When Dr. Novella recently wrote about plausibility in science-based medicine, one of our most assiduous commenters, Daedalus2u, added a very important point. The data are always right, but the explanations may be wrong. The idea of treating ulcers with antibiotics was not incompatible with any of the data about ulcers; it was only incompatible with the idea that ulcers were caused by too much acid. Even scientists tend to think on the level of the explanations rather than on the level of the data that led to those explanations.
A valuable new book elaborates on this concept: Diagnosis, Therapy and Evidence: Conundrums in Modern American Medicine, by medical historian Gerald N. Grob and sociologist Allan V. Horwitz. They point out that
many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong. (more…)
One (dark and stormy?) night in 1882, a critically ill 70 year old woman was at the verge of death at her daughter’s home, suffering from fever, crippling pain, nausea, and an inflamed abdominal mass. At 2 AM, a courageous surgeon put her on the kitchen table and performed the first known operation to remove gallstones. The patient recovered uneventfully. The patient was the surgeon’s own mother.
This compelling story is the beginning of an excellent new biography of William Halsted, the father of modern surgery, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, by Gerald Imber, MD.
When Halsted went to medical school, surgeons still operated in street clothes, with bare hands, and major surgical procedures carried a mortality rate of nearly 50 percent. Suppuration of wounds was called laudable pus. Lister had recently introduced carbolic acid dips and sprays (that were irritating and toxic), but hand washing was discouraged because it was thought to force germs into skin crevices. (more…)
Sleep that knits up the ravelled sleeve of care
The death of each day’s life, sore labour’s bath
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast. –William Shakespeare, Macbeth
The company that makes the Zeo Personal Sleep Coach kindly sent me one of their devices to try out. It’s a nifty little gadget, and if you are a techno geek, you would probably love it. It’s a fascinating toy; but for insomnia, there’s no evidence that it provides any benefit over standard treatment with sleep logs and sleep hygiene advice.
Polysomnography is done overnight in a sleep lab and costs around $1000. It records multiple parameters: EEG, EKG, EMG, breathing, O2, CO2, and limb movements. It is most commonly used to diagnose obstructive sleep apnea (OSA), a serious condition that is linked to hypertension, heart disease, diabetes, metabolic syndrome, stroke, and increased mortality. OSA can be effectively treated with CPAP and other measures. About 50% of snorers have sleep apnea. We typically think of it as a disease of obese, loudly snoring older men, but even young children can have it: snoring is probably never normal in children and should be investigated.
The Zeo is the first sleep monitor available for consumers to use at home. It doesn’t pretend to do what polysomnography does. It can’t diagnose sleep apnea. It is billed as an educational and motivational tool, not intended for the diagnosis or treatment of sleep disorders. A unit that looks sort of like an alarm clock sits on your bedside table and communicates wirelessly with a comfortable soft elastic headband that positions embedded sensors over your forehead to pick up your brain waves. (more…)
When I first heard that a retrovirus had been identified as a possible cause of chronic fatigue syndrome, I withheld judgment and awaited further developments. When I heard that two subsequent studies had failed to replicate the findings of the first, I assumed that the first had been a false alarm and would be disregarded. Not so.
It’s a classic case of wishful thinking outweighing good judgment. One unconfirmed report of an association between the XMRV virus and chronic fatigue syndrome (CFS) resulted in a rush to test for the virus, speculation about possible implications, and even suggestions for treatment. And the subsequent negative studies did little or nothing to reverse the trend.
XMRV is Xenotropic murine leukemia virus-related virus. In the past, there were reports that this retrovirus was associated with prostate cancer, but then other reports found no link. In 2009 a study was published in Science, “Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome” by Lombardi et al., reporting an association with CFS:
we identified DNA from a human gammaretrovirus, xenotropic murine leukemia virus–related virus (XMRV), in 68 of 101 patients (67%) as compared to 8 of 218 (3.7%) healthy controls. (more…)
Everybody knows that colonoscopy is the best test to screen for colorectal cancer and that colonoscopies save lives. Everybody may be wrong. Colonoscopy is increasingly viewed as the gold standard for colorectal cancer screening, but its reputation is not based on solid evidence. In reality, it is not yet known for certain whether colonoscopy can help reduce the number of deaths from colorectal cancer. Screening with fecal occult blood testing (FOBT) and flexible sigmoidoscopy are supported by better evidence, but questions remain. It seems our zeal for screening tests has outstripped the evidence.
Statistics show that the life-time risk for an adult American to develop colorectal cancer (CRC) is approximately 6%. Colorectal cancer is the second leading cause of cancer deaths in the United States. In the US there are currently 146,970 new cases and 50,630 deaths each year. Between 1973 and 1995, mortality from CRC declined by 20.5%, and incidence declined by 7.4% in the United States.
The US Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. (more…)
In 1925, Francis Peabody famously said “The secret of the care of the patient is in caring for the patient.” A new book by Norman Makous, MD, a cardiologist who has practiced for 60 years, is a cogent reminder of that principle.
In Time to Care: Personal Medicine in the Age of Technology, Dr. Makous tackles a big subject. He attempts to show how modern medicine got to where it is today, what’s wrong with it, and how to fix it. For me, the best part of the book is the abundance of anecdotes showing how medicine has changed since Dr. Makous graduated from medical school in 1947. He gives many examples of what it was like to treat patients before technology and effective medications were introduced. He describes a patient who died of ventricular fibrillation before defibrillators were invented, the first patient ever to survive endocarditis at his hospital (a survival made possible by penicillin), a polio epidemic before polio had been identified as an infectious disease, the rows of beds in the tuberculosis sanitariums that no longer exist because we have effective treatments for TB. He tells funny stories: the patient who was examined with a fluoroscope and told the doctor he felt much better after that “treatment.” He describes setting up the first cardiac catheterization lab in his area. No one who reads this book can question the value of scientific medicine’s achievements between 1947 and 2010. Today we can do ever so much more to improve our patients’ survival and health. But in the abundance of technological possibilities, the crucial human factor has been neglected.
Individualized care, which involves the use of science-inspired technology, is not personal care. Alone, it is incomplete. It does not provide the necessary reassurance that can only be provided through a trusted physician who focuses upon the totality of the person and not just upon a narrow technological application to a disease. Time and personal commitment are needed to build the mutual understanding and trust that are fundamental to personal care….the continued acceleration of science, technology, and cost has intruded on personal care in our country. This has also occurred during a time in which American individualism and its accompanying sense of entitlement have become more of a cult than ever before. In the absence of personal attention, patients demand more testing, but testing does not satisfy the need for personal interaction.
Makous invokes the Golden Rule: “Over the course of my career, I learned to treat patients as I would like to be treated under similar circumstances.” (more…)
Scientific studies are not meant to be amusing, but I laughed out loud when I heard about this one. After all the concern about possible adverse health effects from cell phone use, this study tells us cell phone use can prevent Alzheimer’s, treat Alzheimer’s, and even improve cognitive function in healthy users.
They studied transgenic mice programmed by their genes to develop Alzheimer’s-like cognitive impairment; they used a group of non-transgenic littermates as controls. For an hour twice daily over several months they exposed the entire mouse cage to EMF comparable to what is emitted by cell phones. They tested cognitive function with maze tests and other tasks that are thought to measure the same things as human tests of cognitive function. The authors claim to have found striking evidence for both protective and disease-reversing effects. (more…)
Faith healing is based on belief and is about as far as you can get from science-based medicine, but it is not exempt from science. If it really worked, science would be able to document its cures and would be the only reliable way to validate its effectiveness. Miraculous cures continue to be reported on a regular basis: what are we to make of them? In the Healing Rooms Ministry of Bethel Church in Redding, California, people regularly claim to be healed of cancer, broken bones, multiple sclerosis and many other ailments. Page after page of testimonials of cures are listed on their website. Are these cures real? If not, what is going on?
Amanda Winters, a journalist doing a series of articles on Bethel Church, interviewed me for a scientific view of these faith healings. She asked me some very incisive questions and understood my answers. She wrote what I thought was a balanced article, quoting me fairly and at more length than reporters usually allow.
Her article features a patient who believed his flat feet would be healed (bones would crack and form an arch). Healers poked him, blew a shofar at his feet, and covered him with a blanket when he collapsed on the floor. When he got up, his feet were unchanged. But
his faith was not shaken, he said, because he felt so loved and maybe the physical healing was secondary to the spiritual experience he had. (more…)
A correspondent wrote:
I hear all day long on my local radio station commercials for The Water Cure, which was created by a Dr. Batmangelli (I have no idea how to spell his name) promising wonderful cures by eliminating caffeine and alcohol and drinking water and sprinkling sea salt on your food. If you REALLY want to get cured even faster, swim in the ocean everyday.
That’s Dr. Fereydoon Batmanghelidj. His Big Idea was that dehydration is the main cause of disease. It was untenable to begin with, is supported by no evidence, was debunked on Quackwatch several years ago, and Dr. Batmanghelidj died in 2004, so I was surprised to hear it was still being vigorously promoted. But not very surprised. After all, homeopathy is still around.
The Water Cure is another in a long list of alleged miracle cures discovered by “lone geniuses” who are allegedly persecuted by a resistant medical establishment. These stories follow a pattern, and I think it is worthwhile looking at this prime example to understand something of the psychology of self-deception that is involved. (more…)
A recent story on NPR accused the drug manufacturer Merck of inventing a disease, osteopenia, in order to sell its drug Fosamax. It showed how the definition of what constitutes a disease evolves, and the role that drug companies can play in that evolution.
Osteoporosis is a reduction in bone mineral density that leads to fractures. The most serious are hip fractures, which require surgery, have complications like blood clots, and carry a high mortality. Many of those who survive never walk again. Vertebral fractures are common in the osteoporotic elderly and are responsible for dowager’s hump and loss of height. There is also an increased risk of wrist and rib fractures.
Bone density tends to decrease with age. Postmenopausal women are particularly susceptible to osteoporosis when their production of estrogen declines. The risk is increased in people taking corticosteroids and in people with certain diseases like rheumatoid arthritis. Other risk factors are European or Asian ancestry, smoking, excess alcohol, a family history of fractures, vitamin D deficiency, too much or too little exercise, malnutrition, and low body weight.
When a measurement like bone density varies widely in a population and decreases with age, how can we decide where to draw the line and call it abnormal? When does it become a disease requiring treatment? (more…)