Denialism Blog

Denialism Blog

  • Why should I trust you?

    On call one night as a medical student, I was presenting a case to my intern. As I recounted the patient’s ER course, the intern stopped me and said, “Pal — trust no one.”

    That sounded a little harsh to me, but the intern was nice enough to explain further.

    “Look, you’re going to be taking calls from doctors and nurses the rest of your career. They are going to give you information about a patient, but it’s you who will be responsible for everything that goes right and wrong. Do you want to hang yourself on someone else’s evaluation?”

    As any internist knows, there is a perpetual tension between ER and internal medicine docs. ER docs need to save lives and move meat. The snapshot the ER doc gets is sometimes inconsistent with the bigger picture the internist sees, leading to some conflict. It’s inevitable, really, that how the patient looks in the ER will differ from how they are up on the floor several hours later. And this is what my intern was conveying to me.

    Patients will often complain about the parade of students, interns, residents, and attendings who seem to ask the same set of questions, but this was my intern’s point: things change, stories change, clinical facts change, and you better make sure the facts you report are the facts you verified.

    (As an aside, it’s a not infrequent occurrence that a patient’s story will change significantly with the length of the white coat. The indigestion the student hears about becomes the crushing sub-sternal chest pain the attending rushes to the cath lab.)

    I also remind patients that they don’t know which one of us might be called to their bedside in the middle of the night, so it’s best tolerate us all.

    Anyway, this is my long-winded way of getting to the issue of trust. There are ER doctors who I’ve worked with for years and I know pretty well. I know their quirks, and I know that what they tell me is how it is (at that particular moment).

    If I get an ER call from someone I don’t know, I will listen politely, but I’m probably going to see that patient first and re-check everything myself.

    So “trust no one” isn’t precisely the dictum, but it’s a start. Clearly level of trust is influenced by many different factors.

    At January’s ScienceOnline09 conference, Terra Sig’s Abel Pharmboy and I will be hosting a session on blogging and anonymity. It’s a topic particularly important to us as bloggers of medical science. A number of months ago, I “unmasked” myself and never really explained to anyone why. Pseudonyms are a big part of blog culture, and I preferred to keep mine while no longer guarding my real identity (for various reasons).

    I would argue that in the blogosphere, there are three levels of identity: real name identity, pseudonymity, and anonymity. Real name identity is still not the “real person”. People write and behave differently online. Pseudonymity (my particular choice) involves using a pseudonym, but having one’s true name generally known or available. Anonymity is just that—the attempt to keep your real life identity completely secret. Each of these levels has different implications on both how the writer behaves and how the reader perceives.

    Abel has brought the issue of trust forward—both the reader’s trust of the blogger, and the blogger’s trust in the reader. At our session (which we’d love to have you at, but will probably blog about, or better yet, maybe we’ll live blog it and take questions) I’m sure we’ll address lots of these issues, but we’d like to hear from denizens of the blogosphere. Abel’s question was, “do you trust me?” My question to you is, “Do you consider blogger identity when reading, and if so how? And do you find there to be a difference in the three levels of identity?”

    Or of course, ignore my question, and say whatever you wish.

  • Tissue is the issue–revised version

    NB: images in this post are thought to be in the public domain, but were not well labeled, so if you feel they have been posted without proper attribution, please email me or leave a comment. Thanks. Also, this is a revision of a post from yesterday which I’ve pulled secondary to ethical concerns. I’ve deleted the comments so we can start out fresh. –PalMD

    I can’t seem to get this whole “morgellons” thing out of my head (which gives me something in common with the sufferers). Lots of the “literature” on morgellons focuses on the “fibers” which supposedly infest these people. If you google it, you can get pictures galore of these fibers. The advocacy websites are also full of stories of “fiber analysis” from law enforcement. I’m not much for crime lab analyses when it comes to human pathology. Show me the tissue!

    If morgellons were a disease as such, it would cause pathologic changes in the tissue affected. These should be visible on both a gross an microscopic level. Let me show you what I mean.

    A young woman came to see me a few years back with a rash. She had rashes in the past—poison ivy, mosquito bites, chicken pox—but this one was different. It was all over her legs, many of the bumps were raised, and it was spreading quickly.

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  • Here Comes the Downturn Denialism

    We have not played with the Denialists’ Deck of Cards for some time! Let’s pick them up again, because the economic downturn gives all sorts of businesses the opportunity to play the “Bear Market” card.

    i-e9c987e71f4415eb0c74e05a507bc833-qc.jpgStephen Power brings it in today’s Wall Street Journal:

    “We know something needs to be done [to cut emissions], but we’ve got to get the economy on its feet before we do something economically irrational,” said Mike Morris, chief executive of American Electric Power Co. of Columbus, Ohio. Mr. Morris and other executives fear lawmakers will use revenue from pollution permits to pay down the federal deficit.

    “The likelihood that they would try to take these revenues for other purposes, particularly in an economic downturn, is great,” says James Rogers, chief executive of North Carolina-based Duke Energy Corp.


    Do not feel so bad for these guys, because when the markets are up, they play “Bull Market.” If the market is doing well, you should not mess with success.

  • Hmm…ethics…

    Ok, I pulled my post while considering ethical issues, viz this conversation:

    Dianne, PAL:

    I’m out of my depth here, so could you address what the ethical boundaries are for describing a case (even without personal identification) on an open board?

    I’ve always dealt with that one by Just Don’t — and I know it’s overly conservative. And I promise to not take you as too authoritative, but it’s an interesting subject …

    Posted by: D. C. Sessions | October 15, 2008 9:09 PM

    Well, it’s an interesting issue. Generally, cases are fine to present as long as enough details are changed. Given that I’ve lived/practiced in a number of different cities/states, and that the only real identifying info is that the patient is a male in his 60s (which may or may not be true), and i’ve presented a picture that may or may not be the actual patient, the ethics seem to be in my favor.

    NEJM, for example, is a publicly available journal, and regularly presents cpc’s without identifying info.

    Curse/bless you for bringing this up.

    Case presentations are not in and of themselves unethical. The ethical issues involve what is in the patient’s best interest. If a patient is not identifiable, there should be no ethical issue.

    Except when there is.

    Some would argue that a patient can be ethically harmed even if they are not identified, as the information about them belongs to them, and is theirs to hold or release. This, I think, is where the issue of mixing up case details comes in. If the details are not traceable to a particular patient, then there is no harm.

    However, since I am talking about a path report, one could argue that there is an ethical problem.

    There is also a question as to what benefit a patient may or may not derive…

    Hmm…

    Posted by: PalMD [TypeKey Profile Page] | October 15, 2008 9:16 PM

    Discuss amongst yourselves while I consult my betters….

  • Breathing 102—bringing the woo

    (This one is cross-posted over at Science-Based Medicine. FYI. –PalMD)

    If you’ve been a regular reader of SBM or denialism blog, you know that plausibility plays an important part in science-based medicine. If plausibility is discounted, clinical studies of improbable medical claims can show apparently positive results. But once pre-test probability is factored in, the truth is revealed—magic water can’t treat disease, no matter what a particular study may say. So it was with great dismay that I read an email from a reader telling me about parents buying hyperbaric chambers for their autistic children. Let’s review some science.

    In Breathing 101, we talked about how the oxygen delivered to your lungs depends on both the percentage of oxygen in the air, and the air pressure. We looked at how diminishing atmospheric pressure, for example at altitude, makes it harder to breathe.

    Of course it is also possible to expose people to increased atmospheric pressure, which has therapeutic uses in the form of hyperbaric oxygen therapy (HBOT).

    Oxygen delivery to tissue depends on several factors. We already talked about the air itself. Once air gets enters the lungs, most of the oxygen transported to your tissues is carried by the hemoglobin molecules in your red blood cells (under normal conditions). A small amount is directly dissolved in the blood. The amount dissolved in the blood is dependent on (no surprise) the percentage of oxygen and the atmospheric pressure. By increasing the atmospheric pressure from 1 atm (760 torr) to 3 atm, the amount of oxygen dissolved in the blood is enough to meet your body’s needs independent of heme-associated oxygen.

    This is a good thing.

    For example, up here in the Midwest, we have a lot of cases of carbon monoxide (CO) poisoning during the winter. CO binds to hemoglobin much more strongly than oxygen, so even after victims are removed to a normal environment, they are still asphyxiating.

    Carbon monoxide intoxication is one of the primary uses of HBOT. Under pressure, enough oxygen is delivered to the tissues for the patient to survive. Additionally, the increased pressure helps oxygen displace CO so that heme molecules are free to go back to the work of transporting oxygen.

    The original use for HBOT was of course “the bends”. When a person (for example a diver) is exposed to high pressures for a long period of time, nitrogen, which is normally not very soluble in blood, dissolves much more readily. When the diver ascends, the nitrogen bubbles are released from the blood into the tissues, causing widespread damage. HBOT can be used to help a diver “ascend” more slowly, so that the nitrogen comes out of solution in a much less damaging fashion.

    HBOT can also be used to treat a variety of other conditions that are responsive to increased oxygen tension, such as anaerobic bacterial infections. But hyperbaric chambers are not without risk. Small errors can cause big problems, including death.

    Strangely enough, though, you can buy your very own hyperbaric chamber for use in your own home, and parents of autistic children are doing just that.

    So why does anyone think that HBOT might be appropriate for the treatment of autism? Is it even plausible? Autism spectrum disorder (ASD) is a very broad diagnostic category. Autism is a neurobehavioral disorder of inconsistent severity and unknown cause. There has been some decent research into etiology, and in some cases genetic causes have been implicated. There is no reason to suspect that autism has anything to do with decreased oxygen tension.

    As you have no doubt read in this space, autism attracts a wide range of quackery, and HBOT for autism is quacks pretty loudly.

    Whose idea is this, anyway?

    All signs point to a guy named Dan Rossignol. Dr. Rossignol is apparently into every form of autism crankery, including mercury poisoning, mitochondrial dysfunction, and oxidative stress (although I can’t imagine that increased PaO2 is an effective treatment for “oxidative stress”). After spending a few minutes looking through is web-based material, I’m starting to think that this guy can give the Geier’s a run for their money.

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  • Who broke ScienceBlogs?

    Yeah, we know things aren’t working right. Comments are timing out, but that’s the least of it. Our techies aren’t sure yet what’s going on, but they are putting extra hamsters on the treadmill working extra hard trying to get things moving smoothly again.

    Meanwhile, if you comment and it times out on you, don’t worry, it probably went through.

    Stay tuned…

  • Breathing 101

    A letter from a reader (thank you, Mr. “Smith”) got me thinking—could the fight against improbable medical claims be aided by a better knowledge of science? In another attempt to bring complicated science to the masses, today we will learn a bit about how we breathe. The first thing we need to understand is what we breathe.

    Let us speak of air. We know we need it. Most of us know that the oxygen that makes up about twenty percent of it is necessary for life. If you think a little bit more, you probably realize that in addition to the oxygen content, there is another variable that is critical in making air breathable. When we climb a mountain or get in a plane, the air is less breathable. Why is that? The air up there is still 21% oxygen, so what’s the deal?

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  • Is this for real? Racist attacks on Obama from all sides

    I hate having to repost this but there’s a reason. If you watch the GOP rally’s lately, they are becoming filled with hate, with near-violence, with hyperbole calling Obama as terrorist. McCain isn’t my candidate, but that’s it—I may not agree with him, but I know he’s no terrorist; I know he’s not evil. But the GOP is now explicitly calling up it’s more violent, racist base in its desperate attempt to claw its way back to the top.

    A lot of folks around here like primates. In fact, all of the bloggers around here are primates. So a number of us are pretty riled up about a recent story out of Georgia (although I don’t advocate another apocalyptic March to the Sea). There is another poll to crash with the linked story, so go have at it.

    In a similar vein, I posted a piece on my old blog a little while back about an article that wasn’t written by an ignorant redneck, but by a writer for a prominent conservative news outlet. What follows is the repost.
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  • [UPDATED] GG Bridge Suicide Net: Nanny State or Smart Intervention? (Or Both?)

    It seems as though officials have been arguing forever about whether to erect an anti-suicide net along the Golden Gate Bridge. On Friday, the bridge directors voted 14-1 in favor of creating such a net:

    …the stainless-steel net system, which would be placed 20 feet below the deck, and would collapse around anyone who jumped into it, making it difficult, if not impossible, for anyone to leap to their death…

    This has been a fairly divisive issue in San Francisco. Anti-netters argue that that the net will just cause people to kill themselves elsewhere (perhaps by jumping from a building in a business district), that the net will uglify the bridge, and that it will be expensive. They’re probably right on the last two arguments.

    Pro-netters probably have the better public health argument. Among them are people who jumped from the bridge during a bout of depression and lived to regret it. The New Yorker ran an awesome story about the history of Golden Gate Bridge jumpers several years ago, which included anecdotes about those who jumped and survived:

    Survivors often regret their decision in midair, if not before. Ken Baldwin and Kevin Hines both say they hurdled over the railing, afraid that if they stood on the chord they might lose their courage. Baldwin was twenty-eight and severely depressed on the August day in 1985 when he told his wife not to expect him home till late. “I wanted to disappear,” he said. “So the Golden Gate was the spot. I’d heard that the water just sweeps you under.” On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. “I still see my hands coming off the railing,” he said. As he crossed the chord in flight, Baldwin recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable–except for having just jumped.”

    It still will be years before this net is complete. It will be interesting to see, if this intervention is effective, who the last to jump will be. The Golden Gate has inspired some very weird culture, and I’m willing to bet that there will be a group of people attempting to jump in the last days that it is possible.

    UPDATED

    I just went for a run which takes me to a view of the GG Bridge. The warships are in the Bay this weekend for Fleet Week, which is exciting.

    The Chemist, in comments below, remarks about how callous we are as a society to know about this suicide problem for so long, and to do nothing about it.

    But I’d argue doing nothing about it is very San Francisco, and as a non-native, I don’t share this feeling, but there is a feeling here that if people decide to off themselves, it’s their business. There’s a documentary about GGB suicides called The Bridge where they interview friends of people who jumped, and I was struck by how people just kind of accepted others’ decisions to die. It was strange for me, but there is a spirit of individualism here that just does not know boundaries…

    Just check out this excerpt from the New Yorker story linked to above. There is a different mentality here, to say the least:

    The [suicide] coverage intensified in 1973, when the Chronicle and the Examiner initiated countdowns to the five-hundredth recorded jumper. Bridge officials turned back fourteen aspirants to the title, including one man who had “500” chalked on a cardboard sign pinned to his T-shirt. The eventual “winner,” who eluded both bridge personnel and local-television crews, was a commune-dweller tripping on LSD.

    In 1995, as No. 1,000 approached, the frenzy was even greater. A local disk jockey went so far as to promise a case of Snapple to the family of the victim. That June, trying to stop the countdown fever, the California Highway Patrol halted its official count at 997. In early July, Eric Atkinson, age twenty-five, became the unofficial thousandth; he was seen jumping, but his body was never found.

    Ken Holmes, the Marin County coroner, told me, “When the number got to around eight hundred and fifty, we went to the local papers and said, ‘You’ve got to stop reporting numbers.’ ” Within the last decade, the Centers for Disease Control and Prevention and the American Association of Suicidology have also issued guidelines urging the media to downplay the suicides. The Bay Area media now usually report bridge jumps only if they involve a celebrity or tie up traffic. “We weaned them,” Holmes said. But, he added, “the lack of publicity hasn’t reduced the number of suicides at all.”

  • The Plant Liberation Front

    Gautam Naik covers an interesting development in Switzerland. Scientists there must now justify the ethics of genetic research on plants:

    Dr. Keller recently sought government permission to do a field trial of genetically modified wheat that has been bred to resist a fungus. He first had to debate the finer points of plant dignity with university ethicists. Then, in a written application to the government, he tried to explain why the planned trial wouldn’t “disturb the vital functions or lifestyle” of the plants. He eventually got the green light.

    The rule, based on a constitutional amendment, came into being after the Swiss Parliament asked a panel of philosophers, lawyers, geneticists and theologians to establish the meaning of flora’s dignity.

    The rule incorporates the idea that vegetation has an inherent value, and so pointless harm to flora is immoral. Genetic modification is allowed, but a key concern is whether such modifications protect the plant’s reproductive and adaptive ability.

    Defenders of the law argue that it reflects a broader, progressive effort to protect the sanctity of living things. Last month, Switzerland granted new rights to all “social animals.” Prospective dog owners must take a four-hour course on pet care before they can buy a canine companion, while anglers must learn to catch fish humanely. Fish can’t be kept in aquariums that are transparent on all sides. The fish need some shelter. Nor can goldfish be flushed down a toilet to an inglorious end; they must first be anesthetized with special chemicals, and then killed.

    And I can’t resist including this:

    Dr. Keller in Zurich…wants to breed wheat that can resist powdery mildew. In lab experiments, Dr. Keller found that by transferring certain genes from barley to wheat, he could make the wheat resistant to disease.

    When applying for a larger field trial, he ran into the thorny question of plant dignity. Plants don’t have a nervous system and probably can’t feel pain, but no one knows for sure. So Dr. Keller argued that by protecting wheat from fungus he was actually helping the plant, not violating its dignity — and helping society in the process.

    One morning recently, he stood by a field near Zurich where the three-year trial with transgenic wheat is under way. His observations suggest that the transgenic wheat does well in the wild. Yet Dr. Keller’s troubles aren’t over.

    In June, about 35 members of a group opposed to the genetic modification of crops, invaded the test field. Clad in white overalls and masks, they scythed and trampled the plants, causing plenty of damage.

    “They just cut them,” says Dr. Keller, gesturing to wheat stumps left in the field. “Where’s the dignity in that?”