We have an active comments section on our blog, but for some reason some people prefer not to comment there, but to send personal e-mails to authors when they disagree. Some of them make me laugh. Some of them make me despair. We can carry on our struggle better if we know what we are fighting; and in that spirit, I want to describe a recent e-mail exchange.
If an e-mail is filled with angry CAPITALS and abusive language, I know there is no point in responding. But I still get suckered in by the ones that start out sounding as if a productive dialog might be possible; unfortunately, discussions almost always degenerate. In this case, it started with a polite request for my opinion about a specific study. (more…)
It appears that we are near the beginning of a new modality in medicine – the use of computer controlled and powered robotics for therapeutic purposes. At present such technology is in its infancy, but is giving us a glimpse of what it will become.
Recently Vanderbilt University announced that its team at the Center for Intelligent Mechatronics has developed an exoskeleton that paraplegics can wear on their legs to allow them to sit, stand, and walk. This is essentially a mechanized orthotic that paraplegics can wear on their legs. The researchers describe it as a “Segway with legs” – referring to the computer technology that controls the exoskeleton, which responds to the user’s movement. If the user leans forward, then the legs will walk. If they lean back, then they will sit.
Like any technology, you can take either a glass half-full or half-empty view of this device. I will cover both – first the good.
Their system has some advantages over previous systems. It is about half the weight, coming in at 27 pounds while other lower extremity exoskeletons weigh 45 pounds. The exoskeleton is also small enough to fit in a standard wheelchair while being worn, and can be put on and taken off by the user alone. As described above, this system also incorporates intelligent control technology. Users with partial paralysis can have their own movements augmented, while for those with complete plegia the exoskeleton can do all the work.
A recent survey about patient attitudes and desires with regard to health care demonstrate that respect for scientific evidence is still the dominant factor in preferring treatments. (Full study) This is good news, although the numbers could be better.
Researchers asked subjects what factors were important in determining which treatments they would prefer, the scientific evidence, the experience of the clinician, or their own personal preferences. Not surprisingly, most subjects wanted it all, agreeing that all three are important. Scientific evidence, however, scored the highest with 71% rating it as very important (and over 90% as important or very important). Clinical expertise had 61% strongly supported and personal preference, 57%.
Further, patients wanted their doctors to talk to them about the evidence. The phrase they felt had the most impact on their decision to accept a treatment was, “What is proven to work best.”
All of this matches my personal experience as a clinician. At least for the self-selective population of patients who seek out a university physician, patients tend to find recommendations based upon published evidence compelling, and greatly appreciate when I take the time to tell them about the evidence, even if it goes against their initial interests.
This is, I admit, a content free post. July and August are the sunny days here in the great Pacific Northwest, and rather than spend time in front of the computer, I am outside with the kids. To compound matters, I was on call the labor day weekend (I usually write the first draft the weekend before the posts are due) and was very busy. I am finishing this early on Thursday on an airplane to Vegas. My wife and I are taking our first non-child containing vacation in 19 years while my youngest is on a 4 day school trip. Wander the strip, see a show and enjoy the desert heat as a couple and not a family.
I have not had the time to spend researching a topic, so instead I thought I would ramble on about 2.5 topics that have been on my mind. Writing helps to focus my thoughts. Even though I often have residents on service, I still write daily notes as the act of putting thoughts into words is the best way to clarity thoughts. Next week the kids are back at school and I am sure the rains will start up and I will again have time to go into full research mode. In the meantime feel free to ignore this post.
There is nothing to see here. Move along. (more…)
Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.
Something to Consider When You have Back Pain
Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.
It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.
Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.
From an e-mail I received:
As a proponent of SBM, and a someone who places a high value on reason, logic and evidence, I would like to find a physician who shares this mindset.
He went on to ask how he could go about finding one.
Another correspondent was referred to a surgeon by her primary physician, and the surgeon inspired confidence until she started talking about using homeopathic arnica pills to improve healing post-op. How she could determine the technical competence of this surgeon? Was acceptance of homeopathy a reason to shed doubt on her judgment in other areas? Should she seek a second opinion?
I get a lot of inquiries about how to find a good doctor. I don’t have a good answer. I thought it might be useful to throw out some ideas that have occurred to me and hope that readers will have better ideas and will share their experiences about what has or hasn’t worked. (more…)
Two weeks ago I wrote about the demise of the traditional annual physical for healthy adults who have no symptoms.
The First Step: Identifying a Symptom
People who do have symptoms should see a doctor. They should have appropriate evaluations that may or may not include a partial or complete physical exam. One problem is that people may not be able to decide what qualifies as a significant symptom. Could the heartburn actually be a heart attack? Is the fatigue a normal result of exertion, or could it be a sign of something serious? Could my headache be a sign of brain tumor, or should I just take an aspirin? My spouse says I’ve been snoring more: could that be a sign of sleep apnea? What if I just “don’t feel right”?
This is a real dilemma, because minor transient symptoms are a normal part of life. Some of them are due to trivial conditions that spontaneously resolve; some are sensations due to the normal functioning of the body. Some people are more aware of these sensations than others. Paying attention to them tends to make them worse. Some people barely let these minor sensations intrude on conscious thought; others fixate on them and obsess about them. There is a spectrum of human reactions ranging from the stoic denier to the hypochondriac. (more…)
A brief reference on the web site The Quackometer recently drew my attention to a very short book (really more of a pamphlet, in the historical sense) by Dr. Worthington Hooker, Lessons from the History of Medical Delusions, which I thought might be of interest to readers of this blog. Though published in 1850, the book contains many eloquent observations that are just as relevant to understanding how pseudoscience and quackery persist and even flourish in what we otherwise assume to be an age of scientific medicine. The book is available online as a Google eBook, and relatively cheap printed facsimiles are available as well.
Dr. Hooker was a physician, a professor at Yale, and an outspoken critic of homeopathy in it’s early days. His critique of homeopathy still resonates today, and has long drawn the ire of Hahneman loyalists, such as this one who makes reference to Dr. Hooker’s, “periodical fulminations for the destruction of Homoeopathy that have appeared like locusts or cholera at certain dates.” Though Dr. Hooker wrote an entire book discussing homeopathy, Homeopathy: An Examination of its Doctrines and Evidences, he does spare a few words here for this less-than-venerated practice:
The error I have been illustrating is carried to an extreme by the Homeopathist. He attributes palpable results to doses of medicine which are so small that they cannot produce any perceptible effect except by miracle.
The holiday season is upon us. As a bit of a holiday from science-based writing, I thought I would offer some thoughts inspired by the season and not supported by any scientific evidence.
One of my friends refers to Christmas as “The Feast of St. Dyspepsia.” Holidays are indeed an occasion for over-indulging. People change their routine: they have time off work, they travel, spend too much money, go to parties, skip exercising, eat and drink things they ordinarily avoid, gain weight, and then suffer from post-holiday guilt.
Science and Mom both tell us we will be healthier if we eat our fruits and vegetables, exercise, avoid large quantities of alcohol, get enough rest, avoid stress, and control our weight. I would argue that if we follow that guidance most of the time, an occasional lapse is not likely to matter very much. And the pleasure we experience might even be good for our health.
Now for some heretical words.
Science isn’t everything. Health isn’t everything. Even truth isn’t everything. Humans find value in other things like music and mythology, things that bring great pleasure and help make life worth living.
I just returned from a trip to Montreal where I spoke at the Lorne Trottier Public Science Symposium, an annual event that David Gorski spoke at a year ago. My topic was “Puncturing the Acupuncture Myth” and the other speakers were Paul Offit, Edzard Ernst, and Bob Park. I was honored to be in such august company; and we were wined, dined, and cossetted: overall, an experience that will count among the high points of my career. In addition to speaking at the Symposium, I was interviewed on the radio; participated in a roundtable discussion with other doctors, scientists and journalists; and was invited to speak to a large freshman chemistry class at McGill University. I told the students a bit about how I came to be the SkepDoc and some of the things I’ve written about, with “Vitamin O” as an example, and I provided 3 “lessons I have learned” from my investigations that are general principles applicable to other fields:
- Roosters don’t make the sun come up.
- Never believe one study.
- The SkepDoc’s Rule of Thumb: when encountering a new or questionable claim, always try to find out who disagrees and why.
My presentation was recorded and is available as a webcast. Scroll down to “2011/11/08 HallOffit” near the bottom and click on the appropriate symbol to the far right. That saves me having to write a post this week. I think SBM readers will find it pertinent to all we discuss here.