The blogosphere held no fascination for me before my involvement with sciencebasedmedicine.com. I had checked into a few blogs, and found some capturing attention, allowing exploration of ideas and personal views in greater scope than allowed for in scientific papers. But many seemed not to expand discussion after an original post. When the blogger would describe some series of events or ideas, there would follow a series of pro and con short commentaries, whose authors seemed to enjoy sniping at irrelevant issues. The emotional level rose with each series of exchanges. One had to search for pages with comments that expanded knowledge, and were not just argumentative.Some commenters took off on small details in the original.. Then ensued a series of yes I did – no I didn‘t, you said – I said, you said – I meant, you‘re a blank – you’re a worse blank, and on, as readers know.
I wrote an article or two for an online ‘zine, and the format allowed for extended exchanges, like the blogs. Comments followed a similar pattern. They continued for 2 weeks. Same thing happened when I critiqued traditional Chinese medicine, implausible claims, ethics of “CAM” in editorials in an online journal. Questions there were screened by editors, but I filled more space elaborating answers than I was allowed by the word limit to the original articles. I noted that even news items in online news sources were followed by series of comments, challenges, counterchallenges and on they went, often getting uncomfortably personal. Lost in some of this was the meat of the original article as small point after smaller point appeared.
All this is old stuff to most of you readers, but to me, it was new. And I wondered not only about the format and policies that allowed ongoing sniping, but had to look at my own reactions, often surging in the same direction of telling people off. I keep telling myself not to answer snipes, but the temptation sometimes wins. Too much chance to show cleverness and to enjoy that basic, innate joy of putting it to someone who wrote something that really ticked me off.
The internet is arguably the ultimate expression of democracy and the free market. For the cost of internet access anyone can pull up a virtual soap box and preach to the world. There are no real gatekeepers, and the public can vote with their search entries, clicks, and links. Every point of view can be catered to and every special interest satisfied. Type in any obscure term or concept into Google and see how many hits you get (“banana farming” yielded 1,470,000 hits).
There is potentially a downside to this as well, however. Because there are websites fashioned for every opinion and perspective no one has to venture far out of their intellectual comfort zone. Virtual communities of like-minded individuals can gather and reinforce their prejudices, and to varying degrees keep out contrary opinions. This is harmless when dealing with aesthetic tastes, but can be stifling to intellectual discourse.
On the other hand defining the mission, scope, and character of a blog, website, or forum is necessary to some degree. Every site does not have to be a free-for-all. If biologists want a forum to politely discuss biological topics in a collegial fashion they have the right to create a virtual space in which to do that, and whoever owns and operates the site has the right to mandate whatever rules they wish. Allowing political activists to overrun the site and hijack the conversation would be counterproductive. Like most things a healthy balance probably works best.
Medicine’s ethics and basis in science hang by a thread at times. At least in the US of A. I will present a few examples and illustrate them with correlates from other fields in which decisions with wide effects are sometimes made by the whim of one person. And that’s not just the declaring of war or whatever we call it these days.Start with an anecdote of mine from the mid-1970s or so. I somehow got involved in a dispute with the staff of then Gov. Jerry Brown over his proposal to de-license medical practice. He sent out early holistic medicine vibes and viewed health and medicine as fields open to anyone to practice by simply hanging out a shingle. I asked to meet with my state assemblyman and complained about the situation. I stated that physicians determined what medical practice is. He smiled benevolently and broke the news. “No, doc, we (in state government) do.“
I immediately recognized what he was saying. All licensure is granted by the state, and all regulations and laws referring to each occupation’s license are determined essentially by a majority vote and a governor’s signature. All those heroes in the history of medicine and science not withstanding. It was an awakening.
Jerry Brown’s vision did not materialize and he came to recognize holistic and alternative medicines as so much goofy stuff and quackery, as he later confided at a fund-raiser (yes, I went.)
I sometimes lecture on science-based medicine to my colleagues and one of the most common questions I get is how to deal with a patient who expresses belief in unscientific treatments. The dilemma for the physician is that professionalism requires that we do not confront patients regarding their personal beliefs. We are there to inform and advise, not preach. And yet proper medical care is often hampered by unscientific beliefs on the part of patients.
David wrote previously about a case he reviewed in which a woman with a very treatable early stage of breast cancer opted for “alternative” treatment rather than the standard treatment, which carries a > 93% good outcome. As a result her cancer progressed horribly – but she clung to belief in CAM despite its obvious failure in her case. This story highlighted the fact that giving patients proper medical advice sometime requires confronting their false beliefs.
Unscientific and bizarre medical practices are in vogue and are increasingly infiltrating the medical system through a combination of misguided political correctness, stealth, and apathy. This is exacerbating the dilemma for science-based practitioners who are caught between the imperative to do the right thing in accordance with evidence-based guidelines and the default respect for the patient and the desire to maintain a therapeutic relationship.
In my experience, however, these two goals do not have to be mutually exclusive. An uncompromising but non-judgmental approach works very well.
One of the more annoying duties I used to have several years ago at our cancer center was to “show the flag” at our various affiliates by attending their tumor boards. I say “annoying” not so much because the tumor boards themselves were onerous or even uninteresting but rather because traveling to them used to cut into my already limited time for research, given that these tumor boards were always scheduled on days on which I didn’t have to be in clinic or the operating room. In other words, they always took place on my research days.
One of our affiliates was a nearly an hour and a half drive away, and many of them were close to an hour away. When you add up travel time and the tumor board, that’s easily more than three hours eaten up, all too often right in the middle of the day. In actuality, though, several of the tumor boards themselves were quite good, one of which being the aforementioned one that required nearly a 90 minute drive to reach. (It helped that they served a really nice breakfast there, too, but they also have really stimulating discussion about various cancer cases.) One of the weird things about these tumor boards is that I was viewed as–and I quote–the “outside expert.” This was particularly disconcerting the first year I had the job. There I was, fresh out of fellowship, being looked up to as the “expert” by physicians, many of whom who may have been in practice for 10, 20, or even 30 years. Somehow I managed to muddle through without making too big a fool of myself. These days, years later, I almost even feel as though, for breast cancer at least, I am worthy of the appellation of “outside expert.” Experience does matter, I guess.
Playing with More than a Full Deck!
The passage submitted in the W^5/2 #7 wasn’t an easy one, but intrepid translators, for the most part, offered waluable insights:
Readers were virtually unanimous in the opinion that author Jean Watson, when she uttered it, must have been in an, er, alternative state of consciousness. I can’t imagine what gave them that idea. I mean look at her. No, the answer lies elsewhere, but was unknown even to your faithful judge until after he had posted that fateful entry: Ms. Watson can be nothing other than a High Priestess in the Mysterious Order that shall henceforth be known as the Hazy and Harrying Hermeneutics of Hermano©!
Critics of “conventional” medicine delight in pointing out how much harm it causes. Carolyn Dean, Gary Null, and others have written extensively about “death by medicine.” A typical statement (from Mercola.com) says:
A definitive review and close reading of medical peer-review journals, and government health statistics shows that American medicine frequently causes more harm than good. The number of people having in-hospital, adverse drug reactions (ADR) to prescribed medicine is 2.2 million. Dr. Richard Besser, of the CDC, in 1995, said the number of unnecessary antibiotics prescribed annually for viral infections was 20 million. Dr. Besser, in 2003, now refers to tens of millions of unnecessary antibiotics. The number of unnecessary medical and surgical procedures performed annually is 7.5 million. The number of people exposed to unnecessary hospitalization annually is 8.9 million. The total number of iatrogenic deaths shown in the following table is 783,936. It’s evident that the American medical system is the leading cause of death and injury in the United States. The 2001 heart disease annual death rate is 699,697; the annual cancer death rate, 553,251.
To show what’s wrong with this reasoning, let’s substitute “food” for “medicine.” (more…)
One of the criticisms of modern medicine is that doctors prescribe too many pills. That’s true. Patients and doctors sometimes get caught up in a mutual misunderstanding. The patient assumes that he needs a prescription, and the doctor assumes that the patient wants a prescription. But sometimes patients don’t either need or want a prescription.
I’ll use myself as an illustration. I get occasional episodes of funny, blurry spots in my visual field that gradually expand to a sparkling zigzag pattern and go away after 20 minutes. They are typical scintillating scotomas, the aura that precedes some migraines. I am lucky because I never get the headache. My doctor said we could try to prevent my symptoms with the same medications we use to prevent migraine, but there was no need to treat them from a medical standpoint. Nothing bad would happen if we didn’t treat. I told her I didn’t want them treated. They are a minor annoyance; I can carry on with my normal activities, even reading, throughout the episodes, and I have no desire to take pills with potential side effects and with the cost and the hassle of remembering when to take them.
If it had been a typical patient and a typical doctor, the sequence of events might have been very different. The patient might have been more frightened by the strange phenomenon than I was. (I thought the weird tricks my brain could play on me were fascinating and fun to watch, not scary.) The patient might have desperately wanted those threatening symptoms to go away without understanding how insignificant and non-threatening they really were. The doctor might have assumed the patient wanted them to go away. The pills might have been offered and accepted with little thought. (more…)
I, like Joe, am utterly humbled by the translations of the entry in the W^5/2 #6! Namidim (twice), Stu (m’man!), Michelle B (using the Now-Venerated, Awesome Power of Simple Substitution that had Suddenly Swept Stu to SuperStar Status lo! These many W^5/2s ago!), and Michael X (it’s Larry’s turn to cry!) each nailed that passage lacka split hawg through the Penetrating Power of Poignant Parody©.
I thought it wouldn’t happen for a while, if ever, and I tremble as I write this, but…I have no choice but to confer the legendary, coveted, Soaring Standard of Stu® upon each of the four prodigal W^5/2 scholars named above! My hat is also off to homeboy David Gorski, who followed that passage with a Perfectly Pertinent Post-post Posting©, demonstrating such uncanny, spontaneous timing and recall that he must be Duly Acknowledged as one of the Baddest Bosses of the Blogosphere®. (more…)
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…)