Denialism Blog

Denialism Blog

  • Pediatrics

    I’ve been busy, as you might imagine, with work, study, and applying for medical residency. However, I thought it was about time to get people up to date with some of the clerkships I’ve finished in the meantime before letting you guys in on some of the decision-making processes involved in choosing a residency.

    So, time to talk about pediatrics. Pediatrics, despite a reputation for warmth and fuzziness, is a challenging field. Kids aren’t just little adults, and the treatment and diseases of infants are different than those of toddlers, which are different from pre-adolescents, which are different from the problems of teenagers and young adults. It’s an intense mixture of preventative medicine, diagnostics, and a lot of the intangible skills involved in getting the necessary information out of uncooperative patients and distressed parents. One also has to remember that a pediatrician has to spot the rare very sick kid in a field of sniffles, coughs, and possibly malingering youngsters who just want out of school. It’s a helluva a field of medicine, and if anything it has made me more passionate about educating against anti-vaxxers and quacks. For one pediatrics is critically dependent on prevention – which the anti-vax movement seeks to undermine with potentially dangerous consequences. For another, many of the diseases of childhood when they do occur are serious – but imminently treatable if recognized. The idea of a quack tinkering in this field without proper respect for the enormous amount of medicine involved, and potential for harm, is terrifying.

    So let’s talk about a set of pediatric cases and just to piss off the gun nuts, why it’s a good thing that pediatricians screen for guns in homes.

    Let’s emphasize the differences between medicine in different age groups. Because it’s pediatrics the past medical history is easy – they have none. Here are two cases, details altered, but both real patients I saw almost at the exact same time.

    Patient #1: A 2.5-year-old male presents to the ED because her mom is concerned he is “puffy”. She sought care in a PCP’s office 6 days ago who initially treated him for a potential allergic reaction with Benadryl and advised her to return if he did not get better. The child has had no illnesses except for a cold 2 weeks ago, has met developmental milestones and is fully immunized. Mom has lost confidence in her PCP and now presents to UVA, very worried. On physical exam the child appears to be alert, awake, in no acute distress, with completely normal physical exam except for puffiness – non-pitting edema in the extremities and face.

    Should we be concerned? What tests would you order in this patient?

    Patient #2: A 14.5 year old male presents to the ED with a camp counselor with complaint of fainting during band practice (it’s summer and it’s hot). For the last week he has felt unwell, but has been continuing to go to practice and participating in activities. He has had no other illnesses, is fully vaccinated and has a normal physical exam. He has no other complaints except his eyes are “puffy”.

    Should we be concerned? What tests would you order in this patient?
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  • How drunk is too drunk—another foray into medical ethics

    The best ethical questions are real ones. Sure, it’s fun to play the lifeboat game, but when you’re dealing with flesh and blood human beings on a daily basis, games aren’t all that helpful. So here’s a non-life-and-death question: if a patient comes to see you and smells of alcohol, can you add an alcohol level to their blood work without specifically informing them?

    Ethical discussions are best held as, well, discussions, so I’ll lay out some ethical principles and let you discuss before I weigh in further.

    First, any patient who comes to see a doctor signs a “general consent for treatment” which usually contains a phrase such as:

    I request and authorize Health Care Services by my physician, and his/her designees as may deem advisable. This may include routine diagnostic, radiology and laboratory procedures and medication administration.

    Second, for your reference, here is the summary of the AMA’s code of medical ethics.

    And finally, a brief list of the most agreed-upon basic principles of medical ethics:

      Beneficence – acting in the best interest of the patient.
      Non-maleficence – avoid harm to the patient
      Autonomy – the patient has the right to refuse or choose their treatment
      Justice—fair distribution or resources
      Dignity
      Truthfulness/informed consent

    Remember that ethics aren’t a checklist. Real life situations are just that—real, with real people.

    OK, the thread is now open.

  • Looks Like the Same-Sex Marriage Amendment Passed

    Here in California, the Mormons poured millions into an initiative constitutional amendment to ban same-sex marriage, after the California Supreme Court found a right to marry in the State’s Constitution.

    Proposition 8 looks like it has passed. Currently, it’s 52-48 in favor, with 95% of the vote counted.

    I’m really just posting this in order to share this anti-Proposition 8 commercial that was running in California. It might be the most offensive political ad ever. Check it out:

  • Watch the returns here!

    Watch it happen live! And if I can, I’ll though in some useless editorializing.

    Now fivethirtyeight and CNN have excellent widgets to watch as well. Fivethirtyeight.com is especially cool, as it has developed a nice reputation for actually being right. Currently, they are projecting a rather wide victory for Obama.

    Ohio an Penn!!!!!

  • The Adman Can Attack Afflictions!

    The Times’ Amanda Schaffer covers a retrospective of public health posters on display at the National Academies until December 19th, 2008. The catalog (pdf) is online.

    My favorite:

    It reads:

    “No home remedy or quack doctor ever cured syphilis or gonorrhea. See your doctor or local health officer.”

    You could replace “syphilis or gonorrhea” with just about anything! Perhaps we should reissue this poster to deal with the modern quacks!

  • Discourse give me hives

    But a fascinating lesson in scientific discourse is currently underway in the blogosphere. It all started with a harmless little analysis of a letter published in NEJM. The strange part (to those of us who live here) was that the authors responded. On the blog. For real. And they were kinda pissed (in the American sense of the word; I have no idea if they’d been drinking, but probably not. After all, they’re not bloggers).

    Communication in medical research is slow. In general, this can be a good thing. Before research is published in a respected journal, it should be thoroughly reviewed. Follow up letters to the editor are necessarily few and delayed, given the nature of the medium.

    Blogs are changing this. More and more scientists and physicians are blogging about peer-reviewed research, and how this will affect scientific discourse is anyone’s guess.

    (more…)

  • If You're Surpsied, You're Not Paying Attention

    The Journal reports the obvious under the headlines “Tainting of Milk Is Open Secret in China” and “Milk Routinely Spiked in China:”

    Before melamine-laced milk killed and sickened Chinese babies and led to recalls around the world, the routine spiking of milk with illicit substances was an open secret in China’s dairy regions, according to the accounts of farmers and others with knowledge of the industry.

    Farmers here in Hebei province say in interviews that “protein powder” of often-uncertain origin has been employed for years as a cheap way to help the milk of undernourished cows fool dairy companies’ quality checks. When the big companies caught on, some additive makers switched to toxic melamine — which mimics protein in lab tests and can cause severe kidney damage — to evade detection.

    […]

    China’s biggest local seller of liquid milk, Mengniu Dairy Co., and multinational food company Nestlé SA both say they were aware that Chinese farmers and traders added unauthorized substances to raw milk, but that they didn’t know melamine was among them. “We knew there was adulteration” going on for many years, says Zhao Yuanhua, Mengniu’s spokeswoman. Among other common milk additives: a viscous yellow liquid containing fat and a combination of preservatives and antibiotics, known as “fresh-keeping liquid.”

    If you’re buying pet food made in China or anything else for that matter, it’s time to pay more for a product manufactured in a country like America, where we have had oversight and controls on food production for over a century.

  • Allergies of the first kind—type I hypersensitivity explained in context

    If you have kids you have probably been exposed to the idea that more kids have food allergies these days. Well, the data seem to bear this out. There are several hypotheses about why this is so, but not a lot of data. Rather than engage in speculation, I’d like to wade back into the dangerous waters of real science and tell you a little about allergies. Perhaps after you’ve read my grossly oversimplified explication, you’ll come up with your own science-based hypothesis to explain increased childhood food allergies.

    First, let’s talk about what isn’t going on. The Huffington Post, always a target-rich environment for woo-hunters, has a writer named Sloan Barnett. She is about as well-informed about health issues as Bill O’Reilly is about anger management. Two of her recent posts address child health, and both display a stunning level of ignorance. Her fetishization of “green” bears no relation to actual research on childhood health.

    An example of her ignorance?

    But what really stopped me in my tracks was that children with food allergies are two to four times as likely to have related conditions such as asthma or other allergies. And guess whose very own children have nut allergies AND asthma….

    Um, yeah, Sloane. That’s because food allergies, asthma, and related conditions are, er, related! Asthma, allergy, and atopy are all a type of immune dysfunction known generally as type I hypersensitivity. Its determinants are partly genetic, partly environmental.

    Despite many studies, no one knows why this [increase in allergy] is happening. Here’s what I know. My third child, who was raised in a non-toxic home, eating only organic formula and food, recently tested allergy free. Look, I can’t be certain that our new lifestyle is the reason this baby is allergy free, but it sure does make you think.

    Actually, one of the most popular theories in scientific circles is the “hygiene hypothesis” which roughly states that our cleaner and more sterile environment exposes our kids to allergens later. If they had been exposed earlier, their immune systems may have developed a tolerance for common allergens. This hypothesis is based on observational studies that kids raised with pets, on farms and other “dirty” places have lower rates of environmental allergies.

    Still, we don’t know why we have an increase in childhood allergies, and clearly, neither does Sloane. Her evidence is based on what she’s heard and her own experiences, which is worth bubkes.

    Alright, let’s get to a little actual science.
    (more…)

  • If you read no other posts this week…

    …you must at least read this one.

    As first person histories go, this one is tops.

  • Artificial Arbitration at American Apparel?

    Jezebel proclaims: Dov Charney May Be More of a Scumbag than Anyone Realized, and I agree if the reporting on a sexual harassment case, Mary Nelson v. American Apparel, rings true (the opinion is unpublished, and I haven’t obtained a copy yet). Charney is the founder of American Apparel, and has been the focus of several sexual harassment suits over the years for allegedly maintaining a sexually-charged work atmosphere.

    Over at Conde Nast, Karen Donovan reports:

    Female employees have filed three sexual harassment lawsuits against Charney. The last active suit was settled earlier this year, but details about it had not been disclosed until a California appellate court released a decision this week.

    The decision, however, also describes a bizarre piece of theater concocted as part of the settlement proposal. In exchange for paying the former employee $1.3 million, she and her lawyers agreed to a sham “arbitration.” A retired judge picked by American Apparel would agree to stipulated facts and make a finding in the company’s favor.

    […]

    The appellate decision lays out the sham arbitration of the settlement. It stipulated that the arbitrator would absolve Charney of the sexual harassment claims…[on First Amendment grounds]

    […]

    Charney, to be sure, is all for the First Amendment. So much so that the settlement would have included this press release to be issued: “The arbitrator ruled that the marketing materials, sexual speech and much of the conduct about which Nelson complained are protected under the First Amendment’s guarantee of free speech and would not form the basis for any claim.”

    Wow! We all knew that arbitration runs the risk of being tilted toward business interests, but to agree in advance to have an entirely artificial arbitration process in order to whitewash an executive’s behavior? That’s priceless. What would one call this? AstroArbitration? It makes a mockery of a mockery.

    If the arbitrators have any ethics, they’ll quickly adopt rules finding that such arrangements are unethical. We’ll see.