From MSNBC:

Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.

Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine…

Imagine how many people could have received real medical treatment with that money. Imagine how much real medical treatment we could buy with the tens of billions of dollars that American waste each year on alternative health mumbo jumbo.

Blogger and alternative health advocate Catherine Morgan has attempted to address my claim that alternative health is pseudoscience. She writes:

Not surprisingly, Dr. Amy takes a hard line against alternative health practices, but is alternative medicine just pseudoscience? I don’t think so. Just because something can not be “scientifically” proven today, doesn’t mean it won’t be proven in the future. For example, most people believe that when they die they will go to heaven, but there is no “scientific” proof of heaven. Does that mean heaven doesn’t exist? And at one time, before there was proof that the world was round, everyone believed it was flat. Was it flat just because the science wasn’t available to prove it wasn’t? No. Science may not be able to prove that Reiki or Acupuncture (or any other alternative modality) actually works, but that isn’t proof that it doesn’t work either. Let’s face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next. … Even Einstein was wrong sometimes. The only thing we know for sure, is that no one knows everything.

That paragraph is a “greatest hits” of faulty reasoning, including basic flaws in logic, invocations of religious faith, and, my personal favorite, grandiose comparions with Galileo or Einstein (for some reason it is always Galileo or Einstein), while failing to realize that Galileo and Einstein always supplied scientific proof for their claims while their persecutors and detractors were the ones who insisted that scientific proof wasn’t necessary.

Here’s the comment that I left:

“Just because something can not be “scientifically” proven today, doesn’t mean it won’t be proven in the future.”

1. That statement reflects a very serious misunderstanding about the state of knowledge of alternative remedies. It’s not simply that alternative remedies have not yet been scientifically proven to work; the reality is that alternative remedies have been scientifically proven NOT to work…

2. It is the MORAL obligation of advocates of alternative health to be SURE that an alternative treatment is safe and effective before they recommend it. It is morally wrong to advocate a treatment, and to accept money for the treatment if you don’t have proof that it works.

“And at one time, before there was proof that the world was round,
everyone believed it was flat. Was it flat just because the science
wasn’t available to prove it wasn’t? No.”

That statement offers more support for my view, not yours. Simply put, that statement means that what people “believe” about something is completely unrelated to reality. So the fact that alternative health advocates “believe” that alternative health works tells us absolutely nothing about whether it works.

“Let’s face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next.”

That’s not true, either. What is reported (often erroneously) in the media changes from day to day, but what the scientific literature shows does not change in that way. That’s why it is absolutely critical to read scientific papers if you want to know about scientific phenomena.

Alternative health is the medical equivalent of astrology. Just like astrology, it is nothing more than pseudoscience.

Ms. Morgan replies:

…Even though I’m not a scientist, I don’t believe my post reflects a “serious misunderstanding” of alternative remedies.

I’m interested in how you reconcile your strong belief in scientific fact with the placebo effect? If science has proven that a mind/body connection exists in medicine…Is it really that far fetched that alternative medicine might have some benefits as well?

And my response:

I’d like to ask you some ethical questions, and I hope you will take the time to reply.

May I ask why you have not reviewed the scientific literature on alternative health remedies? Isn’t that like writing a book review recommending a new book without having read it?

Don’t you think you have a moral obligation to read all possible evidence on something that has the power to seriously harm people before suggesting that they should risk their health and wellbeing by believing in it?

Let me try to address the question you asked me.

“I’m interested in how you reconcile your strong belief in scientific fact with the placebo effect?”

Why should I have any difficulty reconciling scientific fact with the placebo effect? The placebo effect IS a scientific fact. It was discovered, described and measured by scientists.

Contrary to what alternative health advocates like to claim, scientists are very much aware of the mind-body connection. (Think psychosomatic illness, for example.) Scientists know that it is absolutely imperative to subtract the placebo effect from any evidence that a substance works.

The placebo effect is “psychosomatic.” You can evoke the placebo effect by feeding someone dirt and claiming it is medicine. So when alternative health advocates invoke the placebo effect to show that an alternative treatment “works” they are essentially saying that the alternative treatment is equally effective as feeding someone dirt.

How can alternative health practitioners ethically justify charging people money for a treatment that is no more effective than dirt?

I’ll let you know if there is a further response.

Alternative health is nothing more than a giant scam to separate the scientifically illiterate from their money. The best and simplest example of this phenomenon is the use of herbs and supplements.

Devotees of alternative health like to pretend that herbs and supplements are better because they are “natural,” because they are pure, and because they are not produced by Big Pharma. Nothing could be further from the truth.

First, “natural” is hardly synonymous with beneficial or even harmless. Earthquake, hurricanes and lightening strikes are all “natural” and quite harmful. More to the point, some of the most toxic substances known to man, like the paralytic poisons tetradotoxin and curare, are natural animal and plant products. Anyone who wonders whether “natural” equals beneficial need only contemplate tobacco, opium and cocaine.

Second, even if the active ingredient of an herb or supplement is harmless, it is mixed with contaminants in its natural state. As MSNBC explains:

Lead in ginkgo pills. Arsenic in herbals. Bugs in a baby’s colic and teething syrup. Toxic metals and parasites are part of nature, and all of these have been found in “natural” products and dietary supplements in recent years.

The risks are not simply theoretical:

Millions of Americans take vitamin, herbal or other dietary supplements. Annual sales exceed $23 billion, and more than 40,000 products are on the market. Tens of thousands of supplement-related health problems are handled by U.S. poison control centers each year, according to a report in the New England Journal of Medicine in 2002.

Until last year, supplement makers were not required to report problems to the FDA, and even now they must report only serious ones. The agency estimates that more than 50,000 safety problems a year are related to supplement use.

Because of vigorous lobbying efforts by supplement manufacturers, herbs and supplements are exempted from the rules that apply to medication. Therefore, there is no way for a consumer to be sure that a given herb or supplement contains any active ingredient, or contains too much or too little of the active ingredient. There is no testing to be sure that harmful contaminants are not present. Manufacturers simply grind up leaves and sell them to gullible people, and neither the manufacturers nor the consumers have any idea what’s in them.

Third, and most ironic, the herb and supplement industry is a financial bonanza for … Big Pharma. Sure, the labels on the products are decorated with butterflies and rainbows, but the producers are none other than Bayer, GlaxoSmithKline and Wyeth.

Little herbal stores are only “what the consumer sees when they’re shopping,” while the large companies that supply them are mostly invisible, Silverglade said.

The industry’s little-guy, granola image has been a great marketing asset, allowing it to tap into Americans’ frustration with big medicine, big prices and big risks. Supplement makers are dwarfed by leading pharmaceutical firms, whose drugs command sales in the tens of billions of dollars. Yet the reality is that natural remedy makers constitute a sizable business that doesn’t have to play by the same rules as companies that make prescription or over-the-counter medicines.

In the final analysis, herbs and supplements represent the trifecta of the gullibility of lay people. The active ingredients themselves don’t actually work, the herbs and supplements often don’t contain the active ingredient or contain poisons, and the consumer is paying Big Pharma for the privilege of being scammed.

Herbs and supplements, like all of alternative health, depend on scientific illiteracy. The executives of Big Pharma are laughing all the way to the bank. Not only do they profit from legitimate pharmaceuticals, all of which require major financial investments to develop and assure safety and quality, but they are raking in money from herbs and supplements, without any research, without any quality control, and without any evidence that they work.

What makes a good doctor?

There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient’s signs and symptoms, the ability to identify the patter, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.

Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.

Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient’s situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don’t read the book. In other words, their signs and symptoms can vary from “textbook” descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.

Yet if there is one thing that contemporary American doctors lack, it is time. That’s because the people who “manage” healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients “processed.” That’s not what it means to be efficient in the practice of medicine, though.

In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That’s because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.

How have doctors become less efficient? All the evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomittant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are “processed” faster, but medical care has arguably gotten worse, not better.

The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.

Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster. And that’s not efficiency.

My favorite part of practicing obstetrics was the moment of delivery, helping mom lift the baby to her chest and calling out, “It’s girl!” or “It’s a boy!” It was always a privilege to be part of the deeply personal moment when parents met their newborn child, and to share their joy and excitement.

Although parents are anxious to establish that the baby has ten fingers and ten toes, and is healthy in every way, the announcement of gender is often equally important. The knowledge of gender immediately begins to shape the way the parents view the baby.

You’d think that figuring out the gender would be simple, and it usually is, but once in my career I delivered a baby and could not tell whether it was a boy or a girl. I said nothing about the gender and the tension and distress of the parents were palpable.

The baby was born with a condition known as ambiguous genitalia. It’s just what it sounds like: external genitals that appear to be a cross between male and female. How does it happen?

For the first 7 weeks of development, every embryo appears to be female. In the absence of male hormones like testosterone, the baby will continue to have female external genitals. In boys, the testicles begin producing male hormones and the external genitals undergo further development. The clitoris enlarges into the penis, and the labia fuse together in the middle to become the scrotum.

It is possible for a baby to be a true hermaphrodite, having both ovaries and testes, but that condition is very rare. Ambiguous genitalia are usually caused by an inherited hormone problem that interferes with the development of the genitals. The baby is either a boy or a girl because it has either testes or ovaries, but the external genitals look like a combination of both, making it difficult to identify the gender simply by looking.

I had never seen a case of ambiguous genitalia before that night, but like every obstetrician I had read about it. And one of the things that I had read was that if there was any doubt about the gender, the doctor should not attempt to guess. According to a variety of studies, more psychological damage could be done by the doctor wrongly assigning gender and then having to change it, than by admitting that you didn’t know and consulting an expert to make the diagnosis.

Talk about an awkward situation! As the baby’s shoulders were being born I started to call out, “It’s a …” and stopped. I was stunned into silence. The baby appeared to be a girl with a very enlarged clitoris that looked like a penis, but I wasn’t sure. Mindful of what I had read, I didn’t want to guess. I asked the nurse to call the neonatologist to the room and I showed the baby to the parents. Not surprisingly, they were even more stunned than I was. I pointed out that the baby was healthy, with all other body parts intact, and I explained that the baby almost certainly had a treatable hormone problem, but the parents were distraught.

The neonatologist arrived within minutes and carefully examined the baby. He announced that the baby was a girl and that a treatable hormone problem had cause virilization (male appearance) of the external genitals. Ultimately the baby was diagnosed with congenital adrenal hyperplasia (CAH) the most common cause of ambiguous genitalia. CAH has effects in addition to ambiguous genitalia. It also leads to serious kidney problems, so it is very important that it be diagnosed and treated immediately.

After some time with mom and dad, the baby went to the newborn intensive care unit for a complete evaluation. Replacement of the appropriate hormones was started, and because the virilization of the genitals was mild, no surgical treatment was needed. The clitoris shrunk back to normal size and the baby did very well.

The parents, on the other hand, took a little longer to recover. The entire experience was deeply disturbing to them as it would be to any parents. And I never forgot it.

“Listen to your patient, he is telling you the diagnosis.”

Those are the words of William Osler (1849-1919) often called the Father of Modern Medicine for his contributions to the development of medical education. I first heard them from the chief of surgery at the beginning of my internship. It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than you might think. That’s because most patients are simultaneously offering a lot of extraneous information, and some patients are not completely honest in the information they offer.

In fact, the patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

I suspect that this problem is at the root of many errors of diagnosis. It is obviously much more difficult to diagnose a problem if the patient has an unusually constellation of symptoms. However, the biggest stumbling block is that the doctor believes that if the symptoms make no sense, the patient must be telling the story wrong, or have some other reason for the symptoms such as depression or medication seeking behavior.

That’s the biggest advantage I have when approached by a friend or relative for help with a difficult medical problem. It can sometimes be much easier for me to figure out the diagnosis than it is for the doctor they are seeing. That’s because I start out by believing them, because I know them, and I don’t waste valuable time pondering whether they are honest or reliable reporters of their symptoms.

Recently a friend called me about unusual symptoms his father-in-law was having. The relationship between our families has extended through several generations, and I knew his father-in-law well. He is a distinguished emeritus professor with a piercing intellect and ongoing curiosity and engagement with the academic world. As he approached and passed his 80th birthday, he was afflicted with slowly progressive muscle weakness. He became wheelchair bound and continued to weaken even further. Ultimately, he was barely able to muster the energy to move.

His impressive team of doctors was stymied by the symptoms and took the easy road. They concluded that he was weak because he was old. There was nothing to be done.

His son-in-law called because his children were convinced that something was going on besides normal aging, but did not know what tests and investigations to insist upon. That’s where my advantage came in. I listened to his story and believed him because I knew him and I knew them. I started from the premise that the story must be true and went from there.

Whenever an elderly person develops a global symptom like fatigue or confusion, the first place to look is at their medications. As people become older, they are put on ever increasing numbers of medications to treat various unrelated ills. Often, some of those medications will interact to produce unusual side effects. In addition, as people age, the ability of the kidneys or liver to break down the medication and remove it from the body diminishes. Because the medication stays in the body longer, it has a chance to build up to toxic amounts. A dose of medication that was conservative 10 years before may have slowly become an overdose.

Since whole body muscle weakness is certainly a global symptom, I asked for a list of his medications, and then I went down the list looking for generalized muscle weakness as a rare side effect. I hit the jackpot almost immediately. Pravachol, a statin (cholesterol lowering drug) he had been taking for decades, is known to cause generalized muscle weakness in rare circumstances by damaging muscle cells. The chance of this unusual side effect is increased in the elderly and is further increased in people with diminished kidney function, which happened to be present in this case as well.

I was so excited that I called my friend right away to tell him. I promised to do further research later in the evening, but in the meantime, he started investigating the rest of the list for unusual interactions between drugs. Sure enough, he found that another medication on the list was known to interact with Pravachol to increase the risk of generalized muscle weakness.

We had the diagnosis: Pravachol induced myopathy exacerbated by age, decreased kidney function and interaction with another drug. My friend called his father-in-law’s doctors first thing the next morning, and the Pravachol was discontinued. Recovery began almost immediately. He now feels better than he has in years and has begun to walk again.

The professor called me recently to express his gratitude. He thought I had made an incredible diagnosis. Frankly, I am a bit embarrassed. I didn’t really diagnose anything. He had been recounting the symptoms of statin induced myopathy in detail for months, if not years. All I did was listen.

Can women be trusted to make decisions about their own bodies?

In a previous post, I discussed the rising popularity of genital cosmetic surgery (Extreme Makeover: Vagina Edition). While the concept has been warmly embraced by women, it has elicited reactions ranging from distaste to outrage by others.

Everyone agrees that vaginal and vulvar cosmetic surgery has no medical benefit. Everyone agrees that views of genital attractiveness are strongly influenced by the prevailing culture. The point on which people disagree is whether women can be trusted to make decisions about their own bodies. Reactions range from paternalism and maternalism to acknowledging the possibility of autonomous decision making.

Paternalism is best exemplified by Daniel Sokol, writing in the British Medical Journal. According to Sokol:

The 16th century French author and physician Rabelais was obsessed with vaginas. In one of his stories an old lady drives the devil away by showing him her vagina. Today the devil might recommend she go to the nearest aesthetic surgeon for vaginal rejuvenation. A touch off the labia (labioplasty), a bit of tightening here (vaginoplasty), and voilà: a designer vagina…

Here is my paternalistic view: medical professionals, whether working in the private or public sector, should not succumb to these requests. Although it would be hard to argue that anyone seeking aesthetic genital surgery is unable to make an informed decision, it is plausible to argue that patients’ autonomy is often diminished by strong social or peer pressures.

Sokol at least is honest about his paternalism. Feminists who oppose genital cosmetic surgery seem to be entirely unaware of their maternalism. Their alarm shades into, dare I say it, hysteria. Bonnie Zylbergold asks whether genital “beautification” is plastic surgery or mutilation.

… Dr. [Lenore] Tiefer maintains that … all [genital cosmetic surgery] really produces is a generic model of women’s genitalia… So enraged is Dr. Tiefer, that in 2000 she founded The New View Campaign, an organization devoted to stopping all form of FGCS. The group compares FGCS to Female Genital Mutilation (FGM).

… [P]oints out Dr. [Virginia] Braun, “In both cases, what’s being done is that women’s genitalia are being altered to conform to a certain set of notions and expectations about what genitalia should look like, what they need to look like if they are to be appropriately feminine and appropriately desirable.”

Genital modification may be unnecessary, potential harmful, and the result of peer and marketing pressure, but it is not mutilation. And the claim that female genital mutilation represents a notion of genitalia “beauty” completely misrepresents the procedure. Genital mutilation is performed specifically to deprive women of sexual pleasure in an effort to ensure chastity. In other words, FGM is meant to prevent women from engaging in sexual intercourse, while vaginal cosmetic surgery is meant to enhance a woman’s opportunities for sexual intercourse.

The paternalists and maternalists agree on one fundamental point: women cannot be trusted to make decisions about their own bodies. Individual physicians must refuse to honor their wishes; regulatory agencies must make it impermissible for women to choose genital cosmetic surgery.

It is interesting to note that no one seems to think that men are incapable of making decisions about genital modification. Procedures to lengthen genitalia, prolong erection and otherwise enhance sexual “attractiveness” are equally if not more common among men, yet neither the paternalists nor the maternalists suggest that men must be restrained by their physicians or governmental regulations from making independent choices.

As distasteful as female genital cosmetic surgery may be to its critics, they are wrong to assume that women (and only women) should not be allowed to make these decisions. Rather, the principles that apply to all medical decisions should be invoked. Dr. Michael Goodman, writing in the journal Obstetrics and Gynecology explains:

Patients must be adequately screened, taking note of the ethical principles of autonomy, nonmaleficence, beneficence, justice, and veracity. Patients should be adequately protected and guided to develop reasonable expectations and understand that their genitalia are not abnormal. Surgeons should be adequately trained and experienced and should use universally accepted, accurate, and descriptive terminology. The procedures should be adequately described to patients, and risks and expected outcomes should be fully explained.

Genital cosmetic surgery, like all cosmetic surgery, has no medical benefits, substantial risk of harm and is often undertaken in response to cultural pressure. Nonetheless, informed consenting adults have a right to choose genital cosmetic surgery, just as they have the right to choose any cosmetic surgery.

I left clinical medicine for many reasons, but one of the most important is that caring for patients had become an endless slog of fighting administrators and other doctors. What did we fight about? Money, of course. Administrators did not want to spend it, and doctors did not want to risk doing work for which they might not be paid. I was afraid that one day, because I wasn’t up for a fight, one of my patients would be hurt. I had an experience shortly before I left practice that crystallized those fears.

A young woman who was 6 months pregnant called me one night when I was at the hospital. She had had pain in her leg for the past 2 days and the pain was getting worse. It wasn’t just that the pain was stronger; she had noticed that the pain appeared to be extending up her leg. First only the inside of her calf hurt, now the inside of her calf and her thigh hurt. I told her that she needed to come to the hospital because I was concerned that she might have a blood clot in her leg.

Blood clots in the leg (deep venous thrombosis or DVT) are potentially quite dangerous, and known to be more common in pregnancy. The danger of a DVT is that a piece of the clot in the leg can break off and travel to the lungs where it can cause death.

She arrived around midnight and I went to examine her. There are 5 classic signs of DVT and she had none of them. Her leg was not swollen, she had no tenderness over a major vein, the affected leg was not warmer, the skin over the vein was not discolored, and moving her foot in the prescribed way did not produce the pain typically associated with a DVT. Nonetheless, I had a bad feeling about this woman, and, over the years, I had learned to pay attention to bad feelings.

I explained to the patient that she had none of the signs of a DVT, but I was still worried. I wanted to get an ultrasound study of her leg to be absolutely certain that there was no blood clot. I apologized in advance, since it was unlikely that she had a blood clot, but blood clots are very dangerous and I wanted to be sure. The patient understood and agreed.

I called the radiologist on call and explained the story. I was very careful to point out that the patient had none of the classic signs of DVT, but I wanted the study anyway.

“No,” he said.

“Excuse me,” I replied. “I think I didn’t hear you correctly.”

“No,” he repeated. “I’m not going to scan her leg because she has none of the classic signs of a DVT.”

“Yes,” I said, somewhat exasperated. “I’m aware of that. I just told YOU that she has none of the classic signs, but I wanted to make sure.”

“Well, I’m not doing it because I won’t get paid.” He continued, “A scan in the middle of the night is an emergency and the insurance company will not pay for the scan unless it meets the criteria for an emergency scan. She must have some of those signs of a DVT or they won’t pay.”

We argued back and forth for a while, but he would not budge.

“Okay,” I said. “Just spell your name for me.”

He was puzzled. “Why do you need to know how my name is spelled?”

“Why? Because I am writing at the top of the very first page of the chart.” I cheerfully replied. “That way, when she walks out of the hospital and drops dead, they’ll know just whom they should sue.”

Silence.

“Well, if you’re going to be THAT way about it, I’ll scan her leg,” he said, “but I’m not going to do it right away.”

“Suit yourself,” I replied. “Just scan her leg before the morning.”

That exchange took place at 1 AM. I told the patient that we would have to wait for the scan, and I went to lie down.

At 5 AM my phone rang. The same radiologist was on the line, but now he sounded rather meek.

“Dr. Tuteur? Dr. Tuteur, I just wanted you to know that she has a blood clot in her leg extending from her ankle, up through her calf and thigh, right into her pelvis.”

Not only did she have a DVT, but she had the worst one either of us had ever seen. She almost certainly would have died from a pulmonary embolus if we had sent her home. Instead we immediately began treating her with blood thinners. She stayed in the hospital for two weeks, went home having learned to give herself shots of blood thinner, and ultimately did great. She delivered a healthy baby and had no further problem with blood clots.

Nonetheless, I was shaken up by the experience. She had only gotten the appropriate treatment because I had been willing to fight with the radiologist. In some ways, it had been a matter of luck. I wasn’t busy with other things; the radiologist had aggravated me, and was determined to prevail. I was uncomfortably aware that had circumstances been different, I might have failed to force the issue, and the patient would probably have died.

Why did the radiologist refuse to do the scan? He was simply responding to the incentives and punishments put in place by the insurance company. They didn’t want to pay for emergency scans so they made the requirements onerous. The insurance company was not wrong in assuming that patients without classic signs of DVT probably don’t have one, and they didn’t want to pay for needless scans. The radiologist was not wrong in assuming that this patient didn’t have a DVT and in assuming further that if he did the scan he would not be paid for it.

Almost everyone who has health insurance has fought with the insurer at some point because the insurance company has refused to pay. If you’ve done so know you just how frustrating that can be and how much time it takes. Doctors fight with insurance companies all the time, both to get approval for tests and procedures that patients need, and to get paid for visits, tests and procedures that have already occurred.

Most people don’t realize that doctors are often forced to fight with each other. The perverse incentives and punishments of the existing insurance system mean doctors who are trying to treat a patient must argue with other doctors who fear they will not be paid for their work. Sometimes, rather than fight to the bitter end, a doctor will give up and a patient won’t get a test or treatment that she needs. And sometimes, giving up could have fatal consequences.

I don’t do abortions.

I learned to do them, of course, as most gynecologists of my generation did, and I did them as part of my residency. That experience convinced me that abortions were not consistent with my view of providing patient care. I referred those of my patients who wanted abortions to other providers, and I never did another termination again.

Despite my personal views on abortion, I am horrified, appalled, and deeply outraged by the assassination of my colleague George Tiller. I am also profoundly humbled by his ultimate sacrifice. Tiller knew his life would probably end like this. He had already been shot, his clinic had been bombed, and he constantly received death threats. Yet none of that deterred him from standing for what he believed in.

It is a curious fact about conservative Republicans of this era, that they think the law applies to everyone but them. Abortion is legal, yet they try to interfere with it on a daily basis; legal access to abortion is the result of the political will, and is grounded in the American Constitution, yet conservative Republicans feel free to ignore the parts of the Constitution that don’t suit their prejudices; murder is the ultimate crime, yet they tacitly and actively encourage the murder of abortion providers. Many conservative Republicans feel that religion is so important that they attempt to defy the Constitutional separation of Church and State, yet they apparently have no problem violating the sanctity of a church to commit murder.

Terrorists always believe that the end justifies the means. Make no mistake about it; Operation Rescue and similar anti-abortion organizations are terrorist groups. They use the tactics of terror — harassment, threats, and violence — to impose their personal beliefs upon the rest of the country, which has explicitly rejected those beliefs. And while we’re being honest, let’s acknowledge that conservative Republican celebrities like Bill O’Reilly, tacitly encourage and support terrorism.

George Tiller was far braver than most of us could ever be. He believed that access to late term abortion is, in addition to a legal right, part of the reproductive freedom to which all women are entitled. He was willing to put his life on the line to defend that right, and he paid the ultimate price. He knowingly risked death to stand firm for his vision of healthcare. Who among us would be willing to risk so much for an abstract principle?

George Tiller was martyred by anti-abortionists, who, in addition to flouting the law, are foolish enough to believe that killing doctors will stop abortions. Of the million plus abortions performed in this country every year, almost all are first trimester or early second trimester abortions, and murdering Dr. Tiller will stop not a single one of those. Dr. Tiller was a specialist in late abortions, but there are other such specialists both here and in other countries. Anyone who had the means to get to Dr. Tiller has the means to get to the other providers.

What have the anti-abortion terrorists accomplished? They have revealed themselves as the terrorists they are. They have aroused the horror and support of Americans who might otherwise have little concern about abortion rights. They have strengthening the cause of abortion rights in this country. In other words, anti-abortion terrorists have accomplished absolutely nothing, except the senseless murder of a good man.

Good news, moms and dads! Your teenage daughters are using their budding entrepreneurial skills to become … prostitutes. That’s what Canadian film maker Sharlene Azam alleges in a new documentary and companion book called Oral Sex Is The New Goodnight Kiss.

According to the website:

…Attractive, white, high school girls – 13, 14 and 15 years old – are having sex with up to 7 men a night, several times a week, so they can go shopping. Other girls are selling their virginity for $1000. These are not street prostitutes. “They are the prettiest girls from the most successful families,” explains one expert…

The voices of the girls are cold enough to chill the hearts of the most jaded parent:

“Five minutes and I got $100,” one girl said. “If I’m going to sleep with them, anyway, because they’re good-looking, might as well get paid for it, right?”

“I’d begun having threesomes at a really young age. I did it for attention or because that guy has a connection to get you something that you want — drugs, clothes, whatever.”

Azam believes the phenomenon is new and places the blame squarely on the usual suspects.

The Internet:

Fifteen years ago, if a girl wanted to learn more about horses, she would go to the library and find pictures of horses in meadows. Today, if you type “horse” and “girl” in Google, the first hit is: “American girl licks hung horse dick”.

Celebrity Culture:

…Anyone who has ever stood in a supermarket checkout line knows that, in addition to conforming to an extremely narrow definition of beauty … today’s female pop icons are sex objects to be alternately exalted, ogled, emulated, critiqued, condemned, pitied, and recycled … ad nauseum…

With role models like these, immersed in a culture where sexuality is tied to celebrity status and money, girls are conditioned to feel empowered whenever they are the sexual center of attention.

Television:

Your daughter who may not yet have kissed a boy has probably seen a threesome, girl on girl kissing … and alcohol and drug use on Gossip Girl where there are no consequences and no interference…

But in reality, while the medium may be new, the message is as old as time. Women exist for the use and gratification of men, and have no worth of their own. These supposedly new sexual phenomena are the direct result of ancient beliefs: men are superior to women, women (their property and their bodies) are owned by men, the primary purpose of women is the sexual satisfaction of men.

These teenage Canadian prostitutes, for that is what they are, are the direct lineal descendants of royal mistresses, courtesans, and denizens of the “casting couch.” They sleep their way to what they want, because it is the easiest, quickest way to get what they want. Men are willing to pay for sex and the girls believe that they are exploiting that willingness.

These girls don’t realize that they are the ones being exploited. They sell themselves too cheaply, willing to trade their bodies for trinkets or a bit of discretionary income. This is not about sex, though sex is the medium of exchange. It’s about the dignity and worth of women.

Though they would no doubt balk at the comparison, these girls are no different than their sisters of 500 or 2,000 or 5,000 years ago. They are treated as, and believe themselves to be, nothing more than commodities. They accept that anything valuable in life can be gained only by pleasing men. They assume that women are not entitled to satisfaction during sex; that’s the province of men and women must be paid for their participation.

The solution to this problem is not keeping girls away from the Internet, TV and the celebrity culture. The solution is imbuing girls AND boys, women AND men, with the principle that women are independent moral beings, worthy of respect in their own right, and not objects of amusement for men. The solution is inculcating our daughters with the self confidence to achieve their desires through their own abilities, the self respect to scorn the advances of those who wish only to exploit them, and the sense of self worth that would prevent them from trading so much for so very little.