Homme Fatale

Halfway through the “Bell Curve,” which is an analysis of differences in intelligence between races, I realized what had been bothering me about Charles Murray’s thesis. It wasn’t the accuracy of his analysis, which concerned me, too. It was that he analyzed. The truth, I used to believe, was always beautiful, whether it was what happened in the multiverse at T equals zero, or the historical counterfactual if Neville Chamberlain hadn’t signed the peace accord with Adolph Hitler. After reading Murray’s book, I realized that the truth can be irrelevant, ugly, and utterly useless. Even if the average intelligence of races was truly different, so what? Surely, civilized people must judge each other as individuals, regardless of the veracity of the statistical baggage of their ethnicities.

Murray was castigated, deservedly, for swallowing the bell curve uncritically. But his detractors missed one point. Murray wasn’t just wrong because he was factually wrong or for inquiring. In fact, it was worse, because Murray, it turned out, was wronger than wrong.

Stephen J Gould, in The Mismeasure of Man (man is gender-neutral here) – the most biting critique of the study of human intelligence –recognized the biggest weakness with Murray’s analysis. Gould always had an antipathy to statisticians – his life once depended on his dismissing bland statistics. Gould observed that when using an attribute, such as IQ, to distinguish between two groups, if the within group variation of that attribute is equal to or greater than the difference in the means between the groups, that attribute becomes a useless discriminant. Neither does IQ predict race nor, reassuringly, does race adequately predict IQ.

You should read The Mismeasure of Man. I don’t wish to ruin Gould’s scholarly prose but let me restate his insight – Murray’s analysis was wrong because it was two lazy generalizations, i.e. aggregates of two bell-shaped curves, curves which overlap so copiously that they may as well be one curve. A lazy generalization – what is that, you ask?

What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands which feed it.

Race and gender are thorny issues and are better kept away from Gauss. Recently, it was gender’s turn –  a study found that female physicians have better outcomes than male physicians. This is hardly surprising. In Britain, patients prefer female GPs of South East Asian origin. And if patients prefer female doctors, it follows logically that female doctors will have better outcomes.

But no good deed that is quantified goes unpunished. The study caused disquiet, in part, because instead of celebrating the virtues of female doctors, the media picked up on the vices of male doctors. Because if female doctors are doing better, it must mean male doctors are doing worse, or worse, it must mean that male doctors are a public health menace. This is an incredible problem for our hyper rational times – nothing can be seen for its own sake.

Now, if you’re seeking flaws and obvious confounders in the study, don’t waste your time – there are none. The effect size is real and plausible. Nor will it do good suspecting the researchers of maleficence. One of the co-authors, Dr. Anupam Jena, gallantly, and with infinite patience and boundless grace, defended the paper on social media. Though it is arguable, as David Shaywitz noted, that the researchers would have published the results had the opposite been shown – i.e. if male physicians had better outcomes than female physicians, and I hope that good manners, or at least political sense, will stop the researchers from analyzing the outcomes of doctors based on their race, I have no grounds to doubt the good intentions of the researchers, just as I never suspected Murray of anything but good intentions.

But I’m struggling to see the utility of their findings, in the same way I struggled with the Bell Curve. At a time when patient care is being recognized as a team effort, and a team is made up of both male and female doctors, the study’s Y-chromosomal reductionism seems distinctly out of place.

It may be argued that the one silver lining of the study is that female physicians will be compensated fairly.  That should be the case, as Dr. Vinay Prasad notes, regardless of what the study found. Fairness is a moral, not scientific, imperative. Have we become so insensate that we need science to tell us to do the right thing?

Nor will I quibble that because the study was not randomized the results aren’t valid – not because of the impossibility of randomizing patients to different genders, but because the findings are plausible. A randomized controlled trial is not the only source of truth.

The study led to good-natured banter on social media. It gave men a chance to self-deprecate. There’s something endearing about men putting themselves down in front of women (incidentally, we’re supposed to be funnier, but that hasn’t been rigorously tested) and no doubt quoting this study will make men appear charming at cocktail parties and on first dates, and what better charm than evidence-based charm?

But the study led to deductive leaps which, though seemingly logical, is troubling when you explore them closer, such as this leap: if a drug boasted the effect size of being seen by female physicians, FDA would approve it in a heartbeat. This strikes me as such an odd conclusion that I’m hesitant in refuting it, hesitant because when something seems so obviously incorrect to me, I feel I’m being like Johnny’s defensive grandmother who said “everyone is marching out of step with Johnny.”

The comparison of genders to a drug such as a statin which, though not uniform in its action is uniform in composition, collapses genders into a homogenous artificial singularity. It implies that all men are precisely the same and that all women are precisely the same, and you don’t have to believe that gender is not a social construct to realize the speciousness of that implication.

Since when did physician quality, undoubtedly difficult to precisely measure, bifurcate between genders as uniformly as anatomy and chromosomes do? Let me be clear. The aggregate of physician outcomes is built by doctors who vary in quality. Not to put too fine a point on this, there are good and better, bad and worse, best and worst, male and female physicians. This variation in competence is true even if females, on average, make better doctors than males.

Let me give you an example to make my point clearer. Men are, on average, taller than women. That doesn’t mean that there aren’t short men and tall women, or that the shortest man is taller than the tallest woman. If you randomly and blindly picked a man and a woman and tried to guess their gender based on who was taller, you’d be wrong so often that it’d be an embarrassing exercise.

My own career is testament to such variation. I was put off internal medicine by a female physician and drawn to surgery, which I briefly dabbled with and then left, by a male surgeon. I eventually chose radiology because I was impressed with the diagnostic reasoning of a female radiologist. I also admired how Mrs. Thatcher dealt with male snarkiness, because it is snarkiness in men that I find the urge to slay. The gender influences in my life have been a coin toss. To impose upon me a female mentor would be just as illogical as imposing a male mentor.

You might tell me to “man up and face the facts.” But in this post-fact world it is easy to miss the fact that facts are nothing but blurred point spread functions. Taut singularities, where none exist, aren’t facts, but lazy generalizations.

The most egregious misuse of the study is the extrapolation to “32, 000 fewer people would die prematurely every year if seen by female doctors”, even by the intellectually cool Atlantic. This is a death every twenty minutes, which makes male doctors deadlier than Jihadi John. Cumulatively, over time, we have more blood on our hands than Pol Pot. Keynes warned that starting with a mistake, a remorseless logician can end up in Bedlam. But you can get to Bedlam by logical reasoning without making an initial error.

Let’s assume that the estimate of “32, 000 preventable deaths” is correct. Holding preventable deaths as normative has implications for society. Logical consistency is a terrible beast. It implies that every day the FDA delays approval of a life-saving drug they have blood on their hands. It implies that when people stop taking statins for primary prevention because the media is skeptical of the benefits of statins, and some die prematurely, as statistically speaking a few will, the media are complicit in murder. When we stop thinking beyond quantification, our species risks losing the plot.

I ask, what should be done differently to male doctors? Should male doctors be forcibly feminized? The Ottomans castrated the men who guarded their harems – a prescription, I suspect, even radical feminists might find unpalatable. If patients prefer seeing Roshni over Raj, there’s very little Raj can do without relinquishing his sexuality.

No doubt, some male doctors have something to learn from some female doctors and clearly the attributes which make a good doctor are more prevalent in female doctors. But they’re also present in male doctors. If we’re still unclear what these attributes are, the medical profession is in a pitiful state of such enormity that one struggles to comprehend. These attributes, if they must be stated, are genuine empathy, kindness, making eye contact, attention to detail, analytical skills, decision making, among others. Find a physician, regardless of gender, with such skills and learn from him or her.

We’re slowly shedding racial and gender prejudices. The cure to lazy generalizations of one polarity isn’t lazy generalizations of the opposite polarity. The truth doesn’t always set you free. We need more perspective, not more research. The physician gender-outcome study is unlikely to help either male or female physicians. It will least help patients, who will be taxed with yet another uncertainty – the deadly risk of being treated by a male physician.

Saurabh Jha is an opinionated radiologist who can be reached on Twitter @RogueRad

Categories: Uncategorized

16 replies »

  1. I’d assume, based on Saurabh’s hatred for Dr. Murray’s “The Bell Curve,” Saurabh is in love with the text, “Guns, Germs and Steel.” Here’s is a nice (and very true) assessment of that work….


    “The problem with Diamond’s non-argument is that aptitude tests actually work. A one-hour paper-and-pencil test gives a reasonable estimate of a student’s general problem-solving ability, which is why everybody uses such tests. The Army find that the top scorers make much more accurate tank gunners – it’s hard to ignore a 120-millimeter DU shell.
    Regional scores on IQ tests and other educational tests ( PISA, etc) do track regional differences in S&T achievements. Not perfectly – northeast Asians have the highest scores but have not made the largest contributions to the development of modern technology – but pretty well. Populations that have low average scores on such tests have contributed very little to the development of modern science and technology.”

  2. http://www.aei.org/publication/group-differences-dont-undermine-case-against-racial-discrimination/

    great article with great comments: i especially liked this comment:

    This is exactly true. Murray and Herrnstein’s The Bell Curve demonstrates – simply and elegantly – that an IQ score is a better predictor of one’s long-term outcomes than either their parents’ education or income. Anyone questioning the rightness of Barone’s opinion here should read – with an open mind — the book. To quote Murray (not from the Bell Curve):

    “In a fair society it is believed [by the Left] different groups of people – men and women, blacks and whites, heterosexuals and homosexuals, the children of poor people and the children of rich people – will naturally have the same distributions of outcomes in life: the same mean income, the same mean educational attainment . . . When that doesn’t happen it is because of bad human behavior and an unfair society. For the last 40 years the premise that significant group differences cannot exist has justified thousands of pages of government regulations reaching into everything from the paperwork required to fire someone to the funding of high school wrestling teams. Everything we associate with the phrase ‘politically correct’ eventually comes back to this premise.”

  3. I just finished the text, “IQ and the Wealth of Nations.” If you enjoyed “The Bell Curve,” you should also read this by Lynn and Vanhanen. Very interesting and imho, accurate.

    In Joel Stein’s essay, “My Own Private India,” he writes, “….when I was a kid, a few engineers and doctors from Gujarat moved to Edison because of its proximity to AT&T, good schools and reasonably priced, if slightly deteriorating, post–WW II housing. For a while, we assumed all Indians were geniuses. Then, in the 1980s, the doctors and engineers brought over their merchant cousins, and we were no longer so sure about the genius thing. In the 1990s, the not-as-brilliant merchants brought their even-less-bright cousins, and we started to understand why India is so damn poor.”

    “IQ and the Wealth of Nations” explains why.

  4. Here’s more…


    “Of course, many of the protesters may have been offended by Mr. Murray’s other scholarship, in particular his controversial 1994 book, “The Bell Curve,” written with the Harvard psychologist Richard J. Herrnstein, which examined intelligence, social class and race in America. Or rather, they may have been offended, as many people have been, by what they assume “The Bell Curve” says; only a small fraction of the people who have opinions about that book have actually read it. (Indeed, some people protesting Mr. Murray openly acknowledged not having read any of his work.)”

    And another one below. And by the way, epigenetics is a rounding error in intelligence and achievement. I know it’s in vogue right now.


    and another one-this article is misleading–I am sure Saurabh wants to believe its myth…”The unkillable myth. SAT prep can raise scores by hundreds of points. Many good studies w/ control groups. Effect size: A few dozen points.”


  5. Ten common myths:

    You can’t sum up a person/measure a person’s worth in a single number.’ (Nobody said you could)

    ‘Intelligence tests only tell you how good you are at doing intelligence tests.’ (They tell you much more than that)

    “Your IQ is just a reflection of your social background.’ (IQ only correlates modestly with social background)

    ‘There are multiple separate intelligences.’ (All mental abilities are correlated.)

    `Brain size isn’t related to intelligence.’ (Larger brains are linked to higher IQ.)

    ‘Intelligence is immutable.’ (There’s plenty of evidence for IQ change.)

    ‘Intelligence research is elitist/sexist/racist.’ (Facts don’t have moral values attached.)

    ‘Intelligence tests just measure culturally valued information.’ (They include much more basic tests, like speed.)

    ‘Twin studies have been discredited.’ (They haven’t, and even if they had, other methods tell us that IQ is heritable)

    ‘IQ tests were originally invented for eugenic purposes.’ (The story is complex, but the first test was invented by Binet to help children with learning disabilities.)

  6. William, if the science of mental ability is too emotional of a topic for you, I’m sorry. You and Saurabh seem to want to think that’s it’s Murray alone spouting this. It’s not. It’s thousands and thousands of experts in the field of cognitive sciences. You’re basically ignorant.

    In the next couple of years the gene loci for intelligence will be mapped and then there will be no place to go for emotional people like yourself who will not accept reality.

    “For example, virtually all psychologists believe there is a general mental ability factor (referred to colloquially as “intelligence”) that explains much of an individual’s performance on cognitive tests. IQ tests approximately measure this general factor. Psychologists recognize that a person’s IQ score, which is influenced by both genetic and environmental factors, usually remains stable upon reaching adolescence. And they know that IQ scores are correlated with educational attainment, income, and many other socioeconomic outcomes. ”

    “Psychologists have tested and long rejected the notion that score differences can be explained simply by biased test questions. It is possible that genetic factors could influence IQ differences among ethnic groups, but many scientists are withholding judgment until DNA studies are able to link specific gene combinations with IQ. “

  7. What did Murray call it? the G factor or something?
    Could there be anything real in this concept? The total number of neurons? = IQ? The number of neurons in certain places like frontal cortices? or left frontal cortex? Or the total number of synapses? Or synapses in certain places? Or is it the physiology of the synapses like the rate of release of neurotransmitting chemicals or their receptor efficiency? Why are not folks with great spinal cord neural physiologies like gymnasts, etc., not necessarily great thinkers?

    There are so many permutations of anatomy and physiology and genetics and neural environmental histories that there seems to be no way that IQ can be one thing.

    QED baloney

  8. http://www.politico.com/story/2013/08/opinion-jason-richwine-095353

    “There is a large discrepancy between what educated laypeople believe about cognitive science and what experts actually know. Journalists are steeped in the lay wisdom, so they are repeatedly surprised when someone forthrightly discusses the real science of mental ability.

    If that science happens to deal with group differences in average IQ, the journalists’ surprise turns into shock and disdain. Experts who speak publicly about IQ differences end up portrayed as weird contrarians at best, and peddlers of racist pseudoscience at worst. ”

    “For people who have studied mental ability, what’s truly frustrating is the déjà vu they feel each time a media firestorm like this one erupts. Attempts by experts in the field to defend the embattled messenger inevitably fall on deaf ears. When the firestorm is over, the media’s mindset always resets to a state of comfortable ignorance, ready to be shocked all over again when the next messenger comes along.

    At stake here, incidentally, is not just knowledge for the sake of knowledge, but also how science informs public policy. The U.S. education system, for example, is suffused with mental testing, yet few in the political classes understand cognitive ability research. Angry and repeated condemnations of the science will not help. ”

    “What scholars of mental ability know, but have never successfully gotten the media to understand, is that a scientific consensus, based on an extensive and consistent literature, has long been reached on many of the questions that still seem controversial to journalists. ”

    ” What causes so many in the media to react emotionally when it comes to IQ? Snyderman and Rothman believe it is a naturally uncomfortable topic in modern liberal democracies. The possibility of intractable differences among people does not fit easily into the worldview of journalists and other members of the intellectual class who have an aversion to inequality. The unfortunate — but all too human — reaction is to avoid seriously grappling with inconvenient truths. And I suspect the people who lash out in anger are the ones who are most internally conflicted.

    But I see little value in speculating further about causes. Change is what’s needed. And the first thing for reporters, commentators, and non-experts to do is to stop demonizing public discussion of IQ differences. Stop calling names. Stop trying to get people fired. Most of all, stop making pronouncements about research without first reading the literature or consulting people who have.

    This is not just about academic freedom or any one scholar’s reputation. Cognitive differences can inform our understanding of a number of policy issues — everything from education, to military recruitment, to employment discrimination to, yes, immigration. Start treating the science of mental ability seriously, and both political discourse and public policy will be better for it. “

  9. Dr. Jha, it may interest you to know that, among online patient discussion forums (fora?) that I follow and/or moderate, the sky has not fallen upon male docs since this study was made public. From the patients’ perspective, there doesn’t seem to be a mass firing of male physicians in favour of all those superior women. In fact, there appears instead to be (this is only my observational assessment, of course) a pervasive overall defense, e.g. “My male doctor ______” (fill in the blank: is wonderful, saved my life, etc.)

    Most of us, especially those of us living with chronic illness who regularly see lots of docs both in and out of hospital, got the memo years ago and are not in fact “taxed with another uncertainty”. We already know that going to the ER or being admitted to hospital or just bringing up a concern with your GP is a crapshoot for patients.

    We already get it: differences in personality, communication skills, and especially competence exist. Some male docs are terrific, others far less so. Same with female docs. I prefer to look at other extenuating circumstances (like, was that doc working/making decisions/interacting with patients in the 18th hour of a double shift?)

    I was tragically misdiagnosed by one male doc, and, literally, saved by another two weeks later. Every so often, I publish another roundup on my blog that I affectionately call “Stupid Things Cardiologists Say to Heart Patients”, collected from readers over the years. I can assure you and your readers that these comments represent equal opportunity stupidity originating from both sexes. I use the word “stupid” only as a cautionary warning that such comments can and often do result in dangerous and even fatal outcomes for heart patients, so we tend to take those examples pretty seriously, no matter who says them. But I am also quick to regularly acknowledge analytical skills, empathy, kindness and those other fine attributes you mention where they do exist – and there are lots of them to go around, too.

    In short, patients are not the ones fretting over the outcomes of this study. My advice to those harrumphing in sputtering annoyance is, as we used to say during my 35+ year public relations career: remember that today’s news is tomorrow’s fish wrapping – at least until we see some actionable work on the skill and personality attributes that help create good medicine.

  10. Based upon my recollection of the BellCurve now over 20 years old I think you underate both the data and the conclusions stating it was an “analysis of differences in intelligence between races” which it wasn’t, though some of that data existed and had to exist. You are welcome to your own opinion however misguided, but to put it in the same op ed as the study comparing female and male physicians is ludicrous. Whatever comparison you are trying to make only elevates a lousy study while deprecating a bit of research and analysis that was quite commendable.

  11. And then, the EHR had this to say: “A complete review of systems was negative.” Please, when you have the energy to do so, write an essay about the precision of that statement. It may even be correct to say “impossible.” Thank-you for the discussion about IQ.

  12. Tongue firmly in cheek, I note: “It may be argued that the one silver lining of the study is that female physicians will be compensated fairly. That should be the case, as Dr. Vinay Prasad notes, regardless of what the study found. Fairness is a moral, not scientific, imperative. Have we become so insensate that we need science to tell us to do the right thing?”

    Don’t we need the authors to go back and determine if paying doctors more than other doctors correlates with better performance before we recommend this intervention, based on the evidence? It would be shame to blunt the beneficial effects of trading the Y chromosome for an X with the corrosive effects of filthy lucre.

    Actually, THAT would be a more useful bit of cocktail party data…

    Thanks for your commentary and keep up the good work.