Archive for February 2009
One of the more common approaches that attending physicians take when teaching medical students and residents is the use of clinical pearls. Rather than cold, hard facts, such as the most common form of congenital adrenal hyperplasia being 21-hydroxylase deficiency, these pearls of clinical wisdom are more akin to generally accepted rules of thumb. My personal favorite example is the admonition to avoid poking the skunk. Poking the skunk occurs when labs are ordered which aren’t necessary in the care of the patient. Checking a basic metabolic profile when all you really need is the serum sodium is risky. In fact, it seems that the less vital a particular lab value is to management decisions, the more likely it is going to come back as falsely abnormal, which often leads to further unnecessary tests. I don’t like to stick needles in babies, although you might not think that if you spent a day with me at work, so this particular clinical pearl comes up pretty often on my rounds.
I also make a point, on an almost daily basis, to incorporate pearls of critical thinking into my teaching of medical professionals in training. Naturally, these tend to focus on my particular area of interest, the myriad and often contradictory therapies falling under the umbrella term alternative medicine. As I’ve said many times before, I prefer terms like unscientific medicine, or quackery to be quite honest, over alternative medicine, integrative medicine, or complementary medicine. These are manipulative marketing terms used to lull the general public into acceptance with a false air of legitimacy, and the academic community into the application of a double standard to the evaluation of safety and efficacy of these therapies. There is only one legitimate means of determining whether a treatment works, and that is with science.
One example of a very helpful critical thinking pearl that should be applied to the claims of a large number of so-called alternative approaches to health, is that there is often an inverse relationship between the number of symptoms or conditions supposedly treated by a therapy and the number that is actually treated. This is better expressed with the adage that if something is claimed to cure everything, it almost certainly cures nothing. The number of alternative medical modalities that fall into this category are numerous and experiencing seemingly exponential growth, however the most important example because of its acceptance by the general public as a legitimate and science-based practice is that of chiropractic.
Though nobody, even chiropractors themselves, have been able to define themselves in a way that allows a consistent and practical understanding of just what it is that they do, there are some safe generalizations which can be made. For instance, they tend to be spine-centered rather than the oft advertised “holistic”, and a significant percentage of them categorize themselves as “straight”. This distinction shares a dichotomous relationship with self-described “mixers”, which as the name implies are prone to incorporating a wide variety of decidedly non-spine centered therapies into their practice such as acupuncture, applied kinesiology, or nutritional supplementation, as well as some science-based modalities like standard physical therapy. Mixers outnumber straights by a large margin, and though they do make use of other therapies, they still primarily focus on the correction of a non-existant entity known as the subluxation.
Subluxations in the chiropractic sense, as opposed to the legitimate medical diagnosis, are as polymorphous as one would expect of something invented out of whole cloth* by a former magnet healer and spiritualist over a hundred years ago. Since 1895, the term has evolved into many different forms with all stages still believed in by varying numbers of chiropractors today. The manifestation which likely is accepted by the largest number of currently practicing chiropractors involves a proposed “complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health”. This definition is so slippery as to be rendered utterly meaningless, and is a prime example of the inability of chiropractors to be able to establish a standard definition of who they are and what they do. This fact actually benefits chiropractors however, as it allows for a near limitless scope of practice and the ability to bill many insurance companies for the treatment of a phantom condition.
Regardless of whether a chiropractor is a straight or a mixer, they are likely to claim that they have special insight into your particular complaint regardless of what it is. With rare exception, chiropractors assert their ability to treat not just common musculoskeletal complaints, a category of conditions falsely considered by many to be their area of particular expertise, but the entirety of known medical maladies. Many will even treat one or more of a growing number of fictitious conditions such as adrenal fatigue or Wilson’s Thyroid Syndrome. This is often done overtly with outright claims of personal success in curing conditions ranging from asthma to zoster, with some even touting their ability to treat serious life-threatening illnesses like cancer and HIV.
Straight chiropractors take a different approach, boldly claiming only to treat subluxations, which then allows for the innate healing power of the human body to heal any disease state under the sun via an unimpeded spinal conduit. A critical evaluation of the medical literature reveals a far different reality however. After a little over a century of existence, there is essentially no good evidence that chiropractic care is effective in the treatment of any medical condition, or any made up one either. The one sliver of an exception is the treatment of acute lower back pain, which does appear to resolve under the care of a chiropractor. What they may not want you to know is that it has not been shown to work any better than more standard treatments such as physical therapy and the use of ibuprofen.
*The top link on google when inserting the phrase “invented out of whole cloth” takes one to an article on the history of chiropractic
Traveling this week, I saw an ad that I had not run across before.
Help strengthen your Health with the latest ancient technology
The ad features a drawing of a hand, palm side facing, fingers extended, covered with dots, and each dot bearing a label. The copy reads
Őtzi, a 5,000 year old mummy found in the Alps during 1991, has spurred a whole new vigor into modern research of the Ancient Chinese medical practice of acupuncture. Recent examinations of the mummy found that Őtzi has a number of tattoos that coincide with acupuncture points that would be used to treat various ailments from which he was suffering.
The advertisement copy then goes on to explain the “science” of acupuncture as a way to control and cure chronic pain, inflammation, and body irregularities. The gadget being sold, the Aculife, is claimed to stimulate your qi where you need it most. You turn the device on, and touch it to the various qi points on your hand, and it indicates which ones may have blocked pathways. You then flip a switch and use the Aculife to stimulate that point and restore the flowpath, thereby rendering health benefits by freeing up the blockage. It claims to work by delivering a mild electrical pulse to the point. Acupuncture without the needles or penetration, that is. A sidebar advises “Be your own acupuncturist, diagnose and heal yourself and your family.” Helpful warnings state that you should not use this device if you have malignant tumors, excessive bleeding, or tuberculosis.
Őtzi is certainly a real entity. Also known as the Iceman , he was discovered on the Austrian/Italian border by a hiker. Recent announcements revealed the existence of tattoos, but theories on the markings varied from decorations, religious symbols, to, indeed, some sort of prehistoric acupuncture. But, your skeptical radar (skepdar?) should be pinging.
First, there is no evidence that Őtzi’s markings were for acupuncture. For instance, he was found with hunting implements and stored foods, but no needles. The people of his time knew how to work copper (in fact, his axe was pure copper ), as well as bone, but needles found are generally suitable for sewing hide –blunt and strong.
Second, acupuncture as it is currently known did not exist 5,000 years ago in Europe, and probably not in China. Although some accounts claim that it goes back to 2600 BC, the first detailed description appears in writings from the second century BC. According to Simon Singh, writing in Trick or Treatment (W. W. Norton & Company, 2008), acupuncture was likely first used in Europe in the mid-1800s by a Dutch physician, who coined the term. The Daogung Emperor (1782-1850) removed acupuncture from the curriculum of the Chinese medical school, feeling it was an impediment to progress. However, during the Cultural Revolution, Mao Tse-tung encouraged the revival of this practice. There were two reasons, the first being a way to increase the Chinese pride in homegrown remedies, and the second, to decrease the cost of national health care. He had promised affordable health care. If the Chinese people would first go to low-cost ‘traditional’ healers, it would deflect them from seeking more expensive, Western-style evidenced-based medicine, and this was a way to keep the masses contented for low cost (sound familiar?) His personal physician wrote in a memoir that Mao himself did not believe in the efficacy of traditional Chinese treatments (including herbs, as well), and did not use it himself. Since the placebo effect of the treatment frequently alleviated the symptoms, it was deemed effective and lowered government expenditures. The resurgent interest in Chinese therapies came about in the 1970s, after Nixon’s visit to China. (Too, the well-publicized films of patients receiving open-heart surgery while ‘awake’ were later shown to have been faked.)
Third, the drawing of the hand shows dozens of qi points. The label on each point was so small that neither I nor my seat companion, wearing reading glasses, could make out any of the words, but some tiny sketches beside some of the points showed a spine, the intestines, a heart, and other organs. Presumably these particular points are meant to correspond to the ailments associated with those organs. Depending on which acupuncturist you ask, there are 14, or 12 (or more) meridians. Some schools of acupuncture incorporate yin and yang (sometimes divided into three categories, sometimes into four). Even within the U.S. practitioners, the actual points for needling vary, for the same illness. For such an ancient and supposedly proven therapy, there seems to be a wide range of viewpoints about how many of these points exist. No amount of x-rays, MRIs, CAT scans, or other medical or technical investigative tools have ever shown what qi is, where it is, how it ‘flows’ or how the pathways becomes blocked, but practitioners and their customers are convinced.
While I don’t have to remind readers of this column that the plural of ‘anecdote’ is not ‘evidence’, I occasionally need to remind myself that just because something is old, or Chinese, or widely accepted, doesn’t make it effective outside of the placebo.
Oh, and the ad also claims that the Aculife device is FDA-approved. The Aculife Therapist Deluxe lists for $199.95. For the price, I think a half-dozen massages will make me feel better.
Recently, Galen Rathbun and Francesco Rovero discovered a new species of mammal in the mountains of Tanzania. The new species is a member of the elephant shrew group and is called the grey-faced sengi (Rhynchocyon udzungwensis) It is a relatively small animal (<1kg) that lives on the forest floor. There are only two known small populations in the world.
The grey-faced sengi was initially discovered using camera traps in 2005. Rathbun and Rovero subsequently traveled to some very remote mountain tops in Tanzania to study the animals. During a two-week excursion, they were able to find, study, and capture several specimens.
Does this discovery lead to an increased possibility that there is a sasquatch lurking around the forest of North America? Although the grey-faced sengi is a relatively large animal to have been just discovered, it is a great deal smaller than bigfoot. Yet, this animal was easily observed in a camera trap. It seems much more likely that a large animal such as bigfoot would be seen in these traps quite frequently, if it exists. The ease at which the scientists were able to find the new animal also is a strike against the existence of bigfoot. The expedition to the mountains of Tanzania only lasted two weeks. Even in this short period of time, they were able to find and catch many examples of the sengi. People have been looking for bigfoot for at least the last 50 years and they still haven’t found any solid evidence.
The comparison of the search for bigfoot with the search and subsequent finding of the grey-faced sengi helps to illustrate the improbability of the existence of bigfoot. Together with the total lack of conclusive evidence (like droppings, fur, remains, heat signatures) despite their size and the necessary large breeding population brings the odds of their existence to nearly zero. However, no one can conclusively say that something does not exist, but we don’t know if the invisible pink unicorn exists either.
For an audio interview with Galen Rathbun about the discovery, listen to the Are We Alone podcast (towards the end, but the whole episode is good)