Heal Spiel

How to Get Into Medical School

2009-10-04T00:31:00.000-07:00

Once in a while, I interview pre-med applicants to my school. While the medical students' evaluations are probably influential as only a low-NPV serial-killer screening test, I still very much enjoy doing them. This is because, if the applicants are eventually admitted, I get profuse thank-yous and friendly hellos for the entire subsequent year. Other than this experience, I have no knowledge whatever on the inner workings of the admissions chambers, so my insights are based on some post-call Gladwellian blinks.

Please note that Numbers 1 and 4 should not actually be followed by anyone, and are akin to obtaining a Golden Ticket by serially eating thousands of candy bars, or harassing hundreds of factory employees to unwrap them. It's just not worth it.

1) Take Physics for Poets.
And Literature for Actuaries. PE for Hobbits. Enroll in the easiest courses that fulfill pre-med requirements, and for which you almost certainly can earn an A- or above. The caveat here would be that you'd have to choose a somewhat traditional-sounding major, so it cannot be Fashion Merchandising, Liberal Studies, or Communications. Slightly newer, but still well-respected (and sometimes difficult, depending on your school- be careful!) majors, such as Women's Studies, as well as many interdisciplinary majors (i.e. Latin-American Studies) are considered fine.

My reasoning here is that, when it comes to course-work, admissions committees care mostly (though not exclusively) about Overall and Science GPAs, as well as a notable absence of Cs. A B- in "Physics for Future Nobel Laureates" is worth less than an A- in your standard Calc-based Mechanics course. Don't take any high-stakes gambles.

(For those now tuning in: Do NOT actually follow this advice. Take 4 years of Russian, a Combinatorics class, and a seminar on James Joyce. Keep your life joyous and a bit irrationally exuberant.)

2) Do your Undergrad at State School.
State school makes sense in general, and especially so if you are pre-med. It's generally easier to get an A in the science classes there. I know this statement may draw some contrarian personal testimonies from people who attended The University of Somewhere. The thing is, I know that many of the kids there are just as smart as the ones in Someone University, and that the teacher quality is likely the exact same. But the same student can often be in the top 10% of his Orgo class in a public school (also improving his chances for getting an excellent recommendation), rather than in the middling middle of an equivalent Ivy course.

3)Sign up for at least one test prep program, but not for any live classes.
Study by simply doing as many sample test questions as possible, starting on day one. Then go over the explanations and the reading material for anything you get wrong. You may get many or most questions wrong in the beginning. Still, do not waste time reading through the review books before you start taking practice tests. Take your MCATs in April, not August. Try to get at least a 30, unless you funded your school's infectious diseases institute (Treating Burmese children suffering from infectious diseases is not an acceptable substitute).

4) If Short on Time, Don't Dedicate a Huge Amount of Time to Clinical Experiences
While you should have some shadowing or hospital volunteering experiences, you do not actually need much of it. An EMT who has transported five patients looks roughly the same on an application as an EMT who has worked since age 16, has delivered a hundred babies, and can already interpret EKGs. The AMCAS does ask you how many hours per week you spend on each activity, but 5 hours vs. 10 hours per week probably doesn't get noticed. If stressed and cynical, think of marginal benefits.

(Repeated disclaimer: This advice is about what gets you into medical school, not about what you should do. To become a good doctor, take advantage of every opportunity you can to gain clinical experience. Some people cut corners without any one else ever noticing, but don't allow your values and ambitions to conform to this strategy).

5)Be Specific in your Essays.
When answering questions for your secondary applications, do not write "I am passionate about..." Have a strong, unique opening, even for those one paragraph answers. When addressing why you want to attend a particular school, refer to specific professors or programs. Don't use generic phrases like "Exceptional academics," "Excellent location," or "Outstanding research." Instead, say that you've always admired the [Insert Name] Free Clinic that Dr. [Insert Name] started, and you would like to volunteer there because he sees a lot of patients with [Insert medical condition], which is a disease you may want to specialize in.

(Don't lie. No one will ever know whether or not you are truly interested in that clinic, but to maintain your dignity, try to identify specific features of a school that you do actually care about.)

I know my take on medical school admissions is a bit cynical. However, even the most caring and mission-minded committee members must focus one eye on the US News rankings. The subsequent diplopia means that the theoretically best choices for pre-meds are not necessarily those that insure a successful application. If you find yourself sacrificing too many opportunities, I'd recommend dropping pre-med, enrolling in PA school, keeping your specialty of choice, and becoming a happy, dedicated, and productive clinician.

Psych Consult

2009-09-30T21:44:00.001-07:00

Mr. A is a 40-year old male. After checking in his items with the clerk, and obtaining a full evaluation from the ER doc, the psychiatrist and students begin the interview.

Mr. A: You have to check me into the psychiatric unit. Otherwise, I'm going to hurt somebody! And I'm going to kill myself!

Student: Mr. A., Which do you plan to do first, hurt someone else or kill yourself? [Yes, I know it's a weird question, but we use it to assess the viability of the plan. Some patients take the bait].

Mr. A: Hurt someone else first!

Student: Who do want to hurt?

Mr. A: Anyone who pisses me off! I was already going to hurt at least 5 people today, before I checked in.

Student: How do you plan to harm someone else?

Mr. A.: I'm gonna stab them with a fork!

[After full assessment]

Physician: Mr. A, we're going to admit you into the psychiatric unit of the hospital... students can you please bring over Mr. A's belongings?

Student: Clerk, can you tell us which one's Mr. A's locker?

Clerk: Yeah, it's over here. But he only brought one item with him. I think it was a fork.

The Epistemology of Paranoid Schizophrenia

2009-08-30T20:40:00.000-07:00

Note: All details, including names, ages, and specific descriptions of conversations with staff or patients have been considerably changed. Sorry, I know that reality blogging is more fun than fake medical encounters. Additionally, the discussion exclusively concerns people with relatively mild or well-controlled schizophrenic symptoms, with whom I can easily engage in conversation.

When the psychiatry resident asked for an update on Tracy, I glibly responded, "Still very delusional. Thinks the CIA is after her."

"She's not delusional!" the doctor corrected. "The CIA or the FBI or whatever agency really is after her. Tracy used to threaten killing former President Bush numerous times. During her last hospitalization, I had to argue with the authorities for hours, to convince them that she's safe for discharge." Thus, my near-designation on my patient's record as possessing this delusion, or a "fixed, false belief," that is not "widely held within the context of the individual's cultural or religious group" was in error. Tracy's paranoia was based on truth.

The interesting part, however, of working with schizophrenic patients is generally not figuring out what is false; Patients have spoken of receiving commands from their televisions to overthrow the "vitamin pill industry," and of obtaining classified information that their true parents are Liza Minnelli and Bobby Fisher. Many patients insist that a doctor or nurse can gain remote access to the contents of their brains, via some transhumanistic, genetic link-protocol of sorts. False belief, check.

Determining what falls under cultural norms can be a bit trickier. One patient, David, believes that he and fellow schizophrenics have powers in the "sixth dimension," on an "etherical, astral, plane," a belief that I'd brand as delusional, if I 1) Knew what it meant, curvilinear coordinates not being my forte and 2) The International Headquarters of the Theosophy Society weren't right in my hometown, flagging this as a possible local cultural or religious belief.

The main challenge in assessing delusions, however, lies mainly in determining which are considered "fixed," or intransigent to reason and the passage of time. A binary "yes" or "no" to describe the "fixedness" of a belief is inadequate. Many patients come to the hospital voluntarily, desperate to rid themselves of fearsome beliefs or voices that they know, at least in part, aren't true. Thus, they demand anti-psychotics that deny the pleasure of dopamine, and beg for mood-stabilizing drugs that inhibit norepinephrine-fueled arousal. And those are just some of the intended effects. Side effects include dystonia, neuroepileptic malignant syndrome, the frog-tongued gestures of tardive dyskinesia, and the rabbit-mouthed oscillations of EPS. Patients are often desperate to "unlearn" their beliefs, and hope to foster distrust of the voices in their head, which so distrust everyone around them.

Tom, one of my fellow medical students, asks patients an interesting question: "What do you think is the percent probability that your belief is true, and what is the percent probability that it isn't true?" Lillian, who's convinced that President Obama promised her $1 million, so long as she refrains from eating, (the Cult of the Presidency is the only thing both alive and well in the psych ward) said "About 5% of me thinks it's true, and 95% of me thinks it's not true." Five percent is not terribly much. I'm sure there are plenty of beliefs I maintain with a similar level of certainty that would confer me with at least an Axis II diagnosis, if someone could scan my brain for the latest Bayesian updates. Which leads me to wonder if percentages and predictions can adequately capture the credos that serve as the foundation for diagnosing paranoid schizophrenia.

For those of us with homo economicus pretensions, such stated probabilities may even persuade us that schizophrenic biases are simply standard deviants from very irrational mean population thought content. Indeed, critics of psychiatry often insist that people are deemed psychotic, simply because their delusions don't conform to what all the cool kids are fabricating this season. In this view, once norms change (like they did when the medical professions stopped labeling homosexuality as a disease), many schizophrenics will be considered as peers among the unhinged masses, with all our opioidic (agonistic and antagonistic both), nonsensical beliefs unleashed.

Perhaps we can focus on a more qualitative approach to evaluating "fixedness." After all, numbers don't seem to work with a patient named Mark, who contemplates (at least after he's taken his meds) of the instructions he "receives" from the devil via rap songs on the radio, "they're sometimes real...I don't know... it's so hard to separate in my head." Perhaps, we can ask an Isaac Levi-inspired series of questions, checking off what David considers "serious possibilities," out of a "potential corpora of knowledge and evidence." I can ask David, "Do you think that it's physically possible for you to hear the devil speaking to you, and only you, from the radio? Logically possible? Technologically possible? Psychologically possible?

Defenders of psychiatric designations counter their critics by noting that virtually every DSM-IV diagnosis, including schizophrenia, must involve significant impairment in occupational or social functioning. Apparently, in 2003, 20% of Americans affirmed to pollsters that an HIV vaccine already exists, but is being kept a secret. And yet, I don't see many people staging the proper revolt that such a conspiracy, if actually true, would merit. Aberrant thought content alone is not the rate-limiting-step to being diagnosed as schizophrenic. Many people have negative thoughts about the vitamin pill industry, but only Sally (who has Schizoaffective Disorder, Bipolar Type) embraced her mission by roaming in the streets, "recruiting" fellow revolutionaries (i.e. passing cars), and propelling Los Angelenos into traffic-induced hysterics.

So for paranoid schizophrenics who maintain only 5% certainty about their delusions, perhaps they simply act upon this glimmer of confidence more often than others, like the "Deal or No Deal" folks who, knowing basic math, still reject the banker's actuarially outlandish offer, because, what if the million is in my box? According to polls, many Americans claim that our current president is a foreigner, and is thus ineligible for his elected position, according to our country's most sacred national document. Then we go off to do our laundry and water our lawns. However, there are always those few that can't eat, sleep, or tweet, while harboring such persistent ideations of conspiracy.

A behaviorist might say that, Bayesian self-reports not-withstanding, patients' actions exclusively measure their convictions. Skinnerians will believe our stated fidelity to untruth when they see it! All the rest perhaps just falls under the purview of "symbolic belief." In other words, you may take pride in widely professing that Obama is an alien, but watch your shame when a behaviorist calls you out on your pretense! My humble suggestion: To stay out of the psych ward, you're better off holding certain beliefs as insincerely as possible.

Palliative Care Grand Rounds is Up!

2009-05-06T16:07:00.000-07:00

Thaddeus Pope at the Medical Futility blog does a beautiful job hosting the latest Palliative Care Grand Rounds. For my contribution, I describe an experience working with the family of a 28-year-old patient who died of breast cancer.

Med-staffing Coachella

2009-04-21T15:22:00.001-07:00

Coachella is like a giant exhibition of Roomba vacuum cleaners, where restless young beings motor along toward one end of the giant field, bump into someone or something at the other end, and then head in a different direction, continuously for three days straight. Occasionally, one might stop to check out a band, buy a tofu naan sandwich, or take a puff of something. But mostly you just kind of amble around, smiling with kinship at each person whom you passed by a couple of hours earlier.

This seemingly underwhelming activity is actually quite joyful, and I do plan to one day attend as an actual ticket-holder. This year, I served as a med-student-helper-outer-to-the-EMTs, (but not officially as an EMT, as my license expired a few years back). The Company (not HIPAA) forbids us from speaking even generally about the cases we saw, but I'd say that the biggest progress made involved my riding of an awesome John Deere Gator everywhere. Thus, the lingering childhood resentment over my lack of Power Wheels (Miskeena!) is now officially resolved, sans therapy.

Grand Rounds is Up Again!

2009-04-16T20:38:00.000-07:00

Brought to you by Dr. Guzmán at Pharmamotion. My submission addresses the pressing issue of med student apparel.
Guzmán has a very Canadian post about Gp IIa/IIIb inhibitors (a class of anti-platelet function drugs) over here. I mention this because tonight is the magical night where the fairy godmother comes and I transform into a Canadian at the stroke of midnight. So I'm channeling all my Kafkaesque energies into becoming the pharm video narrator with the pleasant voice, rather than this guy.

Weird Medical Etymology of the Day

2009-04-12T15:47:00.000-07:00

Fornication comes from the word fornix, which means "arch." In Roman times, customers used to identify the brothels by a prominent archway at the entrance. (Coincidentally, we refer to the anterior, posterior, and lateral fornices as components of the uterus, but we also have a fornix in the brain, so interpret that as you will).

HT: My Gross Anatomy Prof

Disclaimer: I take no responsibility for the possibility that this is all urban legend.

Doctors and Speeding

2009-04-10T20:52:00.000-07:00

“The officer proceeded to pull out his gun, point it at my face, and told me to lay face down on the ground, which I did. At this point, my ID card dropped on the floor and I remember him stepping on me, probably putting his knee on my back, and then cuffed me.”

This is how a Dr. Ziworitin of UMC describes his encounter with a cop, after the physician was stopped for speeding, while rushing to hospital for an emergency.
Radley Balko writes, "Even if the cop doubted this guy was a doctor, the cuffs, gunpoint, and a boot in the back all seem more than a little excessive, no?"

The shear theater and spectacle of the violent assertion of power certainly makes ones bristle. However, the outrage over this incident, as well as the outcome of the DPD PR disaster, both make me a bit uncomfortable. Certainly, cops ought to exhibit some common sense. However, people should know that one's emergency does not confer an implicit right to put other people's lives in danger. If we express only populist outrage, (which is distinct from genuine sympathy for the driver's misfortune), we may forget to communicate that it is perfectly reasonable for a cop to stop a car, and tell the driver to slow down (pulling out the gun is...unnecessary).

I don't know how things work here in the U.S., but when I worked as an EMT for the Red Star of David in Israel, we were explicitly forbidden from going beyond a particular speed, even if the patient was in cardiac arrest. So if people facing tragedy deserve to not be harassed and threatened by the cops, the police, in turn, deserve increased public awareness that sensible traffic rules aren't conditional to one's personal, or even tragic, circumstances.

Medical Research Fraud

2009-04-10T19:56:00.000-07:00

Because of "Scrotumgate,", my favorite medical resource, The Thackery T Lambshead Pocket Guide to Eccentric & Discredited Diseases, requires an update.
HT: My Pharm Prof

Grand Rounds is Up!

2009-04-07T22:53:00.000-07:00

Leslie at "Getting Closer to Myself" did a fantastic job of organizing all the posts submitted by a motley crew of medical bloggers. The theme is "Reflections on the way life used to be."
And I got a star next to my name! If I still got stars for doing good work, I'd be on dean's list.

In other world wide web-related news, I have a post up about medical licensure at the "Students for Liberty" blog. It features a sweet parking spot (these things matter to L.A. girls).

The Banality of Marijuana in Medical Education

2009-03-30T19:36:00.000-07:00

In one of our GI lectures, among the interminable pharmacology powerpoint slides that address anti-emetic drugs, the following information appeared:
If an alien guest to our planet perused a pocket pharmacopeia, and had to guess which drug would be "fetishized" over all others, I doubt he'd pick marijuana. Mind you, I'm not convinced that there are many positive benefits for healthy people to take marijuana (and smoking a combustion product is more carcinogenic than using a vaporizer). Yet cannaboids strike me as just another class of drugs with certain indications and side effects, some known, some perhaps unknown. Another anti-vomiting drug, metoclopramide, can lead to tardive dyskinesia (Parkinsonism). Scopalamine, yet another, features a whole slew of anti-cholinergic (antagonistic to the parasympathetic nervous system) effects, and can cause delirium in overdose.

However, when patients with cancer obtain the latter two drugs, we praise modern medicine's ability to provide some alleviation to the horrible side effects of chemotherapy. When patients happen to select the former, we convict their state-law-compliant medical dispensers of crimes punishable by up to 100 years in prison.

Taleb and Pre-test Probabilities

2009-03-23T06:56:00.000-07:00

Arnold Kling comments about Russ Roberts' conversation with economist Nassim Taleb:

I was most interested in the latter third of the conversation, where Taleb talks about his radical empiricism. For example, he argues that medicine makes more progress with trial-and-error than with knowledge of biological processes.

Trial and error would require taking a drug already known to be ineffective, adding a methyl group, testing the new molecule on a statistically significant number of patients, and then methylating again, until we've tested infinite permutations of "little-value-added" functional groups. We'd be bored sick.

One of the reasons why many empiricists object to all the funding that goes into certain alternative medicine projects, such as magnet therapy or reiki, is that, based on our understanding of physiological or biochemical principles, the pre-test probability of such treatments being effective is pretty low. An extreme Popperian would object, insisting that we can't truly know if anything works, before testing it, (and once experiment concludes, we still couldn't be sure). Such agents of uncertainty would be technically correct.

However, science does not mean claiming omniscience nor capitulating to any smidgen of doubt. Science involves taking the information that lies before us, determining what phenomenon is most likely, and using these findings to develop a testable hypothesis. We are occasionally lucky enough to discover a drug whose mechanism of action we do not fully understand (such as in the case of Topirimate for epilepsy, or the prevalent use of beta-blockers of hypertension, long before we knew how it worked). Yet relying on lucky breaks, or "trial and error," rather than "hot on the trail" paths gleaned from discoveries in biology, is like searching for a bank robber by starting with the As in the phone book. Or like seeking out a black swan, by beginning the expedition at a local Los Angeles lake.

Med Students Lobby Congress for Tuition Breaks

2009-03-19T02:56:00.000-07:00

People, I know that we aspiring physicians are all in major debt, but some Americans can't afford the rent for their trailer homes. Let's leave the welfare-for-the-well-to-do-groveling to the AIG execs.

Ross Douthat is Trying to Murder Michael Kinsley! (Or Some other Distortion of Douthat's Views)

2009-03-19T01:48:00.000-07:00

Brad Delong links to "The Daily Beast" and writes:

Michael Kinsley confronts the fact that Ross Douthat doesn't care more than a smidgeon about whether Kinsley lives or dies from Parkinson's disease.

If Kinsley were facing imminent death, and the only guaranteed antidote was a destroyed embryonic stem cell, I'm sure Douthat would fly over in a crimson-colored-cape and perform the destruction necessary to save the day. The fact that Douthat opposes federal funding for promising basic science research, that may one day be used treat PD, is far removed from the notion that Douthat doesn't care whether Kinsley lives or dies. If all of us were certain that could automatically save a life by sponsoring a certain magnitude of stem cell research, most of us would wire donations overnight. We don't do this, and thus admit that Kinsley's life is not immediately and urgently dependent on it. Reducing the situation to two variables (Kinsley's life versus stem cell funding), as well as admitting no degree of uncertainty about the potential effects of both the research and its related public policies, is innacurately simplistic.

Ok, I stood up for the social conservative.

Now, let's get the pluripotent blastocyst-derived inner cell mass differentiation party started!

Update: Before writing this post, I had written the first paragraph, as a comment in Brad Delong's blog (it did not include the more bellicose title of this post). It was taken down, after a few hours. Brad Delong has the right to do whatever he wants on his blog. However, I am disappointed by an academic who is unwilling to tolerate reasonably polite critique.

Who Lives?

2009-03-18T11:13:00.000-07:00

Mr. Smith is a 58-year-old African-American male, who appears at least a decade older than his stated age. He is about 6’0, slim, and features a neatly-trimmed mustache. He sits stooped forward, and relies on a cane to get around. Mr. Smith has a pleasant affect, and even offers to get me a cup of water. His legs show moderate edema, and his eyes feature notable scleral icterus. Mr. Smith is on the list.
Mr. Smith inquires to whether I’m “also on dialysis,” and if I voted for Obama. I told him that I’m attending as a medical student, and that I don’t share my political views in public. Mr. Smith believes that Obama will bring us “back to nature” and will stop “sending jobs overseas.” I smile and tell Mr. Smith that I hope the president helps solve the economic crisis. This is no occasion for pessimism.

Mr. Smith expounds on his dating woes. His last girlfriend was “too needy,” and wanted something more permanent than Mr. Smith was able to provide. Mr. Smith implies that his misgivings were more due to his lack of emotional readiness, rather than the fact that his remaining days are contingent on a fluctuating number on a table, and that, like many of the 101,236 current Americans waiting for an organ, he may die before receiving a much-needed kidney transplant.

I met Mr. Smith, because I happened to sit next to him this past Sunday in a downtown Los Angeles theater, to view “Who Lives?,” a play Sponsored by the Renal Support Network. The production takes place in early 1960s Seattle, and explores the moral anguish afflicting a committee dedicated to choosing the lucky few who will test a curious, but experimentally promising machine, which “removes your blood, cleans it out, and then returns it to your body.”

The panel consists of a devout priest (“God has chosen us for this very important purpose”), an overwhelmed homemaker (“Father, there isn’t anything spiritual about this!”), a blue-collar craftsman (“The workers are always getting a raw deal, so what’s so wrong…”), a pedantic, neophyte doctor (“Disease is just the gross exaggeration of aging”), a pushy Jewish lawyer (“F-ck doctors”), a beautiful, liberated grad student, and some un-endearing blonde guy, who instinctually rejects Black applicants, and focuses the rest of his attention on seducing the grad-student. The group’s task involves ranking people, not merely based on medical criteria, but also each applicant’s presumed “value” to society. Thus, the committee debates the relative "significance" of musicians versus businessmen. The wealthy versus the poor versus the “rags to riches” success stories. Women versus men. Women with children versus men. Fertile women versus infertile women versus men. Blacks versus whites.

Today, such technocratic management of life and death strikes one as pretty abhorrent. Unfortunately, however, I find no solace in our contemporary method of organ allocation. Indeed, while we, as a society, have come to recognize the human infallibility inherent in prioritizing human lives, we now do something far worse, by creating an artificial shortage of life-saving organs, and banning individuals, charities, and the government from paying people for their kidneys.

We invoke all kinds of moral arguments to dissect messy commerce and greed from the prim and genteel art of uprooting a meat-sized slab of tissue, hitching it to various tubes and plumbing out a urine stream. To defend the volunteer-only status of organ donation, liberals and conservatives alike manufacture arguments that they would never entertain, when concerning other topics: “The poor will be the first to give up their organs, and this is harmful!!” (Cs: Should we prevent the needy from obtaining payday loans or eating at McDonald’s? Ls: Ought we to restrict women from obtaining abortion or birth control, even if it posed her some risk?) “It will be racist!” (Check out the demographic makeup of the waiting list.) “It will cheapen the ideal of giving from the goodness of one’s heart! “ (Ls: Do you ascribe the same logic to food stamps? More ceremoniously- “Would you like to sign up today and volunteer to save a life?! Low risk and high 'goodness of heart' satisfaction! No? I, shamefully, haven't signed up either...”) “Legalization will increase violence and coercion!” (Organ prohibition, meet drug prohibition), “Only rich people will be able afford them!” (Rich medical tourists and insurance-holders are generally the only ones who can afford obtaining organ transplants. If legalized, there may still be a disparity between the rich and poor in organ procurement, just as there is in all aspects of medicine, but this does not call for a ban on all medical procedures. However, we can legalize organ sales, and then- depending on whether you favor Heritage or TAP- accept a certain degree of inequality, or fiddle with our health care system, so that the poor can afford organs, as well).

My feeling is that most people oppose economic exchange of organs simply because the whole idea seems very, very unpleasant (yes, to me, too!). But good public policy is not constructed to convenience such a persnickety relic of natural selection as our sense of disgust. We ought to focus solely on whether we are actually helping people like Mr. Smith, who needs additional time to find the fellow freewheeling partner of his dreams.

In “Who Lives?,” while the committee pores over endless piles of pallid folders, the delicate housewife cries out, “We shouldn’t even have the power to make this decision!” However, she and her colleagues at least brave the clearly-understood ramifications of crafting countless letters featuring the dreaded words, “We regret to inform you...” Today, meanwhile, we largely avoid such formalities, by revering our high-minded legal dictates, and remaining casually inattentive to the tragic reality of thousands of end-stage kidneys.

Judging Others

2009-03-13T07:45:00.000-07:00

At Overcoming Bias, Robin Hanson states:

When evaluating someone intellectually, I tend to downplay their degrees, publications, affiliations, etc. and focus on how they handle themselves in intellectual conversation. But most academics have more prudish norms, and consider it rude to challenge prestigious visitors to thoughtfully discuss topics beyond their prepared speech. Thank goodness my favorite lunch partners share my imprudish tastes. :)

I wonder if his method of evaluating intellectual ability may introduce more bias than does checking out the speaker's degrees.

If someone has a fancy education or job, she demonstrates that she was at least able to accomplish something minimally substantial over time (except in rare cases). If you judge someone based on a single conversation, well- What if he was nervous? Sick that day? Expresses himself better through writing than via speech?

I'm still working out my general approach to judging others. Which is the most fair (and possible) strategy: Matthew 7:1 , Pirkei Avot 1:6, or regularly scheduled Bayesian Updates?

Show Your (Well, Other People's) Work!

2009-03-11T22:12:00.000-07:00

Olivia Judson's fabulous blog for the New York Times leads me to wonder:
Why aren't all journalists required to cite their references?

Just Deserts

2009-03-09T02:27:00.001-07:00

I just viewed a Bloggingheads video, which featured Will Wilkinson, of the Cato Institute, and Lew Daly, scholar at Demos, and author of the book, "Unjust Deserts." Daly asserts that, because, capitalism's winners' can attribute much of their success to the intellectual contributions of past innovators, the wealthy Johnny-come-latelies owe some sort of "royalties," to the rest of society.

Robert Nozick once made a similar, "Hey, Those rich guys weren't all that back then," argument, but only to armchair-psychoanalyze the jealousies of the anti-free market intellectual class. He believed their views stem from the sudden weaning of these approval-junky scholars from their teachers' sweet, selective praise:

"Schooled in the lesson that they were most valuable, the most deserving of reward, the most entitled to reward, how could the intellectuals, by and large, fail to resent the capitalist society which deprived them of the just deserts to which their superiority "entitled" them?"

I'm having technical issues using the bloggingheads site (image only appears in the corner), so I will embed my next queued video over here:

Moore's Paradox

2009-03-09T00:11:00.000-07:00

In second grade, I received a poor evaluation on a particular homework assignment. We were given a worksheet, which featured sentences such as:

A) It is raining outside
B) "I like chocolate."
C) "That girl is beautiful."

The teacher told us to ignore whether or not the statements were true, but to focus on whether or not each fell into the purview of fact or opinion. I sincerely believed that A and B were facts, and that C was an opinion. (B was apparently an opinion).

I'm still a bit stubborn about that answer. Can't a lie detector determine, within a certain margin of error, whether or not the anonymous kid indeed enjoys chocolate cake? I suppose this semantic confusion can be avoided with clearer instructions about which aspect of the sentence to evaluate, or with a less hopelessly literal third grader (The girl in the sentence is stating her opinion. Get over it, kid).

In his new communal blog, Less Wrong, Eliezer Yudkowsky mulls over Moore's paradox, Wittgenstein's favorite reflection on assertion versus belief: "It's raining outside but I don't believe that it is." Yudkowsky expounds on this contradiction to differentiate between belief and endorsement. He says,

"It's not as if people are trained to recognize when they believe something. It's not like they're ever taught in high school: "What it feels like to actually believe something - to have that statement in your belief pool - is that it just seems like the way the world is. You should recognize this feeling, which is actual (unquoted) belief, and distinguish it from having good feelings about a belief that you recognize as a belief (which means that it's in quote marks)."

I think that the mix-up largely stems from failing to juxtapose the concepts of truth/falsehood with fact (be it true or false)/opinion . Beauty is neither truth nor falsehood. It's just opinion- until we are given a more specific, working definition (i.e. "Beauty is the democratic consensus").

As Yudkowsky mentions, we use the word "believe" to express a lot of different concepts. For example, we say,

1) "I believe she is beautiful"- If we ignore the fussiness of my third-grade self, we'll call this an opinion, neither true nor false. Perhaps in need of clearer criteria, but certainly not irrational.

2) "I believe it is raining" -A statement concerning fact, which can be proven as true or false", and

3) "I believe in life after death"- A statement concerning fact, which cannot, however, be reasonably proved or disproved.

We also use the word "believe" ways that are difficult to categorize- say, "I believe in liberal/conservative political policy."
Is this statement purely an endorsement that requires no need for evidence (Example 1)?, Or, given clear-cut, agreed-upon goals, can evidence show that one ideology is likely superior (Example 2)? Or is this divide, with its necessary "whole world as laboratory" scientific design so hopelessly flawed and impossible that it is akin to attempting to prove "life after death."(Example 3)?
2 plus? 3 minus?

Is the term "belief" better used to make assertions regarding facts, or is the word better spared for expressions of mere opinion? My problem is that, despite having passed third grade, I'm still not always sure about the category in which my pronouncements belong.

Hal Incandenza on Doctors

2009-03-08T00:31:00.000-08:00

It will start in the E.R., at the intake desk . . . or in the green-tiled room after the room with the invasive-digital machines; or, given this special M.D.-supplied ambulance, maybe on the ride itself: some blue-jawed M.D. scrubbed to an antiseptic glow with his name sewn in cursive on his white coat’s breast pocket and a quality desk-set pen, wanting gurneyside Q&A, etiology and diagnosis by Socratic method, ordered and point-by-point. There are, by the O.E.D. VI’s count, nineteen nonarchaic synonyms for unresponsive, of which nine are Latinate and four Saxonic. . . . It will be someone blue-collar and unlicensed, though, inevitably—a nurse’s aide with quick-bit nails, a hospital security guy, a tired Cuban orderly who addresses me as jou—who will, looking down in the middle of some kind of bustled task, catch what he sees as my eye and ask So yo then man what’s your story?

Random Stuff From This Week

2009-03-05T00:05:00.000-08:00

Last weekend, I attended the California GOP Convention, where I mostly hung out with the Log Cabins (luau themed party with free piña coladas!). Yes, I know I've just outed myself as a Republican, but I consider this choice as largely strategic. My political passions constitute a giant matrix, but, given a de facto two party system, a tiny vector, once political polarity is superimposed. I work for this group.

I went on a mini-hike in Eaton Canyon with the husband (That's me above, taking a break). Roots sweatshirt- yeah, I'm half Canadian. Every year, I pit stop to visit my bubbe (yoy!)in Toronto (eh!), before heading to New York (bitch). Pictures of all the Eaton Canyon waterfalls are trapped my husband's camera at lab, so they'll be up later.

Today, I took the practice boards at my school. I'm kinda screwed- unless the Kaplan Fairy leaves, like $10,000 under my pillow.

I have a 5:45 a.m. AA meeting to attend, as part of my Clinical Medicine course, so I've made a searching and fearless moral inventory of myself, and decided that I'm justified in spending the night blogging and watching the entire season of Top Chef (although some spoiler already told me that the bald yid wins).

Narrative Medicine

2009-03-01T01:25:00.000-08:00

Ms. Smith is a Caucasian 68-year-old morbidly obese (400+ pounds) woman being treated for congestive heart failure. She takes short, labored breaths, and has symmetrical pitting edema in her legs.

Ms. Smith cannot get up to move herself to sit on the bedside commode, so the petite Chinese nurse leaves to request additional help. As the nurse exits the room, Ms. Smith turns to me and says, "She can't do this by herself? What are they paying her for?"

Ms. Smith's father was an abusive alcohol addict. Ms. Smith divorced her husband about 30 years ago, after she discovered that he had cheated on her, the first clue being the gyn's diagnosis of chlamydia and gonorrhea. She had had a hysterectomy at age 28, due to a prolapsed uterus, following birth of twins. When she announced her intentions to divorce her husband, he said, "I wasn't going to stay with you, anyway. I wanted more kids, and you can't have any." Ms. Smith's ex-husband recently died of a stroke, following surgery for prostate cancer. Ms. Smith says "I am glad that G-d let me see him in such pain in my lifetime, the bastard deserved it."

Ms. Smith never leaves her house, but a kind neighbor drops off some groceries about twice a month. She has no relationship with her children or grandchildren, for reasons she did not specify. She has no plans to improve her life (her one pleasure is "spraying her sheets with perfume," which reminds her of the way her mom smelled, and provides an "aromatherapy" feeling). However, she does faithfully take her 13 medications every day.

I asked Ms. Smith what she had to lose by sending her grandkids Christmas or birthday cards. If she didn't have a relationship with them, the worst thing that can happen is that the situation remains the same. Ms. Smith, bitter during most of the conversation,lightened up during my blunt challenge. "Yes. That is true. What do I have to lose?" Then her smile faded. "I just don't think I'd be able to deal with the rejection."

In many ways, I'm privileged to work in a hospital; For better or worse, I get to witness and learn from other people's life mistakes. This is a woman who spends the overwhelming majority of her day watching TV in her bed. It would seem to an objective observer that a genuine attempt to live in any different way ought to be wholeheartedly embraced. Ms. B is not afraid of death ("I'm just waiting for God to take me, when he wants to take me"), but is utterly panicked about sending a Christmas card.

When I see situations like this, I realize just how irrational it is to be nervous about contacting an old friend or putting up an inarticulate blog post or do anything else, for which I might be judged. I see the ultimate futility of caring too much about what other people think.

I suggested an alternative for Ms. Smith- perhaps she can keep journals, which her granchildren could one day read. Ms. Smith started to ramble excitedly, "Yes. It could by my legacy to them. Something for them to know me by...It won't get my voice inflections...but I could still give them advice..make sure they don't make the same mistakes. I can tell them to always stay celibate. That is the only way to stay safe."
I've recently read about "Narrative Medicine," a movement pioneered by Rita Charon, in which patients, even (especially?) those in palliative care, write and reflect about their illnesses. To me, the narrative medicine is particularly seductive, as it provides opportunities for doctors to inculcate values in which they're often criticized for being remiss- empathy, consideration of the "whole" patient, and integration of other fields- all without sacrificing a commitment to evidence-based medicine.

The evidents suggests that narrative medicine may help mitigate pain, or even increase survivorship and longevity. Promoting science-based medicine is not in conflict with recognizing the bio-social-psychological model of medicine, nor realizing that the effects of, say, loneliness can discernible physiological consequences.

I had no major suggestions that were acceptable for Ms. Smith, on how she could perhaps improve her life (Therapy? No Nutrition Counseling? No). She will likely remain alone for the rest of her life. However, she might punctuate her TV-viewing with journal keeping. So, maybe I've my part to ensure Ms. Smith's lasting legacy.
I wonder when I'll start recommending to all the lonely seniors that they ought to start blogs.

Do Not Mess With Dana Stevens

2009-02-18T11:33:00.000-08:00

A few days ago, I wrote a post admiring the writing skills of Dana Stevens, the culture critic at Slate. I then stumbled upon the following review of Stevens, which included such tidbits as,

"The result in Stevens has been some of the most comically overwrought prose this side of an undergraduate civics paper. Two posts by her in, and the Movie Club is the worse for wear....[after quoting Stevens] It’s January 3rd, folks, yet that may be the most inept attempt at a meaningful sentence I digest all year."

I will try (and often fail) to avoid forging ad hominem attacks. However, I am a big believer in defending people, even phantoms whom I've never met, the ones who live in copper wires and fiber optic cables. Thus, I do not draw my own "civility line" at presenting harsh critics in their own words. Therefore, here is more from Freddie DeBoer:
Title of Blog Post from last week:

"The Continuing Fraud of Mickey Kaus"

On Martin Peretz:

"His blog is linked to by mainstream blogs and online magazines. He is a firmly establishment figure. He is also a vulgar and hateful man....he's become a clownish figure..."

And then there are almost 400 earlier blog posts that I don't have the energy to wade through. This all may seem like trying to remove the whips from the sex shop; after all, the civility norms of the internet differ from the general tone of face-to-face conversation or academic journal critique.

However, what irks me is that the following is posted on Freddie De Boer's personal wikipedia page:

"I believe that the irrational anger, out of hand rejection, and defensive zeal with which people on Wikipedia reject postmodernism reveals the degree to which that rejection is the product of doubt and fear...I think nothing can be accomplished without an attempt at genuine dialogue, founded on mutual respect and a good faith understanding of the opponent's viewpoint [words bolded in original]."

As much as I try, I will not always write in a respectful tone. Please call me out on it, as this is something I try to avoid. We all have our bad days. However, if someone mocks people whom I admire, he will be called out on that, as well. We are left with differences of opinion concerning what is respectfully-conducted discourse, and upon whom forceful language is legitimitely proclaimed. Therefore, it's a good thing Freddie's a self-described "post-modernist."

What is Bill Maher's Religion?

2009-02-17T12:07:00.000-08:00

Larry King interviews Bill Maher, February 14, 2009:

KING: From our blog, Chris writes, "Bill, what is your silver bullet for health care?"

MAHER: Well, eat right would be a good start. Stop eating that crap in the supermarket. I think most health problems are from lifestyle choices. This is something no politician ever talks about, because no politician is going to say, get off the couch; you're fat; you know, ask the doctor if getting off your ass is right for you. But that really is the key to it. People don't catch a cold, they hatch a cold by things they put in their body. We have way too much toxicity and too few nutrients.

KING: Do you get a flu shot?

MAHER: Never. Never.

KING: It's a vaccine against the flu?

MAHER: First of all, that's a huge scam. Even if it worked, and I don't believe it does, by the time the actual flu came around, it would have mutated from whatever they shot into you. That is a good example of the corruption --

KING: You eat nothing in a box or in a can?

MAHER: Things that are in boxes or cans generally are not good. But have some peanut butter tonight if you like, Larry.

Here Bill Maher manages to deny the pathogenic cause of disease, as well as blame victims for acquired viral infections, stating that people "hatch a cold." Does Maher feel the the same way about Dengue Fever? Polio?

This is an example of hyperbole gone wild. Is Maher correct that people with suppressed immune systems are more susceptible to suffer an illness? Yes. Do people develop weaker immune systems by eating unhealthy foods? Perhaps. But Bill Maher's misleading statements imply that dietary intake is the primary cause, or at least an extraordinarily significant cause, of developing viral rhinopharyngitis.

In fact, the extensive National Health and Nutrition Examination Survey suggests that, while obesity is responsible for numerous pathological phenomena, overweight and obesity seem to be protective from death via infections¹. (The researchers used a COX model to account for the fact that the obese tend to die earlier from other diseases, before getting a "chance" to die from infections). While one randomized controlled trial (RCT) in mice showed that genetically ob/ob obese rodents were more likely to die from influenza virus than "slim" rodents², another RCT demonstrated that ob/ob obese mice were more resistant to death from the malarian parasite, Plasmodium berghei³. Thus, the research relating to the link between obesity and infectious disease is insufficient to be considered conclusive, and additional studies should be performed on this topic. However, Maher's conjecture that acute coryza (common cold), or other infectious diseases, are largely "hatched" from dietary choices, is invalid.

Even if we were to discover a causal link between eating habits and symptomatic coryza infection,⁴how does Maher know that "toxins" are the culprits, rather than excess fat? Which specific toxins are responsible? Additionally, on what basis does Maher believe that "nutrients" inoculate people from the common cold?

Indeed, many Americans ought to lose weight for other reasons, so at least this embellishment likely has mild consequences.

But then Maher moves on to vaccines.

An estimated 20,000 Americans die from influenza every year. So, if Maher convinces people to avoid a efficacious inoculant, he is behaving very irresponsibly.

Several randomized controlled trials demonstrate the effectiveness of the flu vaccine in children and non-elderly adults, and no scientific study seems to have refuted this. For example, according to the CDC:

A 4-year randomized, placebo-controlled trial of children aged 1-15 years found vaccine effectiveness ranging from 77% to 91%, following only one dose of vaccine given to previously unvaccinated children³."

There is a bit of controversy regarding the efficacy of the flu vaccine in the elderly population. While most well-designed cohort studies have shown that the flu vaccines reduce incidence of influenza infection and death for this demographic ⁴, these data has been contested in a few other studies ⁵. However, let's say we did discontinue vaccination of the elderly. We should then employ even greater care to vaccinate children, in order to decrease the probability of elderly exposure to the virus. (The authors of the Canadian study that challenges the usefulness of vaccination for the elderly, indeed noted, "Placebo-controlled randomised trials show influenza vaccine is effective in younger adults.")

Even if Maher, for some wacky reason, does not recognize the validity of such studies, why does he believe that the findings published in these journals amount to a "huge scam," a fabrication intended to hoodwink the public, and an example of "corruption"? These articles all seem to me like the expected process that takes place to advance scientific knowledge, rather than some large conspiracy. In order to save lives, we rely on the best evidence we have, concerning the costs and benefits of every preventative measure and treatment.

We already know that Maher views religious people unfavorably, and that he maintains staunch views on a whole gamut of topics. However, if Maher distrusts both theological doctrine and scientific research, which Higher Authority does he rely on as his arbiter of truth?

1. Katherine M. Flegal and Barry Graubard, et. al. "Cause-Specific Excess Deaths Associated With Underweight, Overweight, and Obesity" JAMA. 2007;298(17):2028-2037. http://jama.ama-assn.org/cgi/content/full/298/17/2028

2.Alexia Smith, Patricia Sheridan, et. al. "Diet-Induced Obese Mice Have Increased Mortality and Altered Immune Responses When Infected with Influenza Virus." Nutritional Immunology137:1236-1243, May 2007
http://jn.nutrition.org/cgi/content/full/137/5/1236

3. Vincent Robert, Catherine Bourgouin, et. al. "Malaria and obesity: obese mice are resistant to cerebral malaria" Malaria Journal 2008, 7:81

4. Please note that infection with the Influenza virus is always the primary etiology. By "causal link" I mean that dietary habits might lead to increased rate of clinical disease from infection, or decreased ability to kill off the virus.

5. Kathleen Neuzil and William Dupont, et. al. "Efficacy of inactivated and cold-adapted vaccines against influenza A infection, 1985 to 1990: The Pediatric Experience." The Pediatric Infectious Disease Journal:Volume 20(8)August 2001pp 733-740
CDC link that review some of the evidence about flu vaccines is at http://www.cdc.gov/FLU/PROFESSIONALS/VACCINATION/effectivenessqa.htm

6. Most of the research in this area seems to have been

Peter A. Gross, Alicia W. Hermogenes, et. al. "The Efficacy of Influenza Vaccine in Elderly Persons: A Meta-Analysis and Review of the Literature." Annals of Internal Medicine. Volume 123 (7) October 1995 pp. 518-527
http://www.annals.org/cgi/content/full/123/7/518

See also a randomized controlled trial at http://jama.ama-assn.org/cgi/content/abstract/272/21/1661

One study involved a Swedish cohort study of 260,000 age 65 or older. The researchers state, "The relative risks of mortality among vaccinated versus unvaccinated individuals were estimated using Cox's proportional hazards regression adjusted for, and stratified by, demographic factors and comorbid conditions." They found that they needed to vaccinate 297 in 1998/1999, 158 in 1999/2000 and 743 in 2001/2002 (the vaccine was not so great that year) in order to prevent one vaccine related death among the group, let alone prevent incidence of developing an influenza infection.
a. Ortqvist, F. Granath. "Influenza vaccination and mortality: prospective cohort study of the elderly in a large geographical area." Eur Respir J. 2007 Sep;30(3):407-8.

7. Lone Simonsen, Roberty Taylor, et. al. "Mortality benefits of influenza vaccination in elderly people: an ongoing controversy."
The Lancet Infectious Diseases, Volume 7, Issue 10, Pages 658 - 666, October 2007. http://www.annals.org/cgi/content/full/123/7/518.

Confessions of a Cinemaholic

2009-02-14T09:24:00.000-08:00

On days following a horrific exam, I often lounge and loaf and consider a career in frittering and tweeting my time or otherwise "writing stuff on the internet." Then, I occasionally come across something like this,which manages to construct such exemplary commentary on a movie that seems so painfully stupid. I am actually curious about what Dana Stevens has to say about "Gigli" and "Glitter." I am not worthy. Good thing I really enjoy medicine.

Coulrophobia

2009-02-14T04:51:00.000-08:00

Each Friday, my school sends a delegation of medical students out to Juvenile Hall, where we split up in twos, and instruct the kids on rotating topics, such as Decision Making, Dating Violence, Sexually Transmitted Diseases, and Contraception. The teens are aware that, while misbehaving during math class might earn some class cred, acting out during Sex Ed means that one's not man/woman enough to handle the topic. Thus, we enjoy their rapt attention (other than that one fluke pencil-stabbing incident), as we point to Netter illustrations of vas deferens and cervical ora, and pass around examples of dental dams, condoms, and diaphragms.

We thought that we were being all educationally innovative with our "Guess which STD?" Jeopardy game, featuring fun-filled images of condylomata lata and genital warts. However, it seems that we are totally outdone by Derek the Abstinence Clown, with his fun-filled juggling shtick. It is unclear to me what juggling has to do with safe sex (tossing pins leads to tossing machetes leads to, I don't know, neurosyphylis?). Derek has Austin the Seventh Grader balance a ~~phallic symbol~~ cane in one hand, which represents "doing whatever feels right like now." The cane begins to tumble, upon which Austin is summarily chastised.

On Austin's second attempt, Derek asks Austin to focus on his hopes and dreams. He also finally moves out of Austin's way, allowing the kid room to adjust his arm, so that the bottom of the cane can continuously counteract the torque of the top. Newton's Laws and Austin's Hope-Focusing conspire to ensure the cane's successful stability. From this analogy, the junior-high kids learn the imperative of avoiding drugs, alcohol, cigarettes, and especially, pre-marital sex.

Heeeeeere's Derik!!:

Don't Look At Me, I Just Work Here

2009-02-10T03:06:00.001-08:00

Like Kerry Howley, I believe that when it comes to government regulation of in-vitro fertilization gone wild, the bureaucratic cure could be worse than the infertility cure.

However, Kerry sees a doctor who performs IVF as a morally neutral agent, working like an employee at the One-Hour-Photo Shop, shrugging his shoulders as he develops mementos of adultery and scandal, separating his own duties from his clients' sins.

We ought to distinguish crusades of government, as well as the passive observation of moral indiscretions already committed, from the actions of clinicians who potentially cause significant harm. Carrying octuplets to term would almost certainly lead to low gestational birth ages and weights (the California woman's offspring averaged about 2.5 pounds), as well as a dramatically increased risk of abruptio placenta, congenital malformations, eclampsia, or other events that could lead to long-term adverse effects for the products of this Guinness Book adventure. Indeed, someone might find it precious to ensure the birth of a child with Huntington's Disease, so Junior could be "just like mom," but I would decline the request to preferentially pluck such favored follicles.

Of course, we risk committing "IVF refusal ad absurdam"; We begin with objections to embryos with HD, and end with the dismissal of embryos cursed with my characteristic attached earlobes. Additionally, dramatically increased risk does not equal a guarantee of harm. Thus, I understand why conscientious clinicians might not yet object to the implantation of eight embryos. However, I reject the overall notion that a doctor ought to shove fingers in her ears, ignoring the loud protestations of her ventromedial prefrontal cortex, as it shouts that something is not quite right.

Upon public outbursts, such as "How could doctors let her bring so many babies to term?," Kerry counters with

"If there is a problem here, I’m pretty sure it is not that doctors are insufficiently judgmental in matters of female reproduction. Fertility specialists are medical service providers, not religious counselors, not ethicists. I would no more ask a GP whether it is ethical to bring 8 babies to term than I would ask her to hold forth on the existence of souls."

The problem is, the critic does not necessarily esteem the doctor an expert on ethical matters, but merely objects to the doctor's violation of said critic's own ethical views. I'm not concerned with the accountant's opinions on the ethics of tax fraud. But I will denounce him when he unscrupulously helps people cheat.

Some of These Things Are Not Like the Others

2009-02-06T21:26:00.001-08:00

Some statements to start off your Sunday:

1) "The theory of evolution is a myth."
2) "The government should not fund stem cell research."
3) "Vaccinations cause autism."
4) "Funding for the NSF does not belong in a stimulus bill."
5) "We should repeal the Clean Air Act."
6) "Climate Change is a hoax."

Let's start with the easy question: What is similar about all of these statements?

Answer: They are beliefs commonly touted by many conservatives, and are mocked, in turn, by liberals- (although some liberals also agree with statement "3").

Ok, now what is a major difference among these statements?

Answer: Statements 1, 3, and 6 (Group A) are all contradicted by scientific evidence and are not factual. People who believe in them, either don't know or don't care about the empirical findings of scientific research. Statements 2, 4, and 5 (Group B), however, are merely political arguments. There is perhaps a strong correlation between belief in 1, 3, and 6 AND advocacy for 2, 4, and 5, but this does not mean that the two categories are equivalent.

And I believe that this distinction is essential.

If you've read the "Republican War on Science" or many of the posts on Scienceblogs, people will blithely cite, within the same post or sentence, statements from both categories A and B as evidence of the shear philistinism of conservatives or Republicans.

The problem is, people who understand both the possibilities and limitations of science should know better than to conflate these two categories. A true empiricist ought to realize that a fellow empiricist, no matter how seemingly unsuitable his political beliefs, can, at least theoretically, reject Group A while accepting Group B. For example, one might oppose government funding of stem cell research on moral grounds. Or he may not be morally opposed to stem cell research, but believes that public policy should defer to the opinions those who oppose such research. Or perhaps such funding simply conflicts with his views about the proper role of government. The notion that "Legitimate human life morally starts only starts after 'such and such' time," is non-falsifiable, as "legitimate human life" is personally, rather than scientifically, defined. Thus, there is no reason to believe that someone's opinions about the ethics of abortion, stem cell research, and arguably even birth control has anything to do with science, so long as one does not justify such beliefs with unscientific claims.

Some people, for whatever reason, might not believe that the Clean Air Act was a good law. I am reluctant to list such reasons, for one, because I know nothing about the law, but, more importantly, because heated counter-arguments would obfuscate my main point, which is: One's political beliefs, no matter how objectionable, are not necessarily related to one's recognition of the value of the scientific method, empirically-derived knowledge, Reason, or objective standards of evidence. Information derived from Science might help inform our opinions about morality or politics, but our conclusions are ultimately based on personally-formulated ethical "first principles" (i.e. "Do no harm," "Government is a good/bad tool for solving social problems" etc.).

So eager are some scientists to denounce their ideological foes, such scientists betray the public by implying that "science says" that certain legislation ought to be passed, or that certain moral opinions ought to be espoused by all defenders of Reason. They do a disservice to their readers, making it seem as if non-falsifiable statements fall under the purview of science. Thus, the public's understanding of the way science works diminishes. "Politicizing" science can exist on both sides of the aisle.

I can think of one circumstance for which the political is inextricably linked to the scientific, in which case the liberal scientist politicos have a legitimate argument. This involves the issue of advancing false statements within the public sphere to gain a preferred political resolution. In this case, the only moral first principle is "Do not lie"- a principle so nearly equivalent to "Embrace science," that I would concede liberal scientists' stances in applicable cases. Such a situation might include advocacy of the teaching of creationism in biology class, within the public schools. Additionally, while there is nothing "unscientific" about opposing a cap-and-trade policy, if one advertises against such a policy by using bogus data to "show" that "climate change doesn't exist," he would be making unscientific, non-factual statements. The same principle applies to someone who conjures up false epidemiological data to "prove" a purported link between abortion and breast cancer. As a "social liberal," I would usually agree with the liberal scientists, in these cases. However, my opinion is that the relationship between scientific reality and political expediency is, nevertheless, quite messy. When otherwise-empirically-sound scientists leave academia and enter think tank headquarters, they occasionally "skew" or "pick and choose" facts and figures, perhaps out of a political or moral belief that the "ends justify the means," or simply due to plain, old cognitive dissonance. In other words, in politics, much more than in science, (nearly) "everybody lies."

The bottom line is- If someone espouses counterfactual information, call him anti-science. However, if he simply opposes your science-related political opinions, call him something else.

Should Medical Students Make Fools of Themselves on the Internet?

2009-02-02T03:11:00.000-08:00

Researchers at the University of Florida don't think so. They believe that physicians in training ought to remove those keg party snapshots from Facebook, and instead use social networking sites "to enhance their professional identities." The co-authors deplore the fact that medical students reveal their political preferences, relationship status fluctuations, and unsavory interests (they mention "Texas Chainsaw Massacre") for future patients to see.

The problem is, when virtually every professional-in-training has already gone "1 million strong for Obama/McCain/Barr/Nader/Pigasus" or, (for the more brazen), "I would never sleep with a [insert political party here]," then the definition of "professional" has already been, de facto, redefined. Why get rid of (or clean up) Facebook accounts, utilized by 64% of medical students, when it is so much easier to invite the other 36% to join along?

The article states,

"There is some evidence that students do begin to understand the impact of Facebook as they approach graduation. The study found that while 64 percent of medical students had public Facebook accounts, only 12 percent of resident physicians did."

To me, these statistics don't indicate any panicked account closures en masse, but speak to the flood of Mark Zuckerberg's contemporaries who have recently entered medical school, and collectively just say "meh."

One of the researchers argues that

“Doctors are held to a higher standard...There are stated codes of behavior that are pretty straightforward, and those standards encourage the development of a professional persona.”

If someone simply enjoys doing colonoscopies, and also singing karaoke, must he be a man at home, and a doctor in the street? Should we hold doctors to a "higher standard" when it comes to non-medical matters? Does this concept simply re-enforce the old-fashioned notion that doctors are "different from you and me?"

Granted, there are some things doctors could publicize that would convince me to avoid sitting next to him on a bus, let alone let him perform my cardiac surgery. If some-one joined a fictitious "I Hate My Patients Club" or some other ridiculous group, it might be sensible to choose a different doctor. However, by announcing his opinions on Facebook, rather than simply confiding in his poker buddies, the doctor does me the favor, as now I can cross him off my PPO list.

However, with 21st century snark and sarcasm, we can't interpret the significance of someone's membership in even the most unsavory of medical student groups- such as,“Physicians looking for Trophy Wives in Training” (it is unclear to me this is a dangling modifier, or if the medical students emphasize the "training" of the "trophies" more than their own). In this post-modern generation, we don't know if the students actually aspire to this vision of their futures, or if they're actually mocking a largely passé Dr. 90210 attitude, in which marrying boring women¹ is considered desirable.

I suppose that, no matter the intentions, it is still perhaps inappropriate to advertise activities or opinions that would cause offense. But once the details of our lives are inevitably strewn across the internet, someone is going to find something objectionable (My doctor is President of the Barry Manilow Fan Club???) Where would we draw the line? The answer to this might be obvious to some boomers out there, but I can safely say that many of us young folk haven't a clue.

We tend to wistfully look back at those old-fashioned physicians of yore (or at least those of 1960s television)- caring, nurturing, and kind. However, today's doctors can still achieve these qualities without dulling our personas- even "Marcus Welby M.D." opens with Dr. Kiley riding his badass motorcycle.

1. The doc's wife may be intelligent. I've never seen the show.

Quick Overview of My Intro to Urology Clinic

2009-01-29T13:59:00.000-08:00

The first clue about the maturity level of your typical urologist, can be gained from seeing, on the door of the doctors' lounge, a labelled picture of the handsome animal featured above. These urologists strike me as the future incarnations of Kumar, the guy from that White Castle movie.

In contrast to the bawdy behavior of the urologists, one of our patients, Mr. Smith, was the quintessential "gentleman." He thanked us for taking the time to see him. Whenever he referred to any portion of the male anatomy, he said "Sorry, to the ladies, I don't mean to be impolite talking about these things." He was fully aware of his prior condition, and had followed his previous doctors' advice. The juxtaposition becomes especially absurd, however, when you notice the patient's right leg that is cuffed to the bed, and the two police officers sitting in the corner, mindlessly surfing the web, Berreta 92s intimidating from their holsters. The patient has scars on his back and legs, all from multiple previous gun shot wounds. Based on the manners of most of the patients who head over from County Jail, I can only assume that Cotillion is scheduled between recreation and lockdown.

No kid grows up dreaming of becoming a urologist. Even medical students tend to not think of it (I want to work with urine!) The thing is, however, unlike the "stereotypical" image of a surgeon, who might be seen angry and annoyed, the urologists love to make jokes, have fun, and really get along with their patients, all the while doing a cool fusion of medicine and surgery. The two attendings whom my group assisted today are volunteers, who spend one day a week away from their private clinics, just to teach us lowly Second-Year-Know-Nothing-Medical Students. They showed us the procedures for inserting a Foley catheter, doing sonogram assisted prostate biopsies, and performing a cystoscopy. They were all so eager and excited to teach us whatever they could, and we were all having a blast. It's kind of like an old boy's club, but one where young boys and all girls are invited, too.

Response to Comments on My Last Post (Yikes This Can Go on Forever!)

2009-01-29T04:12:00.000-08:00

Hello “Schwartz,”

Thanks for your comments. I’m going to try to quickly respond. Sorry that the sources are messily scattered throughout. I'm aiming to get this done before 6 a.m. Urology clinic.

Adina,Your method of debate is a refreshing change from the usual vitriol. Thank you.I have a couple of initial questions I'll get out of the way first:
“1) Do have experience in statistical analysis or epidemiology?”

I freely admit that I am not nearly an expert in the subjects of statistical analysis or study design. However, when discussing these topics, I hope you will focus on the content of my arguments, rather than on my degrees or qualifications (please note that I do believe degrees are important for some things). In other words, I don’t care if you graduated from clown college. If you make good points, I will afford them the same respect that I would to those of a statistician. As an aside, I have taken non-graduate-level courses in biostatistics, epidemiology, economics, and math. Additionally, I worked for a clinical research study (for only one year).

Did you read the details or any critical reviews of the epidemiology you broadly reference?”

I made sure to read the major components of every paper I referenced. In terms of critiques of the study design, I have read many thorough (unconvincing) rebuttals to a number of the studies I presented at http://www.generationrescue.org/autism/17-studies-against-vaccine-autism.htm and http://www.safeminds.org/research/commentary.html

There are some much better-reasoned review articles available, which address the drawbacks of various studies. For example, this article http://pediatrics.aappublications.org/cgi/reprint/115/1/200.pdf compares a number of epidemiological studies, addressing the purported link between autism and vaccination. They find that Heron’s study fulfills 5/8 epidemiological criteria, and the research of both Hviid and Verstraeten each fulfill 6/8 criteria. In other words, they are strong, but not flawless studies (there are extraordinarily few epidemiological studies about anything that would fulfill all 8/8 criteria). The Geiers’ study, the only one that found a link between vaccination and autism, fulfilled 0/10 criteria. The methodology used in this article review article appears quite sound.

(Parenthetically the third world application of Rota vaccine is relevant but so is the fact that it is currently recommended as a childhood vaccine in the US. The US recommendation is justified as a reduction in cost due to reduced hospitalization, not death. This is far more relevant to your readers when considering the risks.)

CDC: “The number of intussusception cases reported to date after RotaTeq administration does not exceed the number expected based on background rates of 18-43 per 100,000 per year for an unvaccinated population of children ages 6 to 35 weeks.”
http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/alerts_rotavirus_vaccine_rotateq_intussusception_cdc_qa.rtf

"However, these claims have been investigated (Ten studies to show MMR doesn't cause autism. Six that show thimerosal doesn't cause autism, etc.)"
In order to support the notion that the claims of damage have been vaccinated, you would have to produce case studies or at least detailed follow-up for the affected group OR at least you have to illustrate that enough study of children with similar risk profiles were studied en masse. Neither you or Dr. Offit have provided them so right off the bat, the definitive statement that the topic has been studied is not justified in my opinion. In general, you will find that in the cases of vaccine damage very little documentation is available and there certainly is no large cumulative study of affected children. That alone should raise red flags in a system that mandates a medical intervention.

I’m not sure what you mean by similar risk profiles. Do you mean studying patients in a case-controlled study, rather than the current practice of conducting longitudinal cohort studies? (In other words, finding kids who are already known to have autism, and then finding out about their exposures, rather than recruiting kids with known exposures, and then following them to determine if they were later diagnosed with autism).

I’m not 100% sure what kind of study you’re referring to, but if it is a case-controlled study, then I feel that such a study would have little value. A case-controlled study, in this situation, is susceptible to information bias (Differential reporting of past exposure information based on disease status), Selection Bias (Controls and/or cases chosen in such a way that they are systematically more (or less) likely to be exposed than the population from which they were drawn), Confounding. (Failure to measure and adjust for all potentially confounding factors can lead to invalid associations), and Temporal Relationship Problems. (Can’t be certain the exposure preceded the onset of the disease). (Sources of bias copied from Epidemiology Lecture notes created by Dr. Christopher Haiman).

It shouldn't be a surprise that Hannah Poling's case was actually investigated in detail likely only because her father was a neurologist with both the power and wherewithal to ensure her case was studied in detail"In terms of the Vaccine Court, the fact that those girls got money from the Vaccine Compensation Fund is not particularly relevant, because the cases are not judged based on scientific evidence" “

I might have missed it, but I don't see anywhere they state that the decisions are not based on scientific evidence. Medical records and expert assessment were provided in this case, and certainly expert assessment qualifies as scientific evidence. Your definitive statement here is not justified.”

I’m having trouble with this argument. Do you think that if we went to court to resolve a dispute about evolution vs. creationism, then the findings of the court would be scientifically relevant, so long as the judges heard the testimony of experts? I am not sure if you are saying that courts ought to be recognized as legitimate arbiters of a scientific debate, but if so, I must disagree. Courts might invite scientists to testify about their research, but the court itself has no meaningful role in determining of the scientific merit of such testimonies. Because courts must make legal decisions, the public hopes that the courts will do their best to be objective and weigh already discovered evidence appropriately, as well as figure out which witnesses are most credible. Ultimately, however, the legitimate value of scientific findings is determined by the scientific community through the scholarly writing and peer review.

Additionally, I am pretty confident the percentage of “experts” who testified that vaccines cause autism was dramatically larger than the percentage of scientists, in the general population, who agree with that notion. Court cases are misleading, because disproportionate representation leads to an assumption that there is widespread debate about a given issue, when opposition might actually exist among only a small fringe group.

"A team of lawyers (called "special masters") with no medical background, rather than a judge, jury, scientists, or medical professionals, preside over the cases." The Poling case was conceded after a review by the HHS scientists. It never went to a hearing before the Special Masters. The HHS scientists examined the scientific evidence presented and determined that a hearing was not required, as they concluded the act of vaccination contributed to her brain damage (encephalitus) leading ultimately to a diagnosis of Autism. Your own statements don't match the facts and display the bias of Dr. Offit's opinion pieces (where it is difficult to evaluate the level of bias).

The only document relating the Poling case that is provided on the Vaccine Court's website is at http://www.uscfc.uscourts.gov/sites/default/files/CAMPBELL-SMITH.POLING041008.pdf
It states,
“The undersigned [special masters] directed respondent to file a status report after reviewing Dr. Zimmerman’s expert report that addressed respondent’s position regarding petitioners’ claim that Hannah’s seizure disorder was vaccine-related. Petitioners filed the expert report from Dr. Zimmerman after the status conference. Respondent’s review of Dr. Zimmerman’s expert report…On February 21, 2008, respondent filed a Supplemental Rule 4 Report addressing. The respondent stated that “[h]aving reviewed this additional evidence, medical personnel at the Division of Vaccine Injury Compensation, Department of Health and Human Services (DVIC)] now recommend compensation for Hannah’s seizure disorder as sequela of her vaccine-injury in accordance with 42 U.S.C. § 300aa-11(c)(1)(C)(ii).” Id. at 2. Based on respondent’s concession, a damages determination is now underway in this case.”

Please note that the report states that a single respondent, rather than a team of DHHS experts, was asked to review the case (using the files provided by Hannah’s doctor0. The document does not mention the identity of this respondent. He or she could be a member of ARI or Generation Rescue, for all I know. Then the special masters made the final decision. Your account of what happens does not correspond to the account written in the document (See page 2). However, there may additional documents that I cannot locate, so I will look at those, if you know of any.

You seem to make more factual errors about the case of Andrew Wakefield: "Many of Wakefield's co-writers testified in court that he had falsified data, and 10/13 authors retracted their names from portions of Wakefield's most significant study, stating "We wish to make it clear that in this paper no causal link was established between the MMR vaccine and autism, as the data were insufficient.""I am interested in which trial of Dr. Wakefield anyone testified that data was falsified? I suspect you're incorrectly referring to the Omnibus hearing (which you yourself stated was unscientific) which did not involve Dr. Wakefield at all. Allegations against him were made despite the fact he was not a participant in the hearing, and thus he had no opportunity to rebutt the accusations. It would be good for you to clear up this allegation of yours, because as it stands, your statement does not match the facts that I am aware of. Given the diligence of most of your post, you seem to be making quite a few errors around the legal and personal aspects. I can only assume that you have been swayed by the many biased writings of these events without actually understanding the details of the events that unfolded. Wakefield is currently undergoing a GMC fitness hearing in the UK but no transcripts have been published and no verdict delivered so your conclusions appear a bit premature.

You are correct. I apologize for the error, and have placed a correction it in my previous post. Chadwick had testified at the Omnibus Hearing, not at a trial related to Andrew Wakefield. (I confused this case with the hearing for professional misconduct that Wakefield is currently undergoing at the General Medical Council in the U.K.) The extraordinarily detailed testimony against Wakefield, by the primary researcher who had carried out the experiments is quite damning, nonetheless. Please see part of the transcript at http://breathspakids.blogspot.com/2007/06/patrick-holford-and-dr-andrew_28.html
There were other testimonies of many major problems in Wakefield’s research. For example, according to the testimony of Dr. Stephen Bustin, the now defunct diagnostic center that Wakefield used, Unigenetics, claimed to have “detected measles gene using a type of PCR that could detect only DNA." (Offit 171)” The measles virus doesn’t contain DNA, only RNA. Please read about the findings of the 2004 investigation of Wakefield’s laboratory at http://www.spiked-online.com/index.php?/site/article/3562/.

You also make two further misleading statements: First, your wording infers that the retraction was significant despite the fact they only retracted the interpretation not for scientific reasons, but public relational ones as they noted in the section of their statement that you ommited. Second, you infer that the lack of a causal finding between MMR and autism was a new revelation, when it was already explicitly stated in the original paper (discussion section page 641). Your selective quoting makes a big deal out of very little just like the misleading press releases on the topic.

Wakefield was very smart in trying to have it both ways: Always saying that nothing can be known for sure (so that no one can pin anything on him), but then making frightening statements about vaccines to the public. Wakefield et. al. were careful to write “We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described. Virological studies are underway that may help to resolve this issue… We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunization. Further investigations are needed to examine this syndrome and its possible relation to this vaccine.”

Every researcher is aware that no medical study can “prove” anything, so it is silly to write “we did not prove,” in a paper. They seem to imply that they have significant evidence, but that this evidence just doesn’t qualify as “proof.” If you believe this argument is just a petty focus on semantics, then please note that Wakefield used every public opportunity, following the article’s publication, to imply that his findings were indeed significant. In an interview following publication of the article, Wakefield says:

“It is our suspicion that there may well be [a link between MMR and what he refers to as “this syndrome”] but that is far from being a causal association that is proven beyond doubt… Again, this was very contentious and you would not get consensus from all members of the group on this, but that is my feeling, that the, the risk of this particular syndrome developing is related to the combined vaccine, the MMR, rather than the single vaccines…. Again, this was very contentious and you would not get consensus from all members of the group on this, but that is my feeling, that the, the risk of this particular syndrome developing is related to the combined vaccine, the MMR, rather than the single vaccines…Well, the interesting thing is that the damage, the behavioural or developmental change tends to occur quite soon after administration, and this is where, why parents or GPs or paediatricians have been able to make the link, the association with MMR.”

These sound like pretty ominous warnings for an article whose authors are extraordinarily cautious and humble about the significance of their findings. Wakefield even held a press conference about this issue, which prompted segments of the British public into mass hysteria. Vaccination rates fell dramatically, and the incidence of deaths from measles rose.

We may disagree about the significance of the retraction. There were multiple flaws in the study, with or without the retraction. Because you feel that I was omitting information, here is the portion of the paper, to which you refer:
“We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. However, the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent.”

"However, these claims have been investigated (Ten studies to show MMR doesn't cause autism. Six that show thimerosal doesn't cause autism, etc.)"
Going back to this quote, I want to continue driving into the studies you reference through Dr. Offit. First, I'm surprised at your use of such a definitive statement (doesn't cause autism) that really can't be supported by any scientific studies of epidemiology. The conclusion that doesn't cause Autism isn't even that interesting really. We want to know if it contributes to damage including autism (or other problems). The case of Hannah Poling is a great illustration that vaccination alone did not cause the damage, but it certainly appears to have triggered and exacerbated it.

I only addressed the autism issue. If you feel that autism is only of many disorders caused by vaccination, and that autism is the least “interesting” among them, then I guess it’s the anti-vaccinationists' lucky day, because I have no energy to refute the link between vaccines and dozens of different disorders. Yes, you are correct. The studies did not (and cannot) conclude “thimerosal doesn’t cause autism.” I intended to say that we have an extremely low level of uncertainty that vaccines do not cause autism. Please read my last post, in which I spoke about how one can never reject a proposed null hypothesis. See my Xenu example.

This is particularly pertinent with Thimerosal and this leads to my original questions at the top. If you read the details of these studies, you'll find that the two founding components are data on the prevalence of Autism and the estimated cumulative exposure of Thimerosal during infancy. I hope you've read critical reviews of the studies quoted by Offit, and the data they're based on. If you aren't aware, there is wide disagreement on the reliability of the Prevalence data, and there are significant known issues with the Danish Registry, the UK's GPRD, and the US databases over the period of time studied. I recommend at least finding and reading some of the statistical arguments against the use of prevalance numbers in these studies. As you should know, the role (and bias') of the statistician is critical in influencing the outcome because numerous assumptions and adjustments must be made in these studies which are already subject to a high risk of false positives and negatives. When working with difficult, inconsistent, or incomplete data (sometimes withheld from independent public analysis) the knowledge of conflict of interest is quite important.

Yes, I read the critical review on the Danish study of 500,000 children (see links above). Just yesterday, Italy released a study stating that there was no link between autism and vaccination. I don’t believe that the statisticians in all of the different countries, for in all of the different studies are part of some vast conspiracy. Of course, in any discipline (perhaps excepting math), there can be biases introduced in a study. However, these studies generally feature good epidemiological study design. I don’t understand how people who oppose vaccination can be so demanding about the standards of these studies, when they rely primarily on case reports or research from faulty databases (Such as the Geiers’ use of the VAERS database) There is no flawless epidemiological study that shows smoking causes lung cancer. However, I’m sure we can agree that the epidemiological data from around the world have added up to demonstrate clearly that smoking causes lung cancer. Now all of the studies are adding up, and they refute a vaccination/autism link.

The other issue is that these studies only look at the cumulative exposure over a long period of time. We know that the timing toxic exposure to virus' (CRS is a great example) or toxins in fetus' or infants can be quite significant in determine the outcome of damage. We also know that very low levels of heavy metal exposure can also have a significant effect neurological outcomes (ex. lead: http://www.ehponline.org/docs/2005/7688/abstract.html). None of these factors are even remotely considered in these studies, yet you and others including Offit make definitive statements like "doesn't cause Autism". They only studied cumulative dose to be the defining factor, an assumption that does not hold up all the time on it's own. Another aspect that is often ignored (and Contrary to Dr. Offit's published opinion in peer-reviewed journals) the concomitant application of vaccines (MMR and Thimerosal containing) are not actually required study for pre-regulatory approval and generally remain unstudied from a safety perspective. (http://www.cdc.gov/vaccinesafety/00_pdf/draft_agenda_recommendations_080404.pdf)

No matter when the vaccination occurs, if vaccinations indeed caused autism, we would find a difference between the vaccinated group and the control group. Even if we miss a lot of diagnoses by failing to follow everyone to late adulthood, the cases missed should be equal in both groups (or perhaps even greater in the control group- parents of kids who have vaccines are more hypervigilant, due to their concerns, and would likely notice autism symptoms earlier), so this wouldn't skew the results toward the null.

Thus, I don't think that following vaccinated people for a very long time is necessary, unless you believe that vaccines are only responsible for autism diagnoses that become apparent after childhood. In that case, we would see a difference in autism rates, only if we followed children all the way to adulthood. Sounds far-fetched.

Or perhaps you're implying that, even if mercury doesn't cause autism, it does cause neurological disorders that are only apparent adulthood? These new claims about non-autism related neurological disorders are a whole different topic. I don't know why there is a new idea about vaccines every day! Anyway, the absence of a link between vaccination and (non-autism) neurological disorders have been addressed in at least three studies (see Offit 247)or H. Frankel. "Report finds no link between thimerosal and neurodevelopmental disorders." The Lancet, Volume 358, Issue 9288, Pages 1163-1163

In reference to the notion that metals and other hazards are all around us, I don’t see how that would influence the results. Both vaccinated and unvaccinated kids would be exposed to such metals, so we would still need to see an increased incidence of autism for vaccinated kids. Your premise would require that vaccinated kids are subject to fewer “heavy metals” in their daily lives, and that this is the reason why the incidence of autism is equal in the vaccinated and non-vaccinated groups (i.e. the non-vaccinated group got all of their “heavy metal poisoning” from the environment, but vaccinated kids got their's from vaccines, so now the incidence is equal). This sounds farfetched, and is practically irrelevant, because it doesn't matter what would "cause" one's autism, if the chances of "acquring it" are the same, no matter the ubiquitous exposure.

Honestly, I wasn’t aware of the brand new suspicion (i.e. it’s not MMR that causes autism, nor thimerosal that causes autism, but only using the two of them together). After a claim is debunked, it doesn’t follow that a study must be made to investigate an “updated” conjecture. As I said in my last post, whenever new evidence comes along, the proposed causes always seem to keep change.

In terms of environmental exposure, data from the Minamata Bay mercury disaster show that no increased number of children developed autism, which even Aposhian was forced to admit at the omnibous hearing. (He then said that this is because mercury toxicity isn’t dose dependent, and that “This is an ancient form of quotation that until recently we taught in medical schools…we no longer believe that the dose makes the poison”) See Offit 166 and http://www.huffingtonpost.com/arthur-allen/in-autismvaccine-case-r_b_52408.html.

From my perspective that type of language is unsubstantiated by the reality of the limitations of the studies. The fact that Dr. Offit regularly makes public statements of this type (in addition with factual error that require correction) significantly hurts his credibility and I argue exposes his bias. Overstating the conclusions of scientific study, especially ones based on weak data is a reccuring issue. As for MMR, I suggest you read the Cochrane systematic review of MMR studies from 2005/2006: http://www.cochrane.org/reviews/en/ab004407.html.
After reviewing an extensive list of "definitive" MMR studies performed over several decades, they concluded that the study of both efficacy and safety was inadequate. If you read the details, (I suspect you'll find several of Dr. Offit's references in there) you'll see findings of serious methodological issues with seemingly "credible" study also heralded historically by regulatory bodies as "definitive". From this perspective you might understand why I remain skeptical of definitive claims issued by the likes of Dr. Offit.

You are correct that none of the 139 articles fulfilled all of Cochrane’s inclusion criteria. I don’t know how you think a better epidemiological study could be designed, which would adequately fulfill the exacting criteria. No study that is currently being proposed by anti-vaccinationists could possibly suffice, so we would be wasting money if conforming the Cochrane standards was their primary goal. Epidemiological studies have a lot of disadvantages, in comparison to controlled environments with drosophila insects or rats. The Cochrane study does recommend vaccination and says, “Exposure to MMR was unlikely to be associated with Crohn's disease, ulcerative colitis, autism or aseptic meningitis (mumps) (Jeryl-Lynn strain-containing MMR). We could not identify studies assessing the effectiveness of MMR that fulfilled our inclusion criteria even though the impact of mass immunization on the elimination of the diseases has been largely demonstrated… No credible evidence of an involvement of MMR with either autism or Crohn's disease was found.”

Overall, I think there is plenty of justification of continued study. None of these studies you referenced ever examined the long term effects of either MMR or Thimerosal exposure in any RCTs (or as close as we can get given ethical limitations). We know from recent history (HRT being a prime example) that large long term studies often reveal unexpected negative outcomes in treatments assumed and shown to be safe by previous regulatory studies.

There are lots of claims we haven’t studied. In a world of unlimited abundance, I'd say, sure let’s have continuous studies about everything. A million studies. Regardless, NIH-funded studies are currently underway to examine this issue, and many more are planned, so it is a mute point.

"As I wrote on my other post, learning about the experiences of my patients and their families will be crucial for my providing good care, but is not relevant to science-based medicine (excepting in the use of case studies, which have limited value, and which are generally only used to develop hypotheses)."
This is an interesting opinion which I would like to examine outside of the vaccine discussion. Expert opinion still plays a role in evidence based medicine (which is what I assume you meant when using the term "science based medicine"). Cumulative clinical experience forms the heart of expertise. I am concerned that you also dismiss the value of clinical experience in detecting problems. It is exactly the detection of patterns of anecdote that usually lead to further study of issues. The other important factor is that repeated follow-up into similar individual cases may reveal biological mechanisms which can (and should) also be used to form a hypothesis. The fact that disease reporting is mandated by law, yet pharmaceutical adverse event follow-up outside of research settings is voluntary are rife with error is a sad reflection on our priorities in my opinion.

You are incorrect that I dismiss the value of clinical experience in detecting problems. Gaining clinical skills in how to recognize signs and symptoms, in order to form a diagnosis is quite different than assuming to know the etiology of an insufficiently studied disease. A good doctor might develop the clinical skills to recognize autism, but this does not mean he has any knowledge what caused it. Recognizing this requires some humility on the part of the clinician. Yes, I’ve mentioned that case studies, or any other observations, can be used to form a hypothesis.

Again, thank you for bringing a refreshingly politeness to the discussion. I wish you success in your studies. My only suggestion is to drill into the details of the assumptions underlying the evidence you use to justify closing the door on further research. Given the significant challenges facing our newer generation of doctors, I think you should drill into the well documented issues (plenty of peer review studies on this topic) with industry funded peer-review studies, and into the details of the impact that bias can have on statistical analysis. You might find (like I did) that the conclusions you're quoting are based on a lot more assumptions and questionable source data than you would like. (the latter not the fault of the authors, but on the lack of interest/diligence by medical regulatory authorities).
Potential Bias: I have two healthy NT children, one partially vaccinated (older), one unvaccinated (younger)

Thank you “Schwartz.” If you respond to this, I’m going to have to let you have the last word. My adventures in autism blogging are putting a cramp my non-school-related life.

Take Care,
Adina

Response to Anti-Vaccination Parent

2009-01-27T23:00:00.000-08:00

Ginger Taylor, the parent of a six-year-old son with autism, wrote a lengthy response to my previous post, "The Disappointment of Hearing 'Your Results Don't Matter.'" Ms. Taylor sounds like a woman who is truly dedicated to her son's successful development. However, I still find a number of Ms. Taylor's contentions to be unfounded. I am responding to her comments, albeit with a bit of hesitation. I am not an expert on the subject of autism, and do not wish to misrepresent the scientific community. If there are any mistakes, they are solely my own. Here goes:

You seem to have made an assumption here, that certainly would be a reasonable one if Paul Offit and his compadres are your main source of information on biomedical intervention for autism. And that seems to be that just because Jenny McCarthy didn't present the kind of evidence you are looking for to prove the efficacy of the treatments she used when she was on Oprah, and just because Offit says there is none, that they don't exist.

Perhaps it's true that there is better evidence than that which Jenny McCarthy presents("My science is Evan, and he's at home. That's my science¹"). However, I honestly haven't seen such evidence. I've read a lot of anecdotal accounts of "miraculous" recoveries, "immediate" personality changes following administration of the MMR vaccine, and emotional appeals to the public's sense of outrage, but nothing that comports to the standards of science. Advocacy groups, such as Autism Speaks, the Autism Research Institute, and Generation Rescue, all feature many studies of very poor quality, and I can only assume that what they present is the "best evidence they've got."

I am the mother of a 6 year old that regressed into autism following his 18 month vaccinations and have gotten him about halfway back with the evidence based interventions that Offit has derided.

How do you know that you haven't gotten him "back" (I assume you don't mean "cured") simply due to good parenting? Effective behavior modification techniques? A good social environment? There is no way to know if your child improved due to any specific intervention. Don't sell yourself so short. I'm sure that your son's success has a lot more to do with the time and devotion you dedicate to him than to anything that anybody's selling you. There is a long history of blaming autism on "bad mothering²."Parents should feel pride in their children's progress, rather than (unfounded) guilt due to a feeling that they've exposed their children to something harmful.

Offit is not a good source on autism treatment (he does not even treat children with autism, he is an infectious disease specialist), and his vast conflicts of interest should be raising huge red flags for you.

-He is a vaccine patent holder who won't say exactly how many millions he made from RotaTeq, but says it was like "winning the lottery".

-He was reprimanded by Congress for his ethical breaches and conflicts of interest when as a member of the ACIP failed to abstain, but rather voted to put RotaShield on the CDC schedule, effectively creating a market for his own vaccine by insuring that it would go directly into doctors offices nationally the day after it was approved.

-RotaTeq is arguably the least important vaccine on the schedule for children to receive as Rota virus represents a minimal health threat to American children. (CDC's web site recommends that it be treated with rest and Pedialite). If Jenny's message that kids are getting "Too Many, Too Soon" is taken seriously and adopted, and the vaccine schedule is paired down, certainly RotaTeq will be the first to go as it has been confirmed that it causes Kawasaki's disease and fatal Intussusception.

-He has been publicly and repeatedly corrected for spreading misinformation and inaccurate statements about the cases in the vaccine injury compensation program, most notably this past year in both the Wall Street Journal and the NEMJ.

-He is currently being sued for libel by at least one person he wrote about in the book.

-Although he is quoted at least weekly claiming that vaccines have no relationship to autism, he almost never discloses that he is a vaccine patent holder and has major conflicts of interest. CBS News even did a piece on his failure to disclose (Along with AAP and Every Child By Two. And it turns out Amanda Peet is even being paid by Wyeth for her vaccine promotional spots).

-He routinely makes outlandish and irresponsible remarks such as his famous, "theoretically a baby can receive 100,000 vaccines at once safely" absurdity (I wrote to him the first time I saw this in print and was sure it was a misquote, and asked for a corrected quote from him. He replied that it was a correct quote and "that is probably a conservative number".)

(To be frank, we can't under stand why anyone takes him seriously, and suspect that it is his mere bravado that has prevented people from cluing in to the fact that he is not responsible physician.)

So given all the potential for bias here, don't you think that it might be wise to take a hard look at the other side and make sure that the information he is giving you is reliable and complete?

Perhaps Offit is a mean, greedy man, who enjoys slandering people, and who is simply trying to make more money from his Rotavirus vaccine. I don't know him personally, so I have no specific objections to these claims. The problem is, I don't care about Offit's personality or accomplishments or lack thereof. My only concern is whether or not the statements about autism that he states in his book are factual. Luckily, if I'm suspicious about potential conflicts of interest, I can investigate all of his claims independently, as Offit has provided 32 1/2 exhaustive pages of footnotes in his book, all of which refer me to all of the relevant papers and transcripts. If you can show me a place in his book where Offit

1) Falsifies information from these references AND
2) Such falsification is so damning that it undercuts his basic argument (i.e. invalidates the heap of evidence that he provides in the other 246 pages in his book),

then I would certainly take this objection seriously. But none of the arguments presented above satisfy either of those conditions, as they only address why Offit might want to falsify information, not whether or not he actually did so.

(Parenthetically, please know that intussusception occurs spontaneously in approximately 1 out of 2,000 healthy young infants and children per year. The fact that Rotateq may cause intussusception (bowel obstruction) in 1 out of 12,000 patients must be weighed against the fact that the vaccine is generally administered in developing countries, where approximately 475,000–580,000 children die from rotavirus infection each year, according to the WHO. All treatments (and human actions) have costs. You must compare these costs to the corresponding benefits).

Because it is not like you have just one mom, Jenny McCarthy, standing up in public and claiming that she recovered her son from autism using these methods, the same year that her book came out, 2007, the Autism Research Institute documented more than 1,100 cases of kids loosing their autism diagnosis following biomed.

The plural of anecdote might not be data, but is a hell of a clue that any honest, earnest, evidence based loving clinician would be remiss not to examine, to put it politely. Criminal might be a better characterization.

Unfortunately, the studies propagated by the Autism Research Institute do not nearly satisfy the conditions of evidence based medicine. Let's look at one oft-cited ARI-sponsored article: "Effect of pioglitazone treatment on behavioral symptoms in autistic children⁴" in Journal of Neuroinflammation, written with co-contributors Stephen Edelson and James Adams of ARI.

Even after a cursory reading of this article, I find that the study included only 25 children, with no indication about whether the research subjects were recruited randomly or from a population that already subscribes to the researchers' theories. Most importantly, the study featured no control group. Scientific Method 101 says that you can't test a hypothesis without having a control. P values were not reported, so there is no way of determining whether the findings were statistically significant or simply occurred due to random chance. In fact, the authors themselves only conclude only that there should be "further testing," a viewpoint that they presumably shared even before writing the article.

Some people outright deny that the scientific method is a meaningful means of testing alternative medicine. In certain ways, I find the "research" of the ARI to be more pernicious. Their work has the cloak of science, and would seem quite convincing to someone who has no background in basic study design. I probably just prefer the people who outright claim that the scientific method is irrelevant, because at least they're being honest about their beliefs.

I know that you believe that it is "criminal" not to further investigate the claims of people who believe in the vaccine/autism link, because of the shear number of complainants. However, these claims have been investigated (Ten studies to show MMR doesn't cause autism. Six that show thimerosal doesn't cause autism, etc.) ⁵ More importantly, even if there hadn't been so many studies, I reject the notion that "any honest, earnest, evidence based loving clinician would be remiss not to examine" this issue, simply because many people believe in it. I will not "investigate" the claims of HIV denialists. Mass hysteria is a common historical phenomenon. If you are interested in reading an account of hundreds of people who were (erroneously) so convinced that they had been infected by a virus, that they actually began to experience symptoms of nausea and vomiting, please refer to Desenclos, J.C., Gardner, H., & Horan, M. (1992). "Mass Sociogenic Illness in a Youth Center." Revue D'Epidemiologie et de Sant, Publique, 40, 201-208.

Even if i had not reviewed some of the relevant literature, one hint to me that these vaccination claims are baseless would be the fact that the proposed pathophysiology constantly changes, while the culprit remains the same. Originally, it was proposed that the virulence of MMR stems from an infection caused by harmful proteins from the attenuated measles virus that reach the brain⁶. Others then said that MMR induced autism via an "autoimmune phenomenon⁷." Then others started to relate autism to thimerosal, saying it was due to mercury neurotoxicity, or perhaps thimerosal's binding to testosterone, which leads to hyperandrogenism⁸. Today, many activists acknowledge (or at least don't deny) that the vaccines are generally safe, but say that they just should not be administered to kids below a certain age, or that too many vaccines should not be administered during a short period of time (i.e. "Too Many, Too Soon"). The proposed mechanism and subsequent recommendations constantly shift and adapt with new evidence, but never actually disappear.

"her case is scientifically irrelevant, so long as it was not added to long list of comparable patients of a similar demographic."

So ask yourself, if Offit and CDC and AAP and the vaccine industry are so keen on insuring vaccines don't cause autism, and why have then not take Evan and those 1,100 kids, put them in a long list and compare them to patients of a similar demographic? (Why is there no study comparing kids with an autism diagnosis who undergo biomed with those who don't to see how functional they are at age 10 or so?) Jenny has repeatedly called CDC and asked them to examine her son and all the kids like her son, yet they have never contacted her or ARI or any of the parents who have before and after videos all over the internet showing their recovery stories.

Does that lack of curiosity raise any red flags for you?

Do you think that if one medical practice (much less several dozen) announced they had 1,100 cases of people who recovered from HIV/AIDS, all with evaluations, test results, medical records and videos to prove it, that CDC et all would collectively yawn, quote Brinner, claim it is not data and never even pick up the phone to see if an actual cure had been found? Even for just some cases of HIV/AIDS?

Not in a million years.

(...and if that ever happened, San Francisco would burned to the ground by protesters).

So why is it that with all the claims of vaccine regression and subsequent recovery, are you satisfied with the "no association, no know cause or cure" line from the very people, Offit, HHS, CDC, AAP et al, who would be held responsible and be out of their collective posteriors for causing the autism epidemic if it turned did out to be the vaccines?

Especially when they are not showing up in our community to evaluate our claims and examine our kids?

Especially when they are doing everything possible to prevent REAL vaccine research from being done. Like just three days ago when the Federal members of the IACC voting NOT to study vaccine causation" with the funding from the Combating Autism Act (in opposition to the community members, autism parents, who wanted the research done), one of the regional intents of which was to study the possible association between vaccines and autism.

Ask yourself, why won't health authorities do a simple study comparing vaccinated and unvaccinated children, to look for overall health out comes and see if kids vaccinated according to the CDC schedule have more autism, ADD, asthma, diabetes, arthritus and other neurological and immune disorders?

Why does a Congresswoman have to propose a bill to force NIH to do the study? Shouldn't they want to do it? Certainly there are more and more unvaccinated kids out there to study, and if in fact Offits claim that there is absolutely no association is true, then it can only improve vaccination rates to put a study out that can make the claim with authority.

And why... when no such study exists, can anyone make the claim that vaccines don't cause autism? Vaccines as a whole have never been studied, merely a few different aspects of the vaccine program. And they have been studied quite poorly in many cases.

I do not know why you believe the vaccination-autism claim has not been and is not being investigated. The NIH currently has four studies being performed on the subject, in addition to the many studies that already have been performed in a number of different countries. Many thousands of records have been analyzed, with every study concluding that there is no link between autism and MMR or autism and thimerosal. Japan, when it discontinued the use of MMR, did not see any subsequent decrease incidence of autism diagnoses.⁹ Additional studies might be initiated when the six “Centers for Excellence in Autism Research" are created with money from the Children's Health Act of 2000. Millions and millions of dollars have been and will be spent to investigate this unfounded assertion. This money could be better spent on studies that would investigate credible "leads" about the causes of autism (such as the excellent work of the Autism Genome Project).¹⁰

If you feel that these studies are still insufficient, all I can say is that there is only so much money we can use to chase after every proposed claim. If we performed studies to investigate each person's purported "cancer cure," we'd be left with non-useful confirmations of what we already know (i.e. that virtually all of these claims are bunk). Such studies have enormous opportunity costs, as they take away potential funding from plausible hypotheses that stem from prior research and well-reasoned pathophysiological mechanisms, rather than from conjecture. For example, it is a waste of money to study whether or not diluted duck liver cures the flu, (as homeopaths contend)¹¹. At least eating duck liver is harmless. Non-vaccination has led to numerous preventable deaths in developed countries in the 21st century.

I erred when I said, "her case is scientifically irrelevant, so long as it was not added to long list of comparable patients of a similar demographic," because I implied that it would make sense to now add Evan's case to a scientific study. A good study would be double-blind randomized, controlled, trial including a random sample of kids with autism, rather than a cherry-picked selection of kids whose parents oppose vaccines, or whose parents who have already used alternative "treatments." Certain information can be obtained from a cohort study (a study where random children with certain conditions who have or have not had certain exposures are simply "followed" to determine outcomes), but these more necessarily require repeated investigation others, as they introduce a greater number of potential sources of error than randomized control trials.

Numerous randomized controlled trials have been conducted on kids with autism to test "natural," "biological" materials. These include the gluten-free casein-free “special diet" (which has only shown to cause bone density loss),¹² ”dimethylglycine¹³, and (hot off the presses, published just last week!) human immunoglobulin therapy ¹⁴. Needless to say, none of these treatments have proven to be effective. An NIH-sponsored study is underway to study the effects of cod liver oil, Vitamin B6, and Magnesium on kids with autism ¹⁵ (These vitamins are currently repackaged and sold -with a trumped up price- as "Super Nu Thera," to parents of autistic children).

You assert that the testimony of thousands of parents satisfied with "biomed" treatment should be more discomfiting to clinicians. However, thousands of parents swore by "facilitated communication," as well as by secretin, and those thousands of parents were proven to have been influenced by the placebo effect (I am not blaming parents. Nearly everyone, including myself, are at least somewhat influenced by the placebo effect). At least 15 studies were performed to test secretin therapy, a treatment once heavily promoted by the Autism Research Institute.¹⁶ All randomized controlled trials demonstrated that the hormone caused no improvement in autism symptoms, in comparison to the placebo.

Some studies simply cannot be performed, because the proposed intervention is already known to be potentially lethal. For example, chelation therapy can be dangerous, even for someone in an acute condition who is already known to be suffering from heavy metal poisoning. When used on healthy children with autism, who have no measurable increase of "heavy metal toxicity," we put children at risk for the fate of Abubakar Tariq Nadama. Indeed, the NIH extensively planned to perform a randomized controlled trial of chelation therapy, and called it off only when the initial animal testing demonstrated that the treatment caused extensive brain damage in rats.

As for the challenge of how we can "make the claim that vaccines don't cause autism?," my answer is we cannot make this claim, just as no one can make any claim with 100% certainty. We use science-based medicine to diminish our levels of uncertainty, until they become extraordinarily low. The fact that we can not, in any study, conclude that the "null hypothesis (in this case, that vaccines don't cause autism) is accepted," does not mean that it makes any sense to favor the alternative hypothesis (i.e. that vaccines do cause autism). For example, let's say someone made a claim that "Xenu...was the dictator of the "Galactic Confederacy" who, 75 million years ago, brought billions of his people to Earth in DC-8-like spacecraft, stacked them around volcanoes and killed them using hydrogen bombs¹⁷." My null hypothesis would be that this event didn't happen. However, I can never affirm this null hypothesis with 100% certainty, just as I can never state "vaccination doesn't cause autism" with 100% certainty.

So... at the conclusion of my long winded comment, I would like to call your attention to Bryan Jepson's book, "Changing the Course of Autism: A Scientific Approach to Parents and Physicians". I would like to encourage you to read it and then look back at Offit's book and see if he actually is taking apart the case for biomedical research or just going after the easy targets like McCarthy, while ignoring the actual biomedical approach to autism and the science to back it up.

You owe it to your future patients to have actually teased out the truth on this for yourself rather than just swallowing what those who quite obviously and transparently protecting professions and individual careers tell you the truth is.

Upon your recommendation, I read parts of Jepson's book. To buttress his arguments, Jepson heavily cites the work of Dr. Andrew Wakefield. Many of Wakefield's co-writers testified in court [CORRECTION 1.29.09: It was not a court trial but an omnibous proceeding for the Vaccine Injury Compensation Program, for which Wakefield was not on trial. I confused this with the British General Medical Council, which is holding a hearing to examine charges of professional misconduct] that he had falsified data, and 10/13 authors retracted their names from portions of Wakefield's most significant study, stating "We wish to make it clear that in this paper no causal link was established between the MMR vaccine and autism, as the data were insufficient." One witness at Wakefield's trial, Nicholas Chadwick, was the research assistant who had actually carried out the tests for the Wakefield's 1998 Lancet paper. He testified in court that, despite the fact that he informed Dr. Wakefield of the negative PCR test results, Dr. Wakefield reported positive findings in his paper.¹⁸ There were a number of such testimonies, despite the fact that Wakefield gave $30,000-$180,000 to expert witnesses who testified on his behalf¹⁹.

(Parenthetically, Wakefield is also under investigation for subjecting children to unnecessary and risky tests, such as lumbar punctures and colon biopsies, which would be inappropriate for any study, so long as these procedures were not medically indicated. An associate affiliated with the study ended up perforating a child's colon in a number of places.²⁰ Some of the actions that Mr. Wakefield is accused of performing, such as handing out cash to children who attended his son's birthday party, and then collecting their blood as samples, are downright bizarre. He failed to use a random sample of children in his studies, using mostly clients of a trial lawyer, Richard Barr, from whom Wakefield had received, on his own admission, at least $50,000²¹).

In other words, I do not find Jepson's book, which heavily references Wakefield's papers (as well as the work of the Geiers, who also performed poor research), to be particularly reliable.

You clearly, clearly want to make the right decisions for your patients. What if the right decision for some of your patients was not to vaccinate them according to the current CDC schedule (clearly it was the wrong decision for Hannah Poling, Madison Hiatt and the thousands of others who have received a billion of dollars from the Vaccine Injury Compensation Fund)? And the right decision for some of your patients with ASD was exactly what Jenny McCarthy did for her son? And what if you never looked into it because Offit etc told you not to bother?

In terms of the Vaccine Court, the fact that those girls got money from the Vaccine Compensation Fund is not particularly relevant, because the cases are not judged based on scientific evidence. A team of lawyers (called "special masters") with no medical background, rather than a judge, jury, scientists, or medical professionals, preside over the cases. The court's guidelines state that “special masters are not bound by formal rules of evidence” and that both sides should “be creative” in presenting their arguments “quickly and less expensively²².”

The court had no way of verifying whether or not Hannah Poling's autism (caused by an underlying mitochondrial disorder) was indeed aggravated by vaccination. Even Poling's doctor, John Shoffner, an expert in mitochondrial disease, was "genuinely puzzled" by the verdict. As far as I'm concerned, the findings of this court have little to do with science.

Bottom line, if you don't look all sides on this and make your own decision (rather than just joining the Orac insult-o-rama), then you risk taking on their crime of injuring children and withholding needed treatment if 'my side' is right.

I urge you, while you are still very early in your career, to take this subject very seriously and listen to autism parents and see if their concerns, questions and challenges are actually being answered by those you are taking your advice from currently. Are they really dealing with them, or just setting up straw men and knocking them down?
I (and many other parents) would be happy to talk to you about what we have learned and experienced and why we believe as we do, should you earnestly want to investigate autism causes and treatments on your own.

As I wrote on my other post, learning about the experiences of my patients and their families will be crucial for my providing good care, but is not relevant to science-based medicine (excepting in the use of case studies, which have limited value, and which are generally only used to develop hypotheses).

I know that "look at all sides on this" sounds neutral and unbiased, and that I should not "risk taking on their crime of injuring children and withholding needed treatment if 'my side' is right." The problem is that I am confident that I would cause more harm if I spent time to "look at all sides on this" and continued to pore over everyone's counterpoint for these debunked claims. I can spend a lot of time investigating whether or not HAART causes AIDS, or whether oleander defeats cancer, and any other medical claim ever proposed. Nobody can independently investigate every contention. However, doing so would detract from learning to read EKGs or chest X-rays, or performing other tasks that are crucial to avoiding future medical errors and providing excellent patient care.

Every one needs a gestalt about which resources to trust, and on what basis to accept information. A method may occasionally fail, but one chooses it because, compared to all other strategies for acquring information, it provides the greatest accuracy for the most important issues, with the greatest efficiency. To me, trusting a random website would be quick, but unreliable. Doing my own experiments on every issue might be reliable, but extremely inefficient. The best method available for clinicians to acquire scientific information is to use books and journals edited by people whom we know subscribe to a similar epistemoligical approach (i.e. commitment to the scientific method), and whom we know are held accountable for their claims, by the scrutiny of peer review. Will people sometimes falsify data or make errors? Yes. However, after a while, repeatability of experiments stops bad or mistaken research in its tracks.

I figure you might think that this is just a battle of "my favorite studies" versus "your favorite studies," and that the abundance of conflicting papers means that we can't know who is correct (which would theoretically render scientific research to be quite useless, on the whole). While controversy and uneven results can indeed be frustrating, I must say that this isn't a matter of my preferentially selecting studies that would help my case. The scientific method requires "appropriate design and analytic methods...critical to achieve meaningful results." Such methods include "definition of exposures and outcomes, validation of developmental diagnoses, provision of sample size calculations and/or discussion of study power, and statistical methods including techniques to control for potential confounding." One study compared a number of epidemiological cohort studies that investigated a possible vaccination-autism correlation, and found that only the study by the Geiers, (which was also the only study that reported a correlation between vaccination and autism) fulfilled zero out of eight epidemiological criteria. There are a lot of seductive "studies," that we may hope to rely upon, but we can still distinguish the good from the bad, especially with the power of repeatability.

Good luck, Ms. Taylor, and I hope your son's development continues to be successful. I have a family member with an autism-spectrum disorder, and I have observed firsthand the amazing dedication and love that parents put in to careing for these wonderful kids.

Footnotes:

1. Jenny McCarthy on Oprah. Interview by Oprah Winfrey, Oprah Winfrey Show, NBC, September 18, 2007. Source from Offit, Paul A. Autism's False Prophets (Columbia: New York, 2008).
2. Bettelheim, Bernard. The Empty Fortress: Infantile Autism and the Birth of the Self (New York: Free Press, 1972). Source from Offit.
3. Offit. 110-111.
4. Boris, Martin and Claudia C. Kaiser, et. al. "Effect of pioglitazone treatment on behavioral symptoms in autistic children." Journal of Neuroinflammation 2007, 4:3. http://www.jneuroinflammation.com/content/4/1/3
5. Please see the pages-long list of studies in Offit 256-7 and 266-7.
6. Letter from Dr. Wakefield to journalist Brian Deer. 12.2.04. http://briandeer.com/mmr/wakefield-st-statement.htm
7. Waisbren, Burton A. "It is time to face up to the problems of MMR vaccination and its possible relationship to Autism." http://www.waisbrenclinic.com/mmr-autism.html
8. Geier, David A. and Mark R. Geier. "The Biochemical Basis and Treatment of Autism: Interactions between 3 Mercury, Transsulfuration, and Androgens." Autoimmunity Reviews. Retracted by publisher before publication. Available at http://briandeer.com/wakefield/geier-mark.pdf
9. Honda, Hideo and Yasuo Shimizu. "No effect of MMR withdrawal on the incidence of autism: a total population study" Journal of Child Psychology and Psychiatry. 46:6. 572-579. http://www3.interscience.wiley.com/cgi-bin/fulltext/118735419/HTMLSTART Source from Offit.
10. The Autism Genome Project (AGP) Consortium. "Mapping autism risk loci using genetic linkage and chromosomal rearrangements." Nature Genetics. Published online: 18 February 2007, doi:10.1038/ng1985.
11. Vickers AJ, Smith C. "Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes.", Cochrane Database Syst Rev. 2006, Issue 3. Art. No.: CD001957.
12. "Autism in Celiac Disease: Failure to Validate the Hypothesis that a Link Might Exist." Biological Psychiatry. 42(1997):72-75. See other sources in Offit 270.
13. 5. Bolman, William N., John A Richmond. "A Double-Blind, Placebo-Controlled, Crossover Pilot Trial of Low Dose Dimethylglycine in Patients with Autistic Disorder," Journal of Autism and Developmental Disorders 29:3 (1999) 191-194
14. 7. Handen, Benjamin L. and Raun D. Melmed. "A Double-Blind, Placebo-Controlled Trial of Oral Human Immunoglobulin for Gastrointestinal Dysfunction in Children with Autistic Disorder," Journal of Autism and Developmental Disorders
DOI 10.1007/s10803-008-0687-y. http://www.springerlink.com/content/r741394286415x84/
15. "Treating Oxidative Stress and the Metabolic Pathology of Autism" Arkansas Children's Hospital Research Institute. ClinicalTrials.gov Identifier: NCT00572741.
In recruitment stage.
16. A.D. Sandler, K.A. Sutton, et. al. "Lack of Benefit of a Single Dose of Synthetic Human Secretin in the Treatment of Autism and Pervasive Developmental Disorder," New England Journal of Medicine 341 (1999):1801-6. See other studies mentioned in Offit 251-2.
17. Wikipedia article on the Scientology figure, "Xenu." http://en.wikipedia.org/wiki/Xenu
18. United States Court of Federal Claims. Docket Number 98-916Vftp://autism.uscfc.uscourts.gov/autism/transcripts/day10.pdf
19. Full Legal Services Commission Report obtained by Brian Deer via Freedom of Information Act. Available at http://briandeer.com/wakefield/legal-aid.htm
20. R. Ellis, "₤500,000 Payout for Autistic Boy Left Fighting for Life After Being Used as an MMR Guinea Pig." Daily Mail. December 8, 2007. Source from Offit.
21. MP3 audio available at http://briandeer.com/mmr/wakefield-archive.htm and sources cited in Offit page 258.
22. "Guidlines for Practice Under the National Vaccine Injury Compensation Fund." The Office of Special Masters. United States Court of Federal Claims. Available at http://www.docstoc.com/docs/831292/Guidelines-for-Practice-Under-the-National-Vaccine-Injury-Compensation-Program Source obtained from Grant, Andrew. "Inside the 'Vaccine Court.'" Scienceline. http://scienceline.org/2008/07/25/policy-grant-autismvaccinecourt/

The Disapointment of Hearing "Your Results Don't Matter"

2009-01-16T02:48:00.000-08:00

I am not categorically opposed to "alternative medicine," provided that each accepted treatment is properly tested in an ethical and scientifically sound manner (but I just call using acidic Vitamin A to treat acute promyelocytic leukemia plain old "medicine"). However, friends will sometimes advocate for a particular alternative therapy, be it a tincture, muscle manipulation technique, or adjunct cancer treatment, with the the promotion "My relative tried it and she had great results." To which I usually just respond with, "Cool, Thanks."

I respect the intelligence of my friends, and thus usually speak up and engage them in conversation, when I find something they say to be questionable. However, I keep mum when facing a statement about a close one's personal recovery. There is simply no polite way to say "The experience of your relative does not matter."

I am certainly happy if a friend's loved one recovered successfully from his or her illness. But the fact of his recovery has a less than minuscule effect on my views concerning the value of the treatment. I have no idea if the recovery was because of the treatment, despite the treatment, or for some completely unrelated reason. I say a "less than minuscule", rather than a non-existent effect on my confidence in the medication, because the anecdote does teach me "At least one person was able to recover from his illness while (but not necessarily as a consequence of) using this treatment (Treatment A)." The practical effect of this knowledge would be that, were I placed in a hypothetical situation, in which I had to quickly save someone by choosing between said Treatment A or Unknown Treatment B, I would probably preferentially grab Treatment A. I don't anticipate facing such a "deserted island"-like scenario in my lifetime, so I can safely say that I would be no more or less likely to use Treatment A in practice.

I wonder if the harshness of the objection is what makes some people resistant to evidence-based-medicine. What we are basically saying that no matter how much someone suffered, and no matter the magnitude of her eventual breakthrough, her case is scientifically irrelevant, so long as it was not added to long list of comparable patients of a similar demographic. People want to feel like their experiences matter. Nobody wants to simply be a statistic.

The problem is that treating people as individuals, and caring deeply about the welfare of one patient, both requisite components of empathy-based-patient care, are not pertinent components of evidence-based medicine. It is when we take the good intentions of the former, and impose them upon the cold calculations of the latter (or vice-versa), is when we start to provide medical care that is less efficacious, and less empathic, respectively. Empathy requires a dogged commitment to the patient and his relatives, science involves an exacting focus on anonymous people whose names will never be disclosed. Perhaps it is this intense desire to celebrate the personal, rather than the abstract, that drives us to make crucial cognitive mistakes.

While I am angry that Jenny McCarthy's "advocacy" work may harm many children, her biases seem to stem from natural human feelings that arise to deal with uncertainty, to maintain control over our environment, and, most of all, to find personal meaning in our experiences.
I am currently reading Paul Offit's wonderful book, "Autism's False Prophet's," which transcribes Jenny McCarthy's statements on Oprah, including this response to a question:

"My science is Evan, and he's at home. That's my science." [Loud, thunderous applause].

I honestly am not mocking Ms. McCarthy when I say that I wish I could point to the difficult experiences of loved one's illnesses and call them "my science." But no matter my sympathy of the motivations, it is irrational, nonetheless. And it could potentially cause enormous harm.

Paul Offit also presents the transcription of a doctor name Dr. Geier, who testified against vaccinations in court, and who had been peddling his own untested autism medication called "Lupron." Dr. Geier said,

"We presented a new idea on how to treat autism and how to treat mercury poisoning, because these kids aren't autistic, they're mercury poisoned. Although I'm not happy with trying it on children without further research, these people are desperate and there have been some remarkable responses."

"Remarkable responses," "Try it: He had good results," "My family is my science": All of these are erroneous statements that are damaging to health care. One must develop the humility necessary to accept the limited applicability of one's experiences and observations. This is a difficult bias to overcome. But to do so is necessary, because, as Roger Brinner brilliantly quipped, "The plural of anecdote is not data."

Adding Worse Doctors, Getting Better Medicine?

2009-01-14T13:27:00.000-08:00

Edwin Leap worries that, if doctors no longer earn a decent profit, the best and brightest will find no good incentive to enter the healing profession.

He writes:

Physicians have to be paid well in order to continue to practice medicine. It wasn’t always this way. Because, there was a time in modern medicine when the rewards of the practice of medicine were considered higher than mere cash. Why did early physicians expose themselves to epidemics and death? Why did they go to battlefields and learn surgery? Why did they labor with the miserable and poor? Because they sensed the value of human-kind. They were taught, and believed, that every life was valuable in God’s eyes, and that if they ignored their calling, and ignored suffering, they would face God’s wrath. They also believed that if they did right, if they endured under hardship, if they died of the diseases they fought against, they would be rewarded by their Creator.

We are too modern for all that, now, aren’t we? We don’t need mumbo-jumbo, irrational, anti-scientific theories about human worth. We’re post-moderns! We will do right, because it’s good for mankind and good for society and because our reward will be…well, it will be science and knowledge…I mean, it will be the survival of all the fittest for the collective good of mankind in a few eons…it will be…a good review from my boss and a nice retirement with a boat…it will be a vacation and a car and….well, some money will do nicely, if you please.

Reject transcendence if you will. But if you do, prepare large boxes of cash. Because doctors without a sense of temporal and eternal purpose will have to be rewarded financially in order to stay in a long, arduous educational system, in order to work all hours, in order to expose themselves to risks physical, emotional and legal and in order to come back day after day to a job that is sometimes amazing but often quite tedious and frequently quite maddening.

Given that it may make more sense, from a purely economic perspective to become a UPS driver than a doctor, and that the average GPA of pre-medical school matriculants is still about a 3.7, the risk of a sudden doctor dry-up is rather low. I am not sure if it is due to a continuous devotion to "transcendence," but Pre-meds are still undergoing Fear Factor level feats to contest for every last available medical school chair in the country. When all else fails, many pack their bags for four sunny years in Grenada.

The unaccepted applicants are, all things considered, less-qualified on average. Some unaccepted applicants bombed their MCATs, some got a C in Orgo Sophomore Year, some had a stain on their tie during their interviews, and some were simply "more average" all around.

Would these potential physicians be worse doctors than the current matriculants, assuming economic conditions lured the smartest college students to law, business, or package delivery? Perhaps. However, the brutal admissions process doesn't measure some of the most crucial skills necessary to become a doctor: Good patient rapport, observation skills, manual dexterity, superhuman ability to function without any sleep, a healthy self-esteem that can endure frequent criticism, and the motivation to keep up with the latest in science-based medicine (a criterion that automatically excludes many working spinal surgeons). There is no reason to believe that Team A possess these skills to a much greater extent than Team B.

Let's say, however, that the currently shut-out applicants would actually become inferior doctors. Maybe they'd miss a few more crucial diagnoses, screw up a few more procedures, or show up to work with that stained tie, every single day. . The fact is that the stuff they do right might outweigh the probability that they would make a few more mistakes. In other words, while medical errors are an enormous problem, many people do not even have the opportunity to be at risk of being victims of medical errors. They do not have doctors, period, and have no chance to be diagnosed and treated, altogether. If you see the slow-growing elephantiasis and massive tumors being sported in our ED's waiting room, you'd see what I mean.

Imagine a mediocre doctor who goes into a small town with no primary care physicians. The doctor misses a few diagnoses, but also recognizes a whole bunch, all of which would have been undetected otherwise. He administers a lot of STD tests, and performs tons of vaccinations. All things considered, I'd say it's a win.

In other words, we shouldn't only focus on the quality of doctors. Even the best doctors can only see so many patients. Those physicians should be doing the trickiest procedures, managing the most complex clinical cases, and addressing actual emergencies. But let's allow nurse practitioners, physician's assistants, and less-stellar doctors to take care of everyone and everything else. Because poor people without any medical care could really benefit from a lot more "good enough."

HT: Kevin, M.D.

Radiolab on Choice

2009-01-06T14:00:00.000-08:00

Today I listened to a podcast of "Radiolab," the WNYC show hosted by Jad Abumrad, the voice and inflection clone of that other NPRish guy who does "This American Life (Does that voice trainer do some standard laryngoplasty on everyone?) The experimental music and sound effects alone provide a worthy opponent to TV, despite the inability to exploit one of our senses. The topic of the day was "Choices" and the potential psychological perils of its abundance.

People, like myself, who read lots of "happiness studies books" (which is distinct from reading self-help books. Not that there's anything wrong with that...) will recognize some of the usual players who are interviewed, most notably, Barry Schwartz, a professor of psychology at Harvard who wrote "The Paradox of Choice." Schwartz studies how the abundance of available options in developed countries commonly leads to self-doubt, regret, paralysis in decision-making, and an overall feeling of dysthymia. Schwartz believes that government should act to limit people's choices, by paring down, say, the hundreds of peanut butter options at Whole Foods.

Predictably enough, as a libertarian, I disagree with Barry Schwartz's prescriptions, if not his assessments. Even if, theoretically, government were justified in restricting choices without consent, and even if in practice did a decent a job ridding the public of some unnecessary choices, we'd still all have to cope with overwhelming options sooner or later. Schwartz, in his book, even provides strategies for doing so. Since Schwartz presumably doesn't believe in censorship, I'd still have millions of books listed on Amazon to devour. With some benevolent meddler paring down my reading list, I'd still mull over whether to read altogether to move on to cooking dinner instead (using a pared down list of recipes). In other words, people simply have to learn strategies of prioritization. Uncle Sam's wagging finger in the peanut butter aisle would simply help me avoid setting up the an internal Grand Supermarket Shopping Prioritization Strategy Task Force, a necessary step for learning to move on and get stuff done.

Abumrad interviews Oliver Sacks, who outlines his strategy to avoid deliberating on too many time-wasting decisions. He says, "I make a willful choice. Certain things I care about a lot and I worry over, and then there's a whole swath of my life that I just don't even choose." Every week, his housekeeper buys one half-gallon of soy milk, one half-gallon of prune juice, seven apples, seven pears, and several tins of sardines. She will then cook up a gallon of orange jello and a vat of tabbouleh, to be consumed for dinner each night, along with the sardines.

Sacks is so normalized to his menu, that he "never gets bored" with his food. Presumably, his main hedonic pleasure is music. To maximize time invested in such pursuits, he simply ignores other potential sources of joy, such as variety in food. Repetition, however, is not the same as denial: every day, he keeps exactly a dollar in his pocket, to buy a piece of 72% cacao chocolate at the chocolatier on his way home.

Later in the program, Abumrad highlights human irrationality in decision-making, through the concept of "risk aversion," or how our fear losing something overpowers our perceived joy of winning that same item. Mimicking a previously performed psychological study, the djs wandered around outside, offering random bystanders opportunities to play "heads or tails." The djs started out offering one dollar for the strangers' dollar (a proposition rejected by all), but then offered increasingly high amounts of money to match the bystander's dollar. Most people didn't accept the match until the djs reached about two dollars. On the show, the djs then speculate as to why, for most people, loss is twice as "painful" as gain.

Risk aversion is real, but I don't see how it is always irrational. For one, the dj's dollar is not worth the same amount as my dollar. My dollar is already in my pocket. His dollar has to sacrifice some pennies to pay for my trust that this stranger is good for the money, and this isn't just one big scam.

One guy, cited that he "was just not a gambler," and, for reasons other than religion, wouldn't even play if the odds were 100 to 1. Perhaps his view of gambling as different from other economic transactions is irrational (I avoid casinos, not because it's "gambling," but simply because I know my odds of winning are poor. I viewed my regrettable purchase of that "As Seen on TV" Super Slicer as simply a gamble with better odds). However, if the man is a conscientious objector to coin tosses, is that necessarily irrational? Perhaps, due to family history, he knows he may be susceptible to a gambling problem (thus making an irrational decision that is only rational, because it is used to combat an irrational compulsion). Maybe he just wants to die bragging that he never gambled. The problem with these studies, I find, is that the researchers just don't give their subjects enough credit.

Even if there were no doubts about the integrity of the djs, nor any personal opposition to gambling, a more serious error is to assume that a potential dollar won is worth the same as the dollar the person already has. In fact, I suspect Sir Oliver Sacks himself might have refused to play the game of chance. A hundred to one odds might allow the chance to purchase the fanciest products displayed in the supermarket. But he could also lose the opportunity to buy a piece of 72% cacao chocolate on the way home from work.

Update 1/7/09: The very day I wrote this post, I randomly came across this at the "Overcoming Bias" blog. I suppose the Baader-Meinhoff phenomenon is my personal bias of the hour.

Is "Parasites the Correct Word" Continued.

2008-12-05T16:23:00.000-08:00

Commenting on my post, "Is 'Parasites' the Correct Word?,'" the Probe writes:

As for the question whether parasites is the correct word, a semantic analysis as yours does not consider the feelings of those who take the risks, albeit miniscule, and vaccinated their children. Thus, parasite sounds good, and freeloader or leech sounds even better.

You said: "Vaccination is the boy scout of medicine...". I just love this line. Always ready to help. Of course, sometimes the scout and the little old lady get mowed down by a speeding drunk, but, the scout was prepared.

I agree that my analysis might concentrate excessively on semantics over substance, but I think logically characterizing the lapses of non-vaccinators is important. I am wholly convinced that vaccination is one of the most important milestones in medical history, and a major cause for modern human flourishing. However, any time we force someone to do something against his will, there are both ethical and practical consequences. So we must distingish between people who benefit from other's actions from people who directly cause harm, from people who fail to prevent harm, etc.

In other words, I might prefer allowing people to benefit, via herd immunity, from my vaccinating my own children, despite the mild risks imposed on my family, over the inevitable law suits, growing conspiracy theories and other problems that stem from requiring the kooks to vaccinate their kids. For one example of the dangers of a backlash, read this note that I received from someone upset about some pro-vaccination comment I made on YouTube:

I'm assuming that you don't have a child who was injured by a vaccine then. Vaccines are toxins intentionally injected into babies and children FOR MONETARY GAIN OF PHARMACEUTICAL COMPANIES. The CDC knows exactly the harm caused by these vaccines. It's a scam - just like health insurance, cesarean sections caused by induction, and many other facts of American life. Vaccines aren't proven to work anyway. Vaccinate your own kids if you like, but mine are staying AWAY from those toxins!

If we force this person to vaccinate his kids, everything from the kid's future failures in school to his inability to make friends will be immediately blamed on vaccination (In this case, I'd blame the parent...). I'd rather the conspiracy theorist be forced to scramble to find something else to vilify.

Thank you, Probe, for reading my blog. For now, anyone who makes thoughtful comments will get personal responses.

Can't Escape Bacteria

2008-11-04T15:00:00.000-08:00

For some people, the whole world's a stage. For me, the stage is apparently just a world of medical disorders. Today, I was listening to the soundtrack of "Rent," in which Mimi sings about her S+M work at the "Cat Scratch Club." Then I realized: Was Jonathan Larson making a reference to Cat Scratch Fever? Cat Scratch Fever often manifests as Bacillary Epitheliod Angiomatosis, an infection featuring red papules, due to proliferation of small, round, blood vessels. It is caused by the Bartonella Henseli bacteria, which usually enters the body after the host is scratched by a feline. However, it is also a very common Clinical Category "B" symptom for HIV. Was Jonathan Larson making a medical allusion about his character, Mimi, the HIV-positive exotic dancer?

Is "Parasites" the Correct Word?

2008-11-01T01:22:00.000-07:00

Following my post on Amanda Peet's calling parents who don't vaccinate their kids "parasites," I've pondered about the technical applicability of the term.
In ecology, there are three basic categories of symbiosis, or dependant ineractions with members of another species. The definitions, according to the MadSci Network, are as follows:

PARASITISM:
(+/-) Where one organism benefits (the parasite) and the other is
negatively affected (the host). Fleas on a dog are a great demonstration of Parasitism at work.

COMMENSALISM:
(+/--)Where one organism benefits and the other neither benefits nor is
negatively affected. An example is barnacles on a whale - the barnacle gets
a place to live and relative safety, and the whale seems unaffected.

MUTUALISM:
(+/+)Where one or more organisms benefit from the partnership occuring
between them. Clown fish in anemonies and photosynthetic zooxanthallae
algae in corals are both examples of an "intimate" relationship occuring
between two species.

Technically, these terms apply only to interactions among different species, not within a single species, but the term "parasite" is often used colloquially to refer to fellow humans.

However, according to these definitions, Peet should have accused non-vaccinators of being "commensalists." Such people don't generally harm others, yet enjoy the benefits of herd immunity, or the fact that infectious microbes have little chance to spread when there is such a small number of potential human hosts. And if you, like me, understand that vaccines pose virtually no harm, then the only "benefit" extracted is the ability to avoid an extra trip or two to the doctor, and to spare a kid from a shot.

There are circumstances, however, in which refusing vaccination can cause considerable harm to others. Inoculations do not work on immunosuppressed people, because the process requires a functioning immune system. Caccinations work by introducing a "fake" microbe that has similar protein markers to an actual pathogen, but is really a benign imposter. This leads your immune system to copy many lymphocytes (B and T white blood cells) that can recognize and attack any pathogen with the specific protein marker.

Why can't your body just do this to fight the real pathogens when they really attack? They do, but the difference between beating a virulent pathogen and falling prey to it is simply a matter of timing.
Having once been introduced to what the immune system "thinks" is the pathogen, the body creates "Memory" B and T cells. The process of recognition, proliferation, and attack by the immune system would normally take about two weeks, which would often be too late. By having the memory B and T cells immediately always ready on standby, your body can now beat the polio, measles, or other virus before it gets very far. Vaccination is the boy scout of medicine: it does nothing directly to fight or kill any bacteria or virus. It simply allows your body to "be prepared" for the future.

Because the success of a vaccination is dependent on the body's ability to respond to the vaccine and create functional "memory lymphocytes," people with poorly-functioning immune systems (whether due to a congenital deficiency, uncontrolled HIV, certain leukemias, etc.) are non-responsive (or much less responsive) to vaccination. In other words, their white blood cells will be "underenthused," when meeting the "antigen," or specific protein marker, presented by the vaccine for the first time, and their bodies will not create the memory cells ready to respond quickly to the actual attack.

Thus, theoretically, if a non-vaccinated child exposes a pathogen to an immunosuppressed child, then this can no longer be considered "commensalism." The non-vaccinated child (well, his parents) caused others unecessary harm. I do not know how common this possibility is; it may have a very low incidence, and therefore have little practical relevance. If, however, many parents suddenly decided not to vaccinate their children, the incidence would surely increase, could cause major harm to immunocompromised people.

Would this be considered parasitism? The non-vaccinators injured others because of their decision. Then again, they didn't actually injure the same people from whom they extracted benefit. In fact, the non-vaccinators presumably contracted and suffered from the illness, and did not benefit from herd immunity, altogether. However, they still affected others. A world of inusfficient communal vaccination is most dangerous to those for which vaccination is not an option.

Should we force people to vaccinate their children?
On the one hand, I don't believe in forcing people to do much of anything. Also, because of herd immunity, not every one actually requires vaccination, provided that the non-vaccinated children are roughly randomly distributed in the population, and don't live in vulnerable pockets.

On the other hand, while adults can do what they want, parents are required to provide minimum care for their children (not just caring as an emotion, which I'm sure people like Jenny McCarthy possess. Intentions don't always count). Additionally, as explained above, non-vaccinated children are in a position to potentially harm others. Perhaps we should consider this a "tort" issue. That way, parents could do what they want, but must understand that they are responsible (i.e. can be sued) if this decision negatively impacts others.
Even this presents its own complications. Unlike a "slip and fall" or medical malpractice, it is very difficult to determine who directly caused an immunosuppressed person to contract an illness. It could be anyone with whom she came into contact. Additionally, this contention raises the question: Do immunosuppressed have any personal responsibility to avoid place in she might contract a dangerous illness?

I suppose the only good strategy to avoid these problems is to maintain good education and PR about the benefits of vaccination.

I think some of these benefits are plainly apparent through the following charts:

TEN PRINCIPAL CAUSES OF DEATH IN MASSACHUSETTS - 1900
1. CARDIOVASCULAR-RENAL DISEASES
2. INFLUENZA & PNEUMONIA
3. TUBERCULOSIS
4. GASTROENTERITIS
5. MALIGNANT NEOPLASMS
6. DIPHTHERIA
7. TYPHOID & PARATYPHOID
8. MEASLES
9. WHOOPING COUGH
10. SYPHILIS

TEN PRINCIPAL CAUSES OF DEATH IN United States - 2005
1. HEART DISEASES
2. CANCER
3. CEREBROVASCULAR DISEASES
4. CHRONIC LOWER RESPIRATORY DISEASES
5. ACCIDENTS (UNINTENTIONAL INJURIES)
6. DIABETES MELLITUS
7. ALZHEIMER’S DISEASE
8. INFLUENZA & PNEUMONIA
9. NEPHRITIS, NEPHROTIC SYN. & NEPHROSIS
10. SEPTICEMIA
Sources:
1900 Massachusetts data was obtained from one of my pathology lecture notes handouts. I can ask my instructor for the specific source, for anyone who is interested. 2005 U.S. Mortality Data taken from National Center for Health Statistics, Centers for Disease Control and
Prevention, 2008.

Heal Spiel Halloween Edition: Chelation Therapist Taking Our Questions

2008-10-31T03:39:00.000-07:00

Orac at "Respectul Insolence" of Scienceblogs writes about (ok, mainly mocks) Dr. Rashid Buttar, D.O., a physician at the Center for Advanced Medicine and Clinical Research, who "successfully cures" autism via chelation therapy. Chelators are normally used in the case of overdose of iron, arsenic, mercury, or other heavy metals. However, some "practioners" use it to "rid" the body of (unmeasured, but presumed) elevated mercury levels, among other thins, which (if we only wish it enough!), only exist due to a previous vaccination (given years prior). The pesky North Carolina Medical Board forbade Dr. Buttar from continuing to practice medicine on children, but the good doctor is kind enough to solicit our questions, so he can impart his profound knowledge upon the rest of us.

Dr. Orac is collecting questions from his readers. Some people wrote really boring stuff that was all actually relevant to science and evidence-based medicine and stuff. Examples include:

1. Name all papers showing that autistics have higher body burdens of heavy metals, after controlling for diet, pica and urbanicity.

2. Severe heavy metal poisoning is invariably fatal if not treated. Why isn't autism known as a condition that has a mortality rate?

3. How does a heavy metal poisoning model explain the most widely replicated findings in regards to autistic strengths, e.g. better than normal performance in block design tasks?

4. In light of studies that show a genetic link to autism, do you still believe that mercury in vaccines is the only cause of autism?

5. Also, in light of the fact that autism rates have not gone down since the removal of mercury from most vaccines, why do still think there is a link between mercury and autism?

Personally, I thought these questions were BOOORRRIIING, so I decided to ask Dr. Buttar a question regarding my personal health:

Dear Mr. Buttar,

I need some medical advice. I was very concerned about "heavy metal toxicity," and knew iron was a major culprit, so I decided on receiving chelation therapy. Unfortunately, that didn't get rid of every last bit of iron (my hemoglobin and hematocrit levels were still in normal range!), so now I've chosen to puncture my femoral, carotid, and cerebral arteries, and to let my blood flow out until a CBC finally comes back saying that my Fe, ferritin, and transferrin-saturation levels are zero. That's how I'll know that the poisonous metal will be gone for good!
However, while I'm waiting, I'm starting to feel kind of weak. Is this just my body battling those evil autism-causing metals? What should I do next? Perhaps I can chop off that extra lobe on my right lung, or shave off some of the left ventricle of my heart, just to make sure everything in my body is more "in balance" and "in harmony." Do you recommend these therapies? I'm eager to hear your response, because I really respect your amazing understanding of science and how the body works! Oh yeah, and I need a refill on that snakeoil.

Now a bonus quiz for the fans of Dr. Nick-whoops I mean Buttar:
He attended:
a) Mayo Clinic Correspondence School
b) Club Med School
c) Hollywood Upstairs Medical College
Time starts now.

Infrastructure

2008-10-30T22:41:00.001-07:00

David Brooks believes that, rather than bailing out auto companies, or handing money to firms who hire more workers (whom they would have likely hired anyway), we should use the money to invest in a "National Mobility Project," or "a long-term investment in the country’s infrastructure."

It's not a bad idea to build highways. However, The funds for highways are most efficiently derived from toll roads, rather than income or corporate taxes.

Those who drive, and who drive most often, should pay for the construction and maintenance of the highways they use. This system would also amount to a de facto "carbon emissions tax," reduce traffic, and encourage people to consider other modes of transportation, all without raising income taxes.

Fiscal conservatives ought not to disagree with toll roads because, without them, our nation's highways amount to one giant subsidy for drivers. So long as we don't privatise highways, governments should charge for their use.

So, to all the phantom people who watch over the I-10 W: Build a tollbooth! If you promise that there it will no longer be bumper-to-bumper traffic at 3 am on a Sunday night, I promise, in turn, that I will pay the fee with a smile.

Wednesday People Watching

2008-10-30T16:03:00.001-07:00

Last night, I went bowling with some friends. While there were plenty of actual bowling lanes open, the staff decided to play Nintendo wii bowling, using a little TV in the corner. I'm not even saying they made a bad choice. Hey, some people live much more fabulously in "Second Life" than they do in the real thing.

Sam Gosling Disapproves of "Conservative Rooms" (Or, Why I Should Stop Selling My Trendy Books on Ebay")

2008-10-30T13:25:00.000-07:00

Perhaps it's true, that "Liberals...appear to be more open, tolerant, creative, curious, expressive, enthusiastic, and drawn to novelty and diversity, in comparison with conservatives, who appeared to be more conventional, orderly, organized, neat, clean, withdrawn, reserved, rigid, and relatively intolerant."

However, if you're drawing these conclusions based on a study featuring such outrageously sloppy methodology, and whose "findings" lead to such presumptuous "conclusions," the only message I get is:

"Many liberals have an uncanny ability to exploit the term "science," in order to advance their own absurd biases about people with whom they disagree."

Well I'm glad they were able to demonstrate, by searching through people's rooms (no possible biases introduced here!), to world how intolerant those unenthusiastic, incurious, "non-open," (among other "scientific" designations) these conservatives all are.

Pseudo-science is more pernicious than no science at all. Just sayin'.

Preliminary California Election Results!

2008-10-29T16:28:00.000-07:00

Well, at least one ballot can be considered good and counted. That's because I'm telling everyone how I voted:

President and Vice-President: Bob Bar and Wayne Allen Root

I generally avoid voting for third party candidates. Additionally, I feel that the LP shouldn't blindly run a candidate every election. Instead, they ought to use its members as leverage, "auctioning" off the LP endorsement to the party that puts the most pro-libertarian offer on the table. So long as the LP says, "We're not going to vote for either of you, no matter what," both major parties will continue to write the libertarians off as lost causes, and as people whose views needn't be accommodated. The LP will inevitably siphon off votes from the more "libertarian" of the two candidates, leaving the greatest Big Government advocate as the winner.

A lot of my thinking about the relative usefulness of the LP derives from a short, but brilliant analysis by Cato scholar, William Niskanen.

I'm a pretty loyal Republican, and vote for Republicans the majority of the time. So why did I vote for the "Chowderhead" (according to Jack Shafer) from Georgia? As much as I admire his heroism, McCain seems to alter his opinions about the economy each day, and has no coherent economic philosophy. I disagree with him (and especially with Palin) about most social issues. I'm by no means a pacifist, but it's certainly time for the war in Iraq to end. I live in California, where my choice doesn't matter, anyway. However, I do hope that the GOP sees a lot of unexpected votes for the LP ticket, and realizes that many of these voters are members of the GOP, or are GOP-leaning independents. Maybe then, the party will try to win us back.

United States Representative: Charles Hahn

Hahn doesn't mention any social issues on his website, which is generally GOP code for "I care much more about fiscal issues." He says, "I do not support the 700 Billion Dollar bailout of Wall Street companies who made poor business decisions." He is a fellow health professional (dentist). He has black belts in Black Belts in Judo, Jiu Jit-Tsu, and Tae Kwon Do. I don't like Adam Schiff. Moving on....

State Senator: Teddy Choi

I know nothing about him. The sole reason for my vote is that the Democrats keep pushing for bloated, wasteful budgets, and there needs to be some balance up North. Whenever there's an increase in revenue, there's suddenly a exponential increase in spending. Private sector jobs have decreased, but we constantly hire new government workers. We have LAUSD teachers paid to show up and play cards in warehouses, because they are deemed too incompetent to teach kids, but too, I don't know, something, to be fired. The Democrats in Sacramento continue to defend schools with abysmal graduation rates, so long as the politicians receive enough donations from the teachers' union. They keep making stupid rules and restrictions regarding health care. Basically, any Republican with a pulse, who is running for state office, gets my vote.

State Assembly: Brian Fuller See above.

Proposition 1A: High-speed train: No
They say it will cost $19.4 billion and "probably" over $1 billion annually for maintenance costs. Do you know any contractors that charged what they quoted you initially? Exactly.

Proposition 2: Standards for Confining Farm Animals: Yes

Unlike many libertarians, I believe that animals have (minimal) rights. I am concerned that this proposition won't actually decrease the number of confined animals in California, but simply lead the offending farmers to mosey on over to Nevada. Were we to impose a tax on non-humanely-raised meat shipped to California, this would partially accommodate for the negative externalities of animal mistreatment, and would avoid specifically punishing California farmers (The farmers would still face a comparative disadvantage for meat they sell in other states). Nonetheless, I am not sure how significant these effects will be, and I think it's fundamentally wrong to treat animals inhumanely. I voted yes.

Proposition 3: Children's Hospital Bond Act: No.

Money is fungible. They claim it's for children's hospitals, but it is really just money added to the health care system that can be spent however they want, provided that children's hospitals get a certain percentage. We need to reform the health care system, and the worst way to do so is to throw more government money at it. Additionally, I find the commercials with Jamie Lee Courtis telling us that "Prop 3 doesn't raise taxes" to be very dishonest. Of course it doesn't raise taxes. It's worse than that. It's a bond with no specifications for how it will be paid for. It's just debt that gets added to the balance sheet.

Proposition 4: Waiting period and Parental Notification before Termination of a Minor's Pregnancy: No.

I generally believe that minors have too few rights, rather than too many.

Proposition 5: Non-violent drug Offences (AKA marijuana bill): Yes

This is the only state measure that saves us money (2.5 billion!). If you're a fiscal conservative, do you really want to pay for the room and board of a marijuana user in jail for 20 years? If he wants to go to rehab, let him go to rehab. Otherwise, let him do whatever he wants.

Proposition 6: Police and Law Enforcement: No.

Some of the gang-fighting provisions sounded fine. However, you lost me at "Increase penalties for several crimes including... using or possessing to sell methamphetamine."

Proposition 7: Renewable Energy Mandate (20% by 2010): No.

I am not a global warming denialist. I believe we should tax carbon emissions, to account for its negative externalities. However, we should not fight global warming by mandating the use of some mythically economically and environmentally efficient, as well as feasible to implement "high-scale" alternative energies, that have yet to be created. Some sources of "alternative energy" are useful (solar panels pay for themselves in about 20 years, and they are becoming cheaper). However, there is absolutely no way that they can provide 20% of California's energy by 2010, even assuming we had enough short-term cash to invest in so many of them. We all know that the energy companies will instead use biofuels, which have proven to be an all-around environmental, economic, and "global well-being" disaster.

Proposition 8: Ban on Gay Marriage: No.

Ideally, "marriage" would be a term unfamiliar to the state law books. It amounts to one giant source of discrimination against single people, who are most likely to be low-income. However, denying a right to one segment of the population, as well as adding a provision to the constitution regarding marriage is altogether shameful. GOP, if you want to know why you're losing a lot of us....

Proposition 9: Victims' Rights in Criminal Justice System: No vote.

I have no clue about the merits or lack thereof about this one. Victims' rights sounds good, but the fact that its a constitutional amendment leads me to think that this bill is a bigger deal than it seems. I'll leave this one to my fellow Californians.

Proposition 10: Bonus Bucks for Alternative-Fuel Vehicles: No.
Why can't we just institute a Pigovian tax on carbon emissions, for G-d's sakes?

Proposition 11: Redistricting: YES.

This is one of the most important measures on the ballot. Ever notice how our state district map looks like a Picasso piece, with lines and loops winding around indiscriminately? That's because the incumbents carved them out, to insure their own re-elections. This bill sets up a group of Democrats, Republicans, and Independents who sit down to map out the districts. A computer algorithm would be best, but I will not tut-tut this important measure.

Proposition 12: Veteran's Bond Act: No.

I love Vets, but the Department of Defense has a budget, so why can't they spare a dime? You know Federalism is dead when the federal government controls education and health care, while the states are called upon to do one of the few legitimate jobs of the federal government: Caring for our veterans.

CMA vs. "Licensed Health Professionals"

2008-10-28T15:54:00.001-07:00

The California Medical Association (CMA) is concerned that the California Department of Public Health (CDPH) has proposed regulations that would expand the power of non-physicians to perform certain medical procedures. The changes include:

Allowing psychologists to perform medical, as opposed to psychological, examinations (Section 70577);

Allowing "licensed health practitioners" to order restraint of patients (Sections 70577, 71545, 72319,72461, 73409, 79315);

Implying that "licensed health practitioners" may assume overall responsibility of a psychiatric unit (Section 70577);

Substituting "licensed health practitioner" for "physician" as the health professional who has primary responsibility for coordinating care (Section70707);

Allowing admission, transfer, and discharge decisions to be made by "licensed health practitioners" (Sections 70717,70749, 70751, 70753, 71517, 71553, 72515,73517); and
Proposing changes that affect the self governance of medical staffs (Sections 70703, 70706, 71503).

I generally believe that, so long as the patients have obtained full disclosure and have properly consented to non-physicians overseeing their treatments, then doctors should not object. Granted, when it comes to certain medical matters, physicians are more extensively trained than nurses, PAs, and certainly psychologists, and are likely to make fewer mistakes or misdiagnoses (Similarly, most doctors would be fired on Day 1 for incompetence, if they tried to take over a nursing job). However, requiring a physician to coordinate care for every patient comes with other unique costs, which I'll expound upon in a future post.

The power to order "restraint" of a patient or to oversee psychiatric a psychiatric unit is more controversial. In such cases, the patients are either unable or unauthorized to make informed decisions about their care. Even physicians are potentially treating many patients without their consent, a phenomenon that should be tread with caution. Do we really want to expand the number of people with the power to control the movements of a dissenting patient?

Obviously, in an acutely dangerous situation, everyone from the lab tech and billing officer should be allowed to restrain a patient, until the situation is considered secure. But once we've insured every one's safety, we should do all we can to maximize patient autonomy. (I should note that, as much as I respect Thomas Szasz's views on medical paternalism toward psychiatric patients, I support restricting the movements of someone whom I suspect could soon harm someone. Many nurses have been attacked and severely injured in psych units, and preventing such incidents trumps personal liberty).

The CMA is a physicians' lobbying group, so their views on the issue matches the circumstances that would reduce physician competition. Their list of "talking points" include:

Ignores Physician Responsibility for Medical Care

As the most extensively trained health care professionals, physicians are the most qualified to coordinate medical care. The proposed amendments offer that a psychologist may perform medical examinations, not just psychological examinations. This extends activities to psychologists beyond the scope of their professional licensure.

Jeopardizes Patient Safety

By authorizing "licensed health practitioners" to make medical decisions such as ordering restraints and making transfer and discharge decisions, the Department of Public Health is failing to protect public safety and ignoring a number of federal and state laws. Physicians are trained to consider the array of physiological factors that may affect a patient's condition and the regulations should reinforce that authority rather than undermine it. Although CDPH does not regulate health practitioners, it does have a stake in assuring quality standards of care in licensed health facilities as a matter of public health.

Leads to Confusion in Medical Decision Making

The regulations remove specific references to physicians in various situations. The regulations allow a "licensed health care practitioner acting within the scope of his or her professional licensure" to oversee admission decisions and the coordination of patient care. This amendment is overly broad and offers no clarity as to which practitioners are actually responsible for these functions in health facilities. Leaving individual facilities to interpret these regulations and the scope of practice of the various health care providers operating in hospitals may lead to varying standards of care across the state that are also inconsistent with statutory restrictions.

Undercuts the Independence of Medical Staff Committees

The organized medical staff is responsible for the quality of medical care in inpatient facilities. California law has upheld this authority as a part of the prohibition on the corporate practice of medicine. Self-governance and independence in medical quality decision making are foundational to patient safety. The amendments to the regulations propose that the organized medical staff is "subject to the bylaws, rules and regulations of the hospital.

If anybody ends up reading this, what do you think? Do any of the CMA's arguments have merit?

From Mad Libs to Wiki to the Great American Novel

2008-10-28T10:43:00.000-07:00

Because my parents currently live in Detroit, I have long been interested in the tragic implosion of the gritty, industrial city. Thus, Dean Bakopoulos' novel, Please Don't Come Back to the Moon, about the "lost fathers" of Detroit, is waiting patiently on my bookshelf to be eagerly consumed.

Mr. Bakopoulos, perhaps remembering what a drag it all was to craft an entire novel from scratch, or maybe as a result of a stroke of genius, is outsourcing construction of his upcoming novel, My American Unhappiness, to melancholy contributors. The book will feature characters who experience the stated angsts and frustrations of ordinary blog commenters.

Because I've spent the last few weeks beginning to wade through the cannon of behavioral economics and positive psychology (Ariely, Sunstein, Thaler, Schwartz, Gilbert, Csíkszentmihályi, Seligman, Haidt, Lyubomirsky- Kahneman and Tversky don't yet come packaged as pop psych books for the public, but I'll eventually get to them, too), I've been alternatively amazed and frustrated by some of their findings and policy prescriptions. Thus, my source of "American Unhappiness," can be summarized as:

The paralysis caused by too many choices. And behavioral economists who'd like to legally restrict my number of choices.

HT to Megan McArdle by way of Alex Massie.

UPDATE Nov. 1: The following is a clarification from the author [I suspected he wouldn't just cut and paste people's contributions; he's a good writer]:

A friend forwarded me some blogs that mention this group and my next novel and think that I'm asking you to write my entire novel. This is not the case. I'm just saying, like, yeah I wrote 350 pages, and you get to write about five. This is for a small section of the novel in which the main character, Zeke Pappas, wakes up to find a deluge of e-mails from people answering the question on his website: why are you so unhappy?

Just clarifying!

The Moderate Five

2008-10-28T01:56:00.000-07:00

According to every newspaper and pundit, the Republican Party is in shambles. However, there are some organizations whose e-mails and websites seem be getting ever more professional-looking, and whose membership list and donation-filled coffers seem to be growing.

These include:
1) Republican Liberty Caucus (RLC, for which I'm on the California Board of
Directors)
2) Republican Majority for Choice (RMC)
3) Log Cabin Republicans
4) Republican Leadership Council
5) Republicans for Environmental Protection (REP)

Some of the members of the REP are anti-gay marriage. Some supporters of the Log Cabin Republicans are pro-life. Some RMCers don't believe in environmental restrictions. However, the common denominator of all these groups is that they represent the moderate constituencies of the party. Most pundits (except Rush Limbaugh, who writes that the Republicans lost because they weren't Right-Wing enough), believe that these types of people will be the ones needed to shape and re-introduce a new, attractive, GOP.

Right now, the Republican Party needs groups like us even more than we need them. Yet, while I don't speak for other members of the Moderate Five, I sense that we haven't stayed simply due to an imagined increased influence within the party. We stick around because, after our being deemed as "RINOs" during the years of plenty, our party is now in deep, deep, trouble, and we are finally able to prove our allegiance. It would be very easy for us to get on the Dem bandwagon, but we simply don't believe in what they stand for, in comparison to what we Republicans are supposed to stand for. We all anchor our views in the traditional conservative framework of small government, constitutional rights, and personal responsibility. In other words, I cower when I learn about the oxymoronically titled "Fairness Doctrine." I am appalled by the very suggestion that workers might be stripped of their right to cast a secret ballot in elections concerning union participation. I could likely never pull the lever (well, punch those funny tabs in our retro CA booths) for a Democrat.

The Log Cabins, REP, and Republican Leadership Council all officially endorsed McCain. The RMC held out for Giuliani for a while, while the RLC largely pinned their hopes on Ron Paul. (Neither of the latter two groups have since explicitly endorsed any presidential candidate). All of the above groups are willing to officially endorse only Republican candidates (unless there is no Republican running in a particular election). When half the staff of the National Review, most (all?) of the conservatives at The Atlantic, and the rest (Peggy Noonan and Christopher Hitchens, for G-d's sake!) seem to have all abandoned ship, there is clearly still a lot of love coming from the Mod 5. To the right-wing members of our party: We may not be the pretty blond prom queen, but we still show up to the after-party, when you've been ditched by everyone else.

Monday People Watching

2008-10-28T01:10:00.000-07:00

In the Corner Bakery, a middle-aged couple were happily munching on their salads and sandwiches, when a sign by the door, similar to the one below, caught their eyes:

The wife called the nearby busboy over to ask for an explanation of the sign. The busboy couldn't speak English, let alone identify the significance of a "Doesn't actually refer to a specific food item, yet is posted just to save our butts from lawsuits" sign. The busboy called over the very young manager, who gave a stammering, incoherent explanation.

After the manager left, the couple sat silently for about one minute. Eventually, the husband looked around at the crowds enjoying their meals, shrugged his shoulders, picked up his sandwich, and took another bite.

Up and Coming Medical Specialty?

2008-10-28T00:20:00.000-07:00

Unfortunately, to establish the diagnosis of "non-filer's syndrome," one requires a J.D. Astonishingly, only high-profile politicians are susceptible to this debilitating pandemic.

Give Amanda Peet a Cookie

2008-10-27T15:01:00.000-07:00

Reporting on findings concerning the "dangers" of vaccination and the various "cures" for autism, the latest issue of ~~The New England Journal of Medicine~~ US Weekly features Jenny McCarthy's personal story in caring for her son, Evan, who is autistic. McCarthy has been sufficiently chastised by Orac of Respectful Insolence. My focus is on a different kind of celebrity, one Amanda Peet.

Peet, spokeswoman of the organization, Every Child By Two, which works to increase childhood immunization, said in an interview in Cookie Magazine (I know, how was I not made aware that such a publication existed?):

“Frankly, I feel that parents who do not vaccinate their children are parasites...I have a lazy, fluffy, actor-y side that’s instinctive. And I have a side that’s practical and into statistical evidence. I’m not a casual person.”

After an uproar, as well as some snippy comments from McCarthy, Peet apologized, saying,

I believe in my heart that my use of the word 'parasites' was mean and divisive. I completely understand why it offended some parents, and in particular, parents of children with autism who feel that vaccines caused their illness. For this I am truly sorry.... I still believe that the decision not to vaccinate our children bodes for a dangerous future. Vast reductions in immunization will lead to a resurgence of deadly viruses."

This is what I admire about Amanda Peet: Most celebrities avoid controversy (other than those involving sex tapes and cat fights). Raising money to combat breast cancer or HIV is important and admirable, but also relatively uncontroversial (Well, perhaps uncontroversial to the overwhelming number of people who are not AIDS denialists). I sincerely hope that we rid of such horrible diseases in our lifetime (bimhara, biyamaynu, amen, to all the Jews out there). However, the fact is, is that celebrities clamor over who can be the first to have the biggest fundraiser for the trendiest organization that raises the most money to combat AIDS. Some diseases are simply disproportionately favored by the Hollywood glitterati.

Vaccination, however? Not so trendy. Certainly not in a time when only 38% of respondents, in a recent Florida Institute of Technology survey, said they believed that there was no link between vaccines and autism (19% believed there was a link, and 38% weren't sure).

Peet's crusade comes with an even further disadvantage, in that, one can often point to a specific child whose leukemia was cured, due to the benefactor's specific donation, but one can never point to a specific kid who was saved, because she had been vaccinated. We simply don't know which children, without their having received Menactra, would have been the ones to succumb to bacterial meningitis. It's a crapshoot. Thus, Amanda Peet, and all vaccine activists and researchers, get no adorable photo-ops. Preventative medicine is inherently media-unfriendly. All its advocates can do is present boring charts that show how, in the aggregate, inoculation allows for such and such number of kids to likely be spared from death due to infectious disease (and even those are based on statistical models).

One aspect of Amanda Peet's exasperated outburst that I found refreshing was her noticeable anger concerning an idea. I have a prejudice in that I often assume that celebrities, and even many or most people, tend to feel affronted only when they (or their teammates or their ~~cult leaders~~ preferred presidential candidates are personally insulted or disrespected (Yes, I'm aware that the strike-through-thing is passive-aggressive). In contrast, what really irks people like Orac from Respectful Insolence, as well as all the docs at ScienceBasedMedicine, is when people say things that are, G-d help them, CONTRADICTED BY THE EVIDENCE. Yes, the docs and scientists lose their cool sometimes. However, this is because they know that ideas matter, and that results matter, and that the scientific method, arguably the most glorious rubric ever formulated by man, matters. Ironically, while the scientific method has no patience for emotion, passion, conjecture, or desire, its proponents (admirably) treat attacks upon it as a somewhat personal affront, and often react to its critics with zealous fervor.

For example, when a homeopath made a list called "51 Facts About Homeopathy," (My favorite fact is Number 18, which seems cribbed from a confused ninth grader's chemistry notes: "Any remedy up to a 12c or a 24x potency still contains the original molecules of the substance and this is known as Avogadro’s number."), Mark Crislip, painstakingly debunked all 51 of this woman's assertions. As a practicing physician, Dr. Crislip probably has better things to do than discredit every foolish claim posted on the internet. However, I know why Mark Crislip did it. Reading statements that are objectively false, and then failing to address them, feels like a persistent itch that has not been properly scratched. Such reactions are understandable, and even admirable.

The fact that that Amanda Peet calls herself "practical and into statistical evidence," and becomes noticeably distressed by willful ignorance, even when it means that some people will boycott her movies, is understandable and admirable, as well.

UPDATE Nov. 1: Respectful Insolence mentions the Peet/McCarthy showdown.

The Most Dreaded Day in Medical School

2008-10-24T01:48:00.000-07:00

Pelvic examination day, where we must perform the full genital exam on a real, live, person. And it was... totally fine. I thought the ophthalmascopic (eye) exam was more difficult, and more uncomfortable ("While you go on in your investigation to find my macula, are you sure this light scorching my eye won't turn me blind?")

If I get one more email....

2008-10-24T01:31:00.000-07:00

about Joe and all of his electrician and carpenter friends, I will protest until Dave the lab tech, Lynne the pathologist, and Jose the nurse, all from my hospital, get officially added to the top of the GOP Platform.

Stop the Presses

2008-10-23T18:06:00.001-07:00

(of all the other papers). The Times endorsed the Democrat!

Reason Why I Hate the Blogosphere #37593

2008-10-22T16:06:00.000-07:00

Read Ezra Klein's post on Palin's RNC-financed $120,000 wardrobe. Then read the comments thread.

Now read Matt Welch's compilation of angry comments/e-mails that he received after insisting, in the L.A. Times, that, despite all of McCain's many faults, lack of war heroism is not among them.

This was my take on Kleins's commenters:

There are two assumptions that seem to commonly appear in this thread (and on this blog, in general):

1) Everyone who expresses a differing opinion than the one expressed on this blog is a troll.

A troll is someone who deliberately tries to anger people, just for "lulz," or who spews ad hominem attacks or "copies and pastes" a whole bunch of quotes. . You may disagree with some commenters on this thread. However, you will never find the "our shared political views only" thread that you so desire. Listen to people's arguments. Some people have posted silly insults, but others have made reasonable claims as to why Palin shouldn't be condemned, in this particular instance. You are welcome to disagree. That doesn't necessarily mean that those with whom you disagree are trolls.

2) If you defend a person at all, relating to any particular issue, this means you support that person and/or his or her candidacy.

People seem to assume that anyone who defends Palin, in this case, are voting for the McCain-Palin ticket, or that such people had their money "wasted by the RNC." This is a very inaccurate assumption- I neither voted for McCainin either the primary or general elections (I vote absentee), nor did I send the RNC any money. Although we can't completely eliminate our own biases, we should at least attempt to evaluate every contention on its merits, rather than falling back on "if it's the guy on my team that does it, it must be right," as well as the contra-positive. Again, feel welcome to criticize Palin. But when criticism or praise can be predictably determined before the information is presented, that is a sign you have stopped using your minds.

An unacceptable response is, "Well the Right does it, too." Of course many people on the Right do it. As do many on the Left. There is no excuse for sacrificing rational thought, even in the name of political parity.

This was my response to the Matt Welch post:

I say, a pox on both their houses.
This is why, despite my interest in politics, I cherish my days in a non-political job [ok, well, school, really] talking to normal people, who don't start acting like robotic missiles automatically set to deploy whenever a criticism/compliment (no matter the veracity of the statement) is registered, regarding some pre-determined Saviour/Satan.

I recognize that both of the above examples describe instances of deranged Obamaites. They have plenty of McCainite counterparts (and I'm not just talking about the handful of cosummate crazies at the rallies, who appear in those circulating YouTube videos). But they will have to wait for "Reason Why I Hate the Blogosphere #57928." Right now, reading through such people's posts in the name of "research," makes my next lecture to study, "Ventilatory Muscle Function and Neural Control of Ventilation," suddenly seem very, very appealing.

Social Activists vs. Ben and Jerry's?

2008-09-24T13:52:00.000-07:00

I agree with Peta that there is scant evidence that consuming cow's milk is necessary to sustain a healthy life-style (so long as you get your calcium elsewhere).

However, the Peta folks are off their rockers if they believe that human strangers' milk is a "safer" alternative to bovine strangers' milk, and ought to be used in Ben and Jerry's Ice Cream. BSE notwithstanding, humans are immune to most pathogens (as in Johnes Disease, Bovine Enzootic Leucosis, Bovine Virus Diarrhea) that primarily use farm animals as hosts. No matter how much we try to emphasize our differences between one another, humans have very similar immune systems. Therefore, we are much more susceptible to catching anthroponotic, rather than zoonotic infections (While HIV can be transmitted to nursing newborns, it is somewhat, but not definitively, unlikely to be transmitted through drinking human milk that has already been collected).
Additionally, for bovine diseases that can be passed to humans, it is considerably easier to control infections that erupt in populations of cattle, rather than humans, who don't have a friendly farmer to supervise, track, and test them in herds (although I suppose that such actions are what Peta objects to most, in the first place).

Additionally, if people think that the hormones they inject cows with are bad, are they really ready to ingest some of the medications transferred to breast milk, such as Phenobarbitone (anti-convulsant), Dothiepin (anti-depressant), Promethazine (anti-histamine), Doxycycline (antibiotic), and a myriad of recreational drugs?

I don't know about the rest of you ice cream enthusiasts, but I don't want my Cherry Garcia to require a visit to Quest Diagnostics before it makes it to my freezer.

Know-Nothing Pundit With Plenty to Grouch About

2008-09-23T16:16:00.000-07:00

I can't claim to understand much about the whole bailout hullabaloo, but I certainly possess some imprecisely aimed anger toward some mysterious shadowy villain (all I know is that he is a banker by day, insurance broker in the afternoon, and congressman in the dead of night).

We regular, old, Americans are just left rubbernecking at all the chaos to patch the cracking beam that apparently suspends our entire earth, and runs only from Wall Street to the Beltway.

While this bailout may at least mean that my patients and I will be less likely to experience the nuisances of a newly-impossible-to-implement national health care plan (unless congress gets a bit of Havana fever, figuring "we've gone this far already..."), I have a feeling that this bailout business is bad for our country overall.

Yes, my knowledge of economics is rudimentary, but it's also my future three-thousand-something-plus dollars that will be used for those Damn Yankees' latest shenanigans, so I insist that even the ignorant be entitled to ask questions:

If fresh capital is necessary to resuscitate and revitalize these companies, why can't we provide be loans, which must be paid back, once the companies get back on their feet? If these businesses are so valuable, why isn't anybody, anybody (China? Bueller?) else willing to buy them, except for our government? If the companies are worthwhile enough to be "saved," why aren't they worthwhile enough to be bought? Surely someone poking around the coal mine has noticed these elusive diamonds in the rough? I've always assumed that if no one wants to buy something, that means that the something isn't actually worth anything.

Many Americans once thought they had some assets/pensions/employment in these companies, and will surely be very, very devastated to find out that, subjective Bayesians be damned, seven years of plenty doesn't imply seven more. Many might end up losing a lot of money. I say, fine, let's bail some of these people out. What I don't understand is, if the government must redistribute income, why not just:
1) Put the $100 billion on layaway,
2) Figure out who ends up the poorest after this big melt-down, and
3) then hand out the cash?
4) Re-assess the situation and see if more is needed.
5) Repeat

Why spend the money now, before we've even identified who needs it most? Last I checked, the heads of companies didn't apply for jobs at any welfare agency, so we shouldn't give the money to them to dole out. Why not knock on the doors of the Food Stamp Program and Department of Labor, hand them a few billions, along with the memo, "Expect busy day tomorrow." We'd still be helping the potential victims of the predicted meltdown, just distributing the money to those who need it, when they need it.

While most people recognize that sending good money after bad doesn't actually help "save" anything, some are conjuring up psychological explanations about why we must bailout these companies. They talk about an capital freeze that will stem from lack of "confidence" or "faith" in the market. I tend to believe businesses are generally judged based on their monetary value, rather than psychological or religious value. But in case I'm wrong, why don't we hire Dr. Phil and the Pope to ease our troubles, rather than Henry Paulson? We are constantly being told that this bailout must happen quickly, lest our country be destroyed, and all the skeptics be turned into pillars of salt. At least Pope Benedict can then intercede on all our behalves.

Today in Medical School: A Chat Between Two Representatives of the Obama Campaign

2008-09-22T18:35:00.001-07:00

Or at least that's what the health care policy debate felt like.

My school invited E. Richard Brown Ph.D., Director of the UCLA Center for Health Policy Research and Senior advisor to the Obama campaign to debate Dr. Donald Kurth, M.D. Chief of Addiction Medicine at the Loma Linda University Behavioral Medicine Center, Mayor of Rancho Cucamonga, and Chair of the Health Care policy committee for the McCain campaign.

I don't know which speaker did more to advance Obama's ideas for increased government involvement in medicine. For those who argue that competence in running a campaign is more significant than a candidate's actual policy proposals, then today's spectacle might solidify such people's support for Obama. Let me caveat that I am a hard-core free-marketer, who believes that McCain's health care plan is actually one of the highlights of his candidacy (had he also promised to bring our soldiers home from Iraq, and had eased up on some social issues, I would have been writing this from his campaign volunteer headquarters).

Dr. Kurth seems like a kind gentleman, who cares for his patients, and supports his political positions because he believes they will improve patients' lives. Nevertheless, he presented McCain's plan by reading off the McCain/Palin brochures that had already been left on our auditorium seats. He spent a few too many minutes talking about his own professional degrees and experience. His only argument against government-controlled health care consisted of a personal story working for the U.K. National Health Service thirty years ago, in which his advisor, a surgeon, didn't make lots of money, and some patient he met had to wait a few years before receiving his hip replacement. When asked questions about the McCain plan, he admitted that he didn't know the details, and instead continuously repeated the same emotional mantra "Do you want the government to get between you and your patients?" That line was the answer to about seven different questions (admittedly challenging, sometimes antagonistic, questions- this is Obama Country, after all).

After Dr. Kurth's very short presentation, Dr. Brown barely had to open his mouth to "win" the debate. But he went much further than even describing Obama's plan. All parts of McCain's plan that Dr. Kurth was unfamiliar with were explained in detail by Dr. Brown, before he summarily refuted them with facts and figures, rather than personal experiences. It was like watching Lennox Lewis take on my old Tae-Bo instructor.

Without a real sparring partner, Mr. Brown talked for about a half-hour, and got away with quoting every questionnable statistic, and its intepretation as fact (i.e. "48 million Americans don't have health insurance," without a mention that this includes illegal immigrants, whose health costs ought not to be subsidized any more than those of any given world citizen- and I even support immigration reform). If free-marketers believe that socialists advance their causes through romantic emotionalism, rather than rational data, they would be disappointed to see who are currently carrying each movement's torch. Here was one guy, the so-called "Marxist" who came across as professional, fluent in policy, and well-prepared. Then there was the other guy, the "Capitalist," who seemed to have a verbal tic in his constant repetition of "I believe in the free market" and described, very generally, that he has some problems dealing with the government bureaucracies in his medical practice.

(As an unrelated aside, my audience question to Dr. Brown was as follows: "There are many controversial cultural issues in medicine, including abortion rights, medical futility, and transgender surgery. How do you feel that the existence of a National Health Insurance Exchange might affect the debate regarding cultural issues? More specifically, in the case of medical futility, who would decide when the plug is pulled? The patient's family or the people footing the bill, who may not have made the patient's decision for themselves?" The line to pitch questions to the Obama representative consisted of: Me. The line to ask questions of the McCain consisted of at least 6 upset people).

After the "debate," we discussed the two health care plans in our classroom. Considering the overwhelming support for Obama in my medical school, as well as the poor performance of the McCain representative, I have to give my fellow students a lot of credit. They asked a lot of the important questions that made me realize that there are knee-jerk liberals, and liberals who ask and consider probing, relevant questions. In our classroom discussion, some people queried, "How would these plans be paid for?" "How would we insure that costs don't go up if there are coverage mandates? How do we prevent increased premiums for healthy people (or a healthy person exodus from costly plans), once insurers are required to disregard "pre-existing conditions"? Would illegal immigrants be eligible for free care? If not, who would be left to pay for their medical expenses?) Despite my constant feeling of being a political minority in my medical school, I do admire and respect my classmates. It's just a shame that the one opportunity for many people to hear a cogent argument on behalf of the free market was was so devastatingly wasted.

Anesthesia Irreverence

2008-09-20T15:53:00.000-07:00

Courtesy of the Laryngospams, a singing group of CRNAs (Certified Registered Nurse Anesthetists):

And if you mastered the breathing part, here's for the more advanced:

Pelvic Examination Training

2008-09-20T14:00:00.000-07:00

First, a word of warning to all the women out there:
If you see a male second-year medical student with a speculum in his hand, drop everything and run.

Luckily, our victims this week were vinyl dummies, not-unlike the kind sold to lonely middle-aged men who visit unsafely-searched websites. These unenthusiastic volunteers, come with a set of interchangeable parts (Cervix with endocervical polyp! Cervix with neoplasia!, Pregnant 10 week uterus! Two adnexal masses!). The sneaky doctors mix up Eva's (as she is always called) internal organs, so we can test our abilities to palpate and identify her various pathologies. Eva does not charge by the hour, but her $597 fee ought to be returned if you diagnose her correctly.

I've noticed a bit of a difference in how we are taught to perform the male versus female pelvic exams. The gynecologist gets up, and with a soft, sympathetic voice, talks about how she carefully drapes the patient, and eases her into the examination, by first placing her hand on the patient's knee and then thigh (she recommended that all doctors do this, to comfort the patient, but I insist that any male doctor who cares about retaining his license ignore that advice), before performing the exam. All anatomy is referred to by the most professional sounding jargon we have in our medical toolbox. "Sensitivity" and "comfort" are each mentioned about 12 times during her presentation.

In contrast, the urologist is crass and bawdy, talking about his own and others' mastrubation habits, and joking about how Los Angeles doctors, many of them Jews, are clueless about the fact that patients can get severely edematous retracted foreskin, if the patients fail to put it back where they found it. He seems to imply that the most important thing is to reduce the "unmanly" factor as much as possible when you position the patient during the prostate exam ("I call this the last position any male wants to get into"). He described an inguinal hernia as "Dude, where'd my penis go?"

Of course, we are taught to interact respectfully and professionally with all of our patients. But I do wonder if there is a silent understanding among doctors, that some men prefer to have their discomforts dispelled by bluntness and Adam-Carolla-style humor, while women often prefer to be treated with sensitivity. Of course, the above observations are gross generalizations, but it's the impression I've gotten so far, watching the style and mannerisms of the gynecologists versus the urologists. During the pertinent rotations, I'll report back on whether I still find this to be the case, or if generic "doctor-speak" is employed for all.

Another Powerpoint Exhumed!

2008-09-17T15:06:00.000-07:00

I gave this presentation last week for medical students in the training session for "Community Impact," a program in we teach about topics such as "Drugs and Alcohol," "Dating Violence" and "Contraception" to kids in Juvenile Hall. My specific topic addressed job opportunities available for teens, as part of the "Decision Making" module. So unless you happen not to know a kid in the L.A. area who just finished Juvy and is now looking for a job in the neighborhood, this widely-relevant presentation is for you!

Job Tips For Teens

View SlideShare presentation or Upload your own.

Spared from the Powerpoint Graveyard: LGBT Health Care

2008-09-17T12:04:00.001-07:00

Each week, we have a class called "Professionalism in Medicine (PPM)," in which a group presents on a topic concerning medical ethics, health care politics, or community-specific medical needs. We also invite relevant speakers to talk about their experiences navigating our vast American medical morass. For example, this week's topic was "Patients with Disabilities." After watching excerpts from "Murderball," we listened to a man with quadriplegia speak to us about, after his accident, what the doctors did that he perceived as helpful or unhelpful (Helpful: Hooking him up with other patients in a similar situation. Also helpful: Very frank and specific talk about the potential prospects and exact methods for having sex. Unhelpful: Doing anything for the patient that he could do by himself).

When the topic was alternative medicine, our school invited naturopaths, homeopaths, chiropractors, acupuncturists, reflexologists, etc. to speak to us about their practices (Regardless of what any one feels about alternative medicine, it's important for allopathic doctors to be familiar with the practioners' interventions, and to learn how to work with patients and their other health care providers in a productive manners). Next week, representatives from the McCain and Obama campaigns will speak to our class about the candidates' various health policy proposals.

About two weeks ago, my friend and I gave a presentation concerning LGBT health care to our "Professionalism Practice in Medicine (PPM)" class. I addressed basic definitions about sexuality and gender, as well as some pertinent legal issues, while my friend focused on specific health care needs and disparities of the LGBT community. We ended up meshing both our powerpoints, but, because I am not sure if she wants her work advertised on the internet, I'm only posting my portion.

Although I enjoyed giving the presentation, as I waded through some of the many websites, books, and papers dedicated to "LGBT Health Care," I've been pondering some of the pluses an minuses of codifying such a group. In general, I maintain some reservations about addressing "Group-specific Health Care," including "LGBT Health Care." While I didn't mention such concerns in our talk, I wanted to go over some of them here:

Advantages:
1) Higher/Lower Pre-test Probabilities. Lesbian women are at increased risk for breast cancer. If we know and talk about elevated risk of gay men and lesbians for contracting certain diseases, we will be more vigilant in screening them for such diseases.

2) Unique Mental Health Issues/Addiction. Homosexuality correlates with higher rates of depression, drug addiction, and other mental illnesses. LGBT people often face disapproving families, unaccepting religious groups, or simply their own struggles with their sexuality. Knowing this, the doctor can better engage with the patient, talk to her about her troubles, and screen her treatment with anti-depressants or referral to psychotherapy.

3) Fostering Rapport. Most gay or lesbian patients do not suffer from depression or addiction. However, for some people, if the doctor doesn't address or seem to know anything about their sexuality, they may wonder what the doctor would really think about them, if she knew, and cause some distance between the doctor and her patients.

4) Unique Legal Challenges. It's important for doctors to know the laws regarding the authority of a domestic partner over end-of-life decisions, guardianship of a partner's children, extent of insurance coverage from her partner's plan, etc.

5) Possible Extra Need for Privacy. The health records of the "happily-married" senator, who is on the dl, may need to be stored in a seperate place, not to be seen by the rest of the medical staff.

6) Early Identification of Community-Specific Pandemics. Last year, an article addressing a spike in methicillin-resistant staph. aureus among gay men with HIV caused a wind-storm. Many gay activists denounced the article, especially after some Right-wing Christian groups categorized its findings as evidence of strike upon modern Gomorrah. However, fundamentalism and feelings aside, if early identification of group-concentrated pandemics can help us thumb tag each exposure on a public-health map, we can perhaps nip the outbreak in the bud a bit faster.

7) Intersex and Transgender Health: Unique Needs. It's probably a good idea for doctors about sex-reassignment surgery or MTF hormone therapy, considering that these are common procedures for trans-sexuals. Additionally, the controversy involving intersex children have prodded many doctors to take a more "let's wait and see what gender the kid ends up preferring before we chop anything off" for hermaphrodites, and to resist performing immediate surgery on the neonate.

Disadvantages:

1) Group Identity. Some people simply do not want to be classified in some group called "LGBT." They want to just be seen as "Angela" or "Bill," and as having personal health needs.

2) Sexual Fluidity. If we accept Kinsey's notion that the binary view of sexual identity (gay vs. straight) inadequately describes American's multi-layered and diffuse pattern of sexual preferences and experiences throughout life, the border between "LGBT" and "Straight" starts to become somewhat artificial.

3) Discounting Potential Health Risks. Perhaps too much emphasis on someone's sexuality can bias against certain diagnoses. While lesbian women are less likely to contract HPV, some evidence suggests that, if a lesbian develops cervical cancer, it is often diagnosed at a later age. There are many possible reasons for this (lack of medical access, the fact that lesbians don't need birth control and, therefore, see the gynecologist less often). However, some studies also suggest that lesbians are simply are not offered a pap smear at the same rate as are straight women, presumably because doctors see their risk as being low.

4) Avoiding Social Bias. When we focus on LGBT health, we run the risk of calling, for example, HIV, a "gay man's disease." Other than the fact that this could lead to all kinds "told you sos" from the peanut-gallery, some straight people may behave more recklessly, assuming that they aren't at risk for such illnesses.

5) Focusing on Risk Factors. Lesbian women are at increased risk of breast cancer, but this has nothing to do with the gender of their sex partners. Nulliparous women (women who've never given birth), as well as obese women (lesbians are more likely to be obese) are at increased risk for breast cancer. Perhaps it is most useful to focus on individuals' specific causative risk factors, which may or not be correlated with their sexual identities.

So, now that you've heard my spiel questioning the category of "LGBT Health Care," please please enjoy my presentation on that very topic:

Lgbt Health Adina Only

View SlideShare presentation or Upload your own.

Fully Informed Patient

2008-09-16T02:36:00.001-07:00

The New York Times has an article explaining how patients, once they've left the emergency department, are often confused about their conditions and recommended routine follow-ups. Patients' understanding of their illnesses and how to properly maintain and monitor their medications and health status are essential. However, I believe it is a mistake to insist that such knowledge derive from ER staff. In fact, the more we do to enhance this idea that a fully-informed patient should walk out the ED, the more we re-enforce misuse of the emergency department, which can have dangerous repercussions on overall patient morbidity and mortality.

The emergency room should be primarily used for emergencies, rather than health maintenance, and should NEVER serve as the patient's final stop in the body-fixin' assembly line. At an urgent setting, patients should be stabilized and cleared from any immediate threat to their health. Ideally, they should also know what to do when they return home. However, within the very same week, if not the next day, patients should follow up with a visit to the INTERNIST or FAMILY DOCTOR (there are many free clinics in L.A. where patients can see primary care physicians). There, patients can and should inquire more about their condition and general health, to achieve all of the information that they need to maintain control over their day-to-day well-being.

What people must understand is that there are trade-offs to everything. In medical wonderland of the future, people will leave from every medical situation fully informed. I, for one, subscribe to the old-school style of doctoring of partnering with the patient, in which it usually takes no less than an hour to discuss her medical conditions. Talking with patients is one of the reasons why I'm still committed to this messed-up profession.

However, it is impossible for an ER to provide the patient with the information he needs. Attempting to do so might give the patient a false sense that he requires no follow-up with a general practitioner. However the most serious consequence is that, If ER doctors, nurses, PAs, or even the cafeteria lady who happens to be standing by, spent more time fully explaining people's conditions, then the 8+ hour average wait time at my hospital's ED would inevitably be further extended. This could translate to addressing fewer time-sensitive emergencies.
While we may see the patient with the severe MVA or gun shot wounds first, the patient sitting quietly who had severe chest chest pain a few hours ago, and now seems fine, will have to sit around a bit longer. If such patient had an MI, every minute is more muscle tissue lost.

Life is about trade-offs. As we think about the additional enhancements we can theoretically implement in ER, let's be very careful about what our patients might have to give up in return.

I'm Rich?

2008-09-15T06:55:00.001-07:00

Above, is an (admittedly poor quality) picture I took of a heaping pile of many billions of Zimbabwean dollars. Rejoice Ngwenya, a very brave writer and activist from Zimbabwe, had set up the table to impress upon the attendees of Cato University the extent of his country's stratospheric inflation. Such a pile doesn't even buy a loaf of bread, and the people of Zimbabwe either try to flee to Botswana or South Africa, identify something to exchange for food in the black market, or simply starve.

Well today, Mugabe the Terrible finally signed an accord with the opposition leader, Morgan Tsvangirai, allowing them to control roughly equal parts of the government. Perhaps soon the $750,000 bank note that I swiped (today's value: 0.000000939496 USD) from the pile will be worth more of what it advertises! All joking aside, as much as Tsvangirai obviously defeated Mugabe in the election, this power-share concession is a promising opportunity to reduce the tyrranical oppression, let alone disease and starvation afflicting the Zimbabwean people.

She Wants a Job? Well, She's a Victim, and Should Work For Fellow Victims Instead

2008-09-15T03:07:00.000-07:00

This basically sums up (admittedly, with editorialization) the suggestions made by Lawrence Gostin, Law Professor at Georgetown, in an article titled "International Migration and Recruitment of Nurses: Human Rights and Global Justice"in the April 16, 2008 issue of Journal of American Medical Association (Subscription required. Yes, I catch up late).

Due to our country's nursing shortage, U.S. hospitals actively recruit and sponsor worker's visas for nurses who were trained in foreign countries. This represents a considerable opportunity for many health care workers to improve their family's lives, but also a problem for developing countries that face their own (significantly larger) nursing shortages. While Mr. Gostin recognizes freedom of migration as a human right, he volunteers such nurses as martyrs for the ailing people in their own countries, which require "the human resources necessary to ensure the right to health care for their populations."

If maintaining human resources is a required component of respecting civil rights, who logically must be impinging on these rights by reducing the human resource pool? Presumably, workers themselves, who, while choosing to improve their own lives, neglected their "responsibility to contribute to the public's health, safety, and welfare of their home country." Of course, the U.S. is not left off the hook either for this "global injustice." Our country's hospital administrators and bureaucrats are admonished for informing people about better opportunities, as "advocates for global health call active recruitment in low-income countries a crime."

Such criminal behavior does not stem from providing too many perks or incentives to to workers to stay in this country, offers that would certainly aggravate global nursing disparities. Rather, Mr. Gostin, somewhat incoherently, believes that the U.S. contributes to the problem by victimising the nurses, "luring them with misleading promises, and threatening [them] with deportation if they break their contract." Is it a crime to sponsor people to stay here or a crime to prevent them from staying too long?

Nursing is probably one of the most grueling, difficult jobs available, and it is probably hardest for foreign workers, who besides dealing with language or cultural barriers, tend to work for the poorest hospitals. However, if abuse is as pervasive as Mr. Gostin suggests (before he advocates for state laws to prevent discrimination, poor and unsafe working conditions, unequal pay and treatment, as well as other perceived injustices), why would it constitute such a threat to send such workers home? Shouldn't it be a blessing to release people from their shackles? And if people are so desperate to stay here, despite all of the employment regulations that hospitals seem to violate, wouldn't increasing incomes and improving working conditions for nurses only discourage them from returning home, which is Mr. Gostin's goal? After all, Mr. Gostin believes that we have a responsibility to place incentives for workers to "stay at home, or return home after visiting abroad."

Mr. Gostin somehow believes that, if we increased benefits, we'd snatch up fewer foreign workers, who, now flooded with cash, would desire to return home. I'm skeptical. Guarantees of minimum salaries and expansions of benefits would only provide a new flood of nurses, astute enough to apply for entry to this country, whether or not we banned "active recruitment."

Mr. Gostin's fundamental problem is that he struggles to portray both the workers, as well as the people they "neglect," as victims. He also attempts to condemn the United States for offering too many opportunities, as well as too few (or at least for not long enough). Presumably, every inconsistency could be untangled if we assume that all of the hospitals systematically break promises or contracts made at time of recruitment. However, even if we did assume ubiquitous deceptive and exploitative behavior, this would not explain why most workers strongly prefer to stay and work in the U.S.

By designating aggressors and victims for a hodge-podge of perceived, and often contradictory, indiscretions, Mr. Gostin hinders advancement of his central goal, which is presumably to increase the number of health care workers in developing countries. Additionally, so long as people "owe" services, simply because they possess skills and others have needs, whenever such people forge their own paths, choose their own options, and advance their own values, they, according to Mr. Gostin's reasoning, inevitably contribute to violating others' human rights.

Pharm Free

2008-09-14T17:19:00.000-07:00

Among medical students today, the most fashionable accessory is designed by neither Prada nor Fendi. It is that canvas tote thing, similar to the one your grandma brings to the supermarket. Except this one features duct tape plastered over some undecipherable slogan, that once said "Plavix" or "Celebrex." On the duct tape is often written "Pharm Rx." By wearing this bag, the medical student signals to the world that, despite being a future member of a stuffy aristocratic profession, the student is radical, independent, and averse to shilling for Big Pharma.

The problem is, by covering up the name of the pharmaceutical company, the future doctor does his patients and colleagues a disservice. The purpose of "Pharm Free" campaigns is to insure that the physician's recommendations are never inappropriately influenced by bribery, which could harm the unsuspecting patient. However, when a company showers a doctor with gifts, and he discloses this fact to those around him, he at least allows them to form their own opinions about the reliability of the doctor's subsequent professional recommendations. By accepting perks, but refusing to give up the names of his bank-rollers, and by concealing their names on his complementary tote bag, the doc's actions ought to be considered, in the minds of Pharm-Freers, as plain old corruption.

Insurance-Promoted Suicide?

2008-09-13T14:36:00.000-07:00

At Covert Rationing, "Dr. Rich" bemoans physician-assisted suicide and euthanasia. He presents a letter sent by an insurance provider, which advertises to its subscribers that such interventions would be, what Dr. Rich terms, "compassionately offered and cheerfully paid for." Dr. Rich questions the motivations of such promotions as follows:

"When reducing costs and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy."

Dr. Rich is correct that decisions concerning euthanasia are not necessarily driven by pure motivations, a concept especially apparent when "patient choice" is championed inconsistently. However, it does not follow that nobody would recommend physician-assisted suicide or euthanasia if it didn't save a bureaucrat some money (as Dr. Rich seems to suggest), or that it is inherently unethical.

Let's assume that sometimes euthanasia is appropriate, which we'll define as meaning that it is the intervention that the patient would have really, truly wanted, had we been able to glean his choice, unsullied by the pressures of other stake-holders. If the insurance company advocates for euthanasia, its recommendation could be categorized as follows:

1) Inappropriate, but saves company some money (Company as devil)
2) Inappropriate, and the company loses money (Company as accidental devil)
3) Appropriate, and company loses money (the company as merciful angel of death)
4) Appropriate, but also happens to save company some money (company as possible applicant to become devil, but assigned as merciful angel of death.

In option 4, unlike option 2, the company's interests happen to coincide with the best interests of the patient. Therefore, just as we shouldn't automatically accept a company's recommendation when it has something to gain, we shouldn't automatically reject their recommendation, just because it has something to gain. We need to simply work harder to establish and implement the patient's will.

Ideally, the power of the insurance company's biases would diminish if its contracts delineated, at time of patient enrollment, the extent of coverage provided for life support, at various degrees of brain damage. If it were plainly written, "we do not provide continuing treatment for patients in a persistent vegetative state, when such a diagnosis is determined by three separate physicians," then conscientious objectors would choose to take their money elsewhere. They could also pay a higher premium for the expectation that their organs would be kept alive. It would then be up to the hospital and patient's family, when the time comes, whether or not to keep the patient on life support, and who must pay for it. The insurance company ideally decides what medical procedures it covers, not whether such procedures are medically justified.

To me, such issues underscore the potential dangers of implementing universal health care. We could potentially be left with a system, in which everyone foots the bill for ventilators that most would have refused for themselves. Alternatively, we could inappropriately end up pulling the plug on people, as administrators ration away all costly end-of-life care medical in favor of services perceived as more urgent. Inevitably, we'd draw the line at a place that runs counter to the wishes of most patients, who have complex values and needs.

This is not just an economic issue, but a potentially significant instigator of the Culture Wars. As much as social conservatives hate taxes and abortion, what aggravates them most is that their taxes are complicit in providing abortions. Most people have an easier time minding their own business when they aren't footing the bill for other people's perceived unsavory activities. Once the government starts making decisions about the extent of coverage for euthanasia, transgender surgery, abortion, and alternative medicine, every one will find his own beef. Hence, economic issues will increase every one's aggravation concerning social issues.

What about people who can't afford health care? Should they be the ones whose plugs are automatically pulled, because they lack the resources to choose the more expensive option? Ideally, people who care about such people's wishes, concerning this issues, would help fund the life-saving measures of such terminally ill patients. It is a difficult matter that the patients wouldn't get to choose their fates, and yet also a difficult matter that an unwilling sponsor can't choose the fate of his taxes, which may have otherwise gone to someone else's cancer treatment. Yet, one way to solve this problem would be to implement government health care policies in which patients are simply given cash to purchase insurance and treatments. After ranking their own list of medical priorities, patients would choose among private plans. They may choose to buy a plan with comprehensive ventilator coverage, or a plan that comes with extra chiropractic visits.

Admittedly, taxpayers would still indirectly pay for people's health care decisions. But the contrast is analagous to the theoretical (and likely rare) person who spends his welfare dollars on prostitution and drugs, rather than the a person who obtains such goods and services from a benevolent single payer, who compensates pimps and dealers directly. In the latter, the government, on behalf of the taxpayers and society overall, chooses to pay for objectionable services. In the former, we simply gave the person some cash, to spend under his own discretion and autonomy. The choices he makes are ultimately his own.(As an aside- for those who believe that I am calling doctors pimps, please note that I am making an analogy, rather than a comparison. Although doctors as drug-dealers is not as off-base).

When it comes to euthanasia, and all other controversial medical issues, the more we allow people to make their own decisions, the less we have to worry about competing profit motives and our personal moral conundrums.

Pregnancy Pact

2008-09-12T19:11:00.000-07:00

Remember the national scandal a few months ago about the "pregnancy pact" among some teenage girls in Small Town, Massachusetts, which led to cries for increased access to birth control/implementation of abstinence-only education/mandatory curfews for teenagers/increased parental prosecution/development of self-esteem curricula/stricter TV and video game ratings/Focus on the Family take-over of government/ People for the American Way take-over instead?

What those girls did was foolish, but I took on the Judge Kozinski-inspired viewpoint of “The parties are hereby advised to chill.” (An exception goes to the actual girls and their parents; Future daughter, if you're reading this, don't think that kind of irresponsible behavior is tolerated in this house).

At the Tijuana clinic I volunteered at in Colonia Obrera, there were five girls, ranging in ages 13-16,who plopped down on the bench in the makeshift shed-cum-medical office, and gigglingly requested some pregnancy tests. Three of the five turned out to be pregnant, while the other two were so genuinely disappointed by their negative results, that they asked if there weren't some "prueba otra." What this means to me is that some girls, in many little towns around the world, make "pregnancy pacts" with their friends. The difference is that when it happened in the U.S., it led to double-overtime for Fox News staff, while in TJ it was just another group of girls seen in the clinic before we broke for our lunch of nachos and pink water from the cooler. This demonstrates how startlingly rare these things are in the U.S., and maybe we should celebrate that we're doing something right.

Homeboy Industries

2008-09-12T19:03:00.000-07:00

A few weeks ago, Father Greg, founder of Homeboy Industries (a company comprised of former gang members, which runs silk-screening, maintenance, merchandising, and cafe operations around L.A. county) and Treyvon, one such former gang member, came to speak to our medical school class. Father Greg's speech was one of those laugh-and-cry moments (the kind I won't attempt to recount in detail, as literary justice will not be served- but I do recommend that you hear him speak. I warn conservatives that they may have to ignore some angry non-sequiturs directed at Bush Jr.). Treyvon's speech was equally brilliant, and he told his story with a mixture of precise detail, worldly insights, and sage advice. One story he recounted addressed the day he sat in his car with a friend, when the friend was gunned down by a passer-bye. Random brain tissue was left splattered on Treyvon's lap. The friend wasn't in a gang. The hit was meant for Treyvon.

In front of the class, Treyvon asked me directly what I imagined gang members were like. I gave some stammering, incoherent answer. What was I to say?- "Um, According to 'The Wire,' people like D'angelo and Wallace seem to have some heart." The truth is, I know nothing about gang-members, what motivates most of them to join crime groups, or how they feel about what they do. Treyvon's journey involved a drug-addicted mom, an absent dad, a crappy school, little hope for the future, and more convincing images of neighborly brotherhood through gangs than of Ivy league lawns or frat parties. Treyvon now mentors hundreds of kids, is studying to become and audio engineer, and is all-around great guy. He also stated that most gang members, like him, joined the groups because they were desperate to be loved. Mind you, this is a tough-talking 23-year-old with plenty of swagger and bling. Very few med school neurotics would admit that they want to feel loved, although I'd say that it's pretty much a universal human sentiment. Treyvon is a brave guy.

Narcotics Unbound

2008-09-11T23:54:00.000-07:00

Cato Unbound features a typically fascinating essay, this time about creating a "Culture of Responsible Drug Use." Earth and Fire Erowid effectively argue that the notion of responsible drug use has as much relevance now as it does for an idealized post-prohibitionist future. Today, many, many Americans practice self-control regarding psychoactive substances, which are relatively easy for otherwise law-abiding citizens to obtain, especially if one includes legal "drugs," such as alcohol or caffeine. And no matter the endless shuffle of kids charged with "posession," who languish in the Juvenile Hall next to my school, or the bluster and spectacle of high-profile raids on marijuana dispensaries that cater to cancer patients. These shining examples of the DEA's good work (as well as its upcoming "Target America Campaign" which first takes aim at Los Angeles in October), do nothing to temper the reality that even the most socially isolated individual can gain access to the Internet and access to drugs, practically within same Charter Bundle Package. Simply typing in "Amsterdam" and "marijuana," allows one to quickly identify some foreign cannabis collective. The consumer can then immediately mail some cash in a inconspicuous birthday card labelled "To Grandma Adelheit," while waiting around for Ganesha's Dream to arrive.

In 2007, 42% of 12th-graders admitted to having used marijuana, according to a NIH study. When we speak about legalizing responsible drug use, high schoolers are not even our intended demographic. Yet most of these burgeoning adults somehow learn to consider the pros and cons of illicit substances, and end up figuring out how to monitor, or eventually terminate, their intake.

The Erowids' essay, however, never fully touches on the concept of addiction, slowly diminishing self-control, and the subsequent ramifications concerning personal autonomy. Most libertarians would argue that people have the right to decide whether or not use drugs, and to accept the responsibility for drugs' potential risks. But what if, after that first hit, the brain down-grades its stock of pleasure receptors? And if, just a few hits later, the desperate remaining receptors recognize the brain's waning neurohormone activity, and subsequently beg for a spare neurotransmitter to please, please come their way? With enough inconsolable pleading, the person may feel no other option than to "shut up" the receptors by acquiescing to their demands, and taking yet another hit.

Numerous experiments have shown that mice, once introduced to cocaine, will scamper toward the mesolimbic reward impostor instead of food, even if such behavior leads to the mice suffering from starvation and increasingly dangerous electric shocks. Without its first dabble in drugs, the mouse's addiction would have forever remained an unknown potential- a series of dormant nucleotides scripted in his genetic code, never to be unleashed by specific transcription factors. Certain mice, as well as people, may fall on the extreme right of the "genetic susceptibility to addiction" bell curve. However, one is never actually dedicated to a substance, just a chemical compound like any other, before the substance has been properly introduced to the brain.

Thus, what if obtaining that first high constitutes an "original sin" which slowly progresses to a nightmarish path of diminishing self-control, yet increasing physiological and social consequences? Are addicts simply suffering the effects of a single choice made that first day? The frontal cortex, or decision-making part of the brain, eventually starts to play virtually no role in the junkie's mind regarding drug use. This helps explain the abysmal long-term recovery rates for users, even those who attended fancy treatment centers. When it is neurologically proven that someone has lost self-control over addiction, should they still retain the personal autonomy associated with drug use?

Of course, these issues do not apply to certain drugs. It seems unconvincing that marijuana is addictive altogether. Additionally, the activity of the "partial agonist" group of opioids eventually approaches an asymptotic limit in its potential activity. By inhabiting the receptors of more powerful drugs, partial agonists prevent the development of increasing tolerance. It is difficult to determine the merits of banning such substances.

Perhaps better research, as well as screening for genetic risk factors of addiction will enhance people's abilities to become responsible decision-makers regarding narcotics. We know that D1-receptor deficient "knockout mice" refuse to partake in cocaine's pleasures, a fact that may have useful applications for people with a family history of addiction.

Despite the limitations of personal autonomy in reference to drug addiction, it does not necessarily follow that the government has the right to prevent potential addictions by banning controlled substances, nor that prohibiting such substances actually reduces addiction rates. Most advocates of minimum central authority believe that, in general, government failures stem from its relative inferiority compared to an aggregate of rational actors, producing, consuming, and consorting in ways that reflect individuals' personal priorities and rational self-interests.

However, in the case of addictive drugs, it is very difficult to determine when rational self-interest ends, and a drug's potentially freakish domination begins. While this does not mean that the government should intervene, it does impose on libertarians the concept that villains can indeed be of our own making. Whenever we reduce the impositions of government, we add to the moral burden and responsibility to be beared and voluntarily fulfilled by caring family and friends.

Straw Man

2008-09-11T23:15:00.000-07:00

David Brooks touts the findings of modern neuropsychology as evidence that Goldwater conservatism is incompatible with human beings' natural inclination to establish interdependent relationships and collaborative institutions.

But who ever said that we shouldn't form social networks? Libertarians simply believe that such networks should be strictly VOLUNTARY. The "communities" created by government are always mandatory, which inspires more discord than camaraderie. It isn't that libertarians and libertarian Republicans do not believe in charity or community. It's simply that we believe that we should choose the charities and communities with which to associate.
Trust me, many of we libertarians have close friends, from all political spectra and walks of life, whom we care for deeply. We don't need the government to set up play-dates.

The Scarlet VP

2008-09-03T18:02:00.000-07:00

I’m not usually one to yell "sexism" at every turn, but I do hate hypocrisy. When many "progressive" people clamor for Sarah Palin to step down, go home, and take care of her family, such helpful advisors undescore a prevalent bias that a woman's career goals are pretty insignificant. They feel that Palin, as a woman, should easily sacrifice a once-in-a-lifetime opportunity the moment there's an issue involving her soon-to-be-adult daughter.

Even if Palin were pro-choice or pro-comprehensive sex ed (as I am), her daughter still could have gotten pregnant. Earth to fellow sex ed instructors (I teach about contraception and STDs in Juvenile Hall): Providing comprehensive education does not entail actually showing up to the bedroom. You can't control what teenagers do. All of those excuses about her conservative political positions justifying criticism of her family's problems are red herrings.

Why would any "liberal" think that Palin's first responsibility should be to "spare" her family, rather than worry about her career goals? I ask all men out there: Do your careers have such little importance, that you would sacrifice everything you’ve worked for, the moment your 17-year old made a mistake? No, you’d probably work longer hours to make more money, so you could help support the child. And you’d become as successful as possible, to become a role model for your child and grandchild.

In college, I used to see many women wearing shirts announcing “I had an abortion.” It seems that having had an abortion is a source of pride for some people. However, apparently being pregnant is so unbearably shameful, such a huge scarlet letter, that people are saying that Palin should step down simply to avoid “exposing” her daughter or thrusting her into the limelight. Well, there would be no limelight if people stopped acting like pregnancy was the greatest possible scourge for a young woman (And don’t tell me that your mentioning these things are justified because it simply reflects what conservatives believe. You either uphold your principles or you don’t. And you don't take out any potential conservative hypocracies on a 17-year-old, who may be pro-choice, for all you know).

Palin’s son is in the army. Although, this decision is extraordinarily honorable, it involves enormous danger and risk. Yet, we are more “worried” about the young woman who will have a baby in a safe environment than the other kid who is potentially one convoy trip away from getting killed. Do we only feel the need to "protect" girls, rather than boys? Or is it just that this has nothing to do with women’s welfare, and everything to do with pregnancy taboos?

Update 2.12.09 It feels strange reading this post, so many months later. Soon after posting it, I became thoroughly underwhelmed with Governor Palin, as did many others. Was I right to avoid judging her so quickly, and to give her a chance, or should have I been clued in to her lack of qualifications much earlier? Not sure.

Adina and the Terrible, Horrible, No Good, Very Bad Day

2008-08-13T22:00:00.000-07:00

I didn't wake up with gum in my hair, but you'll have to trust me: It sucked.

Tomorrow will be better. I get to see patients again, and in a fancy, schmanzy hospital in Glendale. I will miss County, with its eight-hour average ER wait time, jail ward, and cavalcade of wacky patients. But I don't really speak Spanish much, which was always a frustrating limitation. Let's hope this hospital also features some interesting elements. Otherwise, I'll have nothing much to write about on my blog, and you'll be stuck reading my minute-by-minute Talmudic analysis of the latest Heroes episode.

Religious Minority

2008-08-12T21:13:00.000-07:00

Because I'm doing major mea culpa to the medicine god this week, I don't have time for much thoughtful posting. Therefore, I'm just writing to remind myself of my latest life observations. Because no one actually reads this, it functions as somewhat of a journal, which is fine with me. I'm kind of a solitary person at heart (in that I lament not spending enough time with people, yet can't be bothered to call back amazing friends, and have just skipped a party to sit on couch and drink Sam Adams Black Lager and watch the Olympics with my cats). Thus, I find this whole blog thing kinda soothing.

This week I became a Jew (doing lots of stuff) for Jesus, in the sense that I've been at three different churches for three different purposes in the last three days. And if you count my long religion talk with the Mormon kid who was one of my roommates at the Tijuana trip, and another conversation about the Armenian Orthodox Church with Haig, (who is in six-person clinical medicine group), then that officially counts as five Christian experiences this week. (The first three were at the Episcopalian church that organizes the HHAB medical trip to TJ, the Catholic church I attended to advertise for the USC Free Clinic SNAPP program, and the Salvation Army shelter where I tutor an adorable homeless kid- ok, the last one is not exactly church, but is a place filled with lots of what my friend calls "Christ love").

And yet, I am not a Believer. I should also note, however, that I retain a triumphant, zealous faith and practice in playing draydel for gelt on Chanuka, watching soldiers march in Memorial Day Parades, eating matzah/BBQ veggie burgers to honor my freedom on Passover/July 4th, playing dress up and getting smashed on Purim (it's a real commandment), deeply regretting and apologizing on Yom Kippur, breaking my pseudo-vegetarianism to eat real turkey on Thanksgiving, and greeting people with "ahoy matey" on National Pirates Day.

I find that picking the lucky religion is like classical roulette odds with Russian Roulette outcomes, although choosing a Christian one might narrow the probability to reds vs. blacks. This is because you can dip in one denomination, and still get partial credit from another one (say the bottom rung of the three celestial kingdoms of the Mormons). Or as Paul said: “I know a man in Christ who fourteen years ago was caught up to the third heaven. Whether it was in the body or out of the body I do not know-God knows.” Such different stages of heaven and hell allow for efficient faith differentiation. It is perfect for the Power(s) that Be, in that it captures the "Faithfuls' Surplus," while allowing for the less devout to sacrifice less, so long as they're willing to accept a smaller portion of the Everafter.

However, in the meantime, I'll keep going to temple, planning trips to the Western Wall, and sending my money to the Jewish National Fund, Jewish World Service, and the Simon Wiesenthal Center, et. al. There's something to be said about a religion that endures so exhaustedly that, even if you check out on it, it never officially lets you leave.

Palliative Care

2008-08-11T12:20:00.000-07:00

This post is about a patient, approximately my age, whom I visited at the hospital last year. As usual, names and other details have been changed.

The first thing that I noticed about Maria, was not the oxygen mask into which that she desperately breathed, nor the black and blue marks that whirled along her arms ( inflicted by needles, syringes, and other abusive medical equipment), but her carefully painted fingernails. This was clearly a woman whose family lavished attention upon her. We said hello to 28-year-old Maria, who recognized us with her eyes, but could not respond due to the breast cancer, that had metastasized to her brain, bones and liver. As late as yesterday, Maria was able to express that her pain was a “9 out of 10." Today, she just stared at us intensely.

Dr. Stone, who heads the palliative care office at our hospital, felt that it was perhaps time to discuss with the family about increasing the pain medication, and about how the exhaustive poking, prodding, and procedures, should now be reconsidered. She wanted to explain that Maria could perhaps spend her last days without suffering, and with her family by her side.

Surrounding Maria’s bed were pictures of her as a little girl, as well as of the Virgin Mary, and other Catholic Saints. Taped onto Maria’s bedpost was an image of Jesus, toward which I imagined Maria used to pray, long before the drugs diminished her comprehension. Dr. Stone recommended to Maria’s sisters that there be a family meeting with Father Joe, the hospital’s priest. Instantly, Maria’s sisters felt comforted by the idea. They weren’t as religious as they had been growing up, but they knew that their mother, who was grieving in the lobby, would be happy that a pastor could be present, to console them and help them make decisions during this agonizing time.

I knew that Maria’s sisters would remember every detail of this day forever. I came to this understanding because of the experience that morning in Dr. Stone’s office, when each member of our six-member clinical medicine group went through his and her own experiences dealing with death and loss. Even though it was about the fourth time I had heard each person’s personal story, I found that each retelling provided new details and perspectives. Experiencing the last days of a loved one’s life means that little things begin to take on great importance. Do we take her to the bathroom now or later? Should we give her more pain medication? Does she want to be propped up higher on her bed? These seemingly minor concerns can drive families into tortuous doubt and bitter conflict.

This is why I was most impressed with Dr. Stone’s explanation that palliative care was as much for the patient’s families as for the patients’ themselves. Families are given the opportunity to lay on the couch, talk things over with the palliative care staff, and to drink tea in the office upstairs. The program itself allows them to gain reprieve from nurses who visit the home once a day, an opportunity which does not cost the families extra money. If possible, patients and their loved ones have the opportunity to spend the patient’s last days in their home, rather than in a stale, impersonal hospital ward.

That day in the hospital, I saw Maria’s sister, Carmella express denial that her sister was truly going to die soon, hoping she could “stay alive just until after Thanksgiving.” She was angry, saying her death didn’t make sense because “Maria was the smallest of the three sisters.” Carmella bargained with the doctors about attempting other life-extending measures, if not a whole new round of chemotherapy. Ultimately, she started to feel depressed, realizing by the end that Maria's imminent death was inevitable. However, as Dr. Stone, the nurses, and we students gave Carmella hugs, stroked her tears, and stood with her in silence, she began the process of acceptance, breathing easier, returning our hugs, and realizing how her dear sister could live her final days at greater ease, surrounded by the people who love her.

2008-08-11T00:54:00.001-07:00

I just got back from Tijuana, and have a ton to catch up on (such as the entire first week of medical school- God, I'm gonna be so anti-social the entire week. I haaaate those weeks of "Adina repents for making foolish time management choices").

Anyway, I will just post a review of the Milton Friedman essay that I read today (excerpted from the book
above):

In arguably his most provocative essay, Milton Friedman addresses one of the thorniest issues of our time: the relative superiority of the hamantash (triangle shaped cookie, filled with jam or chocolate and eaten on Purim) vs. the latke (oily potato pancake eaten on Chanuka). For one, Milton Friedman points out, it is unclear whether unhealthy Jewish holiday food constitutes a normative or positive discipline. I understand this epistomological conundrum. On the one hand, flavor is largely experiential and subjective. On the other hand, my bubbe makes the best latkes in town, as determined in a high powered longitudinal cohort study with p<0.05.Nobody's hamantashan or latkes ever came close.
.

Generally, we attempt to overcome bias by presenting both variables neutrally, but Friedman, goes one step further, and makes the radical suggestion of using "negative" terminology for the foods, namely "lob" (as in lobster) and "ham" (as in the pig product). This is Friedman at his most bold, and I am surprised that Naomi Klein hasn't come out with a "carefully" written expose about these most shocking of Friedman's viewpoints.

Application Essay Advice for Pre-Meds

2008-08-06T13:51:00.000-07:00

Because it's pre-med season in town, I will try to post some advice for applicants trying to get through it unscathed. My first topic is about the AMCAS essay.

My suggestions are:

1) Tell a story

2) Feel free to brag, but be descriptive and specific (Not "I worked closely with patients," but "I held so-and-so's hand when she tearfully told me that she was ready to enter the OR."

3) Avoid phrases like "The experience taught me..." and "It was rewarding because...." Just make those things implicitly clear through your writing.

4) Show, don't tell!

Savvy readers will note that all of the above snippets of advice are basically the same. But that is because pretty much all boring application essays make the same mistake.

Pretend you're trying to impress the hot girl in Italian class. Are you going to pick her up by listing all of your extra-curricular activities, or by just making her feel like she'd have fun going kayaking with you this weekend? In other words, show your personality, not your CV.

And now, for your final viewing pleasure, my AMCAS essay. (All of the names that appear in the essay are names of people I met that summer, but none refer to the actual child being described. I will readily admit that I'm a bit of a braggart in the essay, and I will trust my audience to assume that I don't usually try to come off like I have all my **** together (which I don't). I should also note that, although I did at the time want to do international medicine, I am no longer sure that that is the case):

Exiting the subway in the Brownsville section of Brooklyn to begin my first day as head of a camp infirmary, I conjured up childhood memories of my own camp's infirmary, where scraped knees earned Ninja Turtles band-aids, and sore throats were soothed by a good dose of ice pops. This reminiscence, however, was tempered by recollections of my previous summer as an EMT serving in an economically disadvantaged neighborhood in Israel. The realities of domestic violence, acute physical illness, and emotional dysfunction in a population of Ethiopian and Russian immigrants, Ultra-Orthodox Jews, and Israeli-Arabs had dispelled my naive notions of emergency medical care. Would my experience in East New York also bring unexpected challenges? These musings were cut short by my arrival at a dilapidated public school building on a graffiti-filled block, with throngs of boisterous children running around in Camp ******* T-shirts.

As the individual responsible for the physical well-being of the campers, I felt that my primary task was to secure a safe and healthful camp environment. Thus, after helping to organize game of "Simon Says" until all the counselors arrived, I found an unventilated storage closet to function as a medical office, brought in a fan, and, over time, decorated the space with the children's artwork. Ascertaining that there was only one working water fountain for over 100 campers, I coordinated with the counselors to supervise the ongoing refilling of the children's water bottles. After noticing that soap was absent from the bathrooms, and learning that the facilities staff were too budget-strapped or overloaded with work orders to replace them, I bought and allocated soap myself. Finally, I aimed to make the medical office a safe haven for the kids, often playing games or reading with my visitors.

I soon discovered that, while there were few medical emergencies in the camp, there were plenty of ethical, practical, and cultural challenges confronting me. What should I do if, before breakfast, a child says that she is starving because she did not eat dinner the night before? What was my role if a mother told me that she cannot bring her child to the doctor because she lacks health insurance? What of the child who is afraid because she says that her brother often beats her mother? How do I effectively empathize with a child who suffers from sickle-cell anemia? Many of these problems, such as violence, depressive moods, and general illnesses can be found in any community, rich or poor. However, some issues were disproportionately prevalent as this was an economically disadvantaged community.

When I encountered these complex issues, I often dealt with them by consulting with my supervisors and peers. The counselors were role models for me, as most of them were college students from the neighborhood, and brought a wisdom born of experience. At other times, I relied on my own judgment. As an oldest child in a family whose youngest brother is fifteen years my junior, I have had my share of dealing with interpersonal conflicts, scraped elbows, and negotiated truces. Thus, when it became clear to me that five-year old Bianca was manufacturing the illnesses that required her visiting me during reading session, I proactively offered that she read with me during that time-slot.

What impressed me most of all that summer was the incredible power of a caring community. Despite the difficult realities surrounding them, the children were ambitious, intelligent, friendly, and playful. Many would pass my makeshift office, and announce, somewhat inaccurately, "Hi nurse!" Tafari informed me whenever he won relay races, while Kyana always showed me new stickers, earned for good behavior. The parents were kind and supportive, as evidenced by their filling the auditorium on "performance day," as well as the generous home-cooked soul food that they brought.

This interface of medical practice and real-life ethical and practical challenges draws me to public health, international medicine, and perhaps, specifically epidemiology. I want to address issues such as the Ebola virus or the effects of unsanitized water, but also how to make health care economically efficient and sustainable, and to explore the relationship between doctors and the communities they serve. I hope to listen to patients talk about their lives, their assessment of their illness, and their collaborative thoughts on the healing process.

On the last day of camp, many campers came by my office to sign messages on my staff T-shirt. This included eleven-year old Najee, who, while recovering from a stomach ache, had related to me some difficult emotional issues that she was facing. I had developed a good relationship with her and encouraged her to visit the camp social worker. Najee's note to me summed up my goal for the summer and my future goal as a doctor- to develop a meaningful relationship with each patient: "Dear nurse," she wrote. "Thank you for letting me talk in your office and listening to me.”

Safeguarding the Public

2008-08-05T22:18:00.000-07:00

As a medical student, I endorse this ban on the substance shown above, which is a component of virtually every poison and harmful pesticide, and has arguably contributed to billions of deaths throughout history. Always listen to your health care provider. You have been forewarned.

For those skeptics can't go without a proper NMR or mass spec analysis, see the data behind the controversial substance here. Watch that year of orgo pay off before your eyes.

Thoughts on Cato University Lecture III: "Understanding the Economics of Free Markets" by Peter van Doren

2008-08-04T20:57:00.001-07:00

Sonic the Hedgehog was always one of my favorite video game series. I especially enjoyed saving all of the furry animals that had been captured and (depending on which game), turned into robot slaves by Doctor Robotnik.

But defeating mad scientists via Sonic's cannon-ball spin is only one of many approaches to securing animal welfare. People propose to legislate minimum living conditions for animals, or heavily tax meat and animals bred as pets. Private organizations, post videos exposing unsavory animal treatment practices, aiming to influence consumers directly. Or people can act like The Wisconsin Humane Society just did. According to NPR, they simply decided to raise cash and buy out what they consider a "puppy mill," in order to dismantle it. Because I viewed Peter van Doren's lecture, in which he described free markets and various approaches to dealing with social costs, I recognized the Humane Society's deal as Coase's Theorem put to work.

Van Doren (after teaching basic microeconomic principles, and explaining the problems that public goods present) compared the approach of Pigou and Coase toward "negative externalities" or the "social costs" of market transactions. Unlike stealing tangible objects, negative externalities spring up when one party does something with his own property that unavoidably and negatively effects another party. Banning such an action, due to its (possibly minimal) harm to other people would be economically damaging and completely impractical. It is also unfair to harm other people without their consent. So a compromise must be brokered.

A simple example of a negative externality is air pollution caused by power plants. Pigou believes that the person who causes the pollution (i.e. the power plant) should be required to pay all those effected by such pollution (the city) through a tax, calculated as the approximate cost of the inflicted damage. The government would impose such a tax, so there would be little room for negotiation among the various parties. All affected members of the community would become automatic partners in the deal.

In contrast, Coase believed, according to van Doren, that, clear-cut initial property and ownership rights would solve the problem, without a need for central calculation. For example, the initial rule would be "the power plant has an absolute right to pollute the air with sulfur oxides" or "the people own the right to breathe air completely clear of sulfur oxides." In Coase's view, whether the former or latter condition is chosen does not even matter. Whatever the initial rules of "the game," both parties will bargain with each other until they broker an agreement that is equally satisfactory.

Van Doren provides a few examples of Coasian successes, such as the case of the entire 221-resident town of Cheshire, Ohio, which agreed to a complete buyout by American Electric Power Company for $20 million. He mentioned the recent case of Florida's and environmental groups' purchase of U.S. sugar, which translates to more more land reclaimed for the Everglades. Van Doren, who is suspicious of the government's ability to determine the accurate Pigouvian costs, seems to consider himself a Coasian, and believes that "the initial distribution of entitlements itself does not alter the willingness of the parties to exchange the entitlements."

I find Coase's theorem intriguing, but I do have some concerns about it. (I'm sure Dr. van Doren has considered reasonable objections, and has excellent answers for them, all of which would be beyond my scope of knowledge). A summary of some of my concerns (I'm sure that they've been mentioned by many economists): 1) Poor people can't necessarily afford to "buy in" to the table. If they get no chips with which to negotiate, they ultimately get stuck with unfair externalities 2) It is virtually impossible to rally up all relevant parties, which makes the transaction costs are too cumbersome 3) If the "harmer" doesn't have a profit motive, then some negative effects (i.e. extinction of species) can occur, no matter how why high the "purchaser" bids.

Animal rights are, admittedly, a much trickier issue than air pollution. It is difficult to determine whether the "rights" belong to the humans upset by the alleged atrocities imposed on the animal, or belong to the the animal itself. If the latter, this would mean the animal activists actually have no right to negotiate the appropriate limits of animal cruelty. The law (appropriately, in my opinion) treats animals as pseudo-living beings/pseudo-property, and the deal with the Humane Society depicts animals in their "property" incarnation.

However, according to NPR's story, the breeder of Puppy Haven is ready to retire, while the animal rights organization hopes to shut down his whole operation, and deliver the animals to eager families. What results is a market-based exchange, based on clear, well-established private property laws and driven by personal interests and values. Somewhere in Chicago, 97-year-old Ronald Coase may be smiling.

My First Drug Addicted Patient

2008-08-01T17:08:00.000-07:00

This post is about a (likely dual-diagnosis) patient whom I visited last year. As usual, many details have been changed.

When I first saw Ms. Smith, she was sleeping quietly in her dark area behind the curtain, her two legs in casts raised on a tuft of pillows. When I called her name, she awoke and, with a sweet Southern drawl, agreed to talk to me.

Immediately, pandemonium struck. Ms. Smith desperately needed to urinate, and demanded her bedpan right away. I rushed to put on gloves, and handed her the bedpan that was under her bed. However, the bedpan had apparently not been washed after the last time it was used, and Ms. Smith screamed that she did not want it on her clean bed. I nervously washed it with soap and water at the sink, and, in the nick of time, tossed it to Ms. Smith. This was the first of many narrowly averted crises.

During the bedpan incident, I noticed Ms. Smith’s extensive injuries. She had what must have been over 100 stitches lined up along her spine. She moved her individually bundled legs with great difficulty, and was constantly clutched what she called her “busted” rib. She also had cuts and old scars on her chin and scalp, which she later explained matter-of-factly with “my ex-boyfriend was kind of bad.” When I proceeded to ask Ms. Smith about the source of her injuries, a second crisis commenced. Ms. Smith suddenly felt extremely hot, and demanded that the air conditioner be raised. Other patients in the room felt cold, however, so I looked to the nurse to make a verdict. Eventually, a compromise was reached.

Throughout the interview, these interruptions continued. Ms. Smith was clearly in terrible pain, and constantly buzzed for the nurse to administer more pain medication. When the nurse continuously refused, Ms. Smith pleaded and sobbed that the last doses did not go through when she hit the button on the drug delivery machine (I do not believe that Ms. Smith was intentionally misleading- she thought that the machine would beep when the drugs were delivered, until the nurse explained that that is not necessarily the case). Ms. Smith called her nurse so often that eventually she was summarily ignored. This proved to be problematic when Ms. Smith had legitimate concerns.

Ms. Smith had interesting things to say about her 34 years of life, but had trouble staying on point, and every few minutes of conversation were halted by her feelings of pain, or her need to readjust in her bed. While I learned a little about the source of her wounds- apparently it was caused by a (stolen) motor vehicle accident, with her intoxicated boyfriend as the driver - after a while, I realized that I had not broken much ground in my questions, and decided that I would just allow Ms. Smith to talk freely.

Ms. Smith’s chart noted that she had attended college, and her language was relatively sophisticated. However, after about 15 minutes, after I asked her to list all of the injuries she had sustained, Ms. Smith responded, “I’m not usually this religious crazy, but these last few days- by the way, all this is off the record, they can’t publish this-I have learned some things. All of life is based on opposites. Yin.Yang. Keeps the world spinning. Right.Wrong. Good. Bad. You see I could have gone to any university on scholarship, but I went to Southern State University. I wrote a paper about dogs and their origins. My grandfather used to say, “You can lead a horse to water, but you cannot make him drink- but you can put salt in his oats! Get it?” After 10 minutes of rambling, Ms. Smith would become composed and thoughtful, telling me about her childhood.

When I visited again the next day, Ms. Smith seemed to be experiencing some drug withdrawal symptoms, as she was nervously shaking and saying she was cold in the very warm room. After a while, I decided to speak to Ms. Smith principally about her drug use.

This conversation taught me a lot about the power dynamics between drugs, drug users, mental illness, and the physicians who would like for their patients to quit. I once had a certain utopian vision of a prototypical conversation about drugs between a doctor and a patient. The doctor would inquire about how the patient feels about her addiction, and how the substances have changed his life for the worse. The patient would admit that the drugs have hurt him socially, personally, mentally, physically. The patient may never actually quit- he would perhaps rebound after some bouts of trying. But I thought that at least one point was pretty much standard: that the patient would recognize that the drugs were hurting him.

This is why talking to Ms. Smith about this topic was so difficult. Ms. Smith wanted to get back to the drugs when she was out of the hospital. This was not simply because she craved them or because she had poor self-control. Ms. Smith actually believed that the drugs made her life better. When I asked her to reflect upon how the daily use of crack cocaine and ecstasy have changed her life, I thought that maybe she’d find a link between the drugs and her current homelessness, her string of abusive boyfriends, her contraction of Hepatitis B. But Ms. Smith didn’t respond that way. She believed that she never had such good friends as the people she’d met on Skid Row, friends who would tell her where all the good dealers were. She had never been so happy nor had experienced so much fun in her life before she started doing drugs. This really made me ponder- how can you help someone to “get off” drugs if she doesn’t even recognize the harm that the drugs are doing to her? The first step of addiction therapy has to be, at an absolute minimum, a admission and dislike of the addiction. So I just decided to sit and listen, all the while getting schooled on doctors’ limitations to help people.

Thoughts on Cato University Lecture II: "The March of Freedom, 2500 B.C.- 1775 A.D." by Tom Palmer

2008-08-01T14:04:00.000-07:00

“From now, we will be able to look back and tell our children that this was the moment when we began to provide care for the sick and good jobs to the jobless…… this was the moment when the rise of the oceans began to slow and our planet began to heal…… this was the moment when we ended a war, and secured our nation, and restored our image as the last, best hope on Earth. This was the moment, this was the time when we came together to remake this great nation so that it may always reflect our very best selves and our highest ideals.” -Barack Obama, Minneapolis, June 3, 2008.

One thing that often irritates me about progressives is their vision of some perfected future, crafted in their latest folk hero’s image. A desire to improve people’s material condition is admirable. However, there often seems to be a Messianic tinge to the movement, that strikes me of naiveté, and worse, apocalyptic ambition. Such idealism scares the hell out of me, because I know that to carry out a plan to eliminate all war, strife, pollution, unemployment, or other ills, there would have to be some pretty colossal interventions. I guarantee that I much prefer the world I live in now to the one they’ll have “perfected” for me.

However, after listening to Tom Palmer’s excellent speech, “The March of Freedom, 2500 B.C.-1775 A.D.,” he convinced me that libertarians often make a similar mistake. Now, it is true that, over the past few hundred years, technological advances, industrialization, and liberalization have led to significantly improved living conditions around the world. However, too often, people tend to view history as a trajectory, in which we started out as dim-witted barbarians, endured various stages of despotism, all until the clever Europeans instituted constitutional rights with the Magna Carta. In this model, the dominant intellectual discourse continues to progress until now we are America and so can you. This libertarian-scented progressiveness has a few problems, which Palmer implied in his lecture, in which he provided a comprehensive historical account of the campaign for liberty:

1) Liberty, small-government, and personal autonomy are not new concepts, nor are they found exclusively within the Western tradition. Palmer mentioned a quote (I cannot find the source) of a University of London professor who says “Freedom is uniquely Anglo-Saxon. Other languages do not have a word for the concept.” This European exceptionalism is dead-wrong, according to Palmer. For example, in 2300 BC, Urukagina of Mesopotamia (modern Iraq) enacted a judicial code that allowed for private property rights, limited taxes, and a restriction on state monopolies.
The semi-mythical Chinese figure, Lao Tzu, has been revered by Daoists since at least the 4th century B.C. for such teachings as:

“If you want to be a great leader,
you must learn to follow the Tao.
Stop trying to control.
Let go of fixed plans and concepts,
and the world will govern itself.

The more prohibitions you have,
the less virtuous people will be.
The more weapons you have,
the less secure people will be.
The more subsidies you have,
the less self-reliant people will be.”

2)Some of today’s most authoritarian governments are thoroughly modern. Palmer points out that Iran is not some old-fashioned theocracy rooted in classical Islam. It is actually a bizarre amalgam of European fascism, Marxist economics, and Islamic-themed romanticism.

3)Freedom is not the only cherished value. Research indicates that freedom is an important factor in average happiness and prosperity, at least in a cross-sectional studies. However, some people seem to think, that, so long as we establish private property rights, there would be no more pollution or extinction of species. I’m skeptical. I also agree with many of the behavioral economists in that freedom my allow some of us to make short term decisions that lead to life-long regret, which can actually decrease our overall well-being. Some people just can’t handle their freedom. It’s still their prerogative to ruin it.

4) Some people will always crave power; thus power must always be checked. Just because people establish a truly free society, does not mean that the society is any less (or more) fragile. Some great civilizations were conquered. Others were spared by pure luck (Palmer describes the case of Ögedei Khan, who, in 1241, was just about to expand his huge empire to Austria, Germany, Italy, France, and Spain, when he got poisoned and died). And it’s not only central power that poses a threat. If some monster decides to unleash a pandemic, or build an increasingly-easier-to-develop nuclear weapon, G-d help us, because freedom will not (and this notion of an individual's power to initiate harm presents an enormous conundrum to libertarians, as we oppose individualss losing their privacy or agency). This fear means that we can never have a ribbon cutting ceremony, marking the beginning of our new earth. Vigilant oversight of power is not a battle to be won, but a continuous war of attrition. When we all die, the next generation of watchmen will simply have to take over. And others will have to watch the watchmen.

The Third Wave vs. Coverage for the Uninsured

2008-07-31T17:03:00.000-07:00

What is the best way to insure that some folks won't be able to afford health coverage for their strokes, broken bones, and heart attacks?

Simply require insurance companies to cover particular pills and procedures, whether or not this is the patient's preference.

The women at "Feministing" are angry that insurance plans are required to cover Viagra, but not birth control, and are taking McCain to task for it (it is true that he could have constructed a better response to the challenge than embarrassed stammers). I understand their concern, but I don't believe either medication should be mandatory.

First of all, it's a matter of priorities. Yes, prevention is the best medicine, but no one in her right mind would choose a "prevention" plan over a "catastrophic" plan, provided she couldn't afford both. She can assess her family planning options, not her "susceptibility to cancer" options. When various goodies are added to insurance plans, the cost of coverage is unnecessarily increased, and the patient can no longer opt-in for an "I'm not quite as screwed if I get cancer" plan. Of course, a few bucks here or there won't suddenly price-out millions, but all of these consequences occur at the margins.

Second of all, it is questionable whether or not, even for the well-off consumer, it is preferable that her birth control be covered by insurance altogether. Insurance is best for situations that are unpredictable. We are fully aware that we will likely end up paying the insurance companies more than we will cost them, in the long run. Yet, we consider it worthwhile to have the piece of mind that we'll be able afford our treatment if something terrible happens to us. However, birth control pills are a non-emergency, continuous, relatively predictable expense. For such medications, wouldn't it be best to buy directly from the pharmacy, rather than invite an unnecessary middle-man, who arrives with a chock-load of bureaucratic expenses?

Thirdly, the feminist movement is not always consistent when it comes to the concept of "choice." If it is the woman's choice whether or not to have an abortion or take birth control, shouldn't the pharmacist, doctor, or insurance company get to decide whether or not to be complicit in this choice? (I would make an exception for emergency situations or instances where the provider does not inform the woman of all of her options. That could arguably considered professional neglect).

The women of "Feministing" would be wise to consider the unintended consequences of their cause. If they want to help women, they should allow for more affordable coverage for breast, ovarian, and cervical cancer, not birth control.

As an aside, I can never tell anymore when exaggeration of "ideal" women's bodies is considered, by the feminist establishment, as unacceptably sexist or simply ironic re-appropriation. Is it me or do the naked silhouettes on the banner of the Feministing webpage resemble those on the storefront of Orlando's strip club?

Lazy Thursday Gardening and Cooking

2008-07-31T16:36:00.001-07:00

This is my herb garden on the balcony, which overlooks a parking lot. Today, I'm using the sweet basil for my favorite baked ziti recipe. The moral of this story is that I have way too much time on my hands when I'm not in school.

Lessons Learned at the L.A. Gun Club

2008-07-29T22:08:00.000-07:00

1) The first 10 minutes in the booth are the most difficult, because it takes some time to avoid flinching at every "boom." However, after habituating to the sound, it's not too tough getting used to the basic mechanics of loading (I need to use a speedloader), pressing down the slide lock, holding the gun properly, pulling the trigger, and finally releasing the magazine. It's more like learning to play guitar, rather than violin, in that it's easy to pick up and do a decent job, yet difficult to master. I just hope that inserting a central venous catheter will also prove to be as unexpectedly straight-forward.

2) I was predicting that the place would be filled with burly men sporting mullets and neon green sleeveless shirts. However, it was a diverse group, with roughly equal numbers of men and women, and a few hipster boys with Buddy Holly glasses, argyle socks, and Keds. Perhaps NRA involvement is the up-and-coming strategy for bohemian non-conformity.