Yesterday I hear an unexpected black-capped chickadee, mixed with wind in the pine trees. The roar of wind in the pines is great when your inside, but when you’re in a tent, it makes you wonder if you’ll be wind-bound the next day, if a storm will knock down your tent. But I’m loving the sounds of winter this year.

Those of you from the north know the non-sound of snow falling, the “indoors” feeling of sounds after a heavy snowfall. When we do get enough snow around here (my area is in a bit of a snow shadow) I head out on snowshoes a find my self alone in a large metro area, able to enjoy the sounds. The other night I heard howling and yipping, and had no idea whether it was dogs or coyotes (or both).

The frigid weather this past week gave our local landfill-associated ski areas to make a ton of snow. I dragged PalKid out of bed and we’re heading out soon for a day of brief runs on grainy snow. It’s gonna be a blast.

This post originally appeared at ScienceBlogs Denialism blog on August 20th, 2008. The links are old, as are most of the comments, but I’m reposting it anyway. –PalMD

I’ve written a number of times about how a physician must be careful not impose his or her personal beliefs on patients.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.
Conflicted with the doctor’s faith. There’s the rub.

This is a particularly perverse form of proselytizing. It doesn’t involve having coffee with an acquaintance and teaching them the Word. It involves a vulnerable individual, who comes to a qualified professional for help, and is turned away because of “improper” living and thinking. In this case, it is disputed whether the patient was denied care because of being gay or because of being unmarried. It doesn’t really matter. Either reason for discrimination is wrong. What matters is that the doctor felt that treating the patient would violate her own religious beliefs.

The measure of whether a treatment is appropriate is whether it conforms to standard of care, is safe, effective, and ethical (non-coercive, etc.). If a patient presents for infertility treatment, and is medically qualified, she should receive the treatment (assuming she doesn’t breed babies for snack food). The American Society for Reproductive Medicine recognizes this in several position statements. One specifically addresses unmarried and homosexual patients:

–Unmarried persons and gays and lesbians have interests in
having and rearing children.
– There is no persuasive evidence that children raised by
single parents or by gays and lesbians are harmed or
disadvantaged by that fact alone.
–Programs should treat all requests for assisted reproduction
equally without regard to marital status or sexual
orientation.

When you decide to become a doctor, you immerse yourself to the neck in ethical problems for the rest of your career. Patients make bad decisions. Other doctors make bad decisions. Ethically grey conundrums pop up on a daily basis. Standards set by professional organizations help to sort some of these out, but not always. The “most wrong” decision in an ethical debate is the cop-out. For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers. This decision doesn’t just deny them your personal services. It may cause permanent psychological harm to the patient. And that’s not what doctoring is all about.

A doctor in our area was recently indicted for allegedly running a “pill mill”. According to local news reports, patients were recruited to come in and ask for narcotics and the doctor received massive cash payments to write the prescriptions. After the guy was nabbed, his patients (the real ones and the others) spread out in the community looking for new doctors to take care of them (or to write them more narcotic prescriptions).

Another doctor in our area specializes in so-called “holistic” medicine. He runs expensive tests that aren’t covered by insurance. Many of these tests are either of questionable significance and utility, or are run in labs widely known for their “variable” quality. He puts his patients on unconventional mixes of medications and supplements, many of which he apparently sells. He and many doctors like him send their patients to “real” doctors to take care of the rest of the patient’s healthcare.

In the first case, the cops caught up with the guy. The fallout for patients will last for a while as the scramble to find new primary care physicians (there’s a shortage, you know), or have to suddenly deal with a narcotic problem after their source dries up.

In the second case, the doctor will continue to collect cash from patient to whom is is very kind, and who get the answers they want from a kind man.

The second doctor isn’t doing anything illegal. He’s practicing bad medicine, outside of the standard of care, but as far as I can tell, he’s not breaking any laws. And his patients love him. He listens, spends time, and tells them what they want to hear. I looked into ways to get this guy investigated, to have some sort of third party look over his practices, but I couldn’t find one. Complaints against healthcare professionals have to be lodged by patients or their agent. As far as I can tell, in this state there is no way for anyone other than a patient to complain about bad doctors.

This makes some sense. If someone opens a practice across the street from me and my patients start fleeing there, who says I wouldn’t call in a complaint just to hurt my competition? (I wouldn’t obviously, and there’s no incentive even if I were a bad guy. There are plenty of patients for all of us.)

But while doctors clearly breaking the law can get caught and prosecuted, doctors practicing obviously bad medicine are pretty safe. Their patients often love them and wouldn’t think of lodging a complaint. Even if every other doctor in the community knows another doctor is bad news, there’s nothing they can really do.

I may not be completely right. Maybe there’s a way to complain to the medical board in this state. Maybe not. I couldn’t find one, and I’ve never heard of it happening.

Doctors get disciplined if patients complain, maybe get busted for breaking the law, maybe get sued if a patient is unsatisfied, but they don’t get investigated for being quacks.

I don’t have a solution to propose that wouldn’t create layers of bureaucracy and put good doctors at risk of false allegations. But there must be some way to deal with quacks. Their work harms patients and makes my job difficult as I try to tease apart what they’ve done to my patients.

My good friend, the Reverend C. L. Franklin, all of the officers and members of the Detroit Council of Human Rights, distinguished platform guests, ladies and gentlemen, I cannot begin to say to you this afternoon how thrilled I am, and I cannot begin to tell you the deep joy that comes to my heart as I participate with you in what I consider the largest and greatest demonstration for freedom ever held in the United States. And I can assure you that what has been done here today will serve as a source of inspiration for all of the freedom-loving people of this nation.

I think there is something else that must be said because it is a magnificent demonstration of discipline. With all of the thousands and hundreds of thousands of people engaged in this demonstration today, there has not been one reported incident of violence. I think this is a magnificent demonstration of our commitment to nonviolence in this struggle for freedom all over the United States, and I want to commend the leadership of this community for making this great event possible and making such a great event possible through such disciplined channels.

Almost one hundred and one years ago, on September the 22nd, 1862, to be exact, a great and noble American, Abraham Lincoln, signed an executive order, which was to take effect on January the first, 1863. This executive order was called the Emancipation Proclamation and it served to free the Negro from the bondage of physical slavery. But one hundred years later, the Negro in the United States of America still isn’t free.

But now more than ever before, America is forced to grapple with this problem, for the shape of the world today does not afford us the luxury of an anemic democracy. The price that this nation must pay for the continued oppression and exploitation of the Negro or any other minority group is the price of its own destruction. For the hour is late. The clock of destiny is ticking out, and we must act now before it is too late. 

The events of Birmingham, Alabama, and the more than sixty communities that have started protest movements since Birmingham, are indicative of the fact that the Negro is now determined to be free. For Birmingham tells us something in glaring terms. It says first that the Negro is no longer willing to accept racial segregation in any of its dimensions.For we have come to see that segregation is not only sociologically untenable, it is not only politically unsound, it is morally wrong and sinful. Segregation is a cancer in the body politic, which must be removed before our democratic health can be realized.  Segregation is wrong because it is nothing but a new form of slavery covered up with certain niceties of complexity. Segregation is wrong because it is a system of adultery perpetuated by an illicit intercourse between injustice and immorality.  And in Birmingham, Alabama, and all over the South and all over the nation, we are simply saying that we will no longer sell our birthright of freedom for a mess of segregated pottage.  In a real sense, we are through with segregation now, henceforth, and forevermore.

Now Birmingham and the freedom struggle tell us something else. They reveal to us that the Negro has a new sense of dignity and a new sense of self-respect. For years— I think we all will agree that probably the most damaging effect of segregation has been what it has done to the soul of the segregated as well as the segregator.It has given the segregator a false sense of superiority and it has left the segregated with a false sense of inferiority.  And so because of the legacy of slavery and segregation, many Negroes lost faith in themselves and many felt that they were inferior.

But then something happened to the Negro. Circumstances made it possible and necessary for him to travel more: the coming of the automobile, the upheavals of two world wars, the Great Depression. And so his rural, plantation background gradually gave way to urban, industrial life. And even his economic life was rising through the growth of industry, the influence of organized labor, expanded educational opportunities. And even his cultural life was rising through the steady decline of crippling illiteracy. And all of these forces conjoined to cause the Negro to take a new look at himself. Negro masses,  Negro masses all over began to re-evaluate themselves, and the Negro came to feel that he was somebody. His religion revealed to him, his religion revealed to him that God loves all of his children, and that all men are made in His image, and that figuratively speaking, every man from a bass-black to a treble-white is significant on God’s keyboard.

So, the Negro can now unconsciously cry out with the eloquent poet,

Fleecy locks and black complexion

Cannot forfeit nature’s claim.

Skin may differ, but affection

Dwells in black and white the same.

Were I so tall as to reach the pole

Or to grasp at the ocean at a span,

I must be measured by my soul

The mind is the standard of the man.

But these events that are taking place in our nation tell us something else. They tell us that the Negro and his allies in the white community now recognize the urgency of the moment. I know we have heard a lot of cries saying, “Slow up and cool off.”  We still hear these cries. They are telling us over and over again that you’re pushing things too fast, and so they’re saying, “Cool off.” Well, the only answer that we can give to that is that we’ve cooled off all too long, and that is the danger.  There’s always the danger if you cool off too much that you will end up in a deep freeze.  ”Well,” they’re saying, “you need to put on brakes.” The only answer that we can give to that is that the motor’s now cranked up and we’re moving up the highway of freedom toward the city of equality,  and we can’t afford to stop now because our nation has a date with destiny. We must keep moving.

Then there is another cry. They say, “Why don’t you do it in a gradual manner?” Well, gradualism is little more than escapism and do-nothingism, which ends up in stand-stillism.  We know that our brothers and sisters in Africa and Asia are moving with jet-like speed toward the goal of political independence. And in some communities we are still moving at horse-and-buggy pace toward the gaining of a hamburger and a cup of coffee at a lunch counter.

And so we must say, now is the time to make real the promises of democracy. Now is the time to transform this pending national elegy into a creative psalm of brotherhood. Now is the time to lift our nation. Now is the time to lift our nation from the quicksands of racial injustice to the solid rock of racial justice. Now is the time to get rid of segregation and discrimination. Now is the time.

And so this social revolution taking place can be summarized in three little words. They are not big words. One does not need an extensive vocabulary to understand them. They are the words “all,” “here,” and “now.” We wantall of our rights, we want them here, and we want them now.

Now the other thing that we must see about this struggle is that by and large it has been a nonviolent struggle. Let nobody make you feel that those who are engaged or who are engaging in the demonstrations in communities all across the South are resorting to violence; these are few in number. For we’ve come to see the power of nonviolence. We’ve come to see that this method is not a weak method, for it’s the strong man who can stand up amid opposition, who can stand up amid violence being inflicted upon him and not retaliate with violence.

You see, this method has a way of disarming the opponent. It exposes his moral defenses. It weakens his morale, and at the same time it works on his conscience, and he just doesn’t know what to do. If he doesn’t beat you, wonderful. If he beats you, you develop the quiet courage of accepting blows without retaliating. If he doesn’t put you in jail, wonderful. Nobody with any sense likes to go to jail. But if he puts you in jail, you go in that jail and transform it from a dungeon of shame to a haven of freedom and human dignity.And even if he tries to kill you, (He can’t kill you) you’ll develop the inner conviction that there are some things so dear, some things so precious, some things so eternally true, that they are worth dying for.  And I submit to you that if a man has not discovered something that he will die for, he isn’t fit to live.

This method has wrought wonders. As a result of the nonviolent Freedom Ride movement, segregation in public transportation has almost passed away absolutely in the South. As a result of the sit-in movement at lunch counters, more than 285 cities have now integrated their lunch counters in the South. I say to you, there is power in this method.

And I think by following this approach it will also help us to go into the new age that is emerging with the right attitude. For nonviolence not only calls upon its adherents to avoid external physical violence, but it calls upon them to avoid internal violence of spirit. It calls on them to engage in that something called love. And I know it is difficult sometimes. When I say “love” at this point, I’m not talking about an affectionate emotion. (All right) It’s nonsense to urge people, oppressed people, to love their oppressors in an affectionate sense. I’m talking about something much deeper. I’m talking about a sort of understanding, creative, redemptive goodwill for all men.

We are coming to see now, the psychiatrists are saying to us, that many of the strange things that happen in the subconscience, many of the inner conflicts, are rooted in hate. And so they are saying, “Love or perish.” But Jesus told us this a long time ago. And I can still hear that voice crying through the vista of time, saying, “Love your enemies, bless them that curse you, pray for them that despitefully use you.” And there is still a voice saying to every potential Peter, “Put up your sword.” History is replete with the bleached bones of nations, history is cluttered with the wreckage of communities that failed to follow this command. And isn’t it marvelous to have a method of struggle where it is possible to stand up against an unjust system, fight it with all of your might, never accept it, and yet not stoop to violence and hatred in the process? This is what we have.

Now there is a magnificent new militancy within the Negro community all across this nation. And I welcome this as a marvelous development. The Negro of America is saying he’s determined to be free and he is militant enough to stand up. But this new militancy must not lead us to the position of distrusting every white person who lives in the United States. There are some white people in this country who are as determined to see the Negro free as we are to be free. This new militancy must be kept within understanding boundaries.

And then another thing I can understand. We’ve been pushed around so long; we’ve been the victims of lynching mobs so long; we’ve been the victims of economic injustice so long—still the last hired and the first fired all over this nation. And I know the temptation. I can understand from a psychological point of view why some caught up in the clutches of the injustices surrounding them almost respond with bitterness and come to the conclusion that the problem can’t be solved within, and they talk about getting away from it in terms of racial separation. But even though I can understand it psychologically, I must say to you this afternoon that this isn’t the way. Black supremacy is as dangerous as white supremacy. No, I hope you will allow me to say to you this afternoon that God is not interested merely in the freedom of black men and brown men and yellow men. God is interested in the freedom of the whole human race.And I believe that with this philosophy and this determined struggle we will be able to go on in the days ahead and transform the jangling discords of our nation into a beautiful symphony of brotherhood.

As I move toward my conclusion, you’re asking, I’m sure, “What can we do here in Detroit to help in the struggle in the South?” Well, there are several things that you can do. One of them you’ve done already, and I hope you will do it in even greater dimensions before we leave this meeting.

Now the second thing that you can do to help us down in Alabama and Mississippi and all over the South is to work with determination to get rid of any segregation and discrimination in Detroit,realizing that injustice anywhere is a threat to justice everywhere. And we’ve got to come to see that the problem of racial injustice is a national problem. No community in this country can boast of clean hands in the area of brotherhood. Now in the North it’s different in that it doesn’t have the legal sanction that it has in the South. But it has its subtle and hidden forms and it exists in three areas: in the area of employment discrimination, in the area of housing discrimination, and in the area of de facto segregation in the public schools. And we must come to see that de facto segregation in the North is just as injurious as the actual segregation in the South.  And so if you want to help us in Alabama and Mississippi and over the South, do all that you can to get rid of the problem here.

And then we also need your support in order to get the civil rights bill that the President is offering passed. And there’s a reality, let’s not fool ourselves: this bill isn’t going to get through if we don’t put some work in it and some determined pressure. And this is why I’ve said that in order to get this bill through, we’ve got to arouse the conscience of the nation, and we ought to march to Washington more than 100,000 in order to say,  in order to say that we are determined, and in order to engage in a nonviolent protest to keep this issue before the conscience of the nation.

And if we will do this we will be able to bring that new day of freedom into being. If we will do this we will be able to make the American dream a reality. And I do not want to give you the impression that it’s going to be easy. There can be no great social gain without individual pain. And before the victory for brotherhood is won, some will have to get scarred up a bit. Before the victory is won, some more will be thrown into jail. Before the victory is won, some, like Medgar Evers, may have to face physical death. But if physical death is the price that some must pay to free their children and their white brothers from an eternal psychological death, then nothing can be more redemptive. Before the victory is won, some will be misunderstood and called bad names, but we must go on with a determination and with a faith that this problem can be solved. 

And so I go back to the South not in despair. I go back to the South not with a feeling that we are caught in a dark dungeon that will never lead to a way out. I go back believing that the new day is coming. And so this afternoon, I have a dream.  It is a dream deeply rooted in the American dream.

I have a dream that one day, right down in Georgia and Mississippi and Alabama, the sons of former slaves and the sons of former slave owners will be able to live together as brothers.

I have a dream this afternoon (I have a dream) that one day, one day little white children and little Negro children will be able to join hands as brothers and sisters.

I have a dream this afternoon that one day,  that one day men will no longer burn down houses and the church of God simply because people want to be free.

I have a dream this afternoon (I have a dream) that there will be a day that we will no longer face the atrocities that Emmett Till had to face or Medgar Evers had to face, that all men can live with dignity.

I have a dream this afternoon (Yeah) that my four little children, that my four little children will not come up in the same young days that I came up within, but they will be judged on the basis of the content of their character, not the color of their skin.

I have a dream this afternoon that one day right here in Detroit, Negroes will be able to buy a house or rent a house anywhere that their money will carry them and they will be able to get a job.

Yes, I have a dream this afternoon that one day in this land the words of Amos will become real and “justice will roll down like waters, and righteousness like a mighty stream.”

I have a dream this evening that one day we will recognize the words of Jefferson that “all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” I have a dream this afternoon.

I have a dream that one day every valley shall be exalted, and “every valley shall be exalted, and every hill shall be made low; the crooked places shall be made straight, and the rough places plain; and the glory of the Lord shall be revealed, and all flesh shall see it together.”

I have a dream this afternoon that the brotherhood of man will become a reality in this day.

And with this faith I will go out and carve a tunnel of hope through the mountain of despair. With this faith, I will go out with you and transform dark yesterdays into bright tomorrows. With this faith, we will be able to achieve this new day when all of God’s children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing with the Negroes in the spiritual of old:

Free at last! Free at last!

Thank God almighty, we are free at last!

Let’s talk about genocide.Genocide does require many individual acts of murder, but there’s a lot more to it. Gun violence kills about 30,000 Americans a year. If the victims were people with hazel eyes, if people with hazel eyes were being terrorized and forced to live in fear, then US gun violence would be genocide. As it is, it’s just a national tragedy, a  failure of public health, and an embarrassment.

Genocide is organized, it’s systematic, it’s supported by people in power. It’s aim to to terrorize and murder large groups of people who share a trait. One could argue that many of Stalin’s millions of murders were not genocide as the targets shared little in common other than Stalin wanted them dead (there are obvious exceptions with some Soviet ethnic minorities). Naziism still serves as our best example of genocide.

Once the Nazi regime decided that Jews would be the target, they systematically drove German Jews out of business, destroyed their places of worship, shot them, beat them, put them in rail cars segregating and murdering them. The entire power of the state was set against an ethnic group. The Germans, who a few years before had been reduced to an impoverished country with little military might, built a dictatorship and a powerful military using the consent of the people, terror, murder, and propaganda. The majority of Germans didn’t oppose this. Any ethnic minority who was labelled to die did just that because an entire state was set against them.

Lately, a segment of the US gun-nut population has been (non-ironically) comparing gun control to Naziism. It’s really hard to believe any explanation for this idiocy is necessary, but let’s look at this analogy a bit.

What is the supposed tyranny gun nuts want to oppose? When you break it down, read their literature, much of it is directed at the US government and at President Obama in particular. When he was first elected, guns and ammunition flew off the shelves. People completely lost their shit, if they ever had it in the first place.

Obama and Hitler share one common trait: they started as democratically-elected leaders. Barely, in Hitler’s case, as his terror gangs helped ensure his political opponents were in no shape to oppose him. In Obama’s case, Americans decided they wanted him to be president, not any of the other guys. This happened despite attempts to dis-enfranchise likely-Democratic voters. Because we are a fundamentally stable democracy, elections work.

Guns have never played a part in the maintenance of a democracy in the US. Gun ownership in the colonies, which existed for more than a century before the revolution perhaps made it easier to form an army to oppose the Brits, but really, without the external support of France, without the distances involved, the war would have lasted much longer. The colonies were, fundamentally, un-rulable and the real question was how much blood would have to be spilled to prove it.

The civil war, in which a large number of Americans rebelled against what they saw as an unjust government killed people—lots of people. It destroyed large swaths of the country. And the war was not won because Unionists kept guns at home, but because the industrial north could manufacture sophisticated weapons in large numbers.

The so-called disarming of the population feared by the gun-nuts isn’t happening, and if it did (we can only hope), it wouldn’t change our form of government, wouldn’t change our ability to resist tyranny from home or abroad. If the US government really wanted to become a dictatorship (unlikely to ever happen), disarming the population wouldn’t even be necessary. The navy could simply drop a JDAM on people they didn’t like.

But we do have constitutional protections against dictatorship, and they’ve worked for centuries. We have a tripartite government with checks and balances, we have a military that is forbidden from intervening domestically, and frankly, Americans simply haven’t been interested in tyranny as a form of government and have rejected leaders who were interested in it.

The government doesn’t want your guns. But many of us Americans want better control of the firearms trade, want military-style weapons off the market, and would like to see far fewer than 30,000 gun deaths a year. And because we’re sane, we don’t think that gun control means Obama is going to ship some ethnic group or another to camps and kill them.

America hasn’t done genocide well for a long time. When we nearly destroyed the entire indigenous American population we were un-apologetic, but we’ve managed not to repeat ourselves, and we’re unlikely to in the future.

Few things waste more time in my office than the mention of Dr. Oz. While he  he does not endorse products (or so he told me), his exuberance is an endorsement all its own. Oz’s show is filled with biologically inaccurate demonstrations—carny set-ups, really—which are masterfully engaging. He is a terrific showman. What my patients bring to me, though, is Oz’s latest non-endorsement of a miracle cure.

One of the most useless things I’ve seen on his site is his “3-day Detox Cleanse“. What is it? What is it supposed to do?

Eliminate harmful toxins, restore your system, and reset your body with this detox cleanse from Dr. Oz. All you need is 3 days, a blender and $16 a day!

This particular Ozism isn’t a product endorsement, but it is still senseless. What does it mean to “eliminate harmful toxins” or “restore your system” or “reset your body”? From the standpoint of biology, it is meaningless. For the sake of argument, let’s posit that there are “harmful toxins” you need help eliminating. What are they? Why are they in you? Does this “cleanse” really do anything to get rid of them?

Of course not. It’s another sideshow gimmick, a way to call in the pigeons. It probably won’t hurt you, and it may just make you trust Oz all the more. Your body produces toxic substances in abundance, some of which are useful, some of which are not. Carbon dioxide, for example, is potentially toxic, and you manufacture it in great quantities. Your body eliminates it quite  efficiently through the lungs and kidneys. The liver is a whole detoxification factory. It’s pretty damned remarkable. Panaceas don’t exist. You can’t treat a specific problem with a non-specific “cleanse”. That’s just not how biology works.

It’s really very simple: anything that sounds to good to be true usually is. Remember laetrile, which was supposed to be a miracle cancer cure? If it worked you’d know a lot more about it. Remember acai berries? It wasn’t that long ago. Is everyone now walking around thin and happy? How about those Meuller belts and steam boxes from old films.  Seen one lately?

None of these “miracles” has traction because there are no short cuts.

Flu season is tearing through the country so it’s time for a little question and answer session.

Q: What is the flu?

A: Influenza is a nasty virus that can infect many species, especially humans, birds, and pigs. For unclear reasons, flu sweeps across the planet every year, subtypes slowly mutating through the natural proofreading errors as viruses copy their genetic material during “reproduction”. Every so often, different flu viruses will infect the same animal and recombine in a unique way, creating a virus to which no one has immunity. These new strains generally cause widespread pandemics of influenza, like the H1N1 (“Swine”) flu that spread rapidly in 2009.

Q: What’s it feel like to have the flu?

A: Bad. Very bad. Severe muscle and body aches (“Doc, even my hair hurts”), fevers, sore throat, cough. If you’re lucky the flu will only knock you down for several days. If you’re really unlucky, bacteria will grow in the soup left over by your flu-damaged lung cells and you will get pneumonia. The flu and the pneumonia that can follow it kills between 3,000-50,000 Americans yearly.

Q: How good is the flu vaccine?

A: This year’s flu vaccine matches the flu viruses we are finding out there. What isn’t easily answerable is how much less likely you are to get the flu after you’ve had the shot, but data point to a significant decrease risk for getting the flu and a decrease in risk for severe disease.

Q: I got the flu vaccine but got the flu. What’s the point?

A: Some people may develop mild aching after a shot as the immune system meets the virus for the first time. The flu vaccine is not 100% protective. But the word “flu” is tossed around for diseases that are not influenza. Nausea, vomiting, and diarrhea are not typical of influenza but of norovirus and similar infections. Flu shots don’t protect against these. Colds, coughs, pneumonia, bronchitis can all be caused by a variety of viruses and bacteria that are not influenza. The shot will not protect you from these.

Q: Isn’t it stupid to put live viruses in your body?

A: Of course. Unless it’s a vaccine. But injectable flu vaccines are not live viruses. The nasal vaccine is, and people with certain health conditions such as asthma shouldn’t use it. Flu injections are biologically incapable of causing flu infection.

Q: There’s mercury in that stuff, isn’t there? Mercury is dangerous.

A: Some mercury compounds in some amounts in some situations are very, very dangerous. Multi-dose flu bottles contain very small amounts of a mercury compound as a preservative. There compound itself is not dangerous, and it is present in very small amounts, only enough per batch to keep the vaccine from growing nasties.

Q: I don’t get flu shots because I never get the flu. That’s smart, right?

A: This is a common mistake people make. Whether or not you’ve had flu in the past doesn’t affect your risk for getting flu in the future. It’s like a slot machine. Each pull is random. Just because you hit once doesn’t mean it’s more likely you’ll hit again.

Q: How else can I prevent the flu, besides the vaccine?

A: Stay away from crowds. Wash your hands frequently. Don’t touch your face. In rare situations, medication can be given to prevent the flu in high-risk situations. There are no supplements or magic potions than can help prevent the flu.

Q: How can I treat the flu?

A: If you have a confirmed case of the flu, there are medications that can be used if you are diagnosed quickly, but they aren’t that effective. There are no supplements that help. Medications that help treat fever and aching such as tylenol and ibuprofen can make you feel more comfortable. Drinking lots of fluids will help replace the fluid lost in the fever.

Your best shot is to get vaccinated. 

This is a bad one, folks. For over a week, flu-like illnesses have been climbing across the U.S. Hospitals in my area are filling up, leaving patients waiting for hours in emergency rooms and in “virtual beds” (i.e., a hallway with a curtain). This is right on the heels of a recent spike in norovirus-like illnesses (so-called ‘stomach flu’, unrelated to the influenza virus). It’s been a busy time in doctor land.

People with the flu look like absolute crap: sweaty, shivering, pale. They are coughing, and complaining that everything hurts, even their hair. It’s misery. Thankfully, samples being tested are showing that this year’s vaccine is a good match to the circulating viruses (especially the influenza A viruses). That doesn’t mean that vaccinated people can’t get the flu, but they are less likely to, and if they do get sick, they are likely to be a bit less ill than unvaccinated people.

There’s been significant controversy over the last year especially about mass influenza vaccination policies, with experts disagreeing publicly about how big the impact of mass vaccination really is. These arguments are more about policy than medicine, about who to target, cost-effectiveness, and degree of benefit. Clinicians and scientists working with influenza are still recommending vaccination, and it’s not too late.

Just for fun, I cracked open the notebook where we keep the records of flu tests we run in the office.  A definition of an “influenza-like illness” (ILI) has been developed for reporting purposes. It’s pretty basic: a fever of 100 deg F or above, cough or sore throat, and no other cause for the illness.

At our office, we don’t use CDC surveillance methods. We do tend to test for flu in people whom we suspect of having the real thing. Guidelines for testing are pretty loose and subjective, so I tend to check people in whom I strongly suspect flu and in whom a diagnosis would make a difference. For the sake of this discussion, I’m defining all my patients tested as having an ILI.

From the beginning of December until today, here’s the data I’ve put together:

And here’s a similar graph from the CDC:

My graph shows cases rather than percentages, but the percentages are close. We are seeing more ILIs, and more and more of them are testing positive for influenza (usually influenza A). I’m going to keep tracking this, since it’s really, really interesting to medicine geeks like me.

The take home message though is more basic: it’s an early and bad flu season. Wash your hands, sneeze and cough into the crook of your elbow. Get vaccinated. And if you do get sick, the current flu viruses are susceptible to the anti-flu drugs. They’re not for everyone, but it’s worth asking your doctor. The quicker you start the meds, the more likely they are to help.

Happy New Year, folks. Yes, it may be arbitrary, some day on a calendar we’ve invented. It’s not the solstice, equinox, or some other astronomical tick of the clock, but it’s a nice marker to have. It gives us a reminder to contemplate, reflect, and hopefully, spend some time with friends and family. It’s often painful to reflect on the nastier bits of the year that has gone, and I understand why some people push those thoughts away, but sometimes it’s good to look at a disaster, hold it in your hand, turn it around under the light before crating it up and putting it in the basement. It’s also an excuse to savor the good from the past year, maybe look back at the year in photos, or writing, or other personal bits that you can savor and look back on with a smile.

Memory is tricky, of course. It’s far easier to bring to mind recent things than those further in the past, to recall November’s dreams rather than February’s events. It takes a little work, perhaps a glance at the calendar, journal, blog, whatever.

That being said, I’ll now bore you with some of the things that stand out from my year. If you’re not interested, please take my wishes from above and have a happy, healthy New Year.

This year falls in the “good” column for me. Professionally, I’ve finished my second year at my current medical practice, and it’s going quite well. I enjoy it, I love my patients, and I love medicine. Yes, there are things about the practice of medicine that are discouraging or difficult, but these are far outweighed by the good.

I feel like I’ve diagnosed a lot of cancer this year, but I’m sure that’s just a cognitive bias of some sort. Still, there have been times during the year where I’ve had to dole out some pretty horrible news to people I’ve known for many years. It’s almost a “goodbye” in some ways, since cancer treatment tends to consume their lives after diagnosis, and they have little reason to come see me. Often I can follow their progress over the phone or through other patients who know them, but the relationship is fundamentally different, as if the obelisk from 2001 had dropped between us and changed everything.

As of last night, PalKid discovered her beauty. Yes, she’s always been beautiful, but now she sees it in the mirror as something more objective, and it’s kind of sad. I had taken her for a haircut and the stylist spent time blowing out her long hair. The kid came away with a bit of style to her long hair and she loved it. Before going out for New Year’s Eve, she spent time brushing it in front of the mirror, putting on some kid’s lip gloss and generally acting like a stereotypical girl her age. I guess I hadn’t realized she’d gotten so old. Thankfully, most of the time she’s just my hilarious little girl, smart, energetic, and insouciant regarding such ephemera as beauty and fashion. I’m going to savor every minute with her over the next year as she rapidly approaches adolescence and maybe crosses over barriers where I can’t follow.

Writing—my primary hobby—has had a tough year. Because my practice has gone well, time for writing and research has dwindled. While I used to post daily, and tried to make each post substantial, time doesn’t allow that. I’m not a professional writer, I don’t have to write to eat (which is a very good thing!) and I’ve had to tell myself that it’s OK. Thankfully, writers who I’ve met online and in person are generous, friendly, and kind. I’ve tried to take advantage of what they have to tell my about writing, journalism, and communicating with an audience of greater than two. I’m very thankful to the folks on twitter, facebook, and email who have allowed me to dip a toe into the writer’s water, or at least let me imagine I could be part of the tribe.

We moved. For the second time in as many years, my family moved, although not too far. For over ten years I’ve been trying to figure out how to really enjoy living in this part of the country. I no longer mourn my lost time in other places, rather, I enjoy those memories, those snapshots of places that really no longer exist in the way I know them. Here, I have family, and there’s a subtlety to the natural beauty. And being physically active has helped me extend my sense of place. It’s been a little over a year since I started exercising regularly, mostly running, but also some biking, snowshoeing (my new thing), and swimming. Even though it’s not “enough”, it’s made such a difference. I love that my daughter sees me going out to run and sees that as normal. I love stopping to take pictures on the trail, just mementos of the different moods and seasons here.

Still the most important part is family and friends. I don’t have many friends, but the ones I have are keepers. While much of my family is further away than I like, I’m very near my parents, in-laws, and others who share the accidental connection of blood.

So I’m putting this year in the “good” column, much more so than previous years. I hope this new one should be just as kind to you.

Addendum: newer reports say that Hillary Clinton has a cerebral venous sinus thrombosis, a very different condition than described below, one requiring an entirely new post.

According to reports this evening, U.S. Secretary of State Hillary Clinton is being treated for a blood clot. I have no other information than what is in the news reports, but with what little information we have, her story seems typical and frightening.

Venous thromboemboic disease (VTE) is a disease where blood clots—usually in the legs—can break off and lodge in the lungs, causing a life-threatening emergency. Somewhere around 100,000 people die from these clots in the US every year. To understand why, we need a little anatomy lesson.

Human venous system

When blood leaves the heart’s left ventricle, it enters the aorta, the body’s largest artery, and from there is distributed throughout the body. After reaching the capillaries where oxygen and carbon dioxide are exchanged, the venous system takes over. Like the arterial system in reverse, blood courses from veins of increasing size until it returns to the heart at the right atrium.

The heart is a powerful pump, and provides the force needed to pump the blood throughout the body. The return trip isn’t quite as simple. Gravity fights blood flow back from the legs to the heart, and the pumping of the heart has lost much of it’s power. The legs, though, provide an assist. When you use your legs, for example to walk, the muscles help pump blood back up toward your heart, providing enough extra kick to get the job done.

That’s the first bit you need to know, and only half the story. There is another half to the circulatory system, one that runs between the heart and the lungs. To compete the cycle of gas exchange, blood must pass through the lungs where carbon dioxide is again exchanged for oxygen. Low-oxygen blood from the body reaches the right side of the heart and is shot through the pulmonary arteries into the lungs. After passing through capillary beds where the work is done, it returns to the left side of the heart full of oxygen to be pumped again from the left heart to the aorta and the rest of the body.

For the sake of this example, we’ll invent a patient much like Secretary Clinton. She had a recent fall and concussion that led her to take some rest. Presumably she was more immobile than usual. She’s also a person who spends a lot of time traveling, which also involves a lot of sitting still. Since the pumping of the legs isn’t returning blood to the heart as well, blood flow in the legs slows down, and the low flow can lead to blood clotting in the veins. (There’s actually a whole lot of anatomy, physiology, and biochemistry I’m skipping over for the sake of a clear explanation. We can get into that some other time.)

When a blood clot forms in one of the large, deep veins in the leg (deep vein thrombosis, “DVT”) a few things can happen. A person might notice pain and swelling in the calf or thigh. Or they might not. The blood clot may organize and stabilize, or may simply dissolve away. Or it might not.

In the worst case scenario, a blood clot breaks free of the vein wall and shoots up toward the heart. Once it enters the right side of the heart, the pump shoots it directly into the lungs (or the brain in certain circumstances).  If the clot is very small, you may not notice it at all. If it’s very large you may drop dead on the spot.

When the clot lodges in the lungs (pulmonary embolism, “PE”), the heart keeps trying to pump blood out through the pulmonary artery. Since the arterial tree is blocked downstream, the pressure inside the pump rises, and new blood stops flowing from the lungs into the left heart. The entire circulatory system can collapse instantly, killing the patient.

Not every dies of a pulmonary embolism. As stated above symptoms range from none to sudden death. In between these extremes are chest pain, shortness of breath, even fainting (which makes me wonder if in Clinton’s case, the clot may have come earlier than her concussion).

DVTs and PEs require rapid diagnosis and treatment.  Sometimes, in serious enough cases, drugs that actually dissolve the clot are used, but more often patients are given drugs that prevent further clotting while their bodies do the rest.

Hillary Clinton will likely get the best care science has to offer, and will hopefully recover quickly, but her’s is a common story. Immobilization, whether from illness or other reasons, is a risk factor for VTE, and while we may do everything we can to prevent it (moving around, preventative medication) sometime we just get unlucky.