The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
The practice of medicine is an art, based on science.
-Sir William Osler, AEQUANIMITAS
The truth is that many of us have some kind of “extraordinary gift.” For a few of us, that gift is the ability to throw a ball at 90 miles per hour and hit a catcher’s glove. For others, that gift is a form of extraordinary perception. Medical intuitives “see” things that others don’t. Wendy Marks has been described as a “human CT scan.” What no one has been able to diagnose by conventional methods is often seen when Wendy scans a body.
-Boston Women’s Journal April/May 2002
The concept of an art to the practice of medicine comes up frequently and in a variety of contexts. Early on in our medical education, we are exposed to the phrase and what it supposedly means, which I will discuss in more detail shortly. But the art of medicine is always painted (pun intended) in a positive light. I will admit that I have a strong opinion, perhaps biased by my involvement with the science-based medicine movement and an equally early exposure during my medical training to champions of evidence-based practice and the use of critical thinking in the approach to patient care.
Prolotherapy is a treatment technique used for chronic myofascial pain, back pain, osteoarthritis, or sports injury. It involves repeated injections of dextrose solution or other irritating substances into the joint, tendon, or painful tissue in order to provoke a regenerative tissue response. Similar techniques have been used for about a century, but the first formal publication describing prolotherapy dates back to 1956, by Dr. George Hackett. He wrote:
Within the attachment of weakened ligaments and tendons to bone, the sensory nerves become overstimulated by abnormal tension to become not only the origin of specific local pain, but also definite areas of referred pain throughout the body to as far as the head, fingers and toes from specific relaxed ligaments and tendons.
Prolotherapy. A treatment to permanently strengthen the “weld” of disabled ligaments and tendons to bone by stimulating the production of new bone and fibrous tissue cells has been developed.
Initially the concept, referred to a sclerotherapy, was that the injections formed scar tissue to stabilize the joint, tendon, or ligament. The newer concept, called prolotherapy, is that the injections provoke the proliferation of tissue, allowing for limited regeneration. (more…)
I know by now I shouldn’t be, but I am still amazed by how readily so many people buy into the seemingly endless array of bogus sCAM nostrums. Many are marketed and hawked for the treatment or prevention of diseases that are poorly managed by science-based medicine. There are countless examples of dietary supplements that are purported to effectively treat back and joint pains, depression, anxiety, autism, chronic pain, and chronic fatigue; the list goes on and on. The lure for these treatments is at least understandable and, although frustrated that scientific literacy and rational thought loses out, I empathize with the desire to believe in them. On the other end of the spectrum is the even more ethically corrupt substitution of safe and effective treatments with products that are not. I encountered what I find to be possibly the most frightening and dangerous example of this recently at my practice. A family new to the area called to schedule a routine health-maintenance visit for their 5-year-old daughter. When our nurse reviewed the medical records the mother had faxed over, she noted that the child was unimmunized and explained to her that she would need to begin catch-up vaccinations. The mother matter-of-factly stated that her daughter was actually fully vaccinated with a vaccine alternative. She had received a series of homeopathic vaccines from a naturopath. I am not going to discuss this egregious example of sCAM here, though it was addressed in previous SBM posts.1,2 Instead I’d like to focus on another part of the sCAM spectrum. Here lies a form of sCAM that, in some ways, is even more difficult for me to comprehend. These are products invented, marketed, and sold solely for the treatment or prevention of fictitious diseases or problems that exist only in the realm of fantasy. (more…)
The Canadian Parliament, hypothetically protecting consumers since Confederation.
One of the most pervasive yet appealing health myths is the idea that natural equals safe. It’s a statement that’s repeated constantly by manufacturers of supplements and “natural” health products. It’s been the primary argument used, with considerable success, to give these products completely different regulatory structures than exist for drug products. Weaker regulation of supplements and natural health products has been a boon to manufacturers, but the same can’t be said for consumer protection. It’s effectively a buyer-beware marketplace in most parts of the world, with little accurate information available to consumers. But supplement manufacturers aren’t content with the minimal regulation that’s currently in place – they want health “freedom”. In this case, “freedom” means the right to sell any product, while being exempted from safety and regulatory requirements. New Canadian legislation is poised to raise safety standards for drugs and enhance the ability of regulators to recall dangerous products, yet consumers of natural health products are left behind. The legislation proposes to exempt anything considered a “natural health product”. This is not only bad public policy, but it has the potential to cause avoidable harm. After all, shouldn’t users of supplements and natural health products be entitled to the same safety and quality standards as those that use prescription drugs? If the supplement industry gets its way, the answer will be “no”. (There is an opportunity until June 10 for you to provide feedback on this legislation – see below.) (more…)
Bloodletting: a good reason to discard disproven therapies
All of us at SBM have repeatedly expressed frustration at the continuing influx of pseudoscience into the health care system. Judging from comments posted on this site and private communications we receive, our readers share this frustration but are at a loss to figure out how to get through to legislators and other policy makers. Unlike naturopaths and chiropractors, we don’t have the money to hire professional lobbyists. Fortunately, an opportunity to sound off against SCAMs has presented itself, completely free of charge.
Now that the Affordable Care Act enrollment debacle is dying down, the Department of Health and Human Services (HHS) is turning its attention to divining just what the heck Section 2706 of the ACA, the non-discrimination provision, means. (Actually there are other federal agencies involved; to simplify things, here we’ll refer to them collectively as “HHS.”) HHS has opened the issue to public comment, but only until June 10. Let’s take a look at why this is important and what you can do about it.
(There are providers other than chiropractors, naturopaths and acupuncturists involved in this fight. For example, you’ll see public comments from nurse anesthetists and nurse practitioners. But I’m not worried about providers who stick to science.) (more…)
PETA (People for the Ethical Treatment of Animals) has a history of (as the old saying goes) using science as a drunk uses a lamppost – for support rather than illumination. In that way they are typical of ideological groups. They have an agenda, they are very open about their beliefs, and they marshal whatever arguments they can in order to promote their point of view.
Favoring information that supports our current beliefs is a cognitive bias common to Homo sapiens, but ideology tends to take this simple bias to a new level. It can lead to the systematic distortion or denial of science, and render belief systems immune to logic and evidence.
PETA provides us with a nice example of how having an ideological agenda can motivate an individual or a group to embrace dubious science. In an article currently on their website, and making the rounds in social media (this is repeating a claim from at least 2008, but the current article is undated), the group warns: Got Autism? Learn About the Link Between Dairy Products and the Disease. They claim:
The reason why dairy foods may worsen or even cause autism is being debated. Some suspect that casein harms the brain, while others suggest that the gastrointestinal problems so often caused by dairy products cause distress and thus worsen behavior in autistic children.
Saying that “how” dairy harms the brain is being debated implies “that” dairy harms the brain is accepted and not being debated. This is misleading. It is not accepted that dairy harms the brain or is in any way linked to autism, and the evidence is largely against it. (more…)
When I first heard about rope worms, I assumed it was a spoof. Alas, not so!
Rope worms are rope-like meter-long human intestinal parasites that were only recently discovered in the returns of cleansing enemas and are often reported after coffee enemas. Strangely, no one had ever noticed them until 2009. They have never been observed during endoscopy or surgery, during medical bowel cleansing in preparation for surgical or imaging procedures, with x-rays or MRIs, at autopsy, or by any colorectal specialists. Yet according to Nikolai Gubarev and Alex Volinsky, the two of them have never yet found a single patient who didn’t have these parasites.
Two articles by Volinsky, Gubarev, and colleagues (here and here) describe the rope worm and its five developmental stages. They include pictures of each stage. I urge you to take a look. You will be amazed, and not in a good way. You might even bust a gut laughing. (more…)
By now, regular SBM readers should be aware of the Choosing Wisely initiative. Just in case, Choosing Wisely is a campaign developed by the ABIM Foundation to bring together experts from a variety of medical specialties in order to identify common practices that should be questioned by patients and providers, if not outright discontinued. Their ultimate goal was not to establish treatment guidelines or dictate care, but to foster discussion. As I’ve written about in a prior post on the overuse of antibiotics in pediatrics, it doesn’t appear to have caught on. I routinely ask colleagues, residents and students if they are aware of it, and am frequently disappointed by their response.
The American Academy of Pediatrics issued a list of five questionable practices back in February of 2013 and I loved it. All five are important:
- Stop treating viruses with antibiotics
- Stop prescribing and recommending cough and cold medicines for young children
- Stop routine use of CT scans for minor head injuries
- Stop routine use of neuroimaging for simple febrile seizures
- Stop routine use of CT scans for abdominal pain
Imagine a retail pharmacy where some of the medicines on the shelves have been replaced with similar-looking packages that contain no active ingredients at all. There is no easy way to distinguish between the real and the fake.
Another section of the store offers a number of remedies with fantastic claims, such as “boosting” the immune system, “detoxifying” the body, or “cleansing” you of microscopic Candida. They look sciencey, unless you realize that they treat imaginary medical conditions.
A corner of the store offers unpurified drugs supplied as tinctures and teas. The active ingredients aren’t known, and the batch-to-batch consistency of the product is unclear. The store will suggest products for you based on your symptoms.
Walk past the enormous wall of vitamins and other supplements and you’ll find a nutritionist who will tell you what products you should be taking. You’ll also find a weight loss section. From a science-based perspective, this shouldn’t even exist, given no product has been shown to offer any meaningful benefit. But there are dozens of products for sale.
At the back of the store you’ll finally find the pharmacist. A sign on the counter offers blood- and saliva-based tests for food “intolerance” and adrenal “fatigue”, claiming to test for medical conditions that actually don’t exist or lack an evidence base. The pharmacy also offers a large compounding practice, advertising what it calls “personalized” approaches to hormone replacement with “bioidentical” hormones.
Welcome to the “integrative” pharmacy.
You may not see all these features in your local drug store, but they’re coming: claims of a new “integrative” way to provide health care that is changing the face of retail pharmacy. Unfortunately, it’s harkening back to the era of patent medicines and snake oil. It’s not good for the pharmacists and the profession of pharmacy, and it’s even worse for patients. (more…)
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. JAMA
Just just because there are flaws in aircraft design that doesn’t mean flying carpets exist. Ben Goldacre
Wiser heads than I have commented on “Invitation to a Dialogue: Alternative Therapies” in The New York Times. So why add my two cents? Partly because The New York Times wanted brief responses and I don’t do brief. Partly because I write for me; nothing focuses the mind like putting electrons to LCD, except, perhaps, a hanging. Partly we do need a dialog, just not of the kind suggested by the writer. And partly, life has been so busy of late I needed a topic that required no research. (more…)