Category: Essays

Cynicism rolls

“Cynicism rolls down like the water and mistrust like a mighty stream”.

Antisthenes (c. 445 – 365 B.C.), Diogenes of Sinopes (c. 412 – 323 B.C.) and Crates of Thebes (c. 365 – 285 B.C.) are considered the founders of the school of Cynicism.
For a Cynic, the purpose of life was to live virtuously and in agreement with nature. Living such a life meant having the bare necessities for existence and rejecting all the need for wealth, power and fame. One’s life was free from all possessions and property.

The word “Cynic” comes form the greek word κυνικός, kynikos, “dog-like” and that from κύων, kyôn, “dog. They Cynics may have gotten the name form the fact that Antisthenes taught at the Cynosarges (Place of the white dog) school in Athens. Later the Cynics embraced the term. They saw themselves as dogs. Like dogs they were indifferent to how they lived, shameless in their modesty, good guards of their philosophy and discriminating between friend and foe. To quote Diogenes, “Like a dog, I fawn on those who give me anything, I yelp at those who refuse, and I set my teeth in rascals.”

No one epitomized the life of a Cynic more than Diogenes. He rejected the chains of civilization by eating in the street, masturbating in the marketplace, urinating on those who insulted him, defecating in the theatre, pointing at people with his middle finger and living outside in a clay wine jar.
He was also known to walk around in broad daylight with a lamp. When asked why, he responded, “I am just looking for an honest man”.

How true!

In this election season, isn’t that what we are all looking for? Can we find an honest man or woman? Someone’s whose honesty is visible in broad daylight, enhanced with a lamp? Someone indifferent to the trappings of wealth and power, shameless in how they fight for the common man, good guards of the trust bestowed on them and discriminating between right and wrong? Is there anyone out there like that?

Somewhere in the 19th century, Cynics evolved. They dropped the ascetic lifestyle and replaced it with distrust. A disbelief in the goodness and motives of men.
So as we as a people wander the streets in broad daylight like Diogenes looking for honest men and women to lead us, the dearth of such individuals gives us pause. Those we find, those who have fought their way to the top leave us with a feeling of disgust and disbelief in their actions and words.

In the process we think these leaders are motivated purely by self-interest, greed and power. We feel helpless and like dogs “…fawn on those who give us anything, yelp at those who refuse, and set our teeth in rascals.”
How cynical!

Journal Club

Welcome to Journal Club! For discussion today is the following:

Article: Increasing incidence of metastatic prostate cancer in the United States (2004–2013)
Authors: A B Weiner, R S Matulewicz, S E Eggener and E M Schaeffer
Journal: Prostate Cancer and Prostatic Diseases. July 19, 2016

Background
Prostate cancer cells secrete an enzyme called Prostate Specific Antigen (PSA) into the bloodstream. Measuring the PSA level has been a way of screening for prostate cancer. In 2008 and again in 2012, the US Preventive Services Task Force (USPSTF) came out with recommendations to curtail the use of PSA for screening. The argument was that it led to the diagnosis of a lot of low risk prostate cancers that left alone would not grow to endanger life. Also, the test led to procedures that patients did not really need but which could lead to complications eg. impotence. Since 2012, there has been decrease in the use of PSA for screening,
The question among urologists has always been whether this recommendation would lead to ta spike in prostate cancer cases.
A group from Northwestern in Chicago, led by a Dr Edward Schaeffer decided to find out.

Study type
The study was retrospective.
Using the National Cancer Data Base (NCDB), they found all men who had been diagnosed with prostate cancer from 2004 to 2013. From 1089 institutions that reported each year in that time period, they got 767 550 patients.

PSA-Study

The patients were split into risk groups (depending on the extent of the cancer when diagnosed). The groups were low, intermediate, high and metastatic. The incidence of prostate cancer for each risk group was then compared yearly to the incidence in 2004.
Of the 767 550 men, 32% had low, 45% intermediate , 20% high risk and 3% had metastatic disease. They teased out information from the data with appropriate statistical tools.

Results
Of all the groups, the one that saw the most significant increase, relative to 2004 was the metastatic one. In 2004, there were 1685 cases. In 2013, 2890. – a 72% increase. The largest increase was seen in men aged 55 to 69 years. In this group, the increase was actually 92%.
Comparably, the incidence of low-risk prostate cancer actually fell.

Discussion
One can probably argue that the decrease in using PSA for screening may be causing the inability to catch the very aggressive types of prostate cancer. The problem though is that, the increase was seen even before the 2008 recommendation of the USPSTF came out.
Another factor could be an increase in the aggressiveness of prostate cancer. Also the use of MRI imaging has improved diagnosis and that can increase the numbers. Lastly, the population may just be getting older and sicker.
Perhaps the biggest flaw of the study was that the authors didn’t calculate a national annual incidence rate – the number of metastatic cases as a percentage of the US population. They looked at it as a percentage of cases from about a 1000 hospitals. They argue in the paper that with over 700 000 patients,they thought their results reflected national patterns.

Conclusion
Even though this study has it’s flaws, the fact remains that yearly PSAs can help screen for prostate cancer. In patients at high risk – those with a strong family history and blacks – it may be highly recommended. Done yearly, it provides a trend that can be very informative.
The recommendation is to start screening at age 45 in those at high risk and 50 for those at low risk.
For my lay male friends reading this who are black and 45 or older or not black but with a family history, if you haven’t started screening already, please see your primary care physician as soon as possible. By the way, just in case you ask, NO, you cannot do the exam yourself. It is very much unlike a breast self exam that women do!

All they see

As we walked….

Colors-01

He took me to the town square. It was early so the square was empty. We sat on a bench perched on the side of a knoll that overlooked the square. It wasn’t long before two men walked into the square. They both wore brightly colored clothing. Simultaneously, they both started taking to each other. As I watched, I made an observation – they were both talking but neither was listening to the other. I turned towards him, wishing for an explanation but he seemed lost in his thoughts so I stayed silent.
Gradually more men in brightly colored clothing streamed into the square and like the first two men, they also started talking. Each man seemed to direct his speech to all but no one seemed to listen to another. By now, the voices had reached a din and I could make words out. Surprisingly, all I heard were words like “black”, “white”, “red”, “brown” and “yellow”. All I heard were descriptions of color! I strained to listen closer and over and over, all I heard were the names of colors.
Baffled, I turned to him again. His eyes were on me with a wistful smile on his face. Before I could utter a word, he said:
“All they do is speak. No one listens to the other so all they see is each others color.”

We need an Odysseus

The political situation in the US sometimes reminds me of the Trojan war from Greek mythology.
Like the Achaeans (the Greeks), some feel America has lost something beautiful and precious like Menelaus of Sparta lost Helen. Some feel it has been stolen by globalist like that Paris (a Trojan) stole Helen. So they are on a warpath to win this precious thing back.
However, when one looks at the Iliad by Homer or even the Aeneid by Virgil, it is apparent who really won the war for the Greeks. It was not the overbearing Agamemnon, the brash and fearless Achilles or even the courageous Ajax. No. At the end, it really wasn’t about the heroics on the battlefield, because try as they may, the Achaeans couldn’t breach the wall that surrounded and protected Troy.

Odysseus
The Head of Odysseus

It was the smarts, patience and cunning of Odysseus that helped them to breach the walls of Troy and deliver victory. It was his idea for the Trojan horse that helped them recapture Helen.
Brute strength and violence can get you so far. At the end of the day, patience and smarts rule.
I guess Odysseus describes himself best in these words from Book 8 of Homer’s Odyssey:
The gods don’t hand out all their gifts at once,
not build and brains and flowing speech to all.
One man may fail to impress us with his looks
but a god can crown his words with beauty, charm,
and men look on with delight when he speaks out.
Never faltering, filled with winning self-control,
he shines forth at assembly grounds and people gaze
at him like a god when he walks through the streets.
Another man may look like a deathless one on high
but there’s not a bit of grace to crown his words.
O but Olympus would bless this nation with an Odysseus!

The Amazing Professor Leutert

A hush had fallen on the group of young men and women assembled in the lecture hall. One could hear a pin drop.

Professor_Gerald_Leutert_ADA_Dimensionsmalerei®_Benita_Martin

The portly and balding gentleman who stood in front of the chalkboard looked over the group like he dared then to take their eyes off him. Then he spun around and grabbed 2 pieces of white chalk from the tray that was attached to the side of the chalk board. Now facing the chalkboard, he set both hands, each with a piece of white chalk in it, on the board. If one looked closely, only the pieces of chalk touched the board. Keeping the chalk pieces on the board, he swung his hands out in an arc. Both hands worked simultaneously as he drew. Like a conductor, his arms moved around. He reminded one of Kurt Masur, conducting a Bach performance at the Gewandhaus a few miles away.
As he worked, exhibiting his ambidexterity, a collective gasp went up from the collection of young students. They had heard about it but seeing it made it all the more mystical.
Soon he was done and like a maestro, he lay the pieces of chalk down and spun around. The students were on their feet, in thunderous ovation. When the ovation finally died down, he said:
“That is the cross-section of the spinal cord.”

Gerald Leutert was the Professor of Gross Anatomy when I was at the University of Leipzig. He was feared, revered and respected. He was a legend in his day. As first-year medical students, we had heard stories from the older students. The most amazing story was how he drew a cross-section of the spinal cord.
Now a cross-section of the spinal cord looks like two half-ellipses put together, one on the left and the other on the right. Well, Professor Leutert, being ambidextrous, drew both half-ellipses simultaneously and also added in the nuclei, laminae, tracts etc simultaneously. If you cannot imagine the skill it takes to do that, look at the image of the cross-section of the spinal cord below.

SpinalCord copy

Over the years, I have wondered what his intentions were when he made that drawing with so much pomp. Initially I thought he was just showing off. However as first year flowed into second year of medical school and the anatomy lab become a home away from home, I couldn’t overcome the feeling that there was another reason.
The Anatomy Lab. Home of broken dreams and high hopes. Of the end of life fueling knowledge. Professor Leutert ruled it like a king with us as his lowly subjects.
On those days that he came back to inspect our dissections and test our knowledge, it felt like judgement day. Come to think of it, was judgement day! Portly and short, it seemed he could rest his hands on his ample belly. Flanked by two assistants, and holding forceps in his hands like a scepter, he moved from table to table, passing judgement swiftly and mercilessly, in an atmosphere enriched with formalin.
“What is that?”, he’ll ask, picking up the delicate tissue.
“The radial nerve.”
With a nod he’ll be off to the next table.
“What are the structures that border this organ?”, pointing at the liver.
A hint of hesitation and one wilted under a barrage of even more questions, like said organ when cirrhotic.

I survived Anatomy and went on to graduate. All these years that day in the lecture hall has stayed with me. The day that I watched Professor Leutert display his ambidexterity. Recently, the essence of it kind of hit me.
The dear professor wasn’t trying to show off. Not at all. In showing us his dexterity so early, he tried to impress upon us what it took to do a good dissection. He made us realize the importance of learning anatomy and made us gain a deep respect for those whose bodies we had the honor to learn from. He also made us realize very early that medicine is practiced with both the mind as well as with the hands. He was telling us that no matter what specialty we ended up in, we needed to exhibit dexterity and practice medicine with all our senses.
With that he gained our respect. We looked up to him and revered him. Moreover we feared him. Not because he could hurt us. (Well, if one flunked Anatomy, that was it). That wasn’t the reason we feared him though. We dreaded disappointing him. He had set the bar quite high and we all strived to reach it. We feared not reaching it.

Professor Gerald Leutert died in 1999 at the age of 69. Apart from a short stint as Rector of the University of Leipzig, he spent the majority of his over 40-year career teaching and doing research in the field of Anatomy.
In his own way, he managed to grab the attention of the young medical students he was entrusted with and hold it. In the process he formed them, trained them and influenced them. I would know – he got and held the attention of my peers and I and in the process formed, trained and influenced us.

Hello! You Need to Listen!

Sometimes a story makes a point better…

The following is a true story. The names of all the players have been changed.

When Anita turned 6 in November, it seemed to open the floodgates to ear infections. The first time, she complained her right ear hurt, pulled on her ear lobe, cried a lot and felt really warm. Her mum, Lisa Downs, took her to see the pediatrician, Dr Jon Marks. He made the diagnosis after examining her ear and put her on oral penicillin. She was fine in less than a week.

Over the next months, Anita would get several ear infections. Each time, Lisa took her to see Dr Marks, who would examine her and prescribe penicillin. A few times, she noticed that Dr Marks didn’t really examine Anita but just assumed she had an ear infection and wrote for the antibiotic. She had drawn his attention to it and he had reluctantly examined Anita. The last few times they had seen him, he seemed impatient and dismissive. It bothered Lisa.

One Sunday, a few weeks before Anita’s 7th birthday, she again complained of earache. The left ear hurt. Lisa took her temperature and noticed she was running a fever. She gave her 200 mg of Ibuprofen and planned to take her to see Dr Marks the next morning.
They did get to see Dr Marks around noon the next day. He examined her, diagnosed a left middle ear infection and put her on oral penicillin, like always.
Thursday came around and Anita still felt ill, was running a fever and now complained of both ears hurting. She also had diarrhea. Lisa called Dr Marks office and asked to bring Anita back in. After much hemming and hawing on the part of Dr Mark’s nurse, she was given an appointment for the next day.
Lisa took Anita in on Friday. When Dr Marks walked onto the consulting room, he looked vexed. He demanded to know what was wrong. Lisa explained that it looked like the antibiotic wasn’t working because Anita had diarrhea and wasn’t keeping anything in. She also feared that the right ear could be infected too. She asked if Dr Marks would re-examine her and possibly put her on something other than the penicillin.
Dr Marks flat out refused. In a condescending voice, he asked her to take Anita home and finish the course of penicillin and bring her back in a week to see him.
That is when Lisa lost it….!

Dr Pia Henry was one of Dr Marks’ partners. She was walking by when she heard the shouting from one of the Dr Marks’ consulting rooms. She stopped, wondering what to do when the door flung open. Dr Marks stormed out, his face flushed.
“Jon, hey! What’s going on?”, she called after Dr Marks.
He spun around and poked a folder he was carrying in her chest.
“You want it, it’s all yours! They want another opinion!”, he spat out as he let go of the folder and stormed away.

Dr Henry had seen Dr Marks melt down a few times so she wasn’t totally surprised. She just wished he would keep his composure more often. She composed herself and walked into the consulting room where Lisa and Anita waited. Anita was sobbing.
Lisa looked suspiciously at her as she walked in.
“Hi! I am Dr Henry, one of Dr Marks’ partners. He told me you wanted another opinion”, Dr Henry said, introducing herself.
“Yes we do”, Lisa said and filled Dr Henry in.
While Lisa was speaking, Dr Henry took a seat beside Anita on the exam table and put her arm around her. She stopped sobbing.
When Lisa was done. Dr Henry examined Lisa, thoroughly.
“Well. Mrs Downs, you are right. Anita has infections of both middle ears. I think the diarrhea is due to the penicillin. Due to the severity of the infection, I want her to get IV antibiotics for the next 5 to 7 days. You need to bring her in each day for a dose”, Dr Henry said.
Lisa put her head in a hands and started sobbing. Dr Henry walked over to her and lay her hand on her left shoulder.
“Mrs Downs, can I call you Lisa?”, Dr Henry asked. Lisa nodded.
“Ok, you can call me Pia. It will be alright”, Dr Henry said, handing Lisa a box of Kleenex.
“Pia, you doctors need to listen to your patients and their parents. They know best what they are going through”, Lisa said.
“Yes, we do!”, Dr Henry agreed.

They know best what they are going through….
Like Lisa Downs tried to tell Dr Marks, black mothers have been telling society for ages that there is a problem with the way their black sons and daughters are treated by cops and the judicial system. Society however doesn’t believe them. Society thinks they are just being difficult and that if only they took the penicillin, everything would be fine. Unfortunately, the penicillin isn’t helping and all society can say is, “Really? It always works for us?” Even when black mothers say, “Well, it gives us diarrhea”, society says, “Just be respectful and keep taking it. It will be alright.”
Maybe it is time for society to sit up like Dr Henry and listen and listen well. Maybe it’s time for society to examine itself. Maybe it’s time for society to prescribe something else that works. Maybe it’s time!

Just Mercy

Just Mercy…

Just-Mercy

A few days ago, I read this quote by Rep Trey Gowdy, SC during the grilling of the FBI Director, James Comey, that made me laugh out loud. Don’t get me wrong, I think what Secretary Clinton did was grossly negligent but the hypocrisy of politicians gets to me. He said:

“My real fear is a double tracked justice system that is rightly or wrongly perceived in our country as this: if you are a private citizen in the Army and you email yourself classified information, you will be kicked out. But if you are Hillary Clinton and you seek a promotion to commander-in-chief, you will not be.”

Really? A double-track justice system? It already exists!
There is the system for the wealthy and a system for the poor. A system for whites and one for minorities. That latter system may ensnare more minorities usually but it is color-blind in it’s ferocity to deny justice to the poor! If you fall in trouble and have to depend on a public defender, forget about justice!
Don’t believe me? Get the book “Just Mercy” by Bryan Stevenson, an attorney some have described as the “American Mandela”. It will break your heart and change your life. It did mine.

The Session

Ok, let’s start the session.
Hey you there…yea you….Are you mad at what happened last night in Dallas?…All those cops getting killed by that black dude?….B. Thompson, P. Zamarippa, M. Krol, L. Ahrens, M. Smith ….Does it bother you? Are you beside yourself and aghast, thinking of the families and what they are going through?…You are?…Angry at how blue lives don’t seem to matter to some people..You are?….That’s great!
Now, what about Wednesday?….”Wednesday?’, you ask…yea Wednesday!…..were you aghast at the video of the cops shooting Alton Smith in Baton Rouge……or that Philando Castile was shot and left to bleed to death by another cop on Thursday in Minnesota?….Were you pissed? Appalled at how black lives don’t seem to matter to some cops?…You were not?…No…Why not?
Well,I guess that’s why you are here!…Please go and sit in the corner and dig deep into yourself!…Somewhere in there is a feeling called Empathy. When you find it, you’ll know…then come back to the circle.
Now you there!…yea you!…it’s your turn now!…you were pissed at the black guys getting shot by the cops?…Of course every human should be appalled!…but the cops dying leaves in cold?…HuH?…Go to the other corner….dig in too…find Empathy…please try…then come back to the circle….
I’ll turn on some soothing music now…..

The Small Matter of Implicit Bias

“No amount of money can reward the work and sacrifice of policemen, teachers and nurses. Their reward is in Heaven!”
– the late Michael Ghansah

I make the effort to see my patients before they are rolled back for surgery. I can easily say that 3 out of 4 times, when I walk up to the patients, the assembled family members assume I am an orderly who is taking the patient back to surgery. When I introduce myself as the anesthesiologist, the surprise or disappointment is always palpable.
Am I bothered by the reaction? Sure, who wouldn’t be in my situation. One just learns to live with it. The bigger question though is: what drives such an assumption?
Walk through most US hospitals. Most of the doctors are white, the janitors and orderlies are black. The doctors are male, the nurses are women. So implicitly, most people see a black guy and subconsciously think “Orderly”. I know several female colleagues who are addressed as “Nurse”!
It is not the fact that one feels demoted by being seen as an orderly or a nurse. No! It is the implicit bias inherent in the assumption that is bothersome.

Implicit bias!
“….implicit stereotypes and implicit attitudes that are shaped by both history and cultural influences. Implicit biases encompass the myriad fears, feelings, perceptions, and stereotypes that lie deep within the subconscious; they act on those memory records and exist without an individual’s permission or acknowledgement. In fact, implicit bias can be completely contradictory to an individual’s stated beliefs—a form of conscious-unconscious divergence.”

Compared to explicit bias, implicit bias is unconscious. So you may think all women who work in the hospital are nurses even though you do not realize it. An example of explicit bias is known and accepted prejudice or even hatred for a race or people – racism!.

With patients not really being in a position of power relative to me, their biases do not significantly impact my day. The situation is quite different when the roles are reversed. Where the one with the bias is in the position of power. Say the physician one sees in the ER or a sentencing judge or a cop with a gun.
In a 2012 study looking at how pediatricians treated their patients with pain, white patients were more likely to get pain medicine prescribed for pain than black ones.
Researchers found that when controlling for numerous factors like severity of the primary offense, number of prior offenses, use of force etc, individuals with the most prominent Afrocentric features received longer sentences than their less Afrocentrically featured counterparts. So if you had dark skin, a wide nose, and full lips, you were toast!
Racial bias in policing has been in the news lately. Events like the killing of Michael Brown in Ferguson, MO or Tamir Rice in Cleveland have thrust the issue into the news. The killing of Alton Sterling yesterday in Baton Rouge and Philando Castille in Minnesota today have escalated the tensions. Movements like Black Lives Matter, All Lives Matter and Blue Lives Matter have all arisen to defend different parts of the debate.

One thing is for sure though. Implicit bias plays a huge role in law enforcement and the broader judicial system in this country.
Cops intervene disproportionately with blacks and Hispanics. They are arrested or ticketed, searched, stopped or even surveilled more. Blacks are also apt to have force used against them more. One reason is that there could be more crime among minority groups. The other reason is police bias and prejudice. Implicit bias.

Armed

In 1999, a 23-year-old Guinean immigrant, Amado Diallo, was mistaken for a wanted serial rapist and shot by four New York City plainclothes cops. 41 shots were fired. 19 hit him. He died. The cops were indicted, tried and exonerated.
Shortly thereafter, researchers in Chicago and Denver started looking at the issue of implicit bias in the way white cops treated black suspects. They recruited subjects from the community as well as cops. They were shown scenarios where they had to decide to “Shoot” or “Don’t Shoot”. The scenarios contained armed and unarmed whites and blacks.
The subjects who were white ,were more apt to shoot an armed male more quickly if he was black than if he was white. However, they were quicker NOT to shoot an Unarmed White than a Black. Which means, they would shoot an Unarmed Black but not an armed White.
Researchers also found a more pronounced neurophysiological threat response when subjects were faced with a Black suspect and that this correlated with how fast they pressed “Shoot”.
A later study in Denver found that compared to people from the community, cops were less prone to have this bias – that of shooting an Unarmed Black over an Armed White. They attributed this to high quality use-of-force training that several police departments had instituted.
Interestingly, a recent study in Spokane showed that in some cases, cops may use less force against blacks – possibly putting the cop in danger – due to the media and legal backlash.

The good news is that in medicine as well as in Law Enforcement and the Judicial systems, the issue of implicit bias is now recognized and several psychologists are doing some great work in developing training programs to reduce this. The bad news is that progress is slow.
Can implicit bias be totally eradicated? I do not think so then after all we are human and having prejudices is as old as the human race itself. It surely does not excuse the killing of unarmed suspects but it helps to pinpoint where changes can be made.
Often the debate about Policing and Race is split along color lines with most minorities cognizant of a problem and most Whites thinking there is none. Well to my white friends who think there is no problem, I have news for you – THERE IS A PROBLEM!
One should appreciate the work cops do – laying their lives on the line daily to protect us. It is an unenviable job in a society awash in guns. However, the issue of disproportionate use of force against black suspects is an issue that won’t go away unless addressed. It creates mistrust, loss of life and makes cops afraid to do their job because of media and legal backlash.

I’ll end with another experience. We were flying back home and made a connection in Atlanta. As we were boarding, I couldn’t help but notice the passport of the gentleman in front of me. The inscription was in Arabic. My heart started pounding. On board the plane, I looked our for him and kept an eye on him all through the flight. When he headed for the bathroom, my fear went up a thousand notches. My relief when we landed was beyond description. When I decided to write this today, the memory of my reaction came back to me. It was the memory of my own implicit bias.

Padre de Familia

6th episode of the 6th season of “Family Guy”
November 18, 2007

FamilyGuy01

Peter Griffin has lived in the US his whole life. Lately, he is pissed off with all those immigrants. He convinces his boss to lay them all off! In the process, he finds out that he was actually born in Mexico and has no US birth certificate! He gets laid off too, becomes an illegal immigrant and finally learns to have empathy for those foreigners. Finally, he gets the chance to become a citizen and at the interview, has this dialogue with an immigration officer:
Immigration Officer:
Complete this sentence: The land of the free and the home of the blank.
Peter:
Home of the Whopper?

Happy 4th y ‘all!