No one likes unsolicited advice. It doesn’t matter if it’s good advice and it doesn’t matter if it’s well meant. Patients are no exception, even though part of the provider’s job is to counsel patients about their lifestyle choices. Smokers don’t want to be told not to smoke; overweight people don’t want to be told about the risks to their health.

That’s why I always tried to confine myself to the unadorned facts, and carefully excise any value judgments from my comments. Every now and then, though, I couldn’t help myself.

Any gynecologist is depressingly familiar with sexually active young teens and preteens, and the dreadful consequences. I often saw these girls in the Emergency Room in the middle of the night, unaccompanied or accompanied only by teenage friends. Certainly, no one came in with her mother. Perhaps that’s why I was not expecting a discussion of birth control when an affluent mother brought her 12 year old to the office for a consultation.

Improbably, the mother was beaming. Very few people are beaming at their gynecology appointment.

“We’re here for the Pill,” she announced cheerfully.

“The Pill,” I was shocked and it must have showed. “Who’s here for the Pill?”

The mother plowed ahead. “I brought my daughter to get the Pill. She’s sexually active.”

I turned to the daughter. She nodded her head slightly in affirmation.

“I’ve explained,” the mother continued, “that when you are sexually active, you always have to use protection, and the Pill is the best protection there is. That’s why I brought her myself.”

“Well,” I started tentatively, “the Pill is the best protection against pregnancy, but it doesn’t offer any protection against sexually transmitted diseases. Before we get to that, though, I’d like to talk a little more about sexual activity. I turned to the daughter again. “What grade are you in?”

“Seventh.”

“How old is your boyfriend and what grade is he in?”

“He’s 17 and he’s a senior in high school.”

“Yes,” the mother confirmed proudly, “she’s dating a senior.”

“Have you considered,” I ventured, “that might not be such a good thing?”

“What do you mean?” The mother was clearly annoyed.

“I mean,” I said, “that 5 years is a big age gap. There’s a big difference between a seventh grader and a high school senior.”

“So?”

“So, the needs and desires of a 17 year old boy are very different from the needs and desires of a seventh grader. A sexual relationship might seem like a good idea for a 17 year old, but it’s inevitably a bad idea for a 12 year old.”

“But she wants to date him,” the mother responded.

“Yes, she may want to date him, but that doesn’t mean that there might not be an element of coercion involved. Let’s think about this for a minute; what kind of 17 year old boy dates a 12 year old? It’s usually someone who has no success with girls his own age, and has to reach down to much younger children to have a sexual relationship.”

The mother was clearly growing angry. “But I thought you’d be impressed that I brought my daughter in for birth control,” she said, “My mother wouldn’t have done anything like this. She didn’t even tell me the facts about sex.”

“Sorry, I’m not impressed that you brought your sexually active 12 year old in for the Pill. I’m worried that someone is taking advantage of her.”

I kept looking in the direction of the daughter, but she made no response.

“We didn’t come here for your dating advice,” the mother replied heatedly. “Are you telling me that you won’t give her a prescription for the Pill?”

“No, that’s not what I’m saying. If her exam is normal, and she has no risk factors, I’m certainly going to give her a prescription. She’s sexually active and she needs to be protected from pregnancy. And I’m going to talk about condoms, too, since the Pill does not protect against sexually transmitted diseases.”

The mother was not mollified. She sat stonily through the rest of the interview and exam. When I finally wrote the prescription for birth control pills, she snatched it from my hand.

“Thank you,” she said coldly. “That’s what we came for. And by the way, the next time we want your opinion, we’ll ask for it.”

From Japan, the font of video game technology, comes a new game that is possibly the most offensive video game ever produced. The game is RapeLay, a rape simulator game. Yes, you read that right. RapeLay allows you to play a sexual predator in the subway.

RapeLay is surprisingly realistic in its portrayal of the rapist as power hungry sexual deviant. Gaming journalist Leigh Alexander (of websites Gamasutra and SexyVideogameland) thoughtfully downloaded and played the game, so you don’t have to:

The game begins with a man standing on a subway platform, stalking a girl in a blue sundress… Once she’s on the train, the assault begins. Inside the subway car, you can use the mouse to grope your victim as you stand in a crowd of mute, translucent commuters. From here, your character corners his victim—in a station bathroom, or in a park with the help of male friends—and a series of interactive rape scenes begins.

… Although the interactive assaults are difficult to endure if you have a conscience, the game’s text actually provides the most unsettling material. RapeLay relies on the horrendous, wildly sexist fantasy that rape victims enjoy being attacked. After the exposition, the game essentially becomes a simulator of consensual intercourse. There’s kissing. The women orgasm.

The game is realistic in yet another way. It portrays the Japanese phenomenon of the chikan, the subway pervert. The details of chikan, a real practice, not a video game, are horrifying. According to the book The Japanese Disease: Sex and Sleaze in Modern Japan, by Declan Hayes:

… The molestation-minded men get together through the Internet, brazenly advertising for interested parties to join their ranks in chikan associations…

The chikan groups are incredibly thorough, picking out a particular target and trailing her for months until they have a minutely detailed knowledge of her commuting habits. Once they decide to implement their plan to molest her, group members are instructed to board the crowded train at different stations and stand in the particular part of the carriage that … target normally occupies… Once they’re all in the same carriage, they immediately set about surrounding the target and shutting off all possible avenues of escape… [M]embers of the group with go hell for leather groping, poking and molesting the target they have surrounded…

The back-story of RapeLay is that you are a wealthy man out for revenge after being outted as a chikan. As a result:

The objective … is for your “character” to stalk then brutally rape women, as many as possible. Wait, there is a catch: before your character can go into “free mode” to rape other women in the game, he must first rape a mother and her two young daughters, who have “falsely accused you [him] of raping them.” Now the big twist: you cannot get any of the women pregnant. If you do impregnate a woman, you must force her to have an abortion because if she has the child you will be thrown under a train… With several users playing the game, it is possible to gang rape the women …

Not surprisingly, the video game offers politicians an irresistible opportunity to grandstand. New York City Council Speaker Christine Quinn has publicly called for all US video game distributors to refuse to sell Rapelay. Considering that the game has not been released in the US market, the call for a ban is unnecessary. Potential distributors such as Amazon.com and Overstock.com have already announced that they will not carry it. Moreover, a ban is meaningless, since the game is widely available over the Internet.

Will Rapelay encourage players to commit rape in real life? Clearly there is a connection between sexual predation (chikan) and a video game that glorifies rape. The game makers are explicit about this connection. Undoubtedly, those who belong to chikan associations will be drawn to the game, but there is far from obvious that playing the game will turn men into sexual predators. Rapelay is offensive, appalling and worthy of condemnation, but is it harmful? That remains to be seen.

Fred Rogers soothed the fears of several generations of children by explaining why they cannot go down the drain. Mister Rogers was thinking of the bathtub drain, which relies on gravity to empty the tub. Evidently there was no swimming pool in his Neighborhood, certainly not one that relied on a powerful filter system to pull water from the pool.

From 1997-2007, 9 children died after become entrapped in pool drains, and an additional 63 were injured, some grievously. Abigail Taylor, 6 years old, died almost exactly one year ago. In June of the previous summer, Abbey had been playing in the wading pool at the Minneapolis Golf Club when she sat on the wading pool drain. The pool suction was so powerful that it literally disemboweled her, tearing out a large part of her intestinal tract.

According to TwinCities.com:

She survived the initial incident, but the weeks and months that followed were filled with surgeries to try to repair her damaged internal organs…

Abbey got her nutrition through a tube, but that created its own problems. The formula damaged her liver, requiring an organ transplant.

In December, she received a new liver, small bowel and pancreas. There were complications from the surgery, though, including raging infections and a transplant-related cancer that required her to endure chemotherapy.

The accident did not have to happen. Had the wading pool been properly fitted with an anti-entrapment drain cover, Abbey would not have been harmed.

In December 2007, Congress passed the Virginia Graeme Baker Act, named in memory of the granddaughter of former Secretary of State James Baker III. In 2002, the 7 year old girl known as Graeme was entrapped by the drain of a hot tub at a friend’s house and drowned. Her mother tried to save her, but literally could not break the force of the suction holding her to the bottom of the hot tub. It took two men, who broke the drain itself, to remove the little girl from the grip of the suction.

The Virginia Graeme Baker Act required that drains in all public pools and spas be retrofitted with anti-entrapment covers. However, three months after the deadline, approximately 70% of public pools and spas have not undertaken the repair. According to the New York Times:

One reason compliance has been slow is … the safety commission didn’t issue final regulations until just six months before [the law] took effect. Lachocki [head of the National Swimming Pool Foundation] said that left little time for manufacturers to design and ramp up production of drain covers and pumps that meet the new specifications, or for pool owners to line up contractors. He said many pool owners and local authorities are still confused.

But the Pool Safety Council says the equipment is getting easier to find. Spokesman John Procter said the group recently surveyed manufacturers and found they’re catching up. And while the industry cites costs of $10,000 to $15,000 to retrofit some pools, he said most can be fixed for $1,000 to $1,500.

How can parents protect their children?

…The main sign of a faulty drain or drain cover is a continuous swirl of water created by a drain indicating excessive suction. Keep your children away from such whirlpools…

Refuse to swim in pools that do not meet safety standards. Never allow children to swim or sit in a Jacuzzi or spa tub that has not had the drains and their covers safety inspected…

Mister Rogers was right when he declared that children cannot go down the drain completely. He did not realize that they don’t have to go down the drain completely in order to be harmed and that what applies to the bathtub might not apply to the local pool. The deaths and injuries caused by pool drain entrapment cannot be undone, but there is every reason to believe that we can prevent further deaths and injuries. If parents watch for signs of faulty drains, and demand that public pool owners comply with Federal standards, the terrible tragedies suffered by Abbey Taylor and Graeme Baker will not have been in vain.

Working in a hospital is an education in itself. Not just a medical education, although that is the primary purpose of being there, but an education in the human condition. Anything can happen in a hospital. There is nothing too strange, too bizarre or too outlandish. Human frailty and foibles as well as indomitable strength are constantly on display.

Consider the case of the devil’s baby.

The chief resident in obstetrics is responsible for the care of patients who don’t have a doctor of their own. Therefore, when the warden of the state women’s prison called the hospital with a problem, he was put through to the chief resident, and that was me. A patient in the prison was currently nine months pregnant and very upset. She was convinced that she was pregnant with the devil’s baby. They were sending her in by ambulance for evaluation.

“Evaluation?” I was dumbfounded. “What do you want me to evaluate?”

“Just make sure the baby is normal,” he replied. “Show her that she’s not carrying the devil’s baby.”

I couldn’t believe it. “I don’t have to examine her to know she’s not carrying the devil’s baby.”

“Well, she’s already on her way,” he responded. “Just do … something.”

Unfortunately, it was a very busy day. There weren’t any exam rooms available to see her. She was placed in the doctor’s lounge and was forced to wait hours while I dealt with other medical problems before I could get to her, since “carrying the devil’s baby” did not seem to be a medical emergency.

The patient was not perturbed at the wait. In fact, she was enjoying it. She was shackled to the stretcher, but in all other respects, the surroundings were far superior to the woman’s prison. The nurses had gotten her a meal. (“Yes,” I had exasperatedly replied when asked if she was allowed to eat. “We don’t really believe that she is carrying the devil’s baby.”) She was watching television and enjoying a glorious view of the city from her tenth floor quarters.

I swept in with a medical student in tow. “What seems to be the problem?”

She remembered why she was there and her brow furrowed. “I’ve got the devil’s baby inside of me, and I’m afraid.”

The delusions of mental illness are not likely to be changed by reality, but I was obligated to try. I affected a cheerful demeanor. “Oh, I’m sure that your baby is a normal baby and not the devil’s baby at all. How about if I get the ultrasound machine and show you the baby?”

“I don’t know,” she replied. “I’m afraid.”

“No reason to be afraid,” I responded briskly. “You’ll see that everything is okay.”

I got the ultrasound machine and proceeded with a careful examination and explanation of what we were seeing. I traced the baby’s body parts on the screen, all the while feeling extremely foolish.

I traced the baby’s head. “See, no horns.”

I showed her the baby’s body. “No sign of a tail,” I announced cheerfully. “Perfectly normal in every way!”

“I don’t know,” the patient seemed extremely doubtful.

“Now that I’ve shown you that the baby is healthy and normal, I’m going to invite a very nice man to talk to you about your worries. He has lots of experience with people who are afraid of being pregnant with the devil’s baby,” and I headed off to call the psychiatry resident on call.

The psychiatry resident visited with her and decided to hold off on any psychiatric medication until after the baby’s birth, since the patient currently did not seem distressed. We gave her another meal, let her watch her favorite shows on television, and call the ambulance to take her back.

I phoned the warden’s office to inform them. I emphasized to them that she was perfectly fine (except for her delusions) and that the baby appeared to be normal and growing well. “She’s not carrying the devil’s baby,” I admonished, “and if she complains about it again, you should not send her back.”

I thought the matter was settled.

Several weeks later, the secretary on the labor floor paged me to the phone. The prison was on the line again. It was the warden.

“Remember the lady you saw a few weeks ago? Um, well, we have another little problem.”

“Another problem?” I was not in the mood for riddles. “Now what’s wrong?”

“Well, this morning she complained of pain in her stomach, but we didn’t believe her. Oh, no, we weren’t going to fall for her tricks. Last time we sent her to the hospital because she said she was carrying the devil’s baby and she wasn’t!

I could immediately see where this was going.

He continued. “She kept calling us, but we just ignored her. She tricked us before, so we didn’t believe her.”

He finished in a rush, “So she lay down on the floor of her cell and had the baby all by herself. We just found her and called for an ambulance.”

The warden had summoned a nurse from the prison infirmary, who had tied off and cut the umbilical cord. They bundled up the baby, who seemed healthy and content, and the mother, who was not bleeding very much, and sent them in.

She was glad to be back, and thrilled that she could stay for several days. The nurses ordered her favorite foods and arranged for a nice room. I arranged for the visit from the psychiatrist, and pondered the strange way that prison officials manage medical problems. They sent the patient in for “evaluation” when she claimed that she was carrying the devil’s baby, but ignored her cries for help when she was in labor. It’s amazing what you can learn about the human condition when you work in a hospital.

I am very proud of my profession. There is probably no other profession that has done so much to save lives and ease suffering. However, I have no illusions about the very real problems in contemporary medicine. I’ve experienced most deficiencies in medicine, either directly or through family and friends, but my father’s story is probably the one that burns most brightly in my mind.

Elsewhere, I have recounted how my own colleagues in the hospital where I worked diagnosed my father’s cancer but neglected to tell him. A small lung cancer had been seen on a routine chest X-ray more than 7 months before he coughed up blood. By the time he had his first symptoms, the cancer in his chest was the size of his fist.

If that weren’t bad enough, the doctors, my personal friends and professional colleagues, attempt to deceive us about the findings on the original X-ray. It was only because I worked at the hospital, and could access the X-ray myself, that we learned about the original mistake. And that’s not even the worst part of the story.

My father received the diagnosis on November 1. It was a complete shock since he had never smoked, but approximately 10% of lung cancers occur in non-smokers. After the debacle of unearthing the original chest X-ray and confronting the doctors involved, everyone did their utmost to try and cure him. Nothing worked. Despite multiple types of chemotherapy, the tumor continued to grow and press against his lungs. The tumor produced large amounts of fluid that made breathing difficult. Gradually he developed air-hunger, a sensation that is reported to be worse than pain. He felt like he was suffocating even when he was working as hard as he could to draw breath. By December 25th he was back in the hospital again.

Late that evening my mother called me at home. She was in tears. “You must come to the hospital,” she said. “Your father is in such pain and no one will help him.” I nursed my infant son to sleep and headed for the hospital, my hospital, the one where I had trained, where I worked, where I knew everyone and everyone knew me.

My mother was right. When I saw my father, I was appalled. He was sitting bolt upright in bed, gasping for air, and clutching his chest. I paged the intern myself and demanded his presence. He must have run at a brisk clip because he appeared immediately. We were standing in the doorway of my father’s room. I pointed to my father.

“What is the meaning of this?” I demanded.

The intern, to his credit, was abashed. He acknowledged that my father was clearly in terrible pain, and he acknowledge that my father was suffering from air-hunger and was therefore even more uncomfortable. We agreed. Everything seemed settled.

“Go get him some pain medication, “ I insisted.

“Oh, no, I couldn’t possibly do that,” the intern replied. “He’s dying and pain medication might hasten his death.”

I could not believe what I was hearing. Obviously he was dying. Every treatment had failed and there was nothing left to try. There was no hope of recovery. And we were going to withhold pain medication … why? To prolong his death?

“You’ve got to be kidding,” I barked, although he did not look like he was kidding at all. “I insist that he get pain medication this minute.”

“I couldn’t possibly do that,” he said. “I don’t have the authority. I’ll have to call my resident.”

“Fine. Call!” I demanded.

It was well after midnight at this point and he woke up his resident. I could hear that the resident was unwilling to order the pain medication, and I grabbed the phone. The resident insisted that he didn’t have the authority, only the oncology fellow could decide.

So I called the oncology fellow myself and woke him up. “Oh, no,” he declared. He couldn’t possibly order pain medication in this setting, because it might slow my father’s breathing and thereby hasten his death. Only the attending physician on call had the authority to issue that order.

Then I called the attending at home and woke him up. He listened and replied, “Look, Amy, I know you’re upset, but it’s the middle of the night. Why don’t we wait until morning when your father’s own doctor will be back and he can make the decision.”

At this point, I was screaming into the phone, and a crowd of nurses and support personnel had gathered to watch from a discreet distance. “You get in here and tell me that to my face,” I hissed. “ I will not accept it unless you come here and look at him and then dare to tell me to wait.”

I heard him sigh. “All right, all right. What do you want me to do?” I gave instructions for the amount of morphine I thought he needed, and handed the phone over to the nurse so she could record the order. I started to relax.

The nurse hung up the phone and I looked at her expectantly.

“I can’t give that morphine,” she said. “I’m not comfortable with giving medication to a patient so near death.”

At that point I was transformed into Shirley McClaine in the film “Terms of Endearment”, when she was told that her daughter couldn’t have her pain medication just yet because the nurse was busy.

“You’re not comfortable?” I screamed. “Not comfortable? Do I look like I care about your comfort? I don’t think so.

You go get that morphine or I will break into the narcotics cabinet myself and get it, and then I will report you to the hospital administration for failing to follow an order!”

She hesitated. “Oh, all right. If you’re going to be that way about it.”

“Yes,” I said. “I’m going to be that way about it.

She got the morphine and hung a morphine drip. Within 5 minutes my father began to ease back against the pillows. After 10 minutes, he looked at me and smiled. “I feel great!” he said. “I haven’t felt this good in months. This is terrific.”

He slept then, and I wept. He died less than 24 hours later. Throughout the day, he kept telling everyone how wonderful he felt. His last words to me, before he lost consciousness and died:

“Don’t worry, I’m going to be fine. I’m just going to rest for a bit.”

Working in a hospital brings exposure to the human condition in the way that no other job can. Of course you see birth and death, but you also see the results of human foibles like rage, anger and despair. All too often, mental illness plays a (usually harmful) role. Eventually, patient behavior, no matter how bizarre, loses the power to shock. That does not apply to the behavior of the staff. It’s still shocking when they begin to behave like they are crazy.

The story of The Baby in the Wonderbread Bag begins like so many stories of teen pregnancy, with a young girl who has successfully concealed her pregnancy from family and friends. In this case, the 16 year old girl also had a history of mental illness. She appeared in the emergency room complaining of intermittent abdominal pain. Because she looked well, she was advised to wait while patients who were seriously ill were seen before her.

No one paid her much attention until she went to the Ladies Room and blood was seen to flow from beneath the door. When Security broke down the door, the doctors found that the girl had given birth to a premature baby. She had stuffed the baby in a Wonderbread bag, and, at the moment Security had broken in, she was attempting to flush the baby down the toilet.

They rescued the baby from the toilet bowl and pulled him out of the plastic bag. The neonatologist rushed down from the neonatal intensive care unit and resuscitated the baby. He appeared to be about 7 weeks premature, and smaller than expected for this stage of pregnancy. Nonetheless he was healthy and vigorous, despite his brief time in the toilet, and was swept off to the NICU for further care.

That’s when the story gets weird.

Several days later, in my capacity as a chief resident in obstetrics, I was called to the weekly Social Service meeting to provide my input in difficult cases. When I arrived, I found that the Social Service staff calmly discussing whether the Wonderbread Baby should go home with his mother, as if it were perfectly reasonable that she had tried to flush her baby down the toilet. That shocked me.

It’s not that the Wonderbread Baby was the most bizarre thing we had ever seen; it didn’t even come close. The combination of youth, concealed pregnancy and mental illness is all too common at an urban hospital and the results are usually far more deadly. Indeed, even during my years of medical school and residency, the results of this toxic combination had been getting steadily worse.

When I started medical school, a baby born addicted to cocaine had been a standard reason for removing the child from the mother’s care. During the intervening years, cocaine addiction had become so common that it was no longer considered a reason to remove a child. We had been, in the words of a famous sociology essay, “defining deviancy down.” As abuse and neglect of babies had become more common, we kept readjusting the definition of abuse and neglect, so we could continue to send babies home instead of into the foster care system.

Even so, I was not prepared for a staff meeting with participants calmly discussing flushing a baby down the toilet as if it were some sort of reasonable response to an unwanted pregnancy. They asked for my input, and they got much more “input” than they had bargained for. I had been on call and awake for most of the previous night. Therefore, I exhibited somewhat less restraint than I might have otherwise.

“My input? MY INPUT?” I replied, my voice rising in volume, “Have you people lost your minds?”

“This teenager put her baby in a plastic bag and tried to flush him down the toilet!” I continued, “Is it really that hard to figure out that she should not be allowed to take this baby home?”

The lead social worker seemed defensive.

“You don’t have to get so angry about it,” she chided.

I wasn’t finished with my tirade.

“Evidently I do have to get angry, since you don’t seem to realize how bizarre it is to ask for input about whether flushing a baby down the toilet is a risk factor for abuse.”

The whole team looked hurt.

“It is a risk factor. It is a very big risk factor!” I went on. “I’m going to put myself on the line here and state unequivocally that anyone who tries to flush their baby down the toilet should not take that baby home.”

“Well, if you feel that way about it,” the team leader huffed, “then we won’t send the baby home with her.”

“Yes, I feel that way about it,” I huffed back.

The meeting ended on that less than cordial note.

Looking back on it, I can see that what filled me with anger and despair was not the fact that a teenager had tried to kill her baby. Mental illness and desperation are often a lethal combination. What filled me with despair was that seemingly sane people were discussing whether or not flushing a baby down the toilet was acceptable, as if the conclusion might be in doubt.

What’s worse than being rendered impotent and incontinent by prostate cancer treatment? Being rendered impotent and incontinent by prostate cancer treatment that was unnecessary.

Two large, well-conducted studies revealed what doctors have suspected for quite some time. Screening for prostate cancer using the PSA (prostate specific antigen) blood test does not save lives. In fact, PSA screening for prostate cancer does more harm, including impotence and incontinence, than good. Due to their importance, both studies were released online today by the New England Journal of Medicine, in advance of their publication next week.

According to the study, Mortality Results from a Randomized Prostate-Cancer Screening Trial:

From 1993 through 2001, we randomly assigned 76,693men at 10 U.S. study centers to receive either annual screening(38,343 subjects) or usual care as the control (38,350 subjects).Men in the screening group were offered annual PSA testing for6 years and digital rectal examination for 4 years. The subjectsand health care providers received the results and decided onthe type of follow-up evaluation. Usual care sometimes includedscreening, as some organizations have recommended. The numbersof all cancers and deaths and causes of death were ascertained…

Results … After 7 yearsof follow-up, the incidence of prostate cancer per 10,000 person-yearswas 116 (2820 cancers) in the screening group and 95 (2322 cancers)in the control group. The incidence of death per 10,000 person-yearswas 2.0 (50 deaths) in the screening group and 1.7 (44 deaths)in the control group …

Conclusions After 7 to 10 years of follow-up, the rate of deathfrom prostate cancer was very low and did not differ significantlybetween the two study groups.

The two graphs below present the results of the study. The graph on the left represents cases of prostate cancer and demonstrates that PSA screening was much more effective in diagnosing prostate cancer than examination alone. The graph on the right represents deaths from prostate cancer. Despite a significant increase in diagnosis of prostate cancer in the PSA group, there was minimal if any reduction in deaths from prostate cancer.

While deaths from prostate cancer were not decreased by PSA screening, serious side effects were dramatically increased.

Risks incurred from a screening process can result from thescreening itself or from downstream diagnostic or treatmentinterventions. In the screening group, the complications associatedwith screening were mild and infrequent… Medical complications from the diagnostic processoccurred in 68 of 10,000 diagnostic evaluations after positiveresults on screening. These complications were primarily infection,bleeding, clot formation, and urinary difficulties. Treatment-relatedcomplications, which are generally more serious, include infection,incontinence, impotence, and other disorders…

Why did the PSA screening test fail to save lives? The PSA screening test did diagnose more cancers than routine examination, so the test definitely works. The apparently paradoxical outcome is due to the nature of prostate cancer itself.

Most men will develop prostate cancer if they live long enough. However, most prostate cancers are very slow growing and usually do not kill the patient. A man with prostate cancer generally dies of some other cause long before the prostate cancer becomes life threatening. Therefore, the PSA test diagnoses many cases of prostate cancer that do not need to be treated as well as a few cases of prostate cancer that are very aggressive. Not only is there no benefit to diagnosing the slow growing prostate cancers, but there seems to be very little benefit to diagnosing the aggressive cancers early, since some do not respond to treatment even when administered in the early stages.

The second study,  Screening and Prostate-Cancer Mortality in a Randomized European Study, showed a very small decrease in deaths associated with PSA screening. That decrease came at a very high price:

To prevent one prostate-cancerdeath, 1410 men (or 1068 men who actually underwent screening)would have to be screened, and an additional 48 men would haveto be treated.

For every death prevented, 1068 men had unnecessary biopsies, and 48 men had unnecessary treatment. That’s a problem, and it is made far more serious by the life altering side effects of treatment, impotence and incontinence.

Taken together, both studies provide convincing evidence that PSA screening for prostate cancer should be stopped. Too many men are seriously harmed, and very few if any men derive any benefit. The take home message for patients: Don’t get PSA screening for prostate cancer.

On the long running game show Jeopardy, contestants are given the category and the answer, and they have to provide the correct question. So, for example, if the category were HIV/AIDS, and the answer was “condoms,” the correct question would be “What is the safest, most cost effective way to prevent the spread of the deadly disease?”

Evidently the Pope does not know how to play Jeopardy. MSNBC, reporting on the Pope’s arrival in Cameroon at the start of a trip to Africa:

Condoms are not the answer to Africa’s fight against HIV, Pope Benedict XVI said Tuesday as he began a weeklong trip to the continent. It was the pope’s first explicit statement on an issue that has divided even clergy working with AIDS patients…

“You can’t resolve it with the distribution of condoms,” the pope told reporters aboard the Alitalia plane heading to Yaounde. “On the contrary, it increases the problem.”

That is simply flat out false. Extensive research has shown that condoms are the most effective, the safest, and the least expensive way to prevent transmission of the deadly virus. According to Effectiveness of HIV Prevention Strategies in Resource-Poor Countries, published in the journal AIDS:

Studies overwhelmingly demonstrate that condoms are highly effective in preventing HIV transmission. A workshop co-sponsored by four government agencies responsible for condom research, condom regulation, and HIV/AIDS and sexually transmitted disease prevention programs (US Agency for International Development, Food and Drug Administration, Center for Disease Control and Prevention, National Institutes of Health, Bethesda, Maryland, USA) was held in June 2000 to evaluate the published evidence establishing the effectiveness of latex male condoms in preventing HIV/AIDS and other STDs. The workshop panel concluded that consistent users of the male condom significantly reduced the risk of HIV infection in men and women. In fact, condoms appear on average to be at least 90% effective in preventing HIV when used consistently and correctly…

A 90% effectiveness rate is very effective indeed. In contrast, sexual abstinence, the Pope’s preferred method for preventing transmission of HIV has been found to be totally ineffective. A 2007 paper in the British Medical Journal reviewed the effectiveness of abstinence programs in several countries:

…Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results…

Moreover, the use of condoms is safe, easy to teach, and cost effective. In contrast, not only is abstinence ineffective, it is impractical because many HIV positive people are married to HIV negative partners. Abstinence would mean that sex was impossible even within marriage.

The Pope’s response “abstinence” is clearly the answer to an entirely different question: “What method of HIV prevention (which doesn’t even work) is consonant with Catholic doctrine?” The Pope is obviously not interested in the actual effectiveness of the method, and he does appear to be disturbed that millions are dying for lack of effective prevention strategies. That has not escaped the professionals who are striving to decrease the horrific impact of AIDS in Africa:

Rebecca Hodes with the Treatment Action Campaign in South Africa said if the pope was serious about preventing new HIV infections, he would focus on promoting wide access to condoms and spreading information on how best to use them…

“Instead, his opposition to condoms conveys that religious dogma is more important to him than the lives of Africans,” said Hodes, head of policy, communication and research for the organization…

The Pope is entitled to his own agenda, but he is not entitled to be intellectually dishonest. Condoms are clearly the answer to Africa’s fight against HIV, if the concern is preventing transmission and death. When is abstinence the answer? Only if the question is how to die Catholic in the midst of an AIDS epidemic.

While I have lots of unpleasant memories of my training, I don’t have a lot of regrets. There is one case, though, that I cannot forget: I went along with care that I believed to be unethical. I can rationalize it by taking into account that I was the most junior member of the team, with no authority to countermand the patient’s primary doctor or anyone else. I can rationalize it by acknowledging that even today, decades later, I don’t have any better idea of how I should have handled it. Nevertheless, I can’t help thinking I will always regret my participation.

I was on the medical service at the time and was taking call on a Saturday. I was paged to the Emergency Room to bring up a new patient. Mr. Rivera (not his real name) was a 38 year old Hispanic man who had come to the ER for a simple sore throat, and gotten a devastating diagnosis.

Mr. Rivera had had lymphoma when he was 18 and had been treated aggressively with chemotherapy. He was a success story; the chemotherapy had put him into remission and he had lived the intervening years free of any health problems. That’s why he was not particularly worried about his sore throat. He thought it might be due to strep.

The sore throat was caused by strep, but during the evaluation, a routine blood count was dramatically abnormal. Mr. Rivera had a very aggressive form of leukemia, a known long term side effect of his lymphoma therapy. Given the nature of his leukemia, the chances of remission, let alone a cure, were very remote.

Mr. Rivera had always known that leukemia was a potential side effect of his successful treatment. He also understood that it was an extremely serious disease. That’s why, in our very first meeting, Mr. Rivera wanted to discuss his prognosis and insisted on making clear his wishes about treatment and death.

Mr. Rivera had lived through multiple rounds of aggressive chemotherapy to treat his lymphoma. He dreaded more chemotherapy, but if there was a reasonable chance that he would go into remission, he was willing to undergo more chemotherapy. However, if, as he suspected, the prognosis was grim, he would refuse chemotherapy so he could return to the Caribbean island where he had been born, and, as he put it, “die on the beach with his family around him.”

I was not encouraging in the least about his prognosis, but I would not make a definitive statement because, as an intern, I was not allowed to interfere with the primary physician’s relationship with the patient. All information about treatment recommendations and prognosis was to be left to the primary physician. In this case, since the patient had had no contact with any oncologist in the previous 15 years, he was assigned an oncologist from our staff.

I was relieved that I was under no obligation to give the patient the grim news. It was early in my career, and I had no experience telling a patient that he was probably going to die. In my naivete, I assumed that the oncologist would tell the patient the truth, and that the patient would soon be heading to the Caribbean to live out his remaining days with his family.

I had not reckoned on the fact that oncologists can often be very unrealistic. Some oncologists believe very strongly that even the most remote chance of a remission should be pursued aggressively. That generally dovetails nicely with the fact that most patients are desperate to live and are willing to undertake any treatment, not matter how painful or difficult.

Mr. Rivera had already made it clear, though, that he was not desperate to pursue any chance. He understood what it meant to have a potentially fatal illness; it had happened to him before. He understood was aggressive treatment meant; he had already experienced it once before. He was adamant that this time he was not willing to grasp at a tiny chance or remission and probably die in the hospital due to the effects of the cancer and the chemotherapy. If the chance of remission was very small, he wanted to go home and die with his family.

Visiting Mr. Rivera the next day I intended to discuss his plan to forgo chemotherapy and return home. I was completely unprepared to learn that his oncologist had told him that he had an excellent chance to be treated successfully and that it would be a mistake to refuse treatment. As Mr. Rivera recounted this information, he watched my face carefully to see my reaction. He was clearly suspicious of the information he received from the oncologist.

I knew what was coming next and I dreaded it. Mr. Rivera asked if I agreed with the oncologist. Remaining carefully impassive, I told Mr. Rivera that I didn’t know nearly as much as the oncologist and therefore, I couldn’t really answer the question. He seemed unsatisfied, but he did not press me.

I sought out the resident physician, my immediate superior, and confronted him. Wasn’t it true, I demanded, that Mr. Rivera’s prognosis was exceedingly grim? The resident acknowledged that the chance of remission was remote. I wanted to know what we should do next. The resident was shocked. What did I mean by “what we should do?” We shouldn’t do anything. It was not up to us to correct the oncologist or, worse, to undermine him. This oncologist was known to be extremely aggressive and there was nothing we could do about it.

I argued, but he had an answer for every argument, reminding me that we could only get into trouble for pursuing this issue. To my everlasting regret, I took his advice.

Mr. Rivera had a rough time with his first course of chemotherapy. He was very sick and his immune system virtually shut down. As a result, he developed an abscessed tooth, and despite powerful antibiotics, the infection spread deep into his jaw. He was in terrible pain, poorly controlled with large amounts of narcotics.

As the days went by, Mr. Rivera spent his time vomiting, shaking with chills, and writhing in pain. Because of his damaged immune system and the chemotherapy, he was unable to fight the infection and it spread further even though we were treating it as aggressively as we possibly could. Ultimately, the infection spread to bloodstream, and three weeks after he was admitted, Mr. Rivera died without ever leaving the hospital and without ever saying goodbye to his family.

The oncologist felt that we had treated Mr. Rivera appropriately. We had given him every chance to go into remission and have a longer life. I thought we betrayed Mr. Rivera in the worst possible way; we lied to him and we deprived him of the opportunity to die the death he wanted, surrounded by the people who were important to him. What really happened is that the oncologist had substituted his preferences for Mr. Rivera’s preferences. The oncologist simply could not imagine or understand that Mr. Rivera could want something different than he would want in the same situation, and so he ignored him.

In the grand scheme of things, Mr. Rivera would have died anyway, and I was a minor character in the drama that played out. But I cannot help but think that I colluded in a theft. We stole Mr. Rivera’s dream of a peaceful death and replaced it with vomiting, fever and pain. We had no right to do what we did; we were guilty of a terrible crime, not a legal crime, but a crime all the same.

An amazing thing about practicing medicine is that every time you think you’ve finally seen everything, you see something new. Not just something that you’ve never seen before, either, but something that you could not have even imagined.

Consider the case of the young woman who came to the urgent care clinic at our health center one evening. The woman was complaining of severe genital pain; so severe, in fact that she could only walk with her legs widely spaced a part.

That walk is a classic sign of a Bartholin’s gland abscess, a fairly common infection of the glands at the outer edge of the vagina. Bacteria can take up residence in the gland and cause an abscess. Even though the abscess is small, it is extremely painful. The wide stance walk is almost a guarantee of the diagnosis. The triage nurse explained the likely diagnosis to the patient and the fact that the abscess could be easily treated. Rather than looking relieved, the patient appeared embarrassed.

A PA (physician’s assistant) saw the patient, took the history, which was unremarkable, and started the exam, which was quite remarkable. The patient did not have an abscess; she had what appeared to be shallow, but extensive burns around and extending into her vagina. The physician’s assistant was so flustered that she excused herself to call me.

I could not leave the hospital to go to the clinic, because I had a patient in labor who would deliver soon, so I had to rely on the PA’s description. The description certainly fit with that of burns, but I had never seen burns of that kind in any area. Yes, I had seen chemical irritations of various kinds, but it didn’t seem like an injury of this sort was likely to be caused by a new bath soap or detergent.

The PA insisted that the patient’s history was unremarkable, and I insisted that she had not gotten the complete history. It wasn’t her fault; the patient simply didn’t want to reveal what happened. I suggested to the PA that she question the patient about domestic violence, since I had certainly seen vaginal injuries related to violence in the past. I also pointed out that it was important to explain to the patient that we needed to know what happened in order to treat her appropriately.

I was dreading the return phone call, and I imagined all sorts of horrible things that might have happened, but I failed to imagine what really did happen. When the PA called again, she was laughing.

“You’re not going to believe this,” she said, “but the patient accidentally did this to herself with a dildo.”

She was right. I couldn’t believe it. What could the patient have used? I’d heard of all sorts of things in the past: fruit, candles (unlit), and glass bottles, among others, but nothing that could cause burns.

“She used a deodorant stick!”

The patient had used the actual stick of deodorant, which she had pried out of the container (for who knows what reason) and the burns she had were serious chemical burns. We treated her by washing the area to remove any trace of the chemicals and applying the salve typically used for treating burns from gynecologic laser surgery. Oh, and lot’s of pain medication, too, for obvious reasons.

Her treatment plan included her medications, an appointment for follow up, and a recommendation: should she feel the need to use a dildo in the future, she should avoid deodorant, or at least leave it in the container with the cap still on.