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Intermission

Things will be quiet here, while I look after my carpal tunnel...

A theory of b***s***

In the New Yorker:

"One of the most salient features of our culture is that there is so much bullshit,” Harry G. Frankfurt, a distinguished moral philosopher who is professor emeritus at Princeton, says. The ubiquity of bullshit, he notes, is something that we have come to take for granted. Most of us are pretty confident of our ability to detect it, so we may not regard it as being all that harmful. We tend to take a more benign view of someone caught bullshitting than of someone caught lying. (“Never tell a lie when you can bullshit your way through,” a father counsels his son in an Eric Ambler novel.) All of this worries Frankfurt. We cannot really know the effect that bullshit has on us, he thinks, until we have a clearer understanding of what it is. That is why we need a theory of bullshit...

Where do you start if you are an academic philosopher in search of the quiddity of bullshit? “So far as I am aware,” Frankfurt dryly observes, “very little work has been done on this subject." ...The essence of bullshit, Frankfurt decides, is that it is produced without any concern for the truth. Bullshit needn't be false: “The bullshitter is faking things. But this does not mean that he necessarily gets them wrong.” The bullshitter's fakery consists not in misrepresenting a state of affairs but in concealing his own indifference to the truth of what he says. The liar, by contrast, is concerned with the truth, in a perverse sort of fashion: he wants to lead us away from it. As Frankfurt sees it, the liar and the truthteller are playing on opposite sides of the same game, a game defined by the authority of truth. The bullshitter opts out of this game altogether. Unlike the liar and the truthteller, he is not guided in what he says by his beliefs about the way things are. And that, Frankfurt says, is what makes bullshit so dangerous: it unfits a person for telling the truth.

Frankfurt's account of bullshit is doubly remarkable. Not only does he define it in a novel way that distinguishes it from lying; he also uses this definition to establish a powerful claim: “Bullshit is a greater enemy of truth than lies are.” If this is true, we ought to be tougher on someone caught bullshitting than we are on someone caught lying...

"A Lonely, Uncertain Road"

NYT follows some very ill patients as they try to navigate the health care system and choose treatments: Awash in Information, Patients Face a Lonely, Uncertain Road.

The doctor...recited what has become the maddening litany of medical correctness: "We're in the outer regions of medical knowledge," he said, "and none of us knows what you should do. So you have to make the decision, based on your values."

Ms. Gaines, bald, tumor-ridden and exhausted from chemotherapy, was reeling. "I'm not a doctor!" she shouted. "I'm a criminal defense lawyer! How am I supposed to know?"

This is the blessing and the burden of being a modern patient. A generation ago, patients argued for more information, more choice and more say about treatment. To a great extent, that is exactly what they have received: a superabundance of information, often several treatment options and the right to choose among them.

As this new responsibility dawns on patients, some embrace it with a sense of pride and furious determination. But many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming.

I think patients often face a confusing mixture of choices and non-choices, or false choices. Patients aren't usually allowed to dictate treatment. Some things are really not negotiable: to get controlled substances for pain or anxiety, patients must follow doctors' rules (and doctors must follow rules, also). If patients try to circle the drain in front of us, we will do what we must, and may become quite insistent about it. If you are not an operative candidate, you won't get surgery. And just try to win release from a hospital, if docs think you're likely to harm yourself (or others). Some are told, "You can either be a voluntary patient, or we will make you an involuntary patient." Some discover that they are free to avail themselves of a treatment, but that their insurance won't pay for it. They can be furious at the controlling paternalism of physicians (which is often dictated by laws), trumping their personal autonomy.

But the same patients can also face multiple treatment options. The choice of a reasonable, appropriate treatment can be complex. Sometimes there are no really good options - only options that are partly good, and partly bad, in different ways. Suppose that you couldn't survive without one of three medicines. One might make you somnolent, another may cause weight gain, and the third may make you feel ill. It's your choice. Or would you rather that I choose for you? Ideally, we choose together, proceed cautiously, monitor for those side effects, and minimize them as much as possible. We can predict certain risks. (We can usually spot a patient at risk of delirium or falls, at twenty paces.) But many risks can't be predicted with certainty. (See here, and here.)

Hasn't serious illness almost always been a lonely, uncertain road? The best doctors make that road easier to bear. But this article says that many patients feel abandoned by their doctors, and adrift in the system. It's hard to imagine a satisfying solution.

Morning visitor

Hummingbird 5, originally uploaded by shrinkette.

We finally bought a digital camera last night (our first). Meet the little guy who sits in a plum tree outside our window every morning!

Now, how to crop this? We don't know...yet.

2005 World Memory Championships

Via Mindhacks:

The World Memory Sports Council has announced that the 2005 World Memory Championships will take place in the Oxford University Examinations School on August the 13/14/15th. The event will be hosted by the UK Festival of the Mind 2005 which is being organised by The Buzan Organisation and will be open to the public.

What will they be memorizing? Some highlights of the competition:

Decks of playing cards (one hour time limit);
Strings of random numbers;
Strings of binary digits (011010001 etc.);
"Fictional historic and future dates and events" (between 1000 and 2099);
Non-rhyming poems;
Names and faces; and
Lists of random words.

Don't look for me there! (Although much of medical school seemed like a massive exercise in memorization.) Try their online memory games: Random Card Test and Random Number Test. So that's how some patients feel when I test their memory!

The flying saucer shortage

In the Guardian:

It may only be a small, translucent green gleam on the horizon, but there are signs of a crisis in UFO-spotting. Chris Parr, coordinator of the Cumbrian branch of the British UFO Hunters, sent a shiver through the hearts of ufologists with his announcement this week that his group may be forced to wind up. There don't seem to be any UFOs in Cumbria any more.

Or maybe there just aren't any spotters. Parr's statement seemed to leave both possibilities open. "In Cumbria we have gone from 60 UFO sightings in 2003 to 40 in 2004 and none at all this year. It means that the number of people keeping their eyes on the skies is greatly diminished. We are a dying breed in this part of the country. I put it down to the end of The X Files, a lack of military exercises in the area that would produce UFO sightings, and a lack of strange phenomena." A lack of strange phenomena or a shortage of strange people? Take your pick.

It has not been a happy couple of years for ufology. The closure last year of UFO magazine, following the sudden death of its editor Graham Birdsall, was a disaster for the close-knit UFO-spotting community...

Parr's statement echoes those of UFO groups in Indiana and New Jersey, where ufologists are also having a long, dark night of the soul. Meanwhile, a leading Scandinavian ufologist has suggested that "maybe people are just fed up with the UFO hysteria". The sceptics reckon they have enough evidence to pronounce ufology dead.

"The whole UFO thing is a kind of meme," says Susan Blackmore, a psychologist who studies paranormal activity. "It's a craze, a bit like sudoku. UFOs were just a rather long-lived version. But crazes thrive on novelty, and eventually that dies out. It's taken a long time, but it's good that the UFO era is over. My prediction is that it will go away for a long time and then come back."

David Clarke thinks the rise and fall of ufology is a rich subject for study and is currently trying to attract funds for just such an undertaking. "I see it as part of modern folklore," he says. "UFOs are like modern-day angels, and descriptions of meeting aliens are just like descriptions of people meeting angels in the Middle Ages."

In the dentist's chair

...this morning, my mouth full of novocaine and instruments...the merry dentist busy, busy.

And he says, "Say, you're a psychiatrist...tell me, what's going on in the minds of serial killers? How do they rationalize what they're doing?"

Gaaah....gthpskll!

How interesting that a dentist would be curious about recurrent, premeditated, sadistic, homicidal behavior... but ask me about it when I'm completely unable to respond!

Grand Rounds #46 is up...

at Dr. Emer's Parallel Universes. He has some wonderful posts, so be sure to check it out!

The worst of times for OB-Gyne?

Do women need workaholic doctors, who risk their own health to care for them? Who is willing to make such sacrifices? In the NYT, Dr. Alexander Friedman writes:

Obstetrics-gynecology is quietly reeling from a crisis: not the hot, loud, nasty one involving politicians, lawyers and lawsuits but an insidious one of students voting with their feet.

In the last decade, the number of students entering the specialty has plummeted. In 1996 and 1997, applicants for obstetrics and gynecology residencies were lined up around the block. Since then, the number of applicants has gone into free fall. Only 743 graduating medical students in the United States applied for 1,142 residency slots in 2004. More than a third of the slots went to foreign medical graduates or remained empty.

...During my residency interview at Columbia, Dr. Richard Berkowitz, a prominent high-risk obstetrician, assessed the extent of the crisis. "I've been through the best of times and the worst of times," he said. "This is the worst of times."

...Crisscrossing the country and interviewing at different programs, I asked residents, professors and department heads why the specialty had fallen on such hard times. "Lifestyle" was the predominant response.

More than any time in the past, medical students want careers with predictable schedules.

They want to go to their children's soccer games, read for pleasure and not be called in to the hospital at night.

Specialties like dermatology, radiology and anesthesiology offer flexibility. Obstetrics and gynecology does not, and students are turning away from the most demanding specialties in unprecedented numbers.

Obstetrics is consuming and unpredictable. The hours are long and caring for sick patients can blot out all other priorities. The stakes are high: very often you are caring for two patients and not one, and bad outcomes can be catastrophic for a family.

When you do go home, you worry, sleep uneasily and wake up early the next morning. Yet the payoff is always there: you help patients and bring life into the world...

Dr. Friedman is clearly thrilled with his work, but he has also had moments of doubt. When he rotated through a high-risk service, he had no time for relationships, and was not able to visit his own sick grandmother. Yet he says he's prepared to make personal sacrifices. He is completely committed to his profession.

There have always been doctors like him. But if workaholism is a job requirement, and the sacrifices are so extraordinary, then how on earth can we expect to have any obstetricians? I hope we hear more from him, and from the OB-Gyne medbloggers (paging Red State Moron and Well Timed Period!).

On mind-body medicine, history, and sugar pills

Do the most fashionable people get the most cutting-edge symptoms? If a medical procedure - any procedure - suddenly becomes possible, is it probable that doctors will start doing it? If we suspect that a placebo will help a patient feel better, should we prescribe it? Medical historian Edward Shorter discusses psychosomatic medicine, past and present:

If we're talking about today, new illnesses appear first among educated people simply because they are more plugged into medical media. These middle- and upper-class people are the first to begin monitoring themselves or their children for evidence of peanut-butter allergies or excessive tiredness. It is from these relatively small social groups that the symptoms radiate out...

STAY FREE!: You've written that patients today are more sensitive to body signals; they're more likely to go to the doctor for something than they would have a few decades ago. What's the evidence for this?

SHORTER: There are surveys by the National Center for Health Statistics with comparable surveys from the 1930s showing that patients are much more sensitive.

STAY FREE!: That's ironic. On one hand people are less trusting of their doctors, but on the other, they are more trusting of medical science because they believe that they can be relieved of every imaginable symptom.

SHORTER: Our confidence in science and medicine is very well placed. It's just a shame there has been a breakdown in the doctor-patient relationship, because doctors are able to help patients with psychosomatic problems if the patients are willing to trust them.

STAY FREE!: You've said that most of the things people visit their doctors for are psychogenic.

SHORTER: At the typical family practice, about half of patients' complaints are not the result of an organic disease; they are the result of some sort of mind-body interaction. That's what drives family doctors crazy--they see all this hysteria.

STAY FREE!: There needs to be another word than hysteria. It's so stigmatizing.

SHORTER: Of course, doctors don't use that word with patients. They'll say "functional," which means "not organic..."

A fascinating interview from 2003, via Mindhacks. Well worth reading for his thoughts.

We part ways with our views about placebos, though:

STAY FREE!: Didn't doctors used to prescribe sugar pills?

SHORTER: Yes, it was once very common for doctors to prescribe a placebo, and that went on for decades and decades to the benefit of patients, I might add, because placebo remedies really do work. You destroy their effectiveness when you tell a patient, "I'm prescribing baking soda." I have a lot of problems with a particular version of bioethics we have today that says it's unethical to lie to patients. If we can help patients by lying to them, then by all means, lie to them.

Do we really help patients by lying to them? When he says "placebos really do work," we need to look at what sorts of benefits they provide. They validate the non-psychic origin of a complaint, and provide relief from the outside. ("I'm not just anxious...I have a bona-fide illness, and this pill will take care of it!") Placebos also help doctors, obviously. Sugar pills can halt a string of frustrating calls and office visits, and make a doctor look like a genius to a satisfied patient.

But placebos can't help patients learn the reality of their situation and find ways to cope with it. That's the sort of "help" that we psychiatrists try to provide.

Mysteries of human behavior II

In the Telegraph: "The International Bognor Birdman Festival."

You are 35ft above sea level, with a garage door strapped to your back in lieu of wings. The wind drops and you are cleared for take-off. Launching forwards, you jump as a gust arrives and flips your wings up and over, sending you plummeting gracelessly down to smash through the door and into the waters off Bognor Pier. The 30,000-strong crowd wince - that's got to hurt...

International Bognor Birdman combines the sublime with the ridiculous. George Abel first created a "mass rally of leaping idiots", as he called it, in 1971 as a fund-raising event. While those magnificent machines failed to fly, the idea took off.

Today's Birdman is a mix of eccentric madness and intense competition, all wrapped in boundless enthusiasm. There are three classes of machine. The Leonardo da Vinci rewards innovation and creativity. Down the years flying pubs, pianos and over-sized bumble bees have chased Icarian dreams...

Ian Jackson, by day a 34-year-old landscape architect from Alton, is flying off the pier as Santa drawn by four inflatable reindeer. "If they don't fly, they'll be buoyancy aids," says Jackson.

"Anyone can take part in International Birdman Bognor. Entry costs £50. Construction costs vary, with most spending £200-£300 and taking 80-160 hours to build their machines. This year's event is on August 20-21. For more details, see www.birdman.org.uk."

Leisure in America: analyzing Beatles lyrics

"Rocky Raccoon is a particularly clear expression of conflict relating to sexual impulses," says Dr. Michael A. Brog, MD, in Psychiatric Times.

The song tells the story of the gunfighter Rocky who seeks vengeance against a rival who has stolen the affections of the woman he desires, Nancy. He angrily bursts into a room where the two are dancing (the primal scene, we may say), only to be wounded by his rival, who turns out to be the better fighter. While losing Nancy, Rocky is not left empty-handed, for upon returning to his hotel room, he receives consolation by coming across Gideon's Bible, which will presumably teach him to give up revenge and envy in favor of higher ideals. I imagine Freud might see the song as describing the resolution of Rocky's Oedipus complex, where his unobtainable love object is relinquished out of threat of bodily injury from a better fighter. At the same time, moral values become consolidated as a kind of consolation prize."

May I try this, too? Here's the first stanza of "Lucy In the Sky With Diamonds":

Picture yourself in a boat on a river
With tangerine trees and marmalade skies.
Somebody calls you, you answer quite slowly,
A girl with kaleidoscope eyes.

Clearly, the "boat on a river" is Lennon's Id, and "tangerine trees" are his Ego-Ideal. "Marmalade skies" represent Smucker's domination of the world jam market, of which Lennon was particularly apprehensive. "Somebody calls you" refers to his agent's nephew, who was known to call Lennon frequently, earning him a citation for stalking in 1967. Lennon "answers quite slowly" because he is drunk. The "kaleidoscope eyes" are, of course, ridiculous.

Any questions?



(hat tip to Robert Benchley and his "Dream Analysis")

What's your excuse?

Open Loops has started a list:

* I forgot.
* Were we supposed to do that?
* My dog ate my homework (The Classic)...

* My kid's grades are bad because he’s bored.
* She’s not being challenged.
* Everyone picks on my boy; he has to fight back.
* The teacher is picking on my daughter.
* Homework? It’s a weekend!
* What do you mean he failed the test? He completed all the problems. (Unfortunately, he completed them incorrectly)
* That bus driver has it out for my child.

Here are some…interesting…ones that others have heard through the years:

* I was blonde as a child.
* Picasso didn’t do his best work until he was 70.
* So I screwed up; I’m only human.
* I work better under pressure.
* I do some of my best thinking on the golf course.
* Hey, I’m fertilizing these bushes.
* No one will ever know.
* My vote will never make a difference.
* I’ve never been good with authority (or numbers, or charts, or …)
* If it’s left out on a desk, it’s okay to read it.
* If he’s so poor, where’d he get that pen to make that cardboard sign?
* Anyone who’d fall for that big wooden horse deserves to lose!
* Video games are good for my kid’s eye-hand coordination.
* Finders Keepers
* It’s not like he’s never borrowed something from me and never returned it.
* Everybody cheats on their taxes.
* I’m eating for two now.

He asks, "What have you heard lately?" I've heard a few:

The risks of (fill in behavior) are overblown.
(Accused person or event) made me do it.
I'm not sick.
I ran out of samples.
My pills fell in the toilet.

Send him your favorites for his list. (Will some find these useful in ways that he did not intend...?)

I can stop anytime...can't I?

Do you fear that life without the Internet would be boring, empty, or joyless? Do you lose sleep due to being online late at night? I was about to log off for the evening, but wait - I must post this:

"Dr. Grohol's Psych Central - Internet Addiction Quiz."

Where did Dr. Grohol get this? Am I the last person to discover it? It looks like an "Are you a problem drinker?" quiz, modified for compulsive Web surfers.

Don't ask for my score. I'm in denial. I question its validity, anyway...did they control for blogging?

"Blogging Through The Ages"

Washington Post explores blogs written "by, for, and about older people":

'I started blogging because the mainstream media does not cover getting old, except disease, debility and decline,' Bennett said. Her site, to which she posts every day, features links to about 50 other older bloggers and so creates a kind of online community. 'Most of them are not writing about getting older,' Bennett told me, 'but collectively they continue to prove that old people are vital, alive, intelligent and useful...

"A lot of people as they grow older get socially isolated," Bennett said. "That leads to depression and early death. Blogging opens up a world of companionship, and it makes you eager to find out about things, read the newspaper, watch TV," which help make you a better, more informed blogger. Bloggers sometimes exchange e-mails, start corresponding directly and "become real friends," Bennett said. "And no less so for not being face to face. For older people, it's a godsend."

We have so many stereotypes about aging: seniors are all technophobic; aging is always misterable. These bloggers will challenge those myths...and perhaps tells us which of our stereotypes are true! How are they coping with aging? What do they think about their doctors? I need to catch up on these blogs.

Last week's Illustration Friday was devoted to images of aging. Here are some of my favorites:

Grand Rounds #45

Alois, a medical student, is hosting Grand Rounds today. He has nice graphics, and a great variety of health-related posts. Be sure to check it out!