Sunday, December 31, 2006

Evidence based medicine to the rescue

This is from last year’s BMJ but it’s timely. Somebody finally applied an evidentiary standard to all those hangover remedies. The final answer: none of ‘em work. Moderation is the key.

Top 10 issues in hospital medicine for 2006---issue 3: emergency department crowding

ER crowding seems to have reached a crisis level this year, attracting the attention of the Institute of Medicine and the medical blogosphere. The problem is well illustrated in a recent newspaper article from Arizona linked by Grunt Doc.

What’s the solution? The late medical humorist and author Robert Eliot, M.D. was fond of telling the joke about a man who cut his finger with a kitchen knife and went to the ER. After going through the main entrance he came upon two doors. The sign over one door said “critical” and over the other door “stable.” He went through the door marked “stable” and down a long corridor before coming to another set of doors, one of which was marked “illness” and the other “injury.” After going through the “injury” door he came to another set of doors, one of which was marked “blow” and the other “cut.” He examined at his finger, decided that the injury was indeed a cut and went through the appropriate door. The next pair of doors was marked “extremity” and “torso.” He opened the door marked “extremity”, walked down a corridor and found two doors marked “bleeding” and “not bleeding.” Because the bleeding had stopped by this time he went through the door marked “not bleeding” and found himself in the parking lot. Good case management?

Equally humorous was the Institute of Medicine’s solution recently published in the New England Journal of Medicine which said, in effect, “hospitals: cease patient boarding and ambulance diversion by just being efficient.” What’s humorous and patently absurd about this mandate is that hospitals have been under maximum pressure to improve efficiency and patient flow for 23 years. Thanks to the prospective payment system (DRGs) implemented in 1983 their very survival already depends on efficient patient flow. My previous post criticizing the Institute of Medicine is here. More critical commentary on the IOM recommendation can be found at DB’s Med Rants and Kevin M.D.

Hospitals can cut down on ambulance diversion with aggressive bed control strategies, but busy hospitals have not been able to eliminate it. St. Louis University, for example, despite intensive process changes geared specifically toward the problem, still diverts ambulances on average between 30 and 60 minutes a day.

Hospital administrators, reluctant to divert ambulances, sometimes allow their ERs to accept patients even when all inpatient beds are occupied. This results in worsening of crowded conditions since patients in need of admission have no place to go and must be “boarded” until an inpatient bed becomes available. Such boarding can take place wherever space happens to be available such as hallways, one day surgery or observation units or the ER itself with the location determined in many cases by staffing. In some states, however, regulations may dictate where patients can be placed.

Dealing with such conditions requires a spirit of cooperation and a seamless relationship between the ER and the rest of the hospital. Unfortunately, if some of Grunt Doc’s commenters or a recent thread over at the UCSF Emergency Medicine Listserve are any indication there is a culture of finger pointing, an “us against them” mentality which will prove counter productive to any solutions for ER crowding. I commented about this culture of blame here.

Saturday, December 30, 2006

Top 10 issues in hospital medicine for 2006---issue 4: the new Clostridium difficile strain

Clostridium difficile continued to emerge as an important hospital pathogen in 2006 and was the subject of a number of important review articles. I linked to them here, here and here.

What’s different about the new strain? It has a mutation which causes it to produce markedly increased quantities of toxin. This has resulted in an increase in treatment failure, relapse and mortality. The latest review on this hospital scourge was published in the November 21 issue of Annals of Internal Medicine.

Top 10 issues in hospital medicine for 2006---issue 5: perioperative medicine

The relationship between medical and surgical hospital services was adversarial in The House of God, representative of the hospital of a few decades ago. The epitome of good case management was to turf your patient to a competing specialty service whenever the opportunity presented itself. Nowadays that relationship is changing. A model of collaboration between hospitalists and surgeons is emerging.

The year 2006 saw the publication of three new resources in perioperative medicine which merit inclusion in this year’s top ten list:

The proceedings of the second annual Cleveland Clinic Perioperative Medicine Summit appeared in a September supplement to CCJM. There’s a world of helpful stuff there.

Guidelines for perioperative pulmonary risk assessment and management were developed by the American College of Physicians and appeared in the April 18 issue of Annals of Internal Medicine.

After a frustrating back-and-forth on just which patients should receive perioperative beta blockers the American College of Cardiology helped settle the issue, at least for now, with new guidelines.

Top 10 issues in hospital medicine for 2006---issue 6: outsourcing of hospital services

In a February 16 NEJM Perspective piece and an accompanying podcast interview Dr. Robert Wachter discusses new forms of outsourcing now made possible by electronic means including image interpretation, transcription and the electronic ICU (eICU). Outsourcing has been driven primarily by economic considerations and the need for night call relief for physicians. New ideas and wider forms of implementation, however, are likely to bring unanticipated benefits as well as unintended consequences and are sure to spark controversy.

Perhaps the best known forms of outsourcing are remote transcription services and remote interpretation of images. A more novel and ambitious form of outsourcing is the eICU. It is believed that the first eICU in the United States was started several years ago at Sentara Health Systems in the Hampton Roads area of Southeastern Virginia. Evidence suggests that mortality and length of stay in ICUs are improved with a dedicated intensivist model in which there is mandatory care of all patients by a critical care specialist. The Leapfrog Group and others which set standards for quality in health care recommend the dedicated intensivist model. The major problem in implementation is the shortage of critical care specialists. It is estimated that there may be fewer than half as many critical care specialists as there are hospitalists. The eICU may be a way to close this gap in implementation. Evidence that eICUs improve mortality and utilization is beginning to accumulate. This study in the journal Critical Care demonstrated that improvements in outcomes derived from the use of an eICU were similar to those reported for the dedicated intensivist model of on site critical care specialists.

How does it work? This description of the eICU at Sutter Health seems fairly representative. Critical care physicians and ancillary staff monitor electrocardiographic and physiologic data in real time, as well as laboratory data via direct computer interface from a remote location, perhaps hundreds of miles away. The eICU staff communicates with on site physicians and nurses via direct audio and video links, telephone hotlines and computer text messages. High resolution cameras zoom in to check patients’ pupils, examine the skin and read labels on infusion bags. Thanks to real time interface with the lab, the remote team will be aware of critical results before anyone else and when the contractual arrangement with the on site physicians allows, they can give orders directly to the on site nurses. Because the eICU control room is manned “24/7” by staff who are free of the competing demands of hospital rounds and the distractions of pagers the response time to abnormal lab tests and hemodynamic disturbances is shortened.

There are limitless possibilities. The eICU doctors can access physician orders, medication records and progress notes and thus can make daily reviews for compliance with evidence based quality “bundles.” Prompts from the eICU staff to the on site doctors thus have the potential to enhance compliance with DVT prophylaxis and other underutilized quality measures.

The skeptic in me realizes that bright ideas tend to be implemented, sometimes with irrational exuberance, ahead of evidence. The early promise of the eICU needs validation by more studies. In the meantime will it be viewed as a welcome practice enhancement or as something Orwellian? It all depends on your attitude.

Friday, December 29, 2006

Top 10 issues in hospital medicine for 2006---issue 7: medication reconciliation

For years hospitals’ efforts to curb medication errors ignored one of the most important aspects of medication safety: errors which occur at the transitions of care including admission, discharge and transfer from one facility to another. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, which, by the way, in a week or so will no longer be JCAHO) set out to remedy the problem in an initiative known as medication reconciliation across the continuum of care. Although this, one of their more laudable efforts in some time in my opinion, was announced in 2005 it really got into high gear this year thus deserving mention as one of the top issues of 2006.

Although the concept is simple, implementation seems to have proven difficult judging from some of the forums I read. For many initiatives on patient safety big ideas tend to precede evidence, but in the case of medication reconciliation evidence is already trickling in that the process can save lives.

Top 10 issues in hospital medicine for 2006---issue 8: two debates put to rest concerning ALI and ARDS

The ARDS net sponsored Fluid and Catheter Treatment Trial (FACTT) released in May refuted the role of the PA catheter and supported a conservative fluid administration strategy thus helping settle the decades long wet-dry debate.

Top 10 issues on hospital medicine for 2006---issue 9: surviving sepsis guidelines under fire

Judge guidelines by the company they keep and not by the evidence. That seems to be the conclusion of the authors of a NEJM Perspective piece this year which was anything but evidence based. I blogged about it here and here.

There have been other responses to the Perspective article. Dr. Mitchell Levy, FCCM, responding to the criticisms in a recent interview which can be accessed from the Society of Critical Care Medicine podcast page, welcomes the Perspective piece as a starting point for discussion, but believes the authors’ criticisms of the sepsis guidelines are based on innuendo more than evidence. He also cites factual error in the article and wonders if the Perspective authors, whose publishing record seems to be slanted toward criticism of industry, have biases of their own.

He points out that the interests of Eli Lilly actually “dovetail” with the interests of patients because the use of their product activated protein C is supported by high level evidence. “Conflict of interest” is the knee jerk mantra invoked any time industry collaborates with science. But where is the conflict when industry’s role is in line with evidence and facilitates the adoption of best practice?

In another response entitled “Surviving Skeptics” Sean Townsend, M.D. addresses some FAQs about the Perspective piece.

Thursday, December 28, 2006

Top 10 issues in hospital medicine for 2006---issue 10: state of the hospitalist movement

As 2006 draws to a close it’s time again to reflect on important issues in the field of hospital medicine for the past year. As was the case last year the selections are confined to adult hospital medicine and reflect the opinions of a biased committee of one: me.

I ranked the state of the hospitalist movement first last year. I’m ranking it number 10 this time because 2006 saw no movement-defining developments.

Economic pressures a decade ago created a niche for the movement in areas of heavy managed care penetration. The pressures of managed care relented, but a new niche was created as more and more primary care physicians chose to increase their efficiency by dropping hospital practice. These physicians can more easily stay on schedule in their offices, a patient satisfaction advantage counterbalanced by some patients’ frustration with receiving in patient care from strangers.

Some feel that hospitalist medicine is opposed to the agenda of primary care. Robert Wachter, M.D., a leader in hospital medicine, disagreed in a recent interview in Internal Medicine World Report: “Rather than feeling that hospitalists are another nail in the coffin of primary care, I hear from many primary care doctors that hospitalists have helped them tremendously. They realized long ago that they simply could not take care of sick hospitalized patients and manage their office practice simultaneously, and hospitalists have helped them make their jobs more survivable.”

Professional satisfaction seems to be shifting in favor of hospital medicine. It’s at an all time low in traditional primary care practice leading more and more internal medicine trainees to choose hospital medicine. According to Wachter, Society of Hospital Medicine surveys show a high rate of professional satisfaction among hospitalists. Wachter also predicted that the number of hospitalists needed may reach 50,000, a higher estimate than those made previously.

A few decades ago the hospital was a jungle, a combat zone inhabited by people with competing agendas and a culture of blame. Booby traps posed dangers to patients at every turn requiring the vigilance of the “superdoc” to head them off. The dream for the hospital of tomorrow is that of a safe place where a nurturing spirit of teamwork pervades the facility and computer enhanced system improvements all but eliminate errors. Movement along this path may gradually shift the role of the hospitalist from superdoc to systems management team member. But we’re not there yet. It’s a slow journey and in 2006 we’re somewhere between The House of God and the safe place. Systems improvement is too early in its development to solve the problem of patient safety. There will be a role for vigilance on the part of the individual hospital physician for years to come.

Wednesday, December 27, 2006

A master teacher discusses the importance of the electrocardiographic P wave

David Spodick, M.D., professor of Medicine and Cardiology at the University of Massachusetts, comments on under appreciation of the electrocardiographic P wave in Internal Medicine World Report, making the following points:

  • Analysis of the P wave is often neglected in discussions on electrocardiography.
  • Most P wave abnormalities are defined by P wave duration, the upper limit of which is 100ms.
  • P wave duration in excess of 100ms constitutes atrial conduction block, specifically intra-atrial or, more likely, inter-atrial block.
  • Atrial conduction blocks indicate increased risk of atrial fibrillation and stroke, and may reflect left ventricular dysfunction.

Background:

Review by Spodick in Mayo Clinic Proceedings on this subject.

Previous notes from Dr. RW on this subject.

Thursday, December 21, 2006

Woo invades Music City USA

This isn’t the West coast. It’s Nashville, Tennessee, the buckle of the Bible Belt. A recent article in the Tennessean profiles the Nima Holistic Wellness clinic in Nashville and the Center for Integrative Health at Vanderbilt University Medical Center just a few blocks away. Dainia Baugh, M.D., medical director of the Nima clinic, practices Reiki in order to “move energy through the body” according to the article.

What caught my eye was the picture of the pendulum used during the Reiki treatment which, according to the caption, swings in accordance with the flow of the patient’s life-force energy. Now if the body’s energy field moves a pendulum that energy can be harnessed. Use the pendulum’s motion to turn a small generator and store the electricity thus produced. We’re not talking about a large quantity of energy in one Reiki session---maybe enough to charge a patient’s hearing aid battery.

Dr. Baugh’s credentials are impressive. She’s a diplomat of the American Board of Internal Medicine and a former assistant professor of Medicine at Vandy. What do such mainstream credentials bring to the world of woo? According to Dr. Baugh “….our approach to alternative medicine is a little different because it's more scientific.”

Well, if they want to be scientific I suggest they make some controlled observations on the motion of that pendulum. They could start by suspending it over a patient from an inanimate structure rather than the hand of the practitioner. Suspend another pendulum over an unoccupied exam table to control for ambient air currents. Repeat the experiment in other settings with independent observers. It wouldn’t be rocket science. It might make a nice junior high school science project, but it this stuff really works there’s a Nobel Prize in it for someone along with a million bucks in the Randi Challenge.

It’s mysterious to how the energy works. As the Reiki practitioner’s hands move this way and that over the patient how does one keep track of where the energy goes? The Tennessean article offers us hard data on the energy flow of Dr. Baugh’s patient. She lost 20 pounds. If stored as fat that translates into 81,720 Kcal or 34,183,280 joules of energy which left her body. That’s 9.5 kilowatt-hours---not bad if you can harness it.

But I digress. I won’t be convinced until I see that pendulum experiment. I confess I’m not optimistic. I think it’s all woo. The launch of the Vanderbilt center is disturbing. Vanderbilt is on the cutting edge of science yet very traditional. I thought it would be the last bastion of scientific integrity, the last place on the planet where you’d find woo. Is there any hope?

Wednesday, December 20, 2006

Who needs medical knowledge, anyway?

In a recent MedGenMed Video Editorial Dr. Hampton Roy, Assistant Clinical Professor of Ophthalmology at the University of Arkansas for Medical Sciences said: “As physicians, we do not need to carry information about lab tests, medications, or dosages in our heads. We need a reliable ready source of information to consult……” With apologies to Rush Limbaugh, stop the tape! What does he mean, we don’t have to carry information in our heads? Sure, we make no pretense of knowing it all, but don’t we need to know anything? I guess not, in the minds of some. After all, we can just “go look it up.”

And what would that mean for the medical school curriculum? Just turn students loose with lap tops, subscriptions to Up To Date and lots of patients, I guess. Don’t laugh. It’s not far from a proposal in BMJ a few years ago in which the medical school of the future would train doctors primarily to be information hunters, eliminating lectures and exams in anatomy, biochemistry and physiology.

Dr. Roy believes patients can help close the resulting knowledge gap. Referring to the “reams of paper” patients often bring for their appointments he says: “Since we are now ‘partners’ with the patient in terms of diagnosis and treatment, we need to honor the patient's book of knowledge and provide our best guidance system.” But many patients, 44% in this study, have no desire to seek out medical information for themselves. Of those who do, few have the skills in literature searching and critical appraisal needed to apply the principles of evidence based medicine (EBM), without which clinical decision making becomes flawed. The task of making patient decisions evidence based is onerous, as I once blogged here. Although patients often bring their homework to the clinical encounter I’ve yet to be presented with a rigorous, critically appraised summary of the best evidence. If only it were so! More often I’m presented with a drug ad or the latest New York Times article---hardly evidence based.

Sunday, December 17, 2006

Frequently asked questions on woo and mainstream medicine

“Woo” is a term for certain implausible and outlandish claims of complementary and alternative medicine (CAM). The term has recently been popularized on the blogosphere by Orac and others and has been a subject of several recent posts of mine which have drawn numerous criticisms and questions. Rather than address them piecemeal in my comment threads I decided a more effective way to answer my detractors would be in the form of a frequently asked questions (FAQ) post, so here goes.

Many of mainstream medicine’s conventional treatments are not evidence based. Aren’t they a form of woo?
No. Although some conventional methods fail to measure up to best evidence they are at least based on known anatomy and physiology. They have some plausibility in the observable biophysical model in contrast to the “vital forces”, nebulous “energy fields” and “non-local powers of the mind” which are characteristic of woo.

You seem to focus a lot of your criticism on woo. Isn’t non-evidence based conventional medicine harmful too?
Yes, of course. Moreover, there are harmless forms of woo just as there are harmless conventional breaches of EBM. All departures from best evidence are problematic and need to be addressed, whether woo-based or not.

Then why make a distinction?
Because of important differences in the ways the problems manifest themselves. Mainstream medicine applies a double standard and that’s what I’m trying to expose. People in the mainstream are appropriately critical of conventional deviations from best evidence and are trying to correct the situation. But due to the nature of the problem---a complex interplay of system and cognitive failures---the fix is not easy. In contrast (and here’s where the real hypocrisy comes in) mainstream medicine uncritically embraces woo, applying to it a much easier evidentiary standard and often no standard at all. The remedy for the problem of woo would be much simpler, too. Mainstream medicine could simply say no. Woo, by definition patently implausible, is easy to spot. There’s nothing complicated about it. It’s not a system problem. It’s there in mainstream medicine purely by choice. That fact raises another important distinction. If mainstream departure from EBM is a complex system problem and woo is there by choice then woo constitutes a more serious ethical problem.

But if patients want woo shouldn’t we let them seek it out?
By all means. We must respect our patients’ right to choose, and there are plenty of woo facilities outside the mainstream which can accommodate them. It’s quite another thing, though, if we misinform patients by putting our mainstream reputations and credentials behind false promotions. It’s just plain dishonest.

I’ve been reading all these statistics about the increasingly large numbers of patients who are seeking alternative medicine, or “woo” as you call it. They’re even paying for it out of their own pockets. Shouldn’t we in mainstream medicine accommodate them?
Not unless we decide all we’re interested in is taking their money, or in basing best practice on a popularity contest. These don’t strike me as good reasons.

Some woo based methods seem to be little more than relaxation and exercise techniques. What’s wrong with that?
Nothing, as long as you don’t make false claims. Go ahead and recommend relaxation and exercise, but if you promote it, for example, as Qigong you’re promoting all the paranormal theories of “vital energy healing” that go with the package. If you’re a mainstream medical practitioner and put your good name and credentials behind such false claims you’re being unethical.

Now, will this settle the misunderstandings once and for all (as Dr. RW braces for the next salvo)?

Wednesday, December 13, 2006

Pseudoscientific indoctrination of social workers

Pseudoscience may wage a full frontal attack on your hospital or clinic, or it may sneak in through the ancillary services. Here’s some of the woo being taught at the University of Michigan School of Social Work.

If you note strange goings on when the social worker pays your patient a visit you might want to read this.

Recombinant factor VIIa: who, when and how

Recombinant factor VIIa is approved for bleeding episodes in hemophilia A and B patients who have circulating inhibitors to factor VIII and IX, respectively. Most of its use, however, is probably for a variety of off label indications including life threatening bleeding in patients on warfarin or with liver failure. The 2004 ACCP guidelines on antithrombotic therapy, for example, support its use in patients on warfarin with life threatening bleeding.

These off label uses, at times controversial, have created challenges for hospitals at the institutional level due to cost concerns. This paper from the American Journal of Health System Pharmacy describes how one academic institution, the University of Virginia Health System, addressed the problem. Evidence for various off label uses is cited and proposed guidelines for on and off label uses are provided.

Wednesday, December 06, 2006

When woo overlaps mainstream medicine can patients sort it out?

Emily in the latest Grand Rounds says this about my post on alternative medicine: Dr. R.W. Donnell, in Notes from Dr. RW, urges readers to beware of "woo" - scientifically unsupported alternative medicine - particularly when it's combined with allopathic offerings. Dr. RW, and others, I'd like your thoughts. Not to plug alternative medicine - ANY modalities used on patients should be tested if possible in randomized studies - but how can patients be sure that "standard" procedures and treatments are evidence-based? What about that full-body scan, or the drug that's been around so long no one's ever tested its safety in an RCT? Is that not, in effect, a form of woo, too?

How can patients be sure if a treatment is valid? In many cases they can’t----they have to trust us. That’s the whole point about fiduciary duty. Many of the woo providers of the world are easy to spot because they make no pretense about being based on Western science. What the patient sees is what the patient gets. The ethical problem, the real deception, comes from the mainstream’s more subtle promotion, hiding the woo behind its reputations and scientific credentials. It’s one thing when the shaman down the street tells patients they need a colon cleanse. It’s quite another thing, and far more concerning when Vanderbilt----Vanderbilt, mind you---promotes Qigong or UCSF promotes herbal tea to “boost the immune system.”

Emily correctly points out that conventional medical treatments aren’t always evidence based. She asks “Is that not, in effect, a form of woo, too?” The breach between evidence and practice to which she refers, let’s call it the quality chasm, while every bit as serious as woo, is not in fact woo in most cases. The quality chasm is not a result of outlandish or implausible claims, (e.g. that water has memory) and that’s what distinguishes it from woo. The quality chasm results from an extremely complex interplay of cognitive and system barriers to the consistent application of best evidence in practice. Mainstream medicine recognizes the need for widespread system change and promotion of evidence based medicine. Although there’s no simple fix to the quality chasm, many in mainstream medicine are trying, which is in ironic contrast to the fact that mainstream medicine also increasingly promotes woo. For the mainstream, especially academic medicine, to promote woo is to engage in unethical scientific pretense and active deception of patients. It seems to me that the solution to woo in the mainstream is much simpler than the quality chasm: Mainstream medicine just needs to say NO.

Monday, December 04, 2006

Metformin is associated with vitamin B12 deficiency

The mechanism is unknown. Via Archives of Internal Medicine

And it’s been scientifically proven----

---that your support of George W. Bush is inversely proportional to your sanity. The “study” in question, appearing as a press release ahead of publication, is being lapped up by the credulous liberal blogosphere. Orac on the other hand, himself not a big fan of George W., applies his usual dose of hard nosed skepticism, citing data mining, poor design and failure to consider alternate hypotheses, concluding that this study “…sucks. And sucks hard.”

To that I’ll just add that there might be a wee bit of a conflict of interest here---“science” with an agenda, perhaps. At least it was disclosed. Although the author describes himself as a “Reagan revolution fanatic” he believes George W. is “beyond the pale.”

Sunday, December 03, 2006

Atorvastatin and clopidogrel---continued concerns

A while back I reviewed the literature on the interaction between clopidogrel and statins, particularly atorvastatin. Although there were conflicting opinions the prevailing consensus was that the drugs could safely be used in combination. Now comes this study published in the American Heart Journal suggesting that the interaction is clinically significant. This retrospective study using administrative databases from Quebec was restricted to patients prescribed clopidogrel after undergoing coronary stenting. Patients receiving atorvastatin had an increase (!) in a composite outcome for vascular events at 30 days (adjusted OR 1.65, 95% CI 1.07-2.54). A delay in getting the clopidogrel prescription filled was also significantly associated with increased events.

The authors, acknowledging weaknesses in this study, were cautious in their conclusions and called for further studies, but this really concerns me. My take home messages are 1) in the early months following coronary stenting consider using a statin that is not a substrate for CYP3A4 and 2) upon discharge after coronary stenting send your patient straight to the drug store and consider dispensing a couple of clopidogrel tablets!

Saturday, December 02, 2006

Lyme disease activism versus science

It seems some Lyme disease activists are unhappy (via My Left Nutmeg) with the new IDSA guidelines on Lyme disease because of the guidelines’ recommendation for specific objective diagnostic criteria, the non-recommendation of months to years of antibiotic treatment and the non-recommendation of “alternative” nutritional supplements. Armed for battle, they even have the Connecticut Attorney General involved.

Lyme disease has been quack-fodder for too long and guidelines such as these are badly needed.

Friday, December 01, 2006

Auto repairs, alternative medicine and fiduciary duty

I went and got my car winterized the other day, just in time for the impending meteorological catastrophe. They told me I needed, among other things, a radiator flush. They took me through the steps in making the “diagnosis”, dutifully showing me their findings, but it didn’t really matter. Mechanically disinclined not-so-smart consumer that I am I ultimately had to take their word for it. It was one of those reputable quick-lube chains, trusted by housewives and little old ladies, with mechanics who were certified. I didn’t know exactly what that meant, but I figured it was something significant. It probably meant they had a certain level of expertise and could reasonably be expected to apply that expertise honestly to my service needs. In other words I had reason to trust them. I was entitled to certain assumptions about the service I would get, assumptions I couldn’t make if I had taken my car to, for example, the Griner Brothers’ Garage, where it’s strictly caveat emptor.

And so it is with medicine. I know it’s dangerous to compare medicine with auto repair, but there may be a useful analogy here concerning the responsibility of a person in a position of trust (and we’ll restrict the comparison to just that). In medicine we sometimes call it fiduciary duty. Our particular fiduciary duty to patients is to be and do what all those certifications and accreditations lead them to expect. They expect expertise, and for that expertise to be applied honestly. Moreover, the general public perception of that expertise, at least for us in mainstream medicine, is that it’s based on science. Most patients, when offered a particular treatment, believe that. Lacking any desire or ability to verify it independently they simply trust that it’s so. This presents an ethical problem when unscientific treatment methods are offered to patients (call it alternative medicine, call it what you will; I think Orac’s term “woo” should serve our purpose here as well as any other).

Now, in order to really parse the ethics of woo I would propose two broad contextual categories: stand-alone woo and integrated woo. Here are my definitions. Stand alone woo: woo which is offered by a clinic or institution as its major method of treatment. Integrated woo: woo which is promoted by “mainstream medicine”, accounts for a relatively small fraction of total treatment offerings and is more likely to be disguised as science.

This definition is somewhat imprecise and there are fuzzy areas. Some stand-alone woo providers, for example, have “MD” after their names and purport to “integrate” the best of woo with the best of conventional medicine. Nevertheless I place such institutions in the category of stand-alone woo because they major in woo, and that fact is usually patently clear to patient-shoppers. The average consumers know it when they see it.

Integrated woo presents the more serious ethical problem because the mainstream institutions (like, I’m embarrassed to say, my beloved medical alma mater Vanderbilt) are putting their good names, their certifications and accreditations, behind the woo they promote. Patients come, most of them anyway, expecting scientifically based treatment, and may be none the wiser when offered woo. After all, mainstream science-based providers wouldn’t promote something unscientific, would they? Why should patients expect them to? When they receive treatment based on an eclectic, mystical world view it's disguised, implicitly or explicitly, as science. The woo is more insidious, more subtle, which is why it’s all the more egregious. Patients are flat out being deceived unless, as recently suggested by anti-pseudoscience warrior Wallace Sampson, they receive explicit informed consent about the nature of the method being offered.

I have less of an ethical problem with the stand-alone woo providers. For one thing, maybe they don’t know any better. I’m convinced that they (many of them anyway) truly believe in what they do, are trying to make an honest living and have a heart for helping patients. (This is in contrast to the mainstream hospitals and medical schools which know better, or should know better). Secondly, the stand-alones, many of whom are openly dismissive about western science, aren’t nearly as pretentious about any scientific underpinnings as are the mainstream folks. As a consumer you know what you’re getting with the stand-alones. It’s caveat emptor, like going to the Griner brothers’ garage.

So, I say let the stand-alones compete in the open market place of ideas. To those in the mainstream for whom this shoe of integrated woo fits, clean it up. To medical school faculty who remain silent while the largest and most influential activist group of medical students on your campus promotes chelation for everything under the sun that ails a person, wake up. To physicians who care about evidence based medicine, if you see woo creeping into your hospital or clinic, speak out. To those in the mainstream who lend your good name to the promotion of quackery in your institutions, STOP IT! It’s unethical. It’s a violation of fiduciary duty.

Sleep deprivation and obesity

Add this study form rural Iowa to the mounting evidence for a link. Low self reported sleep duration correlated with high BMI. The study didn’t answer the question of causality. Does obesity cause poor sleep or does sleep deprivation contribute to obesity? Increasing evidence points to the latter. I suspect it’s a little of both.

From across the pond

NHS Blog Doctor, in linking to my Grand Rounds, inflated my civic pride by adding a plug for Northwest Arkansas and an image of an Arkansas Sunset. This must have taken some serious Googling! Although I still consider myself a resident of the hinterlands that’s changing rapidly. The NHS Blog Doctor correctly points out that Northwest Arkansas is one of the six fastest growing areas of the United States.

A cluster of sleepy little towns not so long ago, we’re morphing into a major commercial center due in large part to Walmart, whose corporate headquarters are here. The resulting business travel has spawned a thriving service industry, and the population growth has outpaced the influx of doctors. So, if you’re looking for a place to hang your shingle, give us a look.