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The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.


Pens, Pens, Everywhere

I am just starting up my medical practice here in McComb, and on slow days I get more drug reps than patients. For the uninitiated, a "drug rep" is an employee of a pharmaceutical company who visits my office with the purpose of convincing me to write more prescriptions of their product.

There are many thorny issues to explore in this subject, and I will touch on all of them over time. But today I want to tackle the subject of gifts.

Drug reps usually come bearing gifts. They give me something free, which theoretically makes me better disposed towards them and more likely to give them more of my time. Gifts come in many forms but professional ethics dictate a price limit. So they bring cheap stuff -- a few books, post-it notes, a clock or two, all with the name of their drug emblazoned on it. And they bring pens. Lots and lots of pens.

There are people who have the time to worry about such things who argue that accepting pens is a kind of bribery. That when I hold the pen in my hand and see the logo there that it kindles a fire in my soul to write prescriptions for that medication with the passion of a spurned lover. I like to think that the pens aren't worth that much and are not enough to sway me from prescribing the appropriate medication instead of the one on the pen.

I think ethics is very important in medicine. But there is no need for us to be so fastidious that we fuss over every tiny potential for error. I believe in robust ethics -- that is, an ethical outlook that can tolerate the little scrapes and bumps in the road that are normal to life. If my moral code is so weak that I would sacrifice quality patient care for a nice pen, then I have no business living in the world. Sure, the reps want me to write their product. And yes, the pens remind me of their product. But I cannot be so ethically feeble that a simple pen will cause me to disregard all my medical training, as well as my ability to make a rational decision.

If I am that weak, God forbid that someone should present me with a bribe of real value, say, a freshly smoked Christmas turkey, and then ask me to blow up a bridge, because I might do it. A pen is to a prescription as a turkey is to a bridge, or something like that.

Luckily, I am a bit less suggestible than that. I try to be always mindful of the influence of advertising. Accepting a pen is a way of playing ball with the drug reps. They talk to me, and give me useful information about their products. And they also bring free samples, which helps my patients. I think the benefits of the information and the free samples outweighs the drawbacks of accepting a trinket as a gift. And if you've ever gotten a free drug sample from your doctor, I'll bet you do too.


The Genetically Identical Anecdote

Very often lately I have come across the Genetically Identical Anecdote. You've heard it -- this is the argument that a human is 97% genetically identical to a chimpanzee, or an orangutan, or a dolphin, or whatever animal species happens to be of interest at the moment. Usually the statement is made by a naturalist or environmentalist who wants the stress the point that humans are  closely related to animals, or that humans are no better than animals. The argument, while a little jarring, is nonetheless scientifically true: Over 97% of the genes found in the chimpanzee can also be found in our own genomes.

I consider myself an environmentalist, and do not object to people pointing out our kinship with them. But Genetically Identical Anecdote has been overused, and the observation now seems stretched. Most of all, I am bothered by its underlying assumption, that genetic similarity necessarily equates with identity. Genetics, by its very nature, implies a biological determinism. But while many of our characteristics certainly are genetically determined, it is important to note the biological research is now showing that our genetic codes are not necessarily the unalterable script of our lives. There may yet be room for free will after all.

Some genes are expressed only with the right environmental stimulation. For example, you may have genes that help your brain respond to and analyze music. However, if you never hear a musical instrument in your lifetime, these genes may never activate. On the other hand, if your parents drag you to every opera that comes to town, or if you choose to educate yourself in music as you grow up, this stimulation may trigger these genes to express themselves, and you could develop a musical talent that you otherwise would not have had. There is clear evidence that what you are in part is determined by what you expose yourself to. Thus humans, while 97% genetically the same as chimps, nonetheless are different not only because of the 3% genetic difference but also because as humans we expose our genomes to all kinds of stimulations that chimps can't.

There is another problem in the heart of the Genetically Identical Anecdote, and this problem lies with the scientific tendency to stress quantitative versus qualitative observations. It is axiomatic that scientists like to measure things. Scientists are very good at drawing conclusions about observations that can be easily measured, and not so good at evaluating observations that are subjective. It is well known, for instance, that the human body is about 60% water by volume. Yet it would be absurd to conclude from that that a 100 pound woman is 60% identical to a 100 pound bucket of water. Absurd but quantitatively accurate. What makes the woman different from the bucket of water is primarily qualitative, that is, subjective. You cannot put a number or a value on the distinction, but it is bluntly obvious.

In the same way, the Genetically Identical Anecdote stresses what can be measured, genetic material, and ignores what cannot, clear subjective differences between ourselves and other higher primates. While the Anecdote is clearly scientifically accurate, repeatedly stressing it tends to reinforce an argument that may not be true -- that our genes are the only things that make us what we are.


Thanksgiving 2005

Thanksgiving is, without a doubt, my favorite holiday. Free of the overheated commercialism of Christmas, of the lack of spirituality of the other national holidays, and of the misunderstood theology of Easter, it is a holiday of simplicity, a true day of rest and family. There is something blessed about a day of thanks. The one day of the year when we pause, set aside the things we want to have, and take stock in the things we do have.

Thanksgiving's joy is that it is the holiday of Now. In giving thanks we have to ignore what could have been or should have been, and put off thinking about what could be. What counts is what we have. We cannot give thanks for things we do not have yet or things we could have had if things had been different. We also cannot feel thankful for things we have lost.
So today, those of us who take this holiday seriously dismiss all of our hopes and regrets and look at today. Today, when you think about it, is the only thing we really have. Or, as C.S. Lewis once put it,  the light of eternity only illuminates the present moment. We have no awareness other than our sensations now, we have no thoughts other than our present thinking, we have no emotions other than or feelings now.

Living in the moment is one of the fullest and most transforming of virtues. In giving thanks, we live in the moment, and see ourselves as we really are. By making the effort to be thankful about it, we look for the good in what we have. Self-examination is never bad. But self-appreciation, when salted with an appropriate sense of humility, is an expression of grace.

I do not know of another holiday that gives us a similar opportunity to do so much.


Infantile Obesity

A new study from the University of Oregon suggests that children who gain weight rapidly after age 2 will grow up to have heart problemns and become obese.

This study, which was carried out using Finnish medical records from the 1940s, suggests that when food is pushed on children over the age of 2 to help them grow, it tends to create more body fat without necessarily increasing height or muscle mass.

(If you are wondering why Finland, and why the 1940s, here's why. Researchers often use Scandanavian countries for studies because they tend to be homogenous populations. That is, there is not a lot of ethnic variation in the population. This makes comparing data from different cities and towns easier. The reason for using 1940s data is that the researchers wanted to know how these kids turned out when they grew up. You have to go back before 1950 to find children who are now well into middle age. It takes that long for heart disease to show up.)

I have long believed that it is wrong to force children to eat more than they want to. Many parents worry endlessly about their children not eating enough. But kids know when they are hungry. They can read the signals from their own bodies and will eat when they get hungry enough. Forcing children to eat who do not want to only makes them fatter, not healthier.

What should parents do, then? Rather than concentrating on the amount of food children eat, focus instead on the quality of the food they are eating. Providing healthy food options will make for healthy kids. Let the kids decide how much to eat.

The study was published in the October 27 edition of the New England Journal of Medicine.


Katrina #2

Since Katrina, it has been convincingly shown that most of the flooding that occurred in the New Orleans area was not a result of the storm surge overtopping the levees. It was a result of levee failure.

With that knowledge, it it great to see that the Louisiana legislature has determined that absolutely nothing needs to be done. Whew! I was really afraid someone might take seriously the crazy idea that the levee management system should be overhauled, creating a new superdistrict that would make levee planning more efficient and consistent across parish lines.

Thank God the courageous powers-that-be had the backbone to stick up to that rascal Senator Walter Boasso, who has the nerve to put common interest in front of political patronage. Once again the legislature and the governor have bravely defended the good ol' boy networks who really got it done for us in the last storm.

This weekend, when I am out watering my lawn in sunny, beautiful St. Bernard Parish, I'll keep those goodfellas in mind.