ME/CFS Research Review: "On BPS & disease causation: George Davey Smith’s cautionary tale" by Chris Ponting

[forestglip]

A post written by @Chris Ponting on @Simon M's blog, ME/CFS Research Review:

On BPS & disease causation: George Davey Smith’s cautionary tale

First paragraph:

A guide to the Biopsychosocial model recently put out by Long Covid Advocacy ultimately brought me to a 2005 book chapter, written by Professor George Davey Smith, entitled The biopsychosocial approach: a note of caution in Biopsychosocial Medicine: An Integrated Approach to Understanding Illness, edited by Peter White and published by Oxford University Press. The chapter is available from a University of Bristol website. I thought the divergence of opinion between Profs Davey Smith and Wessely was sufficiently interesting to write this short commentary.

 

[Peter T]

A post written by @Chris Ponting on @Simon M's blog, ME/CFS Research Review:

On BPS & disease causation: George Davey Smith’s cautionary tale

First paragraph:

This blog is a clear and concise summary reminding me of @ME/CFS Science Blog’s excellent, though obviously much fuller, series on the various health conditions, including peptic ulcers, that were previously mischaracterised as psychogenic.

 

[rvallee]

Good post. This happened in 2005, and since then there have been hundreds more studies and trials, and absolutely nothing has changed, yet the ideology has firmly established itself as an immovable force, absurdly enough, on the basis of "evidence-based medicine", despite there being no real evidence for any of it. If anything, the evidence has clearly gone downhill, and yet it's more powerful than ever.

I don't know who or what can force things to change, but this is all a very bizarre thing, one of the most bizarre things in history, really. Even on the issue of peptic ulcers, most times it's pointed out as evidence for psychosomatic silliness, I see physicians excusing it with an "akshually" argument that basically mirrors the "functional overlay" excuse that has become standard these days: it might not be the cause, but it's a factor, a big one, and lalalalala can't hear you.

How do we even reach the medical profession with this? The facts are indisputable. And yet they dispute. It's all so clearly irrational and based on vibes and being unable to admit to mistakes.

 

[hotblack]

It's all so clearly irrational and based on vibes and being unable to admit to mistakes

Yes and that’s the real underlying truth about human psychology. Ironically. Our inability to admit mistakes, especially if it challenges our image of self.

This is why I think those invested in these ideas about us are lost and arguing with them is pointless. Our target should be the larger group who are not invested in them.

 

[neurophusion]

Good concise post from Chris Ponting. Just one small issue:

"A year later, Simon Wessely, Peter White and Trudie Chalder, the three principal investigators of the PACE trial, with others, objected to this guideline."

I think he meant to say Michael Sharpe here, not Simon Wessely, since it reads as though Wessely was one of the three principal investigators. The sentence would be better as:

[A year later, Peter White, Michael Sharpe, and Trudie Chalder (the three principal investigators of the PACE trial), with Simon Wessely and others, objected to this guideline.]

But I wonder what George Davey Smith think now, he had a falling out with James Coyne over the PACE trial and then resigned from the editorial board of the Journal of Health Psychology because of the special issue was too hard and one-sided against the PACE trial.

And of course Wessely had to have a swipe at ME/CFS 'activists'. He probably still holds a grudge about being discouraged from the field, which was to be his play thing, and lashes out behind the scenes instead of in public view, now on the NHS England board of directors, a scary thought.

Medicine learnt little from their mistakes about misclassification of illnesses as psychosomatic and only grew more confident that the remaining 'unexplained' symptoms are psychosomatic?

 

[Sean]

Our inability to admit mistakes, especially if it challenges our image of self.

The threat to ego, career, empire, status, place in history, and well above average income and a comfortable retirement is a, um, persuasive package of very powerful disincentives to facing up to the truth.

 

[Chris Ponting]

Good concise post from Chris Ponting. Just one small issue:

"A year later, Simon Wessely, Peter White and Trudie Chalder, the three principal investigators of the PACE trial, with others, objected to this guideline."

I think he meant to say Michael Sharpe here, not Simon Wessely, since it reads as though Wessely was one of the three principal investigators. The sentence would be better as:

[A year later, Peter White, Michael Sharpe, and Trudie Chalder (the three principal investigators of the PACE trial), with Simon Wessely and others, objected to this guideline.]

But I wonder what George Davey Smith think now, he had a falling out with James Coyne over the PACE trial and then resigned from the editorial board of the Journal of Health Psychology because of the special issue was too hard and one-sided against the PACE trial.

And of course Wessely had to have a swipe at ME/CFS 'activists'. He probably still holds a grudge about being discouraged from the field, which was to be his play thing, and lashes out behind the scenes instead of in public view, now on the NHS England board of directors, a scary thought.

Medicine learnt little from their mistakes about misclassification of illnesses as psychosomatic and only grew more confident that the remaining 'unexplained' symptoms are psychosomatic?

Thank you! Good spot. Now fixed.

 

[hotblack]

The threat to ego, career, empire, status, place in history, and well above average income and a comfortable retirement is a, um, persuasive package of very powerful disincentives to facing up to the truth.

Indeed. The question of motivations and incentives structures is an important one as it drives so much of human behaviour.

What is more likely, that a large number of people are motivated to keep themselves in poor quality life through perpetuating false beliefs. Or that a few are motivated to keep themselves in a good quality of life through perpetuating false beliefs.

The other test would be that of a cure, if there were a magic pill or tbh any treatment that would take away these false beliefs. Which group would predominantly jump at it? And it’s that fact which is both missed by many in their understanding of the condition but also used far too often to take advantage of people with it.

 

[hotblack]

I was listening to a talk about flexibility as a psychological approach to the world and dealing with the troubles we face. Noting groundbreaking but a nice talk.

And it reminded me of this. That there isn’t one tool which just works and fixes things. And it’s interesting that many of those proponents of a BPS model of things like ME/CFS and FND, despite what they push and it’s original basis, themselves seem to have a very inflexible approach and think their one neat trick and approach fixes so many ills.

A psychologist could probably write an interesting case report on the behaviours of some in the field, their psychological inflexibility and how they responded to criticism along with their inability to admit they were wrong.

And flexibility is required by the scientific method. It recognises that cognitive assumptions can distort. It requires testing and validation of ideas and questioning of results. It is entirely based upon challenging assumptions and most importantly being open to them being wrong. We only move understanding forwards by being open to that.

 

[Utsikt]

«I had what I thought was a very clever idea as a student, and I’m going to spend my entire professional career defending it!»

 

[Hoopoe]

And it reminded me of this. That there isn’t one tool which just works and fixes things. And it’s interesting that many of those proponents of a BPS model of things like ME/CFS and FND, despite what they push and it’s original basis, themselves seem to have a very inflexible approach and think their one neat trick and approach fixes so many ills.

I believe the dynamic is that society wants to believe that there exists an expert, an explanation, a model, a way forward. And some people get into this role and derive a personal benefit of some sort from it, in the form of attention, status, career, money. They get so invested in it that admitting they were wrong exposes them to a loss that is too large to bear.

It's people who are good at faking expertise, good at exhibiting confidence and playing the role of expert that do well initially. Later the lack of substance of their theories becomes apparent. In the end it's those with true competence that find a solution.

Some of this dynamic also plays out with clinicians. They're afraid of admitting that they don't know and can't help. That's where some of the demand for BPS models comes from. A model so vague that it can be applied to anything that isn't explained and at least superficially seem clever.

 

[Yann04]

Somewhat confusing to me that Peter White both edited this chapter and did the PACE trial.

 

[Felis Catus]

Some of this dynamic also plays out with clinicians. They're afraid of admitting that they don't know and can't help. That's where some of the demand for BPS models comes from. A model so vague that it can be applied to anything that isn't explained and at least superficially seem clever.

I really can't understand that inability to acknowledge that no one knows. Why do some people take it so personally? Even random GPs who have no professional roles outside their surgery and no ambition for anything outside the surgery - what's at stake? No one reasonable expects an individual to know something that no one in the world knows and for which there is no scientific consensus.

 

[hotblack]

Even random GPs who have no professional roles outside their surgery and no ambition for anything outside the surgery - what's at stake?

I want to preface this by saying it is a bit of a generalisation and doesn’t apply to all doctors but…

If throughout your life you have been clever and successful in certain ways, which to become a doctor you will have, there is an element of self image at stake here. Combine that with being the person people come to and demand answers all day every day, expecting you to know things, there’s a professional role and reputation and just habit. And this is on top of a very common human difficulty in saying ‘I don’t know’, it’s everywhere.

So I do understand why it happens and where it comes from. And it is not helped by some patients demanding answers and fixes that do not exist.

 

[Utsikt]

I want to preface this by saying it is a bit of a generalisation and doesn’t apply to all doctors but…

If throughout your life you have been clever and successful in certain ways, which to become a doctor you will have, there is an element of self image at stake here. Combine that with being the person people come to and demand answers all day every day, expecting you to know things, there’s a professional role and reputation and just habit. And this is on top of a very common human difficulty in saying ‘I don’t know’, it’s everywhere.

So I do understand why it happens and where it comes from. And it is not helped by some patients demanding answers and fixes that do not exist.

You also have a legal and ethical responsibility to «make the right choices» all the time. Perhaps it’s easier to trust yourself, rather than to always second guess everything and have to deal with knowing that you’ve probably been wrong and potentially caused harm.

 

[hotblack]

That’s a good point @Utsikt and part of why I wish we could take blame and reputation and ego out of this. It removes a barrier to getting what we need.

The problem is what I see time and time again is that nothing will change in a system full of inertia and unhelpful incentives until someone is made responsible and accountable. At least for making that change.

 

[Utsikt]

That’s a good point @Utsikt and part of why I wish we could take blame and reputation and ego out of this. It removes a barrier to getting what we need.

The problem is what I see time and time again is that nothing will change in a system full of inertia and unhelpful incentives until someone is made responsible and accountable. At least for making that change.

We absolutely need accountability, but I have no idea where you’d start. Even figuring out who would oversee it: when the abusers get OBEs there’s a lot of power behind the current way of doing things.

There’s the saying that academia changes on death at a time - the death of the professor that had the opinion.

 

[Yann04]

We absolutely need accountability, but I have no idea where you’d start. Even figuring out who would oversee it: when the abusers get OBEs there’s a lot of power behind the current way of doing things.

There’s the saying that academia changes on death at a time - the death of the professor that had the opinion.

Reminds me of this quote by Max Planck in a letter to Einstein

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because the opponents eventually die and a new generation grows up that is familiar with it.

 

[rvallee]

I really can't understand that inability to acknowledge that no one knows. Why do some people take it so personally? Even random GPs who have no professional roles outside their surgery and no ambition for anything outside the surgery - what's at stake? No one reasonable expects an individual to know something that no one in the world knows and for which there is no scientific consensus.

At this point it just has to be a tradition that has gained too much momentum to move in any other direction, because every other profession is able to admit to and manage ignorance, it's pretty much part of being a professional. Medicine just seemed to have never grown out of this, and eventually it was just too late, too much baggage and sunk cost, so no one really understands why things are this way, but they're "the way things are done"(TM). Doubtful that anyone actually thinks much about it, it's a social phenomenon, it's too widespread to even think about how it could possibly be wrong.

There is really no explanation, especially because admitting they don't know is a routine part of the job, like every other expert profession. They can and do handle it multiple times per day, when it's either mostly inconsequential, or when they do know that there is nothing to do (e.g. can't regrow an arm, they do know it's impossible). Then there is nothing to be ashamed of, no failure.

Somewhere along the way it has to do with money, how every one of those failures can only be handled by supporting people with resources that don't exist. It's mostly when it costs nothing to anyone that it's admitted. The pressure to keep social costs, especially disability, and any form of support for the sick and disabled is not universally popular at all. A lot of people see it as polluting the gene pool, as supporting the weak and useless, though they'd never admit to it openly.

It's truly one of the most bizarre things in the world. It's like corrupt judges, but somehow worse. It betrays everything we claim to stand for as people, and yet it's so widespread it's not even open to questioning.

Humans are freaking weird.

 

[Sean]

because every other profession is able to admit to and manage ignorance,

While I agree that medicine is one of the worst at doing this, maybe even the worst, it also certainly happens in other professions.