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The “It’s All Good!” Fallacy of Complementary and Alternative Medicine…..

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“Trust me, have I got a deal for you!”

 

As a young mother comforts her feverish and uncomfortable infant, a doctor enters the dimly lit exam room. The child’s mother and the bedside nurse look at him expectantly.

“I’ve got the results. There is an infection in your son’s spinal fluid, which was one of the things we discussed as a possible cause of his high fever and irritablity,” the physician explains to the now crying mother. “We need to start treatment right away and admit him to the hospital.”

After answering the distraught mother’s questions and discussing her child’s treatment plan, the doctor leaves the room and begins to write orders in the patient’s chart. The nurse, eager to begin appropriate therapy looks over his shoulder with a confused look on his face.

“Excuse me doc, but you’ve got to be a little more clear on that order don’t you think?”

Written in barely legible doctor scribble, next to the date and time of the encounter and above his signature and hospital number, is the lone word “antibiotics”.

“What do you mean? This child is sick and he needs antibiotics stat!”

“Sure doc, but which one, how much and how often? Where did you go to medical school again?”

“Clearly you aren’t current on the literature. Antibiotics have been around for decades and have been proven time and time again to treat infections. Millions of people take them every day and are pleased with the results. Now you are wasting precious time that could be spent caring for this sick child!”

The nurse, unhappy with the response, storms off to find assistance from his supervisor. The doctor, confident that he is providing competent medical are for his patient, expresses dismay at how closed-minded some of his colleagues are.

Naturally, the above situation is absurd, and the nurse is completely correct in questioning the physician on his order for “antibiotics”. What antibiotic, or antibiotics, are appropriate and at what dose? Through what route, oral or parenteral (e.g. intravenously or intramuscularly), should the antibiotic be administered? How often should it be given and for what duration? Five days? Two weeks? To condense the large number of antibiotics available in a hospital pharmacy into one all-encompassing term makes no sense.

Antibiotics are drugs, often consisting of completely different chemical structures with significantly different side effect profiles. There are varying degrees of safety and effectiveness with each individual antibiotic depending on the bacteria/virus/fungus being treated, the location of the infection, the age of the patient, and the presence of co-morbid conditions such as renal or liver disease. Calling for “antibiotics” in this fashion would never happen outside of a poorly written (is there any other kind?) medical drama on Lifetime.

As new antibiotics have been developed over the years, they are studied scientifically on an individual basis. Sure there are classes of antibiotics that work via similar mechanisms, such as breaking down a bacterial cell wall, or that might be effective in killing or delaying the growth of the same types of bacteria, but nobody would make a blanket statement, let alone write an order, like the one written by our fictional physician. Unfortunately, this kind of thinking is rampant in the world of so-called complementary and alternative medicine.

The “It’s All Good!” fallacy is employed by individual practitioners, lobbying organizations and even government agencies sympathetic to alternative medicine as a means of deceptively gaining a foothold for their favorite implausible and unproven therapies. Their targets are the hearts and minds of consumers as well as a growing number of practicing medical professionals. Buoyed by media-fueled public awareness that lacks appropriate context, the growing popularity of a variety of bogus therapies, funding from the National Center for Complementary and Alternative Medicine (NCCAM) and clever marketing, the most ridiculous of ideas are now masquerading as medicine in even our most hallowed academic institutions.
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Placebo Speculations

From the Wikimedia Commons.

From the Wikimedia Commons.

 

I have a new term to add to the English language, ebolasmacked, a derivative of the British term gobsmacked. Ebolasmacked defines my life the last few weeks since Ebola, or at last preparations for Ebola, have taken a huge bite out of my time with many interesting twists and turns. I think this is maybe the 9th outbreak (HIV, MERS, SARS, Legionella, H1N1, Avian flu, West Nile, MRSA) of my career and it has certainly generated more hysteria relative to the risk than any to date. Many of my usual pastimes, like SBM (as this essay will no doubt demonstrate), have had to take a back seat to preparing for what should be a very unlikely, but very disruptive, event. We do not want to get caught with our hazmats down should a case of Ebola come through the door.

What makes life interesting, among other things, is the constant realization that the more you know the more there is to know. I like Richard Dawkins’ metaphor in Climbing Mount Improbable where he pictures scientific progress as a series of false summits extending into infinity. It sure seems that way. Every time I think I understand a topic, I find there is still more to learn.

My Dad told me when I graduated from medical school that half of everything I had just learned was probably not true, the only problem is that you didn’t know which half. It was partially true. There have been ideas that have been abandoned since I was an intern, the most famous being that ulcers were due to stress and diet. But a new paradigm has been the exception, not the rule.

The last thirty years have been more about refining knowledge about the complexity of disease and its treatment and, perhaps equally importantly, having a better understanding of the all slings and arrows of outrageous fortune that can make the results of a clinical trial suspect. (more…)

Posted in: Acupuncture, Basic Science, Science and Medicine

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Delaying School Start Times for Sleep Deprived Teens

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In August of this year, a new policy statement from the American Academy of Pediatrics was published which tackled the widespread problem of insufficient sleep in our adolescent population. They even went so far as to label insufficient sleep as “one of the most common, important, and potentially remediable health risks in children.” The statement, which gave a number of recommendations on how to address the problem, made the news rounds primarily because of the call for schools to delay start times until at least 8:30 AM.

I wrote about pediatric sleep in March for a post on the potential link between some sleep disorders in children, specifically nightmares and night terrors, and the development of psychosis. Those claims are suspect but please read that post for a review of what sleep is, why we need it, and what can go wrong with it in children of all ages. For this post, my focus will be on adolescent sleep specifically, and on the role of delaying school start times in improving a variety of health parameters.

What are the common adolescent sleep challenges?

The typical modern teenager faces a variety of challenges to consistently obtaining a full nights sleep, which is considered by most sleep experts to be in the 8.5 to 9.5 hours per night range. This doesn’t mean that every teenager will fall apart if they only get 7 hours of sleep each night, but sub-optimal sleep can adversely affect school performance in many, and even lead to long-term health problems in some children who establish such a pattern during these pivotal years. Hold that thought for now, however.

One obvious reason for insufficient sleep in teenagers, at least it is likely obvious if you have one of your own or have ever spent more than two minutes near one, is technology. Most older children have electronic media in their rooms, if not attached to their bodies in the form of a smart phone. 24-7 access to the internet and social media is a commonly cited impediment to sleep onset. The increasing availability and popularity of energy drinks containing absurd amounts of caffeine among adolescents likely also plays a role as both a coping strategy for daytime fatigue resulting from insufficient sleep, and as a cause of it. In fact, I think I’ve just come up with the topic for my next post.
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The Miracle Cure for Everything

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One common feature of pseudoscience is that proponents of a specific belief tend to exaggerate its scope and implications over time. In the world of physics this can eventually lead to a so-called “theory of everything” – one unifying theory that explains wide-ranging phenomena and displaces many established theories.

In medicine this tendency to exaggerate leads in the direction of the panacea, the miracle cure for everything. Why does this happen?

There are numerous examples. Here is a video of Bruce McBurney trying to sell his Precious Metals Nano Water to investors in the Dragon’s Den. The product is nothing but distilled water with a tiny amount of silver. McBurney claims that this magic water will essentially cure everything, all bacterial and viral infections, and even cancer.

The panacea is also not the sole domain of the lone crank. Straight chiropractors essentially believe that adjusting the spine can cure everything from bed wetting to asthma, and yes, even cancer.

What factors predispose to the panacea claim? (more…)

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Chaperones Needed

I receive a monthly newsletter from my medical board. Among other issues discussed are the results of disciplinary actions for physicians. Occasionally a physician who has boundary issues is required to have a chaperone present when doing exams.

I was thinking that the concept of a chaperone could be more widely applicable. Consider “You Docs: Amazing acupuncture,” the latest from Drs Oz and Roizen. Both are Professors at their respective institutions. Professors. To judge from the ability to read and interpret the medical literature, both should not be allowed near a journal without a chaperone to remind them about cognitive biases, logical fallacies and what constitutes a good clinical study. Looking at their recent review of acupuncture suggests they lack an understanding of all three.

They start with the argument from antiquity, which is not only wrong as a logical fallacy, it is wrong historically when they say:

acupuncture has been a go-to therapy for 5,000 years.

Off by a factor of about 500. They are unaware that acupuncture as currently practiced is relatively new, having been a form of bloodletting until recently when the modern version with steel needlesbecame popular under Mao.

However, in the early 1930s a Chinese pediatrician by the name of Cheng Dan’an (承淡安, 1899-1957) proposed that needling therapy should be resurrected because its actions could potentially be explained by neurology. He therefore repositioned the points towards nerve pathways and away from blood vessels-where they were previously used for bloodletting.

They explain the mechanism of action as stimulating

points in the body that affect chi or qi, the life energy.

without noting that chi or qi is a fantasy. No life energy has ever been measured and virtually every point on the body is an acupoint in one of the multiplicity of styles that are acupunctures. Except, as mentioned in the past, the genitals.
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Posted in: Acupuncture, Science and Medicine, Science and the Media

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Hiccups: From Acupuncture to Quantum Touch

hiccupcure

Foolproof cure for hiccups?

nOne of the most common questions I get in the newborn nursery, especially from first time parents, involves hiccups. Babies hiccup in the womb and most, if not all of them, will have periodic bouts of hiccups in the neonatal period. But many new parents are surprised by their baby’s first spasmodic contractions of the diaphragm. When brought up, it is often to simply acknowledge that their baby had a run of a few hiccups, usually associated with a feed, with some parents expressing surprise and others nervousness. Regardless of their assumed motivation, I always provide reassurance that hiccups are a normal experience for babies, as they are across the entire spectrum of age.

The medical term for hiccups, which I admit I only learned while researching this topic, is “singultus.” We doctors like to use our own peculiar language as much as possible in order to maintain a sense of superiority when dealing with today’s internet savvy customers, I mean patients, and their families. The rumbling of your stomach, that’s actually borborygmus. You don’t have a unibrow above your nose, that’s a synophrys. It isn’t abdominal or pelvic discomfort associated with ovulation that keeps annoying you midway through your menstrual cycle, it’s mittelschmerz. But since this is a forum meant for general public consumption, I’ll use the rather pedestrian and philistine “hiccup” for the duration of the post. (more…)

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If you don’t buy this supplement for your child, you’re a terrible parent

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The supplement industry wants you to buy their products, and they’re not above using a little parental guilt to make you into a customer. In the photo above, the promoter is my local pharmacy, where the large window display caught my eye:

Give your Child The Tools to SUCCEED in School!

Who doesn’t want their child to succeed? And if you knew a supplement could give you or your child a learning edge, would you consider it? I’d imagine many do. Supplements have a remarkable health halo. As a pharmacist myself, I’ve noticed this when speaking with patients – few consumers identify any potential risk or downsides to supplement use. Some don’t even think of them as medicine at all. The marketing has resonated: Supplements are perceived as “safe”, “natural” and “effective”. But whether you’re giving your child a prescription medicine to treat attention deficit hyperactivity disorder, or you’re giving a supplement to “improve focus and brain function”, you’re still administering a chemical substance to a child with the intent of changing brain function. We’d probably think twice before pouring an unknown substance in our car’s gas tank, especially one claimed to boost performance. We’d probably ask for some evidence that it works, and some assurance it wouldn’t harm our vehicle. A decision to use a drug or supplement in a child deserves just as much consideration of benefits and risks. (more…)

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Rationalizing the Ridiculous

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Pictured: Cutting-edge medicine

I remain flummoxed. How do physicians and health care systems, trained in all the sciences that lie at the heart of medicine, justify the use of pseudo-medical interventions with no basis in reality? Rationalization. Making excuses:

a defense mechanism in which controversial behaviors or feelings are justified and explained in a seemingly rational or logical manner to avoid the true explanation, and are made consciously tolerable – or even admirable and superior – by plausible means.

Rationalization of the ridiculous comes in many forms. It has been said that it is a mark of a first rate intelligence to able to hold two contradictory ideas in the mind at the same time and still retain the ability to function. Clever as it is, I suspect the opposite is true. (more…)

Posted in: Acupuncture, Naturopathy, Science and Medicine

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Missouri tackles primary care shortage with “assistant physicians”

Medical school clinical training

Medical school clinical training

A new law in Missouri will allow medical school graduates who have not completed a residency to practice in underserved areas. They will be able to call themselves “doctor” but will be licensed as “assistant physicians” with significant limitations on their practice. (The first link is to Senate Bill 716, the bill that was passed and signed by the governor. It covers several subjects, so you will need to skip to page 8 to find the portion we’re discussing.)

The Missouri State Medical Association supports the new law and helped draft the original bill. It is designed to address the state’s critical need for primary care physicians – 40% of Missouri’s population lives in underserved areas but only 25% of the state’s physicians practice there, according to a 2009 survey. Underserved areas have high poverty rates, high infant mortality, large senior populations and fewer primary care physicians per capita. (more…)

Posted in: Chiropractic, Legal, Naturopathy, Politics and Regulation, Science and Medicine

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Only two months until Skepticon

I don’t recall if I’ve mentioned this before, but I will be speaking at Skepticon in November. (Holy crap, that’s just over two months away. I’d better get my talk ready. It’ll be about the central dogma of alternative medicine. Or some such medically-related topic.) In any case, now’s crunch time, the time of year when Skepticon’s fundraising needs to go into high gear, given that the bills are coming due for the conference.

So give. Give until it hurts. Or buy swag. Or both. And if you’re planning on going, register now instead of later. You’ll be glad you did.

Posted in: Announcements, Science and Medicine

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