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Asthma, placebo, and how not to kill your patients

A number of years ago I was walking along Lake Michigan with a friend (a fellow medical resident) when she turned to me and said, “are you wheezing?  Do you have asthma?”  I had always been physically active and assumed my breathlessness while walking down the trail was due to the thirty extra pounds of pizza and doughnuts I’d acquired during residency.  But she was right: I was wheezing and breathless and it didn’t feel good at all.  I made an appointment with one of the hospital’s lung docs who took a good history, did a physical, and ran some pulmonary function tests.  And I did have asthma.  And it felt much, much better when I used proper medication, a feeling confirmed by my improving lung function tests. (Not too surprisingly, the asthma got even better when I lost 40 lbs and started treatment for my acid reflux.)

I still get mild asthma symptoms from time to time, especially when I get sick, but for many others, the picture isn’t so pretty.  Asthma kills at least a quarter of a million people every year around the world.   If you’ve ever worked in an ER and seen a kid with a bad asthma attack, you’ve earned a healthy respect for the disease.  If you’ve ever watched your own kid gasping for breath, begging you to make it better, you’ve learned to fear it.

As our understanding of asthma has improved, so has our ability to treat it (an ability that is strongly linked to a patient’s socio-economic status.  Mortality has been rising despite the discovery of better treatments.  Wait: let’s pull this out of the parentheses…)…  Asthma deaths and hospitalizations are largely preventable, and disproportionately affect Black and Hispanic Americans. We know how to treat the disease asthma, but don’t know how to treat the people who are affected most. (more…)

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word “doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

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Salt: More confirmation bias for your preferred narrative

Judging by the recent press reports, the latest Cochrane review reveals that everything we’ve been told about eating salt, and cardiovascular disease, is wrong:

The New York Times: Nostrums: Cutting Salt Has Little Effect on Heart Risk

The Daily Mail: Cutting back on salt ‘does not make you healthier’ (despite nanny state warnings)

Scientific American: It’s Time to End the War on Salt

Sometimes it’s possible to completely miss this point. And that’s what’s happened here.

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Honey

I cram for TAM, and, combined with other commitments, not the least of which is that it is finally sunny and warm in Portland, after a year that has resembled All the Summer in a Day,  which leads to a relatively short post.  There are just so many hours in a day and if possible those days need to be spent in the sun.

In my first year in practice I was sitting on a nursing station writing a note when a patient started howling in pain.  Further investigation revealed that the patient had a chronic, open surgical wound and the (old) surgeon had ordered sugar poured into the wound as part of wound care.  The cafeteria mistakenly sent up salt, and a metaphor became reality.  It did pique my interest in both sugar and honey for wound care,  an area where you have to be careful not to fall prey to all the errors in CAM thinking: a reliance on anecdotes, using suboptimal studies as evidence, mistaking a gobbet of basic science as a meaningful clinical application, and not realizing the warping effect of confirmation bias.

That being said, I have suggested honey and sugar for years for patients, and many patients with prior refractory wounds had healing.  And what are the three most dangerous words in medicine?  In my experience.  I have recommended honey less in the era of the wound vac, but there are not an insignificant number of people with insufficient financial resources who cannot afford even simple wound care supplies. Many  of the ointments, creams and special bandages for wound care costs too much.  Patients also like honey as it is natural (people do love to fall for the naturalistic fallacy) and inexpensive, and I always tell patients that the data is iffy, but not stupid. (more…)

Posted in: Herbs & Supplements, Science and Medicine, Surgical Procedures

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SOS DD

What does it take to become a doctor?  Endurance and perseverance help. It is a long haul from college to practice.  But the skill that is most beneficial is the ability to consume prodigious amounts of information, remember it, and recall it as needed.  Although I often relied on ‘B’ to get me through some of the exams.

Thinking, specifically critical thinking, is not high on the list of abilities that are needed to become or be a doctor. Day to day, doctors need to think clinically, not critically.  Clinical thinking consists of synthesizing the history, the physical and the diagnostic studies and deciding upon a diagnosis and a treatment plan.  It is not as simple as you might think.  When medical students start their clinical rotations and you read their notes, you realize they have what amounts to an advanced degree at Google U.  They know a huge amount of information, but have no idea how the information interrelates and how to  apply the that information to a specific clinical scenario.  With time and experience, and it takes at least a decade, students become clinicians and master how think clinically, but rarely the need to think critically.

The volume of data combined with time constraints ensures that we need to rely on the medical hierarchy to help manage the information overload required to apply science and evidence based therapy.  There is just to much data for one tiny brain to consume. Other doctors rely on me for the diagnosis and treatment of odd infections.  In turn, I  rely on the published knowledge and experience of my colleagues who have devoted a career to one aspect of infectious diseases.  There is little time for most doctors to read all the medical literature carefully, and usually little need.  We have people and institutions  we use as surrogates.

Not only is critical thinking usually not required to be a good physician, but medical practice can conspire to give physicians a false sense of their own abilities.  Really.  Some doctors have an inflated sense of self worth.  Who would have thought it?  Spend time with some doctors and listen to them pontificate on politics or economics with the same (false) assurance that have in their true field of expertise, and you will run screaming from the room. (more…)

Posted in: Energy Medicine, Medical Academia, Nutrition, Science and Medicine

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Update on Josephine Briggs and the NCCAM

Dr. Gorski is in the throes of grant-writing, so I’m filling in for him today by following up on a topic introduced a few months ago. It involves a key medical player in the U.S. government: Dr. Josephine Briggs, Director of the National Center for Complementary and Alternative Medicine (NCCAM).

Background

Steve Novella and I first encountered Dr. Briggs at the 2nd Yale Research Symposium on Complementary and Integrative Medicine in March, 2010. I reported here that she seemed well-meaning and pro-science but that she also seemed naive to the political realities of her office and to much of the content of “CAM” (as illustrated by her recommending the NCCAM website, which is full of misinformation; previously I’d noticed her unfortunate innocence of “acupuncture anesthesia,” which is to be expected of most academics but not of the CAM Explicator-in-Chief).

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Posted in: Clinical Trials, Health Fraud, Herbs & Supplements, Homeopathy, Naturopathy, Politics and Regulation, Science and Medicine, Vaccines

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Magnets and Blood Flow

Over the last week I have received numerous questions about a recent study (yet to be published, but highly publicized in the press) in which it is claimed that the application of a magnetic field can improve blood flow. Physics World declared in the headline that, “Magnetic fields reduce blood viscosity.” This is not a bad summary of the study, but then the first sentence claims:

Researchers in the US claim that exposing a person to a magnetic field could reduce their risk of a heart attack by streamlining the flow of blood around their body.

Science Magazine ran with the also tame headline of “Magnets Keep Blood Flowing” but also had some problems in the text of their report (which I will get to).

The amount of press attention the study is getting is a bit odd. It’s a small proof-of-concept study looking at the effects of strong magnetic fields on blood flow in vitro. I suspect part of the reason is the same as why so many people have been asking me about it – magnets are frequently marketed with health claims and these claims are often justified by the hand-waving explanation that magnetic fields improve blood flow. The concern is that this small study will be abused by huxsters to sell refrigerator magnets with unfounded health claims.

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“CAM” Education in Medical Schools—A Critical Opportunity Missed

Mea culpa to the max. I completely forgot that today is my day to post on SBM, so I’m going to have to cheat a little. Here is a link to a recent article by yours truly that appeared on Virtual Mentor, an online ethics journal published by the AMA with major input from medical students. Note that I didn’t write the initial scenario; that was provided to me for my comments. The contents for the entire issue, titled “Complementary and Alternative Therapies—Medicine’s Response,” are here. Check out some of the other contributors (I was unaware of who they would be when I agreed to write my piece).

Posted in: Acupuncture, Basic Science, Chiropractic, Energy Medicine, Herbs & Supplements, History, Homeopathy, Medical Academia, Medical Ethics, Science and Medicine

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Et tu, Biomarkers?

Everything you know may be wrong. Well, not really, but reading the research of John Ioannidis does make you wonder. His work, concentrated on research about research, is a popular topic here at SBM.  And that’s because he’s focused on improving the way evidence is brought to bear on decision-making. His most famous papers get to the core of questioning how we know what we know (or what we assume) to be evidence. (more…)

Posted in: Basic Science, Clinical Trials, Diagnostic tests & procedures, Epidemiology, Science and Medicine

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We get mail

There are a few “laws” of the blogosphere, one of them being that a response to a post that comes more than a few weeks later is generally useless or crazy.  But once in a while, someone takes the time to look at an old post and formulate a thoughtful response.

This is not one of those times.

Or maybe it is.  I’ll report (and editorialize), you decide.

Regarding a piece I first published in September of 2010, a reader writes:

Dear Dr. Gorski:[our managing editor]

I am writing regarding your comments on the following blog

https://www.sciencebasedmedicine.org/index.php/your-disease-your-fault/#more-6747

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written. I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease. I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education. I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I await your response.

Sincerely,

[Name redacted]

What is instructive here is the usual thoughtful but incorrect “reasoning” used by someone with just enough knowledge to think he understands the topic at hand well enough to rebut.  The rebuttal, however, makes use of the usual fallacies that are the fallback position for the ignorant and the mendacious (and I must point out that I think our Dear Correspondent is the former).

Since I wrote the piece, not Dr. Gorski, I take full responsibility for its content and defend my writing personally.  A bit of a fisking is in order to help us all better understand how to think about these questions properly.

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