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Diagnostic Dilemmas

Sometimes diagnosis is straightforward. If a woman has missed several periods and has a big belly with a fetal heartbeat, it’s pretty easy to diagnose pregnancy. But most of the time diagnosis is much more difficult. Alzheimer’s can’t be diagnosed for sure until the patient dies and you do an autopsy. If only we had one of those Star Trek gadgets to point at our patients and give us a quick and accurate answer! Alas! We are far from perfect. All too often, we really have no idea what’s causing a patient’s symptoms. We do a complete workup and still don’t know. What then?

We all know people who have symptoms that a series of doctors have failed to diagnose, who continue to doctor-shop, hoping to find that one doctor somewhere who will find something the others have missed. Occasionally they do; but far more often these people spend a great deal of time and money chasing a will-o’-the-wisp. Sometimes as they are searching, the illness gradually runs its course and goes away. When this happens, whatever they tried last gets the undeserved credit for the “cure.” Sometimes the symptoms persist and these searches consume their life, encourage unhealthy self-absorption, and permanently ensconce them in the “sick” role.

One of the attractions of alternative medicine is that it offers far more certainty than scientific medicine. If your scientific doctor can’t see anything on x-rays, your chiropractor can. He’ll tell you he knows exactly what’s wrong: a subluxation that he can fix. Sherry Rogers will tell you all illness is due to toxins accumulating in your cells and you must “detoxify or die.” Hulda Clark will tell you it’s all parasites that she can eliminate with her magic zapper. Robert Young says the cause of all disease is acidosis. They all have confident, precise answers. Wrong ones.

The One Cause of All Disease?

It’s really easy to figure out what’s causing a patient’s symptoms if you believe there is one simple cause for all disease. While I was writing this I got sidetracked and searched the Internet for “the one cause of all disease.” I found a lot of them, including: (more…)

Posted in: Diagnostic tests & procedures, Science and Medicine

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Christiane Northrup, MD: Science Tainted with Strange Beliefs

After her daughter left for college, Christiane Northrup, MD, went for a morning walk one day. About halfway through her walk she developed an ache in her throat radiating up into her jaw. It felt like a fist was squeezing her esophagus. It persisted even after she returned home. What would you have done?

I think even the average layperson knows that this sounds like a possible heart attack and would call 911 or head for the nearest ER. Instead, Northrup called a medical intuitive who came over and “took out the Motherpeace tarot cards to try to get some clarity.” Together, they interpreted her “heartache” as resulting from her recent disappointment and grief over her family situation. She had unmet needs and it was “no wonder my heart was forced to speak up.”

This behavior from a scientifically trained MD boggles the mind. Christiane Northrup, MD, is a board certified OB/Gyn who has become something of a guru for American women’s health through a series of books, a newsletter, a website, appearances on Oprah, etc. Her third book, The Wisdom of Menopause, has been updated and revised; a friend told me all her menopausal friends are talking about this book. I read it and was appalled. (more…)

Posted in: Book & movie reviews, Science and Medicine

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Reading Medical Literature with a Critical Eye

A long time ago I read a study about what makes a good doctor. Some things you might think were important, like grades in medical school, were irrelevant. What correlated the best was the number of medical journals a doctor read. I don’t know whether that means good doctors read more journals or reading more journals makes a better doctor.

One thing I do know is that most of us could learn better journal-reading skills. When I was a busy clinician, I did what I suspect many busy clinicians do: I let the journals pile up for a while, then tackled a stack when I got motivated. I would skim the table of contents to pick out articles that I wanted to read, then I would read the abstracts of those articles. If the abstract interested me, I would read the discussion section of the article. If I was still interested, I might go back and read the entire article. But until after I retired, I never really developed the skills to evaluate the quality of the study.

I knew enough not to jump on the bandwagon the first time something was reported, because I had seen promising treatments bite the dust with further testing. But I really wasn’t aware of all the things that can go wrong in a study, and I didn’t know what to look for to decide if the results were really credible. I’m not an academic; I thought the authors knew a lot more than I did, and I trusted them to a degree that was not warranted. (more…)

Posted in: Pharmaceuticals, Science and Medicine

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The “Art” of Clinical Decision-Making

Much nonsense has been written about the “art” of medicine. All too often, it amounts to a rationalization for doctors doing what they want to do instead of following the evidence. Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science. Since patients are not all identical, it can be very tricky to decide how to apply the science to the individual.

The New England Journal of Medicine periodically runs a feature called “Clinical Decisions.” They present a case history, then they present 2 or 3 expert opinions on how to manage the case. They stress that none of the options can be considered either correct or incorrect. They allow readers to “vote” as well as to submit comments about why they voted that way. It is understood that the voting is only for interest and to stimulate discussion: it does not result in a consensus.

In April 2008 the topic was the management of carotid artery stenosis. The patient is a 67 year old man who has no symptoms but who is found to have a narrowing of 70-80% in one carotid artery and 20% in the other, putting him at increased risk for stroke. He has other risk factors for cardiovascular disease: hyperlipidemia, hypertension, and overweight. The 3 options are medical management, stent placement, and carotid endarterectomy. (more…)

Posted in: Science and Medicine

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On Being Certain

Neurologist Robert A. Burton, MD has written a gem of a book: On Being Certain: Believing You Are Right Even When You’re Not. His thesis is that “Certainty and similar states of ‘knowing what we know’ arise out of involuntary brain mechanisms that, like love or anger, function independently of reason.” Your certainty that you are right has nothing to do with how right you are.

Within 24 hours of the Challenger explosion, psychologist Ulric Neisser had 106 students write down how they’d heard about the disaster, where they were, what they were doing at the time, etc. Two and a half years later he asked them the same questions. 25% gave strikingly different accounts, more than half were significantly different, and only 10% had all the details correct. Even after re-reading their original accounts, most of them were confident that their false memories were true. One student commented, “That’s my handwriting, but that’s not what happened.”

Just as we may “know” things that clearly aren’t true, we may think we don’t know when we really do. In the phenomenon of blindsight, patients with a damaged visual cortex have no awareness of vision, but can reliably point to where a light flashes when they think they are just guessing. And there are states of “knowing” that don’t correspond to any specific knowledge: mystical or religious experiences. (more…)

Posted in: Book & movie reviews, Neuroscience/Mental Health

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Chiropractic and Stroke

I wonder how many people have heard that chiropractic neck adjustments can cause strokes. It isn’t exactly common knowledge. One organization is trying to raise public awareness through signs on the side of city buses (Injured by a Chiropractor? Call this number) and through TV commercials. I had never heard about this phenomenon myself until a few years ago, when I heard it mentioned on an episode of Alan Alda’s Scientific American Frontiers. I questioned his accuracy, but I quickly found confirmation in the medical literature.

A typical case was that of 24 year old Kristi Bedenbaugh who saw her chiropractor for sinus headaches. During a neck manipulation she suffered a brain stem stroke and she died three days later. Autopsy revealed that the manipulation had split the inside walls of both of her vertebral arteries, causing the walls to balloon and block the blood supply to the lower part of her brain. Additional studies concluded that blood clots had formed on the days the manipulation took place. The chiropractor later paid a $1000 fine. (more…)

Posted in: Chiropractic

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Women in Medicine

Why aren’t there more women in science and medicine? Just because we lack certain anatomical dangly bits, does that mean we’re less capable? Apparently Harvard’s president Lawrence H. Summers thought so. In a classic case of foot-in-mouth disease, he suggested that innate differences between men and women might be one reason fewer women succeed in science and math careers. His comments (in 2005) predictably set off a media feeding frenzy. I won’t even attempt to get into that nature/nurture controversy. Whatever the statistical generalities, the fact is that individual women can and do succeed in those careers. What really matters is whether qualified women today have a fair opportunity to choose their profession and rise in it.

Something very interesting is happening in medicine. It’s happening slowly, quietly, and steadily, with no help from affirmative action programs.

At the beginning of the 20th century about 5 percent of the doctors in the United States were women. In 1970, it was still only 7 percent. By 1998, 23 percent of all doctors were women, and today, women make up more than 50 percent of the medical student population. In 1968 only 1.2% of practicing dentists were women. By 2003, 17% of dentists were women, and 35% of dentists in new active private practice were female. (more…)

Posted in: Book & movie reviews

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Charlatan: Quackery Then and Now

Charlatan: America’s Most Dangerous Huckster, the Man Who Pursued Him, and the Age of Flimflam, by Pope Brock, is not only a rip-roaring good read, but it brings up serious issues about regulation of medical practice and prosecution of quackery. It tells the story of John R. Brinkley MD, who transplanted goat glands into people, and of Morris Fishbein MD, the editor of the Journal of the American Medical Association, who tried to stop him.

The Charlatan

Brinkley was a colorful character whose very first job was a scam, selling a patent remedy. He went to medical school but never finished, eventually buying a diploma elsewhere for $100. A bigamist, drunkard, liar, and con man of incredible audacity, he built up an empire of quackery that made him filthy rich. Apart from his medical adventures, he practically invented modern political campaigning techniques, revolutionized advertising, and was almost single-handedly responsible for popularizing country music and the blues with his radio station.

An impotent patient supposedly told Brinkley, “Too bad I don’t have goat nuts.” So Brinkley gave him some. A few weeks later he went back for a refresher course in surgery (which he failed because of drunkenness and poor attendance). He began to feel that he was gifted and should not be bound by the “jealous sheep ethics” of the AMA. (more…)

Posted in: Book & movie reviews, Health Fraud, Politics and Regulation

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SPECT Scans at the Amen Clinic – A New Phrenology?

Phrenology was a 19th century pseudoscience that claimed to associate brain areas with specific personality traits. It was based on palpating bumps on the skull and was totally bogus. New brain imaging procedures are giving us real insights into brain function in health and disease. They are still blunt instruments, and it is easy and tempting to over-interpret what we are seeing. In his book The New Phrenology William Uttal warns that “the excitement of these new research tools can lead to a neuroreductionist wild goose chase” and that we must be careful not to succumb to new versions of the old phrenology.

The Amen Clinics, founded by Daniel G. Amen, MD, offer SPECT (single photon emission computed tomography) scans to help diagnose and manage conditions such as attention deficit disorders (ADD), mood disorders, anxiety and panic disorders, autistic spectrum disorders, obsessive compulsive disorder (OCD), substance abuse, toxic exposure, brain trauma, memory problems, temper problems, and relationship and marital struggles.

The scans generate colored pictures of the brain that show “areas of your brain that work well, areas that work too hard, and areas that do not work enough.” They do not actually provide a diagnosis, but “must be placed in the context of a person’s life, including their personal history and mental state.” “The goal of treatment is to balance brain function, such as calm the overactive areas and enhance the underactive ones.” (more…)

Posted in: Medical Ethics, Neuroscience/Mental Health, Science and Medicine

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Hormone Replacement Therapy

For years postmenopausal women were told that estrogen was safe. Now they’re being told that estrogen is dangerous. Women are confused. The media haven’t helped; they’ve only increased the confusion and created some myths. Alternative medicine offers the option of herbal remedies they say are safer than estrogen. Suzanne Somers says all of us (even men!) should be taking bioidentical hormones and adjusting our own doses according to how we feel. What’s a woman to do? What does the science really say?

Before the Women’s Health Initiative (WHI) of 2002, there were two main reasons for prescribing hormone replacement therapy (HRT): it relieved perimenopausal symptoms like hot flashes, and it helped prevent osteoporosis and fractures. There was good reason to believe that estrogen might also reduce the risk of heart attacks, but very few doctors (if any) ever prescribed it for the sole purpose of reducing heart risks. And doctors were always aware that estrogen and progestins were powerful drugs and were not risk-free.

There was a time in the mid-20th century when estrogen was thought to be a fountain of youth and women were encouraged to start taking it at menopause and continue for the rest of their lives. That attitude quickly changed as we realized these hormones were associated with blood clots, strokes, and increased rates of some cancers. We also learned that unopposed estrogen caused uterine cancer, and women who still had their uterus had to take progestins along with their estrogen. (more…)

Posted in: Pharmaceuticals

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