife — Bess — who is an ER doctor, and a blog:

We spend so much time buying, storing, corralling, searching, sorting, and thinking about stuff, and then we perish and what happens?

I mean that in a literal way: I die from that squamous cell carcinoma in my neck and lungs, and then what? What happens to Bess?

Have a tissue ready.

There was something particularly irksome about a USA Today article from a few days ago — it prompted 3, count them, three tweets posts Xs from me — and I wanted to figure out what bothered me so. Here is the headline:

Left or right arm: Choosing where to get vaccinated matters, study suggests. Here’s why

No, it’s not the typography, although they should either not have had a full sentence in their headline, or else should have finished it with a full stop. But then they would have lost the chance for the click-baity Here’s why as a prelude to an article ⊕ OK, this can get real confusing real fast since there are two articles I am writing about: the USA Today’s newspaper article, and the research article to which it refers. So, let’s use article for the newspaper, and manuscript for the research article. Because why not? about Real Science™ which — color me astonished — takes a hypothesis-generating study and presents the hypotheses it generated as the final results.

To its credit, the article starts of with a link to the manuscript and the name of the journal where it was published, which is eBioMedicine, part of the proliferating Lancet family, impact factor 11.1. ⊕ Although, you know what they say about impact factors.Good! They also invited an independent researcher to comment. And I am sure that his comments were similar to mine, although of course most of what he said (or more likely wrote in an email) didn’t make it. What ended up on the page were two blurbs about precise vaccination from the director of a Precision Vaccines program. Gasp.

But these are all side attractions. The biggest problem is this: scientists want to compare people who had a two-dose vaccine shot in the same arm to those who had it in different arms; in the manuscript, these were called ipsilateral and contralateral groups. They aren’t randomizing people to one versus the other, ⊕ What they describe as randomization isn’t really so, but that’s a rabbit hole we better not get into. but with these being generally healthy people, and with the participants not having a choice as to where they will get a vaccine, that is not too much of an issue. Then they ask them some questions about vaccine side effects and draw some blood. The questions are about side effects and the blood is to check for “the strength of the immune response”.

Note that they don’t say at the outset that the groups would be different, and how. Would the opposite arm have fewer side effects? Better immune response? If so, in what way? More antibody? Stronger antibody? A different subtype of antibody? Better or worse cellular immunity? Which cell (among dozens)? More cells, stronger cells, or different cells? Or maybe the same side would be better?

The beauty of hypothesis-generating research (for the researcher) is that it doesn’t matter. Whatever you get, you will get it published, sometimes in a double-digit impact factor publication. I’ve sat on many a lab meeting where things like this were proposed and always, always, the comment is that “the results will be interesting whatever they are”. And they are right! But you will not know — cannot know — whether the results you got are based on an underlying physiology, or occurred purely by chance. That is where confirmatory studies come in.

Neither the manuscript nor the article recognize this. Among the many things they looked at, the researchers found two things that were different between the two groups: those who had the vaccine in the same arm had “more” of a certain type of immune cell than the other, and the opposite-arm group had increased expression of a certain marker on yet another type of immune cell. “More” is in quotes because even that is more subjective than it appears — another rabbit hole — but even if true in this sample, it is at best a hypothesis that should lead to another, possibly smaller study, where you focus on these cells, with different operators counting them, and doing additional hypothesis-generating analyses on the side to figure out the why of it, which would lead into yet another confirmatory study… You get the idea.

This is not what the manuscript authors propose. Instead they take their result at face value and concoct a mechanism out of thin air that would explain the result. The journalist then takes the mechanism and presents it as the main research result, the Here’s why of that clickbait headline. There is a high bar for calling anything in science conclusive and the article does have the usual disclaimer that “more research and data is needed”. But the phrase has been repeated so much that it has lost all meaning, something you say to mark yourself as a “believer in science” while with a wink and a nudge you act as if the results were indisputable.

Fortunately, science is a strong-link problem: those who know what they are doing will adjust their beliefs accordingly, and down the line confirm or falsify these preliminary findings. Unfortunately, science doesn’t operate in a vacuum. If its covering of science is indicative, journalism, the fourth estate, is in a hole and digging deeper, taking others with them.

• As of this morning it has reached >17,000 signatures. Yay!
• The Healthcare Unfiltered podcast has two good interviews: the first is with Wes Fisher and his decades-long battle with ABIM; the second is a debate between Aaron Goodman — who started the petition — and Richard Baron, the President and CEO of ABIM
• The debate was a clear loss for Baron: his smooth baritone and even smoother sophistry could not help hide the fact that MOC is a pure money grab. I will lay out the 3rd grade math and 6th grade logic later this week.
• Aaron was too nice on Baron. There should be a second petition: for ABIM to start having accountability, or else shut down. Back in the 1930s when it was founded we may have been ABIM “diplomats” who pay for their certification once then never again. Once you start extracting yearly dues, you no longer have gentlemen diplomats, you have members.
• Richard Robber Baron.

Nassim Taleb has updated his essay against IQ, and I don’t know if Figure 1 there is new or I haven’t been paying attention before, but it is a true eye-opener. It shows how meaningless correlation is in the absence of symmetry, and medicine is full of asymmetries. I shudder to think how much medical literature consists entirely of physicians-cum-naïve statisticians pouring through medical charts gathering data to calculate such correlations. Counting the official and semi-official guidelines based on such flawed papers would be a nice side project.

Aaron Goodman’s petition to eliminate MOC requirements has 16,000 signatures and counting. That’s a lot, but still <10% of ABIM’s 220,000+ active certificate holders for internal medicine alone. So, please sign if you haven’t already!

And if you have no idea what any of these acronyms mean, ABIM’s home newspaper of record has a good overview.

“The American Board of Internal Medicine is under fire for a ‘maintenance of certification’ requirement. Their own tweet didn’t help.":

Frustration among physicians who feel they are being asked to do increasingly more to prove their competency has been building for years and in recent weeks, boiled over for many. At least 12,000 people have signed a Change.org petition, which is open to anyone. Many added their name after the petition’s organizer resurfaced a July tweet in which ABIM suggested their ongoing certification was so easy, doctors could do it while on vacation.

I have been meaning to write about ABIM’s train wreck ever since I signed the petition, but yet again my proscratination has been awarded: Philadelphia Inquirer says everything I wanted to, and then some. Ding-dong…