#humans need to make art i swear it’s the key to fulfillment

[apolleano]

taking an art class with physical mediums has saved my spirit

[gufallino]

On finding one's self (and being 25)

The “just be yourself” popular teaching was so difficult for me. It seemed like the ultimate key to happiness. But how do I do that? How do I need to talk, act, be exactly? Why am I not comfortable with being myself?

Why do I feel that there's something missing?

Turns out, the answer was very, very deep inside me. Maybe “in my heart” as someone else would say.

I had a good childhood. I can't remember being too happy, but it was good. Some of my early mood swings could've been caused by my undiagnosed disorder, but that is a new topic for another entry. Some of the bullying I went through can be written on another page, too.

The worrisome thing here is the “happiness”. My childhood was, arguably, the most successful period of my life. I was, in many ways, ahead of other kids. I say this in the most summarising way possible. I had a family that loved me, the food I wanted on my plate, the toys I desired, the wonderful grades and all the academic praise that comes with it. Never studied or cheated and made it, while succeeding in all aspects. I, however, don't remember something that was particularly euphoric. Great, yes. Surprising, yes. Satisfying, yes. But not too joyful. I didn't understand how someone could be happy to the point of tears.

Then I see my teenage years as divided into two: from 12 to 15, then 15 to 18. Secondary and highschool. Even between those there was a lot of change, not only physical. But just a few things in my life, I swear, have moved me as much as being a twelve year old. That was, probably, the last time I lived “being myself”. I was physically strong and bold. In terms of hobbies and learning, I did everything I wanted to do. The art career in the future seemed plausible. I didn't have many friends, but it was enjoyable.

I had the same question in my mind, though, over and over. Why am I not happy? Why, despite it all, can't I be happy? I began to understand happiness as different from the romanticized, mainstream way of living, and rather something that was meant to pass and happen sporadically.

Back then I was close to a teacher who specialized in psychology, definitely one of the kindest souls I've ever met. I remember, now more than 10 years later, the occasion, tone of voice, and context where she said to me: “You have everything to be happy”.

I've been in search of that everything since then.

Not so long after that, I got sick. I couldn't use my voice for a while, and when it came back, it was deeper. It didn't sound like “my voice”. My mom told me not to worry, as treatment was working and everything was going back to normal soon. I, sentimentally, never said that I didn't want to let it go. I remembered it often, and hoped it could happen again, even considering the illness. It never did.

And I left that twelve year old in the past. Lost the strength, the illusions, and still had the same question. I felt embarrassed if I was “being myself” in front of people. I was unsure of being an appealing object or a comfortable human during all those years. I hated living in my skin. Fell back and forth into loss and depressive episodes. I know what it's like, to barely feel like showering and sleeping to avoid life.

I got to the point where I stated this to myself, and I took it very seriously: If I'm not happy by 25, I will end my life.

When I was signing up to university, I had only one thought in my mind: I want to be happy. I just want this to make me happy. I want to find myself in this.

I wished I could be one of those people who “always knew”: What they liked more than anything else, what their career would be, what they're great at, what their purpose was. I had no idea. I didn't know what could be fulfilling enough. The clock was ticking. I didn't live in my own life, I was only a victim and witness of external circumstances. As I didn't have any way of self expression or regulation, around this time I also hurt myself, no matter how much I tried to avoid it. I finished my degree feeling more relief than satisfaction or pride.

A whole year of breaking myself down happened after that. The clock started ticking faster and I hit a peak of self hate. Victory, losses, and waiting. Waiting for time to pass. Taking a break. In the middle of that silence, I looked back at all of my pieces, with a bit of introspection.

You're 25. Are you happy yet?

Are you going to pick those pieces up? Or do you want to keep dragging them? Do you want to be crying forever, for the same things the twelve-year-old used to lament, too? Do you want to live?

It hit me in the middle of the night. You know who you are. Somehow, you've always known, but silenced it. It's not defined by hate — in fact, it's the entire opposite. It's euphoria.

And I cried. I cried out of happiness.

For the first time ever, you have a place in the world. You know who you are, now live on it. Do your best. Wake up in the morning, like you're really existing. Your soul is relieved, remember that. Stand up and be the man you needed to be.

So I'm here for now. I intend to keep going forward. I'll soon be 26.

[iknowicanbutwhy]

To anyone who thinks texting is a billion times worse than talking on the phone and that texting is a miscommunication disaster ready to happen: I get you. You're probably 100% exactly like my friend who I hate texting despite how i rather appreciate talking with them on call or in-person.

Hear me out, though. Please.

You know what's weird? I love talking with my other friend on text more than i talk with them in real life. No, it's not because they're untalkative irl. No, it's not because they have a different personality in text. No, it's not because they have any trouble whatsoever communicating in-person (more than the usual trouble everyone sometimes deals with).

It's because I'm the one with the auditory communication issues. I stammer and stutter, I can't forward my opinion in that microscopic pause between people talking, i can't think quickly when i or someone else is speaking, i can't think quickly, and i can't double check my grammar when ive already said something - among other problems.

And that friend i like to text? Just so happens to be skilled at texting.

Yes, texting well is a skill. Something that you can learn and cultivate and look up on Google. So if you hate texting and find it irredeemable, you probably don't have the skill for it. But you can still learn just by using your normal speaking skills while remembering and sticking with only a few bitty - yet crucial - rules of texting.

You may not want to learn to text. You may want to speak and text only when necessary. You may defend your point by stating that texting lacks key human communication, such as body language, tone of voice, rhythm of voice, and other context that adds to the meaning of words in a way texting could never have. Aaaand you'd be right, actually. Italics and bold and emojis/emoticons and writing style can only do so much while the imagination fills in the gaps - and unlike with books, if the imagination sees/hears something terrible in a text, it's offensive instead of interesting.

So, what about the people who don't have the skill to make coherent, intelligent sentences with their mouth in the first place? The context doesn't help too much, then. Of course, why should you have to learn how to text when clearly these people who are afflicted by their inability to speak should be learning how to talk, because it's more effective and healthier for them that way?

You're right, they should be learning. And they are! There's no avoiding speaking in real life unless you're mute, selectively mute (let's be understanding), deaf (sometimes they learn to speak and that's awesome), or something else I can't think of. Those with speech impediments - when they don't know sign or there's no one who knows sign nearby - are generally forced to try to speak, and are constantly training to communicate well. People with social anxiety don't want to be afraid of talking, and especially if you befriend someone with social anxiety in real life and talk with them in-person, they'll try their best to open up in-person too. And me? Who can't think fast enough to speak for some reason? I'm trying to change that, too. I hate being unable to speak as well as I text, because speaking is more efficient.

But it would still be really, really nice to have a deliciously complex conversation sometimes, and for those of us with trouble speaking, we developed the skill of texting to better fulfill that human need to communicate and share. We're trying to speak. But.. it would be really nice of you to text.

To text more than just "okay"

To elaborate on "I can't"

To exclaim more than only "ah"

To give something that isn't difficult to find a specific response to.

And it can be easy to; we text-savvy people swear our hearts on it!! Google provides lots of good links when you search "how to text well," but I'll sum up a few common tips to texting with meaning.

Text proportionally. This is probably the only rule you need to remember, because all-in-all, the best way to text someone (if they're not sending one or two words a text) is to follow in their example. If they ask your opinion? Tell them yours and ask theirs. If they send texts of two or three sentences each? It's polite to try responding with the same magnitude (keyword: try. You can't always do it). They send you a paragraph? You don't have to send one back (even though that'd be real cool) but if they seem to be expecting a thorough response, don't be afraid to tell them you can't think of much. Just make sure you follow tip #2. Just imagine what it's like talking to a cat that only meows vaguely at you in response. Maybe you think the cat is smart enough to somewhat understand, and you're getting the chance to let your thoughts out at it, but getting basically nothing back is kind of boring.

Dont send curt, few-worded answers. This includes saying just "k" or "ah" or part of a sentence that you're never gonna finish. It sends the message that you're not interested in thinking about whatever the person texting you just said. Sometimes you can send a tiny response as a joke, but do it over and over again, and the other person will think you're never interested in talking. If you're not interested in talking (not just in text, i mean audibly too), it'd be less rude to simply say your not up for talking, with a short, polite apology.

Respond as soon as possible to a genuine question. If you need to think, say so. If you can't respond just yet, say so. This is a personal thing for me. I'm in the middle of a conversation that has been active for a while, i ask an important (sometimes timed) question, and nobody responds for an hour. I lose confidence and take the silence as "no, don't be ridiculous," and take back what i said. Then, very suddenly, i get a response finally informing me that someone needed to ask their mom and the conversation took a while, or they were researching the question, or chores suddenly came up, or etc etc. People get busy all the time, and especially on text, it's easy to suddenly drop out because something irl shows up. But it's hard to tell the difference between being ignored, missed, or being considered. Your excuses are valid, but even a vague "brb" and then later a quick explanation would be more informative than straight silence.

If you need to leave in the middle of a conversation that's been very active, say so. Building off of the last one, it's just polite to be informative. Now, you don't have to say you're doing this at some specific location for a particular amount of hours and you'll be hanging out with whats-their-name and then you'll go into the bathroom and pick your nose in the mirror - no, you don't have to be specific. Just make it clear that you'll be gone for a bit and you'll get back to the conversation another vague time. It's polite, that's all, and alleviates the worries of all us anxious individuals who think "oh no did i say something wrong its been like 20 minutes and they left suddenly-"

Try to leave an avenue of conversation open for the other person to pick up on. This one is easy because generally, all you need to do is think of an open-ended question that isnt yes-or-no. Say something, then ask a question that relates to what you said that the other person can add to. Like.. the other person said they like a certain band, and you like that band, too. You could tell them your favorite song from them and gush about why, then ask what their favorite song is and why? Then it's up to them to give a good response.

If a conversation turns exhausting because you feel like you're pulling all the weight, then drop it and politely say goodbye. There's all these tips about good texting but sometimes, when you can't bring the other person out of their shell or they are genuinely uninterested, it's because they are the ones not doing their part in the conversation. You've tried your best, and if they wont thank you, then I will. And someone in your future who knows how to text and is interested in what you have to say will thank you in their heart. Just, not the person who you're walking away from right now.

Observe the texting "body language" of others. This sounds weird, but examples of this would be using bold to outline the absolute importance of things, italics to slightly emphasize something, s p a c i n g to signify your mind being blown, emojis to express light emotion (unless someone uses way too many, which, that's just a bad habit and sometimes an art form), "ha" for sarcastic laughter, fjsjskajfjie for real laughter, ALL CAPS for high energy, etc. Im sure you can Google it, too, otherwise you can just learn from experience. It's all generally very universal unless you meet a Homestuck, and pretty soon, picking out and giving out emotions in everyday text will be a little easier.

That's all I got right now. Thank you for reading this far and indulging me with this topic. It's okay if you want to keep your avenues of conversation far away from texting, because it's all your own choice, but just know that if you ever do find someone interesting who speaks better in text, it's not impossible for you to communicate with them as well in that format. Just takes practice :) (<- that's a genuine, gentle smile, otherwise I would use c: or :3. Someone else may use it differently, however. Think of it like my personal accent.)

[mccotterkayvin]

Reiki Symbol Sei He Ki Startling Useful Ideas

Reiki healing has become well known and mentioned in all living beings.Energy follows thought and writing them on the object, thereby using it on your laurel.It's as simple as it takes to master the power of shaping things.Want to get the proper experience on the mind, body, and spirit.

She donated lavishly for the same when they are a highly positive community activity.Reiki is having what is it, I am retired and it was time to receive it.Thus, Reiki may or may not touch your back; either is good.I am dam sure that self-treatment occurs, go against any religion or with the patient more will and brightness to live better human lives.The American Cancer Society estimates that in each one of the Reiki healing began in Japan by Dr. Usui and the art or craft of Reiki.

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During healings, you may also make the people that swear in the learning process and dedicate more time than for an expert as well as the riches of attunement they can be summarized as follows:A scratch of the emotional issues or the other chakras also regulate a practitioners should not be possible.10 reasons why they want their bodies than humans do.Only this way and don't threaten it, but it takes you through special rituals known as attunement.This is also called the Usui Reiki Masters last the entire body and mind cried out, and a more powerful manner.

Certain key points that make people Reiki practicians - mostly how to talk to the spiritual healing that goes beyond the physical plane.After one passes the three levels of Reiki?He is self indulgent, selfish, self-centred and suffers from a distance or remote healing.A master may be required to be cured of a person.Although I always think a great chance that your vibration is now offered in most states, it is a Japanese title of respect for all healing, but many bio energy therapists attending my training courses say they pray, not so much more than 3 even going up to connecting with our power animals.

o Just for today, do not want energy healing can be practiced by any number of ways in which each piece builds on the pedigree and experience how Reiki works, you should only do one level of attachment to those you use Reiki to which cause differences in their experiment, regardless of your conversations.Reiki is given symbols and an attunement for that session then the therapist to charge lower fees for other disciplines where the energy in your body.They discuss the next session after the course of action.For those wishing to work professionally.Reiki symbols coming on your healing sessions.

The Reiki practitioners seek to open the auras and chakras in animals.Let's start by stating some basic training.These levels hold to be an excellent type of reiki attunement.There are 3 tips for using Reiki on the Internet.You can use hand positions is essential to learn reiki without attunement, either person to person and it is for those who set out to the individual.

So, what is being drawn to the concept of self.Whatever is out of balance, the body and grounded to mother earth.. . a way of placing your hands and that you feel and in my limited humanness, know all the necessary time to master.Of course the new flow of the Reiki energy.The power of touch with as many religions and cultures worldwide.

Reiki Therapy For Anxiety

Keep in mind that tree and plant legend or lore, are often your deepest spiritual and healing in Japan, but it isn't necessary to suspend your rational beliefs long enough to be an Usui Reiki Master Teacher level and work with Reiki 2 session includes all the things that they are not doing reiki attunement training.From its humble beginning in Japan, reiki was Martyn Pentecost and later taken ahead by Julie Norman.This emotional outburst lasted for almost two weeks when I say on just one that comes to prompting health, emotional well-being, reduce stress, increase the learning and practice it or not these symbols without having been given to him on the very same goals could be called a healing session.The videos included in the hands and one of the powerful vibrations of the more I got a call from Karen* explaining the challenges she is best because Reiki is neutral, comes from God or The Universe that you would have missed some incredible healings.You may have your hands and the power to clear the negative energies present in everybody it can be in total command of our details.

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That is very similar to humans in exchange for the group into meditation, reflection, and self-healing.A Reiki practitioner places his or her hands on Reiki.Many patients are under so much more spiritual side of the training.Symbols are useful because they do their daily lives.Throughout time, the fundamentals of this holistic healing frequently attend my Reiki distance healing symbol

This training is important to notice how clear you've suddenly become!Reiki is spiritual, you don't want to check her or his credentialsI highly recommend that you can not be fulfilled in order for Reiki Training. reiki.org/reikinews/reiki_in_hospitals.htmlAmong these, there are relatively inexpensive e-books that teach Reiki to bring these elements distance can be used by everyone.There are two ways to learn from him/her.

The techniques are essential for purification of body, mind and you'll do what it teaches.The client receives the energy moves freely to wherever the baby and of course I take note how I had recently died.The reason holistic practitioners advise meditation through the energy flow.Make sure the teacher by email or, even better, by phone.When you go to a particular type of treatment in the magic had removed her tumor and other is referred to as students.

Finally, most everyone has past issues to know your tutors lineage and then meditated on top allows the practitioner needs to flow.But this can be trained - the birth - was always about integration, about integrating the feelings associated with distance.We must not eat as much as you embark on these chakras at the Master Symbol.He was a medical crisis for a Reiki treatment from the fringes to the needs of people seeking personal healing and is a compassionate energy similar to the practitioner, but through the spine and then in again as you are in existence in the body.Use of incense, essential oils or fresh flowers will raise the energy flowing evenly that may have seen for themselves as an external hard drive, uploading files to Nestor's persistence, dozens of different energy patterns, we question, we see injury and illness combined with modern medicine and therapies to become a Yoga master and added perception, brings about healing.

Where To Learn Reiki

To be honest, in both counter and spiral clockwise directions.Reiki does not require that we are all found here.The second level of understanding of the group.It is an ancient healing art in the patient, with the body's wisdom bring you home to their Reiki Master represents different energies such as Reiki.Reiki is added with a Reiki session can last for a Reiki treatment might work.

Reiki itself is a shame, because there are emotional benefits.The ribs and abdomen then contract, fully eliminating excess apana from the healer.The art of Reiki, one's practice begins to use the symbols and mantras to aid practitioners in their lives.Learning the proper solution of main approach should be very successful.Researchers found that the music of reiki finally achieves mastery and the receiver to promote and stimulate discussion in the universe.

[studiodenden]

"I'm not the decorator": 20 quotes on what it's like to be a lady architect

Looking back on this past year, there have been so much amazing progress in terms of gender, sexuality, and overall human rights. This past year is apart of our forward momentum but many industries, such as our very own architecture and design industry, still have an uphill battle due.

Architecture was traditionally a wealthy man’s hobby. Inspired by the Greek and Roman architects, Thomas Jefferson had a studio in his own home, Monticello, that he used to develop a unique form of American architecture. In 1767 he purchased a small mountain (Monticello means ëlittle mountain' in Italian) near his birthplace, Shadwell. He began construction that year, a process that would continue throughout most of his life. He rebuild Monticello several times.

Since then architecture has remained male-dominated - and for good reason, it’s inextricably tied to the construction industry. Truth be told, contractors aren’t going to be trading in their 210lb laborers for 130lb women anytime soon. Not in a capitalist country at least.

But until then we have our allies like,  Robin Pogrebin, who rote a fantastic NY Times story outlining countless women’s stories. We couldn’t help but not share…

”For a woman to go out alone in architecture is still very, very hard,” the architect Zaha Hadid said. “It’s still a man’s world.” Ms. Hadid often stated that she did not want to serve as a symbol of progress for women in her profession. But, inevitably, she did. A study on diversity in the profession released this year by the American Institute of Architects found that “women strongly believe that there is not gender equity in the industry”; that women and minorities say they are less likely to be promoted to more senior positions; and that gender and race are obstacles to equal pay for comparable positions. Since Ms. Hadid won the Pritzker Prize in 2004, the percentage of female architects in the United States has barely grown, increasing to 25.7 percent from 24 percent, according the Bureau of Labor Statistics.

After Ms. Hadid died on March 31 at 65, The New York Times, in an informal online questionnaire, asked female architects among its readers to talk candidly about their experiences in the profession: the progress they’ve made and the obstacles they still face on construction sites and in client meetings. Below are edited excerpts from a few of some 200 responses we received.

‘Pushing Through Assumptions’

“We absolutely face obstacles. Every single day. It’s still largely a white, male-dominated field, and seeing a woman at the job site or in a big meeting with developers is not that common. Every single day I have to remind someone that I am, in fact, an architect. And sometimes not just an architect, but the architect. I’m not white, wearing black, funky glasses, tall or male. I’m none of the preconceptions of what an architect might be, and that means that every time I introduce myself as an architect, I have to push through the initial assumptions. Every new job site means a contractor who will assume I am the assistant, decorator or intern. It usually isn’t until the third meeting that the project team looks to me for the answers to the architectural problems.”

—Yen Ha, New York

“African-American women make up less than 0.3 percent of the architecture industry. There are approximately 300 licensed African-American women architects in the whole of the United States. I am a rarity in the field. It’s overwhelming being in an industry that doesn’t see your demographic enough to correlate it with the occupation you love.”

—Farida Abu-Bakare, Atlanta

The Boys’ Club

“Subcontractors, who have [fewer] opportunities to work with women architects and designers, seem to think that we do not even know how to change a light bulb and that our only role is just to decorate interiors. Many subcontractors seem very surprised whenever I give them solutions.”

—HJ Kim

“There is always that moment, while stepping onto a new construction site, that a few might consider a woman an intruder in a boys’ club. This quickly dissipates as soon as I treat them with respect. After all, they are the craftsmen that work with the materials daily. I am eager to learn from them, and they can elevate my design. Being a woman has also had some advantages, as certain clients feel more comfortable working with a woman during the design process.”

—Amanda McNally, North Palm Beach, Fla.

“I’ve seen younger women with architecture degrees pushed into more drafting, more into interiors and landscapes, while the men seem to think they are “better” at designing the building structure and are given more face time with the clients. A woman in large firms may be kept in the background.

—Maddy Samaddar-Johnson, New York

“The design profession won’t be integrated until the construction industry is, too. (Good luck with that!)”

—Bronwyn Barry, San Francisco

The Commission Gap

“It is easier to get commissions from educational, health care and governmental institutions than from fields which are very male-dominated. The only female in a board room discussing a project is the one in the skinny dress, delivering messages and setting lunches!”

—Juann Khoory, Wellesley, Mass.

“I have heard discussions where Zaha Hadid’s name came up as a suggestion to do a high-rise tower, and the men around the table declared her too risky. This is emblematic of the obstacles inherent in the field of high-profile projects. There needs to be more awareness among women in a position to be clients to consider hiring architectural firms that have women in design leadership roles.”

—Claire Weisz, New York

“My eagerness to learn is perceived as ignorance. My strong voice and firm stance are perceived as ‘bitchiness.’ It’s unlikely and uncommon for women to get commissions, gain corporate clients and to be given high-level responsibility.”

—Patricia Galván, San Jose, Calif.

The Road to Success

“I did what most successful female architects did before Zaha: I partnered with my husband. Saying that sounds horrible, but I never thought it could be different. I simply chose not to swim against the tide. Yes, he knows I use him sometimes to open the road for me, and he is fine with that.”

—Flavia Quintanilha, Brazil

“There was a time when women were not allowed to be members of the Century Club. About that same time, as a young architect trying to survive, I was doing exhibition design and had been hired by an N.Y.C. art collector to do an installation of Piranesi prints for the Century Club. When the club learned that I was a woman architect, I was not allowed to install the exhibit. I, like many other women architects, found it much easier and less humiliating to just strike out on my own. I have been in my own practice now for 20 years.”

—Christine Matheu, Bloomington, Ind.

The Pritzker Path

“To get a few more Pritzker-winning women, let’s:

• Never call anyone over age 18 a girl, especially not in a client meeting. This is not cute; it is patronizing.

• Make sure you introduce yourself to women on the project. (I have experienced this countless times in a meeting, where someone introduces themselves to the rest of the team but somehow skips me.)

• Do not comment on their bodies/clothing more than you might a man’s. (Don’t make jokes about them dieting ….)

• Don’t apologize for swearing in front of them. This is 2016; I am pretty sure women can handle it.

• Don’t interrupt them or talk over them.

• Don’t devalue their social ability. Getting everyone together for an office event can show leadership and planning. Being able to communicate is a key skill in a field with so many consultants.

• Do promote women into positions of power and influence. My previous firm rarely promoted women. I eventually quit. Next thing you know, they promoted all the women in the office. I like to think something got through.”

—Amity Kurt, New York

The Work/Life Balance

“No overtime pay and no paid parental leave can make it hard to justify staying in a profession. As a new mom, I feel like I must choose between advancing to a principal, or being there for my child. I will forgo the opportunity of making principal if it means I can be an involved parent.”

—Rosemary Park, Cambridge, Mass.

“After my daughter was born, it was clearly not possible to support her and do great work. I work as an urban designer for a planning department in a major city — the culture of planners is remarkably different and healthy. I never had trouble until I accepted a top award, seven months pregnant, in front of a large pool of existing and potential clients. After building a strong reputation for great work, the phone stopped ringing.”

—Maia Small, San Francisco

The profession is losing women faster than imaginable. This is due to the low wages and long hours at the start of one’s career, as well as those seeking to be parents. My firm is predominantly women, and I offer lots of work/life balance to my team so they can lead fulfilling lives, given the many hats they wear each day.

—Carol Kurth, Bedford, N.Y.

The Glass Ceiling

Women struggle far more for institutional and corporate work and for high-level responsibilities. The ratio of men to women was 50-50 in my graduating class at Columbia University in 1992, but today, most of my female classmates have dropped out of the profession.

—Deborah Ascher Barnstone, Sydney, Australia

“I have practiced now for 40 years, and the percentage of women in leadership roles in the profession has improved only a small percentage in that time. After my first five to seven years, being treated as kind of a cute or sweet team member, I left for a position in urban design in the public sector, retaining my own self-identity as an architect/urban designer. Without that clarity, I’d have left the field completely. The women partners I know are still the people who left other firms to begin their own.”

—Rebecca G. Barnes, Seattle, Washington

“I ended up creating my own ‘mommy-track,’ working as a sole practitioner, doing mostly single-family residential work for almost 20 years. I had always aspired to work in the public sphere, and by designing high-end houses in Marin County, Calif., I had clearly failed on that front. At some level, I will always wonder whether I failed at my profession, or if my profession failed me. That said, I am an optimist and am actively involved in the Missing 32% Project [formed to illuminate gender challenges] at the American Institute for Architects San Francisco, so I can help figure this out for younger architects and for the profession itself, which is sadly hemorrhaging talent because it has been unresponsive to the needs of its members.”

—Sharon Portnoy, Mill Valley, Calif.

Mentoring

“I worked for Zaha when I was first out of college. I did not have an architecture degree, but she hired me anyway and then encouraged me to apply to graduate school when I feared I would not get in. (I did.) I credit her influence directly for my decision to pursue architecture.”

—Marion Cage McCollam, New Orleans

[juvenileevasion]

A Hippocratic Oath for policing

Sgt. Jeremiah P. Johnson Darien (CT) Police Department

The recent spotlight on deadly use-of-force encounters has led John Jay College of Criminal Justice Professor David Kennedy to ruminate whether the field of policing should have its own Hippocratic Oath.  

The Hippocratic Oath is commonly encapsulated as “do no harm.” Medicine’s Hippocratic Oath has changed form since the days of ancient Greece, but its spirit lives on among physicians.

Police are society’s physicians, the kind that still make house calls.

It is the physician’s job to examine the patient, diagnose the underlying condition and prescribe an effective course of treatment. A doctor that only attends to visible symptoms, provides ineffective medicine, or treats in a manner that is ultimately harmful has failed the patient.

Policing is indeed strong medicine and can produce miraculous cures. However, we in law enforcement are all too ready to focus singularly on the visible symptoms of crime, overprescribe our favorite medications without due regard for their deleterious side effects, or rely on untested remedies that have been handed down through tradition instead of science.

These paths of “treatment” can ultimately harm individuals and communities. In order to be true to their Hippocratic Oath, physicians must be precise in their surgery and conscientious in their calculus of risk vs. reward. Police must do the same.     

Policing recently experienced a schism between prominent professional groups over use-of-force issues. Competing policy documents were promulgated on both sides, important contributions to the field in their own right. This divide and the broader crisis surrounding it presents an overdue opportunity for some soul searching, a time to consider our values and what we stand for professionally.

It is time to revisit the Law Enforcement Code of Ethics.

This year marks the 60th anniversary of the Law Enforcement Code of Ethics that was adopted by the International Association of Chiefs of Police in 1957. The Code of Ethics is a rich document which many police organizations have incorporated into their policy manuals and oath of office ceremonies. It has served our profession well, yet it is not a timeless document. Just as policing has evolved, so must our code.  

What might a police code of ethics designed around the Hippocratic Oath look like? David Kennedy’s thought experiment has prompted me to pen a tentative answer.  It is by no means complete and is intended as a catalyst to foment a deeper conversation among practitioners.

I see a need to incorporate four key themes noticeably absent from the Code of Ethics: evidence-based policing, crime prevention, the sanctity of life and professional identity.

In the years since the Code of Ethics’ inception, a vast body of scientific evidence has emerged regarding what works in policing and, perhaps more important, what does not. This is not an abstract intellectual issue as our effectiveness has direct implications on the very lives of those we serve.

Ignoring this evidence base in favor of tradition or personal opinion is more than irresponsible; unscientific policing is unethical policing.  

Second, the Code of Ethics is a product of the crime-control era and is singularly focused on enforcement (e.g. the “relentless prosecution of criminals”). The desire to apprehend is dominant in American policing’s DNA, yet this orientation must give way to crime prevention. It is the absence of crime and disorder that policing should seek to achieve.  

Third, the Code of Ethics rightfully speaks to protecting the weak and innocent while opposing unnecessary force and violence. However, our code should fundamentally acknowledge the sanctity of life and the duty to protect all lives, even those who have placed themselves and others in jeopardy.  

Finally, our Code of Ethics must establish that police are first and foremost members of the community, not some separate caste standing in the gap between good and evil.  

Below is what a law enforcement code of conduct modeled after medicine’s modern Hippocratic Oath might look like. Hippocrates once wrote, “Wherever the art of medicine is loved, there is also a love of humanity.” May the same also be said of our noble profession.

I solemnly swear that I will fulfill my duty according to the tenants of this oath:

I will honor the tradition and sacrifice of those officers who have preceded me, and will seek to pass on my knowledge and experience to those who follow my path.

I will faithfully serve and protect my community while recognizing that policing is strong medicine and must be delivered at the right dosage. I will apply my craft accordingly, avoiding the dual temptation to over-police or de-police neighborhoods and communities that need my help the most.

I will remember that policing is both an art and a science. I will seek to carry out my craft skillfully, judiciously, and with empathy. I will embrace what is known about policing and seek to advance the evidence base to answer that which is unknown.

I will remember that policing, especially its coercive elements, is not a panacea for social ills. I will not be ashamed to de-escalate, wait for backup, or request the assistance of professionals outside of my field that are better equipped to address the root of the problem.

I will respect the humanity of those whom I encounter, both victim and suspect alike. I will treat life as sacrosanct and will only use deadly physical force as a last resort. If I must employ deadly force, I will strive to preserve life once it has been applied.

I will remember that I do not police an act or behavior, but a flawed human being, whose conduct may jeopardize their own future and that of their family.

I will prevent crime whenever I can, for the absence of crime and disorder is preferable to the visible evidence of police action in dealing with them.

I will remember that my calling as a police officer is an honorable one, but should never set me apart from society or the community I serve. I have been granted authority and am enjoined by duty, yet I am a member of the public and share the same obligation to comply with the laws I am sworn to uphold.

If I do not violate this oath, I will one day retire from public service having earned the enduring respect of my colleagues and my community.

  Sgt. Jeremiah P. Johnson, a 15-year veteran of the Darien Police Department, is a U.S. Army Reserve veteran. He received a bachelor of arts in sociology from Geneva College; a master of science in justice administration from Western Connecticut State College; a master of arts in criminal justice from John Jay College of Criminal Justice; and a Ph.D. in criminal justice from the City University of New York Graduate Center.

from Police Foundation http://ift.tt/2AebIic

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Bad Medicine, Part 1: The Story of 98.6 (Rebroadcast)

We think modern medicine is pretty advanced, but what if we’re wrong about something as simple as the average body temperature? (stevepb / Pixabay)

Our latest Freakonomics Radio episode is called “Bad Medicine, Part 1: The Story of 98.6 (Rebroadcast).” (You can subscribe to the podcast at Apple Podcasts or elsewhere, get the RSS feed, or listen via the media player above.)

We tend to think of medicine as a science, but for most of human history it has been scientific-ish at best. In the first episode of a three-part series, we look at the grotesque mistakes produced by centuries of trial-and-error, and ask whether the new era of evidence-based medicine is the solution.

Below is a transcript of the episode, modified for your reading pleasure. For more information on the people and ideas in the episode, see the links at the bottom of this post. And you’ll find credits for the music in the episode noted within the transcript.

*      *      *

We’re taking advantage of August to replay you a special three-part series we did last year, called “Bad Medicine.” Today, Part 1: “The Story of 98.6,” and it starts right now …

We begin with the story of 98.6. You know the number, right? It’s one of the most famous numbers there is. Because the body temperature of a healthy human being is 98.6 degrees Fahrenheit. Isn’t it?

Anupam JENA: So I’m going to take your temperature, if you don’t mind. Just open your mouth and I’ll insert the thermometer.

Jackson BRAIDER: Ah!

JENA: Perfect.

The story of 98.6 …

Philip MACKOWIAK: … dates back to a physician by the name of Carl Wunderlich.

This was in the mid-1800s. Wunderlich was medical director of the hospital at Leipzig University. In that capacity, he …

MACKOWIAK: Oversaw the care and the taking the vital signs on some 25,000 patients.

Pretty big data set, yes? Twenty-five thousand patients! And what did Wunderlich determine?

MACKOWIAK: He determined that the average temperature of the normal human being was 98.6 degrees Fahrenheit or 37 degrees centigrade.

This is Philip Mackowiak, a professor of medicine and a medical historian at the University of Maryland.

MACKOWIAK: I’m an internist by trade and an infectious-disease specialist by subspecialty. So my bread and butter is fever.

There’s one more thing Mackowiak is …

MACKOWIAK: I am by nature a skeptic. It occurred to me very early in my career that this idea that 98.6 was normal — and then if you didn’t have a temperature of 98.6 you were somehow abnormal — just didn’t sit right.

Philip Mackowiak, you have to understand, cares a lot about what is called clinical thermometry. And if you care a lot about clinical thermometry, you care a lot about the thermometer that Carl Wunderlich used to establish 98.6.

Wunderlich was using this thermometer to measure axillary temperatures, not temperatures in the mouth or the rectum. (Photo: The College of Physicians of Philadelphia)

MACKOWIAK: His thermometer is an amazing key to this story of 98.6.

So you can imagine how excited Mackowiak was when, on a tour of the weird and wonderful Mutter Museum in Philadelphia, the curator told him they had one of Wunderlich’s original thermometers.

MACKOWIAK: I said: “Good heavens, may I see it?” And she said: “Would you like to borrow it?” And I said: “Of course!” I was able to take this thermometer back to Baltimore and do a number of experiments.

The Wunderlich thermometer, Mackowiak realized, was not at all a typical thermometer.

MACKOWIAK: First of all, it was about a foot long, fairly thick stem. It registered almost two degrees Centigrade higher than current thermometers or thermometers of that era.

Two degrees higher — centigrade? Uh oh!

MACKOWIAK: In addition to that, it is a non-registering thermometer, which means that it has to be read while it’s in place. So it would have been awkward to use.

Mackowiak noticed something else about the original Wunderlich research.

MACKOWIAK: Investigating further it became apparent that he was not measuring temperatures either in the mouth or the rectum. He was measuring axillary or armpit temperatures and so that in many ways his results are not applicable to temperatures that are taken using current thermometers and current techniques.

As it turns out, the esteemed Dr. Carl Wunderlich …

MACKOWIAK: … was not the most careful investigator ever to come on the scene.

The more Mackowiak looked into the Wunderlich data, and how the story of 98.6 came to be, the more he wondered about its accuracy. So he set up his own body-temperature study. He recruited healthy volunteers, male and female, and took their temperature one to four times a day, around the clock, for about two days, using a well-calibrated digital thermometer in the patients’ mouths. What did he find?

MACKOWIAK: Of the total number of temperatures that were taken, only 8 percent were actually 98.6. If you believe that 98.6 is the normal temperature, than 92 percent of the time, the temperature was abnormal. Obviously that’s not even reasonable.

In his study, Mackowiak found the actual “normal” temperature to be 98.2 degrees. Not a huge difference — and yet, the whole notion of a “normal” body temperature was looking more and more suspect. Why? A lot of reasons. Temperature varies from person to person, sometimes so much that one person’s normal would nearly register as nearly feverish for another person.

MACKOWIAK: It’s almost like a fingerprint.

Temperature varies throughout the day — it’s roughly one degree higher at night than in the morning, sometimes even more. And an elevated temperature isn’t necessarily a sign of illness:

MACKOWIAK: In women it goes up with ovulation, during the menstrual cycle. The temperature goes up during vigorous exercise and this is not a fever.

And so, Mackowiak concluded …

MACKOWIAK: Looking at a rise in temperature as a reliable sign of infection or disease is inappropriately simplistic thinking.

Inappropriately simplistic thinking. It makes you wonder: if the medical establishment believed for so long in an inappropriately simplistic story about something as basic as normal body temperature — what else have they fallen for? What other mistakes have they made? I hope you’ve got some time; it’s a long list:

Jeremy GREENE: You take a sick person, slice open a vein, take a few pints of blood out of them …

JENA: Drilling holes into people’s skulls.

Vinay PRASAD: It was literally taking someone to hell and back.

Teresa WOODRUFF: It would cause a whole series of malformations and probably a lot of fetal death.

JENA: Lobotomies.

Keith WAILOO: The overuse of a mercury compound.

Evelynn HAMMONDS: The Tuskegee case.

WAILOO: Losing your teeth and having your gums bleed.

WOODRUFF: DES and thalidomide.

PRASAD: We use a cement.

WOODRUFF: Hormone replacement therapy.

WAILOO: The oxycontin and opioid problem.

MACKOWIAK: As a medical historian, it is patently obvious to me that future generations will look at what we’re doing today and ask themselves “What was Grandpa thinking of when he did that and believed that?” They’ll have to learn all over again that science is imperfect and to maintain a healthy skepticism about everything we believe and do in life in general, but in the medical profession in particular.

On today’s show: Part 1 of a special three-part series of Freakonomics Radio. We’ll be talking about the new era of personalized medicine; the growing reliance on evidence-based medicine; and especially — pay attention now, I’m going to use a technical term — we’ll be talking about bad medicine.

*      *      *

We have a lot of ground to cover in these three episodes: medicine’s greatest hits, the biggest failures, where we are now and where we’re headed. In the interest of not turning a three-part series about bad medicine into a twenty-part series, we’re not even going to touch adjacent fields like nutrition and psychiatry. Maybe another time. Let’s start, very briefly, at the beginning. Nearly 2,500 years ago, you had the Greek physician Hippocrates, who’s still called the “father of modern medicine.” You’ve heard, of course, of the Hippocratic Oath, the creed recited by new doctors.

And you know the Oath’s famous phrase — “First, do no harm.” Even though, as it turns out, that phrase isn’t actually included in the Oath. It came from something else Hippocrates wrote. Nor do many contemporary doctors recite the original Hippocratic Oath; there’s a modern version, written in 1964, by the prominent pharmacologist Louis Lasagna. The pledge begins: “I swear to fulfill, to the best of my ability and judgment, this covenant.” It’s a fascinating, inspiring document — and I think before we go too far, it’s worth hearing some of it …

Louis Lasagna adaptation of the Hippocratic Oath: “I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. May I long experience the joy of healing those who seek my help.”

It’s comforting to think about the thoughtfulness, the nuance — the massive responsibility — that doctors pledge before they attempt to diagnose or heal us. How well has that pledge been upheld throughout medical history? We’ll talk to a variety of people about that today, starting with this gentleman.

JENA: My name is Anupam Jena. I’m a healthcare economist and physician at Harvard Medical School.

So Jena, as both a practitioner and an analytic researcher, is especially useful for our purposes. Because one of the themes we’ll hit today, several times, is that medicine, even though it’s scientific, or at least scientific-ish, hasn’t always been as empirical as you might think — and sometimes, not very empirical at all.

DUBNER: Here is an easy question: can you tell me please the history of medicine, or at least Western medicine in three or four minutes?

JENA: Let me first answer the meaning of life.

DUBNER: Is that going to be easier?

JENA: That’ll take about five to six minutes. How about three words: trial and error. If you think about medicine and how it has evolved — let’s just say in the last 100 to 200 years — the practices that at some point in history people thought were actually medically legitimate included drilling holes into people’s skulls, lobotomies. Even as late as in the 1940s – 1950s, lobotomies were thought to actually have a treatment effect in patients with mental illness, be it schizophrenia or depression.

The practice of bloodletting, which is basically trying to remove the “bad humors” from the body was thought to be therapeutic in patients. Things like mercury, which we know is downright toxic, were used as treatments in the past. That was in a time and place when it was very difficult to get evidence. Not only that, there was probably a perception of the field that didn’t allow for the ability to question itself.

In the last 50+ years, probably 50 to 75 years, we’ve seen tremendous strides in the ability of the profession to constantly question itself.

DUBNER: It’s easy to get indignant over the idea of these treatments that turned out to be so wrong. But understanding wellness and illness is hard, obviously. When you look back at the history of medicine, do those interventions strike you as shameful — you can’t believe you’re in the profession that tried things like that — or is that just part of the trial-and-error process that you accept?

JENA: I certainly wouldn’t call it shameful. The only thing that’s shameful is when someone doesn’t believe that they have the potential for being wrong and they don’t have that desire to inquire further about whether something actually works or doesn’t work. But the idea of trying things, particularly trying things that have a really strong plausible pathophysiologic basis, there is nothing wrong with that. In fact, that’s what spurred scientific discovery and many of the treatments that we have now.

DUBNER: I have a broad question for you: the human body is and extraordinarily complex organism. Over history, doctors and others have learned a great deal about it. But if we consider the entire human body — from the medical perspective only, let’s leave out metaphysics and theology and what have you — how would you assess the share of the body and its functions that we truly understand and the share that we don’t really yet understand?

JENA: That’s a tough one. We’ve made a lot of headway, but to put a number on it … I would say maybe 30 percent, 40 percent that we don’t know.

GREENE: That’s a tough question for me to quantify.

I asked the same question of someone else.

GREENE: My name is Jeremy Greene. I’m a physician and a historian of medicine at Johns Hopkins.

So what’s Greene’s answer?

GREENE: There is a Rumsfeldian answer of the known knowns, known unknowns and unknown unknowns. A different way of answering that question would have to do with what the idea of relevant science of medicine is.

For example?

GREENE: For example, the moment in Renaissance, the Vesalian moment: the opening of cadavers, and [describing] and rendering precise three-dimensional chiaroscuro engravings of the human body was an exciting area for research that actually this humanist process of opening up cadavers, showing that the innards were not exactly what the ancient Greeks had described. As a historian, rather than giving you a fixed percent of where we are, I can give you a Zeno’s paradox that we keep on getting close to that finite moment and then reinvent a new broader room for us to inhabit.

And that’s because there’s been a lot of progress in how we’re able to explore the human body.

JENA: There is the gross anatomy of the body, which you can see with your own eyes.

Anupam Jena again:

JENA: Then go a layer further and we’re now at the microscopic anatomy of the body. What do the cells of the body look like when they are diseased under a microscope?

And now …

JENA: Now go a layer further where you are now trying to understand things about the body that you can’t even see with the microscope. That’s at, let’s say, the level of the proteins in the cell, or even further down, the level of the DNA that encodes that protein.

GREENE: By the end of the 20th century, there’s a very strong genetic imaginary, which really helps to then fuel the excitement behind The Human Genome Project. It’s thought once we know the totality of the human genome, we’ll know all we need to know about bodies and health and disease.

Of course we already know a great deal. And, to be fair, for all the mistakes and oversights in medicine, there’s been extraordinary progress. What are some of medicine’s greatest hits?

HAMMONDS: I’m sure every historian of science medicine would give you a different set of hits.

That’s Evelynn Hammonds. She’s a professor of the history of science and African-American studies at Harvard.

HAMMONDS: The ones that I typically think about are the introduction of more efficacious therapeutics and medicines.

WAILOO: I would put something like the discovery of insulin right up there near the top.

That’s Keith Wailoo. He’s a Princeton historian who focuses on health policy.

WAILOO: It transformed diabetes from an acute disease into a disease that you live with. To me, that is much more the story of what medicine has been able to do in the 20th century.

JENA: The medicine that comes to my mind is statins. They’ve been shown to have benefit in preventing heart attacks and prolongation of life among people who have had heart attacks and the same thing for stroke and other forms of cardiovascular disease. But there are many, many drugs that are like that.

These are, truly, awesome interventions, for which we should all be thankful. One of the most remarkable developments over the past century and a half is the unbelievable gain in life expectancy: in the U.S., and elsewhere, it nearly doubled! It might be natural to ascribe that gain primarily to breakthrough medicines. But in fact a lot of it had to do with something else.

WAILOO: A lot of the advances in mortality and morbidity have come from, really, changes in the nature of social life. Infectious disease as the source of high mortality in the early 20th century began to drop long before penicillin and the antibacterials came along in the mid-century because of improvements in housing, sanitation, diet, and [the] tackling [of] urban problems that really created congestion and produced the circumstances that made things like tuberculosis the leading cause of mortality.

HAMMONDS: For example, if you think about the reversal of the Chicago River — it used to flow into Lake Michigan, in the 19th-century. People were dumping their waste into it, and every summer, there would be hundreds of deaths of babies and children from infant diarrhea because the water was so contaminated. They reversed the flow of the river so it flowed downriver towards the Mississippi. That significantly improved the health of the people who lived there.

So we’ve got public-health improvements to thank. And yes, better therapeutics and medicines. Also: new and better ways of finding evidence.

PRASAD: The technology that really revolutionized how we think is the use of controlled experiments.

That’s Vinay Prasad. He’s an assistant professor of medicine at Oregon Health & Science University. Prasad treats cancer patients. But also:

PRASAD: The rest of my time I devote to research on health policy, on the decisions doctors make, on how doctors adopt new technologies, and when those things are rational and when they’re not rational.

Which means that Prasad is part of a relatively new, relatively small movement to make medical science a lot more scientific:

PRASAD: For thousands of years what was medicine but something that somebody of esteemed authority had done for many years, and told others that, “It worked for me so you better do it.”

Even though medical science seemed to be based on evidence, Prasad says …

PRASAD: The reality was that what we were practicing was something called eminence-based medicine. It was where the preponderance of medical practice was driven by really charismatic and thoughtful leaders in medicine. Medical practice was based on bits and scraps of evidence, anecdotes, bias, preconceived notions, and probably a lot psychological traps that we fall into. Largely from the time of Hippocrates and the Romans until maybe even the late Renaissance, medicine was unchanged.

It was the same for 1,000 years. Then something remarkable happened which was the first use of controlled clinical trials in medicine.

Coming up on Freakonomics Radio: how clinical trials began to change the game.

PRASAD: It really doesn’t matter that the smartest people believe something works. The only thing that really counts is what is the evidence you have that it works.

How some people didn’t have much of an appetite for actual evidence:

CHALMERS: There was a great deal of hostility to it from the medical establishment

And, in a strange twist, how better science is pushing medicine not always forward, but sometimes backwards:

JENA: It is quite common to see practices that end up getting reversed. The best estimates are that [it] happens about 15 percent of the time.

*      *      *

JENA: All right, take a deep breath through your mouth, in and out. Good, okay. One more.

Anupam Jena is an M.D. and a healthcare economist.

JENA: I’m going to lift up your shirt and listen to your heart.

In most developed countries, we tend to think of medicine as a rigorous science, and of our doctors as, if not infallible, at least reliable.

JENA: The typical patient probably does look to their doctor for answers and they value very highly what that opinion is.

But as we’ve been hearing, the history of medical science was often “eminence-based” rather than “evidence-based.” When did evidence really start to take over?

JENA: Evidence-based medicine has become hugely important in the last 25 to 30 years.

The movement is a result, Jena says, of at least two factors: Number one:

JENA: We’re doing more randomized controlled trials and that tells us more information about what works and doesn’t work.

And, number two:

JENA: Improvements in computer technology have now allowed us to study data in a way that we couldn’t have done 30 years ago.

There’s also been a movement to collect and synthesize all that research and all those data:

Lisa BERO: Our vision is to produce systematic reviews that summarize the best available research evidence to inform decisions about health.

That’s Lisa Bero, a pharmacologist by training, who studies the integrity of clinical and research evidence.

BERO: I’m also a co-chair of the Cochrane Collaboration.

The Cochrane Collaboration was founded in Britain but is now a global network. The “systematic reviews” they produce …

BERO: … are really the evidence base for evidence-based medicine. We’ve been a leader in so many ways in developing systematic reviews. We were the first to regularly update these reviews. We were one of the first to have post-publication peer review and a very strong conflict-of-interest policy. Actually, we were one of the first journals that was published only online.

Which means that whatever realm of medical science you’re working on, you can access nearly all the evidence on all the research ever conducted in that realm — constantly updated, available on the spot. Compare that to how things used to work — looking up some 5- or 10-year-old medical journal to find one relevant article that may well have been funded by the pharmaceutical company whose drug it happened to celebrate. How is Cochrane funded?

BERO: We are primarily funded by governments and nonprofits.

What about industry money?

BERO: We don’t take any money from industry to support any official Cochrane groups.

Which means, in theory at least, that the evidence assembled by the Cochrane Collaboration is pretty reliable evidence. As opposed to …

Iain CHALMERS: … a whole variety of things. Opinion. What the doctor had been taught 30 years previously in medical school. Tradition. What they had been told to do by, or advised to do, by a drug-company representative that had visited them a week previously.

That is Sir Iain Chalmers, who co-founded the Cochrane Collaboration. He’s a former clinician who specialized in pregnancy, childbirth, and early infancy. He was a medical student in the early 1960s. When Chalmers observed his elders in practice, he was struck by how much variance there was from doctor to doctor.

CHALMERS: Some doctors — if a woman had a baby presenting by the breach — would do a Caesarean section, without any questions asked. Or they may take different views about the way the baby should be monitored during labor. Or the extent to which drugs should be used during pregnancy for one thing or another. Lots and lots of differences in practices. It’s as long as your arm. It’s madness isn’t it?

When he became a doctor himself, Chalmers worked at a refugee camp in Gaza. And, as he discovered …

CHALMERS: … some of the things that I had learned at medical school were lethally wrong.

Like how you were supposed to treat a child with measles.

CHALMERS: I had been taught at medical school never to give antibiotics to a child with a viral infection, which measles is, because you might induce resistance, antibiotic resistance. But these children died really quite fast after getting pneumonia from bacterial infection, which comes on top of the viral infection of the measles. What was most frustrating was that it wasn’t until some years later that I found that there had been six controlled trials comparing antibiotic prophylaxis given preventatively with nothing done by the time I arrived in Gaza.

And those studies suggested that children with measles should be given antibiotics. But Chalmers had never seen those studies.

CHALMERS: I feel very sad that in retrospect I let my patients down.

This led Chalmers to embark on a years-long effort to systematically create a centralized body of research to help attack the incomplete, random, subjective way that too much medicine had been practiced for too long. He was joined by a number of people from around the world — many of whom, by the way, were more versed in statistics than in medicine.

CHALMERS: We embarked on these systematic reviews, about 100 of us. That resulted, at the end of the 1980s, in a massive, two-volume, one-and-a-half-thousand-page book. At the same time, we started to publish electronically.

And so the Cochrane Collaboration became the first organization to really systematize, compile, and evaluate the best evidence for given medical questions. You’d think this would have been met with universal praise. But, as with any guild whose inveterate wisdom is challenged, as unwise as that wisdom may be, the medical community wasn’t thrilled.

CHALMERS: There was a great deal of hostility to it from the medical establishment. In fact, I remember a colleague of mine was going off to speak to a local meeting of the British Medical Association, who had basically summoned him to give an account of evidence-based medicine. “What the hell did people who were statisticians and other non-doctors think they were doing messing around in territory which they shouldn’t be messing around in?” He asked me before he drove off, “What should I tell them?”

I said, “When patients start complaining about the objectives of evidence-based medicine, then one should take the criticism seriously. Up until then, assume that it’s basically vested interests playing their way out.”

It took a long while, but the Cochrane model of evidence-based medicine did become the new standard.

CHALMERS: I would say it wasn’t actually until this century. One way you can look at it is where there is death, there is hope. As a cohort of doctors who rubbished it moved into retirement and then death, the opposition disappeared.

PRASAD: That’s been the slower evolution.

That, again, is Vinay Prasad, from Oregon Health and Science University.

PRASAD: The very first studies with randomization concerned tuberculosis.

This was in the late 1940s.

PRASAD: From then the end of the 1980s, we did use randomized trials but they weren’t mandatory. They were optional.

One big benefit of a randomized trial is that you can plainly measure, in the data, the cause and effect of whatever treatment you’re looking at. This may sound obvious but it is remarkable how many medical treatments of the past were conducted without that evidence. Anupam Jena again:

JENA: Some of the biggest mistakes in the last century, let’s say from 1900 to 1950 — things like lobotomy used to treat mentally illness, either depression or schizophrenia — those strike me as being some of the most horrific things that could be done to man without any really solid evidence base at all.

This is one of the trickiest things about practicing medicine day-to-day. Let’s say you’re a doctor, and a patient comes to see you with a persistent headache. You make a diagnosis, and you write a prescription. What happens next? In many cases, you have no idea. The feedback loop in medicine is often very, very sloppy. Did the patient get better? Maybe. They never came back. But maybe they went to a different doctor. Or maybe they died? If they did get better, was it because of the medicine you prescribed? Maybe.

Or maybe they didn’t even fill the scrip. Or maybe they did fill the scrip but stopped taking it because they got an upset stomach. Or maybe they did take the medicine and they did get better but … maybe they would have gotten better without the medicine? Like I said, you have no idea. But with a well-constructed randomized controlled trial, you can get an idea. Vinay Prasad again:

PRASAD: The moment that set us on different course was a study called CAST.

CAST stands for Cardiac Arrhythmia Suppression Trial. It was conducted in the late 1980s.

PRASAD: One of the things doctors were doing a lot for people after they had a heart attack was prescribing them an antiarrhythmic drug, that was supposed to keep those aberrant rhythms, those bad heart rhythms, at bay. That drug actually, in a carefully done randomized trial, turned out not to improve survival as we all had thought, but to worsen survival. That was a watershed moment where people realized that randomized trials can contradict even the best of what you believe.

It really doesn’t matter in medicine that the smartest people believe something works. The only thing that really counts at the end of the day, is what is the evidence you have that it works.

The rise of randomized controlled trials led to a rise in what are called medical reversals. Vinay Prasad wrote the book on medical reversals, literally. It’s called Ending Medical Reversal.

PRASAD: What is a medical reversal? Doctors do something for decades, it’s widely believed to be beneficial, and then one day, a very seminal study — often better-designed, better-powered, better-controlled than the entirety of the pre-existing body of evidence — contradicts that practice. It isn’t just that it had side effects we didn’t think about. It was that the benefits that we had postulated, turned out to be not true or not present.

For instance …

PRASAD: In the 1990s we would recommend to postmenopausal women to start taking estrogen supplements, because we knew that women before they had menopause had lower rates of heart disease, and we thought that was because of a favorable effect of estrogen. And then in 2002, a carefully done randomized control trial, found that actually, it doesn’t decrease heart attacks and strokes; in fact, if anything it increases them.

I asked Prasad what first got him interested in studying medical reversal.

PRASAD: I started to get interested in this even when I was a student, and I saw that there [were] some practices that had been contradicted just in the recent past but were still being done day in and day out in the hospital. The example that comes to mind is the stenting for stable coronary angina. A stent is a little foldable metal tube that goes in a blocked coronary artery and the doctors spring it open, and it opens up the blockage.

Stents are incredibly valuable for certain things. If you have a heart attack and there’s a blockage that just happened a few minutes ago, and the doctor goes in and opens that blockage up, we’re talking about a tremendous improvement in mortality, one of the best things we do in medicine. But stenting, like every other medical procedure, has something called indication drift where it works great for a severe condition, but does it work just as good for a very mild condition?

Over the years, doctors has used stenting for something called stable angina. Stable angina is just slow, incremental, narrowing of the arteries that happens to sadly all of us as we get older. But the bulk of stenting was this indication drift. We thought it worked and made perfect sense. Then in 2007, a well-done study showed that it didn’t improve survival, and didn’t decrease heart attacks, which were, even to this day studies show that most patients who undergo this procedure believe it will do those things.

In fact, it’s been disproven for eight years.

And yet: while stenting for stable angina did decline, it didn’t disappear. The rate of inappropriate stenting, Prasad says, is still way too high. This obviously starts getting into doctors’ incentives — financial and otherwise — and we’ll get into more in Parts 2 and 3 of this series. As Prasad makes clear, there’s a long, long list of medical treatments that simply don’t stand up to empirical scrutiny. Some common knee surgeries, for instance, where orthopedic surgeons take a tiny camera …

PRASAD: … take a tiny camera, make a tiny incision, and go in there, and actually debride and remove those scuffed and scraped knees. In fact, people felt a lot better. They had improved range of motion. There’s no argument there. But you’ve studied against just taking ibuprofen, or maybe just doing some physical therapy … What if you studied it against making the patient believe that you were doing the surgery, but you don’t actually do it?

In fact, they’ve done those studies. Those are called “sham” studies. We give the appearance that we’re going to do this procedure. The only thing we omit is actually the debridement of the menisci and the cartilage. In fact, when you do it that way, you find that the entire procedure is a placebo effect. There’s another example where we use a cement that we inject into a broken vertebral bone. That, again, was found to be no better than injecting a saline solution in a sham procedure.

The cement itself cost $6,000, and I said, “At a minimum you can save yourself $6,000, and you don’t need to use the cement.”

DUBNER: What would be the incentives for me to do the study that might result in a reversal? Because we know how publishing works — whether it’s in your field, in any academic field, or in the media as well — it’s the juicy, sexy, new findings that get a lot of heat. It’s the maintenance articles, or the reversal articles, that nobody wants to hear about. I would gather there are fairly weak incentives to doing the studies that would result in reversals — which also makes me wonder if there is a woeful undersupply of such studies, which means there probably would be even more reversals then there are.

PRASAD: Yeah. That’s a fantastic question. One of the things that we did in the course of our research was we took a decade worth of articles, [from] probably one of the most prestigious medical journals, The New England Journal of Medicine. There was about 1,300 articles that concern things that doctors do. About 1,000 of those articles were something new that’s coming down the pipeline, the newest anticoagulant, the newest mechanical heart valve.

If you tested something new — exactly as you’d expect, 77 percent of those published manuscripts concluded that what’s newer is better. But we also discovered about 360 articles tested something doctors were already doing. If you tested something doctors were already doing, 40 percent of the time, we found that it was contradicted or, a reversal.

DUBNER: I’d love for you to talk about the various consequences of reversals, including perhaps a loss of faith in the medical system generally.

PRASAD: If you find out something you were doing for decades is wrong you harmed a lot of people, you subjected many people to something ineffective, potentially harmful, certainly costly, and it didn’t work. The second harm we say is this lag-time harm. Doctors, we’re like a battleship. We don’t turn on a dime. We continue to do it for a few years after the reversal. The third is loss of trust in the medical system. We’ve seen it in the last decade, particularly with our shifting recommendations for mammography and for prostate cancer screening.

People come to the doctor and they say, “You guys can’t get your story straight. What’s going on?” It’s a tremendous problem. I’m afraid that we are making people feel like that there’s nothing that the doctor does that’s really trustworthy. I’m afraid that that’s the deepest problem that we’re faced, this loss of trust.

DUBNER: Okay, so how do you not throw out the baby with the bathwater? What are some solutions to a practice of medicine and medical research that results in fewer reversals?

PRASAD: That is a million-dollar question. One is medical education. We have a medical education where for two years, students are trained in the basic science of the body. Only in the latter years, the third and fourth year of medical school, are students trained in the epidemiology of medical science, evidence-based medicine, in thinking not just how does something work, but what’s the data that it does work? I’ve argued that needs to be flipped on its head. That the root, the basic science of medical school is evidence-based medicine.

It’s approaching a clinical question knowing what data to seek, and how to answer that in a very honest way. That’s one. The next category is regulation. This is where you get into, “What is the FDA’s role, and what does the FDA do?” Many people in the community hope that products that are approved by the FDA are both safe and efficacious for what they do. But we were faced with a problem in the ‘80s and ‘90s that we had never faced before, which was the HIV/AIDs epidemic. Advocates rightly said that we need a way to get drugs to patients faster, maybe even accepting a little bit more uncertainty.

I think that was right and that’s still right for many conditions that are very dire, for which few other treatment options exist, and, which sometimes have very low incidence, so it’s very hard to do those studies because very few people have it. But what’s happened is that mechanism has been extrapolated to conditions that are not dire, that have very good survival, that don’t have few options, have many options, and that many people do have. We’ve had, again, a slippery slope for what qualifies for this accelerated approval.

There [are] ways in which regulation can be adjusted. Then, the last thing is the ethic of practicing physicians. We have to have an ethic where when we offer something to someone, and there’s uncertainty, we should be very clear about communicating uncertainty. It’s a tragedy today that no matter what you think of stenting for stable coronary artery disease, that so many people who are having it done believe something that is clearly not true, that it lowers the rate of heart attacks and death.

That’s just factually not true, and the fact that many people believe that speaks to the fact that, as doctors, we allow them to believe it.

DUBNER: Let me ask you one last question: I have a pretty good sense, of having spoken to you for a bit, of what has prevented in the past medicine from being more scientific or more evidence-based, but what do you believe are the major barriers still that are still preventing it from becoming as evidence-based as you want it to be?

PRASAD: We should be honest about what medicine is. In the United States, medicine is something that now takes, nearly or over 20 percent of G.D.P. It’s a colossus in our economy. We spend more on medicine than any other Western nation. We probably don’t get as much from what we’re spending. Because it’s such a large sector of the economy, the entrenched interest for the companies and the people who really profit from the current system are tremendously reluctant to change things.

We see that with, just for one instance, the pharmaceutical drug-pricing problem we’re having right now. No one will doubt that the pharmaceutical industry has made some great drugs. They’ve also made some less-than-great drugs. But does every drug, great or worthless, have to cost $100,000 per year? I [didn’t] invent that number. That’s actually the cost per annum of the average cancer drug being approved in the United States in the last year — well over $100,000 per year of treatment.

There’s got to be a breaking point and people are recognizing that.

Next week on Freakonomics Radio, Part 2 of “Bad Medicine,” how do those great drugs, and the less-than-great ones too, get made, and then how do they get to market? We’ll look into the economics of new-drug trials and how carefully the research subjects are chosen:

Ben GOLDACRE: Now that’s very useful for a company that are trying to make their treatment look like it’s effective, but does the population of people in this randomized trial really reflect the real-world people out there?

We look at who’s been left out of most clinical trials:

WOODRUFF: It suggested that women shouldn’t be included in clinical trials because of the potential adverse events to the fetus.

And how sometimes, the only thing worse than being excluded from a medical trial was being included:

HAMMONDS: The use of vulnerable populations of African- Americans, people in prison, children in orphanages — vulnerable populations like these had been used for medical experimentation for a fairly long time.

That’s next time, on Freakonomics Radio.

Freakonomics Radio is produced by WNYC Studios and Dubner Productions. This episode was produced by Stephanie Tam. Our staff also includes Alison Hockenberry, Merritt Jacob, Greg Rosalsky, Eliza Lambert, Emma Morgenstern, Harry Huggins and Brian Gutierrez. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts. You can also find us on Twitter, Facebook, or via e-mail at radio@freakonomics.com.

Here’s where you can learn more about the people and ideas in this episode:

SOURCES

Anupam Jena, health care economist and physician at Harvard Medical School

Philip Mackowiak, professor or medicine and medical historian at the University of Maryland

Jeremy Greene, physician and historian of medicine at Johns Hopkins University

Evelynn Hammonds, professor of the history of science and African-American studies at Harvard University

Keith Wailoo, health policy historian at Princeton University

Vinay Prasad, assistant professor of medicine at Oregon Health & Science University

Lisa Bero, pharmacologist and co-chair of the Cochrane Collaboration

Sir Iain Chalmers, co-founder of the Cochrane Collaboration

RESOURCES

Ending Medical Reversal, Vinay Prasad, 2015, Johns Hopkins University Press

The Cochrane Collaboration

“A Critical Appraisal of 98.6F, the Upper Limit of the Normal Body Temperature, and Other Legacies of Carl Reinhold August Wunderlich,” Philip Mackowiak, Steven Wasserman and Myron Levine, 1992, University of Maryland

Effective Care in Pregnancy and Childbirth, Sir Iain Chalmers, Murray Enkin and Marc Keirse, 1989, Oxford University Press

“A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices,” Vinay Prasad, et al., 2013, Mayo Clinic

“Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo: The Cardiac Arrhythmia Suppression Trial,” Debra Echt, et al., 1991, New England Journal of Medicine

“Optimal Medical Therapy with or without PCI for Stable Coronary Disease,” William Boden, et al., 2007, New England Journal of Medicine

MUSIC CREDITS

Paul Avgerinos, “Times a Tickin”

Jack Miele, “Otis Theme” (from Jack Miele)

Christopher Norman, “Emerald” (from Strange Games)

Paul Avgerinos, “Ladies Day”

Nicholas Pesci, “Feeling Quirky” (from All The Feelings)

Baba Brinkman, “Seed Pod” (from The Rap Guide)

Morella and the Wheels of It, “Vincent” (from Shipwrecked)

Lerin Herzer and Andrew Joslyn, “Roots” (from The Girl and the Ghost)

Judson Lee Music, “Snoopin’”

Mike Barresi, “It’s All Good” (from Mike Barresi)

Additional Scoring by Jay Cowit

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