"Permission to speak freely?” he said.
I grinned at him over my salad. In school, years ago, we'd asked that question as a warning that what we were about to say was inflammatory or insulting. Because we valued clear communication over the risk of hurt feelings, the answer was always the same. “Granted."
"You're caught in the emotional trap of a society too politically correct to validate one perception of reality over another. If there is zero neurological evidence of a pain stimulus, then what the patient is experiencing is not pain. There may be a strong belief in pain, just as a patient may believe he is Napoleon or that the year is 1890. But treatment for such a belief will be different than the treatment for pain."
I considered what he said. We often encountered men whose sense of toughness caused them to downplay their pain, while others exaggerated tiny hurts. On a completely subjective standard, depending on the patient, you might end up giving morphine for a hangnail and aspirin for first-degree burns. But could there be a totally objective treatment?
"What about beta-endorphins?” I asked. “Surely you have different endorphin levels in your brain than the patient does. Wouldn't that change your perception of pain?"
Whittaker smiled. “Certainly. But beta-endorphins come into play in the hypothalamus—our shunt intercepts the signal above that point, so the endorphin effect has already been realized."
I decided to change the subject. “Can you guess what tomorrow's test will be?"
Whittaker chewed his sandwich thoughtfully. Crumbs stuck in his beard. “I imagine you'll have a battery of sympathologists, including me and some other doctors with no experience on the machine at all. A group of patients will rate their pain on the standard ten-point scale and the doctors will do the same. You've already shown that the type of pain is felt equally by the patient and the sympathologist; tomorrow you hope to test if the degree of pain is equally felt."
I was crestfallen. “So much for my surprise."
"It's the obvious approach,” he said, and then a mischievous smile quirked his lips. “Want me to tell you the results, too?"
I folded my arms. “The great doctor has turned to witchcraft?"
"Simple deduction, my dear Watson. Though in this case it should be induction.” He waved his arms over his coffee and consulted its depths. “I predict,” he said grandly, “that I will, on average, rate pain a point or two lower than the patients, and inexperienced docs will, on average, rate it several points higher."
"How do you know?"
He leaned back in his chair, steepled his fingers, and arched one eyebrow. “Witchcraft,” he said.
Of course he was right. The test was performed, the results tallied and sliced from every angle. The summary graphs showed exactly the pattern Whittaker predicted.
"I'm not prophetic,” he said. “It just stands to reason. To me, most patients’ pain is unremarkable, because I've experienced the worst that's out there. To the patients themselves, with only their own experience to draw from, it's decidedly worse. But for the inexperienced, the pain of a suffering patient is often worse than any they've known."
I flipped through the graphs on my computer. “Doesn't this shake your belief in pain as a measurable quantity?"
"It's the same pain. It's the scale that varies from person to person."
I barely heard him. My attention was captured by the last graph in the collection. “This can't be right."
"What can't?"
The graph plotted the probability distribution of the results, a roughly bell-shaped curve. I pointed to it.
"What do you mean? Test results like this are almost always Gaussian,” Whittaker said.
"Gaussian, sure. But look how far out these outliers are.” I clicked on a data point and the computer displayed the underlying result. “This woman reported her pain as a nine. The other doctors judged it to be between eight and ten. But you reported a three."
Whittaker shrugged. “As I said, I've felt a lot more pain than..."
"Wait,” I said. I brought the original graph back up and clicked on a data point at the other end of the curve. “Here the patient reported a two. The other doctors ranged between one and four. But you judged it a seven. There are other discrepancies as well, with other doctors."
"There's a problem with your data then,” he said. “It's not matched up properly."
"The bell shape belies that conclusion—most of the time, you're tracking just below the trend. It's just on these few."
"Then those few are the ones that are wrong. Check your data."
I shook my head. “Not possible. We cycled the patients through twice to filter out miskeying or gaps in attention. You gave it a seven both times."
"So what are you saying?"
"I'm saying we have to rule out the possibility that the machine doesn't consistently transmit pain stimuli."
"Peter, I've been using this machine for three years now. You can trust me, it consistently transmits pain. Either the data was mixed up, or the patients are lying, or..."
"Permission to speak freely,” I said.
He glared at me. “Granted."
"You're too prejudiced on this subject to judge fairly. Trust me to conduct the test scientifically and keep your personal experience out of it."
For a second, I thought he was going to hit me. Then he laughed. “Good old Peter,” he said. But his knuckles were white.
* * * *
I spread out hardcopies of the graphs on Connie's desk. “You see the problem."
"The outliers?” she asked, her tone plainly incredulous. I'd caught her coming back from a run before she'd had a chance to shower, but she'd wanted to hear my results right away. She wore a blue tracksuit and had tied her hair back in a severe ponytail. Her cheeks and neck were flushed.
"The outliers are significant,” I said.
She shuffled the papers. “Let's start with the averages. If I'm reading this right, the average pain reported by the patients was 5.7."
"True. But..."
"And the average pain reported by the sympathologists was 5.5. This is cause for celebration! Go get yourself a beer. Write it up tomorrow."
This was not going well. I tried to keep my voice civil, to explain rather than get annoyed. “The question is whether the difference in those means is important—whether the machine, or which person is feeling the pain, has a statistically significant effect on the results."
"It's a bell curve,” she said, scratching at her neck. “A bell curve has outliers. It always does. I'm not interested in six sigma cases here, Peter. I'm interested in the trend."
"We did a paired t-test on the data,” I told her. I explained how a t-test could determine if the means of two normally distributed populations were distinct.
"You're telling me a .2 difference is significant?"
I nodded. “It's not just the mean that matters. It's the deviation."
Connie was quiet a long time. “All right, Peter,” she said finally. “I believe you. So what should we do?"
"We need another test."
"To accomplish what?"
"We'll repeat the same basic procedure, with a new battery of patients, but including the outlier patients from last time. If the same discrepancies reappear with the same patients, we'll know we have a problem we can't ignore."
"We can't afford another test."
"We need to. Or else I'll have to include those outliers in my paper and let them speak for themselves."
A lock of hair strayed from Connie's ponytail and stuck to her forehead. She brushed it back. “It's a diagnostic tool. What does it matter if the doctor feels the full severity of the pain?"
"It does matter,” I said. “People believe what doctors tell them. If a family hears that their crying child's pain is slight, they may not seek a solution to a real problem. We can't control how the technology will be used. What if hospitals start dispensing morphine based not on patient request, but on sympathologist recommendation?"
I saw the martyr's look creep back into her face. “I'll say it again,” she said. “We can't afford another test. We just don't have the money. Now maybe, in another few months, if Synthiac gives us the grant we hope..."
"We'll have other projects and other priorities. It'll never get done."
Connie took a deep breath, then let it out slowly. When she spoke, her voice was soft. “A few years ago, when my daughter was only a baby, she had a molar coming in sideways, pinching a nerve. Caused her terrible pain, but she couldn't tell us where it hurt. They missed it on the x-rays, and of course blood work showed nothing. It was a week before we figured it out. A sympathologist could have told us in minutes.
"This is primarily a diagnostic tool. As such, it's passed every test brilliantly. We have no money for another test. So what's it going to be? Are you going to hold up production of an obviously valuable diagnostic tool that, to some patients, could mean the world? Or can you report what we know and leave the philosophical question for another day?"
I sat gazing at my feet. “I don't know."
"Figure it out. If you can't write this paper, I'll have to find someone who can.” She swiped her palms together as if washing them and stood up. “Now if you don't mind, I'd like to take a shower."
* * * *
"She threatened to fire me,” I said. We were back at the White Dog. I had suggested a cheaper venue, but Whittaker offered to spring for the check, and that was enough for me.
He took a huge bite of his leg of lamb and wiped grease from his mustache with a napkin. “There are other universities."
"My grandfather went to Penn. My father spent his whole career as a researcher at Penn. I practically grew up here. This isn't just a job for me; it's my home.” I stared at my Kung Pao tofu, cheeks resting in both hands. “Why does everything have to be about money?"
"You mean, why can't you pursue science at society's cost but with no limits or accountability?"
I threw a toasted peanut at him. It missed and bounced onto the floor. “It stops sounding noble when you put it that way."
"It is noble. Just not realistic."
"Why not? Sympathology is going to change the practice of medicine in significant ways. Why can't the world pay to make sure it changes in the right ways?"
Whittaker shook his head. “I'm with you completely—except in this circumstance. Sympathology works, Peter. I've been doing it for five years."
"Data doesn't lie. You used to believe that."
"Of course it does. Data lies all the time. It just depends on how you slice it. The trick is to look beyond the data to the truth it represents. Yes, it would be nice to prove out the truth with test after test, but cost forces us to efficiency."
"To expediency, you mean."
He put down his fork. “Listen, Peter. Sympathology hinges on trust. If people don't believe it works, they won't accept their diagnoses."
"My paper will show that it works,” I said. “As far as diagnosis is concerned, the tests were perfect. But don't you think I should include my reservations regarding the degree of pain felt?"
"No. You know how it goes. A scientist writes a paper saying Procedure X is 99.9 percent reliable, except for a few complications in one case. Then the media gets a hold of it.” He waved a hand in the air as if throwing words up on a screen. “'Breaking news! Scientists say Procedure X may harm your children! Full story at 11:00!’ Ten people read the original paper; ten thousand hear it on the news. That's the data, but it sounds like a lie to me."
"I know it,” I said. “But what else can I do?"
"You can tell the truth. Tell them that sympathology works."
* * * *
I didn't go home that night. It was September, the evening cloudless and cool, so I wandered down the university streets until I ended up on the South Street Bridge. Halfway across—arguably the best place in the city to see the Philly skyline at night—I stopped and leaned on the rail, trying to clear my thoughts. A few runners passed me, but otherwise the bridge was deserted. I heard the city sounds that usually go unnoticed: the buzz of traffic on I-76, the clang of a Dumpster lid, the moan of a distant siren.
The bridge was an ancient edifice, over one hundred years old, and I kicked crumbling bits of concrete off the edge, watching them tumble into the dark river below. What to do? I had been arguing against Connie and Whittaker's points, but the truth was, I believed in sympathology, too. The machine worked; the procedure worked. It would be a great help to the medical field, particularly for those too young or ill to communicate. And Whittaker was right about the delay a mixed recommendation would cause. I'd known people in the past who were too concerned with ethics—so afraid of being blamed for doing the wrong thing that they did nothing at all. Was that how I was acting now?
Despite the hour, I walked back to the lab to write up my report, still not knowing what it was going to say. The test berth was empty, my office dark. I worked with only the light of my computer screen, typing, deleting, revising, then deleting again. In the end, I wrote two papers. The first contained everything: the outliers, the paired t-test, all of my concerns for how sympathology would be used. The second contained the simple truth of the reliability of the procedure that the testing had, on the whole, revealed.
At four thirty in the morning, I printed out both versions, stapled them, and laid them side by side on my desk. There was no point in going home. I propped my feet up, leaned back in my chair, and tried to sleep. I was exhausted, but my mind was like a dog with a bit of rag—it had something to chew on and it wouldn't let go. The same old arguments spun round and round in my head, made less coherent by weariness. If I submitted paper one, I would possibly lose my job, but more likely just be barred from doing any research that mattered until I quit out of boredom. If I submitted paper two, it was possible that nothing bad would happen at all. But it was also possible that the medical profession would replace true sympathy with sympathology. If the machine could give a skewed result, it was my duty to report it.
And yet. Many scientists greater than me had bent their principles to keep their jobs. Some said it was more a question of “when” than of “if.” There were peer reviews and boards of ethics to watchdog the profession—was it really my job?
When the staff began to arrive for the day, I still had not slept, nor had I decided. I chugged a cup of coffee for concentration, tucked both papers under my arm, and went to see Connie.
Her hair was neatly pinned up, and she wore a white blouse with a blue pinstriped skirt and jacket. She greeted me with a cheery smile, as if she had slept soundly with nothing on her mind.
"Peter,” she said warmly. Then she saw the papers under my arm. “Done already? My goodness, didn't you sleep?"
After the agony I'd been putting myself through, her manner shocked me. I suddenly saw my dilemma from her point of view, and I almost laughed. It was ridiculous, all this drama about a few isolated data points. Even Whittaker, whom I respected above anyone else I knew, had tried to tell me. What a fool I'd been.
Imitating her nonchalance, I said, “You know me. Can't stay away from the lab.” I felt a huge sense of relief—I'd come so close to throwing away my career. I selected paper two from under my arm and tossed it on her desk.
She picked it up. “It's all here?"
"Everything you wanted."
"Glad to hear it.” She examined my face, noticed my rumpled clothes from the day before. “Why don't you go home and get some sleep?"
"I think I will."
I walked to the door, a lightness in my step. The ordeal was over.
"Peter?"
I turned.
"I talked to Synthiac again. If we give sympathology our full backing, they've all but guaranteed us a multiyear grant.” She waved the paper I'd just given her. “If this says what I think it does, it'll be in the bag. Not only that, but they're considering us for their Researcher of the Year award. That would be you—not just you, of course, but as the team lead, you'd be
front and center. It's a monetary award, too, and though it's no Nobel Prize, I hear it's a significant amount.” She smiled. “Just a little cherry for your sundae. Congratulations."
I stared at her, trying to process her words. My brain must have stalled for longer than I realized, because she chuckled faintly and waved her hand in front of my eyes. When I strode forward suddenly, she jerked back, startled. I took the paper out of her hands.
"Peter? Is something wrong?"
"Nothing at all,” I said, swapping the paper with the one under my arm. “I just gave you the wrong report."
* * * *
"I don't want to talk about it,” I said.
Whittaker ripped off a meaty chunk of Philly cheesesteak, heedless of the Velveeta dripping on the table. “Do you regret what you did?"
"Not really. But I know what you think, and I don't want to argue about it."
Whittaker chewed, then swallowed with an audible gulp. After a sip of iced tea, he said, “Permission to speak freely."
"No. Permission denied. That's what I'm saying. It's already done, and I don't want to hear what you think."
"Yes, you do. I was an idiot."
"What?"
"More specifically, I was ‘too prejudiced to judge fairly.’ Just as you said."
"Then—you don't think I made the wrong choice?"
Whittaker shook his head. “I do think you made the wrong choice. I think you unnecessarily delayed the full acceptance of sympathology into medical practice. But I'm embarrassed that I tried to get you to go against your conscience. I was too emotionally attached to the results and you called me on it. You stuck to your principles and preserved your respectability. You should be proud."
I sighed. “And for that, I'll lose my job.” I remembered how cheerful I'd felt when I'd chosen the other course. “If I did the right thing, why do I feel so miserable?"
A corner of Whittaker's mouth twitched. As I watched, his lips curled and twitched again until he broke into a wide, involuntary grin.
"What is it?"
"I have news."
"What kind of news?"
He leaned forward and lowered his voice. “I've been invited to join the Glenn Research Center in Cleveland. NASA thinks sympathology is the answer to their remote medical monitoring problems."
Analog SFF, November 2007 Page 19
