medical ethics

So, what if the solution came along?

Posted on August 1, 2011. Filed under: medical ethics, Medical marketing, Protandim, Self-deception |

Nothing here since January, 2009! Why? I’m reminded of the parents who had a child who never spoke. They took him to pediatricians, speech therapists, witch doctors: everyone they thought could help. Not a syllable came forth. They accepted that he was mute, and got on with it. One day at breakfast, when the child was six years old, he said, “This toast is burnt.” The parents almost collapsed, and with tears in her eyes, the mom said, “Johnny, you can talk!” The child responded, “Of course I can talk; I’m six years old.” Bewildered, his mom asked, “So, why haven’t you ever said anything before?” Without hesitation, the boy replied, “Up ’til now, everything’s been OK.”

So, here’s the deal. I wrote a number of posts in 2008 and 2009 about the medical profession and medical marketing.The blog generated about 10,000 hits, but not much discussion. At the time, I didn’t have anything else to say that I felt was important or revelatory. Now I do. If you have ever read my posts, you know that I am searching, and that I am a student of bias. I rejoice in learning how things work: not how they seem to work, nor how we would like for them to work, nor what the majority thinks about how things work, but how the evidence describes how things work.

Enter Nrf2. Nrf2 is an abbreviation for Nuclear factor (erythroid-derived 2)-like 2, also known as NFE2L2. Your doctor knows this, right? Wrong! When we matriculate into medical school, our teachers typically are not medical doctors, but PhD’s, who have extensive, up-to-the-minute knowledge of their niche. Among the first things they teach us are these two:

  • a vocabulary that is the equivalent of a foreign language, and like any foreign language, it is mastered when the words themselves cause concepts to appear in the brain without translation.
  • basic medical sciences.

Your doctor (and I) have mastered the vocablulary.We can read the peer-reviewed articles, and we have at least the potential to understand what they say. But the basic sciences? There are few practicing physicians who could pass a current freshman medical school test on any of the basic sciences, and the  information is changing at an almost exponential rate. Nrf2 is one of those things that basic scientists, in this case, biochemists, know about that your doctor does not.

Here’s the story. Did you know that oxygen is the source of our ultimate demise? We have to have it to survive, and to create the energy we use daily. But, in producing that energy, one of the products is a nefarious substance called “reactive oxygen species” (ROS). ROS will kill any oxygen-dependent organism. So, it is not surprising that all aerobes have evolved a method for dealing with these destructive ROS “free radicals”. The 25,000 or so genes in the human genome include 4-6 thousand genes that have evolved specifically to deal with ROS. That’s about a quarter of all the instructions that make us who and what we are. How do they do this? By up-regulation of protective enzymes that neutralize ROS, and by down-regulation of associated inflammatory and fibrotic processes stimulated by ROS. This is important. For me, it is revelatory. For your doctor? Maybe not so much.

It was a biochemist who first discovered the protective enzyme, SOD (superoxide dismutase). His name is Joe McCord. Your doctor has his own Wikipedia page, right? As Dr. McCord puts it, the discovery of SOD was the beginning of the solution, but no one knew the problem it solved. And what is the problem? Aging and degeneration itself! What is aging? Surprisingly, to a biochemist/medical school professor like Joe McCord, aging is defined as a ratio. The numerator is the level of protective antioxidant enzymes one’s genes produce, and the denominator is the amount of oxygen one consumes. Up until about the age of 18 -20 years, that ratio in genetically “normal” folks is such that very little degeneration occurs. You’ll starve if you are a doctor specializing in teen-age heart attacks, strokes, hypertension, osteoarthritis, type 2 diabetes, Alzheimer’s, Parkinson’s Disease, coronary bypasses and stents (continue the list to include almost everything non-infectious that eventually gets us), but you’ll be overworked with the same disorders if your field is geriatrics. Why? The ratio of protective enzymes to destructive ROS declines as we age, and oxygen gradually destroys us all.

What if we could stimulate our genes to rev up the protective enzyme levels to what they were when we were young? It would make front-page headlines! Fox News and PBS would find common ground featuring it! Your doctor would be calling YOU to make sure you were aware of this wellness breakthrough! NOT!!

Nrf2 was described and isolated in 1994. It’s role as the key activator for all the “survival genes” has been known to biochemists for over 10 years. There are 2088 peer-reviewed articles about it (as of today) listed on the National Institutes of Health website, Researchers in both independent university roles and as employees of pharmaceutical companies have been frantically searching for methods to activate Nrf2 safely, both to prevent and to treat the ravages of human physical degeneration. It could play a major role in reducing our runaway healthcare costs. EVERYONE’S TALKING ABOUT IT.

Well, maybe not. In fact, among all my physician friends to whom I have mentioned Nrf2, only one has ever heard of it. Furthermore, that one physician is the only one of my doctor friends who seems remotely interested in the concept. What’s going on here?! Artificial-intelligence researcher Eliezer Yudkowsky has observed: You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion. Our medical education system stops teaching science and the scientific method after the early years of medical school; from then on, we learn and memorize prescribed solutions for various problematic scenarios.The system eschews independent thought and investigation. In fact, we are held legally liable for employing methods that deviate from the accepted norms. Those norms come down to practicing physicians through established channels, as I’ve previously mentioned here, herehere, and here. Currently, none of the established channels involves Nrf2 nor its activation, and few doctors make the effort to search for the truth within the confusion.

Enter what I will call a form of “intellectual attribution bias”. According to Michael Shermer in his book, Why People Believe Weird Things, because of this cognitive bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are other people’s position, which they will attribute to emotional reasons. Although major pharmaceutical companies are trying to develop synthetic Nrf2 activators as prescription drugs, the only currently available clinically effective Nrf2 activator is a compound of natural phytonutrients called Protandim. It is classified by the FDA not as a drug, but as a dietary supplement, and it is available not by prescription or in pharmacies, but only through network marketing.

In spite of peer-reviewed studies listed on documenting the compound’s ability to raise Nrf2 activation to unprecedented levels, and subsequently lower oxidative stress to unprecedented levels, practicing physicians are not likely to give it any credence because it doesn’t fit in the mold of their established channels of information. Their position seems to be: “I am an expert, and I haven’t heard of Nrf2 activation. Now you’re telling me that a network marketed supplement could be the most important advancement yet in my own specialty, and I don’t know about it? It’s bulls**t.”

UPDATE: Biogen’s synthetic Nrf2-activator drug Tecfidera was approved in the Spring of 2013 for the treatment of Multiple Sclerosis. Available by prescription only at a cost of about $50,000 annually. Biogen’s research shows that Tecfidera has about 50% of the Nrf2 activation of the natural-ingredient compound, Protandim, which costs $40/month, without Tecfidera’s side-effects.

Here’s an exercise your doctor hasn’t done: go to, and in the search box enter “Nrf2” followed by the name of any disorder that interests you, e.g., “Nrf2 diabetes”. As one enters disorder after disorder, and sees the scientifically documented correlation with levels of Nrf2 activity, one comes to realize that we have evolved to deal with oxygen consumption in a healthy way until we reach the years of reproduction, and then our Nrf2 activity drops off and we begin to die. We can begin to control that now by controlling Nrf2 activation. Doctors treat symptoms and the results of disease. Nrf2 activation removes the cause. The solution, or the beginning of it, has come along: Nrf2 activation. Your doctor doesn’t know about it. Tell him/her. He’ll tell you it’s bulls**t.

If you want to know more, click on “contact retired urologist” at the top of the page and send me a message. Or educate yourself at ABCliveit.

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It’s Big Business!

Posted on January 5, 2009. Filed under: medical ethics, Medical marketing, Sexual issues |

On his blog, Science-Based Medicine, Dr. David Gorski posted about the pharmaceutical marketing technique of “seeding trials”. I had participated in one such ruse, although I was unaware that it had its own official name. As I commented to Dr. Gorski:

Fascinating article. I had never heard the term, “seed trial”, but the one in which I participated was similar to Merck’s.

My practice was exclusively limited to male sexual dysfunction for over 20 years, so when Pfizer came to me to participate in the VIGOR pre-market “clinical research” on Viagra, I assumed it was related to my expertise. Their final application for FDA approval had already been submitted, but the release date was pending the FDA’s action. By regulation, they could not detail the drug to doctors, nor even discuss it, unless the doctor was conducting “clinical research” in a pre-market trial. I was assigned only 10 patients (”to eliminate biases”), paid $1000 each for my inconvenience and expertise, and assigned an “FDA compliance consultant” who flew to my office several times, supervising every word that my “study director” (my nurse wife) entered into the forms. Both being participants, my wife and I were sent to “The Dolphin” hotel at Disney World to discuss the “research” with the other “investigators”. Airport-to-hotel limo, etc., plus an honorarium for attending. I expected some sort of round-table arrangement for the discussion; in actuality, it was held in the completely-filled grand ballroom. Other “investigator meetings” were being held around the country, and there were many others both before and after the one I attended. The only thing the investigators had in common was an American license to practice medicine. Criteria for patient enrollment were: male under 65, no anti-hypertensives, no diabetes, no hx of CAD or PVD, no physically-detectable penile abnormalities, and no previous evaluation for ED (a more pleasant term the Pfizer CEO commissioned to replace “impotence”). In other words, it was designed for 100% positive response. Before the study actually ended, Viagra was released. I never heard anything further about the study, and I don’t find much when I Google “VIGOR Viagra”, except ads.

At the time (I was told), the marketing branch of Pfizer estimated that the first-year Viagra market was $3 billion (it wasn’t, but that was their best data). That’s $8.2 million per day (counting only work days, it’s $13.6 million). By having a fully-detailed prescription-writing corps of doctors on release day, they could readily afford the costs of the elaborate “pre-market trial”, versus the months of non-productive days by having reps come around and detail “cold” docs after the release. They couldn’t afford not to have the “trials”.

My ethics in the issue are suspect, to be sure. I justified it by saying that I already knew all about the drug, there were no competitors, it filled a necessary niche (previously unaddressed) for my patients, and I was going to prescribe it anyway. Mea culpa.

But I was misled, right? Do I have to give back the money?

This fits right in with economist David J. Balan’s recent post on Overcoming Bias entitled “It is Simply No Longer Possible to Believe”. The basis for his post was this article by Dr. Marcia Angell, fomer editor-in-chief of the New England Journal of Medicine. If you have bothered to read this far, you owe it to yourself to read Dr. Angell’s treatise. I did, and I am so embarrassed for my profession.



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Kind vs. Kindly

Posted on November 14, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medico-legal issues |

I’m altruistic, which isn’t the same thing as being kindly. I hold doors open for little old ladies. That’s not the same as liking the people I meet. Eliezer Yudkowsky

You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion.  It is not any different in AGI.Eliezer Yudkowsky

There is a dominant part of me that believes one should never be punished for telling the truth. But that’s not realistic, is it? And so the conflict. Rational thought and behavior trumps etiquette, yet much of life (the way it is actually lived) requires going along to get along.

Suppose a doctor happened to possess a combination of the qualities Yudkowsky describes: an altruist with extraordinary clarity of mind and the power to find truth within confusion. That’s what you’d want in a doctor, right? Apparently not, if public record is of any significance. In fact, I would go so far as to predict that such a doctor would have a miserable litany of malpractice tort actions. Note that I did not say “a miserable record of acts of malpractice.” There is a wide berth between actual malpractice and a tort claim of malpractice.

While it may be quite an unpopular concept, I am persuaded that there exists an independent, sometimes antithetical, relationship between true altruism and kindliness. But try to conduct a medical practice based on true altruism and rational principles: you will be among the leaders in malpractice tort actions. The reason: the altruistic action may not seem like a kind action.

The actual practice of medicine is structured around historical outcomes, either clinically or experimentally. The inescapable problem is that no one knows exactly how humans work. There aren’t any treatments that always work. Consequently, the best-intentioned, most conscientious doctor, the one with extraordinary clarity of mind and the power to find truth within confusion, gets bad results. Since it is not truly science, there is always someone who will say the outcome would have been better if so-and-so. And the tort process begins. Unfortunately, not all doctors are like the one described. They are likely to create even worse outcomes. So, naturally, they will experience even more malpractice claims, right? Not necessarily.

Most instances of actual malpractice do not result in litigation; there are so many available references to this that I am not citing one. What converts a patient into a plaintiff? According to the loss-prevention program of my malpractice insurer, plaintiff polls show that the most important factor is the doctor’s attitude. Kindliness and empathy trump clarity of mind and the power to find truth. My medical generation had no courses in kindliness; in terms of skill and rationality, half of all medical students graduate in the lower half of the class. If kindliness and skill are independent variables, what are the chances that a doctor possesses both? I don’t know; I’m just asking.

Altruistic rationalism is Kind; it is not always kindly. Kill ’em with kindliness.

Addendum after comment: My first father-in-law was a pediatrician. He claimed that most of his patients would recover from their illnesses if he did nothing; a very few would not recover no matter what he did; and in the remainder, he hoped to make a difference in the outcome. In my own practice of penile prosthesis surgery, once the surgical wound was closed, there was essentially nothing I could do to improve the outcome. Because of this, in the early portion of my career, I scheduled my prosthesis patients to return two weeks post-op, the time when I intended to inflate the device to prevent healed wrinkles. During that two-week interval, the patients experienced impressive swelling and discoloration, as they had been advised to expect. My receptionist and my office manager, after a while, suggested that I begin seeing the patients three days post-op, to relieve their anxiety. Their people-skills were far superior to mine, and I followed their advice. Patient satisfaction skyrocketed, although outcomes were unchanged.

To combine these two stories (mine and the pediatrician’s), I firmly believe that people want to be told that everything will be OK. The problem is that some will not be OK, in spite of doing everything “correctly”. Occasionally, as the pediatrician told me, a child with a viral upper respiratory infection will go on to develop viral pneumonia. The parent then wants to know, “Why didn’t you give my child antibiotics?” The doctor knows that not only will antibiotics not help, but also they will actually increase the chance of secondary bacterial infection. After years of dealing with angry parents over unavoidable outcomes, the pediatrician treats the parent, rather than the child; antibiotics are started from the get-go. At this point, one ceases to be a doctor, and enters into the field of public relations.

With prostheses, assuming the surgery was done correctly, the big cause of failure is bacterial infection. Infection occurs at the time of surgery, or perhaps a few hours later, the source almost always being the patient’s own skin or fluids (this has been documented by tracer analyses). In my practice, the rate was just under 1%. Nothing can be done to prevent early signs of infection from progressing to conditions that demand removal of the device. Patients cannot be convinced of this. They intuitively feel that one-chance-in-a-hundred means, “it can’t happen to me.” Consequently, the post-op care in such patients turns to techniques of assuagement and demonstration of concern, which only postpone the ultimate outcome, and actually cause the patient an unnecessarily long convalescence. With the “public relations” approach, the failed patient is unhappy; with straight-forward fact-based actions, he is angry. Angry patients are the first step toward malpractice tort actions. Since we can’t completely eradicate infections, we begin to focus on eradicating lawsuits.

And then we’re not doctors.

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What if doctors were tenured?

Posted on October 31, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Personal philosophy, Self-deception |

Reason is the unique path to knowledge. This is the credo of rationalism. Existence as a pure rationalist may be a highly-prized state, but getting there certainly is not “half the fun”. There is a lot of pain involved in recognizing and discarding long-held positions when they do not pass the rationality test. On the lead page of this site, I state that retired urologist has launched a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry. The sticky point in the quest is the concept of knowledge, a goal that can be approached only along the path of reason, yet, as Robin Hanson has pointed out, doctors are “lousy at abstract reasoning”. I have agreed with him profusely in this earlier post, yet I still had a knee-jerk defensive response to it’s reiteration recently on his Overcoming Bias blog. I, and you, are wired that way.

It seems like a quid pro quo thing going on. “If I’m going to go through the pain of admitting my long-practiced deficiencies, those who so readily identify them for me should do likewise,” or something like that. But no. Not going to happen. Actually, can’t happen may be a more appropriate description. I have become convinced that the human brain is hard-wired to ignore certain of one’s own biases, while readily identifying those same biases in others. It’s not a new concept, nor original. Long before neuroscience was a word, the Biblical writer of the gospel of Matthew asked, “Why behold you the mote that is in your brother’s eye, but consider not the beam that is in your own eye?” Why indeed? Perhaps because it’s unavoidable. It bears repeating that those gifted with more intelligence are more likely than those with pedestrian IQ’s to exhibit this defect (skill?). Via intellectual attribution bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are the position of others, which they will attribute to emotional reasons, even if that position is the same as theirs (Michael Shermer). Via confirmation bias, smart people tend to seek or interpret evidence favorable to their already existing beliefs, and/or to ignore or reinterpret evidence unfavorable to their beliefs. Hanson considers confirmation bias to be a major contributor to ideological fanaticism, the greatest threat to the world, yet he employs it frequently. He can’t help it: he’s very smart.

In fact, he’s so smart that he has tenure. Now, there’s an interesting concept for a libertarian supporter of free markets, idea futures, and outcome-mediated health care plans! Tenure is, at best, an arbitrary system which may or may not reflect effectiveness, yet which virtually guarantees employment and facilitation. Hanson’s espoused ideas revolve around the establishment of “betting markets on controversial issues, in which the real experts (maybe you), would then be rewarded for their contributions, while clueless pundits would learn to stay away.” (quoted here) Yet his own job doesn’t work that way. One would think that when offered tenure, such a person would have turned it down, on philosophical grounds. Ah, but there is the consideration of responsibility to one’s family. Intellectual attribution bias facilitates just such paradoxical behavior, not just in Hanson, but in humans generally.

So comes the question: what if doctors were tenured? Immediately, it comes to mind that all the things Hanson finds wrong with doctors, and the health care system in general, would be magnified. Doctor arrogance, a frequent topic of Hanson’s concern, would soar, perhaps approaching the level of university professors. Health outcomes, as bemoaned in Hanson’s analysis of the Rand Experiment, would surely, and predictably, worsen, as there would be no correlation between quality of work and job security. If there were a doctor agency similar to the insulating university, one could predict soaring rates of malpractice among tenured doctors, since the consequences would be borne by their institution. On the positive side, doctor-related felonies, such as Hanson documents here, would likely decrease, since commission of a felony would be grounds for revocation of tenure. Doctor supply would surely increase, as would the average age of doctors, since, once tenured, there would be no reason to retire and no pressure to perform effectively. In summation, it seems that university professors would view tenure as an excellent idea for university professors, but a very bad idea for doctors. Personally, I agree with the free markets that Hanson talks about, as opposed to the closed market in which he participates.

I am trying to learn how to think differently (more effectively), since my education and profession actually did not include any courses, or even any experience, in clear thinking, sad to say. I know there is a strong bias about the arrogance of doctors, especially given their rather well-documented failure to make a positive impact on *overall* health care in the USA. I abhor the “doctor arrogance” as well. Any arrogance seen in my posts is (usually) unintentional, and comes not from being a “arrogant doctor”, but from the failing of being an “arrogant person”, a quality that seems widespread among intellectuals. The more I learn about how such “ninja-brained” people think, the less I have to be arrogant about. I’m here to learn.


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Doctor education #2… more real-life drama

Posted on October 7, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

I got a call from a pharm rep for a company that markets one of the three well-known pills for treating erectile dysfunction one day about five years ago. She lived and worked in the alluvial plain area of the Mississippi delta. If you have never listened to a woman from “the delta”, as they say, you owe it to yourself to call someone in that area. The female version of the accent is melodiously syrupy; a conversation about anything is musical entertainment. “Yankees” seem to think the drawl is an indicator of ignorance or low intelligence. I assure you, that is not the case. There is a reason that William Faulkner spent most of his time in Oxford (Mississippi, not England), and it wasn’t because it was full of “hicks”. 

She sought me out because I was a “consultant” for her company. At the time, I justified that position by using what I now know is “confirmation bias”. I distinguished myself from the “medical whores” I have previously discussed by reasoning that I never consulted for competing products; that I promoted the one I actually used with my patients; and that I truly believed the product was the best in its field. I saw no conflict of interest, because I was only saying what I would have said anyway, pay or no pay. I should have considered things this way (as told by Kenny Tilton):

Once upon a time my sleazebag ward politician buddy and I were cruising the singles bars back when they had such things and he got nicely eviscerated by a woman we were chatting up. My buddy had said something cynical and she had challenged him on it.

“Oh, I have compromised my principles a few times,” he conceded with a sly grin.

“You can only compromise your principles once,” she replied. “After that you don’t have any.” (more…)

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How do you like this education, doctor?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

Chances are, if your doctor seems quite successful, he is a drug rep. He may not even know it. He surely won’t admit it, especially not to himself. It probably started out as a part of his continuing education.

I wrote: In my next post, I’ll talk about the real leaders in doctor “education”; they weren’t included in this one because it’s not official CME. I’ll also throw in some first-hand, saw-it-with-my-own-eyes anecdotes. Here it is; I know you’ve been waiting with bait on your breath.

You’re sitting in your doctor’s waiting room. You have the first appointment of the afternoon, yet there are five others waiting as well. They are all relatively young women in very nice outfits. They’ve got some cleavage working, and they’re shod in FMP’s, the good kind, maybe Jimmy Choo’s. They don’t seem to be ill. They’re pharmaceutical reps. (NOTE: if your doctor is a woman, these people will instead be athletic-looking youngish men, or perhaps an occasional older, plainer chick, no cleavage. Nothing suggesting competition). They are waiting to help your doctor with his continuing medical education. In fact, statistically, they are the major source of your doctor’s new knowledge about medicines. You will be ushered to an examining room and told, “The doctor will be with you shortly.” One or two of them will see him in his private office before he comes to see you. And so the day will go. (more…)

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Why your doctor thinks what he/she thinks

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics |


When it comes to the source of your doctor’s upgraded medical knowledge, follow the money. I thought that phrase was from Jerry Maguire but apparently it’s not. Whether from the mouth of a sports agent, an investigative journalist, a movie script writer, or just someone who knows what he’s talking about, when it comes to your doctor, chances are it’s right on. Once your doctor finishes his training, he is on his own for further education (the editorial “he”; I’m not going to say “he/she” every time, regardless of PC, and regardless that we will soon have more female doctors than male; that’s another post). All US state medical boards now require doctors to show evidence of Continuing Medical Education (CME) in order to retain their licenses to practice. Talking over a problem in the doctor’s lounge, or calling the old professor to see what’s new, does not qualify as CME. Neither does reading the new edition of a comprehensive textbook (which, by the way, is already years out of date by the time it’s published). So how is CME accomplished? Commonly, there are four ways: (more…)

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Doctor, are you FDA-approved?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics |

For the most part, the “practice” of medicine does not work like a science. I wrote that comment recently on the Overcoming Bias blog. Prior to 1910, when the Flexner Report was released, there were no general guidelines for teaching American doctors. As a result of Flexner’s recommendations, over half of the American medical schools had been closed by 1935, leaving a total of 66. Since then, with the growth in population, the number has climbed to 129, with each of these following the same rigorous standards. There are no “bad” American medical schools (unless they all are bad). All American doctors are trained in a evidence-based curriculum. All “board-certified” doctors must give at least the minimum number of  correct answers on the Board examination, and demonstrate the ability to avoid being fired for the duration of their specialty training, such that the Professor is somewhat obligated to give a recommendation, since the candidate was allowed to complete the program. 

So why isn’t the practice of medicine a “science”? (more…)

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.


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