| Acupoints No. 2 Don't Become a Statistic! Kevin Mutschler, MA, RPP, L.Ac., Dipl.Ac. D-Day: Diagnosis. Nothing is the same anymore. From one instant to the next, your life is transformed. The moment you receive a diagnosis of cancer, the whole world changes. All that mattered yesterday pales with the news of today. Suddenly, all the familiar anchors and reference points that you relied upon to give you meaning and direction in life are gone. In their place stand two new and unwanted signposts. The first, like a public verdict posted after deliberation of the jury of medical experts in the court of medical tests, is named "Diagnosis." The second, following the first just as surely and inevitably as a judge's sentence, is named "Prognosis." These twin pillars, presented to you as if their news were carved in stone, suddenly become the gateway to the rest of your life. But, what are these two new uninvited guideposts in your life? Where do they come from? What gives them their authority? What makes them, and the messages they bear, suddenly the most significant words in your vocabulary? We tend to accept these terms and the specific messages they bring at face value. But, should we? There is actually a lot more to both diagnosis and prognosis than you might think. In this and the next two Acupoints, we are going to look very carefully at just what goes into the making of these medical pronouncements, and even more importantly, what we should and should not make out of them for ourselves and our loved ones. What now, Doc? One of the deepest impressions made upon a person diagnosed with cancer comes not from their doctor's physical exam, nor from their lab reports, but rather, from an obscure body of statistical data on mortality and morbidity collected by the Centers for Disease Control in Atlanta, Georgia. This may seem an odd source for making a strong impression, but it is from this archive of medical statistics that come answers to the suddenly quintessential existential question - "What are my chances, Doc?" It is a very normal reaction after diagnosis to want to know what the chances are that your cancer will develop into a life-threatening condition. Certainly the question foremost in anyone's mind after diagnosis is, "Just how serious is my cancer?" How the answer to that question is formulated, how it is presented, and how it is interpreted, will have the most profound impact of any information a patient is likely to receive after diagnosis. So how is that question answered? How can it be answered? No doctor can say with any certainty how cancer will affect you, personally. This is true simply because there is no way to know for sure what course cancer will take - for you. Cancer is notoriously unpredictable. It is the very nature of cancer to not follow orderly rules. So how can a physician give an answer to the most important question on any patient's mind after they've been diagnosed? Statistics for answers. It turns out that, for better or worse, doctors have turned to citing statistics of "similar cases" to answer patients' questions about their own future. The primary basis for formulating these answers comes from statistics collected by the Centers for Disease Control - after the fact - about morbidity (illness) and mortality (death) outcomes of cancer for other people from all over the country. Here is how it works. You have a diagnosis for a certain type of cancer at a certain stage of disease. When your doctor tells you anything about your likely future, i.e., your "prognosis," he or she is comparing your situation with outcomes for other people of your gender who have had the same diagnosis at your age. This is the only basis for telling you that you have thus-and-such a chance of your cancer becoming life-threatening, or of your surviving your cancer. All this sounds very reasonable. Other people who have had the same cancer diagnosis as you, have had thus-and-such outcomes. These outcomes have been exhaustively and definitively documented by the CDC. What could be more reliable than that? Probably nothing. Figuring the odds. But, why do we frame our medical conversation about this, the most important question you now face, as a discussion of the "odds" of different "outcomes?" Why do you suddenly envision your future in terms of a roll of the dice? Is this way of thinking made necessary by the nature of the disease? Or is it an artifact, a product of the nature of statistical, or "risk" thinking? If it is an artifact, an artificial fact, produced by the peculiar nature of statistical thinking, you had better learn something about this kind of thinking and what relevance it does or doesn't have to your life. Consider this. You didn't use this kind of "risk" thinking to imagine your future the day before your diagnosis. Can you imagine a conversation with your spouse about the college education of your kids in which you find yourself saying, "Well, there is a 37% chance that our son will go to college and graduate, and a 39% chance that our daughter will do the same." It doesn't even make sense to think about your future in these terms. Even though these "statistics" may be "valid" for the population as a whole, you are certainly not going to let this "arti-fact" decide the fate of your children, are you? Statistical Thinking. So why do we suddenly let this kind of thinking take over when we least need it? The short answer is: this kind of statistical thinking is the foundation of medical thinking; and medical thinking controls medical conversation; and medical conversation imposes itself onto your thinking. The fact that medical thinking is built on statistical thinking has many consequences for your understanding of your health. We will focus on some other implications of statistical thinking for medical research in a later Acupoints. For now, I want to help you to understand some very basic and very important limitations of statistical thinking and its relevance or lack of relevance to you and your life. Statistics are not about YOU. The CDC data give us a very clear record of what has happened for other people who have had your diagnosis. And that is all that they do. Disease outcome statistics are always and only about OTHER PEOPLE. They say nothing whatsoever about YOU. They cannot say anything about you, because you do not yet have an "outcome" to be measured. This is not a small fact. Too often patients turn statistics about other people into their own mantra about their own future. Too often we hear a patient say, "My chances of dying from my cancer are one in three." How do they know this? They have been told that other people who have had their type of cancer have a survival rate of two in three. This report about the outcomes for other people, similarly diagnosed, dredged from the CDC archives, gets interpreted, translated, assimilated, and accepted as a statement about "me" and "my" disease. Nothing could be farther from the truth, or more harmful to the patient. Statistics are not about you. Period. This is a very difficult point to get digested. We've already said this, right? But is it sinking in? How can we say this with such certainty? Let's look at it another way. Statistics don't say anything about YOUR future. Besides not being about you, statistics are not about your future. In fact, they are not about anyone's future. Although we could say that statistics tell us something about other people in the past, because we can look backward in time and see what happened to other people in the past, we can't say statistics tell us anything about anyone - you or anybody else - in the future. Why? Simple. Because, we can't see into the future. Statistics are always and only about past events. They say nothing about future events. We give statistics a power they don't deserve when we try to make them predictive. So why have we tried to make statistics do this? We have questions. We want answers. But are we too ready to settle for faulty answers, just to have an answer? For this is exactly what we get, faulty answers, when we try to make statistics about the past tell us something about the future. This is something statistics cannot do. This is a competence that they do not have. No matter how much we want to know about what lies ahead, we can't ask the brakeman riding in the caboose to tell us what lies ahead on the track. He's not looking in that direction. The fallacy of statistical prediction. Nearly twenty years ago, the Space shuttle Challenger stood on the launch pad at Cape Canaveral waiting for ignition in record cold temperatures. Engineers concerned about the effects of the extreme cold on the rubber O-rings that connected sections of the rockets reported their alarm. But launch controllers, comforting themselves with the assurance that there had never been such a problem in the past (there was no statistical ground for alarm) went ahead with the fateful launch. Their ultimate mistake was to assume that data from the past can predict the future. It can't. No matter how much we might think we know about the way things have gone for other people who have had your type of cancer in the past, there is no one -- not your doctors, not the statisticians who compile data for the CDC, not your insurance company, not your lawyer, not your rabbi, not your lamma, not your priest - no one, who can say with certainty what the outcome of YOUR experience with cancer will be. That is a simple fact that none of the above experts and interested parties would dispute. What a statistic is and what it ain't. So, if statistics say nothing about you and nothing about your future, what do they say something about? Let's look at this carefully so that we can really understand fully what exactly is the value of statistics about disease in general, and about your condition, in particular; so that you can know what to do with the statistics that are presented to you in discussions with your doctors and others involved in your care. Statistics are about groups of things or events. When you say that there is a one in six probability that a die thrown on a crap table will come up snake eyes (2), you are simply acknowledging that a die has six sides, and when thrown will come to rest on one of those six sides. When thrown repeatedly, the "chance" that the die will come up with one or two or three dots showing is exactly the same: one in six. You can perform a statistical analysis of any measurable group of things or events. All you need is a group of objects or a series of events, and some defined set of outcomes. For example, you could pick as your series of events, repeated flips of a coin. There are two possible outcomes, heads or tails. What are the "chances" over time that the coin will come up heads? You do the math. What does a statistic mean? Figuring heads or tails is pretty simple and not very consequential. But, what happens when we start using statistical thinking to imagine more important and complicated outcomes? Let's look at the weather, just to pick a subject we all know about. The mechanics of statistical thinking are the same no matter what the subject, and the weather is routinely presented to us in statistical terms. How many times have you heard, "Today, there is a thirty percent chance of rain." But, what does this mean, exactly? Does it mean that in the geographic area of the forecast, there is a thirty percent chance that rain will fall at some time during the forecast period? Does it mean that rain will fall for thirty percent of the day in the forecast area? Does it mean that rainfall will cover thirty percent of the forecast area? Does it mean that if you stand outside all day long there is a thirty percent chance that rain will fall on you where you are standing? As you can see, even something as simple and every-day-ordinary as the daily weather forecast is loaded with ambiguity and uncertainty. We use statistical thinking in so many departments of modern life that we pretty much take it for granted that this kind of thinking tells us something meaningful and unambiguous. But, statistical thinking is really a highly specialized form of inference with very definite limits of relevance. We very rarely fully describe and clarify those limits. Don't you think you should know more about the limitations of statistical thinking before you bet your life on a negative prognosis? Beware of Geeks bearing gifts. The folks who gave you a diagnosis and a prognosis, are technical specialists: lab techs, radiologists, pathologists, and various medical specialists. This is not a bad thing. This is a good thing. You want the people behind your doctor to be experts in their respective fields. But, just remember, these people do not know you. They know lab specimens and "similar case" scenarios. Similarly, the epidemiologists who compile outcome statistics for the CDC are not clinical practitioners. They are technical specialists. Their domain is numbers, not people. They don't know you either. Yet, the statistics compiled by these number crunchers get made into a prognosis that is given to you as if you somehow deserve it by virtue of the diagnosis you have received. Make no mistake, a diagnosis and a prognosis are "gifts" that have been given to you. They were not there before you received them. You may have some objective disease process going on in your body. And that process may have been going on for years before you were given a diagnosis. But, you did not identify yourself as "sick" before you were given a diagnosis. You did not identify yourself as "doomed" before you were given a prognosis. So what changed? Everything changed, of course! But how did it change? A few words were uttered. Everything changed. Don't become a case of Mistaken Identity. Don't mistake your identity for the diagnosis or the prognosis you have been given. You are going to receive a diagnosis. This is a given. If you present yourself for medical care, you will receive a diagnosis. That is the way the practice of medicine works. No diagnosis, no treatment. Makes sense. If you want to be treated, you will be diagnosed. After you receive a diagnosis, if you ask, you will receive some kind of a prognosis. This is going to happen anyway, more or less automatically. The biggest mistake you can make in thinking about cancer is to let yourself start thinking about yourself in terms of the statistics of prognosis. This is a mistake for two big reasons. One is what we've just said above: statistics are about other people in the past. They say nothing about you either now or in the future. The second big reason it is a mistake to start thinking of yourself in terms of statistics, is that when you do, you begin to participate in the process of becoming a statistic. This is a danger that has nothing to do with your medical condition. It is a danger that has everything to do with your mental condition, or more to the point, your mental conditioning. You become what you believe, so believe wisely. We are designed to become what we believe ourselves to be. This is a fact of human nature. This is a characteristic of being a human being. It is the same for any person in any culture. In fact it is the reason why you can raise a child born anywhere into any culture anywhere. There is not much to be done about this fact, except, to be very careful about what you let yourself believe about yourself. If you believe the prognosis you are given is about other people in the past, it will impact you very differently than if you believe the prognosis you are given is your prognosis. When you take a statistic about other people in the past and accept it as a statement about you, it changes everything. Watch how you talk about yourself, you may be... From the moment you say "my prognosis" is such and so, or "my chances" are thus and such, you are actively cooperating in the process of becoming your prognosis. You are taking on the whole mental apparatus of outcome statistics and making it a part of your own identity. Don't do it. There is no reason to do it. You do not benefit in any way by identifying yourself with the outcome statistics of the diagnosis you have been given. So be careful how you talk about yourself, you may be listening! So, what does this knowledge get you? If you can get this understanding deep enough into your brain, it can free you from thinking that your fate is predicted by your prognosis. |
