The Center for Disease Control (CDC) conducts an ongoing telephone survey of medical problems and health care utilization – called the National Health Interview Survey (NHIS). They recently released their data from 2007. This is the first year for which they specifically broke out questions assessing the use of so-called complementary and alternative medicine (CAM).
CAM is a political/ideological entity, not a scientific one. It is an artificial category created for the purpose of promoting a diverse set of dubious, untested, or fraudulent health practices. It is an excellent example of the (successful) use of language as a propaganda tool.
The fundamental intellectual flaw of “CAM” as a concept is that it is made to include modalities that are extremely diverse, even mutually contradictory, under one umbrella. Very deliberately modalities which are scientific and mainstream, like the proper use of nutrition, are often included under the CAM umbrella by proponents in order to make it seem like CAM is a bigger phenomenon than it actually is, and as a wedge to open the door for the more pseudoscientific modalities.
Quacks and their apologists often cite surgery and emergency treatments of traumatic injury and a few other catastrophic or potentially catastrophic events as the only ”conventional” or “allopathic” methods that they consistently recommend. Explicitly or implicitly, for most problems they tout “holistic” or “CAM” treatments. In modern medicine, however, there are plenty of non-surgical and non-emergency treatments whose outcomes are so manifest that even the most exuberant advocates of implausible medical claims (IMC) seem careful to steer clear, lest they blow their cover. Where are the promoters or consumers of homeopathic contraceptives? Why haven’t we heard of a chiropractic adjustment for high blood sugar? How many pitches for Ayurvedic treatments of gout have you seen? There are exceptions, of course, the most notable being the nearly ubiquitous anti-immunization stance among IMC promoters.
Anesthesiology and Implausible Claims
In my day job I specialize in anesthesiology, a non-surgical field whose methods are so obviously effective that little is heard from the IMC crowd. Consider: is it likely that even the slickest of the current crop of snake oil salesmen, if they had the bad sense to try, could talk many people into accepting an implausible method for rendering the body insensible to pain? No, that would require a more effective form of persuasion, such as that used in China to promote “acupuncture anesthesia” from the mid-1950s until the end of the Cultural Revolution in 1976. That’s a story I’ll tell another time.
A few other implausible claims have crept into the broader realm of anesthesiology. Stimulation of the “pericardial 6″ acupuncture point on the ventral aspect of the wrist is said to prevent post-operative nausea. There is little basis for this, the Cochrane Review notwithstanding. Verbal messages, given to a patient under general anesthesia, are said to result in “faster healing.” The major proponent of this claim is Peggy Huddleston, a self-described psychotherapist with an M.T.S. (Master of Theological Studies) degree from the Harvard Divinity School. Ms. Huddleston appears to have parlayed the “faster healing” claim into a successful entreprenurial venture, featuring a website, workshops, CDs, and a book:
Peer-review is a critical part of the functioning of the scientific community, of quality control, and the self corrective nature of science. But it is no panacea. It is helpful to understand what it is, and what it isn’t, its uses and abuses.
When the statement is made that research is “peer-reviewed” this is usually meant to refer to the fact that it has been published in a peer-reviewed journal. Different scientific disciplines have different mechanisms for determining which journals are legitimately peer-reviewed. In medicine the National Library of Medicine (NLM) has rules for peer-review and they decide on a case by case basis which journals get their stamp of approval. Such journals are then listed as peer-reviewed.
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 public is often left to fend for themselves in the marketplace of medical devices and health aids. Current regulations in most countries are inadequate to prevent grossly misleading claims in advertising and to provide adequate evidence for safety and effectiveness for products on the market. So it is helpful for consumers to be aware of the red flags for dubious devices to watch out for.
I came across this ad for The Rebuilder, which purports to be a treatment for painful neuropathy. About 2.4% of the population has some kind of peripheral nerve damage (neuropathy), which means there are about 7.2 million Americans with neuropathy. In most cases there is no cure (although there is effective treatment for some of the symptoms of neuropathy) so it is not surprising that neuropathy is a common target for questionable treatments and devices.
The ad is full of misleading or unsupported claims and blatant misinformation and provides an excellent example of the many features of quackery marketing to look out for.
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.
Polypharmacy essentially means taking too many pills. It’s a real problem, especially in the elderly.
A family doctor gives an elderly patient one pill for diabetes, another for high blood pressure, and another to lower cholesterol. The patient sees a rheumatologist for his arthritis and gets arthritis pills. Then he sees a psychiatrist for depression and gets an antidepressant. He takes a sleeping pill. He takes a laxative. He buys some over-the-counter cold medicine and Tylenol. Then he goes to his local GNC store and buys a smorgasbord of vitamins, minerals, supplements and herbal products. It would be surprising if some of these didn’t interact with each other to cause some problems.
One doctor may not know what the other doctors have prescribed. The patient may not think to tell his doctors about the non-prescription products he’s taking. Or he may not want to admit it for fear the doctors will disapprove. (more…)
The first thing that struck me about him was that he was orange.
It was not a shade of orange I had ever ever encountered before in a patient. It was a yellowish orange, an almost artificial-looking color. At first I wondered if he was suffering from liver failure with jaundice, but this orange was just not the right shade of yellow for jaundice, and his sclerae were not yellow. I also considered whether he was suffering from renal failure, but the orange color of his skin didn’t quite match the rather coppery color that some patients suffering from longstanding renal failure necessitating dialysis sometimes acquire. I was puzzled. His chart said that he was being admitted for surgery for rectal cancer. So I sent the intern in to get the story, do the history and physical, and get him all plugged in for his bowel prep. Believe it or not, there was actually a time when it was not all that uncommon for patients to come into the hospital the night before major abdominal surgery in order to undergo a preoperative bowel prep, rather than being forced by their insurance companies to undergo the torture of drinking four liters of the purgative known as Go-Lytely–a misnomer, if ever there was one!–at home and spending the next several hours having to rush periodically to the toilet, waiting in vain for the liquid exploding out of their hind end to run clear.
My Discussion with Dr. P
After last week’s post, Dr. Peter Moran answered with more salient points. I’ll spend this week discussing those, because I share Dr. Moran’s “interest in examining the kind of messages we are putting out.” Acknowledging the inequality inherent in his not being the blog author, I’ll offer the last word to Dr. Moran by ending this series* and letting whatever comments he may have in response to today’s post be the last, at least for now.
Here is Dr. Moran’s response to my response:
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.)