I have never used those words to a patient or about a patient. I have also never heard a colleague use any similar term to a patient. And yet on many occasions I have had patients ask me, “So you’re telling me it’s all in my head?”
The concept of what are now called psychogenic symptoms is a tricky one for various reasons. There is an unfortunate stigma attached to the notion that our brains can cause physical symptoms. Making the diagnosis is complex. Outcomes are variable and are hampered by the difficulty in communicating the diagnosis to patients. Psychogenic symptoms often mask underlying physiological disease. And the risks of both false positives and false negatives are high.
This complexity leads some to argue, in essence, that psychogenic symptoms do not exist at all – that the diagnosis is a cop out, a way to blame the patient for the failings of the physician. But this approach, ironically, is a cop out, because it seeks to white wash what is a real and complex disorder with an overly simplistic and moralistic approach.
Today the LA Times described a bizarre and troublesome healthcare reform bill provision that would require Medicare to pay for Christian Science Prayer as a medical treatment:
…a little-noticed provision in the healthcare overhaul bill would require insurers to consider covering Christian Science prayer treatments as medical expenses.
The provision was inserted by Sen. Orrin G. Hatch (R-Utah) with the support of Democratic Sens. John F. Kerry and the late Edward M. Kennedy, both of Massachusetts, home to the headquarters of the Church of Christ, Scientist.
That’s the title of a new book by Melvin H. Kirschner, M.D. When I first saw the title, I expected a polemic against conventional medicine. The first line of the Preface reassured me: “Everything we do has a risk-benefit ratio.” Dr. Kirschner took the title from his first pharmacology lecture in medical school. The professor said “I am here to teach you how to poison people.” After a pause, he added, “without killing them, of course.”
He meant that any medicine that has effects has side effects, that the poison is in the dose, and that we must weigh the benefits of any treatment against the risks. Dr. Kirschner has no beef with scientific medicine. He does have a lot of other beefs, mainly with the health insurance industry, the pharmaceutical industry, and alternative medicine. (more…)
I see that the kerfuffle over screening for cancer has erupted again to the point where it’s found its way out of the rarified air of specialty journals to general medical journals and hence into the mainstream press.
Over the last couple of weeks, articles have appeared in newspapers such as the New York Times and Chicago Tribune, radio networks like NPR, and magazines such as TIME Magazine pointing out that a “rethinking” of routine screening for breast and prostate cancer is under way. The articles bear titles such as A Rethink On Prostate and Breast Cancer Screening, Cancer Society, in Shift, Has Concerns on Screenings, Cancers Can Vanish Without Treatment, but How?, Seniors face conflicting advice on cancer tests: Benefit-risk questions lead some to call for age cutoffs, and Rethinking the benefits of breast and prostate cancer screening. These articles were inspired by an editorial published in JAMA last month by Laura Esserman, Yiwey Shieh, and Ian Thompson entitled, appropriately enough, Rethinking Screening for Breast Cancer and Prostate Cancer. The article was a review and analysis of recent studies about the benefits of screening for breast and prostate cancer in asymptomatic populations and concluded that the benefits of large scale screening programs for breast cancer and prostate cancer tend to be oversold and that they come at a higher price than is usually acknowledged.
For regular readers of SBM, none of this should come as a major surprise, as I have been writing about just such issues for quite some time. Indeed, nearly a year and a half ago, I first wrote The early detection of cancer and improved survival: More complicated than most people think. and then followed it up with Early detection of cancer, part 2: Breast cancer and MRI. In these posts, I pointed out concepts such as lead time bias, length bias, and stage migration (a.k.a. the Will Rogers effect) that confound estimates of benefit due to screening. (Indeed, before you continue reading, I strongly suggest that you go back and read at least the first of the aforementioned two posts to review the concepts of lead time bias and length bias.) Several months later, I wrote an analysis of a fascinating study, entitling my post Do over one in five breast cancers detected by mammography alone really spontaneously regress? At the time, I was somewhat skeptical that the number of breast cancers detected by mammography that spontaneously regress was as high as 20%, but of late I’m becoming less skeptical that the number may be somewhere in that range. Even so, at the time I did not doubt that there likely is a proportion of breast cancers that do spontaneously regress and that that number is likely larger than I would have guessed before the study. Of course, the problem is that we do not currently have any way of figuring out which tumors detected by mammography will fall into the minority that do ultimately regress; so we are morally obligated to treat them all. My most recent foray into this topic was in July, when I analyzed another study that concluded that one in three breast cancers detected by screening are overdiagnosed and overtreated. That last post caused me the most angst, because women commented and wrote me asking me what to do, and I had to answer what I always answer: Follow the standard of care, which is yearly mammography over age 40. This data and these concerns have not yet altered that standard of care, and I am not going to change my practice or my general recommendations to women until a new consensus develops.
I must admit, it is possible that our fearless leader Steve has a more robust constitution than I do. I say this because he actually managed to sit through an entire video full of the most bizarre pseudoscience and mangling of physics and medicine that I’ve seen in quite some time.
And that’s saying a lot.
So, behold, Dr. Charlene Werner, an optometrist (apparently) and a homeopath. I warn you, however. If you have any understanding of physics or chemistry whatsoever or if you’ve ever read (and liked) Stephen Hawking’s book A Brief History of Time (or anything else he’s ever written), sit down now. Take a deep breath. Heck, crack open a bottle of wine and down at least half of it before you watch this video. I’m serious. You’ll need it. You might need to lie down, too. In fact, you might need to lie down with a cool washcloth across your eyes.
Don’t say I didn’t warn you:
Truly, the woo doth flow. Like a river. Like the energy from a supernova. From Bozeman, Montana, where, apparently they don’t have enough woo and have to import it from Texas. I haven’t seen such a massive pseudoscientific abuse of physics and chemistry in quite a long time.
There’s been something I’ve been meaning to write about all week, but only just got around to it. There were lots of other things going on at my other online locale, and this topic is such old hat for so many that I really wasn’t sure if it was worth bothering with. My reluctance may also be, sadly, because I’ve become a bit jaded at the nastiness that anti-vaccine groups such as Generation Rescue (i.e., “Jenny McCarthy and Jim Carrey’s Autism Organization”–at least these days) and its erstwile founder J.B. Handley routinely lay down when someone points out that the emperor has no clothes, that vaccines do not cause autism. I’m referring, of course, to Amy Wallace, who wrote what is the best example of an article in the mainstream media about the anti-vaccine movement that “gets it.” The article was called An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All and appeared in WIRED Magazine.
It was a thing of beauty. There was no false “balance” that puts cranks pushing dangerous pseudoscience on the same plane as real scientists like Paul Offit. There was even a section calling out purveyors of vaccine misinformation. Several luminaries of the the anti-vaccine movement were there, including ones discussed frequently on this blog, like Jenny McCarthy and Jim Carrey, and Robert F. Kennedy, Jr. But that wasn’t all! There was even a section on how to debunk anti-vaccine canards. What more could an advocate of science-based medicine ask for?
The last two weeks have brought good news to those who seek to hold chiropractic to the standard of evidence and science-based medicine.
In the first bit of good news, on October 14th Simon Singh was granted permission to appeal the High Court ruling on meaning of the term “bogus” within his original article. I’m sure most readers of this blog are familiar with Simon Singh’s legal battle with the British Chiropractic Association (BCA) regarding an article in The Guardian entitled “Beware the Spinal Trap.” We’ve covered it several times over the last year and will continue to do so as the case progresses. The nuances of the British legal system (or any legal system for that matter) are beyond my ken, and are far better explained by Jack of Kent here. The take-home point is that gaining permission to appeal the ruling on meaning was virtually essential if Simon were to have any real chance of winning this lawsuit.
Even if the BCA should win its lawsuit for libel against Singh, it seems likely to be something of a pyrrhic victory. After all, in the year since this story began, we’ve been belatedly provided with the BCA’s best evidence in support of chiropractic’s efficacy, and promptly treated to its subsequent evisceration. (more…)
I have often mused about the difference between being right and being influential – especially in light of the relative success of the anti-vaccine movement. Despite the fact that there is no evidence for a link between vaccines and autism, celebrities like Jenny McCarthy have manufactured public mistrust in one of the safest, most cost effective means of combating disease known to humankind.
So if scientists are not persuading the public with appeals to carefully designed trials and factual data, how should they make their point? I’m not sure I have the full answer, but I think I might have struck a nerve with the public lately. I decided to try a novel approach to communicating my concerns about pseudoscience on the Internet – and presented 20 slides at 20 second intervals to a conference of ePatients in Philadelphia. I did it with powerful and humorous images, tied together with a long Limerick. Sound kooky? Maybe so… but it resonated, and was received with cheers and applause. Now that’s how we like science to be recognized! (more…)
Not long ago, I wrote a post warning about how funding for non-science-based modalities and, indeed, modalities that are purely religion-based, have found their way into various versions of health care reform bills that are currently wending their way through both houses of Congress. In other words, purveyors of faith healing and purely religious woo are trying to do what purveyors of “alternative” medicine have already done through Senator Tom Harkin, and hijack the health care reform process to codify their preferred unscientific health care modalities as legitimate after science has rejected them.
Now, the Center for Inquiry has launched a campaign to inform and educate our legislators. You can participate by using its talking points (or paraphrasing them or voicing your own objections) to protest:
Congress is considering health care legislation that would in part mandate coverage of non-evidenced based medical treatments such as prayer and therapeutic touch. This would raise the cost of health care for all Americans and represent a violation of the principle of separation of church and state.
The Center for Inquiry asks you to contact your Senators and Representative to voice your strong opposition to the proposal in the Heath Care bills that would mandate coverage of non evidence-based “alternative” medical treatments including spiritual and prayer based healing under the guise of nondiscrimination.
- America needs a health care system that focuses on increasing the health of individuals and reducing the cost of coverage.
- This type of health care system is not possible if insurers are required to pay for medical treatments with questionable at best results.
- If Congress requires that insurers cover alternative treatments such as Christian Science prayer, therapeutic touch, or other non-evidence based medical procedures, the cost of health care for all Americans will go up. This runs counter to the goal that Congress has laid out: to make health care more affordable for all Americans. – If the final version of health care reform includes a public option, this mandate would also force the public insurance plan to cover these treatments. Because the public option is federally funded, the inclusion of the mandate would represent an egregious violation of the principle of separation of church and state.
I agree. It’s time to try to stop the insertion of faith-based quackery like Christian Science “prayer” treatments as reimbursable medical expenses in whatever health care reform bill(s) is/are passed by Congress. You can help by going here and writing to your Congressional representatives and Senators.
Charlene Werner is getting a lot of attention she probably did not anticipate or desire. She is the star of a YouTube video in which she explains the scientific basis of homeopathy. Before you watch it, make sure you are sitting down, relax, and brace yourself for an onslaught of profound scientific illiteracy combined with stunning arrogance. For those with more delicate constitutions I will give you the quick summary:
Einstein taught us that energy equals matter and light, but because matter can be condensed down to a very small space if you remove all the empty space between the elementary particles (I am paraphrasing to make her statements minimally coherent), we can mostly ignore matter. Therefore energy is light, and we are all made of energy – not matter (or at least so little matter, you can ignore it). Stephen Hawking then came up with string theory, which tells us that all matter (which we can ignore) is made of vibrating strings. Therefore we are made of vibrating energy. All diseases are therefore caused by unhealthy vibrational states, and all disease can be treated by returning the body to a previous healthy vibrational state. This can be done with homeopathy, which extracts the vibrational energy out of stuff and places it in a small pill that can be used at any time.
Got it? This is now my favorite example of meaningless pseudobabble from a CAM proponent. Also, I am not picking on some unrepresentative crank – this is as good as homeopathy gets. Werner may be more clumsy and fumbling than more eloquent homeopathy proponents, but when you strip it down, magical vibrations is what you get. But Werner does a fabulous job of exposing the gaping holes is homeopathic nonsense.