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“Complex, multi-component therapy” can be studied well

This August was a tough month for SBM bloggers reading The New England Journal of Medicine (NEJM). Just one week after a review of acupuncture for back pain—in which the authors recommended referring patients to traditionally trained acupuncturists despite data showing that traditional needling does not outperform a blinded sham control (click here here here for the trifecta takedown)— NEJM featured an original article about a study of Tai Chi for fibromyalgia. As critiqued by Dr. Gorski, the control intervention for the Tai Chi study was arguably inappropriate: the test and control groups experienced different intensities of exercise, for different durations of time, led by different instructors with different levels of enthusiasm. The special pleading and the weak design were not of themselves surprising, only their presence in such an august journal.

A group of editorial authors in that same NEJM issue preemptively address the SBM critics by describing Tai Chi as a “complex, multi-component therapy” and thereby implying that an appropriate sham cannot easily be designed. I agree that studying Tai Chi must be trickier than matching drugs to sugar pills. But “complex, multi-component” interventions can indeed be studied in a way that leads to convincing conclusions, as illustrated in the August 25, 2010 issue of The Journal of the American Medical Association (JAMA). A team of Boston psychologists studied a complex, multi-component intervention for attention deficit-hyperactivity disorder (ADHD) and reported their findings in “Cognitive Behavioral Therapy vs Relaxation With Educational Support for Medication-Treated Adults With ADHD and Persistent Symptoms: A Randomized Controlled Trial.” The abstract: (more…)

Posted in: Clinical Trials

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CAM on campus: Ethics

In a previous post I described a lecture given by a faculty member to first-year medical students on my campus introducing us to integrative medicine (IM). Here I describe his lecture to the second-year class on legal and ethical aspects of complementary and alternative medicine (CAM).

Dr. P began his lecture by describing CAM using the now-familiar NCCAM classification. He gave the NCCAM definition of CAM as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.” To illustrate how this definition can lead to surprises, he asked us if the therapeutic use of maggots is CAM or conventional. Although it sounds rather CAM-ish, maggot therapy is used at some surgical centers for wound debridement, he told us, and therefore is part of “conventional medicine.”

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Posted in: Medical Academia, Medical Ethics, Science and Medicine

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CAM on campus: Integrative Medicine

My previous posts have described guest lecturers at my medical school campus, invited by a student interest group in CAM. Those events continue; currently ongoing is an 8-weekend certification course in Ayurveda for the subsidized cost of $1500 (includes “tuition, syllabus, and personal guru”). I could pick on this student group, but what’s the point? There will always be medical students who organize to promote ideas that you or I disagree with, whether it be political, religious, or personal. The fact that Tim Kreider disagrees with a particular student group is not terribly interesting.

The more important issue is how CAM is treated by faculty in the curriculum. Particularly during the preclinical years, medical students are in the habit of transcribing and commiting to memory everything uttered by the professors who grade them. A lack of rigorous skepticism is frankly necessary given how much information we are required to master. Where would CAM fit in among the lectures on anatomy, physiology, and pathology?

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Posted in: Medical Academia, Science and Medicine

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A science-based blog about GMO

Much time, money, and ink is spent in our culture obsessing over what foods are “good” or “bad” for health. Oftentimes such claims are out of proportion with available evidence, perhaps based on reasonable-sounding theories but not so much on convincing data. Here are a few examples of SBM bloggers addressing food and diet: 1, 2, 3, 4.

An interesting subset of food claims relate to the safety of genetically modified organisms (GMO) in the food chain, safety both for individuals and for ecosystems. I’d like to recommend SBM readers to a blog called Biofortified written by graduate students and scientists in plant genetics. The Biofortified bloggers explain hot topics and controversies in genetic engineering, attempting to cut through the wild propoganda in favor of calm science. The authors tend to be more pro-GMO than not—perhaps unsurprising since their careers are spent studying them—but they strike me as quite reasonable in their support. Here are a few posts I liked: on fears about GE crops, on food labels, on anecdotal health claims, on gene patents, on smoking your vaccines someday.

Today is a particularly good time for you to check out Biofortified because they are competing in the Ashoka Changemakers “GMO: Risk or Rescue?” contest. According to Karl, a grad student who writes on Biofortified, theirs is the only “pro-science” group in the running. The prize includes a nice grant and an opportunity to have a conversation with author Michael Pollan. If you like the blog enough to vote for them by this Wednesday 10/28 at 6pm EST, see details about the contest here.

Posted in: Science and Medicine

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Mixed Messages on Campus

The past two months have been my first time working in the hospital, as a third-year medical student in my Internal Medicine clerkship. It’s been exciting not only to see how medicine works but to be a part of the action! It really is striking to see the dramatic increases in proficiency and confidence with each stage of the training. From junior student to acting intern to intern to resident to chief resident and eventually to attending, each year brings both more responsibility and more competence. Importantly, physicians-in-training also get very efficient in seeking out and communicating information. Just like SBM editors read widely and blog prolifically whereas I struggle to put together one post a month, experienced clinicians have responsibility for dozens of patients at a time whereas I feebly tag along with one or two each day. Watching my elders on the medical team, I feel excited about how much smarter and more effective I will become as I progress through my training.

Anyway, I want to share an interesting sight in my hospital last month. There were three 3-foot posters on tripods prominently displayed in the hospital lobby, in the cafeteria, and in other public places. The first one read: (more…)

Posted in: Science and Medicine

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SBM in primary practice: one student’s experience

EDITOR’S NOTE: Dr. Jones is off this week; fortunately, we have this guest post by Tim Kreider, our science-based medical student. Enjoy!

My first clerkship of my third year of medical school was Family Medicine, and I had a great experience. After the first two years spent mostly with books and then a three-year interlude in a basic science lab, these past five weeks were my first extended foray into the world of patient care. I had a few lectures and seminars on campus, but most days were spent in a primary care office learning on the job. I was assigned to an office attached to a community hospital with a Family Medicine residency program, so I was able to work with both attending physicians and residents in training. I learned a lot and gained some much needed confidence regarding my clinical exam skills, which were rather rusty after grad school.

I have heard as a criticism of the SBM mission that practicing medicine “in the real world” is different from what evidence-obsessed, ivory tower dwellers think it should be. Therefore I approached my Family Medicine clerkship as my first chance to see the challenges and realities of practice outside the university setting. How would the practice of community-based physicians compare to the perhaps lofty ideals espoused by academics? (more…)

Posted in: Medical Academia, Science and Medicine

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Medical training versus scientific training

This month I will begin my third year of medical school, after a three-year break for laboratory research. Living alternately in the worlds of med school and grad school has prompted me to reflect on differences between these training programs.

[Obvious disclaimer: I have studied at a single institution, and only for five years.]

I am enrolled in a dual-degree MD/PhD program. About 120 US medical schools have such programs, and the National Institutes of Health funds a third of them (MSTP). The schedule of such programs is generally: 2 years of medical school (culminating in USMLE Step 1), 3+ years of graduate school (culminating in dissertation and PhD), and then the last 2 years of medical school (which I begin this month). The most popular residency choices for MD/PhD graduates are internal medicine, pediatrics, and pathology (match data). Other residencies that attract these graduates include dermatology, neurology, ophthamology, and radiology (survey data). The hopes of those funding the MD/PhD training programs and of those accepting the graduates is that these individuals will become physician-scientists, bridging the divide between lab bench and patient bedside with insights from both. (more…)

Posted in: Medical Academia, Science and Medicine

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Is translational research impaired by an emphasis on basic science?

Sharon Begley, the Science Editor for Newsweek, wrote about translational research in the latest issue, and the tone of the essay reminded me of Begley’s previous piece on comparative-effectiveness research. Being an MD/PhD student (just defended!) I am very interested in the process of communicating “from bench to bedside.” New to science as I may be, I found Begley’s arguments to be overly simplistic and short-sighted. (more…)

Posted in: Science and Medicine, Science and the Media

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How I would run the CAM club

During the past academic year, I have written about CAM on campus for my student newspaper and fancy myself now somewhat notorious among the students who care about the issue. My article in the fall issue was a review of a homeopathy lecture that I described in detail for my first SBM post. In the winter issue I discussed two dueling WSJ opinions and the silliness of the “4 in 10 Americans use CAM” argument, channeling Drs. Gorsky and Crislip. I had a piece planned to wrap up the series, but sadly the spring issue has been canceled because the rest of the editorial staff is studying for USMLE Step 1. This is life at medical school, probably not just mine but universally: huge stresses and time obligations often crowd out extracurricular activities.

I began imagining this essay, an open letter to the campus CAM advocates about how I would direct their programming, just before my run-in with a pair of students unhappy about an SBM post. Before the accusations of unprofessionalism began flying around, I was thinking about how we could find common ground. Are there aspects of CAM that even a self-described skeptic can support? Clearly everyone on campus cares firstly about providing the best possible care for patients. Could the CAM advocates and I be collaborative rather than antagonistic? Some disagreement is inevitable given that I have classmates who have taken coursework in homeopathy and integrative nutrition, but I wondered if I could offer constructive advice on improving the CAM club rather than simply dismissing it as having no place on campus. (more…)

Posted in: Science and Medicine

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