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Is the Annual Physical Unnecessary?

Quality

I was approached by The Wall Street Journal to write an article for their Big Issues in Health Care debate series. The subject was “Is the annual physical unnecessary?” I was to take the “yes” side and an internist was to take the “no” side. I wrote the following article. The editor wrote me a couple of times with questions. The internist pointed out the value of preventive medicine, developing a personalized healthcare plan, and developing a meaningful doctor-patient relationship. I said I wholeheartedly agreed, but I thought those goals could be accomplished just as well (arguably even better) with a periodic health maintenance interview or consultation. I pointed out that the traditional “physical” exam with stethoscope, routine lab tests, etc. provides no further advantages and can be counterproductive, with false positive or harmless findings leading to unnecessary worry, further testing, and expense. I said there was nothing magical about the interval of a year. I don’t know what the optimum interval would be; that could be studied. I suspect it would vary with the patient’s age, medical conditions, risk factors, and other considerations, and might be left up to the judgment of patient and doctor deciding together.

Finally I got an e-mail with apologies, saying they had decided not to continue with the debate because the internist and I agreed on too many important details. While I understand that stirring up a fight is good for selling newspapers, I think it’s a much better thing when people on two sides of a debate reach an agreement. It reassures me that they are converging on the truth. So I thought it would be worthwhile to publish my article here on SBM. (more…)

Posted in: Commentary, Diagnostic tests & procedures

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Functional medicine: The ultimate misnomer in the world of integrative medicine

Functional Medicine practitioners like to make patients think that this diagram actually means something.

Functional Medicine practitioners like to make patients think that this diagram actually means something.

We at Science-Based Medicine often describe “integrative medicine” as integrating quackery with medicine (at least, I often do), because that’s what it in essence does. The reason, as I’ve described time and time again, is to put that quackery on equal footing (or at least apparently equal footing) with science- and evidence-based medicine, a goal that is close to being achieved. Originally known as quackery, the modalities now being “integrated” with medicine then became “complementary and alternative medicine” (CAM), a term that is still often used. But that wasn’t enough. The word “complementary” implies a subordinate position, in which the CAM is not the “real” medicine, the necessary medicine, but is just there as “icing on the cake.” The term “integrative medicine” eliminates that problem and facilitates a narrative in which integrative medicine is the “best of both worlds” (from the perspective of CAM practitioners and advocates). Integrative medicine has become a brand, a marketing term, disguised as a bogus specialty.

Of course, it’s fairly easy to identify much of the quackery that CAM practitioners and woo-friendly physicians have “integrated” itself into integrative medicine. A lot of it is based on prescientific ideas of how the human body and disease work (e.g., traditional Chinese medicine, especially acupuncture, for instance, which is based on a belief system that very much resembles the four humors in ancient “Western” or European medicine); on nonexistent body structures or functions (e.g., chiropractic and subluxations, reflexology and a link between areas on the palms of the hands and soles of the feet that “map” to organs; craniosacral therapy and “craniosacral rhythms”); or vitalism (e.g., homeopathy, “energy medicine,” such as reiki, therapeutic touch, and the like). Often there are completely pseudoscientific ideas whose quackiness is easy to explain to an educated layperson, like homeopathy.
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Posted in: Critical Thinking, Diagnostic tests & procedures, Herbs & Supplements

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Regulating CAM Aussie Style

640px-Flag_of_Australia.svg
CAM proponents view National Health Interview Surveys recording the supposed popularity of CAM, an amorphous conflation of anything from conventional medical advice to mythical methods, as an invitation to unleash even more unproven remedies on the public. My interpretation is quite different. I see the same figures as proof that we are doing too little to protect the public from pseudoscience.

In fact, state and federal governments are acting as handmaidens to the CAM industry by legalizing practices and products that have insufficient proof of safety and efficacy and, in some cases, are so scientifically implausible that they can never meet that standard. The federal government keeps “integrative” medicine centers at major academic institutions and private foundations afloat with taxpayer money by funding research that has failed to improve public health or the treatment of disease, despite seemingly endless trials, because “more research is needed”.

As we shall see, Australia has a more effective regulatory system for dealing with CAM. And the advocacy group Friends of Science in Medicine (FSM), an organization with goals similar to our own Society for Science-Based Medicine, is keeping the government on its toes, investigating violations of the law on its own and reporting them. We in the US could learn something from their two recent successful campaigns attacking misleading health claims. (more…)

Posted in: Chiropractic, Diagnostic tests & procedures, Guidelines, Legal, Naturopathy, Politics and Regulation

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Carotid Artery Stenosis: Surgery, Stent, or Nonsurgical Stroke Prevention?

One treatment for carotid artery stenosis: stent placement

One treatment for carotid artery stenosis: stent placement

The carotid artery in the neck is a common site of atherosclerosis. As plaque builds up, it leaves less room for blood flow and can cause strokes through clotting or embolization. Carotid stenosis is defined as a greater than 70% narrowing of the lumen (the space through which the blood flows in an artery). It can cause symptoms, including transient ischemic attacks (TIAs) and minor strokes; but it is frequently asymptomatic. It can be treated with carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAAS). There has been much discussion about which procedure is better and when it is better not to do either. (more…)

Posted in: Diagnostic tests & procedures, Surgical Procedures

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Lyme Testing

The little burrowing bacteria that bores into your pores to cause Lyme disease, EEEEEWWW!!!

The little burrowing bacteria that bores into your pores to cause Lyme disease, EEEEEWWW!!! Darkfield 400x microscopy image of the 10-25µm long Borrelia burgdorferi spirochaete which causes Lyme disease (1993). Provided by the CDC’s Public Health Image Library (PHIL #6631) via the Wikimedia Commons

I hate those oh hell moments. I was up way too late last night, but who can pass up the opportunity to see Patti Smith playing Horses (and more) for the 40th anniversary of the album. Only 44? Behind the Eagles? No way. I would nudge it up a few more spaces. Hard to believe I was 18 when that album came out. Horses is one of the few albums that made the transition from vinyl to CD. It was a tremendous show, and at 69 Patt performs with the energy and passion of a 29 year old. And she sure can spit. I had the evening off, so food and drinks at Swine until well past midnight. First time my wife and I closed a bar. I am too old for this.

But as I was blearily drinking my a.m. coffee on a dreary PDX morning, I opened the browser to SBM and there was a post by Jann. Oh hell. That means I have a post due tomorrow and I had lost track of the time over the holidays. I thought my next post was next Friday. Oh. Hell. So unlike most posts which I write over a week, this one was done in about 4 hours. And I am sure it will show.

How do you diagnose an infection?

Not always so simple. You always start with a history and, for infectious diseases, an exposure history is paramount. People get what they are exposed to, so you want to know travel, animals, diet, water, sex etc. If you have ridden a horse to have sex in an Indian lake while drinking raw milk (not really an unusual history in my practice; people do the darndest things) you have exposure risks for a variety of infections. If you have not left the Willamette Valley it is unlikely that the cause of the illness is malaria, although you always have to consider that the infection came to the patient rather than the other way around. (more…)

Posted in: Basic Science, Diagnostic tests & procedures, Lyme, Science and Medicine

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Legislative Alchemy 2015: Another losing season for CAM practitioners

legislative-alchemy-image
One of the main, but perhaps underappreciated, reasons quackery thrives in the United States is that the states legalize it by licensing practitioners of pseudoscience as health care providers. These practitioners are placed under the regulatory jurisdiction of, well, themselves. I call the whole deplorable process Legislative Alchemy, and you can see all posts on the topic here. It gives practitioners an underserved imprimatur of state authority and leaves public protection from harmful practices to the oversight of those who are themselves engaging in the very same conduct. Each year, dozens of bills are brought before the state legislatures to establish initial licensure or, once that goal is achieved, scope of practice expansion.

Most attempts fail, but CAM practitioners are a dogged bunch, and they will come back each year until they get what they want. It took chiropractors about 60 years to become licensed in all 50 states. Acupuncturists are almost there. Naturopaths lag far behind, but are slowly gaining ground each year, even if it is only via practice expansion in states where they are already licensed. 2015 was a losing season for all, but not without advancement toward larger goals.

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Posted in: Acupuncture, Chiropractic, Diagnostic tests & procedures, Herbs & Supplements, Homeopathy, Legal, Naturopathy, Politics and Regulation

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Colonoscopy: More Misinformation from Mercola

colonoscopy
Joseph Mercola, D.O., runs the website mercola.com which is full of misinformation, advocates all kinds of questionable alternative treatments including homeopathy, and discourages vaccination and other aspects of conventional medicine.

Like Dr. Oz and Andrew Weil, he is more dangerous than easily recognizable quacks in that he combines some good medical information with egregious misinformation, and readers who know he is right about the good information are likely to wrongly assume everything else he says must be equally true. He’s right about some things, but the safest course is to assume that anything on his website is false unless you can verify it as true by consulting other sources that are reliable. I tried to verify the information in his recent article on colonoscopy. I found outright errors along with fear-mongering and bias. (more…)

Posted in: Diagnostic tests & procedures, Science and Medicine

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Breast Milk Testing: Scaremongering, Not Science

Breastfeeding_baby
New mothers, especially first-time mothers, tend to worry about whether they are doing what is best for their babies. A new service, Happy Vitals, will only add to those worries. We know that breast is best, but these folks make women question whether their breast milk is good enough. They say:

Happy Vitals provides families with the tools they need to monitor and improve the long-term health of their children. With our simple and easy-to-use tests, mothers can learn for the first time about the nutrient make-up of their breast milk, improve their diet and nutrition, and safeguard against exposure to heavy metals and other toxins that are harmful to a child’s growth and development.

After a crowdfunding/pre-sale campaign, they plan to start shipping kits this month. They offer various packages. For $149.95, they will analyze a sample of breast milk for four key nutrients: glucose, lactose, protein, and fat. For $559.95, they will also test for:

  • Four “indicators of immunity”: cortisol, IgA antibodies, IgG antibodies, IgM antibodies.
  • Eleven micronutrients: calcium, folate, iron, vitamin D, vitamin A, ferritin, magnesium, phosphorous, sodium, potassium, and vitamin B12.
  • Four heavy metal toxins: arsenic, lead, mercury, and cadmium (based on samples of infant’s hair and nails.)

(more…)

Posted in: Diagnostic tests & procedures, Nutrition

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“Liquid biopsies” for cancer screening: Life-saving tests, or overdiagnosis and overtreatment taken to a new level?

Could a blood draw be all you need to diagnose cancer and identify the best treatment for it? Not so fast...

Could a blood draw be all you need to diagnose cancer and identify the best treatment for it? Not so fast…

I’ve written many times about how the relationship between the early detection of cancer and decreased mortality from cancer is not nearly as straightforward as the average person—even the average doctor—thinks, the first time being in the very first year of this blog’s existence. Since then, the complexities and overpromising of various screening modalities designed to detect disease at an early, asymptomatic phase have become a relatively frequent topic on this blog. Before that, on my not-so-super-secret other blog, I noted that screening MRI for breast cancer and whole body CT scans intended to detect other cancers early were not scientifically supported and thus were far more likely to cause harm than good. That was well over ten years ago. Now we have a company offering what it refers to as a “liquid biopsy” for the early detection of cancer. I fear that this is the recipe for the ultimate in overdiagnosis. I will explain.

The problem, of course, is that disease progression, including cancer progression, is not always a linear process, in which the disease progresses relentlessly through its preclinical, asymptomatic phase to symptoms to complications to (depending on the disease) death. There is such a thing as disease that remains asymptomatic and never progresses (at which point it’s hard to justify actually calling it a disease). As I pointed out in my first SBM post on the topic, at least three-quarters of men over 80 have evidence of prostate cancer in autopsy series. Yet nowhere near three-quarters of men in their 80s die of prostate cancer—or ever manifest symptoms from it. This is what is meant by overdiagnosis, the diagnosis of disease that doesn’t need to be treated, that would never cause a patient problems.

When teaching medical students and residents, I frequently emphasize that overdiagnosis is different from a false positive because overdiagnosis does diagnose an actual abnormality or disease. For example, ductal carcinoma in situ (DCIS) diagnosed by mammography leading to a biopsy is a real pathological abnormality; it is not a false positive. We just do not know which cases of DCIS will progress to cancer and which will not, leading to a question of how DCIS should be treated or at the very least whether we should treat it as aggressively as we do now, particularly given that the apparent incidence of DCIS has increased 16-fold since the 1970s, all of it due to mammographic screening programs and the increased diagnosis of DCIS and early stage breast cancer has not resulted in nearly as much of a decrease in the diagnosis of advanced stage breast cancer as one would expect if early diagnosis were having an impact in reducing the diagnosis of late stage disease.

Overdiagnosis would not be such an issue if it didn’t inevitably lead to overtreatment. DCIS, for instance, is treated with surgery, radiation, and anti-estrogen drugs. Early stage prostate cancer used to be treated with radical prostatectomy, but now more frequently with radiation. Many of these men and women didn’t actually need treatment. We just don’t know which ones. This is why over the last six or seven years a significant rethinking of screening for breast and prostate cancer has occurred. There has been a backlash, of course, but the rethinking seems to have taken hold.

Not everywhere, of course. (more…)

Posted in: Basic Science, Cancer, Diagnostic tests & procedures, Public Health

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