Sixty years ago, the world was full of miracles. Western Europe was recovering from the devastation of World War II, an agricultural revolution promised to banish the fear of starvation in large parts of the world, and the mythical Mad Men era gave Americans a taste of technology-dependent peace and prosperity unlike any in the past. Despite the technological progress that would soon send animals into space and return them relatively unharmed, Americans, and westerners in general, were still dying of heart disease at a frightening rate. If you, as a middle aged American, experienced chest pain and were lucky enough to make it to a hospital (about 20% of all sufferers would die immediately), you would probably be given nitroglycerin and morphine to control you pain, put on bed rest, and could expect to live a few more years, with limited physical activity.
Heart disease continues to be a top killer of Americans, but there has been a dramatic decline in heart disease mortality in the last 60 years, with age-specific mortality rates dropping 60%. Fewer people are developing heart disease, and those that have it are living longer. It is estimated that in 2000 alone, there were 341,745 fewer heart disease deaths than would have been expected if rates had remained unchanged. This decline has not been driven by a renaissance of alternative medicine. It has been driven by science.
The trend has been going on for many decades, and has been accelerating, although current trends in diabetes and obesity put us at risk for more overall cases of heart disease in the future. So what are we doing right? How have we managed to cut the death rate from heart disease so dramatically?
If you google “low testosterone” you’ll see lots of ads for testosterone replacement. Some are from pharmaceutical companies that sell testosterone, others from obvious snake-oil salesmen.
Both types of ads list vague sets of symptoms, encourage you to believe that they are pathologic, and want to sell you something to make you better. For example, the pharmaceutical company Solvay gives you a handy guide for speaking to your doctor, and a quiz to see if you have “low T”. The quiz asks some questions that may be useful, but also asks very general questions about your sense of well being, and includes this gem:
I don’t feel sick, I just don’t feel like myself anymore. Could I have Low T?
The ad then gives this advice:
Because Low T signs and symptoms may not be clear and apparent, they may seem to be a normal part of aging or assumed to be caused by other health conditions. But talk to your doctor if you have symptoms of Low T. And ask to get tested. All it takes is a simple blood test that can be done during a routine checkup. If you do have Low T, your doctor may recommend treatments that can help bring testosterone up to normal levels and keep them there.
If you have diabetes, you should ask your doctor for a Low T test. The Endocrine Society recommends that all men with type 2 diabetes have their testosterone levels checked. Patients who have been diagnosed with diabetes have an increased chance of also having Low T.
Let’s step back for a moment. What is being claimed is that low testosterone levels in males is a common cause of certain symptoms, and that testosterone replacement therapy can alleviate these symptoms. To evaluate this claim from the perspective of science-based medicine, we need to ask specific questions. (more…)
A question popped up on facebook the other day about Dr. Christiane Northrup, an OB/GYN who has been a frequent guest on Oprah. I hadn’t heard much about her for a while, but a foul taste still lingered from previous encounters with her work. So I went over to her website to see what fare she’s currently dishing up. It isn’t pretty. (Cached version).
This month’s news item is titled “Angst Over Not Vaccinating Children is Unwarranted.” Regular readers will be expecting a typical antivax screed, and they won’t be disappointed, but I’d like to highlight some of the propaganda techniques Northrup uses to advance her dangerous lies.
She begins her story with this:
In June, 2010 there was an outbreak of pertussis (whooping cough) in California that reporters were calling the worst epidemic in 50 years.
There are two problems with this opening sentence. The outbreak is ongoing, and it’s not “reporters” who are calling it “the worst epidemic in 50 years.” The California Department of Public Health reports that the state has seen the largest number of cases in the last 55 years. Of course the state was much smaller 55 years ago, so for comparison they give us an incidence rate: 10.3 cases/100,000 in 2010, the highest rate in 48 years (when the rate was 10.9 cases/100,000). So far in California, there have been 9 deaths. All of the deaths were in babies eight of whom were unvaccinated and one of whom had been vaccinated only days before becoming ill, not early enough to develop immunity.
Earlier this week, my colleague Dr. Gorski explored a common theme in alternative medicine: the idea that all disease is preventable. This implies that all disease has a discrete cause and that individual behavior can mitigate this cause.
If biology worked this way, my job as an internist would be very different. Many people would love to believe that life is this predictable, and that they have that much control over their health, but they don’t. Most disease represents the interaction of environment and genetics, and you can’t change your genes (with a few exceptions, of course).
It’s natural to want to be able to exert an impossible level of control over your health, but when unscrupulous charlatans (redundant redundancy alert!) play on these beliefs and fears, they can cause, rather than prevent problems.
It can be rather frustrating to refute the same old canards about alternative medicine. There’s always been argument as to whether this is even useful. Critics (some verging on “concern troll-ism”) argue that skeptics are convincing no one, others that we are too “dickish”. The first view is overly pessimistic (re: our impact), the second overly optimistic (re: the benign nature of our critics). The truth always bears repeating, even at the risk of becoming the old guy at the end of the bar who always starts his stories off with, “Did I ever tell you…?” The answer is always “yes” but if the story is good, and well-told, it may stand up to re-telling.
We tell many versions of the same story over and over, not just to entertain each other, but to refine our thinking, to convince those who can be convinced, and to point out the weakness in thinking apparent in others. We do this not to be “dicks” but because repeated assaults on reason require repeated defense. Scientific medicine gives us a powerful tool for analyzing new ideas and old ones dressed up in new clothes. It allows us to find ourselves to be wrong in particular facts, if not in our overall approach.
One of the strengths of modern medical education is its emphasis on basic science. Conversely, the basic weakness of so-called alternative medicine is its profound ignorance of science and its reliance on magical thinking. Nowhere is this more apparent than in the attempts of altmed cults to conduct and publish research. From “quantum water memory” to “almost as good as placebo”, the altmed literature is filled with basic failures in the proper formulation and testing of hypotheses.
One of the finest examples of these failures was just published in the journal Homeopathy. Leaving aside for the moment the absurdity of a journal devoted to magic, let’s see what they did here. (more…)
I was a bit torn when trying to figure out how to approach this piece. A reader emailed me about an article in the Huffington Post, and there is so much wrong with it that I felt overwhelmed. My solution is to focus on a few of the problems that can help illuminate broader points.
There is a small but vocal movement of people who refuse to believe that skin cancer caused by sunlight is a significant health risk. These people tend to also believe that the risk is being purposely hyped by others, and that our current approach to skin cancer prevention is causing an epidemic of vitamin D deficiency. Leaving aside the seemingly insane denialism regarding sunlight and cancer, there are two broad problems with this article. The first is pretty bad.
With the summer months upon us I wanted to find out firsthand what exactly the mantra is that dermatologists are telling patients. So I went undercover to several San Francisco dermatologists in order to see if there is legitimate concern about the sun-scare media hype. Are these doctors being sensible or going overboard when it comes to advice on sunscreen use and skin cancer prevention? Is the sky falling with dangerous UV rays or are we being induced into a media panic?
He goes on to give links to recorded conversations, and prints out partial transcripts. He does not specify whether or not he received permission to record these conversations, as required by California law. Whether or not the law requires it, the writer should have disclosed to his readers whether or not he had received permission. This information is important in interpreting the conversations he reports to us.
The next problem is broader, and deals with physicians’ willingness to lie on behalf of patients. The author’s presumably-clandestine recordings of his deceptive visits to dermatologists (catching my breath—this is striking and requires a digression. The act of deceiving these doctors is not only unethical, but can influence the outcome of the visit. Doctors make the assumption that most patients are interacting with them out of good faith, and are not intentionally deceiving them.) (more…)
Dietitians are a critical part of modern medicine. In the hospital, dieticians not only educate patients on dietary treatment of diseases such as diabetes and heart disease; they also evaluate the nutritional status of critically ill patients and develop nutrition plans that may involve tube feeding or intravenous feeding. This is complicated, and takes into account a patient’s nutritional needs, medical conditions, etc. They are highly trained professionals.
If you want to see a dietitian lose it, call them a “nutritionist”. “Dietitian” is a specific profession governed by specific educational and licensing requirements. A dietitian can call themselves a nutritionist, but so can just about anyone else. As with other health care professions, dietitians have good reason to protect their profession. Protecting their profession protects their patients. Dietary fads are among the most prolific of medical scams and good information can be hard to find. Registered dietitians explicitly strive to utilize evidence to guide their practice. And critically, they have a published Code of Ethics.*
As is not uncommon, there are those who, in the name of “health freedom” (and profit), object to the dietitian “monopoly” on nutritional therapy. One way they have done this is to claim the title “nutritionist” and set up a certification system. Once this structure is in place, it’s easier to get states to approve them as licensed professionals. In this second area—state licensing—they are enlisting allies that comprise many of “the usual suspects”. (more…)
Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.
But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.
The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone—the narcotic in vicodin–in emergency center charts increased 170%. This is a big problem.
So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we’ve discussed at length. But absent from that discussion was the evidence.
Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that? (more…)
Naturopathy is an unusual chimera. It is basically a collection of old fashioned medical superstitions presented under a veneer of highly speculative, quasi-scientific assertions. But given its popularity, it is important, from time to time, to evaluate specific claims made by this particular non-science-based belief system.
A reader informed me that he was advised to seek the advice of a naturopath for treatment of his seasonal allergies. Since naturopaths claim to be “doctors plus”, I was curious what they would recommend. Would it be standard allergy treatment with antihistimines and other proven medications along with some sort of vitalistic mumbo-jumbo? It turns out I was half-right.