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Comment Re:Cost of ehalthcare (Score 1) 646

If we compile statistics, we can look for the points where nobody has ever meaningfully recovered.

We do. This is where the guidance to stop resuscitation after 15 minutes without a rhythm comes in. Unless you're a child who drowned in cold fresh water, of course, or an adult who apparently died of hypothermia. The problem is that there are so very many different sets of facts, and people are far more resilient than you can imagine. And in the heat of the moment, we tend to opt to fight rather than to let go. Which is actually OK, I think.

For your example, ECMO can only be useful for acute lung failures including injury. It's useless in chronic cases where the lungs simply aren't going to improve.

Well, yes, ECMO is probably a bad example, because it's by definition an acute therapy that can't be continued more than a few days, at least at the current state of the art. Even there it's a bit questionable in the case of chronic disease exacerbated by acute cardiopulmonary collapse from a (presumably) reversible cause. But other therapies, like the simple $10K/day ICU bed, are much harder to argue against, unless you've given specific instructions. It reminds me a little of the old instructions for tuning a carburetor - turn the screw until the engine dies, then back up half a turn. Most of the really futile ICU cases I've seen didn't START as futile cases, but they sure ended that way.

Most other western countries have a bit less tendency to heroic medicine than the U.S.

I'm not actually all that impressed with medicine in "most other Western countries" as a touchstone for our own. Every country has its own social norms and conventions, all of which fold over into health care. We tend to value privacy, autonomy, personal space, personal choice, and hope for recovery more than most, and it costs us a lot of money.

Comment Re:Cost of ehalthcare (Score 1) 646

I think the problem is that we don't know in advance when the "last days of life" are for anyone. Or at least we don't know if prospectively, and knowing it after the fact is kind of pointless in terms of limiting costs.

If there are treatments that are virtually never helpful, we need to stop using them. There aren't many interventions that actually fit that description, though, and even the most invasive of them - ECMO, for example (basically continuous heart-lung bypass) - have their place in restoring people to health in the right circumstances. Eventually the circumstances are such that death is inevitable, but recognizing that point is not something we know how to do with certainty. Even when we're pretty sure, communicating our own conviction is very hard. And where there is no certainty, there is the great likelihood of erring on the side of treatment.

Hospice care, which tends to be very inexpensive compared to attempts at cure, is helping because it gives people a viable alternative path. Most physicians with whom I deal (a very large number, as it turns out) are big fans of hospice care. Not because it's cheap, but because it helps make the case for avoiding further torture. It's not a bad way to reduce costs, though, and that's not irrelevant.

Comment A doctor's opinion: TFA's got it right. (Score 4, Insightful) 646

I'm a board-certified physician (among other things). There is no way that I would allow my colleagues to inflict the kind of death on me that they are forced to inflict on so many. Part of this is certainly that I know full well that we all exit this mortal coil toes-up, and there's no getting around it. Part of this is the personal reluctance to experience the diminished autonomy, indignity, pain,and hopelessness that comes with fanatically-treated terminal illness.

But a big part of it, I think, is just that I know that there are so, so many things that are worse than simply dying. Dying in agony, for one. Dying after having bankrupted my wife or my children. Dying after being reduced to a stinking thing in a bed long enough that only those who loved me most even want to be near me, and that only because they feel they must. Physicians see these things all the time, and we see the road that leads to them. We're not (that) stupid, and we would rather exit early on that road, not at its terminus.

As long as I have the capacity for joy I will strive to remain alive to experience that joy. When the capacity - or the joy - is gone for good, I have given quite strict instructions not only to my family but to some other clear-headed and insistent people who will do their best to ensure that I too will be gone without further "heroic" intervention.

The only problem that I have with the article is that it pretends that everyone should make the same decisions. Everyone has their own decisions to make, and without my knowledge and experience I might not make the same ones. I think as physicians we owe it to the people for whom we care to educate as well as we can and help them to understand why we might personally decide one way or another. But I will never tell them how they "ought" to decide - it's really their choice. Taking that choice away from a person leads too easily to very real outcomes that are much nastier than simply a life that ends later than it ought.

Comment Re:Let the informed battles begin (Score 1) 413

Aerosols fall out of the atmosphere in a couple/three years. United States and other western nations cleaned up in the 70s into the 80s, so aerosols aren't as much of a problem any more. It is becoming a problem in China and other booming industrial nations with no environmental constraints. Eventually they will get a clue, and clean up their act as well... or their boom will end.

Comment Re:Transgender - 3 meds for the rest of my life (Score 1) 550

Actually, if you were more educated, you'd know that chemical castration is a very effective treatment as well. But you're obviously not ...

What do you think hormone replacement therapy is? I was chock full of testosterone, now I'm full of testosterone blockers and estrogen. Shockingly, that's not very good for the male reproductive system. The dosages are different, but I'm basically on 'chemical castration' meds. Because that's what hormone replacement therapy is.. The treatment you're promoting (which you seem to think will 'cure' trans-ness) is actually what's needed to transition!

Comment Re:Transgender - 3 meds for the rest of my life (Score 1) 550

Except that ... well, there is [hard evidence as to what causes people to be gay or trans]. Look, I'm all for letting you live your life the way you want to, but I'm 100% against disseminating false or misleading information. You're pushing an ideology that isn't aligned with FACT.

Do you have any studies to back up that claim? I'd be really interested in reading them. As I said, there are some interesting clues as to how trans people's brains and bodies are different than typically gendered people. But - from everything I've read - no one is willing to make claim a causal relationship. Or, if they are, they admit they're not sure which way it goes: does having an atypical brain structure make one trans, or does some other (genetic/hormonal/etc) cause of trans-ness result in an atypical brain structure?

There are lots of people that aren't comfortable in their bodies. Not just transgendered individuals. There are people who claim that they should be born as animals, because their spirit is truly that of an animal. Do I believe their arguments? No. I'm close minded like that. In other words, I'm a logical empiricist. Show me proof that you're in the wrong body, and I'll believe you. Until you have something more tangeable than feelings, your opinion and your feelings are just as valid as mine

The proof of the pudding, as they say, is in the eating. That is, I was previously suicidal and depressed. Now, after going on hormones and transitioning, there's been a significant drop in my depression. Mental health professionals don't (usually) send for lab results before putting patients on antidepressants, they talk with the patients and use their training to judge the patient's state. Transitioning works, logically and empirically, and your argument about 'people who claim they should be animals' is on par with people saying gay sex is wrong because it will lead to bestiality: a ridiculous, unfounded, and (quite frankly) illogical argument.

Furthermore, gender is complicated, even though many people pretend it isn't. There are ample examples across the animal kingdom of animals - sans therapist or hormone replacement therapy - expressing 'wrongly' gendered behavior. Why should humans be any different?

Comment Re:Transgender - 3 meds for the rest of my life (Score 1) 550

1) Is there a phsycological element? can some form of mental treatment not help?

It's not totally clear what causes people to be trans, in the same way there's no hard evidence as to what causes people to be gay. (Or straight, or have particular kinks.) That said, there have been some interesting studies indicating trans folks do have some sort of physiological and/or neurological differences compared with the typically-gendered population. I don't know of any peer reviewed studies indicating ex-gay or ex-trans therapies work, which to me says it's not (solely) a psychological issue which should be treated like depression or any other mental disorder.

2) If it isn't phsycological and it is due to some hormonal imbalance, then does taking medication to further change your gender away from your physical gender not simply exacerbate the problem?

That's an interesting question, and not one I have good answers for. Speaking for myself, my hormones were at typically male levels before I went on estrogen. That is, my doctor ran my blood work and showed me that there didn't seem to be any hormonal reasons for my gender discomfort, as the reports indicated I was hormonaly male. I don't have any broader surveys of the trans community, but anecdotal evidence seems to point to the same thing: most (although certainly not all) trans folks didn't suffer from any detectable hormone imbalance. If that were the case, however, the doctor and/or therapist the trans person was working with should be able to help detect that. I think there should be less of a medical gateway before getting hormones than what currently exists, but I do think hormonal transition should include a doctor's care.

3) If it can be treated by altering hormones then why - if a choice is made to take medication for life - is a choice made to alter hormones in the direction of the sex you wish you were, rather than the sex you actually are? Would the latter not make more sense in that you would simply be able to live your life without even having to worry about prejudice, and without having to go through a presumably very painful operation or set of operations?

That's an excellent point, and kind of gets to the hear of the trans experience. It would have been great if there were a pill I could take that would result in the sensation of "Oh! I am male!" But - just as ex-gay therapy hasn't been proven successful - no amount of repression or therapy or abuse or pigheadedness has been able to 'cure' any trans person I know or anyone I've heard of through the news or the grapevine. All the studies and surveys I've read - along with a heap of anecdotal evidence - indicates being trans isn't 'curable' in the sense of bringing comfort to the person in their physical sex.

Let me know if you have any questions. I know this isn't something many people have reason to know much about, so I'm always happy to help educate folks who are honestly curious.


Comment Re:Transgender - 3 meds for the rest of my life (Score 1) 550

My question, then, would be how should society handle people who have chronic illnesses that are nevertheless not catastrophic, and can't afford treatment? Things like diabetes or early stage cancer treatment. Who should pay for that if the individual is unable to afford it?

The 'free market' solution would be that those people get sicker and sicker until ERs, which are required to treat regardless of ability to pay, can cover the immediate issues. But I'd much rather live in a society where that cost is spread out over everyone, so no individual needs to worry about whether they can afford to go to the doctor.

Comment Re:Transgender - 3 meds for the rest of my life (Score 2) 550

I was oversimplifying and I'm sorry I came across as a member of "that part" of the trans community. I know exactly what you mean, and you're right: I absolutely need medical intervention. My issue is that GID is listed as a mental - as opposed to physical - disorder. With your cleft palate example, it's not something you need therapy to get verified as a 'real' cleft palate patient.

I would however, be down for reclassifying GID as a neurological or neuropathic condition, rather than a psychopathology...

It sounds like we're pretty much on the same page. I'm sorry my posts came across otherwise.

Comment Re:Transgender - 3 meds for the rest of my life (Score 2) 550

No, their attitude - as far as I can tell - is wanting to use their service and have them pay for medical expenses is less profitable than insuring healthy people who don't need treatment. In Illinois (where gender identity is a protected class) I have had no problem getting treatment paid for by my insurance when I was under my parents' plan, and have none now that I'm in the state high risk pool. So once insurance companies grudgingly accept me in their system, they acknowledge my concerns are medically valid. But if I can't get into that system, what happens then?

(Illinois, fortunately, does have a high risk pool, and I can - at least for the time being - afford it. But there's a reason trans people have much higher instances of suicide, poverty, sex work, drug addiction, and substance abuse than the general population: because it's really difficult to live in a society that doesn't support you.

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