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Facing Decline and Death

Gawande book

Note: Atul Gawande and his book will be featured on a Frontline episode airing on PBS tonight.

We’re all going to die. (There’s nothing like starting on a positive note! :-) ) We’re all going to die, and if we are fortunate enough to survive long enough to become old, we’re all going to experience a decline of one sort or another before we die: reduced hearing and vision, less strength, poorer memory, etc. As a society, and as a medical profession, we have been reluctant to confront those issues head on. Dr. Atul Gawande faces them unflinchingly in his thought-provoking new book Being Mortal: Medicine and What Matters in the End.

In a simpler time, there were fewer old people; they were respected for their knowledge and were cared for by their families who supplied their increasing needs as age made them more dependent on others; they died at home surrounded by supportive loved ones. Today we warehouse our elders in nursing homes, where they are denied the independence of even making simple everyday choices like when to get up and when to eat. We consign them to a regimented, less enjoyable, less meaningful life; and they frequently die alone in hospitals, connected to tubes and machines.

Doctors are not always good at making it clear to terminally ill patients that they are going to die soon. They are not always good at discussing end-of-life issues and securing advance directives. They often treat end-of-life diseases so aggressively that they end up causing more suffering or even shortening lives. (more…)

Posted in: Book & movie reviews, Cancer, Medical Ethics

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What do we do about politicians and physicians who promote antivaccine misinformation?

Given the ongoing (and increasing) measles outbreak linked initially to Disneyland, it’s hard for me not to revisit the topic from time to time. This time around, there are two issues I wish to discuss, one political and one that is a combination of medical and political. After all, it was just one week ago when New Jersey Governor Chris Christie stepped in it by advocating parental choice in vaccines, as if parents don’t already have a choice. He rapidly had to walk it back, and his ill-considered remarks were almost certainly not evidence that he is antivaccine. They are, however, evidence that he doesn’t understand that we do not have “forced vaccination” in this country (we have school vaccine mandates). Parents already have choice in 48 states, given that only two states (Mississippi and West Virginia) do not allow belief-based non-medical exemptions, be they religious exemptions, personal belief-exemptions, or both, to school vaccine mandates. It also came out that in 2009 while running for Governor, Christie met with Louise Kuo Habakus (who is antivaccine) and the NJ Coalition for Vaccine Choice, a very vocal NJ antivaccine coalition whose member organization list reads like a who’s who of the national antivaccine movement and includes Life Health Choices, the antivaccine organization founded by Habakus. He even wrote a letter promising that as governor he would stand with them in “their fight for greater parental involvement in vaccination decisions that affect their children.”

It’s also evidence that vaccine mandates are becoming even more politicized. Indeed, Senator Rand Paul, on the very same day, provided more such evidence when he claimed on a conservative talk radio show that he’s seen children with severe neurological problems after vaccination, the implication being that he believed these children’s problems were linked to vaccination. Later, in a testy exchange with a CNBC reporter, who asked him whether he had really said that he thought vaccines should be voluntary, Paul sarcastically replied, “I guess being for freedom would be unusual.” Later in the exchange, after repeating the same antivaccine talking points that he had related earlier in the day, he said, “The state doesn’t own the children. Parents own the children, and it is an issue of freedom.” You get the idea. He, too, ultimately had to back off a bit, famously showing himself getting vaccinated for hepatitis A, but given that Paul has had a long history of making similar comments, this was almost certainly strategic.
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Posted in: Politics and Regulation, Public Health, Religion, Vaccines

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SfSBM at NECSS

Screen Shot 2015-01-09 at 1.35.26 PM

A day of Science-Based Medicine, a weekend of science and skepticism

Registration for NECSS, the North-East Conference on Science and Skepticism, is now open. Included in the program will be a day of Science-Based Medicine.

Speakers will be Harriet Hall, Jann Bellamy, David Gorski, Steve Novella and Mark Crislip.

NECSS will be held April 9th–12th, 2015, in New York City at the Fashion Institute of Technology. The SfSBM program will be Friday, April 10 and you can attend one or more of the days. $95 for one day or $195 for the entire conference.

The precise program will be announced soon.

Preliminary Program  (Subject to change)

09:00 – 10:00 60 minutes Registration/Will Call
10:00 – 10:10 10 minutes OPENING: Steve Novella and David Gorski
10:10 – 10:45 35 minutes Speaker 1: Steve Novella
10:45 – 11:20 35 minutes Speaker 2: Harriet Hall.
11:20 – 11:55 35 minutes Speaker 3: David Gorski
11:55 – 12:30 35 minutes Speaker 4: Mark Crislip
12:30 – 02:00 90 minutes LUNCH
02:00 – 02:35 35 minutes Speaker 4: Jann Bellamy
02:35 – 03:35 60 minutes Panel 1 Discussion
03:35 – 03:50 15 minutes BREAK
03:50 – 04:35 45 minutes Q&A from Twitter & Audience
04:35 – 05:20 45 minutes SBM Jeopardy
05:20 – 05:30 10 minutes CLOSING
05:30 – 06:00 30 minutes SBM Business Meeting

For more information and to register, go to NECSS or this registration page.

The Society for Science-Based Medicine is a co-sponsor of NECSS and paid SfSBM members can get a 15% discount using the code SFSBM2015.

Posted in: Acupuncture

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Do two half-truths add up to a complete truth or a complete falsehood?

olivia-twenty-dahl

I swear that the evidence that I shall give, shall be the truth, the whole truth and nothing but the truth

The interwebs are not a court of law, that is for sure. The whole truth. Interesting idea. I have no idea how applicable Godel’s theorems are outside of mathematics, but from a practical point knowledge is always incomplete. There is too much to know and too little time and brain power to acquire perfect knowledge of a topic.

It is why medicine is a challenge. You have to synthesize all the available data, which is often incomplete. You have to decide what is quality information, what is not, and why, and how a given study or fact fits into the overall picture, on the continuous asymptotic journey towards unobtainable total knowledge. But you try for the whole truth, the good, the bad and the ugly.

Half-truths, partial stories, can be hard to challenge. In part because, well, they are half-true. They have an air of truthiness. It is perhaps much easier to counter an out-and-out lie. Well, maybe not. I’m thinking Wakefield here. I suspect that in having to admit that half-truths have some validity, it renders them more believable.

The world of pseudo-medicine, and pseudo-science, is filled with half-truths. I wonder when I read these half-truths whether the author is deliberately avoiding all the information, especially since the rest of the story often results in the weakening the impact of the half-truth. Paul Harvey could have had a field day with the anti-vaccine literature.

One of the greatest challenge facing young people today, is the large scale availability of half truth’s and manipulated facts
– Oche Otorkpa, The Unseen Terrorist

Influenza

Beware of the half-truth. You may have gotten hold of the wrong half.
– Author unknown

Take “Do Not Believe Everything You Read About Flu Deaths” from the October, 2014 Journal of Advanced Practice Nursing. As best I can tell this is a peer reviewed journal. You know, “peer“, as in “to appear partially or dimly.”

I imagine someone squinting over the top of their glasses at the manuscript, muttering, “that ‘peers to be a paper about influenza deaths. Let’s publish it.”
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Posted in: Critical Thinking, Vaccines

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Washington bills: Christian Science no longer an excuse for denying medical care

seal-of-washington

All states try to protect children from neglect, abandonment and mistreatment, such as deprivation of clothing, shelter, food and medical care. This includes civil laws which permit the removal of a child from the home and other protective interventions. Criminal laws protect children as well by, for example, making nonsupport a misdemeanor or criminal neglect a felony.

Washington State law prohibits criminal mistreatment of children and other vulnerable persons, such as the frail elderly, by their caregivers. Criminal mistreatment is defined as the “deprivation of the basic necessities of life:”

food, water, shelter, clothing, and medically necessary health care, including but not limited to health-related treatment or activities, hygiene, oxygen, and medication.

Mistreatment can be either a misdemeanor or felony, depending on whether the defendant’s conduct amounts to criminal negligence or recklessness and the degree of harm caused to the victim. Punishment ranges from 90 days in jail and a $1,000 fine to 10 years in jail and a $20,000 fine.

Unfortunately, parents and other caregivers in Washington have what amounts to an almost literal “get out of jail free” card if the mistreatment takes the form of “treatment” by “duly accredited” Christian Science practitioner: (more…)

Posted in: Faith Healing & Spirituality, Legal, Politics and Regulation, Religion

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How Not to Treat Migraine

Image credit: Wellcome Images, Wellcome Library, London, via Wikimedia Commons.

Image credit: Wellcome Images, Wellcome Library, London, via Wikimedia Commons.

Last week I gave a quick overview of standard treatment options for migraine, a severe form of recurrent headaches. As promised, this week I will address some common treatments for migraine that I don’t think are supported by the evidence.

Acupuncture

Acupuncture is the CAM modality that, it seems to me, has infiltrated the furthest into mainstream medicine, including for the treatment of migraine. In fact the The American Headache Society includes acupuncture on its list of recommended treatments. The reason for this is that acupuncture proponents have been able to change the rules of clinical research so that essentially negative or worthless studies of acupuncture are presented as positive.

I reviewed the evidence for acupuncture and migraine previously, demonstrating the multiple problems with the acupuncture literature in general, and specifically acupuncture in migraines. Most studies suffer from at least one fatal flaw: they are not properly blinded, they do not include a control, they mix acupuncture with non-acupuncture variables (mostly including electrical stimulation in the treatment group), comparison groups are not adequately treated, they make multiple comparisons to maximize chance outcomes, or they are simply too small making them susceptible to all the usual problems of bias in research.

What we don’t see is a consistent and clinically-relevant effect in properly-controlled double-blind trials where the variables of acupuncture are isolated.

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Posted in: Acupuncture, Chiropractic, Neuroscience/Mental Health

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A Scientist in Wonderland

Edzard Ernst is one of those rare people who dare to question their own beliefs, look at the evidence without bias, and change their minds. He went from practicing alternative medicine to questioning it, to researching it, to becoming its most prolific critic. I have long admired his work, and I finally met him in person when we were invited to speak at the same conferences. He shattered my stereotype of the stern, formal, self-important German “Herr Professor Doktor.” He was affable, unassuming, and funny; he was even a jazz musician. I wished I knew more about his history, and my wishes have been granted in the form of his new autobiographical book, A Scientist in Wonderland: A Memoir of Searching for Truth and Finding Trouble.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

Edzard Ernst, the early years

Dr. Ernst was born in post-war Germany; his family had suffered greatly during the war and his uncle had been a general in the Waffen SS. He felt slightly ashamed to be German, and as a result he researched and wrote about Nazi health beliefs and medical atrocities so the history of their misdeeds would not be forgotten.

His father was a doctor, his mother an enthusiastic devotee of alternative medicine who subjected him to homeopathy, ice cold baths, and barefoot walks at dawn through wet grass. Early in life, Ernst began to manifest a tendency towards doubt and irreverence, along with an irrepressible sense of curiosity.

Music was his first love. He earned good money when he and his friends spent their summer vacation busking on the beach at St. Tropez, and he had been seriously considering a musical career until his mother persuaded him to study medicine. He earned an MD in Germany, in an environment where alternative medicine was unquestioningly integrated with mainstream medicine. He received hands-on training in acupuncture, autogenic training, herbalism, homeopathy, cupping, massage therapy, spinal manipulation, even leeches. His first job was in a homeopathic hospital where a colleague chose remedies by dowsing with a pendulum. (more…)

Posted in: Book & movie reviews, Clinical Trials, Critical Thinking

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Screening for disease in people without symptoms: The reality

One of the most contentious questions that come up in science-based medicine that we discuss on this blog is the issue of screening asymptomatic individuals for disease. The most common conditions screened for that we, at least, have discussed on this blog are cancers (e.g., mammography for breast cancer, prostate-specific antigen screening for prostate cancer, ultrasound screening for thyroid cancer), but screening goes beyond just cancer. In cancer, screening is a particularly-contentious issue. For example, by simply questioning whether mammography saves as many lives lost to breast cancer as advocates claim, one can find oneself coming under fire from some very powerful advocates of screening who view any questioning of mammography as an attempt to deny “life-saving” screening to women. That’s why I was very interested when I saw a blog post on The Gupta Guide that pointed me to a new systematic review by John Ioannidis and colleagues examining the value of screening as a general phenomenon, entitled “Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials.”

Before I get into the study, let’s first review some of the key concepts behind screening asymptomatic individuals for disease. (If you’re familiar with these concepts, you can skip to the next section.) The act of screening for disease is based on a concept that makes intuitive sense to most people, including physicians, but might not be correct for many diseases. That concept is that early intervention is more likely to successfully prevent complications and death than later intervention. This concept is particularly strong in cancer, for obvious reasons. Compare, for example, a stage I breast cancer (less than 2 cm in diameter, no involvement of the lymph nodes under the arm, known as axillary lymph nodes) with a stage III cancer (e.g., a tumor measuring greater than 5 cm and/or having lots of axillary lymph nodes involved). Five year survival is much higher for treated stage I than for treated stage III, and, depending on the molecular characteristics, the stage I cancer might not even require chemotherapy and can be treated with breast conserving surgery (“lumpectomy” or partial mastectomy) far more frequently than the stage III cancer. So it seems intuitively true that it would be better to catch a breast cancer when it’s stage I rather than when it’s stage III.
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Posted in: Cancer, Clinical Trials, Epidemiology, Public Health

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Opposing Chiropractic: Persecution or Justified Criticism?

cervical-spine-drawing-m

The saga of chiropractic began in 1895 when D.D. Palmer, a magnetic healer, announced that “95 percent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.” Palmer opened the first chiropractic school in Davenport, Iowa, offering a three-week course of study at the Palmer School and Cure, subsequently renamed the Palmer School of Chiropractic. The school was taken over by B.J. Palmer, the son of D.D. Palmer, in 1906. In 1910, the course of instruction was six months. Kansas and North Dakota were the first states to pass laws legalizing the practice of chiropractic (in 1913 and 1915). By 1921, the Palmer School of Chiropractic, requiring 18 months of study, had 2,000 students, reaching a peak enrollment of 3,600 in 1922. By 1923, 27 states had chiropractic licensing boards. Hundreds of chiropractic schools sprang up, some offering correspondence courses. There were no entrance requirements, anyone could become a chiropractor. H.L. Mencken wrote in the December 11th, 1924, issue of the Baltimore Evening Sun:

Today the backwoods swarm with chiropractors, and in most States they have been able to exert enough pressure on the rural politicians to get themselves licensed. Any lout with strong hands and arms is perfectly equipped to become a chiropractor. No education beyond the elements is necessary.1

Although Palmer’s subluxation theory was contrary to all known laws of anatomy and physiology, the theory was appealing to the general public. Medical science was in its infancy, struggling to find effective and safe remedies for disease and infection. There was no known cure for many common ailments, and many of the medicines used by physicians were ineffective or harmful. In the public marketplace, the door was wide open for snake oil salesmen, entrepreneurs, and opportunists who could mix a concoction or fabricate a new treatment guaranteed to work. With growing numbers of chiropractors treating disease and infection by adjusting the spine to relieve alleged pressure on spinal nerves, offering treatment claimed to be superior to medical care, members of the medical community felt an obligation to oppose what they viewed to be blatant, unbridled quackery.

An old Palmer illustration showing how a displaced vertebra could cause disease by pinching a spinal nerve.

An old Palmer illustration showing how a displaced vertebra could cause disease by pinching a spinal nerve.

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Posted in: Chiropractic

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Selling complementary and alternative medicine: An business ethics perspective

I joined Professor Chris MacDonald at Ryerson University earlier this week to participate in Ryerson’s business ethics speaker series. The topic was CAM:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This presentation — by a philosopher and a pharmacist — aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

If it’s not embedded above, you can watch the whole presentation on CAM and business ethics with this link.

It was great to see so many public members attend and participate. There was an extended Q&A afterwards, with some very thoughtful audience questions. Outside of blogs like this, and those of CAM critics like Edzard Ernst, the practical ethics of CAM provision are rarely discussed.  Watch for more on this topic in the future.

 

Posted in: Announcements, Homeopathy, Medical Ethics, Politics and Regulation

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