Justice - a course at Harvard

Kirkus Review: A Harvard law professor explores the meaning of justice and invites readers on a journey of moral and political reflection, “to figure out what they think, and why.” Does a veteran suffering from post-traumatic stress disorder “deserve” the Purple Heart? Should the U.S. government formally apologize and make reparations for slavery? Is it wrong to lie to a murderer? Following the taxpayer bailout of the company, are executives at insurance giant A.I.G. still entitled to their bonuses? Should a professional golfer afflicted with a severe circulatory condition be allowed to use a golf cart during tournaments? Are you obliged to surrender your criminal brother to the FBI? Although Sandel (The Case Against Perfection: Ethics in the Age of Genetic Engineering, 2007, etc.) concedes that answering the many questions he poses, bound up “with competing notions of honor and virtue, pride and recognition,” is never easy and inevitably contentious, it’s necessary for a healthy democracy. “Justice,” he writes, “is inescapably judgmental.” Using three approaches to justice—maximizing welfare, respecting freedom and promoting virtue—the author asks readers to ponder the meaning of the good life, the purpose of politics, how laws should be constructed and how society should be organized. Using a compelling, entertaining mix of hypotheticals, news stories, episodes from history, pop-culture tidbits, literary examples, legal cases and teachings from the great philosophers—principally, Aristotle, Kant, Bentham, Mill and Rawls—Sandel takes on a variety of controversial issues—abortion, same-sex marriage, affirmative action—and forces us to confront our own assumptions, biases and lazy thought. The author has a talent for making the difficult—Kant’s “categorical imperative” or Rawls’s “difference principle”—readily comprehensible, and his relentless, though never oppressive, reason shines throughout the narrative. Sparkling commentary from the professor we all wish we had.

Link

Evaluation of Thyroid Function in Health and Disease

Evaluation of Thyroid Function in Health and Disease

Canada's Health Care System - Poor Value for Tax Dollars

Are you more impressed by your physician's clothes and car than by his/her healing skills? Something to think about - your taxes are paying for this. From the Fraser Institute

A Country Doctor - Short Story by Kafka

Many patients find that their experiences with physicians are nightmarish or Kafkaesque.
In this story, a doctor undergoes torment.





Strip his clothes off, then he'll heal us,
If he doesn't, kill him dead!
Only a doctor, only a doctor.

Then my clothes were off and I looked at the people quietly, my fingers in my beard and my head cocked to one side. I was altogether composed and equal to the situation and remained so, although it was no help to me, since they now took me by the head and feet and carried me to the bed. They laid me down in it next to the wall, on the side of the wound. Then they all left the room; the door was shut; the singing stopped; clouds covered the moon; the bedding was warm around me; the horses' heads in the open windows wavered like shadows. "Do you know," said a voice in my ear, "I have very little confidence in you. Why, you were only blown in here, you didn't come on your own feet. Instead of helping me, you're cramping me on my deathbed. What I'd like best is to scratch your eyes out." "Right," I said, "it is a shame. And yet I am a doctor. What am I to do? Believe me, it is not too easy for me either." "Am I supposed to be content with this apology? Oh, I must be, I can't help it. I always have to put up with things. A fine wound is all I brought into the world; that was my sole endowment."

Dunning-Kruger: Does your doctor suffer from this condition?

"Kruger and Dunning set out to test... hypotheses on human subjects consisting of Cornell undergraduates who were registered in various psychology courses. In a series of studies, they examined self-assessment of logical reasoning skills, grammatical skills, and humor. After being shown their test scores, the subjects were again asked to estimate their own rank, whereupon the competent group accurately estimated their rank, while the incompetent group still overestimated their own rank. As Dunning and Kruger noted,

Across four studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although test scores put them in the 12th percentile, they estimated themselves to be in the 62nd.

Meanwhile, people with true knowledge tended to underestimate their competence. A follow-up study suggests that grossly incompetent students improve both their skill level and their ability to estimate their class rank only after extensive tutoring in the skills they had previously lacked.

They won Ig Nobel Prizes in Psychology in 2000 with their report Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments."

Link
Also see Downing Effect

A Doctor's Rx for CEO Decision Makers

A Doctor's Rx for CEO Decision Makers
by Jerome Groopman, MD

From the essay:

Doctors, like business leaders, make mistakes. Some errors are purely operational. A pint of blood is mistakenly transfused into Joan Smith rather than Jane Smith, and Joan goes into shock. A young doctor writes an incorrect dose of chemotherapy on an order sheet, and a woman with breast cancer dies from the toxic effects of overtreatment. A neurosurgeon operates on the wrong side of the brain because an X-ray was mislabeled as "right" rather than "left." These kinds of errors make headlines, trigger lawsuits, and terrify patients and their families; in the academic world, such mistakes prompted the Institute of Medicine to publish the landmark article "To Err Is Human" in 1999. Leaders in health care took the IOM recommendations to the business world for solutions. Lessons learned in high-risk industries such as air travel and nuclear energy were applied to hospitals. Anyone who has recently had a medical procedure or treatment has benefited from the checks and double checks that have become routine. To ensure that the right patient receives the intended care, health care professionals, like airline pilots, now follow strict protocols.

However, operational mistakes account for only a small percentage of medical errors. The overwhelming majority reflect poor thinking. In fact, 15% to 20% of all medical conditions are misdiagnosed. A middle-aged man's indigestion, treated with antacids, turns out to be a heart attack; a child's chronic headache is due not to "family stress" but to a brain tumor; a grandmother's fading memory is not early Alzheimer's disease but vitamin B12 deficiency. Such diagnostic errors reflect shortcomings in physicians' thinking rather than technical mistakes. In 2007, a national conversation began in the medical field about how best to address these errors of judgment. Business practices were not the solution this time; in fact, CEOs and other senior managers would do well to adopt the strategies that physicians are pursuing.

Senior doctors, like CEOs, traditionally have cast themselves as confident, autonomous decision makers; they take pride in their rapid analyses and sure-footed recommendations. Their judgments filter through the hierarchy in much the same way that decisions in a company are disseminated from the corner office. However, in sharp contrast with most businesses, hospitals convene regular meetings where all faculty and trainees—from the chief to the beginning medical student—revisit cases that had poor outcomes. At these forums, participants are beginning to dissect doctors' misguided thought processes, not just discuss bodily organs. This shift has required that even the most esteemed physicians acknowledge their fallibility in an effort to teach others and to improve themselves.

Medicine is drawing on the work of cognitive scientists—particularly Amos Tversky and Daniel Kahneman, who three decades ago explored the benefits and risks of heuristics, or shortcuts in thinking. Heuristics help to explain the 15% to 20% of cases where we get it wrong. My extensive research on misdiagnoses shows that even the most seasoned physicians are highly susceptible to anchoring error, or seizing on the first bit of clinical information that makes an impression. Similarly, all doctors recall dramatic past cases of theirs and mistakenly apply them to the case at hand, a so-called availability error. Another cognitive trap is attribution error, whereby a physician relies on a stereotype to which he attributes all of his patient's complaints. Menopause, old age, and stress are common categories that physicians glibly invoke as explanations for vague symptoms without digging more deeply for other causes. Contrary to the image of the doctor as authoritarian, dismissive of criticism, and resistant to self-analysis, physician leaders are starting to welcome the insights of cognitive science to help them avoid errors of judgment, in part because they have recently seen the benefits of rectifying operational errors. By making themselves vulnerable, physician leaders have now begun to encourage those lower down in the hierarchy to question decisions more freely and think more broadly.

"...hospitals convene regular meetings where all faculty and trainees—from the chief to the beginning medical student—revisit cases that had poor outcomes..."
We wish...

Link

MTBI Rehabilitation: The Patient's Perspective

A useful article for those who are putting their lives back together after medical error.

MTBI Rehabilitation: The Patient's Perspective
by
Constance Miller, MA
October 27, 1998

A Presentation made to the
Consensus Development Conference on
Rehabilitation of Persons with Traumatic Brain Injury
National Institutes of Health
Bethesda, MD

My interest in Mild Traumatic Brain Injury, MTBI, grew out of my own MTBI in a 1982 car accident. Prior to that life changing event I enjoyed a full, rich lifestyle that included women's rights and health care advocacy as well as a brief career as a university professor.

On that fateful day in 1982, I bumped my head in a car crash and my world turned upside down. When I came to I felt as though I had been disembodied, disconnected from myself and my past. The sensation was one of being outside of my body; viewing myself from afar. It was as though my head was in the clouds and my feet were planted in some strange yet familiar place.

There were blank spots in my memory and gaps in my consciousness. Words eluded me and my thoughts were frequently out of control. Sounds were muffled and sometimes irritating, and worst of all, nothing made sense. I thought to myself, this is spooky, suddenly for some unknown reason the world had become a strange and scary place.

Instinctually, I felt that something was very wrong although I was hard pressed to get others to confirm my impressions. I desperately needed answers. Much to my horror, the answers that were offered were the wrong answers. It did not take long for me to realize that my very life was at stake. In the blink of an eye I had been transformed from a vital, mid-career professional to one of the undead.

Essentially, life as I had known it no longer existed for me. I had become a mere shadow of my former self. Yet something in myself propelled me onward as I launched into the task of creating a new self and a new identity out of the wreckage of my life. Fortunately, my pre-injury accomplishments enabled me to unlock the mystery of MTBI, and create a new life for myself.

I was relieved to find that the answers to the mysteries of MTBI were known to medical science. I applied what I learned to restoring myself and to selecting and educating my doctors and lawyers. Then, I put everything into a self-help guide called From The Ashes. Then I founded the Head Injury Hotline to advise people on the syndrome, on good care providers, on legal options, and on social and career services available to them.

Continues at Link
Brain injury checklist symptoms may match those of thyroid problems.

TED Talks: Our buggy moral code

At TED, Dan Ariely talks about people who cheat - and why they do.

With all the information coming out about faked and ghostwritten medical papers, we know that Ariely's thoughts and observations have relevance in health care. Any patient who has been given short shrift by a doctor - getting less than their due in a fifteen minute appointment - knows this is true. This link discusses people in the medical profession who take advantage of patients who have brain injuries.

Is your doctor cheating you?


URL link - http://www.youtube.com/watch?v=nUdsTizSxSI

Tardive Dyskinesia and missed diagnosis

"Miracle Drugs" Cause the Worst Plague
of Brain Damage in Medical History

(This is taken from Chapter 4 of Peter Breggin's book, Toxic Psychiatry.)
. . . antipsychotic drugs have been termed "neuroleptics," in that these drugs' actions imitate a neurological disease. - American Psychiatric Press, Textbook of Psychiatry (1988)
It is also clear that the antipsychotic [neuroleptic] drugs must continue to be scrutinized for the possibility that their extensive consumption might cause general cerebral dysfunction. - Unpublished paper coauthored in 1978 by Igor Grant and others, including Lewis Judd; comment expurgated from published versions

Every violation of truth is not only a sort of suicide in the liar but is a stab at the health of human society. - Ralph Waldo Emerson

Roberta had been treated for several years with the "miracle drugs," neuroleptics such as Thorazine, Haldol, Mellaril, and Prolixin. My medical evaluation described her condition:
Roberta is a grossly disfigured and severely disabled human being who can no longer control her body. She suffers from extreme writhing movements and spasms involving the face, head, neck, shoulders, limbs, extremities, torso, and back - nearly the entire body. She had difficulty standing, sitting, or lying down, and the difficulties worsen as she attempts to carry out voluntary actions. At one point she could not prevent her head from banging against nearby furniture. She could hold a cup to her lips only with great difficulty. Even her respiratory movements are seriously afflicted so that her speech comes out in grunts and gasps amid spasms of her respiratory muscles.
Roberta's current psychotic disorder is most probably also a product of neuroleptic-induced brain disease. Her inappropriate affect - giggling and superficial smiling while in great distress - is typical of brain damage. Roberta may improve somewhat after several months off the neuroleptic drugs, but she will never again have anything remotely resembling a normal life.

Tardive Dyskinesia and Tardive Dementia
Roberta had an unusually severe case of tardive dyskinesia (TD), a disease frequently caused by the neuroleptics. The term "tardive" means late developing or delayed; "dyskinesia" means abnormal movement. Tardive dyskinesia is a movement disorder that can afflict any of the voluntary muscles, from the eyelids, tongue, larynx, and diaphragm to the neck, arms, legs, and torso.(1) On rare occasions it can occur after a few weeks or months, but usually it strikes the individual after six months to two years of treatment.

Any of the neuroleptics can cause tardive dyskinesia. The total dosage probably affects the likelihood of this happening, but the dose relationship is not easily demonstrated, and any amount must be considered dangerous. While some symptoms improve or even disappear after removal from the offending medications, most cases are permanent. There is no known treatment for tardive dyskinesia.

Often the start of disease goes unnoticed, because the drugs that cause it also tend to suppress the overt symptoms. Thus the disease percolates out of sight, finally breaking through with uncontrollable twitches, spasms, or writhing movements. Whenever possible, patients should try to stop the drugs periodically to check for abnormal movements.

Roberta also had tardive dementia, a global deterioration of her mind and mental faculties caused by the drugs. While tardive dyskinesia is a firmly established disease, tardive dementia remains more controversial within the profession, although evidence for its existence seems incontrovertible.

Had She Seen a Different Doctor ...

Roberta was a college student getting good grades, mostly A's, when she first became depressed and sought psychiatric help at the recommendation of her university health service. She was eighteen at the time, bright and well-motivated, and a very good candidate for psychotherapy. She was going through a sophomore-year identity crisis about dating men, succeeding in school, and planning a future. She could have thrived with a sensitive therapist who had an awareness of women's issues.

Instead of moral support and insight, her doctor gave her Haldol. Over the next four years, six different physicians watched her deteriorate neurologically without warning her or her family about tardive dyskinesia and without making the diagnosis, even when she was overtly twitching in her arms and legs. Instead they switched her from one neuroleptic to another, including Navane, Stelazine, and Thorazine. Eventually a rehabilitation psychologist became concerned enough to send her to a general physician, who made the diagnosis. By then she was permanently physically disabled, with a loss of 30 percent of her IQ.(2)

More "Mild" Cases of Tardive Dyskinesia

Most cases of tardive dyskinesia are labeled "minimal" or "mild," compared to "moderate" or "severe." But imagine how you would feel if your mild case of tardive dyskinesia made you stick out your tongue periodically in front of other people, or if you had to blink your eyes spasmodically or crane your neck oddly, or if your voice screeched a little out of control, while others were watching or listening.

Link

Any of these psychotropic medications can cause TD - Tardive Dyskinesia.


When thyroid and other physical diagnoses are missed by physicians and psychotropics are prescribed, the result may be a loss of quality of life or permanent disability.

How Big Pharma controls doctors and medical education

Some links...

NPR - Medical schools and drug firm dollars

Pharma lobbying contributions

How the drug industry gets its way

WSJ: How pharma relies on doctors to sell its products

J. Moncrieff - An unholy alliance - psychiatry and the influence of the pharmaceutical industry

How the drug companies keep tabs on doctors

How the drug industry uses nonprofits to push its agenda

Blind Faith: What happens when drugs, science and money mix?

Big Pharma reaping profits from disease mongering


"One of the first duties of the physician is to educate the masses not to take medicine."
~ Sir William Osler

The Blindmen and the Elephant

by John Godfrey Saxe

It was six men of Hindustan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind)
That each by observation
Might satisfy the mind.

The first approached the Elephant
And happening to fall
Against his broad and sturdy side
At once began to bawl:
"Bless me, it seems the Elephant
Is very like a wall".

The second, feeling of his tusk,
Cried, "Ho! What have we here
So very round and smooth and sharp?
To me 'tis mighty clear
This wonder of an Elephant
Is very like a spear".

The third approached the animal,
And happening to take
The squirming trunk within his hands,
Then boldly up and spake:
"I see," quoth he, "the Elephant
Is very like a snake."

The Fourth reached out an eager hand,
And felt about the knee.
"What most this wondrous beast is like
Is mighty plain," quoth he;
"'Tis clear enough the Elephant
Is very like a tree!"

The Fifth, who chanced to touch the ear,
Said: "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"

The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
"I see," quoth he, "the Elephant
Is very like a rope!"

And so these men of Hindustan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right
And all were in the wrong.

So oft in theologic wars,
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean,
And prate about an Elephant
Not one of them has seen!

Has your doctor or medical team seen and read your ENTIRE file?

PR: Let's Speak for Ourselves

"The role of PR is important because the question of sincerity helps you decide whether to trust their bacon in the future.
If standard PR tactics are being unfurled, it's harder to know....
Firms may put words in client's mouths, vet their ideas and advise on whether to speak at all. A huge number of Canadian journalism grads end up in PR. Some go directly; others have distinguished careers first, then switch. And a depressing quantity of news stories, especially in areas such as medicine, now come from well-produced PR packages sent on behalf of pharmaceutical firms and the like. Caveat viewor."

Link

Patient advocacy best-practice resources are in our Links column.

NYT: When patient handoffs go terribly wrong

"Handoffs are supposed to mitigate any issues that arise when doctors pass the responsibility for patient care to a colleague. “But that requires investing time and effort,” Dr. Arora said, “and using handoffs as an opportunity to come together to see how patient care can be made safer.”

Most of the time, however, handoffs are fraught with misunderstanding and miscommunication. Physicians who are signing out may inadvertently omit information, such as the rationale for a certain antibiotic or a key piece of the patient’s surgical history. And doctors who are receiving the information may not assume the same level of responsibility for the care of that patient. “Handoffs are a two-way process,” Dr. Arora observed. “It’s a complex interplay.” Missed opportunities to impart important patient information result in more uncertainty for the incoming doctor. That uncertainty leads to indecision which can ultimately result in significant delays during critical medical decisions."

Proper assessment and diagnosis should not be rushed through like a Triage situation. When your "specialist" sees you without having read your record and for a mere 15 minute consultation - as per "hospital policy" - your life can be ruined.

Article here

Tyee: To Save Big Health Dollars, Put Doctors on Salary

A Canadian nurse says that to reduce medical costs and waste, we need to put doctors on a salary. Link

"As a retired nurse who has seen first hand the health system's inner workings, I propose a different reading of rising costs, and a different way to cut them:

Let's take the business out of medicine and put the doctors on salary.

I offered this same advice last year when the provincial government conducted a "Conversation on Health" survey, during which many people voiced their opinions and solutions. Here is my logic.

Pulling in patients

The Ministry of Health itself points the finger at the rising costs of rates paid to physicians and the increased usage of lab and x-rays services. Such costs rose by a whopping seven per cent in 2007, and have continued to escalate at an alarming rate.

Having worked in a medical clinic, I saw the physician spend an inordinate amount of time and energy figuring out how to get paid more from MSP. It seemed to me that if the business were removed from his practice, his time would have been spent practicing medicine, and everyone would benefit from it.

Needless to say, my voice is barely a whisper in the grand scheme of things. We need someone who has the courage and vision to face down the Canadian and American Medical Associations and save our health care system from extinction. Where is Tommy Douglas when we need him?"

Bill Moyers on the Health Care Industry

Money-Driven Medicine.
Not just in the USA, either. Pity...
Link and Transcript http://www.pbs.org/moyers/journal/08282009/transcript1.html

Times of London: What's the Canadian word for 'Lousy care'?

Canadian health care costs a fortune - $40B per year in Ontario alone. People in Canada should be the healthiest in the world. What's gone wrong? Link