Science-Based Medicine

“I don’t seem able to get it straight in my mind….”
― Ken Kesey, One Flew Over the Cuckoo’s Nest

Influenza is going gangbusters at the moment. I like going to Google Flu trends as well as the CDC flu site to see what flu is doing. Using Google searches as a surrogate for infections is an interesting technique that public health officials have tried with less success in other illnesses but is not without utility. Behaviors of populations can presage a problem, my favorite example is the first hint of the 1993 massive Cryptosporidia diarrhea outbreak in Milwaukee was a sudden shortage of Kaopectate and Peptobismol. It appears there are more patients with flu like symptoms this year than  at the height of the H1N1 epidemic of 2009. We have lots of flu like illness, and per the CDC there are buckets of confirmed influenzaflu, but so far the season, while probably having more cases than 2009, the outbreak is clinically not the same.

Compare and contrast, the two words that defined undergraduate liberal arts essay assignments. Get out your blue books and compare and contrast influenza outbreaks from 2009 and 2013. You have one hour. Continue Reading »

Science journalist Sharon Begley wrote a recent piece in The Saturday Evening Post about Placebo Power. The piece, while generally better than the typical popular writing on placebos, still falls into the standard placebo narrative that is ubiquitous in the mainstream media. The article is virtually identical to a dozen other articles I have read on placebo effects in the popular press, and most significantly fails to even question that narrative.

Begley is generally one of the better science journalists, although I have had my disagreements with her – specifically over her attitude toward the relationship between skeptics and the media. She seems to have a distorted and negative view of skeptics and does not think that the media can or should help us in our “debunking crusade.” (The term itself speaks of a fundamental misunderstanding of the modern skeptical movement.)

I have also parted ways with Begley over her view of the relationship between science and medicine. She seems to have a fairly negative view of doctors, fueled in part by her imperfect grasp of medical science. This is the risk with even the best lay science journalists – science is often complex and it is difficult to master the nuances if you are not an expert and steeped in the evidence and the community. Further there is a tendency for people in general (including journalists) to go along with an appealing and available narrative. (For journalists those narratives that are appealing are the ones that make good headlines.) These shortcomings are present throughout her recent article on placebos.

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I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.

Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.

Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. Continue Reading »

With New Years’ weight loss resolutions freshly made, let’s take a science-based look at another of the latest diet books being promoted by various public relations agencies. In my last post we explored the claims made by the hysterical Eat To Save Your Life authors in their book featuring a demonic cheeseburger on its cover jacket. Today I will review, Shred: The Revolutionary Diet ‚ 6 Weeks, 4 Inches, 2 Sizes, by Ian K. Smith, M.D.

I’m not sure what images the word “shred” conjures up for you, but if they have anything to do with muscle-bound, uber-lean bodybuilders on steroids you will be pleased to note that this book has nothing to do with them. In fact, what you’ll find in this book is a rather practical and healthy eating and exercise prescription with recipes and careful calorie counting. You’ll also find one fairly harmless chapter of liver detox pseudoscience, and an odd command to stare at yourself in the mirror at the beginning of week six.

Quietly stand in front of the mirror, and look deeply into your eyes as if you’re trying to see all the way into the depths of your soul… [p. 167]

The purpose of this visual exercise is never explained.

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Today marks the five year anniversary of the blog. I was not part of the initial stable of writers, my first entry published Jan 31. As I remember it shortly thereafter they browbeat me into writing twice a month. I had a lot of hesitancy participating as I was uncertain I could keep up with the twice monthly writing requirements. I am a slow writer and a slower typer, but it has been one of the most intellectually rewarding experiences of my life.

I have become a better writer, but more importantly a vastly better thinker, as a result of interactions with SBM. I have also been convinced I have some sort of language processing disorder as I still can’t see how those pesky typo’s disappear during my countless rewriting only to reappear in the final draft. Either WordPress inserts them automatically or it is magic most foul.

Five years on, and a new year, are as good an arbitrary time as any to reflect on both the past and future of SBM. As I age the more I am of the opinion that I have the carte blanche of the elderly to say whatever I want. It’s all about wearing the purple. Continue Reading »

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. Continue Reading »

Any sociological question is likely going to have a complex answer with many variables that are not easy to tease apart. We should therefore resist the temptation to make simplistic statements about X being the cause of Y. We can still, however, identify correlations that will at least inform our thinking. Sometimes correlations can be triangulated to fairly reliable conclusions.

When the data is complex and difficult to interpret, however, evidence tends to be overwhelmed by narrative. The recent Sandy Hook tragedy is an excellent example. No one knows exactly why the shooter did what he did, so it is easy to insert your own preferred narrative as the explanation.

Another example is the phenomenon of so-called complementary and alternative medicine (CAM). Why has it been increasing in popularity (and is it, really?). Is it slick marketing, relaxed regulations, scientific illiteracy, a gullible media,  or the failures of mainstream medicine? You can probably guess I think it’s all of these things to some degree. The most common narrative I hear by far, however, is the latter – if people are turning to CAM it must be because mainstream medicine has failed them. This version of reality is often promoted by CAM marketing.

The evidence that we have, however, simply does not support this narrative. Studies show that satisfaction with mainstream medicine is not an important factor in deciding to use CAM, that CAM users are generally satisfied with their mainstream care, and they use CAM because it aligns with their philosophy, and they simply want to expand their options.

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Fever is a mighty engine which Nature brings into the world for conquest of her enemies.”

— Thomas Sydenham

The occasional abnormal elevation in body temperature associated with infection is as much a part of the human condition as abstract thought or the desire to lose weight without exercise or cutting calories. Commonly known as fever, this powerful yet misunderstood physiologic response has been documented in a variety of animal species including fish, reptiles and of course humans. We have all had fever at least once in our lives, and probably several times. And many of us have undoubtedly spent a few anxious nights cradling febrile little ones, afraid more of the repercussions of the fever itself than the potential sequelae of the underlying cause.

Along those lines, fever is one of the most common reasons for parents to seek medical care for their children, with roughly a third of pediatric acute care visits related to it, as well as a frequent impetus for late night nursing calls to sleepy hospitalists. Actually only about half of after-hours calls are about fever but who’s counting. Unfortunately most medical professionals, including many pediatricians, have a poor understanding of the pathophysiology of fever, and their panicked approach to its management in many children involves unnecessary laboratory tests, imaging studies, and doses of broad spectrum antibiotics. It also adds to parental anxiety and helps to establish a vicious cycle as patients of over worried caregivers tend to undergo more aggressive evaluation and treatment.

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Science is the Concept by which
we measure our reality
I don’t believe in magic
I don’t believe in I-ching…
I just believe in science…and that reality.

John Lennon. Sort of.

As regular readers of the blog are aware, I am science/reality based.  I think the physical and basic sciences provide an excellent understanding of reality at the level of human experience.  Physics, chemistry, biology, anatomy, biochemistry, physiology, evolution etc. provide a reliable and reproducible framework within which to understand health and disease.  My pesky science may not know everything about reality, but day to day it works well.

“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. – Hamlet (1.5.166-7).”  

Perhaps, but all the medical advances in my lifetime have been not yielded new science, just (amazing) variations and extensions of known processes.  I sometimes think the blog should have been called reality based medicine, but science is the tool by which we understand reality, and while the tool is constant, our understanding of reality is prone to changing.  An understanding of the rules of the universe combined with an awareness of the innumerable ways whereby we can fool ourselves into believing that those rules do not apply to us is part of what makes a science and reality based doctor.

We are often told of the need to keep an open mind, but I like to keep it open to reality.  Not that I do not like fantasy and magic, it is a common category for my reading.  I just finished Red Country by Joe Abercrombie, and while I love the world he has created, I would not want to apply the rules of that imaginary world to my patients.   Well, one exception.  As Logen Ninefingers  would say, “You have to realistic about these things.” Fictional worlds should be limited to the practice of art, not the practice of medicine.
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So-called complementary and alternative medicine (CAM) is largely philosophy-based medicine rather than science based. There are a few core concepts that are endlessly recycled in various forms, but it is mythology and culture, not grounded in the rigorous methods of science that allow us to tell the difference between our satisfying fantasies and hard reality. Sometimes proponents of such philosophies try to cloak their beliefs in the appearance of science, resulting in what we simply call pseudoscience.

Harriet Hall coined an excellent term to refer to such pseudoscience -” Tooth Fairy science.” In her metaphor, pseudoscientists sometimes act like scientists by describing the details and statistics of their claimed phenomenon (such as examining all the details of the Tooth Fairy phenomenon) without ever testing the reality of the phenomenon itself. The fundamental concept at the core of their belief is never challenged, or only superficially so, and they proceed prematurely from their faulty premise.

Another term that I find extremely apt is “Cargo Cult science,” a term coined by Richard Feynman. This is a reference to the cargo cults of New Guinea – the pre-industrial tribes were observed building straw mock-ups of control towers, planes, and runways in hopes that the planes they observed flying over head would deliver their cargo to them. In other words – the cargo cults mimicked the superficial appearance of an aviation infrastructure but had none of the real essence or function (because of lack of understanding). This is a perfect analogy to much of what passes for science within the world of CAM.

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