Wednesday, August 28, 2013

Man's inhumanity to everything

kw: book reviews, nonfiction, animal rights, polemics

The book jacket blurbs claim that Rory Freedman has become the "rock star advocate" for animal rights. It helps to have a bestseller on the shelves (Skinny Bitch, 2005, with Kim Barnouin), but there is little further evidence. However, she is a compelling writer. Her new book, solo authored, is Beg: A Radical New Way of Regarding Animals.

The book begins on an autobiographical note, but personal stories thin out rapidly. This is a manifesto for the vegan lifestyle, and an excessively preachy listing of awful things being done to animals, whether it is pet breeding and animal showing, food animals—from eggs and milk to steaks and chops—or hunters' targets, she lists the worst of the worst as exposed primarily by PETA (People for the Ethical Treatment of Animals).

It is a fact that many people mistreat animals. More to the point, people who feel otherwise powerless mistreat each other, animals, their dwellings and possessions, and even themselves. Also, a certain number of men (and a few women), at every level of wealth and power, are psychopaths and abuse everything as long as they can get away with it; the stupider ones can't even think ahead far enough to get away with it and so become career criminals.

But most folks aren't abusers. Case in point: I've worked at a "meat packing plant", that is, a beef slaughterhouse. I wasn't working on the killing floor, but in a cleanup area. But once in a while, if I got to work early, I'd wander onto the killing floor and observe. It was an efficient operation, and while speed was of the essence, once I got over the "gross factor", I observed that the man using the captive bolt "stunner" (it splits the brain) was careful, and took an extra second to be sure the beeve was indeed "stunned". He had the power to slow the line long enough to repeat the stun if needed and I saw him do so once. He said when I asked him, that he'd once had a poorly stunned animal go onto the line, and, "The sounds it made gave me the willies! Never again!". Was this plant better than most, or average, or what? I don't know. Yes, there are abuses, but most people do have a conscience.

Ms Freedman covers all the bases, so far as I can tell. I suggest that everyone read this book, and then investigate for yourself, what level of animal abuse is realistically out there. I take it as a given that the PETA data are exaggerated. But, as Churchill said, "Even a fool is right once in a while", and the PETA folks are no fools. Just driven, and afflicted with tunnel vision.

The book's last couple of chapters make a case for being at least vegetarian, and for being vegan if at all possible. She claims, as many have, that the vegan lifestyle is healthier and that vegans live longer. This is an issue I have followed for decades. To date, the premise cannot be either proven or disproven. However, I do have a clue. The largest group of vegetarians on Earth is found in India, where the majority of the people eat no meat (I don't know about eggs or fish, but adults in India use no milk either, because nearly all are lactose intolerant). Life expectancy in India is 67 years, compared to 77-79 for Western cultures. Of course, India is rapidly rising from Third World status of just a couple decades ago, so we need to stay toned on this one. The public health infrastructure there is comparable to America 60-80 years ago, but improving rapidly. However, I know a great many people of Indian heritage who have lived in the U.S. for decades, and maintained their traditional, vegetarian cuisine. They don't seem to live exceptionally long. And, it is quite possible for a vegetarian to become obese. Fat people die sooner than more ordinary folk. And let's remember the other end of the spectrum. The country with the highest life expectancy is Japan, over 80 years, and there are nearly no vegetarian Japanese. They just emphasize meat a lot less than Westerners.

I say, balance in everything. I know where Ms Freedman is coming from. In the face of a lot of unreasonable people, it doesn't pay for her to take a reasonable tone. So, even though the dog on the cover seems to go with the title Beg, it is Rory Freedman who is begging, for a hearing among those who do not wish to hear.

Monday, August 26, 2013

Decoding botany

kw: book reviews, nonfiction, botany, nomenclature, dictionaries

Do you think you want to be a botanist? The prime asset to beginning a botanical career is a classical education. That's right, the Trivium (Grammar, Logic and Rhetoric) and the Quadrivium (Arithmetic, Geometry, Music and Astronomy). And Grammar, including both Latin and Greek vocabulary, was traditionally taught in Latin; "grammar" is the study of the Latin rules of sentence construction. In fact, prior to the mid-19th Century, all seven subjects were taught in Latin. This would not be a bad idea today, particularly for anyone entering a biological science.

For those of us who prefer a more glancing acquaintance with formal botany, at least a course or two in Latin and Greek vocabulary would be a big help. Then, if you want just a smattering of "latinate" word knowledge, you would do well to read through Latin for Gardeners: Over 3,000 Plant Names Explained and Explored by Lorraine Harrison. The core of the book is a dictionary listing of the 3,000 or so terms with very brief meanings. For example, a few items from the "F" pages:

fenestralis fen-ESS-tra-lis
fenestralis, fenestrale
With openings like a window, as in Vriesia fenestralis

fibrillosus fy-BRIL-oh-sus
fibrillosa, fibrillosum
fibrosus fy-BROH-sus
fibrosa, fibrosum
Fibrous, as in Dicksonia fibrosa

Certain prefixes are also shown, including

Used in compound words to denote many

Used in compound words to denote many

I picked a pair that includes one from Latin and one from Greek; both are used. It would have helped just a bit more if the author noted that multi- is from Latin and poly- is from Greek. A simple L and G in the listing would do. 3,000 of those would not take up much extra space. A regular rule, not always followed, is to use a Latin prefix with a Latin determiner and so with Greek. An example that keeps the rule is polycarpus; -carpus is from Greek for a fruit or seed pod, but originally meant "wrist". Your carpal bones reside in your wrists and the back of your hands. A plant named polycarpus has many fruits.

If this were only a dictionary it would be pretty dry fare. But the author has included biographical notes on 15 "plant hunters" (AKA explorers) and 20 plant genera such as Helianthus and Quercus (sunflower and oak). There is also a small "Latin in Action" blurb every 3-4 pages, and short essays on "plant themes" that include groups of words related to, for example, color or fragrance. I would like to have seen a section just on the prefixes and suffixes, perhaps even a matrix or table showing the many suffixes that go with each prefix, by means of a check mark or block. A big lack is explanation of Genera. Only 20 are described, and Delphinium, for example, is not one of them. How to know the word is derived from "Dolphin"?

All that aside, it is a good book to keep handy for looking up the meaning of a species name. Quercus rubra? Aha! Red oak! If you want to dig deeper into Biological Latin (quite distinct from Classical Latin or the Church Latin all Roman Catholics had to learn until about 1975), a good place to start is this BayGardens article, and the links it contains.

Thursday, August 22, 2013

Genetic byways

kw: book reviews, nonfiction, genetics, essays

It is a rare book in which I learn something from every chapter, but such is The Violinist's Thumb: And Other Lost Tales of Love, War, and Genius as Written by Our Genetic Code, by Sam Kean. At first, I expected a kind of send-up of Stephen Jay Gould's The Panda's Thumb, but not so. Rather, the book is a delightful exploration of some lesser-known stories told with and by DNA, from the pen of a sprightly writer.

The title episode is not a chapter subject, but part of one: Chapter 12 explores the genetics of art, artistic expression and ability, with Niccolò Paganini as the centerpiece. Paganini's short career as a violinist was so remarkable the Catholic church refused to bury him on sanctified ground, suspecting he had a pact with the devil. His promiscuous private life and generally atheistic tendencies didn't help. He was actually inflicted with a genetic defect that left his connective tissues exceptionally loose, thus his fingers, and his left thumb in particular, could perform reaches on the violin's neck that were considered unhuman. While he became the greatest violin virtuoso ever known, he suffered continual illnesses, fragile skin, a shortened career, and an early death (well, not too early: age 58), what some called "payback" for his incredible talent.

Other talents with a genetic link include "perfect pitch", the ability to recognize a note and whether it is exactly in tune. Different sources state that this ability is found in between one and ten persons per 10,000, but is much more prevalent among those who have a close relative or two with perfect pitch. Good relative pitch is more common (perhaps 10% of us): This is the ability to properly tune an instrument such as a guitar or even a piano using a single perfect tone for reference. Until I bought an electronic tuner a few years ago, I tuned instruments using a tuning fork, the 440Hz "A". People with lesser skills can usually tune a guitar if they have a well-tuned one or a piano to compare with ("good relative pitch"). Electronic tuners make it much easier for folks with poorer pitch discrimination to tune a guitar or banjo or mandolin. My grandfather could tune a piano, including the proper "stretch" above and below the middle two octaves, by first tuning the A above Middle C to a 440Hz fork, and going from there.

But not everything is genetically determined. Kean explores epigenetics—which lends partial support to that anathema of natural selection, "inheritance of acquired traits"—and shows how certain life experiences can affect children and even grandchildren and further. Shades of Biblical curses "to the third and fourth generation".

He also reveals the real obstacle to human cloning. Primate ova have a more complex and delicate system of spindle structures that participate in cell division. Removing and replacing the nucleus from a sheep ovum to produce Dolly, and later successes with cats and several other species, depended on extracting the nucleus while leaving the spindle system intact. This is just barely possible (one success in 400 ova, in the case of Dolly) with more robust mammalian ova, but no technique has yet been even imagined that will work for human or ape, or probably even monkey, ova.

The biggest learning for me is that DNA doesn't unwind cleanly when being duplicated or expressed to mRNA. A cluster of enzymes snips one strand of the DNA, lets a bit of unwinding proceed, then re-welds it. This has to happen properly many times for the expression of a single gene, and an untold number of times during mitosis and meiosis, when DNA is totally unspooled and duplicated. I didn't learn whether this snip-weld sequence occurs only on the "copy" strand (the one not being expressed), but I suspect that is the case. I also wonder if it is the same in bacteria…

The big mystery resulting from the Human Genome Project, now a decade in the past, is why humans have so few genes, something like 24,000. It was confidently predicted in the 1990s that we must have 100,000 or more. Known protein-coding segments of our DNA make up only 2% of the 3 billion bases, about 60 million. At least 8% of our total DNA came from viruses, and possibly much, much more. But those and the rest of that 98%, far from being the "junk DNA" that some benighted scientists once sneered at, seem to include a very large "regulatome" (my coining), that not only determines when a "gene" is expressed, but which of several proteins to make from it via RNA editing. The central dogma of genetics—DNA to RNA to unique protein—is now long dead. A protein is now realized to resemble a sentence made from several words, rather than a single long word. Editing gathers a number of components, from one or more "genes", to produce the sentence. This is what turns 24,000 protein coding segments (we need a new term; "gene" is enormously inadequate!) into a few million proteins and peptides.

Genes are not destiny. This is similar to physiology; if you get an "exploratory" CT scan, the radiologist will probably point out between 5 and 15 anomalies. None of them is likely to cause trouble. Some imaging centers, with idle scanner time and a large mortgage to pay on it, advertize things like whole body scans. You know the proverb: look for trouble and you are sure to find some. Many people carry "the gene for" something, but never experience what that something is. And now that you can get your whole genome sequenced for one or two thousand dollars, should you? I say, don't look for trouble unless you have a real reason for doing so, such as three out of four grandparents who died in their 50s of heart attack. Even then, the DNA sequence won't tell you anything new. You still have to eat your veggies, get your weight down, and exercise and maybe you'll survive into your 60s. With different grandparents, perhaps you'd live to your 80s or 90s, but remember Jim Fixx? He was a member of Mensa and a long distance runner who died of a heart attack at age 52. Was that such a shame? Because without all that running and eating well, he'd have died much earlier, like most of his relatives. He did what he could with what he had. That's the most any of us can ask for.

Cause and effect are hard to untangle. People studied Einstein's brain to find if he had something special they could see. He did have an extra-large parietal lobe, which might have helped his genius. But was it inborn (we don't have his parents' brains to compare), or was it because he was an accomplished violinist? Did a big P-lobe make him a better violin player or better scientist, or did his violin playing make him a better cosmologist, P-lobe or no? He thought so. We don't know enough about both genetics and the nurturing of young geniuses to tell, even a little. It'll take decades of study to learn even a little, and perhaps we would be the poorer for it, rather than for the better.

A song chorus I wrote in 1996 says, "We are dealt the cards, but our own hand we play". This could be a theme for half the chapters in this book. What we think we know is still just a trifle compared to what there is to know.

Sunday, August 11, 2013

A philosophy of illusion

kw: book reviews, nonfiction, philosophy, surveys

John Gray probably didn't set out to survey the field of philosophy when he began writing The Silence of Animals: On Progress and Other Modern Myths. But in the end, he surveyed the field pretty well. The book's title comes from an extended quote by Max Picard, which begins, "The silence of animals is different from the silence of men." The excerpt goes on to speak of the "heavy" silence of animals, "like stone." Gray quotes Picard only to disagree with him, focusing instead on the human desire for silence that cannot be achieved, because we are so noisy inside.

I wonder if silence-seeking has any hold at all on the modern generations. It seems there is no ear upon the street that does not have an earbud stuffed into it. I was recently asked by a young friend why I am never seen listening to music. I replied, "I have a constant sound track running in my head." She nodded thoughtfully, knowingly: I am a songwriter, though I am not prolific, and it takes me years to write a single song. Regardless, there is music enough in me to fill many lifetimes. Perhaps the inner sound track of most folks is not so melodious as mine, and must be drowned out with the contents of one's iPod.

But Gray's point is not silence or its lack anyway. It is to show that progress is a myth we must tell ourselves in order to have a reason for going on. Perhaps the couch potatoes have it right. Perhaps they realize, dimly though they may see, that passively taking it all in is better than the "striving after the wind" of which Solomon wrote.

In three long chapters that weave together 20-plus threads, Gray demonstrates from every angle that we cannot live without myths, because the intake of our senses is so illusory. He rightly notes that science represents our striving to extend our senses and make them more reliable. Thus, to replace our feeling that this thing is warmer or cooler than the other, we have a series of thermometers that cover various ranges from absolute zero upward, even to the thousands or millions of degrees (or more) that exist (thankfully) in distant spaces. He cares little for science, and equally little for experience. It is hard to determine just what he might be, as I find no positive statement in the book.

Reading it motivated me to gather a short list of the "more major" philosophical trends, selected only in that they could be distinguished from one another in my own mind:
  • Presocratic philosophy (actually, there were several, but they get lumped as one these days)
  • Academical philosophy
  • Cynicism
  • Stoicism
  • Scepticism
  • Neoplatonism
  • Christian
  • Scholasticism
  • Rationalism
  • Empiricism
  • Idealism
  • Solipsism
  • Liberalism
  • Evolutionism (biology is just the tip of the iceberg)
  • Pragmatism
  • Materialism
  • Existentialism
  • Postmodernism AKA Logical Positivism
  • "New Scientific" philosophy
To which I would add that branch of rationalism I call "sensibilism". I judge things by "is that sensible?" To some it may represent a merger of existentialism with logical positivism, in that "sensible" can mean "of the senses" equally as "making sense logically". It has been fashionable for 50+ years, when any discussion gets too deep and people disagree, particularly if religion or politics were brought up, for someone to say, "Well, I have my own philosophy." Taken to its logical end, this means there are actually some 7 billion philosophies out there, which means philosophy is an illusion also. Ha! Thought so.

I came away from the book with less than I had when I began, but that seems to be the author's intent.

Wednesday, August 07, 2013

The Psychopath Factory

kw: book reviews, nonfiction, cults, escapees

I really wish this book were fiction: Beyond Belief: My Secret Life Inside Scientology and My Harrowing Escape by Jenna Miscavige Hill. I really wish it were fiction, but it is not. Born into a Scientology family, at age six or seven Jenna was separated from her parents so they could—"for the greater good of humanity"—work a grueling schedule on church staff. Her parents were trusted with great responsibility, at least in part because her father is the older brother of David Miscavige, the leader of all of Scientology since the death of L. Ron Hubbard in 1986.

For the first eight years or so, she thought she was living a normal life, though she didn't like it much. She was one of a couple hundred kids who were raised at The Ranch in the California desert. A small contingent of adults managed the older kids, who supervised the younger ones, and all (except the adults) quite literally slaved to clean up the rundown buildings and landscape the grounds. As one of the youngest, Jenna could do little hard physical labor, so she became a kind of medic (with some sort of 3-letter-acronym title) to the rest. She cleaned and bandaged scrapes and cuts, dispensed aspirin and other medicines. While her parents were stationed comparatively nearby in Hemet, California, she saw them one or two times per month. Later, her mother was sent to Florida ("Flag", the headquarters of Sea Org, the training center for the most dedicated staff). Her father was busier and busier, and some years she saw them no more than once, usually at Christmas. The long separation led to marital troubles, and her mother had an affair, which landed her in RPF, the Scientology prison camp for Sea Org sinners. Not long after her parents were reunited, they left Scientology, and were "declared" SP's or Suppressive Persons. Think of Excommunication on steroids. Offered a chance to leave with them, Jenna declined. Jenna was 16. She and they had no contact for at least a couple of years.

Did you ever hear the proverb about the fly living in a vinegar bottle? Never tasted sugar, and doesn't know it exists. Such is the ingrown world of a powerful cult. Although Jenna had begun to realize she didn't have to doubt herself all the time, it took her another 8 years to get to the point that she felt she had to leave. By this time, she was married, and she and her husband tried to go through the church-accepted "exit" procedure because he didn't want them to be "declared" and thus lose contact with his relatives. The process was so grueling and invasive, she eventually refused to continue, and after much sturm und drang, now with her husband's full support, the two of them fled.

Reading the book, I wonder how she retained her sanity. Her experiences were an exercise in systematic production of insanity, from which she gradually, miraculously, recovered. The Scientology mind control system was carefully thought out and finely honed by Hubbard, who by 1950 had already become very rich from writing science fiction. In SF circles, he was a World Builder, capable of imagining a complete and consistent world, and rendering it in a narrative that draws the reader into its imaginary milieu. Dianetics and the books and lectures that followed as he built the "church" of Scientology became Hubbard's tour de force of world building, a consistent all-encompassing system of mind control that, had he known about it, Mao Zedong would have co-opted.

I've observed Scientology, mostly from a distance, for over 45 years. I was in my late teens when I read parts of Dianetics. I didn't read it all, because it was all hype with asserted "proofs" but nothing a fellow could substantiate. I had my first direct contact with Scientology in 1968, when someone at work invited me to a lecture. There was some kind of illustration, with about 8 items arrayed up a ladder, with a Buddha-like figure at the top. After a short introduction, most of the "lecture" consisted of an explanation of each of the 8 points (such as "Group Survival", a couple of steps above a more self-oriented point), then asking in the audience for a show of hands, who "understands" the point. After that, asking for another show of hands, who believed they had "internalized" the point. I don't recall what the last point is, something about wholeness and all of humanity, but I still had my hand up. The moderator directed a quizzical look my way. I said, "I am a Christian. When someone becomes a child of God, that comes as a gift. It is where we start, and we go onward from there." I noted shock, followed by rather murderous looks on a few faces, so I stood and slipped out of there. To my relief, the fellow at work didn't contact me after that.

Unbeknownst to me, a few years later a close relative I'll call Jason became involved with Scientology and began "auditing". I don't know how he paid for it, because auditing is expensive. It is a 1-on-1 process with an auditor and an "E-Meter", a klutzy kind of lie detector (a sensitive resistivity meter attached to a pair of soup cans you hold in your hands). The auditor questions a subject, watching the needle of the meter, and helps them get rid of "engrams" (this is a real psychological term, but isn't closely related to the way Scientologists use the term). The goal is to get rid of all engrams and become "clear". In about 1970 it was reported that getting "clear" cost about $10,000. If auditing costs have risen at the same rate as a loaf of bread, the cost today is about $60,000. Of course, if getting everyone "clear" were the only goal, things would stop there. But there are 8 steps of something called "OT" (for Operating Thetan) after that, at absurdly high cost. People who are having a hard time paying for all this are offered staff positions. Scientology staff members (Jason was one for a number of years) work on projects and get free room and board plus a bit of money (it was $15 per month in the 1970s) in return for free auditing.

Nobody is perfect, so new problems that arise in people's lives need to be cleared with further auditing. Auditing for staff is more arduous, and is actually a kind of brainwashing torture. Someone who gets to their wits' end and acts out beyond some limit can get RPF time. Jason was in RPF for a while, perhaps close to the average "sentence" of 2 years. Later, his father helped him pay some hoked-up debt he had, and got free of Scientology for a while. Today, nearing age 60, he runs a small business, but has on-and-off business relationships with members of Scientology. I suppose he is a "public Scientologist" now, the kind that pays for any auditing and other services he receives. He certainly makes more than $15 a month! We talk from time to time, but nothing about Scientology any more. He is still under their spell of unrelenting positivity about everything to do with Scientology. He may have private dissenting thoughts, but you'd never know it.

Read the book. You'll see for yourself how terrifyingly thorough their brainwashing techniques are. The ideal Scientologist is a perfect psychopath. Able to totally fool a lie detector, because he or she is in total control of all emotions, including familial ones. Family can be discarded (as Jenna was) to further the mission. Everything, but Everything is subservient to the goals of the organization. Power over lesser staff is exercised pitilessly and thoroughly. Jason is the only member of my extended family who has had daily acquaintance with handguns (outside the military)...or needed to. A cadre of Scientology operatives are the only group that ever raided an FBI office (to destroy documents about Scientology) and got away with it. Jenna M. Hill was one of the lucky ones, someone who cannot be manufactured into a psychopath. Someone with a conscience.

Sunday, August 04, 2013

Getting doctors to be doctors again

kw: book reviews, medicine, doctors, advice

There is a strong parallel between medicine and religion. Even more, the contrast between "doctoring" and genuine medical practice is like that between religion and faith. My favorite proverb about religion is
The core of religion is a checklist. You can hang it on the wall. A robot could perform the checklist perfectly. You cannot.
This is why I say that my faith is not a religion. Faith is a divine relationship; religion is a specified practice. What about doctoring? Doctors today make explicit use of checklists, which they often call "pathways", to "work up" a patient who comes to them with a particular "chief complaint". A wry joke going around is, to get seen quickly in an emergency room, when you tell the receptionist why you are there, make sure that you mention your chest hurts. Of course, that means you'll be there at least 24 hours and spend an extra $10,000.

If you actually try this, you will find yourself on the "Chest Pain Pathway", which involves a series of tests, including a CT scan, and an overnight stay for "observation". If you don't actually have any chest pain, you will still have a hell of a time getting off the pathway. There are hundreds (thousands?) of such "pathways".

The modern doctor will listen to you only for a few seconds, until you say something that triggers one of the pathways. If 10-15 seconds pass and no pathway is yet identified, the doctor will interrupt you with a series of questions, always of the yes/no variety. Once you mention the "right words" that trigger a pathway, even in passing, more yes/no questions follow, and pretty soon the doctor will stand and say "we'll do a couple of tests" while heading for the door. Less than a minute will have passed. If you happen to be a rambling storyteller, particularly if you are under great stress and confusion, you may not yet have talked about the real reason you are there! But now you are on a pathway, and you may never get off it (because you may die, or be sent home with "no finding").

It is estimated that at least 100,000 people die in U.S. hospitals due to "misdiagnosis". In most cases, it would be more accurate to say they died without a diagnosis, because they were killed by the hunt for one.

To literally save your life, you first have to do everything you can to stay off one of these pathways, because here's the dirty secret. A pathway is designed to minimize the chances you will sue the doctor, or at least make it very unlikely that you could win a malpractice lawsuit. They are NOT designed to lead to a diagnosis. But, it is becoming apparent that pathways themselves are a kind of malpractice.

Drs. Leana Wen and Joshua Kosowsky call this "cookbook medicine". I call it "robot medicine". A robot can do it; you don't need a doctor for that (look up "Symptom checker" and try the one at WebMD, for example). Robot medicine is a practice of "ruling out", and you'll hear a doctor say, "This may be a heart attack," (you mentioned chest pain) or, "We have to rule out a cranial hemorrhage" (you used the words "worst headache"). Drs. Wen and Kosowsky have written When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests to help you and me learn to stay off such pathways and drive a doctor to diagnosis.

Another proverb you probably know: To a man with a hammer, everything looks like a nail. The very availability of CT scanners, and the readiness of insurance companies to pay for CT scans, means that scanners are massively overused. Ditto for MRI and PET and other scanners, and for increasingly specific (and costly) blood tests. Excess CT scans are particularly worrisome, because even the most modern, low-dose scan exposes you to 500-1,000 times the radiation of an old-fashioned X-ray. ER's ought to have a chart on the wall:
  • Got chest pain? Prepare for an overnight stay, 3-4 blood draws and a CT scan. Equivalent radiation dose (ERD): 400 chest X-rays.
  • Terrible headache? 2 blood draws and a CT scan of the head. ERD 500 dental X-rays.
  • Abdominal pain with diarrhea? Prepare to spend the night, plus 3 blood draws, a sigmoidoscopy [actually a good idea!] and an abdominal CT scan. ERD 600 X-rays.
And so forth. Just for grins, if the radiologist has any trouble reading the CT scan, or notices any anomaly, you'll get a second CT scan (or if you are lucky an MRI scan: there is no radiation), with a different IV of contrast "stuff". Many folks are allergic to the contrast injection, such as my wife, who is allergic to both media that are used for kidney X-rays. Meaning she can never have another X-ray looking for kidney problems.

Properly used, CT scans save lives. But they come with a known risk: a 1-2% increase in the chance of getting cancer after 20 years or so. If, as some contend, 98-99% of CT scans are unnecessary, then it is a wash, a life lost to cancer for every life saved.

In the past it was not so. An early chapter of the book traces medical history over the past 20 centuries. Of the four stages of medical practice, the third may have been the best. From the time of Pasteur and Koch, and into the early era of antibiotics, doctors were very diligent to get a good "history" from a patient, plus they had a growing number of effective remedies, both medicines and surgical techniques. Prior to the 1960's, diagnosis was king. The most effective doctors had a quality known as Augenblick (German for "eye blink"). My uncle's father was one such. He could diagnose many, many conditions at a glance, yet he always took time to hear what the patient said (or the person who brought the patient in, if the patient was unconscious). The history might modify the eyeblink diagnosis. He took nothing for granted, but also had enormous common sense. If a patient arrived at the hospital with a note from him, the doctors there knew the diagnosis was a good one.

Diagnosis is still king, but the king is in hiding. Doctors practice defensive medicine, particularly in the ER. This consists not in driving to a diagnosis, but in "ruling out" rare conditions that could lead to a lawsuit if they are missed. The way a good entry interview ought to go is simple. You tell your story and the doctor listens to all of it. If you aren't a good storyteller (some doctors use the disparaging term "poor historian", but such doctors ought to go be plumbers or something), the doctor will ask questions to move the story along; preferably, questions not of the yes/no variety. At some point, the doctor will have a short list of possible diagnoses. The questions that follow are designed to distinguish among these competing diagnoses. This is called differential diagnosis. At some point, one idea is the most likely, and this is the working diagnosis (sometimes there will still be two, and that may be the actual case, that you have two things wrong at once). A good doctor won't just do all this in his head, but will discuss the possibilities with you, and will tell you the working diagnosis, or perhaps the last two possible diagnoses, with suggestions for making a final distinction. Only then can effective treatment begin.

It helps to learn to be a better storyteller. Consider chest pain. It is sure to trigger a "chest pain pathway", unless you first mention that you helped your cousin move yesterday, and carried one end of her piano. If you can also press a finger to one spot, saying, "It hurts the most right there", you have a chance of knocking your doctor off the pathway, and getting appropriate help for a pulled muscle in your chest. If not, you could be swept along with the momentum of the pathway, and go home a day or two later, with a CT scan or two under your belt and at least 3 fresh needle sticks. And, nothing for your pulled muscle.

The word "doctor" means "teacher". Prior to "modern medicine", a doctor taught all her patients how to recognize what symptoms meant, and what to do about it. Doctors didn't ask yes/no questions until late in the process, to distinguish provisional diagnoses from one another. During the history-taking phrase, the questions were open-ended, intended to get every scrap of information you could deliver.

To help your doctor arrive at the right diagnosis, and thus to treat you for the right condition, these days you have to help out, a lot! To this end, Drs. Wen and Kosowsky spend half the book training us to use their "8 Pillars to Better Diagnosis":
  1. Tell your whole story. This means making sure the doctor gets it all, particularly that which worries you the most (don't let embarrassment hold you back; tell it all). And don't answer yes or no to yes/no questions; use them as a springboard to tell more of your story. When the doctor interrupts, interrupt right back (as nicely as you can).
  2. Assert yourself into the doctor's thought process. I'd have used the word "insert", but the authors are emphasizing that you have to be assertive, almost pushy, to keep the doctor collaborating with you.
  3. Participate in the physical exam. Of course, show the doctor "where it hurts", so to speak, but also ask what he is thinking. Ask for jargon words to be explained.
  4. Make the differential diagnosis together. Ask for the doctor's list of ideas. If none make sense, say so and ask, "What else could this be?" The initial net needs to be broad, but seek a balance. 100 vague possibilities are not a differential diagnosis.
  5. Partner for the decision making process. Continue to ask how this or that possibility can be most simply eliminated, or how any one could be confirmed.
  6. Apply tests rationally. Don't agree to "ruling out" tests for low-probability conditions unless your doctor can make a good case why every symptom you have described fits that condition, and none of them in themselves make it less likely. Be sure you understand what every test is meant to distinguish or determine.
  7. Use common sense to confirm a working diagnosis. The visit is not over without a working diagnosis. But it has to make sense.
  8. Integrate the diagnosis into the healing process. The doctor must tell you what to expect from the treatment she prescribes or recommends, and how it relates to the diagnosis. The working diagnosis may not have been the right one, so knowing what to expect can clue you in that something isn't quite right.
Nobody will remember these points during an ER visit, or even an office visit, so one third of the book consists of exercises and practices to help you get very familiar with the process. No longer can you and I afford to passively "let the doctor do the doctoring", because we will almost always find ourselves being pushed toward one of the "pathways". These pathways are not helpful to you, but to the doctor's malpractice insurance carrier. Throughout, the authors stress that we must be respectful with the doctor, not confrontational, because, after all, we went to him for his help, and such help will be harder to elicit if we offend him. If your doctor is thin-skinned and arrogant, do everything you can to change doctors.

My most important take-away from this book is a question that I need to ask: "Doctor, what will this test determine? What is the diagnosis you wish it to confirm?" If the doctor intends to "rule out" something, don't agree to it. Demand (nicely) a differential diagnosis, and ask where the test fits into that.

I am in the process of getting a new doctor. A couple weeks ago my wife made an appointment for me (shoulder strain) with my primary care physician. John is a good doctor, one who listens much better than most, and we've developed a good working relationship. But a week later, his office called to say that he had retired, there is now a new doctor taking over the practice, and did I still want the appointment? Well, what choice do I have? Now that I am on Medicare, it is hard to find a doctor who will take a new patient. I accepted the appointment. Now I have a new doctor to train. I'll make copies of the relevant parts of WDDL and study up, so when I see him a couple days from now, I can start off on a good footing and gain an appropriate collaborative relationship.