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The Pollyanna Phenomenon and Non-Inferiority: How Our Experience (and Research) Can Lead to Poor Treatment Choices

Pollyanna, a popular children’s book written in 1913 by Eleanor H. Porter, introduced the world to one of the most optimistic fictional characters ever created. She always saw the good in people and her approach to life frequently involved playing “The Glad Game”, where she attempted to find something to appreciate in every situation no matter how unfortunate. She was glad about receiving crutches rather than a doll one Christmas because it was great that she didn’t actually need them. She teaches this philosophy to those around her, even her cantankerous Aunt Polly, and the entire town is transformed into a veritable Mayberry, USA. Later, when she actually does require the use of crutches, her resolve is tested but she triumphantly finds a silver lining.

The Pollyanna principle, first described by Matlin and Stang in 1978 and also known as positivity bias, is a psychological tendency for people to place greater importance on, and assume better accuracy of, descriptive statements about them that are positive. This goes on behind the scenes while our conscious brain tends to dwell on what is perceived as negative stimuli. Though many folks do come across as pessimistic, we are subconsciously biased to accept praise and reject criticism. Anyone who isn’t clinically depressed is on some level more like Pollyanna than Eeyore.

This positivity bias also plays a large role in how we remember past events. As has been covered extensively in prior posts here on SBM, and on Dr. Novella’s excellent Neurologica blog, memory isn’t a replayed video or audio recording of prior events and our interpretations of them, but rather is a reconstruction that is prone to errors during processing and editing that accumulate over time. This leads to false memories that feel no less real than our recollection of what happened five minutes ago.

In this case, the Pollyanna principle results in positive information being more accurately processed and recalled than negative experiences. It also causes our memory of negative events to gradually become less negative as the years go by. I couldn’t have done that terribly during my first high school trumpet solo because I remember people telling me it was pretty good afterwards, right?

So what does this have to do with the practice of medicine? Biases that affect memory also impact how physicians and patients interact. I once assumed the overnight care of a child who had undergone a lumbar puncture performed by one of my female colleagues earlier that day. I ordered no tests and performed no procedures during my brief exposure to the family—yet over a year later when I admitted the same child for a completely different reason I was accused of being the terrible doctor who had unnecessarily subjected their baby to a spinal tap during the last hospitalization. Even after I showed them the documentation which proved that I had nothing to do with that (very appropriate) decision, and that I did not put a needle in their child’s spine, they refused to accept the evidence and had great difficulty trusting my diagnosis and recommendations.

There is a phenomenon in medicine, again named after the overly optimistic heroine Pollyanna, that augments the negative impact of the fallibility of human memory on medical practice with the bias towards an overly optimistic interpretation of some types of medical research and of our own clinical experience. This Pollyanna phenomenon can lead physicians to make poor choices, especially regarding which antibiotic is the best choice for a particular infection. And this is particularly common in pediatric practice, in my opinion.

The concept of a Pollyanna phenomenon in medicine has primarily been used when critiquing the approach of using increasingly broad antibiotics for the treatment of pediatric otitis media—ear infection—but it applies to a number of other bacterial infections frequently diagnosed in children. These include community acquired pneumonia, strep throat and sinusitis, three common reasons children are prescribed an antibiotic. But ear infections stand out as a clear front runner in this regard, so that is what I’ll focus on.

Ear infections are extremely common in children, again being by far the most common reason that a young child will receive an antibiotic. And even though the total number of visits for ear infections, and subsequently the total number of prescriptions for antibiotics to treat these infections, has decreased significantly over the past 20 years, still more than 80% of children will be diagnosed with one by their fifth birthday. The reasons for the decrease are myriad and include insurance issues that keep kids out of clinics, the success of the pneumococcal (PCV7 and now PCV13) and influenza vaccines, and public education campaigns aimed at teaching parents about viral infections. It’s also possible, though I have my doubts, that doctors have helped a bit by better-acknowledging other reasons for there to be fluid behind the ear drum than an acute bacterial infection.

But it isn’t all good news. According to a 2010 study in Pediatrics, there has been essentially no change at all in the percentage of visits billed for otitis media that end in an antibiotic prescription. Today, 76% percent of children diagnosed with an ear infection get an antibiotic compared to 80% in the mid 90’s. This despite the significant clinical experience of most other developed countries, reams of research papers and the 2004 publication of joint AAP/AAFP clinical practice guidelines which strongly recommended that we simply observe children over 6 months who have uncomplicated ear infections. There should have been a huge drop in the percentage of kids with ear infections receiving antibiotics but we’ve pretty much just ignored the recommendations.

The 2004 recommendations also included helpful guidelines on how to actually diagnose ear infections, particularly focusing on criteria stating that there should be more than just fluid behind the ear drum. They also required evidence of inflammation, such as redness and pain, and symptoms that are acute in onset. But there was too much wiggle room in the guidelines. They could be interpreted in such a way that children with another common condition, serous otitis media, could be diagnosed with an ear infection when presenting with fluid behind the ear drum and complaints of pain but no evidence of inflammation.

But even with this wiggle room, at the very least the days of the “asymptomatic ear infection”, an entity which both of my kids were diagnosed with at well child check-ups during infancy (both after 2004), but for which I refused treatment, should have been numbered. A new set of guidelines was published in 2013 which tightened up the criteria for diagnosis, requiring direct visualization of significant bulging of the ear drum from inflammation and purulent fluid. It will be interesting to see if we respond with a change in practice.

The 2004 guidelines also spelled out clearly what the most appropriate antibiotics for use in treating ear infections were. They further covered in what order antibiotics should be prescribed should an ear infection prove refractory to amoxicillin, the first line choice for the vast majority of cases. This was an effort to avoid overuse of unnecessarily broad agents and the risk of antibiotic resistance in the community.

Still more bad news, again coming from the widely publicized 2010 study in Pediatrics. Not only does it appear that we continued to prescribe antibiotics for any kid within arm’s reach that had fluid behind their ears, we’ve become increasingly careless in our antibiotic choices with very broad oral antibiotic agents, namely the third generation cephalosporin cefdinir (Omnicef) becoming increasingly popular. Use of cefdinir increased from 7% to 14% of all prescriptions for otitis media, frequently being used in place of amoxicillin and amoxicillin-clavulanic acid, the antibiotic recommended for severe infections or as second line for an amoxicillin treatment failure. Two silver linings did come out of the data however. Use of the recommended first line agent, the older, cheaper, more narrow spectrum and actually more effective drug amoxicillin did increase, and there was a 71% increase in the appropriate use of pain medications.

So why would a physician choose to prescribe an antibiotic, in this case a more expensive drug that has less efficacy killing the bacteria you want dead and actually increases the risk of future antimicrobial resistance in other types of infections? Well, there are a lot of reasons. Cefdinir may be more expensive, but it tastes better, can be dosed less frequently, and carries less risk of causing antibiotic associated diarrhea than amoxicillin-clavulanic acid. But in the case of ear infections, the downside of using it or a similar oral antibiotic in that class named cefixime (Suprax) outweighs the benefits.

There are more reasons, some decidedly more cynical. Drug company marketing, pressure from reps and the ease of use when there are readily available samples in the office all likely share some of the burden of blame. Still the most likely reason, if I had to hazard a guess, is more along the lines of something Pollyanna would come up with. Many physicians simply think that these antibiotics are as, or even more, effective than amoxicillin, and they really just want their patient to feel better. They want their patients’ caregivers to get sleep and be able to return to work. And they want return business too. Well maybe Pollyanna wouldn’t have come up with that last one.

But believing that an antibiotic is a better choice when it clearly isn’t is not an acceptable excuse. Are the doctors, nurse practitioners and physician assistants who write for cefdinir all incompetent? I have no doubt that some are but maybe there is reason to give them the benefit of the doubt. The deck is stacked against us a bit when it comes to these decisions after all. As I’ll get to, sometimes our own literature gives a false impression of efficacy.

Often there is a false perception that because an antibiotic is broader in its spectrum, meaning that it treats a wider variety of pathogenic bacteria, that it is better or “more powerful” than older and more narrow spectrum antibiotics. But as Mark Crislip once wrote,

the only thing in medicine that has 100% sensitivity and specificity is when a health care provider uses the terms “big-gun”, “strong” or “powerful” in relationship to antibiotics they know nothing, zip, zero, zilch about the treatment of infectious diseases.

Now I perhaps wouldn’t go so far as to say that they have no understanding of treating infectious disease. At least they are prescribing an antibiotic and not, say, a homeopathic remedy. I’ve just put The Glad Game to good use and I must say that I do feel a little less grouchy. But Dr. Crislip is absolutely right in that it’s not a good sign.

An antibiotic that is best at killing the bacteria causing the infection, and I mean really gets in there and makes them wish that their mommy-daddy had never undergone binary fission, may be extremely narrow spectrum. A staph-specific penicillin such as oxacillin is a much better choice for a sensitive staph infection, even a life threatening one, than vancomycin. It just doesn’t matter if a drug can kill 50 other types of bacteria if it can’t kill the one eroding into your mastoid process.

But sometimes it isn’t so clear that one antibiotic is better or worse than another. Both our clinical experience and the results of our research can be misleading. And so, finally, we’ve come full circle and are back to the Pollyanna phenomenon.

In 1992, a paper was published in The Journal of Pediatrics that looked at “the comparative efficacy of antibacterial agents for acute otitis media.” The authors looked at randomized, double-blinded trials of antibiotic therapy for ear infections that used both clinical and bacteriologic outcomes. Clinical success was determined by the patient’s signs and symptoms of illness resolving and bacteriologic success by the use of tympanocentesis. This involves using a needle to retrieve, in a sterile fashion, fluid from behind the ear drum that can be sent to a lab for culture of pathogenic bacteria if present. In many of the studies, tympanocentesis was performed both before and during treatment, which allowed for measuring the rates of sterilization of the fluid.

What they found is the Pollyanna phenomenon, where even the worst choices don’t seem that bad after all. For antibiotics that cleared bacteria out of the inner ear 100% of the time, the patient’s symptoms resolved 93% of the time when it was known to be caused by a bacterial infection based on tympanocentesis and 89% of the time when the ear infection was diagnosed only clinically. So roughly 1 out of 10 kids being treated with a drug that wipes the floor with the potentially offending bacterial pathogen won’t get better as expected in the real world, where tympanocentesis is rarely performed outside of an ENT office. And when a drug was used that had virtually no bacteriologic efficacy, the patient’s symptoms resolved in 71% of proven bacterial ear infections and in 74% of those diagnosed clinically.

In a nutshell, when we measure how well an antibiotic works for otitis media based on what is essentially subjective clinical improvement, drugs that kill the bacteria seem to be less effective than they really are while drugs that are one step above placebo appear to be work pretty well. This is a pattern that will always be seen when the condition being treated is largely self-limited, as ear infections have long been known to be, and may be actually caused by a viral infection which won’t respond to any antibiotic. This is why so many other countries stopped treating most ear infections with antibiotics long before our recent attempts to change, and it is why chiropractors think that their spinal adjustments work.

So it should be easy to see how an individual physician might incorrectly believe that the antibiotic they have chosen has worked, and why they might continue to use it time and time again despite it being a poor means of actually doing what they intend it to do. But there is more to the Pollyanna phenomenon. It also amounts to what is essentially a methodological “Glad Game” when designing studies that test the efficacy of a new antibiotic.

When attempting to see if a new antibiotic works, it can be challenging to design a trial that fits the mold of the randomized controlled trial that we all know and love. Ethically there can’t always be a placebo group that would leave subjects with a diagnosed bacterial infection untreated. In pediatric research, historically most antibiotic studies have not had a placebo control group and were designed as non-inferiority trials. This means exactly what it sounds like. Their goal is to demonstrate that the new drug is not unacceptably worse than the standard of care treatment, which may have also been based on non-inferiority trials. But non-inferior does not necessarily mean equivalent.

So in the case of cefdinir (#1, #2), comparisons to established treatments for ear infections have largely shown it to be comparable in effectiveness. But, as you can likely imagine, its efficacy is actually unclear because of the spontaneously-resolving nature of otitis media. When pharmacokinetics and pharmacodynamics are also looked at, true effectiveness can be triangulated.

In general, oral cephalosporins like cefdinir are not absorbed well, are easily rendered inactive by sticking to proteins in the blood, and don’t last long in the body. This leads to the level of drug available to kill the offending bacteria dropping below what is needed faster than other choices, which is a set up for resistance issues. For this and several other reasons, such as poor postantibiotic effect and tissue accumulation, cefdinir and cefixime are never better than amoxicillin or amoxicillin-clavulanic acid for killing susceptible bacteria. And the bacteria that cause the overwhelming majority of ear infections (and pneumonia) almost always are.

Non-inferiority trials are not all bad. They are necessary in many types of infections, particularly when they are not self-limited or frequently blamed when the actual culprit is a virus. It would be horribly unethical to compare the use of a new antibiotic for MRSA meningitis to placebo, and naturally a study such as that would never be approved. And if two antibiotics truly were determined to be equivalent in effectiveness, factors such as palatability and ease of dosing can be very meaningful as they may improve adherence to treatment recommendations.

But in the case of infections such as otitis media, community acquired pneumonia in young children, and acute sinusitis, the high rate of spontaneous resolution raises legitimate questions about the value of non-inferiority trial findings. Of note, in 2010 the FDA actually published nonbinding recommendations addressing this very subject. They called for increased use of superiority designs in these conditions and for better justification of the non-inferiority margins and efficacy endpoints used in trials involving infections that are not self-limited.

Conclusion

Pollyanna saw the best in every person, and found something positive in every situation. This is an admirable outlook on life, but one that doesn’t necessarily always translate well to the practice of medicine, especially when it comes to choosing the right antibiotic. We are all susceptible to the same biases and errors in logic, and not surprisingly there are similar issues in medical practice and research.

The Pollyanna phenomenon, an artifact of how we assess the success of our recommendations and study antibiotic effectiveness in largely self-limited bacterial infections, has likely led many physicians to make poor treatment choices. There is no better example of this than in the treatment of pediatric acute otitis media, where we have exposed many children to antibiotics that may only seem to be working but definitely increase the risk of developing resistance in the individual and the community. An understanding of pitfalls such as this, and awareness of the science behind expert treatment recommendations, can improve the care we provide our patients.

Posted in: Clinical Trials, Pharmaceuticals

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79 thoughts on “The Pollyanna Phenomenon and Non-Inferiority: How Our Experience (and Research) Can Lead to Poor Treatment Choices

  1. Danielle says:

    Perhaps one of the reasons that Omnicef prescriptions have increased is due to misdiagnosis of Amoxicillin allergy. My daughter presented with a rash the first time she was prescribed Amoxicillin for an ear infection, and at the time it was diagnosed as an allergy. So now she has been branded as allergic to this medicine, never to receive it again it seems.

    The rash occurred when she was an infant, and she suffered no discomfort or other adverse effects from it. My later internet research turned up that this could actually have been a non-allergic rash – not that uncommon. Yet her “Amoxicillin allergy” is the biggest, boldest thing on her medical chart. After that single incident, she was prescribed Omnicef about half a dozen times for later ear infections.

    1. Clay Jones says:

      True allergy to penicillin based drugs is a reason to avoid their use. There is a little more nuance to the use of Omnicef than I could get into in the post. It is also true that many children diagnosed with an allergy are not allergic. Without a history of severe allergic reaction It is generally okay to do a trial in the office or hospital and see how it goes. Many viruses cause a rash and many children with viruses are given antibiotics so it gets confusing. In the case of true allergy, using a drug like Omnicef isn’t the end of the world. It does typically do the trick, or at least the ear infection just gets better on its own, it just isn’t as good as the other options and has that pesky issue of resistance.

      I didn’t get into it to avoid being too lengthy, but amox is also the best choice for pneumonia. We have resistance data that shows that amox covers strains of pneumococcus much better than Omnicef for instance, but many many doctors don’t realize that, I guess because they didn’t read the 2011 updated clinical guidelines on pediatric pneumonia. I believe that the confusion is that far too many doctors think that oral 3rd generation cephalosporins like Omnicef are equivalent to the famous IV 3rd generation ceftriaxone (Rocephin). Their pharmacokinetics and dynamics are very different. In fact, 3rd line treatment for refractory ear infections is ceftriaxone, not Omnicef, but I see so many docs use it for that purpose.

      1. mousethatroared says:

        I guess this is off-topic, but I wonder about the best way to balance suspected medication side effects (particular medication only used occassionally or rarely) with just choosing an alternative, which may be slightly inferior.

        I was given bactrim a couple years ago and got a rash (trunk, neck, arms, thighs) and really large sore in my mouth a week or so later. Now when the nurse asks about drug allergies at the doctor’s office I don’t know what to say. I kinda hum and ha through, probably not an allergy, but can we avoid it if the drug’s not really needed. I don’t think there’s a slot for that on the form, though. :)

        More on topic. I like the way that you (Clay Jones) tied a cognitive bia into the medical decision making process. (Okay, it’s not the first time that was done on SBM, but I thought it was well described). Thumbs up!

        The book How Doctors Think, uses a similar approach. People may find it interesting.

        1. Clay Jones says:

          That’s tough. That sore could have been an apthous ulcer (“canker sore”) and not related to the drug. Was it on the inside cheek where your teeth come together? But bactrim is associated with some pretty nasty idiopathic reactions that involve the mucous membranes. They aren’t allergic in nature but warrant avoiding sulfa drugs.

          1. mousethatroared says:

            The sore was on my palate (roof of my mouth) by my back teeth.
            But it wasn’t unique, I’m had similar, it was just worse than normal. I don’t want to fuss online trying to figure it out. Just occurred to me as an example of balancing uncertainties when making medication choices.

            I suppose the thing to do would have been to see my doctor when it happened. But I had other health issues I was dealing with and didn’t want to seem like a whiner. She might have fired me ;)

            Probably best to just figure it out if I ever need bactrim again.

            1. Egstra says:

              My experience with Bactrim suggests that the skin reactions arrive faster and become more severe each time one takes it. I now have a permanent mark on one leg — not a big deal, but certainly a reminder.

        2. therion2k9 says:

          I know how you feel. I got a rash (all over my body) some hours after finishing a whole pack of amoxicillin (no symptoms while taking them) and was thus diagnosed with an allergy against amoxicillin. I’m not absolutely sure if I have one though.

          I wonder if it would be beneficial to get an allergy test. I mean, can’t the major medications be tested with a simple prick test?

          1. MadisonMD says:

            can’t the major medications be tested with a simple prick test?

            Not with high reliability. Most of the time, the offending chemical is a metabolite that only occurs when the drug passes through the liver. You’d have to know the precise metabolite for an accurate prick test.

            1. therion2k9 says:

              Thanks so much for that clarification. Then I keep avoiding Amoxicillin — Cefpodoxim does the job without problems.

        3. Lytrigian says:

          After once going into shock after received an injection of local anesthetic, presumably lidocaine, I figured I was allergic to it, and I told doctors that whenever I was asked about medication allergies.

          Well — since the dentist didn’t bother telling me WHAT he was injecting me with that I can recall, I’d actually say “novocaine”, but then I’d describe the circumstances so I assume knowledgeable MDs would guess at what I’d actually gotten. As I am now too, but I was later told that novocaine was almost never used at the time.

          I was also told that true lidocaine allergies are very rare. And indeed, it turned out to be some kind of strange reaction where I’d go into shock if any significant part of my body was numbed for any reason. I even had a mild version of it happen at a gym, when a pinched nerve during a lift made my shoulder go temporarily numb. Now when I go to the dentist I ask for nitrous before the injection; this seems to settle whatever stresses cause this reaction and it doesn’t happen.

        4. Kultakutri says:

          I ran into a similar problem the other day and it turned out to a rather bizarre set of circumstances.

          I have some sort of nasty reaction to latex. I was told by two different surgeons and one orthopedist that having bits of my epidermis peeled off with plaster to reveal a nasty mess of itchy blisters and welts, or in the orthopedic case, less nasty mess of itchy blisters and welts in the shape of bandage on my mouseitis afflicted paw that this thing is latex allergy. For some reason I can’t really figure out, they never tested me for that and I’m always mentioning fancy reactions to stuff to my allergist, including an obvious allergic reaction to cypress pollen, and cypresses don’t grow in my general area, I just lived two countries away for a time. I doubt that I wouldn’t have mentioned these skin reactions but I’m not sure and in the hospital records, there’s no mention of it, as I found out in an unsuitable time. I however never got tests for antibiotics, the allergist just wrote it down.

          So, I went to get my planned vanity surgery, I was asked about allergies, gave them a list of antibiotics that cause nasty things and, latex, I said, long exposure makes nasty things to my skin.

          The hell broke loose and I was basically chased out of the hospital and denied the surgery because they don’t have latex-free surgical gloves and I need an affidavit from the allergist before the hospital will order them, and getting them will take ages because… add some bullshit. Nobody expressed the slightest bit of doubt about the antibiotics thing.

  2. rork says:

    “true effectiveness can be triangulated.” I would like to argue that if a thing can be measured, let’s just measure.
    In the paragraph after that, Jones seems to be arguing that cefdinir SHOULD be less effective, perhaps ignoring data that in practice it is not. I preferred the other arguments that it is as effective in practice, but has greater risks, in the paragraph after that. Maybe I got hung up on the exact wording, so I quickly add:
    I very much appreciated review of the trouble of comparing a new treatment A to standard B, and finding them about the same, but still not being sure how well B really works, and so uncertain about A as well. Thankyou.

    In cancer world I was a bit perplexed in October when there was much news of “Dovitinib Fails as Third-Line Option in Kidney Cancer”, where it failed to beat sorafenib in an epic battle of the tyrosine kinase inhibitors. It actually did slightly better, but didn’t drive p below .05 for the primary endpoints. Decision theory (and economics of competition) tells me that maybe it should be approved though. Posterior probabilities of it being superior are above .5 but probably not near .9, so there’s some risk that it isn’t actually better. Any lessons on where my line should be are appreciated. (PS: In the long run we may know which mutations do better or worse with which compound, but obtaining such knowledge will be costly and time-consuming.)

    1. Clay Jones says:

      The way to truly know if it is effective would be to have a placebo control group but that isn’t always ethically possible. You can do non-inferiority studies and look at end points like how long did it take to have symptoms improve. That might help tease out if it works better than the standard drug. But I meant triangulate in that you can look at the head to head trials which may be less helpful, and also at the pharmacokinetics and dynamics. They can give you an idea of prior plausibility for plugging into our interpretation of the trials.

  3. windriven says:

    ” they refused to accept the truth and had great difficulty trusting my diagnosis and recommendations.”

    Do physicians, especially PCPs, ever fire patients? Other professionals – CPAs, attorneys, etc. fire clients from time to time.

    1. Andrey Pavlov says:

      Yes, we do, but it is uncommon. I’m not experienced enough to really comment so hopefully someone else who is can, but yes, I have seen physicians “fire” patients.

      1. mousethatroared says:

        Hm, how the severance package? ;)

        1. weing says:

          I give one month of availability for emergencies.

          1. mousethatroared says:

            @weing, I was joking about severance – but that’s thoughtful of you.

    2. nancy brownlee says:

      I’ve been ‘fired’ twice. Once for having an unusual disease that the doctor (internist) wasn’t happy about having in a patient- Carcinoid. He said as much, in the registered letter I received the day after my first appointment with him.

      The first time was by an internist whom I’d been seeing for five years. I questioned his billing methods rather too persistently, I was later told by a nurse who had left his employ. I believe it- she worked for him for ten years and left on her own hook; no sour grapes there.

      It was a very rough patch for me- I lived in a small town, had (have) a rare disease, which I knew more about than did any physician within easy distance. The complications of the disease make it important, I think, to have an internist as my PCP- but it hasn’t always been possible.

      1. Andrey Pavlov says:

        Hmmm… as I said, not experienced or knowledgeable enough to really comment, but these seem like bad reasons to fire a patient. The few times I have seen it happen was for much more intractable issues that were primarily focused around the patient-physician relationship and definitely not taken lightly at all. To me, that seems like the most reasonable (if not only) reason to fire a patient – when, for whatever reason(s), the patient-physician relationship has become irreparably damaged to the point where it is no longer a therapeutic interaction.

        I welcome more experienced thoughts and comments.

      2. weing says:

        “I’ve been ‘fired’ twice. Once for having an unusual disease that the doctor (internist) wasn’t happy about having in a patient- Carcinoid. He said as much, in the registered letter I received the day after my first appointment with him. ”
        That doesn’t sound like a good reason. The main reason I fire patients is because of their failure to follow-up on tests, adhere to meds, not showing up regularly, and rarely if they try to dictate therapy that I don’t agree with.

        1. nancy brownlee says:

          I didn’t think it was a good reason, either! Even so, I’d have been much less irked about it if he had simply told me, during that first interview, that he was more comfortable limiting his practice to virtually moribund, extremely elderly patients. Which, as it turned out, was the case. His practice was not closed to new patients- but he was very picky about who he added.

        2. goodnightirene says:

          I expect to be fired by my allergist for non-compliance. I decline to use steroid inhalers/nasal sprays as they stimulate my appetite. I lost weight following a diabetes diagnosis, have maintained it for eight years and will not deliberately cause weight gain. I think there’s a trade off. I have opted to work harder at avoidance of asthma triggers.

          This decision has left me with being afraid to call the docs when I have symptoms short of an all out emergency. It seems to be a stalemate as I know they will say they can’t help me if I won’t use the meds. I guess I have “fired” them?

          1. Lytrigian says:

            This sounds like the kind of issue you ought to discuss with them, actually.

          2. MadisonMD says:

            steroid inhalers/nasal sprays as they stimulate my appetite

            GNI: Are you sure? I would imagine the amount absorbed would be dwarfed by the cortisol made in your adrenals. Perhaps the very idea is self-fulfilling.

            1. Calli Arcale says:

              In my personal experience (DANGER! ANECDOTE TERRITORY!), the inhaled stuff doesn’t do the same things to me that the oral steroids do. I had the impression that was sort of the point of inhaled steroids, actually; you don’t need to take enough to saturate your whole body in order to heal your lungs if you have a way of applying it directly to the lungs. But I could be wrong.

              I know my grandma (severe asthma) had terrible side effects from her oral steroid regimens, but did much better once the steroid inhalers became available for her instead.

            2. CHotel says:

              Systemic bioavailability of nasal steroids varies greatly from as low as 0.5% (Fluticasone and Mometasone) to as high as 40-50% (Beclomethasone, Flunisolide, Triamcinolone). A lot of that data comes from trials in kids regarding concerns in growth retardation though, I’m not sure how comparable it would be for adults. Some of the higher absorption levels at high doses could certainly have mild systemic effects though.

              Reference: http://www.rxfiles.ca/rxfiles/uploads/documents/otc-topical-nasal-steroids.pdf (Rx Files is an amazing Academic Detailing program from Saskatchewan that publishes some of the best drug comparison charts I’ve ever seen)

        3. nancy brownlee says:

          @Weing
          I’d like to be clear about one more thing – I am not a difficult or a non-compliant patient! But- not being a passive person, to start with- I am forthright about my preferences and I do ask a lot of questions. My Carcinoid was diagnosed fourteen years ago and I was symptomatic for almost a decade before that. I went through the usual roster of “it’s IBS, no maybe Crohn’s, nope, you sure you don’t drink a lot? I think you must, it’s a panic attack, hmm, nothing here, it’s somatoform…”

          Even after a solid diagnosis, the amount of utterly incorrect “information” that came from some doctors was disturbing – and enlightening. But much, much better information about the disease is readily available today, for physicians and for patients. I’m just glad I lived through it.

          1. windriven says:

            “But- not being a passive person, to start with- I am forthright about my preferences and I do ask a lot of questions.”

            And you deserve a physician who is comfortable with that. It took me a long time to find my internist but now I happily drive the 100 miles it takes to see her.

            1. Andrey Pavlov says:

              Agreed. Sounds like y’all would be the kind of patients I like. But who knows how that may change over the years. Maybe I’ll get jaded and won’t to put up with your sass ;-)

      3. mousethatroared says:

        nancy brownlee “I’ve been ‘fired’ twice. Once for having an unusual disease that the doctor (internist) wasn’t happy about having in a patient- Carcinoid. He said as much, in the registered letter I received the day after my first appointment with him.”

        I’m not sure I’m clear – Did he not believe the diagnoses or didn’t feel his background/experience was sufficient to treat your condition? In the later case, the nice thing to do would have been to refer you to someone who he thought was more well suited.

        I guess if there wasn’t anyone more well suited in the area, that seems like an ethical quandary. What do internists usually do when they feel they are in over the head with a patient with a rare condition.

        1. nancy brownlee says:

          @Mouse
          “the nice thing to do would have been to refer you to someone who he thought was more well suited.”

          Yes, it would have- but he didn’t. I have supposed that he was simply not comfortable with confrontation- rejecting a patient face-to-face. It’s understandable, it protects the doctor from an angry or hurt reaction from a patient- but it’s also pretty chickenshit.

          The long damn limping trek from doctor to doctor, in that first 6-7 years after diagnosis, was instructive. But I didn’t lose confidence in the scientific medical process- just some of my optimism about how well and faithfully it’s practiced! I also learned a huge amount about the disease- thanks in large part to a surgical oncologist name Gene Woltering, who has spent thousands of hours educating carcinoid patients about the optimal management of the disease.

          1. mousethatroared says:

            “Yes, it would have- but he didn’t. I have supposed that he was simply not comfortable with confrontation- rejecting a patient face-to-face. It’s understandable, it protects the doctor from an angry or hurt reaction from a patient- but it’s also pretty chickenshit.”

            Agreed – I had a doctor who sent me a certified letter, when a phone call with an explanation would have been much better. We were doing fertility treatment (ov stimulation, not IVF) and there had been a mix-up in communication with the doctor, nurse and I, which resulted in less than optimal timing, no pregnancy. This wasn’t the first time the doctor and nurse hadn’t been in sync. Not the worse thing in the world, but not a happy thing, considering the expense of the drugs, and how miserable I felt taking them. But the doctor promised to look into it, so cool…but, then he never called us or returned our call.

            We consulted his partner for a second opinion on how we should proceed (they were the only ones that our insurance covered at all) Then about a week later we received this certified letter from the first doctor, saying there had been no error on him or his staff’s part, in a very lawyerly way. We hadn’t even voiced dissatisfaction, much less think of some kind of legal action.

            I guess that’s one reason a patient might fire a doctor. ;)

            We never had a miscommunication with our adoption agency and they always returned our calls and kept us up to date. Although I’m sure that others would report a reverse experience (difficult adoption agency, easy fertility clinic)

            Sorry, long, I’m just rambling/reminiscing today.

        2. MadisonMD says:

          What do internists usually do when they feel they are in over the head with a patient with a rare condition.

          A responsible internist would refer, phone an expert, or at least do some research. Even if the expert is far away, a single visit can be enough to get an opinion and treatment plan.

      4. Kathy says:

        i was “fired” by a dermatologist last year. I needed a (possible) melanoma on my arm tested and, if necessary, removed. When I told him I scar badly he did a wild hairy backflip and almost shouted at me that he refused to do anything as I was bound to sue him. Maybe he’d had a bad experience in the past?

        1. mousethatroared says:

          @Kathy, I hope you found another doctor to do your biopsy?

    3. windriven says:

      @Andrey and weing

      This seems quite reasonable to me, especially the idea of giving them a month to find a new sucker physician.

      I’m a manufacturer and have the luxury of just pricing unpleasant customers away.

    4. MTDoc says:

      We don’t use the term”fire”, but the term “refer” comes to mind. Of course, we are very careful about which of our consultants we refer them to. Sometimes it’s actually a win-win situation. In a competitive marketplace, the “difficult” patient usually refers him or her self.

      1. windriven says:

        When I lived in New Orleans I sometimes ran around with a group of lawyers. Lunches with that lot were really a trip. Those guys had far more colorful expressions than ‘fire’. I’ve also seen one attorney ‘referral’ made as a practical joke on another attorney.

        As an aside – I got all my best lawyer jokes from those guys.

    5. I have fired only two patients. One of them was purposely missusing a nonaddictive but potentially dangerous medication I prescribed, and the other was enabling the former. It wasn’t so much what they were doing, but the fact that dealing with them made me blindingly angry. I cannot be an effective doctor for people with whom I am angry.

  4. Joanna says:

    My son’s pediatrician always prescribed amox until he developed an allergy to it, and then she switched to omnicef. Considering I used to have to ask my NP to help me get the amox down his throat, the switch to something he would take readily made my life a lot easier. He finished every last drop of the amox prescriptions, because I know about the dangers of not finishing them, but there were times the battles left me in tears. It really makes me wonder if there is anything they can do to make amox a little less gross for extremely fussy 4 year olds.

    1. goodnightirene says:

      All four of mine took amox without a fuss, but they were not picky eaters either. I think I was also what would now be called “strict”, but what I thought of as “no-nonsense”. Taking medicine or having something hurt at the doctor were presented as VERY SERIOUS BUSINESS and they seemed to accept it.

      I also gave a lot of amox to a number of babies and children I had in my home daycare when my fourth was young and don’t remember any difficulty (but who knows if that’s an accurate recollection?) :-)

    2. mousethatroared says:

      “but there were times the battles left me in tears. It really makes me wonder if there is anything they can do to make amox a little less gross for extremely fussy 4 year olds.”

      You probably tried this, but my daughter is particularly resistant to taking medication…it’s almost as bad now that she’s 11. I’ve found that a bribe is helpful. I pick up a bottle of the favorite soda pop (we don’t have it at our house except for parties) and pour a glass, have it ready and in view for immediately following swallowing the medication. Seems to ease the struggles a bit.

      If that hasn’t work for you, my deepest sympathy. I REALLY dread medication struggles, they are completely demoralizing.

      1. Nashira says:

        That’s the same tactic my parents use to get their dog’s allergy pill down her. She started refusing it, even when wrapped in cream cheese or lunch meat, til we got in the habit of making a big show of there being a much bigger piece of human food in our other hand… just waiting for her to take the pill.

        Bribery: It works!

  5. goodnightirene says:

    Forgive me (and correct me) if I have missed something, but WHY are we still treating all these mostly self-resolving ear “infections”?

    Note: I was out of regular coffee beans this morning and have only had decaf :-(

    1. nancy brownlee says:

      “WHY are we still treating all these mostly self-resolving ear “infections”? ”

      Compassion, probably, plus a dontor’s fear that a sleep-deprived parent is going to climb into their bedroom window and shoot the heartless SOB. Middle ear infections are fiendishly painful, the pain may last for days, and they often don’t “self resolve” before an ear drum ruptures- and the rupture rarely happens before the baby, toddler or little kid has been sobbing with pain for hours. Having had the infections myself- repeatedly, with some hearing loss- and having one child who had them- repeatedly- I’d rather give Amoxicillin than codeine.
      The little drainage tubes were a huge relief. I wish I’d had ‘em for me.

      1. Clay Jones says:

        That is not at all how the vast majority of ear infections go. 80-90% resolve without treatment with no rupture of the ear drum. Most are mildly symptomatic. There are, right now, likely many thousands of children running around with ear infections whose parents will not seek medical care.

        1. nancy brownlee says:

          @Clay Jones
          I’m sure that’s true. Those are not the ear infections to which I was referring, obviously. A ‘silent’ ear infection which resolves itself just fine with no (or minimal) fever, no pain, and no further problems, isn’t likely to produce a screaming toddler and a desperate parent, is it?

          “There are, right now, likely many thousands of children running around with ear infections whose parents will not seek medical care.”

          So the doctor never sees them. But any parent with any brains at all has to figure out when it’s reasonable to take the kid to the doctor. A kid who’s had a cold for a week or ten days, whose cold is improving and who’s had no fever for several days- if that child suddenly is feverish again and crying with ear pain – that kid probably has a bacterial ear infection, and it needs to be checked out.

    2. Clay Jones says:

      The way to truly know if it is effective would be to have a placebo control group but that isn’t always ethically possible. You can do non-inferiority studies and look at end points like how long did it take to have symptoms improve. That might help tease out if it works better than the standard drug. But I meant triangulate in that you can look at the head to head trials which may be less helpful, and also at the pharmacokinetics and dynamics. They can give you an idea of prior plausibility for plugging into our interpretation of the trials.

  6. Newcoaster says:

    Since my office based family practice skews to the over 50 crowd, most of the paediatric OM I see is during one of my ER shifts. Invariably these are in the middle of the night, with a harried and sleepless parent who just wants their child to stop crying and go to sleep .( Ironically they are usually dealing with a harried doctor who just wants to go to sleep as well!) Having the conversation about no indication for ABX with anxious strangers in the wee hours is always challenging, since they have got themselves up, dressed, and driven to the ER, so there is a high expectation that something is going to be done, and that usually means their agenda includes leaving with a Rx.

    I’ve had many parents leave angry and swearing when I’ve told them their child just has a viral infection and analgesics are all that is needed. If the parent seems reasonable and understanding, I will occasionally give them a Rx for amoxicillin with instructions not to use it unless the condition deteriorates over the next few days. Unfortunately I have no way to track how often those are filled, which would be interesting.

    I have no explanation for the increased use of cephalosporins you talk about. I suspect it is doctors who don’t keep up with the literature, and think they are doing the patient a favour by using one of the “big guns”. I’ve certainly seen patients brag about that, and I think it gives patients more of a “special” feeling if they are given a newer, more expensive drug instead of one of the older cheaper ones.

    Regarding the issue of doctors firing patients, of course we do ! Patients fire doctors all the time, or doctor shop until they find one they either get along with , or think they can manipulate. ( my sis in law chooses her GP based on whether he will make referrals to the specialists she wants to see, or prescribe the medications she wants) It doesn’t happen often, and there are guidelines about how to go about it, such as agreeing to provide emergency care for a period of time. One is also supposed to provide a written notification explaining the reasons, and sometimes to make an effort to find them another physician.

    Most of the time when I have fired a patient it is because of non-compliance or non-adherence after repeated attempts to work with them. They don’t go for the tests, they don’t take their prescriptions and don’t follow medical advice. I don’t know why those types bother going to a doctor in the first place. Another type are the rude, abusive, disruptive, always late or frequent “no shows”. Anyone who threatens me or my staff will be fired automatically. Occasionally it is just a basic personality conflict…they push my buttons or I push theirs, and that is usually a mutual firing. I have never fired a patient simply because they have complex or rare medical problems, that is actually one of the challenges I enjoy about this job.

    1. mousethatroared says:

      Regarding pain control with an ear infection. My sister told me that there are ear drops that work great as local analgesic for painful ear infections, but I’ve never heard of anyone in my area being prescribed them. Does such a thing exist? Seems like it would work in cases where you want to control pain, but not to use an antibiotic.

      I can offer a good reason to use antibiotic with ear infections, besides pain. My son gets ear infections one to two times a year due to his craniofacial condition. His doc does seem careful to confirm it looks like an infection, not just effusion (although that’s another story). He very rarely has pain, he just complains of things sounding funny, or I find I have to holler to get him to notice me. The problem is, they don’t seem to self-resolve and if we try to wait it out, (thinking it’ll pass in a few days) it just seems to end up blocking his ear tube and risking a ruptured drum, which could result in mild hearing loss or pushing out the ear tube which would mean ear tube replacement. A number of other people I know who have differences in their ear canal (congenital hearing loss, etc) have the same issues.

      1. Clay Jones says:

        Sure, I would not lump children who are risk for ear infections, such as kids with craniofacial abnormalities, into this necessarily. But this applies to the overwhelming majority of kids. One reason why so many parents think that their child’s ear infections don’t improve on their own, and I’m not implying this is the case with you, is that they don’t have an ear infection. Many many kids are diagnosed with an ear infection because they have fever and fluid behind their ears, and often have no findings of inflammation. Doctors are quick to say things like “that ear drum looks a little red”, but often the ear drum can’t even be visualized well or it’s pure fantasy. Many of these children have viral upper respiratory infections that won’t get better with antibiotics. So when they return to the doc, still with a febrile kid who is snotty and miserable 2 or 3 days later, and there is still fluid behind the ears which can take weeks to go away, they are told that the ear infection hasn’t responded to antibiotics. So they are switched to Omnicef or Suprax, another 2-3 days go by and the kid’s cold is better and the antibiotics get the credit. This scenario plays out all the time.

        1. mousethatroared says:

          That’s interesting. I think I didn’t understand that before.

          No worries, I have a child in the more typical category too. I’m good with the fact that the needs of the majority of the kids are different. I was just pointing out the exception, because I’ve had a couple of non-doctors folks (crunchy types and people concerned with antibitotic over use) get on me about the antibiotics and tubes with my son.

          1. mousethatroared says:

            Actually, misunderstandings about special exception with antibiotics/ear infections can go both ways. My MIL seems to think that our PED is better* than my SIL’s because our PED prescribes antibiotics more (for my son’s ears). I’ve explained, but she doesn’t seem to get that it’s more an exception rather than a rule.

            *well our PED rocks, so it may be true, but not for this reason.

      2. Harriet Hall says:

        “ear drops that work great as local analgesic”

        The name is Auralgan. Contraindicated with ruptured eardrums or ear tubes.

        1. mousethatroared says:

          Ah, I can see why it’s use might be kinda limited, then. Thanks HH.

    2. Clay Jones says:

      Yes, the Safety Net Antibiotic Prescription (SNAP) approach is the answer. You write a prescription with a date of expiration set 2 or 3 days later and tell the parents to fill within the next 1-2 days if their child is not improving. The majority of parents will not fill the prescription and antibiotic use will be decreased. I have never understood why this is not common practice. I recommend the approach.

      1. TwistBarbie says:

        That’s a great idea. I’m in pharmacy and I think I’ve only seen docs do this once or twice. On the plus side I have never ever seen a script for Omnicef, maybe it’s not available in Canada. I don’t have children yet but I often wonder what I would do if they had symptoms of an ear infection. As much I’d I’d like to wait it out, my personal experience with ear infections as a child was traumatic. Several occasions of ruptured drums have left me with substandard hearing. It’s easy for me to say I’d go with the science now and hold off on the antibiotics, but I’m not sure what would happen if my wee darling was squalling in pain all night. Damn my fallible human brain!

        1. Clay Jones says:

          Just to be clear, some ear infections do require treatment with antibiotics without waiting. Children under 6 months and kids with severe symptoms should be given an appropriate antibiotics. My issue is with the treatment of kids with mild-moderate symptoms, which make up the vast majority of cases.

          1. Jay Gordon says:

            Bactrim and similar medications should be reserved for very specific needs. They lead the list of S-J causing meds.

            The age of a patient–under six months–might make antibiotic usage more likely, but severity of pain does not make antibiotic use more likely to work.

      2. Birdy says:

        I’ve had a few physicians write a ‘just in case’ scrip. As the parent (or patient) it’s nice to have that ultimate decision handed to me. I have not filled most of them, since the issue was typically self-limiting. As it is, when I go in to a clinic where the doctor does not know me, I tell the physician I’m not looking for a scrip unless they actually think it is indicated since many walk-in clinic physicians seem to reach reflexively for the prescription pad to placate the many people who feel ‘ripped off’ if they wait for two hours only to leave with a diagnosis of ‘it’s a virus.’ I’m okay with that.

        I see a physician to get their opinion. I do not see a physician to have them act as a prescription vending machine.

        1. Andrey Pavlov says:

          I see a physician to get their opinion. I do not see a physician to have them act as a prescription vending machine.

          Ah, if only more people were like you. We’d probably have better patient interactions and better reimbursement. The best way to get money as a physician? Do procedures. My friend is going into interventional radiology. He could do a dozen LPs, paras, thoras, whatever in a day which requires very little cognitive skill (because it would be me ordering them, for example) and make a lot more money than I would sitting around and thinking about plans of action for ICU patients.

          It’s easier to bill for things done than time spent thinking. And it is more satisfying to most people to have something done than just get advice. I used to have people in the ER regularly demanding a CT scan, despite there being no reason for it at all. Why? Because they didn’t wait 4 hours to be told its self limiting and to go home.

        2. mousethatroared says:

          I’m with you Birdy. I take the kids to the doctor when I think there’s a risk of a negative outcome that needs medical attention, such as strep, pneumonia, ear infection (see above) etc. If the pediatrician gives me a good reason to feel comfortable that my kids are safe without medication, (no step, no signs of bacterial infection) I’m good. I do appreciate any tips they have for comfort measures or things to watch out for. Our doctors are good about saying, “looks like a virus, but if the symptoms doesn’t resolve in x days, come back”.

        3. Stephen S. Rodrigues, MD says:

          I like the term “Vending Machine” or pushbutton medicine which is what modern medicine has devolved into because of material mechanical minded scientific dogma laced idea we have here. (did you get that term from me?)

          Without open minded free thinking researchers and providers this is all we are going to have.

          Unless health care is detached from employment, is cash and carry, and truly free market; With money back guarantees, vending machine is all we gonna get.

  7. LegMed says:

    I thought we were doing better and at least marginally reducing unnecessary ABX for OM with “expectant” therapy. Especially when we’re hard nosed about it and post-date the prescription. Nicht wahr?

    As to terminating an extant physician-patient relationship, you have to give clear notice and a chance to find care elsewhere. It’s not settled that sending them to my ER is sufficient. This becomes an issue for the patient needing specialty care.

    It may surprise folks to learn that in BOTH medical AND law school, there are discussions of ethical responsibilities, including the idea that everybody who needs one should be able to have the services of a doctor and a lawyer. But then there’s that pesky 13th Amendment. I will offer that lots of us do lots of volunteer/pro bono work.

    1. weing says:

      “As to terminating an extant physician-patient relationship, you have to give clear notice and a chance to find care elsewhere.”
      That is true. Otherwise you could be accused of abandonment.

  8. Jessica S says:

    Very informative article. My son, who is 3, was treated with ABs for ear infections (both ears) at both his one year old and two year old well-child visits. In both cases, he had been sick for over a week before the visit, and both times I was surprised to hear that his ears looked “really red” as he had showed no signs of discomfort. She prescribed the ABs due to the fact that he had been sick for a week or more, acknowledging the “wait and see” approach if he had only just started a runny nose, etc. Maybe I should have pushed back, or at least asked if we could hold onto the script to see if recovered without any sign of further ear pain. If we happen to find ourselves at another WC visit with the same situation, I think I’ll ask if we could at least hold onto the script for a few days to see what develops. I know I could do that without having to ask, but I do like to communicate fully with my doctors – I imagine they appreciate it, rather than thinking I’m just not following what they recommend! :)

    Anyhow, very good discussion, as always!

  9. Stephen H says:

    I’m curious. (No, I won’t leave this comment to that one statement).

    You comment about the Pollyanna principle on memory. I wonder whether this is true for everyone. I, for instance, have been diagnosed with Asperger’s*. My memory seems to focus largely on negative events, which I analyse over and over. I still, for instance, have nightmares about high school but only vague recollections of playing the lead role in a school musical (with most of the latter being about me making a mistake at one performance).

    So has there been any research on whether positivity bias is the same across various cultures, ways of thinking and so forth?

    *I mean autism. There is no autism but autism! (I am not impressed with the removal of Asperger’s as a separate condition from DSM-V, leaving just this enormous “autism” category of diagnosis that does not give any useful indication of what condition the diagnosee actually has, or suggest to a third-party medical practitioner what treatment is appropriate).

    1. Clay Jones says:

      @JessicaS Bilateral ear infection is actually an indication to treat even if the symptoms are milder, but there still should be bulging membrane with evidence of inflammation. It is often very difficult to actually see the ear drum in a squirming 3 year old, especially if the ear has wax build up obstructing the view. I never recommend trying to dig the wax out with rare exception because it is more likely to cause injury than to benefit. Viral infections often leave kids sick for 1-2 weeks. Even fever can last that long though that isn’t too common.

      @Stephen From what I’ve read, we consciously tend to focus on negative memories but there is a subconscious bias towards the positive. I guess that would be difficult to tease out because you likely wouldn’t realize that you were doing it.

  10. dragondoc says:

    Is there any data on how this compares with non-US prescribing? Having worked in the UK and New Zealand in paediatric/general practice settings I’d say most in both environments are fairly good at minimising antibiotic use for these, with plenty of backing from organisations like NICE. And there are quite a lot of guidelines pointing away from broader spectrum agents.

  11. Dr. Pullen says:

    The lab between science and practice is leading some to take N-of-one studies to a new level, with cooperation between competing institutions, patient involvement, and great potential. Check out this interview with Dr. Tony Blau from Seattle. http://drpullen.com/cancercar-redefiningbestcando

  12. Stephen S. Rodrigues, MD says:

    This may of interest to some of you:
    Science Set Free: 10 Paths to New Discover
    Sheldrake offers the “ten dogmas of science” that he thinks need to be treated with more suspicion than they currently are:
    That nature is mechanical.
    That matter is unconscious.
    The laws of nature are fixed.
    The totally amount of matter and energy are always the same.
    That nature is purposeless.
    Biological inheritance is material.
    That memories are stored as material traces.
    The mind is in the brain.
    Telepathy and other psychic phenomena are illusory.
    Mechanistic medicine is the only kind that really works.
    http://www.amazon.com/o/ASIN/0770436706/thedailygrail

    http://www.skeptiko.com/rupert-sheldrake-censored/

    1. Thor says:

      What in the world does your comment have to do with the subject of this post, namely the Pollyanna phenomenon, antibiotics and pediatric otitis media? Sometimes I wonder about people’s mental facilities. Imagine partaking in a discussion about, say, climate change and out of the blue someone says, “I just read an article about how Pluto was changed from a planet to a dwarf planet”.
      What? Please spare me.

      1. Stephen S. Rodrigues, MD says:

        “Mechanistic medicine is the only kind that really works.”
        The flawed logic of material medicine dogmas and the flawed science that is based on.

    2. WilliamLawrenceUtridge says:

      But Steve, Sheldrake is a moron, so why should we care what he thinks? The reason why those positions of science exists is because of the massive body of evidence supporting every single one of them. He may think they are “dogma”, but only by redefining “dogma” the same idiotic way you do – by pretending that recognition of a large body of interlaced, mutually-supporting facts that have been validated in millions of experiments and observations is somehow “dogma”. It’s not, it’s research. You and Sheldrake both get no respect here for the same reasons – you insist that somehow your personal experience is enough to overturn an enormous amount of previously-existing, contradictory work, but you aren’t willing do to the careful, rigorous work that might support (or more likely, disprove) your beliefs. So you get mocked.

      Also, you completely neglect to recognize the massive amount of research that indicates how erroneous beliefs like yours get established and maintained. It’s generally through the narscisistic insistence that you can’t be wrong, essentially cognitive dissonance theory. Seriously, we know how people like you get suckered into their beliefs, that’s why you get laughed at. Like now – psychic phenomena are real? AHAHAHAHAHA moron.

  13. Stephen S. Rodrigues, MD says:

    Sorry guys I won’t be back for a while … out to lunch! :)

    1. weing says:

      “out to lunch!”

      You sure are.

      1. WilliamLawrenceUtridge says:

        I’m going to make a psychic prediction – Steve will be back, and show no evidence of having learned anything, or having read anyone else’s comments. Somebody call James Randi! And Rupert Sheldrake! I’ve revolutionized physics!

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