Image courtesy of Alex Wild, click image for link

Not all hallucinations are disturbing, but most probably are.  They can be categorized by which sense is involved or by cause.  Schizophrenics often experience auditory hallucinations, hearing voices that are not actually present.  Many people can experience olfactory hallucinations, usually smelling foul odors that no one else can detect.  These are often caused by specific problems in the brain or nose.  A classic cause is seizure in the temporal lobe of the brain.

Visual hallucinations aren’t that common and usually aren’t associated directly with mental illness as auditory ones are.  Most of the time, visual hallucinations are caused by chemicals such as drugs, or by withdrawal from drugs.  Sometimes they are caused by specific brain disorders.  A classic cause of visual hallucination is delirium tremens, or acute alcohol withdrawal.  Victims often have disturbing visual hallucinations (one of my favorites being skeletons fighting with swords on the IV pole, although in that case, the patient wasn’t all that disturbed by it).

As if that weren’t enough, alcohol withdrawal is often accompanied by an additional type of hallucination called formication (from Latin formica ant). This is a tactile hallucination usually described as a feeling of bugs crawling on the skin.  It’s rarely pleasant.

Delusions differ from hallucinations.  Rather than being a sensory problem, they are a thought problem.  People with delusions believe something that is demonstrably false and cannot be convinced otherwise.

Which brings us to what is surely not the end of the story of “morgellons syndrome”.  Over the last few years, patient advocacy groups have militated for further investigation of this putative skin disease.  The disease is characterized by a variety of symptoms, most of which are cutaneous and include itching, sores, and foreign substances arising out of wounds.  Most physicians view this as a variant of delusional parasitosis, an illness where people believe they are infested but no proof of infestation can be found.

Patients typically have a pattern of skin lesions indistinguishable from damage done by scratching, and the fibers and other substances, when analyzed, have been found to be common substances such as clothing fibers.  Even a brief perusal of morgellons advocacy websites will demonstrate the hostility with which this analysis is viewed. Sufferers believe they are truly stricken—and they are. But the enemy is within rather than without. Their brains have convinced them that their skin is crawling with various sorts of things and they cannot be convinced otherwise.

A few years ago, the CDC decided to investigate what they have labelled “unexplained dermatopathy”.  This week, the results of their study were published in PLoS ONE.

The investigators focused on Northern California, where there seemed to be many case reports.  They sifted through charts and invited those who described the syndrome to join the study.  What they found was that cases were rare, but were associated with significant disruption in quality of life.  They also found a significant incidence of neuropsychiatric disorders.  A remarkably large percentage of patients had hair samples testing positive for drug use, but the specific drugs are not reported, nor is the validity of the hair sampling technique.

In sum, there was a set of patients who reported disturbing skin sensations and wounds, who were disproportionately unhappy and may have been using drugs.  But which way does the arrow of causation go?  Does a mystery disease cause people to become depressed and use drugs, or does psychiatric disease and/or drug use cause a delusional syndrome? Delusions and hallucinations caused by psychiatric disease and substance use are well-documented.  The other way ’round is a bit murkier.

Some clues are found in the study.  Many cases began around the same time the internet picked up on morgellons suggesting a folie a deux/plusiers —a shared delusion (this also suffers from a correlation vs. causation problem).  Also, the skin changes among patients were diverse, too diverse to be easily explained by a single non-psychiatric cause. Pathology findings most commonly showed skin changes due to sun exposure and trauma such as scratching.  Finally, the “fibers” and other objects emerging from the skin were found to be common substances like threads from clothing and were not emerging from the skin but rather were enmeshed with skin debris.

This will not be the last word on this particular variant of delusional parasitosis.  The definition of a delusion is a fixed, false belief, one that is not dislodged by data or knowledge.  The inability to accept the diagnosis is part of the illness itself.  The challenge to clinicians will be to treat these patients delicately, with respect, acknowledging their real distress and attempting to guide them toward proper treatment.

References

Pearson, M., Selby, J., Katz, K., Cantrell, V., Braden, C., Parise, M., Paddock, C., Lewin-Smith, M., Kalasinsky, V., Goldstein, F., Hightower, A., Papier, A., Lewis, B., Motipara, S., Eberhard, M., & , . (2012). Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy PLoS ONE, 7 (1) DOI: 10.1371/journal.pone.0029908

More commonly, she has trouble falling asleep.  She requires a parent to stay with her until she’s out.  This is usually more my problem than hers, but lately it’s started to bug her.  Last night she was tossing and turning and looked at me in frustration.

“Daddy, I’m never going to fall asleep! Never ever!”

This I understand.  So many complaints of childhood seem mere annoyances to adults.  How much sympathy can you have for a child who claims to be bored while surrounded by toys?  How can a chubby adult understand why a kid won’t eat anything but an occasional chicken nugget?

Tonight she was what most parents would call “over-tired”.  I only read a few paragraphs of Moby Dick and she lost it.  She wanted more and was nearly inconsolable.  My wife came up and wiped her nose and rubbed her back, calming her until she dropped off to sleep.  It was magic.  Until I got up and bumped into the dresser, extending bedtime by another fifteen minutes.

Even these frustrating moments are drops of ecstasy into our lives.  I give a lot of bad news out during the day, enough that it sometimes weighs down on me, fracturing the boundaries set up to protect both me and the patient.  This is one of the reasons I’ve cut back a little bit on some of my overtime. Without time for self and family, it’s not possible to deal with the psychological consequences of developing important relationships that are fostered in part to be able to give devastating news.

And so I lie in bed with my family, watching my wife soothe my worn-out child, feeling the warmth and strength of the closeness, but knowing—really knowing—its fragility, a fragility best not shared too readily.

Crap.  Waking up late + fog = late to work.

Part of my drive follows a lake shore, so I turned off early hoping that  a climb away from the lake would see some clearing.  It did, just a little, but enough to get me to work on time, which is fortunate as I’d double-booked my seven a.m.

My patients give me a good run down of the hour-to-hour weather.  The first few complained about the fog; the next few the pouring rain; after that, the unseasonably warm temperatures  (mid-50′s).  Then the wind; that report was redundant as the windows were vibrating with a low tone, rain falling sideways in sheets across the parking lot.

I was hoping the warm temperatures would hold out until after work.  It’s been two days since my last run and I’m trying not to skip two days in a row.  When I stepped out the office building door, the wind hit me, driving sharp pellets of sleet into my face.  Crap.

But I’ve got gear.  I got home, got out of my work clothes and into my running outfit which gives my daughter no end of giggles.  The balaclava didn’t slow those down any.  I hit the road and immediately my left knee started to complain.  At forty-four, I figure that’s not unexpected, so I ran through it until the sleet hitting my face distracted me.

I’ve discovered a lot since I started running.  One of the most startling discoveries is that I can actually do it.  Sometime in the middle of a run I look down and think, “I can’t be doing this.  How could I be doing this?”  It almost paralyzes me until I turn up the music.  The other thing I’ve found is that foul weather makes me run faster.  Today I ran fast.  Too fast.  The frozen peas on my shin are telling me I better lay off a little.

So that’s what I’ll do—for now.  As the roads ice up, I’ll keep icing all the sore bits and set the alarm a little early.  I have a feeling it’s going to be a rough drive to work tomorrow.

Meridians of so-called Traditional Chinese Medicine

In 1994, I first put my hands on a human cadaver.  When we first received it, the head and hands were wrapped.  The rumor was that this would help us to adjust to the humanity of the thing more gradually.  When we did uncover the hands, the nails were painted, giving the meat a sudden, undeniable humanity.

Over the months, my friends and I slowly dissected this person, finding nerves, veins, arteries, muscles.  At the same time we learned the microscopic anatomy.  We learned how chemistry drove the smallest units of muscles, causing the whole to contract and lift an arm. We learned how specialized channels in the gut could be poisoned, causing cholera patients to dehydrate and die in hours.

We learned how the immune system could be taught to fight influenza; the mechanism by which common antibiotics poisoned cell wall formation in bacteria; the horridly complicated function of the smallest functional unit of the kidney called the nephron.  We stood on the shoulders of giants. I loved it.

The first two years of medical school is an intimate visit with the inanimate.  Living patients are scarce; the knowledge the human machine is the focus.  We stayed in the labs until the middle of the night examining our cadaver, looking into microscopes and comparing what we saw to pictures in books.  We traced out biochemical pathways on chalkboards.  Never did we see anything corresponding to a meridian or to the four humors, or any other pre-scientific medical ideas. They were clearly a fiction, one dreamed up by our ancestors to explain something insanely complicated.

In the third year, when we did finally see patients regularly, it all came together—slowly.  It’s a medical aphorism that patients don’t always read the textbooks.  Their diseases may not follow expected patterns.  And the addition of real human desires and fears complicates everything.

It takes years to learn how to use medical knowledge to help real people, but you can tell immediately how comforting a word or gesture can be.  During that period of perceived incompetence, while you learn how put book knowledge into practice, we reach for things we already—hopefully—know: how to comfort people.

So-called alternative medicine seems attractive at this point because it purports to focus on the compassion, the relief of symptoms. Let’s look into why this is a false compassion.

During my third year internal medicine rotation, some of the nurses were practicing “therapeutic touch” on our patients. Since none of us knew what this was, we asked them to stop doing things to patients without an order.  Soon after, a remarkable article showed up in the Journal of the American Medical Association.  A young girl, with the help of her parents and a well-respected physician, conducted a study on therapeutic touch showing its underlying theory to be fictitious.  The alleged energy fields being manipulated by practitioners could not be found to exist.

This was a revelation for me.  It brought it all together: the lack of alternative medicine findings in biology or anatomy, the mystical nature of altmed, the claims that the effects could not be measured by “traditional, scientific means”.  I came to realize that there was no such thing as alternative medicine.  There was only medicine shown to work, and everything else.

I did go through my “shruggie” phase—after all, if acupuncture makes my patient feels better, than what’s the harm? (In the case of acupuncture, one of the harms may be hepatitis C.)

What I found, though, is whatever good may have come from some altmed practices, it didn’t even compare to the harm. Patients were taking buckets of supplements, undergoing potentially harmful procedures, and turning away from medicine proven to work.

This whole process took me years.  The rhetoric of alternative medicine is seductive; the truth of real medicine beautiful but messy. How can we teach people to sort out real medicine from everything else?  For a layperson, there is no sure way, but here are some hints for laypeople and for doctors who haven’t thought much about it.

• If a claim goes against the basic rules of nature, it’s probably bunk. Homeopathy, where substances are diluted beyond existence, claims to treat all manner of problems, but for this to be true, we would have to overturn our basic understanding of the universe.  Unless the data are close to unrefutable, I’ll stick with the model of the universe we already have.
• If a treatment relies on an energy or pathway in the body that cannot be seen in the anatomy lab or detected in some other way, it doesn’t exist.  So-called energy fields purported to run through the body have never been detected.  Meridians of qi have never been detected.  Subluxation complexes of chiropractic have never been detected.  Therefore, they are unlikely to exist.
• If someone claims that their healing method can’t be measured by modern science, they are wrong.  It is nonsense on its face.  If someone claims an effect, then it is measurable. For example, if someone says that reiki treats a disease, then it should be easy enough to create a study where one group gets fake reiki and the other gets “real” reiki.  There.  You’ve measured it. There is no medical intervention that cannot be measured in some way.
• If someone is charging you an exorbitant price for something seemingly simple, it’s probably a rip-off.  Energy bracelets, crystals, special supplements, sea salts—none of these things contain anything special, nor should they cost a lot of money.  Most real doctors prescribe medicines and interventions that they don’t directly profit from (directly being the key word).  Some specialties, such as dermatology and ophthalmology may sell items directly related to their practice, but most other specialties do not.  As an internist, there is nothing I can think of that I could ethically sell to my patients.
• If a practitioner tells you not to go to regular doctors, then they are trying to kill you, whether they know it or not.
• If a practitioner claims to have special tests that no one else has access to, such as mouth swabs for toxins or special tests for Lyme disease, something is fishy.
• If a practitioner claims there is a grand plot by pharmacy companies or “mainstream medicine” to hide a cure, they are either criminal or crazy.  Real doctors want to help people, and real cures are very, very profitable.
• If a practitioner is a “brave maverick”, bucking the stodgy power structure of traditional medicine then he is more likely a dangerous rogue and believes his intuition is smarter than science.
• Older is not better.  Just because something is ancient doesn’t make it good. In fact, the opposite is usually true, as ancient medical beliefs are usually pre-scientific and fictitious.
• If it sounds too good to be true, it probably is.  This is an old rule, but useful.  If some drug or procedure really makes you live longer, or cures a horrible disease, it will eventually be available everywhere.  Patients and doctors will demand it.  But most of these claims never pan out.

This is just a few hints, not a comprehensive list.  And certainly, these don’t work all the time.  A cancer specialty center will probably have new tests that aren’t available everywhere, but this is the exception.  Web sites like What’s the Harm, Quack Watch, and Science-based Medicine have lists of questionable practices and make useful references.  But the easiest thing to do is to find a doctor you trust and run things by them.  Patient come to me all the time with ads from the paper or printouts from websites.  I explain to them what the context is and whether it’s worth while to follow up on them.

Medicine has spent the last century-and-a-half maturing into a real science.  We know that human body is part of the same universe as everything else, made of the same “star stuff”.  Understanding and improving medicine requires a scientific approach to a real, physical problem. The practice of medicine requires a thorough dedication to science and a deep well of compassion.  With either missing, we do our patients a disservice.

It is during a surgery rotation when a medical student perhaps feels least competent. Not only is there an enormous amount of book learning, there are the physical skills that take years to develop.  Most of the time you pull on a retractor and answer questions, record vitals and pull out drains. My instructor, who in the OR hurled Spanish invectives like scalpels and called every med student, “Pullgoddamyou”, was gentle as a kitten with conscious patients. When I was in his office an elderly woman came in for a superficial biopsy. He had treated her for years and she trusted him.  After spending time talking to her and calming her, he numbed up the area and went to work. But the patient was tearful, from the pain and also from the knowledge that the biopsy was not going to give her good news.  I reached up an took her hand, then quickly released it, uncomfortable with my spontaneous act of intimacy.  Dr. Gruff looked at me and said, “No!  Hold her hand!  That is compassion, that is being a doctor!”

Compassion can be learned, or at least a simulacrum of it. Hopefully it comes naturally to most doctors, but for those who is does not, and cannot be taught, there are specialties that don’t involve much patient care.  Radiology, pathology, and a few others involve very little patient interaction, but are essential to the modern practice of medicine.  While the surgeon waits, hands folded in the OR, the pathologist quickly prepares slides and calls up with an answer that can be the difference between a small biopsy or a radical cancer surgery.  Sitting in the barber’s chair one day, the barber asked me to take a bottle of wine to a radiologist.  His wife had gone in for minor surgery and the radiologist had discovered an early cancer on a routine x-ray, saving the woman’s life.

I’d guess that most people, when thinking of a doctor, think of their own doctor, a primary care physician or an OB/GYN.  Hopefully this is someone they’ve come to trust, someone who can give them the tools to stay as healthy as possible and to treat them with compassion when they fall ill.  This part of medicine: this rapport, this compassion, is essential to good patient care.  A patient who likes you, and who you in turn like, is more likely to trust in and benefit from your advice.

But compassion is not enough.   In medicine, compassion unguided by science can be dangerous.  When you have strep throat, do you seek out a compassionate clergy or friend with no medical knowledge, or a doctor?  The doctor knows that untreated, strep can lead to abscesses, rheumatic fever, and can (but does not usually) cause permanent damage.  She knows that strep is easily killed by certain antibiotics and not by others.  She knows when the sore throat is more likely to be a virus and should be treated with hot tea and chicken soup rather than drugs.

Physicians are daily witnesses to the power of compassion, and like any power, compassion can corrupt. A compassionate act often has immediate and satisfying results. Treating hypertension gives neither the physician nor the patient immediate satisfaction.  It is the reduction of the risk of heart attack and stroke, a benefit that accrues over time, that makes treatment worthwhile.  But doctors like anyone else would love to see an immediate reaction, something unlikely in a patient with a disease without symptoms.  Patients are rightly skeptical about treating a disease which causes no discomfort.  It is up to the physician to work with the patient to help them understand the importance of treatment, to use their rapport to help the patient understand the benefit.

Sometimes the doctor and the patient unconsciously conspire to gain immediate satisfaction where none should medically exist.  Of the two, the physician should know better.  When doctors recommend unproven or implausible treatments with the idea that it may make the patient feel better they enter a folie a deux. We know how to treat high blood pressure with diet, exercise, and medication.  It might not make you feel better immediately but it will save your life.  Compassion will help bring the patient around. But how about adding on some hypnosis or acupuncture?  These feel more “real” to the doctor and the patient, but are no more real than a sugar pill.  If there is any benefit to these, it is through the same mechanism the doctor uses in the exam room: a hand on the shoulder, a cocked ear, a smile.  It is compassion without the benefit of actually treating the disease.

There is nothing wrong with compassion. In fact it is necessary to get the most benefit out of the patient-doctor collaboration.  But it is not, in itself, powerful enough to cure infection, to prevent strokes and heart attacks.  Compassion plus medical science is good doctoring.  Compassion plus no science is charlatanism.

In Part III, how to spot the difference.

PalKid is sitting across from me at the computer, back to the window. I’m hoping the deer will come up to the fence.  They use the right-of-way frequently though the browsing there is a bit sparse.  When they do, I can turn her around to see them.  They’ll either freeze in place or leap away, white tails flashing beneath the leafless trees.

It’s really quite beautiful, but a day best appreciated sitting by a fire with hot chocolate watching through a pane of glass.

Remarkably accurate anatomical sketch by Vesalius

For nearly five years, I’ve been writing about medicine.  One of the questions I hear the most is, “when it comes to my health, who do I believe?”

Anyone who’s read my writing knows I’m critical of so-called alternative medical practices.  I’m also critical of the abuse of mainstream medical practices.  I’ve had years of education devoted to studying human medicine.  How is a layperson to know what works and what doesn’t, what is real medicine and what is hucksterism disguised as medicine?  Let’s explore how a non-physician can think critically and skeptically about health and medicine to make good decisions for themselves and their family.  In my mind, I’ve subtitled this series, “An Introduction to Medical Skepticism.”

The study of human medicine goes back, presumably, to the beginning.  Gods, spirits, ill-winds have always been invoked to explain illness.  ”Malaria” means “bad airs”, even though we now know it’s caused by a small organism transmitted by mosquitoes.  As humanity became literate, human illness was studied and observations recorded systematically.  Hippocrates of Cos, who probably lived and practiced around the 4th century BCE, wrote excellent observations on the natural history of many common illnesses, descriptions that modern doctors easily recognize.

In the 15th century, Andreas Vesalius dissected cadavers, recording his findings in beautiful and mostly accurate drawings.  While human anatomy was probably well known to agrarians who slaughtered animals, and warriors, who slaughtered people, Vesalius’ writings and pictures provided one of the most accurate catalogs to date of gross (non-microscopic) human anatomy.  A century later, William Harvey gave the first complete description of the circulation of blood through the human body (probably; Ibn al-Nafis gave a partial description a couple of centuries earlier, while Europe was still immersed in the Dark Ages).

Through this time, as the anatomy and some basic physiology of the body was being described, real understanding of how the body works still eluded physicians.  Doctors, such as they were, still held to ancient beliefs on cause and effect, mostly described using the “humors” or “temperaments” model, attributing disease to imbalances of “black bile”, “blood” or other important substances.  A disease believe to be caused by excess blood could be treated by bleeding, for example.

It wasn’t until the 19th century that any real understanding of what we now call physiology began to appear.  This is when medicine began to become more frankly materialistic (in the sense of “not supernatural”).  At the time, it was widely believed that life was fundamentally different than non-life in that it was imbued with some sort of vital principle.  In 1828, chemist Friedrich Wohler synthesized urea, the first documented synthesis of an organic compound—compounds found in living things—from inorganic materials.  This was thought to be impossible, as organic chemicals were supposedly fundamentally different from inorganic ones, imbued somehow with a “life force”.

Wohler and his contemporaries showed that life is made of the same chemicals as everything else.  Scientists began to believe that the human body must act by the same laws and processes as everything else in nature (though many still held on to an idea of a “soul” or something like it).  Once it was realized that human beings were no different from any other part of the natural world, they could be studied without referencing ill humors or vital principles.  Scientists and doctors began to study the function of the human body and how we might use this new understanding to help people.

The 20th century birthed the practice of scientific medicine.  The Flexner report attempted to standardize medical education, something that could be done because of the shared understanding that medicine was now a science rather than a branch of religion. Deborah Blum’s The Poisoner’s Handbook follows doctors and chemists who use this new knowledge. Her narrative takes place in the early 20th century when doctors and chemists struggled to understand illness and death caused by poison.  Without an understanding of biology, chemistry, and physiology, these breakthroughs could never have taken place.  There was nothing easy and nothing supernatural about the discovery of how poisons worked and could be detected.  It took hard work and a thorough understanding of science.  From studying the damage done by poisons, they helped advance the science of how the human machine works.

Every advance we have made in preventing and treating disease is based on our understanding of the science of the human body. This combined with the use of statistical analysis has allowed us to live longer and healthier than our ancestors could have imagined.

In Part II, the piece that makes medical practice whole.

MrsPal pulled out the car this morning—and didn’t stop.  She ended up at the edge of our neighbor’s lawn.  Getting up the driveway is equally challenging, but MrsPal is hard to stop.  After dinner out, we pulled into the neighbor’s circular drive, got a running start, and shot up into the garage (thankfully stopping before hitting the back wall).  Figuring a good spread of Midwestern salt might help, I put on my boots and grabbed a bag, and stepped out of the garage.  My feet felt disconcertingly light on the snowy asphalt.  I started scattering the salt lightly, walking slowly and carefully, until hitting the steepest part of the drive—and slid the rest of the way down on my ass. The salt came to a rest next to me, mockingly.  I tried to climb back up, but it was a no-go.  I rolled over to the grass and hiked back to the house, snow clinging to the wool of my overcoat, hands bruised, wife and daughter giggling lightly.

They warned, I ignored.

Anatomy and physiology cover the normal workings of the human body.  Pathology and pathophysiology cover what goes wrong with these processes.  Human biology is very well—if incompletely—understood.  And while it is complex, there is nothing spooky or supernatural about it; it’s just biology (and chemistry, physics, etc.).

And while there is nothing supernatural about human medicine, it’s not in any way mundane.   It’s beautiful, fascinating, at times even mysterious.

Imagine a medical student who didn’t buy this whole science thing.  Imagine he’s in the anatomy lab, his lab partners meticulously hunting for the thoracic duct and the azygous vein (“which azygous vein, the right or the left?”).  He looks at the mess of meat on the slab and thinks, “all that is well and good, but where’s the qi? I can’t find my merridians!”

This is the folly of so-called “other medicines” like Traditional Chinese Medicine or Ayurvedic medicine.  They are based on millennia of pre-scientific folk lore, often mixed with excellent observations about the natural course of diseases.  But they don’t hold a cupping candle to medicine based on how the body actually works.  If you know anything about biology, reading something like this piece from the Huffington Post seem silly, absurd.  But people take it very seriously.

Aside from being logically inconsistent, the piece, called “Less Bloat, More Gloat: Using Chinese Medicine to Fight Winter Fat” should have been listed under “fiction”.  The logical inconsistency comes in the first paragraph.  After the title’s “fighting winter fat”, the author, talking about weight gain in the winter, says:

You’re most likely experiencing water weight. Those skinny jeans fit a little skinnier, your fingers and ankles feel swollen, your eyes look like the aftermath of a party girl who got a little too tipsy last night, you feel bloated and you just know everyone will be talking about your newly risen muffin top at the party.

So is it fat, or is it “water weight”?  The author, Grace Suc Coscia, has a bunch of initials after her name, none of which convince me that she would know the difference.  From her bio:

Grace combines ancient wisdom with cutting-edge science to empower clients to stay lean and sexy for life. For the past 12 years she has maintained a busy practice in Venice, California. Grace integrates a science-based combination of Eastern medicine, Chinese herbology, acupuncture, and genetic, adrenal, and food sensitivity testing to help clients attain efficacious results that transcend the limited Western medicine perspective.

There is nothing here that makes sense.  Here’s the thing: we’re not talking about “cultural hegemony” or “traditional knowledge”; we’re talking about biology.  Biology doesn’t care what you believe about the human body.  The way it works is the way it works, and no appeal to ancient folk lore can change this.  Let’s take a look at Coscia’s “science-based combination”.

Traditional Chinese medicine and herbology focuses on a cycle of five elements to which nature rotates. Since you’re part of nature, you also experience these changes. From this Eastern perspective, winter becomes the water season. That’s one reason why water weight becomes such a drag during the frigid months.

Where do you even start with this kind of idiocy?  Let’s get one thing straight: there is no “cycle of elements”.  There are about 118 known “elements”, fewer that naturally exist.  These elements are palpable, measurable, and make up everything around us.  They don’t metaphorically comprise everything that is; they are all matter (barring a few possible exceptions such as dark matter).  This is not some sort of metaphor or analogy.  This is how it is. There is no “Eastern perspective”, no “water season” that causes “water weight” in winter months.

She does mention that salt intake affects water balance.  But that’s about the only thing that makes sense.  Among the gems:

And don’t forget winter is water season. Drink eight to 10 glasses of purified water throughout your day, but minimize liquids during meals since too many liquids can dilute your stomach acid and inhibit protein digestion.

Wait—are we getting too much water or too little?  I lost track.  And don’t get me started on “adrenal support”.

I love fiction.  I’m currently reading Moby Dick to my daughter, a surprisingly funny novel given the seriousness of its themes.  But few things are as serious as human health, and making up stories about it is neither entertaining nor instructive.  It’s dangerous.

I’ll leave you with this little sample of fictional medicine.

Leapin’ lizards! Man-eaters were quite the acrobats

See the problem?  It’s a story about modeling the movements of velociraptors.  While ‘raptors may have eaten meat, they most definitely did not feed on human flesh, Jurassic Park notwithstanding.  It may seem like nit-picking, but it’s hard enough educating the public without headline writers tossing a fossilized femur into the works.

Want to learn about the evolution of dinosaurs, mammals, and everything else?  Read Written in Stone, by Brian Switek.  I’d recommend reading it while sitting at the computer so you can google up pictures and other information that parallel and supplement the book.  If you read it, we’ll have one more person who will do a spit take on seeing headlines like this.

My recent obsession with decision to start running was my family’s fault.  I’ve pushed  the memories of my wife’s illness into the darker nooks, but I’m not entirely free of it. My wife doesn’t have that luxury of forgetting; it’s obvious to her every day.  The latest challenge has been anemia.  Her blood count has been slowly dropping, and she’s now at the point where she feels tired and weak.  While I’m on my run, she’s mustering the energy to finish the most basic tasks.  She’s been getting intravenous iron infusions and they’ve given me a whole new perspective on what my patients endure when I write a “simple” order.  She has terrible veins, and it often takes an hour and six nurses to get the IV in.  Several hours after the infusion, she feels crappy, with muscle pains and nausea.

Her perseverance and a new respect for the fragility of things inspired me to take better care of myself.  And while I’ve tried to keep things out of mind in order to get on with life, it comes back to me in more subtle ways.  When my wife started to feel ill last week I noticed I became cranky, didn’t sleep well, and was generally out of sorts.  By the time it turned into a run-of-the-mill—albeit unpleasant—bronchitis, I felt fine (she, however, did not).

Continuing on the topic of adjustments, we moved recently, which has been wonderful in many ways, despite the Great Vole Crisis.  PalKid loves her new, very pink room, but she’s still getting used to the place.  She’s shown up in our bed quite a few times over the last month, and while she’s really, really cute and cuddly, it doesn’t make for a good night’s sleep for the grownups sharing the bed.   I’ve spoken to other parents who have marveled at the ability of such a small creature to take up such a large space.

Last night the kiddo came home from her first skating lesson. She’s been asking for a long time, and it seemed like a good activity to try out.  She came home glowing.  I haven’t seen her this happy and excited since her last trip to the American Girl Store.  In fact, I think she was even happier.  She was able to stay up on skates, felt that sense of accomplishment, that relaxing warmth you get after exercising in the cold.

When I was a kid, my folks and I used to go cross country skiing at a local golf course.  It was usually on a Sunday, and we’d come home tired, and happy, and sit in front of a fire drinking hot chocolate and watching football.  I look forward to the day when my family is ready to take off on a winter’s day for a run or a hike, come home and collapse on the couch fighting over who makes the hot chocolate.

The letter could have been written by any public or private school principal, any educator in denial about bullying.  I’ll allow that I may have failed to understand the letter’s meaning: it’s not terribly well-written.  But it is illustrative of a wider concept—that while bullying is a serious problems, “our own” school’s policies or moral foundations immunize us to its worst effects.

No public or parochial school is immune to bullying.  Bullying is a serious problem, one that is easy to ignore, especially if you feel your own community or school is somehow “immunized” by good moral foundations.  It is a problem that must be specifically addressed, within a particular moral framework or in a secular one.

Bullying is a slippery concept.  As states begin to discuss anti-bullying legislation, disagreements arise regarding what exactly bullying is. In Michigan, the legislature wanted a “religious exemption” that would essentially allow bullying if it arose from a sincerely held religious belief.  This was obviously problematic to those of us who don’t want to give kids a licence to shout “Christ-killer”, “fag” and other “deeply-help beliefs” as the beat the crap out of someone.

While most people with a conscience believe bullying to be wrong, there is scientific evidence to support this idea as well.  For example, a recent Finnish study showed both bullying and being bullied predict future psychiatric problems.  Still, most people tend to focus on bullying as a moral problem—hurting kids is bad—rather than a public health one.

Why should we need anti-bullying laws? The letter referenced above claims that children can learn the right thing without a law.  Aren’t parents and other adults responsible for curbing bad behavior?

The insanity of this idea is obvious to those of us who see how child-bullies grow up into adult-bullies.  Parents often enough shrug off their children’s bad behavior, chalking it up to the normal pains of growing up.  But simple childhood fights and disagreements are very different from bullying.  Bullying is a pervasive pattern of abuse leveled at a particular person, not a simple, transient fight.  And adults are part of the problem.

No school, no matter how good its intentions, how strong its moral convictions, is immune from bullying problems.  Without objective data showing the success of  an anti-bullying program, we should assume the worst: that bullying is an ongoing problem.

Bullying is a behavior found in all religious and ethnic groups, and simply espousing a higher moral code is no guarantee of immunity.  In all communities we must protect our children from the destructive effects of bullying.  We must guard against complacency, against that idea that a good policy or a specific set of religious beliefs guarantees the safety of our children.   For bullying policies to be effective they must track data, must continuously assess effectiveness.  This requires that school officials see bullying as more than “kids being kids”, and see a policy as more than something to check on a list of school supplies, like chairs and desks.  Kids aren’t furniture.

“The last guy I was with saw mostly Medicaid patients, and mostly just wrote prescriptions for Vicodin.  He didn’t really do much medicine, didn’t really spend time with patients.”

About 4% of American medical school graduates go into primary care medicine.  Part of it is math:  not many smart people leaving medical school with $200,000 of debt will choose specialties with the worst pay.  But many of us are passionate about what we do and are willing to make the sacrifice (not much of one, really) and practice for lower pay and more bureaucracy.  There are a number of ways to make up for this financial “shortfall”.

Medicaid—government-sponsored care for the poor—usually pays very, very poorly (although this may be changing).  Some doctors see this as a disadvantage, and, like me, refuse to take Medicaid.  Others see opportunity, enrolling thousands of Medicaid HMO patients, too many really.  They collect the enrollment fees, so many that it’s nearly impossible to get an appointment.  The system encourages bad practice.

I doubt this is all that common, but most physicians know of a colleague who engages in this sort of less-than-ethical behavior.  Others engage in frankly criminal behavior, such as taking cash for narcotic prescriptions.

But these are a small minority.  Most primary care docs work hard to take care of their patients.  This may mean squeezing sick people into an already-crammed schedule, or spending time listening to patients that could otherwise be used to finish phone calls and paperwork.  I start on time most days, but never finish on time—people just aren’t that predictable.

One of the most important things we can do as doctors is listen.  Giving a patient time to talk will let them bring up more uncomfortable or painful complaints.  It may give a widow comfort, or some hope to a man just diagnosed with cancer.

But compassion and a good ear must be matched by sound knowledge and a skeptical disposition.  I learn a lot of medicine from my patients, colleagues, and my own reading.  I also learn a lot from bad doctors.

There are a number of so-called holistic doctors in town who claim to practice “individualized” medicine.  What this really means isn’t clear.  My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients.  What “individualized” care seems to mean in this other context is “stuff I made up to make that patient feel more unique and special.”

Examples abound, such as “bioidentical hormones” (a fictional concept earning real dollars), and all sorts of dubious supplements, often sold from the office of the doctor who prescribes them—so you know it must be good!  Most of these doctors have ways to earn money outside of insurance, such as the sales of supplements, unproven treatments, and other cash-on-the-barrel deals.  These days, most medicines are relatively inexpensive (I can treat most heart patients with medications costing less than $30 per month).  Patients should be very skeptical of doctors selling their own branded potions for obscene prices.

Being a real patient and a real doctor is work.  There are no easy outs.  When you have diabetes, you have to work at self-care, improving diet and exercise, inspecting your feet, taking medications properly.  When you are the doctor treating the diabetes, you have to know the risks and benefits of various medications, which patients are likely to need them, which can try lifestyle changes first.  You have to know to refer your diabetics to eye doctors, to give them the proper vaccinations, to check their urine for protein and what to do about it when it’s there.

Many of these so-called alternative doctors may do that (although in my experience, they refer the patients back to me for the “real medicine”).  But they may also sell cinnamon supplements (shown in some studies to modify certain diabetes parameters, in others not to, but never shown to improve real outcomes like heart attack prevention).  Others may sell fancy salt (really, I can’t make that up), pumping up it’s supposed salubrious properties (with a cost of $6/lb, vs. $8/25 lbs of normal salt).

These practices make patients feel good, feel cared for, and sate our thirst for the “old ways”, for a supposedly more natural way to health, which is, in a word, goatshit.  Natural usually means “I made it up out using nice-sounding words.” Making things up, even with the most caring  demeanor, is wrong.  It is immoral.

All medicine involves uncertainty.  You can’t be a doctor without tolerating a great deal of the discomfort of uncertainty.  But decisions have to be made on sound science for them to be effective and ethical.  Selling magic (except in the most Clarkeian sense) is not part of our job.

Our real job is hard, time-consuming, and not as profitable as the “holistic” medicine business.  But it’s right for our patients.

I started running about a month and a half ago, and I was terribly apprehensive.  I never liked running, and I thought that starting now, in my 40s and out of shape, I was on a fool’s errand.  But…not so much.  What I tell patients about exercise—it gets easier, etc.—turns out to be mostly true.  My first few runs were about a mile and not a lot of fun.  But it gets easier, sort of.

I usually run very early or very late.  It’s dark, cold, quiet and peaceful.  My house is at the top of a hill, so the beginning of the run is relatively easy. But then the fun starts.  The loops I do are usually sinusoidal.  In one direction, the run starts steep, the other follows an easier grade.  When I run the steep downhill first, the whole run is miserable.  When I run the easier grade, the uphill battles at the end seem relatively easy.  Why the hell is that?

Then there’s my knee.  My left knee has taken a little abuse over the years.  When I used to portage canoes, it’s the leg I would use to kick the canoe back onto my neck.  And then there was the bike commuting in San Francisco.  I figured my knee might limit my running, and I was partially right.  When I first start out, it’s a bit sore, but then doesn’t bother me a bit.  Except a run the other day.  I went a little too far and had to stop to walk the rest of the way home.  It was bitter cold, but I didn’t notice until I’d been walking for a bit.  The wind was cutting straight to my skin.  So I picked up the pace and tried to run home.  No dice.  My knee wouldn’t let me take more than a couple of strides.  In general, the running has improved my knee.  Go figure.

What I don’t know about running could fill a textbook.  I’m determined to take it slow so that I can keep going.  My only fear at this point is injury, and I have no desire  to overdo it.

For anyone scared of starting, I gotta tell you, this has been awesome.  Yeah, it sucks starting out, but if you give yourself a break physically and emotionally, it feels better by the day.

The good news (and I’m happy to lose the business) is that cigarette smoking has diminished significantly over the last few decades, although not equally in all populations. It would be hard to deny that the 1964 Surgeon General’s report on smoking helped begin this decline.

But smoking rates in the U.S. have leveled off at about 20% (once again, dependent on the segment of the population you look at).  No one can rationally deny that ill-effects of smoking, so why is anyone still doing it?

Everyone knows the answer, but few acknowledge the implications.  Nicotine addiction is powerful, therefore prevention efforts focus on both prevention of starting smoking and on helping people quit.  Smoking usually starts in the young, and the more smokers adolescents are surrounded by, the more likely they are to smoke. We traditionally think of adolescents as being a group particularly difficult to influence, but if they are influenced to smoke, the can be influenced not to.  For example, states with stricter smoking laws help prevent cigarette use.  Once they start, getting them to stop is an uphill battle.

Exposure to advertising is a risk factor for starting smoking.  Theoretically, regulating advertising should help modify smoking habits, and evidence supports this.

The current battle over cigarette package warnings should be seen in this context.  If more graphic ads help prevent people from starting to smoke, great, let’s do it.  That’s an important part of the battle.  But since peers and family have such a strong correlation with cigarette smoking, we need to take the fight to the smallest levels of society, especially targeting communities with higher smoking rates.

A recent study of blood pressure screening in African American barber shops had encouraging results.  We need wide-spread community-level interventions.  We have to take into account that many smokers have a lower level of education than non-smokers.  Ads have to be aimed at proper education levels, but ads that speak down to people probably won’t be taken well.

The ad industry is pretty damned smart.  If they can get poor kids to spend their hard-earned cash on an expensive and deadly habit, they can probably help prevent it.

But once people start to smoke, we have a problem.  Most of my patients who smoke want to quit, but it’s not a matter of willpower.  More insurance companies are starting to pay for smoking cessation programs, although most don’t pay for the drugs that are usually required to help people fight the tenacious neurochemistry that keeps them smoking in the first place.  A typical prescription for Chantix costs about as much as one month of a pack-per-day habit, but has to be payed up front, unlike thirty packs of cigarettes.

I’m all for graphic cigarette ads.  I’m all for draconian smoking regulations that prevent people from smoking in public and at work.  But we need a comprehensive national smoking policy, one that any physician can guide people to, one that targets prevention and cessation in every community, one that makes it harder to start and easier to quit.