We hear a lot about medical malpractice suits and how they affect the practice and the cost of medicine. Doctors sometimes get the feeling that a lawyer is looking over their shoulder as they interact with patients, and sometimes they practice “defensive medicine,” ordering unnecessary tests and doing what they think would look best in court rather than what is really in the patient’s best interests. One of my colleagues in the Air Force, a psychiatrist, said at his retirement ceremony that he considered his career a success because he had never been sued. That struck me as a sad commentary on what it means to practice medicine today.
Some of my preconceived ideas on the subject of malpractice were challenged by a recent survey. Medscape asked 3,480 U.S. physicians about their experience with malpractice suits. 60% of responding physicians reported they had never been named in a lawsuit, 31% had been sued in conjunction with other defendants like hospitals, and only 9% were sued as individuals. (more…)
I recently wrote about the claim that acupuncture can improve vision in patients with macular degeneration. In response, I received this e-mail:
At Discovery Eye Foundation we have an education and outreach program for people with age-related macular degeneration, the Macular Degeneration Partnership. We are constantly getting calls from people who have heard of a new “cure” or a way to stop their vision loss. It is always hard to interject reality into the conversation and hear the hope leave their voice, replaced by frustration or despair.
The e-mail suggested I write an article providing guidelines for consumers to help them evaluate the validity of treatment claims for themselves. On SBM we are constantly stressing the need to apply critical thinking to what you read, and the many pitfalls to be avoided. I’ll try to synthesize some of the principles into a handy list of questions. (more…)
Last week I wrote about doctors who order unnecessary tests, and the excuses they give. Then I ran across an example that positively flabbered my gaster. A friend’s 21-year-old son went to a board-certified family physician for a routine physical. This young man is healthy, has no complaints, has no past history of any significant health problems and no family history of any disease. The patient just asked for a routine physical and did not request any tests; the doctor ordered labwork without saying what tests he was ordering, and the patient assumed that it was a routine part of the physical exam. The patient’s insurance paid only $13.09 and informed him that he was responsible for the remaining $3,682.98 (no, that’s not a typo). I have a copy of the Explanation of Benefits: the list of charges ranged from $7.54 to $392 but did not specify which charges were for which test. It listed some of the tests as experimental and not covered at all by the insurance policy, and one test was rejected because there was no prior authorization. (more…)
While cleaning out some old files, I was delighted to find an article I had clipped and saved 35 years ago: a “Sounding Boards” article from the January 25, 1979 issue of The New England Journal of Medicine. It was written by Joseph E. Hardison, MD, from the Emory University School of Medicine; it addresses the reasons doctors order unnecessary tests, and its title is “To Be Complete.” Today we have many more tests that can be ordered inappropriately and the article is even more pertinent and deserves to be re-cycled. He says,
When challenged and asked to defend their reasons for ordering or performing unnecessary tests and procedures, the reasons given usually fall under one of the following excuses…
This post is dedicated to two people who are frequent commenters on SBM, Stephen S. Rodrigues and Peter Moran. Rodrigues is an MD/acupuncturist who tries to persuade us that acupuncture is effective. Moran is a retired surgeon who objects to insulting language and thinks more can be accomplished by trying to better understand why people turn to CAM and by explaining the facts and reasons politely and dispassionately. He has claimed that he “could probably help [Rodrigues] understand better why his views are not having much impact.”
I recently wrote about supplements for age-related macular degeneration (AMD). There is evidence that the supplement mixture tested in the AREDS trial slows the progression of moderate to advanced disease. That is based on a good scientific study, although the study has not been replicated and there is reason to interpret its results with caution. Dr. Rodrigues commented with a link to a website advertising the Santa Fe acupuncture protocol, saying that he uses the method in his office and it helps some of his patients with AMD. The website claims that the Santa Fe acupuncture protocol will reverse vision loss from macular degeneration in 4 days or your money back. That is a bold claim. I will try to explain, as politely as possible, why I reject the claim, and why the evidence for it is unacceptable. (more…)
A correspondent asked me to look into the science behind the health claims for turmeric. He had encountered medical professionals “trying to pass turmeric as some sort of magical herb to cure us from the ‘post-industrial chemical apocalypse.’” It is recommended by the usual promoters of CAM: Oz, Weil, Mercola, and the Health Ranger (who conveniently sells his own superior product, Turmeric Gold liquid extract for $17 an ounce).
Turmeric (Cucurma longa) is a plant in the ginger family that is native to southeast India. It is also known as curcumin. The rhizomes are ground into an orange-yellow powder that is used as a spice in Indian cuisine. It has traditionally been used in folk medicine for various indications; and it has now become popular in alternative medicine circles, where it is claimed to be effective in treating a broad spectrum of diseases including cancer, Alzheimer’s, arthritis, and diabetes. One website claims science has proven it to be as effective as 14 drugs, including statins like Lipitor, corticosteroids, antidepressants like Prozac, anti-inflammatories like aspirin and ibuprofen, the chemotherapy drug oxaliplatin, and the diabetes drug metformin. I wish those claims were true, because turmeric is far less expensive and probably much safer than prescription drugs. It clearly has some interesting properties, but the claims go far beyond the actual evidence. (more…)
What AMD does to vision
Four years ago I wrote about the premature marketing of a diet supplement for macular degeneration before the results of a trial to test it were available. Now that we know the results of that trial, a follow-up post is in order.
Age-related macular degeneration (AMD) is a leading cause of blindness. The incidence increases with age; it affects 10% of people by age 66-74 and 30% of people by age 75-85. There are known risk factors including genetics and smoking, but there is no effective prevention. There are multiple diet supplement products on the market that are advertised as “supporting eye health.” Some are based on evidence from randomized, controlled studies; but the advertising hype goes beyond the evidence and tends to mislead consumers. There is evidence that supplementation may slow the progression of moderate to severe AMD, but there is no evidence that supplements are effective in milder disease or for preventing AMD from developing in the first place. (more…)
Sisyphus and his endless task
My BMI is 21, but my e-mail and Facebook accounts must think I’m fat. I am constantly bombarded with messages about miracle weight loss solutions, and most of them are diet supplements featured on the Dr. Oz show. Back in December I wrote an article about Garcinia cambogia, Dr. Oz’s “newest, fastest fat buster.” I made this prediction: “I confidently expect another “miracle” to supplant Garcinia in the Land of Oz in the not-too-distant future.” I was right. The e-mails about Garcinia have recently been outnumbered by e-mails about a new Dr. Oz miracle weight loss supplement, forskolin. Actually, I think he discovered forskolin before he discovered Garcinia, but the forskolin propaganda seems to have reached a critical mass in the last few weeks.
The Land of Oz
A Dr. Oz episode on the “Rapid Belly Melt” aired a month ago, on May 5. He set fire to a paper representation of a fat belly to show how forskolin “works like a furnace inside your body.” The paper ignited, went up in flames, and revealed a non-flammable model of muscle tissue inside to show how forskolin burns fat, not muscle, and to illustrate how quickly it works. (more…)
When I first heard about rope worms, I assumed it was a spoof. Alas, not so!
Rope worms are rope-like meter-long human intestinal parasites that were only recently discovered in the returns of cleansing enemas and are often reported after coffee enemas. Strangely, no one had ever noticed them until 2009. They have never been observed during endoscopy or surgery, during medical bowel cleansing in preparation for surgical or imaging procedures, with x-rays or MRIs, at autopsy, or by any colorectal specialists. Yet according to Nikolai Gubarev and Alex Volinsky, the two of them have never yet found a single patient who didn’t have these parasites.
Two articles by Volinsky, Gubarev, and colleagues (here and here) describe the rope worm and its five developmental stages. They include pictures of each stage. I urge you to take a look. You will be amazed, and not in a good way. You might even bust a gut laughing. (more…)
One size rarely fits all. Most medical knowledge is derived from studying groups of subjects, subjects who may be different in some way from the individual who walks into the doctor’s office. Basing medicine only on randomized controlled studies can lead to over-simplified “cookbook” medicine. A good clinician interprets study results and puts them into context, considering the whole patient and using clinical judgment to apply current scientific knowledge appropriately to the individual.
CAM practitioners claim to be providing individualized treatments. Homeopaths look up symptoms like “dreams of robbers,” “sensation of coldness in the heart,” and “chills between 9 and 11 AM” in their books, and naturopaths quiz patients in great depth about their habits and preferences; but they don’t have a plausible rationale for interpreting the information they gather. And they have not been able to demonstrate better patient outcomes from using that information.
A new concept, “precision medicine,” was recently featured in UW Medicine, the alumni magazine of my alma mater, the University of Washington School of Medicine. Precision medicine strives to provide truly individualized care based on good science. It identifies the individual variations in people that make a difference in our ability to diagnose and treat accurately. Peter Byers, MD, director of the new Center for Precision Diagnostics at the University of Washington, calls it “the coolest part of medicine.” (more…)