Over the past year in the world of psychiatry there has been a small hubbub about a book that was released last April entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Its author is Robert Whitaker, a science journalist who has an expertise in issues involving psychiatry, having written a previous book entitled Mad In America: Bad Science, Bad Medicine, and The Enduring Mistreatment of the Mentally Ill. The gist of Whitaker's book is that the very treatments used for psychiatric illness (that is, drugs) for the past generation may, in fact, be driving the epidemic in the first place, prolonging and worsening psychiatric symptoms.
Needless to say it is a provocative hypothesis, but for the most part it has not yet taken hold in the collective consciousness in the manner of Rachel Carson's Silent Spring, to which vague comparisons could be made. As of now it ranks only 19th in the amazon.com category for "Mental Illness," being edged out by such books as Will I Ever Be Good Enough? Healing the Daughters of Narcissistic Mothers as well as The Sociopath Next Door (which particularly sounds like a remarkably silly book). Part of its modest showing has to do with the media coverage, mostly limited to smaller outlets such as Salon and New Scientist; a local NPR station in Boston covered Whitaker's address to the department of psychiatry at Harvard earlier this month. Time had a brief dispatch, and The Boston Globe published a review, somewhat oddly, by a pediatrician specializing in lung and sleep disorders. Without the media flap, the book's sales appear to have faltered.
This last review by Dr. Daniel Rosen is particularly interesting because he finishes his review, which roundly criticizes Whitaker's contentions, by making a dark allusion to the dangers of agreeing with Whitaker's thinking. "Thabo Mbeki [the president of South Africa at the turn of the century] refused to accept that AIDS was caused by the HIV virus, believing instead that it was a side effect of malnutrition and the medications used to treat AIDS itself," Rosen noted. "Those who would seize the opportunity to cast psychiatry as a discipline into the rubbish heap without consideration for the benefits it has brought to so many would do well to remember how Mbeki’s inability to distinguish between theory and fact exacted such an enormous toll in human life and suffering."
It's an interesting little maneuver because, without explicitly saying so, Rosen essentially proclaimed that Whitaker's book belongs to a completely different class of book than the kind a reader would naturally assume he was discussing, which is to say that Rosen was accusing Whitaker of writing dangerous nonsense rather than acceptable heresy. And the two categories are as different as they could be in the world of science and medicine.
The typical mechanism of scientific progress relies on the establishment of heresies. Let's say we have some model about how stomach ulcers come into being: people think that it's related to stress, and doctors who read the literature prescribe a bland diet and tell people to chill out. Then along comes someone who's been doing biopsies of patients with ulcers and reports a new bacteria that's pretty much impossible to grow, but is clearly there, and thinks that it's this weird new bacteria, and not a stressful lifestyle, that is the cause of ulcers. This someone--after doing further research on his little bacterium--writes papers, gives talks at various conferences, and essentially argues with the scientific establishment that he's right and the old way of thinking about ulcers is wrong. Eventually, enough people are convinced by his data and adopt the new model. What I've just described actually happened and involves the discovery of the bug Helicobacter pylori by Dr. Barry Marshall in Australia in the early 1980's; by the late 1990's the H. pylori model was universally accepted. It's what you'd call standard, acceptable heresy, and science thrives on such a process.
The problem that very simple-minded people frequently are unable to appreciate, however, is that just because science works by overturning conventional beliefs, it doesn't mean that anything goes, or that just because some theory isn't shared by mainstream scientists, it must by definition have some merit. So a lot of writers and thinkers of science distinguish this form of thinking from "acceptable heresy" by regarding it as "dangerous nonsense." In the world of science, the two most dangerous forms of nonsense is that a) evolution isn't really true, and b) man-made global warming doesn't exist. In the world of medicine, the two would be a) vaccines cause autism, and b) HIV is not the cause of AIDS.
Which brings us back to Dr. Rosen's comparison of Robert Whitaker and AIDS denialists: it's Rosen's way of telling people that they shouldn't even bother, that Whitaker's work is not acceptable heresy, but rather dangerous nonsense. And Whitaker got the point of that right away: he posted a same-day reply in his blog at Psychology Today decrying that particular rhetorical trick, calling it "a bit over the top" in what wins points for remarkable restraint.
The question is: who is right? Should we agree with Dr. Rosen, think of Whitaker as a purveyor of dangerous nonsense, and throw it on the ash heap of silly attacks on medicine, or should we give Whitaker's argument a wide berth and read his book with care? For me, this is not an idle question as I haven't read the book, and I've been wondering whether I should put it on my reading list, and if so, how high should it go?
The answer is that I think Whitaker's probably solidly in the camp of acceptable heresy (which doesn't mean I think he's right, only that I am taking his contentions quite seriously). Anatomy Of An Epidemic is going on my reading list, and may go pretty high, for at least three reasons:
a. Whitaker clearly did his homework. One doesn't need to have a Ph.D. in statistics, or be a psychiatrist, to see that Whitaker researched his subject thoroughly, and for me that counts a great deal. Far too often people hostile to science rely on clinging to single studies as proof of their rightness. Whitaker sought to undertake what appears to be a comprehensive survey of the literature and ask the singularly heretical question is all of our modern therapy making a difference for the better? But even a causal glance at the reviews makes clear that he has done due diligence in trying to assess what the entire field knows. It's entirely possible that his interpretation of the data is flawed, as psychiatrist-blogger Dan Carlat thinks (part 1 here and part 2 here), but he isn't cherry picking data in order to further his pet theory, an intellectual strategy that drives me nuts.
b. Studying outcomes in psychiatry is a tricky business. One of the reasons why AIDS denialism is dangerous nonsense is because it's really not that hard to follow the progression of HIV viral load through sickness and death. In other words, outcomes are pretty clear. I have personally witnessed what happens to some patients who have stopped taking their antiretrovirals (small, nonstandardized nonexperimental data to be sure, but persuasive data nonetheless). In other fields, like cardiology, studying the effect of this-or-that drug is comparatively easy, because you are often measuring death as the main outcome, which as outcomes go is pretty fixed. In psychiatry, by contrast, outcomes are much more slippery: "feelings" are notoriously hard to standardize, and even in more severe cases such as schizophrenia, I remain skeptical that you can easily and cleanly reproduce results in clinical trials. As a consequence, I'm inclined to listen to multiple interpretations of effectiveness data, including those that question the value of the entire enterprise--and I'm inclined to listen to it in a way that I wouldn't if I hear an attack on HIV meds, for which there is far too much data to suggest anything other than their effectiveness.
c. Other people whose opinions I respect think highly of him. It's of course the weakest of the three reasons, but still counts for something. Particularly when one has to deal with sorting garbage from gems, it helps to have a trusted figure offer their two cents. E.g. Carlat: "[Anatomy Of An Epidemic] is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment. Put it on your reading list, and join the debate."
It is, and I will.
--br
Sunday, January 30, 2011
Saturday, January 22, 2011
HIPAA, Medical Writing, and the Problem of Disclosure
Recently I saw a patient whose case I very much wished to write about, but as far as I was concerned she was off limits. The problem was that the particulars of her case could allow readers to figure out her identity without too much effort. Although "Billy Rubin" is a pseudonym, I don't zealously guard my pseudonymity, and an intrepid reader could figure out not only my actual name, but the hospitals where I work, and if anyone in the area of that hospital happens to read about a patient whose story is unusual, it won't be hard to connect the dots, and voilรก, I have just casually violated this patient's privacy. Without discussing the particulars of her case, there was nothing to discuss, so I shelved the idea.
My own policy about writing about patients follow these rules:
Jerome Groopman is one of medicine's more famous writers, and his most recent book is How Doctors Think, a book that delivers on its title as an explanation of the kind of reasoning that drives medical decision making from the doctor's perspective. I have a few quibbles about the book but it's a very good read for both physicians and laypeople. That said, he starts out the book by illustrating a case of a woman (whom he refers to as "Anne Dodge") who lives in western Massachusetts. She had been progressively losing weight and given the psychiatric diagnosis of anorexia and bulimia by her physicians, but her boyfriend suspected a missed diagnosis and urged her to see Groopman's colleague, Dr. Myron Falchuk at Beth Israel-Deaconness Medical Center in Boston. He proceeds to find the correct diagnosis, celiac disease, possibly saving "Anne's" life as a result.
Nowhere does Groopman tip us off that any of these details are altered so we can't identify this woman, and the medical particulars, when combined with her personal history, could easily lead someone to identify this patient. Groopman likewise doesn't let us know that "Anne" gave permission for him to write about her so that he doesn't have to hide her identity. From my perspective, you've gotta do one or the other, and in the age of rapidly decreasing privacy, you have to do it every time you discuss a patient with "the public." Either make it clear that nobody could figure out the identity of the actual person, or make it clear that it was okay with the patient to write about them, or include so few details that it's effectively an anonymous affair. (I still think the book is worth the read and don't mean to imply that Groopman is a careless doc--anyone who reads his work knows this ain't true. But I did, and still do, find it troubling about the book.)
If anyone out there has encountered similar issues where they have felt squeamish when reading a medical professional's discussion of a given patient, or is familiar with any formal considerations about the ethics of medical writing and the problem of disclosure, do let me know.
--br
My own policy about writing about patients follow these rules:
- Never write about a patient where the particulars of the story could lead a reader to suspect with a high degree of confidence the actual identity of the patient;
- If I write about a patient with some idiosyncratic quirk, I change the details of the patient's description enough to preserve their anonymity--details like where they are from, what they do for a living, even their sex; and
- I let people know that in advance.
Jerome Groopman is one of medicine's more famous writers, and his most recent book is How Doctors Think, a book that delivers on its title as an explanation of the kind of reasoning that drives medical decision making from the doctor's perspective. I have a few quibbles about the book but it's a very good read for both physicians and laypeople. That said, he starts out the book by illustrating a case of a woman (whom he refers to as "Anne Dodge") who lives in western Massachusetts. She had been progressively losing weight and given the psychiatric diagnosis of anorexia and bulimia by her physicians, but her boyfriend suspected a missed diagnosis and urged her to see Groopman's colleague, Dr. Myron Falchuk at Beth Israel-Deaconness Medical Center in Boston. He proceeds to find the correct diagnosis, celiac disease, possibly saving "Anne's" life as a result.
Nowhere does Groopman tip us off that any of these details are altered so we can't identify this woman, and the medical particulars, when combined with her personal history, could easily lead someone to identify this patient. Groopman likewise doesn't let us know that "Anne" gave permission for him to write about her so that he doesn't have to hide her identity. From my perspective, you've gotta do one or the other, and in the age of rapidly decreasing privacy, you have to do it every time you discuss a patient with "the public." Either make it clear that nobody could figure out the identity of the actual person, or make it clear that it was okay with the patient to write about them, or include so few details that it's effectively an anonymous affair. (I still think the book is worth the read and don't mean to imply that Groopman is a careless doc--anyone who reads his work knows this ain't true. But I did, and still do, find it troubling about the book.)
If anyone out there has encountered similar issues where they have felt squeamish when reading a medical professional's discussion of a given patient, or is familiar with any formal considerations about the ethics of medical writing and the problem of disclosure, do let me know.
--br
Wednesday, January 19, 2011
Salon's Retraction on Vaccines, and Blog Revamp
I just returned from a symposium sponsored by the New England Science Writers on science and medicine blogging; it was truly invigorating to listen to some tips from some fellow travelers, all of whom have a good deal of experience and heavy-hitting credentials as they blog on issues dear to my heart. Their thoughts have inspired me to do the blogging equivalent of a facelift, so there will be some changes in the coming days. An important change will be that I will revamp the links, adding some and losing others.
One of the additions is Retraction Watch written by Adam Marcus and Ivan Oransky (Ivan spoke eloquently and humorously at tonight's symposium), a blog devoted to tracking the retractions taking place in scientific literature "as a window into the scientific process," as they say. It is a fascinating blog and makes for a kind-of scientist's version of The National Enquirer. Though behind the tawdry headlines (and reading some of the scientific shenanigans really does require a strong stomach) lies a journalist's concern for the accuracy in scientific research, and more broadly a serious concern for transparency--both critical elements in a healthy, functioning democracy. The Billy Rubin Blog is officially a fan! (And, with blogs like this, he is wondering what his own purpose in blogdom is.)
One of the pieces Retraction Watch discusses is a piece I've linked to on Facebook but not on the Billy Rubin Blog: the recent retraction by Salon of their own anti-vaccine article of 2005. Salon gets huge credit for coming clean on its past mistakes, not just in admitting the specific errors of the piece, but in saying that it was wrong to the core. The link in Retraction Watch notes how Rolling Stone, which wrote a similar piece entitled "Deadly Immunity" also in 2005, has removed the article from its website without ever owning up to its general wrongheadedness, even issuing a "correction" that acknowledged they were wrong on some specifics, but with a generally defiant tone that most lay readers would assume meant that Rolling Stone wasn't really disowning it.
This all reminded me of the 2006 article by "journalist" Celia Farber in Harper's Magazine essentially contending that AIDS wasn't actually caused by HIV after all, and which led me to cancel my 12-year subscription to the magazine. (Please don't actually follow the link unless you plan to read this point-by-point rebuttal here, or get a general introduction to AIDS denialists here.) It was a depressing, though relatively little noted, episode in the history of American intellectualism and a huge blot on one of America's great magazines of ideas.
Retraction Watch includes Salon's retraction alongside periodicals more commonly thought of as "journals"--that is, "magazines" written on technical matters by and large for specialists. But Salon reaches not only more readers than these specialized publications, but is writing about science and staking claims about the validity of science just like all these other organizations whose collective feet are held to the fire when faulty or, much worse, fabricated data grace their pages. Yet the errors of a publication like Salon, just because they are written by lay writers, are no less excusable, and Salon should be commended for coming clean. (To my knowledge, Harper's has never issued a retraction of the Celia Farber piece, as far as I am aware, for instance.)
--br
One of the additions is Retraction Watch written by Adam Marcus and Ivan Oransky (Ivan spoke eloquently and humorously at tonight's symposium), a blog devoted to tracking the retractions taking place in scientific literature "as a window into the scientific process," as they say. It is a fascinating blog and makes for a kind-of scientist's version of The National Enquirer. Though behind the tawdry headlines (and reading some of the scientific shenanigans really does require a strong stomach) lies a journalist's concern for the accuracy in scientific research, and more broadly a serious concern for transparency--both critical elements in a healthy, functioning democracy. The Billy Rubin Blog is officially a fan! (And, with blogs like this, he is wondering what his own purpose in blogdom is.)
One of the pieces Retraction Watch discusses is a piece I've linked to on Facebook but not on the Billy Rubin Blog: the recent retraction by Salon of their own anti-vaccine article of 2005. Salon gets huge credit for coming clean on its past mistakes, not just in admitting the specific errors of the piece, but in saying that it was wrong to the core. The link in Retraction Watch notes how Rolling Stone, which wrote a similar piece entitled "Deadly Immunity" also in 2005, has removed the article from its website without ever owning up to its general wrongheadedness, even issuing a "correction" that acknowledged they were wrong on some specifics, but with a generally defiant tone that most lay readers would assume meant that Rolling Stone wasn't really disowning it.
This all reminded me of the 2006 article by "journalist" Celia Farber in Harper's Magazine essentially contending that AIDS wasn't actually caused by HIV after all, and which led me to cancel my 12-year subscription to the magazine. (Please don't actually follow the link unless you plan to read this point-by-point rebuttal here, or get a general introduction to AIDS denialists here.) It was a depressing, though relatively little noted, episode in the history of American intellectualism and a huge blot on one of America's great magazines of ideas.
Retraction Watch includes Salon's retraction alongside periodicals more commonly thought of as "journals"--that is, "magazines" written on technical matters by and large for specialists. But Salon reaches not only more readers than these specialized publications, but is writing about science and staking claims about the validity of science just like all these other organizations whose collective feet are held to the fire when faulty or, much worse, fabricated data grace their pages. Yet the errors of a publication like Salon, just because they are written by lay writers, are no less excusable, and Salon should be commended for coming clean. (To my knowledge, Harper's has never issued a retraction of the Celia Farber piece, as far as I am aware, for instance.)
--br
Tuesday, January 18, 2011
Billy Rubin To Orthopods: Man Up or Drop Dead
A rant:
In the pecking order of physicians, both in terms of salary and status, I'm not especially high up there. As an infectious disease doc, I make a bit more than primary care docs, a bit less than hospitalists, a lot less than some of my fellow internal medicine subspecialists such as gastroenterologists and cardiologists, and a whole lot less than general and plastic surgeons. All of which is fine with me, as salary wasn't the main reason I got into medicine in the first place, and I have always put very little stock in status. Moreover, I have always maintained a huge level of respect for the vast majority of cardiologists and surgeons, most of whom are not only consummate physicians but incredibly hard workers as well. I'm content to play the bottom-feeding catfish to their swordfish (cardiologists, in this somewhat strained analogy) or shark (general surgeons, of course).
Also in this metaphorical fishbowl of American medicine are the clownfishes: small but beautiful, always the envy of the other fish in that they draw the admiring stares from people while flitting through the tank. Orthopedic surgeons are the clownfishes. They're not a big subspecialty: of the roughly 22,000 residency positions available last year, only 641 were for orthopedics. But oh, do they do well: the median income of an orthopod is estimated to be over $400,000 (!). Hence, a lot of very good medical students in med schools in the US work very, very hard as they pine for the joys of knee arthroscopy, laminectomy, and hip replacements, to say nothing of the Cabernet Sauvignon or trips to Bermuda that await.
One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.
Again, bone surgery is not what interests me so I'm not trying to rain on their parade, and I'm not trying to cry about unequal compensation. I do think, however, that with all that compensation comes a few obligations.
Take, for instance, the patient that I saw this weekend while covering for the local ID physician at the nearby community hospital. My pager chirped early Saturday morning and I got one of the hospitalists on the line. "Billy, I'm not sure what's going on with this lady, and she's not even 'mine'," said the hospitalist, meaning that he wasn't the attending of record, but just a consultant managing the medical issues. The attending of record was an orthopedic surgeon from one of those "Sports Medicine Associates"-type groups (not the real name). It turned out that the patient had gotten a new hip eleven days before, and her postoperative course was complicated by a fever that never seemed to go away, even though cultures, x-rays, a CT scan of the hip, and a few other tests turned up nothing. Plus her white count was normal.
I relate this story not because of its "House"-like interest (though MDs out there are welcome to take a crack at the diagnosis), but because during those eleven days she was not once seen by the orthopedic surgeon who put the new hip in. Nor was she seen by the surgeon's partners who were on call; she got visits from three different Physicians Assistants, all of whom assured her that she was on the mend (she wasn't) and would be discharged the next day. Eleven days!
You know what? I don't care that the clownfishes make the big bucks until I see a patient not merely suffering (sometimes that's unavoidable), but feeling abandoned, which is inexcusable! I know that they're just doctors of bones and not real doctors at this stage of their careers, and that they can't manage anything other than deciding between a press-fit stem and a cement-stem, but the patients don't know that! It's fine, let me and the other consultants who actually know how to be doctors of people do the real work of taking care of the patient--I'm handsomely compensated as far as I'm concerned, even if it's a third of what they make. Just try to make the patient feel like you care! So Man Up, you asshole, and see your fucking patient! She's sick!
Lest you think I'm overstating the case, take a look here at this 2007 NYT article about "specialty" hospitals not being able to handle sick patients. Not all of these specialty hospitals are completely orthopedics, but a lot of them are. You know what's really rich about this? These hospitals are often built by the physicians themselves because they want to cut out "traditional" hospitals so that they can receive even higher levels of compensation. Amazing! (And yes, "rich" was an intentional pun.) Physician salaries are often a delicate matter to discuss, because docs want to be well paid, but this isn't just your typical societal working-out of a doc's salary. This is greed! Good grief.
When I signed off for the weekend to the regular ID doc, I related this story. He sighed. "Yeah, we have really had problems with that group over the years," he said. "The amazing thing is that when something goes wrong and the patient doesn't just recover in three days like normal, they tend to get mad at the patients for sticking around."
--br
In the pecking order of physicians, both in terms of salary and status, I'm not especially high up there. As an infectious disease doc, I make a bit more than primary care docs, a bit less than hospitalists, a lot less than some of my fellow internal medicine subspecialists such as gastroenterologists and cardiologists, and a whole lot less than general and plastic surgeons. All of which is fine with me, as salary wasn't the main reason I got into medicine in the first place, and I have always put very little stock in status. Moreover, I have always maintained a huge level of respect for the vast majority of cardiologists and surgeons, most of whom are not only consummate physicians but incredibly hard workers as well. I'm content to play the bottom-feeding catfish to their swordfish (cardiologists, in this somewhat strained analogy) or shark (general surgeons, of course).
Also in this metaphorical fishbowl of American medicine are the clownfishes: small but beautiful, always the envy of the other fish in that they draw the admiring stares from people while flitting through the tank. Orthopedic surgeons are the clownfishes. They're not a big subspecialty: of the roughly 22,000 residency positions available last year, only 641 were for orthopedics. But oh, do they do well: the median income of an orthopod is estimated to be over $400,000 (!). Hence, a lot of very good medical students in med schools in the US work very, very hard as they pine for the joys of knee arthroscopy, laminectomy, and hip replacements, to say nothing of the Cabernet Sauvignon or trips to Bermuda that await.
One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.
Again, bone surgery is not what interests me so I'm not trying to rain on their parade, and I'm not trying to cry about unequal compensation. I do think, however, that with all that compensation comes a few obligations.
Take, for instance, the patient that I saw this weekend while covering for the local ID physician at the nearby community hospital. My pager chirped early Saturday morning and I got one of the hospitalists on the line. "Billy, I'm not sure what's going on with this lady, and she's not even 'mine'," said the hospitalist, meaning that he wasn't the attending of record, but just a consultant managing the medical issues. The attending of record was an orthopedic surgeon from one of those "Sports Medicine Associates"-type groups (not the real name). It turned out that the patient had gotten a new hip eleven days before, and her postoperative course was complicated by a fever that never seemed to go away, even though cultures, x-rays, a CT scan of the hip, and a few other tests turned up nothing. Plus her white count was normal.
I relate this story not because of its "House"-like interest (though MDs out there are welcome to take a crack at the diagnosis), but because during those eleven days she was not once seen by the orthopedic surgeon who put the new hip in. Nor was she seen by the surgeon's partners who were on call; she got visits from three different Physicians Assistants, all of whom assured her that she was on the mend (she wasn't) and would be discharged the next day. Eleven days!
You know what? I don't care that the clownfishes make the big bucks until I see a patient not merely suffering (sometimes that's unavoidable), but feeling abandoned, which is inexcusable! I know that they're just doctors of bones and not real doctors at this stage of their careers, and that they can't manage anything other than deciding between a press-fit stem and a cement-stem, but the patients don't know that! It's fine, let me and the other consultants who actually know how to be doctors of people do the real work of taking care of the patient--I'm handsomely compensated as far as I'm concerned, even if it's a third of what they make. Just try to make the patient feel like you care! So Man Up, you asshole, and see your fucking patient! She's sick!
Lest you think I'm overstating the case, take a look here at this 2007 NYT article about "specialty" hospitals not being able to handle sick patients. Not all of these specialty hospitals are completely orthopedics, but a lot of them are. You know what's really rich about this? These hospitals are often built by the physicians themselves because they want to cut out "traditional" hospitals so that they can receive even higher levels of compensation. Amazing! (And yes, "rich" was an intentional pun.) Physician salaries are often a delicate matter to discuss, because docs want to be well paid, but this isn't just your typical societal working-out of a doc's salary. This is greed! Good grief.
When I signed off for the weekend to the regular ID doc, I related this story. He sighed. "Yeah, we have really had problems with that group over the years," he said. "The amazing thing is that when something goes wrong and the patient doesn't just recover in three days like normal, they tend to get mad at the patients for sticking around."
--br
Wednesday, January 12, 2011
Billy Rubin, The Patient
Over the past year I have been having increasing difficulty with my breathing, having frequent episodes of wheezing and chest tightness, to the point where over the summer I could no longer exercise. I had never had such a problem before, but knew enough to know that albuterol would temporarily halt the symptoms. I stole some of my son's albuterol nebs, and the incredible relief they brought made me realize that I shouldn't be self-medicating and so I arranged an appointment with my doc. His take (after noting my room air pulse oxygenation of 93%--abnormally low for a 40 year-old with no major medical problems) was that I had new-onset asthma probably due to reflux, and while I was skeptical, I duly arranged to take a battery of medications, including the acid suppressor protonix, a steroid nasal spray, a steroid inhaler, and most importantly at that time, a two-week tapering course of prednisone, which by the end had me feeling like a million bucks and allowed me to get back on my bike again.
Two months later, though, despite being nearly completely faithful to the medications, I was tightening up again. Each week exercise became harder and harder, and I got more and more reliant on the albuterol (which helps symptoms but doesn't fix the problem). I went to see an ENT doc and he found nothing. My doc shrugged and suggested that I see a pulmonologist. When I called to make an appointment, though, the first opening they had was in mid-February, and I was getting worse by the day. Finally, by last week I had reached the end of my rope and decided to prescribe myself a steroid taper. Treating yourself as a doctor is definitely not considered smart, but I felt I had little option. When the pulmonologist had a cancellation a few days later, I came in and sought to apologize for the self-medication. After she listened to both my story and my lungs, though, she looked me straight in the eye. "You sound terrible, even now, a few days after you've started the prednisone," she said. "You absolutely did the right thing; I just can't believe you waited as long as you did." Well, how about that, I thought, Billy Rubin, model patient!
Then came the conversation about cats.
I knew it was coming. Anyone who suffers from asthma is advised to minimize exposure to a variety of allergens known to (or at least suspected of) drive the pathology in the first place. So my pulmonologist asked me if I had cats. I replied I had three. She paused, then said, "you may need to consider placing them somewhere." (Disclosure--I can't remember if those are her precise words but it's damn close.) Place them somewhere?
Doc, you seem nice and all, but I ain't getting rid of the cats.
A story leaps to mind. Back in med school I had a classmate whose wife had just delivered. She had two cats who had lived with her for about ten years and regarded them as "her kids," but the process of having human-based children had a profound effect on her. "I just came home from the hospital and looked at them," she told us, "and I said, 'Oh my God, they're just cats!' It was like I never really realized it until I had my own."
The family joke around the Rubin household is a bit different: I'm fond of saying that I have two and a half children and two and a half cats, the third cat being a good deal more than just some friendly fur that eats food and wants its box cleaned. This little feller sleeps with us, cries when we leave, comes right to the door as soon as we walk in and jumps straight to my shoulder. The other two are your basic cats, and while I'm very partial to them I suppose that I could banish them if my life were threatened. But this third cat? My baby? Oh, you must be kidding.
During my infectious disease fellowship, I had a clinic with a few patients who had advanced HIV and owned cats. Cats, especially the outdoor ones, carry a parasite called toxoplasmosis that's harmless to them and is in general harmless to us. However, those with compromised immune systems have to be careful--thus warnings against changing your cat's litter box if you are pregnant, are a transplant recipient, or you have advanced HIV. Usually there's some easily found solution so that the person at risk doesn't have to change the box, but twice I had patients who simply didn't have options: it was change the cat's boxes themselves or get rid of the cat. Both times I suggested they consider getting rid of the cat.
I remember both of these moments because I remember the looks I got in response to my suggestion. It was the same look I gave Doctor Pulmonologist last week.
In medicine, sometimes the equations are simple and so is the advice. But the solutions (and the docs that give them) have to take into account the whole of the person: knowing what's adjustable and what's non-negotiable. I don't blame my doc for her advice--it is, after all, the right initial advice to give--nor do I have any trouble with the clinical detachment that she delivered it. She's supposed to be detached! As we continue to visit, though, I'm hoping that she'll come to appreciate how very un-simple the equation of getting rid of some cats would be for Billy Rubin, The Patient.
--br
Two months later, though, despite being nearly completely faithful to the medications, I was tightening up again. Each week exercise became harder and harder, and I got more and more reliant on the albuterol (which helps symptoms but doesn't fix the problem). I went to see an ENT doc and he found nothing. My doc shrugged and suggested that I see a pulmonologist. When I called to make an appointment, though, the first opening they had was in mid-February, and I was getting worse by the day. Finally, by last week I had reached the end of my rope and decided to prescribe myself a steroid taper. Treating yourself as a doctor is definitely not considered smart, but I felt I had little option. When the pulmonologist had a cancellation a few days later, I came in and sought to apologize for the self-medication. After she listened to both my story and my lungs, though, she looked me straight in the eye. "You sound terrible, even now, a few days after you've started the prednisone," she said. "You absolutely did the right thing; I just can't believe you waited as long as you did." Well, how about that, I thought, Billy Rubin, model patient!
Then came the conversation about cats.
I knew it was coming. Anyone who suffers from asthma is advised to minimize exposure to a variety of allergens known to (or at least suspected of) drive the pathology in the first place. So my pulmonologist asked me if I had cats. I replied I had three. She paused, then said, "you may need to consider placing them somewhere." (Disclosure--I can't remember if those are her precise words but it's damn close.) Place them somewhere?
Doc, you seem nice and all, but I ain't getting rid of the cats.
A story leaps to mind. Back in med school I had a classmate whose wife had just delivered. She had two cats who had lived with her for about ten years and regarded them as "her kids," but the process of having human-based children had a profound effect on her. "I just came home from the hospital and looked at them," she told us, "and I said, 'Oh my God, they're just cats!' It was like I never really realized it until I had my own."
The family joke around the Rubin household is a bit different: I'm fond of saying that I have two and a half children and two and a half cats, the third cat being a good deal more than just some friendly fur that eats food and wants its box cleaned. This little feller sleeps with us, cries when we leave, comes right to the door as soon as we walk in and jumps straight to my shoulder. The other two are your basic cats, and while I'm very partial to them I suppose that I could banish them if my life were threatened. But this third cat? My baby? Oh, you must be kidding.
During my infectious disease fellowship, I had a clinic with a few patients who had advanced HIV and owned cats. Cats, especially the outdoor ones, carry a parasite called toxoplasmosis that's harmless to them and is in general harmless to us. However, those with compromised immune systems have to be careful--thus warnings against changing your cat's litter box if you are pregnant, are a transplant recipient, or you have advanced HIV. Usually there's some easily found solution so that the person at risk doesn't have to change the box, but twice I had patients who simply didn't have options: it was change the cat's boxes themselves or get rid of the cat. Both times I suggested they consider getting rid of the cat.
I remember both of these moments because I remember the looks I got in response to my suggestion. It was the same look I gave Doctor Pulmonologist last week.
In medicine, sometimes the equations are simple and so is the advice. But the solutions (and the docs that give them) have to take into account the whole of the person: knowing what's adjustable and what's non-negotiable. I don't blame my doc for her advice--it is, after all, the right initial advice to give--nor do I have any trouble with the clinical detachment that she delivered it. She's supposed to be detached! As we continue to visit, though, I'm hoping that she'll come to appreciate how very un-simple the equation of getting rid of some cats would be for Billy Rubin, The Patient.
--br
Wednesday, January 5, 2011
The Whitewashing of Mark Twain
The most appalling tidbit in this story about an English professor who has redacted the word "nigger" from Mark Twain's novels The Adventures of Huckleberry Finn and The Adventures of Tom Sawyer is not the preciously childlike logic motivating his actions, thoroughly childlike though it is. The professor, one Alan Gribben of Auburn University, Montgomery--more thoughts on the Auburn connection anon--said that he felt that the more polite term "slave" should be put in "nigger"s stead, in part, because he was approached by a number of local teachers who said they would love to teach the book, but can't because "in the new classroom, it's not really acceptable." No, what is truly, deeply appalling, even beyond this triumph of bowdlerizing stupidity is that Gribben actually justifies his decision in the wake of critical e-mails he has received. "None of them mentions the word. They dance around it," he says, and one can hear a certain tone of schoolmarmish pride.
At the Billy Rubin Blog, while we unquestionably react viscerally and angrily to the casual use of such words, we do not shy away from mentioning words that have real power to broadly offend in American society (of which we would only list two: the aforementioned "nigger," and "cunt") simply because such words are deemed impolite.
[A digression: "bitch" used to be in this category but has attained a certain level of acceptability, with restrictions: noting that you've had a "bitch of a day" in polite chit-chat with colleagues won't raise eyebrows, but referring to one of the female SCOTUS Justices as a "bitch" certainly would. And obviously people immediately think of various words that in part helped launch the career of comedian George Carlin--"shit," "fuck," "motherfucker," "twat," "cocksucker," et cetera--words which might induce a scowl by others at work or play for their overall rudeness, but have basically become accepted at all but the most austere gatherings of the D.A.R. or Focus On The Family. Indeed, some of Carlin's words that couldn't be mentioned on television in 1978 are considered fully acceptable, if perhaps vaguely crude: "piss," "turd," and "fart" (this being a favorite word of Benjamin Franklin's...Billy delights in having selected writings of Franklin sit in his bathroom with the large title "FART PROUDLY!" referring to an essay of the same name). Such words, while having perhaps the power to titillate, almost never except in the most tight-wadded communities have the power to immediately and thoroughly offend. "Nigger" and "cunt," however, maintain an absolutely-out-of-bounds status in more social situations than any other words currently in use in the US. And we are, of course, ignoring the fascinating-but-complicated appropriation of the word "nigger" by African-Americans themselves. Suffice it to say that no sane white person would utter the word except among like-minded racists.]
Professor Gribben's exultation of prissiness (and the similarly comic reactions of at least some mainstream media outlets such as USA Today, who refused to actually write the word "nigger" since their policy prohibits it, admirable though such misguided intentions are) ironically misinterprets Twain in more than one way. The clear error, as explained by Jonathan Turley, who delicately tries to avoid the direct use of the word himself, invokes the notion that "to truly appreciate great works of fiction, such books must be read with an understanding of the mores and lexicon of its time." (The blog Rightpundits.com--we can safely assume that the Billy Rubin Blog concurring with such a site is rare if not unprecedented--merely decries the nonsense but doesn't bother to take the time to argue the point since it seems obviously ludicrous, an attitude toward which I am not entirely unsympathetic.) That said, Gribben's logic is not merely embarrassing because it fig-leafs Twain's equivalent of David (though my favorite has always been Pudd'nhead Wilson), but because it seems to operate on the logic that since Twain's work is great, Twain therefore is a Great American, and Great Americans by definition could not have possibly meant to use "nigger" the way most white people actually meant "nigger" until only 20 years ago, and it goes without saying, still used as the butt of jokes in a good many social circles, though much more discreetly.
But the reality is a good deal more complicated, and Gribben's attempt to anoint Twain as saintlike in his pursuit of racial equality ignores the fact of Twain's actual, explicit racism, and astonishingly manages to undervalue his incredible contributions to the American discussion about race (at least from this white Jewish kid's late-20th century perspective). Take, for example, Twain's love of the minstrel show, which without question would make Gribben blush himself into oblivion: "If I could have the nigger show back again in its pristine purity and perfection I should have but little further use for opera," he waxed nostalgic in his Autobiography published in 1906 [my emphasis]. How does Whitewasher-In-Chief, Professor Gribben account for such an unguarded and honest remark from his hero? Could the autoclaved Twain ever have uttered such ugliness?
Illustrating Twain's contradictions, though, should never be used to create the shibboleth that Twain was just another white racist who used the word "nigger" without care or concern for the people it referred to or those who used it. Twain unequivocally maintained a palpable disgust at slavery and the inequalities between whites and blacks, and did so quite vocally throughout his adult life. If one can read Pudd'nhead Wilson and not feel the rage against racism fly off page after every page, then one perhaps belongs in Professor Gribben's little Sam Clemens picnic of decorum, where the finer aspects of human cruelty are swept under the rug in the attempt to tell comforting bedtime stories, where nobody curses and all are treated with respect.
The actual Mark Twain, though, wrote about the real world, and he unleashed his vehemence at the peculiar racial injustices of America over the course of decades. Before he became the affable, wry man as portrayed by Hal Holbrook--Mark Twain! Utterer of Witticisms! Large Mustache and Pre-Einstein Hair!--he was a guy willing to skewer existing attitudes at great personal risk. The following is an essay that Twain wrote while living in Buffalo entitled Only A Nigger, commenting with acidity in the newspaper The Buffalo Express (of which Twain was part owner) on the lynching of an innocent man in 1869, and deliberately emphasizing the word "nigger" by putting it in quotation marks. Twain himself calls deliberate attention to the word--it's no accident! How would Professor Gribben even begin to try to teach this essay to his innocents, sunk as it is in the mire of foul language?
At the Rubin Blog, we consider ourselves to be at one with Twain's rage, though of course the issues have changed (but see the following paragraphs) and we do not believe that Professor Alan Gribben's Dolores-Umbridge-inspired prettyfying of American history does anyone any good as it generally short-circuits the justifiable rage that one could muster about any number of political issues. Such is the dismaying attitude not only of a silly professor in Alabama, but of the vast majority of political pundits and various television celebrities, all of whom would assiduously avoid saying "nigger" but who would be loath to remark on racial matters with anything approaching honesty.
Case in point: as one final note, I can't help but relish the irony that such a rationale is being dished out by an employee of Auburn University, which if you haven't been paying attention, is about to play for the national championship. Look at their webpage, which as of this writing has a gleaming picture of their star quarterback Cam Newton! Cam has been at the center of a number of stories detailing inappropriate transactions between various schools and his father in a "pay-for-play" arrangement.
How badly does this story stink? It depends on whether you choose to point the finger at Newton and his family, or rather the system which blithely chews up and spits out players, the vast majority of whom do not have a future in the NFL. This system does this, moreover, with generally little regard for a given player's education (or indeed, their eligibility to attend such schools), but rather in the quest for tens of millions of dollars in advertising revenue as funneled through ESPN and other major networks. Most of the colleges of the major conferences such as the SEC, Big-10, ACC, Pac-10 and former Big-12 have large numbers of football players, a good many of whom are African-American and frequently are descended from the very people that Twain wrote about; these players are being systematically exploited in ways that any impartial observer would at least find vaguely similar to the economic system of slavery that every Serious Thinker publicly declares as a thing of the dark ages. And what is the skin color of most of the boosters and coaches and University students that come to the stadium on Saturday ready for the rah-rah-rah! as long as their players are winners, damned be everything else? I'm thinking they're mostly white.
Go team!
Sometime soon: Billy Rubin, The Patient.
--br
At the Billy Rubin Blog, while we unquestionably react viscerally and angrily to the casual use of such words, we do not shy away from mentioning words that have real power to broadly offend in American society (of which we would only list two: the aforementioned "nigger," and "cunt") simply because such words are deemed impolite.
[A digression: "bitch" used to be in this category but has attained a certain level of acceptability, with restrictions: noting that you've had a "bitch of a day" in polite chit-chat with colleagues won't raise eyebrows, but referring to one of the female SCOTUS Justices as a "bitch" certainly would. And obviously people immediately think of various words that in part helped launch the career of comedian George Carlin--"shit," "fuck," "motherfucker," "twat," "cocksucker," et cetera--words which might induce a scowl by others at work or play for their overall rudeness, but have basically become accepted at all but the most austere gatherings of the D.A.R. or Focus On The Family. Indeed, some of Carlin's words that couldn't be mentioned on television in 1978 are considered fully acceptable, if perhaps vaguely crude: "piss," "turd," and "fart" (this being a favorite word of Benjamin Franklin's...Billy delights in having selected writings of Franklin sit in his bathroom with the large title "FART PROUDLY!" referring to an essay of the same name). Such words, while having perhaps the power to titillate, almost never except in the most tight-wadded communities have the power to immediately and thoroughly offend. "Nigger" and "cunt," however, maintain an absolutely-out-of-bounds status in more social situations than any other words currently in use in the US. And we are, of course, ignoring the fascinating-but-complicated appropriation of the word "nigger" by African-Americans themselves. Suffice it to say that no sane white person would utter the word except among like-minded racists.]
Professor Gribben's exultation of prissiness (and the similarly comic reactions of at least some mainstream media outlets such as USA Today, who refused to actually write the word "nigger" since their policy prohibits it, admirable though such misguided intentions are) ironically misinterprets Twain in more than one way. The clear error, as explained by Jonathan Turley, who delicately tries to avoid the direct use of the word himself, invokes the notion that "to truly appreciate great works of fiction, such books must be read with an understanding of the mores and lexicon of its time." (The blog Rightpundits.com--we can safely assume that the Billy Rubin Blog concurring with such a site is rare if not unprecedented--merely decries the nonsense but doesn't bother to take the time to argue the point since it seems obviously ludicrous, an attitude toward which I am not entirely unsympathetic.) That said, Gribben's logic is not merely embarrassing because it fig-leafs Twain's equivalent of David (though my favorite has always been Pudd'nhead Wilson), but because it seems to operate on the logic that since Twain's work is great, Twain therefore is a Great American, and Great Americans by definition could not have possibly meant to use "nigger" the way most white people actually meant "nigger" until only 20 years ago, and it goes without saying, still used as the butt of jokes in a good many social circles, though much more discreetly.
But the reality is a good deal more complicated, and Gribben's attempt to anoint Twain as saintlike in his pursuit of racial equality ignores the fact of Twain's actual, explicit racism, and astonishingly manages to undervalue his incredible contributions to the American discussion about race (at least from this white Jewish kid's late-20th century perspective). Take, for example, Twain's love of the minstrel show, which without question would make Gribben blush himself into oblivion: "If I could have the nigger show back again in its pristine purity and perfection I should have but little further use for opera," he waxed nostalgic in his Autobiography published in 1906 [my emphasis]. How does Whitewasher-In-Chief, Professor Gribben account for such an unguarded and honest remark from his hero? Could the autoclaved Twain ever have uttered such ugliness?
Illustrating Twain's contradictions, though, should never be used to create the shibboleth that Twain was just another white racist who used the word "nigger" without care or concern for the people it referred to or those who used it. Twain unequivocally maintained a palpable disgust at slavery and the inequalities between whites and blacks, and did so quite vocally throughout his adult life. If one can read Pudd'nhead Wilson and not feel the rage against racism fly off page after every page, then one perhaps belongs in Professor Gribben's little Sam Clemens picnic of decorum, where the finer aspects of human cruelty are swept under the rug in the attempt to tell comforting bedtime stories, where nobody curses and all are treated with respect.
The actual Mark Twain, though, wrote about the real world, and he unleashed his vehemence at the peculiar racial injustices of America over the course of decades. Before he became the affable, wry man as portrayed by Hal Holbrook--Mark Twain! Utterer of Witticisms! Large Mustache and Pre-Einstein Hair!--he was a guy willing to skewer existing attitudes at great personal risk. The following is an essay that Twain wrote while living in Buffalo entitled Only A Nigger, commenting with acidity in the newspaper The Buffalo Express (of which Twain was part owner) on the lynching of an innocent man in 1869, and deliberately emphasizing the word "nigger" by putting it in quotation marks. Twain himself calls deliberate attention to the word--it's no accident! How would Professor Gribben even begin to try to teach this essay to his innocents, sunk as it is in the mire of foul language?
A dispatch from Memphis mentions that, of two negroes lately sentenced to death for murder inthat vicinity, one named Woods has just confessed to having ravished a young lady during the war, for which deed another negro was hung at the time by an avenging mob, the evidence that doomed the guiltless wretch being a hat which Woods now relates that he stole from its owner
and left behind, for the purpose of misleading.
Ah, well! Too bad, to be sure! A little blunder in the administration of justice by Southern mob-law; but nothing to speak of.
Only "a nigger" killed by mistake -- that is all. Of course, every high toned gentleman whose chivalric impulses were so unfortunately misled in this affair, by the cunning of the miscreant Woods, is as sorry about it as a high toned gentleman can be expected to be sorry about the unlucky fate of "a nigger." But mistakes will happen, even in the conduct of the best regulated and most high toned mobs, and surely there is no good reason why Southern gentlemen should worry themselves with useless regrets, so long as only an innocent "nigger" is hanged, or roasted or knouted to death, now and then. What if the blunder of lynching the wrong man does happen once in four or five cases! Is that any fair argument against the cultivation and indulgence of those fine chivalric passions and that noble Southern spirit which will not brook the slow and cold formalities of regular law, when outraged white womanhood appeals for vengeance? Perish the thought so unworthy of a Southern soul! Leave it to the sentimentalism and humanitarianism of a cold-blooded Yankee civilization! What are the lives of a few "niggers" in comparison with the preservation of the impetuous instincts of a proud and fiery race? Keep ready the halter, therefore, oh chivalry of Memphis! Keep the lash knotted; keep the brand and the faggots in waiting, for prompt work with the next "nigger" who may be suspected of any damnable crime! Wreak a swift vengeance upon
him, for the satisfaction of the noble impulses that animate knightly hearts, and then leave time
and accident to discover, if they will, whether he was guilty or no.
At the Rubin Blog, we consider ourselves to be at one with Twain's rage, though of course the issues have changed (but see the following paragraphs) and we do not believe that Professor Alan Gribben's Dolores-Umbridge-inspired prettyfying of American history does anyone any good as it generally short-circuits the justifiable rage that one could muster about any number of political issues. Such is the dismaying attitude not only of a silly professor in Alabama, but of the vast majority of political pundits and various television celebrities, all of whom would assiduously avoid saying "nigger" but who would be loath to remark on racial matters with anything approaching honesty.
Case in point: as one final note, I can't help but relish the irony that such a rationale is being dished out by an employee of Auburn University, which if you haven't been paying attention, is about to play for the national championship. Look at their webpage, which as of this writing has a gleaming picture of their star quarterback Cam Newton! Cam has been at the center of a number of stories detailing inappropriate transactions between various schools and his father in a "pay-for-play" arrangement.
How badly does this story stink? It depends on whether you choose to point the finger at Newton and his family, or rather the system which blithely chews up and spits out players, the vast majority of whom do not have a future in the NFL. This system does this, moreover, with generally little regard for a given player's education (or indeed, their eligibility to attend such schools), but rather in the quest for tens of millions of dollars in advertising revenue as funneled through ESPN and other major networks. Most of the colleges of the major conferences such as the SEC, Big-10, ACC, Pac-10 and former Big-12 have large numbers of football players, a good many of whom are African-American and frequently are descended from the very people that Twain wrote about; these players are being systematically exploited in ways that any impartial observer would at least find vaguely similar to the economic system of slavery that every Serious Thinker publicly declares as a thing of the dark ages. And what is the skin color of most of the boosters and coaches and University students that come to the stadium on Saturday ready for the rah-rah-rah! as long as their players are winners, damned be everything else? I'm thinking they're mostly white.
Go team!
Sometime soon: Billy Rubin, The Patient.
--br
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