Category Archives: medicine

They Solved It! They Solved It!

Geriatricians have solved the hard problem of consciousness! From the July 1st issue of American Family Physician: “Some validated scales, such as Pain Assessment in Advanced Dementia…use objective measures to assess pain intensity and response to intervention.” The objective measures: abnormal breathing pattern, increased vocalizations, observed tension in the face and body, and capacity to be calmed by caregiver voice and touch. In short, agitation is synonymous with pain. And how do we know this? Because the researchers have observed that opiates attenuated agitation in their subjects with advanced dementia. That’s how the scale and its underlying assumptions were validated at once.
Many have questioned the utility of philosophy. Well, here it is. The PAINAD scale is valid, no doubt. This is something that can be determined by definition. If two different people observe the same demented patient, it is quite likely, predictably likely, that the observers will come up with the same score on the scale. But that begs the question. The real problem is not coherence. Coherence does not make truth. The real problem is the truth of the claim that agitation represents pain in a person with advanced dementia. Such information is not available to us, at least not in the defined, quantifiable way which we would prefer.
We can’t know anybody’s pain, really. That’s because it is everybody’s pain that gives us the concept of pain in the first place. The sensation I experience when I grab an electric fence, for instance supervenes on the action of the fence charger, the conductivity of my body and the ground, activation of peripheral nocioceptors, mediation by inter-neurons in my spinal cord, and finally my thalamus and cortex where it is contextualized as my very own experience of shock. My experience of the shock from the fence, indeed all my pain experience, is unique. In the case of a shock from the electric fence, my experience is trivially unique – to the extent that I can predict my friend’s response if I tell him why he shouldn’t touch the fence. But the pain-concept supervenes on all those unique experiences in the same way that my own experience supervenes on the collection of events surrounding my hand’s contact with the wire. A thing called pain doesn’t appear out of the process. If that were so, I should have ready access to it and the PAINAD scale would be unnecessary. I would just slap some electrodes on the patient’s skull and watch for the pain signature in his cortical electrical activity. But I can’t, nor will I in the future, though I might have such a tool. Cortical electrical patterns might be the narrow point in the pain experience, the place where the difference in my experience and the patient’s is most trivial. But I must still correlate the activity with some report from the individual or a set of individuals in a similar condition. Some kind of PAINAD-type analogy will always be the best that I can do.
So what does this application of philosophy to pain treatment tell me? What use is philosophy? First, it tells me that I should not expect to fix everyone’s, or anyone’s, pain by stimulating their opiate receptors. The experience becomes pain-type only when it is put in context. We can easily imagine pain experiences where the opiate receptors play a very different role. Take the poet’s description of the pain of a broken heart. Do we write off his report entirely as a quaint analogy as opposed to our serious ones? If so, how is his report effective in communicating a sense of the experience to us? What do we say when we find out that he used laudanum and found some partial relief? Addressing the mechanisms of pain can only go so far, because mechanisms only go so far in explaining the painfulness of an experience.
The application of philosophy to pain can save me from a different pragmatist’s mistake in treating pain as well. I’ll pick on my surgical colleagues for a moment. On multiple occasions, I’ve had a surgeon tell me, “Nobody ever died from pain.” Inevitably, this little bubble of wisdom surfaces in reference to a patient whose pain management has passed from the surgeon to myself. My knee-jerk response is to point out that nobody ever died from hip arthritis either, but surgeons are still quite happy to replace hip joints. Yet I understand the pragmatic meaning of the statement: people have died from opiate overdoses, so we can’t just capitulate to a person’s demands for ever-increasing doses of opiates to treat their pain. As noted above, the notion that simply stimulating opiate receptors necessarily fixes pain is misguided. But there is a subtext. Death is measurable. Respiratory suppression due to opiates does something, and therefore it is real in way in which pain is not. When you get right down to it, pain can be ignored. But it isn’t that easy. The human condition won’t be ignored anymore than it will be medicated. The hard problem remains hard. It isn’t hard because our subjectivity is some spooky ectoplasm or narcissistic property. It isn’t hard because our experiences will never move a dial or tip a scale. It is hard because things which explain and are explained have a reality to them as much as things which do something, yet we’re stuck working with the functional things, like the observed behaviors in the PAINAD scale. So we have a tightrope to walk. We can only ever come close to helping others with problems like pain, and only then if we act comprehensively. We can never completely succeed. But that doesn’t mean we must fail. We can just never get too sure of ourselves when we do something like suppress a demented patient’s agitation with an opiate – and think we can call it good.

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The Chthonic

It had a periodicity to it, but not like anything man-made. Instead, it was like a geyser. As it rose to the surface it swirled chaotically around hidden shelves and side-channels, so its interval was uneven. The uncertainty contributed to our tension, the nephew’s most of all.
“Yeeeeeeeeeee!” she screeched, then closed her mouth and relaxed again.
Between screams, she looked as peaceful as a Buddha. Perhaps, her caretakers speculated, the discomfort of prolonged immobility or some occult infirmity drove the screaming. We had given her increasing doses of pain medication, to no avail. Perhaps she somehow had enough consciousness remaining to experience the dislocation of facing the present without access to the immediate past, not knowing moment to moment how she got in the bed, why she felt like she did, whose arm lay at her side, whose mouth was screaming. We had given her anxiolytics and she just kept screaming. Perhaps she was bedeviled by visions. We gave her our best potions against inner demons and her timing did not falter.
“This is Hell,” said the nephew, “She is in Hell. I want this to stop.”
She had chosen well, or someone had. Sometimes, the decision about who would oversee the death defaulted to hereditary proximity, geographic factors, and availability. This nephew had some connection to her beyond practicality. Of course, he spoke for himself. No one knew what her vocalizations signified. We had taken our best guesses and come up short. What he wanted now was not a treatment. He wanted a cure for it all. To be clear, it was not euthanasia he was requesting. He wanted us to ablate whatever remained of her consciousness. He wanted oblivion, or at least its appearance.
It wasn’t killing, but it was taking something away from someone who appeared to have so little. We were always wary of treating extrinsic things, of giving medications to fix a person’s bad relationships or discomfort with herself. It was different for the dying though.
Everything was becoming extrinsic for her. She couldn’t be crying out for something. That time had passed. At best, her screams expressed something which we could not know, but something which was less specific, less relevant to anything inside, as she came closer to death.
He was right. The screams meant what he said: this is Hell; I want this to stop. I had an obligation to her and no choice in the matter. Of course he spoke for himself.
“I will do as you wish,” I said.

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Dr. Van Helsing Does Not Practice Primary Prevention

As recommendations for treatment of hyperlipidemia become broader and more generic, drifting toward the poly-pill conclusion, I can’t help but think of Dr. Van Helsing’s predicament in Dracula. In the story, though he has information which suggests the possibility of primary prevention, he practices secondary prevention. It is only after the symptoms appear – Lucy’s mysterious anemia and the rash of similar cases following her death – that the doctor suggests putting garlic around the windows. He has to wait. He’s in a story, so he knows the horrible truth all along, but he can’t reveal it without his patients sending him packing. Every doctor understands Van Helsing’s predicament. Few can see his patients’ logic however. It is one thing to indulge a crazy old man’s belief in vampires. It is quite another to indulge a crazy old man’s belief that a vampire has moved into the old mansion down the street and has begun to prey upon the household.
When doctors tell patients to treat public health problems, like cardiovascular disease prevention, on an individual basis, the patients take it as if they were being asked to put garlic around their windows because there have been vampire sightings in their neighborhood. They are slightly incredulous. And, the patients are right.
If we medical professionals are to treat asymptomatic individuals based on a 10 year risk calculated from epidemiologic data, for a disease which they have may or may not have started to develop, we must be honest with them. We have to admit that medication is the best that we can do, ask for their help, as a group, and then make it easy for them to help. Doctors don’t like to treat populations, though. Individualized care and patient centered care are the current watch words. But the greatest successes of medical science have been the opposite sort of effort. Nobody thinks that we should stop immunizing people for pertussis and move to an individualized prevention program with regular swabs for the pertussis bacteria and antibiotics for every runny nose. The approach is ostensibly patient centered, and it really is in a way, just like Dracula’s interest in Lucy and Mina is patient centered. Looking down from the established high ground, it’s easy to recognize the shift to an individualized strategy for preventing whooping cough as impractical and myopic. Medical professionals are clever enough to avoid bad moves from the general to the specific. However, decisions to move from a dysfunctional individualized program to a population based program can trip up anyone, even though the determining factors are the same.
The problem is Van Helsing’s problem. At the level of the vampire hunter’s interest, garlic around the windows is garlic around the windows. He’s like Dracula that way, for whom young ladies full of blood are young ladies full of blood. Dracula and Van Helsing are at risk of availability bias, cognitively and practically, as are all the physicians with lipid profiles, risk calculators and statistical correlations at their fingertips. There is a insidious, vampiric class of maneuver from population-based conclusions to individualized care. But the patients’ motivations lie outside of the action’s focus, and that focus is therefore myopic. It does matter to patients whether the doctor is asking them to deck the sills in order to cut down on the incidence of vampire attacks or because they should fear the vampire staring at them through the window. The latter request involves adopting an astringent manner of thought and behavior, the stuff of anxiety disorders. The former is an appeal to solidarity and public safety. We shouldn’t be surprised when the same people we’ve been instructing to fear the vampire outside their window come in demanding that we do something about the pale figure lurking behind their cough, in their prostate, or under their nipple. Having ceded the high ground, we’ve no credible response.

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The Word from the Land of Absolute Relativism

“Look at all this shit!”
He waved the stack of envelopes at me.
“Look at this one.”
He held up the letter on top. It was from another hospital and marked, ‘Important: Do Not Discard’.
“These are the ones you have to be careful to discard.”
He threw it in the wastebasket, and followed it with the rest of the unexamined mail. I was far enough into my training not to be shocked by this sort of thing. I’d weathered surgeon’s tirades and soaked up jaded, callous humor in the emergency room. Still, my experience with this psychiatrist had me believing for years afterwards that, in his specialty, like sought like.
“This kind of clutter is the enemy,” he continued, opening the top drawer in his desk.
He scooped out a handful of keys.
“Look at these! I don’t know what this is for,” he said, holding up a sturdy door key. Into the bin it went.
He tossed a few more, then dumped the remainder back in the drawer with an expression of disgust.
“We’ve wasted enough time,” he declared, “better show me the case.”
I handed him the chart, with my history on top. He lingered on the assessment at the bottom of the page. Residents sometimes began to sweat when attending physicians paused too long in their documentation review. I did not in this case, because the assessment was not mine in the first place; the patient brought her diagnosis with her from the last admission. He grunted and moved on to the ancillary notes, containing the comments from psychiatric nurses who had evaluated the patient.
“Jesus Christ! Did you read this?”
Now I began to sweat. I hadn’t read the nurse’s notes. He handed me the chart with a shake of his head. I’d gotten lucky; the question was rhetorical. Curiosity displaced my anxiety and I began to read with interest. Immediately, I realized what he was on about.
At the bottom of the page, several of the nurses (a cabal?) postulated that dark forces were at work in the patient’s life. The assessment dwelt upon the young lady’s practice of witchcraft, not as an expression of alienation in a personality dangerously adrift, but as an activity with sinister efficacy. I looked up at him as I finished reading.
“How can we hope to do anything for the patients when we’re up against this kind of stupidity from the staff? Borderline,” he stated, returning to my assessment, “Do you really believe that?”
I shrugged. She had the black nail-polish sign, which every trainee knew was pathognomonic for borderline personality disorder.
“There are some people that fit the bill, but mostly the term is an epithet applied to people who we don’t like because they are frustrating. It’s the DSM used as a cudgel, and it justifies our bringing these people into the institution when their community becomes too frustrated with their behaviors. They come in for a few days or a few weeks until they’ve cooled off, then they go back out with the same problems, to the same problems. So this kind of inpatient treatment is like firing into the tree line: it’s good for keeping the enemy’s head down, but it’s not good for hitting anything.”
His words were familiar in structure and reference. At home that evening, I poured through my memory and my boxes of books, and I eventually placed them. They recalled an image from Heart of Darkness.

Once, I remember, we came upon a man-of-war anchored off the coast. There wasn’t even a shed there, and she was shelling the bush. It appears the French had one of their wars going on thereabouts. Her ensign dropped limp like a rag; the muzzles of the long six-inch guns stuck out all over the low hull; the greasy, slimy swell swung her up lazily and let her down, swaying her thin masts. In the empty immensity of earth, sky and water, there she was, incomprehensible, firing into a continent. Pop, would go one of the six-inch guns; a small flame would dart and vanish, a little white smoke would disappear, a tiny projectile would give a feeble screech – and nothing happened. Nothing could happen. There was a touch of insanity in the proceeding, a sense of lugubrious drollery in the sight; and it was not dissipated by somebody on board assuring me earnestly there was a camp of natives – he called them enemies! – hidden out of sight somewhere.

The image stuck and grew stronger over the years until I ceased to see my preceptor as chief among madmen and came to see him as Marlow on the boat. He was the lone relativist in a wilderness of absolutists who considered borderline personality more than a label on a charge sheet (it is that at least, for the Diagnostic and Statistical Manual which codified the term is a tool intended to itemize mental illness for billing). For his fellow wardens of the institution, there existed a borderline personality fact about certain people, caused by borderline personality pathologies and amenable, potentially, to borderline personality treatments. He saw them firing into a continent. He did not, of course, live in the land of absolute relativism, where everything is an onion made of layer upon layer of motives and relations with no pertinent core. He believed in borderline personality as a country over yonder. It recognized certain commonalities, but those commonalities arose in the villages. They accrued; they did not come down from on high.
He cared about how seriously the nurses, psychologists and patients took diagnoses, not because relativism was true. He cared because absolutes did not obtain. Worse, absolutes destroyed. On occasion, bullets fired into the tree line did hit something, and that something was an enemy by definition. Over his career, he’d seen victory declared over schizophrenia and the state institutions emptied onto the street. He’d seen the profession take a pass on intractable diagnoses, like personality disorders. He’d heard from his predecessors about neurosurgical solutions considered quite successful in their time. It wasn’t that relativism was true, it was just that truth didn’t work that way. It wasn’t diagnosis-friendly, and the truth about psychology all the less so.

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12/22/13, 0200

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When I came back from the emergency call, I expected to find her drinking. She had been upset with me, with her job, with something big and shadowy which I had been trying to get her to describe for the last year. Actually, I hoped to find her drinking. Sometimes she got drunk and wandered, or drove, off and I had to go looking for her. I couldn’t afford to do a search that morning; I was on call.

Her car was in the driveway, but she was not asleep in our room. That late, there was one other place in the house to check. In the early hours, she liked to sit downstairs and watch the fire when she was feeling agitated. I walked down to the basement and there she was, sitting on a cushion in front of the wood stove. But her posture was wrong, and then I noticed the rope and saw that she was not sitting on the cushion, but was suspended a few inches above it. I ran to her and slipped a finger through one of her belt loops, but the stitching popped loose as I began to lift. When I did manage to lift her I heard no in-rush of air. In that moment, I knew that we had lost, me and her. I couldn’t accept it right away though; I had to try to get her back. I dithered for a for a few moments. To cut her down, I would have to let her weight come back on the rope. I knew I would not outlive that act. It took every speck of my mental discipline to let her hang again. I severed the rope and went through the motions of resuscitation, with the expected results. I’ve been going through the motions ever since.

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I spent seventeen and a half years with her. We met in medical school during an Ob./Gyn. rotation. After a prolonged reconnaissance, she talked a mutual friend into approaching me. The friend, a traditional woman who’d immigrated from Vietnam as a child, had been instructed to ask me if I was: 1) gay 2) married 3) in a relationship. All that came out was the question about marital status, mumbled quickly with eyes averted. Though it lacked the impact of the full set of questions, the inquiry was strange enough. It was strange to have any woman show any interest in my relationship status, period. I’m not exactly what most women would consider a “catch”. I cut my own hair. My nose has been broken on several occasions, and let’s face it, the thing sticks out enough in the first place to be at risk. Attempts at orthodontia undertaken during my childhood were not entirely successful. And although I’ve suffered from loneliness, much of it has been the consequence of a solitary temperament. Besides, I’m a climber, and so quixotic. Maybe my wife recognized a shared vision in that last quality, but if so we were probably ill-matched. She may have been better off had she chosen Sancho.

She was an artist. At the age of five, her parents caught her in the garage coloring in the fender of their new car with a crayon. The car was the wrong color, and she intended to fix it. As an adult, she spent a year trying to paint a scene from a photograph of Mt. Columbia. I tried to talk her out of it. The intriguing things about the photo were its detail and flatness. The brain could see different depths in the scene because the camera didn’t commit to any one perspective. The conventions of painting did not permit the same insouciance. She kept at it until she had a damaged trochlear muscle in her eye from looking back and forth from the photo to her painting. When she finally gave up, it was with a sense of bemused fatalism. Failures and frustrations brought up a black bile in her. My bile was always yellow.

When I had to forego climbing opportunities or persist in a profession which I have always considered ethically bankrupt, I boiled. I never got angry at her. On the contrary, she was my solace. But living in the same space as a whistling kettle begins to wear on a person. She finally set me straight. I got the parts of my life teased apart, once I realized that they must be kept apart or else destroy each other. As a climber who values climbing’s unitary action, the admission was difficult. I had to concede that, despite my wishes, all was not climbing, and acknowledging that all was not climbing did not invalidate anything.

She accomplished the turn-around by convincing me that some sentiments are irreconcilable. Feelings of frustration with everything, and so nothing in particular, real expectations based on our ideal desires of other people – and the same feelings toward ourselves – must be accepted as absurdities about us and byproducts of conflict within each of our identities. We cannot bring those feelings into line and make them reasonable in context of anything that we signify. She convinced me, but I could not do the same for her.

Since her death, I have had two dreams about her; the first, two days after I found her and the second, the day after I came back from the undertaker. I usually don’t remember dreams, but these were bad enough to intrude into waking memory. The first was a straight forward nightmare. She was sitting on the cushion in front of the fire with her eyes closed, crying. The tears were black and she just kept on crying them though they ate into her eyes and face.

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In the second, I had just walked into the house and she was standing in the kitchen. She was older and taller than she had been in life, and she was smiling. She began to explain that she hadn’t really died, she had just staged an elaborate ploy to get away and sort things out for herself, and it had worked. She said she was sorry for the trick; there was just no other way. I started to forgive her and asked what she wanted to do now, what she wanted to do differently. But as I spoke, I noticed that she was standing partly inside the counter and her eyes were sad. My arms felt heavy then, and I looked down to see the box of her ashes in my hands.

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The Dry Cat Food Paradox

So close, yet so far...the Tetons

So close, yet so far…the Tetons

I’ve recently had the privilege of attending a continuing education conference in Jackson, Wyoming. As a climber who thinks of himself as primarily an alpinist headed to the Tetons, I should have felt like the proverbial cat who ate the canary. Instead, I left my gear in the basement. It wouldn’t have fit in the car with all the ski equipment and clothes anyway (the whole family of four was signed up for the trip). It wouldn’t have done me any good even if it did fit. Four months out of the year, those mountains are shut down due to a horrendous snowpack. When conditions allow, the climbing is still high up and far back.

It turns out that it is almost as hard for a climber to subsist on Teton routes as it is for a cat to live on hunted birds. Signs of compensation for these difficulties were everywhere in Jackson. Right around the corner from the conference center, was a sign for the “Teton Ice Park”. When the first morning of lectures ended, I walked up to take a look. What I saw was the result of  a noble effort, but one obviously born of desperation. An enterprising guide service had run a few hoses over a 40 ft. retaining wall to produce about five, moderately-angled chunks of ice. The ice park rented gear, but I decided to utilize a different compensatory facility – the climbing gym just outside of town. It turned out to be quite nice.

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Back in the conference center that evening, I was mulling over the dissonance of indoor climbing in the Tetons when the next set of lectures began. Maybe I should have been paying better attention to the speakers. However, it was a series about nutrition, and though the subject is interesting, the hard science behind it could be covered in about fifteen minutes rather than the three hours allotted  As I considered my Teton climbing experience, I kept coming back to the viewpoint which kept me in the Black Hills for all these years: alpine climbing is more about training than actually climbing. Adaptation to harder routes in the mountains paradoxically required less time climbing mountains. Living in a place like Jackson resulted in strong legs and weak skills. Unless a climber availed himself of  an artificial training facility, the volume of technical climbing needed to improve was just not accessible, at least to anyone with a job. My mind wandered back to the lecturer. He was talking about the Paleo Diet and I found it strangely relevant to the contradictions involved in trying to be a good alpine climber.

Guide service storefront.

Guide service storefront.

This diet is supposed represent our nutritional heritage. It encompasses the type and mix of foodstuffs our hunter-gatherer ancestors adapted to eat. Therefore, runs the logic of the diet’s proponents, it is the mix of foods that we ought to eat to  maximize our health and longevity. On the menu is lots of meat and a few plants. Grains and legumes are out. We should eat more like cats than cows, the speaker admonished. To back up his assertion, he flashed a slide on the screen with a picture of a cat at the top and a chart favorably comparing the body compositions of hunter-gatherers with those of cats.

The picture looked a little like my cat, but my cat thrives on dry cat food. I say “thrives”, because I have a dietary comparison-state for her. She was a stray who showed up in our garage when the weather got cold. Before coming to live in our house, she had, in fact, been subsisting on the cat version of the Paleo Diet – fresh, free-range mouse and bird meat. She wasn’t doing so well. She was thin and listless. After a few weeks living inside and dining on kibbles, however, she was tearing around the house like a maniac, destroying rolls of toilet paper and climbing the curtains.

Here are the first four ingredients listed on her cat food label: chicken by-product meal, corn grits, chicken fat, tuna, brewer’s rice. One would expect a wild cat to catch birds, but I doubt one ever took down a tuna, much less an ear of corn or rice. Still, a cat’s ability to live a long and active life eating nothing but rock-hard brown morsels shouldn’t surprise us. Evolution makes the most  of things, not necessarily the best of things. Wild cats developed the capacity to survive on mice and birds. Cats are therefore well suited to that diet. That doesn’t mean that there isn’t a diet better suited to cats. Perhaps humans are much the same.

A subsequent  slide showed a Kung! tribesman butchering an antelope with a stone tool, and then a chart with cholesterol levels and heart disease rates demonstrating the sterling health of various modern hunter-gatherers. Unfortunately, the health data for the Tarahumara, a group of indigenous people living in Mexico and renowned for their feats of long-distance running, look just as good. The Tarahumara subsist primarily on corn, beans, chiles, and beer.The answer to this dietary conundrum is not found in the diet, but what comes with the diet. Both the Kung! and the Tarahumara are incredibly active, and they do not suffer from surplus. The Paleo diet is not the answer to our health problems. No such simple answer exists.

Of course, there are limits imposed by natural adaptation and on artificial adaptation. Artificial answers are also incomplete. To be a good alpinist, one must climb a certain number of big routes in the mountains. But plate after plate of summits will limit a climber’s potential in the end. Though it isn’t complete in itself, some artifice is required as well. Likewise, when my cat came to live in the house, she didn’t just get dry food, she got a warm, stress-free place to sleep, immunizations, and anti-parasitic medicine. I’m sure she would not be so healthy if we limited our involvement with her to setting out a plate of kibbles on the driveway.

Of the billions of humans alive now, most are suffering from the short-comings of an agricultural, and subsequently an industrial, society and a few are suffering from its excesses. As the most realize the economic, social and technological benefits which drove the move to agriculture in the first place, they no longer get the grace period which the few enjoyed. The harms of excess come right along with the initial development. We can’t simply go back, though. Solutions will require some artifice, and may have an unsatisfying appearance – less like grass-fed beef  and more like a bowl of dry cat food or an indoor climbing gym in the Tetons.

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Cult of the Range-Fed Turtles

When my best childhood friend grew up, he decided to become an archaeologist. During his graduate training, he was in charge of  a dig in the Mississippi river valley which unearthed an odd structure. In the midst of the native people’s dwellings, was found a circular enclosure made of closely spaced wooden posts and containing a large pile of turtle shells. The undergraduates were eager to speculate about the purpose of the structure, but my friend cautioned them against it.

“We can’t be sure of its use,” he said”, and we can’t just guess based on what we might use an enclosure like that for today. We can’t just assume they were running a turtle ranch here. Why would they do that with a river full of turtles just a quarter-mile away? We have to put it in context of the surrounding village and the environment of the time, look for other examples and see if there are any modern structural analogs. Then we can make a guess, but it will still just be a guess.”

The next day the professor in charge of the dig came around on a rare site visit to see how things were proceeding. The students were eager to show him the mysterious ring of posts with its pile of shells.

Upon seeing their find, the professor remarked without hesitation, “Huh, must have been a turtle pen,” and promptly resumed his walking tour of the dig.

I don’t know if archaeology has an excuse for this kind of thinking, but medicine does:

Life is short. The art is long. Experience is difficult.

– Hippocrates

We can be forgiven for resorting to teleological assumptions now and again in medicine. With limited time and incomplete information, we must sometimes act on hypotheses which attribute function to structure and purpose to processes. Lucky for us, there’s plenty of slop in the system, so even if we’re wrong at the start, we usually get a second chance. We are trying to get away from teleology, though. “Evidence based medicine” and “scientific medicine” are the names that we have given that effort.

We are trying to get away from teleology because we have been burned by it. We thought that the body made pus to fight off bacterial infections, so for years, when we saw people with respiratory illness cough up phlegm with pus in it, we gave them antibacterial medications. We were wrong, not just about the purpose of pus, but in attributing a purpose to pus. Again, it was an understandable mistake, given the long history of debate regarding the merits of pus. Was it a good sign, or a bad one? Should we encourage or discourage its formation? It turns out we shouldn’t have been focusing on the pus at all, but on    the outcome of our purposeful intervention in the underlying process that produces the pus.

Purposeful results and final causes apply prospectively to human endeavors alone, and even there it’s often difficult to tell whether, when our actions are associated with the desired result, the outcome is due to our actions or simply due to fortuitous circumstances. Applied retrospectively or to processes and structures beyond our control, teleology is a sure mistake.

When we assign an endpoint to a process, we presume causation and correlation must be proven. Humans are notoriously bad at that. In systems which we can’t duplicate or control, we can always tell a causal story (I’m looking at you evolutionary psychology, intelligent design, cosmological fine tuning). But those stories are just interesting rationalizations, sharing the merits of a fairy tale in that they reveal more about us than the subject matter. Our fairy tales are harmless when they are about the universe, the origin of life, turtle ranches or anything else beyond our control. When we tell teleological stories about processes we do seek to influence (and can) we court tragedy.

The practice of bleeding was based on one such tale: the story of homeostasis. We still tell it today, but we tell it as metaphor instead of fact. The story is based on the simple observation that, when a person becomes ill, they go through a series of changes in their physical state which ultimately ends in either the restoration of their previous state, or death. Having observed other systems, the Greeks thought that the process of illness looked like a disequilibrium. Having observed associated changes in fluids which emanated from the body, they attributed the disequilibrium to an imbalance in those fluids. We can hardly blame them for the limits of their observations. We can’t fault their hypothesis. However, we can fault their method.

They didn’t just postulate an imbalance in the humors as a cause of illness, they presumed a balance of the humors as a state the body sought. The difference in these two points of view is subtle, but crucial. If  the balance of fluids is seen as descriptive  then restoring health by balancing the fluids remains a working hypothesis. It admits that other factors may determine the observed equilibrium. It leaves open the possibility that the observed flux of humors is a secondary phenomenon. Most important, it leaves physiologic equilibrium as a simple description, instead of presuming that it is a purpose with causal powers.

Given a description and a working hypothesis, physicians would look at their efforts to balance a patient’s humors with a critical eye. As a teleological assumption, with equilibrium as a “final cause” under Aristotle’s system, the idea creates an entirely different viewpoint. With  humoral balance rooted in the body’s design, variances in expected observations must be due to inadequate methods or incomplete knowledge of the humors. For this version of the “balancing the humors” hypothesis, failure is not an option.

Now, the ancient Greeks may have weathered this kind of assumption better than their heirs. They loved to fight with each other. In the face of inconsistent outcomes from humor-balancing interventions, they were likely to call Aristotle and Hippocrates idiots or just ignore the under-girding theory of causes altogether in favor of their own pet theory. Definitive statements naturally took a healthy beating in the Greeks’ intellectual environment. The Romans, and the Europeans who came after them, were much more pious.

As a result, no one questioned the teleological assumption, out of reverence for its sources, and the vital fluids persisted in medical thought owing largely to the idea of homeostasis by design. No matter how apparent the flaws in our understanding of the blood, bile and phlegm, they were somehow attached to the homeostatic goal of the body. As long as physicians saw that equilibrium as the body’s goal, they could reconcile any discrepant observations with the over-arching story and persist in practices such as bleeding. It fell to investigators outside of the medical profession to discover the secondary nature of the humors. Only then did the practices aimed at balancing the fluids truly begin to fade.

But long after bleeding and the balance of fluids fell by the wayside, the tale of homeostatic purpose continued to plague medical science. Physicians continued to view physiology as directed toward an end. For example  the heart was seen not to pump blood, but to be a pump. Therefore, medical students were instructed to never administer medications called beta-blockers to patients with heart failure.

Beta-blockers stick to proteins in the membranes of  heart cells called beta receptors, which normally bind adrenaline. Via the beta receptor proteins, adrenaline stimulates the heart to pump faster and with more force. In heart failure, the heart can’t contract forcefully or fast enough to keep up with the volume of blood returning to it from the veins. If the heart is a purpose-built pump, beta blockers should be anathema in the setting of heart failure. But in reality, when given to stabilized heart failure patients, beta blockers reduce long-term mortality by about one-third.

We don’t yet know exactly how these medicines achieve such a feat. We do know why they are not inevitably detrimental in heart failure. It is because the heart pumps, but it is not a purpose-built pump. The heart is instead a group of cells which inhabits a specialized niche in a system of many cells all with complimentary and competing characteristics, existing in a state of equilibrium which, in deference to tradition, we call homeostasis.

Our physiology doesn’t try to maintain homeostasis any more than erosion tries to form a natural arch. The arch forms (rather than crumbling like the sides of a stream-bed) because it is geometrically stable given the geology. The arch persists because it is geometrically stable, and so we frequently see natural arches where the climate and geology allow. Nobody marvels at this, speculating about a conspiracy between sandstone and weather patterns. Then again, few people have an emotional stake in natural arches. The same is true of our physiology, minus the low stakes. There is no overall homeostasis sensor or hormone in the body. There is no homeostasis conspiracy.

So, we have abandoned the notion of purpose in physiology, and that simple maneuver has allowed us to discover things like the survival benefit which beta blockers produce in heart failure. This move is the principle behind the randomized, controlled clinical trial. All along, it wasn’t ignorance holding us back, but the project of rationalizing our knowledge to traditionally understood, teleological models.

Of course, the questions driving evidence based medicine don’t start from nowhere. Scientific medicine asks questions based on the results of previous investigations and hypotheses derived from basic science discoveries regarding the components of physiology and their relationships. Some of these hypotheses are even most easily stated in terms of purpose. But those statements are now understood as metaphor, rather than bare fact.

Beyond the fecundity of this change in method, the move away from teleology finally brings some redemption for poor Hippocrates. Rather than using it as an excuse, we can understand his aphorism, “Life is short. The art is long. Experience is difficult “, properly again – as an admonition about method. Be skeptical. Remember that your viewpoint is limited. Watch out for overarching narratives. Good advice, and not just for medicine, but for all those turtle-ranch theorists out there (I’m looking at you intelligent design, cosmological fine tuning, evolutionary psychology…).

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There’s a Pill for That

While waiting for labs with me in the ER yesterday, a younger colleague made an offhand comment about quitting medicine. She felt frustrated because, instead of helping people get over their health problems and get on with their business, she spent her time treating public health problems in the clinic and emergency room. Even worse, she had begun to feel complicit in the distortion. I didn’t know whether to offer congratulations, condolences, or both. Most medical professionals never get that far. They continue to feel good about encouraging dialysis for blind, depressed diabetics with one remaining limb and prescribing cholesterol-lowering medication to nonagenarians. Thereby, only the superficial dissatisfactions of their jobs remain.

I don’t think that doctors should feel guilty about the public health problems confronting them in clinics. Nobody planned for our society to fail us. We spent so much of our history working so hard to make life easier and more certain that we just didn’t notice when we started working harder and harder to make life easier than we needed. The illusion of increasing certainty helped us zoom past the point of diminishing returns. Once enough surplus accumulated to ensure against starvation, twice the surplus seemed to offer twice the insurance against shortage, but the excess would only mold and spoil the lot. Our surplus is spoiling in us now, clogging our blood vessels and glycosylating our nerve fibers.

A solution to the problem lies beyond the scope of clinical medicine. The only solution may be time and economic dissolution. The furor over limiting soft-drink sizes in New York City does not bode well for self-conscious alternatives. But medical professionals can feel bad about their complicity in the whole scheme, because our business is to tell people that there’s a pill for all that.

We tell the public that we can “treat” and “manage” diabetes, coronary artery disease and heart failure. The proper terms would be “attenuate” and “temporize”. The proper terms would imply a lack of control however, and a sense of control is what we’re selling as much as medication or surgery. We keep the illusion of control on offer in the name of comfort. We want our patients to feel free from anxiety about their health. They should feel empowered, and they do, which is good since they will still be physically ill under treatment, just a bit less so than when they consulted us.

I guess there really is a pill for surplus-mold, at least on a psychological level, but it will cost those who take it a lot of money, and the motive to seek out the roots of their ailment. Besides, it will keep the doctors feeling good about something they shouldn’t be doing. It may appear to buy some time, but it won’t cure anything.

You Eyeballin’ Me?

ATTENTION

ATTENTION

An older gentleman lay on the gurney. His son had brought him in from the ranch suffering from abdominal pain. I pushed on his liver.

“Does that hurt?”, I asked.

“Well,” he replied after a moment’s reflection, “it ain’t sore, but it is a little tender.”

Attention

Attention

Tender, not sore. Twelve years and I still don’t know what the hell that means. A former colleague grew up in Wyoming, and since she habitually spoke more than three words in a day (not including ‘Yep’ and Nope’) I asked her a couple of times to explain it to me. She just looked annoyed and said it didn’t matter. I finally understood that she was right. The difference between sore and tender is clinically irrelevant.

attention

attention

‘Tender’ does not have any distinct denotative value, only a connotative one. It still bothers me not to understand its meaning. I’d like to think language can give me a working knowledge of other people’s thoughts and feelings. My expectation of understanding is not realistic. Symbols and their associated concepts just approximate the sets of unique experiences that constitute our shared mental universe. It’s all a big analogy of me to you, words or no. While imprecise, the analogy has one great advantage: it is durable. I may not be able to compare my experience of tenderness to the rancher’s to any good effect, but I can achieve a dialog with the dogs.

Attn.

Attn.

I can even predict the salamander’s response to me looking at it and it can anticipate my response to it clawing at the glass. All of us know our perceptions of each other are about something, which allows us to form these relationships, however vague and riddled with projection they may be (though the salamander does not beg food from people who are not looking at it or objects moving outside the glass, it does respond to the cat staring at it and she is surely looking in with a different intent than it understands).

Attention

Attention

I’m pretty sure I share an extensive mutual understanding with the mammals in the house, even the ones with ear-buds. I’m less confident about what passes between myself and the slimy monsters in the terrarium, but after a day of contemplating human tenderness with all its consequences and deficiencies, an amphibian’s intentional stare is the most reassuring.

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Carnival of Adverse Selection

A Canadian friend once told me that he did not understand the American political system and asked if I could explain it to him. I told him that it was basically an exercise in pest management. On the one hand you have your smarmy rats (Democratic politicians) and on the other you have your vicious rats (Republican politicians). The first kind you don’t even want near you, the second kind you just want to stomp. Either way you’ve got an intractable rat problem, so mostly you just try to ignore them as best you can and get on with your life.

Sometimes though, they crawl across the kitchen counter in broad daylight and then you have to pay attention to them. That happened to me during the last Presidential debate. I was doing my best to ignore it, but we have a radio in the garage with a power switch stuck in the ‘on’ position and the debate was playing in the background. I had it successfully tuned out until they started talking about health care and Romney, who’s turning out to be a particularly nasty little ankle-biter, came with the crazy talk.

Here’s what he wants to do about health insurance:

  • Block grant Medicaid and other payments to states, limit federal standards and requirements on both private insurance and Medicaid coverage. The state can structure a cost-share program however it wants?  It can still shift costs to the Emergency Rooms of Medicare-participating hospitals and to the Medicaid programs of richer states (a kind of internal ‘self deportation’ which already happens to a limited extent)? I can’t imagine what the states might do? These changes are supposed to lead to innovation, and they will – just more the sort of innovation that financial system deregulation allowed.
  • Unshackle Health Savings Accounts by eliminating the minimum deduction requirement and allowing people to use the account funds to pay premiums. HSA’s are a nice product for a very limited income range. If you make too much money or too little to make the tax savings worthwhile, a HSA makes no sense. The proposed changes won’t change that. So, why make the changes? Hang on a minute, I’ll get to that.
  • Allow consumers to purchase insurance across state lines. Recall this is the now minimally regulated insurance product. Watch the insurance companies gobble each other up as they try to recruit all those newly available good risks. Watch high risk people get filtered out of the broader  insurance pool as the generous benefit plans become increasingly burdened with these individuals, and the prices for those plans go up and up, in turn prompting lower risk people to leave for cheaper, less generous benefit plans. Will Romney & Co. adequately fund a reinsurance plan to keep this from happening? Not to worry, people with chronic problems can still go to the ER, right? People can preemptively accomplish this adverse selection themselves via purchasing pools, right?
  • Medicare will become a premium support program. The premium support and benefit requirements will be fixed at the current levels in Medicare. If costs go up, the market will determine how people make up the difference. And in time, like gravity takes care of shoddy construction projects (who really needs architects or building codes), the market will take care of things by channeling the high risk people into the more generous plans (Medicare), driving those plans’ costs out of sight and eventually, driving those plans and high risk  people out of the market. I can almost hear the invisible hand slapping – see adverse selection and cost shifting above. (It’s actually worse than that – Medicare has a normative effect that goes beyond its simple economic effects but that is a story too long and tangential for the moment.)

So, why make the changes if they entail all these predictable distortions? Free market fundamentalism is the answer. Markets aren’t a highly effective tool for these guys, they are a moral imperative. So in their view, markets must be good for every application. Just set up a market and have faith; it will solve any problem. Regulation and critical analysis aren’t caution, they’re apostacy. I’d usually ignore this crap, like I ignore people praying for rain, but this is more like praying that your kid gets better from leukemia in lieu of consulting an oncologist. I feel like I’ve at least got to say something.

So, for all who wondered what could be worse than Obamacare – it’s this happy horse shit. These two rats are scampering across the counter in broad daylight with this mess, and they need stomping, (metaphorically of course).

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