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Is IV Sedation Over-Used?

We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients.

I recently had a bone marrow aspiration. The written instructions said not to eat or drink for 6 hours before the procedure, to bring someone to drive me home, and to expect an IV. I suspected from these instructions that they were planning to use IV sedation, and I was right.

I questioned the need for sedation. I am prejudiced about bone marrow aspirations. I observed several and did one myself during my internship. When I had finished, the patient asked me when I was going to start. We did the procedure at the patient’s bedside in a multi-bed ward with no sedation, only local anesthesia. So my prejudice was that the procedure was no big deal and was not terribly painful.

I can imagine that some patients may be terrified by the idea of a needle going into their bone and may want to be sedated and not remember the experience. But I was not anxious about it, and I saw no need for the fentanyl and Versed they wanted to give me. I figured it would only prolong my time in the hospital, produce amnesia, expose me to a small risk of adverse effects, and leave me groggy; so I asked to opt out. They readily agreed – although they did keep asking me if I was really sure I didn’t want it. They would not have offered the option of no sedation if I had not known to ask. (more…)

Posted in: Pharmaceuticals, Surgical Procedures

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Mathematically modeling why quackery persists

ResearchBlogging.orgIt’s often puzzled me (and, I daresay, many other skeptics and boosters of science- and evidence-based medicine) why various forms of quackery and woo that have either about as close to zero prior probability as you can get and/or have failed to show evidence greater than placebo in clinical trials manage to retain so much traction among the public. Think homeopathy. Think reiki. The former is nothing more than sympathetic magic prettied up with science-y sounding terms, while the latter is nothing more than faith healing given a slant based on Eastern mysticism and religion instead of Christianity. Indeed, reiki was even inspired by stories of Jesus’ healing powers, complete with a trip into the wilderness for fasting and prayer, resulting in revelation. Or consider acupuncture, a modality that is seemingly more popular than ever, even invading the very sanctum sanctorum of the ivory towers of academic medicine, yet every study of which that is done under rigorous conditions with proper placebo controls shows it to be no more efficacious than a placebo. It’s easy enough to shake one’s head and chalk it up to irrationality, ignorance of science, or even religious faith, but I’ve always been dissatisfied with such glib explanations, even though admittedly I have myself used them on occasion.

That’s why a study released last week in PLoS One by Mark M. Tanaka, Jeremy R. Kendal, Kevin N. Laland out of the Evolution & Ecology Research Centre, School of Biotechnology & Biomolecular Sciences, University of New South Wales, the Department of Anthropology, University of Durham, and the School of Biology, University of St Andrews, Fife, respectively, entitled From Traditional Medicine to Witchcraft: Why Medical Treatments Are Not Always Efficacious. Besides loving the title, I also like the methodology, which in essence adapts the tools of modeling evolution and the spread of traits throughout a population and asks the question: Why do ineffective or even harmful (or, as the authors characterize them, “maladaptive”) treatments for various illnesses persist in populations? The results are surprising and counterintuitive, yet ring true. In essence, the authors conclude that the most efficacious self-treatments are not always the ones that spread and that even harmful treatments can spread. Both of these observations are entirely plausible based on the prevalence of usage of common woo and quackery, and what the authors have done, in essence, is to model mathematically why quackery persists.

Indeed, the authors set the stage:
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Posted in: Basic Science, Clinical Trials, Science and Medicine

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Harvard Medical School: Veritas for Sale (Part V)

September 26, 2002

Kimball Atwood, M.D.
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Dear Kim,

I have now had time to look into the allegations in your letter of June 14th which, incidentally, I shared with Dr. David Eisenberg and he with several others. I have sought consultation about our exchanges and the gist of my response follows.

Some of your concerns and allegations are very helpful and constructive. Perceptions are particularly important in controversial fields where there is limited objective proof. Your cautions and interpretations in this area have been very useful to us.

Some of what you said is just plain wrong. This includes the allegation the Harvard has “a stake” in the area and therefore would not look into your allegations objectively. Relatedly, Dr. Howard Koh has written us a construction of the events in the Massachusetts Special Commission that is strikingly different from yours. And Dr. Anthony Komoroff has pointed out that many of your comments about the InteliHealth treatment of CAM are now grossly out of date as the material inherited from another provider has been reviewed by HMS faculty and modified. [Indeed, you have referred in other correspondence to modifications you have noticed.] Dr. Komaroff also commented on the misleading way your citation the treatment of homeopathy was disconnected from the rest of the paragraph.

Some of what you said is a matter of taste or interpretation, where even well intentioned people may disagree. In this particular area I have weighed your arguments carefully and, in places, learned from them.

But I think the biggest difference may be in a misperception about what our purposes are. The Council of Academic Deans of Harvard Medical School approved beginning a Division of Research and Education in Complementary and Alternative Therapies with exactly the focus described. Our goal is to do peer-reviewed basic and clinical research on the claimed, but unproven, efficacies of complementary and alternative approaches to therapeutics. The recent scientific sessions and requests for proposal held by the Division are clear testament to this intent. In addition, in common with the Association of American Medical Colleges and most of the allopathic schools of medicine, we intend to teach our students something about CAM and in particular how to assess its claims rigorously. We do not, repeat NOT, have any intention of making our students CAM practitioners. They have enough to do learning what we have always focused on.

Sincerely,

Daniel D. Federman, M.D.

cc: David M. Eisenberg, M.D.

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Posted in: Health Fraud, Medical Academia, Medical Ethics, Science and Medicine, Science and the Media

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Homeocracy

Recent comments on homeopathy again resulted in references to the 1994 Pediatrics paper by Jacobs et al on use of homeopathic remedies for childhood diarrhrea.  The authors of that paper concluded from their blinded study that homeopathic remedies, tailored to the individual infants and children, were effective in reducing the number of diarrhea stools and thus in shortening the illness.  The paper has been widely referenced and reported to have proved  homeopathy efficacy, and the critiques have been argued by homeopaths as irrelevant, as has been done by Mr. Ullman.

In this short series I want to recount my experience with the report, its predecessor, and its two major sequellae, as well as its effect on systematic reviews of homeopathy.  I will begin with a description of the first two studies, concentrating on their methods. Then I will discuss the results of the 1994 Pediatrics report and the authors’ interpretation of the results. Then (I hope last) I will discuss the third paper which the authors claimed supported findings of the first two and the meta-analysis which combined data from all three. If you are imagining why this  series interests me, and imagining the worst, you are probably right. The sequence will  help to reveal how some of the information in “holistic” and “alternative” systems become published, and despite critiques and disproofs through a sort of systematic deconstructions, still develop wheels of their own and enter the fund of general knowledge seemingly forever. Or, at least for several decades, until a social belief switch is finally turned off.
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Posted in: Basic Science, Clinical Trials, Homeopathy

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Differences Of Opinion

After my fairly recent awakening from shruggieness  (i.e. a condition in which one is largely unaware of or uninterested in CAM) I decided to discuss my concerns about pseudoscience with my friends. One particular friend is a nationally recognized physician who believes in the importance of accurate health information and the promotion of science. However, he sees no urgent need to warn people against snake oil, and so long as it’s correctly labeled he doesn’t seem to mind it co-existing with scientific alternatives.

My friend and I had dinner a few weeks ago, and our conversation was both animated and disappointing. I somehow felt inadequate in conveying my objections (both ethical and scientific) to the promotion of pseudoscience. My best explanations were met with cheerful rebuttals, and while not intellectually convincing to me, those retorts satisfied my friend just fine. I guess the bottom line was that he was more interested in maintaining his position than reconsidering it… and so it left me feeling rather frustrated and a little sad.
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Posted in: Science and Medicine

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More On Fourteen Studies

Recently my co-blogger David Gorski wrote an excellent analysis of the latest propaganda effort from the anti-vaccine crowd – a website that attempts to deconstruct the fourteen studies most often cited to argue for a lack of association between vaccines and autism. As David pointed out, there are many more than 14 studies which demonstrate this, and no credible studies showing that there is any correlation. David covered some of the 14 discussed studies, and today I will discuss one more.

On that anti-vaccine propaganda site J.B. Handley begins his introduction with this logical fallacy:

Of all the remarkable frauds that will one day surround the autism epidemic, perhaps one of the most galling is the simple statement that the “science has spoken” and “vaccines don’t cause autism.” Anytime a public health official or other talking head states this, you can be assured that one of two things is true: they have never read the studies they are talking about, or they are lying through their teeth.

Of course this is  a false dichotomy, or forced choice.  I personally know of many people, including myself and David, who have both read all the studies and are telling the truth about our opinions that they do not support a link between autism and vaccines. It seems to be inconceivable to Mr. Handley that an informed professional could honestly disagree with his opinions – such is the nature of fanaticism.

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Posted in: Vaccines

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Commercial deception: undeclared drugs in herbs and other dietary supplements

Back in February, an acupuncturist in Key West, Florida, was arrested on charges of using a physician’s credentials to obtain controlled substances and other prescription drugs.  While some of these drugs were for the individual’s personal use, the Key West Citizen reported from arrest records that the acupuncturist had obtained other drugs for her patients, including anxiolytics, a muscle relaxant, and sedative sleep aids.

While it is not clear if the individual in question specifically mixed those drugs with herbal or homeopathic remedies available at her practice, the demographics of her clientele are likely to be inconsistent with the use of prescription drugs.

Why do I propose this hypothesis and where would a practitioner get the idea to mix prescription drugs with herbal products to make them appear effective?

Why, the dietary supplement industry, of course.
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Posted in: Health Fraud, Herbs & Supplements

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Evolutionary Medicine

I have been asked to review a pre-publication proof of a book that will be published in May 2009: Evolution Rx: A Physician’s Guide to Harnessing Our Innate Capacity for Health and Healing by William Meller, MD. It offers “a primal yet radical new view of why we act and feel the way we do, why we get sick and how we heal. This new perspective, known as evolutionary medicine, looks at how our Stone Age ancestors lived, loved, got sick and got well over millions of years, which leads to guidelines for living longer healthier and happier lives today.”

He says we are the way we are because that’s what it took to adapt and survive throughout our evolutionary history. To some extent, that’s true, but that’s not the whole story. Sometimes we are the way we are because of an accident of evolutionary history that had no bearing on survival. Sometimes we are the way we are because a useless trait was linked to a useful one and came along for the ride – what Stephen Jay Gould referred to as “spandrels.”

The problem with evolutionary explanations is that we can never know for sure if they are true. We may be inventing “Just So Stories” like Rudyard Kipling’s “How the Camel Got His Hump.” Our explanation may seem perfectly reasonable but we may not have all the information and there may be a better explanation that simply doesn’t occur to us. (more…)

Posted in: Book & movie reviews, Evolution

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Primary care challenge

In this space we’ve read about the efforts of “alternative” practitioners such as naturopaths to gain the moniker “primary care provider”.  I’ve been wondering a bit about this.  I’m a primary care physician.  Specialists in internal medicine, pediatrics, and family medicine provide the bulk of primary care in the U.S. They attend a 4-year medical school, complete a 3-4 year residency, take their specialty board, and then work as experts in the screening, prevention, diagnosis, and treatment of common diseases.

So, what I’d like to do is give you a typical scenario from an internal medicine or family medicine practice.  It’s a simple one, one you might see on Step II of the USMLE boards or on a shelf exam for an internal medicine rotation.  I’d like to offer alternative practioners, especially naturopaths, an opportunity to show how they would approach the clinical scenario so that we can see what kind of primary care they provide.

Yes, every patient and every situation is different, but there are some general ways to approach health and disease based on the evidence.
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Posted in: Health Fraud, Science and Medicine

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Welcome back, my friends, to the show that never ends, part II: Generation Rescue, the anti-vaccine propaganda machine, and “Fourteen Studies”

I hadn’t planned on writing about the antivaccine movement again this week, so soon after having had to subject myself to yet another round of Jenny McCarthy on Larry King Live and a truly execrable Generation Rescue “study.” I really hadn’t. For one thing, there’s just so much nonsense laid down by antivaccinationists these days that it’s utterly impossible for one blogger to keep up with it all. I could write about them every single day and still not counter the sheer mass of pseudoscience, misinformation, and general ignorance that antivaccine activists spout each and every day, and because this is Autism Awareness Month lately the misinformation has been coming particularly fast and furiously. Sometimes, however, there arrives a bit of misinformation that is so egregious that it requires some response, regardless of how burned out on the topic I might be; so I guess I’ll just have to suck it up and plunge into the morass again.

The reason is that, in retrospect, I now realize that the Jenny and Jim antivaccine propaganda tour was clearly merely phase I of Generation Rescue’s April public relations offensive. In rapid succession last week, courtesy of J.B. Handley, the founder of Generation Rescue, who in order to have a couple of famous faces fronting his organization has allowed himself to be displaced, so that Generation Rescue has now been “reborn” as Jenny McCarthy and Jim Carrey’s Autism Organization (the better to capitalize on her D-list celebrity yoked to Jim Carrey’s formerly A-list (but rapidly plunging) celebrity), announced Generation Rescue’s latest initiative in a post on its antivaccine blog Age of Autism entitled Fourteen Studies? Only if you never read them.:
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Posted in: Politics and Regulation, Public Health, Science and the Media, Vaccines

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