The American Academy of Family Physicians journal American Family Physician (AFP) has a feature called Journal Club that I’ve mentioned before. Three physicians examine a published article, critique it, discuss whether to believe it or not, and put it into perspective. In the September 15 issue the journal club analyzed an article that critiqued the process for developing clinical practice guidelines. It discussed how two reputable organizations, the United States Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) looked at the same evidence on lipid screening in children and came to completely different conclusions and recommendations.
The AAP recommends testing children ages 2-10 for hyperlipidemia if they have risk factors for cardiovascular disease or a positive family history. The USPSTF determined that there was insufficient evidence to recommend routine screening. How can a doctor decide which recommendation to follow? (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.
A recent survey about patient attitudes and desires with regard to health care demonstrate that respect for scientific evidence is still the dominant factor in preferring treatments. (Full study) This is good news, although the numbers could be better.
Researchers asked subjects what factors were important in determining which treatments they would prefer, the scientific evidence, the experience of the clinician, or their own personal preferences. Not surprisingly, most subjects wanted it all, agreeing that all three are important. Scientific evidence, however, scored the highest with 71% rating it as very important (and over 90% as important or very important). Clinical expertise had 61% strongly supported and personal preference, 57%.
Further, patients wanted their doctors to talk to them about the evidence. The phrase they felt had the most impact on their decision to accept a treatment was, “What is proven to work best.”
All of this matches my personal experience as a clinician. At least for the self-selective population of patients who seek out a university physician, patients tend to find recommendations based upon published evidence compelling, and greatly appreciate when I take the time to tell them about the evidence, even if it goes against their initial interests.
How are you feeling today? Tired? Is it your active lifestyle wearing you down? Or is it a sign of something more serious? Complaints about fatigue seem ubiquitous. Perhaps it’s a product of a culture with little downtime. Yet from a medical perspective, fatigue can’t be dismissed with a simple instruction to “get more sleep”. When approached in the pharmacy, I take the perspective that anyone actively seeking advice on treatment probably needs a medical assessment. That’s not something I can offer, but I try to impress upon patients the importance of finding the cause, rather than reaching for any quick fix that may be for sale. (5-hour Energy, anyone?) And I can use the opportunity to discuss the appropriate role of supplements for treating fatigue. (more…)
Sometimes science works the way it’s supposed to. Scientists make hypotheses, test them by gathering preliminary evidence, and then argue about the inevitable conflicting results. Eventually better and better evidence is gathered until a consensus is achieved. Actually, I think that is how science usually works, it’s just that most questions in science are narrow and technical and don’t command media or public attention. Those that do tend to be the more enduring controversies or where a particular special interest (ideological, social, corporate, etc,) is involved.
In medicine scientific controversies may take on a life of their own, or become manufactured controversies (manufactroversies) that endure long past any genuine scientific debate. Such false controversies are often driven by patient groups who feel they are not being treated fairly or honestly, or by practitioners who do not want to give up on their favorite (lucrative) modality. This leads to a disconnect between the scientific controversy and the public controversy – a frequent theme on SBM.
I am happy to report that one such controversy has taken a turn for the good – a recent study has provided fairly definitive evidence that chronic fatigue syndrome (CFS) is not associated with either the XMRV or the pMLV viruses. The study was a consensus trial with both sides in the controversy collaborating to address all the criticisms of the earlier conflicting studies.
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…)
In the last 20 or so years, the popularity of so-called “complementary and alternative medicine” began to lure physicians (M.D.s and D.O.s) into employing CAM treatments, or what is now rebranded as “integrative medicine.” Of course, CAM use by a physician necessarily requires some deviation from the “conventional” standard of care. Because deviation from the standard of care can be grounds for discipline by the state medical board, state legislatures and medical boards in the United States have had to grapple with just how much medical practice acts and regulations should accommodate CAM use by physicians.
As it turns out, less than you might think.
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…)
What a wonderful world it would be if cancer patients could extend their survival time by mobilizing their immune systems by eating the right foods, practicing yoga, and venting their emotions in a support group. The idea that patients can enlist their immune systems to fight the progression of cancer is deeply entrenched in psychosomatic medicine and the imagination of the lay public, and evidence to the contrary has been sometimes bitterly resisted. Of course, cancer patients can use psychological techniques to relieve stress or find emotional relief in support groups and thereby improve the quality of their lives. But the prospect of being able to improve the quality of life pales in comparison to the promise of being able actually to extend life.
The hope that psychosocial intervention extends lives attracts philanthropic contributions to cancer centers and justifies research programs to determine just how psychological processes affect cancer. It is a lot easier to obtain funding if we promise to slow progression of cancer than if we merely claim to offer patients solace and support or to be study ways to reduce stress and improve emotional well-being.
No mechanism by which the mind can alter the course of cancer has been convincingly demonstrated. But the jury was still out until the late 2000s, when well-resourced, carefully designed trials — with survival as the primary endpoint — repeatedly failed to show that psychological interventions were effective. My colleagues and I asked at the 2006 European Health Psychology Conference whether we could “Bury the Idea…” that psychotherapy could extend lives of cancer patients, and this was followed by our systematic review of the available data, “The Conflict Between Hope and Evidence.” Investigators who had undertaken ambitious, well-designed trials to test the efficacy of psychosocial interventions echoed with “Letting Go of Hope” and “Time to Move on.” For some of us, to make claims in earshot of cancer patients that we could extend their lives with psychotherapy was perpetuating a cruel hoax.
I love reading quotes by the likes of Karl Popper in the scientific literature. A recent replication of Bem’s infamous psi research, Feeling the Future, gives us this quote:
Popper (1959/2002) defined a scientifically true effect as that “which can be regularly reproduced by anyone who carries out the appropriate experiment in the way prescribed.”
The paper is the latest replication of Daryl Bem’s 2011 series of 9 experiments in which he claimed consistent evidence for a precognitive effect, or the ability of future events to influence the present. The studies were published in The Journal of Personality and Social Psychology, a prestigious psychology journal. All of the studies followed a similar format, reversing the usually direction of standard psychology experiments to determine if future events can affect past performance.
In the 9th study, for example, subjects were given a list of words in sequence on a computer screen. They were then asked to recall as many of the words as possible. Following that they were given two practice sessions with half of the word chosen by the computer at random. The results were then analyzed to see if practicing the words improved the subject’s recall for those words in the past. Bem found that they did, with the largest effect size of any of the 9 studies.