Topics, as I noted a fortnight ago in my uniquely misspelled and ungrammatical way, never die**. Or even fade away. There are popular ideas that persist in the world that have little to do with reality. In the reality based world of medicine there are concepts that refuse to die. Atelectasis causing fever or the need to ‘double cover’ Pseudomonas. Neither are true, yet every year medical students tell me that is what they have been taught. It is said the only way new ideas take hold is for those that hold the old ideas to die off. So maybe 50 years from now those medical myths will be gone.
Popular culture also its myths. Take the immune system. Please. It is not a bicep that can be made stronger with a little exercise. It is a complex network of cells and proteins. There are antibodies (IgG (with five subtypes, IgM, IgA, IgE),the complement pathway, polymorphonuclear cells, monocytes, lymphocytes in a profusion that rivals beetles. God, I think, has an inordinate fondness for lymphocytes. There is the Toll system, the cytokines and lymphokines, the non-specific defenses like cilia and mannose binding lectin and on and on and on.
I have a journeyman’s understanding of the immune system, what is needed to understand why a given patient has an infection, although there is little I can do to reverse the immunologic defects: abnormal antibodies from Waldenström’s or low mannose binding lectin levels from liver disease are not amenable to clinical intervention. (more…)
David Gorski recently pointed out that Science Based Medicine is going on five years. Amazing. That there would be so much to write about day after day comes as a surprise to me. Somehow I vaguely thought that ‘controversies’ would be resolved. Pick a SCAM, contrast the SCAM with reality as best we understand it, and, once the SCAM was found wanting, it would be abandoned. Why would rational, thoughtful people persist in the pursuit of irrational behavior, contradicted by the universe?
Ha. More the fool me. I would never have guessed that these SCAMs are harder to kill than Dracula (at least one version of Dracula). Stake them and back they come*.
I have tried to avoid repeating repeating information found in prior posts by myself and others, in part because I am lazy and in part because, well, I have said it before. Just look it up. I have come to realize (all too slowly) that each blog entry should be self contained and that much of the old material is lost in the corn maze (an punning homophone) that is WordPress. Reading my second favorite computer reinforces the realization that each post often needs to be an island universe, complete in itself.
Flu season is upon us. If there is such a thing as flu season. H1N1 started at the furthest point in time you could get from the traditional start of the flu season. It is an interesting question as to whether global warming will alter the flu season, as it has the RSV season. Classically influenza is a fall/winter disease and fall started today.
It is perhaps worthwhile to review what is known about influenza. (more…)
This is, I admit, a content free post. July and August are the sunny days here in the great Pacific Northwest, and rather than spend time in front of the computer, I am outside with the kids. To compound matters, I was on call the labor day weekend (I usually write the first draft the weekend before the posts are due) and was very busy. I am finishing this early on Thursday on an airplane to Vegas. My wife and I are taking our first non-child containing vacation in 19 years while my youngest is on a 4 day school trip. Wander the strip, see a show and enjoy the desert heat as a couple and not a family.
I have not had the time to spend researching a topic, so instead I thought I would ramble on about 2.5 topics that have been on my mind. Writing helps to focus my thoughts. Even though I often have residents on service, I still write daily notes as the act of putting thoughts into words is the best way to clarity thoughts. Next week the kids are back at school and I am sure the rains will start up and I will again have time to go into full research mode. In the meantime feel free to ignore this post.
There is nothing to see here. Move along. (more…)
I do not want to get all angsty and omphaloskeptic, but I have been thinking more of late about the purpose of the blog and my role in it. Blogs,and the people who write them, are ephemeral. It takes a unique personality and commitment to churn out these essays and commit them to the ether. Especially since Michelson and Morley.
I have never given much thought as to who our readers are, at least as a composite. I read most of the comments on every entry and have certainly developed a mental picture of some of our regular commenters, although I suspect I probably do not have even the gender correct most of the time. The commenters represent a tiny fraction of the regular readers and an even smaller fraction of occasional readers. It occurs to me I haven’t a clue who the real audience of this blog is.
I write first for my own education and entertainment, then for the slightly bored and overwhelmed medicine resident, since that is who I spend most of my time educating at work. Someone educated with an understanding of basic medicine but has more important things on their mind than a need for a detailed understanding of why homeopathy is complete nonsense. I doubt the majority of my readers are health care workers and I suspect continuing medical education is not a major part of the blog.
I never considered SBM to be a consumer protection group, but this week my wife showed me a half page advertisement in the local paper, and I realized that not only was the advertisement a good topic for blogging, but consumer protection is a fundamental result of this blog. There really is no site on the interweb that looks at both SCAM and real medicine with quite the same skeptical eye. Here is the headline:
A Special Wellness Report
New Medicine Based On An 88- Year Old Theory By Albert Einstein Can Help Almost Everyone Who Is Sick Or Injured! (more…)
It feels like I live in the real world example of Ray Bradbury’s All the Summer in a Day but for the last two weeks we have had sun and heat and it has been glorious. I get Christmas and Thanksgiving and New Years as vacation, but who needs that? I need July and August to live the vida loca in the Oregon summer. Who wants to blog when I can be outside, at concerts, golfing, hiking and…
Yes Dr. Gorski. I did agree to write an entry every other Friday. Yes Dr. Gorski. I know you have the documentation. Yes Dr. Gorski, I do not want any of that information made public. No one needs to know that I wanted to be a naturopath when I was young. Sigh. Yes, Sir, I will get to blogging. Damn those youthful indiscretions. Let’s see how little I can do and meet my obligations with the powers that be.
My professional career is based upon inflicting death, and in my time I have obliterated uncountable numbers of unicellular organisms. If there were such a thing as Karma, I would certainly return in the next life as a rabbit in a syphilis lab. But there isn’t, and I can kill and kill with a clean soul. There is no guilt or hesitation in killing unicellular life, or even multi-cellular life, as long as it cannot be seen without a microscope. I start to get a wee bit squeamish as soon as I can see a life form. I tend to not kill bugs or animals, unless, of course, they can be eaten. If it tastes good, all bets are off. But as a tree hugger, I tend to look upon killing wildlife and extinctions as a bad thing. (more…)
There is a tradition in medical training called Journal Club. The first rule of Journal Club is you do not talk about Journal Club. In Journal Club, at least in the iterations in which I have participated, one article is selected by an attending, everyone reads it, then the strengths, weakness and applicability are discussed by the group. Usually a top notch, ground breaking article was the focus, one that had high potential clinical impact. But since they were good articles in good journals, there was not a lot to learn about in reguards to critical thinking. While the attending would put the article in context and maybe discuss some rudimentary statistics, there was little that was discussed about the quality of the study. The main take home from every study was to question the applicability of the results to populations that were not old, white males, since it seemed all the ground breaking studies back in the day were a VA Cooperative study of one sort or another.
As I remember it, there was not really a conceptual frame work with which to evaluate studies. Bayes theorem, and its application to clinical medicine was never explicitly discussed outside of testing, where you have to consider the prior plausibility of the patient having a disease before you can decide if the test results is a true positive or not. In Portland, Oregon, the chance that a Lyme serology is a false positive is much greater than a test done in Portland, Maine. Generally speaking in the information overload state that is the practice of medicine, clinical trials are generally taken at face value and tests are considered infallible. Which is a shame, as I wonder how much suboptimal medicine is inflicted on patients by not considering prior plausibility and how accurate a given test is in either ruling in or out a disease. There seems to be a whole industry built around treating patients with no risks for Lyme but have positive tests of doubtful provenance. We never discussed the prior plausibility and its effect on the outcomes of a studied treatment. (more…)
Summer time is finally here in Oregon, and I will confess that I have spent little time on blogging. The sun is out, my kids are out of school and home from college, and really, who wants to spend their time writing when you could be on the golf course or at the beach with the kids. I say this as a mea culpa for what follows.
One of the saving graces in medicine is just how hard it is to harm people and how much trauma humans can withstand and survive. When I am on call for my partner I cover a Level 1 trauma ICU and the hallway leading to the unit is lined with photographs of some the trauma survivors. Over the years I have helped take care of many of these patients and I remember the extent of the injuries and the intensity of the care required to pull them through. Most of the survivors are young; it is the young who have the physiologic reserve to deal with the stress of injuries and their consequences.
Still, human physiology is amazingly resilient, especially of there are no co-morbid conditions to interfere with healing. With a little, and sometimes a lot, of support, I am constantly amazed at what people can sometimes survive. Modern medicine can pull people through who would have certainlu died 20 years ago.
There are two way to hurt people: what you do and what you do not do, the harms of commission and omission. Harm can be obvious with surgery. Oops, sorry I left my watch in there. I definitely do not have what it takes to be a surgeon. Or you can prescribe a medicine with a known side effect. Most SCAM’s, by doing nothing, are not prone to this sort of harm. Chiropractic and acupuncture are the notable exceptions, but even then it is hard to tear a vertebral artery or drop a lung unless the patient is extraordinarily unlucky. Of course one of the things you learn in medicine is that occasionally someone is extraordinarily unlucky and has a rare, but not unexpected, complication of an intervention, SCAM or otherwise. (more…)
As I have mentioned in the past, almost all of my practice is inpatient medicine, doing infectious disease consults in acute care hospitals. I only spend three hours a week in the outpatient clinic, so I have a skewed perception of medicine and disease. The patients I see are sick, really sick, often trying to die and are a complicated collection of abnormal labs and deranged physiology.
I remember finishing residency thinking that a potassium of 2.8, a hemoglobin of 9.8 or a bilirubin of 4.5 wasn’t all that bad, losing track of normal physiology amongst all the medical pathology. I never did lose track of normal vital signs (VS): pulse, respiration, blood pressure and temperature. Like trying to be the fifth Beatle, over the years other values have vied to become the fifth vital sign: pain level or O2 saturation, but none have the importance of the fab four. I can live without pain*, but I can’t live long if the other vital signs are abnormal for extended periods of time. Watching the vital signs return to normal is often an important variable that signifies the patient is improving. (more…)
Disclaimer: I am a paid Medscape blogger and writer, and since they are in part supported by advertisements from the Pharmaceutical companies, indirectly I am in the thrall of Big Pharma.
I found Harriet’s post on the Medscape Connect topic of How do you feel about Evidence-Based Medicine? interesting.
I wondered about the breakdown of the comments by both specialty and opinions about SBM. So I read the 226 comments and classified them by field and response. I classified each response as disapprove, approve or nuanced. It is not, obviously, a legitimate survey and there was more than a little subjective interpretation in deciding how to classify the responses. I have no doubt that others would get different results; it is not methodologically sound analysis. The discussion was in the Family Medicine & Primary Care section, so it is unlikely to be representative of any population, including that of Family Practitioners and Primary Care Physicians. I would bet, as in alternative medicine and most topics, Shruggies predominate and are the silent majority.
Even though I belong to what a commentator referred to as the not so silent “militant wing” of SBM, I was surprised at my results: (more…)