The Grumpy Doc – Page 2 – Grumpy opinions about everything.

Of Echo Chambers And Filter Bubbles

On September 27, 2024

The time has come, the Walrus said,
To talk of many things:
Of shoes – and ships – and sealing-wax –
Of cabbages and kings –
Louis Carroll
“The Walrus and the Carpenter”

Introduction

Recently, I have been researching the role of social media and the spread of modern propaganda. One of the things that surprised me, although it probably shouldn’t have, is how rapidly misinformation spreads over the internet as compared to verifiable fact-based information. I choose to use the term verified or verifiable rather than true or truth. It seems to me that we have entered an age where each person decides on their own version of truth. Truth has become relative. It’s based not on verifiable and reproducible facts but rather on who said it, where you read it, or if you agree with it. If it doesn’t fit with your preconceived notions, it can’t possibly be true.

A study by three MIT researchers found that false news spreads more rapidly on the social network Twitter (now X), by a substantial margin, than does factual news. “We found that falsehood diffuses significantly farther, faster, deeper, and more broadly than the truth, in all categories of information, and in many cases by an order of magnitude,” reported Sinan Aral, a professor at the MIT Sloan School of Management.

They found the spread of false information is not due primarily to bots programmed to disseminate inaccurate stories but rather due to people intentionally retweeting inaccurate news items more widely than factual statements.*

To better understand how social media impacts propaganda, it is important to understand how this phenomenon occurs. This leads to two related concepts, Echo Chambers and Filter Bubbles.

Echo Chambers

An echo chamber is a social structure in which individuals intentionally surrounded themselves only with those who share similar views and opinions. Within these chambers, dissenting opinions are either absent or actively suppressed, leading to the reinforcement of existing beliefs. On social media, echo chambers are created by users themselves, as they choose to follow, like, and share content that aligns with their views while ignoring or blocking contrary perspectives. This self-selection creates a feedback loop where individuals only hear what they already believe, which further entrenches their views.

Filter Bubbles

While echo chambers are largely the result of individual choices, filter bubbles are often shaped by algorithms. Social media platforms and search engines use algorithms to curate content for users based on their past behavior, what they click on, like, or share. The stated intention behind these algorithms is to provide users with content that is most relevant to them. But we shouldn’t overlook that it is also a method to make users more receptive to focused advertising and other forms of influence. The net result is a significant narrowing of the variety of opinions presented.

Individual Choice

Both echo chambers and filter bubbles limit the diversity of information by consistently show users content that aligns with their established interests and beliefs, isolating them from conflicting viewpoints and leading to a narrow and sometimes distorted understanding of the world. Over time, this can result in a skewed perception of reality, where the individual believes that their perspective is universally accepted or unquestionably correct.

While echo chambers and filter bubbles are often discussed in terms of algorithms and platform design, it is crucial to recognize the role of individual decisions in their creation and perpetuation. Each time we choose to follow a particular account, share a piece of content, or engage in a discussion, we are making decisions that shape our information environment.

The choices we make, whether to engage with diverse perspectives or retreat into familiar territory, have a profound impact on the information we encounter and share. When we choose to engage only with like-minded individuals and content, we contribute to the formation of echo chambers. Similarly, when we rely on algorithms to curate our content without seeking out alternative viewpoints, we become trapped in filter bubbles.

Echo chambers and filter bubbles are not exclusive to any political affiliation, religion, ethnicity, or social class. They are found across society. The willing acceptance of echo chambers and filter bubbles is the antithesis of critical thinking. When we fail to recognize that we are not considering alternative views, regardless of our political orientation, we are succumbing to indoctrination rather than education. We become unthinking automatons rather than critical thinking individuals who decide what is best for ourselves. Failure to actively engage with the information that we receive, to ensure that we receive multiple viewpoints (even those with which we disagree) and then failing to critically evaluate everything presented is a sure recipe for a loss of freedom.

*The paper, “The Spread of True and False News Online,” was published in Science, 9 March 2018

A Simple Guide to Understanding Common Blood Tests

By John Turley

On September 21, 2024

In Medicine

Introduction

Blood tests are a common part of both health maintenance and diagnostic visits. Doctors order blood tests to assess and monitor various aspects of a patient’s health. Blood tests can help detect illnesses, confirm a diagnosis, or monitor ongoing health conditions. For example, a complete blood count (CBC) checks for conditions like anemia or infection, while a lipid panel measures cholesterol levels to aid in assessing heart disease risk. Blood tests can also monitor organ function, such as the liver and kidneys, ensuring they are working properly. They are used to track how well treatments, like medications, are working, or to detect side effects that might not be immediately apparent. Additionally, blood tests provide crucial information about electrolyte levels, hormone balances, and metabolic activity, helping doctors make informed treatment decisions. Overall, these tests give doctors a detailed look at the body’s internal functions, often identifying potential issues before they become more serious or even apparent.

Understanding Normal Ranges

Before discussing the individual tests, let’s look at how you should go about understanding the results that are being presented. Blood tests are reported quantitatively, that is the results are shown as numbers. Along with the value for your individual test you will find the reference range. This is the range of normal values from low to high established by the lab. It can vary slightly from lab to lab. Values from one lab are not always directly comparable to those of another. Individual labs may also change their reference range from time to time.

How are these normal ranges established? They are established through population studies that consider large samples of healthy individuals and look at factors like sex, age and ethnicity. The standard normal values are developed using a bell-shaped curve. “Normal” is usually defined as those test results that fall within two standard deviations of the mean, that includes about 95% of all results. This leaves about 5% of the normal healthy population with test results that will be slightly outside the normal range presented. That’s why it’s important to discuss your individual results with your doctor to get a better understanding of where you fit in the normal range and whether a minimally abnormal result is of true clinical significance.

Commonly ordered blood tests

1. Complete Blood Count (CBC)

A CBC measures the different components of your blood, which includes:

Red Blood Cells (RBCs): These carry oxygen from your lungs to the rest of your body. Low levels could indicate anemia. There are also several conditions that can cause elevated levels.
White Blood Cells (WBCs): These help fight infections. If they’re too high, it might mean an infection, inflammation, or other conditions such as leukemia.
Hemoglobin: This is the protein in red blood cells that carries oxygen. Low hemoglobin often points to anemia which can be caused by several underlying problems.
Hematocrit: This is the percentage of red blood cells in your blood. It helps to diagnose anemia or dehydration.
Platelets: These help your blood clot. Abnormal levels can lead to excessive bleeding if levels are low or excessive clotting problems if levels are high.

Why it’s important: CBC is a key test to diagnose infections, anemia, or clotting issues.

2. Comprehensive Metabolic Panel (CMP)

A CMP checks the body’s metabolism and organ function. It includes:

Electrolytes: Sodium, potassium, and chloride are vital for nerve and muscle function. Abnormalities can cause weakness or heart arrhythmias.
Blood Urea Nitrogen (BUN) and Creatinine: These measure kidney function. High levels may indicate kidney disease.
Glucose: Blood sugar levels; important for diagnosing diabetes.
Liver Enzymes (ALT, AST): Elevated levels can indicate liver damage.
Albumin: A protein made by the liver; low levels may be associated with liver or kidney disease or other metabolic disorders.

Why it’s important: The CMP gives a broad view of how your liver, kidneys, and metabolism are functioning.

3. Thyroid Panel

The thyroid panel includes:

Thyroid-Stimulating Hormone (TSH): Signals the thyroid to produce hormones. High TSH often means low thyroid activity (hypothyroidism), while low TSH can indicate overactivity (hyperthyroidism).
T3 and T4: These hormones regulate metabolism. Abnormal levels can affect energy, weight, and mood.

Why it’s important: Thyroid issues can cause fatigue, weight changes, and mood disturbances; this panel helps evaluate the cause of those conditions.

4. Hemoglobin A1C

This test measures your average blood sugar levels over the past 2-3 months. It’s used to:

Diagnose diabetes: An A1C of 6.5% or higher from most reference labs indicates diabetes.
Monitor diabetes: For people with diabetes, it helps gauge how well blood sugar is being controlled.

Why it’s important: A1C is crucial for diagnosing and managing diabetes, as it provides a long-term view of blood sugar control. A1C will be discussed in more detail in a future article on diabetes.

5. Vitamin D Levels

Vitamin D helps regulate calcium and phosphate, which are important for bone health. Low levels are common and can lead to:

Bone weakness: This can cause conditions like osteoporosis.
Fatigue and muscle pain.

Why it’s important: Many people are deficient in vitamin D, and low levels can increase the risk of bone fractures and other health issues.

6. Vitamin B12 Levels

Vitamin B12 is essential for nerve function and producing red blood cells. A deficiency can cause:

Fatigue and weakness: Low B12 can lead to anemia.
Nerve damage: Tingling, numbness, or memory problems may occur with long-term deficiency.

Why it’s important: Identifying B12 deficiency is key, especially in older adults, as it can prevent neurological and cognitive problems.

7. Prostate-Specific Antigen (PSA)

PSA is a protein produced by the prostate gland. High levels of PSA can indicate:

Prostate cancer.
Benign prostatic hyperplasia (BPH): An enlarged prostate, which is common as men age.
Prostatitis: Inflammation or infection of the prostate.

Why it’s important: PSA is used primarily for early detection of prostate cancer, especially in men over 50. PSA will be discussed further in a future article on prostate cancer.

8. Cholesterol Panel (Lipid Panel)

This test measures fats in the blood, including:

Total Cholesterol: High levels indicate increased risk of heart disease.
Low-Density Lipoprotein (LDL): Often called “bad” cholesterol, high LDL can lead to plaque buildup in arteries.
High-Density Lipoprotein (HDL): Known as “good” cholesterol, HDL helps remove LDL from the arteries.
Triglycerides: Another type of fat that, when elevated, raises the risk of heart disease.

Why it’s important: Monitoring cholesterol is crucial for heart health, as high cholesterol is a major risk factor for heart disease and stroke.

Significance of Abnormal Results

Abnormal test results don’t always mean something immediately serious, but they can be early warning signs. For example:

High glucose or A1C: Could indicate diabetes or prediabetes.
Low red blood cells or hemoglobin: Suggests anemia, possibly from iron deficiency or chronic disease.
High liver enzymes: May indicate liver inflammation or damage, possibly from alcohol use or infections like hepatitis or overuse of medications such as acetaminophen.
High PSA: Could be a sign of prostate cancer, but it could also result from less serious conditions like an enlarged prostate or a prostate infection.

Review your blood tests with your doctor. The better you understand your individual results, the better you can participate in your own health management. This knowledge can be empowering when choosing the health care plan that is best for you.

The Grumpy Doc says see your doctor and ask questions. Your doctor should never be offended by questions; they will be glad you are taking an active interet in your health care. Take a written list of your concerns with you so you don’t forget what you wanted to ask. Even The Grumpy Doc occasionally forgets things (as difficult as that may be to believe).

A Philosophical Chuckle

By John Turley

On September 18, 2024

In Humor

Words to live by.

The Pot Predicament

By John Turley

On September 13, 2024

In Commentary, Politics

Recently, the Charleston City Council passed a bill to reduce the penalties for the possession of marijuana for personal use. This started me thinking about marijuana and its long intertwining with my generation. I first became aware of marijuana in my early teenage years, more than sixty years ago. At that time, possession of marijuana for personal use was a crime, as it still is in much of the country now, and it remains a federal crime. Soon after I became conscious of the whole thing, marijuana was incorporated into President Nixon’s war on drugs.

This is a war which sadly we continue to lose. This doesn’t stop us from pouring resources into a part of that war that doesn’t need to be fought. For as long as I can remember, we have continued to prosecute and imprison people who possess marijuana for their own use. I’m not going to discuss possession of marijuana for distribution, that’s a separate problem, one I think will take care of itself if we properly address marijuana for personal use.

Laws against personal use of marijuana remind me much of the failed experiment of prohibition. If people want something enough, they will find it regardless of what the law says. Most of the people imprisoned for personal possession of marijuana represented little or no threat to society as a whole and no one benefited from their imprisonment.

I know the arguments for and against. The health arguments on the pro side say it relieves glaucoma, chronic pain and anxiety. On the con side, there are arguments saying that it is addictive, it can cause cognitive delay and accelerate the development of psychosis. There have been many arguments surrounding marijuana as a gateway drug. I haven’t seen any convincing evidence that restricting personal use of marijuana makes any difference in use of other drugs. The only exception may be those cases where people become hooked on fentanyl or heroin that has been used to lace their marijuana.

My argument against laws criminalizing personal use is that they don’t work. We have spent millions, perhaps billions, of dollars and hundreds of thousands of law enforcement hours to enforce laws that in the long run have no real benefit.

I think it would make better sense to legalize marijuana for personal use. That way, like the alcohol and tobacco industries, it can be regulated with inspections and oversight activities. Customers would know it had not been contaminated with other dangerous drugs. It could also be taxed and distributed through businesses that would benefit from legitimate sale. The tax revenue could be used to fund drug treatment plans for our serious opioid crisis. That is the one war on drugs that we must win but in which we continue to fall further behind. Redirecting funds from marijuana enforcement to opioid treatment and enforcement will help save lives.

If personal use of marijuana is legalized, criminal distribution will rapidly fall away as there will be no profit. The street corner pot dealer will become a historical footnote, much like the prohibition era bootlegger.

I know some of you are thinking I must be an old hippie sitting around my living room smoking a joint and listening to the Grateful Dead. Even though I came of age in the Age of Aquarius, I’ve never tried marijuana and have no plans to do so whether it’s legalized or not. I have no objection to it, it’s just that as a younger man I preferred beer, as I got older, I migrated to wine and martinis, and now I’m too old to change.

The bottom line is this: we live in an age of limited resources, and we need to decide how we are going to utilize those resources. I would like to see us take those financial and human resources and utilize them to address the opioid and methamphetamine crises. We are currently wasting too many of these precious resources trying to enforce unnecessary and ultimately unenforceable laws against personal possession and use of marijuana. If we legalize personal possession, we will reduce crime and all but eliminate the illegal trafficking in marijuana.

That is my grumpy opinion.

A Book Report

By John Turley

On September 8, 2024

In Commentary, History, Politics

On Tyranny: Twenty Lessons From The Twentieth Century

Timothy Snyder

I don’t believe I have written a book report since I was a freshman in college. This is a small book that I believe is well worth your time to read. I mean small book quite literally. It’s about 4 1/2 inches by 6 1/2 inches and only about 126 pages of fairly wide spaced text. You can read the entire book in an afternoon and still have time left over. The book is also available as an audiobook, and it’s combined with Twenty New Lessons From Russia’s War On Ukraine. I got the audio book and listened to it as well. That will take about eight hours to complete.

I’m calling this a book report rather than a book review because I want to tell you what’s in the book rather than what I think about it so that you can form your own opinion. First, I’ll give you an overall impression. It’s thought provoking and raises issues of concern to us today. You may not agree with it. I don’t agree with everything that he said. I found some of his 20 lessons to be redundant because I thought he was stretching to get 20 lessons for the 20th century. I also found one or two of them to be painfully obvious. What follows is just a summary of the book. Read it and e-mail me or call me if you’d like to discuss it. I will send the book to the first person who asks for it, but only if you promise to pass it on when you’re finished.

Doctor Snyder is a professor of history at Yale University. He specializes in Central and Eastern Europe and has spent considerable time in Ukraine. He’s the author of 15 books and reads five European languages and can converse in ten.

Preface

The book begins with a preface in which Doctor Snyder establishes the importance of historical awareness. He describes the failure of some 20th century European democracies and their descent into authoritarian rule. He uses these examples to illustrate how democracy cannot be taken for granted. He makes the argument that democracy is fragile and must be defended. He further argues that even in the United States, the continuation of our democracy is not a given and we must fight for freedom and maintain constant vigilance over our democratic processes.

Each of his twenty lessons is contained in a separate chapter, varying from a few pages to a single sentence.

The Twenty Lessons

Do Not Obey In Advance: Many authoritarian regimes have achieved their power from the people’s willingness to conform without being forced. Do not comply with unjust policies that are not being actively enforced.
Defend Institutions: Democratic institutions such as courts, the press, and unions are an important part of a free society. We must support and defend them against attacks and subversion.
Beware The One-Party State: A multiparty system is crucial for the survival of liberty. The rise of a one-party system often precedes the decline of democratic government.
Take Responsibility For The Face Of The World: The use of symbols in public spaces matters. Authoritarian regimes can shape public perceptions by co-opting national symbols and using them to create division rather than unity. Be vigilant for and challenge symbols of hate and remove these symbols from our public spaces.
Remember Professional Ethics: Professionals, especially those in law, medicine, education and government service must uphold ethical standards, even when pressured to conform to the aims of authoritarian regimes. Their integrity is vital for maintaining democracy.
Be Wary of Paramilitaries: Resist the rise of unofficial armed groups that support authoritarian figures. Such groups may eventually take the place of the legally constituted police and military services. “When the men with guns who have always claimed to be against the system start wearing uniforms and marching with torches and pictures of a leader, the end is nigh. When the pro-leader paramilitary and official police and military intermingle, the end has come.”
Be Reflective If You Must Be Armed: If you are part of law enforcement or the military, refuse to participate in unjust actions or repressions of the population. Ensure that those who bear arms do so with a deep sense of responsibility and ethics and a great regard for the value of democracy.
Stand Out: Authoritarian regimes thrive on compliance. Demonstrate opposition publicly and show visible descent and encourage others to show resistance whenever possible.
Be Kind To Our Language: Be precise in your use of language and avoid repeating the phrases made popular by authoritarian leaders. Independent thinking is facilitated by the careful use of language. Manipulation of language is a powerful tool for the control of the population.
Believe In Truth: Truth is the linchpin of justice and democracy. Uphold and defend objective truths. Reject the false narratives or “big lies” spread by authoritarian regimes. Make every attempt to shed light on their falsehoods regardless of how often or loudly they proclaim them.
Investigate: Seek out reliable sources of information. Support independent journalism. Identify, evaluate and encourage trusted sources. Do not accept any claims by the authoritarian regime without your personal verification. Remember critical thinking is important to resisting manipulation.
Make Eye Contact and Small Talk: Build personal connections within the community to foster solidarity and resilience. Visible civic involvement demonstrates unity and a commitment to democratic principles.
Practice Corporal Politics: Participate in protests, marches, and public events. Physically demonstrating support and civic engagement shows a strong commitment to democratic principles.
Establish A Private Life: Protecting your privacy from surveillance is essential. Authoritarian regimes often invade personal spaces to control and manipulate individuals.
Contribute To Good Causes: Support organizations and causes that defend democracy and human rights. Both financial and moral support will strengthen resistance.
Learn From Peers In Other Countries: Understand how some nations have succumbed to authoritarianism while other nations have resisted it. Learn from their experiences and strategies.
Listen for Dangerous Words: Be alert to the use of language that demonizes opponents or glorifies violence. Such rhetoric often precedes more severe actions against targeted groups. Be sensitive to efforts to convert the population to harmful ideologies through repeated derogatory speech.
Be Calm When The Unthinkable Arrives: Stay composed in moments of crisis and resist the urge to act impulsively. Authoritarian leaders often attempt to exploit chaos to seize power. Be alert for such attempts and be ready to counter them.
Be A Patriot: True patriotism involves defending democratic values and principles, not blind loyalty to a leader or party. Waving flags and shouting slogans is not patriotism. Defending democracy is the true mark of a patriot.
Be As Courageous As You Can: “If none of us is prepared to die for freedom, then all of us will die under tyranny.” (That is the total of this lesson; perhaps the most important one of all.)

Epilogue

The book concludes with an epilogue entitled History and Liberty. In the epilogue Doctor Snyder discusses his theories of the Politics of Inevitability and the Politics of Eternity.

The Politics of Inevitability is the belief that history naturally progresses in a linear forward direction typically towards a better future. It assumes that liberal democracy and capitalism will inevitably spread across the world leading to a more prosperous and freer global system. Human forces are seen as predictable and human activity is often downplayed. People who live under the politics of inevitability tend to believe that the current state of affairs will persist because it represents the end point of political and economic evolution.

The Politics of Eternity, on the other hand, rejects the linear progression of history and emphasizes a cyclical view. It supposes that nations are perpetually threatened by external forces. It glorifies a supposed golden age of the past that is idealized and mythologized. It views current politics as a struggle to return to that idealized past.

I found his discussions to be more theoretical than practical. I can see aspects of both in most current societies. I invite you to please read this and I would love to discuss it. I may be missing something in his presentation of inevitability and eternity.

In Conclusion

If you are concerned about the survival of democracy, read this book.

Dr. Google Will See You Now (Revised)

By John Turley

On September 3, 2024

In Commentary, Medicine

There are few words that cause more trepidation among doctors than having a patient start off a visit by saying, “I was reading on the internet”. It’s not that we don’t want our patients to be well informed; a knowledgeable patient is an important part of successful health care. It is what we call the therapeutic alliance.

What we worry about is what they may have been reading on the Internet. There is a lot of good information available, and I always encourage my patients to learn as much as they can about their own health issues. There are many professionally researched and peer reviewed medical websites. They include such commercial sites as Medscape and WebMD. They also include patient advocacy sites such as the American Diabetes Association and the American Heart Association. And, of course, there are the government sites such as the Centers for Disease Control and the National Institutes of Health. All these present the best available science and benefit from rigorous research and review.

That is not to say that they won’t change. Science evolves and knowledge improves. What is our best knowledge now may at some point in the future be proven wrong. However, your best chance of getting solid information is on these well documented sites.

What I worry about are the undocumented or unverified websites that provide what can best be called rumor or conspiracy. Any time a patient tells me,” I was reading on the Facebook page “The Truth About….,” I cringe. Any Facebook page entitled “The Truth About…” is unlikely to contain much truth.

False information takes on a life of its own on the internet. The big lie almost always buries the truth. Long after the article that was the basis for a false claim linking the MMR vaccine with autism was withdrawn by the British medical journal The Lancet, and long after the physician who wrote the article was found by the British General Medical Council to have falsified the data and long after he lost his medical license, the study is still quoted by many anti-vaccine people as being a fundamental truth.

Even when the authors of such false information repudiate it, people still believe it. It becomes part of the legend that “they” forced the author to remove it. No one ever explains who “they” are or why “they” want to keep the public in ignorance. Of course, there is never any source documentation or research reference.

The websites espousing false medical information may be second in number only to those espousing false political information. At times it seems that the more outlandish the claim the more readily their adherents will believe it. It doesn’t even seem to matter that this type of information is frequently published anonymously. You would think the readers would wonder why a person in possession of such great knowledge would refuse to take credit for it. They will frequently require you to make a purchase or enter a credit card number before you’re allowed in on the secret. Clear references from reliable sources are almost always absent. If they do refer to reliable sources, check and make sure their claims are actually backed up on the site they reference.

How do you evaluate reliable medical websites? First, they should have clear authorship; the site should identify the author(s) and their credentials. There should be frequent updates. Health information should be current. You should look for a publication or review date. There should be clear citations as reliable sites will provide references for their information. The site should be objective in tone; the content should be balanced and should not be focused on selling you something. And finally, reputable sites will have clear privacy policies on how they handle user data.

In summary, I want all my patients to be well informed and take an active interest in their health care. I encourage you to Google any medical questions you have. Just be sure that what you are reading is accurate and verified and scientifically based. Are the authors, their qualifications, and their affiliations clearly identified? Are reliable references cited? Has the article been peer reviewed by experts in the field? Is the article little more than a cleverly prepared sales pitch? Don’t allow conspiracy theories and “crackpot science” to have a detrimental effect on your health.

If in doubt, ask your doctor. If you don’t trust your doctor to give you factual information and prefer to consult with anonymous pseudo medical websites, then perhaps it’s time to find a new doctor. But please, think twice before disregarding the advice of someone whose entire professional life is dedicated to your good health.

Something To Make You Smile

By John Turley

On September 3, 2024

In Uncategorized

Despotism In America

By John Turley

On August 13, 2024

In History

Recently, I was listening to a series of lectures based on Democracy in America the classic review of politics and society in the United States during the 1830s. Alexis de Tocqueville (1805 – 1859) was a young Frenchman who visited the United States for nine months in 1831 and 1832. Ostensibly, he was here on behest of the French government to review the prison system. His personal goals were much broader.

He and a friend, Gustav de Beaumont, visited much of the United States. They interviewed citizens, reviewed documents, attended community meetings and observed federal, state, and local governmental activities of all branches: executive, legislative and judicial. They also collected books, newspapers, and documents. They visited cities and rural areas in the north and in the south. They even ventured as far as Wisconsin, then western edge of the American Frontier.

While they did produce a report on American prisons, which were then relatively progressive in the United States compared to the rest of the world, de Tocqueville had in mind all along that he would write a critique of the United States as he saw it. This eventually became a four-volume set published between 1835 and 1856.

I first became familiar with de Tocqueville when I read a much-abridged version of Democracy in America for an Early American History course. I believe it was probably about 250 pages. That is brief compared to the 926-page behemoth that I recently bought online.

I was interested not so much in what I remembered from my previous reading of his works as I was with what I didn’t remember. In particular, in one of his last chapters, de Tocqueville talks about the conditions under which despotism may arise in America.

As I have done previously with the writings of historic people, I’m going to present de Tocqueville’s writings in his own words without comment or analysis by me. Keep in mind that he wrote 180 years ago. It’s not as amazing that he got some things wrong, as it is how much insight he had into the problems that may potentially arise in America.

The excerpts in this post are from Book 4, Chapter 6: What Sort of Despotism Democratic Nations have to Fear.

I had remarked during my stay in the United States, the democratic state of society, similar to that of the Americans, might offer singular facilities for the establishment of despotism; and I perceived, upon my return to Europe, how much use had already been made by most of our rulers, of the notions, the sentiments, and the wants engendered by this same social condition, for the purpose of extending the circle of their power.

But it would seem, that if despotism were to be established among the democratic nations of our days it might assume a different character; It would be more extensive and more mild; It would degrade men without tormenting them.

I think then that the species of oppression by which democratic nations are menaced is unlike anything which ever existed before in the world: our contemporaries will find no prototypes in their memories. I’m trying myself to choose an expression which will accurately convey the whole of the idea I have formed of it, but in vain; the old words “despotism” and “tyranny “ are inappropriate: the thing itself is new; and since I cannot name, it I must attempt to define it.

The first thing that strikes the observation is an innumerable multitude of men all equal and alike incessantly endeavoring to procure the petty and poultry pleasures which they glut their lives. Each of them, living apart, is a stranger to the fate of all the rest – his children and his private friends constitute to him the whole world of mankind; as for the rest of his fellow citizens, he feels them not; exists but in himself and for himself alone; and if his kindred will remain with him, he may be said at any rate to have lost his country.

Above this race of men stands an immense and tutelary power… That power is absolute, minute, regular, provident, and mild. It would be like the authority of a parent, if, like that authority, its object was to prepare men for manhood; but it seeks on the contrary to keep them in perpetual childhood: it is well content that the people should rejoice, provided they think nothing but rejoicing.

… What remains, but to spare them all the cares of thinking and all the troubles of living?

After having thus successfully taken each member of the community into its powerful grasp, and fashioned them at will, the supreme power then extends its arm over the whole community. It covers the surface of society with a network of small, complicated rules, minute and uniform, though which the most original minds and the most energetic characters cannot penetrate, to rise above the crowd. The will of man is not shattered, but softened, bent, and guided: men are seldom forced to act but they’re constantly restrained from acting… It does not tyrannize but it compresses, innervates, extinguishes, and stupefies the people…

Subjugation in minor affairs breaks out every day, and is felt by the whole community indiscriminately. It does not drive men to resistance, but it crosses them at every turn, till they are led to surrender the exercise of their will.

It is in vain to summon the people, which has been rendered so dependent on the central power, to choose from time to time the representative of that power; this rare and brief exercise of their free choice, however important it may be, will not prevent them from gradually losing the facilities of thinking, feeling and acting for themselves and thus gradually falling below the level of humanity. It had that they will soon become incapable of exercising the great and only privilege which remains to them.

The nations of our time cannot prevent the conditions of men from becoming equal; but it depends upon themselves whether the principle of equality is to lead them to servitude or freedom, to knowledge or barbarism, to prosperity or to wretchedness.

The illustration at the beginning of this post is not intended to be a portrait of de Tocqueville, but rather illustrative of the time.

Understanding Medical Care Guidelines

By John Turley

On August 7, 2024

In Commentary, Medicine

An important discussion to have with your physician.

Trivia question: What are medical guidelines? Are they rules we must follow or are they simply suggestions or are they something in between?

As we get older and have more frequent visits to the doctor, we are bound to hear one of them say, “according to the guidelines”. To understand how the guidelines apply to you, it is important to know how and why they are developed. You also need to know if there are ever times when you shouldn’t follow them.

At the end of this article, I’ll tell you about my experience with one specific guideline, and how strictly following it possibly could have led to a bad outcome for me. But first, let’s learn a little more about medical guidelines.

Medical care guidelines, also called clinical guidelines, come in two general classes. There are guidelines for preventative care and guidelines for the management of disease processes.

Guidelines have several goals. They are intended to improve public health by recommending evidence-based preventive and treatment measures to help reduce the incidence and severity of disease and improve overall public wellbeing. They’re designed to optimize resource utilization by preventing unnecessary treatment and screening tests. They are also intended to reduce health care disparities by ensuring that all recommended treatments are widely available and are based on the most up-to-date evidence so that health care across the nation is at a uniformly high level of quality.

Sources of Guidelines

Preventative care guidelines have to do with such things as cancer screening, cardiovascular health, vaccinations and immunizations, and lifestyle improvement such as diet and exercise recommendations. Disease management guidelines are developed to ensure the best possible treatment for diseases such as hypertension, diabetes and pulmonary disease.

Guidelines are developed by physician groups such as the American College of Physicians and the American Academy of Pediatrics. They are also developed by advocacy groups such as the American Cancer Society and the American Diabetes Association. Government organizations such as the Centers for Disease Control and Prevention and the National Institutes of Health also develop and promulgate medical care guidelines.

The United States Preventative Services Task Force (USPSTF) is an independent panel of experts in prevention and evidence-based medicine. They issue recommendations on a wide range of preventive services including screenings, counseling and preventative medications. The USPSTF rates medical care recommendations from Grade A, those with a high certainty of substantial benefits, all the way to Grade D, those services that are not recommended due to having no benefit or having harm that outweighs benefits. Their recommendations can be viewed at www.uspreventiveservicestaskforce.org.

Preventative care guidelines

Preventive care guidelines are designed to help identify and mitigate potential health issues before they become significant problems. They help to ensure adequate screening for significant disease processes. They are also designed to help avoid unnecessary screening which may lead to unnecessary treatment and cost.

Preventative care guidelines include such things as mammogram recommendations, colonoscopy recommendations, blood pressure and cholesterol screening, and prostate cancer screening. Preventative care guidelines also include recommendations for vaccinations both for children and adults. Recommendations on diet and the use of vitamins and supplements are one area where the guidelines seem to change frequently.

Treatment guidelines

Treatment guidelines provide a roadmap for managing specific medical conditions. These recommendations encompass diagnostic procedures, therapeutic interventions, and follow-up care to ensure optimal patient outcomes.

Treatment guidelines include recommendations for such things as initiation of blood pressure management and diabetes management. They provide recommendations for diagnostic modalities and specific medications and dosages.

For example, treatment guidelines include blood pressure levels at which medication should be started, the goal of treatment and specific medication, depending on what other medical conditions the patient may have. Similarly, there are blood glucose management recommendations for diabetics that are tailored to specific patient populations. The use of bronchodilators and pulmonary rehabilitation and oxygen therapy for lung diseases are also the subject of a series of guidelines. Treatment guidelines continually evolve as new medications are developed and our understanding of disease processes improves.

Understanding the variability in guidelines.

While the guidelines developed by the various organizations share a common goal of improving patient care, their methodologies and focus areas can differ, reflecting diverse perspectives and priorities within the medical community. There’s not a single set of guidelines that are fixed across all specialties. While the various guidelines are generally in agreement, some may have slightly different recommendations for such things as the onset and aggressiveness in treating hypertension or diabetes. There may be variations in the guidelines for diagnostic testing such as mammograms or colonoscopies. For example, the USPSTF recommends biennial mammograms for women aged 50 to 74, whereas the American College of Surgeons advises annual mammograms starting at age 45 and transitioning to biennial screening at 55. The discrepancy lies in differing interpretations of the balance between benefits and harms of more frequent screenings.

Some guidelines may also become outdated, not reflecting new medications or new treatment plans. Even where there are variations, all guidelines strive to be evidence based, patient centered, and up to date.

Additionally, guidelines need to be individualized to meet the needs of each patient. The overall guidelines are based on the most effective health care for the population as a whole. Some patients may require specialized screening or treatment. For example, women who have a family history of early onset of breast cancer or of genetic mutations may require screening at an earlier age or more frequent screening. Men with a family history of prostate cancer at a young age or of a particularly aggressive prostate cancer may require earlier screening including biopsies or may need screening beyond the age that general guidelines recommend screening is no longer necessary.

My Experience

Several years ago, I received a diagnosis no one wants to hear. Cancer! Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for five years.

But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.

It starts with the PSA, the prostate specific antigen. This is something every man over 40 should know about and every man over 50 should consider getting checked.

So, what is the PSA? It is a protein that is produced by both cancerous and normal cells of the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test your family doctor can order as part of your annual work up.

What are the recommendations for the PSA? The USPSTF has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer. Please note the phrase “consideration of screening”. This is not a firm recommendation.

A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer. Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the prostate. It is possible, though unusual, that a cancer could be missed in the biopsy process

Additionally, most prostate cancer is very slow growing. Most men who have prostate cancer later in life will generally die of something else before they would die of prostate cancer. However, a small percentage of men will have a high-grade prostate cancer that can progress rapidly and cause their death.

I’m going to use my personal experience as a way of explaining why it is important to have a discussion with your physician about guidelines. The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a set of blood tests that we draw for people annually for their physical exam. I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.

My PSA came back slightly elevated. Since it was a very minor elevation, I followed the guidelines and waited six months and repeated it. At that time, it increased only a small amount. The guidelines suggested repeating it again in six months. I have to admit though, I have never been a wait-and-see kind of guy. I scheduled an appointment with a urologist.

The urologist and I discussed the options. He told me that the elevation was slight, and we could wait and repeat it in 6 months or if I wished we could do a biopsy. I decided on a biopsy and then after receiving the biopsy results and having further discussions, I eventually decided on surgery. It was my decision, as it should be, made in consultation with my physician and my family.

The post-operative pathology report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had extended beyond the capsule of the prostate. Fortunately for me it had not metastasized and had not spread to the lymph nodes, nor had it extended beyond the fat layer surrounding the prostate. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the outcome may have been different.

What’s the bottom line?

Does my experience mean that the guidelines should be ignored? Far from it, I made an informed decision, in conjunction with my physician, on what was best for me. Additionally, I have followed the guidelines in the management of my hypertension and high cholesterol.

Healthcare guidelines are essential in promoting preventive care and effective treatment and in helping clinicians provide high-quality, evidence-based care. But the guidelines are just that, guidelines they are not “set in stone” rules for healthcare. It’s important for you to discuss your health care with your physician. Be an informed health care consumer. Ask how the guidelines are being used to manage your health care and how they may be affected by your family history or personal history. You and your physician should be involved in joint decision making. Your individual plan will generally follow the guidelines while having some variation based on what is the best care for you. And that’s what the guidelines are all about, making sure we are able to provide the best possible health care for all of our citizens.

A Thought For Today

By John Turley

On August 1, 2024

In Commentary

A lie doesn’t become truth, wrong doesn’t become right, and evil doesn’t become good, just because it’s accepted by a majority.

–Booker T. Washington