Your "orgasm face"? Cosmo and the pornification of women

I'll be traveling intermittently over the next two weeks, and will occasionally repeat an old column. This article originally appeared on my Open Salon blog in November 2008.

Waiting in the drugstore recently, I was startled by a glimpse of the cover of Cosmopolitan Magazine. No, it was not the display of copious cleavage, nor the breathless tone of the article titles. It was the title of one article in particular: Your Orgasm Face; What He's Thinking When He Sees It.

As a gynecologist, I've had unique opportunity to view the consequences of increasing sexual openness. It appears to be a bonanza for young men, generally at the expense of young women. Men get all the benefits; women carry all the risks. Men get laid, get action, get lucky and women get pregnant, get sexually transmitted diseases, get infertile, get cervical cancer.

And all in exchange for what? Young men are almost always sexually satisfied by their relationships. Young women? Not so much ... because young men are often inexperienced lovers more concerned about their own enjoyment than anything else.

The idea that women exist solely for the sexual satisfaction of men is the basis of pornography. What is surprising and depressing is that young women are being encouraged by other women to believe that they exist only for the sexual satisfaction of young men.

Pornography is the objectification of women, generally described as:

Portraying women as physical objects that can be looked at and acted upon, and failing to portray women as subjective beings with thoughts, histories, and emotions. To objectify someone, then, is to reduce someone exclusively to the level of object.

In pornography, the objectification of women is sexual. Women are physical objects that can be looked at and acted upon sexually. They have no thoughts, feelings or needs of their own.

That does not, in itself, mean that pornography is bad. As long as the viewer understands that it is fictional and unrealistic, it can be viewed as nothing more than a sexual outlet. The problem occurs when people begin to believe that it is a realistic depiction of women, and that women do exist only to satisfy the sexual needs of men and have no sexual needs of their own.

The relentless use of sexual imagery to sell products and gain attention can be blamed for giving young women the idea that their role in life is to satisfy the sexual needs of men. It is an unfortunate, and unintended consequence of sexualizing large swaths of contemporary culture. Altogether more disturbing, because it is intended and explicit, is the way that women's magazines have encouraged women themselves to believe that their chief value is as objects for the sexual gratification of men.

There are many offenders, but Cosmopolitan Magazine tops the list, for its sheer variety and lack of subtlety, if nothing else. The cover of this month's Cosmo includes articles on Total Body Sex, the Naked Quiz and The Trick that Attracts Hot Guys Like Crazy. But even Cosmo has reached a new low with the featured article Your Orgasm Face; What He's Thinking When He Sees It.

As if the objectification of women in men's magazines were not bad enough, encouraging men to believe that women exist only for their sexual pleasure, women’s magazines are emphasizing the point: Not only are your sexual needs and desires irrelevant, ladies, but you will be judged if you dare to express them. What matters about your sexual needs is not their fulfillment, just the effect that your fulfillment has on men’s enjoyment.

Cosmo reminds women that not only are they being judged for sexual attractiveness (evidently the only characteristic of concern) by breast size, weight and facial features, now they are being judged on how they look during sex. You might be pretty, you might be thin, you might be well endowed, and that will convince him to take you to bed. That's not where it ends, though. He’s still entitled to judge your performance during sex and finding you lacking.

I don't get it. Why do we tell young women that they are free to be soccer stars or astronauts, and then barrage them with signals that the only thing that really matters is sex? This relentless "pornification" of women violates everything we claim to believe about gender equality.

What does he think about your orgasm face? Why should any woman care? Only someone who believes that she exists for the sexual satisfaction of men would consider the question to have any relevance at all.

I hallucinated during surgery ... and I was the surgeon

I recently read that the prestigious surgery training program at Massachusetts General Hospital is in danger or losing its accreditation. It's not because it has failed to properly train surgeons, or because of mistakes. The program may lose its accreditation because the trainees, also known as interns and residents, have worked more than the maximum of 80 hours per week. The hospital seems to have clearly violated the rule, but I find myself strangely ambivalent about both the rule and the punishment.

My ambivalence is rather surprising because I suffered under a program that had no limits on hours. As an OB-GYN in training, I spent five months on the surgical service during my internship year. I routinely worked about 105 hours per week, and I was awake for all 105 of those hours. The schedule required each intern to be on call every 3rd night. Therefore, the schedule was arrive at the hospital at 5 AM on the first day, work all day, then through the night on call, meet the rest of the team at 5 AM the next morning and work another full day until 7 PM (38 hours straight). The I would go home to sleep and return at 5 AM the next day and work until about 7 PM (14 hours). The 3rd day was another 14 hour day, and then the cycle would start again.

You don't know what tired is until you have repeatedly worked shifts of 38 hours. Surprisingly, the long hours results in very few, if any, mistakes, but it turned idealistic medical students into jaded, impatient doctors. And it resulted in some very bizarre episodes. On more than one occasion I fell asleep standing up while holding retractors during surgery. It didn't matter that much since my job was simply to stand there, but it did result in me getting chastised. One night while checking lab results on the computer, I fell asleep on the keyboard and woke with the imprint of the keys on the side of my face.

My most notable transgression while sleep deprived, though, was when I began hallucinating during surgery when I was one of the surgeons. It was a relatively minor case, and my role was simply to assist, but I kept forgetting where I was and talking to people who were not there. This resulted in gales of laughter from everyone else in the operating room. When the case was finished I was allowed to go home early (5 PM) since I clearly could not be trusted to care for patients.

The system was brutal in the extreme … and yet. And yet it taught me to be a doctor, to take complete responsibility for someone else's life, and to never give up, no matter how long it took, until the best possible result was achieved. It was drilled into me that the patient came first; my comfort: my hunger, my tiredness was meaningless. All that counted was what the patient needed.

Looking back, I still think that 105 hours per week was too many, but I am honestly not sure if 80 hours a week is enough. At 80 hours per week, the interns and residents are essentially doing shift work, going off regardless of whether the patient is doing well or poorly. It also allows interns and residents to kick the can down the road, to slough of what should be done for the patient today, figuring that the next person can do it tonight. Finally, it is not clear that 80 hours per week allows enough exposure to different patients, different surgeries and differing ways that patients manifest illness and get well.

The surgery program at Massachusetts General Hospital has violated the rules, and if the rules mean anything, the hospital must be reprimanded and possibly punished. The real question, though, is whether 80 hours work weeks lead to better doctors and better patient care, or simply fewer hours.

Overweight people live longer

A new study from Canada, one of the largest of its kind, has confirmed yet again that overweight people live longer. The study, published in the journal Obesity, followed over 11,000 Canadian adults for 12 years. The study found:

Overweight (BMI 25 to <30) was associated with a significantly decreased risk of death (RR = 0.83, P < 0.05). The RR was close to one for obesity class I (BMI 30–35; RR = 0.95, P >0.05). Our results are similar to those from other recent studies … showing that when compared to the acceptable BMI category, overweight appears to be protective against mortality…

Morbid obesity increased the risk of death, but underweight increased it even more:

A significant increased risk of mortality over the 12 years of follow-up was observed for underweight (BMI <18.5; relative risk (RR) = 1.73, P < 0.001) and obesity class II+ (BMI >35; RR = 1.36, P <0.05).

In other words, for a woman who is 5'5" tall, and "ideal" weight is considered to be 114-149 lbs. But those women weighing 150-174 lbs actually lived longer than those weighing less than 150 lbs and women weighing 180-204 lbs lived as long as women of "ideal" weight. Those most at risk for shorter lifespan were women weighing less than 114 pounds.

As the authors indicate, this study merely confirms what decades of scientific evidence have already demonstrated. Contrary to the conventional wisdom, overweight people live longer.

It's worth asking: if the scientific evidence shows that overweight is protective, why has it become conventional wisdom that being thin is healthiest? The answer, I believe, is prejudice. Simply put, being overweight is associated with being poor.

As I have written in the past, many American predilections are grounded in economic status, and weight is no different. When poor people were thin because they didn’t have enough to eat, being overweight was a sign of status. Similarly, when poor people were tanned because of working outside, white skin was a sign of status. When poor women couldn’t afford anesthesia for childbirth, access to chloroform was a sign of status.

Now, of course, status is associated with a midwinter tan (courtesy of a tropical vacation), a commitment to "natural" childbirth, and, especially, being thin. Wealthy people are thin, and celebrities are thin. Indeed, we are so obsessed with being thin as a sign of status that both women's magazines and celebrity magazines are filled with diets and the tales of people who have successfully lost weight.

By implication, the overweight are poor and less desirable. The idea that being thin is healthier also dovetails nicely with another American fantasy: that we can control our health by what we eat.

Of course morbid obesity is a serious health problem with potentially deadly consequences. However, simply being overweight is not only safe, but actually appears to be protective compared to "ideal" weight. That’s what the data really show.

Thin is in, because it is viewed as a sign of economic status, and an indication of personal rectitude, but it is not justified by the scientific data, nor by the fact that weight is now a proxy for wealth. Like any prejudice, it is not justified at all.

Can we please stop pretending that preventive medicine saves money?

Conventional wisdom about healthcare reform rests on a big lie. Most major proposals for healthcare reform depend for financing in part on the purported savings from preventive care. The problem is that preventive care does not save money.

No less an authority than the Congressional Budget Office has pointed out that both the scientific and the financial literature indicate that preventive care is at best a break-even proposition, and may actually cost money. Members of Congress and proponents of healthcare reform have expressed shock at the CBO’s findings, but it's not really surprising when you consider what preventive care is, what it can do, and what it costs.

A fundamental lay assumption about health is that all people could be healthy if we simply tried hard enough. That's a corollary to the American fantasy that we have far more control over our health than we actually do. While personal habits and the environment do have an impact, health is largely beyond our control, depending as it does on genetic factors, natural pathogens like bacteria and viruses, and the inevitable wear and tear of aging. In fact, most people, if they live long enough, are sure to get sick. Thus preventive healthcare, even at its most effective, can only postpone disease or turn fatal diseases into chronic diseases.

The benefits of preventive care to the individual are beyond dispute. It is obviously better to be healthy or at least healthier than to be sick. The benefits to society, on the other hand, must be balanced against the costs of preventive care, and, it turns out, preventive care costs quite a bit.

The CBO explains the different costs of preventive care:

The direct cost of the preventive service;

The cost of treating any adverse reactions to the preventive
service;

The cost of follow-up testing and treatment for patients with positive screening tests; and

The cost of treating unrelated diseases that occur because of an individual's extended life span. (emphasis in the original)

These costs can vary widely depending on the specific type of preventive care. Consider Pap smears, the test for cervical cancer. Pap smears are relatively inexpensive and have no adverse reactions. However they have a high false positive rate (many more women have abnormal Pap smears than have cervical cancer and pre-cancer). Every woman with an abnormal Pap smear will need to have an intensive follow up exam with special instruments and biopsies of the cervix, but most won’t have the disease. Early cervical cancer is relatively easy to treat successfully, leading to many more years of productive life. Ultimately, of course, a woman cured of cervical cancer will go on to develop other medical problems that will cost money. On balance, though, the costs of prevention are small, and the benefits are large.

On the other hand, diseases like AIDS have a very different cost benefit ratio. HIV testing for the virus is relatively inexpensive, and the follow up testing is not expensive, either. However, the treatment is extraordinarily expensive and it does not cure the disease. It can cost upwards of $10,000 a month for anti-retroviral medication. And the medication merely turns a disease that is fatal in the short term, to a chronic disease that may last years and is often fatal in the long term. The benefits to the patient and his family are, of course, incalculable, but the financial costs are massive.

That does not mean that we should stop HIV testing or other extremely expensive forms of preventive care. We are ethically mandated to provide testing and treatment, even though it costs a considerable amount. It does mean, though, that we must shed out delusions that the "cost savings" of preventive medicine can finance healthcare reform.

Associated Press writer Carla K. Johnson reports:

Legislation pushed by Senate Democrats mentions "prevention" repeatedly. The Senate panel heading up health reform also calls for more research on prevention...

President Barack Obama as recently as April said investing in prevention "will save huge amounts of money in the long term." And it has become almost an article of faith among Republicans, Democrats and business leaders that prevention reduces health care costs.

But the Congressional Budget Office last week issued a statement on health care overhaul that dismissed the notion that prevention saves money. Prevention "would have clearer positive effects on health than on the federal budget," the CBO said...

[R]esearcher Peter Neumann of Tufts Medical Center said counting on disease prevention to save money "promises painless solutions to our health cost problems. I don't think they're going to be painless and they have to be done."

Healthcare reform is going to involve extremely difficult financial choices, and the sooner we stop pretending that preventive medicine will minimize the need for such financial choices, the better off we will be.

I couldn't figure out the correct dose, so I just gave her the whole bottle.

Medical errors are a very serious problem in the United States, causing harm to tens of thousands of patients each year. A substantial proportion of those problems are actually nursing errors, not really medical errors at all, and many of those are medication errors: wrong dose, wrong medicine, wrong method of administration. And some are truly spectacular failures of judgment.

When I was a chief resident, I admitted Mrs. B who had a history of a near fatal pulmonary embolus (blood clot in the lung) in her first pregnancy. She survived after treatment with anti-coagulants (blood thinners) and went on to have a healthy baby. Mrs. B was advised that if she ever got pregnant again she should call her doctor immediately. That's because pregnancy is a hypercoagulable state making pregnant women much more likely to develop blood clots. She needed to be started on injectable blood thinners as early in her pregnancy as possible to prevent the development of another embolus.

Most medications have a set dose, or at least a dose based on the patient’s weight. Blood thinners, however, have no set dose. Each patient needs a different amount to achieve the right balance between reducing the risk of blood clots and still retaining enough clotting ability to prevent internal bleeding. The patient was admitted to the hospital to find the correct dose for her.

In the end, the correct dose for Mrs. B turned out to be 5600 units twice a day, a rather large dose. Since heparin came in glass vials containing 1000 units per cc (cubic centimeter), each injection contained more than 5 cc of heparin. It was very painful for the patient to have such a large amount injected each time. Mrs. B reminded me that when she took heparin to treat her pulmonary embolus she used a more concentrated version, 10,000 per cc. She needed only slightly more than ½ cc in each injection, and it was far less painful. I promised her that I would arrange for the more concentrated version of heparin.

It should have been sufficient for me to write the order for 5600 units twice a day using heparin 10,000 units per cc, but mindful of the potential for confusion, I wrote a far more detailed order and attached a note to the chart alerting all the nurses to the change. I emphasized that the patient would be getting the exact same dose of heparin. The only difference is that it was dissolved in a tenth the amount of sterile water.

Imagine my surprise when, sitting outside the nurses station med room, I overheard the following conversation at "report," the hand over of patients from one nurse to the next.

"Dr. Tuteur changed the heparin order. Remember Mrs. B was getting 5600 units of heparin twice a day? Remember how we gave her heparin from 5 and 6/10th vials of medication? Now the heparin comes in 10,000 units in each vial," the first nurse reported.

"How do you get 5600 units out of a vial of 10,000 units?" asked the second nurse.

The first nurse breezily replied, "Oh, you can't. That's just impossible."

"So what did you do?" the second nurse inquired.

"I couldn't figure out what to do, so I gave her the whole bottle!"

The nurse had given Mrs. B a massive overdose of heparin. Had she received another such dose, she probably might have had a stroke or other form of internal hemorrhage. As it was, her blood was so "thinned" that she was not allowed out of bed for 48 hours for fear that she might bump herself and develop a life threatening hemorrhage.

It was just a matter of luck that I overheard the nurses' conversation. Otherwise, the grievous mistake would not have been discovered until after the patient was desperately ill or dead. It was not simply one error, but a long chain of mistakes: failure to calculate the correct dose (by simple division), failure to ask for clarification when the nurses didn’t understand the order, and the completely inexplicable decision to give the contents of the entire bottle when she couldn’t figure it out.

I wish I could tell you that this was a rare error, but it was not. Many times my patients received too much medication, or received an intravenous medication too quickly, or didn't get a medication at all. We can put into place systems designed to reduce errors, but if nurses don't understand how to calculate a dose, and don't understand that they must always get clarification if they have any doubt, patients will continue to be injured by nursing errors.

Is God a narcissist?

Anyone who doubts that God has been created in the image of Man would do well to contemplate God’s supposedly bottomless need for praise. The God of the world’s three monotheistic religions is nothing more than an ancient tyrant writ large, reflecting the social hierarchy of ancient civilizations. God, like a Pharaoh, apparently requires an endless diet of praise, flattery and supplication. Without strenuous and continuous efforts at placation, God, moody and unpredictable, may lash out in ways that cause grievous harm.

The belief that God needs to be praised and flattered is a feature of all three monotheistic religions, but it is most obvious in Fundamentalist Christianity. I was forcibly struck by this fact in reading and writing about a family who recently lost a baby to a potentially preventable cause at a homebirth. During labor, the mother supposedly suffered a rare and often fatal complication, amniotic fluid embolus. Her baby died (though it is not clear whether the baby died before or after the embolus) and the mother ended up intubated in the hospital ICU.

The reaction of the family and its Fundamentalist supporters has been to carefully ignore the multiple disasters that have taken place, and praise God repeatedly and fulsomely for not having killed everyone involved. The mother was "led" by her religious convictions to make a foolish and dangerous choice to give birth at home; she was led by her religious convictions to ignore the signs that something was very wrong; she experienced a rare and devastating complication; the baby is dead; she is fighting for her life in a hospital ICU.

Other people might be angry at these tragic developments, but the family and its coreligionists simply ignore these disasters. No blame can be attributed to God, because God apparently cannot handle, and therefore must never be exposed to, criticism. God must be flattered by insisting that he is always right, no matter how cruel and tragic the outcome. Instead, focus is directed toward the fact that the tragedy has not been a completely unmitigated disaster. God must be praised for "healing" (i.e. not killing) the mother.

God, portrayed as an unreasoning tyrant, and must be placated like an unreasoning tyrant. God is just a bigger version of Pharaoh. Yes, God, you struck down a woman and her unborn child, leaving the woman desperately ill and the child dead, but we are ever so grateful that you, in your endless wisdom and as the result of your praiseworthy judgment, saw fit not to kill the mother, too.

The husband wrote on his wife's blog:

Praises to Our Lord and the healing Master! [My wife] is truly a miracle of God’s healing power and a testimony of His strength. [She] was quickly treated for AFE (amniotic fluid embolism) when we arrived at the ER on Friday…

I know what the outcomes usually are and that my wife has dodge a bullet but I believe in the power of prayer and have been humbled by so many people praying for my wife. God is so good and is the rock in which our family stands!

God's healing power? He's the one who struck her down and killed their son. The fact that he didn't kill her too is hardly a testimony to his healing power.

This is the same view of religion that is on display at major sporting events, as when a receiver scores a touchdown and then points toward heaven to give credit to God. Now we know why God has no time to address thorny problems like the starving multitudes in Darfur. He is too busy checking out who is praising him and awarding them touchdowns.

This God is a petty God, a narcissist who exists on praise and flattery. There's no better sign that this God is nothing more than the creation of Man, the figurative equivalent of the carved idols of old. He is in every respect the image of a human tyrant, with all the worst foibles of any human being.

Homebirth midwives are quacks

There's very little that makes me angrier than the unnecessary deaths of babies. That’s why homebirth often makes me very angry indeed.

In the US, most doctors and certified nurse midwives refuse to attend homebirths because of the danger. Therefore, most US homebirths are attended by "direct entry" midwives (DEM), aka certified professional midwives (CPM). These are just fancy names for midwives with no medical training. The statistics on neonatal death at homebirth are so appalling, that Midwives Alliance of North America (MANA), the trade union for homebirth midwives, refuses to release the death statistics to the public; they are available "friends" of midwifery.

American homebirth midwives are grossly undereducated, grossly undertrained, and downright dangerous. The national and state statistics bear this out, but nothing illustrates it better than a real life example. This tragedy was brought to my attention by a commenter who had been following the story on the mother's website.

Carri, a mother of 8, had been planning an unassisted homebirth. I recently wrote about this appalling stunt and its high death rate (Stuntbirth). Carri had had 4 successful unassisted deliveries and was planning a 5th. As the due date approached, even Carri, as deluded as she was about the safety of unassisted childbirth, could not deny that her uterus was much larger than expected, and she sought the "advice" of Brandi, a CPM, at Central Indiana Home Birth Midwives.

Brandi diagnosed twins (without the aid of ultrasound), and noted elevated blood pressure. She advised the typical homebirth midwives quack "treatment," a high protein diet, which, not surprisingly, accomplished nothing. As the pregnancy advanced, first one week beyond the due date, then two weeks, then almost three, Brandi counseled waiting for nature to take its course.

And nature did take its course. Carri's baby is dead, and she is now fighting for her life in an ICU. The presumed cause is an amniotic fluid embolus.

There was only one baby, not two. That's at the top of the long and horrifying list of mistakes. It is unheard of for a responsible practitioner to diagnose twins when only one baby is present on ultrasound, but Brandi assured Carri that one baby was "hiding" behind the other.

Even more appalling, if possible, is Brandi's reaction when she heard only one heartbeat. According to Carri (posting on MotheringdotCommune):

One time the midwife gets two heart beats and the last time she just could not find the other and felt okay to let it be because there was active movement ...

It would be laughable, were it not deadly. The homebirth midwife "diagnosed" twins, then clung to that delusion even though there was only one baby on ultrasound, and only one heartbeat.

Not surprisingly, someone deluded enough to believe that there were twins when only one baby could be seen was also deluded enough to believe that a clearly pathological pregnancy was normal. Carri measured much larger than expected even though there was only one baby. Almost certainly, there was a massive excess of amniotic fluid (polyhydramnios), both a sign of problems, and a risk factor for future complications (including amniotic fluid embolus). Carri's abnormally elevated blood pressure was untreated by the quack remedy that was "prescribed." Pregnancies over 2 weeks past the due date have a dramatically increased risk of stillbirth, as well as life threatening birth complications. The midwife pretended that this was not so.

So now Carri's baby is dead, and Carri is fighting for her life.

People need to understand American homebirth midwives are a second class of midwives with less education and training than other American and European midwives. The standards for direct entry midwives, in terms of educational requirements and clinical training, are far below those of any other midwives in the industrialized world. American homebirth midwives are, by and large, quacks, and babies are dying as a result.

Addendum: One of the things I find most interesting is how everyone involved understands that the refusal to seek real medical care led to this tragedy. Carri's family has removed the posts detailing her actions in the weeks leading up to the catastrophe, and MotheringdotCommune has removed the posts by Carri and those responding to her. The baby died possibly because of unassisted birth/homebirth, and now supporters and the family want to remove the evidence.

What Jon and Kate should say, but won't

Jon and Kate Gosselin have announced that they will issue a "life-changing decision" on June 22 during their hit reality TV show, Jon and Kate Plus Eight. The Boston Herald described the commercial airing in advance of the one hour special episode:

"Recently, we've made some life-changing decisions - decisions that will affect every member of our family, ones that we hope will bring each of us some peace," Kate says in the spot.

The promo features giant graphics with phrases like "A family in turmoil" and "A relationship at a crossroads" flashing across the screen.

Here's what they ought to say, although I know that’s never going to happen. They ought to say:

After deep and soul-searching reflection, and with the aid of our pastor and strong religious faith, we have come to the conclusion that we can no longer continue appearing on television. We have been married for 10 years and recently renewed our vows. We take those vows seriously.

Marriage is a promise to stay together through good and bad. No one needs to promise to stay together when things are good, so in essence, marriage is a promise to stay together and stand by each other when things are not good. As the public is aware, each of us has gone through a period of sadness and confusion. It seems like it might be easier to separate, but marriage is not about taking the easy course.

To honor the unbreakable commitment that we made to each other before our family, friends, and before God, we have regretfully come to the conclusion that we need time and privacy to repair our relationship. We need to concentrate on each other and our family, and a TV show and publicity tours are simply not compatible with what our family needs now.

We love our children more than life itself, and we know that more than anything, more than money or fame, our children need to grow up sheltered under the umbrella of the strong relationship of their father and mother. We want to show our children the true meaning of marriage and commitment. We are willing to forgo the temporary rewards of money and fame for the more lasting rewards that come from putting marriage and family before anything else.

We thank the public for being guests in our home and lives, but there comes a time when the guests must leave. We appreciate the love and concern that so many have show to us, and we hope that everyone will respect our need for privacy at this time. There will be no more TV show, no more books, and no more publicity tours for the foreseeable future.

In truth, this is a financial and emotional sacrifice for us, but marriage and children often require sacrifices of both partners. Although it is a sacrifice, we expect profound rewards: the deepening of our commitment to each other as spouses, friends and parents of eight precious children.

That's not what they are going to say, of course. They are going to announce a separation, or even a divorce. And they are going to continue to capitalize on the boost in popularity that a troubled marriage has brought them. That's why they put out press releases, why they are staging a "special episode" and why they are running commercial spots to promote it. They are no longer a family, but merely a business, and business is booming even as their family falls apart.

The man who wouldn't stop bleeding

Surgeons can do amazing things. They can remove an appendix that is about to burst, bypass blocked arteries in the heart, or even carefully excise a tumor from the brain. But surgeons never work alone. They always depend on the human body’s intrinsic abilities, the ability to clot blood, the ability to combat bacteria, and the ability to heal.

A surgeon knows that if he removes a gangrenous appendix the patient will get better, but it isn't the removal that makes him better. The surgeon assumes that the stitches will stop the bleeding at the site where the appendix was removed, the immune system will clear away the residual infection, and the skin and deeper tissues will heal themselves together again.

I always assumed that, too, until I met the man who wouldn't stop bleeding.

Met is probably the wrong word, since my first encounter with him occurred while he was under general anesthesia on the operating table. It was early in my internship year and I was called to the operating room to provide assistance during a disaster of major proportions. A young man undergoing a surgical repair of a damaged artery would not stop bleeding. I was called merely to hold the retractors that kept the surgical wound open so that the surgeons could see the area in question. Another intern had been holding them for many hours and I was sent to relieve him.

The surgery, which had been scheduled to last 2-3 hours, had been going on for more than 12 hours with no end in sight. On the wall of the operating room hung the empty plastic bags that had contained the 40 units of blood that had been given to the patient thus far. As I stepped to the table, having gowned and gloved, I could see that the wound was filling with blood as fast as the surgeons could suction it away. One of the surgeons noticed my presence and explained what was going on.

The young man, in his late twenties, had been diagnosed an aneurysm of the main artery feeding one of his legs. An aneurysm is a weakening and ballooning out of a blood vessel wall that will ultimately rupture (and kill the patient) unless surgically repaired. It usually occurs in people over age 60, generally smokers. While the surgeon who had planned the operation had recognized that an aneurysm in a young person is quite unusual, he hadn't fully considered why this unusual event had occurred. Unfortunately, he quickly found out when he attempted to repair the artery.

The artery in question, indeed all the patient's arteries, were unusually weak. We later learned that the patient suffered from a rare genetic disease that made his artery walls abnormally thin and weak. At the time, all we could see was that the artery would not hold stitches.

The aneurysm had been excised during the first hour of the surgery. In the subsequent 11 hours, the surgeon, ultimately aided by two colleagues, struggled to close the residual hole in the artery. Yet every time they successfully stitched it closed, one or more of the sutures tore through and a torrent of blood poured from the artery. The situation was truly desperate, and desperate situations call for desperate measures.

It was impossible to close the blood vessel perfectly, as would have been required in any other patient. The decision was made to close the artery as completely as possible and to control the residual bleeding with pressure. Just like you or I might stop the bleeding from a cut by applying pressure, we would try to do the same, except that the pressure would need to be applied inside the body, not outside.

The wound was packed with as much sponge and gauze material as could fit inside, and the incision was left often. The patient was transferred to the intensive care unit with the recognition that either the bleeding would gradually stop or the patient would die. The patient left the operating room 16 hours after he had entered it and the vigil began.

Amazingly, and against all odds, the bleeding slowed and eventually stopped. Although the artery itself was defective, the patient retained the ability to clot blood, and the combination of blood clot and pressure ended the bleeding. No one dared to risk further bleeding by removing the packing, so it was decided that the wound would be left often to heal itself from the bottom up.

And that is precisely what happened. Within several days, the artery healed itself, and we began gently changing the packing each day. It took 3 months for the wound to heal completely, with progress measure by the gradually decreasing amount of gauze sponges that could be fit inside the wound. Initially I would arrive at his bedside each day with a seemingly inexhaustible supply of gauze to replace the old packing. After 3 months, I needed to bring only a large surgical bandage to cover the wound.

Ultimately the patient walked out of the hospital alive, a tribute to the body’s ability to withstand tremendous trauma and to heal itself, even under less than ideal conditions. Unfortunately, the story does not have a happy ending. There was no way to treat underlying genetic defect in his arteries and several years later another aneurysm developed in a different artery. This time the surgeons could not get the bleeding under control no matter what they tried, and the young man eventually bled to death.

The Zicam scam and the gullibility of the American public

You've got to hand it to the folks at Matrixx Initiatives. They managed to convince millions of Americans to paint the inside of their noses and throats with a toxic heavy metal that is ineffective in its stated benefit and destroys the nerves responsible for the sense of smell.

Matrixx marketed Zicam as a cold remedy. There is no evidence that Zicam has any effect on colds, but there is decades of data showing that zinc, the purported active ingredient, can damage the sense of smell. Indeed, since 2006, Matrixx Initiatives has been forced to pay $12 million dollars to 340 people who claimed that Zicam destroyed their sense of smell. Hundreds more lawsuits are still pending.

So how did Matrixx manage to convince Americans to apply a toxic heavy metal to sensitive internal tissues? They called it a homeopathic remedy and that allowed them to avoid having to prove that Zicam was effective or even safe. And, they relied on the gullibility of the American public and its current love affair with all things "natural."

The Obama Administration is working to close the legal loophole that allows companies to market "natural" remedies without proving that they are effective or even safe. In the meantime consumers can become less gullible. The first step is to understand how we know whether a substance works. Answering the question goes far beyond giving the substance to individuals and asking them about their perceptions.

The study of drug efficacy and safety is pharmacology. Pharmacology can be roughly divided into two areas: pharmacodynamics, how the substance acts on the body and pharmacokinetics, how the body acts on the substance.

Here are some basic questions that must be answered to find out how the drug works on the body:

How does the drug work? What is the active ingredient? What effect does the active ingredient have on the body?

What is the dose-response? In other words, as the dose of drug increases, does the response increase?

What is the ED50, the dose that produces a response in 50% of subjects, also known as the median effective dose?

What is the maximum effect that can be produced by the drug, also known as efficacy?

What is the therapeutic window? For every drug, there exists some concentration which is just barely effective and some dose which is just barely toxic. Between them is the therapeutic window where safe and effective treatment will occur.

In addition, we need to know how the body interacts with the substance.

How does it enter the body?

How is it removed from the body?

Does it have effects on other parts of the body besides its stated therapeutic effect?

What did the makers of Zicam know about their product before they put it on the market? The only thing that they knew is that the active ingredient is zinc. They did no testing that would tell them the mechanism of action, the dose response or even the effect of the zinc on other tissues of the body. Therefore, at no time did they have evidence that the drug was either safe or effective, yet they sold it anyway.

Determining drug efficacy and safety is complex. It is absolutely imperative to study the pharmacodynamics and pharmacokinetics of a substance before anyone can claim that it is effective or safe. As the case of Zicam illustrates, when it comes to "natural" remedies, these questions have not even been asked, let alone answered.

Sex discrimination feminists can believe in

It's pure and systematic gender discrimination based on the notion that men are better and more valuable than women. It leads to the deaths of females and distorts the societies of its practitioners. It is a third world practice that is being enthusiastically imported in the first world, and feminists are making no effort to stop it.

I'm talking about the practice of selectively aborting female fetuses because males are valued more highly. It is the modern equivalent of infanticide, and it is widely practiced in countries such as China and India, where it is distorting population dynamics with ominous results. Now comes word that gender based abortion is making inroads in the US.

According to economist Jason Abrevaya:

The evidence from the California natality data is particularly striking for Indian births between 1991 and 2005: second-born children are 0.9 percentage points more likely to be boys, third-born children 6.6 percentage points more likely, and fourth-born children 8.1 percentage points more likely. Moreover, Indian parents are significantly more likely to have a boy (and a terminated pregnancy since last birth) if they have had only daughters previously. [This] suggests that the unusually high boy percentages among third- and fourth-born Indian children in California would be consistent with gender-selective abortion rates of around 10%. ...

The data on Chinese families is similar, suggesting that literally thousands of female fetuses are aborted in the US each year simply because they are female, and therefore less desirable.

It is the purest form of sex discrimination imaginable, yet the people who should be most outraged are maintaining a studied indifference. This issue ought to pose a serious moral quandary for feminists On one hand, as abortion rights proponents, they believe in the centrality of a woman's unfettered right to control reproduction, including the right to abort a child that she does not want. On the other hand, selective abortion of girls is clearly a product of sexist values that place a premium on the lives of boys, and treat girls and women as second class citizens.

Unfortunately, feminists are willing to look the other way at this obvious and cruel form of gender discrimination because they apparently value an unfettered right to abortion more highly than the lives of unborn girls. They are willing to countenance the deliberate, sexist practice of selective female abortion in order to "protect" the right to abortion.

It's worth asking why they aren't willing to countenance restrictions on abortion to protect unborn girls. The answers aren’t pretty.

First, acknowledging that sex selection by abortion is morally wrong would mean acknowledging that all abortions are not equally justified. The prevailing belief among feminists appears to be there can be no bad reasons to have an abortion.

Second, and perhaps more important, acknowledging that sex selection by abortion is morally wrong would mean that abortion involves something more than scraping amorphous "tissue" out of the uterus. While it would not confer personhood on an embryo or fetus, it would confer qualities such as gender and the potential for moral value that abortion rights activists would prefer to forget.

The end result is that feminists have collectively decided to look the other way as thousands of female embryos and fetuses are destroyed each year for no better reason than the belief that men are superior to and more valuable than women. Ironically, gender based selective abortion is sex discrimination that feminists can believe in.

Genzyme, corporate pig

In an industry noted for greed, sharp tactics and lack of social conscience, the drug company Genzyme has managed to set a new standard for depravity.

Yes, depravity. Genzyme's latest strategy for amassing outsize profits, proudly described by company executives in today’s Boston Globe, is, in my judgment, nothing short of morally depraved.

Genzyme, as its name implies, has pioneered the use of genetic engineering techniques to create and manufacture drug treatments. The greatest potential of genetically engineered drugs lies in treatment for so called "orphan" diseases, those they afflict very few people, not nearly enough to form support groups, charities and public advocacy groups that pay for treatment. Although many companies have had success in creating novel, highly effective treatments for orphan diseases, they find it hard to profit from such treatments, because demand is very low.

Orphan diseases, by their very nature, are often difficult to diagnose and require sophisticated medical equipment and training to even identify. The chances of an orphan disease being diagnosed in the third world, let alone being treated, are extremely remote. Genzyme's new corporate strategy is to search the third world for children suffering rare diseases, provide the technology and equipment to make the diagnosis and then attempt to force the government of the third world country into paying for the extraordinarily expensive treatment by diverting money that would otherwise be used to provide basic medical care for large numbers of people.

The idea is pure genius. By identifying a specific child who will die without treatment, by informing the child’s family that a lifesaving treatment exists, but will be withheld without full payment the drug company is able to exert far more pressure on the specific government than they could by a simple announcement that 1 or 2 children in any given third world country might benefit from the treatment.

The Globe details how this technique works in practice. Consider Tania, the Costa Rican girl, who is dying of the rare genetic disease Gaucher's. Tania’s family did not know what was killing her, and they would never have known, if it were not for Genzyme’s efforts to find and identify Tania, and inform her family of the treatment that could save her life, the drug Cerezyme, at the cost of $160,000 per year:

Genzyme created divisions within the company to find overseas patients ...

Costa Rica was part of this plan, a nearby country whose government, though poor, dedicates much of its budget to healthcare. Company executives began flying to the region and meeting with the person most likely to diagnose a Gaucher patient: Dr. Manuel Saborio Rocafort, who runs the only medical genetics department in Costa Rica. So when Saborio heard about Tania, not only did he know that he should test her for Gaucher disease, but he had the testing kit ready: Genzyme had provided it.

But Genzyme did not go to the trouble and expense of finding and diagnosing Tania in order to save her life. Their avowed corporate strategy involves letting her die, unless Costa Rica will pay the full $160,000 per year for Cerazyme. Absolutely no discount is allowed.

Lest anyone doubt that this is a deliberate corporate strategy, consider:

In Genzyme's new glass Kendall Square headquarters, the president of the firm's international group, Sanford Smith, keeps a brass gong outside his office. Every time a foreign government agrees to pay for one of the company's drugs, he takes out a mallet and rings it.

Presumably, they rang the gong for Tania when Costa Rica agreed to pay the full price, the only price at which Cerezyme can be obtained. Yet the Costa Rican government is not without misgivings:

The Costa Rican healthcare system has survived paying for Tania's medicine. What worries its leaders is the precedent. Energized by Genzyme's success, more companies have developed high-tech drugs for other rare diseases. Genzyme's pricing approach has become the standard for similar drugs...

It is difficult to imagine a corporate practice that is more ethically and morally depraved: deliberately identifying third world children whose lives can be saved by extraordinarily expensive drugs, refusing to provide those drugs at a discount or for free, and then ringing a brass gong to announce that another third world country has been blackmailed into diverting a large share of its healthcare budget to one child, and away from simpler medications and strategies that could save thousands of lives.

The executives responsible for this strategy should be ashamed.

Stuntbirth

Dooce has discovered stuntbirth, also known among aficianados as freebirth or unassisted childbirth (UC).

...I accidentally stumbled upon a show about a new fad in childbirth called Freebirthing where women have their babies at home without the aid of a nurse or midwife or any trained professional. And at one point there was this three-year-old kid going WHY IS MOMMY SCREAMING LIKE THAT?! And the woman is clawing at this head coming out from between her legs, and she's all GET IT OUT! GET IT OUT! Except, there is no one there who knows how to get it out, and her husband is just standing there shrugging like DUDE, THIS WAS YOUR IDEA!

She says, "...you've got to have a special combination of bravery and stupidity going on to attempt such a thing." I agree with the stupidity part, but I suspect that bravery has nothing to do with it. It's all about competitive mothering. Hence the progression of ever more bizarre claims and practices in an attempt to claim superiority for one's self. A says, "I had my baby in a birth center" and B says, "Oh, yeah, well I had my baby at HOME" and C says, "Well, ladies, I can top that. I had my baby at home BY MYSELF!"

Stuntbirthers like to pretend to themselves and others that this is how birth happens in nature (no, across all times, places and culture, birth is assisted), that birth is so deeply personal and "sexual" that a couple must experience it alone (really, then why are you posting a video of it on YouTube for all the world to see?) and that it is safe. The entire practice would be nothing more than a punch line were it not for the fact that it kills babies, in fact a startlingly high proportion of the babies whose mothers were ignorant enough to embrace this stunt.

On one of the leading UC support boards, there was recent crowing and self congratulation among the members that their neonatal death rate is 8/1000. They seemed to have no idea that this is 20 times higher than the neonatal death rate for uncomplicated, low risk hospital birth. Unassisted childbirth is nothing more than medical neglect, and babies are dying or rendered permanently disabled because of that neglect.

Perhaps more compelling than the statistics is the fact that both the leading American and Australian advocates of UC have ended up with dead babies as a result. Laura Shanley, the American, likes to boast that she had 4 wonderful unassisted births, but she has actually had 5. She deliberately and knowingly gave birth to a premature baby alone at home and, over the next several hours, watched him die without ever summoning help.

In April of this year, Janet Fraser, Australia’s leading advocate of UC, experienced the death of her baby during labor. Fraser had proudly boasted to an Australian paper that she had no prenatal care of any kind, and planned to have no medical assistance at the birth. Her baby paid the ultimate price for her idiocy.

Tragically, unassisted childbirth has no benefit for the baby and poses very serious risks. It is a form of medical neglect based on appalling ignorance and extraordinary selfishness and self-absorption. In short, it is nothing more than a dangerous stunt.

The AMA, still crazy after all these years

There's nothing worse than doctors who refuse to learn from their own mistakes.

The latest pronouncement from the American Medical Association opposing publicly funded healthcare (single payer) is foolish on its face, but it unforgivable when turns out that it is merely a recapitulation of a thoroughly discredited policy of the past. The fact that it is not in line with the views of the vast majority of American physicians makes it worse, and goes a long way toward explaining the increasing irrelevance of the organization.

The support for reform of the healthcare system has never been greater. The AMA, in a move supremely out of step with the majority of Americans, not to mention the majority of American physicians, has declared their opposition. According to The New York Times:

...[I]n comments submitted to the Senate Finance Committee, the American Medical Association said: "The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans."

The wording is rather ironic. Forty years ago, the AMA declared its opposition to creating a public health insurance option people over age 65, complete with dire predictions of the destruction of American medicine. That public health insurance option is known as Medicare, and far from destroying American medicine, it ushered in a golden age for American physicians.

The current opposition to healthcare reform, like the opposition to Medicare, is consistent with the AMA's sad and sordid history of vociferous opposition to any attempt at healthcare reform. Truman first proposed universal compulsory health insurance in 1948. As Robert Ball explains:

The AMA's opposition approached hysteria. Members were assessed dues for the first time to create a $3.5 million war chest-very big money for the times-with which the association conducted an unparalleled campaign of vituperation against the advocates of national health insurance. The AMA also exerted strict discipline over the few of its members who took an "unethical" position favoring the government program.

But AMA is no longer the force in American medicine that it was in the past. In the 1960's, at the height of opposition to Medicare, the AMA claimed at least 70 percent of American doctors as members. Today, the AMA represents only a third of American doctors, most of them elderly. Almost 90 percent of doctors over age of 70 are members, but fewer than 35 percent of those aged 30 to 49 belong to the AMA

Its decline in membership and influence can be traced to its political positions and financial arrangements. Indeed, the majority of American physicians favor a national healthcare plan:

Of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program, while 32 percent said they opposed it ...

"Many claim to speak for physicians and represent their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support national health insurance," said Dr. Aaron Carroll of the Indiana University School of Medicine, who led the study...

The Indiana survey found that 83 percent of psychiatrists, 69 percent of emergency medicine specialists, 65 percent of pediatricians, 64 percent of internists, 60 percent of family physicians and 55 percent of general surgeons favor a national health insurance plan.

The AMA is opposed to healthcare reform? Who cares? They don’t represent American physicians and they don't represent the American people. The represent the worst of American medicine, a dying breed that deserves to fade into ignominy.

Ten years and $2.5 billion dollars later alternative health is demonstrated to be worthless

From MSNBC:

Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.

Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine...

Imagine how many people could have received real medical treatment with that money. Imagine how much real medical treatment we could buy with the tens of billions of dollars that American waste each year on alternative health mumbo jumbo.

Alternative health, the placebo effect, and dirt

Blogger and alternative health advocate Catherine Morgan has attempted to address my claim that alternative health is pseudoscience. She writes:

Not surprisingly, Dr. Amy takes a hard line against alternative health practices, but is alternative medicine just pseudoscience? I don't think so. Just because something can not be "scientifically" proven today, doesn't mean it won't be proven in the future. For example, most people believe that when they die they will go to heaven, but there is no "scientific" proof of heaven. Does that mean heaven doesn't exist? And at one time, before there was proof that the world was round, everyone believed it was flat. Was it flat just because the science wasn't available to prove it wasn't? No. Science may not be able to prove that Reiki or Acupuncture (or any other alternative modality) actually works, but that isn't proof that it doesn't work either. Let's face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next. ... Even Einstein was wrong sometimes. The only thing we know for sure, is that no one knows everything.

That paragraph is a "greatest hits" of faulty reasoning, including basic flaws in logic, invocations of religious faith, and, my personal favorite, grandiose comparions with Galileo or Einstein (for some reason it is always Galileo or Einstein), while failing to realize that Galileo and Einstein always supplied scientific proof for their claims while their persecutors and detractors were the ones who insisted that scientific proof wasn't necessary.

Here's the comment that I left:

"Just because something can not be "scientifically" proven today, doesn't mean it won't be proven in the future."

1. That statement reflects a very serious misunderstanding about the state of knowledge of alternative remedies. It's not simply that alternative remedies have not yet been scientifically proven to work; the reality is that alternative remedies have been scientifically proven NOT to work...

2. It is the MORAL obligation of advocates of alternative health to be SURE that an alternative treatment is safe and effective before they recommend it. It is morally wrong to advocate a treatment, and to accept money for the treatment if you don't have proof that it works.

"And at one time, before there was proof that the world was round,
everyone believed it was flat. Was it flat just because the science
wasn't available to prove it wasn't? No."

That statement offers more support for my view, not yours. Simply put, that statement means that what people "believe" about something is completely unrelated to reality. So the fact that alternative health advocates "believe" that alternative health works tells us absolutely nothing about whether it works.

"Let's face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next."

That's not true, either. What is reported (often erroneously) in the media changes from day to day, but what the scientific literature shows does not change in that way. That's why it is absolutely critical to read scientific papers if you want to know about scientific phenomena.

Alternative health is the medical equivalent of astrology. Just like astrology, it is nothing more than pseudoscience.

Ms. Morgan replies:

...Even though I'm not a scientist, I don't believe my post reflects a "serious misunderstanding" of alternative remedies.

I'm interested in how you reconcile your strong belief in scientific fact with the placebo effect? If science has proven that a mind/body connection exists in medicine...Is it really that far fetched that alternative medicine might have some benefits as well?

And my response:

I'd like to ask you some ethical questions, and I hope you will take the time to reply.

May I ask why you have not reviewed the scientific literature on alternative health remedies? Isn't that like writing a book review recommending a new book without having read it?

Don't you think you have a moral obligation to read all possible evidence on something that has the power to seriously harm people before suggesting that they should risk their health and wellbeing by believing in it?

Let me try to address the question you asked me.

"I'm interested in how you reconcile your strong belief in scientific fact with the placebo effect?"

Why should I have any difficulty reconciling scientific fact with the placebo effect? The placebo effect IS a scientific fact. It was discovered, described and measured by scientists.

Contrary to what alternative health advocates like to claim, scientists are very much aware of the mind-body connection. (Think psychosomatic illness, for example.) Scientists know that it is absolutely imperative to subtract the placebo effect from any evidence that a substance works.

The placebo effect is "psychosomatic." You can evoke the placebo effect by feeding someone dirt and claiming it is medicine. So when alternative health advocates invoke the placebo effect to show that an alternative treatment "works" they are essentially saying that the alternative treatment is equally effective as feeding someone dirt.

How can alternative health practitioners ethically justify charging people money for a treatment that is no more effective than dirt?

I'll let you know if there is a further response.

Clueless devotees of supplements don't know what's in them or who makes them

Alternative health is nothing more than a giant scam to separate the scientifically illiterate from their money. The best and simplest example of this phenomenon is the use of herbs and supplements.

Devotees of alternative health like to pretend that herbs and supplements are better because they are "natural," because they are pure, and because they are not produced by Big Pharma. Nothing could be further from the truth.

First, "natural" is hardly synonymous with beneficial or even harmless. Earthquake, hurricanes and lightening strikes are all "natural" and quite harmful. More to the point, some of the most toxic substances known to man, like the paralytic poisons tetradotoxin and curare, are natural animal and plant products. Anyone who wonders whether "natural" equals beneficial need only contemplate tobacco, opium and cocaine.

Second, even if the active ingredient of an herb or supplement is harmless, it is mixed with contaminants in its natural state. As MSNBC explains:

Lead in ginkgo pills. Arsenic in herbals. Bugs in a baby's colic and teething syrup. Toxic metals and parasites are part of nature, and all of these have been found in "natural" products and dietary supplements in recent years.

The risks are not simply theoretical:

Millions of Americans take vitamin, herbal or other dietary supplements. Annual sales exceed $23 billion, and more than 40,000 products are on the market. Tens of thousands of supplement-related health problems are handled by U.S. poison control centers each year, according to a report in the New England Journal of Medicine in 2002.

Until last year, supplement makers were not required to report problems to the FDA, and even now they must report only serious ones. The agency estimates that more than 50,000 safety problems a year are related to supplement use.

Because of vigorous lobbying efforts by supplement manufacturers, herbs and supplements are exempted from the rules that apply to medication. Therefore, there is no way for a consumer to be sure that a given herb or supplement contains any active ingredient, or contains too much or too little of the active ingredient. There is no testing to be sure that harmful contaminants are not present. Manufacturers simply grind up leaves and sell them to gullible people, and neither the manufacturers nor the consumers have any idea what's in them.

Third, and most ironic, the herb and supplement industry is a financial bonanza for ... Big Pharma. Sure, the labels on the products are decorated with butterflies and rainbows, but the producers are none other than Bayer, GlaxoSmithKline and Wyeth.

Little herbal stores are only "what the consumer sees when they're shopping," while the large companies that supply them are mostly invisible, Silverglade said.

The industry's little-guy, granola image has been a great marketing asset, allowing it to tap into Americans' frustration with big medicine, big prices and big risks. Supplement makers are dwarfed by leading pharmaceutical firms, whose drugs command sales in the tens of billions of dollars. Yet the reality is that natural remedy makers constitute a sizable business that doesn't have to play by the same rules as companies that make prescription or over-the-counter medicines.

In the final analysis, herbs and supplements represent the trifecta of the gullibility of lay people. The active ingredients themselves don't actually work, the herbs and supplements often don’t contain the active ingredient or contain poisons, and the consumer is paying Big Pharma for the privilege of being scammed.

Herbs and supplements, like all of alternative health, depend on scientific illiteracy. The executives of Big Pharma are laughing all the way to the bank. Not only do they profit from legitimate pharmaceuticals, all of which require major financial investments to develop and assure safety and quality, but they are raking in money from herbs and supplements, without any research, without any quality control, and without any evidence that they work.

How making doctors more "efficient" has made them less efficient

What makes a good doctor?

There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient's signs and symptoms, the ability to identify the patter, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.

Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.

Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient's situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don't read the book. In other words, their signs and symptoms can vary from "textbook" descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.

Yet if there is one thing that contemporary American doctors lack, it is time. That's because the people who "manage" healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients "processed." That's not what it means to be efficient in the practice of medicine, though.

In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That's because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.

How have doctors become less efficient? All the evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomittant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are "processed" faster, but medical care has arguably gotten worse, not better.

The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.

Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can't make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster. And that's not efficiency.

Congratulations, it's a ...... I'm not sure what it is.

My favorite part of practicing obstetrics was the moment of delivery, helping mom lift the baby to her chest and calling out, "It's girl!" or "It's a boy!" It was always a privilege to be part of the deeply personal moment when parents met their newborn child, and to share their joy and excitement.

Although parents are anxious to establish that the baby has ten fingers and ten toes, and is healthy in every way, the announcement of gender is often equally important. The knowledge of gender immediately begins to shape the way the parents view the baby.

You'd think that figuring out the gender would be simple, and it usually is, but once in my career I delivered a baby and could not tell whether it was a boy or a girl. I said nothing about the gender and the tension and distress of the parents were palpable.

The baby was born with a condition known as ambiguous genitalia. It’s just what it sounds like: external genitals that appear to be a cross between male and female. How does it happen?

For the first 7 weeks of development, every embryo appears to be female. In the absence of male hormones like testosterone, the baby will continue to have female external genitals. In boys, the testicles begin producing male hormones and the external genitals undergo further development. The clitoris enlarges into the penis, and the labia fuse together in the middle to become the scrotum.

It is possible for a baby to be a true hermaphrodite, having both ovaries and testes, but that condition is very rare. Ambiguous genitalia are usually caused by an inherited hormone problem that interferes with the development of the genitals. The baby is either a boy or a girl because it has either testes or ovaries, but the external genitals look like a combination of both, making it difficult to identify the gender simply by looking.

I had never seen a case of ambiguous genitalia before that night, but like every obstetrician I had read about it. And one of the things that I had read was that if there was any doubt about the gender, the doctor should not attempt to guess. According to a variety of studies, more psychological damage could be done by the doctor wrongly assigning gender and then having to change it, than by admitting that you didn’t know and consulting an expert to make the diagnosis.

Talk about an awkward situation! As the baby’s shoulders were being born I started to call out, "It’s a ..." and stopped. I was stunned into silence. The baby appeared to be a girl with a very enlarged clitoris that looked like a penis, but I wasn't sure. Mindful of what I had read, I didn't want to guess. I asked the nurse to call the neonatologist to the room and I showed the baby to the parents. Not surprisingly, they were even more stunned than I was. I pointed out that the baby was healthy, with all other body parts intact, and I explained that the baby almost certainly had a treatable hormone problem, but the parents were distraught.

The neonatologist arrived within minutes and carefully examined the baby. He announced that the baby was a girl and that a treatable hormone problem had cause virilization (male appearance) of the external genitals. Ultimately the baby was diagnosed with congenital adrenal hyperplasia (CAH) the most common cause of ambiguous genitalia. CAH has effects in addition to ambiguous genitalia. It also leads to serious kidney problems, so it is very important that it be diagnosed and treated immediately.

After some time with mom and dad, the baby went to the newborn intensive care unit for a complete evaluation. Replacement of the appropriate hormones was started, and because the virilization of the genitals was mild, no surgical treatment was needed. The clitoris shrunk back to normal size and the baby did very well.

The parents, on the other hand, took a little longer to recover. The entire experience was deeply disturbing to them as it would be to any parents. And I never forgot it.

Doctor, listen to your patient

"Listen to your patient, he is telling you the diagnosis."

Those are the words of William Osler (1849-1919) often called the Father of Modern Medicine for his contributions to the development of medical education. I first heard them from the chief of surgery at the beginning of my internship. It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than you might think. That's because most patients are simultaneously offering a lot of extraneous information, and some patients are not completely honest in the information they offer.

In fact, the patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients' stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

I suspect that this problem is at the root of many errors of diagnosis. It is obviously much more difficult to diagnose a problem if the patient has an unusually constellation of symptoms. However, the biggest stumbling block is that the doctor believes that if the symptoms make no sense, the patient must be telling the story wrong, or have some other reason for the symptoms such as depression or medication seeking behavior.

That's the biggest advantage I have when approached by a friend or relative for help with a difficult medical problem. It can sometimes be much easier for me to figure out the diagnosis than it is for the doctor they are seeing. That's because I start out by believing them, because I know them, and I don't waste valuable time pondering whether they are honest or reliable reporters of their symptoms.

Recently a friend called me about unusual symptoms his father-in-law was having. The relationship between our families has extended through several generations, and I knew his father-in-law well. He is a distinguished emeritus professor with a piercing intellect and ongoing curiosity and engagement with the academic world. As he approached and passed his 80th birthday, he was afflicted with slowly progressive muscle weakness. He became wheelchair bound and continued to weaken even further. Ultimately, he was barely able to muster the energy to move.

His impressive team of doctors was stymied by the symptoms and took the easy road. They concluded that he was weak because he was old. There was nothing to be done.

His son-in-law called because his children were convinced that something was going on besides normal aging, but did not know what tests and investigations to insist upon. That's where my advantage came in. I listened to his story and believed him because I knew him and I knew them. I started from the premise that the story must be true and went from there.

Whenever an elderly person develops a global symptom like fatigue or confusion, the first place to look is at their medications. As people become older, they are put on ever increasing numbers of medications to treat various unrelated ills. Often, some of those medications will interact to produce unusual side effects. In addition, as people age, the ability of the kidneys or liver to break down the medication and remove it from the body diminishes. Because the medication stays in the body longer, it has a chance to build up to toxic amounts. A dose of medication that was conservative 10 years before may have slowly become an overdose.

Since whole body muscle weakness is certainly a global symptom, I asked for a list of his medications, and then I went down the list looking for generalized muscle weakness as a rare side effect. I hit the jackpot almost immediately. Pravachol, a statin (cholesterol lowering drug) he had been taking for decades, is known to cause generalized muscle weakness in rare circumstances by damaging muscle cells. The chance of this unusual side effect is increased in the elderly and is further increased in people with diminished kidney function, which happened to be present in this case as well.

I was so excited that I called my friend right away to tell him. I promised to do further research later in the evening, but in the meantime, he started investigating the rest of the list for unusual interactions between drugs. Sure enough, he found that another medication on the list was known to interact with Pravachol to increase the risk of generalized muscle weakness.

We had the diagnosis: Pravachol induced myopathy exacerbated by age, decreased kidney function and interaction with another drug. My friend called his father-in-law’s doctors first thing the next morning, and the Pravachol was discontinued. Recovery began almost immediately. He now feels better than he has in years and has begun to walk again.

The professor called me recently to express his gratitude. He thought I had made an incredible diagnosis. Frankly, I am a bit embarrassed. I didn’t really diagnose anything. He had been recounting the symptoms of statin induced myopathy in detail for months, if not years. All I did was listen.

Extreme Makover: Vagina Edition (part 2)

Can women be trusted to make decisions about their own bodies?

In a previous post, I discussed the rising popularity of genital cosmetic surgery (Extreme Makeover: Vagina Edition). While the concept has been warmly embraced by women, it has elicited reactions ranging from distaste to outrage by others.

Everyone agrees that vaginal and vulvar cosmetic surgery has no medical benefit. Everyone agrees that views of genital attractiveness are strongly influenced by the prevailing culture. The point on which people disagree is whether women can be trusted to make decisions about their own bodies. Reactions range from paternalism and maternalism to acknowledging the possibility of autonomous decision making.

Paternalism is best exemplified by Daniel Sokol, writing in the British Medical Journal. According to Sokol:

The 16th century French author and physician Rabelais was obsessed with vaginas. In one of his stories an old lady drives the devil away by showing him her vagina. Today the devil might recommend she go to the nearest aesthetic surgeon for vaginal rejuvenation. A touch off the labia (labioplasty), a bit of tightening here (vaginoplasty), and voilà: a designer vagina...

Here is my paternalistic view: medical professionals, whether working in the private or public sector, should not succumb to these requests. Although it would be hard to argue that anyone seeking aesthetic genital surgery is unable to make an informed decision, it is plausible to argue that patients' autonomy is often diminished by strong social or peer pressures.

Sokol at least is honest about his paternalism. Feminists who oppose genital cosmetic surgery seem to be entirely unaware of their maternalism. Their alarm shades into, dare I say it, hysteria. Bonnie Zylbergold asks whether genital "beautification" is plastic surgery or mutilation.

... Dr. [Lenore] Tiefer maintains that ... all [genital cosmetic surgery] really produces is a generic model of women's genitalia… So enraged is Dr. Tiefer, that in 2000 she founded The New View Campaign, an organization devoted to stopping all form of FGCS. The group compares FGCS to Female Genital Mutilation (FGM).

... [P]oints out Dr. [Virginia] Braun, "In both cases, what's being done is that women’s genitalia are being altered to conform to a certain set of notions and expectations about what genitalia should look like, what they need to look like if they are to be appropriately feminine and appropriately desirable."

Genital modification may be unnecessary, potential harmful, and the result of peer and marketing pressure, but it is not mutilation. And the claim that female genital mutilation represents a notion of genitalia "beauty" completely misrepresents the procedure. Genital mutilation is performed specifically to deprive women of sexual pleasure in an effort to ensure chastity. In other words, FGM is meant to prevent women from engaging in sexual intercourse, while vaginal cosmetic surgery is meant to enhance a woman's opportunities for sexual intercourse.

The paternalists and maternalists agree on one fundamental point: women cannot be trusted to make decisions about their own bodies. Individual physicians must refuse to honor their wishes; regulatory agencies must make it impermissible for women to choose genital cosmetic surgery.

It is interesting to note that no one seems to think that men are incapable of making decisions about genital modification. Procedures to lengthen genitalia, prolong erection and otherwise enhance sexual "attractiveness" are equally if not more common among men, yet neither the paternalists nor the maternalists suggest that men must be restrained by their physicians or governmental regulations from making independent choices.

As distasteful as female genital cosmetic surgery may be to its critics, they are wrong to assume that women (and only women) should not be allowed to make these decisions. Rather, the principles that apply to all medical decisions should be invoked. Dr. Michael Goodman, writing in the journal Obstetrics and Gynecology explains:

Patients must be adequately screened, taking note of the ethical principles of autonomy, nonmaleficence, beneficence, justice, and veracity. Patients should be adequately protected and guided to develop reasonable expectations and understand that their genitalia are not abnormal. Surgeons should be adequately trained and experienced and should use universally accepted, accurate, and descriptive terminology. The procedures should be adequately described to patients, and risks and expected outcomes should be fully explained.

Genital cosmetic surgery, like all cosmetic surgery, has no medical benefits, substantial risk of harm and is often undertaken in response to cultural pressure. Nonetheless, informed consenting adults have a right to choose genital cosmetic surgery, just as they have the right to choose any cosmetic surgery.

Yes, the patient might die, but I'm not going to help unless I get paid.

I left clinical medicine for many reasons, but one of the most important is that caring for patients had become an endless slog of fighting administrators and other doctors. What did we fight about? Money, of course. Administrators did not want to spend it, and doctors did not want to risk doing work for which they might not be paid. I was afraid that one day, because I wasn't up for a fight, one of my patients would be hurt. I had an experience shortly before I left practice that crystallized those fears.

A young woman who was 6 months pregnant called me one night when I was at the hospital. She had had pain in her leg for the past 2 days and the pain was getting worse. It wasn't just that the pain was stronger; she had noticed that the pain appeared to be extending up her leg. First only the inside of her calf hurt, now the inside of her calf and her thigh hurt. I told her that she needed to come to the hospital because I was concerned that she might have a blood clot in her leg.

Blood clots in the leg (deep venous thrombosis or DVT) are potentially quite dangerous, and known to be more common in pregnancy. The danger of a DVT is that a piece of the clot in the leg can break off and travel to the lungs where it can cause death.

She arrived around midnight and I went to examine her. There are 5 classic signs of DVT and she had none of them. Her leg was not swollen, she had no tenderness over a major vein, the affected leg was not warmer, the skin over the vein was not discolored, and moving her foot in the prescribed way did not produce the pain typically associated with a DVT. Nonetheless, I had a bad feeling about this woman, and, over the years, I had learned to pay attention to bad feelings.

I explained to the patient that she had none of the signs of a DVT, but I was still worried. I wanted to get an ultrasound study of her leg to be absolutely certain that there was no blood clot. I apologized in advance, since it was unlikely that she had a blood clot, but blood clots are very dangerous and I wanted to be sure. The patient understood and agreed.

I called the radiologist on call and explained the story. I was very careful to point out that the patient had none of the classic signs of DVT, but I wanted the study anyway.

"No," he said.

"Excuse me," I replied. "I think I didn't hear you correctly."

"No," he repeated. "I'm not going to scan her leg because she has none of the classic signs of a DVT."

"Yes," I said, somewhat exasperated. "I'm aware of that. I just told YOU that she has none of the classic signs, but I wanted to make sure."

"Well, I'm not doing it because I won't get paid." He continued, "A scan in the middle of the night is an emergency and the insurance company will not pay for the scan unless it meets the criteria for an emergency scan. She must have some of those signs of a DVT or they won't pay."

We argued back and forth for a while, but he would not budge.

"Okay," I said. "Just spell your name for me."

He was puzzled. "Why do you need to know how my name is spelled?"

"Why? Because I am writing at the top of the very first page of the chart." I cheerfully replied. "That way, when she walks out of the hospital and drops dead, they'll know just whom they should sue."

Silence.

"Well, if you’re going to be THAT way about it, I'll scan her leg," he said, "but I'm not going to do it right away."

"Suit yourself," I replied. "Just scan her leg before the morning."

That exchange took place at 1 AM. I told the patient that we would have to wait for the scan, and I went to lie down.

At 5 AM my phone rang. The same radiologist was on the line, but now he sounded rather meek.

"Dr. Tuteur? Dr. Tuteur, I just wanted you to know that she has a blood clot in her leg extending from her ankle, up through her calf and thigh, right into her pelvis."

Not only did she have a DVT, but she had the worst one either of us had ever seen. She almost certainly would have died from a pulmonary embolus if we had sent her home. Instead we immediately began treating her with blood thinners. She stayed in the hospital for two weeks, went home having learned to give herself shots of blood thinner, and ultimately did great. She delivered a healthy baby and had no further problem with blood clots.

Nonetheless, I was shaken up by the experience. She had only gotten the appropriate treatment because I had been willing to fight with the radiologist. In some ways, it had been a matter of luck. I wasn't busy with other things; the radiologist had aggravated me, and was determined to prevail. I was uncomfortably aware that had circumstances been different, I might have failed to force the issue, and the patient would probably have died.

Why did the radiologist refuse to do the scan? He was simply responding to the incentives and punishments put in place by the insurance company. They didn't want to pay for emergency scans so they made the requirements onerous. The insurance company was not wrong in assuming that patients without classic signs of DVT probably don’t have one, and they didn't want to pay for needless scans. The radiologist was not wrong in assuming that this patient didn't have a DVT and in assuming further that if he did the scan he would not be paid for it.

Almost everyone who has health insurance has fought with the insurer at some point because the insurance company has refused to pay. If you've done so know you just how frustrating that can be and how much time it takes. Doctors fight with insurance companies all the time, both to get approval for tests and procedures that patients need, and to get paid for visits, tests and procedures that have already occurred.

Most people don't realize that doctors are often forced to fight with each other. The perverse incentives and punishments of the existing insurance system mean doctors who are trying to treat a patient must argue with other doctors who fear they will not be paid for their work. Sometimes, rather than fight to the bitter end, a doctor will give up and a patient won't get a test or treatment that she needs. And sometimes, giving up could have fatal consequences.

Dr. George Tiller, Martyr

I don’t do abortions.

I learned to do them, of course, as most gynecologists of my generation did, and I did them as part of my residency. That experience convinced me that abortions were not consistent with my view of providing patient care. I referred those of my patients who wanted abortions to other providers, and I never did another termination again.

Despite my personal views on abortion, I am horrified, appalled, and deeply outraged by the assassination of my colleague George Tiller. I am also profoundly humbled by his ultimate sacrifice. Tiller knew his life would probably end like this. He had already been shot, his clinic had been bombed, and he constantly received death threats. Yet none of that deterred him from standing for what he believed in.

It is a curious fact about conservative Republicans of this era, that they think the law applies to everyone but them. Abortion is legal, yet they try to interfere with it on a daily basis; legal access to abortion is the result of the political will, and is grounded in the American Constitution, yet conservative Republicans feel free to ignore the parts of the Constitution that don’t suit their prejudices; murder is the ultimate crime, yet they tacitly and actively encourage the murder of abortion providers. Many conservative Republicans feel that religion is so important that they attempt to defy the Constitutional separation of Church and State, yet they apparently have no problem violating the sanctity of a church to commit murder.

Terrorists always believe that the end justifies the means. Make no mistake about it; Operation Rescue and similar anti-abortion organizations are terrorist groups. They use the tactics of terror --- harassment, threats, and violence --- to impose their personal beliefs upon the rest of the country, which has explicitly rejected those beliefs. And while we’re being honest, let’s acknowledge that conservative Republican celebrities like Bill O’Reilly, tacitly encourage and support terrorism.

George Tiller was far braver than most of us could ever be. He believed that access to late term abortion is, in addition to a legal right, part of the reproductive freedom to which all women are entitled. He was willing to put his life on the line to defend that right, and he paid the ultimate price. He knowingly risked death to stand firm for his vision of healthcare. Who among us would be willing to risk so much for an abstract principle?

George Tiller was martyred by anti-abortionists, who, in addition to flouting the law, are foolish enough to believe that killing doctors will stop abortions. Of the million plus abortions performed in this country every year, almost all are first trimester or early second trimester abortions, and murdering Dr. Tiller will stop not a single one of those. Dr. Tiller was a specialist in late abortions, but there are other such specialists both here and in other countries. Anyone who had the means to get to Dr. Tiller has the means to get to the other providers.

What have the anti-abortion terrorists accomplished? They have revealed themselves as the terrorists they are. They have aroused the horror and support of Americans who might otherwise have little concern about abortion rights. They have strengthening the cause of abortion rights in this country. In other words, anti-abortion terrorists have accomplished absolutely nothing, except the senseless murder of a good man.