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Science, Evidence and Guidelines

Disclaimer:  I am a paid Medscape  blogger and writer, and since they are in part supported by advertisements from the Pharmaceutical companies,  indirectly I am in the thrall of Big Pharma.

I found Harriet’s post on the Medscape Connect topic of How do you feel about Evidence-Based Medicine? interesting.

I wondered about the breakdown of the comments by both specialty and opinions about SBM.  So I read the 226  comments and classified them by field and response.  I classified each response as disapprove, approve or nuanced.  It is not, obviously, a legitimate survey and there was more than a little subjective interpretation in deciding how to classify the responses.  I have no doubt that others would get different results; it is not methodologically sound analysis. The discussion was in the Family Medicine & Primary Care section, so it is unlikely to be representative of any population, including that of Family Practitioners and Primary Care Physicians.  I would bet, as in alternative medicine and most topics, Shruggies predominate and are the silent majority.

Even though I belong to what  a commentator referred to as the not so silent “militant wing” of SBM, I was surprised at my results:

Medscape Results
Speciality Disapprove Approve Nuanced
Family Practice 19 2 6
General Practice 4 1 1
Psych 13 1 3
Neuro 11 1 1
Anesthesia 9 1 1
Prevention Medicine 1
Radiology 2 1
ID 1
ER 3 2 1
Internal Medicine 9 2 1
Ortho 5
Dermatology 2
Occupation Medicine 2
Surgery 7 2
Peds 3 1 1
Allergy 1 1
Ob 6 1
Endocrine 2
Pulmonary 3
ENT 2 1
Ophthalmology 1
Other 4 1 4
Urology 4 1 1
Oncology 2 1
Cardiology 1 1 1
Critical Care 3 1 1
Pulmonary 3
GI 1 1 1
Pathology 2
Total 124 (72%) 19 (11%) 29 (17%)

 

It was the lack of nuance that amazed me. That docs had issues with EBM/SBM should be given.  I have issues with SBM, but like democracy, it is superior to all the alternatives.  And the inability to differentiate between EBM/SBM and the guidelines upon which they are based flabbered my gaster.  I have never been able to come to grips with the concept that people who should know better, don’t appear to.  Being perfect myself, I am taken aback when others are not.

There is an intellectual hierarchy in medicine, and at the top, of course, are infectious disease doctors.   I leave it the commentators to rank the various specialities based on their response to EBM, since my referral base may be reading this and work is slow enough as is thanks to all the quality initiatives to decrease hospital acquired infections.

Besides, any list would be based entirely on confirmation bias and the personality of the specialists I work with.  I also work in an internist dominated, inpatient medicine teaching hospital, so my bias is towards evidence and science, since I have be able to quote chapter and verse when I teach the residents. What makes me expert in Infectious Diseases is partly experience, which has made me a better diagnostician every year I am in practice, and my futile attempt to master the ID literature, which makes me better at choosing a treatment.  But does the greatly extolled (at least for the EBM naysayers) experience make me better at treatment? I don’t know for sure, but I doubt it

Some examples.  P. acnes is an anaerobic bacteria that causes occasional post-operative back infections and artificial joint infections.  It is an odd bug, being such a part of the normal flora it can fester for years with little in the way of classic inflammatory signs and symptoms.  It is resistant to metronidazole, my usual go to drug for anaerobes.  The treatment is usually high dose penicillin, and I see maybe a case a year, tops.  I have a smattering of cases where penicillin did not appear to be effective, but when changed to clindamycin the patient rapidly improved. Perhaps they would have improved anyway; most do.  But as a result I have this nagging unsupported by the literature ‘feeling’ that clindamycin is better for P. acnes.

Or MRSA.  From the published data,  all the current treatment options, when compared to a beta lactam  for susceptible organisms, suggests that all antibiotics for MRSA stink on ice.  From the amount of data, i.e. preponderance of information, the rank order, and rank it is,  for treating MRSA  is perhaps vancomycin = daptomycin = linezolid => quinolone or TMP/Sulfa plus rifampin > ceftaroline (for MRSA pneumonia it is linezolid > vancomycin > ceftaroline = quinolone or TMP/Sulfa + rifampin  with no daptomycin on the list).  What I think,  in my Eldunarí, that the real order is ceftaroline > daptomycin > linezolid  = quinolone or TMP/Sulfa + rifampin with vancomycin last, with lots of caveats depending on the specific staph and the organ infected.  I have no doubt that other ID docs would rank the drugs differently. My experience, bias, and interpretation of the literature can be conflicted depending on how I approach what I am reading and the patients I have treated in the past; although I bet the literature will catch up with me someday. It always does :-)

It is an interesting challenge when treating a given individual since the study population may not be reflected in my particular patient and then applying bias and hubris becomes very tempting.  I am very careful when I talk to house staff to differentiate my recommendations that are based on studies, based on extrapolation from known data and those that are my opinion, based in part on the three most dangerous words in medicine (in. my. experience).

It requires remarkable intellectual effort to not give in to my bias and not come up with rationalizations to justify my opinion.  Working in a teaching hospital makes that easier, since I have to make sure the residents know the ‘right’ answers so they will pass their boards.  And someday they will be in practice, having to make decisions without the support of the faculty, and have to make the ‘right’ decisions that will benefit their patients as well.  Right being in quotes as a recognition that medicine changes, and I get to bore/amuse the residents about what we did in my day, when every PVC received lidocaine, asthma was treated with aminophylline, we had no CT scans and I wore an onion on belt, as was the style of the day.

I have long noticed that many docs do not think like me (i.e. an internist) and I was influenced years ago by an article in the Annals  (sorry Harriet) called Reflections on Internal Medicine and Family Medicine  by an FP doctor. Obviously, training for breadth will have a different emphasis than training for depth.  A metropolitan subspecialist needs a vastly different skill set than a small town generalist and that  will be reflected in their training and approach to medicine

The money quotes

Internists are trained in the classic deductive reasoning model of differential diagnosis. Family physicians are trained in this model of problem solving on internal medicine services, but, in practice, they often take a less structured and more empiric approach to clinical reasoning that is based in clinical epidemiology.

and

Internists, especially those in academic medicine, may underestimate the degree of nonconformity and rebellion required of U.S. medical students who entered family medicine in the 1970s and 1980s. It is these students who now fill the faculty ranks of family practice programs around the country. Nowhere is this nonconformity more evident than in the ambivalence with which family physicians have integrated themselves into academic medicine. The importance of this counterculture mentality in the character of the family physician can best be understood by reading the works of Gayle Stephens, which are considered classics in family medicine. Stephens is one of the philosophical fathers of the family practice movement, and his book, The Intellectual Basis of Family Practice, has inspired a generation of family physicians. An understanding of the culture of family practice will help to explain much of the independence and cynicism that so often seem to characterize the family physician.

So I should not surpassed the overwhelming antipathy revealed in the Medscape comments by those in the field of FP and GP, which were particularly dismissive of evidence, often erroneously confusing evidence with guidelines.

In my own field the guidelines have remarkably little evidence to back them up, although in ID we do have the distinct advantage in treating individual patients that it is often the purpose to eradicate large swaths of microbial life; I am glad there is no Karma or I would dread the payback in the next life. Outcomes in ID are often more binary than most specialties; either I cured your infection or I did not.

Still the guidelines in ID, as noted in the ID literature, are lousy with opinion instead of evidence:

Approximately one-half  of the recommendations in the current guidelines are supported by level III evidence (derived from expert opinion). Evidence from observational studies (level II) supports 31% of recommendations , whereas evidence based on >1 randomized clinical trial (level I) constitutes 16% of the recommendations… The IDSA guideline recommendations are primarily based on low-quality evidence derived from nonrandomized studies or expert opinion.

They say that the IQ of a committee is the average IQ of the committee divided by the number on the committee and it occasionally shows in the guidelines.  Sometimes the advice is stupid, or at least brain dead.  The pneumonia guidelines suggest, with no data, “In general, when switching to oral antibiotics, either the same agent as the intravenous antibiotic or the same drug class should be used.”  That simple comment is a sure way to jack up costs and breed resistance.  Not that my opinion is necessarily better, although my IQ is divided by one, but most patients with uncomplicated pneumonia who respond promptly probably require no more than amoxicillin or doxycycline, although I can pepper that statement with several pages of caveats.  It still amazes me that for a common infection like pneumonia, we still do not really know the optimal treatment:

Most patients with CAP have been treated for 7–10 days or longer, but few well-controlled studies have evaluated the optimal duration of therapy for patients with CAP, managed in or out of the hospital. Available data on short-course treatment do not suggest any difference in outcome with appropriate therapy in either inpatients or outpatients.

Or take the  acute bacteria rhinosinusitis (ABRS) guidelines

High-dose” (2 g orally twice daily or 90 mg/kg/day orally twice daily) amoxicillin-clavulanate is recommended for children and adults with ABRS from geographic regions with high endemic rates (≥10%) of invasive penicillin-nonsusceptible (PNS) S. pneumoniae.

High dose amoxicillin high dose should be enough to treat penicillin-nonsusceptible S. pneumoniae, at least for a relatively trivial infection like sinusitis.  But here is the deal: S. pneumoniae doesn’t make a beta lactamase, an enzyme that degrades amoxicillin, which they point out in the text.  For S. pneumoniae, clavulanate, which inhibits the beta-lactamase, adds nothing to the treatment over amoxicillin except diarrhea and cost  and is recommended for the odd H. influenza in the sinus of adults, which does make a beta lactamase,  as they mention:

H. influenzae was isolated in 36% of patients with positive bacterial cultures consistent with ABRS, compared with 38% for S. pneumoniae and 16% for M. catarrhalis. Unfortunately, the rate of β-lactamase–producing H. influenzae was not reported in this study.

After their convoluted argument, they finally conclude

Thus, the recommendation of amoxicillin-clavulanate in adult patients with ABRS is primarily based on in vitro susceptibility data and the current prevalence rates of β-lactamase production among H. influenzae.

Why even bother?  Not confidence inspiring, although I understand the reasoning, it is awkward at best: You want to give more amoxicillin if you have high endemic rates  of invasive penicillin-nonsusceptible (PNS) S. pneumoniae but due to the potential for  H influenza you want  amoxicillin-clavulanate instead.   I suspect the commentators on Medscape who complain about guidelines were not doing so due to a fine reading of the content in the context of an understanding of an extensive literature, but more in rebellion against being told what to do by the man: insurance companies and the smarting pants academics.  I share their concerns, but for different reasons.

There is science and evidence, and often I do not really know what do with the results, even when impressive.  Recently the NEJM  published an article that demonstrated that azithromycin, when compared to other agents, was associated with ‘excess deaths’  The overall increase in deaths was small, although not if you were one those in the excess.

“Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses.”

The paper is EBM/SBM, an epidemiologic study.  How do I approach such a study?  First, I will admit, is a gut check.  Was I surprised at the headline?  Nope.  Quinolones, azoles and macrolides are all known to have effects on the cardiac conduction system.  This is in contrast with a report that quinolones were associated with an increase in retinal detachment.  While quinolones are known to affect connective tissue, I am a bit more skeptical about this one.  I would like to see it confirmed.

The azithromycin study I am more likely to take to heart.  The problem with the study is that while it demonstrated those with cardiac problems were more likely to have the adverse reaction,the main indication for the antibiotics was sinusitis or bronchitis.  Will the same effects happen for other infections?  What is the risk and benefit?

For example, in both sepsis and pneumonia, receiving a macrolide is associated with increased survival compared to those who do not.  Also, acute pneumonia, where there is survival benefit from a macrolide, is one of many infections with increased vascular events, including arrhythmias and heart attacks.  Since macrolides are part of the guidelines for the treatment pneumonias, are we seeing more deaths from the drug or the infections for which it is being used?   That being said, I would be less likely to use azithromycin for ‘trivial’ infections like sinusitis and bronchitis that I would for more life threatening infections.

What do you do if you think experience trumps data and evidence?  The risk was increased from 47 to 245 per million doses azithromycin given, making it unlikely that an experienced provider, with 3 to 6000 patients will ever be likely to inadvertently kill a patient with azithromycin.  In my experience, I never killed a patient with azithromycin. That you know of.

That is the problem with experience based medicine.  Experience will always be insufficient to recognize rare yet important complications or the beneficial effects of therapies applied to populations such as treating hypertension.  SBM should be the basis of medicine, but its application will often require the ‘art’ of medicine.

 

 

Posted in: Epidemiology, Medical Academia, Pharmaceuticals, Science and Medicine

Leave a Comment (81) ↓

81 thoughts on “Science, Evidence and Guidelines

  1. daedalus2u says:

    As someone who grew up in the 60′s and 70′s, the rebellion was against authority, not against reality (although many are confused about which is which). Those who were confused grow up to be the authorities which the next generation must rebel against.

  2. MedScape has an article saying chiropractic is useful for blood pressure control. I no longer read anything there.

  3. rork says:

    Thankyou for this post. One of the best living with dirty uncertainty I have ever read.
    Just one error: There is one specialty to rule them all, and we aren’t even docs. You will be corralled.

  4. rork says:

    … at least in my dreams.

  5. David Gorski says:

    It’s no secret that there is a sizable contingent of doctors who don’t like EBM/SBM-based guidelines. As you point out, the reason tends not to be nearly as analytical as the reasons you gave to be skeptical of some of the ID guidelines. Rather, it’s the pure human dislike of being told what to do by The Man. There’s also a bit of an Ayn Randian streak in doctors. Far too many of us do tend to think our training and intelligence make us able to synthesize the torrent of data coming out of the fire hose of EBM/SBM on our own without help and to delude ourselves into believing that we don’t suffer from the same cognitive flaws as other human beings that lead us to misinterpret the literature and our experience to support our pre-existing beliefs. Witness the Association of American of Physicians and Surgeons, if you don’t believe me. It’s an organization that opposes EBM/SBM because its membership consists of doctors who think they are “mavericks.” Or, as I put it four years ago:

    …the AAPS is devoted to “different doctors” who don’t meekly follow science- and evidence-based guidelines, as the rest of what he views to be the “herd” does or adhere to nitpicky little things like the careful science that leads to those guidelines. No! AAPS doctors are different and, by inference, better, more capable of independent thought than the rest of us poor, pathetic “sheeples.” Or at least so the leadership of the AAPS apparently thinks. Indeed, reading JPANDS [Ed note: The Journal of American Physicians and Surgeons] , I sometimes suspect that the editors really don’t care all that much whether what is being published constitutes good science or not. All that seems to matter is that it be “maverick” and buck the existing paradigms. Certainly, the journal is not particularly receptive to criticism or to issuing corrections or retractions, as Joseph at Autism Natural Variation demonstrated when he criticized the Geier & Geier paper mentioned earlier.

    The leadership of the AAPS and apparently many who publish in JPANDS seem to be a bit too enamored of their self-proclaimed “maverick” status and give the appearance of thinking that, like Ayn Rand’s hero, they’re “supermen” whose egoism and genius will inevitably prevail over timid traditionalism and social conformism. Reining them in with evidence only interferes with their autonomy and prevents them from exercising their genius for the good of their patients. If only the “herd” could appreciate that! No wonder JPANDS has published several articles with titles such as Evidence-based Guidelines: Not Recommended, The Effect of Peer Review on Progress: Looking Back on 50 Years in Science (featuring another scornful dismissal of the “herd instinct” and “conformity” and a fair amount of exaggeration of how much scientific progress is due to “violent confrontation” of old paradigms and how much is due to the slow accumulation of knowledge), and editorials attacking evidence-based medicine. To the AAPS, evidence-based guidelines are unacceptable limits on the autonomy of physicians, as are any government regulations or third party payer systems.

    I think that over time this hostility towards EBM/SBM, which is far more based on pure cussedness and not liking being told what to do, will wane, as newer generations of medical students raised on EBM/SBM become established in practice.

    Finally, as for which specialty is most science-based, obviously it must be oncology. :-)

  6. windriven says:

    “as newer generations of medical students raised on EBM/SBM become established in practice.”

    Are they being raised on EBM/SBM? Or are they being raised on New Age fantasies of reiki and acupuncture?

  7. nybgrus says:

    We are being raised on EBM. But this “open mind” and aversion to “dogma” is still rife.

    I just had a discussion with a colleague who is on rotation with me. She is smart, skeptical, and interested. We were having a civil and academic discussion about the utility of CAM and what the definition even means. I won’t bore everyone with the details, but her gut reaction was that whilst CAM and baseless therapies should be avoided, we mustn’t be so “dogmatic” as to close off options when the evidence runs out.

    In clarifying the point with her she was trying to say that there is a limit to the amount of knowledge we have to apply and when we run out we shouldn’t be closed-minded to other options that might possibly work just because they don’t (yet) have evidence to support their efficacy.

    So I asked her a hypothetical based on one of my current patients with whom she is also familiar. Ms. Smith had an ex lap and debulking for Stage III ovarian cancer and on POD#1 was found to have significantly decreased renal function. After some testing we determined she had pre-renal azotemia and that she needed to be tanked up. The problem is she has a serious cardiac history and we can’t fluid overload her.

    So I said, what if we ran out of options and Ms. Smith’s renal function continued to decline and she became quite ill. We are all standing around the bed and nobody has an answer – we’ve done everything in the guidelines and everything in the evidence. First problem is how do we choose from the literally inexhaustible list of potential therapies with no evidence? Silence. OK, let me hand you a gimme – a helpful and conscientious CAM practitioner pipes up and says that he’s got a jar with “eye of newt” in it and states that it has a long history of use for kidney problems, although there is nothing but anecdotal data and small case studies to support this claim. Should we use “eye of newt” on our patient? Well, sure, she says.

    OK. What dosage should we give? What dosing regimen? What route of administration? How long should we give it for? What should we look for to determine toxicity or adverse reaction? How will it interact with the other drugs she will be on? What are the pharmacokinetics, metabolism, and elimination? Etc, etc.

    I went on. Lets say we give the “eye of newt” as prescribed by Dr. CAM. The next day we see Ms. Smith. There are 3 options – her renal function improved, stayed the same, or got worse. If it improved, how can we be sure that the eye of newt did it? If it got worse, how can we say the eye of newt didn’t do it? What if the eye of newt takes a few days to kick in and we need to just keep administering it? What if it did work and if we D/C it she will return to renal failure? What if it did work and if we keep administering it it will become toxic to the liver? How will we know when to stop or how long to try it for?

    So you see, it isn’t dogmatism to insist that only treatments with some evidence of efficacy are used – it is the only possible way of doing things. And I am not dogmatic to insist this. If you have good anecdotal evidence that eye of newt is good for kidney function…. investigate it! Maybe I’ll by stock in newts if the preliminary data looks good. But you can’t expect me to prescribe it for a patient without any sort of evidence or data about it!

    This becomes easily and plainly obvious in (somewhat) more dire scenarios like that above. The only reason it is even a conversation point is because this stuff is mostly relatively innocuous and used for self limited disease in otherwise healthy people. It is clear to see how that does not translate to less healthy people with degenerative and potentially life threatening conditions. It should also be clear how it shouldn’t apply to anyone at all.

    She said she was impressed and had some stuff to think about.

  8. David Gorski says:

    Are they being raised on EBM/SBM? Or are they being raised on New Age fantasies of reiki and acupuncture?

    Paradoxically, both.

    It is, of course, the shortcomings of EBM (that we believe SBM can remedy) that resolve the paradox. The EBM paradigm values clinical trials, particularly randomized clinical trials above any other form of evidence. That allows advocates to justify doing clinical trials on completely implausible treatments (homeopathy or reiki, for example), because the EBM paradigm doesn’t allow one to reject something like homeopathy or reiki on basic science arguments alone, even though both violate multiple laws of physics and chemistry. In addition, the random noise and bias inherent in clinical trials guarantees that there will always be seemingly “positive” trials of placebos like homeopathy and reiki to which EBM aficionados can point as “scientific evidence” that their woo works.

    In any case, I was talking about hostility to EBM and EBM-based guidelines, which I do believe to be decreasing as a younger generation of physicians comes of age. The problem is, not being hostile to EBM is not the same thing as rejecting quackery. The very problem with EBM that we keep pounding away on is that EBM and the “integration” of quackery into EBM are not necessarily incompatible. SBM and quackery, on the other hand, are incompatible. That’s one reason why we propose modifying EBM to become SBM.

  9. Harriet Hall says:

    Since internists, ID docs and oncologists are obviously at the top of the totem pole and family doctors are way at the bottom, shouldn’t I get some kind of recognition for having clawed my way to a position at the top? I was somehow able to overcome the deficiencies of my education to become an editor of SBM. While the exception doesn’t prove the rule, I am clearly exceptional. You should all bow down and worship me. :-)

  10. nwtk2007 says:

    Although many in health care are of the mind set that they don’t like to be told what to do, I think you could clarify that to say that they do not like insurance companies to tell them what to do; or not to do. Most of what is seen as EBM and guidelines are nothing more than weapons used by insurance companies to deny payment for services rendered. It would be hard to find an office based practitioner who would not have that opinion of any guidelines; evidence based or what ever. Its also not centered upon the alternative types of treatments such as homeopathy or Reiki or other such non-sense. Its down to that which most here would offer up as very clearly evidence based treatments. Additionally, as long as insurance companies are funding these guidelines or using them as such it will be that way. Their attitude towards evidence, no matter what types, is much the same as skepticalhealth’s is towards chiropractic. If a study shows real evidence, then they ain’t gonna read it no more.

  11. WilliamLawrenceUtridge says:

    A Paolini reference? I’m soooooooo disappointed.

  12. Harriet Hall says:

    @nwtk2007,

    “If a study shows real evidence, then they ain’t gonna read it no more.”

    Please provide examples of studies that show real evidence for chiropractic that we have refused to read.

  13. WilliamLawrenceUtridge says:

    Much of what underlies chiropractic is bunk – subluxations, the idea that spinal manipulation can impact the immune system and the like.

    However, I myself go to a chiropractor as a sort of poor-man’s physiotherapist. Spinal manipulation has been quite useful to me for back pain, neck pain, muscle knots and other musculoskeletal complaints. My chiropractor provides me with exercises to do that have been quite helpful in strengthening muscles to offset sprains and strains, and given me advice on how to avoid injury in the future.

    Unfortunately he has also opposed vaccination and tried to sell me vitamins. I ignore that, because I’ve read textbooks on nutrition, anatomy and physiology that indicate he’s clearly wrong.

    Chiropractors should accept what they can realistically do – physical manipulation for musculoskeletal problems. They aren’t doctors and they shouldn’t pretend they are.

  14. Mark Crislip says:

    I live to disappoint.
    They were a fun (audible) read and a good anodyne to the technical reading and intensity of a day of work

  15. @nwtk2007, in this reference I was talking about the absolutely ridiculous “pilot study” that supposedly demonstrated the ability of NUCCA therapy (I believe) to treat hypertension. The fact that MedScape posted that as a legitimate study, and that it’s still on their website, is such a disgrace that I will no longer use the source.

    Are you suggesting that chiropractic is proven to be effective for the treatment of hypertension?

  16. nwtk2007 says:

    @Harriet, why would I even bother. But I am not referring to just chiropractic.

    The point was that the so-called EBM guidelines are just a tool used by insurance companies to deny payment for services rendered; evidence based or not. The effect is wide spread among your people as well, ask just about any practitioner in the healthcare field. That is why folks don’t like EBM/guidelines. In fact, if the EBM guidelines show real evidence for the effectiveness of a procedure, they will just not use that one (they won’t read it) and will use another. OR, they’ll just refuse to acknowledge the evidence.

    Additionally, when it comes to the efficacy of a procedure being used over another, many times it’ll depend upon the administrators of the facility to put pressure on the docs to use it or not to use it. Once again, evidence based or not.

    Now if the motivation to tell a doc to use a procedure or not were truly based upon evidence then I doubt the doc would actually mind. But when the motivation is to prevent payment for a service they certainly will balk at it. By the same token, if a doc makes money on a procedure or service then he/she isn’t going to want to have someone tell them it isn’t evidence based and should not be performed.

    Basically, money talks, evidence walks. At least in the real world.

  17. Harriet Hall says:

    @nwtk2007,

    You have offered a cynical opinion about the formulation and motivation of evidence-based guidelines and about their rejection by clinicians.
    I could offer a competing opinion: that evidence-based guidelines are formulated by conscientious medical experts whose only motivation is to improve patient outcomes, and that most clinicians welcome evidence-based guidance.

    How could we determine which of us is more correct?

  18. Scott says:

    I’ll also point out that cost effectiveness and medical effectiveness have quite a bit of overlap, though it’s certainly not complete. And that doctors AND patients are just going to have to learn to accept that procedures, etc. which aren’t genuinely cost-effective simply can’t be offered.

  19. nwtk2007 says:

    @Scott – In a way you are correct and in a way you are not. If a procedure is supported by evidence and is effective it might also be very expensive; much more so than many less effective procedures. And I must say that if an insurance company were to hear your remark regarding what doctors and patients are “just going to have to learn to accept”, then you might be their next CEO.

    @Harriet – that cynical opinion is an opinion based upon many years of working with insurance companies and the many, many discussions with a good many other practitioners, mostly MD’s and DO’s. It is interesting that you say consensus because some of the ones I have seen called EB-guidelines are nothing more than that, a consensus of opinions, which the vast majority of providers disagree with. Its a big reason why so many are dropping out of private practice. You should know that.

  20. nybgrus says:

    Its a big reason why so many are dropping out of private practice.

    That don’t make no sense, mate. Private practice is where a physician can have the most autonomy to ignore guidelines, evidence, and recommendations. Going anywhere else significantly hinders that autonomy.

    And yes, as Scott very correctly said medical effectiveness and cost effectiveness overlap to a great degree. Following guidelines is simply best practice and those who don’t are deluding themselves by thinking that they know better than the relevant panel of experts whose sole job it was to read and understand the corpus of evidence and synthesize the guidelines. If you think that you have read just as much to be able to contradict the guidelines then the ethically responsible thing to do is demonstrate this to the relevant consensus bodies and make your case. Not pretent to be a cowboy and do whatever you want anyways.

    Not even physicians are immune to the fallacy that they can become supreme experts on a topic by cursoriarily reviewing the literature and then banking on “experience.” Indeed, because of our advanced education it becomes all to easy to have such hubris and forget that in today’s day of modern scientific medicine we are all part of a team which is part of a larger system.

    Of course you wouldn’t find such hubris in fields like aerospace engineering or skyscraper building. And in the rare instances that you do it always leads to disastrous consequences. That is truly the current failing of medicine – this retained and undeserved cowboy-esque superiority complex.

  21. Harriet Hall says:

    @nwtk2007,

    “It is interesting that you say consensus”

    It is interesting that you thought I said that when I didn’t. Makes me wonder if your carelessness in reading is mirrored by a carelessness in forming opinions.

  22. nwtk2007 says:

    nybgrus – “That don’t make no sense, mate. Private practice is where a physician can have the most autonomy to ignore guidelines, evidence, and recommendations. Going anywhere else significantly hinders that autonomy.”

    I don’t know where you practice but it sure as heck isn’t the US with our health insurance companies to deal with. Nor are you dealing with auto liability insurance or workers compensation insurance carriers; at least not the ones which operate here in the US. Speak with anyone in billing and collections for private practice docs in the US and you’ll get the same story. The decrease in collections based upon “best practice” guidelines, EBM guidelines, what ever you want to call it, is driving them out.

  23. WilliamLawrenceUtridge says:

    The point was that the so-called EBM guidelines are just a tool used by insurance companies to deny payment for services rendered; evidence based or not. The effect is wide spread among your people as well, ask just about any practitioner in the healthcare field. That is why folks don’t like EBM/guidelines. In fact, if the EBM guidelines show real evidence for the effectiveness of a procedure, they will just not use that one (they won’t read it) and will use another. OR, they’ll just refuse to acknowledge the evidence.

    I’m quite heartened by the fact that EBM is used to define what an insurance company pays for. Keeps premiums down, I don’t want to subsidize someone else’s homeopathy habit, or (referencing another thread) CCSVI procedure.

    The real issue is, as usual, that someone is insulted or offended because EBM doesn’t favour their personal brand of unproven CAM. Selecting evidence you like, and discarding the evidence you don’t, is indeed a big problem – and doctors are just as vulnerable as the rest of us unless they are scrupulously attentive to the evidence, and intellectually honest enough to admit their beliefs may be incorrect.

    Additionally, when it comes to the efficacy of a procedure being used over another, many times it’ll depend upon the administrators of the facility to put pressure on the docs to use it or not to use it. Once again, evidence based or not.

    Which again underscores the point that people don’t really understand EBM or use it properly. This needs to change, and hopefully it will. The answer is not to make every person’s opinion equal.

    Now if the motivation to tell a doc to use a procedure or not were truly based upon evidence then I doubt the doc would actually mind. But when the motivation is to prevent payment for a service they certainly will balk at it. By the same token, if a doc makes money on a procedure or service then he/she isn’t going to want to have someone tell them it isn’t evidence based and should not be performed.
    Basically, money talks, evidence walks. At least in the real world.

    A common attack of CAM promoters is on the greed of pharmaceutical firms and doctors as motivations. Certainly, corporations as profit-maximizing entities are strongly motivated by money. Doctors are as well, and fortunately they tend to be well remunerated for their services. And certainly it would be nice to have a fee or remuneration strategy that favours positive outcomes and following EBM guidelines. But your bare assertion that doctors care more about money than they do patients is quite insulting, and little more than a talking point. Do you have any indication or, even better, evidence that doctors kill patients with more expensive procedures beyond your mere assertion? If you don’t, perhaps you shouldn’t make such an insulting claim merely because you falsely believe it happens to justify your pet unproven beliefs.

  24. WilliamLawrenceUtridge says:

    Dr. Crislip:

    I live to disappoint.
    They were a fun (audible) read and a good anodyne to the technical reading and intensity of a day of work

    There are innumerable better books in the genre. Brandon Sanderson’s Mistborn trilogy I am reading a second time, Terry Pratchett’s Diskworld series is always awesome, and F. Paul Wilson’s Nights Dawn series has a whole mess o’ violence and dirty bits to entertain and amaze. Paolini’s just so…badly written. If you took away that boy’s thesaurus, I’m sure the books would be a good third shorter.

    It’s like finding out one of your favourite actors are Scientologists :)

    You don’t read L. Ron Hubbard, do you? If you do – please lie about it…

  25. @nwtk2007, I’m rather confused that you believe you can speak authoritatively in regards to how doctors practice, when you yourself are not a doctor. I’m further confused by some of your statements, because the vast majority of your profession is based around charging people for things that have either never been shown to be effective, or have been shown to be ineffective. Perhaps you are deluding yourself in order to drown out some of the guilt you feel for practicing shady and shameful “medicine.” You know, “Hey, the real doctors do it, so I can do it too.”

  26. @nwtk2007,

    By the same token, if a doc makes money on a procedure or service then he/she isn’t going to want to have someone tell them it isn’t evidence based and should not be performed.

    Let’s cut to the chase and be completely honest. Doesn’t this represent about 98% of what chiropractors do, 99.99% of what naturopaths do, and 100% of what acupuncturists do?

  27. nwtk2007 says:

    @William, where oh where did I assert that doctors kill patients with more expensive procedures.

    @skeptical, I am much more familiar with the medical profession than I am the chiropractic community. I find it amazing that the commentators here are so out of touch with regular practice. Perhaps you should come off Mt Olympus and get to know the real world.

    Incidentally, I don’t think doctors care more about money than their patients or their care but they are ever finding that they are paid less by insurance companies who use the excuse, not always but quite often, that the treatment is not medically necessary based upon some guideline which is taken to be evidence based. At other times it is just an adjustor with no training what so ever, or a nurse, making the claim, citing EBM and denying payment.

    Just read a bit feller’s. Ya’ll are in need of educat’in.

    This might actually be why there are so few MD’s who like this blog. You sometimes just don’t get it, do you? I guess you fit in where you get in.

  28. nybgrus says:

    as usual chock full of assertions without any basis in reality nor evidence to back them up. There are so few MDs who like this blog? Care to tell us what part of your ass you pulled that particular bit of info from? Or do you have access to site statistics that nobody else does and which somehow track the credentials of the commenters?

    But as for your attempted refutation of my previous point… I didn’t say that private practice necessarily offers complete and utter autonomy to do as you wish. But it is certainly more free than any alternative – i.e. working for a large hospital corporation as an employed physician. In private practice you can do whatever you can get paid for and that means whatever you can get away getting paid for – cash, insurance, or both.

    In a large system you have pretty good oversight and an actual boss that can censure you for inappropriate practice and billing. In private practice the worst that can happen is you dont get paid (well, unless you are committing outright fraud of course). But elsewhere you can get censured or even fired for disregarding guidelines established by your employer.

    And yes, I would imagine it would be more difficult to get insurance companies to reimburse quackery and frivolous treatments as a DC “treating” all kinds of chronic back pain and non-existent conditions. And if you treat ashthma, colic, and enuresis with a back cracking… yeah, guidelines would reasonably say not to reimburse. Duh.

  29. Heh. I always appreciate when someone spams a bunch of links without actually reading them. I only clicked the last one that you posted, on kevinmd.com. The very brief post essentially said that doctor salaries aren’t what they used to be because new doctors don’t want to work as hard as they did in the “old days.”

    I don’t see how that supports your argument.

    However, it does create a nice segway for the people here who practice legitimate medicine:

    In our area, our hospitals used to require any doctor who had privileges there to take call, so that every speciality was covered at all times. For people of some specialities, ie orthopedics, neurosurgery, etc, this sometimes lead to rather brutal lifestyles. However, a loophole was found and now doctors are no longer required to be on call, and this has lead to some rather inconvenient gaps and poorer quality of care.

    An example: we have two neurosurgeons in our area. They split call, so that they are only on call weekday nights for 2 weeks, and then the other one takes over for the same call schedule. Some weeks there is no neurosurgery on call. No neurosurgery on call on the weekends ever. So a stroke patient comes to our ER. CT head leads us to believe its ischemic. What’s the next step in treatment if it’s within the time frame? Right. Well, we don’t do it. Why? Because if the patient starts bleeding into their brain, we don’t have a neurosurgeon to call to see the patient immediately.

    In fact, we have been trying to arrange a city-wide protocol for stroke patients to be air-lifted to our biggest neighbor city that has neurosurgeons on call 24/7. How pathetic is it that we can’t provide standard-of-care for stroke patients because we don’t have enough neurosurgeons on call?

    It’s easy for us to sit there and bad-mouth these extremely intelligent doctors because they don’t want to work too hard. But, at the same time, can you imagine that you finally finished medical school, and you finally finished a brutal residency, and now you just want to practice, but a hospital is trying to strong-arm you into sharing call with 1 other doctor? That absolutely sucks. They shouldn’t be forced to be on call, but at the same time we can’t provide the best care to our patients because they don’t want to take the brutal call schedules that were expected years ago.

    It’s rough. It’s easy to forget that doctors have lives, and want to spend time at home with their families.

  30. ^ that was for nwetk2007, not nybgrus.

  31. PJLandis says:

    None of those articles cited above by nwtk2007 say anything about EBM/SBM guidelines causing doctors to leave private practice; they all refer to insurance costs, low reimbursement, and one references insurance companies dictating treatment options. I’ve never heard anyone on this blog ever recommend turning evaluations of the best evidence available into step-by-step how-to manuals.

    You might be able to twist that last one into a condemnation of EBM/SBM, but that would apply to any attempt to determine best practices. It’s a classic example of throwing the baby out with the bathwater. Misuse of EBM/SBM evidence doesn’t make them any less useful.

    I’m not sure why complaints about insurance practices have turned into a backlash against SBM.

  32. The insurance companies no doubt make it harder and harder to make a good living. Let’s consider this example: Medicaid patient comes into the office with a broken foot. You take the x-ray and diagnose it. You have boots in the office that would be perfect for the patient (if anyone has broken a foot, you know how much better a boot is than a cast, a cast is miserable, and a boot you can at least take off for bathing, etc.) Medicaid will not allow you to fit the patient with a boot and bill for the boot. In fact, they won’t even reimburse you for the cast you end up having to put on. The doctor eats the cost of the cast once the diagnosis of the broken foot is made. If you want the patient to get a boot, you have to send them to a medical supply company and it will take about 6 weeks for approval for the boot. How long do you think it takes a bone to heal? Right…

    That’s f-ed up.

    Or: a patient comes in complaining of joint pain that should respond to an intra-articular steroid injection. Medicaid will pay for either the office visit, or the injection, but not both. So if I want to treat my patient, I have to eat the cost of the steroid, anesthetic, and syringe.

    Or: if I own any part of a MRI facility, I am not allowed to send patients to it, because I’m treated like a criminal and I “may” be inclined to send patients there unnecessarily just to make more money. Meanwhile, quack chiropractors can run and operate their own x-ray machines, despite the indisputable fact that they are unable to treat any condition that is diagnosed by x-ray, and they have infinitely less training on how to operate an x-ray machine than an x-ray tech (which I have to hire and pay a nice salary to.)

    So yes, it is true that it is more difficult than it used to be to make money when dealing with some insurances.

    Do you know what the usual answer is for doctors when faced with the difficulties of Medicaid? Just don’t accept it. So the government, in their “infinite wisdom” of trying to give health care to the poor ends up f-ing them out of healthcare. In our area, if you want to see a neurosurgeon on Medicaid, good luck. You’re going to be traveling over a hundred miles. Ortho? There’s one within 120 miles. Neuro? Maybe 1, but it’s over 80 miles from here. Even family medicine? There’s only a few in the area. Good luck getting in.

    The (rustichealthy) conspiracy-theorist cynic in me wonders if the government purposefully makes Medicaid horrible to deal with so that more and more doctors will drop in so that the government doesn’t have to pay for healthcare.

    … Let’s not even get into the whole thing about how a typical Medicaid patient is more of a headache than a typical non-Medicaid patient. (Dr. Hall -> the only time we’ve ever exchanged nasty words was re: Medicaid patients, please I respect you so much, let’s not go down that road again.)

    So yeah, there is potential for less money to be made in private practice, for sure. But it’s not due to “having to adhere to EBM guidelines”, it’s due to decreasing insurance reimbursements, etc, due to things like crappy doctors accepting lower and lower contracts just to get patients, etc [Think: a crappy doctor that doesn't get patients, accepts a lower reimbursement from insurance companies, and then these insurance companies offer lower rates, and then these doctors are what are offered to their customers. Now other doctors end up having to compete with these low-ball prices from a crap doctor.] There’s a great book that talks about the things that set all of this off.

    Fortunately, there are more than enough patients out there, and the vast majority of doctors don’t have to accept Medicaid and are still booked solid. That sucks for Medicaid patients, but it’s the governments fault. I’ll leave the rest of the political discussion out of it.

  33. nwtk2007 says:

    Sad that your bias is so strong such as to limit your thinking. Also sad that you are such croney’s for the insurance scam using evidence based medicine to deny your bill.

    Health insurance companies and HMOs will review your claim or pre-certification request to determine if the treatment is “medically necessary.” based upon EBM guidelines. If the insurance company or HMO determines the treatment is not medically necessary, it will deny the pre-certification request, or deny or reduce payment for the claim. Its that simple.

    Even if you get a peer review done, it will be a doctor of the insurance companies choosing. Simple fact: if a peer reviewer puts is/her stamp of approval on too many procedures, he/she won’t be a peer reviewer much longer.

    Your eyes are wide shut and you have bought into the insurance scheme. They control you.

  34. nwtk2007 says:

    PJLandis – “None of those articles cited above by nwtk2007 say anything about EBM/SBM guidelines causing doctors to leave private practice; they all refer to insurance costs, low reimbursement, and one references insurance companies dictating treatment options.”

    Insurance costs referred to are usually malpractice costs. Reimbursement is often reduced if a procedure is considered not-medically-necessary (based upon EB-guidelines), and insurance companies dictate treatment by denying payment for what they consider not-medically-necessary (based upon EB-guidelines). Additionally, they don’t cover certain procedures based upon EB-guidelines.

    EBM guidelines are their tool to deny, delay and defend. Its their mantra. The articles don’t use the term EBM or evidence based guidelines, but they are at the heart of what they do.

    Some guidelines are, as was stated, just a consensus of opinion or even a summary of averages of procedures performed, so to speak. Thus if a doc goes over the average, there is denial. The next set of guidelines are based upon newer averages, which are now lower because anything form the previous year which went over the average was denied. Thus in each consecutive year the allowed treatments will be decreased.

    The myth of lower costs being equated with more efficient care or more “best-practice” is BS. The insurance companies know this. They read comments like the ones here and laugh all the way to the bank. They have you so in their “good hands”.

  35. nybgrus says:

    a chiro and a conspiracy theorist. it just keeps getting better and better :-D

    EB guidelines – while not perfect – are a reflection of best practice. The best way to get physicians to actually practice best practice is to not pay them when they step outside that practice. In other words, you aren’t being denied payment because Big Insurance wants to save money but because you shouldn’t have been doing [X] in the first place.

    Of course, reasonable people can argue what the guidelines should say and there are indeed examples of where they are poorly written and implemented. I’m not about to argue that. But the principle behind the application is perfectly valid.

  36. nwtk2007 says:

    Conspiracy? Its a fact sir.

    You say the insurance companies aren’t denying payment because they want to save money? I am LMAO!! Truly.

    Only a peer review doctor would actually claim to believe that, not that they really do.

  37. nybgrus says:

    coming from someone who claims there are plenty of “facts” to support chiropractic as a valid therapeutic modality… and at the same time denies facts that chiro schools are still teaching rank quackery….

    yep. you’re just chock full o’ great facts :-D

  38. @nwtk2007, nybgrus is still a med student. He has little, if any, experience dealing with insurance companies. In my experience, US med students get zero experience in billing & coding, and we get the basics during residency training, only bc we had to bill the pts for the program.

    I personally do not believe that every decision made by a high schooler at an insurance company is made directly off EBM guidelines. If this were true chiropractic would not be covered whatsoever.

    In fact, insurance companies will regularly pay for the cheaper but not quite as good item instead of the better more expensive item. I gave a great example above re: booting a broken foot. They won’t pay the doctor for the boot, but they will approve and pay for the boot if the patient brings the prescription to a med supply company… after six weeks, by which time the bone is already healed. So doc is left to cover the cost of casting (which sucks) the bone themselves. Can you imagine the media outage if a patient had simple bone fx and left an ortho’s office w/out a cast and was told to wait six weeks for the boot to be approved?

    Further, in fact, many medical decisions are made without a strong EBM guideline. Interesting discussion in hospital few days ago among multiple disciplines. Everybody knows LAC therapy for H pylori. Well, new data (look on UpToDate) finds LOAD therapy has higher cure rates, but is more expensive (I believe due to Alinia) than LAC. But we don’t know if it’s cost effective (greater cure rate means less repeat testing and treatment) and nobody had experience with dealing w/ insurance companies for them providing coverage.

    Or… Pradaxa, a direct thrombin inhibitor, is a great replacement for Warfarin bc you don’t have to screw around with keeping the INR therapeutic (but can’t reverse w Vit K). It’s expensive. It’s FDA approved for anti coagulation in Afib pts to prevent stroke, but not yet approved for DVT prophylaxis (it is in Canada). So this drug is likely safer than warfarin for DVT pts, but bc we haven’t yet done a study on it for this case, or bc of FDA approval (I dontvknow) it has to be prescribed off label and the pt would have to pay for it.

    Oh, and all this talk about doctors “getting paid”: if the insurance doesn’t pay cost is passed on to the patient. Wife recently switched PCPs and he ran a slew of unnecessary lab work (I was livid.). We got stuck paying the path lab for the tests.

    So, it really goes both ways. If you do unnecessary crap then the insurance companies don’t pay, and they shouldn’t bc (in theory) that raises cost of health care. The doc should let the pt know ahead of time and if the pt wants the test then by all means go for it. At the same time, insurance companies are ridiculously stupid and are a nightmare to deal with. It’s not one or the other, it’s both. And more.

    Sorry for the horrible style of this post. It was typed with one finger on iPad.

  39. ^ nwrk, if any of the medical jargon above confuses bc you only pretend to be a doctor, let me know ;)

  40. WilliamLawrenceUtridge says:

    @William, where oh where did I assert that doctors kill patients with more expensive procedures.

    nwtk2007, my comment was prompted by this part of yours:

    By the same token, if a doc makes money on a procedure or service then he/she isn’t going to want to have someone tell them it isn’t evidence based and should not be performed.

    Your comment implied that doctors would harm their patients if it increased their incomes – i.e. that the treatments doctors choose are motivated by greed. I simply can’t see any other way to read it

    The overall point of Dr. Crislip’s post, as I read it, is that doctors are more willing to select treatments based on biases due to familiarity and experience – not greed. While Dr. Crislip is asserting the quite understandable idea that doctors are just as vulnerable to blind spots and cognitive biases as anyone else, your far more offensive assertion is that doctors will ignore evidence in favour of remuneration.

    Please, correct me if I’m wrong. And if you continue to insist that doctors are willing to harm patients to increase their income, please provide evidence for that assertion. And though it’s more than a little tu quoque, aren’t you a proponent of chiropractic? With a much shakier evidence base for pretty much everything but musculoskeletal complaints? Do you think chiropractors can treat things like infectious diseases?

  41. nwtk2007 says:

    @William, my comment doesn’t imply even remotely that a doctor would harm a patient to increase their incomes. It simply meant that some docs, not many, always prescribe “that which they do”, thus they might be opposed to having someone telling them that “what they do” isn’t medically necessary. In the context of what I was talking about, that is all it meant.

    @ skeptical, I only pretend to be a doc in the examination and case management process. (Insert smiley face here.) Most of the time I pretend more or less to be a PT/exercise physiologist/etc. Occasionally I pretend to be a chiropractor, too. Manipulation is a part of my bag of tricks as well you know.

    Now as to being confused by the complex medical examples you have provided, well I’ll have my daughter translate it for me this afternoon in between her discussions of anime and discover channel shows. Of course I’ll have to pry my eyes away from the Le Mans coverage on the old boob tube…or US Open, or some other such as I will indulge myself in between yard work and the house work us single dads get to do so much of.

    I quite agree with you, at least the point you make regarding costs and informing the patient regarding what the ins will cover and what it is they won’t.

    @William, as to being more offensive than Dr Crislip, well, I plead guilty from experience. But admittedly, I’ve seen it go both ways and by far and away the majority are the good kind who want to do the right thing for their patients despite the remuneration factor.

    But basically, Dr Crislip concluded that docs just don’t like to be told what to do. I would simply add to that; docs don’t like having EBM guidelines being used to cancel the remuneration for their services and probably feel that they are better off without giving insurance companies that type of ammunition which they abuse to the nth degree as regards to denial of said remuneration. (Of course remuneration probably the wrong word to use here as it imply’s pay from an employer and docs certainly don’t work for the ins company.)

  42. WilliamLawrenceUtridge says:

    nwtk2007, this is a direct quote of your statement, with emphasis added:

    By the same token, if a doc makes money on a procedure or service then he/she isn’t going to want to have someone tell them it isn’t evidence based and should not be performed.

    Perhaps to you it doesn’t read like you’re accusing doctors of putting greed before health. To me, it very much does. I don’t know how else to read the bolded section.

    If you find your doctors less than impressive, you could have a series of bad doctors. However, your discussions on this board also suggest a rather large chip on your shoulder against the medical system.

    Another question – aren’t you a chiropractor, or training to be one? Are you planning on giving away your services for free? Because otherwise, calling out doctors for being remunerated is more than a little hypocritical.

    If you’re genuinely concerned about remuneration for non-EBM services, perhaps you could advocate your state representatives require insurance companies to reimburse doctors better for adhering to EBM guidelines. I can only see this as a good thing, though it may erode the reimbursement of chiropractors as well since most of their interventions are not particularly strong in terms of evidence.

  43. nybgrus says:

    @skeptical:

    yes, you are correct. Hence why my discussion on the topic was more academic/theoretical. I do not know exactly how insurance companies decide reimbursement schemes nor how effectively those are implemented. I have heard many bad things and hoops to jump through, but I have also seen cases where the hoop is one that shouldn’t be jumped through (i.e. the doc really shouldn’t have been ordering that test/drug because it wasn’t indicated and was complaining that the insurance wouldn’t let him do it unless he changed the coding for the visit).

    In that sense, I am referring to an idealized situation. The evidence base is not only the best, but really the only way to have an efficient and effective medical system. If genuinely good guidelines based on solid evidence are developed and then implemented in an intellectually honest manner (yes, I know I am already asking a lot) then that will de facto lead to a better and cheaper medical system. That will also lead to many doctors who once did it “their way” and “used experience” to make decisions will suddenly find their decisions and therapies are longer reimbursed. It is these guys that would buck against it and say the system is bankrupt and it is those that I am referring to.

    Hope that clears up my point and my perspective on the topic.

  44. BillyJoe says:

    nwtk: “Now as to being confused by the complex medical examples you have provided, well I’ll have my daughter translate it for me this afternoon in between her discussions of anime and discover channel shows.”

    Funny, I was thinking the same thing. |:
    [There's a double entendre in there for you, Skep. I hope you're up to it. O:]

  45. nwtk2007 says:

    Here’s the thing nybgrus, insurance companies shouldn’t decide reimbursement schemes. Are you, a doctor, going to let a HS grad or nurse, for that matter, decide the medical necessity of your treatments? Do you actually trust their interpretation of evidence regarding your care of a patient? And why are the “hoops” there to begin with?

    One thing though, the patient is ultimately responsible for their medical bills. They don’t seem to understand that.

    And BJ, I don’t think he’ll get it.

  46. Harriet Hall says:

    Insurance companies have to decide what to reimburse, otherwise they’d have to pay for anything and everything and costs would go through the roof. HS grads may be the ones who apply the guidelines to individual claims, but I think it is people with medical expertise who evaluate the scientific evidence to determine which procedures are medically indicated and to formulate the guidelines in the first place. If their decisions are faulty, that’s a problem; but it doesn’t invalidate the principle of basing decisions about effectiveness on adequate evidence. Is there a better way?

  47. PJLandis says:

    So…We need to hide all the good evidence from the insurance companies? Or prevent insurance companies from deciding what they can pay for because they’re not all doctors? Even worse, everything on this blog is just innocent, yet dangerous, support for corrupt insurance companies!

    These sounds like the type of criticisms of EBM and insurance that a chiropractor would come up with.

  48. mousethatroared says:

    Really wonderful article, Mark Crislip. A pleasure to read.

    DU2 – apparently we are the same age and you are spot on.

    Regarding Rork – David Gorski exchange. Reading the comments on this blog (a bias selection) It seems to me that many of the Med students that are into SBM feel they are rebeling against the establishment/teacher’s who rely upon anecdotal evidence, or endorse CAM practices. So, another generation of rebels that may influence the practice of medicine with their anti-establishment tendencies. :)

    Insurance companies – arghh, It seems if they really used evidence for their payment decisions, their decisions would make more sense. Of course there’s a lot of times that they are evidence based and their decisions make sense. It’s just that the exceptions are so very glaring.

    Not being a medical person, I can’t add my own specialty to the intellectual hierarchy. Being a parent I will say…in my experience, pediatricians and pediatric specialists are at or near the top of the communication skills hierarchy, and good communications skills make you seem more intelligent, at the very least.

  49. nybgrus says:

    It is clear that insurance companies do not base all of their guidelines and reimbursement scheme on the evidence. If they did they would not require plain film x-rays prior to MRI for patients with low back pain persisting for greater than 6 weeks and radiating to the extremities. They also would not reimburse for CAM treatments. And they also would not reimburse for a full yearly physical, as Dr. Hall’s article discussed.

    Sometimes they just go with a “one size fits all approach” because from a business standpoint that makes more sense. Allowing for HS grads to have to make choices – such as the exemption to the “plain film first” rule – means that you have an extra source for potential money loss. Either you will get people incapable of making such decisions making lots of bad ones, or you will have to pay much more money to train better people and then pay them a higher salary. Costs are contained by limiting choices and approximating the evidence so that the HS grads that nwtk is maligning can perform their jobs.

    Sometimes they reimburse based purely on marketing. Offering payments for Reiki or reflexology will not provide any health benefit to the patient and will only serve to spend more money. Anybody with half a brain should know that. But it is offered because then more people will buy the insurance because people like the “extra” coverage. Sometimes it is offered as a total package to seem more attractive from a PR front, sometimes it is offered as a paid extra coverage for those who are woo inclined. Either way it has nothing to do with evidence and everything to do with PR.

    And sometimes it is because they haven’t caught up with the latest evidence. And in this case, probably PR as well. “You mean I can’t get a full physical every year??”

    As Dr. Hall said, the principle of using evidence to guide medical reimbursement is solid. The application becomes muddied because insurance companies want to make money and there are ways to do so that do not involve strictly following evidence.

  50. weing says:

    Insurances are mainly about making money and not keeping down costs. They get to keep 15-20% of the collected premiums for themselves. If the cost of care rises, they just jack up the premiums. They then get to keep 15-20% of a larger amount.

  51. nybgrus says:

    @weing:

    So succinct. I like it. LOL

  52. nwtk2007 says:

    Interesting comments. I would point out that it is not maligning HS grads to say that they should not be denying payment for services based upon lack of medical necessity or lack of evidence. No doctor on the planet will accept that as well they shouldn’t. Nor should it be a doctor who has never seen or examined your patient.

    Can there be a better system, absolutely, and there should be. Let evidence determine what can be ultimately covered but the doctor has to be the one deciding medical necessity since he/she would be the one on the hook for not performing procedures needed that are medically necessary. The reason being, if a procedure is not performed due to insurance denial (based upon EBM) or even EBM guidelines which suggest delay of a procedure and the patient suffers for it, it won’t be the insurance company who is now liable for malpractice.

    Additionally, the medical community needs to get united on there willingness or not, to accept lower and lower reimbursements on insurance plans. It should be noted that in most states, the occupations codes for the medical professions do not allow clinics to waive deductibles or patient cash responsibilities such as co-pays. Although I doubt the medical community will unite on the use of EBM guidelines, they could at least unite in their willingness or unwillingness to have insurance companies continue to reduce reimbursement all the while increasing their premiums.

  53. nwtk2007 says:

    One additional point, if an insurance company wants to provide coverage for CAM procedures then in today’s world, that’s their business. It would be up to the medical community to educate their doctors regarding the validity or lack thereof for different treatments. It would seem that the medical community is willing to defer to the insurance companies in this regard.

  54. @nwtk2007, so what you’re saying is that legitimate medicine should be held to a different standard than CAM? Ie, one is held to evidence-based standards, and the other, CAM, is held to the whim of the insurance company. Yeah, I can see that. Thank you for admitting and pointing out that your field is bogus and that you knowingly and willfully rob and steal from the sick and dying.

  55. nwtk2007 says:

    In so far as saying that “my field” is bogus. Sure, portions of all healthcare are bogus. The debate about bogosoty does not begin or end with your opinion alone. Nor does it mine.

    In your bias and slant against all things chiropractic you fail to see the point. Insurance companies can cover anything they wish for what ever reason. An addition to what I have been saying; they can accept or ignore evidence as the see fit. No matter the evidence or lack there of, if a policy doesn’t cover certain things then it just doesn’t.

  56. nybgrus says:

    Let evidence determine what can be ultimately covered but the doctor has to be the one deciding medical necessity since he/she would be the one on the hook for not performing procedures needed that are medically necessary.

    The point is that the evidence decides what is medically necessary. It is nonsensical to say that the evidence decides what gets paid for but that the doctor magically thinks his way into it being medically necessary when there is no evidence for it. That is the whole point of this discussion and what Dr. Hall was trying to say. Medical reimbursement based on evidence means that what is medically necessary is reimbursed and vice versa.

    In your bias and slant against all things chiropractic you fail to see the point.

    There is no bias against chiropractic. There is no evidence to support it and much evidence to show that the vast majority of it is useless at best and harmful at times.

    Insurance companies can cover anything they wish for what ever reason. An addition to what I have been saying; they can accept or ignore evidence as the see fit.

    I absolutely agree with you here. The nuance I would add is that private insurance should do just that. Public insurance, like medicare, should not. It should be entirely governed by evidence.

  57. nwtk2007 says:

    nybgrus, you fail to distinguish between medical necessity and effective care which is based upon evidence. Medical necessity is determined by the situation. The doctor decides upon a treatment plan based upon what he perceives as what is medically necessary. And, in theory, the doctor will utilize procedures and treatments which have been shown to be supported by evidence (studies AND anecdotal evidence).

    As to evidence determining what is covered, it just seems like insurance companies might want to cover procedures which have been proven to be supported by evidence, or not; its their choice. Interesting your comment about medicare. Who would decide what is supported by evidence and what is not. It will be difficult to stop corrupt politics from entering into this, ie – http://www.alternet.org/story/141875/obama%27s_deal_with_big_pharma/ I would venture to say that a consensus of MD’s on the efficacy of all procedures performed by all medical sciences would contain a broad spectrum of procedures and treatments which some would say are supported by no evidence at all.

    And I’ll not go into the evidence for chiropractic. Chiropractic is NOT just manipulation. Sorry but that’s a fact. Its true that much of what some chiro’s do is not supported by evidence while much of what other chiro’s do IS supported by evidence (physical modalities, both passive and active). The bias I refer to is the attitude born of seeing anything what-so-ever done by a chiro as being not supported by evidence. It just ain’t so. Just the word chiropractor raises the hair on skepticalhealth’s skin.

  58. nybgrus says:

    you fail to distinguish between medical necessity and effective care which is based upon evidence

    No, you fail to see that they are the same thing.

    A medically necessary treatment cannot lack evidence. In some cases, that evidence may be stronger than in others. In outpatient settings – and especially in primary care settings – the preponderance should have strong evidence. In extremely rare, extreme, or acute cases evidence may be thinner and clinical judgement may take a larger role. However, even then clinical judgement must be based in some sort of… yup, you guess it! Evidence. Biological plausibility at a minimu is necessary.

    Mere anecdote is not enough. And anecdote can certainly not determine medical necessity.

    So yes, I am aware that medical necessity is based on the situation. That is why guidelines govern the situation and therapy. It is not just “Giving morphine works” as a guideline. There are many variables to take into account when giving morphine… all of them evidence based and with guidelines.

    As for who should decide? Legitimately science based professional bodies. The USPTF for instance. Or the professional bodies of the various specialties of medicine. A complete literature review should be done, balanced with prior plausibility, and then guidelines issued.

    Things like CAM and the vast majority of chiropractic simply would not meet that criteria and thus should not, by definition, be included in guidelines.

    And yes, I am aware that not all of chiro is manipulation. It has become evident to me throughout the course of the past year that I am likely more well versed in what chiro actually is than most of the chiropractors here. The core of it is manipulation, the evidence based components are exceedingly small, and the rest of it is all special pleading for continuing to do whatever it is y’all want to and hoping that someday, maybe, the evidence will catch up.

    I don’t get my hackles up over it like Skeptical, but he really isn’t terribly far off the mark.

    Oh, and before you tell me that you aren’t like that… well, I’m not talking about you. I’m talking about the field of chiropractic. And if you aren’t practicing the quackery that is most of chiro, then you are either doing extremely little and/or going well outside your scope of “practice” as it were.

  59. PJLandis says:

    Just for my curiosity, if a Chiropractor isn’t basing his practice on the concept of subluxations then isn’t that just a physical therapist or something similar?

  60. nwtk2007 says:

    @nygbrus, I was responding to your comment, “The point is that the evidence decides what is medically necessary. It is nonsensical to say that the evidence decides what gets paid for but that the doctor magically thinks his way into it being medically necessary when there is no evidence for it. That is the whole point of this discussion and what Dr. Hall was trying to say. Medical reimbursement based on evidence means that what is medically necessary is reimbursed and vice versa.”

    Read the first sentence. Also, I said evidence should determine what is covered by a policy and that the doctor should decide medical necessity, not an insurance company. I also pointed out that insurance companies will use any guidelines against the doctor. In other words they will force the doctor to adhere to the nth degree of the guidelines, or take the guidelines out of context to deny payment. They will refuse to acknowledge any situation which might go beyond the guidelines allowances also. Thus with each passing year, less and less will be allowed (paid for). Which goes to my original point of why many doctors don’t like guidelines. I really don’t think a doctor should have to argue medical necessity with an insurance company.

    @PJ, yes, ultimately chiro’s are essentially a PT.

  61. @nwtk2007, chiropractors are PTs in the same way that nurses are doctors. You cannot say that you are “essentially a PT” because you don’t have the same quality of training as a PT. First of all, you are statistically lower quality students. You have less training on physical therapy treatment modalities than PTs do. This is an indisputable fact because chiropractic school wastes semesters on things like x-rays, subluxations, and all sorts of other crap. So, your statement should have read “ultimately chiro’s are crappy PTs who also practice quackery and pretend to be a doctor.” It’s rather pathetic that chiropractic, which is by definition a quack profession that attempts to correct spinal subluxations, has been relegated to being an extremely low quality PT. Boy, I bet you wish you could go back in time and choose a different profession.

  62. WilliamLawrenceUtridge says:

    nwtk2007, are you a chiropractor or chiropractor in training? You may have mentioned it in the past, I don’t remember.

    If so, and you believe chiropractors are physiotherapists, why did you enter chiropractics instead of physiotherapy?

  63. nwtk2007 says:

    @William, I have been a chiro since 1994. As to why I went into it, well, I can blame a PT. No kidding. An old girl friend of mine became a PT back in the 80′s and was the one who recommended chiro to me. In her opinion, based upon what she had seen and experienced, the chiros could do pretty much all they, the PT’s, could do, at least in terms of physical medicine, but are not dependent upon a referral from MD’s, whom she had a bit of a low opinion of. At the time I was looking at the PT schools in the area as I was a teacher looking to do something different. The PT schools I spoke to were very uppity, so to speak; had their noses in the air (an attitude I have seen continuously over the years). Both schools came up with problems in my prereq’s. I have 17 hours of psychology and 18 of statistics, but no class specifically called abnormal psych and no class called general statistics. One school waved the stats requirement and the other waived the psych requirement. To make a long story short, that combined with the recommendation from my PT friend, lead me to DC school.

    @skeptical, don’t even go there. You appear to be very smart and knowledgeable but on this you are very much mistaken. There are obviously some things PT’s are schooled on that chiro’s are not and in those arena’s, they own it; things such as debridement, which are not in our scope of practice. But in the arena of physical medicine ie – rehab, passive and active modalities, work hardening/conditioning, etc. I think we have’em. At least the docs I have worked with and myself do. Now do I wish I had decided on a different profession, well, that’s another story. I occasionally wish that I had just stuck with teaching but then, I still teach at a local community college. Or, I could have just gone med school but at the time I was in my late 30′s and it seemed a bit of a long education process at that age. I do wish there weren’t so many quackey chiro’s out there. But after working with so many MD’s I have come to realize that quackery is not limited to chiroville. Many a maroon walk the street with the MD moniker.

  64. WilliamLawrenceUtridge says:

    nwtk2007, what do you think of:
    - subluxations
    - vaccination
    - drugs
    - surgery
    - homeopathy
    - innate intelligence

  65. nwtk2007 says:

    Is this an application?

    Subluxations – silliness in terms of inhibiting the flow of innate intelligence (more silliness)

    Vaccination – a necessary evil, but who knows the final answer on that one. My kids were vaccinated as was I. I was told the paralysis and autism was only temporary. I’m still waiting.

    drugs – not just for breakfast anymore.

    surgery – love it. I do free-lace as well as gynecology.

    homeopathy – I don’t see any reason to be afraid of them. Oh that’s phobia. Ok, also nonsense unless pure water can cure me and carry a reverse image of molecular structures…which it can’t.

    innate intelligence – better than outnate intelligence

  66. WilliamLawrenceUtridge says:

    I’m asking because a lot of people paint all chiropractors with the same nutter brush, but your comments in the past has led me to believe you might be what you said earlier – basically a physiotherapist. Your rejection of the two main forms of chiroquackery (subluxations and innate intelligence) reinforce this fact. Since your replies for most of the other terms are pretty flippant as well as deliberately obscure and allusive, it’s hard to tell what else you think.

    You spend a lot of time lecturing other commentors here, and those commentors spend a lot of time lecturing back. Most seem to lump all chiros into the same bucket – subluxation-believing woomeisters. My inkling was you weren’t in this bucket, you were in a “chiros are flavours of physios” bucket.

    This further reinforces the fact that I don’t see much need in engaging with you – you’ve discarded the worst offences of your profession. I think you spend a lot of time defending bad company (since chiros are responsible for a lot of antiscientific claims). I think you’d be better off taking an approach similar to Sam Homola and advocating for a renaissance of the profession as physical manipulation specialists focussing on back pain. I think your arguments would benefit from the recognition that a lot of your peers do believe in a lot of crap, and that your profession could use an enormous change in focus. But since your arguments seem to rely on fairly valid interpretations of evidence rather than rhetorical devices and poor logic, I’m fairly uninterested in taking them apart or digging further.

    And with that, I leave this discussion.

  67. nwtk2007 says:

    True, flippancy runs in the family. And I don’t mean to lecture but I just feel the need to set things straight from time to time. Its really the only thing that draws me into any discussion here. If I can’t add something I stay out of it.

    The members here are very into “engaging” the chiro’s. In their engagements they do, indeed, use a broad brush. I think it might surprise you to know some of their connections to chiropractic. Some appear on other anti-chiro sites, like they’re obsessed with the notion of ridding the world of chiropractic and refuse to acknowledge that all are not total quacks. Some are former chiro’s or former chiro students. I won’t name names and to be honest, I haven’t seen those around this blog much of late.

    I doubt I could limit myself to just lower back pain as old Sam does but I do honestly wish the “straights” out there would just go away. I do find it interesting that such a huge portion of the medical world are embracing so much of what they call CAM. I don’t think It’ll last though.

    Anyway, thanks for the quiz. Sorry to be so allusive regarding some of the topics but I think I was clear on the pertinent ones.

  68. nybgrus says:

    There is a reason to paint the broad brush – chiro is quackery. The accepted fundamental basis is still subluxation, the professional bodies representing the field still demand inclusion of subluxation, courses are still taught on it in every DC school examined, and the licensing exam includes subluxation theory questions and even an add on exam for acupuncture. The vast majority out there are indeed chiroquacks as well.

    The point being is that it is not wrong to call chiro quackery – it is. By calling yourself a chiro and defending the degree, but saying you aren’t “one of those” chiros and actually practice evidence based medicine, you are basically making the same argument as saying that you went to voodoo shaman school, defending the degree, but saying you aren’t “one of those” voodoo shamans and you actually practice evidence based medicine. There is a discongruence in what the degree actually means and what those like you practice.

    It was the same for the osteopaths – they were total quacks as well (and still are in Australia). Here in the US, they reformed their curriculum, did away with all of the really quacky $hit and almost all of the less quacky stuff. And then they actually went and started entering real EBM based residency programs to complete their training. In other words, they became legit.

    That is what your profession needs to do – not keep clinging to subluxations and trying to prove that the stuff you’ve already been doing will actually start to work. And that is why chiros are painted with a broad brush that way – it is genuinely deserved.

  69. WilliamLawrenceUtridge says:

    Nybgrus, while you might be able to say “chiropractic theory is quackery”, you can’t say “all chiropractors are quacks” anymore than you can say all doctors are science-based practitioners. There are exceptions to every rule – Jay Gordon is one, Joe Mercola another, Andrew Weil a third and Dr. Oz a fourth. And Sam Homola who posts here is an exception among chiropractors. The chiropractor I see restricts his practice to primarily muscle and bone compliants as well (though there is still subluxation rhetoric and he does sell vitamins).

    This is why when I have engaged with nwtk2007, I have made a point of asking why s/he doesn’t advocate for cirriculum changes in schools, or a greater separation of “mixers” from “straights“. By treating all chiros as a “straight”, you alienate the mixers. Making the distinction between the two seems a valuable practice.

    But I completely agree with what you propose for the profession as a whole – drop the subluxations and become a branch of physiotherapy.

  70. nybgrus says:

    WLU – the issue being is that there is no way to tell someone like nwtk apart from anyone else with “DC” after his/her name. I am happy making the distinction on an individual level – but that requires actually knowing the specific chiro.

    Correct me if I am wrong, but the purpose if this forum is not to create a list of non-quacky chiros. It is to discuss whether and why the field of chiro is quackery. So when chiros come on here and try and defend chiropractic by citing themselves as being evidence based, that is completely useless dialogue. It does not demonstrate any validity to the field of chiropractic, any more than citing Dr. Oz destroys the entire field of medicine.

    So yes, I am happy to acknowledge that Homola and nwtk are evidence based. And if I knew them in person and could establish a professional rapport with them I might be willing to refer them patients*. But that is not an interesting topic of discussion, as you yourself have pointed out.

    *I say might because quite frankly no matter how well I knew them and how certain I was that they weren’t quacky I would still hesitate. Because my patients won’t have the sophistication to distinguish the minority of evidence based chiros from their quacky brethren. And what if my patient moves? Or finds a cheaper chiro? Or just doesn’t have a good rapport with nwtk? Or any other myriad reasons for my patient to choose a different chiro. Now he/she will reasonably believe that I believe chiro to be a legitimate field and that anyone with DC after his/her name is trustworthy. That is the real reason why I still must paint with a broad brush – the good apples out there simply can’t make up for the bad ones. The profession needs a reboot from the ground up in order to have any chance of legitimacy. Individual efforts are laudable, but ultimately useless.

  71. Scott says:

    While there are exceptions to the rule, it’s not in general feasible for a layperson to tell whether the particular chiropractor they’re talking to is reasonable, or a quack. Which unfortunately means that the reasonable exceptions can’t really be considered viable healthcare options either.

    In order to become credible professionals, the reasonable chiropractors will have to either reform the chiropractic profession by getting rid of the quackery (highly unlikely to happen since the definition of the profession is based on magic AND the great majority of chiropractors are indeed quacks), or establish themselves as an entirely new profession. While is also highly unlikely to happen – there are too many practical obstacles which I doubt need enumeration.

    Chiropractic simply is not salvageable. It’s unfortunate for those who have the degree but are reasonably science-based anyway, but that doesn’t change the facts.

  72. herbalgram11 says:

    to nybgrus: ( “A medically necessary treatment cannot lack evidence. ” )

    Oh, but it does in the allopathic world. Not only is yesterday’s ‘truth,’ or so-called evidence-based medicine, today’s fallacy – just refer to the recent exposé of the antibody-mediated-immunity myth on which vaccination has built its emporium of sham medicine – but, worse, vested interest in medicine and a cult of mumbo-jumbo mystique promotes corruption and fraud that manipulate the truth.

    A good starting point for delving into these netherlands of deliberate obfuscation might be found in Steve Hickey’s & Hilary Roberts’ book,

    “Tarnished Gold – The Sickness of Evidence-based Medicine.”

    There are undoubtedly many honourable people involved in allopathic medicine who have the public’s best interest at heart and who believe they’re acting in the public’s best interest – but medicine should hardly be a trade based on a belief system.

    The proof of the medical pudding should be in the eating, and as far as this is concerned, let’s face it, drugs are not beneficial for biological systems, they do not cure. Nutrition, high-dose nutritional supplements and herbal medicines do.

  73. Chris says:

    So, herbalgram11, what exactly is the proper herbal remedy for hypotension due to obstructive hypertrophic cardiomyopathy?

    Not only is yesterday’s ‘truth,’ or so-called evidence-based medicine, today’s fallacy – just refer to the recent exposé of the antibody-mediated-immunity myth on which vaccination has built its emporium of sham medicine

    And do tell us your plan to prevent measles, with references.

  74. weing says:

    @herbie,

    “the recent exposé of the antibody-mediated-immunity myth on which vaccination has built its emporium of sham medicine”

    I presume you still haven’t read the paper about this and are just quoting someone’s misunderstanding of it. Are you so afraid of reading the actual paper and coming to your own understanding of it? If you have read it and that is your conclusion, then you get an F.

    “The proof of the medical pudding should be in the eating, and as far as this is concerned, let’s face it, drugs are not beneficial for biological systems, they do not cure.”

    They are not beneficial because they do not cure? That’s your criterion for beneficence? Cure?

    “Nutrition, high-dose nutritional supplements and herbal medicines do.”

    Because you say so?

  75. Chris says:

    I wonder if herbie will even try to answer my what happened with measles in one decade question.

  76. Chris says:

    herbalgram11, I just checked the SMB posts that you have commented on. On most of them I posted some simple questions. And on each of those threads you ignore me.

    Why?

  77. weing says:

    I guess herbie also thinks that antibiotics are herbals, or considers them nutritional supplements, or is on the side of bacteria during an infection, as antibiotics are certainly not beneficial for them.

  78. nybgrus says:

    I’ll reiterate, as weing did, that your understanding of the Harvard paper is completely wrong. If you read beyond the abstract you clearly have zero comprehension of it.

    I would say nice try, but all you are able to do is parrot the same inanity so it really wasn’t even a nice try.

  79. WilliamLawrenceUtridge says:

    Herbalgram11, I’m basically re-iterating above points, but with weblinks.

    I was the first person to respond to your post about the mouse study apparently invalidating all vaccination. In a thumbnail sketch, a single study on mice using a single virus doesn’t re-create smallpox, which was wiped out due to vaccination.

    There are undoubtedly many honourable people involved in allopathic medicine who have the public’s best interest at heart

    How kind of you to notice.

    and who believe they’re acting in the public’s best interest – but medicine should hardly be a trade based on a belief system.

    It’s not, it’s based on science, which requires theoretical predictions to be validated based on empirical evidence. “A trade based on a belief system” describes CAM, including herbalism. If herbs have medicinal effects, this can be demonstrated empirically. Further, those effects are based on molecules acting on biological systems. Those molecules can be synthesized or extracted into purer forms that are then rendered more absorbable, more effective, or more targetted, to produce the same effects with fewer risks, and with more predictable pharmacokinetics. Hooray.

    The proof of the medical pudding should be in the eating, and as far as this is concerned,

    Once again this talking point has already been addressed in another comment – specifically me noting the enormous increases in life expectancy since the advent of modern medicine. The thing is, we had herbs before we had drugs, and people died younger, and in far greater numbers.

    let’s face it, drugs are not beneficial for biological systems, they do not cure. Nutrition, high-dose nutritional supplements and herbal medicines do.

    So you ‘ve got a couple logical and factual errors here. The term “beneficial” is pretty loaded. If you define “beneficial” as “helping a biological system perform its function”, you are correct. Drugs are not beneficial in that they interfere. But if you define beneficial as “reducing morbidity, mortality and symptoms for the whole organism”, drugs are fantastic. They interrupt processes which are pathological, such as febrile seizures, liver failure, blood clots causing strokes and countless others. Antibiotics certainly disrupt the biological systems of bacteria, hooray! Antivenom interrupts the effects of venom. Analgesics reduce pain. Unless you consider death by systematic infection or snake venom or the experience of preventable pain to be good things, I say hooray for drugs.

    Nutrition has a strong role in human health. At a minimum, proper nutrition prevents scurvy, beri-beri, goitre and other deficiencies. Whole foods eaten in appropriate amounts also seem to have a role in preventing cancers. Proper nutrition with a balance of micronutrients and macronutrients, in conjunction with adequate exercise and ideally excellent genetics, is extremely good at preventing lifestyle conditions like obesity, heart disease and type II diabetes. But there are very few conditions for which high dose vitamins are a treatment. I know of the use of high-dose vitamin K to counteract acute doses of anticoagulants, and high-dose niacin for various blood lipids. However, the results come with a cost – anosmia for niacin (not to mention lack of effectiveness in decreasing deaths and increased risk of stroke) and though rare, hypervitaminosis K also has risks.

    Not that herbal medicine contributed anything to this knowledge. We had “herbal medicine” for millenia before we had real medicine, and it apparently was far, far less helpful than vaccination and water treatment – both based on empirical research producing the germ theory of disease. This is compared to herbal medicine, which brought us the idea “if it looks like an eye, it’s good for the eye because of God”.

    So while nutrition does cure (more accurately, cures deficiencies and prevents lifestyle conditions), high-dose vitamins do not, bar a few rare exceptions, and herbal medicines for the most part don’t. Plants evolved biological active molecules for their benefits, not ours.

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