I have been involved in infection control and in what is now called quality for my career. Since infection control issues can occur in any department, my job involves being on numerous quality related committees (Medical Executive, Pharmacy and Therapeutics, etc) where I have witnessed or participated in what seems to be innumerable quality initiatives.
It always gripes my cookies when someone says “Get your own house in order,” because that is a person who evidently is arguing from ignorance. Since To Err is Human was published at the turn of the century, the hospital systems in Portland and across the country have invested significant time and money into quality improvement. Do a Pubmed on ‘Hand Hygiene Compliance’ in the last decade; there are over 400 references. Or ‘deep venous thrombosis prophylaxis’ — over 5,000 references. Or ‘ventilator associated pneumonia prevention’ — over 750 references. Pick a topic related to safety and quality and search the literature, and you will find a remarkable amount of research into the best ways to decrease morbidity and mortality in the hospital.
Hospitals, at least those in my city, take safety and quality very seriously, and by applying the results of these studies, there has been a marked decrease in mortality and morbidity in my institutions. Compared to historical controls, we estimate we have, in the last 2 years, prevented about 600 hospital acquired infections and over 200 deaths. (more…)
In the last post on acupuncture, I noted that the University of Maryland offered reflexology along with other supplements, and complementary and alternative medicine (SCAMs). I was uncertain as to the particulars of this SCAM, and this post is a result of those investigations.
Although messy in reality, science is a tool that gives us an idea as to how the real world functions. People will observe some aspect of nature, often for a lifetime, and from those observations discover a pattern in the data. Tycho Brahe spent a life carefully measuring the orbits of the planets; the data was used later by Kepler to determine that the planets orbit in an ellipse with the sun at one of the foci. If you have knowledge of the history of science, you realize what an amazing feat this represents, both in the measurement of the orbits and the analysis of the data. Careful observation, analysis of the data, then conclusions.
This is in contrast to SCAMs, where so many of the interventions are discovered by revelation, and then developed independently of data and observation. Palmer and chiropractic, von Peczely and iridology, Usui and reiki are examples. These geniuses discovered aspects of existence unseen by anyone before or after.
The bar on this blog is set high. The entries are often complete, with no turn left unstoned. Yet, not every topic needs the full monty with every post. The blog has extensive evaluations on many topics, and new medical literature doesn’t require another complete analysis. Many new articles add incrementally to the literature and their conclusions need to be inserted into the conversation of this blog, like a car sliding into heavy traffic. My eldest son just received his driver’s license, and car metaphors are on my mind. As are crash metaphors and insurance metaphors.
So in response to this need, a need only recognized by me, I give you Short Attention Span SCAM. Occasionally I will summarize a few recent studies and their key points as they relate to prior posts at SBM.
Humans love to find patterns in the world. Sometimes patterns exist, sometimes they are imaginary. Sometimes you can see a pattern that may be interesting and ignore its significance. As a resident I used to say that anyone who smokes three packs of cigarettes a day has to be schizophrenic, it was meant more as a joke, when, in fact, it was later discovered that tobacco helps ameliorate the symptoms of schizophrenia. I need to pay more attention.
Part of my job is to look for patterns as a key to the patients diagnosis. Diseases and pathogens tend to (more or less) cause reproducible signs and symptoms and looking for that pattern is often the most helpful clue towards finding the diagnosis. Of course things are never as easy as one would like, as you have to consider whether you are seeing common manifestations of a common disease, uncommon manifestations of a common disease, common manifestations of a uncommon disease and, the hardest, uncommon manifestations of an uncommon disease. When I have a complex or uncertain cause, I explicitly run through that, and other, litanies so I do not miss a unusual diagnosis.
Chronic Fatigue Syndrome (CFS) has, at least to my way of thinking, two patterns. I see the occasional CFS patient in clinic and, I hope, pay attention to their disease patterns. I keep in mind I may be seeing a pattern that does not exist, but looking for disease patterns is what doctors are trained to do.
I realize that the New England Journal of Medicine (NEJM) review of acupuncture has already been covered by Drs. Gorski and Novella. But my ego knows no bounds; so I thought I would add my two cents, especially since this review, more than any paper I have read, generates a deep sense on betrayal.
There was a time when I believed my betters. Then the Annals of Internal Medicine had their absolutely ghastly series on SCAMS, the publication of which was partly responsible for interest in the topic. Since that series of articles, I have doubt whenever I read an Annals article. When a previously respected journal panders completely to woo, they lose all respectability. Sure, the editors that were responsible for that travesty are long gone, but the taint remains. I tell my kids that once a trust has been violated, it is difficult to get it back. The Annals has permanently lost my trust, I am afraid.
But we will always have Paris. I mean the NEJM. The NEJM is the premier medical journal. Just because an article is published in the NEJM doesn’t mean it’s right; the results of clinical trials are always being superseded by new information. But the article has supposedly been rigorously peer reviewed. Its like Harvard and… Oops, Bad example. Harvard, as we have seen, has feet of clay, and so, evidently, does the The New England Journal of Medicine.
Goodness, gracious, great balls of fire, the editors of the NEJM have fallen into the depths of nonsense with this one.
Dad always thought laughter was the best medicine, which I guess is why several of us died of tuberculosis.
We have a saying in medicine that you can’t kill a jerk. Not that we try to kill anyone, but that particularly unpleasant individuals, rife with psychopathology, survive whatever illness comes their way. The corollary is that particularly nice people are prone to having horrible diseases with unpleasant outcomes. We all know intellectually that it is not true, but there is an ongoing feeling in health care providers that somehow patient personality determines the consequences of their diseases. As an aside, I am often left with the explanation for patients that the reason for their odd infection comes down to bad luck. Everyone responds something to the effect that “Typical. I get all the bad luck.” I have never had a patient say, “That’s odd, I am usually so lucky.”
On the question of nurture versus nature, raising two children has convinced me of the relative lack of importance of nurture in the personalities of my children. While abusive/pathologic environments will certainly lead to pathologic personalities, for the average child raised in middle class America I can’t help but think that, to quote Popeye, “I yam what I yam and that’s all what I yam.” I expect to be schooled in the comments on that subject. Yes, I read the Blank Slate and have some understanding of the literature. And yet. My kids, my friends kids. I watch them grow in what is (and isn’t) a similar environment and end up with diverse personalities that often appear present before they can speak. I am well aware of the multiple logical fallacies that lead to that conclusion. Parenthood and medical practice (where people seem to do the same damn stupid things over and over) have lead me to the conclusion that free will is mostly a myth and we are mostly programmed to behave the way we do. Discuss. It is not the main point of the post, but my bias.
There are two topics about which I am a crank. The first, as you might have guessed, is alternative medicine. The other is pharmaceutical reps. Drug companies are somewhat schizophrenic. They have amazing scientists who invent drugs that treat an astounding array of diseases. Then, they take these drugs and turn them over to marketing, to be sold with all the enthusiasm and truthiness of a late night infomercial.
In the spirit of openness, I will say that I have not talked to a drug rep in 20 years. As far as industry supported gifts and food, I have not taken a pen or eaten pizza from industry in almost 30 years, since I was a fourth year medical student. I have accepted one gift over the years. Years ago, when the Pfizer rep left, he sent me Fleets enema with a Unasyn sticker on it. I still have it in my office, unused. But you never know when it might come in handy.
Being an absolutist about industry gifts does have downsides. It is distracting to sit in an auditorium filled with the smell of pizza and not eat any; somehow the PB&J I bring with me doesn’t smell as sweet. Administration has received one letter complaining about me that was ostensibly from an employee, but curiously was printed from a windows folder that had the same name as the levofloxacin rep. Just a coincidence, I am sure.
Some Universities have more cachet than others. On the West coast it is Stanford that has the reputation as the best. There is Oxford, Yale, MIT, and maybe Whatsamatta U. I would wager that in most people’s mind the crème de la crème is Harvard. Harvard is where you find the best of the best. If Harvard is involved, a project gains an extra gobbet of credibility. Brigham and Women’s Hospital also has a similar reputation in the US as one of the hospitals associated with only Harvard and the New England Journal of Medicine. Premier university, premier hospital, premier journal.
So if Brigham and Women’s Hospital and Harvard Medical School are offering continuing medical information (CME) for acupuncture, there must be something to it, right? A course called “Structural Acupuncture for Physicians” must have some validity.
I have discussed two articles from the web site Medical Voices, one with 9 questions, the other on mumps. There are, I think, 18 web pages of articles about vaccines on that web site. I am uncertain as to the true number of pages of information as the navigation buttons at the bottom of the pages do not always seem to function correctly. That such a problem exists suggests that no one has bothered, like me, to go through the web site to read all the essays. Or maybe it is me and the price of using the Chrome browser. Anyway, there are a large collection of essays that serves as a rich vein of iron pyrite to mine for topics. At about 5 entries to a page, evaluating at a pace of about one monthly, it would take years to analyze all the misinformation on Medical Voices.
It occurs to me that at the center of each article is a nut of misinformation (or sometimes as many as nine) that serves as the core fallacy of that article. I want to emphasize that I am using ‘nut’ as a metaphor for seed, not in its other, more colloquial, meaning. So rather than an in-depth evaluation of each article (although some will warrant a future, more through review), I thought it would be interesting to identify the nut in each article and why it is wrong. So, in the spirit, but not the intellectual rigor, of Generation Rescue‘s “14 Studies“, let’s sort through the nuts …
I write this post with a great deal of trepidation. The last time I perused the Medical Voices website I found nine questions that needed answering. So I answered them. One of the consequences of that blog entry was the promise that Medical Voices was poised to “tear my arguments to shreds.” Tear to shreds! Such a painful metaphor.
They specified that the shred tearing would be accomplished during a live debate, rather than a written response. While Dr. Gorski gave excellent reasons why such a debate is counterproductive, I am disinclined for more practical reasons. I am a slow thinker and a lousy debater and have never, ever, won a debate at home. If I cannot win pitted against my wife, what chance would I have against the combined might of the doctors and scientists at Medical Voices? My fragile psyche could not withstand the onslaught.
Still, there is much iron pyrite to be mined at Medical Voices and it may provide me for at least a years worth of entries. Please forgive me if I seem nervous or distracted. I have a Sword of Damocles hanging over my head and it may fall at any time. My writings may, without warning, be torn to pieces by the razor sharp logical sword of Medical Voices. Or maybe not. It is my understanding that Medical Voices will only answer with a debate, so maybe I am safe from total ego destruction.
This month, as I perused Medical Voices, I found it difficult to choose an article. So much opportunity and I have limited time to write. I finally decided on Why the New Mumps Outbreak Puts You At Risk by Robert J. Rowen, MD.