Friday, December 5, 2008

Is "Parasites the Correct Word" Continued.

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

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

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

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

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

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

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

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

Tuesday, November 4, 2008

Can't Escape Bacteria

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

Saturday, November 1, 2008

Is "Parasites" the Correct Word?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


1900 Massachusetts data was obtained from one of my pathology lecture notes handouts. I can ask my instructor for the specific source, for anyone who is interested. 2005 U.S. Mortality Data taken from National Center for Health Statistics, Centers for Disease Control and
Prevention, 2008.

Friday, October 31, 2008

Heal Spiel Halloween Edition: Chelation Therapist Taking Our Questions

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

Dr. Orac is collecting questions from his readers. Some people wrote really boring stuff that was all actually relevant to science and evidence-based medicine and stuff. Examples include:
1. Name all papers showing that autistics have higher body burdens of heavy metals, after controlling for diet, pica and urbanicity.

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

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

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

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

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

Dear Mr. Buttar,

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

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

Thursday, October 30, 2008


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

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

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

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

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

Wednesday People Watching

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

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

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

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

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

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

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

Wednesday, October 29, 2008

Preliminary California Election Results!

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

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

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

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

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

United States Representative: Charles Hahn

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

State Senator: Teddy Choi

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

State Assembly: Brian Fuller See above.

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

Proposition 2: Standards for Confining Farm Animals: Yes

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

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

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

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

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

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

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

Proposition 6: Police and Law Enforcement: No.

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

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

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

Proposition 8: Ban on Gay Marriage: No.

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

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

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

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

Proposition 11: Redistricting: YES.

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

Proposition 12: Veteran's Bond Act: No.

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

Tuesday, October 28, 2008

CMA vs. "Licensed Health Professionals"

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

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

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

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

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

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

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

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

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

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

Ignores Physician Responsibility for Medical Care

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

Jeopardizes Patient Safety

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

Leads to Confusion in Medical Decision Making

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

Undercuts the Independence of Medical Staff Committees

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

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

From Mad Libs to Wiki to the Great American Novel

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

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

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

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

HT to Megan McArdle by way of Alex Massie.

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

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

Just clarifying!

The Moderate Five

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

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

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

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

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

Monday People Watching

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

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

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

Up and Coming Medical Specialty?

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

Monday, October 27, 2008

Give Amanda Peet a Cookie

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

Peet, spokeswoman of the organization, Every Child By Two, which works to increase childhood immunization, said in an interview in Cookie Magazine (I know, how was I not made aware that such a publication existed?):
“Frankly, I feel that parents who do not vaccinate their children are parasites...I have a lazy, fluffy, actor-y side that’s instinctive. And I have a side that’s practical and into statistical evidence. I’m not a casual person.”
After an uproar, as well as some snippy comments from McCarthy, Peet apologized, saying,
I believe in my heart that my use of the word 'parasites' was mean and divisive. I completely understand why it offended some parents, and in particular, parents of children with autism who feel that vaccines caused their illness. For this I am truly sorry.... I still believe that the decision not to vaccinate our children bodes for a dangerous future. Vast reductions in immunization will lead to a resurgence of deadly viruses."

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

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

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

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

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

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

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

Friday, October 24, 2008

The Most Dreaded Day in Medical School

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

If I get one more email....

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

Thursday, October 23, 2008

Stop the Presses

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

Wednesday, October 22, 2008

Reason Why I Hate the Blogosphere #37593

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

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

This was my take on Kleins's commenters:

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

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

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

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

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

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

This was my response to the Matt Welch post:

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

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

Wednesday, September 24, 2008

Social Activists vs. Ben and Jerry's?

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

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

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

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

Tuesday, September 23, 2008

Know-Nothing Pundit With Plenty to Grouch About

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

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

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

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

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

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

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

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

Monday, September 22, 2008

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

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

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

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

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

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

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

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

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

Saturday, September 20, 2008

Anesthesia Irreverence

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

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

Pelvic Examination Training

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

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

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

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

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

Wednesday, September 17, 2008

Another Powerpoint Exhumed!

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

Spared from the Powerpoint Graveyard: LGBT Health Care

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

So, now that you've heard my spiel questioning the category of "LGBT Health Care," please please enjoy my presentation on that very topic:
Lgbt Health Adina Only
View SlideShare presentation or Upload your own.

Tuesday, September 16, 2008

Fully Informed Patient

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

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

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

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

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

Monday, September 15, 2008

I'm Rich?

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

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

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

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

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

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

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

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

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

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

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

Sunday, September 14, 2008

Pharm Free

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

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

Saturday, September 13, 2008

Insurance-Promoted Suicide?

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

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

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

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

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

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

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

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

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

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

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

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

Friday, September 12, 2008

Pregnancy Pact

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

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

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