Category: Updates

Psychiatrist Simon Wessely suggests that doctors in his field have a deeper appreciation for complexity than other medical professionals do:

Not for us the simplicities of some other parts of medicine. Here is a cancer – take it out. There is a bug – kill it. In psychiatry, the ability to tolerate uncertainty is an essential skill. Because we have to negotiate fuzzy boundaries – between eccentricity and autism, between sadness and clinical depression, between hearing voices and schizophrenia – and there will always be boundary disputes.

Far from backing away from such debates, my experience of psychiatry is that we relish them. We are not the only branch of medicine that argues about classification – so do tumor biologists – but the difference is that the issues that we face in classification are more readily understood by the general public. If there is a little bit of crisis, like argument and discussion it keeps us on our toes, alert to new developments, and is an antidote to complacency.

Update from a reader and neurologist:

I’m a bit behind on my Dish reading, but just saw the post that you referenced from Dr. Wessely, and really have to call complete and utter crap on it.

This is one of the most enduring tropes in medicine, where every specialty sees itself as special and more extraordinary than their peers in lesser specialties. While were all guilty of it from time to time, it’s rare that I’ve seen someone bold enough to put it to print (from the President of the Royal College of Psychiatrists no less!). It would be like me denigrating cardiology by likening the vascular system to something marginally more complex than the pump and plumbing for my pool.

Nothing in medicine is ever as clear cut. Furthermore, we all treat more than a disease; we treat a patient (and often the family issues/fallout arising out of the patient’s disease). And because patients are complex, individual creatures, management has to be tailored not just to the illness, but to them.

Even in cancer, it is not quite as simple as Dr. Wessely suggests. Take prostate cancer for example. Do we have to treat it? The majority are slow growing and aggressive intervention is not always warranted. Psychiatry does itself no favour by promoting exceptionalism.

A personal story from the in-tray adds some critical context:

I have read this conversation with some interest, because it is all too close to home. Tomorrow, my wife and I are transferring a frozen embryo after a fresh transfer failed in late August. For these reasons, I have become all too conversant on the subject matter … yet it is a conversation that one rarely has beyond our own home. (I will note that my wife and I are very lucky in that we both have extremely generous coverage and a non-trivial cache of frozen embryos to work from; it is unlikely that we will have to ever do another egg retrieval.)

I think the piece you quoted by Pamela Mahoney Tsingdinos, along with your reader, needs to be placed in a bit more perspective. In Tsigdinos’ case, I suspect the experience she has had (which I can completely empathize with, as fertility treatment is emotionally exhausting) has led to a somewhat jaded perspective. I think a similar critique is in order for your reader.

In any given month, a perfectly fertile couple only has about a 20% chance of conceiving a child if they are trying.

So, a fertile couple doing it the “old fashioned” way, has a roughly 80% fail rate. Suddenly, the 23% success rate of frozen eggs does not seem to shabby, no? In fact, the very study that Tsigdinos cited to support her argument reached a positive conclusion relative to the achieved probabilities. This is why fertility doctors do not take on patients until they have been trying for a year without success; prior to that point, the lack of conception may very well be just due to bad dice rolls.

Here is a PDF on Penn Fertility data on embryo transfers. Of note, they are talking about embryo transfers, which is after the first culling of eggs. They do not appear to post data on frozen eggs but do state the following:

Pregnancy using already retrieved, frozen donor eggs is an incredible step forward and is possible because of the dramatic improvement in egg freezing technology. Methods of rapid freezing called vitrification are now used effectively to freeze eggs. Several large studies have been conducted using frozen donor eggs and indicate that pregnancy rates are no different when fresh or frozen eggs are used.

Under normal circumstances during ovulation, a series of things has to go right in order for a child to arrive. Sex has to happen at the right time, egg and sperm need to meet – the right egg and sperm need to meet – implantation needs to occur, and then the body needs to get on board with the pregnancy. A lot can and does go wrong between a couple having sex and a baby being the result. In fact, one of the most frustrating parts of fertility treatment is the unknown. As of now, in the midst of infertility treatment, our infertility remains “unexplained”.

The problem here is that we are talking about eggs, and our perspective gets skewed when we pull them out of a woman’s body and get to actually trace the failure rates. IVF is instructive in thinking about this. The general rule is that 50% of the retrieved eggs will not fertilize and/or reach a point where transfer is a viable option. Of the resulting 3- and 5-day embryos, a further 50% will not result in a child. What does that mean? We are back in the same ballpark of 25% of retrieved eggs resulting in a child. This is indeed sobering when you break it down, particularly for older women with weaker egg reserves. If you pull less than 8 eggs, the probabilistic expectation is for a single child to result (if that). That, however, needs to be placed alongside the fact that a fertile couple trying for 8 months would be expected to produce <2 children.

With the advent of vitrification as a technique, I suspect we will see freezing become much more common in the years ahead. The practice my wife and I are going to has data that suggests frozen embryo transfers may result in a higher rate of pregnancies than fresh transfers. If true, the reason is most likely a byproduct of the hormonal treatments involved in stimulation and retrieval. An even greater advantage is that freezing effectively stops the clock on egg/embryo aging. So, if you freeze an egg/embryo at age 25, you can transfer it at age 37, and genetically it will be as if you conceived the child at 25 (this has significant benefit given the data we have on egg reserves for 35+ women).

None of this is to suggest that freezing eggs should suddenly become Plan A. There are very real and scary potential side effects of the stimulation and retrieval process, and I worry about the long-term impact on my wife’s health.

That being said, I think expanding coverage for this procedure should be applauded, since it creates an option for women. What the data pretty much universally suggest is that women are much better off making a decision about having a family prior to hitting age 35. After that, the statistics begin to drop rapidly. So if you are an early 30s woman who wishes to have a family but are not ready to do so for whatever reason, freezing and banking eggs is something well worth considering.

Again, yes, the vast majority of the collected eggs will fail to result in a pregnancy – but that’s life, just as is the case in the wild.

Update from a reader:

Your reader is pretty much on the money. I went through two IVFs and have friends who did live and frozen transfers. Those are the stats.

The only kibble I have is about egg freezing versus embryo. Embies do well through the freezing process and the thawing. Eggs? Not so much. They are not like sperm, which also freezes and thaws fine. Eggs are much more fragile.

If companies were offering to help women harvest and fertilize eggs to create embryos for future use, THAT would be truly useful. But they aren’t. It feels more like a con.

That said, why has no one broached the subject of young men storing away their young healthy sperm for future use? The research on older fathers gets grimmer as time goes on, with a laundry lists of mental health, learning disorders and autism now being linked to “old” sperm.

A woman is born with all the eggs she will ever have. They age with her, but they were generated when she was so unlike males whose sperm quality gets spottier all the time because of the DNA damage we all pick up as we age, a woman’s eggs don’t have that particular downside to worry about. Which is why it would be great if they froze well – but they don’t.

Andrew D. Blechman notes a collaboration between the Montana Department of Transportation and the Confederated Salish and Kootenai Tribes that “led to the creation of the most progressive and extensive wildlife-oriented road design program in the country”:

The 56-mile segment of Highway 93 now contains 41 fish and wildlife underpasses and overpasses, as well as other protective measures to avoid fatalities. As creatures become accustomed to the crossings, usage is increasing—at last count, the number was in the tens of thousands. Motion cameras have captured does teaching their young to run back and forth through the crossings, much like human mothers teach their children to safely cross a street.

Wildlife crossing structures are such a smart idea that it’s difficult to understand why they’re still a rarity in this country. But by insisting on rebuilding highway infrastructure to address the needs of wildlife, the Salish and Kootenai tribes have led the way toward a greater sensitivity to fragmented habitats. Highway departments around the country are now studying their example.

Update from a reader, who points to a “pretty extraordinary photo sequence”:

Loved that photograph of the animal high-line. I’m sure I am not your only Florida reader who will bring this up, but we’ve been helping our beleaguered Florida panthers cross the road for decades now. Back in the 1980s, the National Wildlife Federation teamed up with panther advocates to file suit against the DOT to do something to stop the carnage on I-75 (the main artery connecting Florida’s coasts that bisects the panther’s habitat).  The DOT eventually added 23 crossings, which by all accounts, has at least slowed this beautiful animal’s extinction. (Numbers are sketchy but there are less than 200 left). Here’s a photo of a panther making a safe crossing that I found in the Naples Daily News:

Pretty extraordinary photo sequence because Florida panthers are notoriously shy and rarely photographed in the wild.

Another reader:

The thread just made me think of this West Wing classic for a Wolves Only Roadway!

Previous Dish on a similar highway in Canada here.

During this relatively slow news week, a reader draws our attention to “the latest thing blowing up (a small corner of) the Internet”:

Kathleen Hale, YA author and fiancée of Simon Rich (Frank Rich’s son) wrote this article about her experience with a nasty review on Goodreads of her non-yet-published book.  She became obsessed with the reviewer, who was also a book blogger.  Hale eventually discovered that the reviewer was operating under a false identity, stolen photos, made-up job, faked vacation photos, etc.  Against all advice, Hale decided to confront the reviewer, to find out why she had it in for her, going so far as to find her real name and address, pay for a background check on her, and go to her house.

What makes the story so interesting is the reaction to it. I don’t know if Hale thought she would get a sympathetic reaction to her confession, but she has instead set off a firestorm.

Her book now has hundreds of 1-star reviews on Goodreads, calling her a crazy stalker and vowing never to read any of her books.  The book bloggers are out in force, determined to destroy her.  No one cares that the reviewer faked her identity, equating what she did to J.K. Rowling using the Robert Galbraith pseudonym. Hale probably went too far, but I have tremendous sympathy for her frustration with having to sit back and silently take the mean-spirited reviews. (Goodreads strongly discourages authors from responding to reviews.)  But I cringed when I read her article, because I knew she was going to make things much much worse for herself.

Along similar lines to Kathleen Hale’s obsession with her bad reviews is this article by Margo Howard, the daughter of Ann Landers, lamenting the reviews of pre-publication copies of her book by members of the Amazon Vine community. Ms. Howard’s article displays a not-entirely-surprising lack of awareness of the real world.  I think her mother would have advised her to keep her mouth shut.

Writing requires thick skin, something that blogging out loud for years certainly gives you. Erin Gloria Ryan sounds off:

I sympathize with Hale’s feeling of helplessness in the face of what felt to her like people unfairly turning on her. And I’m sure most people who have ever written online understand the feeling of wanting to have a face-to-face conversation with a vitriolic critic. It’s that fantasy confrontation, where all of your stored l’esprit de l’escalier flows freely. I’ve even skimmed the Twitter feeds of professional and romantic rivals after a drink too many, an hour too late. I get that urge.

But you do not go to somebody’s house. You do not call somebody’s place of employment. You do not pose as a fact checker and demand personal information. You definitely don’t call a girl with an eating disorder fat while pouring hydrogen peroxide onto her head, and you do not run away laughing like a maniac after the fact. Hale’s thoughts are defensible; her actions are not.

About that, um, peroxide incident:

This weekend, a tipster sent us this piece Hale wrote for Thought Catalog two years ago, wherein she describes a chance run-in with Lori, a troubled girl with an eating disorder who had, years ago, accused Hale’s mother of sexual abuse. … A sympathetic judge let Hale off without punishment [after pouring the peroxide], but that didn’t stop her from doing what she referred to in her Guardian piece as “light stalking;” she says she followed Lori’s movements online. One day, she contacted her via AOL Instant Messenger, and within an hour, a police officer showed up to give her father a firm talking to about how his daughter shouldn’t stalk a girl she once assaulted.

Zooming out, Michelle Dean places Hale’s “nutso behavior” within a literary tradition of sorts:

Off the top of my head, I can think of the following nutty anecdotes […] of authors concerned that someone has been insufficiently admiring of their work:

1. Richard Ford spitting on Colson Whitehead at a party because Whitehead gave him a bad review;

2. Richard Ford (a theme emerges) sending a copy of Alice Hoffman’s book to Alice Hoffmanwith a bullet in it;

3. Norman Mailer and Gore Vidal literally butting heads before their famous fight on the Dick Cavett Show;

4. Robert Frost setting a fire at Archibald MacLeish’s reading because, I guess, he did not care for MacLeish’s poetry;

5. After Mary McCarthy said of Lillian Hellman, again on the Dick Cavett show, that, “every word she writes is a lie, including ‘and’ and ‘the,'” Hellman proceeded to sue everyone involved for over $2 million; and

6. About eighty different stories about Hemingway fighting with literary rivals.

Previous Dish on stalking here. Update from a reader:

This kind of thing isn’t limited to just authors; this story from a few years back involves a bookstore owner in San Francisco.

Pew looks at how conservatives and liberals consume their news:

When it comes to getting news about politics and government, liberals and conservatives inhabit different worlds. There is little overlap in the news sources they turn to and trust. And whether discussing politics online or with friends, they are more likely than others to interact with like-minded individuals, according to a new Pew Research Center study.

John Avlon is distressed:

A few decades ago, politicians sent talking points to talk radio hosts. Today, talk radio hosts and online echo-chamber pundits send talking points to politicians. They keep their readers and listeners addicted to anger. The durable wisdom of the late, great Sen. Daniel Patrick Moynihan—“everyone is entitled to their own opinion, but not their own facts”—gets discarded when people come to political debates armed with their own facts.

Justin Elis’ take is more nuanced:

On their face, these findings might seem to lend support to the idea that we’re becoming a country of smaller and smaller filter bubbles, personalized universes of news and people that fit our own interests. But the connection between how Americans get news and their political polarization is not black and white.

Pew found that on Facebook, the majority of people only see political posts they agree with some of the time. That’s also reflected in the real world, as Pew found people on all ends of the political spectrum tend to get a mix of dissent and agreement on politics in their every day life. 58 percent of consistent liberals and 45 percent of consistent conservatives say they often get agreement and disagreement in their conversations on politics. For people with mixed political views — Pew’s middle ideological category — that jumps up to 76 percent.

Christopher Ingraham makes note of the least trusted outlets:

Overall, four of the top five least-trusted news outlets have a strong conservative lean: Limbaugh, Fox News, Glenn Beck and Sean Hannity. MSNBC rounds out the list. The most trusted news outlets, on the other hand, tend to be major TV networks: CNN, NBC News, ABC News, CBS News, with Fox at No. 5.

The Pew Study notes that “liberals, overall, trust a much larger mix of news outlets than others do. Of the 36 different outlets considered, 28 are more trusted than distrusted by consistent liberals.” By contrast, among conservatives “there are 24 sources that draw more distrust than trust.”

On the topic of distrust, Kilgore highlights a telling detail:

BuzzFeed has the dubious distinction of being more distrusted than trusted among every single ideological category. Pretty impressive for a relatively “young” site, eh?

Congrats, sponsored content. Update from a reader:

As a grad student who has studied polarization, the Pew study isn’t all that surprising (although it is very useful in confirming what many have long assumed.)  I think it may be time, however, to challenge a long-standing assertion of polarization studies.  As Bill Bishop has argued in The Big Sort, Americans seem to be increasingly segregating themselves along partisan/ideological lines.  Not only are our neighbors more likely than before to share our political views, but we also are probably consuming the same kinds of political news and cultural products.  This extends to Facebook as well.  Some people argue this creates an “echo chamber” that merely reinforces our political beliefs.  In other words, the more Fox News we listen to, the more conservative we become.

But I wonder if there isn’t an opposite effect going on as well.  The proliferation of media outlets also makes it easier for us to bump into dissenting views.  Unlike the 1950s-1980s, when there was one monopolistic media establishment that kept the heated rhetoric toned down, now there are many outlets, giving us all greater opportunity to encounter viewpoints that we find abhorrent and that we can’t believe others harbor.  Facebook didn’t so much create an echo chamber as expose us to the private opinions of people we previously assumed were “sane” in their opinions.  Consuming partisan news isn’t so much about finding the truth as it is like running for cover in a crazy world.

Another reader:

So according to that graph you posted, Liberals “are more likely to defriend someone on a social networking site because of politics”. Boy has this been true in my own experience (I’m about as far right politically as it’s possible to be). I have had significant disagreements with old and new friends alike on Facebook and Twitter over the past few years, and I have never once defriended anyone, and my conservative friends (at least the ones I’m closest to) have not done so either. But I most certainly have been told off and immediately defriended by some left-leaning friends over one relatively simple disagreement or the other.

Anecdotal yes, but I think it’s probably true in general that there is little room for disagreement allowed, and certainly less tolerance, for differing opinions on the left than on the right. Your graph and the source would seem to validate this as well. I assume that this comes from the self-righteousness and extreme confidence that modern progressives have that they are sole arbiters of truth and justice, with sole claim to the mantle of righteousness, much like they have (many times accurately) portrayed the right to be from days past. To me this point is beyond dispute: there is MUCH less tolerance for differing opinions and beliefs on the left than there is on the right today. The left is simply blind to the deep strains of religious bigotry of many in their ranks, if nothing else.

And another:

I think it’s probably worth noting that liberals are more likely to defriend conservatives over politics, but the chances are good that they weren’t very close friends in the first place (although you can find many laments over the end of long-term friendships on the left, often precipitated by relatively mild pushback and a stream of abuse in response). I’m from the Deep South originally, and of course everyone back there “knows” that Obama is a Muslim socialist, because between Fox and talk radio and right-wing churches and the NRA, that’s what all self-described respectable, well-informed people hear (plus, Democrats are the party of black people, who are widely seen as lazy, violent, and ignorant). I effectively defriended almost everyone there many years ago when I left; social media allowed for at-arms-length reconnections without my having to pretend that I had any interest in the ideology or institutions it was such a relief to leave.

FWIW, I just hide the crazies, and have been defriended a couple of times by conservatives (one a relative to whom I used to be close) even though I’m rarely aggressively political except in political fora or among like-minded acquaintances. The truth is that a) I don’t always want to know what people are thinking about important issues, and b) I do think less of political conservatives, because I consider it a mean, regressive, often self-serving inclination in practice. That’s why I left an area in which it is so unquestioned … and a state that uncoincidentally ranks at or near the bottom of every quality-of-life measure.