Maggie's Farm

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.

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.

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.