Call or Write your Senators . . .

Tell them to cut the crap and Confirm Donald Berwick.

Reflections on COMET

That's the Communication, Medicine and Ethics conference I just attended. First, I'm very happy to say that we honored Elliott Mishler last night, who is 87 years old and still going strong. In the circles I travel, he's really famous, but I expect most readers have never heard of him. Elliott is best known for discovering what he called the Voice of Medicine and the Voice of the Lifeworld, which is a way of saying that medical encounters, in general, are cross-cultural. People don't have to be from an exotic clime or speak Albanian to find themselves in a strange world when they go to see the doctor, or enter the hospital. And rather than reaching out to cross the chasm, doctors tend to try to force us to operate in their universe, without necessarily giving us much help.

A commenter on the previous post gives a very concrete example -- failure to give basic, helpful anticipatory guidance. How often, when your doctor has written a prescription, have you had a meaningful conversation about the alternatives, the possible side effects, and the benefits vs. alternatives or doing nothing? I will bet your typical experience is "Here, take one of these pills twice a day." The profession nowadays expresses the ideal that patients should make "informed choices" and that decision making between physicians and patients should be "shared."

I'm not sure it's meaningful to talk about "shared" decisions. Either the people agree, in which case it's trivial, or they don't, in which case someone will prevail. Shared decision making ultimately has to mean that the doctor convinces you to do things her way, because otherwise you will do what you want. After all, they aren't legally allowed to strap you down and pump in pills or cut you open without your permission.

However, it is very rare for people to possess the information and understanding they need to engage meaningfully in health care decision making. After all, doctors are experts. That's why they make the big bucks. If we could know everything they do, we wouldn't need them. What we don't yet understand very well is the essential scaffolding that people need to be functionally empowered to make decisions that make sense for them. Without deep and detailed knowledge of the biological science, there are likely to be a few basic ideas and probabilities that are really relevant to your choices. But exactly how an explanatory model of disease and treatment can be judged to be accurate enough to be functionally equivalent to a scientifically complete model, and how explanatory models interact with people's decision rules, is difficult ground.

What I am saying is, there is no excuse for physicians not to give us basic information, that is easy to understand, and that would really matter to us. But it is more challenging for physicians and patients to enter into each others' worlds far enough to truly achieve partnership. It would be rather grandiose to adopt that as a mission for this blog, we'll see if we can't advance the cause a bit anyway.

It's just so embarassing . . .

... to talk about sex. At least that's what I found out when we analyzed a whole bunch of audio recorded routine outpatient visits of people living with HIV. This conference is quite interesting and there's a lot to report on, but in the few moments I have right now I'm first going to tell you about my own presentation.

We happened to have these transcripts that we first collected for a different study and then I said, what the heck, let's look at physician counseling of patients about safe sex. According to consensus guidelines by all of the major organizations in the U.S. concerned with HIV care, docs are supposed to do a quick screen in every visit for sexual risk, and provide a brief behavioral intervention. The idea is, over time, to reduce people's risk of transmitting the virus to others, and of becoming re-infected with a strain of HIV that might be resistant to the meds they are taking, or of acquiring a sexually transmitted infection.

Nice guideline, but docs don't do it. Out of 118 visits in our database, only 10 featured any discussion of sexual risk behavior at all and only four of those included any sort of counseling to reduce risk. Using our super duper special coding system, when there were conversations about sexual risk, patients made many fewer reports about their own behavior than when discussing diet and tobacco use; and physicians gave more information, but fewer instructions. Mostly, they just asked, "Do we need to talk about safe sex?", the patient said no, and that was that.

Appallingly, we had patients who came in with sexually transmitted infections, and/or actually told the doctor they were engaging in unsafe sex with multiple partners, and the physician did not respond with any counseling to reduce risk behavior. One guy even said that there were men who were actively trying to become HIV infected, and wasn't that strange? The guy apparently obliged them. But the doctor just choked, and changed the subject.

There are a few problems here. One is that doctors aren't trained to do this kind of counseling. They don't know what to do, so they just avoid the subject. They are afraid the patient will feel judged, and their relationship with the patient will be harmed. And they are just uncomfortable with the whole subject. We live in a very repressed society and doctors are a part of it.

It's not enough to promulgate guidelines. You need to equip the providers with the skills and self-efficacy to follow them. There are plenty of other examples but this one is quite compelling.

Off on a comet

For the next three days I'll be at the conference on Communication, Medicine and Ethics, which means I get a free trip to Boston. I'm presenting tomorrow, but meanwhile I'll report on anything interesting I hear. I don't know what the WiFi situation is at the conference venue yet, but I'm hoping for full Intertubes access. If I don't have it, however, there won't be a post till this evening.

The practice of medicine is 90% talking and listening, neither of which often gets done very well. But we know 100 times as much about the other 10%.

Drive-by Blog

I only have a couple of minutes today, so I'll just follow up briefly on yesterday's post. We may seem to be at a historical high in the snake oil game. Of course pretty much all of medicine was bogus until around the second quarter of the Twentieth Century when medical science started to figure a few things out and doctors could do more harm than good. For quite a while medical advances such as antibiotics, immunization and rapidly improving surgical techniques built tremendous cultural authority for M.D.s and the stuff that was taught in medical school.

But I think we may have had a revolution of rising expectations. A lot of problems, notably cancer, many autoimmune disorders such as MS, psychological and developmental disorders have turned out to be much less tractable than people expected. When the scientific establishment appears to have let people down, they are often prey for people who claim that "they" don't want you to know about the miracle cure. Biomedicine can also seem dispassionate, incomprehensible, impersonal, and it really is painful and scary sometimes. Chemotherapy, surgery, powerful pharmaceuticals, all can be extremely unpleasant. The claim that there is ancient wisdom that can heal in a gentler and perhaps miraculous way can seem very appealing.

Sometimes practitioners fool themselves. People often get better on their own, or feel better after they undergo some soothing intervention that involves touching, perhaps, or other kinds of supportive contact, and the provider is easily convinced that she or he has really got something important. From there, confirmation bias takes over. There are also a lot of charlatans out there -- cynical con artists who just want to steal from you.

Leaders of the International Society for Stem Cell Research grew so alarmed at the proliferation of scams that they have set up an entire program to warn people against the charlatans. I have long linked to Quackwatch and if you go there you will be astonished by the endless list of frauds and nonsense that they have had to debunk. It's a never ending struggle. Don't get taken.

Composting the bull excrement

I can't remember if I've mentioned it before, but I get a veritable torrent of missives from publicists touting every sort of fraud, quackery, hokum, bunkum and crap you can imagine. I generally just hit the delete key, but I have decided to establish a policy of occasionally putting one of these con artists through the compost grinder.

The latest is from one David Gruder, who describes himself as

"a clinical psychologist, . . .the Mental Health Coordinator of the non-profit Energy Medicine Institute. As the Founding President of the Association for Comprehensive Energy Psychology in 1999, he has been a pioneer in applying insight and techniques from time-honored healing traditions for enhancing mental health.

Gruder complains that the APA has been denying psychologists continuing education credits for learning his method of "energy psychology," which is evidently "time honored" by 11 years of him touting it.

Energy Psychology involves procedures such as tapping on acupuncture points at the same time that a traumatic memory or stressful trigger is brought to mind. The technique appears to send signals in the brain that counteract the stress response. It has been shown to be effective with a range of disorders, from simple phobias to irrational anger to severe PTSD.

"Shown to be effective," has it? Gruder says "Increasing numbers of articles and reports documenting the effectiveness of carefully administered Energy Psychology techniques have been appearing," but he only refers to one: a conference abstract. It's impossible to glean from conference abstracts any details of how a study was conducted or how credible it might be. He says this was a randomized controlled trial but he presents the results this way: "The data show that PTSD symptoms were dramatically reduced in 49 military veterans. Forty-two of them, an almost unheard of 86 percent, no longer scored within the PTSD range after six sessions. There was only one drop-out. The gains persisted at 6-month follow-up. Compare this with the 9 of 10 drop-out rate in VA programs."

A randomized controlled trial requires, guess what, a control group. This says nothing about any control group. Hmm. He is actually comparing his results to some unspecified, unmatched comparison group. We don't know what the initial state of these 49 individuals was and whether it is in any way unusual for 42 of them not to "score within the PTSD range," on some unspecified measure, after six sessions -- which covered an unspecified period of time, and during which we have no idea what else was going on with them. In other words, this is total bunk.

I did a PubMed search on "energy psychology" and I got exactly 3 hits. Three. Here they are:

Randomized trial of tapas acupressure technique((r)) for weight loss maintenance: rationale and study design.

Elder C, Gallison C, Lindberg NM, Debar L, Funk K, Ritenbaugh C, Stevens VJ.

J Altern Complement Med. 2010 Jun;16(6):683-90.PMID: 20569037 [PubMed - in process]
2.

Pilot study of emotional freedom techniques, wholistic hybrid derived from eye movement desensitization and reprocessing and emotional freedom technique, and cognitive behavioral therapy for treatment of test anxiety in university students.

Benor DJ, Ledger K, Toussaint L, Hett G, Zaccaro D.

Explore (NY). 2009 Nov-Dec;5(6):338-40.PMID: 19913760 [PubMed - indexed for MEDLINE]Related citations
3.

Energy psychology and thought field therapy in the treatment of tinnitus.

Pasahow RJ.

Int Tinnitus J. 2009;15(2):130-3.PMID: 20420336 [PubMed - indexed for MEDLINE]Related citations

The first one doesn't even report results. It describes a trial which is proposed but has not been conducted. Oh yeah, it's published in the Journal of Alternative and Complementary Medicine. The second one is a three-arm trial with, get this, 5 subjects in each arm. None of the methods involved tapping on acupuncture points, as far as I can tell. The end point was reduction in test-taking anxiety among students, not PTSD or any other mental disorder. The third one is a report of two (2), yes 1 + 1 case studies. The condition being treated is stress from ringing in the ears.

So "Doctor" Gruder, I call you a liar. Pants on fire.

It's the S.O.S.

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries.

That's the Commonwealth Fund again, updating what we already know.

Among the seven nations studied—Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States—the U.S. ranks last overall, as it did in the 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, coordination, efficiency, and equity. The Netherlands ranks first, followed closely by the U.K. and Australia. The 2010 edition includes data from the seven countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care.

And yep, we're still spending twice as much as the rest of them in order to get the lousiest results. One more thing -- the rest of those countries are damn commies. The dead hand of government is strangling the wondrous creativity of free enterprise in health care. But the facts will never get in the way of a bullshit story about "freedom" in this delusional country.

Realms of belief

This analysis in the Proceedings of the National Academy of Sciences has gotten some attention in precincts where people are interested in such things, but it hasn't led to any prominent corporate media mea culpas that I have noticed. And perhaps the scribblers and yackers don't believe it should.

In a nutshell, more than 97% of scientists who are actively publishing in the field of climatology are convinced that human activities are causing a rise in global C02 which in turn is causing global climate change. Furthermore, those who are not convinced have much less publication, and what they do have is in lower impact journals.

To the authors, and the scientists involved in the Intergovernmental Panel on Climate Change reports, this shows that media coverage of the issue, which reflexively "balances" findings of anthropogenic global warming with denials, is in fact unbalanced. It gives false credibility and stature to a position which is at best marginal within the relevant scientific community.

I agree with that assessment but I also know what the deniers will say: that the apparent scientific consensus is self-perpetuating because contrary views can't get published. It's nonsense of course. The vast majority of these publications don't specifically or directly make any conclusions about AGW, they deal with various bits and pieces of the climate system and its history. To generate the big picture of climate change, you have to put a whole pile of pieces together and you have to add up the relevant weights of several lines of theory and evidence. What the publication record shows is the relative scientific productivity and expertise of the investigator, not his or her adherence to a particular supposedly politically correct belief.

But, that ain't gonna cut any mustard with the deniers, because they just don't admit of the same criteria for credibility. Most people, most of the time, think backwards, from belief to evidence. Our tendency is to notice, or give more weight, to bits of evidence that seem to support our current beliefs; to assemble the evidence into supportive structures; and to discount or ignore contrary evidence. It's called confirmation bias and the resources people have to exercise it are truly impressive.

Forty one percent of Americans believe that Jesus will return by 2050. Only 46% consider it unlikely. I saw a guy reading a book on the subway this morning, Señales de su Venida (Signs of his Coming), and what he is reading is a systematic marshaling of evidence to convincingly demonstrate that we're in the End Times. These folks are convinced by an irrefutable assemblage of facts about the current world that correspond to elements of the Revelation of John, as interpreted by people with the right expert credentials -- ordained ministers of evangelical churches. Obviously what I have to say about the subject is not credible because I'm not an expert. So there.

Those who do not remember the (ficititious) past . . .

are doomed to repeat it.

My liege, I did deny no prisoners.
But I remember, when the fight was done,
When I was dry with rage and extreme toil,
Breathless and faint, leaning upon my sword,
Came there a certain lord, neat, and trimly dress'd,
Fresh as a bridegroom; and his chin new reap'd
Show'd like a stubble-land at harvest-home;
He was perfumed like a milliner;
And 'twixt his finger and his thumb he held
A pouncet-box, which ever and anon
He gave his nose and took't away again;
Who therewith angry, when it next came there,
Took it in snuff; and still he smiled and talk'd,
And as the soldiers bore dead bodies by,
He call'd them untaught knaves, unmannerly,
To bring a slovenly unhandsome corse
Betwixt the wind and his nobility.
With many holiday and lady terms
He question'd me; amongst the rest, demanded
My prisoners in your majesty's behalf.
I then, all smarting with my wounds being cold,
To be so pester'd with a popinjay,
Out of my grief and my impatience,
Answer'd neglectingly I know not what,
He should or he should not; for he made me mad
To see him shine so brisk and smell so sweet
And talk so like a waiting-gentlewoman
Of guns and drums and wounds,--God save the mark!--
And telling me the sovereign'st thing on earth
Was parmaceti for an inward bruise;
And that it was great pity, so it was,
This villanous salt-petre should be digg'd
Out of the bowels of the harmless earth,
Which many a good tall fellow had destroy'd
So cowardly; and but for these vile guns,
He would himself have been a soldier.
This bald unjointed chat of his, my lord,
I answer'd indirectly, as I said;
And I beseech you, let not his report
Come current for an accusation
Betwixt my love and your high majesty.

Hotspur's complaints are precisely those of a certain general we hear of today. The king's lieutenant is annoying and effeminate. Hotspur has a war to fight along with the rest of his Manly Men, and he doesn't need this womanish civilian garbage. He apologizes for the unfortunate outburst and the king agrees to move on.

But as we know, Hotspur was in fact plotting sedition,* and if the king had been a little bit smarter, he would have sent him straight on to the Tower. Just sayin'.

*This is a non-partisan observation. Had I been around at the time, as a kinsman of Owain Glyndŵr, I would have been all in favor of Hotspur's disloyalty, however inherently repugnant, purely as a means to an end. As it happens, this time around, I'm not.

My how you talk . . .

It seems Senate Republicans are going to oppose Donald Berwick as director of CMS because he has made some shocking, appalling public threats to murder your grandmother. Among the Hitlerian eugenicist opinions he has shamelessly enunciated are:

The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.

In his book, “Escape Fire: Designs for the Future of Health Care,” Dr. Berwick sharply criticized “the dangerous, toxic and expensive assumption that more is better.” He insists that the nation can cut health costs without harming patients because vast sums are misspent.

“I have said before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,” he said in an interview in the journal Health Affairs in 2005.

Dr. Berwick has championed efforts to “reduce the total supply of high-technology medical and surgical care” and to consolidate services in regional centers.

Long before the uproar over “death panels” last year, Dr. Berwick was urging health care providers to “reduce the use of unwanted and ineffective medical procedures at the end of life.”

“Using unwanted procedures in terminal illness is a form of assault,” he said in 1993 at the annual conference of his institute. “In economic terms, it is waste.”

On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.

In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was “in love with the N.H.S.” and explained why it was “such a seductress.”

“The N.H.S. is not just a national treasure,” he wrote; “it is a global treasure.”

Among its virtues, he told a British audience, is that “you cap your health care budget.”

Instead of trying to protect the wealthy, Dr. Berwick wrote, the British recognized that “sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just must redistribute wealth.”

Dr. Berwick offered a suggestion to the British: “Please don’t put your faith in market forces.”

“In the United States,” he wrote, “competition is a major reason for our duplicative, supply-driven, fragmented care system.”

Well I've just fallen onto the fainting couch. Thank God we have the Republican Party to save America from this amoral monster. "The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an “expert on rationing.” Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.”

Yep. That's about right.

The truth leaks out . . .

But hardly anybody pays attention. Adm. Thad W. Allen of the Coast Guard, the “incident commander” in charge of operations at the wrecked well, updated reporters on a telephone conference call this morning. (June 21)

Several questions were asked about the integrity of the well bore, the drilled and lined hole descending several miles from the seabed to the oil and gas deposits far below. If the lining is fractured, no effort to cap the well at the top would be safe because oil could flow up through the earth outside the well with no options for suppressing it. (Think of how leaks in a pressurized garden hose worsen if you close the nozzle at the end.)

“We don’t know the exact status of the well bore,” Allen said. He said that one reason the “top kill” procedure was abandoned was the realization that the well bore could be compromised.

Well okay then. Every element of the doomsayers' case that has been subject to verification so far has turned out to be true:

* The pressure of the petroleum reservoir was too great for any available technology to resist;
* The flow of petroleum with entrained silicon has been eroding the internal structure of the blowout preventer and the well head and the flow of oil has been increasing over time;
* The well bore may well be structurally damaged and the oil may find new paths to the surface.

The relief wells are in a race against even worse disaster. The whole thing could fall apart and be essentially unstoppable. I can understand why the people in charge don't want to say this publicly but as we debate whether to resume deep water drilling the public needs to know exactly where we stand and what the risks are. Even if they get this thing stopped some time in August, it will matter that we came so close to unimaginable horror. The people need to be told the truth.

Uninhabitable?

As you know if you have been paying attention (and I know you have or you wouldn't be among our exceptionally sophisticated readership), For March–May 2010, "the combined global land and ocean surface temperature was 14.4°C (58.0°F) — the warmest March-May on record. This value is 0.73°C (1.31°F) above the 20th century average. The combined global land and ocean average surface temperature for January–May 2010 was the warmest on record. The year-to-date period was 0.68°C (1.22°F) warmer than the 20th century average."

I know, I know, it's all a hoax by an international conspiracy of scientists who want to impose one-world communistofascioislamosocialism. But what if it isn't?

The weather in Iraq lately has not been exactly hospitable to human life, with temperatures above 50 degrees Celsius (122 degrees Fahrenheit) for several days in a row. (I know, I know, it's a dry heat. But dry roasted is still roasted.) So it's not surprising that the people are staging angry protests over the lack of electricity.

Here's the problem that seems not to have occurred to very many people. Iraq is one of the hottest places on earth, but all those desirable sunbelt locations, and the Republican heartland from Arizona to Virginia, would already be really lousy places to live without air conditioning. I can guarantee you that Congress would move the national capital to Oregon if they didn't have AC. So what happens as the temperature keeps rising and the price of fossil fuels keeps going up along with it? Do Dallas and Atlanta become ghost towns? Or do we figure out a better way?

Just something to think about.

Participant Observation

I don't think I mentioned it here, but yesterday I had minor outpatient surgery. There's no reason for secrecy -- I had a lipoma removed. These are basically harmless fatty tumors. Usually the best thing to do is just leave them alone but this one had gotten quite large -- much bigger than the typical 1.2 inches mentioned in the linked article -- and was in an inconvenient location just below my belt. So I decided to get rid of it.

The procedure itself was no big deal. It took about 25 minutes, using local anaesthesia. It was quite painful as it turned out -- the tumor had encapsulated a nerve and even though they kept pumping in lidocaine it was ineffective. I expect a lot of people would have freaked out, but I have a high pain threshold. However, once it was over I had surprisingly little pain. I'm at work now, walked to the subway as usual, and I'm not taking any pain killers. It's barely sore at all.

That said, as a patient advocate I have plenty of items for the suggestion box. They made me show up at 12:30, for surgery scheduled at 2:45 and ultimately done at about 3:45. In between, the total amount of stuff they had to do to me required about 15 minutes, dribbled out in 3 minute doses with immense gulfs of nothing in between. They also had absolutely no concern for my dignity. This is quite typical of the medical institution: procedures are organized for the convenience of staff with essentially no consideration for patients.

First I had to see an "admitting officer." This guy has a private office all his own. His job is to ask me sensitive questions such as my name and address and emergency contact information, and to get me to sign a form consenting to surgery -- which is not actually the informed consent form, which comes later. This one had almost no content and required no explanation. Then they had me go and sit in the waiting room for 30 minutes. They provide no reading material, but I'd been smart enough to bring my own.

Eventually a woman called my name and had me go to a changing area where I had to remove all my clothing and put on two of those open cotton robes they make patients wear, one open in back and the other open in front; pajama pants; and cloth slippers. Then they sent me back to the waiting room to sit for another 30 minutes in that humiliating costume. I finished the NYT and the Boston Globe and now all I could do was sit there.

Then another woman called my name and escorted me to the surgical suite, where I sat alone for another 20 minutes in a room painted with childish cartoons of underwater creatures featuring big googly eyes and bright smiles, including a sea star wearing sun glasses. Again, no reading material. Finally a nurse came and asked me some questions: did I know why I was there, where was the lesion, was I allergic to latex or any drugs? She went away and 15 minutes later a resident came in who asked me the identical questions. He went through the informed consent form -- the real one this time -- and had me sign it. Then the surgeon came in and asked me the same questions for the third time, and marked the tumor with a sharpie.

After a briefer time alone, another nurse came in, to ask me the same questions again. When I told her that I was a medical sociologist, she got very interested. She is really honked off about medical students nowadays. They show up for rotations sloppily dressed, unkempt, and unshowered. They stand around the foot of the stretcher chewing gum and texting. She described young women with their white coats open to reveal bare midriff, people who didn't bother to comb their hair or brush their teeth (I guess she detected halitosis). I was surprised -- I would have thought they had a dress code -- but I'm going to pass this on to some friends at the medical school. She was also apologetic about all the pointless waiting. She explained they have to leave slack in the schedule in case of emergencies. So at least one person gives a shit, for what it's worth.

Anyway they finally got around to cutting me. They positioned a drape so I couldn't see what they were doing, which I suppose is generally a good idea but they didn't ask my preference about that. They did respond when I expressed pain and tried pumping in more lidocaine though as I say, it didn't work. The surgeon was generally very businesslike and brusque with me in all our interactions but she did briefly apologize on her way out of the room -- with me lying strapped to the gurney and appropriately infantilized -- leaving the resident to close.

The nurse met with me again in the room with the cartoon fishies to give me follow-up instructions and make a follow-up appointment. Then they all just split and left me on my own to find my way back to the changing room -- actually I had to figure out that was the thing to do, it was unclear whether there was any other next step. The changing area was unattended, but fortunately I was not in any pain at that point and I didn't have much trouble changing. I then had to take the initiative to go to the reception desk to ask for a pair of scissors to cut the ID band off my wrist.

So, the bottom line for me was, technically a good result and I'm glad I went through with it. I'm a self-sufficient person and I didn't need a lot of reassurance or hand holding, but I expect a lot of people are anxious or confused in these circumstances and they would not have gotten much help or comfort. It seems to me it would be quite easy for them to do better. I'm not entirely sure why they don't.

Somebody needs to answer this, now

As you may recall, fairly early in the Deepwater Horizon disaster, I quoted a petroleum engineer who claimed that sand entrained in the gusher would steadily erode the well casing, leading ultimately to a totally uncontrolled eruption of petroleum from the reservoir. In the weeks since, there has been a steady flicker of claims around the fringes of the blogosphere that the well is structurally damaged and that oil is already emerging directly from the sea floor.

These claims have appeared from commenters at The Oil Drum, where the front pagers generally pooh poohed them, and at various other places, most of them not particularly credible (e.g., World Nut Daily). I haven't mentioned them here because what do I know?

But they keep circulating. Now the assertion is steadily moving onto more solid ground, and an Oil Drum commenter has caught the attention of Casaubon's Book and been treated respectfully by the Drum masters.

Here it is, if you dare. It's a long argument, but he marshals plenty of evidence and sounds might convincing. I'm going to quote the really, really ugly part:

I am convinced the erosion and compromising of the entire system is accelerating and attacking more key structural areas of the well, the blow out preventer and surrounding strata holding it all up and together. This is evidenced by the tilt of the blow out preventer and the erosion which has exposed the well head connection. What eventually will happen is that the blow out preventer will literally tip over if they do not run supports to it as the currents push on it. I suspect they will run those supports as cables tied to anchors very soon, if they don't, they are inviting disaster that much sooner.

Eventually even that will be futile as the well casings cannot support the weight of the massive system above with out the cement bond to the earth and that bond is being eroded away. When enough is eroded away the casings will buckle and the BOP will collapse the well. If and when you begin to see oil and gas coming up around the well area from under the BOP? or the area around the well head connection and casing sinking more and more rapidly? ...it won't be too long after that the entire system fails. BP must be aware of this, they are mapping the sea floor sonically and that is not a mere exercise. Our Gov't must be well aware too, they just are not telling us.

All of these things lead to only one place, a fully wide open well bore directly to the oil deposit...after that, it goes into the realm of "the worst things you can think of" The well may come completely apart as the inner liners fail. There is still a very long drill string in the well, that could literally come flying out...as I said...all the worst things you can think of are a possibility, but the very least damaging outcome as bad as it is, is that we are stuck with a wide open gusher blowing out 150,000 barrels a day of raw oil or more. There isn't any "cap dome" or any other suck fixer device on earth that exists or could be built that will stop it from gushing out and doing more and more damage to the gulf. While at the same time also doing more damage to the well, making the chance of halting it with a kill from the bottom up less and less likely to work, which as it stands now?....is the only real chance we have left to stop it all.

Maybe that's why Mr. Obama inflicted all that drivel on us about prayer at the end of his speech. Maybe that's really all they've got at this point.

In any case, we need the president or a responsible spokesperson such as Admiral Allen to address this. Is it true or not? Obviously Tony Hayward knows and if he knows Barack Obama better damn well know too. We all need to know. Now.

A fact based opinion

As anybody who has been reading for a while knows, I'm of the opinion that some screening tests are oversold. I'm particularly skeptical of prostate cancer screening, because you get a whole lot of overdiagnosis -- i.e., "cancers" that never would have caused a problem if they weren't detected, but cause big problems when you get surgery, radiation and chemotherapy -- and false alarms -- PSA levels or physician's perception of a palpable abnormality that result in biopsies and associated sturm und drang but are benign. I'm also totally down with not starting mammography until 50 and maybe only every two years. As always, family history or other risk factors change the parameters big time, so educate yourself, talk to your doctor, and make your own decision.

However, these opinions are based on studying the research and understanding the specific facts about each screening modality. I do not have some generalized anti-screening ideology. And so we come to screening colonoscopy. It's more expensive than mammograms or PSA tests, but it's still more cost effective and has much less downside. So-called Ductal Carcinoma in Situ, DCIS, the non-invasive lesions often found by mammography, and "indolent" prostate cancers, often never progress to cause disease. They may even spontaneously remit. But if they are found by screening, they result in surgery and/or radiation and/or highly toxic chemotherapy.

The progression from a polyp in the colon to cancer, however, is much more predictable; and it's also pretty slow, which means the screening interval can be long. Best of all, pre-cancerous lesions can be removed during the colonoscopy itself, without invasive surgery, which means you get actual, real prevention as well as early detection out of the deal.

This is the most thorough recent review I could find. It's complicated and geeky -- read it at your peril. But the takeaway is simple. If you live in a rich country where treatment is available, screening is well worth it. Colonoscopy at age 50, and every ten years thereafter or more frequently if there is an indication, is extremely cost effective. These authors estimate $800-$2,200 per DALY (Disability Adjusted Life Year) which is a much better buy than an annual check up, even better than medication for high blood pressure. Some estimates even give the cost as zero because of the possibility of actually preventing cancer. And the population level benefit is substantial -- 18 million DALYs gained per year. However:

Adoption of screening policies between the ages of 50 and 80 will only eradicate a small portion (between 14%-24%) of the existing colorectal cancer burden, since the application of the compliancy rate to the intervention efficacy, even in the case of colonoscopy every 10 years will only result in a 24.1% reduction in incidence.

What this means, in English, is that we don't get the full benefit because lots of people don't do it. Yeah, it's a pain in the ass. But it beats the hell out of the alternative.

The weirdest thing about this story . . .

Is that there is an Association of Professional Animal Waste Specialists, and that they apparently maintain a meticulous history of the craft.

As president, he didn't really float my boat . . .

But Jimmy Carter has turned out to be an excellent former president. (And any self-styled "supporters of Israel" out there who feel otherwise can kiss my grits.) One most excellent undertaking of Mr. Carter's has been the eradication of Dracunculus medinensis, the Guinea worm, which causes the disease Dracunculiasis.

It is truly gross. Sayeth the WHO:

In the human body, the larvae are released and migrate through the intestinal wall into body tissues, where they develop into adult worms. The female worms move through the person’s subcutaneous tissue, causing intense pain, and eventually emerge through the skin, usually at the feet, producing oedema, a blister and eventually an ulcer, accompanied by fever, nausea, and vomiting.

And that is a long worm, actually crawling out of the person's body. People often try to relieve the pain by putting their feet in the river, where the larvae can be released to be eaten by water fleas and starting the cycle over. Fortunately, the organism requires the human host to complete its life cycle, which means that it can be eradicated by the brute force method of filtering water fleas from drinking water, killing the fleas with chemicals, and educating communities so that infected people do not allow the worms do not come into contact with bodies of water when they emerge.

In a remarkable public health success story, the worm has been eradicated from most of its former range and is now found in only Sudan, Ghana, Mali and Ethiopia. The bad news is of course that these areas are impoverished and remote, and Sudan in particular is politically chaotic. Nevertheless the campaign is continuing in these areas and succeeding. The Carter Center has been a major sponsor of the effort.

I got an e-mail from the producers of a film about this campaign, called Foul Water, Fiery Serpent, and they have posted substantial excerpts. By all means check it out. When this campaign finally succeeds and Dracunculus medinensis no longer exists, some of the world's poorest and most vulnerable people will have a chance to build better lives.

There's good news and . . .

well, kind of bad news. KWC suggested I discuss this report in the new NEJM, which you aren't allowed to read because you're commoners, but it is discussed for the benefit of the rabble here.

It turns out that people in northern California who have excellent health insurance -- specifically Kaiser Permanent members -- had a sharp decrease in the rate of heart attacks from 2000 to 2009, and were also more likely to survive if they did have one. It's partly -- at least a little bit -- due to lower rates of smoking, but it's mostly due to more people taking pills to control cholesterol and blood pressure and reduce the risk of blood clots. As we are all too well aware, diet, activity patterns, and fatness have been getting worse, not better.

Fortunately, the pills are available as inexpensive generics and for the most part have few and mild side effects. A scare story came out just yesterday about a weak association between angiotensin receptor blockers and cancer, but only a minority of people take ARBs and they are more expensive than the alternatives anyway. Some docs, unfortunately, will prescribe them as first line treatment for hypertension because a few patients get a dry cough and itching from angiotensin converting enzyme inhibitors, but really -- try the ACE inhibitors first and only worry about it if you do have a problem, which you probably won't. If you do, you can just stop.

But, this is only good news as long as people can afford medical care, the industry keeps making billions of pills, and people keep taking them. It's kind of unappealing esthetically -- wouldn't you rather have everybody be fit and eating their veggies? And people in poor countries or people here who can't get health insurance don't benefit. And you can be sure we'll still have the latter for the foreseeable future, even with the recent legislation.

Ironically, uninsured people who do have heart attacks can still go to the ER and get the emergency treatment that benefits them, although they aren't likely to get the follow up care. But we don't bother to give them the cheap pills that would have prevented the problem in the first place.

The Doctor is In the Moment?

Physicians are trained to be biological technicians; they learn how to be healers of humans -- or not -- more or less by accident, by observing their preceptors in their clinical rotations and residencies. The idea of trying to systematically equip them with communication skills, and an understanding of how people are likely to respond to everything they say, is really quite novel.

One of the hardest things for anybody to do is to deliver bad news. Doctors often have to do it, so you would think they would be good at it, but many of them are not. It just isn't part of what traditionally goes into assessing clinical competence or conferring professional prestige. Two Italian physicians discuss the problem of bad news thoughtfully, and the journal is kind enough to make the essay available. Their first recommendation seems pretty obvious -- the doctor must look into his or her own psyche and understand how this task creates fear.

It is an extremely difficult task but if done properly it leads the doctor to construct that therapeutic alliance which allows the patient to listen to bad news without being overcome by it; to hear a possible truth, said with delicacy, without being dismissive or brutal and without shame. Life itself can also be perceived as a fatal illness but it is possible to live it serenely tearing away the mask of this obscure illness without being petrified by it.

Then there is simply a right way and a wrong way to proceed.

It is necessary to find a private area where the patient can feel as comfortable as possible without interruptions from colleagues or telephones and dedicate ample time to the conversation (listen and be listened to). Allow the patient to choose if he or she wishes to see the doctor alone or in the company of a family member, a relative or a friend. . . .

Leaving aside for a moment the approaches which clinical and psychological research have identified to help make this task less painful and for which a doctor is never totally prepared, the way to break bad news is never easy. Perhaps individualized disclosure and a shared decision-making process bring the patient to the bad news not in accordance with a pre-fixed standard but in a way which takes into account the patient's history, character, cultural level, capacity to understand and many other variables which can at that moment influence the impact of bad news.

It is extremely difficult to respect all these variables and for this reason the job of the doctor, if he or she has established this objective, is even more delicate because in the end bad new is bad news and whoever has to announce it, share it, help and support it must have or acquire those abilities which allow him or her to communicate confidently and delicately with kindness and honesty.

One of the most difficult tasks all physicians face, one at which many do not succeed, is to feel real caring, empathy and respect for patients; without being overwhelmed or emotionally scarred by all the bad things that happen to them. Some adopt a defense of callousness and indifference; others become over-involved and start to depend on their patients for emotional gratification. There is a place of maturity, compassion and strength which is hard to get to and hard to stay in, but finding it is central accomplishment of a healer.

Apologies . . .

I was very busy yesterday with meetings and what not -- I don't know how people like PZ Meyers and Orac manage to pump out acres of blog every day while maintaining active research programs -- and I was also somewhat inarticulate with rage. There's a lot of that going around.

Anyway, I know I tend to harsh your mellow a bit too much, but today I'm going to give y'all some very important, unsolicited and possibly obnoxious advice: Hang up the Goddamn phone and pay attention to your driving! Amy Ship figures that as a primary care doc, if she's supposed to ask her patients about tobacco and alcohol and unsafe sex and all that jive, she had better ask them about cell phone yacking and driving and encourage them to cut it TF out.

I agree. Among my many vices, I happen to be a pedestrian, and I can't tell you how many times morons who were talking on the phone and driving with one hand or their knees have damn near killed me. As Ship tells you, as long as you're yacking on the phone you might as well be doing jello shots because it is precisely as dangerous as driving drunk. Ergo, it is not just stupid, it is immoral, because you are risking the lives of all the people around you in order to indulge in pointless, probably moronic chatter.

Please note that Homo sapiens got by just fine without mobile phones for 450,000 years. Ergo, it is impossible that your phone call is necessary, and highly unlikely that it is even important. Personally, I am sick and tired of listening to women break up with their boyfriends over the telephone on the sidewalk. My brother was heading to his car in the parking lot of the hospital where he works (that's the only thing we have in common) and here was a young woman yelling into her cell phone "Joey, pick up the Goddamn phone! Joey, why don't you answer the @@#$%^ phone! Joey!" Then a guy standing 10 away turned around and said "What? WTF do you want?" I was walking home from the subway and one of my neighbors was just ahead of me, talking to his wife on the phone about refinancing their mortgage, then he got home and said "Oh, I'll hang up now, I'm home." He couldn't have waited three minutes to have the conversation?

I see these people walking, and driving, and eating in restaurants, and paying for their purchases and making deposits at the bank and they're talking on the phone the entire time. Who the hell are they talking to? Why is it so much more important than interacting with the actual real world in which they are existing and the real people who are in it? It was completely unnecessary ten years ago, in fact it never even occurred to anybody that it might be desirable.

It isn't. Hang up the goddamn phone.

Who's fault is this really?

A couple of good investigative stories hitting the bit-o-sphere that don't reflect well on BP or the Minerals Management Service. First, Abrahm Lustgarten and Ryan Knutson of Pro-Publica report that:

A series of internal investigations over the past decade warned senior BP managers that the company repeatedly disregarded safety and environmental rules and risked a serious accident if it did not change its ways.

The confidential inquiries, which have not previously been made public, focused on a rash of problems at BP's Alaska oil-drilling unit that undermined the company’s publicly proclaimed commitment to safe operations. They described instances in which management flouted safety by neglecting aging equipment, pressured or harassed employees not to report problems, and cut short or delayed inspections in order to reduce production costs. Executives were not held accountable for the failures, and some were promoted despite them.

Similar themes about BP operations elsewhere were sounded in interviews with former employees, in lawsuits and little-noticed state inquiries, and in e-mails obtained by ProPublica. Taken together, these documents portray a company that systemically ignored its own safety policies across its North American operations - from Alaska to the Gulf of Mexico to California and Texas.

But as Ian Urbina tells us:

[W]hen BP officials first set their sights on extracting the oily riches under what is known as Mississippi Canyon Block 252 in the Gulf of Mexico, they asked for and received permission from federal regulators to exempt the drilling project from federal law that requires a rigorous type of environmental review, internal documents and federal records indicate. . . .

On the Deepwater Horizon, for example, the minerals agency approved a drilling plan for BP that cited the “worst case” for a blowout as one that might produce 250,000 barrels of oil per day, federal records show. But the agency did not require the rig to create a response plan for such a situation.

If a blowout were to occur, BP said in its plan, the first choice would be to use a containment dome to capture the leaking oil. But regulators did not require that a containment dome be kept on the rig to speed the response to a spill. After the rig explosion, BP took two weeks to build one on shore and three days to ship it out to sea before it was lowered over the gushing pipe on May 7. It did not work.

(The rig’s “spill response plan,” provided to The Times, includes a Web link for a contractor that goes to an Asian shopping Web site and also mentions the importance of protecting walruses, seals and sea lions, none of which inhabit the area of drilling. The agency approved the plan.)

But this is not Tony Hayward's fault, or Dick Cheney's fault. It's the fault of all of us, because we refuse to open the window and look outside our fool's paradise. Petroleum makes our world possible, and to admit that it just isn't possible any longer is to surrender all of our illusions. This catastrophe -- and it's worse than they have yet admitted -- was caused by the reckless desperation of a dying civilization. We'd rather try to wring out a last decade or two of bread and circuses by gambling the planet on a doomed quest to wring our black tar heroin from the most fragile and most perilous places, in deep denial of the risks and known consequences. And when even that final chance is gone, then what? We just refuse to look.

For a U.S. politician to propose a carbon tax, or a ban on oil drilling, or the national commitment that would really be required to transition to a sustainable energy economy before it is too damn late would be political suicide, because nobody in this narcissistic, arrogant, blockheaded country has the courage to live in reality.

Another Open Door Crashed Through

CBS News, largely to its credit I suppose, has invested in a major act of investigative journalism to tell us what we already know: "Medical Overtreatment May Be Making Us Sicker." They cover the main points I've been ranting about here since I learned how to make an anchor tag:

• Too much use of imaging that involves ionizing radiation".

• Doctors prescribe antibiotics tens of millions of times for viruses such as colds that the drugs can't help.

• As major health groups warn of the limitations of prostate cancer screening, even in middle age, one-third of men over 75 get routine PSA tests despite guidelines that say most are too old to benefit. Millions of women at low risk of cervical cancer get more frequent Pap smears than recommended; millions more have been screened even after losing the cervix to a hysterectomy.

• Back pain stands out as the No. 1 overtreated condition, from repeated MRI scans that can't pinpoint the trouble to spine surgery on people who could have gotten better without it. About one in five who gets that first back operation will wind up having another in the next decade.

Okay, more people watch and read CBS News than read Stayin' Alive, so I guess it's helpful that they are pretending to have made a major discovery that nobody knew about before. Actually, of course, every serious student of health care policy is well aware of these facts and that's why we want to have comparative effectiveness research and cost effectiveness analysis, but you know what happens when any politician dares to say so aloud: Sarah Palin and her Army of Idiots start screaming about death panels and euthanasia. It's just incredible to me that the political discourse in this country is so enslaved to ignorance, and that the more we try to push the facts on people the harder they resist.

Drill Baby Drill is of course in the same category: we can suck our outer continental shelves dry and gasoline will cost 2 cents a gallon less in 2030. Maybe. If we're lucky. Or, if we blow out another well, it might cost more. Whatever. That's the truth, but to the Army of Idiots offshore drilling is the path to energy independence. Who cares about the truth when you've got a good sound bite?

Update: Just Came across this new article in Health Affairs: "Few consumers understood terms such as "medical evidence" or "quality guidelines." Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decision making." 'Nuff said.

Barack Obama apparently doesn't know it . . .

. . . but he is in fact president of the United States. photographs of dead and dying oil-soaked animals are at last appearing widely in the corporate media, but for weeks now reporters have been blocked from fouled areas of coastline by police who claimed to be taking their orders from BP and the Coast Guard. I understand that Coast Guard officials have denied issuing such orders, but it is implausible that local police would have taken orders from BP if someone -- whether the Coast Guard or Bobby Jindal -- hadn't told them to, and the federal government didn't do anything about it.



"I'd like my life back."




Now we learn that the federal government in fact had the video which BP withheld from the public, showing the true magnitude of the gusher, for 20 days before it was finally released, during which time BP persevered in the lie that the flow rate was only 5,000 bbl/day. As the Center for Public Integrity tells us in the above-linked post, "U.S. Coast Guard incident logs show that within hours of an explosion aboard the Deepwater Horizon, officials were warning of a massive spill and attempting to repair malfunctioning equipment — events missing from the White House's official timeline." And more on this from ABC. Also, from WaPo, "Last week, [reporter] Jackson was also unable to book a flight over Grand Isle from a charter plane company in Belle Chasse, La., because the owner could not obtain permission from BP's command center to enter restricted airspace. BP, the Federal Aviation Administration and the Coast Guard were refusing access to planes carrying media . . . " Apparently they have now changed this policy, but the bottom line is, BP was in control of Gulf air space for more than a month, with the collusion of two entirely separate federal agencies.

I obviously don't think that Obama should have taken personal responsibility for sealing the well -- only BP can do that -- but he should have taken command of the scene and made sure that the people learned the truth, and that reporters and stakeholders had access to the affected wetlands.

While the truth about the destruction of the Mississippi delta is finally coming out, I must say I was very disappointed in Rachel Maddow last night. She spent almost her entire program complaining that the oil companies hadn't invested enough in cleanup technology. The essential issue here is not that we haven't invented magical ways of cleaning up undersea well blowouts -- it's that we should not be drilling for oil a mile under the sea in the first place. As Andrew Revkin points out, the entire reservoir into which the Deepwater Horizon drilled is estimated to contain the amount of petroleum the United States consumes in 5 days. Instead of spending billions of dollars and risking catastrophe for 5 days worth of oil, cleanup technology or no, we have to stop using it.

That's not the lesson Bobby Jindal has learned, however. He's furious at Obama for declaring a moratorium on offshore drilling and he wants to get back to it yesterday.

He's probably insane, but on the other hand, it's easy to see why any politician in Louisiana would be likely to take this position. Americans are hurting, badly, from the worst job market since the Great Depression. "According to the BLS, there are a record 6.763 million workers who have been unemployed for more than 26 weeks (and still want a job). This is a record 4.38% of the civilian workforce. (note: records started in 1948). It does appear the increases are slowing ... " "President" Obama doesn't appear to have noticed this either.

Why is this supposed to be a secret?

While the corporate media have not been shy about saying that the oil well blowout is a big disaster, for some inexplicable reason they have been very deficient at showing actual disastrous facts. This article in the New York Daily News, by two of its staff reporters, tells us that it's all a big secret:

Here's what President Obama didn't see when he visited the Gulf Coast: a dead dolphin rotting in the shore weeds.

"When we found this dolphin it was filled with oil. Oil was just pouring out of it. It was the saddest darn thing to look at," said a BP contract worker who took the Daily News on a surreptitious tour of the wildlife disaster unfolding in Louisiana. His motive: simple outrage.

"There is a lot of coverup for BP. They specifically informed us that they don't want these pictures of the dead animals. They know the ocean will wipe away most of the evidence. It's important to me that people know the truth about what's going on here," the contractor said.

snip

After checking that he was unobserved, he motored out to Queen Bess barrier island, known to the locals as Bird Island. The grasses by the shore were littered with tarred marine life, some dead and others struggling under a thick coating of crude. "When you see some of the things I've seen, it would make you sick," the contractor said. "No living creature should endure that kind of suffering."

You know that if the nightly news were showing pictures of that, the public outrage would turn white hot. But they aren't, because BP is swearing its contractors to secrecy and the reporters aren't sufficiently enterprising to go and look. It's not just that vast areas are closed to fishing; the marine life really is dying.

Show us the pictures.

The Prez disappointed me slightly less today

I've been itching to do a post about how B. Hussein Obama has not seized the moment provided by the god awful catastrophe in the Gulf of Mexico to tell the people what they need to hear, whether they like it or not: We need to end the petroleum age, as fast as we possibly can. Instead he's been spouting about how we still need to develop offshore oil but we just need to do it safely. He's pretty much steered clear of the crisis facing humanity because, I guess, who wants to be an even bigger downer when we're all bummed out already?

Today, he started to change the tune. Not enough, but he's moving. But will he exercise real leadership in this time of grave peril, step up like FDR to address the nation and tell them the truth, as Richard Heinberg does here? Or is it too perilous politically to try to save the world? As Heinberg explains, and as ought to be obvious, the fundamental cause of the destruction of the northern Gulf of Mexico is that all the easy oil has been found. If we are going to continue to feed our addiction, we're just going to keep going deeper and deeper into the ocean and further into the Arctic and look for the Black Tar Heroin in more and more dangerous and difficult and fragile places. The pressure in the Deepwater Horizon reservoir is 12,000 PSI, which as we now know, is completely uncontrollable by current technology. But we're drilling in water twice as deep. To quote Heinberg:

In short, the Deepwater Horizon story is not just an environmental tragedy. It is a story about the limits of both extractive technologies and the increasingly complex societal systems that support them. It’s a reminder that the whole project of basing unending economic growth on ever-increasing rates of extraction of depleting nonrenewable resources is wrongheaded from start to finish. And it’s a signal that hopes for our economy to magically “dematerialize” have turned out to be just that—mere hopes. . . .

[T]he era of cheap, easy petroleum is over; we are paying steadily more and more for what we put in our gas tanks—more not just in dollars, but in lives and health, in a failed foreign policy that spawns foreign wars and military occupations, and in the lost integrity of the biological systems that sustain life on this planet.

The only solution is to do proactively, and sooner, what we will end up doing anyway as a result of resource depletion and economic, environmental, and military ruin: end our dependence on the stuff. Everybody knows we must do this. Even a recent American president (an oil man, it should be noted) admitted that, “America is addicted to oil.” Will we let this addiction destroy us, or will we overcome it? Good intentions are not enough. We must make this the central practical, fiscal priority of the nation.

Alright Mr. President, seize the day. This is what you must tell the people. Shatter their illusions. Face the light.

Neither good nor bad . . .

it is what it is. Medicalization, that is. I referred a while back to Peter Conrad's "The Medicalization of Society. Now Peter and colleagues have calculated the medical expenses associated with 12 "medicalized" conditions in the U.S.. (Abstract only for the little people.)

Now, you may feel that is a step forward that some of these conditions have been medicalized; you may have your doubts about others. They are: Anxiety Disorders, e.g., "Social Anxiety Disorder," formerly known as shyness; Behavioral disorders including ADD and ones from which I occasionally suffer such as Oppositional Defiant Disorder and Intermittent Explosive Disorder; Body Image Disorders, i.e. people don't like their nose or their tush so they get surgery; Erectile Dysfunction; Infertility; Male Pattern Baldness; Menopause (treated with hormone replacement therapy); Normal pregnancy and delivery; Sadness, now called minor depression and treated with pills; Obesity, formerly known as fatness; Sleep Disorders; and Substance Use Disorders - gradually medicalized since the 1960s and now often treated with pills such as Suboxone and Welbutrin.

Peter and the gang don't find these to be a major contribution to overall medical spending - in the 70s of billions a year, which used to be a lot of money but which is less than 4% of overall medical spending in the U.S. And they don't try to figure out whether we're getting our money's worth for all this. That's actually a very complicated question that has to be analyzed on a case-by-case basis. With respect to some of these, there is a respectable case to be made that much of medical intervention is in fact counterproductive, but those are controversies I'm not going to take on with this post.

What we can say more generally about most of these, however -- and which is more or less what Peter says -- is that turning them into medical conditions puts the focus on the individual who, in one way or another, doesn't fit in to social expectations or has a problem induced by the social environment; and so turns attention away from the social context. Third graders who don't like to sit quietly in rows all day and concentrate silently on boring tasks now have a disease, for which they are fed pills which in any other context are illegal, addictive drugs of abuse. Men and women who undergo normal processes of aging take pills to try to preserve an illusion of youth. People who don't conform to cultural ideals of beauty, or who fear that they do not, undergo painful surgery. And so on.

Does this entirely make sense, or is there a better way?