Archive for: April, 2011

Alternative medicine: same thing, different words?

Apr 30 2011 Published by under Absurd medical claims, Medicine

When discussing the absurdity of religious disagreements, peacemakers often make the point that all religions believe in one underlying Truth or Deity, that all religions are guided by the idea that we should be excellent to each other.  I don't believe this, but it serves as a useful analogy.

In medicine, those trying to bring together science-based practitioners and alternative practitioners (or more honestly, alternative docs trying to justify their practices) often argue that we are simply using different words for the same concepts, that one person's chi is another one's "life force", "energy", or some such thing.

In religious arguments, no one can be proven wrong about who's god is the real one, but it can be pretty well determined whether or not religions "believe in" the same underlying principles.    One question deals with the unanswerable, the other with written texts and observable practices---in other words, data.  The same is true for medicine.

The idea that there is some sort of animating force travelling through channels or meridians in the body is an old one.  Sometimes the language is explicitly mystical, and sometimes it is couched in science-y words.  Chiropractors speak of "subluxations" blocking the flow of something-or-other and causing disease.  Whether such a phenomenon exists (it doesn't) is easily discovered.

Lay people very often buy in to vitalist ideas about human health. It goes well with our propensity to believe in mind-body dualism, with religious ideas of soul. People like to believe things, like to find patterns to organize their world based on their own observations, even if these observations are based on false premises.  This is why we have professionals.  We don't let anyone design a bridge, but someone who understands the physics involved.  And we shouldn't let people practice medicine if they have a fundamental misunderstanding of how the body works.

All this is in support of the premise that Dr. Oz is no longer a real doctor, but more of a mystic.  Currently his website is hosting a series on "Fighting Fat with Ayurveda".  Ayurveda is a form of pre-scientific medicine from the Indian subcontinent.  It is based on thousands of years of tradition, but has been largely abandoned by those who can afford real medicine.  It shares with other traditional systems vitalist ideas of unmeasurable life-forces.

As I read the first part of the series I am struck by two patterns.  First, it shows a supposedly real doctor (Oz) implicitly supporting disproved ideas about health and failing to give the real data. Just as disturbing is the "carnival barker" tone of the series:

Over the next several weeks, I will be sharing some of the most powerful ayurvedic secrets for removing amafrom your body and helping you achieve your weight loss resolution.

This idea that there is some secret out there for fat people, diabetics, people with cancer, or whomever, a secret so powerful yet simple, is patently absurd, yet alluring.   But what follows could have been lifted from any internet quack site.  It is a list of symptoms that supposedly tells you if you have excessive "toxins" in your body.  The whole idea of "toxins" being the cause of disease is also old, and also not based on reality.  It's not that toxic substances aren't important, it's that the word is not used the same by real doctors and quacks.

But the language!  Vey's mir, it could have been lifted from any Morgellons, chronic Lyme disease, or other fake disease websites.

The first step is to determine if you have an excessive amount of toxins in your body. If you answer “yes” to the majority of the statements below, you have an excessive accumulation of ama:

1.  I tend to feel obstruction/blockages in my body—constipation, congestion/heaviness in the head area, blocked nose, or a general feeling of non-clarity.

2.  When I wake up in the morning, I do not feel clear; it takes me quite some time to feel really awake.

3.  I tend to feel tired or exhausted mentally and physically.

4.  I get common colds or similar ailments several times a year.

5.  I tend to feel heaviness in the body.

6.  I tend to feel that something is not functioning properly in the body – breathing, digestion, elimination or other.

7.  I tend to feel lazy (i.e., the capacity to work is there, but there is no inclination).

8.  I often suffer from indigestion.

9.  I tend to spit repeatedly or have a bad taste in my mouth.

10.  Often, I have no taste for food and no real appetite.

11.  My tongue is often coated with a thick film, especially in the morning.

Everyone has some or many of these complaints at one time or another, and many of these are normal.  Most people get several colds a year.  Most people get indigestion.  These vague statements are usually designed, in my opinion, to show how "common" an imaginary problem is by making all readers victims of this excess of ama.  And on many websites, such lists, in my opinion, are simply used to draw in pigeons for the fleecing.

Believers in alternative medicine and real doctors are most certainly not talking about the same concepts using different words.  We physicians are talking about real, measurable, testable concepts; things that can be seen, touched, altered.  They are talking about imaginary energies and toxins that cannot be demonstrated to even exist, much less be manipulated to improve health.

There is a long history of real medicine, flaws and all, saving lives and improving health.  All the rest is based on dreams and greed.

16 responses so far

Brief update

Apr 28 2011 Published by under Fatherhood, Medicine, Narcissistic self-involvement

When MrsPal was young she babysat for a local doctor's family. One of her charges is now a resident at my hospital, another a successful business woman, another a teacher if I recall correctly. The father is the head of my state medical specialty society and is one of the finest doctors I know. His wife, with whom my wife shares a unique closeness, has been at the bedside nearly as much as my mother-in-law, helping with everything from showering to answering emails to keeping the flowers fresh. And my mom-in-law has spent hours every day at the bedside, keeping her daughter company, watching over her recovery.

MrsPal is still hanging out in the hospital, and I'm still learning how much work she puts into getting PalKid where she needs to be from moment to moment. If it weren't for the help of friends and family---and a very loving and loyal babysitter---I have no idea how we'd do this. My wife seems to inspire a closeness in her friends, who are in and out of her room visiting, and are constantly calling, texting, emailing, and calling me with offers of babysitting.

I had a close call today: on my way from office to hospital, PalKid's teacher called---Daisy Scouts was cancelled, and she and PalKid were hanging out doing homework. I turned the car around, grabbed the kiddo, and went to my folk's place, where we were fed and watered and generally spoiled for a while. This required missing yet another hospital shift, but my little pal is requiring a lot of love and attention at the moment.

After a good shower, I removed her nail polish (yeah, yeah...) and I'm letting her try to trim her nails for the first time. She's actually not bad at it, and doesn't need reading glasses. If I can get her to fall asleep by eleven, I'll count myself lucky. If we don't get any more thunder tonight, I'll count myself luckier.

7 responses so far

Thunder and lightning

I'd be asleep right now if a loud clap of thunder hadn't sent me bolt upright.  Fortunately, my daughter's only reaction was to mutter senselessly, turn over, and snore peacefully. She's slept with me nearly every night since her mother has been in the hospital.   She's done remarkably well with unexpected changes, even sleeping at a friend's house.  At night she mentions missing mommy, but generally she's her usual charming self.  Last night she realized she'd left her favorite pillow at her friend's house, and that broke her.  She sobbed uncontrollably for her pillow until finally, at nearly midnight, my friend came by in her PJs and dropped it off.

We stopped by another friend's house last night.  It turns out that when there's a crisis, friends are a good thing to have.  She played with the other kids and I ate sushi with the adults, two of whom she refused to believe were married because "girls don't marry girls"---except of course when they do.  She'll figure that one out eventually.

Despite her sticking to me like glue, she's getting pretty tired of a boring old adult, so I just dropped her at another friend's house to play and paint Easter eggs, so for a while at least I get a break from single parenthood.  At least it's a temporary single parenthood.  I was chatting with a colleague yesterday who recently lost his wife.  I am also even more amazed that MrsPal gets done everything she needs to in a day.  I've bent my work schedule nearly to the breaking point and it still takes all the help I can get just to get PalKid where she needs to be from moment to moment.

I don't really know yet how PalKid is processing this whole thing, except that I have a little bedfellow every night, one that despite her diminutive stature can turn a king sized bed into a small palate.

Hopefully she'll enjoy the whole Easter egg thing and come home nice and tired.  Daddy needs some sack time.

16 responses so far

Oz and Aphorisms

Apr 17 2011 Published by under Medicine

I've frequently written that medicine is hard work.  It's work for the doctor, work for the patient, and work for the society as we make national decisions about health care.  There are few shortcuts in the prevention and treatment of disease.  It takes ongoing research at the bench and at the bedside, and then sorting through the chaos as the battle plan meets the enemy.  Real people don't always behave as the textbooks suggest, and even if we know, say, that quitting smoking saves lives, we can't always make it happen.

This is why I find simplistic medical aphorisms to be so offensive.  They are rarely helpful, sometimes harmful, and give a distorted view of what medicine can and cannot do.  An apple a day does not keep the doctor away, and although a diet that relies more on fruits and vegetables is beneficial, it is no guarantee of anything.

Dr. Oz and other medical charismatics love aphorisms.  They make good sound bites, they're easy and quick to read, and consumers love them, but cui bono?  Certainly not patients and others seeking to improve their health.  These naive maxims serve only the narcissistic and economic needs of modern medicine men.

A reader pointed me to this particular piece at Dr. Oz's website, which reads more like an add on the back of a glossy magazine than useful advice from a real doctor.  It's called "28-Days (sic) to Prevent a Heart Attack."  Heart attack prevention happens to be something I know a bit about.  Primary prevention (preventing a first heart attack) and secondary prevention (preventing subsequent heart attacks) is one of an internists most important tasks, given that heart disease is one of the three top killers of North Americans.  We've gotten very good at this through helping people stop smoking, encouraging proper exercise and dietary habits, and treating diabetes, high blood pressure, and high cholesterol.  We have decades of data to guide us (and as an engineer recently pointed out to me, without data, it's just another opinion).

So what does Dr. Oz recommend?

Week 1: artery maintenance.  Oz's recommendation: flax seed oil, baby aspirin, and stretching.  The real data?  Avoid tobacco, keep a healthy cholesterol level and blood pressure through diet, exercise, and drugs when needed, and control diabetes.  Aspirin as primary prevention is a bit controversial.  We know it can prevent a first heart attack, but we also know that in people without many risk factors, the rate of complications from aspirin therapy may negate its benefits.  In secondary prevention, aspirin saves lives unequivocally.

Week 2: challenge your heart.  He recommends exercise.  This is not controversial.

Week 3: lower your blood pressure.  He recommends fruits and vegetables.  The more complex answer?  Dietary changes can help control blood pressure. Certain diets, such as the DASH diet, have been proven to help lower blood pressure, but that is different from "controlling" blood pressure.  To prevent heart disease, blood pressure should be kept within a certain range, one that is sometimes achievable through diet and exercise, and sometimes not.

Week 4: reduce stress.  Seems reasonable.  This isn't as potent a risk modification as the others, but it's not a bad thing.

Here's my science-based alternative to Oz's simplistic month of prevention.

  1. Have your risk for heart disease assessed by a professional.  Some useful---although imperfect---tools exist to put a number on your risk, such as the Framingham Heart Score.
  2. Identify the most important risk factors in your life: smoking, cholesterol problems, high blood pressure, and diabetes.  Work with your doctor to develop a life-long strategy to lower your risk.  You may need drugs to help with any of these, you may not.  In some cases, if you already have heart disease, the data show that you almost certainly will need drugs to prevent further heart attacks.
  3. Don't give up.  In quitting tobacco, relapse is the rule.  When you relapse, go back to your doctor for help rather than giving up.  Missing medications, giving up on exercise, returning to bad dietary habits are all common, and rather than avoiding your doctor in fear of getting a finger-wag of shame, go back and ask for help.
  4. There are no simple, magic answers.  There is no one plan, one pill, one supplement, or one doctor who can help you avoid heart attacks.  Every family medicine doc, internist, and cardiologist is trained in this, and the best ones keep up with the data as it changes, and can help apply what we know to you as an individual.  No TV show or website (including this one) has answers that are applicable to everyone or that are always effective.  Have questions for your doctor?  Write them down and ask, and if you can't get satisfactory answers, find another doctor (remembering that sometimes the correct answer is "I don't really know").

Everyone knows that good eating and exercise are good.  Having someone repeat it over and over, and telling you it is a sure thing to prevent heart attacks is idiocy.  Set goals, aim toward them, and use the data to guide you.

11 responses so far

Heart disease deaths dropping, but we can do better

Apr 11 2011 Published by under Medicine

Here's a re-post on an important topic.  New posts to follow.  --PalMD

 

Sixty years ago,  the world was full of miracles.  Western Europe was recovering from the devastation of World War II, an agricultural revolution promised to banish the fear of starvation in large parts of the world, and the mythical Mad Men era gave Americans a taste of technology-dependent peace and prosperity unlike any in the past.  Despite the technological progress that would soon send animals into space and return them relatively unharmed, Americans, and westerners in general, were still dying of heart disease at a frightening rate.  If you, as a middle aged American,  experienced chest pain and were lucky enough to make it to a hospital (about 20% of all sufferers would die immediately), you would probably be given nitroglycerin and morphine to control you pain, put on bed rest, and could expect to live a few more years, with limited physical activity.

Heart disease continues to be a top killer of Americans, but there has been a dramatic decline in heart disease mortality in the last 60 years, with age-specific mortality rates dropping 60%.  Fewer people are developing heart disease, and those that have it are living longer.   It is estimated that in 2000 alone,  there were 341,745 fewer heart disease deaths than would have been expected if rates had remained unchanged.

The trend has been going on for many decades, and has been accelerating, although current trends in diabetes and obesity put us at risk for more overall cases of heart disease in the future.  So what are we doing right?  How have we managed to cut the death rate from heart disease so dramatically?

Several studies have helped illuminate the answers.  There have been different relative contributions from primary prevention (preventing  new cases of heart disease) and secondary prevention (preventing recurrent cases).  A recent study in the American Journal of Public Health analysed data from 1980-2000.  The authors found that most of the reduction in deaths from heart disease (nearly 80%) were due to primary prevention, specifically decreasing smoking rates, and improvements in blood pressure and cholesterol levels.  Society-wide reductions in smoking, blood pressure, and cholesterol are saving hundreds of thousands of lives in the U.S. every year.

The smoking rate in the US is still hovering around 24%.   More than half of people with known high blood pressure do not have their blood pressure under control.  This study shows us that we can easily prevent more heart attack deaths through education and through better adherence to extant treatment guidelines.   Reducing heart disease deaths isn't hard, and it won't take miracles. We just have to want to do it.

*Similar trends have been seen in other English-speaking countries

References

Hurlburt CW (1927). THE CARDIAC CRIPPLE. Canadian Medical Association journal, 17 (11), 1305-9 PMID: 20316574

Sytkowski PA, Kannel WB, & D'Agostino RB (1990). Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham Heart Study. The New England journal of medicine, 322 (23), 1635-41 PMID: 2288563

FRY J (1964). CORONARY HEART DISEASE IN GENERAL PRACTICE: NATURAL HISTORY OVER TWELVE YEARS (1950-1961). Proceedings of the Royal Society of Medicine, 57, 39-42 PMID: 14114173

Centers for Disease Control and Prevention (CDC) (1999). Decline in deaths from heart disease and stroke--United States, 1900-1999. MMWR. Morbidity and mortality weekly report, 48 (30), 649-56 PMID: 10488780

Young, F., Capewell, S., Ford, E., & Critchley, J. (2010). Coronary Mortality Declines in the U.S. Between 1980 and 2000 Quantifying the Contributions from Primary and Secondary Prevention American Journal of Preventive Medicine, 39 (3), 228-234 DOI: 10.1016/j.amepre.2010.05.009

Wijeysundera HC, Machado M, Farahati F, Wang X, Witteman W, van der Velde G, Tu JV, Lee DS, Goodman SG, Petrella R, O'Flaherty M, Krahn M, & Capewell S (2010). Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994-2005. JAMA : the journal of the American Medical Association, 303 (18), 1841-7 PMID: 20460623

15 responses so far

"This bodes some strange eruption..."

Apr 06 2011 Published by under Medical Musings, Medicine

So that rash isn't anything horrid apparently.  My dermatologist, who is wonderful, described it as a mixture of eczema and very dry skin (sort of a mix of eczema craquelé, atopic dermatitis, and xerosis).  She advised less frequent lukewarm showers, good moisturizer, and a high-potency steroid cream.  Hopefully, the change in weather will allow us to get some humidity into the house, but the shower thing is a problem.  I work in small rooms with sick people, so I shower once in the morning to avoid offense in the exam room, and once in the evening to avoid contagion at home.  The doctor recommended a week in Florida, but that's not on the agenda.  The steroids should do it though, eczema being one of those diseases where the immune system is a bit irrationally exuberant.

Antibody molecule

Speaking of immunologic illnesses, I was confronted last weekend by an annoying case of common variable immune deficiency (CVID).  The primary problem in CVID is a failure to make sufficient quantities of antibodies, the chemicals that mark biologic invaders for destruction.  Antibodies are part of the adaptive arm of the immune system that recognizes specific invaders.  The immune system also has a passive arm that can respond to molecules that look generally like invaders.  Antibodies though are very specific.  One may recognize a particular surface molecule on a staph bacterium, another an influenza virus.

The arms of the "Y" on the immunoglobulin molecule are the end that bind to antigens (molecules that form parts of various bacteria, viruses, and other invaders) and can bind very specifically, like a lock and key.  Given the millions of foreign molecules we are exposed to, many of which are harmless, how can we possibly maintain a library of antibodies against invaders?

The immune system, specifically a type of white blood cell called a "B-cell", creates antibodies whose structures are random.  Not every one of these will bind pathogens.  During development of immune cells, this part of the immune system is very closely regulated, so that immune cells that recognize "self" molecules are turned off.  This culls out cells that would attack us, and (normally) leaves the ones we need to patrol for invaders.  If an antibody happens to find an antigen that fits, it will bind, setting off a cascade of changes which will ultimately lead to production of more of that antibody.  This way, a large repertoire of potentially useful antibodies are created, but only the ones that are needed are produced.

As a wise physician once told me, "antibiotics never cured anyone," meaning that antibiotics generally help our own immune system gain control of an infection.  In CVID, antibody production is impaired, so when the patient becomes ill, antibiotics may not be sufficient to save them.  While penicillin may inhibit bacterial cell wall synthesis, antibodies can not only mark bacteria for destruction, but send out a chemical signal to call in more immune cells, evening the odds.

Patients with CVID often become much more ill from common infections that patients with normal immune systems.  Since these patients cannot make enough of their own antibodies, one possible treatment is to give them antibodies from someone else.   Since the antibodies are floating around in the plasma, perhaps we could simply give the patient a plasma transfusion.  The problem here is that any single donor may not happen to have the specific antibodies needed.  If, for example, my CVID patient had an infection with Streptococcus pneumoniae serotype 7F, but the donor had never been exposed to that and therefore did not have antibodies, the plasma would not be helpful.  The solution is to take plasma from thousands of donors, pool it, and divide it up so that each unit will have a wide variety of antibodies.  This is remarkably effective.

So as I spend my precious minutes under the lukewarm shower, I'll contemplate the wonder that is the immune system, and the hard work that has gone into giving us the ability to manipulate it, allowing me to scratch less, and preventing another patient from dying of a normally curable disease.

 

14 responses so far

Not an entirely benign form of expression

Apr 04 2011 Published by under Politics, Uncategorized

In light of recent events, I'd like to repost this piece on book burning, originally from September 9, 2010. --PalMD

 

This week's post on book burnings spurred some interesting discussion (h/t Simon Owens).  One thread of these discussions is the nature of book burning itself.  From a completely ahistorical perspective, book burning is simply "speech".  The burning of a book by a private citizen, or group of citizens, is simply an act of expression akin to writing an editorial or giving a speech.  In the legal sense, this is probably true, and should be.  Anyone should be allowed to burn a book, a flag, a cracker---anything they want in accordance with local laws (e.g. ordinances regarding such things as fire, not designed to limit speech).

But book burning has a history, a context. State-sponsored book burnings in Nazi Germany may be the most extreme manifestation, but book burning as a way to intimidate and to "erase" ideas has a long history.  Just as publishing and disseminating ideas is a powerful tool, physically destroying these is both powerful and violent. While many literate people find abhorrent the idea of burning a book because of the ideas it contains, they may consider it a quirky but mostly-harmless form of expression.

It is not.

Book burning is a violent and threatening act.  This isn't to say it should be outlawed, but it must be acknowledged.  As with any such act, context is also important.  If I were to burn a journal of mine from seventh grade, no one would care.  But a pubic destruction of, say, the Qur'an is very different.  It is also different from the infamous "Crackergate" of PZ Myers.  Dr. Myers intentionally "desecrated" a communion wafer, and while this was offensive to many Catholics (and I found it personally distasteful) it did not create a significant threat.

Catholics are not a "despised minority" in the U.S.  It is unlikely that the public desecration of something Catholic would lead to an existential threat to the Catholic population (something that was very different a century ago when Catholics, especially Irish and southern Europeans, were systematically discriminated against).  This doesn't make Crackergate "OK", but it puts it on a different level in a continuum of intolerance.

Muslims, on the other had, are at risk.  The anti-Muslim rhetoric in the U.S. continues to escalate, creating real fear and real harm.  The planned Qur'an burning in Florida flames this hatred.  It creates a real threat to a minority already under siege.

And I find hatefully disingenuous those who say, "but Muslims aren't doing enough to stop terrorism!"  What is my friend and colleague who is a Muslim from Karachi supposed to do about "terrorism"?   She is already against violence. Is she supposed to join the Marines?  Is she supposed to give up her career and tour the country denouncing terrorism simply because someone who shares a (at least arguably) similar religious background did something bad?

Hateful, threatening acts like book burning must be called what they are: bigoted, evil, violent.

26 responses so far