Archive for: February, 2009

Thanks for the roffles, PZ!

Feb 19 2009 Published by under Absurd religious wingnutery

I don't link to Pharyngula very often---our content just doesn't intersect that much, but I followed a link from today's post and had a good laugh.
You see, some comedian creationist cult leader put out a new book, and the reviews on Amazon are a real hoot. From one review:

My only disappointment with the proofs provided in this book is that my favorite, Eve, isn't listed among them. Evolution could have made her look like anything at all--like Rush Limbaugh, a big hairy wookie, or a naked mole rat for example. There's no way Adam would have tapped that. Instead, God chose to fashion one of Adam's ribs into something soft, curvy, beautiful, and desirable (Yes, he did make that little sailor in the boat impossible to find, but that's only because you're not supposed to touch it).

Sometimes I think that the only response to the anti-science, misogynistic, anti-semitic, virulently anti-gay rhetoric of these creation cults is a good laugh at their expense.

5 responses so far

Flu update

Feb 19 2009 Published by under Medicine

It's been a slow flu season this year---until now. In the last week I've seen people dragging themselves into the office looking like absolute hell---fevers, cough, severe muscle aches---in other words, they've got the flu.
The latest CDC data shows a marked increase in flu activity.

usmap05_small.jpg

A large percentage of isolates are influenza A, type H1N1, which is currently resistant to one of our antiviral medications oseltamivir (Tamiflu). Of 110 influenza isolates collected so far in Michigan this season, 74 are A(H1N1). The strain is still susceptible to zanamivir (Relenza), rimantadine, and amantadine. Flu A (H1N1) isn't any nastier than any other strain of flu, but knowing the resistance pattern is important when planning treatment.
So, ladies and gents in the medical field, it's time to strap in and get ready. It's only going to get nastier from here. And it's not to late to vaccinate.

22 responses so far

Deirdre Imus---dangerous, stupid, or both?

It seems the same questions keep coming up when looking at the cult leaders of the infectious disease promotion movement. When you listen to them preach or read their liturgy you can't help thinking, "dumb, evil, or both?" I think I'm going to vote for "both" when it comes to Deirdre Imus. Her sermon last week in the Huffington Post was so far over the top that my nose is still bleeding from climbing her tower of intellectual excrement.
Her title advises health consumers, "On Vaccinations: Consider the Source and Follow the Money."
I don't know what that means, but Deirdre explains, "When presented with conflicting information on a critically important health issue I generally follow two simple rules...educate myself on the issue and 'follow the money.'"
I followe a less loquacious rule: follow the medical evidence. This is a very different kind of investigation. Whatever "follow the money" means, it doesn't mean anything about how valid an intervention is. When evaluating a single study, one of the factors to look at is funding and support---along with study design, statistics, etc.. No one factor is dominant. If a study appears to have valid results, then the funding source, while interesting, is less important. If they study is repeated and the results aren't replicated, it might be interesting to see what the funding sources were for the original study and whether these influenced the results. For example, the original Wakefield MMR study published in The Lancet seemed to show an association between MMR, colon disease, and autism. The study design was rather crappy, with only 12 subjects, but still the results were interesting. However, when other groups tried to replicate the study, Wakefield's findings were not replicated. Was this because of his crappy study design or some other more nefarious reason? It turns out that Wakefield had a financial stake in his results being positive. His financial stake does not itself invalidate his study--its crappy design and his falsifying of data is what makes it invalid. The financial stake simply helps to explain "why".
Imus follows the money straight to Paul Offit, a vaccine expert who's great toe contains more medical knowledge than Imus's brain. She makes all sorts of implications regarding behind-the-scenes shenanigans (emphasis mine):

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17 responses so far

Where the rubber meets the road there is silence

Feb 18 2009 Published by under Medicine

Before I started medical school I worked at a clinic that served the deaf and hard-of-hearing community. I was the "front office", greeting patients, answering the phone by TDD/TTY or by relay service (this was before the existence of text messaging, instant messaging, or anything else that relied on cell phones or on the internet---none was in common use). I learned some rudimentary ASL (simple, polite phrases), and was introduced to the deaf community. It was simply fascinating. I learned about the controversies surrounding deaf culture (such as cochlear implants, assimilation, and literacy). We had an interpreter on staff, and many of the clinicians were fluent in ASL, so interpretation service wasn't usually a problem.
But what about out in the community at large? Sharing the same space as our office was a program dedicated to HIV in the deaf community. The deaf are at increased risk of HIV disease for a variety of reasons, many of which center on communication. Many deaf Americans are fluent in ASL, but not in English. Educational materials aren't widely available. Communication with the health care community can be a nightmare---for example, "positive" in ASL refers to something good, so if you tell an ASL'er that they are "HIV-positive", this can be a disaster without a very skilled interpreter. When I was at the center they developed a variety of materials, including a (very explicit) picture book on how one can or cannot acquire HIV.
The deaf often have critical communication needs when seeking health care. Proper communication can be the difference between life and death. So what is a deaf person to do when visiting a doctor? How can they meet their communication needs?

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10 responses so far

Dumb or dissembling? We report, you decide

Feb 18 2009 Published by under Absurd medical claims, Medicine, Vaccination inanity

There was a piece of good news on vaccine front this week. The first judgments from the Autism Omnibus Trial were announced, and the special masters (who served as judges) agreed with the rest of the reality-based community in ruling that vaccines do not cause autism. The rulings weren't subtle, using phrases such as "misled by physicians who are guilty, in my view, of gross medical misjudgment". This is the Dover of the "other" ID promotion movement.*
Like any cult, however, the infectious disease promotion movement is unlikely to be persuaded by any level of evidence. This, despite protestations that they are not "anti-vaccine", but simply "pro-safety" or some such narishkeit. Anyone who is "pro-health" will be pro-vaccine, unless they are lying, stupid, or both.

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12 responses so far

Right is right, right?

Feb 17 2009 Published by under Absurd religious wingnutery

I'm getting really tired of this nature vs. nurture debate when discussing homosexual rights. It's always interesting to investigate the origins of human behavior, and occasionally something is found to be purely genetic, but I suspect that sexuality, like many human attributes, has a complex mix of biological and non-biological causes. That doesn't piss me off. What pisses me off is the insistence by right wing religious cults on "proving" that homosexuality is a choice.
Sexuality phenotype is a tough concept if you really think about it. The harder you try to nail down the difference between "gay" and "straight" phenotypes, the slipperier the concept becomes.
When we try to judge people by whom they love, or by whom they choose to have sex with, there are some problems other than the obvious one of "IT'S NONE OF YOUR GOD DAMNED BUSINESS." Sure, there are some people who appear to be really, really gay, or really, really straight, but what does that really, really mean?
If someone identifies themselves as "gay", and only has sexual relationships with people of the same gender, they may still love people of the other gender. What makes each type of love different? There are plenty of intimate partner relationships that are sexless---does that make the relationship more or less gay or straight? On which relationships do we judge someone's sexuality phenotype?
This is where religious cultists such as evangelical Christians (the most prominent and influential cult in the U.S.) are poisoned by their own ideology. Cultists are "splitters"---you're one of us, or you're one of them, but you must pick sides. Subtlety is scornful, perhaps even sinful. So everyone must be a particular religion, have a particular belief about abortion, and have a specific type of sexuality. You can't be "kinda sometimes gay" or "anti-abortion, but sort of pro-choice too". You also can't be a proper cult member and accept the scientific view of biology.
This is where the science becomes less important. The origins of human sexuality are interesting, but completely irrelevant when discussing civil rights. It doesn't matter whether someone is born gay or straight---each of us is equally deserving of civil and human rights, independent of the specifics of our race, gender, sexuality. People who are focused on the "choice" of homosexuality are about to "choose" to deprive others of their rights. If science were to identify the "gay" gene on the short arm of chromosome 4, they would simply start to oppress homosexuals before they are born. (Imagine the debate behind the closed doors of the churches regarding abortion and a "gay" gene that can be identified in utero.)
The "biology of gay" debate is, and has always been a steaming bucket of crap designed to allow people to be bigots. No matter the ultimate answer (and I don't think there is one), the people asking the question have only one conscious desire---to control others and deprive them of basic human rights.

14 responses so far

Morning Report #2

Feb 16 2009 Published by under Medicine, Morning report

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. It is best read above the fold first, and then going below the fold after digesting the first part adequately. --PalMD
A fifty year-old woman presented to her primary care physician with hemoptysis (bloody cough). She has a history of emphysema and tuberculosis, which was treated about 25 years ago. She has smoked about one pack of cigarettes per day for the last 41 years. She has a productive cough a few months out of every year, but this is the first time that she has had bright red blood in her sputum. She denies any weight loss, and she has stable, mild shortness of breath. She denies chest pain.
["deny" is medical-speak for having been asked and responded in the negative]
Her physician found her to be relatively hypoxic (low on oxygen) with an oxygen saturation of 89% on room air (normal being in the mid to high nineties). Her lung exam was significant for very quiet breath sounds in all auscultated lung fields. Because of her low oxygen level, he admitted her to the hospital for further work-up.

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20 responses so far

Stimulus package to include evidence-based medicine

Feb 16 2009 Published by under Medicine

The New York Times is reporting that the economic stimulus bill will include over a billion dollars to fund research into medical evidence. This is a good thing, but it's bound to be controversial. I've mentioned before that we need to spend money to improve our medical infrastructure, and this could be a step in the right direction.
Much of what we do in medicine is science-based, and much of it has evidence to support it, but some does not. There are plenty of open questions about how we practice medicine, and in order to deliver safe, quality care, we need answers. For example, a recent study in the New England Journal of Medicine compared surgical and non-surgical therapy for arthritis of the knee. Surgery made logical, scientific sense, but it had never been carefully compared to non-surgical therapy. The study showed that conservative therapy, which is cheaper and less invasive, was just as effective as surgery. This doesn't mean that surgery will never help, but it is strong evidence that we should treat arthritis of the knee more conservatively. Studies like this aren't free, but if their results are reliable and repeatable, they may save us a lot of money and possible surgical complications.
So the idea of investing more money into comparing medical treatments makes sense, both scientifically and economically. Now there's a lot of predictable schreing about this, and since my L5 nerve root is still an issue, it's making me extra cranky.

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.
In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person's health care by enforcing clinical guidelines and treatment protocols.

I'm not sure that the legislation says anything about enforcing clinical guidelines, but to be fair, there is some implication along those lines.
And so what? Right now, my patients' insurance programs do exactly the same thing---if I prescribe an angiotensin receptor blocker for blood pressure control, I'm going to be asked to justify why I am giving this rather than the cheaper and as-effective ACE-inhibitor. The answer is usually that the ACE-I caused side-effects, but the question isn't stupid. Why should an insurer pay more when an equally effective, cheaper alternative is available?
If we have more evidence to work with, we can continue to make even better decisions regarding care. It may seem intrusive, but it's not very different from what we do already. And honestly, I'd like to know if I'm more likely to get relief of my radiculopathy from surgery or conservative therapy. I will not be offended in the least if my surgeon got a call from my insurer asking if surgery was really my best option, as long as the answer was supported by good evidence.
It rings rather hollow when people protest against gaining more knowledge. Libertarian types complain that this will inevitably lead to government interference (and it might, and maybe it should) but to ignore the need for evidence is absurd. We, as physicians and patients, need more knowledge, not less, and we shouldn't be afraid of where the data lead. It's a no-brainer. But then, some people are a little short on brains.

8 responses so far

Sunday paean

Feb 15 2009 Published by under Medicine

Science is hard. But science, and the methodological naturalism that underlies it, has proved to be the best way to observe, describe, and explain our reality. Sure, people can come up with ridiculous straw man arguments like, "but how do you measure love?" but these arguments ring hollow. (We measure "love", a behavior, by the observable behaviors that human beings report when they are "in love".) To a scientist, the appeal to magic to describe the world is difficult to understand, since the real puzzle is so much more fun. If, for example, you discover the cause of a particular disease on the genetic and molecular level, you can predict how you might affect the natural history of that disease, and rationally develop treatments for it. That's one of the reason it's difficult for us to understand improbable medical claims---they take the beautiful complexity of reality, and turn it into a parlor game.
I bring this up because of the birthday of one of my science heroes, Charles Darwin. Like Mendel, Pasteur, Crick, Watson, and many others, he discovered basic, important principles about a particular scientific field (biology). Because his findings were so important, evolutionary biology is sometimes erroneously called "Darwinism"---this is quite an honor, but not quite proper, as modern evolutionary theory is built on the foundation so eloquently laid out by Darwin, but has gone in directions which, while he probably could have imagined them, he did not have access to.
Science has its heroes, and they are "beatified" for various reasons. For Darwin, it was being able to so clearly document his discoveries. For Einstein, it was his ability to make intuitive leaps and prove them. One of my science heroes is Stephen J. Gould, a somewhat controversial figure in evolutionary biology. His popular essays taught me the basics of evolution, and even how to think scientifically. He also wrote with heart. It is probably not too much of a stretch to say his writings helped me to choose the study of medicine.
Medicine, as I practice it, is not a science in and of itself, but rather the "operationalization" of science---or it should be. If we define medicine simply as the attempt to make people well, then there is no difference between medicine and shamanism. If we extend it to the prevention and treatment of human disease informed by scientific analysis and practices, then we are almost there. If we add the phrase, "with compassion", we've pretty much got it right.

Modern shamans
, the ones who offer to cure whatever ails you with whatever potion or magic trick they happen to be selling, are simply fulfilling the desire to make people feel better (that is, assuming they are honest but deluded, rather than con-artists). They claim compassion, but deception is not compassionate. Diverting people from real care is not compassionate. Leaving out the science leaves out the compassion, as without science, you cannot help a patient.
The same phenomenon exists is the other sciences, albeit a bit differently. If the modern shamans are the "false prophets" of medicine, then the creationists and other reality-deniers are the false prophets of biology. A prophet is generally considered to be someone with "special knowledge" based on the supernatural, and a compulsion to share that knowledge. The scions of the biology-denial movement, such as Michael Egnor and William Dembski, are prophets, not scientists. They are driven to evangelize their supernatural beliefs about life, and to try to tear down the "established" norms of science, as if science is just one of a myriad of possible "ways of knowing".
To come up with realistic, testable ways of describing reality is very difficult. Scientists struggle for years to find a good way to isolate and test voltage-gated sodium channels, impossibly small biological machines with impossibly important implications for health. Prophets bypass this by proclaiming them "designed" and leaving it at that. They don't have any way to extend that knowledge into clinical discoveries. Prophets feel they are conduits of divine knowledge. No scientist has ever been that arrogant. (Let's see one of these prophets go through a thesis defense in a biology department).
In science, it's possible to have heroes without deifying them. The complaint that we deify Darwin is simply wrong, but a predictable error. If you, as a prophet, feel that all truly important knowledge is a gift of the supernatural, then anyone who has access to that knowledge is either divine, or near-divine. Scientists don't really get this. When we sing the praises of one of our heroes, we also see their faults. We know that they saw something important, but that the knowledge they found could have been found by other intelligent and diligent colleagues. But they did it first, and they did it well.
So today, I sing the praises of my scientific but all-too-worldly heroes, like Darwin, Gould, Osler, and the thousands of scientists laboring every day to help us understand our world. They are not divine, but their discoveries, made without the help of a Hotline to Heaven, are all that more remarkable.

7 responses so far

Notes from Honduras V

Feb 12 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip. Part IV is here.
Leaving
Our final evening in Juticalpa saw the reunion of the medical teams that had been sent to the outlying countryside. Our friend Jeremy returned essentially unscathed but with a few stories from the hinterlands. His group was lodged in a small house in a distant village. They bathed with buckets of river water from a basin outside the house, ate as their hosts did, and without electricity, fell into the rhythms of local life. Unfortunately for Jeremy, these rhythms included a two-step to the toilet. His illness thankfully lasted in its severest form for only a day. On one occasion a pick up truck raced up the gravel path to his host's house and two men, guns in their belts, insisted on seeing the gringo doctor who gave their sister a medicine that caused a rash. A local doctor also staying in the house convinced them to turn around and go home.
After washing up, we all assembled for an evening at a local restaurant, and a number of people went later to the local disco, really just a patio along the highway. We were informed that ever since the check-your-gun-at-the-door policy was implemented there had been very little violence. I chose to turn in early.
We had to be on the road at six a.m. to get to Teguz in time to meet the next incoming group. We had only one truck, but we were not burdened by the duffels full of medicine we had brought on our arrival. Six of us piled into the truck bed with our bags, at we headed into the mountains. At this early hour, clouds still clung to the mountains, and we huddled down in the back of the truck to keep warm as we rose into the pine forests.
On our arrival to Teguz we had several hours before our flight to explore the city. Our guide was Ulysses, a young Nicaraguan-Honduran doctor. Both of his parents were also doctors in the city. We stopped briefly at their apartment, a decaying cinder block building on a narrow street. The apartment was well-kept and cozy, and reminded us that our resident's salary back home was probably not so bad. Our morning included a visit to a souvenir shop and lunch at McDonald's. We stepped into the hamburger joint from the hot, crowded street and were greeted by a gust of cool air, and a security guard with a large gun. He smilingly let us pass, and we ate our Big Macs unmolested. Our fellow diners were clearly of the local professional class, with cell phones, pagers, and clean shoes.
At the pace we were going, it was hard to stop and think about the trip we had just ended. As we settled into our seats on the plane, a business man next to me informed me that the only flight worse than the landing in Teguz is the departure, with the plane rising abruptly as the short runway turns into a ravine. As I sat and pondered this, the pilot announced over the loudspeaker that he had met some people in the parking lot who had worked with a group of doctors from Chicago, and they had asked him to say goodbye for them. A warm feeling settled over me, and as I closed my eyes, I felt the plane roll toward the ravine, and jump into the air.
Final Notes
It's been ten years since I went to Honduras, an event which has marked me deeply. It was a difficult time in my life---I was a new intern, I had a sick family member--and I'm sure part of me was looking for escape and adventure (not that the hospital wasn't adventure enough!). I've only read through this a few times, always adding some editing, and I'm not as disappointed with it as I thought I'd be. It's both more and less naive than I'd hoped. Though I'm hardly old, there is something about being young and succumbing to dreams of adventure mixed with altruism. How much good did we really do down there?
We saw many patients with hypertension, but what was the sense in treating them with the one pill we had available? We could only give them a week's supply. I drained an abscess near the eye of a young girl, which I hope made a difference in her life. One man stumbled in after lunch, grabbed our bucket and vomited. I asked if he we a drinker, and the villagers replied, "No, he is a Christian," something which is not exactly contradictory back home. It tuned out he had been spreading pesticide, and forgot to wash his hands before lunch. We had to bribe a man with a pickup truck to take him to the city. I don't know if he survived.
We gave out vitamins like candy, and M and M's like vitamins. What I hope we did bring was a sense that these isolated villagers hadn't been forgotten in the disaster, and perhaps we helped them hang on while the country was rebuilt.
Or maybe not, but I hope that our compassionate motives did the people there even a fraction of the good it did for me. Perhaps some day, when I'm not struggling to raise a family, I'll get back to the Village of the Vultures. Maybe some of the old folks will share their stories of the great floods, and maybe one or two will even remember a few well-meaning Americans who spent a week with them.

4 responses so far

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