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What are words for?

Do you hear me

Do you care

Do you hear me

Do you care

My lips are moving and the sound’s coming out

The words are audible but I have my doubts

That you realize what has been said

You look at me as if you’re in a daze

It’s like the feeling at the end of the page

When you realize you don’t know what you just read

What are words for when no one listens anymore

What are words for when no one listens

What are words for when no one listens it’s no use talking at all

I might as well go up and talk to a wall

‘Cause all the words are having no effect at all

Missing Persons on blogging. Or so I thought. I was surprised to learn the song was written by the brothers Gibb.

Words are important. I try and choose my words carefully when writing so that they accurately reflect not only my thoughts but reality. When I speak, not so much. My frontal lobe filters often fail if I think might I might get a laugh.

I tell housestaff, precision of writing reflects precision of thought. It is one of the reasons I write; the act of writing forces some coherence into what can be muddled and inchoate thoughts. Even though I have residents who write notes, I always write my own. Often I do not make a final decision as to a plan until I put pen to paper, or electrons to screen. Writing crystallizes thought.

Not, evidently, for everyone, as 10 Facts About the Flu Vaccine and the Flu nicely demonstrates. (more…)

Posted in: Epidemiology, Vaccines

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I refute it thus

Reality is one honey badger. It don’t care. About you, about your thoughts, about your needs, about your beliefs. You can reject reality and substitute your own, but reality will roll on, eventually crushing you even as you refuse to dodge it. The best you can hope for is to play by reality’s rules and use them to your benefit. Combined with a little luck (nothing quite as beneficial as being a white, middle class male in the US) you might have a reasonably healthy health.

The most reliable way to understand reality is science and the scientific method. Used wisely you may have a shot at minimizing morbidity and mortality. Deny or ignore it and reality don’t care. Reality will get us all.

We all have our biases, recognized and unrecognized. I often see the world in terms of infectious diseases. When I read Team of Rivals: The Political Genius of Abraham Lincoln I enjoyed the politics and personalities but I was struck by how people constantly died young of infectious diseases. We don’t see mortality in the young anymore for a variety of reasons: better nutrition, an understanding of the pathogenesis of disease, clean water, flush toilets and vaccines.
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Posted in: Epidemiology, Public Health, Science and Medicine, Vaccines

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Survey Says…

Surveys are evidently a popular way to get a paper published. Put “complementary alternative medicine survey” into Pubmed and get 2,353 hits. I would have trouble coming up with a hundred groups about whom I would be interested in their use of SCAMs, but I tend to be a lumper rather than a splitter. But if you want to know about SCAM use in chronic pain patients in one Singapore hospital, the information is available.

I am a survey magnet and a remarkable number of people send me dead tree and electronic surveys which I generally ignore. So people like me, those who ignore surveys (but support public television), are underrepresented in surveys. But evidently there is no group whose attitudes about SCAM are not amenable to analysis including my medical brethren, Infectious Disease doctors.

So I was understandably curious when I was sent a link to “Infectious Diseases Physicians’ Attitudes and Practices Related to Complementary and Integrative Medicine: Results of a National Survey“. The abstract makes it sound like my colleagues are a bunch of ignorant rubes who just fell off the turnip truck: (more…)

Posted in: Acupuncture, Clinical Trials, Critical Thinking, Homeopathy, Science and Medicine

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A Different Perspective: Placebo, SCAM, and Advertising

Summertime, time, time

Child, the living’s easy.

Fish are jumping out

And the handicap, Lord

Handicaps high, Lord so high

~ Janis Joplin

It is summer. Time for the kids and the outside, not the computer. What follows is a summertime blog entry, for which I admit to feeling guilty for the comparatively little time I have spent on it, but as I have said before, no dying patient has ever told me “Doc, I wish I had spent more time at work.”

Mt. Hood has been a constant feature to the east my entire life. The mountain, on a clear day at least, is Portland’s most impressive geologic feature. If you are in the right part of the city, you may see Mt. St. Helens or the tips of Jefferson, Adams and even Rainier, but Mt. Hood dominates. It is solitary mass of rock, (diminishing) ice and snow only 50 miles from where I live. I have spent uncountable hours hiking in the Mt. Hood wilderness. When I think of Mt. Hood, in my mind’s eye it is from the perspective of west Portland looking east.

Last week was our yearly summer vacation in Sunriver, just south of Bend Oregon on the eastern side of the cascades in the Oregon High Desert. Driving north/south on highway 97 puts Mt. Hood in a different perspective. From the high desert you can see the huge swaths of the Cascades: calderas, mountains, lava fields and cinder cones. You see Mt. Hood differently. Not a single mountain to the east, but part of a chain of recent and distant historical volcanic activity along the Rim of Fire. Photographs do not do the view of the Cascades justice from this vantage point.

The eastern view puts Mt. Hood in a broader geologic and time perspective. It is still the same Mt. Hood, but in a different context. Like running into a nurse outside of the hospital, you have to recalibrate the context in which you understand and know the person.

I have written on placebo, the placebo effect, and its relationship to SCAM. To my understanding the preponderance of literature indicates there is no placebo effect upon any objective medical problem, only a change in the patients perspective of the problem. (more…)

Posted in: Basic Science, Clinical Trials, Science and Medicine

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Religion and SCAM

I do not worry much about being dead although the process of getting there gives me pause. I have witnessed a few unpleasant deaths and I hope to never see the Grim Reaper coming my way.

One of the more awful and pointless deaths occurred early in my career. I had a patient with hepatitis C and cirrhosis. He had low platelets, low clotting factors (many of which are made by the liver), a previously undiagnosed clotting disorder, and a mouth full of bad teeth that were removed all at once when he acquired dental insurance.

Then he started to ooze blood from his extractions. An ooze that did not stop, it was a constant trickle of blood that would not clot. After several visits to his dentist he almost passed out and came to the emergency room. After 4 days he had bled out about half his blood volume, his haemoglobin had gone from 12 to 6. At this point we geared up for transfusions of red cells and clotting factors and he let us know that he was a Jehovah’s Witness and, no thank you, he would not accept any blood or blood products.

For the next week he continued to ooze despite all the interventions we could come up with to stop the bleeding and he remained adamant in his refusal of transfusions of any kind, despite the risk of death. At about a hemoglobin of 2 he had a large stroke and severe muscle pain from ischemia. At 1 he had a large heart attack and died. If you could rank deaths as pointless and horrific, this would be in my top 10. And I was struck at how nonplussed the family was, accepting this completely preventable death matter-of-factly. (more…)

Posted in: Science and Medicine

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Who you gonna believe, me or you own eyes?

Mrs. Teasdale: Your Excellency, I thought you’d left!

Chicolini: Oh no, I no leave.

Mrs. Teasdale: But I saw you with my own eyes!

Chicolini: Well, who you gonna believe, me or your own eyes?

Duck Soup. Funniest movie ever.

If I could choose a super power, it would be neither flight nor invisibility, but the ability, like Triad, to separate into multiple people so I could accomplish more. I find that my multiple personality disorder is not all that efficient at getting things done. The Goth cowgirl? Lazy.

So sometimes I have to cut corners. As this post goes live I am at TAM helping with panel discussions and workshops and the only way I can get a post up is to cannibalize my lecture. Dr. Gorski will not let me post the slides and be done with it; those managing editors can be so unreasonable. Full sentences. Proper spelling. Good grammar. Sheesh. Some people.

The topic of my presentation is the cognitive errors that lead people to believe in nonsense and is, or was, a brief tour of the flawed ways in which we think and how the brain allows everyone to be under the false impression that fictions are real. (more…)

Posted in: Critical Thinking, Science and Medicine

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Homeopathy Ramblings

There needs to be a SCAM index, some quantitative tool, a formula for ranking the SCAMs, so one SCAM could reign supreme, to be definitely declared the the goofiest of all SCAMs. Perhaps (number of adherents)x(number of Pubmed publications)x(age of SCAM) all divided by a plausibility factor.

Homeopathy would win and any SCAM index that did not rank homeopathy at number one would have to put up a very convincing argument indeed that their formula was not somehow fundamentally flawed.1

For first time readers, homeopathy is based on several fictions, totally divorced from reality, made up in the 1800′s.

The first law,2 with less reality than Joe Abercrombie’s, is, “similia similibus curentur,” or “let like be cured by like”. Substances which cause specific symptoms can be used to cure diseases which cause the same symptoms.  If like cures like, I am uncertain what moonlight, one of many fanciful homeopathic nostrums, would cure. Lycanthropy? (more…)

Posted in: Clinical Trials, Homeopathy

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Two Viewpoints

Most of what I read professionally is directed towards reality-based medicine. I spend my professional energies thinking about the application of reality to killing various and sundry microscopic pathogens.

The conceptual framework I use, and that used by others in medicine, does not concern itself with the application of the Supplements, Complementary and Alternative Medicines that occupy the attention of this blog. In acute care medicine SCAMs are of virtually no importance yet the approaches we need to take with patients and medicine are, with slight changes in emphasis, as applicable to SCAMs as real medicine. You need to remember, however, that the topic is not necessarily based in known reality.

Two viewpoints in JAMA caught my attention this month, both more thoughtful and reasoned than I am probably capable of. While focused on the application of reality-based medical practice, they apply to the topics of SBM as well. (more…)

Posted in: Clinical Trials, Medical Ethics, Science and Medicine

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People Encouraging Turtle Agony*

Lest anyone think I am a heartless bastard, I would like it to be known that I do not like to see any creature suffer or die. I am the kind of person who, when finding a spider in the house, is likely to catch it and toss it outside. I always think, “I can’t squish the end result of 6 billion years of evolution”. Except mosquitoes. Those I squish with glee. Infection vectors can die die die die.

I like animals and hate to see them suffer unnecessarily. Like sticking them with needles. Frontal lobes are nice to have. They can let you know that pain is coming and provide preparation and compensation. Once I had a steel bar smack me on the head, opening up a six-inch cut to the bone. No, my brain was not affected, thank you very much. Everything predates the head trauma. When the ER doc numbed the scalp for sutures, he missed the last half-inch and I felt the needle. Knowing what was going on I steeled myself and let him do the last two sutures with no lidocaine, since the needle hurt only a little worse than the lidocaine injection. I have had many other unpleasant medical procedures in my 56 years but knowing what was coming and understanding why makes it easier to tolerate a needle popping into the knee joint or an abdominal drain being pulled.

Animals, and young humans, lack the ability to comprehend the what and why of pain inflicted as part of medicine. Adults can make a conscious decision to be endure pain and fool themselves into thinking it is of benefit. No pain, no gain. Animals can make no such choice.

For example consider sea turtles, who, apparently, are subjected to all sorts of nonsense at the New England Aquarium including acupuncture and laser therapy. As is obvious, I am no veterinarian, the only animal of which I have any understanding of anatomy and physiology is a human, but even with that background it is remarkable what is reported from New England. I used to say the ‘B’ students went into journalism; given the credulous reporting perhaps the standards have been lowered. They certainly have for marine biologists and veterinarians, who are evidently shortchanged in their education. (more…)

Posted in: Acupuncture, Basic Science, Energy Medicine, Science and Medicine, Traditional Chinese Medicine

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Whack em hard/Whack em once and Stroke

There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw

I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system.  My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.

Man, that’s awful. Is she doing OK?

Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.

I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall.  I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.
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Posted in: Chiropractic, Clinical Trials

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