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Irritated by the Skeptical Inquirer. Again.

I have a confession. I have been interested in issues skeptical since high school when I came across a copy of the Zetetic at Powells. In the pre-digital era I had a complete library of Zetetic-Skeptical Inquirers (SI) that a decade ago was tossed in the recycle bin along with a similar collection of MacWorlds. I have been interested in skepticism a long time and, here is my confession, I no longer find much of the subject matter covered by SI all that interesting. Even big ticket topics like the existence of God are uninteresting. It is not that the topics are not important, they are, and each generation has to relearn why Bigfoot or haunted houses or UFO’s are nonsense. But for me it is a large serving of been-there, done-that.

So while I subscribe to SI, it is more from a sense of obligation to support institutions I think are important than from an expectation that I will be either educated by the content or entertained by the style of the writers. I usually skim the magazine while accomplishing tasks that do not require my full attention probably because SI is the only magazine I still receive in dead tree format, the rest of my life being digital.

So I ran across “Taking our medicine: What hope for skepticism in healthcare?” by Kenneth W. Krause and after skimming it I was irritated. So I read it again and I was more irritated, which is often a good sign. But I could not quite put a finger on what it was. So I read it again and then went for a walk and thought about it.

All the facts were fine. I had no issue with the content of the article. It was the adjectives that irritated me. And the essay was, from my perspective, incomplete. It was like reading a relationship/birth control article by the Pope. Sure, he knows the facts of the situation, but not being an active participant in the process and with an agenda to promote, vital information will be missing or distorted.

Regular readers of the blog know my background. For the last 24 years I have spent most of my waking time taking care of inpatient infectious disease patients in Portland, Oregon. My hospitals are not for profit and several are teaching hospitals. As Chair of Infection Control I have also been involved in many of the quality and safety initiatives in my hospitals. I have gone from the young whippersnapper to one of the old geezers at my hospital and am one of the few who have institutional memory as to what has happened in health care over the last quarter century.

For those of you who want some Science-Based medicine with links and references, this essay will come up short. This is a reflection about what it means to be a physician and how it may impact patient care. It is based on me and my experiences and observations. It is probably not applicable beyond the walls of my hospital and perhaps the walls of skull. Just today I was talking with a colleague who travels widely as part of her job and she was contrasting the culture of East coast and West coast medicine and noted that in Portland we have a distinct shortage of ABHD’s (arrogant butt head doctors) and that the academic docs in ****** (I do not want her to even remotely be at risk for getting in trouble) are a vicious bunch of backstabbers. So your mileage may vary.

The basic thesis of the essay is probably summed up by the following quotes:

[The] so called “medical-science” and American healthcare in particular prospers best in a self-serving culture of secrecy, arrogance and denial.

and

Medical overuse is a money-hungry green monster, say healthcare experts Rosemary Gibson and Janardan Singh. It not only “thrives on the fact that too little scientific evidence exists to justify a great deal of today’s medical practice,” it also “wants to prevent good science from informing policymakers and the public about what really works.”

He characterizes patients as “easy marks” evidently about to be swindled by “common and expensive overuse” of the medical industrial complex. Evidently doctors and hospitals are conspiring to give everyone unneeded expensive care.

There is no shortage of perverse rules and regulations with unintended adverse consequences in medicine. The biggest change I have seen in health care revolves around length of stay. In the old days a patient would be admitted, you would do a history and physical and generate a differential diagnosis, a list of possible processes that could cause the patients symptoms.

The patient has, say, a fever of unknown origin (FUO), a notoriously difficult diagnostic problem. In the old days the definition for FUO was a fever that persisted after 14 days of evaluation in the hospital. 14 days in the hospital. Wow. And I was always amused that Madeline was evidently admitted for a month for a simple appendix removal. But I digress.

Then you would order tests for the more likely causes, wait for the tests to come back, evaluate them, then do the next tier of tests, methodically working though the possibilities, sometimes taking several weeks to reach a diagnosis.

These days with length of stay an important driver of cost and reimbursement when a patient is admitted, all possible diagnostic tests are ordered at once, regardless of how likely the result will be. It drives me nuts to see, but in the era of short hospital stays it is better to get everything all at once and see what the final diagnosis is. It is one change that certainly drives increased testing. This is one example of many where rule changes in payment or care have had unintended adverse consequences for diagnostic testing. No good deed ever goes unpunished.

The article makes doctors and hospitals all sound like greedy dirt balls out to scam our patients and he gives numerous examples of the over use of medical care and its consequences, all driven by the need to make money. And I will reiterate: all his examples are true. But incomplete.

Everyone wants to make money, even ID doctors. Hospitals are expensive. The payroll, infrastructure and utilities are expensive. My hospitals spend millions a year in free care on the un- and underinsured. There are some doctors and institutions that are driven primarily by the need to make money, but making money does not appear to be the primary driver for testing for those I work with.

Medicine has a lot of uncertainty in diagnosis and treatment. I have been at it for 30 years and it does not get easier with time, you just get more comfortable with your limitations. I wonder how much increased medical utilization revolves around the more fundamental concepts of responsibility and accountability.

When I see a patient I am responsible for making the right diagnosis and treatment and often there is a lot of uncertainty with both. If I am wrong people can suffer and die. Even if I am correct, the decisions I make can result in harm or financial ruin. It is often our responsibility and accountability to our patients that can drive medical testing.

After my Dad retired from a career as a cardiologist I noticed he became more alert and active and I commented it must be nice to be rested after a lifetime of night time calls. He said it wasn’t the calls that ruined his sleep, although he received enough of them, but it was the worry that kept him awake. The worry that his patients would do poorly and the worry that he was doing all he could to make them better. I understand that worry. Bedtime is the time to perseverate about patients, to worry and fret about them, often to the detriment of a good night’s sleep.

Early in my career I had a patient admitted Friday afternoon with fevers for two weeks, a new aortic insufficiency murmur and conjunctival hemorrhages. Endocarditis (a heart valve infection), I thought. Get blood cultures and start antibiotics and I didn’t think I needed to call the tech in for a weekend ECHO. Aortic valve endocarditis is a dangerous disease that can decompensate quickly, but the patient had no signs or symptoms of valve failure so there was no need for the ECHO as the patient had no indication for surgery. I left for the weekend.

When I get back from the weekend the blood cultures were still negative and I was puzzled. They should be growing something by now so I ordered the ECHO and there was no endocarditis. Instead there was a dissecting ascending aortic aneurysm, a very rare mimic of endocarditis. I have not seen one like it before or since. I had sat on a dissecting aneurysm for 72 hours.

I do not know what is the worst thing that can happen in your job. In mine it is that through error, omission or commission, I injure or kill someone. You cannot imagine the sense of mortification I felt that I had missed a diagnosis that easily could have killed the patient. He was repaired and did quite well, but to this day I cringe when I think of the case. It is not for medical-legal reasons. I do not give a rat’s ass about being sued. I care about not hurting patients. I care about making them better. The more certain I am with my diagnosis, the more likely I am to not miss an unexpected diagnosis and the more likely I will give the appropriate therapy.

And that is nothing compared to the feeling when you discover that a patient who you thought was doing well has taken a turn for the worse. A couple of years ago I had a malaria patient who was admitted on Thursday and by Friday I thought he was doing well. But when I returned on Monday he was on a ventilator and ECMO, almost dying from severe malaria. I did nothing wrong mind you, it was the natural history of the disease. You can do everything right and still have a bad outcome. But that horrible sinking feeling of dread in the pit of your stomach you get when a patient does poorly is something everyone wants to avoid. It is horrible when a patient does badly because I am responsible and accountable for that patient, even if I do nothing wrong.

And that in turn is nothing compared to the feeling when a patient dies. Jesus. Even though I did everything right, a death is awful. The horrible sinking feeling of dread in the pit of your stomach is magnified many-fold. I am responsible and accountable for my patient and death and complications are a failure of that responsibility. As a recent blog entry noted

“Of course,” the young surgeon said, with complete sincerity. “Everything is my responsibility.”

That responsibility has consequences, the most important of which is

When a person trusts you with his life, the bucks stops with you.

I want to maximize the chance that my diagnosis is correct since the consequences of being wrong can be horrible. It is a difficult calculus as to how much uncertainty about the diagnosis is reasonable. How many tests do you need to maximize diagnostic certainty? A lot of tests get ordered to increase the certainty. You need the right diagnosis to embark on the correct therapy.

There is also the worry that the patient has an unlikely process that if missed could be catastrophic. If you think a patient could have a pulmonary embolism, a blood clot to the lung, you will probably order a CT even if it is low probability because if the patient did have a PE and you miss it they could die. And as a corollary you remember those surprise diagnosis of the past, the ones you didn’t expect that were revealed on CT or MRI. Sometimes testing yields unexpected and important pathology and those cases often have an excessive effect on future testing.

And unfortunately part of diagnostic utilization is due to the ghosts of failures past. If you have ever missed an unusual diagnosis on a prior patient you will remember it far more clearly than your successes. And if a similar clinical situation arises, or even one that is close, you are likely to order the tests even if the diagnosis is unlikely.

It is always a difficult road to walk: you want an accurate diagnosis, you know that everything you do can cause harm, you do not want to miss a catastrophic diagnosis and you do not want to repeat past mistakes. And this in the context of initial uncertainty as to the diagnosis.

And above all I want to help people get better. I doubt most people reading this will believe it, but what drives most of us in medicine is to make our patients better. I want to relieve their suffering, cure their infection, improve their health and get them back to their life. Unfortunately the medical literature so often is not clear cut as I would like as to what to do for patients. It is a constant problem applying the literature to a specific patient who may not match the profile of the patients in a study. You have to do your best with what you have and above all you have to do your best for your patient.

Arrogant is an interesting term used for physicians. It has certainly been used to describe me. The interwebs say it is “having or revealing an exaggerated sense of one’s own importance or abilities.”

Which is a curious adjective. I am expert in my specialty and few in the US have my knowledge base or my experience. There are about 8,000 ID docs and 660,000 physicians in the US out of a population of 314 million people. With the exception of those ID docs who have been at it longer than me, it is safe to say I know more ID than most doctors and everyone else in the US. If you are admitted to the hospital with an ID problem, there is no way you will ever be able to gather the knowledge required to make an independent decision about your diagnosis and therapy.

I find it odd how the expertise of physicians is denigrated. I do not see it with engineers (if drivers were more involved with bridge building we would have better bridges) or pilots (flights would be on time if more passengers were involved with flying the plane), although I suspect there are even more jailhouse lawyers than ersatz physicians.

An even more difficult problem in health care is health literacy, which is “the ability to read, understand and act on health care information” and depending on the demographic, affects half of Americans. We have a physician in our system with an interest in health literacy who has been a champion for improving and simplifying the material provided by the hospital. As an example, we are rewriting all out material so it is at a 6th grade reading level, the US average. As Dr. Breger likes to point out in his lectures, half of patients do not have the wherewithal to understand medical care, and

40-80% of medical information is forgotten upon leaving the provider’s office or facility and nearly half of the information retained is incorrect.

What we really need is a better class of patients and physicians, where all the patients are strong, all the doctors are good looking, and all the health care is above average. But we are stuck for the time being with humans, with all their flaws. While most would like their physician to be an unholy blend of Marcus Welby, a boy scout and God, the reality is vell, Doctors are just zis guy, you know?

It would be nice for patients to aggressively represent their own interests, but most cannot, especially when they are ill. Probably half the patients I see in follow up do not remember having seen me in the hospital because of medications, stress, sleeplessness and other factors. Perhaps my bedside manner sucks as well. For good or ill, given the complexity of medicine and the limitations of many patients, it is my responsibility as your doctor to be your advocate and to strive to make the right diagnosis, start the right therapy and get you better. The best most patients can get is a Readers Digest understanding of their disease.

The characterization of medicine as filled with money grubbing bastards who provide unneeded and dangerous care for profit is true, but narrowly true, one small aspect of health care, and of all human endeavors (except, of course, journalism), but not all of health care.

“Taking our medicine” was at its core the kind of essay I would expect from the Health Ranger or Dr. Mercola, although not reaching the levels of total nonsense of Food Babe in its understanding (my current standard for the ultimate in health illiteracy).

“Taking our medicine” has familiar construction I often find in the SCAM world. I see similar articles every day; it is the first time in my faulty memory to find a Mike Adams-style essay in the skeptical world. These essays have a pattern:

1) Present facts but make sure they are without nuance or context. Mention the deaths from health care but conveniently fail to mention the responses: The Institute for Healthcare Improvement’s 100,000 Lives Campaign, which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals. Or the 5 million lives campaign. Or any number of quality improvement initiatives that have occupied my time and improved patient care.

The amount of work we have done to decrease complications in my institutions has been prodigious. We have applied, to use Mr. Krause’s quoted phase without his intended irony from the quotes, “medical science” to patient care and in our system we estimate that we have prevented over 2,000 infections and 200 deaths since 2006. Mentioning medical complications without noting the response to those deaths is a sure sign that the author is disciple of Andrew Lang.

As is, I suppose, putting doctor in quotes, as he does in the essay. It is probably the equivalent of calling me Mr. instead of Mark or Doctor or Crislip or hey you. In the blog comments, calling one of us Mr. is probably 100% sensitive and specific that the writer is a wackaloon, especially if addressing Harriet or Jann.

2) Use inflammatory adjectives and phrases that cast your protagonist in the worst light possible: self-serving, secrecy, arrogant, denial, money-hungry, green monster, highly-caffeinated, gleefully sell anything, easy marks, misplaced trust, lucrative, cozy economic relationship, forsake journalistic integrity (no, not the author in SI, a different forsaker), dysfunctional, left in the dark, etc.

3) Make sure there is an aura of conspiracy. Doctors and hospitals are monolithic institutions that are working to prevent you, the consumer, from knowing the truth so that they can bilk you out of your hard earned money, harming you in the process.

4) Make sure the protagonists are represented as totally evil and without redemption. Never mention the good. We probably killed Kenny as well.

5) Have simple, yet all encompassing, solution. Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. ~H.L. Mencken. Twain or Mencken as Americas best writer ever. Discuss.

Kevin Trudeau may be heading to jail, but the spirit of his oeuvre now lives on in SI.

Or maybe not. Perhaps I am a gullible, biased and naive, an apologist for the medical-industrial complex. It is probably my ongoing confirmation bias, but the only two articles I can remember concerning real medicine in SI are this one and the Spector article and they were both suboptimal. At least when SI has an article about a SCAM they have authors who know the topics; I am not so sure it applies to real medicine.

Again, every problem with medicine noted by Mr. Krause is true and I can come up with many more. Medicine in the US is a mess in many ways and I have no good answers short of making me the all-powerful emperor of healthcare.

Medicine is also an incredible profession. At the end of the day I can look in the mirror and know that I have made someone’s life better, I have relieved suffering, cured a serious illness, prevented an early death, decreased morbidity, made the diagnosis missed by another, eased anxiety. In my job I make the world materially a little bit better every day through the practice of good, science-based medicine.

I am also of the opinion that being a doctor is more than being a “human being providing a competitive service.” It is odd as a lifelong skeptic and atheist to consider medicine a higher calling, with obligations and responsibilities for service to my patients that transcends a technical-financial relationship. But I do. It is why I have patients, never clients or customers. That is an old school attitude that I do not always live up to, but I try and it marks me as an anachronistic dinosaur. Damn it Jim, I’m a doctor with all the intangible responsibilities that accompany the job.

I find the job impossibly complicated, filled with uncertainty and I never seem to have enough knowledge. If I am lucky and careful, I get through the day without complications or bankrupting my patients. But I start every day with gleeful anticipation of the challenge, the responsibility and the fun that I know is to come and finish each day satisfied that I did my best for my patients with the tools at my disposal. Despite the many flaws there is no better job or more noble profession.

Posted in: Random Thoughts Cause I Can, Science and Medicine, Science and the Media

Leave a Comment (110) ↓

110 thoughts on “Irritated by the Skeptical Inquirer. Again.

  1. Cory says:

    Two comments:
    1. You are pretty much right on with all your thoughts
    2. They blew by your (and my) “old-school” exit on the Interstate about 20 miles back

  2. David Gorski says:

    Thank you, thank you, thank you! I was going to take this article on because it irritated the hell out of me too, but I just never got around to it, mainly because it’s only available in the dead tree version, and I like to quote what I’m deconstructing. Being lazy, I hate not being able to cut and paste. Even so, I might still do it, because I don’t think you covered everything that irritates me about the article. In the meantime, you’re (mostly) irritated by the same things I am.

  3. Marisa says:

    What an earnest and thoughtful post, especially the conclusion. Careful there, your humanity is showing.

  4. Republicus says:

    I remember seeing the struggle described here in my own parents, even though as a physiatrist and opthalmologist it was usually about quality of life rather than life-or-death. Growing up with that constant stress probably had the most to do with my decision not to pursue medicine, even though it probably would have between a better decision economically than history or language.

    So here’s to the good ones: thanks for everything.

  5. Angora Rabbit says:

    What he said. Thank you, also! Mr. Krause’s “essays” on science have been annoying me for years. I don’t know what his qualifications are, but they are not due to scientific expertise. His “essays” in my area of expertise, nutrition, are off-the-mark and ill-informed. The basic research is not there. I have a lot of respect for Kendrick Fraser from his past work, but this one leaves me cold and, frankly, irritated. Thank you for calling Mr. Krause on the carpet.

  6. goodnightirene says:

    I quit reading SI long ago for the same reasons.

    Thanks for the very thoughtful essay and for sharing such personal anecdotes. Most of my docs have been closer to your standard (from what I can tell, and I do think I read a bit over a 6th grade level), but I have come across the other type. I try to judge them by their expertise, not their personalities, especially if they have specialist knowledge that I need. Better a highly competent orthopedist with attitude than a touchy-feely gynecologist who recommends a bit of “bio-identical” hormones for the hot flashes.

    My point is that I would want you to treat me for malaria even if you hated beer and loved Jesus as your personal Saviour and I would want Dr Gorski to treat me if I had breast cancer even though he once brought me to tears by ripping me for an innocent enough (but misunderstood) comment on his other-not-so-secret-blog.

  7. Ed Whitney says:

    Don’t read the SI; read “Skeptic.” Same section of the bookstore periodical section and worth a lot more.

  8. Michael Finfer, MD says:

    I don’t think that doctors, for the most part, are being malicious when playing the over-utilization game. They couch what they do in terms of science, but the results are sometimes not pretty. Take, for example, urologists and prostate cancer. In my area, the urologists have moved the entire process of diagnosis and treatment of prostate cancer into their offices, biopsy, pathology, radiology, and radiation therapy. What seems to be happening is that everyone gets annual PSA’s (no longer recommended), and everyone with a cancer diagnosis, regardless of age, grade, or stage, gets radiation. The urologists that I work with have done that, and we have not seen a radical prostatectomy in at least four years. I routinely refer patients who might might benefit from surgery to referral centers because I cannot consider our guys to be capable of doing those procedures any longer. Also, notice how vocal the urology community has been at opposing any attempt to limit PSA screening. To me it is just self serving. At the same time, I think that the urologists truly believe that they are doing what is best for their patients, however, I doubt that what has been happening is scientifically justifiable.

    I have no solutions. I think it is going to be extremely difficult to get a handle on stuff like this and get costs and practices back in line with what they should be since the regulators have allowed stuff like this to become so widespread.

    I think we have to accept that, at some point in at 30+ year career, we are all going to do something that causes significant injury to, or results in the death of, a patient. We all try very hard to avoid it, but we are all human, and bad things will happen, albeit very rarely. We just have to try to have the safest possible systems and try to minimize significant adverse events.

    1. windriven says:

      We decoupled people from direct exposure to the cost of their medical care beginning in the 1950s. I suspect that if the urologists had to look their patients in the eye and ask if that would be cash or credit card (for the whole cost) rather than billing an insurance company things might work rather differently.

      I am not suggesting that insurance disappear. But third party paid insurance (i.e. employer paid) is clearly part of the problem. Not nearly enough Americans face the horror of writing a $3000 check each month for their family’s coverage. So the costs of medical care are abstract. We spend ~$8400* per person per year in this country on health care. For a family of four that is $33600. In Denmark the same family costs ~$17,200.

      Damn I hate the new typeface. How is it that a tilde prints like a minus sign and there are no discernible italics?

      1. mousethatroared says:

        @windriven – In Denmark do families pay more of their healthcare costs out of pocket? Or are the lower costs due to the fact that the government negotiates prices?

        I have become strongly suspicious of the popular idea that having the patient pay more of their healthcare would result in lower health care costs. My suspicious is based on two reasons. One, I’ve never seen any actual data demonstrating successfully lowered costs through the use of that idea. Two, I’ve seen good economic arguments against the idea (Krugman’s for one). Three (wait, I said two, but this one’s an anecdote, so it doesn’t count) I’ve had both healthcare plans with very high deductibles and low deductibles and as far as I can see, they don’t noticeably change my behavior, sure I felt incredibly guilty about having to get an incredibly expensive ct scan that (maybe) ruled out kidney stones for ongoing abdomen pain, but what was I supposed to do? Should I not get a test that a doctor recommends, when I’m actively in pain, because I don’t want to spend the money? On the other hand (with a low deductible plan), I have avoided an (I assume) expensive endoscopy because my stomach pain suddenly disappeared. Don’t tell the doctor, because she still wanted me to have it. Why, because having medical tests, regardless of how much I pay, isn’t on my list of fun ways to spend an afternoon.

        MRI on Thursday….weeee what a blast.

        Sorry, that descended into sarcasm. It’s not directed at your, windriven. I am overly sensitive because I seem to spend a lot on healthcare and don’t see a lot of viable* alternatives.

        *although I do get suggestions, yoga, supplements, herbs, anti-depressants, etc. ;) Anyone have good evidence of those alternative’s effectiveness with cervical radiculopathy? {ducking}

        1. windriven says:

          Mouse, I mention this more to relate the history of how we got where we are than a prescription for the future. We aren’t going back to 1947. My personal preference would be for a socialized system. It pains me to say this but I don’t see another way.

          The Danes pay essentially nothing out of pocket – it is entirely through taxes. Danes pay quite high taxes but purchase a high level of efficient government services. We are stuck in a situation where it is easy enough to see socializing the payment side of the equation but how do we wring waste and inefficiency out?

          American physicians don’t earn significantly more than Danish physicians. Denmark controls some pharmaceutical costs better than we do. But these are nibbling around the edges. We spend twice what the Danes spend for essentially the same level of care. Physicians aren’t getting the difference. I can promise you that device companies aren’t*. So where is $1.25 trillion dollars in excess spending going? Somebody is making an s-load of money.

          *One of the products I make are the anesthesia masks that doctors use during induction. There is a huge amount of technology involved in rotation ally molding that air-filled cushion, there is almost 3/4 of a million dollars in manufacturing equipment, and I make these masks in a state with the highest minimum wage in the nation. But I sell them to your hospital literally for less than you pay for a Slurpee. So I can tell you with certainty that I’m not seeing any of that 1.25 million million dollars.

      2. WilliamLawrenceUtridge says:

        I’m not sure what you’re seeing, but my italic show up when I code them properly, and I can see your tilde…

        1. windriven says:

          You must be the golden child. ” ” gives me nothing and a tilde gives me a minus sign.

          1. windriven says:

            The empty quotes were intended to show the standard bracketed i and slash i. ‘

      3. Dan says:

        Windriven, I could not get through Whole in whole. There was way too much science-bashing for my tastes, and way too little evidence cited. If you can cancel your Amazon order, it might save you both money and time (not to mention neural memory space). He had some good points at the beginning, but then it became just a repetitive screed against nutritional science as currently practiced. Sour grapes by the author?

        1. windriven says:

          Thanks for the advice! On my way to New Orleans so I haven’t ordered it yet. Guess I’ll save my money.

      4. Lytrigian says:

        Not nearly enough Americans face the horror of writing a $3000 check each month for their family’s coverage.

        So… that horror would be a good thing?

        Sorry, no. I get enough horror just seeing the EoBs from my employer-provided insurance, for which I still must contribute about $400/month. (Pretax, but still.) Since many of the charges are related to equipment and treatment for my severely disabled son they’re usually covered by Mediaid, but it’s not a great feeling.

        Medicine is not like other businesses. I’m not shopping for the best deal on a can of baked beans. My life, and the lives of my family, are on the line based on the decisions made. Should I forgo the Ketocal we now rely on to (mostly) control my son’s seizures because it happens to cost an exorbitant amount of money? What should I do instead? I can’t exactly stuff bacon down his G-tube. The Onfi and the lamotrigine that also keep his seizures down: does it make sense to shop around for almost-as-effective drugs when we already experimented with a range of them when he was younger and found this combination to be the most effective? Should I control his spasticity with doses of baclofen large enough to sedate him for half the day, or was the implanted pump that can do the same thing with microdoses sent directly to his spinal cord a worthwhile investment?

        Should I have left his pneumonia untreated years ago, when the local hospital declared treating him outside their competence and had him transferred to Lucille Packard? That was expensive as hell, after all.

        The ordinary calculus of the marketplace is so out of line with how we use medicine that a free market in the usual sense can’t possibly exist here.

        1. windriven says:

          “So… that horror would be a good thing?”

          Of course not! You missed my point entirely. We have allowed the cost of our healthcare to soar far beyond what other people pay because we are disconnected from the cost. In Denmark the government keeps a careful watch on healthcare costs because they pay essentially 100% of those costs and because Danish voters expect their government to deliver high quality services efficiently.

          In our country who is in charge of cost control in health care? Your employer shops plans but the insurers are all playing on the same field – they can only press so far before hospital groups decline to contract with them and that is bad for the insurance business. The government plays a similar game in that they make noises about cost control but create so many exceptions and loopholes that cost constraint is a paper tiger. Socialized medicine is the only answer. It chokes me to say it. But we’ve tried the so-called free market* approach and we’ve seen how that works.

          *there is absolutely nothing that resembles a true free market in the health care industry.

    2. Young CC Prof says:

      It’s impossible to get costs “back where they should be” without letting people die who could have been saved. We CAN reduce costs to those of socialized medical systems, by implementing a socialized medical system or something that accomplishes the same ends, devised by someone much cleverer than me.

      However, the inexorable reason that health care costs climb is that technology improves. Once, people with advanced cancer, or kidney failure, or heart disease, were just nursed until they died. Now, we can actually treat the problems, for a mere $300,000 or so.

      If we implemented every possible efficiency, kicked out the private health insurance companies, negotiated for drug and device prices, etc, we could maybe cut our health care costs in half. Any more than that, care will suffer.

      1. Kultakutri says:

        Most countries, if not all, of the European Union, have similar stats in health outcomes but spend much less money for them. I’m not an expert in healthcare economy but maybe the Europeans are onto something, somehow.

      2. windriven says:

        @Young CC Prof

        Kultakutri makes an important and quite accurate point. Many of our European friends enjoy outcomes equal to or better than our own at literally half the cost. Health care in Sweden, Denmark and Germany is exceptionally good and costs about $4000 per person per year less than we spend.

        I’ll be happy to send you a load of citations if you’re interested in learning more. The problem that we face is disassembling the inefficient structures that we’ve built over the last fifty years. There are many ones that must be gored. I don’t have real confidence that it can ever be done.

        1. Self Skeptic says:

          @Windriven,
          I’m happy to say, I completely agree with you on this. :)

  9. WilliamLawrenceUtridge says:

    When was it written? I can’t find anything about it on the interwebs. Even his page at CSICOP doesn’t have it listed (but it does have a bunch more medical articles).

    A tiny, gleeful part of me always relishes when there is infighting among skeptics, I think it is necessary to keep us humble and remember that we’re not a homogeneous mass.

    1. Chris says:

      As noted it is only in print format on real paper, as CSICOP does not put its articles online. You will probably find it on the magazine rack of a bookstore.

  10. windriven says:

    Every other Friday isn’t enough. Indeed, the world needs more Mark Crislip.

    Americans want the best health care in the world and given their druthers they’d rather have someone else pay for it. Instead what Americans get is something like the 37th best health care in the world and they pay through the nose for it.

    Americans can get an appointment to see their attorney or their CPA in a day or two. But an appointment to see their doctor can take 8 weeks. They spend an hour with their CPA for $150 and 10 minutes with their physician for the same price. They see hospital bills that charge $9 for an aspirin*. They see a bottle with 30 pills in it that costs as much as their car payment. WTF?

    I can take the other side of this argument and explain that our less than stellar outcomes can be explained by, among other reasons, suboptimal care for those of us who lack good medical insurance. But I cannot explain the cost side and I’ve studied it pretty carefully.

    We spend 18% of GDP on health care. Denmark, among the highest spenders of the major European countries spends 9.8%, just over half. And Denmark provides health care for 100% of its citizens.

    Physician earnings in Denmark aren’t remarkably less than in the US. So … where is the extra roughly $4000 per patient per year ($1.25 TRILLION total in extra spending EVERY YEAR) going? We waste per patient as much as Denmark spends per patient.

    All of this by way of saying that we do a great job with the medicine of medicine. But we do a shitty job with the business of medicine. Everyone can see the mess. It shouldn’t be a surprise that everyone bitches about it. And the economics of health care are so murky, so overrun with obfuscatory accounting practices and cost-shifting that it is all but impossible to get a good fix on just where the problems lie.

    So the folks in the white coats, the faces of health care, get blamed. Not fair. Not hard to understand.

    *Some years ago I got a bill from a New Orleans hospital that included a charge of $18 for a nasal cannula that the company that I then worked for sold to that hospital for less than 50 cents.

    1. WilliamLawrenceUtridge says:

      Can anyone explain to me the opposition to federally-funded health care in the United States? I don’t understand how the US thinks that they alone are brilliant enough amongst the world to not need a federal plan, and how this is reconciled with the extraordinary costs paid for the apparently horribly flawed options that currently exists?

      1. mousethatroared says:

        Are you asking why changing health care delivery and payment for 300 million people is controversial?

        I’d actually be amazed if it wasn’t controversial…I’m imagining our population being gradually replaced by a hive of alien pod people who all gleefully agree.

        1. WilliamLawrenceUtridge says:

          It more seems to me, as a foreign observer who gets most of his news from Jon Stewart, that the issue isn’t the “how” of a federal health care system. It’s the “whether”. As in, people seem to object to the very idea of such a federally-funded system. That baffles me.

          Perhaps I’m wrong. But even Obamacare isn’t health care reform – it’s health insurance reform. You’re not getting health care, you’re getting health insurance. Which still seems like half measures.

      2. windriven says:

        No. I can explain the opposition to ACA but not to a socialized health care system. I hate to even admit this but it has become clear to me that some on the political right*, secure in their platinum plated employer-paid health insurance, believe that their neighbors don’t need quality health care and if they do need it, they are clearly too lazy to earn it. Like vacationing in the French Alps and wearing Gucci loafers, health care is not for the cannaille. They’ll tell you this on the steps of their church cause that all love their Jesus and they’ll all have their flag decal in the window cause I guess they’ve never listened to John Prine** .

        *I would consider myself an economic conservative. What I describe above is something rather apart from that, I think.

        ** Probably too obscure a reference. Prine has a song with the refrain, “but your flag decal won’t get you into heaven anymore…”

    2. Bruce Hamilton says:

      Karl Denninger has been writing what I consider to be the definitive analysis of the business of US medicine for several years. See http://market-ticker.org/akcs-www?archive-list=Market-Ticker&cat=Health+Reform

      In a nutshell: we need to stop arguing about who pays, and take the necessary steps to drive down the consumer costs by 75%, by getting rid of the various government-enforced monopolies, such as anti-trust exemptions.

      1. windriven says:

        I’ve read through some of his posts on the link you’ve provided. Am I wrong in inferring that his take is that everyone in the health care industry wants to eff you and that everyone remotely associated with Obamacare wants to eff you and your pet chihuahua?

        One of the posts I read was similar to the situation mentioned by Dr. Finfer above where urologists who own their own radiation gear prescribe the bejesus out of it. Isn’t that good old entrepreneurship? How will clearing anti-trust exemptions address this problem?

        1. Bruce Hamilton says:

          “Good ol’ entepreneurship” is fine if individuals are paying directly, but not if the products are perceived by the end users as “free” because government or insurance is paying.

          1. windriven says:

            Really? You do not see a conflict when your diagnostician also has a huge investment in diagnostic or therapeutic equipment? In the case that Dr. Finfer mentions, urologists owning their own radiation gear prescribe radiation treatment at much higher rates than science supports.

            More gear and more procedures do not necessarily translate to better care. They certainly do not translate to more cost-effective care. Our competitors in Europe with socialized medical systems are beating the bejesus out of us delivering great care at half the cost. I’ll be happy to talk Friedman and Von Mises all day long but the empirical evidence is that the socialist model works best in health care delivery.

  11. Ed Whitney says:

    A separate word about shared decision making: involvement of patients with their own care is advisable when there are at least two reasonable courses of action and the values and preferences of the patient become an important element of planning care. For example, symptomatic herniated lumbar discs can usually be managed in more than one way. The largest and best randomized trial showed that surgical decompression gives the best chance of an early and satisfactory recovery, but there were substantial crossovers during the trial, and the study also showed that nonoperative management can also be successful, but may take time and active participation by the patient. In such circumstances, explaining the choices in terms that the patient can understand is good medicine. Patients who shudder at the thought of surgery can be informed that conservative treatment is an option, while patients who are willing to go under the knife can be informed that this gives them the best chance of an early resolution of symptoms. For acute cauda equina syndrome from a large herniated disc, on the other hand, the doctor needs to make it clear to the patient that this is an emergency requiring prompt surgical decompression.

    Countless other scenarios share a similar pattern.

  12. mousethatroared says:

    Wow – This almost a Gorskian length piece!

    Very nice counter argument. I’m not a SI reader, but hopefully they will print contrary responses to the article in a following issue…sounds like it’s needed.

    On the economics of medicine. Maybe this is remedial to you all, but here is an interesting report with some comparisons of how health care dollars are being spent in different nations.

    My summary – U.S. fewer doctor, fewer visits to doctors, less hospitalization, more imaging, similar medications, but everything costs more in the U.S. Even if doctors ordered the same number of MRIs that they do in France – we would still be spending significantly more on MRIs. As far as I can see…the increased imaging isn’t resulting in more procedures, more hospitalization or medication. (could be missing something).

    I don’t have access to the SI article…is it suggesting that higher spending in the U.S. is due to over treatment by doctors? I would wonder, in light of this commonwealth fund report, if the SI articles facts are even correct.

  13. mousethatroared says:

    Also – I can’t believe anyone put doctor in quotes. Pretty sure that doesn’t meet typical journalistic standards.

    1. Mark Crislip says:

      As I think about it, maybe it was for grammatical reasons. It was: “…frequently insist we address them by the lofty title of “doctor”.”

      Given the quotes for “medical science” in the next paragraph and the dismissive tone of the article, I took the quotes as sarcastic. My grammar-fu is weak.

      1. mousethatroared says:

        Hmmm, interesting point, the title of doctor. I have never thought about it, but on my son’s cleft team the doctors all go by Dr this and Dr that (this includes the dentists, orthodontists) and the other medical professions, such as the team speech pathologist go by first name. Although, I would suggest the team SP recommendations have more weight in topics that are relevant to her expertise, regardless of going by her first name.

        I have never for one moment got the impression that the title was being insisted upon….though. It’s sorta like a pastor, it’s just the title. I am a bit of a traditionalist when it comes to titles, though. So maybe it’s just me.

        1. windriven says:

          “I am a bit of a traditionalist when it comes to titles, though. So maybe it’s just me.”

          I’m with you mouse. I was irked when the WSJ stopped reflexively referring to everyone by their honorific (Mr. Jones, Dr. Smith, Ms. White, President Obama). There is a line between excessive devotion to form and cascading social degeneracy but I’m pretty sure we’ve crossed it ;-)

        2. Self Skeptic says:

          I remember when “Ms.” was very controversial, not so long ago (from my aging Boomer perspective.)

          http://www.nytimes.com/2009/10/25/magazine/25FOB-onlanguage-t.html

          “snip

          In some quarters, recognition of Ms. was slow in coming. The New York Times waited until 1986 to announce that it would embrace the use of Ms. as an honorific alongside Miss and Mrs. Eighty-five years after The Sunday Republican’s unassuming contribution to our modern lexicon, The Times admitted that the “void in the English language” had been filled.”

  14. calliarcale says:

    I stopped reading SI a long time ago — around the time of Asimov’s death, actually; they had some lovely tributes to him — because it had become too repetitive. It is unfortunate to hear that some of the writers have bought into the narrative of evil money-grubbing doctors, which is ironically one of the main debate tactics of the whackaloon contingent. Perhaps bathing so long in the woo left them vulnerable to some of the somewhat less insane messages soaking in?

    Part of the reason the message is so commonplace, though, is because of that kernel of truth. We *know* people die because of medical errors. We *know* there are stories of rampant overcharging (though the reasons for the overcharging are nowhere near as simple as it seems). We *know* there are arrogant SOBs who go into medicine, just like there are arrogant SOBs everywhere else. And by the time we’ve lived a few decades, we’ve probably had the joy of seeing or even paying a very large hospital bill. And it’s frustrating to realize that doctors are not in fact the perfect gods we’d like to them be, able to make us better every time.

    So the message, though wrong or at least lacking in nuance, is very compelling. While it’s disappointing to see an SI contributor falling into it, I suppose it shouldn’t be too surprising. Skeptics are human too, and again, this message is very compelling.

  15. mousethatroared says:

    Just an aside (sorry, triple post)- I appreciate the 6th grade reading level material. I suspect that 12th grade reading level medical information would have a hell of alot of vocabulary that I did not learn in school in the 80′s. Also, often the literature I get is post-op instructions for my son…(which means it’s always presented after a sleepless night at the hospital with only substandard hospital coffee as a stimulant) or I’m not feeling well myself, or I’m primarily focused on dealing with the medical person in front of me.

    The last time I took my daughter to the Pediatrician I ended up leaving with 6 prescriptions (she had poison ivy, which had become infected AND strep throat…god, that child) The brief, simple printed, patient treatment summary I received was just the ticket. It’s not high literature, I do not need to be intellectually challenged by my or my children’s medical care.

    1. mousethatroared says:

      Whooops! It was only 5 medications, sorry. ;)

  16. Gary says:

    I can’t imagine having the burden of responsibility that a doctor, particularly a surgeon, has. I wouldn’t be able to sleep nights.

    I was entrusted with very highly classified information in my professional career and all I had to worry about was that I would blurt something out somewhere, sometime. Perhaps such a mistake could have caused deaths somewhere, sometime but I managed to sleep because the “victims” were hypothetical, not people with names like a doctor’s patients.

    May you continue to have the strength to bring health and rationalism to the many

  17. Stella B. says:

    We physicians are the face of medical care even though we are a minority of the workers. Nobody wants to be sick and sick people wind up projecting their anger on the most obvious representative of the medical system. I tried to remember that when people were angry at me for the failings of medicine. It took me several months of retirement to reduce my anxiety level, though! I still feel bad about the patients who died either expectedly or unexpectedly and think of them from time to time.

    Windriven: You need to move. My former practice had urgent care locations open 365 days a year and we could also usually get you in for a same day appointment in our office, if you called in the morning. Specialists were also readily available. As an older person turned patient, I have not found scheduling for myself to be difficult either. Living in a big city does have its benefits.

    1. David Gorski says:

      We physicians are the face of medical care even though we are a minority of the workers.

      To be fair, it’s also because we’re viewed as the captains of the ship, so to speak, the ones giving the orders, and in the “good old days,” we really were the captains of the ship. We’re still (mostly) in charge, but no longer the unquestioned leaders, which is probably (mostly) a good thing.

    2. windriven says:

      Thanks Stella but I’d rather wait to see my regular internist. Urgent care is great for urgent care. I was talking about routine appointments. When you have a legal issue do you want to go in and talk to a lawyer or do you want to go in and talk to YOUR lawyer who has long familiarity with you and your legal issues? Just sayin’

      And Portland, OR is a pretty big city.

  18. RobLL says:

    When I suffered from a likely statin overdose both the Internist and Neurologist absolutely refused to consider that statins may have been involved.

    Both of my Internists refused to consider that lower blood glucose levels may improve my general health. Ophthalmologists were encouragers.

    I have seen no evidence that doctors in general operate on a scientific basis. Some, yes; most, no.

  19. mho says:

    A wonderful patient and advocate I met a number of years ago had to work really hard to convince her surgeon to attempt a very risky surgery. She insisted that she would really rather die quickly, under anesthesia, than a from a certain, painful and drawn out death from her ovarian cancer. She was an astute and, I’m sure rare, patient.

    She lived three more years after that surgery.

  20. Self Skeptic says:

    Dr. Crislip, I don’t understand why this SI article doesn’t just roll off you. If you haven’t been convinced by Kassirer’s “On the Take”, Angell’s “The Truth About the Drug Companies,” and Goldacre’s “Bad Pharma”, that there is a big problem with mainstream medical recommendations, why not just ignore this, as well?

    The problem that mainstream medicine is currently facing, is not that ordinary doctors like you are intentionally mistreating their patients to get more money.

    The problem is, that you aren’t making enough effort to distinguish between:

    (1) honest science-based medical guidelines (including those that are say “we don’t know yet, here are some possible choices,” and

    (2) guidelines that are fatally flawed, either due to pharmaceutical company interference, or some equally manipulative academic’s pet theory, that has been turned into practice guidelines.

    This results in practicing clinicians being easy dupes, and your patients becoming easy marks.

    Spending time complaining about bizarre CAM offerings is distracting you all from doing the work needed, to recognize #2 above, and stop being gullible participants in them. If the majority of doctors routinely recognized these scams, and rejected them, the problem would disappear overnight. The sleazy experts would be disciplined, and ambitious academics would then avoid smearing their own names by participating in these activities.

    But because the majority of doctors and medical institutions shy away from recognizing the problem, it seems like it will go on until the public rebels. I’m sure you can see that they’re likely to make a hash of it.

    Wouldn’t it be better if you doctors fixed it, before it gets to that point?

    1. David Gorski says:

      Spending time complaining about bizarre CAM offerings is distracting you all from doing the work needed, to recognize #2 above, and stop being gullible participants in them.

      Ah, the old “Why don’t you blog about what I consider to be important?” gambit. An oldie moldy. I’ve lost track of how many times I’ve seen that one and how many times one of us has answered it. Yawn.

      Of course, one notes that I don’t see any examples provided of guidelines that are “fatally flawed” due to the nefarious influence of pharmaceutical companies.

      1. weing says:

        “Of course, one notes that I don’t see any examples provided of guidelines that are “fatally flawed” due to the nefarious influence of pharmaceutical companies.”

        On another thread he was referring to IDSA guidelines for treating Lyme disease. Although, to me it seems, if Big Pharma had a hand in them, everyone would be on long term antibiotics.

        He is obviously smarter than the rest of us and is capable of differentiating between the actual science based guidelines and the fatally flawed ones. Never mind that they are only temporary and change when more information comes in.

        See, if he went to medical school, he would only have studied the stuff that was correct. We, stupid bastards that we were, wasted half our time studying what was wrong. He also apparently doesn’t subscribe to any pet theories of academics.

    2. vadaisy says:

      The problem is, that you aren’t making enough effort to distinguish between:

      (1) honest science-based medical guidelines (including those that are say “we don’t know yet, here are some possible choices,” and

      (2) guidelines that are fatally flawed, either due to pharmaceutical company interference, or some equally manipulative academic’s pet theory, that has been turned into practice guidelines.

      This results in practicing clinicians being easy dupes, and your patients becoming easy marks.

      “Guidelines” are just that – guidelines. They are to be used as a guide for physicians when treating patients. They are not laid out in stone. No one I know has ever been denied reasonable care because of a guideline recommendation. Not even a Lyme patient. The medical system is full of guidelines. Even rheumatolgists have guidelines on how to diagnose and treat autoimmune diseases. Guidelines abound across all medical fields. Only the Lyme disease patient-medico sect attacks guidelines in such a dysfunctional, unproductive manner.

      As to the conspiracy-minded allegations of manipulative academics and IDSA guideline members, all guidelines are made by core groups of physicians and other experts. Not every single rheumatologist in the world actively participated in the making of their society’s guidelines. Point being, your pleas are unrealistic and you are being manipulative to those who do not have the experience to discern your manipulations from the real truth – the ill patients.

      “Manipulative academics”? Is that like Dr. Raphael Stricker falsifying clinical trial results for HIV/AIDS patients? A founder and leader of ILADS he is? Or, kickbacks from home infusion companies so as to falsely diagnose patients with Lyme disease? – Dr. V. Shah seemingly still recommended to patients by the Lyme Disease Association and on their “Lyme-literate” provider listing? Which home infusion company was giving him the kickbacks? A “Lyme-literate” one? Any reporters want to research that?

      “Pharmaceutical company interference”? You are conveniently neglecting to mention that there is no accounting for supplement company interference, or specialty lab interference. Supplement companies have no oversight. They can offer all the kickbacks, bribes they wish and not get caught. Same goes for doctors who own stock or ownership in those companies. The most lucrative ones are those with headquarters and practices in other countries. Criminal doctors who hide from the oversight of insurance companies and hospital affiliations can most easily funnel their profits (kickbacks) to their overseas accounts and medical practices. There is no “interference” for them. Ever hear of Trudeau? Millions in overseas accounts. Millions!

    3. Mark A Crislip says:

      Kassirer , Angell, and Goldacre gave reasoned, nuanced discussions of the topic, not a Health Ranger screed. I expect better of SI, though I suppose not longer.

      When I gave a talk last week on Common SCAM Myths, the first question was something about the failings of drug company studies and why didn’t I cover that.

      Because, Jesus, it is not the Goddamn topic. It is like giving a talk on the rules of golf and the first question is about rugby

      1. David Gorski says:

        That’s almost always one of the first questions I get after doing a talk on CAM. So predictable. So annoying. If I had wanted to give a talk about pharmaceutical company malfeasance, I would have given a talk on pharmaceutical company malfeasance.

    4. Sawyer says:

      I’ve often wondered about the overall distribution of topics on this blog. While I’m sure all the contributors have their own reasons and preferences and could defend their writing much better than I could, I would like to throw out one major justification for their primary focus on CAM.

      Pharmaceutical companies do a lot of shady things, but no matter how evil they become, the next generation of scientists will always be reasonably equipped to smell out their BS. Doctors that care deeply about their patients can always be a bit more cautious when prescribing a drug. Journalists can always pick up a new story about shoddy standards in a pharmacy or laboratory. Whatever sins are being made today by Big Pharma can, in principle, always be addressed. Unless I missed something, statistics and biochemistry are still being taught at universities.

      Alternative medicine is another matter. It’s not just that CAM companies are copying Pharma’s greedy money-making schemes. They are attempting to completely undermine 20th century science. They’ve weaseled their way into not just politics and industry but into academia. They want to teach medical students pathetic standards for laboratory methodology, that anecdotal experiences are on par with statistical tests, and that anatomy and chemistry can be discarded whenever inconvenient. Taking advantage of a rapidly evolving world of journalism, they insist all medical news give two sides to every story in the name of balance. Patients are encouraged to make decisions with doctors not via informed consent, but by assuming that 2 hours on google makes them just as knowledgeable as someone with 20,000 hours of education and clinical experience.

      If these ideas truly takeover mainstream medicine, they CANNOT BE CORRECTED. It’s not just that facts or theories will be wrong. It’s that the analytic tools used to separate fact from fiction will no longer be taught to doctors and scientists. There will be no base level or knowledge to rebuild a workable medical system, let alone do new research.

      Given this looming threat, I have no problem with SBM playing defense against CAM. I’d like to see a good critique of pharmaceutical companies a bit more often, but I’m not demanding anyone take their finger out of the CAM dike to do so. An ounce of CAM prevention is worth a pound of Big Pharma cure.

      1. windriven says:

        Amen, brother.

  21. Mike Callahan says:

    I was an early subscriber to SI in the late 70s and into the 90s but also became bored with all the attention given to bigfoot, spoonbenders and psychics. I was more interested in pseudoscience that was doing real harm like alternative medicine. SI hardly covered quacks as much as I thought they deserved. Randi’s coverage of the psychic surgery quacks was good but I wanted more. Along came the internet and soon I was reading Quackwatch. Now we have so many accomplished bloggers, especially at SBM. I love it.
    I had a nasty case of leukemia and then a bone marrow transplant so I have met a lot of doctors along the way. My caretakers have all been good people with good intentions. It bothers me to hear alternative providers lump all these good people I have come to love as shills for big pharma and money grubbing predators. It’s unfortunate that that insidious meme has infiltrated the people at SI.

    1. Chris says:

      I also subscribed from the early 80s into the mid 90s. I unsubscribed when I dropped almost all print magazines just to reduce clutter in a house full of small children.

      I thought of resubscribing a few years ago, and found it was repeating the stuff I had read earlier*. Plus, like you, I found more relevant information, especially since I was running into lots more pseudoscience than the average parent because my oldest had medical/developmental issues.

      It does not take much for everyone to think they are an expert in speech development, seizures, etc. For some reason I preferred the care/advice I received from Children’s Hospital (including their resource center and phone line) than the other mom at the playground, the house painter, and some silly books I checked out from the library.

      One of those silly books was What To Do About Your Brain-injured Child by Glenn Doman. It was a book length advertisement for his institute in Pennsylvania that made parents do intensive physical therapy on their kids. And if it didn’t work, it was the parents’ fault. The first time I encountered Dr. Novella was his article explaining that “patterning” does not work:
      http://www.quackwatch.com/01QuackeryRelatedTopics/patterning.html

      * Though I did buy a DVD of the SI archive a couple of years ago.

  22. All the facts were fine. I had no issue with the content of the article. It was the adjectives that irritated me.

    Gee arent YOU black, said the pot to the kettle..

    1. Self Skeptic says:

      I’m pressed for time. I’m at my mother-in-law’s, and will speak to her doctor tomorrow about her care. Sorry this is so long; I lack the time to make it short. ;)

      So I won’t go into detail about which guidelines, recommendations, whatever you want to call them, are most suspect, from an objective viewpoint. I’ll talk about those which concern me right now. This is a summary; I have virtual stacks of papers and a pile of books on these drugs and issues. So please don’t think I’m jumping to conclusions, on too little information.

      You do all get it, that the primary medical literature is being systematically spammed by pharma-designed and -funded studies, right? Kassirer, Angell, Goldacre, and many others have documented this.
      Here’s what this means:
      Once the primary reports are biased toward making the drugs look better, the ensuing systematic reviews will be biased (even the Cochrane ones.)

      Once the systematic reviews are biased, the clinical practice guidelines based on them will be biased. It’s kind of like evolution; once the idea clicks for you, you see that it has to work that way.

      If you can’t see that, then…maybe you have a problem with “motivated reasoning.” That the literature is stacked, is certainly not good news to any of us who depend on mainstream medicine for healthcare. But that’s no excuse to deny it.

      The current drugs I’m investigating are the statin, and Alzheimer’s drugs, on behalf of my 88 year old mother-in-law (though someone is sure to throw “anecdotal” around, just so we know that they know the jargon.)

      She’s taking a statin for modestly high cholesterol (despite never having had a hint of cardiovascular trouble), and her memory is getting bad. Her carotid artery is clean. Her doctor wants to keep her on Lipitor and give her Namenda (memantine). She already tried Aricept (gabapentin), had a bad reaction, and vehemently refuses to take it ever again. Good.

      Namenda is made and marketed by Forest Labs. Are they a reputable company, or one of the science fakers? I checked. They’re sleazy:

      http://www.cbsnews.com/8301-505123_162-42842789/forests-lexapro-ghostwriting-budget-was-100k-emory-on-the-payroll/

      http://www.cbsnews.com/8301-505123_162-42844567/jagged-little-pill-when-drug-companies-forget-to-mention-suicide-risks/?tag=bnetdomain
      Take a look at these: there are a few great extracts from Forest Lab’s leaked marketing plan for Lexapro, and a timeline of how they broke the news of psychiatric side effects to the FDA, that is priceless.

      Back to Namenda. Here is some of the data:
      http://www.rxlist.com/namenda-drug/clinical-pharmacology.htm
      From the same site, here’s what patients say.
      http://www.rxlist.com/script/main/rxlist_view_comments.asp?drug=namenda&questionid=fdb77936_pem&page=2
      You all may not care, and I can imagine all the reasons you would give to ignore patient reports. I take each of these with a grain of salt; but cumulatively, I give them some weight. Maybe 20%. I no longer believe that drug company RTCs have 100% weight, and patient reports have 0%.

      I plan to go over the data, and figure out how they Forest made it look its best, as well as possible from what is revealed. I have no doubt that they put its best foot forward, it’s just a matter of how.

      One of the papers, I forget which, says has a small benefit in 29% of moderate to sever, and no effect in mild Alzheimer’s (which my mother-in-law is thought to have, though I’d like to see how she is, after a couple of months off Lipitor. You know about the FDA warnings about diabetes and memory loss, in addition to the muscle problems, from statins, I presume.)

      Statins:
      Did you see the new statin guidelines? Yikes. They’re expected to double the number of people, recommended to be on statins. Does this smell like a scam, or what?

      Needless to say, like all guidelines these are based on analysis of the published RCTs, which come from the manufacturers/marketers, which are huge pharma corps, and so will have exaggerated the benefits and understated the harms. (If you know of an honest big pharma corp. that doesn’t do this, let me know. I would think they would have been driven out, in the race to the bottom, but nice surprises are always possible.)

      I’m sure statins are good for men who have had MI’s, or signs of CVD, and maybe for women with those risks. Bad family history, high inflammatory markers, sky-high cholesterol, maybe take statins; personal choice. I might do it. For the rest of us, it may be one of those “Neurontin for everything” campaigns.

      Dr. Crislip, you said somewhere that you just assume that a drug is half as good as the company says. Sounds reasonable. At this point, I feel my MIL should stop Lipitor and postpone Namenda.

      Now, all I have to do, is explain this tomorrow, to the young doctor, who I suspect thinks the academic experts are as good as saints, and as powerful as gods. I’ll leave out the sleaze report, and emphasize the probable harmlessness of a temporary drug holiday for my MIL. Maybe we can agree to give it 6 months. What a fun day.

      PS: Lyme disease is irrelevant to the current discussion, which hinges on pharma influence distorting science, and physician naivety. LD is between Weing and me; we live in the Northeast, he’ s a doctor and I’m a scientist. I wouldn’t discuss LD with Dr. Crislip, who doesn’t practice in a region where it is hyperendemic.

      1. windriven says:

        Wow, and I thought I was arrogant.

        ” At this point, I feel my MIL should stop Lipitor and postpone Namenda.
        “Now, all I have to do, is explain this tomorrow, to the young doctor”

        All this on the basis of some CBS news reports? I’m sure the ‘young doctor’ will appreciate your curbside Dr. Google.

        SBM has touched on many of the issues that so irritate you. And it is true that the professional literature is contaminated with distorted studies – also touched on in these pages.

        Science doesn’t always get to the truth as quickly or as directly as we’d like. But it does, given time, converge on it. If you have a better method we’d all love to hear it. Until then, science is the best we’ve got.

        1. Self Skeptic says:

          @windriven,
          You missed this, in my message: “This is a summary; I have virtual stacks of papers and a pile of books on these drugs and issues. So please don’t think I’m jumping to conclusions, on too little information.”

          The young doctor agreed to a statin holiday for my MIL, until her next appt. on Jan. 3rd.

          I’ll have to check if that’s long enough to see the improvement reported in the patients who have statin-induced memory loss, as reported here, for example:
          http://www.ncbi.nlm.nih.gov/pubmed/19558254
          I suppose someone will point out that Golomb has made a career out of looking at statin side-effects. Yes; and I think it’s a career well spent. Such a widely used class of drug should be watched very closely. The muscle side-effects have been downplayed, too, even though they are widely accepted to exist; but the marketers say they’re rare. Other studies (refs on request) say they happen to 20 – 25% of people taking statins.

          In general, I think educated people who take mainstream recommendations at face value, are succumbing to learned helplessness. Where is the vaunted skepticism and critical thinking? There is a lot that a person can do, to improve the odds of detecting pharma or other mistakes and scams that are currently popular in maintream medicine. I have a big advantage, being a scientist, but educated people with a normal ability to use logic and skepticism, can do it too.

          A GP doctor, and even specialists, aren’t really motivated to figure these things out, since s/he is much safer legally, just following the current “standard of care.” But the patient or patient’s family has the biggest imaginable incentive to detect, and avoid, these errors. Even if no scams are involved, the details relevant to one particular patient may suggest not using one-size-fits-all recommendations.

          For example, in my MIL’s family, there is a history of extraordinary sensitivity to drugs. My family seems to be relatively impervious to side-effects – I’ve never taken a drug and had a bad effect from it. But my MIL has three first-degree relatives that I know of, who avoid even caffeine, alcohol, and OTC drugs,, because they feel their effects so strongly and unpleasantly. It seems like a no-brainer to me, to see how she does off statins, considering that she has no risk factors except moderately high cholesterol, and she’s a very small woman of 88.

          Anyone who think it’s crazy or arrogant to research the drugs you or your family is taking, and weigh the pros and cons, is a sitting duck for big pharma’s marketing campaigns.

          1. weing says:

            “Anyone who think it’s crazy or arrogant to research the drugs you or your family is taking, and weigh the pros and cons, is a sitting duck for big pharma’s marketing campaigns.”

            If you are referring to statins, most of them are now generic. I’m fine with researching the pros and cons however, even if there is no big pharma marketing to avoid. .

            1. Self Skeptic says:

              No, it’s the Namenda I’m worried about, from the pharma angle. That’s why I included the info about Forest Lab’s marketing reputation in a previous post. See the financial info, below, about Namenda.

              Statins were blockbuster earners in their day, and we can be sure that all the marketing tricks were employed, to help make that happen. I haven’t been researching the statins long enough to have strong opinions on their value. Everyone seems to agree that they are good for men who have definite evidence of CVD including history of MI, and if that’s really true, I think it’s reasonable to extend that recommendation to women, in the absence of firm evidence to the contrary. Primary prevention seems foggier. It seems clear that the side effects have been seriously under-appreciated; they seem to affect at least 15 – 20% of people taking them. Muscle pain is bad, especially for people who being told to exercise more. But doctors often scoff when patients report their possible statin side effects, I’m picking up from patients. The original RTCs claimed that side effects were negligible, except for very rare rhabdomyolysis.

              The idea that statins are harmless and good for you, is now so engrained in our culture, from all the marketing we’ve been exposed to, that I’m going to have to dig carefully to get at some approximation of the truth about them. That will take a while. I do need to find out, because my LDL is creeping up. I have no other risk factors, though; I’m more worried about diabetes, which runs in my family, despite normal BMIs.

              Regarding Namenda and Forest Labs:

              http://finance.yahoo.com/news/forest-labs-fiscal-2q-profit-130712507.html
              “Forest Labs fiscal 2Q profit up, helped by Namenda, newer products; raises forecast for year

              Oct 22, 2013 9:07 AM

              “NEW YORK (AP) — Forest Laboratories Inc.’s fiscal second-quarter earnings more than tripled from last year, when the drug developer’s revenue sank after a key product lost patent protection.

              “The New York company’s stock rose Tuesday before markets opened as its results trumped Wall Street expectations and it raised its profit forecast for the year.

              “Forest said sales of its Alzheimer’s treatment Namenda and of newer products helped lift revenue 12 percent in this year’s quarter.

              snip

              “Revenue from Forest’s antidepressant Lexapro plunged 93 percent in last year’s quarter, as cheaper generic versions of the drug reached the market. Lexapro had been Forest’s top-selling drug for years. This year, revenue from Namenda rose 11 percent to $407.8 million, thanks in part to a once-a-day version the company started selling earlier this year.”

              1. weing says:

                “The idea that statins are harmless and good for you, is now so engrained in our culture, from all the marketing we’ve been exposed to, that I’m going to have to dig carefully to get at some approximation of the truth about them.”

                Is that really true? I tell my patients that there is no such thing as a harmless drug. http://www.jaccjournaloftheacc.com/article/S0735-1097(13)01403-4/

                Just because Namenda is making a profit doesn’t necessarily make it a bad drug. I find all those meds for dementia frustratingly inadequate. How do I monitor slowing of the rate of decline? That’s sort of like slowing the dying process. Sometimes the inner surgeon in me wants to get out.

            2. agitato says:

              Question: When a drug, for example Lipitor, loses its patent protection and can be made generically, why doesn’t the original pharmaceutical company, in this case Pfizer, lower the price to whatever the generic is.?

              1. Harriet Hall says:

                Why doesn’t Pfizer lower the price of Lipitor to the same as generic? Because patients are willing to pay more for the brand name; some people think it is superior even though the generic meets the same standards.

              2. Max says:

                “the generic meets the same standards.”

                Unless it’s made by a dishonest Indian company.
                http://www.cbsnews.com/news/leading-generic-drug-maker-faked-test-results-for-fda-approval/

                “Many of those drugs are made in India, and it turns out a leading manufacturer, Ranbaxy, often skipped the required steps for approval of its generic drugs…
                [Whistleblower Dinesh Thakur] points to an incident where his young son was prescribed a Ranbaxy antibiotic for a fever. ‘He kept getting worse, so we got another company’s formulation and the fever went away,’ he says.”

          2. windriven says:

            “The muscle side-effects have been downplayed, too, even though they are widely accepted to exist; but the marketers say they’re rare. Other studies (refs on request) say they happen to 20 – 25% of people taking statins.”

            OK, I’d like to see some references. Statins are widely prescribed and it would seem to me near impossible to cover up a fifth or a quarter of the prescribed population having significant myopathies.

            As to the tentacles of Big.Pharma, Dr. Crislip just reported in the latest Puscast, dismal results for the use of statins as adjunctive therapy in the treatment of certain infections. Positive results would have been a boon to statin makers. This is not to say that pharmaceutical companies don’t have a long and disgusting history of misusing science as a marketing instrument; clearly they do.

            “For example, in my MIL’s family, there is a history of extraordinary sensitivity to drugs. ”

            I take a generous reading of this sentence and presume that you do not mean all drugs, only stimulants and alcohol. Suggesting sensitivity to essentially all drugs sounds suspiciously like some sort of pharmaceutical Morgellon’s.

            Finally, in http://www.ncbi.nlm.nih.gov/pubmed/12885101, Wagstaff reports 60 claims of memory loss in a 5 year sweep (1997 -2002) of MedWatch data. Given the number of statin users during that period, 60 strikes me as a number that might well be noise rather than signal.

            ” I wouldn’t discuss LD with Dr. Crislip, who doesn’t practice in a region where it is hyperendemic. ”

            My PCP is a female internist. Are you suggesting that I not discuss, say, a UTI with her because she doesn’t have a penis and I do? Crislip certainly doesn’t need any defense I can offer. I’ll just note that ignoring the opportunity to discuss LD with a board certified ID specialist of his experience is … well, I think I’ll let your comment speak for itself.

            Your relative is 88 and exhibits what I believe you characterized as ‘mild Alzheimer’s.’ you do not wish to treat her with memantine, a drug used to treat Alzheimer’s, and you do wish to take her off statins. I think I’ll let that stand on its own as well.

            I don’t know if statins actually cause memory loss in a small subset of users. Maybe so. I can’t immediately think of any drug that doesn’t have some reported ADRs. What strikes me is your apparent inability to balance small numbers of ADRs against clinical benefits for large numbers of patients.

            1. Self Skeptic says:

              @Windriven,
              What is your training and experience? Maybe I could understand better, your disbelief that I (or that anyone?) can collect and evaluate this evidence, if I knew whether you have relevant experience in medical or biological research design and execution.

              I know people who can use PubMed and other sources wisely, who don’t have formal training in it, and conversely, I see a lot of doctors who don’t even try – so I don’t want to imply that it’s my credentials that entitle me to question medical dogma.

              But I would like to understand why you’re willing to give up, without even exploring the resources that are now available to us all, thanks to Harold Varmus and other pioneers of open access to taxpayer-funded research.

              1. windriven says:

                “What is your training and experience?”

                I am a physicist and own a couple of small medical manufacturing companies. And I don’t doubt that you or any other intelligent and educated person can collect and evaluate evidence. I think everyone should be very skeptical and should challenge their physicians.

                But I also put a good deal of value on the education and experience of experts including physicians. I can research, say, meningitis. But I am never going to have the context that an ID specialist is going to have. That doesn’t imply blindly following whatever a given physician has to say. But if you don’t have confidence in your physician it means that you need a new physician, not that you know more about meningitis than physicians know.

                I’m not smart enough to know everything I need to know about anything. So I work hard to surround myself with the best surrogates I can find. I challenge them and question them. I understand that there can be significant differences of interpretation among well-informed experts. Ultimately, if I don’t think my surrogate is up to snuff I change surrogates. But I very rarely ignore the counsel of the ones I keep.

                Maybe you’re just a whole lot smarter than me.

              2. agitato says:

                Looking forward to your Tuesday post on statins Dr. Hall.

            2. Self Skeptic says:

              @Windriven asked for references supporting my contention that it’s reasonable to suspect a statin prescription, as perhaps being unnecessary, or even harmful. Here is a sketch, in two parts, of what underlies my concerns about statins for primary prevention, in people with low to moderate risk factors, like my 88-year-old MIL, with no clinical or other evidence of CVD (she had carotid artery imaging a few years ago, and it was clean.) The main problem on which I’m focusing here, is that statin side effects that lower people’s quality of life, seem likely to have been, and to be, under-reported. This skews the harm/benefit ratio.

              This happens quite often, due to self-fulfilling prophecies caused by Bayesian reasoning. If doctors are told something is unlikely, like side effects due to statins, then when the patient tells them they think they’re having such a side effect, many (most?) doctor dismiss it, because they’ve been taught that statins are well-tolerated (see comment #19 by RobbLL above, for an anecdotal example). This dismissal based on perceived likelihood is sometimes expressed in a more science-y way, as saying that the “prior probability [of significant statin side-effects] is low”. This kind of self-fulfilling prophesy can go on for decades, in medicine (and for millennia other fields of human endeavor), believe it or not. (Examples on request – or better, research it yourself. Spoon-fed information isn’t as convincing, or memorable, as self-acquired information. Although that may only be true for non-authoritarian personalities, now that I think about it.)

              Another way of putting it, is that since doctors are taught “when you hear hoofbeats, think horses, not zebras” that a herd of zebras can go by, and the doctor won’t even look out the window, to see if there are stripes. And if anyone tells him they saw the stripes, it’s discounted as an “anecdotal” report, probably caused by misinformation on the internet. ;)

              The other side of the coin is that the public has been trained to believe that without statins, their risk of a heart attack is high. In other words, not only have the side-effects been minimized, but the benefits have been over-hyped. At some point we’ll have to dive into the details of that mess, but right now, let’s mostly focus on the side-effects part, of the harm/benefit ratio.

              I’m provisionally accepting on authority that statins are useful for secondary prevention, and that more than half of the people who take them don’t notice any side effect. Dividing medications into “good drugs” and “bad drugs” doesn’t make sense to me; it’s all in the details of use.

              Other intelligent, educated, mainstream people share my skepticism that statins have been overhyped; you can see that in the articles, and especially comments, recently published in the New York Times and Wall Street Journal about the new guidelines and “risk calculator” being promoted by the American Heart Association and the American College of Cardiology:
              http://www.nytimes.com/2013/11/18/health/risk-calculator-for-cholesterol-appears-flawed.html?pagewanted=1&_r=1&

              http://online.wsj.com/news/articles/SB10001424052702303789604579195631485531014
              This WSJ article doesn’t approach the controversy, but the comments do.

              Here’s some COI information about the guideline panel from Forbes, which isn’t exactly a med-skeptic site:
              http://www.forbes.com/sites/edsilverman/2013/11/20/the-new-cholesterol-guidelines-and-conflicts-of-interest/

              Here’s some more information, with attitude, about reasons to mistrust the strongly-stated version of the “cholesterol hypothesis” which underlies high use of statins, from David Newman, whose book Hypocrite’s Shadow I enjoyed.
              http://www.huffingtonpost.com/david-h-newman-md/statins_b_4277001.html

              By the way, for those who think that marketing of statins has doesn’t count any more in considering biases of guidelines, because they’ve gone generic: generic drugs are still profitable; they just aren’t as absurdly profitable as on-patent drugs. And, the biases instilled into medicine during marketing campaigns don’t change, just because the big push is wound down after the big profits are in the bag.

              To reinforce the knowledge that marketing campaigns are waged by publication blitzes of PubMed listed research and review articles, in respectable journals, not just in ads, please re-read this article:

              http://www.cbsnews.com/8301-505123_162-42842789/forests-lexapro-ghostwriting-budget-was-100k-emory-on-the-payroll/?tag=bnetdomain

              “Forest Labs budgeted $100,000 for ghostwriting articles about its antidepressant Lexapro. The news came in a copy of Forest’s 2004 Lexapro marketing plan, unveiled by the Senate’s Special Committee on Aging. The document (which you can download here) says Forest budgeted $100,000, including “honoraria” for authors, for articles that would appear in medical journals, consumer publications, and on the internet (click to enlarge image). ”

              See my following post for the journal articles.

              1. Self Skeptic says:

                Oops, I misspelled Dr. Newman’s book title. It’s “Hippocrates’ Shadow.”
                http://www.goodreads.com/book/show/3153853-hippocrates-shadow

                As penance, I will now re-read the Oath of Hippocrates, who is said to have been a highly observant physician, and caring.

              2. weing says:

                “The main problem on which I’m focusing here, is that statin side effects that lower people’s quality of life, seem likely to have been, and to be, under-reported. This skews the harm/benefit ratio.”

                Seem likely? Really?

                Regarding your zebras comment. If a patient is experiencing symptoms on a drug, it’s most likely due to the drug and not some zebra.

                “The other side of the coin is that the public has been trained to believe that without statins, their risk of a heart attack is high.”

                Your evidence for this claim? The public thinks their risk of MI is over 20%? That has not been my experience, but that is anecdotal. I’m willing to accept it if you have the evidence.

                “Other intelligent, educated, mainstream people share my skepticism that statins have been overhyped;”

                You don’t really mean that, do you? You meant to say that you are sure they have been overhyped and you are skeptical of statins. At least, that’s what I infer from the rest of your comment. BTW, I read those comments. There were a lot of stupid ones that share your skepticism, too.

              3. Self Skeptic says:

                @Weing,
                My follow-up comment with the evidence hasn’t posted yet; it’s either in moderation (though I didn’t get a notice of that) or it never reached the site. I’ll post it again, and deal with potential double posting problems later, since you are so eager for it.

                BTW, I’ve been following up on the article you posted from Duke, in the JACC, about simvastatin decreasing fitness and mitochondia gains, in a small sample of sedentary overweight patients starting an exercise program. Very interesting! I don’t have enough background re: mitochondria to have an feeling for how this fits into the existing literature; I was just reading about it when I checked SBM and found this latest comment of yours. Thanks for the ref.

              4. Self Skeptic says:

                @Weing,
                PS: I just tried to post my evidence again, but again there’s no sign of it. Maybe it’s because it’s too long; I’ll wait a while to see if it shows up, and if it doesn’t, I’ll break it up into two shorter parts and see if that works.

              5. weing says:

                If there are a lot of links, it takes longer to show up. So I’ve been told.

              6. Self Skeptic says:

                It’s still not here. I’ve already posted it twice, and I don’t want to make extra work for the moderator, so I guess I should wait longer. Usually posts aren’t completely lost, just delayed. And this one does have a lot of links.

                Meanwhile, I’ll just answer your questions that aren’t in that post. I think I’ll answer them one at a time, to avoid the problem with long reference-rich posts getting delayed. Although each of those questions will require a rather long post, itself. That’s okay, I think research is fun. :)

                I need to experiment with how to add emphasis, so people can just skim a long post and get the points, so let me try the “strong” tag: Test of strong.

                Next up: “rare” side effects as zebras.

              7. Self Skeptic says:

                Side effects and zebras:

                Weing said: Regarding your zebras comment. If a patient is experiencing symptoms on a drug, it’s most likely due to the drug and not some zebra.

                SS response: I’ll explain further: the “zebra” here is a drug side-effect that is said to be uncommon. Anything that has been labeled “rare”, functions as a mental zebra.

                When my evidence post(s) appear, you can see that the estimate for total side effects from statins range from 1% to 25% or higher, depending on who did the study and how the study is done. If you believe the low estimate (which can be expected to be promoted by the drug companies), then even muscle pain due to statins can become a zebra. As it is also subjective (can’t be seen or measured), non-specific (common to many conditions), vague (as in “aches and pains”, and common in otherwise healthy people (gardeners, athletes, etc.), you can imagine how it could be brushed aside, as useless for diagnosis.

                Memory loss due to statins, even more than muscle pain, is seen by almost everyone as rare. That makes it a zebra, I personally don’t know how common it really is, and probably never will. It’s never going to be a hard number, because until it gets to the Alzheimer’s diagnosis stage, it gets mixed in with mild memory loss as a normal effect of aging, as in “senior moments.” If, as the new cholesterol guidelines suggest, everyone over a certain age (62? see previously posted stories on the new risk calculator) gets prescribed statins, then the increased risks caused by statins will be undetectable, because it will be the new normal, indistinguishable from normal effects of aging. But the patients will suffer from these side effects, even if they become statistically “normal.”

              8. windriven says:

                “The main problem on which I’m focusing here, is that statin side effects that lower people’s quality of life, seem likely to have been, and to be, under-reported.”

                Citation? Why do these ADRs seem so likely to you to have been under-reported? I am at an age where a great many of my friends and neighbors take statins. Yet I know of only a single acquaintance who had an ADR and that was after taking Baycol. Now this of course is entirely subjective. But you claim ADR rates ranging up to 25%. Where does this come from? I have never seen reported rates greater than 2%.

                Claims of memory loss related to statins have been studied – do a Pubmed search on ‘statin memory loss’ – and found to be trivial.

              9. Harriet Hall says:

                There are plenty of reports of cognitive problems on statins, but they are largely anecdotal and reported by untrustworthy sources. The anecdotal evidence has done just what it is supposed to do, triggered controlled studies to see if the symptoms are more common on statins than off, and those studies have been done.

                Not only did the most recent systematic analysis “not suggest an adverse effect of statins on cognition” http://www.ncbi.nlm.nih.gov/pubmed/24247674

                but a recent meta-analysis showed that statins REDUCED the risk of Alzheimer’s and dementia http://www.ncbi.nlm.nih.gov/pubmed/23225700

                My Tuesday post will be about the new cholesterol guidelines. And they definitely do NOT mean “everyone over 62″ will be on statins. Let’s put this discussion on hold until then. Stay tuned.

              10. weing says:

                “Memory loss due to statins, even more than muscle pain, is seen by almost everyone as rare. That makes it a zebra”

                The principle is if the patient is on a drug and experiencing something like memory loss or whatever, the first procedure is to make sure it is not the drug that is causing the symptom. At least, that’s what I was taught. Regarding memory problems and statins. The research that I am aware of shows perceived memory problems in patients on statin but objective testing is not finding a difference. Brain scans do show differences between statin users and non-statin users. I don’t think this study is completed however, so take this with a grain of salt.

              11. Self Skeptic says:

                @Windriven,
                Didn’t you see, I’ve tried (twice) to post the evidence, since yesterday morning. It was supposed to follow my post #2 above that begins “@Windriven asked for references…”

                This post #2, which did get posted, may help you understand why I think you can’t just go PubMed and expect to get an unmanipulated assortment of papers, that roughly represents what is known. That is certainly the way to start, and will give you a feel for the rationale behind any “current standard of care.” Drug company stacking is a problem, however; the leaked Forest labs ghostwriting/marketing plan, is typical. Again, see Kassirer, Angell, Goldacre.

                Then there is the problem of medical hierarchy, or lack of independent thinking, which exists for utilitarian as well as cultural/historical reasons. This makes most clinical papers function rather as human microphones for the dominant expert’s views, which makes a simple PubMed search an incomplete and perhaps misleading exercise.

                In some fields, I presume, the dominant experts are both honest to the core, and competent scientists, and good policy makers. (Though that’s an extremely big order, isnt it?) But currently, I rather doubt that these new statin guidelines can pass scientific muster.

                Dr. Hall and I will probably have diametrically opposed views of how to deal with bias in the literature. Correct me if I’m wrong, Dr. Hall, but might one say that you don’t think that “expert consensus” has been as extensively co-opted by the drug companies and others special interests, as I do? And maybe you think that peer review is functioning well enough, to ensure that bad science from prestigious experts will be kept out of the reputable journals?

                So we’ll disagree, and people at SBM have self-selected to favor Dr. Hall’s view.

                Nevertheless, I’ll continue to present the KAG view, because there might be some nascent medical skeptics reading this site. Look what happened to Ben Goldacre.

                Right now, the problem is that my post containing the evidence I promised, and that Windriven and Weing are requesting, won’t go through. Possible explanations are (1) too long or (2) too many links.

                I’ve now broken it down into 4 smaller posts, and will try to send them this afternoon. The previously sent ones can be deleted later, if they ever show up.

              12. Harriet Hall says:

                “Dr. Hall and I will probably have diametrically opposed views of how to deal with bias in the literature.”

                I’m well aware of the many sources of bias, but the scientific process is collaborative and self-correcting. In most cases, the chances that you can do any better by ignoring the current consensus and replacing it with your own opinions based on less evidence are small.

              13. Self Skeptic says:

                Part 2: Statins, a brief and incomplete summary of caveats

                The divergence between side effects noted in clinical practice, versus those reported in the foundational RTCs (which, again, can be assumed to be distorted by marketing goals, according to Kassirer, Angell, and Goldacre) crops up over and over, when reading the literature. For example, it is described here in passing, though that is not the focus of the paper (the diagnosis they settled on, was active giant-cell (temporal) arteritis.

                http://www.ncbi.nlm.nih.gov/pubmed/16467550
                N Engl J Med. 2006 Feb 9;354(6):623-30.
                Case records of the Massachusetts General Hospital. Case 4-2006. A 79-year-old woman with myalgias, fatigue, and shortness of breath.
                Kay J, Finn DS, Stone JR.
                Source
                Department of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, USA.
                PMID: 16467550 [PubMed - indexed for MEDLINE]

                “The incidence of statin-associated myalgias ranges from 1 to 5 percent in the randomized, controlled trials in which the symptom is reported.2 This level did not differ markedly from that of placebo in most trials. This small percentage, however, is in vast contrast to the clinical experience; 25 percent or more of patients in surveillance databases report myalgias, with the average between 5 to 10 percent.2 The cause of this large discrepancy between the clinical-trial experience and the outpatient-practice experience is unclear…”

                See also this paper, which makes a case for personalizing statin therapy:

                http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678834/
                Viewpoint: personalizing statin therapy.
                Keidar S, Gamliel-Lazarovich A.
                Rambam Maimonides Med J. 2013 Apr 30;4(2):e0008. doi: 10.5041/RMMJ.10108. Print 2013 Apr.
                PMID: 23908858 [PubMed] Free PMC Article
                “Side-effects of statin therapy vary, and a significantly increased rate of new-onset diabetes9 is among the observed adverse events. But the main complaint affecting 10%–20% of patients is muscle pain, which has a significant influence on quality of life and often results in reduced therapy compliance.10 Therefore, exposure of healthy subjects to lifelong statin therapy needs clear and solid evidence for benefits which outweigh the adverse events.”
                snip
                “In Israel, many thousands of subjects with very low FRS (less than 6%), mostly women, are treated with statins (personal knowledge). In a recently published study,16 half of low-risk patients who underwent CCTA showed no vascular pathology. Thus, a large proportion of subjects from this category will be treated with statins, and, of these subjects, at least 10%–15% suffer from myopathy but are still encouraged by their physicians to continue the medication. ”
                snip
                “As P.K. Shah has previously well formulated17: “If the goal of using a statin is to reduce atherothrombotic cardiovascular events, then it is unrealistic to expect those patients without significant atherosclerosis to benefit from statin therapy even if they have hyperlipidemia. In such subjects, one can only expect side effects.””
                [emphasis added]

                Here is a BMJ article, and a short, cogent response:
                10-Minute Consultation
                Myalgia while taking statins
                BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5348 (Published 14 August 2012)”
                which includes the following:

                “A 56 year old man with type 2 diabetes complains of uncomfortable muscular aches in the arms. He started taking simvastatin 40 mg daily some months ago and has no other medical history of note.

                “What you should cover
                Explain that myalgia with statins is common, affecting 5-10% of patients in clinical trials of statins.
                Assess how severe the symptoms are. Do they affect his quality of life? Some patients may develop mild myalgia with statins but are willing to continue treatment because of the substantial cardiovascular benefits they attain (in diabetic patients, numbers needed to treat to prevent one cardiovascular event is 33). ”

                One of the comments on this paper went like this:

                http://www.bmj.com/content/345/bmj.e5348?tab=responses
                “Re: Myalgia while taking statins
                21 October 2012
                The authors described many drug related alternatives for this patient intolerant of Simvastatin but one obvious option was omitted. According to their own data on numbers needed to treat, even this high risk patient has only a one in 33 chance of benefitting from the prescribed simvastatin. If these figures were presented to the patient he may well opt for no treatment at all given the statistical likelihood that he would not actually benefit from cholesterol lowering therapy. Often, no treatment remains the best treatment.”

                (Please proceed to Part 3: Statins, a brief and incomplete summary of caveats.)

              14. windriven says:

                @weing

                There have also been a number of anecdotal reports of statins improving memory and, as Dr. Hall mentions in another comment, at least one meta-analysis suggesting statins reduced risk of Alzheimers and dementia.

                The better/poorer inconclusive argument suggests to me a lot of sifting through noise in search of a signal that may well not exist.

                @Selfie

                I think I understand your arguments, I just don’t find them convincing. I look forward to seeing your larger response broken into smaller chunks. Perhaps I will have an ‘aha’ moment.

                But I’m also reminded of Feynman’s caution that if one can’t explain something in a few sentences they don’t understand it themselves. I wonder if your palpable dislike of pharmaceutical companies and their tactics doesn’t color your thinking on this?

              15. Self Skeptic says:

                @Windy,
                Yes, I expect that we’ll disagree. You already said you are comfortable choosing surrogates, and following their advice. In other words, you have a bias toward believing your chosen authority figures.
                I have a bias toward being skeptical of authority. I may provisionally believe them, if I have to make a very quick decision. Sometimes what they say is true, and sometimes it isn’t, though they think so. If I have an acute medical problem, I’ll have to take it on faith, and hope I get lucky at the hospital. But if we’re talking about a long-term condition or illness, I’d rather research it myself.

                In other words, our biases are opposed; yours toward authority, and mine toward skepticism. So we won’t reach the same conclusions. The SBM bloggers share your bias; I’m here to point out that skepticism is possible, and perhaps desirable, in medical matters.

                I never thought I’d convince you, or any of the SBM bloggers. But there may be less opinionated people, attracted by the title “Science-based Medicine,” who find the idea that we can check these things for ourselves, appealing. Isn’t that what science is all about?

                I’m interested in all kinds of mistakes in medicine. I’m not even sure that drug company influence is the biggest one. It’s just the one that is most easily provable. My feeling is that if these big-footprint companies are routinely allowed to distort the medical literature, and none of the participating academics are ever held accountable or even embarrassed, then the peer-review and career-advancement systems are broken. That means we have to include other sources of information than the academic experts, to figure out the best approximate truth.

                The idea that evidence outside of formal science “counts,” may be anathema here. And I suppose there are a lot of educated people, maybe the majority, who really shouldn’t trust in their own ability to assess evidence. So I’ll just offer examples of how it can be done, and then people who are interested will have to try it, and see if it serves them well.

                I guess if I were you, I’d want to make sure that my chosen medical authority figures, are adequately skeptical, in response to the marketing that goes on under the guise of science, in medicine.

              16. windriven says:

                @Selfie

                “In other words, our biases are opposed; yours toward authority, and mine toward skepticism.”

                You don’t know me of course, nor I you. But this actually made me laugh out loud. I have always had an almost pathological problem with authority and authority figures (Cartman voice: respect my authoritiiiiiiiiiiiii).

                We do not disagree on the importance of skepticism, nor about each of us having primary responsibility for our lives including our health care. Where you and I diverge is that you believe that you can sort through sometimes arcane, often contradictory research in areas that are not your own specialty and come up with a better read than those who have devoted a fair bit of their lives to it.

                I have a profound respect for what I don’t understand. I have a profound respect for others who dedicate their lives to being very good at something. That does not mean that I think they are infallible. It does not mean that I accept anything at face value. Everyone has blind spots, biases, hunches and so forth. But serious people know where their blind spots and biases are. And this goes back to choosing your surrogates carefully.

                When you research statins or anything else, you are sorting through the work of surrogates – unless you have conducted your own large RCT on the subject. You are picking through other people’s work in an area that is not your specialty. But you have no way to interrogate them. You do not know their reputation among their peers. And you do not have the depth of knowledge to know what you don’t know as you read their papers.

                A good surrogate has spent their life working the jigsaw puzzle that is their specialty. Their puzzle is not complete and will probably never be nearly complete. But they have many more pieces of the puzzle than I and they have assembled them into large swatches of the puzzle while I have just a handful of pieces that I’ve fit together.

                To quote Harry Callahan, “A man’s got to know his limitations.” I know most of mine, though I discover more each day. And I work hard to understand the limitations of my surrogates.

                As a last stab, imagine that your life depended on your traveling to a specific peak in the Santa Rita mountains of Patagonia. You have 4 days. You start off knowing little more than where Patagonia is. You can (A) google your target peak, transportation methods to get there, supplies necessary to make the trip and the ascent, fundamentals of mountain climbing, etc., (B) learn about guides and outfitters who specialize in ascents in the Andes and choose one help you.

                Me? I’m a (B) guy. I’ll keep learning all along the way. I’ll keep asking questions and challenging why this route is the best route. I might even change guides. But I’m not going to go it alone unless I have no other options.

              17. Self Skeptic says:

                Part 3: Statins, a brief and incomplete summary of caveats

                Then there’s this, also in the BMJ, very recently:
                http://www.bmj.com/content/347/bmj.f6123
                “ANALYSIS
                Should people at low risk of cardiovascular disease take a statin?

                “BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6123 (Published 22 October 2013)
                Paywall

                “John D Abramson, lecturer 1, Harriet G Rosenberg, professor emeritus2, Nicholas Jewell, professor3, James M Wright, co-managing director and chair4
                Author Affiliations
                1Department of Health Care Policy, Harvard Medical School, 39 Spring Street, Ipswich, MA 01938, USA
                2 Department of Social Science, York University, Toronto, Ontario, Canada
                3Division of Biostatistics, School of Public Health Department of Statistics, University of California, Berkeley, CA, USA
                4Therapeutics Initiative, Departments of Anesthesiology, Pharmacology and Therapeutics and Medicine, University of British Columbia, Vancouver, BC, Canada
                Correspondence to: J D Abramson john_abramson@hms.harvard.edu

                A review of statins for primary prevention of cardiovascular disease could alter guidance for those with a 10 year risk of less than 10%. John Abramson and colleagues argue that statins have no overall health benefit in this population and that prescribing guidelines should not be broadened
                [italics in original]

                “The 2013 Cochrane review of primary prevention with statins concluded that they reduce all cause mortality and cardiovascular events without increasing the risk of adverse events among people at low risk of cardiovascular disease (<10% over 10 years).1 However, just two years earlier, a Cochrane review had concluded that existing evidence did not support the use of cholesterol lowering statins for people with <20% 10 year cardiovascular risk: “Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life. Caution should be taken in prescribing statins for primary prevention among people at low cardiovascular risk.”2 This conclusion was consistent with the 2006-08 guidance from the National Institute for Health and Care Excellence (NICE)3 and the 2011 update of the American Heart Association’s guidelines for the prevention of cardiovascular disease in women, both of which recommended statin therapy only when the 10 year risk of disease is 20% or greater.4 "

                And so on, and so forth. Many respectable sources share my concerns. That doesn't mean they're right, but it does mean they aren't some kind of fringe view.
                {Continued: see Part 4 of 4.}

              18. Self Skeptic says:

                Part 4: Statins, a brief and incomplete summary of caveats

                More detail about statin-associated memory loss:

                I moved this abstract about reversible memory loss due to statins down to the bottom, because I think many peoples’ eyes glaze over, when they see academi-speak. But of course, this kind of information is crucial, when researching a medical subject. Ideally, one would go over the data with a fine-toothed comb, but it’s not open access, so non-professionals are stymied by a pay-wall. Suffice it to say, the FDA put a warning about possible memory loss (and diabetes) on the drug label in 2012. You may think that such warning labels are meaningless, and I agree they could be wrong. I guess they may even benefit the company, in that if it is later shown convincingly that they have this effect, the warning label might protect them from liability. In any case, this concern has reached the point of mainstream credibility.

                {added just before posting: there are some brand-new papers claiming to demonstrate show that statins don’t cause memory loss. Needless to say, I will investigate these carefully, lest they be drug company products, or by true-believers. There are also some new ones claiming to prove value in primary prevention, but I can’t access the data to see exactly what risk factors they are suggesting as suitable, for primary prevention. I would guess that they are of a piece, with the new guidelines, and risk calculator. }

                Here’s the abstract of the article I referenced above, from the UCSD Statin Effects Study. (The home page for the Study is here:
                https://www.statineffects.com/info/
                Article abstract is here:
                http://www.ncbi.nlm.nih.gov/pubmed/19558254
                “Pharmacotherapy. 2009 Jul;29(7):800-11. doi: 10.1592/phco.29.7.800.
                Statin-associated adverse cognitive effects: survey results from 171 patients.
                Evans MA, Golomb BA.
                Source
                Department of Medicine, University of California-San Diego, La Jolla, California 92093-0995, USA.
                Abstract
                STUDY OBJECTIVE:
                To characterize the adverse cognitive effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins).
                DESIGN:
                Patient survey-based analysis.
                PATIENTS:
                One hundred seventy-one patients (age range 34-86 yrs) who self-reported memory or other cognitive problems associated with statin therapy while participating in a previous statin effects study.
                MEASUREMENTS AND MAIN RESULTS:
                Patients completed a survey assessing statin-associated, cognitive-specific adverse drug reaction (ADR) characteristics, relation of the ADR to specific statin and dose (or potency), and time course of symptom onset and recovery. Visual analog scales were used to assess the effect of the cognitive ADRs on seven quality-of-life domains. Demographic and clinical data were also collected. To target cognitive ADRs with a probable or definite causal relationship to statins, the Naranjo adverse drug reaction probability scale was used: 128 patients (75%) experienced cognitive ADRs determined to be probably or definitely related to statin therapy. Of 143 patients (84%) who reported stopping statin therapy, 128 (90%) reported improvement in cognitive problems, sometimes within days of statin discontinuation (median time to first-noted recovery 2.5 wks). Of interest, in some patients, a diagnosis of dementia or Alzheimer’s disease reportedly was reversed. Nineteen patients whose symptoms improved or resolved after they discontinued statin therapy and who underwent rechallenge with a statin exhibited cognitive problems again (multiple times in some). Within this vulnerable group, a powerful relationship was observed between potency of the statin and fraction of trials with that agent resulting in cognitive ADRs (p<0.00001). Quality of life was significantly adversely affected for each of the seven assessed domains (all p<0.00000001).
                CONCLUSION:
                Findings from the survey suggest that cognitive problems associated with statin therapy have variable onset and recovery courses, a clear relation to statin potency, and significant negative impact on quality-of-life. Administration of a patient-targeted questionnaire is a feasible approach that provides a useful complement to other ADR surveillance approaches.
                PMID: 19558254 [PubMed - indexed for MEDLINE]
                Publication Types, MeSH Terms, Substances"

              19. Harriet Hall says:

                If you hope to persuade readers on the basis of a single 2009 study when I have already provided a link to a 2013 systematic review that said the opposite, I think you will be disappointed.

              20. windriven says:

                @Self Skeptic

                “The 2013 Cochrane review of primary prevention with statins concluded that they reduce all cause mortality and cardiovascular events without increasing the risk of adverse events among people at low risk of cardiovascular disease (<10% over 10 years).1 However, just two years earlier, a Cochrane review had concluded that existing evidence did not support the use of cholesterol lowering statins for people with <20% 10 year cardiovascular risk"

                Existing evidence two years ago. That is the important part that apparently doesn't resonate with you. Statins continue to be studied. The patient-years of statin use, benefits, and ADRs grows rapidly. Science happens. Views are refined.

                ***

                Yes, I've looked at the Pharmacotherpy 2009 before. For me the problem is self reporting and all of the biases and inconsistencies that come with it:

                "Patients completed a survey assessing statin-associated, cognitive-specific adverse drug reaction (ADR) characteristics, relation of the ADR to specific statin and dose (or potency), and time course of symptom onset and recovery."

                Interesting that we can read the same literature and come to wildly different conclusions. I suspect it has much to do with the signal to noise ratio though as time goes on it seems to me that the signal is getting stronger.

          3. Dave says:

            What does your MIL think of all this? It sounds like you’ve already decided she should be off these drugs and had already cast your opinion of her doctor before even meeting him (“Now, all I have to do, is explain this tomorrow, to the young doctor, who I suspect thinks the academic experts are as good as saints, and as powerful as gods.)
            Granted the risk/benefit profile of these meds in an 88 year old is narrow. These are the exact cases where a discussion with the PATIENT and a feel for their desires is important.

            1. Dave says:

              Incidentally, I have a pretty good idea what the “young doctor” truly thinks about academic experts, based on my own personal experience and discussions with multiple physicians – some of them are wonderful role models who are concerned, caring and worthy of emulation, some are jerks who should remain locked in a lab where they wont be inflicted upon patients, and some of them are somewhere in between. You sure have a one-dimensional stereotyped idea of the profession.

            2. Self Skeptic says:

              @Dave,
              I see that my comment about the young doctor offended you. Maybe I should have avoided that bit of sarcasm. It certainly irritates me when others use sarcasm, so I shouldn’t do it myself. I apologize.

              Your assumption that I was quick to take action, without adequate research, and without being asked, seems like a more questionable criticism. I would have though that by now, you could see that I’m not exactly simple-minded. I’m sure I’m sometimes wrong; but it’s not for lack of due diligence.

              In a nutshell, I know my MIL a lot better than any doctor does.
              What she wants, is so obvious that it seems almost silly to say it; she wants to feel as well as possible, and not to be prematurely disabled. She makes jokes about how she tried to get her (late) brother, a pharmacist and then MD, to make them a pair of suicide pills, for when they got old. But that’s irrelevant here, because there’s no good evidence that the statin will prolong her life, at this point.

              As to how she feels about taking a drug that hasn’t been shown to provide benefit for people who fit her profile (primary prevention, no risk factors except age and moderately high cholesterol, clean carotid artery on imaging), I can assure you that she would refuse. She is (was) only taking the one drug. That’s quite rare, at the age of 88. I respect her doctor for his restraint.
              She had to quit playing tennis and golf at the age of 83 because of peripheral neuropathy (numbness, not pain, fortunately) and he didn’t put her on any questionable neurological drugs. Good job. She then started having muscle pulls and muscle pain – but she’s 88, for Pete’s sake. The statin occurred to me, and I mentioned it, to her, but didn’t push it. She interprets her doctor’s advice, as saying that the statin is keeping her from having a heart attack or stroke. Since we’ve all been told that heart disease is the #1 killer, it sounds reasonable. That’s too simple, of course, but I think it’s how most ordinary people understand their statin prescriptions.

              Muscle pain and numbness of feet that make walking difficult, aren’t life-threatening. But Alzheimer’s is something else again. Sure, these may very well not be statin side effects. But since the statin isn’t realistically indicated anyway, why take the risk?

              She did take a full course of prednisone for a bad case of poison ivy a few months ago. I thought that might be risky because of an infectious disease problem she may have, plus her advanced age, but I didn’t interfere. She had no acute bad effects from it, fortunately.

              And as to why I’m involved in her care, it’s because she has chosen me as the family member to help her with medical decisions. She doesn’t have a computer, she knows I like to do research, so I’m the one. This is a compliment, but it’s also a responsibility.

              Have you helped any of your parents through the end of life, yet? I served the role of medical researcher for both my parents; my brother is a social psychologist and I’m a biologist, so I was the obvious choice for technical information gathering. You might get a more nuanced picture of the important role of family in medical care of the aged, once you’ve been through it. Dr. Gorsky refined his views on palliative care at end of life, because of personal experience with his MIL.

              As to this particular doctor, he’s been treating my MIL for about 5 years now, and overall, I think he’s doing a good job. He’s a DO, but I’m not biased about that. He is conscientiously following guidelines. He sent her over to Wegman’s supermarket, to take advantage of a free offer for her atorvastatin, and I found that to be charming and thoughtful (even though I doubt the value of the statins for her, as you know.)

              I now think it is unrealistic to expect anything more than kindness, respect, and conscientious guideline execution, from a primary care doctor involved in a typical HMO or PPO set-up. There is no time in our system, to do literature research, or to personalize care for each individual patient.

              I myself have a PPO doctor for obvious things where I think guidelines are adequate, and a private consulting doctor for things where I think the guidelines are skewed enough to be harmful. (I was very lucky to find a doctor, who shares my values – I don’t want to suggest that everyone can get this kind of relationship, just by finding a doctor in solo practice and keeping insurance out of it.) We discuss the evidence and I make a decision. The insurance company will pay for prescriptions from this private MD, so it only costs me $175 for a half-hour appointment. (People spend that kind of money routinely, for more frivolous things.) This privately practicing MD has already researched the issues in the same way I do, regarding the guidelines that look questionable, so we are basically comparing our notes about pros and cons, rather than engaging in an authoritarian interaction.

              Again, I apologize for being sarcastic, and I ask that you rethink your impression that I’m relatively lacking in discernment, with regard to doctors’ and our health care system’s common strengths and weaknesses.

              1. Dave says:

                If you’re interested, the current issue of Mayo Clinic proceedings has an article reviewing statins and cognitive problems.

      2. weing says:

        “(If you know of an honest big pharma corp. that doesn’t do this, let me know. I would think they would have been driven out, in the race to the bottom, but nice surprises are always possible.) ”

        I can think of one study that was honest. That would be PROVE-IT. It was funded by BMS and showed their competitor drug to be superior. They had clearly expected otherwise. I am still hoping that comparative effectiveness studies will help us get to the bottom of which drugs help and how much. In the meantime, I can only hope we are better off than when Osler said to use the new drugs before they stop working.

      3. mousethatroared says:

        Self Skeptic ” I wouldn’t discuss LD with Dr. Crislip, who doesn’t practice in a region where it is hyperendemic.”

        And obviously, people living Washington never vacation in or move from lyme endemic areas like Minnesota, Wisconsin, Western Michigan or New England?

        Personally, I really hope that an infectious disease expert in any part of the country can identify and treat lyme disease.

        1. vadaisy says:

          What is your training and experience? …if I knew whether you have relevant experience in medical or biological research design and execution.

          I wouldn’t discuss LD with Dr. Crislip, who doesn’t practice in a region where it is hyperendemic.

          Obviously, a medical degree specializing in the treatment of infectious diseases and over two decades of practice in critical hospital care settings does not qualify as “relevant experience” for SelfSkeptic. Only “Lyme-literate medical doctors” are qualified enough for SelfSkeptic. Yawn.

          Keep up the good fight.

  23. Timothy Norfolk says:

    Mark – you comment on interference by non-specialists in medicine. Try my field of education, especially in math and science. Every politician, parent and business person ‘knows’ how to do it better and cheaper.

  24. Dr. Crislip.
    My thanks for this thoughtful reaction to the tiresome cynicism that passes for insight into healthcare these days.
    I think this should be required reading for pre-meds.

    Thanks,
    - Taurus Londono (MD/PhD hopeful)

  25. TBruce says:

    This article also irritated me greatly. I found it to be inflammatory, hyperbolic and and sloppy. I don’t have the article at hand, so I can’t post my specific criticisms (maybe later). I was, however, interested in the background of Mr. Krauss. He is a personal injury lawyer, so his medical knowledge might be a bit skewed. If my research is correct, he also became infamous last year for writing an utterly tactless e-mail to a local TV news anchor, criticizing her for being overweight and setting a bad example for the girls in the audience. When she made the e-mail public and commented on how hurtful it was, he doubled down, patronizingly offering her guidance and support to help her lose weight.
    Mr. Krauss appears to be an obnoxious loudmouth. I am disappointed that SI has published such an unhelpful article.

  26. Self Skeptic says:

    Harriet Hall said,
    “I’m well aware of the many sources of bias, but the scientific process is collaborative and self-correcting. In most cases, the chances that you can do any better by ignoring the current consensus and replacing it with your own opinions based on less evidence are small.”

    I find these sentences contradictory. Implementing the collaborative and self-correcting features of science doesn’t happen by an act of god; it requires that each person assess the primary evidence and the offered consensus opinion, for him- or herself, and point out the weaknesses and faults that need to be corrected. Sources of bias on the guidelines panel, and known contamination of the primary medical literature due to drug marketing plans, complicates this analysis in current medical science. But a realistic assessment requires taking these factors into account.

    It’s part of the culture of science, that if one hasn’t invested the effort to do this independently, one should be modest in expressing opinions, so as to avoid amplifying possibly incorrect conclusions, by mere repetition.

    It sounds like you’re saying you won’t even try to critique any consensus statement, because you’ve given up on the possibility of assessing evidence for yourself. In that case, I don’t see what there is to write about. Maybe to criticize, for insubordination, the doctors and scientists who are looking at the evidence in detail, and making reasonable critiques of the offered consensus? I hope not; that would be shooting down the essential collaborative and self-correcting function, in action.

    1. Harriet Hall says:

      The collaborative and self-correcting thing only works then the collaborators and correctors are scientists with an expert knowledge of their field and good judgment built on long experience. They know about biases introduced by drug companies and take them into account. I don’t think I’m smarter than they are. Why do you?

      Note: we do criticize panels when there is good reason to. Paul Offit explained in his book that a single individual succeeded in railroading the committee decision to remove thimerosal from US vaccines. The committee agreed that there was no evidence that thimerosal was harmful and no reason to remove it, but he thought it should be removed on the precautionary principle, “just in case.” He threatened to hold his own press conference and publicly attack their decision if it differed from his own. They reluctantly did what he wanted because they didn’t think that removing it would lead to any harm (but in fact it did: at least one baby died because the hospital decided not to vaccinate him until a thimerosal-free version was available.) That kind of thing usually comes out, and is an exception to the rule.

    2. windriven says:

      “I find these sentences contradictory. Implementing the collaborative and self-correcting features of science doesn’t happen by an act of god; it requires that each person assess the primary evidence and the offered consensus opinion, for him- or herself, and point out the weaknesses and faults that need to be corrected”

      No, not so much. The collaborative and self-correcting features of science work by evidence far more than by interpretation. In this case the preponderance of evidence points to the efficacy and broad (but not universal) safety of statins. Changing this won’t happen because you or I or someone else interprets the evidence differently. It will only happen if additional data is developed that disputes earlier data.

  27. Dave says:

    For those interested, such as Self Skeptic, the November issue of the Mayo Clinic Proceedings and the November 19th issue of the Annals of Internal medicine have sytematic reviews of short and longterm cognitive effects of statins. To quote from the Mayo’s abstract, “In patients without baseline cognitive dysfunction, short-term data are most compatible with no adverse effect of statins on cognition, and long-term data may support a beneficial role for statins i n the prevention of dementia.”

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