Tuesday, February 27, 2007

Why focus on woo?

I appreciate my detractors. By raising unanticipated counter arguments they help me sharpen my focus. They make me think. My recent post on pseudoscience promotion by UCSF drew this anonymous comment:

“RW: I'm somewhat surprised by your vitriol towards the weird alternate crap. As an advocate of evidence-based medicine, you know that a small fraction of what doctors do is proven in any truly scientific way (double blind randomized studies, etc.). Rather, they generally do what they've been trained to and what sort of works . . . isn't that what alternative medicine is based on?In other words, there is no rational basis to choose between competing mythologies.”

I’ve gotten comments like this before with the common theme that alternative woo is no worse than non-evidence based conventional medicine. Many readers think my outrage is selective.

As I tried to explain in this post one important difference lies in the area of scientific plausibility: “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.” Viewed in that context they can hardly be construed as “competing mythologies.”

The commenter needs to understand that although I want doctors to practice evidence based medicine my focus is not on what individual doctors do. It’s the hypocrisy of mainstream medical institutions (journals, medical schools, hospitals) claiming to be all ethical and evidence based while promoting unscientific and even fraudulent claims that has my attention.

My intention is to expose such hypocrisy in mainstream institutions whenever I find it. My hope is that, with occasional help from the big players, the drum beat will grow loud enough to cause some influential person or persons in academic medicine, or perhaps the AAMC, or maybe even the IOM (on second thought, don’t expect that to happen anytime soon) to pound their fist on the table and say “enough’s enough!”

Monday, February 26, 2007

UCSF lends its good name to woo

Lots of uncritical promotion of woo is to be found here in The UCSF Guide to Integrative Medicine. Although the fine print has the usual disclaimer that Inclusion of a therapy, resource, or practitioner in this guide does not imply endorsement by UCSF, the Integrative Medicine Network, or the Osher Center for Integrative Medicine and many chapters dutifully acknowledge the lack of randomized trials for a given modality, many sections contain uncritical descriptions or, worse, promotional comments about implausible claims. For example, the section on Ayurvedic medicine contains this testimonial from a fibromyalgia patient after undergoing Aruvedic “cleansing”: “By the third day I felt so much better physically I was able for the first time to walk down the stairs, then up the stairs, then I was able to cut my pain medication in half.”

Sunday, February 25, 2007

A doctor’s life on line 1986-2007

In October 1984 I attended the annual meeting of the Arkansas state chapter of the American College of Physicians, held at a resort on Greers Ferry Lake near Heber Springs Arkansas. The buzz between sessions was DRGs, new that year and the subject of much anxiety and frustration. The assortment of topics across the subspecialties of Internal Medicine was so-so. One talk by Richard Wheeler, M.D. of the department of Medicine at the University of Arkansas grabbed my attention. It would not only change my practice but revolutionize my professional life. Dr. Wheeler talked about medical searching on line. He told us there was an electronic version of Index Medicus called Medline and mesmerized us with a demonstration of how anyone with a home computer, a modem, some telecommunications software and a subscription to one of the commercial information retrieval services could do comprehensive literature searches right from the comfort of home. It was more difficult back then because the Internet was not ready for prime time, there was no World Wide Web and there were no web browsers.

A 1986 review article titled Computerized Reference Management: Searching the Literature from the American journal of Roentgenology explains how it was done and gives today’s reader a sense of the novelty of on-line medical searching in those days. The introductory section reads “The literature may be searched by hand with Index Medicus or by computer with MEDLINE, but the contrast is striking.” On the next page is this statement: “Until recently, only librarians and specialists with extensive training performed on-line bibliographic searching. Now, using a computer terminal, a modem, a telephone, and a password, a radiologist can have access to a wealth of information.” The article listed several commercial literature retrieval services that were available by subscription including Knowledge Index, Paper Chase, Dialog and BRS/Colleague.

In 1986 I purchased my first home computer, an Apple IIc. Since on line research was not popular at the time resources were hard to come by (especially in the hinterlands where I lived) and it took several months to put the pieces together and begin searching. An Apple Personal Modem had to be purchased separately. Telecommunications software was not easily obtainable in stores but eventually I stumbled on Apple Access. Next I had to find a telecommunications network (I used Tymnet) and an information retrieval service. I chose BRS/Colleague which featured not only Medline but also a full text collection which could be linked to from some Medline citations. (BRS/Colleague eventually became Ovid Medline). Boolean searching was self taught using the tutorial contained in the BRS/Colleague user manual which arrived in the mail along with my password. Up and running at last, I was hooked.

There were no “pages” displayed. Text which scrolled down the screen was saved on a 5.25 inch floppy disk for printing later. The whole thing was cumbersome but over time I ascended the learning curve. By the time I became proficient and comfortable my “setup” was becoming obsolete, but after all that effort I was reluctant to change. Besides, the system met my medical searching needs nicely for years. By the early 90s the Apple II series was discontinued. 5.25 inch floppies were no longer sold and there was no support from Apple. Shortly thereafter, with the advent of Mosaic, the first web browser, the World Wide Web became practical for home use. Despite these advances I stuck with my Apple IIc, recycling my old floppy disks until 1998, when, under pressure from my wife and kids, I relented and purchased a desktop PC equipped with Windows 98 and America On Line. Now not only was Medline searching suddenly easier but there was also Medscape, Virtual Hospital and Cyberounds. The Apple IIc was immediately retired.

The medical Internet has grown and information retrieval is much better now, but there may be a downside. As is true in clinical practice, the ease and convenience that comes with new technology can lead to a decline in basic skills. Though the formal discipline of Boolean searching is as necessary now as it was 20 years ago for precise and comprehensive searching, today’s new and more user friendly resources don’t require the skill and many don’t even support it.

Here are some fun facts and links I ran across during my research for this post:

Although Al Gore didn’t invent the Internet he introduced a bill in the Senate which provided funding for the development of the first web browser.

The futuristic looking computer used by Dr. Floyd (Roy Scheider) on the beach in the movie 2010 is an Apple IIc.

Apple II’s history.

The Obsolete Computer Museum.

Old Computers.

Old-computers.com.

Saturday, February 24, 2007

The Dinosaur on Internal Medicine, Family Practice and primary care

The recent discussions on Internal Medicine as a specialty must have pushed The Dinosaur’s buttons. Well, a dinosaur should be able to remember a time when everybody knew an internist was a specialist. The Dinosaur wants to corner me with questions like “Describe to me when, who and why I should refer to you?” and “Do you expect me to say something like this: ‘Well, Mrs. Smith, now that you have multiple complex diseases, I think you should be under the care of a specialist. I'd like you to go see an Internist. They won't provide your primary care [what exactly is that in this context? Immunizations?] but because they enjoy the complexity and diagnostic challenge, I think you will benefit from their style of training and deeper understanding of complex diseases.’ Huh?”

DB of Med Rants has given us a clear description of the concept of Internal Medicine. But Dinosaur’s questions mock DB’s conceptual description by trying to trap us into proposing an airtight, concrete categorization which he/she could shoot down with numerous counter examples and which would not be applicable to the real world where specialty boundaries, no matter what the specialty, are fuzzy. Who treats hypertension? FPs, internists, cardiologists and obstetricians, all of whom can do it well. Which specialties treat strokes? It depends on many factors including the resources available in the community and the comfort level of the individual physician, but it could be FP, IM or neurology. Who should manage ventilators in the ICU? Again, the answer is “it depends.”

I learned how Internal Medicine functions as a specialty from my former private practice in a multispecialty group which had a lot of family practitioners. Although patients didn’t walk through the door with labels that said “multiple complex problem patient” everybody knew who they were, at least after an encounter or two. The FP, who treated hypertension just fine, might send me the hypertensive with renal disease who was refractory to a three drug regimen. If my hypertension patient called in with an eye injury I would direct him to the FP, more than happy to see the patient, especially thankful that I had taken over the care of his pneumonia patient who, the previous day, developed ARDS and required transfer to the ICU. Everyone understood the difference between Internal Medicine and Family Practice, the result of which was an optimal collaboration for the benefit of patients.

The point of my ranting was never to define the scope if Internal Medicine, or any other specialty, in absolute terms. And though such absolutes would have little meaning in today’s clinical world the specialty of Internal Medicine has important distinctions.

I struggle to understand to what extent Dinosaur agrees with me, but the final paragraph of yesterday’s musing (whether Dino realizes it or not) agrees with me wholeheartedly: “Once you present yourself as willing to take care of anyone who walks in the door, you are by definition offering Primary Care, whatever you call yourself. If you see yourself as a specialist -- and want to be treated like one -- it's probably best to start by acting like one.” Indeed. Just what I’ve been saying, perhaps spoken better than I did! Too many internists, right in line with the American College of Physicians, have forsaken the identity of Internal Medicine by presenting themselves merely as doctors who are “willing to take care of anyone who walks in the door.” That’s a conceptual problem that needs fixing if we wish to avoid the dissolution of Internal Medicine.

Friday, February 23, 2007

Woo for what ails you from the American Medical Student Association

Volume 1 issue 1 of the ICAM (Integrative, Complementary and Alternative Medicine) Newsletter is up, featuring IV vitamin therapy for chronic fatigue, garlic to fight high blood pressure and infections of all sorts, shamanism to enhance your neurotransmitter systems and Ayurvedic Medicine for just about everything!

Thursday, February 22, 2007

Is Internal Medicine Obsolete?

My post about the lack of support from the American College of Physicians for Internal Medicine as a specialty drew some interesting comments. An anonymous family practitioner said “I have had contact with several internists lately who are VERY discouraged with the state and role of general internal medicine today compared with 10 or so yrs ago. Asked to see more pts, spend less time with each, do more things outside traditional internal medicine- Ortho, Gyn, etc..and I feel sorry for them in a sense. At least I was trained and feel more comfortable with some of these other areas but the internists that I know, have not.” That’s well put and pretty much mirrors Retired Doc’s concerns.

Another commenter missed the point with this: “For all the talk in the previous post you linked about how internists deal with adult patients, it sounds from the complaint about having to deal with birth control that the doctor you're linking really wants to deal with male patients, or if s/he has to see a female, it sounds like s/he doesn't want to deal with her as a whole person.” It has nothing to do with men’s versus women’s health. Retired Doc also lamented internists being asked to do dermatology procedures and evaluate corneal abrasions. The commenter goes on: “Many people have a uterus, ovaries, a vagina. These are part of the complexity of women's health. If you can't handle that complexity, then don't claim to do adult medicine, claim to do men's health.” I’m sure Retired Doc would refer a patient with testicular pain to a urologist just as fast as he would refer a patient with abnormal uterine bleeding to a gynecologist. But here’s the real point the commenter missed: We’re NOT claiming to do “adult medicine”, at least not primary care adult medicine! That’s the whole point Retired Doc and I are making. Adult primary care medicine is a simplistic notion that the ACP is shoving down internists’ throats, and that’s the problem.

DB , who is President of the Society of General Internal Medicine, has ranted about this many times, most recently here, stating “I personally reject the primary care label to describe general internal medicine”. Internists are specialists, OK? Internists are not just “doctors for adults” as the ACP defines them. Not even “general” internists.

As I said before the ACP does some good things. If they believe the specialty of Internal Medicine is obsolete I can respect that point of view and am willing to debate it. I just wish they’d be honest about it. Why don’t they come out and say they focus on adult primary care and quit pretending to represent Internal Medicine? They might as well call for the dissolution of Internal Medicine as a specialty and merge with the American Academy of Family Practice.

Since the ACP swallowed up the American Society of Internal Medicine in 1998 there remains only one organization, SGIM, which still represents and promotes the specialty of Internal Medicine.

Wednesday, February 21, 2007

What’s out there in the world of cyber CME?

On line CME is increasing in popularity because it’s easy to access and, in most cases, free. A review of on line CME in the November 17 2006 issue of Medical Economics features interviews with several experts including Dr. Bernard M. Sklar who maintains this huge repository of CME web sites (add it to your book marks—it’s the most comprehensive listing I’ve seen).

Although the first on line CME provider was Cyberounds, the current leader is Medscape. Part of Medscape’s appeal is that its CME, like that of about 70% of CME sites, is free. This is not without controversy since most free CME is underwritten by commercial sponsors. Out of concern about biased content some doctors, the same ones who refuse to see drug reps or attend CME meetings underwritten by drug companies, refuse commercially sponsored on line CME. Sklar estimates that these doctors are in the minority making up 10%-15% of CME users. However it’s a very vocal minority and one that is lobbying vigorously for an end to all forms of industry supported CME for the rest of us. If they have their way Medscape, CE Medicus, emedicine and many other free sites will be gone. Perhaps in an attempt to convince doctors that all would not be lost PharmedOut, a web site which appears to oppose drug company marketing, has compiled a list of non industry supported free CME offerings. Although the list looks impressive at first glance, the range of content is very limited. Most of the sites are government supported, including questionable offerings from the National Center for Complementary and Alternative Medicine. Let’s face it, if industry support went away tomorrow, CME would be much less accessible and prohibitively expensive for some. We’re all for open access, aren’t we?

A relatively new form of on line CME consists of so called “point of care” activities in which content is searched for based on a clinical question, often related to a patient encounter. In order to obtain credit the user must document the purpose of the search and how the information was applied. UpToDate has this format for its CME offering. I used it extensively last year and found the on line documentation process for obtaining credit very user friendly.

Despite the increasing popularity of on line CME Dr. Sklar predicts there will remain a large demand for traditional CME meetings with didactic lectures, despite the fact that the CME thought police would like to curtail most forms of didactic instruction.

Tuesday, February 20, 2007

The American College of Physicians no longer supports Internal Medicine as a specialty

----and it might as well be official. I’ve been talking about this for some time, and yesterday Retired Doc nailed it with this post about his impressions of the General Internal Medicine section of MKSAP 14.

Citing the subsections on contraception and uterine bleeding he asks “Does the American College of Physicians (ACP) believe and encourage that internists should be adequately expert and trained to go through the vagaries of abnormal uterine bleeding complete with ordering ultrasound and doing a endometrial biopsy? Some of the questions seem to imply just that.” He notes that these items along with others promoted by ACP such as derm procedures and group sessions for smoking cessation counseling are not among the reasons he became an internist. Ditto to that.

He goes on: “A section on corneal abrasions implies internists need fluorescein strips and Wood's lights in their office as the expectation is that not only will such patients be evaluated by the internist but treated and the internists will have the patients come back for follow up observation to see if a referral to an opthalmologist is needed.”

I’ve done just about every edition of MKSAP since completion of residency. I agree with Retired Doc. Each successive edition seems increasingly geared to teaching internists to be like family practitioners. Don’t get me wrong about ACP. They have some wonderful educational resources. But I’m increasingly inclined to believe that they no longer promote Internal Medicine as a unique specialty, and Retired Doc’s post only serves to confirm that.

Background: Internal Medicine has an identity crisis and the ACP is doing nothing about it.

Monday, February 19, 2007

CAM “research” often fails the test of plausibility

In his intro to Dr. Wallace Sampson’s video editorial on faulty CAM research, Dr. George Lundberg, Editor in Chief of MedGenMed declares “I like to think an idea should not be preposterous when you start working on it.” (And pouring millions of dollars into it). To bad the National Center for Complementary and Alternative Medicine (NCCAM) doesn’t think so.

Dr. Sampson points out that not too many years ago medical scientists relied on plausibility (i.e. consistency with known chemical and physical laws) in deciding what to research. Not anymore. Nowadays they’ll lavishly fund research on an idea “just because it’s there.”

Ironically the CAM explosion and its associated faulty “research” on implausible claims has been driven in part by EBM as Dr. Sampson points out, and as implied in the title of the editorial: “Whatever Happened to Plausibility as the Basis for Clinical Research and Practice After EBM and CAM Rushed in?” Proponents of EBM have popularized the notion that biologic plausibility is not important in evaluating scientific claims and should be de-emphasized. Although this extreme of empiricism distorts EBM it has been widely accepted in the scientific community. I addressed this problem in my recent Medscape Roundtable Discussion on EBM.

PROACTIVE re-analysis: pioglitazone prevents recurrent stroke

This was presented at the 15th World Congress of Cardiology.

Via Internal Medicine World Report.

Sunday, February 18, 2007

Community associated methicillin resistant staphylococcus aureus---it’s not the old MRSA exported to the community

Community associated methicillin resistant staphylococcus aureus (CA-MRSA), as I blogged before, is a newly emerging pathogen, distinct form the formerly more familiar hospital associated MRSA. It now increasingly arises from within health care facilities and thus should no longer be defined by the setting in which it is acquired. Its distinguishing characteristics include unique drug sensitivity and virulence patterns.

A review in Seminars in Respiratory and Critical Care Medicine discusses CA-MRSA infection with an emphasis on pneumonia, which can occasionally manifest as a severe necrotizing infection in younger patients.

Anna Nicole Smith case raises questions about doctors treating celebrities

According to this article about famous patients, treating a celebrity could be hazardous to your profession by luring you away from evidence based medicine.

Friday, February 16, 2007

More physics majors getting into med school?

Apparently so. Maybe it’s a good thing given the rising credulity toward bogus “energy” theories in medical school these days. I wonder how many of these physics majors join AMSA?

Via Kevin M.D.

Anna Nicole Smith---the plot thickens

The medical blogosphere’s response to the death of Anna Nicole Smith is beginning to read like a virtual CPC. So far myocarditis, serotonin syndrome, cardiomyopathy, congenital heart disease, heritable disorders of connective tissue, pulmonary embolism, WPW, ischemic heart disease, Brugada syndrome and drug overdose and/or interaction have been posited.

Methadone garnered more attention in the last few days following reports that it was found in her refrigerator. As I posted here methadone could have caused an arrhythmic death. It causes prolongation of the QT interval and torsade de pointes, effects which would not be mitigated by narcotic tolerance or the use of Narcan. These electrophysiologic effects are under appreciated and may be responsible for many of the deaths recently reported in association with abuse of methadone.

Monday, February 12, 2007

Deep into woo

The American Medical Student Association recently sponsored its 2007 Circle of Healers Retreat. I knew there was woo at these gatherings but had no idea of the depths. This blogger says the event featured workshops on therapeutic drumming and shamanistic journeying.

Leukotriene inhibitors

Leukotriene inhibitors are popular agents in the treatment of asthma and allergic rhinitis. Although their use has outpaced evidence there are well defined roles. Here’s a summary of what’s evidence based and what’s not from American Family Physician.

Sunday, February 11, 2007

The hospitalist movement: where is it headed?

Niraj L. Sehgal, MD, MPH and Robert M. Wachter, MD reviewed the hospitalist field in the January 2007 issue of Resident and Staff Physician. It’s on a roll and there are plenty of opportunities. The authors offer tips for trainees considering a hospitalist career.

There is controversy over whether hospitalists improve outcomes. The authors briefly address that question by citing this review appearing in 2005 which concluded that “most evaluations” found hospitalist care to be associated with reduced charges and lengths of stay with no significant difference in quality of care or patient satisfaction. The analysis was compromised by lack of randomization in many of the cited studies. Sehgal and Wachter failed to cite this very large multicenter study presented the same year at the Society of Hospital Medicine which showed no difference in outcomes or utilization between hospitalists and non hospitalist peers. Do hospitalists provide better or more efficient care? Although we’d like to think they do we don’t have an evidence based answer.

Noninvasive ventilation following extubation

Noninvasive ventilation following extubation has not been shown to be beneficial in unselected patients. This study, reviewed in Critical Care, suggested that it is useful in selected patients with high risk, the characteristics of which are outlined in the article.

Saturday, February 10, 2007

Distortions about disease-mongering

The excerpt of the documentary Big Bucks, Big Pharma: Marketing Disease and Pushing Drugs opens with accusations that experts, influenced by the pharmaceutical industry, are re-defining sickness. In response to Thursday’s post on this subject a commenter said “In my understanding, the accusations disease-mongering usually apply to primary prevention i.e. labeling people who were considered ‘healthy’ yesterday as ‘sick’ today because of the lowered guidelines and thus increasing the number of people who are considered to have a disease.” That’s a widespread misconception. The video does accuse industry of redefining sickness through direct to consumer ads and influence on guideline writers, but where’s the evidence to back up that assertion?

Let’s look at cholesterol recommendations. The current guideline and a frequent target for accusations of disease-mongering is the NCEP Adult Treatment Panel-3. What are its recommendations for healthy persons? For individuals with no history of atherosclerosis and 0-1 risk factors it calls for consideration of drug treatment for patients with an LDL cholesterol of 190. This is hardly an aggressive target, and hardly a level a reasonable person would regard as healthy. But note the word consideration. That means that, as explained in the text of the full report, drug therapy should be recommended for such patients only after documented failure of a trial of hygienic measures such as diet and exercise.

It is only for patients with atherosclerosis, diabetes or a constellation of conditions defining very high risk that the guidelines recommend aggressive treatment to low targets. But that isn’t disease mongering. Such patients, especially those with atherosclerosis, already are sick.

Friday, February 09, 2007

Anna Nicole and Daniel Wayne Smith

Amid speculation on the causes of the deaths of Anna Nicole Smith and her son Daniel there has been mention of methadone. Daniel Wayne Smith was taking methadone. The conclusion of pathologist Cyril Wecht who performed a second autopsy on Daniel was that methadone in combination with Zoloft and Lexapro resulted in death due to cardiac arrhythmia. Moreover, the investigation concluded that there was no evidence of foul play or “suicidal overdose.” If all that’s true it’s possible that the methadone in his system caused torsade de pointes which progressed to ventricular fibrillation. It is doubtful that Zoloft or Lexapro played a significant role, as they are not arrhythmogenic in therapeutic doses, and their pharmacokinetic interactions with methadone are of minimal clinical significance. But as I blogged here the proarrhythmic effect of methadone does not require overdose or drug interaction. It appears in moderate therapeutic doses.

This morning Kevin M.D. cited a report that Anna Nicole Smith “kept passing out” before her death, a presentation typical of torsade. In various news reports multiple drugs including methadone have been mentioned in connection with her death.

I blogged here about the recent FDA alert and suggested precautions to be followed in the care of patients taking methadone. Better yet perhaps methadone, like meperidine, should disappear from clinical use as a pain reliever.

Accusations of disease-mongering and medicalization---are they evidence based?

The pharmaceutical industry has been under fire for its marketing practices. The latest barrage of accusations is about disease-mongering and medicalization. The idea is that the pharmaceutical industry carves out new markets for its products by inventing diseases and inflating the public perception of diseases.

Some of the more shrill industry critics are featured in the documentary “Big Bucks, Big Pharma: Marketing Disease & Pushing Drugs”, which can be viewed from this blogpost by Big Red Pill. The video deals mainly with direct to consumer (DTC) advertising, a major focus of the purported disease-mongering.

I don’t like DTC ads. But drug companies are going to market their products one way or the other. Public pressure may change how they market their drugs, but it isn’t likely to change the amount they spend on marketing. The constant hammering against physician marketing has been effective. It’s led to an increase in DTC advertising. But I digress.

Near the beginning of the video Marcia Angell, author of The Truth About the Drug Companies: How They Deceive Us and What to Do About It accuses drug companies of re-defining what it means to have hypertension and high cholesterol. Wrong, Dr. Angell. Although treatment targets have been lowered no one has “re-defined” hypertension. Hypertension is and always has been defined as blood pressure which exceeds a threshold for cardiovascular risk. Recent evidence suggests that that threshold is much lower than previously believed. An analysis of one million adults in 61 prospective studies demonstrated that the threshold is at least as low as 115/75. These data, rather than any “re-definition of hypertension” by the drug companies, are the basis for the lowering of blood pressure goals in recent guidelines. Over the years we’ve gradually become more aggressive in treating hypertension and data cited in the JNC-7 report suggest that this effort has reduced stroke, coronary events and heart failure. So what are you saying, exactly, Dr. Angell? What fault do you find with these data? You evidently believe we should go back to older, higher BP targets, right? What BP target do you feel would be appropriate and how would such higher targets help patients?

And what about cholesterol? I don’t see anyone defining high cholesterol or making it into a disease. The disease is atherosclerosis. We moved beyond worrying about what’s defined as high or low years ago in favor of setting treatment targets appropriate for the patient’s risk. These treatment targets have been lowered not because of any re-definition of high cholesterol by industry, but because it’s supported by evidence. So, again, Dr. Angell, let’s play fair. You evidently don’t agree with the new treatment targets. What’s wrong with the evidence I’ve cited? What targets do you think would be appropriate and what evidence do you have to support your proposed targets?

The narrator goes on to state that “Big Pharma normalizes even the most obscure health disorders and presents them as common.” Then, as if to illustrate that point, the video cuts to an ad about restless leg syndrome (RLS) which says that nearly 1 in 10 people have the problem. So how does this ad present an obscure health disorder as common? In fact evidence supports the statement in the ad. The figure of 1 in 10 individuals is not in dispute if one checks published research, something the producers of the video didn’t seem to bother to do.

Then Dr. Bob Goodman of No Free Lunch fame weighs in and accuses industry of taking common everyday maladies and “medicalizing” them. He asserts that of all the things they do this is the one thing he would label as “evil.” But he doesn’t really define what he means by medicalization. And while he points out that such “medicalization” might make a person realize that he or she is not healthy or (gasp) end up taking a prescription medication he doesn’t explain what’s really wrong with that. I wish I could pin him down. Is medicalization anything more than defining a problem? The idea that common everyday miseries are defined and characterized is nothing new. Constipation has its own ICD-9 code as does headache. Medicalization?

The video is unconvincing. If accusations of medicalization and disease-mongering are to amount to anything more than half truth and innuendo some questions such as those I have posed here need to be answered.

Tuesday, February 06, 2007

Homeopathy fails the test again

Mayo Clinic Proceedings reports this systematic review. But as I said before I see little point in this sort of exercise. Research and meta-analyze homeopathy ‘till you’re blue in the face and you’ll settle nothing. It’s not going to stop the woo-pushers. Medpundit quotes a spokesperson for the Society of Homeopaths as saying: It has been established beyond doubt and accepted by many researchers, that the placebo-controlled randomised controlled trial is not a fitting research tool with which to test homeopathy.

Despite the findings of a systematic review in Lancet a year and a half ago that homeopathy is useless it continues to be promoted uncritically by medical schools and the American Medical Student Association.

Some mainstream woo-pushers, not wanting to seem totally shameless, try to give woo the trappings of evidence based medicine. Here’s the recipe: test an implausible claim and throw in a little chance variation. Combine that with a massive dose of publication bias and voilĂ !—evidence based woo!

I’d pay more attention to some of those “positive” woo studies if either there was a plausible mechanism or the empiric evidence was strong. For me the strength of the proof required is inversely proportional to the plausibility of the claim. I’d be much more interested in these clinical “studies” on homeopathy if the folks at MIT would come up with a mechanism by which water has memory.

Monday, February 05, 2007

Need an alternative income? Try alternative medicine!

Alt med is one of several ways doctors, faced with declining fees, supplement their incomes according to this Time report. Concerning a pathologist who began selling “magnetized water” to folks, a friend says “I trust little about him since he started with the magnetic water because I know he knows better: he passed physics to get into med school. But now he can finally afford that Range Rover he's had his eye on.”

Acid-base resources

Here’s a collection of links compiled by Clinical Cases and Images.

Sunday, February 04, 2007

The ethics of complementary and alternative medicine: where the rubber meets the road

I’ve gone on and on about how the promotion of pseudoscience by us in mainstream medicine is unethical. But how are those ethics applied in the real world? It’s a safe bet there are woo consumers in your practice, since 34% of patients in one survey reported using alternative medicine, and the vast majority of patients who use alternative medicine also use conventional medicine. (Doctor, have you looked in your spouse’s medicine cabinet lately?)

There may be risks in telling such patients the uncompromised scientific truth about their treatment choices. They may become offended and leave your practice. If you come across as dismissive about herbs they’ll feel uncomfortable discussing them and may even conceal their use. What’s a doctor to do?

I can recall patients so deep into woo it was a way of life. It had become a major part of their world view, holding together their precariously balanced psychological defenses. In such cases a debunking from me might have caused psychological trauma. I saw no point in driving those patients away. Although likely to reject much of my advice they often needed my services. I usually felt I could help them in some way. How could I be honest without harming them?

A common justification by mainstreamers for their pseudoscience promotion is that doctors must respect patients’ beliefs and choices. Implicit in that argument is the tired canard that telling the truth about unproven methods and respecting patients’ choices are mutually exclusive. My own experience with patients is different. It is possible to tell the truth with respect and agree to disagree. If the patient is deeply steeped in woo I simply acknowledge our opposing world views and explain that in order to maintain a sense of professionalism I must remain true to the world view I believe in and was trained in and in which is western science. In this manner it is possible to respect patients’ beliefs without agreeing with them. It is not necessary to promote quackery, even implicitly, to treat patients with respect. I’ve found that even patients who are extremely into woo accept this approach.

The November 17 issue of Medical Economics addresses this problem in What would you do? Alternative Medicine. Doctors were asked how they would handle a patient who, after two unpleasant rounds of chemotherapy for colon cancer with metastasis to regional lymph nodes, sought treatment at an alternative medicine center. 8% said they would agree to collaborate with the alternative medicine center, no questions asked. 71% indicated they would “work with” the alternative medicine center even though they could not support its methods. 21% said they would refuse to collaborate with the center and urge the patient to continue with conventional treatments. I would have difficulty answering this survey. How does one “collaborate” with an alternative medicine center? One respondent put it well: "Patients may choose their treatment, but my collaboration implies my endorsement, and I can only endorse treatments that have some likelihood of success. Even if patients don't demand some scientific basis for treatments, it's my duty to require it for anything I recommend."

Saturday, February 03, 2007

New guidelines address controversies in diagnosis and treatment of venous thromboembolism

Two companion papers, one in the Annals of Family Medicine and one in the Annals of Internal Medicine provide new guidelines for the diagnosis and treatment of VTE. Here are some highlights of the guidelines, which are available via the links above as open access full text.

The Wells prediction rules (provided in tables 1 and 2 of the diagnosis guideline) are validated by evidence. They do not perform as well in patients with co morbid conditions or prior VTE, in which cases clinical judgment becomes more important.

D-dimer testing is useful in selected patients with low probability Wells scores to exclude VTE and obviate further testing.

Between V/Q scanning and CT pulmonary angiography, available evidence suggests that clinical circumstances and judgment should dictate the initial selection of tests, neither of which is supported as the initial test of choice over the other. There is a popular misconception that CT is the clear method of choice. I addressed that misconception here and here.

Low molecular weight heparin (LMWH) is superior to unfractionated heparin (UFH) for treatment of DVT to decrease risk of mortality and major bleeding. (Editorial note: morbid obesity and kidney disease alter the pharmacokinetics of LMWH making laboratory monitoring necessary. Such monitoring requires special tests such as anti-Xa activity which are not available in real time in many hospitals. In such situations UFH should be used).

LMWH is acceptable, though not established as the clear choice over UFH, for initial treatment of PE. Published experience with LMWH for PE is limited.

Outpatient treatment of DVT with LMWH has been validated. The guideline stipulates that the necessary support system must be in place. (Editorial note: What’s an adequate support system? The devil’s in the details. If you’re a hospitalist or an ER physician considering outpatient treatment ask these questions: Does the patient have a payer source for the LMWH? Who will administer the shots--patient, family, home health nurse? Who will be responsible for following the INR during the transition from LMWH to warfarin?).

Compression stockings should be routinely used, to prevent post thrombotic syndrome (a point I made previously here).

Duration of warfarin therapy: 3 to 6 months if VTE is due to transient risk factors; at least 12 months (indefinitely) in cases of spontaneous recurrent VTE; consider “extended duration” treatment for initial spontaneous VTE. (“Extended duration” is poorly defined, but follow up periods in studies were as long as 4 years).

Long term treatment with LMWH “may be preferable” to warfarin in selected patients such as those with cancer and those whose INR is difficult to control.

For all the nuances and caveats, read both articles in their entirety.

(Hat tip to Physician’s First Watch and Retired Doc.

Friday, February 02, 2007

Code what?

Here’s an indispensable resource in hospital medicine: Wikipedia’s listing of hospital emergency color codes.

And, if you’re hanging out in the ER listening to incoming ambulance calls here are the 10-codes.

Concise ACLS review

June 2006 Mayo Clinic Proceedings, now available as open access full text.

Thursday, February 01, 2007

Medical student blogger: Why all the fuss about medschool woo?

Orac, Kevin and I were taken to task for “whining” about the increasingly pervasive uncritical promotion of pseudoscientific fluff in medical school curricula. The author of Over my med body sets up this straw man: “They’re whining as if this is the most scandalous thing to have happened to American Medicine” and goes on to cite mainstream medicine’s questionable ties with drug and device companies.

The promotion of pseudoscience by academic medicine is unethical to be sure, but no one’s taking the position that it’s “the most scandalous thing to have happened to American Medicine.” Let’s get one thing straight. I acknowledge that there’s plenty of questionable promotion in medicine outside the field of woo. If my outrage about woo seems selective it isn’t because I don’t share the concerns about other types of ethical breaches.

I focus on the problem of woo for a number of reasons, one being that it’s under appreciated. The ethical problem of medicine’s ties to drug and device companies is on everyone’s radar screen. There are books, web sites and a documentary movie devoted to the problem. They cite legitimate issues, but I choose not to join the chorus because it’s being beaten to death while the problem with woo is largely ignored. Moreover there are organizations such as the American Medical Student Association whose concern about the drug companies undermining evidence based medicine seems disingenuous when they invoke chakras and promote therapeutic touch (pp43-46, Between Heaven and Earth) and promote chelation therapy for arthritis, lupus and spider bites (p 20, Complementary Therapies Primer).

Over my med body goes on with “Either way, many patients use CAM, whether I think it’s a good idea or not–and honestly, I’d much rather have some sort of idea about what CAM is and what I need to know about it than be ignorant of it completely. Some herbs affect medication dosages, for instance.” Fair enough. Medical students need to know what’s out there in the world of CAM so they can be aware of drug interactions and other consequences of alternative modalities. That’s not the type of teaching I object to. But as I’ve documented here, here, here, here, here and here, and has been systematically reviewed here, the “teaching” of medical students concerning CAM is largely promotional, unscientific and uncritical. That’s a big problem. Maybe it’s not the worst problem facing medicine, but it’s a problem that needs to be exposed because it’s not being addressed.

Update: Orac beats me to it, and weighs in here.