Friday, May 25, 2007

the logic of medical diagnosis

Tuberculosis is caused by the tubercle bacillus. In order to get a confirmed diagnosis of tuberculosis, the bacillus must be found in the tissue. Other signs/symptoms, like apical opacities on the chest x-ray and cough, confirm the suspicion of TB, and may serve as "presumptive" critieria if the tubercle bacillus cannot be cultured from tissue, but if you ask any physician or read any general medical text, you will be told that the tubercle bacillus is the cause of TB. So one might ask: "Oh, doctors, why doesn't everybody exposed to the tubercle bacillus get TB?" Reasons like insufficient exposure and a strong immune system are cited in response to that question. Therefore, exposure to the bacillus is necessary, although not sufficient, for the development of tuberculosis. An example of a necessary but not sufficient causative agent.

Given that a cause can be necessary although not sufficient, let's look for cases where other combinations of necessary or sufficient agents are deemed causative by medical science. Please consider the case of smoking and lung cancer. An oft-cited statistic is that smoking causes about 90% of lung cancers. This figure includes former smokers, even those who quit decades before diagnosis. We know that smoking is not sufficient to cause lung cancer because 80% (or so) of smokers do NOT get lung cancer. (I am not a paid spokesperson for the tobacco industry; please bear with me here.) We also know that smoking is not necessary to develop lung cancer (of any histological type) because 10-13% of people diagnosed with lung cancer are never-smokers (disregarding the remote smoking question for the time being.) So here is a case of medical science concluding causality from a condition that is neither necessary nor sufficient to develop the disease.

I have asked physician colleagues what the criteria for causality are. Why things like gender, age, racial heritage, and so forth are treated as nuisances (confounders) versus causes when they are plainly linked to the disease. I've never gotten a satisfactory answer, or at least one that was logically sound to me. If only men are susceptible to prostate cancer, then having a prostate gland is a necessary, but not sufficient, condition for prostate cancer. If medical diagnosis is driven by logic, and if other medical causes are necessary but not sufficient, then what is the logical basis for excluding male gender from the list of causes of prostate cancer, particularly when we know that male hormone deprivation shrinks prostate tumors? Take away the "cause" and the problem becomes solvable. Maybe it's just too obvious that to have prostate cancer, you must have a prostate gland. Or perhaps demonizing maleness is anathema to medical hegemony, which is based in male power and domination. Perhaps we cannot consider maleness a problem in the way we regard a bacillus. We never have done so, although the medical machine does have a long tradition of treating most female ailments with removal of the uterus. (For more information on this statement, search the etymology of the word "hysteria.") I say this knowing that about 50% of young physicians are women - nothing kept them from joining up with the winning side. That wouldn't change their gender, now would it?

on suicide

It is, of course, fundamentally selfish. Selfish to think that you, of all people, shouldn't have to put up with all this shit. Yes, you're right - this place is harsh, unjust, and ugly. No one said you'd have to deal with this. But no one said you wouldn't either. And anyone (like your cheery mother) who did say that lied.
Remember that suicide is terribly painful to others. They shouldn't have to deal with grief, guilt, and shame for generations because of your act. Suicide is more shameful, wrong as it is, in our society than murder.
If you do decide to do it, at least have the decency to do it properly. Don't merely shoot your face off, like the young man I met in the trauma ICU. Don't take just enough Xanax to spend the night in the Emergency Department, feeling more and more stupid as you slowly wake up. And don't take just enough Tylenol to damage your liver, so you can walk around yellow-eyed and swollen the rest of your life.
Suicide damages families. I know of a woman who killed herself, and the family tells each other stories about why and how, and some of them make up their own stories, and a lot of the facts don't fit, but no one mentions that. She killed herself in 1934, when my father was 16.
Don't think suicide ends it all. Nowhere near. It's an ugly start to sharing the pain that others didn't even know you were suffering. So start this way instead:
1. Tell someone - doesn't matter who as long as they know you.
2. Consider whether, as you are about to suck air into your lungs one last time, you might regret the choice. What will you do then? Nothing but die.
3. Think: no one else wants this. Only you want this. And maybe the devil. Don't give him the satisfaction.
If you believe in near-death experiences, people who've tried to kill themselves report much less satisfying experiences than others. Neutral, not joyful. I am counting on the joyful part of death myself.
I'm asking you, as someone who has seen too many people who've tried it and as someone who's contemplated it herself, not to do it. The voices that say you should are liars. The promise of ending your suffering is a lie.
So just try to go on - please.

the truth about angels and saints

So they say to be merely a nurse is to help. Help sick people, poor people, dirty-faced little kids in need of hugs, and of course, to help doctors cure people. We are helping angels. We are saints. We are warmth in a cold, tiled hallway. We wear white dresses with white stockings, white shoes and usually white faces, too. Even after that chemo patient threw up on you and that drinker vomited blood all over the room, you still somehow remained white.

Nurses don't talk back. That surgeon who said you were ripe for the picking, like a nice, round, red cherry....he didn't really mean anything by it. They are just that way. When you felt the power drain from your body, and then when you felt powerless for not being able to keep from feeling powerless, it was just your feelings.

Everybody knows caring is not as good as curing. Everybody knows that talking with, monitoring, watching out for and teaching can't halt a killing blood clot in its path toward a feckless brain or image an athlete's torn meniscus with micron-sized resolution. Everybody knows nurses do what we are told, and things go just fine.

No one ever promised you wouldn't get backaches and heel spurs and bad dreams and reasons to burst out crying driving to the grocery store on Saturday morning. Yes, you may know the anatomy, pharmacology, pathology, psychology, theology and technology - but you are famous for smiling and doing what you're told so use that and nothing else, dear.

$33.75 an hour regardless of your graduate degree and 24 years of experience- every other weekend's mandatory: that's the contract language. The least experienced all work the night shift; it's always been that way. You get 15 minutes' break every 4 hours; that's the law. Try not to work overtime; it costs the hospital so much. the way, we're short on Thursday and Friday - could you come in? It's unappealing for saints to negotiate, assert, determine, diagnose, advocate, act up, speak up and even save a few lives. Just don't talk about that part, okay? Clock out and go home, make dinner, put the kids to bed and kiss your husband, and when he is asleep, then think and grieve.