It has been tough in Portland this year. The Trailblazers, our NBA, and only professional team, started out on a tear, then went right down the toilet. It is painful to see such promise dribbled away. Sigh. Why is elation always followed by disappointment? Everyone and everything has feet of clay. Except Cassius Marcellus.
At the beginning of March the NEJM had a wonderful essay, What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava. The essay concerns a patient who is ‘diagnosed’ with cancer at an integrative medicine exhibition and the resultant diagnostic and therapeutic debacles that follow.
Quacks lie. In some ways, that’s what separates us from them. Real doctors are stuck with the messy truth: with bad news, with uncertain outcomes. It’s this reliance on the truth which gives us much of our credibility.
Laws forcing doctors to lie to patients take me back to reading Kundera in the 80s; the hovering fear that everyday actions might bring the authorities to your door. These feelings affect every portion of your life, whether you are a patient or a doctor. Lying in service of the state is pervasively oppressive. Laws requiring doctors to lie have become a popular tactic in the abortion wars.
Let’s look at Texas’s law, it’s requirements, and internal contradictions.
I’m currently putting the finishing touches on a presentation for the The Ontario Public Health Convention next week, where I’ll be speaking, with occupational therapist Kim Hébert, about the anti-vaccine movement and social media (SM): how antivaccine advocates use it, and the challenges and opportunities for public health advocates. I’m pleased to see Seth Mnookin, author of The Panic Virus and someone whose work is likely known to many SBM readers, is one of the keynote speakers – his perspective will be valuable for the public health crowd which has traditionally relied on fairly static “key messages” for disseminating information on vaccine safety and effectiveness. The panel discussion of which I am a part will be an examination of challenges and opportunities presented to public health advocacy, and particularly vaccine advocacy, in a Web 2.o environment. What seems clear is that the old public health channels don’t cut it anymore: these methods are distant and insufficient to address the wide and rapid spread of misinformation in an era of social media. We all remember the anxiety over H1N1 just a few years ago – and judging by the poor uptake of the vaccine, it seemed the anti-vaccine movement had some success in propagating fear, uncertainty, and doubt. I’d almost forgotten about this chestnut from the Health Ranger himself:
We frequently deal with fraud and quackery on this blog, because part of our mission is to inform the public about such things, and also they are great examples for explaining the difference between legitimate and dubious medical claims. It is always our goal not just to give a pronouncement about this or that therapy, but to work through the logic and evidence so that or readers will learn how to analyze claims for themselves, or at least know when to be skeptical.
One skepticism-inducing red flag is any treatment that claims to treat a wide range of ailments, especially if those ailments are known to have difference causes and pathophysiologies. Even claiming that one treatment might be effective against all cancer is dubious, because cancer is not one disease, but a category of disease. We are fond of pointing out that there are many types and stages of cancer, and each one requires individualized treatments. As an aside, it is ironic that CAM proponents often simultaneously tout how individualized their treatment approach is, but then claim that one product or treatment can cure all cancer. Meanwhile they criticize the alleged cookie-cutter approach of mainstream medicine, which is actually producing a more and more individualized (and evidence-based) approach to such things as cancer.
In any case – my immediate response to any article or website claiming to treat most or all cancer is to be highly skeptical, but I reserve final judgment until after I read through the details. What kinds of evidence are being presented to support the claims, and what are the alleged mechanisms of action? Are those making the claims being cautious like a scientist should, or are they being promotional like a used-car salesman?
A recent study claiming a potential treatment for many types of cancer has been making the rounds. The title of the article being circulated is, One Drug to Shrink All Tumors. What made me take immediate interest in this article was that it was not on a dubious website, sensational tabloid, or even mainstream news outlet, but on the news section of the American Academy for the Advancement of Science (AAAS) website. This is a report of serious medical research. The title, I suspect, is perhaps a bit more sensational than it otherwise would have been because of a geeky nod to the “one ring to bind them all” Lord of the Rings quote. Regardless of the source and the headline – what is the science here?
I know a woman who is a survivor of colorectal cancer. At one point, doctors had given up hope and put her in hospice, but she failed to die as predicted and was eventually discharged. She continues to suffer intractable symptoms of pain with alternating diarrhea and constipation. I don’t have access to her medical records, but she tells me her doctors have talked about irritable bowel syndrome (IBS) and have also suggested that the heavy doses of radiation used to treat her cancer may have caused permanent damage to her colon. Whatever the cause, her symptoms have seriously interfered with her mobility and her quality of life. Her health care providers have recently recommended questionable treatments in what I think can be construed as using CAM as a dumping ground for difficult patients.
Colonoscopy hadn’t shown any obstruction, but one of her doctors had hypothesized that her symptoms might be due to impaired bowel motility in the irradiated area. She was desperate enough to consider surgery if there was a chance that bowel resection or colostomy might improve her symptoms. She belongs to a large, well-known HMO with a good reputation. She asked her primary HMO physician who thought the idea was plausible and referred her to a surgeon. The first surgeon said surgery was not indicated and referred her to another surgeon on staff. In addition to being board certified in general surgery, the second surgeon was allegedly board certified in something related to CAM (my friend can’t remember his exact words and has been unable to verify any such credentials online).
The surgeon recommended acupuncture, not once but twice. My friend’s husband (who teaches statistics at a nearby community college) told the surgeon that he was fascinated by the challenges of double-blinded studies of acupuncture and that he was aware of no benefits beyond the placebo level. The surgeon then retreated a little and suggested that the primary benefit of acupuncture in treating IBS was the “relaxation” effect.
I do not understand the interest many appear to have in their bowels and the movement there of. But then, I pay little attention to most of my body functions as long they are functioning within reasonable parameters, and as I get older the definition of reasonable is increasingly flexible.
The elderly especially seem to obsess about their bowels. My theory is that since they have often lost taste, smell, hearing and are alone with little direct human touch, a good BM is the only remaining physical joy left, and when it is compromised they are understandably upset.
Still, the concept of colonics for ‘detoxification’ strikes me as more humorous than repellent, despite the lack of efficacy and documented complications of the procedure. Under normal circumstances, when it comes to the colon it is probably better to be removing substances than to be introducing them. (more…)
Author’s note: This will inaugurate a series of occasional posts observing the wheels of justice grind slowly over “CAM.”
In a previous post, I posited that CAM practitioners might well subject themselves to liability for the tort of fraudulent misrepresentation. This misrepresentation could be based on both the lack of scientific evidence of effectiveness and the lack of scientific plausibility for their treatments. One example was homeopathy, which, as Dr. Steven Novella aptly stated,
we can summarize . . . by saying it has extreme implausibility and the clinical evidence shows lack of efficacy. It should not work, and it does not work. There is no legitimate controversy about this.
In the last couple of years five lawsuits have been filed against Boiron, a somewhat prickly company based in France and the world’s largest manufacturer of homeopathic products. In 2011, Boiron had $520,000,000 in sales, although some of this revenue comes from its other products, such as dietary supplements. The plaintiffs are consumers who purchased Boiron’s homeopathic “remedies” and who now allege that they were deceived by Boiron’s false and misleading representations, allegations Boiron denies. Four of the lawsuits are pending in California and one in Illinois.
All of the suits are filed as putative class actions, which generally proceed like this: a plaintiff claims she was injured in a certain manner by the defendant’s conduct and that there are numerous others who were injured in the same, or a similar, way. She asks the court to allow her to proceed with a class action in which she will represent all those other people. In essence, the class members become plaintiffs themselves and are bound by the results of the case. (They can’t, for example, bring their own individual lawsuits.) If the plaintiff is successful, all class members are entitled to relief, including monetary damages. (more…)
In 2009, during the “Obamacare” debate that was dominating the news, Atul Gawande wrote an article in the New Yorker that was widely praised and cited, including by president Obama himself. The article is a thought-provoking discussion of why some communities in the US have much higher health care costs than other regions. I took two main conclusions from the article.
The first is the success of the Mayo model – organizing care as a team approach. The idea here is to pool optimal expertise in the care of each patient. Greater expertise leads to “more thinking and less testing,” as Gawande puts it. I agree with this. It takes expertise to be comfortable not doing a test. Often testing is ordered because a physician does not feel secure in their diagnostic assessment.
The second main conclusion was the McAllen model, a town in Texas that has double the average Medicare costs per capita in the country. Gawande concluded that these increased costs are likely due to the culture of medical practice in the region, leading to greater unnecessary care and procedures. He wrote:
The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
Is that, however, a necessary conclusion from that data? The data support the conclusion that McAllen (the highest cost region) uses many more medical procedures than El Paso (the lowest cost region), but does that necessarily equate to “overuse” of medicine? Evidence does not support the conclusion that the population in McAllen is sicker than El Paso, but it is also possible that El Paso simply underdelivers care.
From an e-mail I received:
As a proponent of SBM, and a someone who places a high value on reason, logic and evidence, I would like to find a physician who shares this mindset.
He went on to ask how he could go about finding one.
Another correspondent was referred to a surgeon by her primary physician, and the surgeon inspired confidence until she started talking about using homeopathic arnica pills to improve healing post-op. How she could determine the technical competence of this surgeon? Was acceptance of homeopathy a reason to shed doubt on her judgment in other areas? Should she seek a second opinion?
I get a lot of inquiries about how to find a good doctor. I don’t have a good answer. I thought it might be useful to throw out some ideas that have occurred to me and hope that readers will have better ideas and will share their experiences about what has or hasn’t worked. (more…)