Deus ex machina

Many of you were too busy trying to ace organic chemistry to know what a deus ex machina is. For those of you who managed to squeeze in a classics course, please stick with me anyway.

Deus ex machina (“god from the machine”) is a literary device. In ancient Greek literature, a complicated dilemma was sometimes solved by having one of the gods literally pluck the unfortunate protagonist off the stage from the arm of a crane. It’s sort the ancient version of the Superman gambit—don’t like the ending? Just turn back time by reversing the rotation of the Earth. In either scenario, an impossible dilemma is circumvented by an improbable escape.

I bring this up because the machina is also used in debates. A valid logical argument (OK, philosophers, please hold your horses…this is the 101 course) requires true premises and a conclusion that must follow. For example:

All humans are mortal

I am human

Therefore, I am mortal

The premises are very likely to be true, and the argument as constructed is valid. The conclusion is very likely true.

Mercury is toxic

Vaccines contain mercury

Therefore, vaccines are toxic

This argument is a properly constructed, superficially valid syllogism. If the premises are true, the conclusion is true.
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Can’t get into med school? Legislate your own doctorate!

I guess it’s not just doctors watching this one—an alert reader and a fellow SciBling both picked up on this one. Apparently, in my neighboring state of Minnesota (really, check the map), home to Greg Laden, PZ Myers, and lutefisk, doctor wannabes have legislated themselves into “doctorhood”. You see, there is this entity called a “naturopath”, or “naturopathic doctor”, which is some sort of shaman that likes to think that if you study woo long enough, it becomes science.
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On being a doctor—humility and confidence

The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge. I supervise residents—they make the decisions, but it’s my name and my ass on the line, so I keep a close eye on things. Some teaching physicians dictate every decision on patients, some do nothing at all. I try to keep toward the end of the spectrum that allows for resident autonomy. When I’m presented with a case, and asked what I would do, I cry foul:

You are the doctor,” I say. “Tell me what you’re planning. I’ll tell you if I disagree, and I’ll let you know if I disagree enough to override your decision.”

This technique must, like all others, be tailored to the individual learner, but I want them to worry—I want them to think, “if I don’t do this right, no one else will, and a patient will be hurt,” because that is what the rest of their careers will be—being awakened in the middle of the night out of a sound sleep, having to make a quick assessment, and being reasonably sure that you’re right.

Except I’ve got their backs.

Of course, that confidence can lead to arrogance. It’s an occupational hazard. If it’s simply a personality quirk then it’s annoying. If it includes a lack of humility, a lack of knowing what you don’t know, then it is as dangerous as indecisiveness.

It takes years of training to develop the decision-making skills that go into being an effective attending physician.

This is one place where we part ways with the cranks and quacks.
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A little HIV knowledge

A few months ago, I gave you a short primer on the immunology of vaccines. It’s time now for another short, oversimplified primer, this time on the immunology of HIV. This was originally up on the old blog, but it will provide some necessary background for upcoming posts (I think).

HIV denialists form a persistent little cult, and one of their newest leaders is Gary Null. Despite their small size and dearth of academic heavy-weights, they are quite loud, and can affect health policy.

Let’s delve into the immunology, and, once again, please forgive the over-simplification.

HIV—nasty non-critter
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Journalist becomes the story: Discover Magazine luvs teh denialists.

HT erv.

This is truly annoying because it is so patently wrong. It’s wrong in lots of different ways, but I’ll help point out some of the major flaws. What happens when journalist becomes the story, rather than reports it?

You see, there is this journalist, Celia Farber, who apparently has been following the HIV denialists since the beginning. From reading this interview with her in Discover Magazine, it would seem that she is suffering from some sort of Stockholm Syndrome. Not only that, but the journalist interviewing her shows a complete lack of suspicion, and seems to be one of those modern journalists who thinks that everything has two valid sides to report on. Not everything does.

Instead of chronicling the history of HIV denialism, she has truly drunk deep of the Flav-R-Ade. Ever wonder how to tell if a journalist has lost her objectivity? How about this?

It’s changed in that so much of what the orthodoxy proclaimed has not come true. The paradigm has failed miserably on virtually all counts. So the orthodoxy right now is particularly venomous and vicious against anybody who is what they call an AIDS denialist.

Uh oh. I sense someone begging the question. The interviewer follows up with a WTF.

What are the failures of the paradigm?

Good question, but I would have also asked, “WTF is the ‘HIV paradigm’?”

Response? Right out of the HIV denialist handbook: (all emphasis mine, –PalMD)
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Never say “hopeless”

I can’t tell you the number of people who complain to me about having their hope taken away. Exactly what this means, though, isn’t always clear.

Sometimes an oncologist will tell them (so they say) that they have a month to live. Sometimes their cardiologist tells them (so they say) not to travel to their grandson’s Bar Mitzvah. Sometimes the spine surgeon tells them their back will always hurt, no matter what. So they say.

Patients tell me a lot of things. I’m not always sure what other doctors really told them, but what is important is what the patient heard. The oncologist might have said “incurable” but followed it up by “but treatable for years.” I suspect after hearing “incurable”, not much else gets in.

One thing I’ve finally learned after a number of years is that patients actually listen, even if you don’t think they do. What they hear is a different story. Depending on their mood and circumstance, they may hang on single phrases, subtle inflection, the way your eyes dart.

To be an effective physician, you must also be an actor of sorts; not in the sense of pretense, but in the way you pay attention to everything your words and body do, and how your audience reacts.

I had a patient a few years back, a very pleasant older woman, who came to me with difficulty in swallowing. There can be a number of different reasons for this. A radiographic study, however, showed a lesion in her esophagus that was almost certainly cancer. Normally, I won’t speak on the phone to people about such things, but she and I had decided for various reasons that this would be the best way to communicate. I told her about the results:
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Why hospice matters

I recently lost a close family member to cancer. She was old, she had been ill a long time; it still hurts. But in her dying, she made some wise choices. She was a very bright woman, and retained her mental capacities right up until the end. This gave her the opportunity to decide how she would approach death. She chose to enroll in hospice.

Hospice is widely misunderstood, partly because of the way we misunderstand death in the U.S. Instead of an inevitable part of life, death here is seen as an enemy to be fought at all costs, no matter the futility. Intensive care units, which were designed to care for people with a severe but potentially curable illness are full of the incurable—people on ventilators who will never breathe on their own again, who will never have a significant interpersonal interaction again.

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Try and beat this one, alties!

I’m not going to lie to you. This post contains some actual science. WAIT! Don’t click away! I’ll make it palatable, I promise!

It’s just that this is such an interesting story, and I can’t help sharing it. It is a shining example of one of the great successes of modern medical science, and stands in such stark contrast to the unfulfilled promises of the cult medicine crowd, with their colon cleanses and magic pills. This is the story of a real magic pill.
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