You can tell what a doctor does for a living by the ICD-9 codes they have memorized. There is an ICD-9 code for nearly every medical condition. Weightlessness is 994.9. Must be there for NASA, I have yet to see a weightless patient. Decapitation by guillotine is E978. There, I suppose, in case Marat returns from the dead. There is an ICD-9 code for the initial visit after being sucked into jet engine (V9733XA) and one for subsequent visits (V9733XD). Why do I suspect V9733XD has yet to be used?
780.6 is my personal favorite. Fever. All my patients have fever and 780.6 was certainly the first ICD-9 code I committed to memory. I have an endless interest in fever and after last Fridays post I thought I would toss in my two cents worth. I will remind my readers that I am an adult ID doctor (who I treat, not necessarily how I behave) and unless specifically mentioned, all that follows applies to those who can legally drink, vote and serve in the military.
98.6 F. It is not normal body temperature. Well it is. But it is not. 98.6 F as average body temperature is an enduring medical myth. (more…)
The ancient Greeks posited a system of health and disease based on the four humors: blood, phlegm, black bile and yellow bile. According to this system, health is defined as a harmony of these four humors and disease is caused by an imbalance among them. Restore the balance, and health is restored. Bleeding is a familiar example of humoral medical treatment based on a diagnosis of an “excess” of blood. Fortunately, the humoral system of diagnosis and treatment died out with the advent of modern scientific medicine.
But as David Gorski asked (sarcastically, of course) in his presentation on quackademic medicine at CSICon in October, if supposedly ancient philosophies of diagnosis and treatment such as Traditional Chinese Medicine and Ayurveda are so beloved by CAM proponents, despite their implausibility and lack of evidence of effectiveness, why not the humoral model of health and disease? Why not include humorism in the CAM practitioner armamentarium?
We can’t stress often enough that anecdotes are not reliable evidence; but on the other hand, patient stories can serve a valuable purpose in medical education. Hearing how a disease affected an individual patient is more powerful than reading a list of symptoms in a textbook and is far more likely to fix the disease in the student’s memory. When I think of Parkinson’s disease, the first thing that comes to mind is my first patient with Parkinson’s and how he responded to levodopa; and the first thing that may come to many people’s minds is Michael J. Fox. Of course, we must realize that they may not be typical examples; but putting a face to a diagnosis serves as a memory aid and a hook to hang the rest of our knowledge on.
In his new book, The Power of Patient Stories: Learning Moments in Medicine, Paul F. Griner, MD relates more than 50 stories that distill the wisdom he has developed over a 58-year career of practicing medicine and teaching young doctors. He describes them as “stories that provided a learning moment for me.” It’s interesting to see how much medicine has changed over his professional lifetime and yet how cases from the 50s and 60s are still highly relevant. Ethical dilemmas and lessons about medical practice come alive under his pen. Each story is followed by incisive questions and exercises that engage the reader and challenge him to think about the issues. (more…)
On my recent trip to Nashville for CSICon, I took advantage of the long hours on the plane to read Breakthrough: Elizabeth Hughes, the Discovery of Insulin, and the Making of a Medical Miracle, by Thea Cooper and Arthur Ainsberg. One of our commenters recommended it. I’m not sure who (was it Chris?), but I want to thank you.
It’s the history of insulin told from the perspective of the scientists and of a typical patient, and it touches on a number of issues that we have addressed on SBM. It shows how science works to save lives, in stark contrast to the empty promises of CAM. (more…)
Over the past weekend, I had the opportunity to attend CSICon in Nashville, Tennessee. The Committee for Skeptical Inquiry (“CSI”) combats all sorts of pseudoscience, including creationism/creation science/intelligent design and alternative/complementary/integrative medicine. Our own Team SBM was ably represented by Harriet Hall, David Gorski and Kimball Atwood, whose presentation highlighted the credulous acceptance of CAM in some medical schools, and by Steve Novella, who gave a talk on the placebo effect and its exploitation by CAM proponents. Among many other presentations were those on the Mayan calendar and the end of the world, unmasking of (supposedly) paranormal events, and the neurobiology of memory. Pseudoscience was given a well-deserved thrashing by rational minds.
On Saturday, I once again had the pleasure of hearing Eugenie Scott ,Ph.D., the virtually one-woman anti-creationism campaign who founded and heads the National Center for Science Education (NCSE). As I listened to her talk I couldn’t help but being struck by a number of similarities in the weaknesses apparent in arguments for creationism/ creation science/intelligent design (or “ID”)and those for alternative/complementary/integrative medicine (or “CAM”). I doubt the two groups like to think of themselves as ideological twins, but gosh, they sure do look alike.
In 2011, chiropractor J.C. Smith published The Medical War Against Chiropractors: The Untold Story from Persecution to Vindication. He promises an exposé comparable to Harriet Beecher Stowe’s exposé of slavery in Uncle Tom’s Cabin. His thesis is that the AMA waged a shameless attack on competition, motivated only by money. I think the reality is closer to what he quoted from Dr. Thomas Ballantine, Harvard Medical School:
The confrontation between medicine and chiropractic is not a struggle between two professions. Rather it is more in the nature of an effort by an informed group of individuals to protect the public from fraudulent health claims and practices.
The book is self-published, long-winded, repetitive, and flawed. It is a vicious screed crammed with bias, half-truths, insulting language, and innumerable references to Nazis and racial prejudice. In my opinion, Smith not only fails to make his case but degrades chiropractic.
I intended to read Sam Kean’s new book The Violinist’s Thumb: And Other Lost Tales of Love, War, and Genius as Written by our Genetic Code just for fun. I was expecting a miscellany of trivia loosely gathered around the theme of DNA. But I found something much more worthwhile that I thought merited a book review to bring it to the attention of our readers. Kean interweaves entertaining stories into a somewhat disjointed but nonetheless valuable history and primer of genetics. The title refers to Paganini, whose DNA created the unusual joint flexibility that facilitated his unprecedented feats of virtuosity on the violin.
Editor’s Note:Dr. Gorski was on a rare vacation last week, recharging his batteries. As a result, there is no new material by him this week. Fortunately, Ben Kavoussi was ready with another in his series of posts on traditional Chinese medicine. Dr. Gorski will return next week; that is, if he doesn’t return even sooner because he can’t stand to be away from SBM for two whole weeks.
The established laws of nature do not support Oriental Medicine’s claim of Yin and Yang and Five-Phases Theory. Oriental Medicine’s main theory was constructed when our civilization had limited methods to understand our surroundings, and as such, it is only an ancient illusion.1
— Yong-Sang Yoo, MD, PhD, Chairman of the Committee for Medical Unification, Korean Medical Association, 2010
Yong-Sang Yoo is one of the strong and growing voices in Korea that is calling for an end to the national insurance coverage for Oriental Medicine.
Similarly, Professor Zhang Gongyao of the Central South China University petitioned the central government of China in 2006 to abolish support for Oriental Medicine because it has “no clear understanding of the human body, of the functions of medicines and their links to disease. It is more like a boat without a compass: it may reach the shore finally but it’s all up to luck.”2 Zhang Gongyao and fellow critics have consequently blasted China’s traditional medicine as an often ineffective, even dangerous derivative of witchcraft that relies on untested concoctions and obscure ingredients to trick patients, and employs a host of excuses if the treatments do not work.3
Bloodletting is used in Oriental Medicine to relieve excess “heat,” meaning fever, sore throat, joint pain, muscle sprain, as well as inflammation. It is often practiced in unsanitary conditions.
A Product of Archaic Thinking
The arguments of Yong-Sang Yoo and Zhang Gongyao are reminiscent of those of William R. Morse, Dean of Medical School at West China Union University, who wrote in 1934 that China’s traditional medicine was a “weird medley of philosophy, religion, superstition, magic, alchemy, astrology, feng shui, divination, sorcery, demonology and quackery.” Morse added that Chinese diagnostic methods “border on the ridiculous and possibly cross the line into absurdity.” Harvey J. Howard — a Dean at the Peking Union Medical College — also wrote in 1934 that “the great majority of these Chinese medicines reminds one of the list of remedies suggested by the third witch in Shakespeare’s Hamlet.”4
The term “evidence-based medicine” first appeared in the medical literature in 1992. It quickly became popular and developed into a systematic enterprise. A book by Ulrich Tröhler To Improve the Evidence of Medicine: The 18th century British origins of a critical approach argues that its roots go back to the 1700s in Scotland and England. An e-mail correspondent recommended it to me. Can’t remember who, but I would like to thank him.
Francis Bacon (1561-1626) differentiated between “ordinary experience” (chance observations) and more objective “ordered experience” (methodological observations). Both of these involved empirical knowledge. It’s hard to get back into the mindset of his time, when most physicians rejected empiricism as the sphere of quacks and surgeons. Tröhler helps us understand why they did:
…since antiquity, the mark of distinction of a learned man had been the certainty of his knowledge. A doctor knew — he did not need to test his kind of knowledge empirically because this would imply acknowledgement of uncertainty.
This is yet another response to the recent “Integrative Medicine in America” report published by the Bravewell Collaborative. Drs. Novella and Gorski have already given that report its due, so I won’t repeat the background information. Inevitably, I’ll cover some of the same points, but I’ll also try to emphasize a few that stand out to me. Most of these have been discussed on SBM over the years, but bear repeating from time to time. Let’s begin with:
If it Ducks like a Quack…
Misleading language is the sine qua non of ‘integrative medicine’ (IM) and its various synonyms. The term itself is a euphemism, intended to distract the reader from first noticing the quackery that is its distinguishing characteristic. As previously explained, Bravewell darlings Andrew Weil and Ralph Snyderman, quack pitchmen extraordinaires, recognized nearly 10 years ago that if you really want to sell the product, you should dress it up in ways that appeal to a broad market.
Let’s see how this is done in the latest report. Here is the very first sentence:
The impetus for developing and implementing integrative medicine strategies is rooted in the desire to improve patient care.
Who would disagree with improving patient care? (Try not to notice the begged question). Here’s the next paragraph (emphasis added): (more…)