INTRODUCTION

Bene ascolta chi la nota.
("He listens well who takes notes.")

-- Dante Inf. 15:99

My task, as your principal instructor in pathology, will be to teach you (1) the common ways the body fails, (2) the common ways the body responds to injury, (3) the common diseases, and (4) how to reason about disease.

Pathology's contribution to your grade-point average and licensure exam score is important. Although the foremost quality that residency programs consider is probably your reliability, your demonstration of pathology knowledge on exams is still important.

Further, you'll be bombarded with questions about pathology on rotations, and you'll be judged by your answers.

Understanding is the key. To succeed in this course, you must try to understand (when applicable) instead of just memorizing. The worst advice someone can give you is: "There's no time in medical school to understand principles, you must simply memorize".

This is not impossible. Most of us probably know more rock-and-roll lyrics than there are words in "Big Robbins". We learned the lyrics easily because we knew the tunes. The key concepts in pathology will be the tunes that enable us to learn the "little details" that we need for patient care.

You can learn because, and only because, you are able to say as you go along, "This makes sense."

THINK. Your licensure exam is intended to test you ability to think, as well as your knowledge base. Master the key concepts early. Preview the material for each lecture beforehand. After you hear a lecture or read a paragraph in a book, try to rephrase it (whisper, write) in your own words. Review the material in the evening following the lecture, while it is still fresh; this will save you time. Talk with your friends, and explain what you're learning to each other. And look at pictures early.

This seems to take more time. But it will save you time, even in the short run, because it is much more efficient. It's like running your motor with your car in gear, rather than in neutral.

My promise to you is that, if you spend an hour in one of my lectures, you'll get more out of it than if you'd spent the hour with your book. You'll see pictures, hear anecdotes, watch me make sketches, and walk away with an overview onto which you can place your after-hours learning. A lecture is more effective than reading a book only if it engages you. I will attempt to do this. What I will not do is read you my notes paragraph-by-paragraph. If this kind of "disorganized" lecture isn't to your taste, you're free to sit toward the back of the classroom and read to yourself instead, or read the newspaper, or whatever.

Only fools try teach skills in the lecture format. You'll actually DO pathology during the labs, and you'll remember these experiences years after you've forgotten the lectures.

{19409} slice of life hooked up to a computer

In the past, students who have had difficulty with pathology have often had one or more of the following identifiable problems.

• Falling behind and cramming. The medical students in the flick Gross Anatomy could do it, but that's Hollywood.

• Memorizing rather than understanding; passive learning instead of active learning. If your incredible short-term memory got you through "Organic Chemistry", it probably won't get you through "Pathology", which is a quantum leap more material. Find some way to organize the material to suit your learning style. (Some students have a sheet for each organ, dividing up categories of disease. This is just a start.) Never read over an unfamiliar word without looking up its meaning. If your learning system is going to break down, it will break down in here. (If you're worried about your brain failing, probably it's your learning system breaking down.) With all the synonyms and concepts, word-associations won't work. Get help early.

• Over-dependence on a study group. If you can't read for yourself, and pace yourself by asking your own questions, you are in trouble.

• A weak undergraduate background, perhaps due to factors listed above.

• After a bad experience of some kind, finding excuses not to study, and dumb things to do instead of studying (i.e., avoidant coping). This makes easy things hard and is, even in the short run, a life-ruiner. (See J. Nerv. Ment. Dis. 178: 525, 1990; Med. Educ. 31: 163, 1997).
• Problem relationships. This is a bad time to fall in love, or to go through a painful separation. This is a bad time to have to take care of a family member, or to be in a co-dependent or hostile-dependent relationship, to have a long commute, or to deal with a major family issue (financial crisis, sectarian problem, alcoholism, etc.)
Bachelors: As a medical student, you are an extremely desirable targets for sexual entrapment. This is a taboo subject but one with which you must be familiar for your very survival. If you do not know what the risk is, or how to protect yourself, please talk to somebody who does. I'm available.
• Studying with background music (or even talk-radio or TV). Music is a potent distractor. If you are in academic difficulty and you tell me you study with your music on, then don't ask me to believe that you are serious about your studies.
• Medications. It's worth mentioning here that benzodiazepines ("Valium" and family) often cause amnesia. If you take these "to help with your anxiety which is interfering with learning", you're asking for trouble. Likewise, avoid anything with the amnesic alkaloids atropine or scopolamine (i.e., some "dry up your nose" remedies). Using propranolol "for anxiety" probably isn't a good idea, etc., etc. And beware of "muscle relaxants".
• Problems with the English language. English is the language of modern medicine. If English is not your first language, it still must be the language in which you think about medicine. I strongly recommend that you speak English, and only English, at school and at home, even if this "offends" your family members. Right or wrong, patients will be totally unsympathetic to a student-doctor who isn't fluent in English. In particular, if you still tend to omit the "s" at the end of plural nouns, your patients will not accept you as a caregiver. They are right to feel this way. If you need help, have one of your classmates practice with you.

• Try to keep caffeine use to a minimum. It is mildly habituating, and there is a rebound tiredness-and-headache withdrawal syndrome. I suggest that, at least on weekends, you avoid the stuff altogether.

• Mild wiring problems. Some students may have mild reading or learning disabilities, or mild attention deficit disorder, that get unmasked by the intensive learning experience. There are people who can help diagnose and treat these problems.

• If you have an alcohol or chemical dependency, get help now.



• If you are developing obstructive sleep apnea, have some other parasomnia such as restless legs, or think you may have lupus, thyroid disease, or iron deficiency anemia, or have a real problem with allergy, get treated.

• If you have some other chronic or disabling illness (no need for a list), you may need to postpone your pathology education.

Cramming is the worst thing you can do, because the minute you get into it, you forget it.

-- Joe Montana

Further, you can't learn day-to-day unless you get enough sleep most nights.

There's a little bit written on pathology education, but not much (Hum. Path. 29: 750, 1998). If a medical school department responsible for the introductory pathology course "doesn't teach for the boards", perhaps the focus is on memorizing clinical protocols (Calgary: Acad. Med. 70: 186, 1993), or on current research, or the teaching is simply poor.

If public speaking is a problem for you, there's some great practical advice in Am. J. Nurs. 94(3): 64, Mar. 1994. advice on dealing with your fear in Nursing 21(8): 108, Aug. 1991, and bibliotherapy in J. Nerv. Ment. Dis. 178: 172, 1990, and Am. J. Psych. 151: 408, 1994. Fear of public speaking is extremely common and causes a lot of unhappiness: Arch. Gen. Psych. 53: 169, 1996. Even the surgeons, not noted for soft-heartedness, are screening their new students for public speaking phobia before they encounter disaster (Am. J. Surg. 176: 41, 1998). I'm no psychiatrist, but I suspect that paxil, propranolol, monoamine-oxidase inhibitors, and d-cycloserine (new wonder-drug for public-speaking: Arch. Gen. Psych. 63: 298, 2006) are less likely to help you in the long run than simply confronting your fear. Come in prepared. If you need, I'll even coach you some, and unlikely as it seems now, I'm nicer than the types you'll meet when you present next year in "Morning Report".

New skydivers may be told to put their anxiety in a bottle, and throw the bottle out of the plane just before they jump. Then chase the bottle and try to catch it on the way down. If this helps, I will take your bottle before you start.

In a study of year-one medical students (Acad. Med. 65: 586, 1990), the strongest quality-of-life predictor was strong social ties. You must work on keeping your social network in shape. If you are having difficulty, or don't know how, get good advice.

For one subgroup of students "at special risk", a no-nonsense trio of teachers found that the key is attitude: "injustice collecting / entitlement" fails, while "shut up, take-charge, work hard" succeeds ("locus of control" is what they call it; Acad. Med. 68(3), Webb letter). Surprised, America?

In any case, on the morning of the exam, if you are fairly certain you are going to fail (i.e., you haven't made it through the book or your notes), let the me know ahead of time. I'll worry less.

Can you love anyone without making him work hard? Can you do your best for anyone without educating him?

-- Confucius (Analects XIV.7)

Please feel free to interrupt lectures with questions. There are very few "stupid questions", only questioners who are foolish enough to remain lost. Don't take us too far afield during lecture, but otherwise, ask. However, please don't ask, "Is X associated with Y?" That's telling me you're cramming for a poorly-written multiple choice test, rather than trying to understand. Anyway, I use lots of synonyms on exams, so word-associations won't help much. You may ask, "What's the real relationship between X and Y?" That tells me you want to understand.

This pathologist would define health (after Freud) as the full physical and mental capacity to work, play, and love others, and disease (again after Freud) as internal problems that cause pain and/or interfere with a person's ability to work, play, and/or love others. I consider health to be a primary good, and will repeatedly say so. You may prefer a different definition, or not want to bother with a definition.

Note that this definition applies to disease in animals also (and perhaps even in plants). Many, if not most, of the diseases we'll discuss also occur in animals, and probably predate the human race.

Don't call changes that are not really health problems "diseases". Because of people losing their insurance, we now sign out biopsies showing "fibrocystic disease" of the breast as "fibrocystic change" instead.

Not everything we'll describe in this course is a disease. The big heart of an aerobic athlete is something a pathologist can describe, but is desirable, and no kind of a health problem. In the 1970's, the American Psychiatric Association had the good sense to remove homosexuality from the list of "diseases". Some "diseases" (i.e., sickle cell trait, hemochromatosis gene) are mixed blessings, other "diseases" (Gilbert's, XYY, thal minima) are basically lab curiosities, milder versions of Thomsen's "myotonia congenita" merely gives you big muscles without working out, a man may either love or hate his big-brown-hairy androgen-hyperresponsive Becker's nevus, some cultures did or do go gah-gah over left-handedness or thal-minor, and every skin pathology book has a description of freckles.

Top row: Achondroplasia (considered desirable in some cultures), baldness-hirsutism (considered attractive or unattractive), Becker's nevus, cross-dressing (stigma, unwanted compulsion, and/or source of enjoyment), deafness (many deaf resent being called handicapped, especially where sign language is widely spoken; this was intensely politicized in the late 1990's as some "multiculturalists" / "advocates for the deaf" tried very hard to prevent young children from obtaining cochlear implants), Ehlers-Danlos (the unusual joint structure may confer superior musical ability, as with Paganini), homosexuality (once a "disease", now mainstream) Bottom row: Gilbert's disease (an abnormal lab finding with no health consequences), hemochromatosis (fatal if neglected, but offers advantages), left-handedness (carries a tremendous stigma in some cultures, where the left-handed go to great lengths to conceal their "disease"), myotonia congenita, serial killer ("They look just like everybody else" -- Wednesday Addams), dissatisfied straight who'd like to be "bi" -- some adults are now asking psychiatrists for help with this (J. Homo. 15: 7, 1988), XYY "stereotype of the karyotype".

My own favorite example is William Blake, the great English artist, poet, and humanitarian thinker. Blake's "visions" and "voices" strongly suggest schizophrenia, and sometimes they terrified and baffled him. His contemporaries considered that Blake's "genius" and his "madness" (both of which were obvious) must be part of the same process. But even today, I don't think any reasonable person would consider Blake "diseased" or "disabled".

A disease process is one of the generic mechanisms common to many diseases, i.e., inflammation, mutation, multiplication of infectious organisms, edema, thrombosis, and so forth. Alternatively, it can mean "pathogenesis". There is little reason to use the term "disease process".

Pathophysiology literally means "how physiology is altered by disease". If you know physiology, you can easily tell what is going to happen when you understand the pathogenesis of a disease. As a result, the term has a special meaning in medical education -- a course in disease that de-emphasizes pictures, taught by physicians who are not pathologists or surgeons. Usually it is run by internists.

Some medical schools do this. The students end up without mental pictures, and with a lot of word-associations instead. This may be what you want if:
• you do not plan to look at the biopsies you take;
• you intend to skip over the tissue photos in journals;
• you don't plan to do surgery (because you'd need to know what you're seeing)
• you intend to approach x-ray interpretation as a rote memory task
• you prefer the special edition of "Sports Illustrated" without the pictures
• generally, if pictures don't help you make sense or remember.

Over 25 years as a medical school teacher has taught me that the common request, "Teach us more pathophysiology!" really means "Teach us physiology." I'm always honored, and we can always review normal "fiz" in lab.

At allied health schools, "pathophysiology" is the term for the course on disease, almost always directed by non-physicians.

In trivial-untreatable non-disease, the mainstay of therapy is education coupled with a sense of humor. A bodybuilder friend went from hating to loving his Becker's nevus upon receiving my advice: "Tell people that's where a bear licked you". A man with morphea is "Linoleum Man"; a man with treated hemochromatosis sports an "Iron Man" shirt; a man with multiple small lipomas "was conceived during a campfire-marshmallow-toast"; "My birthmark is an erogenous zone"; "Vitiligo? You have to pay extra for a two-tone chassis"; etc., etc.

Science and opinion. The first produces knowledge. The second produces ignorance.

-- Hippocrates, Laws of Healing

Public health, i.e., studying what influences, and how we might better influence, the health of our communities, is a proper part of a meaningful pathology course. I will be blunt. And you should be upset.

If I simply say, "Iodine deficiency causes goiter and lots of people are sick from this", it makes the world's poor folk sound foolish or indifferent. They aren't.

If I blame the goiter-belts' corrupt, moronic and tyrannical politicians, I am only telling the truth. There are not two sides to this business.

And the existence of widespread, crippling iodine, iron, and vitamin deficiencies in today's world offends me much more than the truth should offend you, Doctor.

Poverty, as used by social scientists, means a total income less than three times the cost of a varied, nutritious diet. Absolute poverty means total income less than the cost of a diet that will enable a person to work at maximum efficiency. Presently, one person in seven lives in absolute poverty.

"The developing world" is a euphemism for the poor nations. The causes of world hunger are complex, but it seems both cruel and patronizing to say "the developing world" when some (not all) of these countries are actually deteriorating. I prefer not to use the term, though again, this may "offend" someone.

One objective of this course is to help you understand popular and media claims about health and disease. Now's a good time to offer some more definitions. You'll want to know these for talking with your friends (and adversaries!) These are mine, but they work:

Science: Trying to learn about the world systematically, taking elaborate precautions against deception (especially self-deception). Advancing knowledge by testing hypotheses and developing theories, grounded in looking at the world as it really is.

Nature: The world of physics, chemistry, molecules, botany, zoology, astronomy, geology, human biology and pathobiology, the brain and its hard-wiring, the experiences and desires common to all human beings. Studied by the natural ("hard") sciences and general psychology.

Theory: An idea about the world that has consistently enabled people to make successful predictions. The round earth, the periodic table, the structure of the atom, the circulation of the blood, the earth orbiting the sun, plate tectonics, the genetic code, the expanding universe, Darwin's common descent of living things, Feynmann's quantum electrodynamics. Newton's and Maxwell's physics was true until Einstein's relativity and Planck's quantum theory added greater predictive power, and there have been further improvements.

Propagated error: Ill-grounded speculation or erroneous data that gets passed from author to author until it is ultimately corrected (and it will be). For several years after the first human karyotype, biology textbooks copied an original miscount and described 48 human chromosomes. Recently-corrected errors (each of which I called as such, years before their official correction) include the mechanism of action of selenium dandruff shampoo, herpes 8 cell proliferation being cancer ("Kaposi's sarcoma"), the rarity of primary progressive tuberculosis, and the 1960's and 1970's baloney about "sudden infant death syndrome". In my opinion, errors still in propagation include splinter hemorrhages as a sign of endocarditis, and the initial passage through the lungs of the deep cutaneous yeast infections. I will protect you from exam questions about these.

Pseudoscience: Using the language and authority of science, without using its methods. Astrology, Freudian psychoanalysis, Marxism, medical quackery, creation-science / "intelligent design" (in contrast to the religious-ethical doctrine of creation), hypnotic memory-enhancement, "dianetics", facilitated communication for autism (i.e., using autistic kids like ouija-boards), anti-immunization activism, anti-fluoridation activism, "contemporary gender theory", crackpot racial stuff, many others. Pseudoscience is about politics and big money. Dealing with pseudoscientists is distasteful and can be dangerous. Because their target audience wants to feel intellectually and morally superior and will not examine the subject fairly, pseudoscientists launch vicious personal attacks at anyone who tries to argue with them. Point out obvious untruths, and the discussion immediately turns into "Okay, we lied. You're still the bad guy. Now let's hear you explain this one...."

Junk science is one step above pseudoscience. It's a term, mostly used by lawyers, for poor natural-science (old studies, bad studies, discredited studies; also statistics and tables out of context as in pseudoscience) used in arguments directed at the public or in court. Real work is cited accurately, but very selectively and misleadingly. Much of this is obviously intentional by agitprop writers who have no reason to tell the truth. Today's grown-ups are well-aware of this, and generally (and rightly) dismiss "new information about health risks" and "warnings of impending environmental catastrophes" as junk science. This is regrettable, since this prevents the public from taking some real dangers seriously.

Sub-science: My term for disciplines that try to study areas of major human concern but in which the methods of science (measurement, experiments) are difficult to apply. Emotion and ideology come to dominate the practitioners, and since the sub-sciences have an enormous influence on politics, this is bad.

Much of "health maintenance", "mental health", "child protection", "psychology", "sociology", and "educational science" belong here.

Aphorisms are prominent in the sub-sciences and pseudosciences. These are statements that one wouldn't think are true, but that distill the passionately-held personal impressions that people decide are true BEFORE the usual methods of science have been applied. Aphorists usually claim that those who do not agree with them are wicked.

We've all heard these, and seen the damage they cause. "Children never lie about sexual abuse." "No one would lie about being raped." "Retinal hemorrhages with folds, near the macula, are pathognomonic of child abuse." "A baby cannot smother on bedclothes, on the mattress, or by overlying." "_____ will greatly improve race relations." "Nobody would intentionally smother a baby." "After a few years of communism, human nature will change." "This race / gender is virtuous and that race / gender is wicked." "This behavior must be / cannot be the result of emotional abuse / sexual abuse / political discrimination." "Dreams are wish-fulfillments to keep us asleep, and the symbols are sexual." "Children learn to read better if you forbid the study of phonics." "We are all born the same." "No mental patient truly requires long-term medication." "Criminals have low self-esteem and can be helped by efforts to raise their self-esteem." "The planets and zodiac predict character and destiny." "This particular authority cannot be in error / contain fiction."

Even Virchow's dictum that "cancer cannot arise in an epithelium" (!!) remains a monument to the human capacity for self-deception. (Virchow did not consider those who disagreed with this aphorism to be wicked. But his mistake did lead to disaster.)

Of course I find that this psychological mechanism explains many other instances of intolerance too. You need to decide for yourself.

Why do smart people persist in believing stupid things? They seek out confirmation and support for their emotionally-held beliefs, and supplying these is an industry (Sci. Am. 287(3): 35, Sept. 2002).

Literary "theory" is a special case; the current ideology is "il n'y a rien hors la texte", which is obviously not true, and what's happening right now to college English departments is lamentable. Today's "postmodernism" fad, especially as represented in the works of Michel Foucault ("the era's greatest intellectual"), appears to me to rest upon confusing sub-science (and the harm it does) and real science (and the real knowledge it produces). I have never met or seen anything by a postmodernist or "social constructionist" who actually seemed to know any science.

Culture: Behaviors and attitudes that are not hard-wired into human beings, but are passed along from generation to generation to enable us to live together in relative peace, health, security, and satisfaction, instead of merely living the way that animals live. Studied by the other "soft" sciences and especially the sub-sciences.

The culture war: Probably as ancient as our species, the three-way struggle for control of human culture by the Left, the Right, and the naïve naturalists. The usual tactic is to present whoever doesn't want what you want as an unreasonable extremist of one of the other two categories.

Ideology: Any stupid-unreasonable-unscientific idea that some people believe passionately. In our world, the ideologies do enormous harm and little good. Followers of ideologies are ideologues. (You may prefer "suckers", "ditto-heads", "dupes", or any of the other synonyms.) Leaders of ideological movements get money and/or political power. Followers find companionship and feel intellectually and morally superior, and without having to be kind or decent to those around them. Typically ideologues mean well, and they leave the movement when, and only when, they find out they've been deceived intentionally. In my experience, every human being with a mental age of 12 or higher is interested either in science, or in one of the ideologies. I strongly recommend science, not ideology, to people with the responsibility of looking after other people's health and guiding public opinion. You can talk to me about it if you want.

Malicious, cynical deception is rampant. Bearing on medicine alone, it's the basis of the entire anti-immunization movement, the HIV-doubters, militant vegetarianism, militant anti-biotechnology activism, and everything about "animal rights" that today's public actually sees. Gresham's law operates, and reasonable people are driven out, silenced, or ignored.
* No one likes doing animal work, and there is a good deal of ongoing effort to develop systems that can answer some of the same questions in other ways. Right or wrong, thanks to the militants, it is now more difficult to do research on animals than on people (BMJ 334: 182, 2007). The best review to date is Sci. Am. 294(1): 84, 2006.

Tolerating a diversity of opinions is fine. Giving respect to obvious lies is profoundly immoral. If you don't know this, you don't belong in medical school.

Politics: How people work with and against each other to distribute limited opportunities and resources. Especially in health care and education nowadays, every dollar that a special interest group demands is a dollar taken from somebody else. The fact that everybody prefers to ignore this basic truth explains many of the characteristics of public debate.

Right-wing (conservative) politics: Honest, thinking conservatives focus on how wealth and opportunities are created and defended, rather than how they are distributed. Distinguish good, decent conservatives from right-wing ideologues (traditional anti-science-religionists, majority-culture racists-sexists-hatemongers, the anti-contraception crowd, the folks responsible for apartheid, today's pseudo-Christian mudslingers and pseudo-Islamic terrorists, etc.) Each of these ideologies is a public health problem.

Right-wing ideologues, being unreasonable and having their facts wrong, claim moral superiority and attack science and reason; almost without exception, they claim to be motivated by religious zeal. Right-wing ideologues portray honest, reasonable people as diabolic.

Good, decent conservatives look to science as the means to a higher standard of living, plus personal and national security. Think about it.

Left-wing (liberal) politics: Honest, thinking liberals focus on getting wealth and opportunities redistributed by the government, rather than creating or defending them. Distinguish good, decent liberals from left-wing ideologues (anti-science nature-mystics, minority-group racists-sexists-hatemongers, the "entitlement-rights-victims-political-correctness" crowd, the drug crowd, the animal-liberation folks, the magic-thinking brand of environmentalism, the folks responsible for communism, etc.) Each of these ideologies is a public health problem.

Good, decent liberals look to science as the means of ensuring a safe, clean environment, and the way to counter the ignorance and lies that form the underpinnings of prejudice and actual injustice. Think about it.

Left-wing ideologues, being unreasonable and having their facts wrong, claim moral superiority and attack science and reason; this is almost always in the name of the poor, the oppressed, the women, the minorities, and the alienated. Left-wing ideologues portray honest, reasonable people as wicked oppressors of the helpless downtrodden.

Today's postmodernists take early-1900's psychiatry at its least scientific (which really WAS institutionalized pseudo-knowledge that often wrongly stigmatized and oppressed people) as the prototype of medicine. It seems to me that these people are wrong to apply their analysis of stupid sub-science to genuine science and human reason.

Left-wing ideologues, who pretend to be "scientific", typically use the word theory when they mean "ideology". For the failure of "gender theory" to predict findings about sexual violence, see Violence & Victims 9: 95, 1994, Int. J. Law & Psych. 14: 47, 1991, the only two empirical studies on medline. The term "gender theory", once widely-used, has now vanished from the medical literature. The other favorite militant-Left term, "critique", is more of an admission that we're doing propaganda, not science.

Religion: Whatever people think deals with matters of ultimate concern. Various religions have varying contributions from science, ideology, secular philosophy, and revelation (whatever the latter is). Some definitions of religion would require some belief in the supernatural (i.e., causes outside the familiar subject-matter of science); other definitions would not.

Naïve naturalism (scientific reductionism): Two reasonable terms for the attitude (common but by no means the norm among scientists or those who admire science) that the extraordinary success of the natural sciences in adding to human knowledge and power means that human ideas about "the transcendent", "God", and so forth must be untrue.

Especially at high levels, scientists do tend to be much less likely to profess orthodox religion (i.e., to pray expecting results, and to believe in an afterlife): Sci. Am. 281(3): 88, Sept. 1999.

"The naturalistic fallacy", sometimes put forward by (and more often falsely attributed to) science-oriented people is this: "Because something happens this way in nature, therefore it should happen this way in human society."

The task of science, therefore, is not to atttack the objects of faith, but to establish the limits beyond which knowledge cannot go and to found a unified self-consciousness within these limits.

-- Virchow

Ethics: Trying to understand what we mean when we say "right" and "wrong", and why. Its real purpose in a pluralistic society like ours is to influence politics (i.e., trying to influence who gets what limited resources and opportunities, through selective moral indignation). Private work in ethics, i.e., the hospital ethics committee, usually focuses on finding precedents and common-sense for defending yourself when you're trying to do the right thing and/or the expedient thing and protect yourself in the process. By contrast, public discussions of "ethics" are often (not always) as one-sided and unreasonable as those from the most intolerant and dogmatic religionists. As you already know, ideologues always present themselves as highly moral, and their opponents (scientific thinkers, ideologues of other camps) as evil, venal, and immoral. Science acting alone cannot tell you what's right or wrong, but the best way I know to end up making a bad decision is to pretend that the world is something that it isn't, i.e., to ignore scientific knowledge. And it's been my experience that this is exactly where most (not all) public discussions of "ethics" are conducted -- in an atmosphere of make-believe and mud-slinging.

Great villains believe they're right.

-- Jean-Claude Van Damme, KC Star 12-23-95

Never underestimate the power of very stupid people in large groups.

-- Author unknown

When all think alike, then no one is thinking.

-- Author Unknown

The best lack all conviction, while the worst
Are full of passionate intensity.

-- Yeats

We thought, because we had power, we had wisdom.

-- Stephen Vincent Benet, "Litany for Dictatorships" (1935)

Mundus Vult Decipi.
The world wants to be deceived.

-- Latin Proverb (Martin Luther?)

It isn't what we don't know that gives us trouble, it's what we know that ain't so.

-- Will Rogers

Against stupidity, the gods themselves struggle in vain.

-- Schiller, "Maid of Orleans"

Believing is easier than thinking. Hence so many more believers than thinkers.

-- Bruce Calvert, mathematician

Opinions founded on prejudice are always sustained with the greatest violence.

-- Hebrew Proverb

A person about to speak the truth should keep one foot in the stirrup.

-- Mongolian Saying

Hoax: Deliberately falsified evidence, usually concerning something of grave importance, almost always targeting left-wingers or right-wingers. Important hoaxes in recent times include Carlos Castañeda's non-existent Yaqui sorcerers (he could not produce his field notes, acquaintances say he spent his time in the library reading books on shamanism, real Yaqui experts say they're obviously fake, and real Indians were outraged), the Paluxy River footprints "that proved humans lived at the same time with dinosaurs" (the creationists who carved the best ones confessed long ago, and this kind of fabrication is typical of classic "creation science"...), the Calavaras skull (a human skull supposedly found in very old strata; the "scientific source" for this often-cited "evidence for creation" is an old tabloid newspaper), the "Amityville Horror" fabrication (when the book wouldn't sell as horror-fiction, the author repackaged it as fact), Ferdinand Marcos's "gentle Tasaday tribe" (slum-dwellers transported to the jungle, talking their version of pig-Latin; the perpetrators targeted left-wingers who wanted to believe that a community could survive "in peace and harmony with nature" and without knowing how to fight, and the real anthropologists knew right away that it was a fraud because there was no "kitchen midden", i.e., no garbage dump), everything about Laetrile (right-wingers getting rich off other right-wingers), the popular books supposedly written by former members of powerful satanic cults ("Satan Seller" by Mike Warnke, "Michelle Remembers" by Michelle Smith, others; I'm pleased to note that these people were all exposed as fakes by their fellow-Evangelicals), Immanuel Velikovsky (didn't take college physics, and it shows), the Bermuda Triangle (Lawrence David Kusche took a year out of his life to examine the actual records of the supposed mysterious disappearances, and of course the accounts in the big-money books were massively falsified), and T. Lobsang Rampa's entire body of writings (when "the high Tibetan lama" turned out to be a Mr. Cyril Hoskins, the son of an English plumber, he claimed a "soul transplant" but could not read or speak a word of Tibetan). I would have liked to believe that Alex Haley had indeed miraculously traced his "roots" to Gambia, but the court proceedings brought out the sad truth about his elaborate, utterly cynical racial hoax. Sun films' documentary on the discovery of Noah's Ark (shown on TV in 1993) was the end-result of a skeptic's successful effort to demonstrate the lack of scientific standards at the most influential creationist organization; the "wood from the ark" was store-bought lumber steeped and boiled in teriyaki sauce, and a sniff would have been enough to reveal the hoax (let alone some honest tests on the wood). The famous "multiple-personality disorder" patient "Sibyl" was shown in 1998 to have been induced under hypnosis after a psychologist reviewed audiotapes between the therapist and the book author. The book helped cause the disastrous "repressed memories" fiasco of the 1980's to mid-1990's, which ended with tens of thousands of ruined families and huge successful legal judgments against therapists who had induced false memories. Fox TV's 2001 piece on the moon landings being faked was itself a masterpiece of bunko artistry (how it was done: Sci. Am. June 2001). During the 2005 "Intelligent Design" trial, it became clear that Michael Behe, the only scientist who ended up willing to testify under oath, knew that his claims about the "irreducible complexity" of the clotting cascade were fallacies. "Historical revisionism" (holocaust-denial), crackpot biology (left-wing, right-wing), and most of the Kennedy assassination conspiracy theories are built on lesser hoaxes (along with fallacies and personality smears, of course). Scientists are much harder to fool, and in spite of what you've been told, most didn't make much of "Piltdown man" even decades ago. As physicians, you need to be able to recognize hoaxes, preferably before they are exposed. Your patients will ask you about them.

The impact of disease on humankind is tremendous. The subject is never "just academic". Each of us will have some first-hand experience with the content of a "pathology" course.

The citizens of today's western democracies are the healthiest humans who have ever lived. This is due almost entirely to the knowledge, technology, and improved standard of living produced by the much-maligned "dominant culture" characterized (at its best) by an emphasis on science, personal liberty, democratic government, free enterprise, and the work ethic. Contrary to what you may have been told (by "liberals", "greens", or "conservatives"; some of the latter still lie about the "healthy Hunza people of the far Himalayas"), we are far healthier than "indigenous peoples", past or present (pull up "indigenous people / tribes / tribal" on the medline if you don't believe me).

* Something's just not right -- our air is clean, our water is pure, we all get plenty of exercise, everything we eat is organic and free-range, and yet nobody lives past thirty.

-- Two cave men
   New Yorker cartoon, 2006

How the "Hunza" crock was perpetrated on the public is reviewed at length in Dan Georgakas's "The Methuselah Factors". The Hunza community itself played to the West's Shangri-La fantasies.

In the 1990's, we heard a tremendous amount about "cultural relativism" and "multiculturalism." Your lecturer (who gives his race as "human" and thinks everybody should do the same) appreciates multiculturalism, or what is left of it, so long as its proponents are understanders, peacemakers and enrichers (like in their rhetoric).

The term "multiculturalism" has been also been popular with pseudoscientists, "theorists" without data (know the type?), stereotypers, and neo-segregationists. Thankfully, this never had much impact on medicine. And please be careful. No matter who you are, there are people who are looking for the flimsiest excuse to portray you (yes, you) as some kind of malicious bigot. As someone involved with science, you must be especially careful talking to "journalists" that you do not know well..

Multiculturalists begin by observing how human attitudes and behaviors differ from culture to culture. Ideological multiculturalism jumps to the conclusion that all of our beliefs and behaviors are culturally determined. This is contrary to common sense, common experience, and a large body of empirical evidence from field anthropologists about what all human cultures have in common. The benign ones include trying to appease divine beings, having fashions in hair styles, having group sing-alongs, seeking privacy for toilet functions, and (I've been told) the nyah-nyah tune with which children taunt a hapless peer. And despite your lecturer's admiration for humankind in all our rich diversity((he hopes you will reject the a priori claim that "You should not judge another's cultural practice or belief about the world." (Nowadays, new moral imperatives are a dime a dozen, and they can't all be right.) You may find this articulated on college campuses, though not much in the hard sciences. I have noticed that since 9/11/01, the movement off-campus seems to have ended.

Today, the word "multicultural" in an article by and for physicians is usually is a euphemism for "multiracial" / "multiethnic", while the word "multiculturalism" has nearly vanished except in lists of supposed professional virtues (Acad. Med. 80: 366, 2005). Martin Luther King's dream was of a colorblind America, and today most people who are really trying to reduce racial prejudice try to de-emphasize categories and focus on what we all have in common (J. Pers. Soc. Psych. 78: 635, 2000). How the "multiculturalism" collapsed in the democracies without even the Left being unhappy: Br. J. Soc. 55: 237, 2004 ("inherent deficits and failures of multiculturalism policies, especially in socio-economic respect...")

As a physician, you'll do well to learn something about the idiosyncrasies of ethnic groups, especially those that may impact on how you communicate with each other and whether they comply with your instructions. Presumably you're already a good enough listener and human being to respect what people tell you they want. Even the sociologists and anthropologists (the disciplines most famous for radical multiculturalism) now tell physicians, "Engaging with other cultures does not imply that all cultural norms should be accepted uncritically, as there may not always be room for compromise" (no kidding; Med. J. Aust. 176: 174, 2002). When Yale (not exactly a bastion of social conservatism) teaches multiculturalism to its medical students, they just hear about what communications styles and techniques might work best, and about possible attitudes toward disease that might help or hinder therapy (Acad. Med. 72: 428, 1997). Despite laments that most medical schools do not have "separate courses addressing cultural issues" (Acad. Med. 75: 451, 2000), I would not want to see a medical school teacher stand up and say "You need to know that ____ people believe ____, ____, ____, and ____, and they do ____, ____, ____, and ____, so as a doctor you must ____, _____, ____, and ____ with them."

Actually looking at the influence of "culture" on health and disease does not always show humankind at its best. ____ men object vehemently to their wives doing breast self-exam. If a man of the _____ culture fails economically, his family discards him. ____ intravenous drug-users generally refuse to use condoms. In the country of ____, the active partner in a homosexual relationship is perfectly acceptable, while the passive partner is a social outcast. In modern industrial nation of ____, there has never been an organ transplant surgery simply because people don't care about people they don't know. "In [the country of] ___, young people who suspect they may be infected with HIV will avoid a definite diagnosis while at the same time seek to spread the infection as widely as possible." And so on. See JAMA 285: 1075, 2001; Med. Anthro. 17: 363, 1997; many others. And if "all cultures are of equal value" or "you cannot judge another culture", how can we talk about our own civilization having made moral progress over the years, say by banning slavery or by giving women the vote?

One more note for health-care providers interested in the "multiculturalism" business: Don't fall into the trap of telling someone else, "You are of thus-and-such culture, therefore you are/want/believe thus-and-so." You will end up looking as foolish as the physician who was forced to disclaim, "All persons must be treated as individuals first, not as stereotyped members of a cultural group" (West. J. Med. 158: 201, 1993 for the not-at-all-funny story). I note with pleasure that even the ideologically-minded nurses are now repudiating ideological multiculturalism in favor of truth and common sense (Nurs. Inquiry 3: 3, 1996; J. Adv. Nurs. 23: 564, 1996; J. Prof. Nurs. 12: 159, 1996; the latter prefers "a transcultural ethics grounded in moderate realism"). Most recently, medical students overwhelmingly reject the sort of "cultural sensitivity training" that plays politics and/or pigeonholes people (article contains euphemisms: Acad. Med. 78: 1191, 2003).

The improvement of medicine will eventually prolong human life, but the improvement of social conditions can achieve this result more rapidly and more successfully.

-- Virchow

Following Rudolf Virchow's lead, your lecturer believes that good health is a fundamental value basic to all of humankind, and therefore hopes you will reject supposed "cultural values" that will predictably lead to impaired function / poor health (my list, closely modelled on Dr. Virchow's work):

• torture, mutilation, child abuse, slavery (in today's world it exists where there is anarchy or corrupt government: Sci. Am. 284(4): 80, April 2002), and mistreatment of the sick, by whatever names these vile practices are called and however they are supposedly justified;

• rejection of real democracy, whether in the name of "security", "cherished cultural traditions", "religion", "empowerment and liberation", or some stupid right-wing or left-wing ideology;

• preventing the free exchange of information about, and inquiry into, the world as it really is; promoting stupidity, ignorance, lies, and prejudices of whatever kind, even in the name of "spirituality", "caring", "love", "defending the helpless innocent", "promoting self-esteem", and so forth;

• making decisions affecting others based on bad information ("witch hunts" of any kind, refusing rational medical care, lack of sanitation, unsound diets, and so forth);

• genuine and actual oppression of women and minorities;
• lack of reasonable access to health care;
• preventing, or otherwise discouraging, people from practicing contraception in order to limit the number of their children to what they can afford;
• lack of opportunity to obtain useful education and job training, to choose one's own career based on one's real interests, ambitions, and abilities, and to become fluent in the common language of education, government, and trade;
• lack of reasonable security of person and property;
• lack of opportunity or incentive to save and invest money, and to use land and resources efficiently; absentee landlordism; heavy-duty socialism;
• failing to reward, or actually punishing, extra effort in school or at work; preventing people from profiting from their individual skills, good ideas, research, and inventions;
• the stupid, futile wars that result from all the above (your lecturer would include our hopeless "war on drugs" in this list, as well as all the current international and civil armed conflicts; some reasonable people will disagree with this particular listing)
• alcohol abuse;
• tobacco abuse (i.e., anything but a good peace-pipe).

These world-level political-social problems are the over-riding causes of both ill-health and general misery on our planet. No "culture" (or any other group) has a monopoly on good or evil; but the next time someone tells you that "All cultures are of equal value", compare the number of people trying to enter, and trying to escape from, the U.S., Canada, and Western Europe. Then be grateful.

To clarify: I know no secular meaning for the word "value" except as a statement of what real-life people want. "Multiculturalism" or no, "values clarification" or no, really get to know your neighbor "across cultural lines" and you'll almost always meet someone who wants the same things you do. These begin with good health, economic opportunity, personal self-determination, and respect. Etiquette and buzz-words differ among ethnic groups, and a good physician learns to avoid misunderstandings.

Your lecturer first placed these thoughts online in 1994. They are echoed especially in Ruth Macklin's "Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine". Prof. Macklin comes up with pretty much the same ideas as your instructor: humaneness (i.e., being healthy rather than in pain) and humanity (i.e., having others allow you to choose your own path). See also Health Care Analysis 8: 321, 2000; Soc. Sci. Med. 60: 1347, 2005 (the author in this traditionally far-left wing journal says, "Get them healthy and just claim you're not interfering with their 'culture'").