Medical School Admission Criteria: a discussion

 It is very difficult to get admitted to a medical school.   At UBC, only about 10% of applicants are accepted.   

This leads to extreme competition.  Students admitted to the program  have average university grades just under 90%, and average standardized test scores (from the MCAT) just under the 90th percentile.  

Even if you have average university grades above 90%, it is no guarantee of admission.  Only 26% of applicants with such high grades are accepted.  

Therefore, there are other factors which increase the likelihood of admission, aside from grades and standardized test performance.  These are so-called "extracurriculars" such as history of volunteering and "leadership activities," reference letters, and performance in a "multiple mini-interview," which involves responding in a desired fashion, within a time limit, to various hypothetical scenarios with a sequence of 10 different interviewers.  

I understand the need to have multiple criteria to judge applicants.  But I would like to make the case here that the current selection process is not particularly efficient or fair, it has a very strong bias against people with particular personality types, despite those people being very well-suited to be excellent physicians, and also leads to years of unhealthy, expensive, and wasteful frenzied competition before starting medical school.  There is also a bias in favour of people from wealthier families, since such people would more easily be able to afford years of volunteering, cultural exploration, club leadership, MCAT prep courses, tutoring, etc. instead of having to work long hours for years near minimum wage to support educational expenses.  

Imagine who the best future surgeons would be.  They would likely have excellent hand-eye coordination, tactile skills, mastery of fine details such as of anatomy, immense patience with meticulous tasks, and ability to remain calm and focused for long periods of time.  Some of them might be not be "neurotypical."   Many of the most talented such people would not necessarily have great social skills, would not be inclined to volunteer at Big Brothers or at nursing homes, would not be on the executive of university clubs, would not have a history of musical or drama performances, would not seem impressive in rapid interviews, and also may not have high grades in biochemistry or English.  I don't believe that any of the relevant surgical talents described above are assessed at all in the medical school admissions process.  

The current medical school admissions process therefore excludes many of the best future surgeons.  For many other future surgeons who are fairly accepted, they would have spent perhaps years of extra time padding their CVs with life activities that they were not really interested in, just to keep up with the pre-med competition game.  This is a waste not only for these individuals, but for society as a whole (we have budding surgeons who have several fewer years of professional life due to them having spent these years doing CV padding activities).  

Another result of the pre-med competition process is that candidates will be well-motivated to pad their academic transcript with easier courses, so-called "grade boosters," while avoiding difficult or challenging courses which tend to have a low class average.   The challenging courses would lead to improved scholarship and wisdom, but people have to avoid them because they could drag their grades down.  Most medical colleges do not take into account the difficulty of the courses that people take.  In any case, one of the advantages of a standardized exam such as the MCAT is that everyone in the world takes the exact same exam, so there is no selective avoidance of difficult material.  

The competition to show extracurricular volunteering and "leadership activities" also creates a bias against introverts.  Many of us are quiet, shy, with relatively solitary habits.  Such gentle, quiet people often would make excellent physicians: people who are calm, good listeners, patient, kind, intelligent, sensitive, and skilled.  But for a person with this personality style, group involvement, group leadership, and many types of volunteering, are just simply unpleasant or impossible.   I am an example of such a quiet, shy, relatively solitary person.  

We should have a selections process that chooses people who are likely to be competent, skilled, and stable.  We should have a process that makes it hard for a psychopathic person to get admitted.  The existing process does select for competence, stability and skill indirectly through grades, even though most of the actual grades have little to do with skills that would be of clinical use during a medical career.   A psychopathic person is less likely to have consistently high grades and a good volunteer record.  But many psychopaths could present themselves very well in cross-sectional interviews, while many non-psychopaths who are simply shy or reserved would bomb the interviews.  

What would be reasonable to change the process?  I don't think there's an easy answer.  I think that grades and MCAT should continue to have a prominent impact on admissions, despite some of the biases involved. Maybe this is unavoidable.   People should be rewarded, rather than penalized, for taking difficult courses that may have lower average grades.  It would seem very reasonable and practical to be rewarded in the admissions hierarchy if you have proven experience or skill in health care work or in relevant skills; for example, people who have worked in nursing or other allied health fields, as a paramedic, in an anatomy lab, as a technician, doing other work requiring long hours of meticulous focus, veterinary work, or psychotherapeutic work.  I think that much less weight should go to performance in a cross-sectional interview process, since this is extremely prone to biases which are not relevant to future medical performance (this reminds me of Kahneman's descriptions of biased and meaningless selection interviews from "Thinking Fast and Slow").  I think that showing "leadership skills" should have minimal impact on admissions, and people should not be penalized in the process for not showing "leadership skills."   Furthermore, those who are most ambitious to show such "leadership" are often the worst leaders.  

"The Biology of Desire: Why Addiction is Not a Disease" by Marc Lewis

Marc Lewis explores the neurobiology of addiction in this short book, with proposed approaches to better understanding and helping people who are struggling with addictions.  

He comes across very clearly as a compassionate person, with a good understanding and personal experience in this area.  Probably someone who would be good to have as a therapist or support in the context of addictive problems.   

The book presents several case stories, which is always a compelling style in describing health care issues.  They could be a source of inspiration that could help people in their own journeys through addiction.  But of course testimonial accounts have only limited value in a scientific study, since they can introduce very strong biases in the reader, if not accompanied by references to large controlled studies.    

He has good reasons for disparaging what he calls "medicalization" of addiction, and emphasizing his opinion that addiction should not be considered a "disease."    Many of these reasons involve emphasis on what most of us would consider "bad medicine," i.e. institutional or even punitive treatment, simple remedies such as drug treatments given without addressing social or psychological issues, etc.    He particularly disparages psychiatrists, as though he thinks all psychiatrists enjoy the narrow or excessive brandishing of labels and dispensing of medications without attending to deep understanding, therapeutic compassion, and a biopsychosocial focus, with patients.  

So I found this part of his message to be tiresome.  Excessive narrow "medicalization" of almost any issue is not good medicine.  Almost any health condition, such as type II diabetes, heart disease, hypertension, and certainly conditions such as anxiety or depression, have spectrums of severity or chronicity; there are very important psychosocial factors, often present for years before the onset of the condition, that influence symptoms, severity, and progression.   There are feedback loops involving behaviour which cause spiralling exacerbations or rapidly accumulating harms in all of these conditions.  And treatments for diabetes or heart disease need to involve understanding and help with lifestyle, social, and economic factors affecting these conditions, with long-term goals in mind.    But it is not necessary to avoid calling diabetes a "disease."  Rather, the approach should be, in my opinion, to recognize that any disease state occurs on a continuum.  In many cases, there is no clear-cut line between disease or non-disease.   The word "disease" does not necessarily imply permanence, or need for invasive, narrow,  or institutional treatments.  For example, we could agree that viral pharyngitis is a disease, but is not one which normally requires medical intervention.  Just as in addiction, many conditions uncontroversially considered "diseases" or at least pathological states, such as pneumonia, COVID, migraine, sciatica secondary to disc prolapse, psychotic episodes, or brain injury, can often  recover on their own without any treatment at all; but for some sufferers of these conditions, the symptoms become relentlessly chronic or more difficult to deal with.    Just because something has the possibility of improving on its own, or through lifestyle improvements, after days, months, or years, does not mean that it shouldn't be considered a disease.  Furthermore, the improvements in many conditions can sometimes be associated with improved perspective or lifestyle, but sometimes the improvements are just random.  Many patients I've seen have engaged in all the healthy perspective-taking and good lifestyle habits you can imagine, but are still afflicted by the same tormenting symptoms.  Other patients somehow recover from severe problems without changing their lifestyles much at all.  

Hypertension is a disease, with multifactorial causes, which often requires medication but always requires attention to lifestyle factors.   Simple, overly reductionistic medical treatments can sometimes help with certain disease states (such as repairing a broken limb) but in many or most disease states, medical treatments are only one branch of helping.  The other branches require attention to lifestyle factors, community or social supports, and possibly an existential focus, to help people regain an awareness and passion for long-term goals.  But this multi-pronged focus is what I consider to be normal medical care.  

Lewis argues that because the neurobiology of addiction features entirely "normal" activations of normal brain pathways, akin to learning or falling in love, addiction therefore should not be considered a disease.  But many conditions in medicine feature activation of normal physiologic functions as a component of their pathology.  For example, inflammatory states resulting from infection (this is a major pathology in COVID) are activations of the body's defenses to fight off pathogens, but the inflammation itself ends up causing severe tissue destruction.  The processes are all "normal" but the circumstances of the disease state (germ + host) cause the reaction to be disastrous.  A clear understanding of disease states, mechanisms, and medical interventions to interrupt this cycle, are indicated to save lives and prevent widespread tissue destruction.  

Addictive states can lead to similar destruction of bodies, minds, relationships, and careers.  Just because the mechanisms involve activations of normal neural pathways does not mean we should avoid diagnostic language.    Problems associated with pathologizing labels, such as stigma (from others or from self) do not mean we have to avoid such labels entirely, but it may mean that the labels should be used with care and humility, rather than in a pejorative manner.  

There is interesting neuroscience describing addictive processes, but sometimes discussion of this can devolve into making overly strong literal claims (e.g. about neuroplasticity), often based on compelling testimonial accounts, without as much robust statistical evidence to back these up.  This is a pitfall I've seen with other authors touching on this, such as Doidge.  The use of the neuroscientific language then becomes a tool of persuasion, which sounds impressive to most people.  But it is much more important in this area to back up claims, especially those based on case studies or testimonial accounts, with careful reference to large controlled studies.   

Lewis has good ideas and a passion for his subject, but his focus on addiction not being a "disease" is needless--it is to some degree a semantic squabble, which subtracts needlessly from the impact of his book.  

The Elephant in the Brain & The Folly of Fools

 Two more books to recommend:  

The Folly of Fools (2011) by Robert Trivers and The Elephant in the Brain (2018) by Kevin Simler & Robin Hanson are both about the human tendency to engage in deception: not only the deliberate deception of others but the deception of self.  

Trivers approaches this issue from the point of view of genetics (he was the first to characterize the evolutionary biology of reciprocal altruism).  The capacity to deceive can be beneficial to survival, as we see in many species of animals, and in many human examples.   But such deception can only work up to a certain point, an equilibrium point in terms of frequency, otherwise the strategy fails.  If deception was too frequent, the evolved strategies to counter deception would render the deceptive strategy ineffective.  Similarly, cheating can be an evolved strategy, but if cheating occurs too frequently in a population, it would no longer be effective due to widespread awareness and countermeasures in the population.    

Trivers goes on to argue that self-deception is a type of advanced deceptive strategy.  The capacity to effectively deceive others is enhanced if we can deceive ourselves.  If you REALLY believe you can win a fight (despite poor objective evidence), you are more likely to convince your opponent that you can win, and therefore are more likely to actually win, even if you utterly lack fighting skills. 

Unfortunately, self-deception leads to many serious problems in society.  Trivers goes through many examples, showing that horrible accidents, wars, biased research, and religious phenomena, are often driven by self-deceptive factors which end up causing disastrous results.  

His chapter called "religion and self-deception" is particularly recommended.  

While I consider this book important and highly recommended, I did find it often to be quite informal in reasoning, punctuated by forays into humour, but this could be a bit problematic when he is wandering into areas (for example about politics, wars, and religion) that many people could be quite sensitive or easily offended about.  There are bound to be sections in this book which could cause people some offense.  

The Elephant in the Brain is quite a remarkable review of ideas from social psychology and behavioural economics.  There is influence from Kahneman, Trivers (The Folly of Fools is referenced), Haidt, and many other leaders in the research of this area over the past decades.  I think it's astounding that these two authors, who are not specialists in these areas, produced such a comprehensive and compelling summary of this research.  

The thesis of this book is that humans have a powerful motive to signal membership in groups.  The tendency to form ingroups is a powerful human trait, evolved over millions of years.  Group membership allows us to trust and collaborate with our group members, for safety, defence, maintaining a food supply, dealing with illness, finding a mate, and raising children.  But unfortunately, this tendency to form ingroups can become such a powerful motivation, often without our awareness, that it overwhelms reason, fosters needless and often terrible conflict with outgroup members, and can become very destructive or at least inefficient.    And the phenomenon tends to perpetuate itself, since members of ingroups (be it political or religious or cultural) tend to socialize, mate, and have children with fellow ingroup members.  

They refer to Bryan Caplan's argument about education, showing that a great deal of education leads to only an indirect signal of skill or competence.  Most people do not use subject matter they learned in university very often if at all in the work they do afterwards.  Instead, the degree and grades serve mainly as a competitive signal to employers about capacity to achieve work, conform stably to demands, etc.  I have reviewed Caplan's book elsewhere (I do have some disagreements about this).  

The authors show that political and religious membership have powerful ingroup effects.  The tendency to form strong beliefs about elements of religious doctrine can be understood as a badge of group membership; if one can engage in successful self-deception about these doctrinal elements, it is all the more effective as a group membership badge.    The beliefs become shibboleths which can allow some feeling of trust with co-believers, and a sense of distrust or frank dislike of outsiders.  Such belief systems can develop independently of rational moral reasoning.  While all religious systems contain positive insights about morality (e.g. "love your neighbour as yourself", "blessed are the meek", "blessed are the peacemakers," "judge not lest ye be judged", "do unto others as you would have them do unto you," etc.), the moral prominence of these beautiful insights is often lost in a cloud of doctrine that becomes more about maintaining an emblem of group involvement, an "us" vs. "them" mentality.  This mentality is a manifestation of an evolved trait pushing all humans towards group involvement, formation of local communities in which we can feel trust and belonging, but with the unfortunate consequence of having outgroups which we would not trust, and which we would treat with less positivity, warmth, and generosity.  

The same phenomena occur in political beliefs.  While there could be core rational beliefs about positions on a political spectrum, with regard to preferred economic strategy, international affairs, management of public works, etc., a great deal of political involvement involves doctrinaire beliefs that are badges of group membership, and which have nothing to do with any understanding of policy.  Most people don't even know what the policy positions are, exactly, of the candidates they vote for.   Many others support their ingroup's politicians even though the associated policies would be harmful to themselves economically or socially.    We have tragically seen this happen during the pandemic.  Extreme beliefs about vaccines, masks, etc. became emblems of political group membership; many people made decisions about these issues not because of rational evidence (which strongly supported vaccine and mask use, for the protection of everyone's health, including the anti-vaxxers' own health and well-being), but because of the beliefs of fellow ingroup members in political or religious factions.  Masks and vaccines have almost nothing whatsoever to do with religion or politics -- they are simply common-sensical public health measures -- but once these issues became badges of group involvement, the issue spiralled into disaster, to the detriment of everyone.  This is an extreme example of the phenomenon shown in the famous children's study, where kids randomly given shirts of a different colour end up forming hostile ingroups, opposed to each other.  In the case of the pandemic, a great deal of anti-vax belief was simply driven by factors akin to having a different shirt colour, just to show difference from an opposing outgroup.  

In both books, reference is made to psychiatric theory as an example of self-deception.  Psychoanalytic theory is basically a set of ideas akin to religious doctrine, with a strong ingroup community of "believers" who couch discussion of psychiatric issues through the lens of a theoretical system which is mostly fictional.  As with religions, there are core beliefs in psychoanalysis which reflect deep insight and wisdom.   For example, the idea of psychological defenses came from psychoanalysis, and is ironically an insight into the tendency for humans to engage in self-deception, with the implication that we should try to become aware of our defences, and to be able to set them aside.   Similar insights warning about self-deception can be found in religious texts.  But most of psychoanalytic theory is arbitrary, based on bizarre inferences made from case reports, coloured by the already biased opinions of the therapists.   But as with religious practices, much of the therapeutic value in psychoanalysis has nothing to do with the literal belief system, it has to do with the practice itself.   Visiting a trusted minister or priest, who would most likely be kind, gentle, understanding, supportive, and wise, could be a wonderfully healthy practice, as could a meditative practice of daily prayer, or visiting a congregation of loving friends.   These healthy and possibly healing effects would occur regardless of the belief system held by the group.  Similarly, the practice of psychoanalysis (or psychodynamic therapy more generally) requires frequent visits with a wise, compassionate, gentle, kind therapist who probably has some useful feedback about life problems, and there would be a healing effect of simply having a stable therapeutic relationship over a long period of time, irrespective of the fictional theoretical belief system held, such as strict Freudianism.  

While we can empathize and even endorse the benefits of ingroup membership phenomena, I believe it behooves us to strive for improved rationality, to guide our knowledge and decisions so as to benefit ourselves, our neighbours, and the world in the most effective way.  Societies across the world have improved in this way over the centuries, as Steven Pinker has shown us (see Enlightenment Now), but we have a lot of work to do to continue progress in building a just, peaceful, prosperous society.  

In both books, we are wisely cautioned to look to ourselves for our own self-deceptions.  It is another human tendency to see self-deception or folly in others, while not noticing our own.  In my case, I recognize this will be a work in progress.   I surely have beliefs or practices that are products of my ingroup or other biases; I hope that I will be able to keep working on better awareness of these issues over time, in service to my patients and to myself.   

Review: Shrinking Violets: The Secret Life of Shyness, by Joe Moran

 Joe Moran's book is a nice exploration of various historical figures (such as authors, poets, and musicians) who had what he calls "shyness."  Moran alludes to his own shyness as well.  

A thematic goal of the book is to understand shyness as a part of the tapestry and variety of human life, as opposed to a pathology that requires treatment, or that is even treatable at all.  

Moran is a good writer--he's an English professor, and it is always a delight to read a book in this type of genre written by someone with a mastery of the language.  

This book is interesting as a historical or biographical journey, but I found it quite limited as a serious study of shyness from a psychiatric point of view.  First of all, "shyness" is a very limited term to describe the many varieties of anxiety, introversion, personality styles, and autistic traits likely present in some of his case studies.  

Near the end of the book, Moran encourages a position of gentle acceptance of shyness, but this acceptance seems to disparage the potential value of attempting to help people manage or change their social anxiety or avoidance using therapeutic techniques.  One chapter is even called "The War Against Shyness," which is a pretty strong condemnation of the therapeutic culture.    

There are many shy people, who have what might be considered social anxiety or autistic traits, who might find therapy helpful, to improve social skills, to find ways of facing fears more comfortably, or even to reduce anxiety a notch (including with the help of medication).   We should always have modest or limited expectations of therapy; also we need to take care to affirm an accepting rather than a pathologizing stance, particularly when social behaviour and experience always exists on a spectrum.  Yet the best of modern therapy is affirming and accepting; it just helps people to suffer a little bit less, to help people have a little bit more freedom in their lives to do things they might find meaningful, enjoyable, or essential for survival or prosperity.  

Review: Blueprint by Nicholas Christakis

 I am happy to have discovered Christakis and his work, in an area I would call “evolutionary sociology” or “mathematical sociology.”  

Blueprint: The Evolutionary Origins of a Good Society is an excellent companion to books by Steven Pinker, Jonathan Haidt, and Richard Dawkins, and even behavioural economists such as Kahneman, looking at issues concerning the genetic components of individual and group behaviour, and the intersection or interplay between “genetic” and “environmental.”     Christakis shares Pinker’s general optimism about human progress, though through a social and anthropological lens rather than a strictly individual, rationality-based one.  Haidt and Christakis both look at dynamics of group differences, Haidt as a psychologist, Christakis as a sociologist.  And Christakis looks at gene-environment interaction on a group level, a continuation or elaboration of Dawkins idea of an “extended phenotype.”  

Near the beginning of the book, there are very interesting case studies presented about small groups that isolated themselves from the rest of society, either through choice (e.g. the Shakers), or through disaster (shipwrecks), then having to develop some means of survival, stability, or happiness.  Some organizational styles were successful, especially when there was some form of effective but not overly rigid leadership, combined with respect for individual differences, and a culture encouraging playful interactions.   Some styles led to failure (a very low survival rate), such as if warring factions developed, “Lord of the Flies” style, or if the community was either too anarchistic, too insular, or too tyrannical.  

Christakis introduces network analysis of groups, which I would like to learn more about.  I consider this to be in the mathematical discipline of “graph theory,” another nice example of pure mathematical concepts and modern data science allowing us a deeply insightful view of aspects of human nature.     I consider this type of analysis especially important in this age of online connectivity, which has the potential to amplify or distort connectivity phenomena, leading to powerful forces of social change, leadership, and spread of ideas or culture.  

After finishing this, I am motivated to finally start Christakis’ next book, Apollo’s Arrow, which is about  the COVID pandemic, again studying it through the lens of sociology and group dynamics.  

A general takeaway point from this book, from my perspective as a psychiatrist, would be to even more strongly value an understanding of social and group dynamics in a person’s life, to understand the nature of connections, connections of connections, group memberships, friendships, communication, and community, in much greater detail, as a component of understanding psychiatric phenomena and strategizing about therapeutic help, rather than stopping at the level of individual psychology only.  

The Urge: Our History of Addiction, by Carl Erik Fisher

The Urge: Our History of Addiction, by Carl Erik Fisher is a good book about the history of addiction, weaved together with a story of the author's own alcohol use problems and rehab.  

The original use of the word "addiction," as Fisher shows us, was more general or broad, referring to situations we might now consider "behavioural addictions," habit problems, or just very strong preferences.    This usage of the word, despite objections from some addictions specialists, may be most accurate from a neurobiological point of view, according to recent evidence.  

He emphasizes many times how addictive phenomena lie on a continuum of severity in different people and within the same person at different points in time, and are influenced strongly by social, economic, and political circumstances.   For some people addiction is a symptom of, or a means of coping with, horrible environmental circumstances.  For others, it is a trap leading to loss of control even when environmental circumstances have improved or are normal.  

Understanding and helping addiction problems has had an interesting history, with some compassionate medical and community help approaches evolving since the 1800s, but often interrupted or negatively influenced by social factors such as stigma or criminalization.  

I agree with his conclusions, that addiction treatments need to be individualized, and that there can be various different causes or problems which underlie addiction for different people.  AA or other 12-step groups can be valuable for many people, but this is not the only effective approach.  Other group styles, such as the "SMART" program, can be preferred.  Abstinence-based models of treatment may be preferred or necessary for some people, but for others it is effective to aim only for moderation without abstinence.  Some people do not want or need peer or group support, and prefer one-on-one counseling.  Others may prefer to manage their addictive problems alone; Fisher cites data showing that many people with addictions can recover without any therapeutic treatment at all.   There are medications that can help, such as naltrexone.  

Fisher acknowledges the importance of loss of control in addiction, and of the phenomenon of denial which delays or prevents many people from seeking help.  

There have been big problems in addiction management that must change.  First, there needs to be much more availability of addiction treatment programs for those who desire or need them.  There should not be economic biases causing some groups to have less access than others.  For opiate addiction in particular, there needs to be easier availability of methadone or buprenorphine maintenance for those who would like to try this approach.  Harm reduction strategies in general have a very strong evidence base.  

Second, public health interventions can be simple and effective, such as restricting the advertising or marketing of addictive products (such measures have been useful for reducing tobacco use in the population).  There is still a big corporate influence on policy (from the alcohol or gambling industries, for example), which should not be allowed to continue.   Third, there should be less focus on prohibition and criminal punishments, which in general have often made addiction problems worse, particularly by focusing expensive social resources on law enforcement rather than on community improvement and rehabilitation.  

Belief Bubbles, Delusions, and Overvalued Ideas

 One of the most important posts that I've written on my blog, in my opinion, has been "Political polarization, propaganda, conspiracy theories, and vaccine hesitancy: a psychiatric approach to understanding and management," initially published on September 1, 2021 but edited and updated numerous times since then.   I check periodically how many people visit my blog, and I see that there are relatively few.  If I could recommend just one of my articles to be published widely, it would be that one, since I think it is so important regarding individual and public mental and physical health issues in the world today.  

The topics in that post focused on misinformation, propaganda, and deluded beliefs regarding the pandemic.    

I frequently see similar issues at play in my daily work as a psychiatrist.  

What causes fixed false beliefs?  When would we call these "delusions" as opposed to overvalued ideas, or simply examples of erroneous thinking?  

In psychotic states, the mind creates delusional beliefs without any reinforcement from a social community.  This is caused by genetic factors, abnormalities in dopamine circuitry in the brain, magnified by psychosocial stress.  As a result of the individual nature of psychotic illness, fellow members of the community can easily recognize the problem, and hopefully attempt to help.  Such delusional beliefs are unlikely to spread in a social network.  

There are examples of "shared psychotic disorders" in which an individual may have a primary psychotic illness, leading to close associates or family members adopting the same beliefs.  But this is a relatively rare phenomenon.  

A much more challenging problem occurs when false beliefs are spread in a social network.  In this case, the beliefs may or may not have anything directly to do with the other beliefs or values within the social network .  For example, extremist anti-vax beliefs are more common in particular religious or political groups, but vaccines have very little to do with theology or ideology.   The process of ideological spreading in these cases is analogous to what Dawkins calls a "meme", though driven not by a natural selection process, but by a process akin to "sexual selection."   In "sexual selection" traits such as peacock feathers propagate together with traits for recognizing and desiring the initial trait.  For example, bird songs or feather colours are sexually selected due to the song or feather itself and the desire of other birds to recognize or value the song or feather.  The song or feather comes to be an emblem of the species itself, rather than having other adaptive or communicative value (bright or decorative feathers do not lead to improved flight).  Many examples of "mass delusion" such as anti-vax beliefs are likely similar; they have become emblems of membership in particular religious or political communities, which are found to be attractive by those within the communities, even though the beliefs are harmful to the group and contrary to the group's positive values.  In this way, they are ironically similar to a virus:  anti-vax dialogue and behaviour has become much more prevalent or even dominant in these religious or political groups, such that the groups' core values or policies are utterly neglected or contradicted.   People from outside these groups would be disgusted by this phenomenon, leading to the groups becoming more insular, decried as hypocritical and immoral by outsiders, and obviously less able to offer charismatic outreach.  In particular, values such as love, care, and freedom are profoundly contradicted by beliefs which decry life-saving public health protections.  

Anti-vaccine and other "anti-public-health" propaganda is extremely harmful to society; it causes needless suffering, death, and economic hardship.  The propagation of such ideas is shockingly dissonant with the core values of many of the groups associated with it.  Disparate groups have endorsed such beliefs, leading to an unusual medley of fundamentalist religious groups, biker gangs, and racist groups joining in protests or defiance against vaccine and public health mandates. 

It is very difficult to address or improve problems of this sort.  When beliefs have been adopted as an emblem of a tight-knit social community, they are strengthened greatly by group association, and group members will defend these ideas from outsiders, almost like people might defend their home or family from invaders.   These ideas become adopted as almost sacred core values,  as though the beliefs (in this case about vaccination, wearing masks, etc.) were enshrined in a sacred religious text such as the Bible.  

As with psychotic illness, there are degrees of severity.  In mild cases of psychosis, affected people may be able to question their beliefs or request help; in more severe cases they have the insight to know that others would see their beliefs as paranoid, so they are able to refrain from discussing their beliefs, even though they still are fully believing their delusions.  In more severe cases, people will start expressing, or casually "slipping in"  the paranoid ideas in casual conversation (even with a psychiatrist) almost as though to test or evaluate the conversational partner, perhaps to seek a kindred believer or to be warned about a "nonbeliever."  As with some examples of religious practice, "believers" may seek to attempt to "convert" others as though expressing the delusion has a sacred value.   

I think it's pretty important as a psychiatrist to gently inform people that there are delusional beliefs going on.  With entrenched delusions this may need to be done with the greatest care and empathy, but I do think it needs to be discussed at least a little bit, otherwise there is a risk of the person feeling their delusions have been endorsed.  In the case of socially-spread overvalued ideas, it's a more difficult process to address in a therapy setting.  In some cases the discussion risks spreading to a focus on ideas concerning religious or cultural beliefs, which are generally off-base.  But when new "contagious" beliefs are spreading in a social network, straddling the boundary between a "cultural belief" and a "delusion," unbridled and harmful spreading is more likely.  This is similar to the epidemiological dynamics of COVID itself:  COVID is deadly, but its death rate is low enough to insert itself into populations in a seemingly harmless way, until a few weeks or months later when hospitals and ICUs are overflowing with severe cases.  Ironically, if the mortality rate of COVID was much higher, it might be easier to control at a community level, because there would be more unity of action.

As I discussed in my "political polarization" post, there are many social actions that can help this situation.  It is most valuable for rational, persuasive pro-vaccine, pro-public-health members of affected social groups (such as religious leaders, truckers, political leaders on both sides of the political spectrum, police, military personnel, alternative health care providers, and people formerly part of the anti-vax movement but who have changed their position) to speak out as educators and leaders.   Scientists and public health officials, etc. should still do their best to offer effective public communication, with efforts to reach out to these groups, but they are less likely to have a substantial impact in these communities, since they will be dismissed or derided as threatening outsiders.   Some of the communicative efforts from scientific leaders could at least involve building a better rapport with disparate communities, so that scientists would not be seen as elitist or part of an "ivory tower," out of touch with the rest of the population.    Meanwhile, there is evidence that the rest of us should continue to do our best to combat the spread of misinformation, and to do our best to speak the truth, rationally, resisting the urge to give up in frustration.  

Recommended Reading 2021: an updated book list

 Updated list of interesting books that I encourage checking out:

Steven Pinker: Better Angels of Our Nature: Why Violence has Declined  (2012)

Steven Pinker: Enlightenment Now (2019)

Hans Rosling: Factfulness (2018)

These three books, aside from being enjoyable and informative to read, also give a message of hope, that there are things actually getting better in the world, thanks to science, reason, and progress in justice, despite the world's many ongoing gravely serious problems.   They do not discount the gravity of ongoing problems, but are a nice antidote for the resignation or despair that can set in when faced with an onslaught of depressing daily news about politics, environment, disease, war, etc.  

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Thomas Picketty: Capital in the Twenty-First Century (2017)

This is a masterpiece, a historical analysis of wealth disparity and taxation, making an extremely compelling moral and economic case for introducing a better progressive system of wealth, income, and estate taxation.  This is not "socialist" as Picketty does not advocate state control of the market, but does advocate for fair regulation and progressive taxation in order to prevent regression to a pre-20th century societal style of wealthy aristocrats idly owning an increasing majority of national wealth, while most others work hard to hover near the poverty line, with little chance to progress beyond that level.  I find this issue of great importance as a psychiatrist, because it touches on the issue of managing poverty and fairness, permitting access to personal and community growth, in a way that is grounded in freedom and justice.  

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Richard Prum: The Evolution of Beauty (2018)

Almost every book or documentary I've seen dealing with evolutionary biology has emphasized natural selection as the main force of evolutionary change, while often only mentioning sexual selection in passing.  This book deals with sexual selection, a phenomenon first described by Darwin but relatively neglected in the next century.  This is of interest because Prum argues that sexual selection leads to a type of "co-evolution" in which esthetic choices lead to changes in culture which often improve autonomy, especially for females.  As a psychiatrist I think it is interesting as another emphasis of the cultural and biological foundations of esthetic choice-making in humans.  At the very least, interesting ideas to think about.  

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Daniel Kahneman: Thinking: Fast and Slow (2013)

Daniel Kahneman: Noise: A Flaw in Human Judgment (2021)

Kahneman's books are must-reads for any person.  His 2013 book is a masterpiece, an introduction to the subject of biases which influence human judgment.  I can't emphasize enough how important this subject is in the modern world, where our judgments are constantly influenced by factors within ourselves, and from external sources, which we are not aware of.  It is of relevance in psychiatry or mental health because of the importance for wellness to make healthy, well-informed, unbiased judgments, and because of the exaggeration of biases caused by depressive or anxious states.  

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Jonathan Haidt: The Righteous Mind: Why Good People are Divided by Politics and Religion (2013)

This is an incredibly important book, of the greatest relevance for the problems we face in the world in the past few years.  It is a compassionate look at the psychology underlying political, ideological, and religious difference, with recommendations of ways we can mend these differences and reduce polarization.  

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Paul Bloom: Against Empathy: The Case for Rational Compassion (2016)

This is a nice application of the psychology of bias, as described by Kahneman and others, to the practice of altruism and of caring for other people.  Bloom is a brilliant Yale psychologist, initially from Montreal, who has shown that typical reflexive emotional biases can cause our altruistic behaviour to be surprisingly misdirected, or unfair to those who need it most.  I don’t agree with all of his points, but I think this book is essential reading for a person interested in fairness, compassion, altruism, and justice.  

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Nicholas Christakis, Blueprint: The Evolutionary Origin of a Good Society (2019)

Nicholas Christakis, Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way we Live (2020)

I'm pleased to have discovered Christakis.  Blueprint is a great sociological study of group dynamics-- interesting descriptions of groups surviving on their own in remote locations or after shipwrecks; or groups separating themselves from the rest of society, including small religious enclaves, and an interesting introduction to the mathematical structure of group dynamics in communities.  

Apollo's Arrow is a nice review of the sociology of pandemics, including those from long ago as well as Covid since 2020.  The only critique is that it was published in late 2020, which is only about halfway through the Covid story as we know it today.  

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Robert Sapolsky, Behave: The Biology of Humans at our Best and Worst (2017)

Of course, on a psychiatrist's reading list, pretty important to include a title on neuroscience!  This is a great, detailed but readable introduction to how the brain works, with a particular focus on neuroanatomy and neuroendocrinology.  There are a few shortcomings, but overall highly recommended.  Everyone should be introduced to this subject matter.  

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Maria Konnikova, The Confidence Game: Why We Fall for it, Every Time (2017)

Konnikova is a psychologist who has studied con artists.  This book is an entertaining story of spectacular con artistry over the past century, with some commentary on the psychology of con artists and their victims. This subject is incredibly important today, because we are not only prone to being conned by financial scams, online fraud, etc. but also in choice of political leaders, as we have seen beginning in 2016.   We see that con artists can often be so persuasive that even after they are exposed and prosecuted, victims sometimes still support them, because of how effective the con was, and how humiliating it could be for a victim to admit or understand what happened.  Once again, we see this in particular political leaders since 2016.  

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Ellen Peters, Innumeracy in the Wild: Misunderstanding and Misusing Numbers (2020)

Ellen Peters show us the extent to which the majority of people have poor understanding of mathematics, even at a basic level of interpreting simple data.  This is of great importance because so many of the decisions we have to make in the world today, both on a personal and a political level, require clarity of understanding of issues that are best described in a quantified way,  and an ability to understand and question data intelligently.  

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Judea Pearl, The Book of Why (2018)

This is a book about the science of causality, which could be considered a branch of statistics.  This subject is important in order to understand information in such a way as to guide decision making rationally, and to overcome biases.  The first half of the book is most interesting, with a survey of the history of statistics, stories of particular important theorists whose ego unfortunately slowed down progress in the field (a common theme in history!), and with an introduction to thinking of problems through a lens of causality.  There is some discussion of the theory underling AI (artificial intelligence) which is going to be an extremely important area in all of our personal and cultural lives, from this point forward in history.   The second half of the book gets more technical, and in my opinion this material would be better presented in a textbook with worked examples, rather than in an ordinary text.  

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John Kelly, The Great Mortality: An Intimate History of the Black Death, the Most Devastating Plague of All Time (2006)

This is an exploration of a very important historical event, arguably the worst thing ever to have happened in human history.  The Black Death, starting in 1347, killed, quite suddenly, up to 50% of the population.  The scale of this pandemic was hellish beyond anything we can imagine.  It is obviously relevant in the context of our current pandemic.  Even though the Black Death occurred over 650 years ago, we still see the same extremities of human behaviour showing itself during our present pandemic, despite all the wisdom we've accumulated over the centuries.  This includes fanatical groups with bizarre theories of causation about the problem; racist extremists who blamed minority groups for the disease, leading to mass killings; and some heroic figures who tried to help, at tremendous risk to themselves.  

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Robert Cialdini, Influence: The Psychology of Persuasion (2006)

Cialdini is a psychologist who specialized in persuasion, initially by studying the tactics used by successful salesmen.  He identifies six major factors increasing the effectiveness of persuasive communication.  This subject matter is relevant for scientists, community leaders, and health care professionals, in order to convey health information in a way which is more likely to lead to positive change.  Obviously, this is incredibly relevant during the pandemic.  The other reason to be acquainted with this area is to be empowered to identify unwelcome persuasive techniques being used by marketers, politicians, or pundits, to avoid being conned or manipulated.   Unfortunately, I see that Cialdini's subsequent work has been of similar material directed mostly towards businesses and marketers, without further major contribution as a psychologist. But this initial book remains as a must-read.  

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Richard Dawkins: The Selfish Gene (1987)

Richard Dawkins: The Ancestor's Tale (2004) 

Richard Dawkins: The God Delusion  (2006)

Dawkins is one of the greatest science writers.  The subject of evolutionary biology should, in my opinion, be familiar to everyone.   This is not a dry subject--Dawkins' stories of animal life cycles are often fascinating and beautiful, akin to watching an Attenborough nature documentary.   And the scientific thinking is often spectacularly incisive.   In my opinion, Dawkins' often scathing critiques of religion are really critiques of fundamentalism in all its forms, and in my opinion are really just challenges to people of faith to be able to accommodate scientific understanding of the world into a belief system which is not rigid or unjust.  This is relevant for psychiatry and mental health, both because evolutionary factors obviously contribute to the existence of all human traits and problems,  but also because the subject matter itself, and the way in which it has been received by society in the past two centuries, has been impacted by psychological factors including ingroup biases.  

I specifically mention The Ancestor's Tale because at the time I read it, it struck me as my favourite Dawkins book.  

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Steven Pinker: Rationality: What it is, why it seems scarce, why it matters (2021)

This book is nice review of other material that would be familiar if you've read some of the other books suggested here, such as by Haidt, Kahneman, and others.  The genre is extremely important because our country and the whole world has been afflicted by waves of what Pinker calls "my-side-ism" or "motivated reasoning," driven by ingroup biases, tribalism, polarization, magnified by partisan news sources and misinformation.   Pinker is always carefully rational, a pleasure to read, with measured optimism and suggestions of ways we can improve the dire problems we are facing.   

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Astronomy Today 

Steven Hawking; A Brief History of Time (1998)

I include these books here, because I just think everyone should know something about astronomy and cosmology.  It's a foundation of understanding the universe and its history, it's wonderfully interesting, and as a psychiatrist I find that it helps us to cultivate a sense of awe and wonder about nature, the world, and reality, in a way which is deeply enlivened by the science, and which does not require superstitions or mystical thinking.   In my opinion, it is an example of how scientific understanding rather than pseudoscience deepens our experience of the world, of nature, and of our humble role as humans in the universe around us.   I think it's pretty important to know what the sun is made of, how far away it is, how old it is, what will happen to it in a few billion years, how far away the stars are, where they came from, etc.  For me it is an intersection of the existential with the scientific, something of great importance to psychological well-being.  

I would like to add similar titles relating to science subjects such as quantum mechanics, relativity, chemistry, paleogeology, and pure mathematics, as I think these are also sublimely interesting, in the same way that astronomy is, with similar existential impacts on mental health and well-being.  

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Video Documentaries

All of David Attenborough’s nature documentaries are, in my opinion, essential as part of enjoying nature and understanding the world.  Starting with Planet Earth, in 2006, the photography is spectacular.  A great way to learn, to be inspired, to enjoy nature, and hopefully to be motivated to do more to protect our world’s environment.  I consider an appreciation and personal experience with nature to be an important component of maintaining good mental health.  Another reason to watch Attenborough is because he is one of the great people, one of the great souls, of the past hundred years, in terms of character, integrity, values, and intellect. 

Neil deGrasse Tyson’s 2014 remake of Carl Sagan’s Cosmos series is another great documentary looking at the history of science, with a particular personal look at interesting people, many of whom you might never have heard of, who made great contributions to understanding and improving the world.  

The Mind, Explained is a good series of short documentary episodes (20 minutes each) looking at particular aspects of how the mind works (including subjects such as anxiety, focus, attention, etc.).  I’m impressed how much information they are able to pack into such brief episodes.  They might not always give a full picture of each issue, but are a great introduction.