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I am Albert Einstein, and I heartily approve of this blog, insofar as it seems to believe both in science and the importance of intellectual imagination, uncompromised by out of date emotions such as the impulse toward conventional religious beliefs, national aggression as a part of patriotism, and so on.   As I once remarked, the further the spiritual evolution of mankind advances, the more certain it seems to me that the path to genuine religiosity does not lie through the fear of life, and the fear of death, and blind faith, but through striving after rational knowledge.   Certainly the application of the impulse toward blind faith in science whereby authority is treated as some kind of church is to be deplored.  As I have also said, the only thing that ever interfered with my learning was my education. I am Freeman Dyson, and I approve of this blog, but would warn the author that life as a heretic is a hard one, since the ignorant and the half informed, let alone those who should know better, will automatically trash their betters who try to enlighten them with independent thinking, as I have found to my sorrow in commenting on "global warming" and its cures.
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Abysmal level of GP thinking exposed in the Times

Anyone who suspects that medical thinking at the GP level is composed more of superstition than evidence-based medicine need look no further than the Abigail Zuger column in the Times’s Science section today for confirmation of their worst fears.

Ironically the title of this embarassing self-exposure is Scare Yourself Silly, but the Real Terrors Are at Your Feet. As the introductory paragraph makes clear, the theme is the promising one that the Avian Flu scare is just another seasonal alarm, a distant and unlikely threat compared with, say, the very real danger of hospital infection.

Just in time for Halloween, the usual yearly ritual of terror by headline is now playing itself out in medical offices everywhere. Last year it revolved around flu shots; a few years ago it was anthrax and smallpox; a few years before that it was the “flesh-eating bacteria”; and before that it was Ebola virus, and Lyme disease and so on back into the distant past. This year it’s the avian flu….

That Klebsiella is one scary germ. It’s in hospitals all over the country, and by now it’s probably killed a thousandfold more people than the avian flu.

Her patronising tone seems out of place, however, and not just because it is the notoriously low standard of hygiene in hospitals that allows the newly antibiotic resistant bacteria to run rampant. It seems inappropriately smug because of the indications in the piece that Ms Ziegler’s thinking on AIDS is as underresearched as the ideas of her uninformed patients.

A few years ago, a young woman waited patiently to be seen in our office after hours. She was a patient of one of my colleagues, but she couldn’t wait for their scheduled appointment; she needed to see someone right away.

“I’m worried I have Lyme disease,” she said. “I have all the symptoms. I think I need to be treated.”

“But you have AIDS,” I said.

“I’m tired and weak and I have fevers and sweats. I’ve lost my appetite. I can’t think straight. I’m losing so much weight!”

She had seen a TV news report on Lyme disease, and then she had checked the Internet. All her symptoms were right there.

“But you have AIDS,” I said. “And you don’t want to take meds. That’s why you’re feeling so bad.”

“I’m really scared about Lyme disease,” she said. “I really need to get treated.”

“If you want to be scared, how about that untreated AIDS of yours?”

We looked at each other. It was an impasse. The fact that logic was on my side mattered not at all: evidently the real was just a little too real for her. How much better to find another illness to be scared of, obsess over, get treated for, get rid of.

Eventually she coerced my colleague into testing her for Lyme disease and treating her despite negative tests. Then she decided her symptoms might actually be due to a brain tumor, instead. And so it went, until she died of AIDS.

The number of questions this little vignette raises is so high that one wonders if her editors at the Times have any critical faculties left. What does “have AIDS” mean in this context? Was the patient merely “HIV positive” and without any symtoms of ill-health until this presentation? Even standard AIDS theory states that the dreaded virus can lie dormant for up to twenty years before causing problems. Why should Abigail assume that any and all symptoms of ill health were the result of “having AIDS”?

Why did the patient think it was Lyme disease, and not the many other possible causes of her rather general symptoms? Why did the patient feel that “AIDS” was not the cause of her symptoms? Given her implied hypochondria, this would be a surprising inconsistency. Perhaps the unfortunate woman had stumbled upon the HIV review literature which Abigail is ignoring or more likely has never read.

Why did the colleague treat the patient for Lyme disease, apparently to humor her, when it was so clear to Abigail that she “had AIDS”? And what happened in the end? At what point did the woman “die of AIDS”? What were her deadly symptoms, presumably more than fatigue, loss of appetite, fever and sweats? What disease would they have been interpreted as if the all consuming mental framework of “AIDS” had not swallowed every other possibility in Abigail’s mind, or the mind of her primary physician, who was presumably persuaded by that point that it was “AIDS” after all?

The degree to which we are expected to take for granted that Abigail knows best seems excessive given the number of holes in her screed, which in tone and content seems as foolish as she seems to think her patients are.

Doctor has to know best, of course, otherwise why are we paying him or her? But in this case perhaps Abigail should abandon her petty arrogance and connect with her patients a little more fruitfully, paying more attention to what they have to say, and communicating more to them. At the very least, she might consider whether or not a patient whose “drug habit” she is aware of but doesn’t mention to him is a patient being treated responsibly.

(show)

The New York Times

October 25, 2005

Essay

Scare Yourself Silly, but the Real Terrors Are at Your Feet

By ABIGAIL ZUGER, M.D.

Just in time for Halloween, the usual yearly ritual of terror by headline is now playing itself out in medical offices everywhere. Last year it revolved around flu shots; a few years ago it was anthrax and smallpox; a few years before that it was the “flesh-eating bacteria”; and before that it was Ebola virus, and Lyme disease and so on back into the distant past. This year it’s the avian flu.

“I was crossing Third Avenue yesterday and I was coughing so hard I had to stop and barely made it across,” a patient told me last week. “I’m really scared I’m getting the avian flu.”

I just looked at him. What could I say? He has smoked two packs of cigarettes a day for the last 50 years. He has coughed and wheezed and gasped his way across Third Avenue now for the last 10 years. His emphysema is not going to get any better, but it might stop getting worse if he were to stop smoking.

He made it clear long ago that this is not going to happen. When it comes to the whole cigarette/health question, his motto, apparently, is “What, me worry?”

But the avian flu – now there’s a health scare a person can sink his teeth into. So scary and yet, somehow, so pleasantly distant. So thrilling, so chilling, and yet, at the same time, so not here, not now, not yet. All in all, a completely satisfying health care fear experience. Unlike his actual illness.

Scary movies give children nightmares. Scary health news gives adults the extraordinary ability to ignore the immediate in favor of the distant, to escape from the real (and the really scary) into a far easier kind of fear.

A few years ago, a young woman waited patiently to be seen in our office after hours. She was a patient of one of my colleagues, but she couldn’t wait for their scheduled appointment; she needed to see someone right away.

“I’m worried I have Lyme disease,” she said. “I have all the symptoms. I think I need to be treated.”

“But you have AIDS,” I said.

“I’m tired and weak and I have fevers and sweats. I’ve lost my appetite. I can’t think straight. I’m losing so much weight!”

She had seen a TV news report on Lyme disease, and then she had checked the Internet. All her symptoms were right there.

“But you have AIDS,” I said. “And you don’t want to take meds. That’s why you’re feeling so bad.”

“I’m really scared about Lyme disease,” she said. “I really need to get treated.”

“If you want to be scared, how about that untreated AIDS of yours?”

We looked at each other. It was an impasse. The fact that logic was on my side mattered not at all: evidently the real was just a little too real for her. How much better to find another illness to be scared of, obsess over, get treated for, get rid of.

Eventually she coerced my colleague into testing her for Lyme disease and treating her despite negative tests. Then she decided her symptoms might actually be due to a brain tumor, instead. And so it went, until she died of AIDS.

Of four patients I saw in a single hour last week, three announced how scared they were of the avian flu. I reassured them, but there was quite a bit I did not say, and here it is.

I did not say: If you want to be scared, then how about that drug habit of yours you think I don’t know about? How about the fact that you are 100 pounds overweight and eat nothing but junk? How about the fact that in a few short months Medicaid is going to stop paying for your very expensive medications and no one knows how just high that Medicare Part D deductible and co-payment are going to be? I did not say: If you want something to be scared of, how about the drug-resistant Klebsiella that is all over this very hospital, an ordinary run-of-the-mill bacterial strain that has become so resistant to so many antibiotics that we’ve had to resurrect a few we stopped using 30 years ago because they were so toxic.

That Klebsiella is one scary germ. It’s in hospitals all over the country, and by now it’s probably killed a thousandfold more people than the avian flu.

But you don’t hear much about our Klebsiella. Like our bad habits and our dismally insoluble health insurance tangles, our antibiotic-resistant bacteria are with us, right here, right now. Apparently they all lack the drama, the suspense, the titillating worst-case situations that energize our politicians and turn into a really newsworthy health care scare.

They’re all just too real.

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