Some people have made the mistake of seeing Shunt’s work as a load of rubbish about railway timetables, but clever people like me, who talk loudly in restaurants, see this as a deliberate ambiguity, a plea for understanding in a mechanized world. The points are frozen, the beast is dead. What is the difference? What indeed is the point? The point is frozen, the beast is late out of Paddington. The point is taken. If La Fontaine’s elk would spurn Tom Jones the engine must be our head, the dining car our esophagus, the guard’s van our left lung, the cattle truck our shins, the first-class compartment the piece of skin at the nape of the neck and the level crossing an electric elk called Simon. The clarity is devastating. But where is the ambiguity? It’s over there in a box. Shunt is saying the 8:15 from Gillingham when in reality he means the 8:13 from Gillingham. The train is the same only the time is altered. Ecce homo, ergo elk. La Fontaine knew his sister and knew her bloody well. The point is taken, the beast is moulting, the fluff gets up your nose. The illusion is complete; it is reality, the reality is illusion and the ambiguity is the only truth. But is the truth, as Hitchcock observes, in the box? No there isn’t room, the ambiguity has put on weight. The point is taken, the elk is dead, the beast stops at Swindon, Chabrol stops at nothing, I’m having treatment and La Fontaine can get knotted.

— Art Critic

Ambiguity. Medicine, like art, is filled with ambiguity, at least the way I practice it. Most of my practice is in the hospital. I am sometimes called to see patients that other physicians cannot figure out. And that puts me at a disadvantage, because the doctors who were referring patients to me are all bright, excellent doctors. Often the question is ‘Why does the patient have a fever?’ or ‘Why is the patient ill?’ Sometimes I have an answer. Most of the time I do not.

I am happy, however, to be able to tell the patient what they don’t have. I can often inform the patient and their family that whatever they have is probably not life-threatening or life-damaging, just life-inconveniencing, and most acute illnesses go away with no diagnosis. I always put the ‘just’ in air quotes, because illnesses that require hospitalization are rarely ‘just.’ Just without quotes is reserved for the antivaccine crowd and applied to the small number of deaths from vaccine preventable diseases in unvaccinated children. John Donne they ain’t.

We are excellent, I tell them, at diagnosing life-threatening problems that we can treat, and terrible at diagnosing processes that are self-limited. Of course diagnostic testing is always variable. No test is 100% in making a diagnosis, and often with infections I cannot grow the organism that I suspect is causing the patient’s disease. So for hospitalized patients, ambiguity and uncertainty are the rule of the day.

However, the situation is much better than they used to be. I am now one of the oldest physicians practicing in my hospital. After 21 years most of the prior old guard has retired or died, leaving me. I have gone from being the young whippersnapper to the old geezer in what to me seems to be a blink of an eye.

However, the advantage to being old is you get to bore people with the stories of your gloried past. I remember a time, I tell the residents, before CAT scans, before third-generation cephalosporins, before PCR diagnostics. I remember the beginning of the AIDS epidemic, when we saw young men dying of an unknown illness. I still vividly remember my first AIDS patient, dying from disseminated MAI, who offered me a chocolate from his box of candy. I declined. I told him I wasn’t hungry. He told me “I would have to spit in your mouth to give you AIDS.” I did not know that at the time. No one did. Today I would eat the candy.

Times have changed, mostly for the better. AIDS has gone from an unknown disease with a short life expectancy to a mostly chronic manageable illness whose pathophysiology is understood in remarkable detail. Medicine advances. It is often an uncomfortably slow and aggravating process, because diagnostics and therapeutics that look promising at the beginning often turn out to not live up to their promise. Kind of like many people I have known.

Some therapeutic interventions have remained in limbo my entire practice. Steroids, as an example, have been tried for every illness except for Cushing’s disease. In almost every instance they have been found wanting. When I was an intern, every patient with a neurologic event was put on aspirin and Persantine. I don’t think Persantine is used much anymore. Common admission diagnoses were an aminophylline toxicity and digoxin toxicity; both drugs are rarely used today since we have less toxic and superior alternatives.

Certainly my practices changed dramatically over the last 21 years. I used to make a living from diseases that are rapidly becoming of historical interest. Ventilator-associated pneumonia, line-related sepsis, AIDS opportunistic infections, neutropenic fever’s, diabetic foot infections in smokers, all used to be common admitting diagnoses that resulted in infectious disease consultation. No longer.

Despite the wackaloon opinion that doctors are in it for the money, combined with big pharma greed, the last 21 years has seen a concerted effort on the part of the medical industrial complex to decrease the diseases we treat for living. This is not only true in infectious diseases, but cardiologists have been at the forefront of stop smoking and lipid control. The same is true of pulmonary doctors. Every physician fights the battles of obesity in the outpatient clinic. Much of the time physicians try to put themselves out of work. And in infectious diseases it seems to be successful. That is why at TAM 9 this year I plan on letting everyone buy me a beer. I’m sure the rest of the SBM crew would feel the same way. But no lite beers, puh-leaze.

Medicine does advance.

There is an infectious disease therapy that superficially resembles acupuncture and homeopathy: ribavirin. A drug with few proven benefits. Like most SCAMs, case reports, uncontrolled series and wishful thinking has kept ribavirin alive and around for my entire practice. I say superficially as most SCAMs now have a proven lack of benefit. Ribavirin is an antiviral medication that has probably been tried on virtually every virus, but has never been shown to have efficacy by itself in almost any infection. It is of benefit in RSV, and combined with interferon for the treatment of hepatitis C.

Ribavirin is a broadly active antiviral has rarely been tested in randomized controlled trials. Many of the infections that are allegedly treated with ribavirin are not common in the United States. So when a question of West Nile virus, dengue virus, Tick-borne Encephalitis Virus, Yellow Fever Virus, Lassa fever, Crimean-Congo hemorrhagic fever, or Hantavirus appears, the answer is ribavirin. But is the answer the correct?

This leads to an interesting editorial from several years ago in the journal Clinical Infectious Diseases entitled How Medicine Advances. How?

The editorial concerned an article on a study that looked at the efficacy of ribavirin in the treatment of Japanese encephalitis virus. Significant time, money and effort has been expended using ribavirin for diseases like Japanese encephalitis. But there have never been randomized clinical trials to demonstrate or deny the efficacy of ribavirin in the treatment of Japanese encephalitis. Until 2009 that is.

In CID that year they published a randomized placebo-controlled double-blind study that evaluated the effectiveness of ribavirin in the treatment of children who had Japanese encephalitis. And ribavirin was found to do nothing.

What was striking about this trial, as pointed out in the editorial, was that the study was done in the poorest part of India, it was done in children, and it was done with a definitive rigor that allowed the issue of ribavirin (always with the caveats of orally and at the dose given) to be put to rest for the treatment of this one infectious disease. A little more ambiguity in medicine has been removed.

I think the final paragraphs of the editorial sum up nicely why we do science-based medicine and the importance of doing clinical trials to determine what does and does not wor:

Kumar et al., whose study is published in this issue of Clinical Infectious Diseases, are to be commended for refusing to bow to any of the complexities reputed to make clinical trials impossible. In Uttar Pradesh, India’s most populous and poorest state, Kumar and colleagues sustained over 3 years the first randomized, placebo-controlled, doubled-blind trial of ribavirin for the treatment of the most vulnerable patients—children (age, 6 months to 15 years)—to be hospitalized with acute febrile encephalopathy, and they per- formed seroreactive testing for IgM anti-bodies to Japanese encephalitis virus. By so doing, they established that oral ribavirin, at the dosage used in their study, did not improve either early or late outcomes. By demanding scientific justification for investment in this mode of therapy, they have both encouraged searches for more-effective interventions and prevented the expenditure of scarce resources ineffectively.
Both faith and science are important components of the art of medicine. We ought not to mistake one for the other.

I wish, besides sarcasm punctuation marks, we had whiny little baby tags punctuation marks, since the lament of many a SCAM proponent is that their particular intervention can’t be tested because of “complexities reputed to make clinical trials impossible.” Riiiiggghhhhttttt, Mr. Powers. It is easier to curse the darkness than to light a candle.

There is then the more difficult application of applying the data. If someone has a long history of being committed to a treatment, it is surprisingly difficult to get individuals and groups to alter their behavior. I expect the urge to give ribavirin for Japanese encephalitis will rapidly fade. Not so the urge to balance qi, fix subluxations, or realign the energy flux. Wait. The last is either reiki or Galaxy Quest. The latter at least is recognized as fiction. Unfortunately, there are many other infections for which people will try ribavirin and for which there are no randomized placebo-controlled clinical trials. Ribavirin will continue to be a drug mostly searching for a disease.

But still medicine progresses. Studies get done, there is an incremental improvement in our understanding of the diagnosis or treatment of the disease. And slowly and painfully medicine changes. Emphasis on slowly. Change has to be balanced with the knowledge that much of the information we have in medicine is not final. When I talk about studies with residents, I try and be careful to mention the often endless caveats about the applicability of the results beyond the study population. Back in the day it seemed that all coronary artery disease studies were done in old, white male veterans. Probably widely applicable, but maybe not. But at least as an old white man, I can be taken care of.

There’s an old saying that goes something like ‘be neither the first to abandon the old nor be the first to use the new.’ I certainly feel that way about antibiotics. Over the years new drugs have been approved, released into widespread use, and then found to have serious side effects that resulted in their being withdrawn from the market. So I’m always a little leery about new medications and new treatments unless I do not have other options.

So I look back on 21 years of infectious diseases 25 years of being a physician and note the incredible changes that have occurred. Diagnostics that have improved, therapies that have improved, and more importantly diagnostics and therapies that have been abandoned. Abandoned because they were shown not to work. Medicine advances.

Contrast that with the bête noire of this blog: supplements, complementary and alternative medicine. Anybody who subscribes to reality-based medicine would say at this point that the preponderance of data strongly points to the conclusion that most SCAMs do not work. Acupuncture, homeopathy, energy medicines, etc. do not materially alter disease. Yet has any of these ever been abandoned? Nope.

It would seem that they are being embraced, at least in academic institutions. SCAMs are an archetype example of failing up. It has been noted that with SCAMs that better and better studies show less and less effect until well-designed studies show no effect. For the last decade it would seem the greater the failure, the greater the spread into academia and the more popular the SCAM. By the same standards we should be using internal mammary artery ligation for coronary artery disease, high dose chemotherapy with bone marrow transplant for breast cancer, and continue to suppress all abnormal cardiac rhythms in heart attack patients. All the interventions failed spectacularly, and so should be embraced, each with their endowed Chairs.

SCAMs probably are growing for the financial benefit. Since standard medicine has declining reimbursement and most alternative therapies are out-of-pocket, it’s a good cash cow for institutions that want a flow of money and are not picky about their intellectual standards. Not only are the standard SCAMs proliferating, they often combine in most peculiar ways to come up with new variations. Doctor Moreau would be impressed with the slow mutant reassortments: acupuncture (at least 6 kinds) morphing into acupressure, laser acupuncture, acupuncture with tuning forks and color, and soon there will be dark energy acupuncture. You heard it here first. Don’t get me wrong, I am jealous. I would love to combine ID with cardiac bypass surgery and make some real cash, but they just don’t mix. Sigh.

It is said that the majority of medical practice has no basis in science-based medicine. Certainly in the practice of infectious diseases in the hospital, that is often the case. I will see an organism in a odd place, for example a Gemella endocarditis, and there are no long-term randomized placebo-controlled clinical trials to determine what the best therapy is for the treatment of a Gemella endocarditis. There probably never will be. It is so rare that it is probably impossible to generate enough cases to do a clinical trial. I am stuck with the basic principles of biologic plausibility and in vitro antibiotic susceptibilities and that is often enough. I know that if I can kill the bug in the test tube, I can often kill it in the patient as well. In the absence of clinical trials, reality can reliably determine effective therapy.

It is quite a stark contrast between SCAMs and of medicine and how they are practiced. Medicine changes. Or perhaps it would be better to say medicine evolves. The old is be shown to be worthless. It is abandoned, and patient care overall improves. Even when there are no good clinical trials to guide therapies, often we have prior plausibility and biologic plausibility to help guide our therapies. Not always, as ribavirin demonstrates, but we have to fight the war with the armies we have. Advances have not been without their side effects and bad consequences, as no good deed ever goes unpunished, but medicine still adheres to the Victorian principle that human societies are perfectible. And while we always fall short of our goal, what has accomplished has been admirable.

SCAMs persist with no improvement, no evolution, and are increasingly discredited by reality. Nothing is ever abandoned, instead persisting, mutating and growing. With alternative memes, what determines replicative fitness is not, apparently, the real world. Oh well, it gives me something to write about.

Posted in: Clinical Trials, Science and Medicine

Leave a Comment (41) ↓

41 thoughts on “Ambiguity

  1. BillyJoe says:

    ‘be neither the first to abandon the old nor be the first to use the new’.

    Just be quiet about it though.
    …because, if everyone jumps on that bandwagon, the old will never be abandoned and the new never embraced. ;)

  2. windriven says:

    Medicine does advance. You have laid out a typically thought-provoking and humorous juxtaposition of the march of modern medicine against the stagnation of quackery.

    So how do we square the magnificent achievements of modern medicine with the increasing embrace by the medical establishment of all things canard? Yale. Harvard. OHSU and UW here in the northwest have complementary and integrative medicine programs. Cleveland Clinic. In fact, of the major multi-hospital medical center programs I looked at (far from an exhaustive survey) only Ochsner seems to lack some form of so-called CAM program.

    What gives? More importantly, how can the tide be turned?

  3. rork says:

    “what determines replicative fitness is not, apparently, the real world”
    My take might be that the real world does determine the fitness, it’s just a world with some weak-minded people, where lying (or delusion) can be an advantage. Dumb memes for dumb people or something like that. Part of that world also contains punishments for lying though – thanks for adding to the supply of that. My brain is now (better) infected, though maybe inoculated is the better metaphor.

  4. Doctors have a very difficult time saying, “I don’t know”. This is especially true when discussing patients, and when speaking to patients. After all the years of studying and training how could a doctor not possibly know. As you have pointed out, though, there are many instances where we do not know what is going on, or what is wrong. The battery of tests will soon follow. If this still does not yield an answer, then we revert to ambiguity. Ambiguity allows us to discuss a patient intelligently without actually saying “I don’t know”.

    Dr Sam Girgis

  5. Panthera spelaea says:

    It’s long been a maxim of mine that medicine advances while “alternative medicine” recycles.

    Since I have done a lot of reading in the history of patent medicines, medicine shows and “alternative medicine”, it is very often when some quack promotes a new “miracle cure” I can recognize it as having been huckstered long before. One prime example would be the “gallstone flush” which is an old medicine show trick that uses Epsom salts, lemon juice and olive oil to produce saponificated lumps that may look like gallstones but are anything but.

  6. icewings27 says:

    Dr. Girgis brings up a great point. Doctors feel this pressure to give a definitive diagnosis and an instant cure. A lot of that expectation comes from us – the patients – because somewhere along the way we got this idea that medicine should fix every little complaint and ailment we may have.

    I have had the good fortune of finding several doctors who are more than willing to discuss the shortcomings and the unknowns of their specialties in regards to my particular case. One of the best ways to facilitate such a discussion as a patient is to come prepared to the appointment. Know some medical terminology, know the current treatments, know about some proposed or experimental treatments on the horizon. Ask intelligent questions and express your doubts or concerns.

    It is amazing how quickly a doctor will sit back, relax, and have a truly congenial discussion with you about his knowledge, experience, and the ambiguities of his specialty, as soon as he realizes that you don’t expect him to wave a magic wand and make all your problems disappear.

  7. Th1Th2 says:

    As you have pointed out, though, there are many instances where we do not know what is going on, or what is wrong. The battery of tests will soon follow.

    That explains why Modern Medicine can only manage to cause 783,936 iatrogenic deaths a year. Just imagine if they actually have known the answers, that figure could have reached a billion. Some progress.

  8. aeauooo says:

    “Doctors feel this pressure to give a definitive diagnosis and an instant cure.”

    I suspect that the pressure is very real; that a definitive answer and instant cure are what consumers want for their money.

    More often than not, I suspect that when a provider says, “I don’t know,” it is an honest statement, and as such, it should be an acceptable statement.

    A health care consumer is usually free to find a provider who is willing to give the answer that she or he wants, even if that answer is a lie or made out of ignorance.

  9. Chris says:

    Please ignore the troll, Th1Th2, with her imaginary number and speaking in Thinglish.

  10. vicki says:

    I assume that my doctors are honest if they say “I don’t know.” That’s not the only point, though. I still have to decide what to do: go home and try to tough it out? Talk to another doctor? Go home and try to treat the symptoms?

    “I don’t know, but we can do some more tests” is different from “I don’t know, so I’m sending you to someone who might” is different from “I don’t know whether it’s A or B, but this antibiotic will help either way” is different from “I don’t know, and neither does anyone else. I’m sorry. Here’s something that might help the symptoms.” The hard part, for the patient, is figuring out whether, if their doctor doesn’t know, there’s a reasonable chance of finding one who does.

  11. “Steroids, as an example, have been tried for every illness except for Cushing’s disease.”

    There were a lot of chuckleworthy lines in this post, but that’s the one what made me spray milk out my nose. An excellent little piece of medical humour.

    Ambiguity denialism is rampant in CAM (by necessity, almost by definition). I’ve been compiling notes for an article about clinical overconfidence in CAM, and it will have to include a link to this post.

  12. Harriet Hall says:

    If your doctor doesn’t know what you have, he may still know what you don’t have.

    How about “I don’t know, but we have ruled out everything that is likely to be life-threatening and there is no need for further tests at this time. Let’s work on relieving your symptoms and improving your quality of life rather than going on a wild goose chase to try to pin down a diagnosis when that may not be possible.”

  13. aeauooo says:

    “There were a lot of chuckleworthy lines in this post, but that’s the one what made me spray milk out my nose.”

    I nearly choked on my asparagus on that one.

  14. JPZ says:

    “There’s an old saying that goes something like ‘be neither the first to abandon the old nor be the first to use the new.’ ”

    That’s how I feel about technology too.

    Your Gemella sp. comment is interesting, and I think there is an additional aspect to consider. Medicine has the advantage of accumulating and publishing case-reports to increase knowledge about extremely rare conditions. In CAM, case report equivalents are tucked away into one person’s experiences without the weighing and evaluation needed.

  15. AusShane says:

    Ah Th1TH2 the standard disingenuous response – a figure rectally extracted is meaningless. If you want to use numbers to prove whatever point your response has try learning some basic mathematics.

    If you are trying to make some comparison between the risk/benefit ratio between ‘modern’ medicine (undefined) and I presume ‘ancient/natural/blah blah’ medicine (again undefined) I would advise caution.

    Perhaps you could give us statistics on the numbers of iatrogenic deaths caused by such traditional techniques as blood letting and laudable pus? or perhaps skull trephining?

    And then perhaps compare them with the documented successes?

    How many people died of digitalis overdose before Withering worked out the science of that ‘natural’ therapy?

    I know don’t poke the Troll

  16. Harriet Hall says:

    Th1Th2 is impervious to reason and uses his own personal language; I have tried diligently to carry on a logical discussion with him more than once and have given up in frustration. I won’t answer him, but I will comment on one thing for others who might be interested:

    “that explains why Modern Medicine can only manage to cause 783,936 iatrogenic deaths a year. Just imagine if they actually have known the answers, that figure could have reached a billion.”

    I say, Just imagine if Th1Th2 had treated those people. The figure (a wrong figure, by the way) would have had a much greater chance of reaching a billion. Among other things, if we had followed his principles, smallpox would still be with us, still endemic or epidemic, and would still be killing 30% of people who developed a “natural” infection.

  17. Chris says:

    The figure “783,936” is wrong just by its very exactness. There is no way to say that each and every year that is the exact number that succumbed to actual medical care. This is what is pointed out in the first chapter of so of Proofiness.

    The silliness of this exact number and its use by Th1Th2 was discussed on a another blog whose name automatically prevents publishing. So please do not feed the troll.

  18. Chris says:

    Sigh, well I did try over ten hours ago:

    # Chris on 03 Jun 2011 at 2:50 pm

    Your comment is awaiting moderation.

  19. Chris says:

    … which I followed with a link on a blog that discussed the silly use of that number.

  20. Ken Hamer says:

    “I have gone from being the young whippersnapper to the old geezer in what to me seems to be a blink of an eye.”

    Fear not; age and treachery will defeat youth and skill.

  21. BillyJoe says:


    How about “I don’t know, but we have ruled out everything that is likely to be life-threatening and there is no need for further tests at this time. Let’s work on relieving your symptoms and improving your quality of life rather than going on a wild goose chase to try to pin down a diagnosis when that may not be possible.”

    Sounds like that covers all escape routes to the sCAMster’s door. :)

  22. Mark Crislip says:

    The correct number is 783,938, not 783,936. They forgot a couple. One was a Hungadunga. They left out a Hungadunga! And the most important one, too! And Kenny. Oh my god, they killed Kenny. Those bastards.

  23. JPZ says:

    “And Kenny. Oh my god, they killed Kenny. Those bastards.”


    Acutally, I always suspected Kenny had crystals and healing stones strapped to his body under that jacket. Its working well for him, don’t you think? ;)

  24. pmoran says:

    Th1th2 is quoting the hoary old Null/Dean figures, which included 115000 deaths attributed to bedsores! They can apparently be laid at the door of modern medicine, as can a similar number of deaths from “malnutrition”!

    There is nevertheless no getting around the fact that taking an active pharmaceutical, attending a doctor, undergoing an investigation, or having even a minor operation all carry some risk.

    Only a proportion — about a third– of deaths from those risks are considered preventable within present medical capabilities.

    We should therefore not necessarily envisage, or push for, or especially, be thought to be pushing for, a medical system wherein these are the only options.

    That is unachievable –also irrational, on scientific grounds. The act of being treated seems to bring certain comforts and benefits regardless of the activity of any remedies resorted to. A great many medical outcomes are similarly independent of treatment efficacy.

    We can still attack the risky, quacky and fraudulent areas of folk and “alternative” medicine with better regulation, information — and, if so inclined, the banging together of heads (metaphorically).

  25. Harriet Hall says:

    “We should therefore not necessarily envisage, or push for, or especially, be thought to be pushing for, a medical system wherein these are the only options.”

    So you are suggesting that instead of a system based on effective science-based treatments with possible side effects we should offer any and every kind of safer but likely ineffective treatments? I don’t think so. I have no problem with informed patients having the option of choosing other treatments outside of our system, but I think offering all those options within our system would be a mistake. We need to maintain some standards if we expect to gain our patients’ trust. We can aim to make use of some of those nonspecific effects of treatment within our system.

  26. Th1Th2 says:


    Th1Th2 is quoting the hoary old Null/Dean figures, which included 115000 deaths attributed to bedsores!

    Bedsores are one of the hideous decay of Modern Medicine.


    Bedsores are often fatal – even under the auspices of medical care – and are one of the leading iatrogenic causes of death reported in developed countries, second only to adverse drug reactions.

  27. pmoran says:

    Th1Th2, That Wikipedia entry also has too broad an understanding of “iatrogenic”. Bedsores are are rarely ever due directly to medical treatment.

    They require a patient to be severely disabled for OTHER reasons. There are usually also economic strictures limiting the quality of the available nursing care and apparatus.

  28. Chris says:

    pmoran: please. Thank you.

  29. pmoran says:

    Harriet: So you are suggesting that instead of a system based on effective science-based treatments with possible side effects we should offer any and every kind of safer but likely ineffective treatments?

    No. By “medical system” I meant the entire medical scene inclusive of mainstream, folk, hobbyist and “alternative” medicine.

    We science-based doctors usually have a sense that we OWN medicine. We don’t really, as shown by billions of dollars spent elsewhere.

    We are a major player. Our opinions are generally respected, giving us some ability to shape those bits of medicine that lie outside our ambit, and it is attitudes towards that arena that I mainly had in mind. Sorry for any ambiguity.

  30. Jan Willem Nienhuys says:

    That funny number comes from Death by Medicine (2003), by Drs. Gary Null, Carolyn Dean, Martin Feldman, Debora Rasio and Dorothy Smith. It represents about one third of the annual death rate in the US at the time of publication of the book. I guess one can even increase that ‘iatrogenic death rate’ by counting as iatrogenic any death occurring within a month after seeing a physician.

    But to imagine that the annual US death rate might be going up to a billion, is certainly a mighty feat of creative thinking.

  31. David Gorski says:

    Indeed. There are approximately 2.4 million deaths in the U.S. every year:

    It’s quite the stretch of the imagination to think that close to 1/3 of all deaths in the U.S. every year are due to iatrogenic causes, but that’s the claim made by Null and his merry band of quacks.

  32. “Bedsores are one of the hideous decay of Modern Medicine.” – Th1Th2

    Modern medicine has allowed us to extend the lifespan of humans, and allowed us to live much longer with chronic conditions such as hypertension and diabetes. If it were not for modern medicine, patients would not reach the state were they would become so incapacitated that they can not even move and develop bedsores. Without modern medicine, the average lifespan of a person would be to their 40’s or 50’s instead of to their 70’s or even beyond. At a lifespan of 40’s or 50’s there would be no bedsores.

    Dr Sam Girgis

  33. Jan Willem Nienhuys says:

    I took my data from

    which is a bit more succinct.

  34. JPZ says:

    “That explains why Modern Medicine can only manage to cause 783,936 iatrogenic deaths a year. Just imagine if they actually have known the answers, that figure could have reached a billion. Some progress.”

    So wait, if they “knew the answer” they would have created a Doomsday device to kill all CAM practitioners detached from Modern Medicine and people without access to adequate healthcare and every man, woman and child in the United States and anyone else who got too close?

    Damn, knowledge IS power. :))

  35. David Gorski says:

    One notes from the census data that, while births have been steadily increasing since 1999, the number of deaths has stayed pretty much the same, suggesting fewer people dying each year as a percentage of the entire population.

  36. Zetetic says:

    The Th thing sez:

    “That explains why Modern Medicine can only manage to cause 783,936 iatrogenic deaths a year.”

    Iatrogenic death estimates (there is no definitive count) are all over the map. The highest counts trotted out by alt-med promoters are typically compilations of the highest possible estimates for each type of death cherry picked and added up from multiple sources.

    So let’s just do the numbers in the USA for your quote of 783,936 iatrogenic deaths/year to see how bad it really is:

    37 million admissions in 5795 AHA registered hospitals (AHA 2009)
    117 million visits to hospital emergency departments (CDC 2007)
    88 million visits to hospital based outpatient departments (CDC 2007)
    902 million visits to non-hospital based physician offices (CDC 2007)

    1.144 BILLION (1,144,000,000) opportunities to precipitate an iatrogenic death incident.

    Your premise put forward is a not very well veiled “See – Doctors kill patients all the time” assertion that supposes that the entire system of health care delivery is hopelessly flawed. Iatrogenic death statistics reflect so many confounding and contributing factors, many uncontrollable in any case. There is the severity of the condition of the patient, previously unknown medication allergies, undocumented medication side effects, product labeling issues, technical/mechanical defects in equipment, non-adherence to professional standards of care or established organizational protocols and procedures, and lack of experience, knowledge or training. Every death in a hospital, expected or untoward, is investigated and lessons learned are incorporated into the imporvement of future practice.

    The practice of medicine isn’t perfect and nobody claims it is – And mistakes do happen. Any preventable death is, of course, a travesty and to the general population, the aggregate number might sound frightening. But iatrogenic deaths don’t really have the shock value you promote when compared to the sheer volume of quality health care delivered in the United States.

  37. LMA says:

    As someone who has struggled through life with a long series of probably interconnected but poorly understood diseases (irritable bowel syndrome, interstitial cystitis, asthma, clinical depression, spondylosis, eczema to name but a few), the most important thing I can convey to anyone in medicine is to treat your patients with compassion and intelligence, and not to assume they’re stupid or crazy. I can easily see where a slightly less educated, less skeptical me would be going on a weekly basis to see a CAM quack simply because life with these conditions can be so miserable and CAMers offer sympathy and the appearance of sincerity if nothing else. There have been medical doctors in my past who have made me feel as if they believed I was crazy and confabulating for reporting to them my symptoms and frustrations when prompted (don’t ask me “is there anything else you’d like to tell me about” if you don’t want to take it seriously! My best doctor, OTOH, is a rheumatologist who assures me that yes, he believes there is something physiologically wrong with me, no, that thing is not that I’m mentally ill (beyond being depressed), and that researchers are working on making the connections that will, hopefully, some day result in better treatments for me. No, he doesn’t have anything better than methotrexate for me to try this month, but hang in there, he believes I can. That “no solution” is the best solution of all.

  38. pmoran says:

    I sometimes have a bit to say about the limitations of mainstream medicine. Why? Because they are clearly a powerful yet often overlooked factor driving CAM use.

    They are but one side of the coin. I am just as staggered as Mark at the advances that have occurred within my own field (surgery) within my lifetime.

    Anaesthesia has become remarkably safe. Pain relief is vastly better. Surgical capabilities and success rates have expanded remarkably. Endoscopic surgery now spares many patients painful wounds, weeks in hospital and allows patients to resume normal activities within a week or two rather than months. Intensive care saves people from conditions that were previously hopeless.

    My one regret is that I will not be around to see what advances occur over the next fifty or sixty years.

  39. David Gorski says:

    Indeed. I have maybe another 15 or 20 years in my career, which should allow me to see plenty (although I hope the rapid advances aren’t so dramatic that they push me to the sidelines as an old surgeon who can’t keep up).

  40. AJ Gregg says:

    It’s good to hear people talk about this elephant in the room. Reminds me of one of my favorite quotes: “Clinical uncertainty is the sociology of medicine.”.

  41. From Dr. Atul Gawande’s wonderful book, Complications:

    These are the moments in which medicine actually happens. And it is in these moments that this book takes place–the moments in which we can see and begin to think about the workings of things as they are. We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.

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