REFLECTIONS

Reunions are times for reflection, and my medical school class reunion is soon. There has been much to reflect upon, as 60 years is a long period in one’s life even though it is a microdot in the history of mankind. There have been hundreds of thousands of personal experiences during that time, all of which have enriched my life, and indeed I have been blessed.

In addition to those times with patients, I have witnessed momentous changes in all aspects of medicine. Things that were undreamed of during our student days are now routine and taken for granted. Newly invented diagnostic procedures are more efficient and precise. Scans have replaced many previously unreliable and time consuming tests. Antibiotics were invented. Vaccines virtually eliminated many serious illnesses. Now, no mother would hold her child in her arms while watching it die of diphtheria as did my grandmother, and there are few doctors left who have ever seen diseases so common in our day that they were accepted as a normal part of life.

While we were still in medical school, anti-depressant and anti-psychotic drugs were marketed, and within two years, 70% of state hospital patients, many of whom would have otherwise spent the rest of their lives in institutions, were discharged. Cardiologists who were limited in their treatments by very few medications now actually are able to visualize occluded coronary arteries and unplug them by sticking a catheter through the heart and into the coronary arteries, much as your plumber opens a clogged drain. Even more unbelievable was the idea that organs, especially the heart, could be transplanted. If that isn’t ghoulish enough, now there is talk of manufacturing organs from stem cells. And we must not forget, like it or not, this is the digital age, and computers have become an indispensable tool in all aspects of medicine, with even robots now entering the picture.

One day many years ago, during my internship, I found myself assisting in surgery to repair an abdominal aortic aneurysm, the first such surgery to be performed in the state of Ohio. The body’s largest blood vessel was in the process of bursting, and the patient was brought into the OR literally screaming in pain for which massive doses of morphine had no effect. One of the nurses was kept busy wiping the sweat from the surgeon’s brow to prevent it from dripping into the abdominal cavity as he worked. After 6 hours and gallons of blood, the patient died on the table, and the surgeon was barely able to make it to the dressing room, totally exhausted. Today, that procedure is routine and can sometimes be done without even opening the abdomen.

IS IT ETHICAL?

As is the case with most major scientific achievements, there have been many unintended consequences, and we are confronted with ethical questions, most of which have no acceptable answers. There are all those end-of-life dilemmas such as when to “pull the plug.” In my day, death was the enemy, and we considered ourselves ethically-bound to preserve life at all costs. Death was defined as lack of a heart beat, but with life support systems now in general use, it is possible to keep a heart beating indefinitely. Today, families are faced with the heart rending chore of agreeing to the withdrawal of such support. I have seen family members whose grief is compounded by the irrational belief that they were complicit in their loved one’s death. This problem has found a solution through asking patients to sign notarized documents promising to die appropriately and in a timely manner.

On the other hand, our newly found technology may preserve a life of pain and suffering and leave the physician to question the preserve-life-at-any-cost dictum. This has contributed to a newfound focus on “quality of life.” As a consequence, there are now five states permitting physician assisted suicide. We old fashioned guys and gals were bound by oath and a code of ethics to always do our utmost to save lives and never, under any circumstances, to end them. Although, there were undoubtedly occasions when a physician may have been overly generous with his doses of morphine for a patient who was finding it difficult to die. I suspect a similar treatment plan is often used in the terminal stages of hospice care today.

It is not surprising that these changes have generated controversy. There are those who feel dying should remain in the hands of God, and to violate the sanctity of life, no matter the rationale, is a most grievous sin and should be illegal. Strangely, some of those same people may feel that capital punishment is justified. There is also the argument that to accept assisted suicide is to go down a slippery slope from which there may be no return. Proponents of that position are not impressed with the safeguards put in place to prevent it being misused e.g. for depressed mental patients or for those elderly infirm people who are made to feel they are a burden.

MO’ LIFE MO’ PROBLEMS

The successes of medicine have also been responsible for cultural and political problems. There have been remarkable increases in longevity. During my lifetime, life expectancy has increased nearly 20 years in spite of the adoption of unhealthy lifestyles by many of us. This longer lifespan has contributed much to the current problems with social security as the actuarial tables, used at its inception in 1935, grossly underestimated the increase in lifespans. A longer lifespan allows some to outlive their savings, resulting in the creation of “sandwich families” where parents find themselves caring for both their children and their parents.

It has been well documented that healthcare expenses increase drastically as a population ages. A Kaiser Foundation study reports that the average person’s medical expenses double at age 70, triple at 80 and increase five times at 90. It seems likely that the future will see the average person living even longer, and the problem will be compounded by all those baby boomers joining the ranks. It is little wonder that the bean counters are predicting a major crisis for Medicare. It is enough to make an old person like me apologize for living so long.

OUR MOST COMPLICATED FIELD

Of all the accomplishments in medicine, none holds more potential for raising ethical, moral, and religious questions, while at the same time promising the elimination of some of our most terrible diseases as does the field of genetics. The sequencing of the human genome was completed in 2003 after a 13 year period of collaboration by scientists worldwide. It was made possible by the development of extremely powerful computers, which were able to compile the huge amounts of data needed to identify and catalog the billions of DNA connections present in our genes. This has been hailed by many as the greatest scientific achievement of all time with the promise to unlock many of the secrets of life.

This research has made it possible to identify the location of mutations responsible for many of the inheritable diseases, and now, even more remarkable, a procedure called CRISPR (an acronym for a string of big words that I couldn’t remember even if I tried) makes it possible to actually remove a portion of DNA from a gene and replace it with DNA which has not been corrupted by mutation. With the repair completed, the condition can no longer be passed on to the progeny. The unraveling of the make-up of the genome promises to result in discovery of many genetically influenced diseases and further our understanding and elimination of those illnesses that “run in the family.”It is also possible to use CRISPR to modify the genetic make-up of bacteria and trick them into becoming friends rather that attackers. There seems little doubt that these discoveries will revolutionize the practice of medicine and further increase human longevity.

MORE THAN MEDICINE

Genetic manipulation of this sort has been found to be useful in a variety of areas other than medicine, including chemistry, biotechnology, and the life sciences, but the development of genetically modified foods seems to have gained the most attention and criticism. Nineteen European countries have banned GMOs, apparently out of fear that some botanical Frankenstein monster might be created, thereby refuting scientists’ reassurances of their safety. Other experts insist no danger exists and point out that we have made changes to the nature of living things for a long time with a methodology both cumbersome and lengthy.

Since the Stone Age, man has used selective breeding to modify the genetic make-up of both plants and animals. Witness the number of breeds of dogs we have, all of whom are direct descendants of wolves. On the botanical side, it is said that corn evolved from a Mexican weed with a seed pod smaller than your finger, which, thanks to the selective breeding initiated by Aztec farmers 9,000 years ago, we now have a plant which is said to provide 21% of the world’s food. Production of desired changes by this process is time consuming, often requiring hundreds or even thousands of years. Now, there is the potential to produce those changes in a single generation. There are already instances in which resistance to drought, disease, and pests have been accomplished.

LOOK OUT SEX ED

Many say that the genome is a “blueprint of life,” and as such it does seem that caution is in order before beginning to tinker with it. It is theorized that it will soon be possible to have “designer babies,” who can be ordered with whatever characteristics that are important to the parents. Imagine what Hitler could have done with the help of CRISPR in his zeal to develop a master race. Since there is no aspect of a person that is not designed and controlled by genes, the changes which could be accomplished are limitless. An even spookier thought is the possibility that life could be created by man. After all, DNA has been synthesized and is readily available, and it is deemed possible to construct a synthetic gene. If the construction of one synthetic gene is possible, why not an entire genome?

TECHNOLOGY AGE

As with almost everyone else, I have dived headlong into this “Brave New World” of digital bliss. In a previous blog, I commented on warnings about artificial intelligence by a few guys who know about that stuff, and I also wrote about the replacement of people by machines. There has been speculation as to the effect of prolonged viewing of violent video games on kids, and recently evidence has been collected that kids’ attachment to their cell phones has all the qualities of addiction. I have also witnessed the birth of satellites, the internet, social media, space travel, atom bombs, jet airplanes, GPS systems, robots, television, and computers, to name few of the awesome things developed in the relatively brief time I have taken up space on this planet. Those few years have produced more advances in science and technology than happened through all of history. I am impressed and a little scared.

The ability for society to take advantage of all the marvelous achievements of our day without destroying itself, in my opinion, should be job one. It appears to me that our young people are strongly encouraged to learn technical skills and seek an education focused on math and science. Granted, there is great need for such occupations. Consequently, they are lucrative, but there is an even greater need for those who can view these changes from a distance. In that vein, I believe there has never been a greater need for a liberal arts education, yet it seems few share that view. We need philosophers, theologians, historians, artists, poets, writers e.g. professions not directly immersed in high tech stuff. I believe it is more important to know where we are going than how to get there. This is especially true during this time when events are changing so rapidly that there is hardly time to contemplate unintended consequences.

In medicine, when a new procedure or treatment is prescribed, physicians are taught to do a risk-benefit assessment. That is based on the premise that body parts are all linked together, so any changes in one organ are apt to result in changes somewhere else. In the case of the burgeoning technology which threatens to overwhelm us, I believe that it is important for those knowledgeable, but not directly involved in the research, to do risk assessments, also, in order to predict some of the side effects of technology. These ideas should be debated and become “Breaking News,” and perhaps even receive as much coverage as the rescue of a dog who fell into a well. In medicine, we have the FDA, which regulates drug and equipment development, but all that digital stuff, which I don’t understand, garners no press until it is out there, undoubtedly doing both good and bad.

Perhaps the greatest challenges facing generations to follow lays not in developing new technologies, but in learning to control those from mine.

Note from the editor: In case you were wondering, CRISPR stands for Clustered Regularly Interspaced Short Palindromic Repeat.

Much of my life has involved trying to understand people.  Since more than half of my patients were females, it follows that I should know something about women by now.   Unfortunately there is that gender barrier which makes it difficult for me to put myself in their shoes, both literally and figuratively.  Even though I feel I must have learned something after all those years, I identify with Freud, who allegedly said that after all his years of study, women still remained a mystery to him.

In my case, the problem was made more difficult because I had no sisters. As a child, I viewed girls as fragile little flowers who must be protected by those of the opposite, stronger and more sensible sex.  Although some admittedly showed signs of intelligence, I thought their inherent sentimentality impaired their ability to make rational decisions.  At that time, there were already signs that this societal norm was fracturing in spite of a great deal of male resistance.  For example, the right for women to vote was still viewed as a big mistake by many.

RESPECTED OR DEVALUED?

Since I grew up as a compliant, conservative midwesterner, I was naturally compliant with the rules I was taught about girls.  Consequently, I learned to open the door for them, not to swear in front of them, and never ever to strike or physically harm them in any way. This latter admonition was considered to be not only unfair due to man’s superior strength, but unmanly, and manliness was all important for almost all boys, and still is for most of us.

At about the age of five, I learned all about the anatomical differences between girls and boys from a very worldly 12 year old distant cousin.   Detailed exploration of her physique proved beyond a shadow of a doubt that we were anatomically different.  The experience did explain why my mother frequently chastised my brother and I for not lowering the toilet seat.

In the old days, boys got most of their sex education from locker room banter, which was, as you might suspect, not always accurate; needless to say, I entered medical school not nearly as sophisticated in such matters as I pretended to be.  We learned a lot about the anatomy and physiology of women but not much about the experience of being a woman.  During our clinical rotations, we were privileged to participate in the treatment of women, the treatment of their family members, and the birth of the women’s children.  It was heady stuff.  From there, it was on to a stint in family practice and eventually to psychiatry, where there was not much emphasis on the study of the differences between the male and female psyche.

WHERE THE RUBBER HITS THE ROAD

It was by living with a spouse and three daughters that I began to understand a bit about how female brains work.  From the beginnings of their lives, it was clear that the girls were more prone to outward displays of emotion than their brother.  Based on a totally unscientific study of these four kids, I remain convinced that the differences were present at birth.

Some have suggested that the female’s nurturing instinct is simply a learned behavior, for one would not expect to see significant hormonal influences in toddlers. Yet I believe I have seen evidence of such behaviors very early in my daughters’ lives, which leads me to believe female brains are hardwired for nurturing.  Indeed, the job of nurturing is done without training by females throughout the animal kingdom, so why would we expect Homo sapiens to be any different?

NO WONDER I AM A SUCKER FOR GADGETS

In his book, The Essential Difference: Male and Female Brains And The Truth About Autism, psychologist Simon Baron-Cohen concluded that boys and girls exhibit different behaviors at birth.  Female babies were noted to pay more attention to social stimuli, such as human faces or voices; while boys were attracted more to nonsocial, or spatial, stimuli, such as the movement of a mobile above his crib. Baron-Cohen concluded that these traits will persist as these babies grow into adulthood because male and female brains are wired differently.  Additionally, the use of modern scanning technologies shows great promise toward the enhancement of our understanding of such differences.

REAL MEN DON’T CRY

It has long been said that females are more sensitive to others’ feelings and, therefore, are more empathic than men.  This does not mean that men are devoid of empathy, but that their empathy is perceived differently.  Researchers have identified two different kinds of empathy which they call affective and cognitive.  Affective empathy actually involves experiencing another person’s feelings and is more common in women, while cognitive empathy, characteristic of men, is triggered by imagining oneself in the same situation.  To feel sorry for another’s misfortune is different from actually experiencing his or her sadness.  In light of this, it is safe to say that when a woman says “I feel your pain,” she actually means it.  Likewise, she will also be capable of sharing in your joy.  A survey of the women in my life has confirmed this phenomenon exists, and they gave examples of situations in which their ability to function was affected from sharing a friend’s grief.

As women strive for equality, there has been an effort to minimize the differences between genders, which has led to serious debates and questioning of conventional wisdom.  It could be characterized by the lyrics of that song in the 1950 musical film Annie Get Your Gun: “Anything thing you can do, I can do better.”  In one definitive study, a large group of students in the grades 2 and 3 were given tests designed to measure empathy, then retested when they had reached an average age of 14.   The results verified the hypothesis that the girls were more empathic than the boys, especially on the affective scales.  Moreover, the difference that was present at the younger age increased as the children grew older.

FOLLOW THE MONEY

These days, if one wants to learn about human behavior, he needs only to look at marketing research, for these people know more about us than we know about ourselves.  The power of the internet has allowed them to accumulate massive amounts of data which has been used to chronicle much information about both individuals and groups.  One such treatise on the subject confirms “that there are inherited differences between… the way men and women think, perceive, and remember information.”  It goes on to say, “Girls watch faces. Boys watch objects.”

The authors conclude that “segmenting by gender is crucial if businesses are to make their websites more enjoyable and profitable.”  One might conclude that if the bean counters think it, then it must be true that men are really from Mars and women from Venus.

IT MIGHT GET STICKY

That these differences exist makes perfect sense from an evolutionary point of view since the talents of both sexes allow them to function at a high level when performing the specialized functions required of members of traditional families.  Nevertheless, it is true that times are changing, and those roles could change as technology turns us on our heads.  We undoubtedly will see dramatic changes in our world, which will require many different kinds of talents.  In many ways, it is conceivable that these changes may result in role reversals that we now find difficult to imagine.  Many changes are already occurring, and I plan to ruminate further on the subject in my next blog.

Meanwhile, I very much agree with French experts who respond to comments about the disparities between the sexes with the phrase: “vive la difference.”

Throughout history there has been no shortage of conspiracy theories.  There appears to be no group of people who are immune to the acceptance of unproven explanations and stories which are often passionately embraced.  The theory that UFOs have made contact with us and that our government has kept it secret to avoid alarming the populace has remained intact for more than half a century.  Charismatic cult leaders have often used conspiracy theories as recruiting tools.  Imagined conspiracies can be used to excuse failures of all kinds, or as weapons to discredit or harm others.  Though most could be categorized as harmless gossip, some can have devastating consequences.

THIS STUFF IS NOT NEW

During World War II thousands of American citizens of Japanese and German ancestry were incarcerated due to an unfounded theory  that many had immigrated to the U.S. in order to become spies or saboteurs.  In the infamous hearings orchestrated by Sen. Joe Mccarthy in the 1950s, he insisted there was a vast communist conspiracy afoot to overthrow the government.  Many were accused of treason, which although unproven, left many lives in ruin.

The assassination of President Kennedy spawned a host of conspiracy theories.  Those named as responsible for the shooting included, Russia, Mexico, Fidel Castro, the Mafia, the CIA, and even President Johnson.  There was a successful movie rife with complex plots which legitimized the conspiracies in some minds.  The Warren Commission, which was assembled to investigate, was widely discredited by those with their own conclusions as simply another attempted cover-up.   The commission was appointed by Johnson, which raised the question as to their possible involvement in the assassination.  In such manner conspiracy theories spread and grow.

THE LATEST POLITICAL TALENT

Our new President is no stranger to conspiracy theories having served as the self- appointed promoter of the birther movement.  His continued drum beat that Obama was born in Africa, and therefore an illegal president provided him with a great deal of free publicity and support from the Obama haters.  He spiced up his climate change denials by adding the whole thing was a Chinese conspiracy.  During the campaign, he alluded to allegations of Clinton misdeeds of many years ago even mentioning the theory that they may have arranged for the murder of Vince Foster whose death had been ruled a suicide. He resurrected the old birther mantra when he learned Cruz was born in Canada, and when that did not gain traction, suggested that Cruz’s father may have been implicated in the Kennedy assassination.

His assertions that the entire democratic process was rigged, that the media were “all crooked” and should not be believed, and his questioning of the integrity of the justice system did little to “make America great again” but rather undermined his believers’ faith in our government.  We can only hope that their disillusionment did not extend to the questioning not only our government, but also our form of government for that type of thinking is what has led other countries down the path toward authoritarianism.

BELIEF MAKES IT TRUE

In politics, such stories are common, but in this election we have been bombarded with them.  In a previous blog I made mention of the phenomenon of confirmation bias which results from our tendency to accept as true, information which is consistent with our own beliefs.  I have since happened onto an article that addresses the problem in great detail.  A study by a group  of Italian sociologists led by a Dr.  Quattrociocchi (no I can’t pronounce it either) followed the Facebook reading habits of over 1 million of their countrymen, and their paper confirmed what had always been suspected, but with some interesting twists.

The results of their study titled ‘Inside the Echo Chamber” was published in the April issue of The Scientific American.  In this innovative study, they were able to separate readers into two groups – those who read scientific material versus those who were regular conspiracy theory consumers.  There appeared to be very little interaction between the groups i.e. the ones who read science rarely read any of the conspiracy theory material while the conspiracy theory aficionados likewise avoided the science websites, whereas both groups tended to communicate only with those of like mind.  It should not be surprising that those of a more scientific bent would be more skeptical of unsubstantiated theories.

Those of both groups were found to have wide ranging social networks in which opinions generally conformed to their own, but those who consumed conspiracy news spread it more widely, which may help explain how such stories go viral.  Of more concern was the authors’  conclusion, based on a yet unpublished study, that the so called debunking of a conspiracy theory actually reinforces one’s belief in it.  Such a conclusion does not bode well for the effectiveness of fact checkers in their job of correcting misinformation foisted on the masses.  As a matter of fact, attempts to correct “fake news” especially when pursued vigorously may simply convince the theorist that the conspiracy is wider than he thought since he knows that ordinary news sources cannot be trusted.

PARANOIA COMES IN ALL SIZES

This refusal, or perhaps inability, to question one’s beliefs is also seen in an extreme form in the minds of patients who are delusional and/or paranoid.  I do not suggest that all conspiracists are psychotic; however, any psychiatrist will confirm that it is useless to try to change the mind of those suffering from delusional thoughts.  Such efforts are likely be interpreted by the patient as due to your having been duped or that you are a participant in the imagined conspiracy.  That latter phenomenon is probably at least partially responsible for the relatively high risk of assaults and worse on mental health professionals.  The same phenomenon in milder form may also account for the difficulty of fact checkers to change minds.

IF JOE SAYS IT, IT MUST BE TRUE

The Media Insight Project  http://www.mediainsight.org/Pages/%27Who-Shared-It%27-How-Americans-Decide-What-News-to-Trust-on-Social-Media.aspx, a collaboration between the Associated Press NORC and the American Press Institute, did a well controlled study  that indicated people were more likely to accept information passed on by a friend as truth than if the same story came directly  from its original source.  This factor seems also to promote more rapid spread of information and its companion, misinformation.  They also note that Facebook was second only to TV as a source of news about our recent election. They state  Facebook is closing fast and predicted soon to occupy the number one spot.

Dr.  Quattrociocchi  states “conspiracy thinking arises when people find themselves unable to determine simple causes for complex adverse circumstances,” which I am convinced is too simple an answer.  People are curious by nature which has served us well in our quest to dominate the planet; however can also make us vulnerable to absorbing unproven explanations.  Oft times the mere mention of a half-truth may be enough to encourage us to fill in some blanks and come up with a plausible theory.   We like to know secrets about others but to divulge them is even more pleasurable.  Some call this gossip, and at times the process can be quite competitive.  Remember the school yard chant: “I know something you don’t know!” We pass on the information after securing promises that it will be kept secret knowing full well that it is likely to be passed on at the first opportunity.  The juicier the better for the more outrageous the more superior we feel.

GREAT SPORT

It is also true that conspiracies are interesting, sometimes even fascinating.  I for one am a voracious reader of spy novels and mysteries which of course are always rife with conspiracies, and I am certainly not alone in that.  Conspiracy theories are an excellent excuse for failure, and it is also useful to put them in play in anticipation of possible failure as in “the system is rigged”.  This strategy can not only help save face, but if one can actually convince himself it is true will leave his self- esteem undamaged in the event of failure.

Events surrounding our most recent election campaign have generated a great deal of interest in the use of such stories.  In a previous blog I talked a bit as to how the Russians and perhaps others have been able to use the internet as a tool to attempt to influence the outcome, and how its ease of access allows information of all kinds, real and  unreal, to be promulgated at little expense to large groups of people.  Although his participation  in those nefarious activities are unproven, we do know that our President has demonstrated considerable talent making use of stories about people, groups and institutions which are later proven to be without substance.

WHERE ARE THEY WHEN WE NEED THEM

People are by nature curious, and curiosity makes for fertile ground in which explanations real or imagined can be sown.  One would think that our President’s failure to be more forthcoming would elicit conspiracy theories galore.  Issues such as his tax returns , foreign business dealings,  the alleged Russian connection, etc., would leave one needing only to fill in the blanks left between what is known to produce juicy conspiracy theories of the highest order, yet surprisingly the opposition hasn’t to my knowledge come up with any Manchurian Candidate type conspiracy theories.

While writing this rambling essay I happened on to a website featuring the political satire of Will Rogers, and was amazed to see how timely they are 100 years later. His comments about the effect of money, and untruths in politics lead one to believe that little has changed.   The quote in the picture I thought particularly apropos.  We could use the genius of a guy like Will Rogers today.

It seems clear that conspiracy theories will always be with us, for they appeal to many for a variety of reasons.  We can only hope that they will not be routinely fabricated in order to discredit a candidate for office.  The information highway is already fraught with so much misinformation that the ordinary voter finds it difficult to know the truth about a person or an issue. To paraphrase Jefferson, democracy cannot survive without an informed electorate.