American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, October 24, 2016

Bullets and the burden of innuendo

One of the favored arguments of the guns-for-all campaign is that the best response to a gun in the hand of a bad guy is a gun in the hand of a good guy.

Don't worry; I have no intention of taking us into any of the usual quagmires. I am not going to talk about rights, tyranny, the Constitution, or the meaning of a militia, let alone the placement of a comma. Rather, I want to confront something that should reside safely on common ground: the difference between a good guy, and a bad guy.

We obviously can't throw around those terms and not require them to mean something. If they do mean anything, we should be able to say what it is. Of course, it's possible that good guy and bad guy, in common with pornography and junk food, are easier to spot than to define. But let's try just the same.

I think one readily agreed upon distinction, as it pertains to the guns in hand with which we began, is that a bad guy cares a lot less about who s/he shoots than a good guy does. A bad good with a gun is, in order to be a bad guy, presumably willing to shoot a good guy. A bad guy with a gun is obviously willing to shoot another bad guy who isn't on the same team.

A good guy with a gun, in contrast, is obligated to care about who s/he shoots with it. I trust we can all agree that not caring who you shoot surrenders your right to be 1 of the good guys. That should be an easy one.

But now we have a potential problem with that original proposition. A bad guy has a gun, and is quite willing to use it and find out after, if ever, the particulars of the chap at the receiving end. A good guy with the very same gun, in order to be a good guy, has to verify those particulars quite carefully before pulling the trigger.

All other things being equal, it's pretty clear who is likely to win this shootout. But as I hinted at the start, this isn't about guns—it's about good and bad—so let's move on.

What's true of bullets is almost identically true of innuendo. A bad guy wielding verbal abuse and propaganda against an adversary doesn't have to check facts; they can just fire away. A good guy, whether seeking retaliation, or self-defense, or even a preemptive assault can't get away with that. If they try, they no longer qualify as a good guy. By definition, a good guy can't use the methods that make a bad guy bad. They can't just make stuff up.

This gets ominous for good guys pretty fast. Imagine that a bad guy, in service to their bad ways, finds bad things to say about a good guy they oppose. Imagine that what they say is distorted, and out of context, and more false than true, but with just a bit of truth for good measure. The good guy, though basically good, is nonetheless human and imperfect, of course.

The good guy, being good, feels obligated to address that bit of truth, however disproportionately small it may be, and whatever it may represent from human imperfection, to a loss of patience, to a slip of the tongue, to a lapse in judgment. As soon as they do, the bad guy, being bad, is at liberty to pounce, and shout: See! I told you so. His/her friends shout along, too, generally using social media as a megaphone, and amplifying the distortion.

But put the shoe on the other foot. Any given good guy may at times spin a tale in a direction they favor, or exaggerate. In general, though, they stick far closer to the objective truth than the bad guy because, again, if they didn't, they wouldn't be good in the first place.

So the good guy criticizes the bad guy with an argument that is mostly true. The bad guy's response? Deny it, and disparage it. Bad guys have a weapon in their arsenal that good guy's simply can't use: bad guys can lie about lying. They can lie about having lied about lying. Once you're good with being bad, there are no rules. It's a position that makes you practically bulletproof.

A good guy can't do this, because if ever they do, they are no longer good. This is all implied by Edmund Burke's famous admonition regarding evil in the world, but was consigned to the fine print.

My point, obviously, is that a hail of innuendo, like a hail of bullets, is apt to favor those who fire without compunction. Compunction is clearly part of what differentiates good guys from bad guys in the first place, in any definition worth considering.

If you've discerned that I might be writing from personal experience and proprietary passion, you are quite right. I am far from an exception to the rule about human imperfection, but I try very hard to be a good guy, and to do good in the world. When I want to know if I am trying hard enough, I look into the eyes of my wife and my children. I have fought the very fight I am describing- and despite the burdens of innuendo, have every intention of fighting on. But I do concede that at times, the burdens of innuendo are heavy.

Lately, I have had cause to think such burdens put me in some rather rarefied company. I'm not the only one to reflect in that direction.

Whatever else they may be, presidential candidates are humans, and thus subject to these same exigencies. But presidential candidates don't live normal routines. Their every gesture is scrutinized, and when opportune either to garnish or tarnish, amplified ad infinitum. It's as if some tiny epidermal blemish were blown up a thousand times and posted as your profile picture. Saying it was you wouldn't be false, exactly, but no one who knows you would recognize you.

The relevance? Not all “lies” are created equal. Finding some tendency to dissimulate in all concerned does not a draw make.

Consider the implications as the spirit moves you. As for me, I will be rooting for the good guys to win in the end, in spite of it all; doing my utmost to remain on the right team- and hoping no one gets shot.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

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One of the most popular anonymous blogs written by an emergency room physician.

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