Archive for: September, 2010

K is for kidney, also Kalamazoo

Sep 30 2010 Published by under Medicine

(An attendee at my talk this week reminded me about the somewhat sketchy history of synthetic erythropoietin.  Aside from its use as an athletic doping agent, I was only vaguely aware of other controversies, including allegations of kickbacks.  I'm excited and horrified to have the chance to read up on this. --PalMD)

A man came to see me in the office recently for a host of problems, especially weight loss, weakness, and fatigue which had become progressively worse over the previous months.  On physical exam, he appeared pale, but there were no outward signs of ongoing blood loss.  As part of the evaluation, I sent his blood off for some specific tests.  His blood count was low.  He had slightly low iron levels, which together with the low blood count suggested he might be slowly losing blood from somewhere.   In men his age, that somewhere is usually the colon, and often due to a colon cancer. (He was also not taking any medicines that might cause stomach ulcers.)  Thankfully, no cancers were found when he underwent a colonoscopy.  I gave him iron supplements, bringing his iron levels to normal, but he remained anemic, with no other blood abnormalities.

Another laboratory finding was reduced kidney function.  Red blood cells are produced in the bone marrow under the control of a hormone called erythropoietin (EPO).  EPO is made in the kidneys, and less kidney tissue equals less EPO. Like most hormones, EPO is regulated by feedback. Normal kidneys produce proteins that aid in the production of EPO, but in the presence of sufficient oxygen, these proteins are broken down rapidly.  As oxygen levels drop, these "transcription factors" are not broken down as quickly, and more EPO is produced.  The EPO travels to red blood cell precursors, telling them to become mature red blood cells.  More red blood cells means better oxygen delivery, which cuts back on EPO production.  But even at low oxygen levels if there isn't enough kidney tissue, there isn't enough EPO to tell the marrow to make red blood cells.  Patients with chronic kidney disease will all eventually become anemic.  That's some fascinating science.

Having grown up near Detroit and having lived in Chicago, I've driven by Kalamazoo countless times, but I've never stopped there---until today. Today begins the annual meeting of the Michigan chapter of the American College of Physicians.  The meeting is part of the apparatus that keeps doctors up to date.  I was asked by my hospital to help out with one of the learning sessions.

To maintain my status as a board-certified internist, I must participate in the American Board of Internal Medicine's Maintenance of Certification process.  This process culminates in the board exam, which is taken every ten years.  Leading up to the exam are mandatory learning modules, some of which are a bit like board questions.   For this meeting, I've been given a set of these questions (but not the answers) to present as teaching tools.

The first question that I'll be presenting is about anemia in chronic kidney disease (CKD), which turns out to be a great example of the way science-based medicine works.   To know how to approach a medical problem requires asking the right questions. First, is the anemia of CKD even a problem?  It turns out that it is, causing decreased quality of life through symptoms such as fatigues, weakness, and difficulty breathing.  Does treating the anemia relieve these symptoms?  Yes it does.  Does treating the anemia prolong life?  Well, not so much, and the treatment can, in fact, shorten life.

In the past, the only treatment available was blood transfusion, and multiple blood transfusions come with their own set of risks.  But over the last several years, we've learned to make EPO that can be given as an injection.  We've found that these injections do indeed lead to increased blood counts and reduced symptoms.  And it seems reasonable to suppose that giving these shots until the blood count is normal is the best way to go about things.

But it's not.  Studies have found that when EPO is given with a target blood count in the normal range, the rate of serious adverse events is significant (by adverse events, I mean heart attacks, death---you know, serious).  What the studies also found is that aiming a bit lower reduces the symptoms of anemia without killing the patient.

The accumulation of this valuable knowledge has taken decades of bench science and clinical research.  It illustrates one of the most important points in clinical medicine: an idea that makes sense and seems plausible is only a starting point.  If we had continued to aim for normal hemoglobin levels in CKD patients, we would probably have killed people.  By studying the problem systematically, we have created a relatively safe and effective therapy.  That's also some impressive science.

3 responses so far

Asking the right questions (retitled)

Sep 29 2010 Published by under Journalism, Medicine

I've been criticized in the past for focusing on criticism of bad health reporting, rather than aiming some positive reinforcement at the good pieces.  Well, here you go.

The story (byline Genevra Pittman) is about lasers used in smoking cessation, an idea with limited plausibility (unless...you suspend tobacco execs over a tank full of sharks with frickin' laser beams attached to their heads, or something).  The idea isn't new (lasers, not shark tanks); ads for laser smoking cessation have been in papers and the internet for years.  Tobacco is a tenacious and deadly addiction, and treatment of this addiction is often unsatisfying.  The use of lasers and other "acupuncture-like techniques" to assist in smoking cessation is popular and profitable. "But does it work?" asks the Reuters piece.

There are a couple of ways to answer this question: a flood of anecdotes, or a systematic evaluation of the plausibility of the claims, and of the data.  Advertising normally focuses on anecdotes.  This approach has the advantage of allowing people to pick the stories they like, highlight them, and use them to promote their business.  Data are much trickier, and more fickle.  They can lead you, as a promoter of lasers, to places you may not want to go.

Does it work?

The Reuters piece gives a good summary of the claims made by a laser smoking cessation clinic.  Laser smoking cessation is basically a variant of acupuncture. Rather than needles, low energy lasers (low enough energy to have no sensible effect on tissue) are aimed at certain "points" believed by practitioners to have some sort of physiologic significance.  The article cites these claims in an objective, rather than promotional tone, then asks the Right Question.  Does it work?

That question is deceptively simple, and often asked and answered improperly in mainstream media pieces. Pittman examines the source cited by the laser promoter, summarizes its findings, but rather than stopping there, she asks the right expert.  She found one of the authors of the Cochrane Collaboration's systematic evaluation of acupuncture techniques for smoking cessation.  She explains his caveats about the single citation supporting laser therapy and problems with the study, including its reliance on patient self-reports.  But one question was left out of both her report, and that of the Cochrane Collaboration.

Can it work?

Cochrane came to the (likely correct) conclusion that the use of acupuncture (including laser therapy) has not been shown to aid in smoking cessation.   The Cochrane Collaboration has been an invaluable resource for evidence-based medicine, but, like most EBM resources, often fails to ask one important question: can this even work?

This is what many of us see as a fundamental flaw in the current approach to evidence-based medicine.  EBM certainly understands the concept of probability, but often fails to use it properly.  While EBM will talk about Bayesian statistics and likelihood ratios, it often fails to take into account what they mean when it comes to implausible claims.

Implausible claims are those that, if confirmed, would cause us to re-examine our fundamental understanding of chemistry, physics, and biology.  The classic example is homeopathy, an 18th century belief system that has become popular among many alternative medicine practitioners.  It relies on a form of vitalism, a made up "Law" of Similars, and if it truly worked, would require us to abandon proved concepts such as the law of mass action (and our understanding of physics as a whole).

The problem with implausible claims (aside from their implausibility) is that when tested, they can, through chance alone, lead to positive results.  This allows supporters to cherry pick favorable data, despite the fact that these data are likely false positives.

If we were to create a hierarchy of implausibility, homeopathy would certainly be near the top.  Acupuncture would be just a bit lower.  It's not inconceivable that sticking needles into someone (or zapping them with lasers) would have some sort of physiologic effect.  According to the owner of the laser clinic, it works like this:

"When you smoke a cigarette, you artificially tell your brain to release endorphins," Frank Pinto, the owner of Innovative Laser Therapy, told Reuters Health. Therefore, quitting leads to a quick drop in endorphin levels, he said.

"The laser basically stimulates the nerve endings to tell the brain to release a flood of endorphins" to boost a patient over that initial 3-5 day hump of withdrawal symptoms, he said.

That sounds superficially plausible (one study in rodents found the neurotransmitter adensoine released after the animals were stuck with needles). But if it's true, then any noxious stimulus could have the same effect, rendering the need for identifying non-existent "meridians" and the use of  expensive equipment moot.  But laser therapy seems to be even less plausible than other acupuncture modalities.  According to Cochrane:

Low level laser therapy produces nosensation, and there is still some uncertainty whether it has a physiological effect on normal tissue. From the researcher’s point ofview, laser therapy has the advantage that both patients and practitioners can remain masked to group allocation by using defunctioned laser apparatus.

In other words, placebo-controlled studies are easy because you can't actually tell if the laser is on or off unless you peek at the switch.

The Reuters article by Pittman is a fine example of how to approach unusual or hyperbolic health claims.  Its primary deficiency is one shared by many scientists examining such claims: a failure to ask "is this even possible".

5 responses so far

Nothing could possibly go wrong with this plan

Sep 29 2010 Published by under Uncategorized

India has been subjected to some pretty fierce criticism in the lead up to the Commonwealth Games being hosted in New Delhi.  Organizers have been berated for shoddy construction and unsanitary athlete's quarters.  Some athletes have pulled out of the games.

But India is prepared for what may be one of the greatest threats to the Games:

Organizers of the Commonwealth Games in India say they will try to prevent wild monkeys from disrupting the event by deploying a team of larger, fiercer monkeys to scare off their smaller cousins.

And we think we've got problems.

2 responses so far

Women's Health?

Sep 27 2010 Published by under Medicine

Last week, my colleague Scicurious sent out an email about the lack of quality health reporting in magazines aimed at women. She was particularly appalled by what she saw when she picked up a copy of Women's Health at the gym.   I was also appalled, if not surprised, by the poor quality of the information, including the usual propaganda about vitamin supplements, the immune system, and sexual health.

The broadest view of the problem of media portrayal of women's health  in the U.S. indicts our society's view of women.  Media aimed at women focus on and magnify society's desire to see women cook better, look better, and fuck better.  There is little quality reporting in popular magazines about the most common health problems women face.

Let's start by looking at what you believe kills people in the U.S., then we can look at the data (the observant reader will notice some interesting details about the poll templates, named "Thinking Woman" and "Thinking Man", respectively.)

_____________________

Continue Reading »

16 responses so far

Christiane Northrup: more bad medicine

Sep 23 2010 Published by under Absurd medical claims, Medicine

A question popped up on facebook the other day about Dr. Christiane Northrup, an OB/GYN who has been a frequent guest on Oprah.  I hadn’t heard much about her for a while, but a foul taste still lingered from previous encounters with her work.  So I went over to her website to see what fare she's currently dishing up.  It isn’t pretty. (Cached version).

This month’s news item is titled “Angst Over Not Vaccinating Children is Unwarranted.” Regular readers will be expecting a typical antivax screed, and they won’t be disappointed, but I’d like to highlight some of the propaganda techniques Northrup uses to advance her dangerous lies.

She begins her story with this:

In June, 2010 there was an outbreak of pertussis (whooping cough) in California that reporters were calling the worst epidemic in 50 years.

There are two problems with this opening sentence.  The outbreak is ongoing, and it’s not “reporters” who are calling it “the worst epidemic in 50 years.”  The California Department of Public Health reports that the state has seen the largest number of cases in the last 55 years.  Of course the state was much smaller 55 years ago, so for comparison they give us an incidence rate: 10.3 cases/100,000 in 2010, the highest rate in 48 years (when the rate was 10.9 cases/100,000).  So far in California, there have been 9 deaths.  All of the deaths were in babies eight of whom were unvaccinated and one of whom had been vaccinated only days before becoming ill, not early enough to develop immunity.

The precise reason(s) for this outbreak are unclear, but there are probably a number of factors.  Pertussis outbreaks are cyclical, so increases in disease incidence are expected, but not to this extent.  The vaccine itself is imperfect, and immunity wanes fairly quickly.  Adults who have not been re-vaccinated can serve as a reservoir of the disease.  While adults do not normally become seriously ill (although I’ve seen plenty of cases of adults with pertussis coughing so hard that they fainted and injured themselves), adults can pass it on to those who do suffer more dire consequences: infants.  There are also significant reservoirs of disease in communities of vaccination refusniks throughout California, and while these communities tend to be wealthy, it is the poor who suffer.

Because the vaccine is not completely effective and not terribly long-lasting, herd immunity is even more important, and adults younger than 65 who haven’t had a tetanus shot in the last 2 years can get a TDaP, which includes a pertussis booster.

But since Christiane Northrup doesn’t believe in pesky things like germs and cellular and humoral immunity, she doesn’t get it:

Getting your child or yourself immunized is a culturally agreed-upon ritual, designed to shore up your first chakra. The first chakra, or first emotional center, of your body controls your bones, joints, bone marrow, blood, and immune system.

It’s sometimes hard for me to believe that someone who isn’t under the influence of a controlled substance can write something like that without a shred of irony.  She goes on to cite---I kid you not---Sherri Tenpenny, a noted antivax loon who writes for the Huffington Post.

Most people don’t know that the pertussis vaccine doesn’t provide lifetime immunity! Unlike chicken pox, having the disease once doesn’t protect you from having it a second time. This is why I don’t believe there was an epidemic at all. According to my colleague Dr. Sherri Tenpenny, who I consider to be the foremost medical expert in vaccine safety, “Outbreaks of pertussis are cyclical and tend to peak every two to five years, regardless of the vaccination rate….” Further, “Your child can be fully vaccinated and still contract pertussis.”

Um, no.  Outbreaks occur cyclically, but outbreaks this large do not.  Neither is Tenpenny a medical expert in vaccine safety.  Nor are doctors ignorant of the imperfections of the pertussis vaccine.

This negates accusations of California health officials who assert that when parents don’t vaccinate their children, they can create a rampant resurgence of diseases, like polio or pertussis. These conditions are thought to be under control because of mandatory vaccinations. Our society buys into something that Dr. Tenpenny calls herd immunity: If we vaccinate as many people as we can, especially the healthy ones, it will protect those who are young, elderly, and immuno-compromised. Unfortunately, this isn’t true. Just because you are healthy and vaccinated against pertussis, you can still carry the disease without knowing it and become sick or infect others

This negates no such thing.  And Tenpenny didn’t invent “herd immunity”.  We’ve already established that the vaccination is imperfect.  What is she suggesting?

Babies under six months of age are at risk the most for contracting pertussis and dying from it. Babies have very narrow bronchial passages, which block air flow to the lungs. Sadly, this causes death in some. Six died in California this year as of July 21, 2010. The CDC believes that these same children are at risk because they aren’t fully vaccinated before six months (if you follow the recommended vaccination schedule).

There’s much you can do to support your infant’s health, the most important of which is to breastfeed her. It’s well documented that breast milk contains antibodies against all kinds of germs a newborn is likely to encounter, organisms to which her mother is already resistant.

So, Northrup is saying that because the vaccine is imperfect, we should simply toss up our arms and give in to an horrible, asphyxiating death?  Or is she saying we should rely on a potential passive immunization from breast milk, breast milk which her earlier comments imply no longer contain pertussis antibodies?

I was going to skip the rest of her article, but when I read her take on meningococcal meningitis, I shuddered.  Not only is her advice dangerous, it betrays a fundamental lack of medical knowledge.

The meningitis vaccine is one of the safer vaccines, because it’s acellular. That means there is no live virus in the vaccine. It’s also not preserved with mercury or other toxic material that are still in many vaccines. When my youngest daughter went to college, I threw in the towel and had her vaccinated. (I’m referring to the one given to college-age children, not infants.) It just wasn’t worth the fight with her school’s administration at the time. But I was ambivalent, and would have opted out if it had been easier to do.

Three childhood vaccines protect against meningitis: Hib, pneumococcus vaccine, and meningococcus vaccine.  Meningococcus is most relevant in certain populations and situations, such as college dormatories and military barracks.  She is correct in stating that the vaccine contains no live virus.  One of the main reasons for this (aside from the manufacturing process) is that meningococcus is a bacterium, not a virus.  While Northrup doesn’t come across as entirely against this vaccine, her decision is based purely on superstition and convenience rather than reality:

The main reason kids get sick when they’re in college is they are run down. Meningitis is no different. Like pertussis and HPV, typically a child will be sick and recover—it’s not fatal. The main reason these adult children get sick is due to a shaky first chakra.

Ten percent of people who get meningococcal meningitis die.  They do not get sick because of their “chakras” but because they have been colonized by a dangerous bacteria (not a virus) that becomes invasive, and once it does, you’re in big trouble.

I’m not simply troubled by Northrup’s truth- and fact-impaired version of the science of immunology and infectious disease.  I’m more troubled by her representing herself as a doctor and an authority on health, when she doesn’t know a bacterium from a virus and thinks chakras are real.

She is a danger to the public health, and for the sake of public health, she should retire into obscurity.

18 responses so far

How to get into medical school

Sep 22 2010 Published by under Medical education, Medicine

First, this piece is not a how-to guide for getting into medical school; the title is a shameless ploy.  But I use this ploy for good, and not for evil.  Through conversations with a number of non-medical colleagues, I've been forced to think a bit more about premedical and medical education.  A letter from a reader (which is presented in a highly altered version below) made me decide to more thoroughly and publicly examine the educational arc that turns undergrads into doctors.

Dear Pal:

I am an academic scientist at a university where I often teach and advise premedical students. I can't tell you how many kids come in to my office for advising sessions saying they want to go to medical school and then get upset that Yes, they really have to take Organic, Calc AND Biochemistry. Then it turns out that they got a D in one semester of intro Bio and Physics and are holding down a solid 2.3 GPA. WTF? I'm not going to tell them the can't go to med school (there may be places they can get in, for all I know), but last I checked it was kinda tough to get into med school.

Should I bother with the reality check? I kinda feel like that isn't my job.

Let's step back and examine the mechanics of becoming a doctor.  Becoming a doctor is a hard, long, expensive road.  Most practicing physicians have had four years of undergrad, four years of medical school, and at least three years of residency (and significantly more training for subspecialists).  In the U.S. the average medical school debt burden is about 156,000 USD.   That is somewhat above the average yearly salary for a primary care physician.  Paying back these loans has a non-trivial effect on quality of life and on specialty choice.  Given the hard work, the time, and the debt, no one should go into medicine unless they really believe they will enjoy it.

That's not something that's easy for an eighteen year old to figure out, but spending time with doctors and with patients is a good start.  Before I applied to medical school, I spent some time at a pediatric urology clinic at a major university hospital.   That experience help solidify my interest in medicine, but I've met others for whom these experiences have pushed them in the other direction.  But evaluating your own desire to enter a lifelong profession is always going to be an educated guess.  When you're 19 years old, it's impossible to know what the future may bring, but you should at least do some soul searching and gain some experiences that would help lead you to a good decision.

Once an undergrad has arrived at a (hopefully well thought out) decision to pursue medicine, they have some serious work ahead of them.  As my correspondent discovered, there are some adolescents who do not quite get the idea that prerequisites are required.  Medical schools usually publish their admission requirements online, so no one can plead ignorance.  Whether or not you agree with the standard premed coursework, it still has to be done, and done well.  The statistics on medical school admissions are clear: if you have lousy grades or lousy MCAT scores, your chances of getting into medical school are minimal.

Something noted by a number of my colleagues is that some medical students seem to approach pre-medical education as a checklist: get good grade in organic chemistry; volunteer in lab; help sick people at homeless shelter.  There's nothing inherently wrong with this, as long as the student realizes that there is a reason for these activities beyond gaining admission to medical school.  But they must also be cognizant of the future responsibilities they are taking on.

Just as I have little sympathy for a premed student who doesn't want to complete the required coursework, I have little sympathy for the common TA complaint that, "those pre-med gunners only care about the grade and don't really care about redox reactions."  It would be terrific if all pre-meds loved all science,  but sometimes it is enough understand the material enough to do well.  That is a minimum, and as an undergraduate advisor, I do think it is your responsibility to tell a student early on that, like it or not, medical school admission comes with a rigorous set of required course work, and that this course work must be done well to have any reasonable hope of being admitted to medical school.

No one likes to hear that they aren't progressing well toward a desired goal, but if you want to pursue medicine for the right reasons, and cannot succeed in the required coursework, there are other vocations that are both interesting and altruistic.  There are also resources available at most universities to help students who aren't succeeding.  I would rather help someone alter their dreams while they are young.  While an undergrad advisor shouldn't tell a student they can't be a doctor, they can show them the stats and tell them they are unlikely to get into med school.   If the student is still committed, then they need to make every effort to improve their grades to become competitive.

17 responses so far

What about the ethics we don't share?

Sep 22 2010 Published by under Medical ethics, Medicine

As I thought a bit more about the doctor who wrote the letter to the editor we discussed yesterday, I wondered how two similarly-trained doctors (he and I) could come to such different conclusions about ethical behavior.

The generally agreed upon set of medical ethics we work with has developed over centuries.  Patient confidentiality, for example,  was demanded by Hippocrates of Kos.  But many of the medical ethics we work with are fairly modern developments that reflect the thinking of our surrounding society.  The changing weight of patient dignity and autonomy vs. physician paternalism is such an example.

Of course, not everyone agrees on all ethical principles.  Ideally, formal ethical statements for a profession are developed as part of a continuous, representative discussion.   Not all ethics are the result of a formal process however.  In the U.S., there is no one organization that represents all doctors; doctors generally operate independently, with the only legal requirement to practice being a state licence.

Decisions about ethics (or meta-ethics) should normally be made transparently.  The American Medical Association (a group that many doctors---including me---do not belong to) publishes a code of medical ethics.  They keep an online public record of past codes of ethics and of the process itself.   Though the AMA isn't representative of all doctors, it does represent many, and has had an ongoing discussion on ethics for well over a century.  Many other professional groups, including my own (the American College of Physicians) also have  detailed ethics manuals.

There are currently nine core principles listed by the  AMA, principles reflected in the more specific ethical statements published in the Code.  And while laws may reflect ethics, ethics aren't laws.  Just as there are no universally accepted set medical ethics, there is no universal mechanism for enforcing ethical behavior.  When an ethical violation intersects with a legal one, doctors may be punished.  Beyond that, what makes an ethical physician?

Why should physician's adhere to any code of ethics? Can't we just each rely on ourselves as individuals to do what's right?

As doctors we are given extraordinary privileges and responsibilities.  Physicians have always recognized that this demands high standards of behavior.  The way we act professionally must take into account not just what we each believe, but what our patients and our society believes.  Ethics are easy if we all have the same values.  Ethics get hard when we don't share beliefs. And when we don't share beliefs, we must at the very least remember our core principles, those of helping our patients, and not causing them harm; of granting them autonomy and privacy; of treating them with basic human dignity.

One of the more modern ethics in medicine is that of justice, especially justice as it relates to supporting the availability of health care for everyone.  I know many physicians who would look at AMA principle #9 ("A physician shall support access to medical care for all people") and think, "that sounds a lot like socialism. I hate socialism." The justification for this ethic is laid out in detail, and reminds us that health care is a societal good, and that it should be available to all, especially the most vulnerable.  What it doesn't say is how we should provide this care, only that these decisions should be made through an ethical process.

Some doctors bristle at any ethics that appear on first glance to conflict with their personal political beliefs.  What these doctors must remember is that their responsibilities as doctors is to their patients and to society.  If they truly believe the poor are more likely to receive adequate, affordable health care when it is delivered without a contribution from a public welfare system, then they are wrong, but not necessarily unethical.  If they simply wish to abolish government provision of health care for the poor because they don't approve of certain behaviors, they are behaving in a way that does not best serve their patients or society.

9 responses so far

Miscellania in tres partes

Sep 20 2010 Published by under Medical ethics, Medicine

First, a big "Willkommen" to my new German readers.  Apparently my Pope post was picked up by a German blog, and some of those folks have been nice enough to come by and leave some comments.  I often wonder if the war created a clearer message for the German post-war generation than it did for others.  Even among Americans who have heard of the Holocaust, few seem to understand its historical context.

Next, go get a cup of coffee and read today's post at Respectful Insolence. It addresses questions raised in a New York Times article last weekend, important questions about research ethics and how they mesh with the discovery of new, promising chemotherapy drugs.

Finally, there is a horrid little letter circulating on facebook.  According to Snopes, it was published as a letter to the editor in a Mississippi newspaper last year.  I present it here as further evidence that a certain subset of Americans are immoral, clueless, shitbags (Hey, Deutschlanders, check this out.)

Why Pay for the Care of the Careless?

During my last shift in the ER, I had the pleasure of evaluating a
patient with a shiny new gold tooth, multiple elaborate tattoos and a
new cellular telephone equipped with her favorite R&B tune for a
ringtone.

Glancing over the chart, one could not help noticing her payer
status: Medicaid.

She smokes a costly pack of cigarettes every day and, somehow, still
has money to buy beer.

And our president expects me to pay for this woman’s health care?

Our nation’s health care crisis is not a shortage of quality hospitals,
doctors or nurses. It is a crisis of culture — a culture in which it is
perfectly acceptable to spend money on vices while refusing to take
care of one’s self or, heaven forbid, purchase health insurance.

Life is really not that hard. Most of us reap what we sow.

Respectfully,
ROGER STARNER JONES, MD

First, let's be clear who he is writing about.  This doctor uses very clear dog whistles that imply that the patient is African American (gold tooth, R&B ring tone).  This immediately sets a specific tone: the patient is poor, Black, and therefore beneath being treated with basic human dignity.

But even pretending for a moment that this isn't an obvious racist screed, there are even more flaws with Dr. Jones's "analysis". This doctor objects to the government spending money on health care for someone with "bad habits" and who isn't, in the doctor's estimation, sufficiently frugal.

He uses this example to show how Medicaid (government medical assistance for the poor) is a waste of resources since poor (and presumably Black) people don't conform to a certain set of behavioral standards.  (Medicaid, by the way, primarily targets children and their parents, rather than childless adults.)

Physicians are, of course entitled to their own political beliefs, so let's assume that the obvious tone of disdain for his patient was absent from the letter.  The question then becomes,  should public assistance (for health care, food stamps, etc.) be tied to specific behavioral goals?  If so, why?  And how?

It is impossible to set behavioral goals for public assistance.  Do we really want to be in a position to punish people for being dependent on nicotine?  Do we want a panel to judge if a particular purchase made by a welfare recipient was non-frugal enough to cut off their assistance check?

Some people would like to do just that, or more likely, they would like to eliminate any form of government assistance.  This is a view born out of an inability to empathize in any way with the suffering of others.  This and his punitive desires  are clear in his letter when he suggests that a poor person purchase insurance, and when he states that life isn't hard and we should reap what we sow.

This point of view is objectionable in the way it dehumanizes the poor, the way it demands certain behaviors from the poor in exchange for basic human services.  As the letter shows, certain behaviors---those associated with minorities---are particularly despised.

While Dr. Jones's political views reveal him to be a  crappy human being, they also show him to be lacking in the basic empathy necessary to be a good doctor.  "Why pay for the care of the careless?"  Because we are "careless" from time to time, and because it's the right thing to do.

As physicians, we are daily in grave danger of rendering unhelpful judgments on our patients based on behaviors which we consider "bad". It is our calling, our responsibility, not to render judgment but to help them change in whatever way they can.

As physicians we must continually ask ourselves, "is what I am doing or planning in the best interest of this patient, or am I doing it more to please myself?"

In Jones's case, the answer is obvious.

27 responses so far

Ratzinger's day of non-atonement

Sep 18 2010 Published by under Politics

Today is Yom Kippur, the Jewish Day of Atonement.  For religious Jews, this is a critically important time of the year, and even many secular Jews use this as a time of increased self-scrutiny.  The religious purpose is to ask forgiveness: forgiveness of others for having wronged them, and forgiveness of God for having wronged Him.   But being truly contrite, and directly asking someone for forgiveness is difficult.   Setting aside a day (or week, really) to focus on the task highlights its difficulty and prevents us from hiding from the task.  This is a day focused on apology, on real introspection, a real attempt to contact those you've wronged and ask forgiveness---and to grant forgiveness to others.  This is not a time for "non-pologies", statements like, "I'm sorry you were offended by what I did."  This is a time for empathy, to wonder what it would be like to be the person you've wronged, and to apologize in a way meant not to make yourself feel better, but to comfort the ones you've wronged.

Yom Kippur is one of only a few days of the year when Jews light Yahrzeit (remembrance) candles for those who have died.  Perhaps at a time when Jews feel particularly close to God, and particularly in peril, they ask God not only to forgive them, but to take special care of those we can no longer care for.  And there can be no apologies and no forgiveness without memory.  We strive to remember our transgressions of the last year, but we cannot control the gates of memory once they have opened, so as we search ourselves, we also honor those who are left only as memories.

As we remember those who have died, many of us cannot help but think about the Shoah, the murder and destruction of Europe's Jewish community.  It's an unavoidable fact for many of us, especially as we see the diminishing numbers of survivors in our communities and wonder who will tell their stories when they are all gone.

This made some of the comments given by Joseph Ratzinger even more painful.  They were offensive to memory, and offensive to the idea of forgiveness.  They also injure us by making harder to grant forgiveness to a man who makes such hurtful public statements.

While it would be convenient to ignore the rantings of the head of a particular religious group, Ratzinger is a powerful and influential world leader.  Ignoring his pronouncements would be giving silent assent to his dangerous misreadings of a history that is still burnt into our minds and hearts.

Upon landing in the UK during the Days of Awe---the time between the Jewish New Year and Yom Kippur---this former head of the Inquisition (yes, those guys are still around) blamed all the woes of the world (including the Holocaust) on atheism, and somehow arrived at the conclusion that we'd all be better if we were religious.

The profoundly idiotic words that came from Josef Ratzinger are his. I know that many Catholics believe what he says, many do not. Given the autocratic nature of the Church, it would be terribly unfair to blame millions of Catholics for the demented utterances of their appointed---not elected---leader.

One of his UK speeches opens with the usual historical background, which as far as I know is correct, but then loses it.

The evangelisation of culture is all the more important in our times, when a ‘dictatorship of relativism’ threatens to obscure the unchanging truth about man’s nature, his destiny and his ultimate good.

There are some who now seek to exclude religious belief from public discourse, to privatise it or even to paint it as a threat to equality and liberty.

Yet religion is in fact a guarantee of authentic liberty and respect, leading us to look upon every person as a brother or sister.

I understand that this dribbling old ex- ("reluctant") Hitler Youth may be starting to lose it, but I'm sure he can see the inherent contradictions in these ridiculous statements.  Every religion thinks that their path is the only true path.  That Ratzinger could believe that religion is some sort of "guarantee of authentic liberty and respect" makes him either an idiot or a raving loon of a zealot.   Religion itself has never guaranteed any such thing.  People have used the language of religions to justify all sorts of action, good and bad, so it is de facto a guarantee of nothing.  The "evangelisation of culture" is inherently anti-humanistic, as it assumes that J. Ratzinger and those who agree with him have the only correct answers.  It is anti-equality and anti-liberty, as it sets up a dichotomy of those-who-agree-with-Joe, and everyone else.

Given that Ratzinger certainly picked out every word carefully, I'm guessing he actually means this stuff.  It's also reasonable to assume that he chose the phrase "dictatorship of relativism" very carefully. The word "dictatorship" is meant to evoke specific images: jack-booted Nazis, goose-stepping Communists, and other godless atrocities.  It is certainly not meant to evoke the beneficent dictatorship of the fatherly Pope (or the fires and racks of his Inquisition).

Ratzinger goes on to explain why we need religion:

Society today needs clear voices which propose our right to live, not in a jungle of self-destructive and arbitrary freedoms, but in a society which works for the true welfare of its citizens and offers them guidance and protection in the face of their weakness and fragility.

I see no reason why secular voices which propose a "right to live" are "arbitrary".  The Declaration of Independence is no more or less arbitrary than a Papal Bull, and doesn't rely on adhering to a single creed.  That's part of the genius of it.

But the real offense to memory comes in another proximate speech.  The Holocaust was perpetrated by Europeans, led by German Nazis.  It was not an act inflicted upon them by a Nazi state that suddenly arose, creating its own values and beliefs.  Nazism worked in part because it affirmed the darker angels of European nature, allowing them---requiring them---to act on their generations of hatred.  To ignore these catholic (small "c") origins of the European murder of Jews is to be blind to history.

Ratzinger cannot claim ignorance, so statements like this one must have some purpose:

Even in our own lifetime, we can recall how Britain and her leaders stood against a Nazi tyranny that wished to eradicate God from society and denied our common humanity to many, especially the Jews, who were thought unfit to live.

Ratzinger uses this to frame his argument for religion in Europe.  He tells us that if we had been sufficiently religious (and by "we" he presumably means not me and my people, but everyone else), the Holocaust could not have happened.  But Nazis were not an "atheist" force.  They were the violent id of European history unfettered.  The systematic murder of Jews had been perpetrated by Catholics, Protestants, and Orthodox Christians for centuries.  The Nazis allowed this to flourish, and put their industrial might behind it.  They did not create it.  This makes his next comments more ridiculous:

"I also recall the regime's attitude to Christian pastors and religious who spoke the truth in love, opposed the Nazis and paid for that opposition with their lives.

"As we reflect on the sobering lessons of the atheist extremism of the 20th century, let us never forget how the exclusion of God, religion and virtue from public life leads ultimately to a truncated vision of man and of society and thus to a 'reductive vision of the person and his destiny'

The attitude of the Nazis to Christians who spoke out was similar to their reactions to others who spoke out, except sometimes less extreme. There was, unfortunately, no large religious or secular movement in opposition of the Holocaust, and to claim otherwise is offensive. To use this false history as an argument against "atheist extremism" (whatever that may mean) is a crime against memory. But the crime continues:

"Today, the United Kingdom strives to be a modern and multicultural society.

"In this challenging enterprise, may it always maintain its respect for those traditional values and cultural expressions that more aggressive forms of secularism no longer value or even tolerate.

"Let it not obscure the Christian foundation that underpins its freedoms; and may that patrimony, which has always served the nation well, constantly inform the example your Government and people set before the two billion members of the Commonwealth and the great family of English-speaking nations throughout the world.

To tell the world that religion is a shield against intolerance, and that secularism and atheism is the cause of intolerance is insane. But unlike true insanity, Ratzinger bears true culpability for his statements.

Today is the Jewish Day of Atonement, a time of memory, introspection, and forgiveness.  Discovering and correcting my own faults and asking for forgiveness will be difficult, but I will try.  But I'm not ready to forgive those who commit dangerous offenses against against history and memory.  I'm just not that good a person, and for that, I ask forgiveness.

25 responses so far

"Dr." Ann de Wees Allen is standing in the way of her own fame

Sep 16 2010 Published by under #FWDAOTI

I won't name the people who tipped me off to this story---no hat tips, no links.  I don't want to endanger them.  This story may just be too controversial, too risky.  It's about a naturopath named "Dr." Ann de Wees Allen.

It's not that it's so dangerous to write about naturpaths and their assault on medical science and on logic itself.  But apparently, it is NOT AT ALL COOL to use the name "Dr." Ann de Wees Allen.  You see, "Dr." Ann de Wees Allen claims that it is illegal to use the name "Dr." Ann de Wees Allen without written consent from her lawyers.   I have a problem with this.

How are we to tell the world about "Dr." Ann de Wees Allen's amazing accomplishments?  You see, according to "Dr." Ann de Wees Allen's website, she is an "alpha scientist".  That's pretty cool, so I don't know why she wouldn't want people to write things like "'Dr.' Ann de Wees Allen is an alpha scientist!!11!!"  In fact, according to her website, "Dr." Ann de Wees Allen is "in the forefront of scientific breakthroughs" including such things as nanotechnology, "sickle cell polymorphisms", and, most intriguing, "edible computer chips" (Frito-Lay ™, watch out!).

I think it's even more important to point out the accomplishments of an alpha scientist like "Dr." Ann de Wees Allen because she gives hope to budding alphas everywhere.  This hope comes form her ability to be an "alpha scientist" despite a lack of any significant contributions to the scientific literature.  And if we couldn't write her name, how would we be able to tell anyone that "Dr." Ann de Wees Allen is the "queen of arginine"?

I can maybe see her being a little worried about idiots though.  There is a website out there calling itself "Ripoff Report" that says some pretty mean things about her.  I'm going to share with you some of those mean things so that you can empathize with "Dr." Ann de Wees Allen.

HER CLAIM TO HAVE A DOCTORATE DEGREE IS ALSO UNVERIFIED. NOTHING SHE HAS SAID PROVES ACTUAL, LONG OR SHORT TERM ASSOCIATION WITH TRUE SCIENCE.

WHILE HER PRODUCT SEEMS TO TRIGGER MOST OF THE KNOWN BENEFITS OF L-ARGININE THERE IS NOTHING SPECIAL ABOUT IT OTHER THAN THAT IT IS HEAVILY OVER PRICED AND ITS POINT OF SALE AND PRICE IS LITTERALLY ALL OVER THE MAP.

See what I mean?  Sure, "Dr." Ann de Wees Allen may use 26 point fonts on her webpage, but is that cause to use all caps?  But the mean all caps guy did say some nice things about her to:

IF YOU NEED A NICE LOOKING WEB SITE WE DO ADVISE YOU CONTACT HER AS SHE HAS, AT LEAST, ABSOLUTELY PROVEN TO KNOW HOW TO HANDLE THAT WELL.

I really hope that "Dr." Ann de Wees Allen considers the children, especially girl children who may wish to become the next "queen of arginine", although that may be a hereditary position. Still, the idea holds.  Her fame and success must not be left unsung.

30 responses so far

Older posts »