Maggie's Farm

An annual re-post -

Why is the CDC based in Atlanta? Because Georgia was the center of malaria in the US, and elimination of malaria from the US was the CDC's first job. It's hard to imagine, but through the 1940's malaria was endemic in the southern US, and prior to that in the northeast too. Every doc in New England used to treat malaria routinely.

DDT was a major factor in the elimination of malaria in the US, but it remains a common disease in the Third World, in the southern hemisphere. And, sadly, DDT harms lots of other things, too, besides mosquitoes but probably isn't as evil as Rachel Carson claimed.

The long history of malaria would make a fascinating book. I'll just share a few facts: the germ which causes malaise, fever, and anemia is a plasmodium, a wierd one-celled bug. There are 4 varieties. The vector (meaning the thing that distributes the bug) is of course an anopheles mosquito, which squirts the germ into the human bloodstream with its anticoagulating saliva. The plasmodium reproduces in your red cells, then goes loose in your blood, where it is presumably sucked up by an innocent mosquito who spreads it further. Humans are the host of this bug (meaning their reproductive home). Like any parasite, the goal is to keep the host alive, while reproducing itself. If you kill your host, you sort of defeat your purpose (like over-taxing productive people), so malaria is more likely to cause chronic illness than death, except in the otherwise vulnerable. Fascinatingly, the sickle-cell trait of Africa confers resistance to malaria. Nature is amazing, which makes being an MD an astonishing privilege.

Prevention is simpler than treatment. Treatments include derivatives of sweet wormwood, as discovered in China in 300, and derivatives of cinchona bark (quinine), as discovered by the Spanish in the 1600s. The quinine treatment/preventative of course gave rise to the finest drink of the British Empire - the Gin and Tonic, which exemplifies the idea of making a virtue of necessity. A Brit will drink nothing without either gin or wine in it. Add a lime and the Limey can prevent scurvy too, as was attributed to Captain Cook. Thus truly a superior medicine for both body and soul.

Does the brand of gin matter? For martinis, yes. For gin and tonics, not to me anyway.

Diagnostic errors remain the leading reason - or excuse - for medical malpractice lawsuits by the swarms of hungry sharks which parasitize American's fine physicians - the best physicians in the world. Kevin, MD.

All the more reason for docs to be irrational - or rationally irrational - in spending your money (either yours directly, or the insurance company's money - which was your money).

If you have a headache, I am going to order an MRI of your head which will cost you between $700-1100 in my area. I know darn well that you don't have a tumor, but I could be wrong 0.3% of the time. So I'll order the MRI, because you will want me to, and my law suit defensiveness will want me to. Still, I will know that it is poor medicine.

Indeed, I know that your particular pattern of headache, and your exam shows it to be a Common Migraine, and not a tumor, not an aneurysm, not a stroke or subdural, etc. And I know that all sorts of guidelines have been constructed, such as these. Well, you can toss the guidelines for all I care.

The Barrister's recent series on error

(Part 1 - Fun with the Null Hypothesis,  
Part 2 - False Positives and False Negatives,  
Part 3 - Risk of Inaction and Opportunity Cost) 

applies beautifully to modern medicine. There is almost no end to the amount of your money we can spend to try to reduce our False Negative rates - our Type 2 errors. And they will occur, regardless. 

It is very unpleasant to be sued. It damages a doctor's enjoyment of his art, it absorbs huge amounts of time and energy, and it damages his relationships with all of his patients. And, finally, it has nothing to do with his competence and everything to do with the greed and litigiousness of his patient. 

I pay 42,000/year for malpractice insurance as a GP, and I have never been sued. I know guys who pay 160,000. You are paying those bills.

A re-post from 2005:

Norm has posted some interesting data from a recent study on the differences in libido between men and women. The results sound like that medical research spoof about the 20-year, 70 million dollar government study which proved the surprising fact that diet and exercise are important for weight loss.

This new study offered the startling conclusion that men have higher sexual needs than women.

More specifically, the study says that men need sex every five days, and women every ten. My opinion: This study only applies to Brits.

Everybody should get some CPR training, with regular refreshers. You never know when someone is going to go down at the supermarket, in church, at the movies, in a parking lot, or at a baseball game. Be the person who knows what to do.

In the tension of the moment, it's hard to think straight unless you are in an ER with support and help. And people collapse all the time, usually for minor and relatively benign reasons. But sometimes it's an arrhythmia, or a heart attack-related arrhythmia, and, if so, it's your chance to try to save a life as long as you aren't too far from definitive help. In the wilderness, forget it. They're a goner if they quit breathing. CPR is a temporary thing.

Online CPR certification here. (with sound). It's best to practice it with a dummy, though. I have only had to perform this once in a non-medical setting. A rainy, cold, wet parking lot. She survived, but with mild brain damage from hypoxia (the cause of her collapse and subsequent respiratory failure was a ventricular arrhythmia of unknown cause). And I cracked a rib or two, but that hardly matters when someone is "trying to die," as docs call it.

I had a friend who went through a hell of a time with a pulmonary embolism (a very common life-threatening and commonly life-ending event in all ages) four days after a flight from Rome to New York. I would have thought that the stats were higher, but it appears that the occurrence of deep vein thrombosis (clot formation, in this case usually in the legs, which, when they get loose, are carried to the lungs) is only doubled during travel of four hours or more - whether car, plane, bus, etc.

The solution might be a baby aspirin, but best is to keep those legs moving a bit instead of sitting immobile for long trips. Get up, walk around, stop the car and walk in a circle, whatever. Or just twitch your legs restlessly the entire trip, as if you had ADHD. That will help prevent this terrible problem.

I do not post often enough, so I am grateful that Bird Dog keeps me on the Soros-sponsored payroll.

Our worthy and self-sacrificing editor emailed this piece to me from Stumbling and Mumbling, a pleasantly cantankerous economics-oriented Brit blog. Apparently the Brit NHS has a euphemistically-named "National Institute for Health and Clinical Excellence," (does that sound like something out of Brave New World?)whose job is to decide what treatments the government will pay for with your tax dollars. They try to apply cost-benefit analysis to your problem.

Of course, such a process necessarily politicizes medical treatment by making every treatment, and every disease, a political football, with the loudest voices and the squeakiest wheels and the most pathetic stories winning out. And also turns every person into an expense item on a spread sheet, thus making it cost effective for everyone to die promptly without burdening their neighbors, at the precise moment when they cease to generate tax revenue. Citizens become, in essence, farm animals on a government plantation.

The potentially-fatal flaw in democracy is that people can vote themselves "free" stuff, because there is no end to that childish wish. But with each "freebie," there is a loss of autonomy, of self-reliance, of adulthood, and of freedom.

American patients are accustomed to have their problems insulated from government cost-benefit committees. They are accustomed to freedom, which can cost a bit more. And if they require low-cost or free care, they can go to any clinic they want, almost everywhere in the US. I work in one, for nothing, in Providence, one day a week, and have done so for 20 years - but you have to prove that you are poor. You may not take advantage of our good intentions. And if you sue us, you can, should, and will, go to hell.

Well, that was a digression from the point at Stumbling that I wished to highlight. He noted that no other government "programs" are subjected to cost-benefit analysis, except for medical treatments.

Now, you just have to wonder, why might that be?

I have faith that, in general, Americans will never sell their freedoms for a bowl of lentils.

To a Fat Lady Seen From the Train

O why do you walk through the fields in gloves,
     Missing so much and so much?
O fat white woman whom nobody loves,
Why do you walk through the fields in gloves,
When the grass is soft as the breast of doves
    And shivering sweet to the touch?
O why do you walk through the fields in gloves,
    Missing so much and so much?

Frances Cornford wrote that - the charming form is called a triolet.

Our editor asked me to comment on Dr. Helen's piece on fat people. As a doctor, I tend to be a "Do as I say, not as I do" sort of guy. I smoke cigars and I am pleasantly, or some might say prosperously, or some might say, grandfatherly, well-fed.

When patients of mine are seriously overweight, I tell them straight out. The word fat does not bother me. I have a model in the waiting room of five pounds of adipose tissue designed to get a reaction. It is disgusting.

As someone who did my share of general surgery earlier in my career, I can tell you that fishing through gallons of yellow adiposity, getting your gloves so greasy you cannot hold the scalpel, is no damn fun. If you are fat, and saw what you look like under the skin, you would be horrified.

Another complication recently published is that obesity makes it more difficult to make a diagnosis. It's called "study or exam limited by body habitus."

However, I also understand that the flesh is weak, and that staying in youthful shape after 45 is no mean feat. It takes work and discipline, and the evidence that it leads to longevity or health is minimal. However, being in good shape adds a lot to quality of life. On the other hand, being obsessed with health is for the crazies.

Plus there is the vanity factor: few guys will look at a fat girl, and no gals will look at a fat guy - unless he is rich or powerful. But, at some point, unless we are narcissists, we accept reality and don't care all that much.

Final word: If you are too fat, I will say that. And, if you care, I will tell you how to deal with it. But your life choices are not my problem, beyond that: your doctor is not your Momma, nor is he/she responsible for your health. Your health is in your hands, and God's, and nature's. My only responsibility is to give you advice as your friend, and to try to help you when you get sick.

Is it moral to sell your kidney? Your placenta for stem cells (or does it belong to your kid?) What are the ethics - if any - and morals of commerce of the human body?

Which is an indirect way of asking what the morals and ethics of capitalism are. We know what many libertarians would say, but what would each of us say?

Eric Cohen at New Atlantis has a fine wide-ranging essay on the subject, covering Calvin, Voltaire, Weber, Adam Smith, Irving Kristol, etc etc.: Biotechnology and the Spirit of Capitalism.

Couple of quotes:

In 1991, with the last vestiges of communism crumbling and the Cold War ending, Irving Kristol warned that the greatest threats to a capitalist future were spiritual and cultural. “In a sense,” he said, “it is all Adam Smith’s fault. That amiable, decent genius simply could not imagine a world where traditional moral certainties could be effectively challenged and repudiated. Bourgeois society is his legacy, for good and ill. For good, in that it has produced, through the market economy, a world prosperous beyond all previous imaginings—including socialist imaginings. For ill, in that this world, with every passing decade, has become ever more spiritually impoverished.”

In the end, Smith’s error was his lack of “eschatological realism.” Man is not simply an average being who seeks to improve in material ways. He is also an imperfect being who yearns for perfection, a mortal being who yearns for immortality, and an ambitious being who sometimes believes that he can make others more perfect or less mortal through his own mastery of nature. And so Adam Smith’s world of practical commerce—a great success—is still haunted by the Protestant desire for other-worldly grace and by Voltaire’s desire for “terrestrial paradise.” We demand that material progress offer salvation—which is exactly what socialism once promised and what biotechnology may promise in the future. Or we demand that material progress be abandoned in the name of salvation—soberly, by those who seek to preserve sacred retreats in a profane world, or radically, by extremists who seek to dismantle modern life altogether.

Read the whole thing. It's an education.

As a guy who has been in practice for many years, I have no doubt that doctors' decisions are the reason American medical attention is as expensive as it is.

However, what Kling in his excellent and important piece at TCS omits is the extent to which such decisions are driven by patients and their families. Most patients, offered the option that "this might help," opt for it. And the docs go along with it, even if the statistical gains are marginal to none. In other words, they replace their measured judgement with the "consumer's" choices. "Doc, do everything you can." I see it every day, and have done this countless times myself.

And why not, if someone else is paying the bill? Do we love outselves too much? Or do we want to believe in magic? (Also, bear in mind that the physician ordering your test or procedure makes no money from that.)

As a consequence of "consumerization" and litigation, the band of "elective" procedures and tests shrinks ("elective" used to imply that Major Medical insurance would not pay for it), while the band of the routine expands, including the marginal, the useless, the "heroic," the hopeless, the experimental, and the optional. Many extremely expensive cancer treatments would be on that latter list, plus allergy "treatments," plus even routine annual physicals which I believe are a waste of time and money - my list would be quite long, and I could easily annoy every medical specialty.

In the good old days of medical authority, before people came up to you and said "I read on the internet that there's a doctor in Arizona who says...", physicians were capable of carrying the burden of making good decisions for their patients. And when folks were ready to go, we let them go: we would never treat pneumonia in the ICU in Alzheimer's patients. That is not rationing - that is sane decision-making. And we all pay the bill.

Thus American medical care is more expensive, but minimally more effective, than other places: we spend our extra money on the margins, and on terminal patients, where outcome is not meaningfully affected. A classic example comes to mind: Mickey Mantle, with metastatic lung cancer and dying, gets a liver transplant for his cirrhosis. I doubt a physician recommended that, but they probably did say it was an option, and he said "sure." It probably gained him a couple of weeks of torture and misery, in the hospital.

Kling considers all of the possible causes for medical costs, and concludes:

That leaves (D), with its radical suggestion that America's culture of medical practice is at fault. I arrived at this conclusion as an economist, looking at the data that contradicts the alternative hypotheses and also at a variety of studies, cited in my book, that show little relationship between health care outcomes and the supply of medical services.

Since writing my book, I have come across the work of Nortin Hadler, an MD who, coming from a very different direction, arrived at the same conclusion that I did about America's medical culture. In 2004, Hadler published The Last Well Person: How to Stay Well Despite the Health-care System

Hadler takes on many popular forms of health care in America, from alternative medicine to colonoscopy screening to anti-cholesterol drugs to heart bypass surgery. In his iconoclastic view, all of these therapies have benefits that are too small in terms of either statistical significance or common sense to warrant widespread use (he qualifies this by saying that certain narrow target populations do in fact benefit from these approaches).

Hadler steps on some very sensitive political toes. Americans want to hear that our doctors "save" men with prostate cancer. Hadler sees it is a common, slow-acting ailment that can be left untreated (there is a less-common variant that is more dangerous). We want to believe that talk-show hosts who scold people to get mammograms, watch their cholesterol, and submit to the indignities of colonoscopies are doing the public a service. Hadler argues that we should take a more stoic attitude toward the risks that we face.

Please read the whole thing.

From Kevin, MD:

Anytime the government gets involved in do-gooder projects, they screw it up.

Their motive is generally some combination of "caring" and vote-buying, and the effect is usually a reduction of freedom and choice, a diminution of personal responsibility, and numbers of people working the system.

I am not convinced that there is any huge national demand for more government involvement in medical care. We already have Medicaid for the poor, and Medicare for both the wealthy and the non-wealthy older folks. More and more doctors are opting out of Medicare, though. I no longer accept it, mainly because the coding is impossible to understand, and if I make a mistake, it is a felony. I would rather offer charity when needed, as docs have done forever. But I no longer do any costly procedures.

However, medical practice has changed, and the costs of procedures is large. Every responsible person should have Major Medical coverage these days unless you are so wealthy that paying $20,000 for a bypass, or $16,000 for a hospital stay after being hit by a truck, or $100,000 for a dubiously-effective long drawn out treatment for metastatic cancer, is easy for you to pay out of the checking account.

In addition to the costs of running a hospital these days, and the cost of procedures, there is no doubt that concerns about law suits have increased the cost of medical care. Prudent and practical medical judgement becomes replaced by fear-driven decisions, resulting in enormously expensive tests in search of the 1-in-10,000 possibility. Thus, between the costs of malpractice insurance and the cost of low-probability tests, trial lawyers, insurance companies, and hospitals are the beneficiaries of medical insurance. They all get paid.

Who are the people who really "need" Major Medical insurance, but lack it? Not the poor - they are covered. Not the over-65 - they are covered by their under-65 neighbors via Medicare taxes. Not the prosperous - they buy it, or are insured through work. It's the under-65 non-poor (and their families) who have either not arranged their lives in such a way as to buy or to obtain coverage through work - and illegals. Plus those with chronic problems who cannot buy insurance and are unemployed. That is who we are talking about when we talk about the "uninsured." In Mass., most of the uninsured turn out to be young single men who don't want to spend the money on it - their foolish choice should not be our problem. A healthy married couple, both working at Walmart, with a family income of $56,000, can certainly afford to buy medical coverage, although it might mean driving an older car.

In my opinion, any medical insurance law ought to recognize that those are the targets for it. Also, any medical insurance law should be Major Medical - with a choice of deductibles anywhere between $500-10,000. And no coverage for quackery and elective things such as chiropractic, yogurt enemas, homeopathy, gym memberships, abortions, routine check-ups, herbal wraps and massage "therapy." While everyone wants a free lunch, there is none. Somebody pays the bill - either you, or your next-door neighbor pays it for you.

As I always say, if you want to have a body, and kids, then figure out how to take care of them. It's part of being a grown-up. Do what you have to do, and make good choices. Life is hard. Nobody promised us a rose garden.  Utopian dreams of government "solutions" usually end up turning into nightmares, while emptying our pockets, nurturing an un-American sub-culture of weakness, dependency and entitlement, and reducing our freedom. 

If you cannot take care of kids, or would rather buy a new car, do not have kids. It's your choice. They can be expensive, but do not dump their expenses on your next-door neighbor. That is lame unless, due to grieveous misfortune, you need charity. Americans love charity, but they hate to be ripped off by people with options.

Kesler has a follow-up piece on the Mass. laws, looking at its shortcomings. And a conservative Mass. reader offers a fine rant in our Comments about the unwelcome burdens of government's efforts to do things for him.

Recent posts on the subject: Scroll down. Other pieces we have done on the subject here and here.

Image: MRI of the head. Cost: $400-800. There happens to be a brain inside that one.

A Massachusetts reader offers this:

What are you guys smoking over there? Here I am in Massachusetts, without health insurance, and with a family of four, and all that has happened is on top of having to pay full freight for my family's doctor bills, I get fined $1000.00 for the privelege.

I don't want your stinking welfare greenstamp department of motor vehicle government cheese copay paperwork foodstamp prepaid doctor tax charity ward let a millionflowers bloom supervision of my family's medical situation, thank you very much.

Catastrophic medical insurance is currently illegal in Massachusetts. All they had to do is allow me to purchase what I could get if I lived 50 miles west, which is REAL LIVE INSURANCE, that is, they would pay if something unexpected, substantial, and expensive happened. And it would cost me a couple hundred bucks a month. But no, I have to pay full freight for every lamebrain thing that every knucklehead who has a job with benefits wants tax free, like gym memberships and aromatherapy and acupuncture and reiki massage and "mental health," ie, I'm a miserable failure as a human being and I want to talk to another miserable failure that went to community college for psychology about it, at great expense. Oh, yes, let's not forget all middle age men that need free blue pills because what a mean spirited thing it would be middle age men didn't wander the earth with extra free hardons.

And so "insurance" becomes paying in advance for others to get what they don't need or deserve, to the point where "Insurance" costs 1200 a month and if something catastrophic did happen, would bankrupt me anyway, because instead of paying $50 for an office visit for an imaginary ailment, but having a real catastrophe paid for, the powers that be would prefer paying $5 dollars copay for an office visit to their yogurt enema wellness healer, but have to chip in 20% for cancer therapy, which would bankrupt anybody that has to worry about the cost of health insurance in the first place.

I am totally sympathetic to what you are saying. I wrongly assumed it was catastrophic health insurance, which used to be called "Major Medical", which is the only kind of medical insurance that makes sense to me. Perhaps we are too gentle with the People's Commonwealth. I am not in favor of insurance for yogurt enemas or yoghurt massages either. What are we smoking? Upmann Magnums. (We call it mid-day "relaxation-inhalation" therapy, paid for by our insurance, of course.)

Massachusetts has a new medical insurance law. I don't understand it all, but Bruce Kesler likes it, and he studies these things.

The key is that you are required to be insured. Like with car ownership - if you own a body, you have to insure that darn thing yourself so you don't dump your maintenance costs directly onto everyone else. And taking care of one's health and one's family's health is a greater source of pride than taking care of the car - or should be.

Interestingly, it turned out that most of the uninsured in Massachusetts were young single men - they figure they are invincible, and they would rather buy beer and cars and F150s and deer rifles and Ezra Pound poetry and new outboard engines.  That is natural - irresponsible, but entirely natural.

I don't think it will have much effect on the private practice of medicine, so that is a good thing. Hospitals will like it: they will get paid. And people should like it, because it keeps politics out of medical care...hopefully.

Read Kesler's piece here. This could be ground-breaking.

PS: Welcome, HH readers. Check out our blog - we are sure you will want to bookmark us! Our April Fool's Day satires were pretty good.

PSS: Dissent from a Massachusetts reader - scroll up.

Do you have Adult ADD? Take this quick test:

1. Do you sometimes get up to get something out of the refrigerator while watching TV?

2. When reading a technical text or doing homework, do you sometimes wish you were watching The Sopranos, or going to bed, or going out with friends?

3. When you have a huge pile of bills and paperwork, do you think "Aw, shit"?

4. Have you ever clicked "OK" or "I Agree" or "Next" on a website without reading all of the information?

5. When you are supposed to be focusing on something tedious, do you ever think about sex or other kinds of fun?

6. Have you ever opened a box from the bottom instead of the top?

7. Have you ever used a digital camera without memorizing the manual first?

8. Have you ever had trouble finding your keys?

9. Have you ever stared out the window, thinking "I'd rather be fishing?"

10. When you are online, do you move from site to site without spending at least 15 minutes perusing Maggie's Farm in detail?

If your answer is "Yes" to one or more of these questions, you definitely have ADD. See a doctor immediately before it gets worse.

Since around three pandemics occur each century, it is inevitable that a next one will appear. But will it be of the H5 bird type?

Research over the past year suggests not. It is comforting to know that this flu is a greater danger to birds than to people, unless you spend a lot of time with infected birds. So as the media dramatically report the movement of H5 flu in birds, this seems to be more of ornithological interest than human-medical.

Roe v. Wade provided a "right" to kill an unborn baby for any reason.

The morality and politics of that decision remain alive and unresolved. The decision failed to abort - or should I say "kill" - the issue. In fact, it raised more moral and political issues.

One effect has been to take a lot of the fun out of, and to add a lot of financial risk to, the practice of Obstetrics. The concept of "wrongful birth" captures it. From an important piece in the NYT:

At present, courts in about half the states recognize wrongful birth as a subset of medical negligence or allow lawsuits under the more general malpractice umbrella if a doctor's poor care leads to the delivery of a child the parents claim they would have chosen to terminate in utero had they known in time of its impaired health. In some of these states, like New York, where the Brancas' case was tried, emotional damages — compensation for the distress incurred by having an impaired child — cannot be recovered. No matter the legal context, terminating a wanted pregnancy is no one's first choice, but for the time being at least, when faced with a fetus that will become a severely handicapped child, all the choices are bad. At this moment, we are fairly adept at finding chromosomal flaws and horribly inept at fixing them. There is no chemical or surgical remedy if you find out your child-to-be has cystic fibrosis, fragile X, Down syndrome, Tay-Sachs, anencephaly — the list goes on and on. As Leon Kass, former chairman of the President's Council on Bioethics, has noted, in prenatal cases, often the only way to cure the illness is to prevent the patient.

The first significant wrongful-birth lawsuit involving a disabled child, Gleitman v. Cosgrove, reached the New Jersey Supreme Court in 1966. One plaintiff was the child's mother, who had contracted rubella early in her pregnancy in 1959. Worried, she consulted her doctor and was assured that her unborn baby would be fine, despite the common understanding that rubella early in pregnancy can lead to birth defects. The baby in question was born with "substantial defects. . .in sight, hearing and speech." Interestingly, the court recognized the physicians' failure as well as the parents' anguish and attendant financial burdens although it still decided in favor of the defendants, in part, it seems, because it did not want to enter the ethical thicket inherent in finding for the parents. "A court cannot say what defects should prevent an embryo from being allowed life.. . ." the opinion reads. "Examples of famous persons who have had great achievement despite physical defects come readily to mind, and many of us can think of examples close to home.. . .The sanctity of the single human life is the decisive factor in this suit in tort. Eugenic considerations are not controlling. We are not talking here about the breeding of prize cattle."

By 1978, however, when the next significant wrongful-birth case was decided by a higher court, the 1973 Roe v. Wade decision had established a woman's right to choose — that is, to terminate a pregnancy. The new case, Becker v. Schwartz, involved a geriatric mother (a medical term for a pregnant woman over 35) who was not advised by her doctor that her advanced age put her unborn child at greater risk for birth defects. Her child was born with Down syndrome, and shortly thereafter the mother sued. This time, the New York State Court of Appeals found in favor of the family, declaring it had the right to seek financial damages for the added cost of raising a child with a disability. The court, however, refused to allow the claim of emotional damages. It did recognize the family's suffering, but reasoned it "may experience a love [for their child] that even an abnormality cannot fully dampen."

The H5N1 Bird Influenza is spreading during the bird migration, as predicted. None in the Western Hemisphere, yet. Thus far, this will be a problem for those handling birds, and bird farmers. Be careful with your pheasants this fall, Mr. Free Market.

There is no evidence of a mutation which could endanger human populations on a large scale. Kill your parakeet and parrot and make a nice little soup out of them - and hope for the best. There may have been some hysteria about the Bird Flu - but it remains a risk that hangs over all of us.

(Image: bird-fancier planning Cockatoo Stew for dinner.)

The problem with vaccines is lawsuits. Companies are afraid to make vaccines. And in the current environment when quacks and trial lawyers blame vaccines for everything from autism to ADD to ingrown toenails, the manufacturers don't have a prayer with an Alabama jury.

Why should they bankrupt their companies by trying to help people?

I have been around long enough to remember polio. Folks, getting vaccinated for disease is your choice. But only a true ignorant fool would not have their kids vaccinated in these times.

The problems began with the famous Cutter Case. The all-knowing Dalrymple covers the medico-legal story in a book review in City Journal.

Update: Just stumbled into this piece on the subject on the excellent Overlawyered blog.

Western Civilization males are widely afflicted with this debilitating disorder. The cause is unknown, but some theorize that it is caused by the "Hen Flu," which shrivels up the testosterone-producing cells in the testes, along with the tubules which carry the hormone to the blood.

Active research is going on in Australia, because this presumably viral ailment has not arrived there as of yet, making the study of uninfected males easier.

However, it is unfortunately endemic in European, American, and Canadian males, and is transmitted, we believe but cannot confirm, by an unfirm handshake and a tendency to smile too much. It appears to be male-specific.

Many of the symptoms are behavioral rather than physical, suggesting that the virus attacks areas of the brain as well as the testes. Typical behavioral symptoms include reflexive submission to aggression, eagerness to please, lack of pride, quick abandonment of familial heritage and ideals, a fear of firearms, absence of normal male drooling over attractive females, absence of normal male patriotism,  and a deterioration of the instinct to defend family and compatriots. All can be summed up by the Omega Male Syndrome. Typical physical symptoms include occasional cold-like symptoms, the occasional cough, and fatigue, especially late at night and after drinking sessions.

The only two reliable tests for this disorder, until the viral antibodies are further identified, are the Drool Test and the Adrenaline Response Test. In the former, test subjects respond to scantily-clad strippers, while measuring devices record saliva production, hardness of privates, and tendency to touch and sexually harrass. In the latter, test subjects are handed a military M16 while target images are passed by the target range. The number of holes in the Islamo-Fascist Jihadist image seem to be a reliable measure of the progress of the disease.

The only known cure is to read Maggie's Farm daily. Multi-million dollar studies by the CDC are ongoing to determine the mechanism of this therapeutic effect. The CDC is hopeful that these studies will further our understanding of brain-body interactions.

Very disappointed to see some of my favorite Justices on the wrong side of this one.

This is not to make any medical point, even though it is medical practice across the USA to non-assist pain-ridden dying patients to "comfortably" slip away on morphine.

My point is political: this is a state issue. Like abortion - if a state wants it, it's up to them, despite all of the complex moral considerations. Power to the people! Not to the Feds, who have no monopoly on wisdom or life experience. May I refer our readers to Amendments lX and X ?

Having said that, though, I'd hate to see us become a country where the ill and infirm are expected to go away to save us money and trouble and inconvenience - which is what abortion is about, as I see it. That would be a Brave New World.

"Health Care"

Never, ever, use the term “health care” in my presence.

There is no such thing, and the words - and whatever concept, if any, which lies behind them - is anathema to me.

A word to the wise: medicine is an art, not a science. Yes, it is built on science, but it goes far beyond science which is why it is more of a priesthood than engineering. Not to disparage engineering, which I respect enormously. But the entire concept of the kind of Internist/GP medicine which I and many others practice is built on an idea of an intimate relationship and committment to an individual person and their life.

Medical treatment does exist, and so does “having a doctor” to keep an eye on your life and physical and emotional well-being and to take a professional/personal interest in your life, and especially in any "lack of health".

Nothing called “health care” does any of those things.

Doctors care about you; "health care" is an industrial/economic/bureaucratic concept in which you are little more than a potential expense item, but preferably a profit center – whether the "system" - to borrow a socialist concept -  is a government monopoly or an HMO or insurance company or whatever.  The industrial/economic concept does not “care,” nor does it “provide” “health.”  Only God and nature can provide health, and only a physician with whom you have a personal relationship, and with whom you have a personal contract, will “care” about you, because that is what they were made for.

In the modern-day “health care” environment, I am beginning to see that people have deeper and longer relationships with their electricians and plumbers (and I am not referreing to Lonely Housewives) than they do with “health care providers,” and it burns my ass, because that is not what being a physician is all about. It used to be that the specialists were the ones without the long-term relationships with patients: you were referred to them for a particular purpose, which they addressed, and then they came back to you. Nowadays, with “health care,” there is no “you” to come back to. When I see what is happening to Medicine today, it makes me want to cry.

Let me just tell you this: when I had my heart attack at 64 and my doc came into the ER and checked my EKG and said "Ed, it's an MI but you're gonna be OK and get back to work in a week or two", from a guy who had known me for 20 years, it meant more than you could imagine.

If the “health care consumer” wants doctoring to be a cheap commodity offered by a random Dr.-of-the-day “health-care provider”, well, it’s their choice. Do not come to me for that. I believe I have much more to offer than that.

But health – that I do not have for sale. No-one can sell that. And “care” is never for sale, is it?

Whiners and Ambulance Chasers 

The reason I cannot get any more flu shots this winter is because American drug companies no longer wish to make them. Why? Fear of law suits and side-effects. If a company is sued and hassled out of existence, they won't make anything for us, will they?

When the whiners, hypochondriacs and con-artists team up with the trial lawyers for their mutual enrichment, watch out.

The reason I can no longer prescribe an excellent drug, Vioxx? Law suits. Same with silicone breast implants for post-mastectomy people, now finally available again after driving Dow Corning bankrupt (because the whole legal case was a con job). My list goes on and on. Oh - and for a really big one - Tamiflu. Who's making it? Not one of the great US pharmaceutical innovators, no - Roche. Buy some, if you can - good luck.

If law suits drive Merck out of business, there will be two big losers: the American patient and the shareholders - and a handful of extremely big winners: the lawyer-predators for whom it is no more than PR that they help "the consumer." Pure BS - they help themselves and themselves only. Like that bozo whathisname - the dopey smiley guy with the hairdo and dental work who made many millions from cerebral palsy, as I recall, and ran for VP with cut-and-run Kerry.

You cannot preach to the trial lawyers - it's just a good slip-and-fall game to them. But patients need to know that all medicines and medical procedures have risks and side effects. We may as well just tell you that anything could go wrong with you if you take an aspirin - because it's possible. You could bleed out your stomach, become hypotensive, and have a stroke, then fracture your skull on the bathroom sink as you fall, and break your arm when you land on the floor. It's happened.

There is no benefit in life without a risk - however small. Life is not safe, and bad luck should not require involuntary compensation from your neighbors. Voluntary help? Definitely. Dr. Miller has a good piece on the subject at TCS: One quote:

Regulators’ increasing sensitivity to safety concerns -- sometimes at the expense of the availability of essential drugs -- may have become contagious: Drug manufacturers, too, seem to have begun to “err on the side of safety” to a degree that causes safe and effective drugs to be taken off the market voluntarily.

Consider Tysabri, only the sixth medication approved -- and the first in several years -- for the treatment of Multiple Sclerosis (MS), a debilitating autoimmune disease that affects the central nervous system. The stunning results of the drug’s testing in clinical trials -- the frequency of clinical relapses was cut by more than half -- induced FDA to grant accelerated approval last fall. MS patients eagerly put their names on waiting lists to get the medicine.

But this ray of hope for MS sufferers was short-lived. By the time that several thousand patients were being treated with Tysabri, three confirmed cases of a rare neurological disorder caused by a virus were reported. (Because the drug suppresses certain aspects of the immune response, regulators, clinicians and the drug’s developers had from the beginning been sensitive to the possibility of infections as a side effect.)

Immediately -- some would say prematurely -- the manufacturers of the medicine voluntarily halted production and distribution and withdrew Tysabri from the market. MS victims and many neurologists were bitterly disappointed.

Read the whole article.

The Caduceus of Hermes and the Staff of Asclepius

These are two entirely different things which look similar. The caduceus, a traditional symbol of Western medicine, is in fact the staff of Hermes and has nothing to do with the 1200 BC Greek physician Asclepius, who was later deified, as the Greeks were wont to do with their impressive people.

The caduceus story in brief: Tiresias, the blind seer and soothsayer, was said to have tried to separate two copulating snakes with his staff, which act transformed him into a woman until he was able to undo his act by repeating it, making him the first serial transgenderista. (Fair warning to snake-handlers.) Somehow, this staff, with the two snakes in love, was passed on to the god Hermes (Roman Mercury), the messenger god and the escort of the dead. (Hermes was a derivation from the Egyptian bird-headed god Thoth, to whom is attributed the authorship of The Book of the Dead.) The word caduceus is a derivation of the Greek karykeion, or "herald's staff." The association of the caduceus with medicine was an odd one, as in the 1600s Hermes was taken on as the symbol of alchemy (hence "hermetic", referring to magic and the occult) and hence to medicine.

The more appropriate symbol of medicine, and increasingly in use, is the staff of Asclepius, the god of healing - one snake only and no wings of Hermes. The Asclepia were the Greek medical schools (Asclepion - singular) and healing centers. Was the original sign that Greek physicians hung at their doorways a worm on a stick, signifying their ability to de-worm people? It's not clear. But the asclepia were known for keeping non-venomous snakes around, for some reason. Pets? More detail on the subject here - a piece which I was surprised to find addressed exactly what I had intended to.

Insurance

Getting some Tamiflu for your family and loved ones is simple insurance. You pay the $95. for a box for one person, and you pray that you will never need it. Or you can just hope that Mommy Government will or can miraculously save you from a pandemic. But Nature is far more powerful than any government. I, optimistically, doubt we will need it - but I have mine. It's a lot cheaper than dying: compare the cost with the cost of a coffin. Some hedge fund, you just have to imagine, is already long the funeral industry, just in case. And you know those guys have the medicine: they ain't stupid.

Medical Advice or a Stock Tip?

These people make a medical mask which kills the bird flu virus. No, I know nothing about the company and don't even know whether they are public or private, nor do I have time to find out. Alas, they do not make them for birds.

Call Your Doctor Today

As you know, the avian flu is moving into Europe. Time has a piece on the 1918 flu epidemic. Our piece on the subject a few weeks ago remains informative and valid.

Call your doctor and ask him to stock up some Tamiflu and/or some vaccine for you and your family. While its effectiveness may be questionable, Tamiflu is all we've got. You have two choices - "Let the govt take care of me" like the dopes in New Orleans, or take care of it yourself like a grown-up. With luck, you won't need it, but you might.

The trout get interested in food again, in the fall. Gwynnie is the big fisherman, not me, but I will be up there in the Adirondacks towards the end of October for a Cast and Blast (trout and grouse) long weekend. And we will of course stop by to see Fran Betters, inventor of the AuSable Wulff, rod-maker, and generally eccentric fellow, who is the proprietor of the Adirondack Sport Shop in Whiteface, pictured here.

Bad News

As I suspected, Tamiflu is losing its effectiveness. I doubt it ever was very effective. My post last week remains the word on the subject, here.

Diet and Cancer

I forgot to link this piece in the NYT earlier this week, concerning what is known about the relationship of diet to cancer. It's a question about which I am frequently asked by patients. There is very little definite knowledge on the subject, despite what we hear periodically on the news. Take all that with a grain of salt, because generally reporters don't understand this sort of information, and they know nothing about statistics and causality. NYT piece here.

Apropos of this subject, my dear oncologist friend Dr. Boyd has just written a book - The Cancer Recovery Plan -  on the subject of cancer recovery, inclduing diet, which I commend to you. Check it out here on Amazon.

But remember, dear friends - whatever you eat, however you live, you will die, eventually, from one thing or another. Carpe diem.

What is "transgender"?

The question came up at dinner with friends Saturday night. Lots of the wives were Smithies (in their 60s+, dare I say?) and they were talking about how their Alma Mater had become a haven for the sexually confused and deviant. They were nostalgic for the old Smith days of weekend trips to Yale and Dartmouth for a wholesome romp and some drinks and hopefully a husband. By skillful application of their charms, they all married very well indeed, and relatively happily too, if appearances are any measure (which they aren't).

I had to admit that I had heard of transgender, but didn't understand it at all. So I tried to read up on it, and I still do not quite get it, but I can see that it all stems from this idea of "gender," a recent concept, sort of a wierd one, introduced by Dr. John Money, a shrink and a famous sex researcher at Hopkins. The notion is that one's anatomy and one's psychology are not always in sync. But I can reach back to medical school and psychiatry classes and, as I recall, Freud said that humans are all mixed up and perverted, psychologically anyway - whether it's conscious or unconscious, so I do not find the fact that many or even most people fail to fit a male or female stereotype particularly interesting - I never met anyone who did, unless they were either putting their best foot forward, or play-acting. We are all made differently. And when it comes to sex change operations, I would no sooner get near one of those than to an abortion. For me, such things are not medicine - they are barbarism and not any part of the Hippocratic Oath I took - which I take to forbid abortion by physicians, in addition to the famous forbidding of cutting "those laboring under the stone". (That was for lowly surgeons, not physicians.)

So as not to look stupid, among the things I read was this piece by Carl Bushong, which I found to be basically happy horse s-,  basically true things about people but drawing drastic conclusions from superficial psychology. And this "true self" stuff sounds a little too pop-psychology for me, a little too self-involved. (I guess everyone is kinda transgendered, but who worries about it? Well, I guess adolescents and young folks do a lot of navel-gazing, especially where it's in fashion. Still, if youth wants to navel-gaze, I'd suggest that they worry more about their character and about how they plan to make a living than about their "sexual identity" - if such a thing even exists. The kids today are spoiled, self-indulgent brats: didn't Socrates say that? And, in Socrates' day, seems like all the young folk were transgendering themselves silly in the gymnasium - the fellas, anyway.)  But, at this point, I am out of my league and will ask Dr. Bliss to take this one on for me.

Avian Influenza - Bird Flu

Bird Dog has forwarded me posts by Instapundit and Rick Moran, both of whom have been keeping an eye on the Bird Flu happenings in Asia and Russia. Rick's series of pieces on the subject here. Here's my brief medical background on the story - kindergarten virology.

Viruses are hardly living things in the usual sense. They are tiny packages of genetic material, either DNA or RNA, in a protein wrapper. They are inert until they enter their host (which can be an animal, plant or even bacteria), at which time they enter the cells of the host and replicate. Thus they are obligatory parasites, and each virus has a preferred host. The photo is an electron micrograph of a human influenza virus, in which you can clearly see the helical genetic material inside the spiky protein package.

There are thousands of virus varieties, and most do not cause disease. After all, it is not in the interest of a parasite's future to kill or seriously tax its host. For example, the usual Avian Flu virus typically lives in the GI tract of wild birds without causing any trouble.

Animals protect themselves naturally against disease-causing viral invasion by creating antibodies – killer proteins – which attach themselves to the protein “antigens” in the viral wrapper. However, the animal must have time to create such effective antibodies (known as "immunity") before it dies. Immunization comes from either surviving the disease, or is induced via vaccines, which contain virus surface proteins, permitting antibodies to be produced.

The family of influenza viruses, all of whom use vertebrates as hosts, are among the most commonly associated with disease in humans. There are three varieties of flu virus, Types A, B, and C, and all can infect and cause disease in humans. Type A flu viruses can infect many varieties of animals but their natural host seems to be wild birds, hence “bird flu”. Subtypes of Type A flu viruses are named by the proteins (antigens) in their wrappers.  “H5N1” is the one with which we have become concerned.

The problems with viruses and disease are that 1. not being alive, they cannot be killed with antibiotics, and 2. viruses change readily through mutation, altering their infectiousness. They change through “antigenic drift”, which are slow minor changes (of the sort that render a flu vaccine from 2004 ineffective against a new flu “strain” in 2005), and through “antigenic shift,” which are abrupt major changes. Avian flu is prone to both. Thus avian flu has changed to become an infectious disease in their bird hosts, mostly domestic poultry but increasingly in wild birds too. And thus avian flu has already mutated so that it can cross the "species barrier"  - to be able to reproduce in new hosts - so as to be able to infect man and other animals.

To date, H5N1 requires physical contact with infected bird material to cause infection in man. There have been dozens of such deaths in Asia over recent years and, when it occurs, it seems to have a 55% mortality. However, infectious disease experts predict that a mutation will occur to make H5N1 contagious – ie spread from human to human in the air, like the regular influenza we are familiar with. Because there is little natural immunity to this virus among humans, such a mutation will create a "pandemic" – a widespread and dangerous epidemic. Jakarta is currently the focus of concern.

Why aren't more people jumping up and down and screaming "the sky is falling" about H5N1? Well, there is this little thing called "denial" - "New Orleans will never flood"; and there is a sense that the infectious disease folks have cried wolf in the past; plus it's all complicated and far away - and we don't think the break-out has happened, yet. Should we wait for the levees to fail before we get excited, blaming, and planning? This is an historic opportunity for public health organizations to get in front of a major problem, and I suspect that they will. Australia has just issued a warning, and the business world is on top of things - see this week's conference hosted by Deutsche Bank.

What can be done? First, cases, when they occur, need to be quarantined (which would have saved millions of lives worldwide with AIDS). Second, people in an at-risk area need to be immunized. Currently Jakarta has 10,000 vaccine doses, and 12 million people. Let us all hope that the vaccine factories are working overtime. Third, anti-viral drugs need to be warehoused on a massive scale, even though their effectiveness is unclear against H5N1. This disease could go global very quickly, once it starts. We have been forewarned, and we know what to do to try to minimize a danger which man does not have the power to prevent.

(One last thought: Those of us living in the secure and highly comfortable USA have become a bit arrogant when it comes to the power of nature. We would like to imagine that, when bad things happen like hurricanes, crime, earthquakes, plagues, war, ordinary diseases, accidents, bad luck, or plain death itself, someone dropped the ball. No. We are a little transient part of nature, and our proper response is one of awe in the face of nature's power in relation to ours. Nature is bent on killing each one of us, in time, and our species too, eventually - God or no God, government or no government, doctor or no doctor, vegetarian or carnivore, good or evil. We are created to be destroyed, which is a strangeness which goes far beyond my job description and my pay grade into a realm which I view as theological hard-hat territory.)

A Call for Physicians in NO

Please, fellow bloggers (and normal humans, too) - help me spread this info around. Guys and gals in group practices with good coverage can probably get away for seven to ten days or so. Maybe senior Surgical and Medicine Residents, too. From the Medscape.com home page:

Telling a young, seemingly healthy patient that they have terminal cancer

Every physician has had to do this hundreds of times, but Dr. Bob wrote it down. "How do you deliver a death sentence?" Dr. Bob explains how he does it. I wish I had written this piece, but Bob did it better than I could have done. The saddest part is always trying to find a way to offer hope, when you know that, statistically, there is none. We sometimes feel like liars, but we need to believe in the power of hope and prayer, despite the terrifying inevitability of the truth of the numbers. There's a lot more to being a doctor than playing golf, folks. Trust me.

Restless Leg Syndrome

Known as the most common disease nobody knows about, Restless Leg Syndrome (RLS) effects 6-9% of the population, to varying degrees. Typically producing a deep feeling of leg discomfort at night, relieved by motion, when it is severe RLS can interfere with sleep and cause daytime drowsiness. It also can cause significant discomfort, approaching pain, on long flights and train trips when movement is restricted. No-one dies from it, but it can be a real annoyance, and it is often mis-diagnosed or dismissed.

I myself have a mild case of it, and it makes me nuts on airplanes, mainly. I cannot sleep on planes and like to stand up next to the bulkheads. For the many who are bothered by RLS, there are effective treatments now if it bothers you enough. Neurologists tend to be the ones who would be familiar with the new treatments for this poorly-understood ailment. The latest information is available on Medscape.com, which I cannot link right now.

Abortion: One Doctor's View

I have participated in my share of D&Cs, many years ago, and maybe some elective ones that I cannot or do not want to recall. I am no politican, and no lawyer, but I can read the Constitution which is deliberately written in plain English so as to be understandable to the average farmer or country doctor like me, and I think it's fairly clear that the Federal Govt has no business getting into such matters - these seem like 10th Amendment matters, to be left either to the states or to the people - ie freedom. Wasn't the whole point of the Constitution to limit the power of the Feds so as not to recreate a distant tyranny like the one we had just driven away? As for the morality, it seems to me to pit two moral ideas against one-another: the value of human life vs. the value of personal freedom and self-determination. I tend towards the life end of that argument, and find the latter a bit new-age and narcissitic (there is no Commandment: Thou Shalt fully realize and fullfill thyself in a convenient and consequence-free manner), but things can get tough in real life and I am capable of sympathy. Anyway, overturning Roe v. Wade is not on my personal agenda, but it would not be a catastrophe, and would let the unfortunate, miserable battle be fought where it probably belongs, among the people, through politics. The Supreme Court is not the Sanhedrin.  In the end, though, if you don't use birth control and don't want a baby, as the Dylanologist would quote, "My advice is to not let the boys in." If you haven't figured it out yet, gals and ladies - boys have very little brains when it comes to a pretty girl and no court will ever be able to change that. It's called "biology." In the 70s they used to talk about "empowerment": control and master your own emotions and your own bodies, ladies, where the rubber meets the road, as it were. That is true empowerment - self-mastery.

Avian Flu

Bird Dog forwarded me a piece by Rick Moran about the spread of avian flu, and the possibility that China could be concealing its true impact, including human-to-human transmission, which would be something new for this virus. I agree with Rick - let's follow this scary story, and let's get some reporters off their duffs and into China to see what is really going on over there. The CDC reports that the virus is becoming more pathogenic to mammals, and that such viruses mutate faster than had been thought. Human-to-human transmission of a virus which is resistant to ordinary anti-virals, and which seems to have about a 50% mortality rate, would result in a modern-day plague. The key issue is whether it has mutated so as to permit inter-human transmission. I must admit I hate to contemplate that, especially having read The Black Death last month. (Photo is a nesting Common Tern, one of my favorite birds here in Narragansett Bay.)

Pain Control and the Law

It can be easy for modern folks to forget how recently medicine has been able to provide relief for serious pain. Yes, the ancient Greeks had aspirin - willow bark - but until narcotics, derived from the poppy, arrived, and ether, for surgical procedures, physicians could not offer much for pain, which may be the most common complaint of patients. A nice summary of the history of pain treatment here.

We distinquish chronic from acute pain. With acute pain, of course, we try to identify the cause and to fix it. For chronic pain, where we know the cause, for example, cancer, arthritis, back problems, and a vast variety of others, narcotics often end up being the only thing we have to offer. Sure, we send patients to pain clinics, neurologists, acupuncturists, etc., but narcotics are what we use when all else fails. They work, they are not evil, and they are a blessing to mankind. And yes, they are addictive or at least habit-forming, but with chronic pain or terminal cancer pain, you don't worry about that. Why would it matter?

What bothers me is when law-enforcement begins to worry about doctor prescribing, but I always figure it's a lot easier for them to go after docs than after drug dealers with 9 mm handguns, vast networks, street smarts, secrecy, etc. With docs, you just walk into their office with pharmacy records. Easy, but accomplishes nothing worthwhile. There may actually be MDs out there who prescribe narcotics in a criminal fashion, but they are so few as to be of no significance, while illegal drug-dealing is a billions-of-dollars business in the US. Not to excuse them, but it isn't exactly a major American crisis. All docs get pretty good, but never perfect, at discriminating drug-seekers from pain patients.

When, as is known to happen, patients with narcotics prescriptions sell or otherwise distribute their pills to others, it's not the doc's responsibility and it's not his doing. John Tierney in the NYT has an excellent piece on how legal intimidation can interfere with humane treatment of patients in pain, and his piece also shows how the "War on Drugs" has been totally ineffective. And when you read a case like this one featured in the current Time magazine, it breaks your heart. Any DA who thinks he's a hero for prosecuting a pain specialist is lower than whale poop. But it's much easier than going after the bad guys.

About twenty years ago, we went through one of these phases, when docs were fearful of making patients, even terminal patients, addicted. It was a silly medico-cultural fad, but it passed, and physicians resumed treating pain patients adequately. And the invention of the morphine pump has been, in recent years, a God-send. I would hate to see medicine forced back to the 1970s and 80s when docs were looking over their shoulders, worrying more about anything other than their patients' pain. And if you are a patient with pain, you will agree with that.

Spiritual Diseases

I like Dr. Bob, and I commend him for taking on a blog single-handedly, and for sticking with it. I doubt that he really knew that there was a writer in him, but the writer in him knew it, and out it came. As a Christian physician, Bob is able to see the spiritual dimensions of addictive and compulsive "diseases" in a way I find refreshing, and free of gobbledy-gook:

The paradox about 12-step programs–which have the only reliable track record for successful recovery from addiction–is that they emphasize the disease as the problem, and honesty, integrity, and personal responsibility as the solution. They do not excuse the behavior while admitting the disease, and this blend of honesty and humility, acceptance and tough love, works like nothing else. It is, as recovering alcoholics are quick to point out, a spiritual program: the Catch-22 of a body which craves alcohol without limit and a mind which denies the resulting problems cannot be solved any other means.

But as any recovering alcoholic will tell you, the problem is not the booze; it is not even the obsessive, irrational mindset which drives the drinking. Both these problems are symptoms of an underlying decay, one of spiritual dimensions, characterized at its core by extreme self-centeredness. The pursuit of happiness by feeding this monster creates not the promised joy but rather pain and emptiness. Alcohol hides that pain for a while, until the monster, growing ever stronger by its constant feeding, kills its host spiritually, emotionally, and often physically.

But addiction is hardly alone as a symptom of this dark core. The list of destructive behaviors arising from its belly is endless: obesity, sexual promiscuity, compulsive overwork, materialism, computer obsession, gambling, the pursuit of beauty over character, the lust for money and power. Some may be biologically-driven; some learned behaviors or dysfunctional coping. All seek to fill a hole with no bottom, providing the wrong salve for the pain, and more of the same when the salve makes the wound fester.

Read entire.

Living Wills

No-one enjoys anticipating their death, and plenty of folks seem to postpone dealing with it, but it is the grown-up thing to do. Having a Living Will is as important as having a will and, if you are young without kids, the Living Will is more important. Yes, your family and your doctor will probably decide to "let you go" if you are hopelessly damaged, but what if they aren't around? What if they are confused?

The CSM goes through what is involved.

The Illiterate Surgeon

In Africa - amazing and heart-breaking NYT audio-visual  story.

Diet and Breast Cancer

For all of the hype and pseudo-science and random blather about diet and cancer, we finally have a fact. The fact is that low-fat diets reduce recurrence of breast cancer. This is a big deal. Not that it prevents cancer, but reduces recurrence. I will strongly advise every breast cancer patient accordingly.

Piece in the NYT.

The Female Orgasm

Is it a vestigial occurrence, or is it evolutionarily adaptive? Everyone wants to know. Certainly not everything in the biological world is adaptive. Curious? Sure you are. Read here.

Medecins Sans Frontieres

Doctors without Borders. I admire this organization, I support it with money, and God bless the physicians who give their time. It is a high expression of the medical profession. In fact, I offered myself to them a few years ago, but could not be away for their minimum length of time committment, but I forget what it was. Several months. I could have given 1-2 months with a locum tenens, but that's all. The message is that these docs give a lot.

Interesting fact on their site: the media-sexy Marburg virus killed 200 - Malaria kills millions every year, but makes no headlines. Another interesting fact: MSF has treated 1000 in Haiti for gunshot wounds since December, mostly political disputes. Nice country.

Medical Dummies

I hadn't heard about the new medical dummies until I saw it in The New Yorker. I have to say that I think it's a wonderful thing, mainly for medical emergencies. There is nothing wrong with American medical education - best in the world - but the fact is that when you graduate, and it's your first night covering a NYC emergency room as an intern, you do see things you've never seen before, and you don't have time to think.

I'll never forget one night in my first month when I was the only medical intern on duty in the ER. I had 17 patients in there. One acute MI who coded and didn't make it, one respiratory failure who didn't make it, a rule-out MI who didn't have one (we didn't do the enzymes then), a bad asthmatic who finally did well, a total-body disintegration from a nursing home, a drunk with acute pancreatitis, a diabetic with an acute hyperglycemia who we got under control but later died of aspiration pneumonia, various gomers here and there trying to either die or to fall off their gurneys ("Gomers go to ground", remember House of God? Good book), an arrhythmia or two - can't remember, an upper GI bleed vomiting blood, and who knows what else.  With time to think, I could have taken care of any one of them fine. After a year of that, everything became routine.

In the ER, it's about rapid, accurate diagnosis. What is surgical, what is medical, and what can wait. Diagnosis is easy in books, tough in real life. Not only do I wish I had had a week to be challenged by one of these new dummies, I wouldn't even mind it now, even though it's been decades since I've done ER work. I've heard that aviation simulators can almost give pilots heart attacks, so I'm sure that a few hours with the dummy would be quite an adventure. Worth paying for.

Read the piece about medical simulation. Written with The New Yorker's usual craftsmanship.

What "Health Care" Crisis?

The crisis is that too many folks expect free stuff.

But before I get rolling, a few minor points. First, I will not call medical care "health care." What does "health care" mean? Second, nor will I call Physicians "health care providers." Please. Even in this day of high-tech medicine, many doctors remain identified with the medical priesthood in which we are privileged to hear your confidences and confessions, to probe your body and your mind with kindliness and the best of intentions. Honestly, it's quite a burden and an unimaginable responsibility for those outside the profession. Third, health is not a right. It's the product of good luck, some self-care and responsibility, good genes, and God's grace. And it is something that no-one can keep. We have a built-in self-destruct program, such that every good day after age 40 - when Mother Nature no longer needs us - is a gift.

Why do medical costs rise? Because we do more than we used to do, to help people. Twenty years ago, a new knee was a rarity and experimental. Now it's routine, but it can't be cheap. Remember how many folks were lurching around on canes 30 years ago, with bad hips and bad knees? How often do you see that now? And the huge numbers of cardiac invalids we used to have to make house calls on - where are they now? Not to mention the depressives, the phobics, the invalid diabetics, the bad back invalids - you name it. We haven't extended the life span much in the past 40 years, but we have done a heck of a job with quality of life.

I have often conjectured that the real reason politicians like to talk about health care is so no-one suggests government-run single-payer, single-provider legal care. In a Republic, you could make a case that everyone is entitled to the same legal care, because there's a political right involved. Ask the legal beagles at Bainbridge or View from 1776 - it might be Constitutional.

But there is no right to medical care any more than there is a right to a car, or car insurance or nice vacations, or, for that matter, a right to good health. I see it no-where in the Constitution - not even the hint of a penumbra of an aura of a fog. Part of being a grown-up in a free country is taking responsibility for your family's well-being. Or don't have a family. In Europe, the whites have basically stopped breeding, because of the expense. The adults want to be children. So if everyone who isn't insured went out and bought catastrophic medical insurance, which is inexpensive and rational, instead of a new whatever, there would be no problem at all. That's probably what Medicare should have been.

And don't believe those statistics about medicine in Canada, England, France, etc. They don't do half of what we do routinely. If they did, then how come the wealthy from those countries all come to the Mayo Clinic, New York Presbyterian, Yale-New Haven, and Mass General, etc. for treatment? They want the best, and they don't want to be rationed. We are the world leaders in medicine, in medical innovation, and in pharmaceuticals, and we do it with no bureaucracy at all (except in the hospital administrations, and even there, it's small) and with no rationing at all.

My opinion: It ain't broke, so don't fix it. Don't listen to whining businesses - they just want someone else to pay for the coverage; don't listen to whining people - they just want a hand-out and will buy a new TV or a new car but want to gripe about medical care; and don't listen to the Leftys - they just want the govt to run everything...one totalitarian step at a time. Let's all try to feel fortunate that we are free to buy what we need here in the USA. And if you have fallen on really hard times, we have medical charity everywhere, plus Medicaid.

Tim Worstall has written a fine open-minded piece which explains clearly the different approaches used in Western countries here: Click here: TCS: Tech Central Station - Health in the Balance

And Arnold Kling makes the economically rational case for catastrophic insurance - which I have and which most docs have - here.  From his piece: "Ask an economist what is the best type of health insurance, and he or she is likely to respond "catastrophic coverage." Our assumption is that rational consumers should be motivated by risk aversion and low cost. Risk aversion means that they should be concerned about mitigating the impact of severe, expensive illnesses. The low-cost way to do this is with catastrophic health coverage. The most familiar form of catastrophic coverage is health insurance with a high deductible."

And then read Dr. Bob on the subject of charity care - he does what many if not most of us do.

Scam City

Every MD in America knew that the trial lawyers pulled off a huge scam with the silicone breast implant deal. Destroyed one fine and innocent company, and had every con-woman and deranged hypochondriacal female in America in on it.

And isn't it just fine to now look at the science, and to find out that silicone breast implants are harmless? Personally, I feel the purely cosmetic use is ridiculous - accept what God gave you. Speaking as a fellow, trust me - whatever you have is very nice and very lovely indeed, especially if you have a good heart. But for breast cancer reconstruction - well, it's important to lots of women. The silicone is better than saline, many folks feel.

I want to see all the $ returned, including the zillions that ended up with folks like that jerk who ran with Kerry - what was the name of that greasy sleazeball trailer-trash guy with the hair?

Read here.

Left-Handed, Left-Eyed, etc.

Southpaws do have it tough. I am one, and I'm surprised we aren't an aggrieved minority so we could get free money. There's no doubt left-handedness is abnormal and maybe due to a touch of low oxygen at birth. It messes with your handwriting, but mainly with your shooting and tennis. Brain confusion.

If you are left-handed, and left-eyed - no big problem. You shoot lefty and if you want, you can buy a lefty gun, but I doubt it's worth the trouble unless you shoot competitively. (Easy to tell which eye is dominant - roll up a piece of paper and look through it like a telescope - which ever eye you use - that's it.)

If you're right-handed and left-eyed, it gets interesting. Mixed dominance for sure. Ideally, you would shoot lefty and play tennis righty, and just adjust and assume you'll never get to Wimbledon.

Bill Hanus offers advice on this age-old dilemma here. Hey Dylanologist - I know this applies to you, big guy.

Allergy

Allergy, like depression, is taken seriously mainly by those who have had it. And by the docs and researchers who deal with it. A truly effective treatment would be a blessing not only for the very few with life-threatening food or bee-sting allergies, but to all of the asthmatics, the dog- and cat-allergics, and the hay-fever snifflers.

A new treatment may be in store, if you can hang on for a few more years: Click here: The New York Times > Health > A Therapy for Cat Allergies, Thanks to Mice

Socialized Medicine

I am agin' it. If you think Canada is bad, look at England. At least England allows private medicine. This piece grossly understates the real issue, which is that bureaucrats run the system: "The UK is good at developing new medical technologies, but bad at making them available to patients, a draft version of a government report says. The study blamed the centralised way the NHS was run for failing to make the most of breakthroughs in areas such as scanners and ventilators."

Read entire and be glad that you're in America: Click here: BBC NEWS | Health | NHS 'not making most of progress'