Archive for the ‘Medicine’ Category
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
I am young enough to not have experienced practically all of the vaccine preventable illnesses first hand as either a physician or a patient. But that doesn’t mean I don’t have a healthy respect for the amount of morbidity and mortality that they can cause. With one in particular, Haemophilus influenza type b (Hib), I at least know a large number of older pediatricians who have seen many cases. The vaccine against Hib was developed in the early 1980’s and nearly wiped this dreadful condition out here in America, but I have heard countless stories of residencies spent seeing young children with fatal or debilitating meningitis presenting with brains full of pus and children being suffocated by rapidly progressing epiglottitis, and the thought of this illness returning sends shivers down my spine.
At one time, Hib affected 20,ooo children each year. Since the vaccine, many states see one or two cases yearly and often none. Hib bacteria is still prevelant, but high vaccine rates and herd immunity have kept our young children safe. Unfortunately, the return of this disease may be happening, and if it does it will be because of the anti-vaccine nonsense that has so overtaken this country over the past two years. I received an emergency news alert from the CDC today revealing that Minnesota reported 5 cases of Hib in 2008, the largest number in children under 5 since 1991.
The alert provided some details of the cases:
“Three patients had received no vaccinations due to parent or guardian deferral or refusal of vaccinations. One of the unimmunized patients, a 7-month-old infant, died of Hib disease. Two of the remaining children received age-appropriate immunizations. One child, a 5-month-old, had received two Hib immunizations. The other child was 15 months old and was fully vaccinated for age but, subsequent to Hib infection, was diagnosed with an immune deficiency (hypogammaglobulinemia).”
Three of the children were not vaccinated, one had a condition which hampers the ability for the vaccines to work, and one had been fully vaccinated. That is not suprising, as no vaccine is 100% effective, and it perfectly illustrates the importance of herd immunity. There is a persistent and pushy minority of people in this country, led by clueless celebrities and pseudojournalists, who are so blind to the reality of science that they are willing to sacrifice not just the safety of their own children by refusing vaccinations, but that of every child in this country. It isn’t just the unvaccinated that are at risk. There are also the children too young to be immunized against Hib and other diseases, or with real medical contraindications as opposed to manufactured ones in addition to those in which the vaccine doesn’t confer protection.
This may end up as being only a statistical fluke, but increasing rates of vaccine-preventable illness are an inevitable result of increasing numbers of parents refusing to protect their children. We have already seen major spikes in measles infections, another potentially deadly diseases. The situation is a few years ahead in England, where there have also been outbreaks of measles as well as mumps. Hib is considerably more dangerous and if there are large outbreaks more children will certainly die.
If you know anyone who is considering refusing vaccinations for their child, please direct them to the CDC’s online information. Or, convince them to read Paul Offit’s recent book Autism’s False Profits. You may save a life.
As a young mother comforts her feverish and uncomfortable infant, a handsome doctor enters the dimly lit exam room. The child’s mother and the bedside nurse look at him expectantly.
“I’ve got the results. There is an infection in your son’s spinal fluid, which was one of the things we discussed as a possible cause of his high fever and irritablity,” the physician explains to the now crying mother. “We need to start treatment right away and admit him to the hospital.”
After answering the distraught mother’s questions and discussing his treatment plan with her, the doctor leaves the room and begins to write orders in the patient’s chart. The nurse, eager to begin appropriate therapy looks over his shoulder with a confused look on his face.
“Excuse me doc, but you’ve got to be a little more clear on that order don’t you think?”
Written in barely legible doctor scribble, next to the date and time of the encounter and above his signature and hospital number, is the lone word antibiotics.
“What do you mean? This child is sick and he needs antibiotics stat!”
“Sure doc, but which one, how much and how often? Where did you go to med school again?”
“Clearly you aren’t current on the literature. Antibiotics have been around for decades and have been proven time and time again to treat infections. Millions of people take them every year. Now you are wasting precious time that could be spent caring for this sick child!”
The nurse, unhappy with the response, storms off to find assistance from his supervisor. The doctor, confident that he is providing competent medical are for his patient, expresses dismay at how closed-minded some of his colleagues are.
Naturally, the above situation is absurd, and the nurse is completely correct in questioning the physician on his order for “antibiotics”. What antibiotic, or antibiotics, are appropriate and at what dose? Through what route, oral or parenteral, should the antibiotic be administered? How often should it be given and for what duration? Five days? Two weeks? To condense the large number of antibiotics available in a hospital pharmacy into one all-encompassing term makes no sense.
Antibiotics are drugs, often consisting of completely different chemical structures and with significantly different side effect profiles. There are varying degrees of effectiveness of each individual antibiotic depending on the bacteria/virus/fungus being treated, the location of the infection, the age of the patient, and the presence of comorbid conditions such as renal or liver failure. Calling for “antibiotics” in this fashion would never happen outside of a poorly written (is there any other kind?) medical drama on Lifetime.
As new antibiotics have been developed over the years, they are studied scientifically on an individual basis. Sure there are classes of antibiotics that work via similar mechanisms, such as breaking down a bacterial cell wall, or that might be effective in killing or delaying the growth of the same types of bacteria, but nobody would make a blanket statement, let alone write an order, like the one stated and written by our fictional physician. Unfortunately, this kind of thinking is rampant in the world of so-called complementary and alternative medicine. It is employed by invidual practitioners and by large government agencies as a means of deceptively gaining a foothold for unproven therapies with little or no plausibility. Their targets are the hearts and minds of consumers as well as a growing number of academic medical institutions. In a number of instances, proponents of these therapies, buoyed by the media-fueled pseudopopularity of a variety of bogus therapies, funding from the National Center for Complementary and Alternative Medicine (NCCAM), and clever marketing, have managed to set up shop in our most hallowed halls of learning.
A common saying amongst advocates of science-based medicine, and skeptics taking on the suprisingly successful incursion of unproven therapies into academic medicine, is that there is really no such thing as alternative medicine. I agree with this completely and would add that there is no such thing as complementary or integrative medicine either, regardless of what NCCAM puts on its website. These are marketing terms meant to distract healthcare consumers and providers from the reality that these therapies have either not been subjected to proper scientific study or that they have failed that study and are held aloft only by a foundation of tenacious, anecdote fueled belief.
When proponents of alternative medicine, far too many of which being influential lawmakers, call for financial support in the form of taxpayer money, they tend to use a similar tactic. They hold up a small group of therapies that have been shown to be effective, typcially entities involving stress reduction, positive lifestyle changes like increased exercise and smoking cessation, improved nutrition, or various herbal remedies, as symbols of how wonderful alternative medicine is. This ignores two important realities. Not suprisingly, these proposed symbols of the success of alternative medicine have been co-opted from the science-based medicine which discovered them and established their benefit. More importantly, these alt med proponents are ignoring the fact that the overwhelming majority of what is considered CAM, whether legitimately or not, is absolute quackery. In other words, just because a good massage helps your migraines or decreases your fatigue it doesn’t mean that non-existant molecules of poison ivy will cure your itchy rash. The use by proponents of terminology like alternative medicine is just as preposterous as our handsome young doctor writing an order for antibiotics. Which alternative therapy? Acupuncture? Homeopathy? Quantum Reiki? And for what indication? Each individual treatment must be investigated for efficacy and safety with the tools of science, not the machinations of politicians and idealogues.
In the not too distant past, treatments supported only by sloppy anecdotal evidence or poorly designed studies that were still being offered to consumers and patients as effective had a name. Rational minded folk were unapologetic when describing a bogus cancer cure or an implausible and disproven treatment for depression as quackery. But over the past couple of decades the quack has become the alternative medicine provider and the bogus treatment has morphed into alternative medicine, CAM, or integrative medicine. This was no accident. The change in terminology has served proponents of quackery quite well by successfully leading the public to think that these therapies or just another way of achieving health. Some may be, most will not. Only science can provide the answers. In the meantime, no therapy should be allowed to circumvent science because of semantics.
Several news sources and blogs have recently reported on a study looking into the benefit of transcendental meditation (TM) in children diagnosed with ADHD. A January 5th report from Reuters Health, a news service which claims to be “internationally recognized as unbiased, authoritative, timely and dependable, with the reputation for quality that one expects from a Reuters company“, actually serves as a perfect example of how not to cover science or health news. With a skeptical mindset, a few minutes of spare time and an internet connection, I was easily able to discover the dubious reality behind this “landmark” research.
The study, led by “cognitive learning specialist” Sarina J. Grosswald, involved the instruction in TM techniques of 10 students previously diagnosed with ADHD and enrolled in a private school for children with learning disabilities. These students were followed over three months, at the end of which they were evaluated for improvement in a number of areas. According to the Reuters’ piece,
“After three months, Grosswald and her colleagues found, the students reported lower stress and anxiety levels, while their also improved, based on questionnaires given to teachers and parents.”
Impressive. For those who are confused, TM is a form of meditation developed by Maharishi Mahesh Yogi in the 1950’s which involves the repetition of a meaningless sound, or mantra, while sitting quietly with eyes shut. This allows the practitioner to quiet the mind and discover the “source of thought”. The mind and body are then able to achieve a state of calm and, according to proponents, reap myriad medical benefits far beyond that of simply increased peace of mind. Believers in TM have also been known to claim that an extension of the technique can lead to fighting crime with their minds and flying. I’m not kidding.
This is a pilot study published in a online education journal edited by graduate students, something which does no inspire confidence in me. I do not think that a reputable peer-reviewed medical journal would have accpeted it. At least the authors do admit in the discussion section that it would be inappropriate to make claims regarding a cause and effect relationship between TM and any improvement in ADHD symptoms based on these results. That doesn’t stop them from making bold statements regarding the benefit of TM, however, as I will soon get to.
The flaws in this study are numerous. The number of subjects is too small, there is no control group and it isn’t blinded. The study reveals that some of the children are on medication but it does not take into account the possibility of recent changes in medical therapy, or improved compliance while on the study. It is based purely on self-report and subjective questionairres and there is very high liklihood that a placebo effect could have been the sole responsible factor in the subjects’ apparent improvements. The authors then call for larger and better designed studies, something which I don’t think is justified for these reasons, but my problem with this study, and concerns regarding the credulous take by the media, go much deeper than what I’ve already explained.
What led me to dig deeper after reading the Reuters’ report was the following quote:
“The effect was much greater than we expected,” lead researcher Sarina J. Grosswald, a cognitive learning specialist in Arlington, Virginia, said in a written statement.”
I wondered why the researcher had expected an effect and hypothesized that there may be a connection between the researchers and TM more significant than academic curiosity. I was quickly able to discover that Grosswald is a hardcore believer in TM. Just read this quote by Grosswald from a website called Ask The Doctors, which provides a forum for specialists to answer questions related to TM and health:
“The TM technique is the exact opposite of harmful. It reduces your risk of getting serious chronic health problems like hypertension, diabetes, and heart disease. In fact, research on the Transcendental Meditation program shows that people who practice it go to the doctor about 50% less than the general population. And if they are in the hospital for some reason, their hospital stay is 50% shorter, on average. For some conditions, the need for medical care is as much as 87% less for TM meditators. Practicing the Transcendental Meditation technique is one of the best things you can do for your health.”
She clearly does not come across as an unbiased investigator. In reading her other responses on the “Ask The Doctors” website, and especially after listening to a 16-minute talk she gave in 2005, when this research actually took place, which is posted on a Maharishi Vedic Education Development Corporation sponsored website that focuses on “ADHD, the Mind and the Transcendental Meditation technique” called Insights in Health, it is obvious that she is a true believer. That doesn’t prove the research is bogus by itself, but it is a red flag.
A more concerning red flag, and one which was also discovered in the talk given by Grosswald, is the fact that the 10 children involved in the study may have been coached. In the last few minutes of the presentation, Grosswald presents clips of the children meeting with the TM proponents prior to the initiation of the study, where it appears that they are told what the expected outcome of the trial is, that their symptoms will improve with TM.
Not only are these kids aged 11 to 14 being told what the expected outcome of the study is by study investigators, the headmaster of the school, Linda Handy, can be seen at the very end of the video discussing how amazing the technique is and how it will change the students’ futures for the better. I am forced to question whether the teachers, whose evaluations of the study subjects’ behavior and performance are an integral component of the study conclusions of positive effect, might have been hesitant to give a negative evaluation when their boss is clearly also a true believer.
In the acknowledgments section, The authors thank the Abramson Family Foundation for funding and the Institute for Community Enrichment for support. The Abramson Family Foundation is an organization which believes that TM can help students achieve the full potential of their brain.
“The Abramson Family Foundation has been funding research on Transcendental Meditation and providing scholarships for students to learn the technique for the past 20 years. This has been a rewarding investment in the youth of our nation. Here is a common sense approach—a sound and scientific way—of fulfilling the purpose of education, which is to create intelligent, dynamic, happy, healthy and successful human beings.”
Of note, Grosswald sits on the Board of Advisors for the foundation. Joining her on the Board is none other than the school headmaster Linda Handy. Whatever doubt I had in my lack of enthusiasm for this study fell by the wayside upon that discovery. While it may not have been intentional on the part of the study authors, the school headmaster, or the pro-TM funding organizations, this study was designed in a way that coulnd’t possibly yield anything other than a positive result. And calls for further study, especially with public funds in addition to the over twenty million already spent by the NIH on TM, are unwarranted.
It wasn’t difficult to look at this study and see that the claims being made by TM supporters aren’t valid. It wasn’t even that hard to uncover the connections between the investigators, the school where the study was conducted and pro-TM organizations. Yet I was unable to find one news report that displayed even the slightest amount of critical thinking, instead reading like press releases from TM believers. The current state of science and health reporting is rather depressing, and I don’t see things improving any time soon as more and more dedicated science writers are falling prey to the poor economy.
It isn’t official yet, but I’ve now seen multiple news reports declaring that CNN’s own Dr. Sanjay Gupta has been chosen by President-Elect Obama as the next Surgeon General. The best I can come up with on this development is that it could be worse. I’ve never been impressed with him, and he has displayed a concerning misunderstanding of the vaccine-autism manufactroversy in the past. But at least it wasn’t Mehmet Oz, Andrew Weil, Deepak Chopra, Dr. Jenny McCarthy, etc, etc. We’ll see I guess. I’d like to see Steven Novella take on the position to be honest.