Editor’s note: Today we present a guest post from fourth-year medical student Joshua Horton, about the looming problem of antibiotic resistance. Welcome!
Antibiotic sensitive (left) and resistant (right) bacterial colonies. They probably shouldn’t be that close together.
I read a study recently that alarmed me: acute bronchitis is a condition that rarely requires antibiotics, but three quarters of patients presenting with this condition receive a prescription for antibiotics. Even more worrisome, this statistic has not changed in 20 years. To those of us on the cusp of a career in medicine – I am a fourth year medical student – this is terrifying because we are going to have to deal with the consequences. Antibiotic overuse leads to:
- Increased morbidity and mortality for patients infected with resistant bugs
- Unnecessary and exorbitant healthcare expenditures
- The potential to cultivate multi-resistant bacteria that could spread to pandemic proportions
We still take them for granted, but antibiotics are a finite resource. Each time we breed a bug that is resistant to a particular drug, we are forced to relinquish that gun from our armamentarium. With fiscal impetus for pharma to develop new antibiotics waning, we may have reached a point of no return. That’s why this study scared me. Hopefully, clever techniques based on behavioral theory designed to reduce antibiotic prescribing may pull us back from that edge – read on to learn more. (more…)
I was looking over a recent class catalog from my alma mater, University of Oregon. I see the Astronomy Department is having a day devoted to astrology, inviting astrologers to talk about their profession. And the Chemistry department is having alchemists give an overview on how to change base metals into gold. And, to green our energy, the Physics Department, where I acquired my undergraduate degree, is having a symposium on perpetual motion machines. I am so proud.
But not when it comes to SCAM (Supplements, Complementary and Alternative Medicine). Medicine is strange in that has no issues embracing pseudo-science. My medical school, OHSU, had an afternoon devoted to Integrative Medicine for the third year medical students, with lectures by a chiropractor, a traditional Chinese pseudomedicine practitioner, a naturopath and an integrative medicine practitioner. They also had a small group discussion of a case of irritable bowel syndrome where one of the discussion leaders was a……Qi……….Gong………..master. Really. I would be so pissed if I was going $166,000 in medical school debt and I was being taught about the approach to ANYTHING by a Qi Gong Master. It was a day to ignore that whole ‘science’ thing in the name of the school. (more…)
Reports of a disturbing chain of events that ended in the likely preventable death of a 19-month-old Canadian child have made the rounds this week. The case was discussed by friend of Science-Based Medicine Orac (who I believe is some kind of a protocol droid) on Respectful Insolence two days ago. But even if you’ve read that excellent post, please continue reading as I have updated information and, I believe, additional insight into this unfortunate outcome.
If this is your first encounter with the story, prepare to be angry and frustrated but don’t presume to know everything that happened. The numerous news reports, beginning back in 2013 when the parents were first charged and the case went public, are not all well-written and there are discrepancies between accounts. Add to that the announcements and fundraising efforts by the family on Facebook and various other crowdfunding websites, and their alleged side of the story as reported by disreputable sources steeped in pro-woo/anti-vaccine bias, and we have one confusing mess of facts and a heap of conspiracy claims to boot. The only aspect of this case that is completely irrefutable is that a child suffered and died, and that he was failed by people who should have known better. (more…)
The greatest strength of science is that it is self-critical. Scientists are not only critical of specific claims and the evidence for those claims, but they are critical of the process of science itself. That criticism is constructive – it is designed to make the process better, more efficient, and more reliable.
One aspect of the process of science that has received intense criticism in the last few years is an over-reliance on P-values, a specific statistical method for analyzing data. This may seem like a wonky technical point, but it actually cuts to the heart of science-based medicine. In a way the P-value is the focal point of much of what we advocate for at SBM.
Recently the American Statistical Association (ASA) put out a position paper in which they specifically warn against misuse of the P-value. This is the first time in their 177 years of existence they have felt the need to put out such a position paper. The reason for this unprecedented act was their feeling that abuse of the P-value is taking the practice of science off course, and a much needed course correction is overdue. (more…)
Real medicine is built on high quality data. That’s one lesson I learned through my rehabilitation as a former naturopath. I can assure you that this principle does not apply to naturopathy or any of the other types of alternative medicine, which are mostly based on anachronistic traditions, magical thinking, and poor academic integrity. I now know that real medicine incorporates any therapy scientifically demonstrated to be effective and safe, regardless of origin. Therapies that fail to demonstrate effectiveness remain alternative for good reason.
I made a sharp turn in my career when I realized this, but I was recently surprised to learn that a failure to respect the data can sometimes also characterize medicine. I’m not trying to fool anyone with an appeal to hypocrisy (often used by alternative medicine zealots to argue that their beliefs are somehow valid simply because medicine has problems). But I do want to draw attention to a problem with medical research, which has the potential to undermine science-based medicine and take us down the dark path of misinformed medicine — medicine based on incomplete data.
Most people probably don’t realize that a majority of clinical trials do not report their findings.[1–3] About half of trials conducted before 2007, before it was legally required to register and report clinical trials, have never been published.[4, 5] Even since stronger legal mandates were enacted, most clinical trials still are not registered or reported.[1–3] As a result, there is a huge amount of clinical data unknown to the medical community and not available to clinicians or patients.
This effectively means that medical decisions can be based on incomplete information, not only diminishing the effectiveness of treatments but also eroding the perceived plausibility of medical interventions over time. This is what Sense About Science’s AllTrials campaign is all about: ensuring that all clinical trials register and report results in a publicly-available database. I see it as an obvious and straightforward means to improve medicine. (more…)
I had the pleasure of speaking on the topic of chiropractic and the newborn baby earlier this week at a meeting of the Boston Skeptics. There is a video of the talk online for anyone interested in learning more. And if you haven’t yet, please read yesterday’s post on chiropractic and babies by Sam Homola.
My introduction to pediatric chiropractic
Although I was aware of the existence of chiropractic well before beginning my medical training, I was blissfully ignorant of the full scope of what many chiropractors actually do on a daily basis. My belief that they practiced solely as “doctors of the back” was shattered early in my pediatric training at Vanderbilt while on a pulmonary medicine rotation when I was asked to consult on the child of a well-known musician who lived in the area. The patient, perhaps only hours from respiratory failure, had been brought to our emergency department only after chiropractic treatments had failed to manage a severe asthma exacerbation.
That encounter, as well as another around the same time involving a child with a throat abscess being treated with acupuncture, inspired me to dig deeper into the general concept of alternative medicine. I even went so far as to approach a local chiropractor who had set up a table at a Nashville YMCA to promote chiropractic prevention and treatment of the flu. Dr. Fakename happily allowed me to spend a day in his office, and even brought in his own child to demonstrate his approach pediatric care.
Needless to say, Dr. Fakename failed to convince me of the benefits or need for chiropractic involvement in pediatric healthcare. When the discussion turned to routine childhood vaccines, I heard the party line on the subject for the first of many times. Dr. Fakename was not against vaccines, he was in favor of giving families all of the facts. He gave me some reading material, and a book suggestion or two, which provided nothing but potential and unproven risks with no mention of the well-established benefits and proven safety of immunizations. I’ll never forget what his wife, who had brought their child in for the demonstration, whispered to me during a moment of distraction: “Don’t worry, we vaccinate our kids. I make sure.”
By the end of my residency I was a full blown skeptic of a variety of alternative medical modalities in addition to chiropractic, and had built a reputation as someone interested in and knowledgeable on the subject of quackery. I even gave a grand rounds on pediatric CAM with a focus on chiropractic which I’m proud to say drew a standing room only crowd that included folks from the community interested in alternative medicine as well as from the brand new integrative medicine center at Vanderbilt. I had even been asked to serve as a resident representative, however that invitation was quickly rescinded after my skeptical talk. (more…)
My article “Pediatric Chiropractic Care: The Subluxation Question and Referral Risk” was published in the 2016 February issue of the journal Bioethics. The abstract summarizes the message of the article:
Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a “vertebral subluxation” or a “vertebral subluxation complex” alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations─the International Chiropractic Association and the American Chiropractic Association─support chiropractic care for children, care that includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.1
The first objection to my article came in a January 30 Facebook posting by Milehighchiro, a subluxation-based group: (more…)
Is genomic testing as useful as pharmacies claim it can be?
Despite science’s ability to develop sophisticated and targeted new drugs, predicting the effect of a drug in an individual is still maddeningly difficult. Not every drug works for everyone that takes it. Similarly, the very same drug can be well tolerated in some, but can cause intolerable side effects in others. So-called “targeted therapies” were supposed to improve our accuracy, by focusing on specific targets on cells. That’s been good – but not sufficient to make drug treatments more consistently effective. Pharmacogenomics is the relationship between your DNA and how your body responds to drugs: how they’re absorbed, how they work, and how they’re eliminated from the body. It has been heralded for some time as the white knight of drug therapy. The genome revolution was supposed to remove (or dramatically reduce) the uncertainty in medicine, telling us which drugs will work more effectively, and which we might want to avoid. And to some extent, the genome-based treatment era is already here. There are over 100 drugs approved by the Food and Drug Administration (FDA) now that include genomic information in their prescribing information. For a small number of drugs, genomic testing is warranted. Increasingly, genomic testing is more accessible, moving from the research bench directly into retail pharmacies for sale when you pick up your prescription. Given pharmacies have a less-than-stellar record of selling laboratory testing that isn’t validated or even useful, I was immediately skeptical when I saw a new story on pharmacy-based genomic testing. Titled “Your pharmacist’s secret weapon: How your DNA can help perfect your medication,” it appeared in last week’s Globe and Mail: (more…)
Pictured: Joshua Tree. Not pictured: My bleached bones. I hope.
A short post this week. Last weekend was a busy call weekend and as I type this I am heading for Palm Springs for a long weekend of hiking in the desert. If there is no entry in 14 days, look for my bleached bones somewhere in Joshua Tree.
Some observations about a recent article in the once-respected Annals of Internal Medicine, whose recent articles on acupuncture suggest their motto should be “The Annals: we have one too many ns.”
First there was, “Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial,” and now “Acupuncture for Menopausal Hot Flashes: A Randomized Trial.”
Spinning yin deficiency
Why do the study? Why do any acupuncture study? Negative studies will not change practice. There are no reality-based reasons to think that acupuncture would be effective for any process. All the high quality studies show no efficacy. (more…)
Caring for a young infant, although a potentially rewarding means of producing a labor force for chores and minor home repairs, can be a trying ordeal for both new and experienced parents. The peaks and valleys of parental experience can leave a caregiver both exhilarated and agonizingly frustrated during a single hour of childcare, let alone the first few months. It is not an uncommon experience for a parent to rapidly alternate between extreme states of emotional arousal, one minute gazing down at their sleeping baby with seemingly limitless feelings of joy and love, and the next panicking at the perception that it has been too long since their baby’s last breath.
Babies, especially stupid ones, require near constant attention during the first several weeks of life, and that’s if it is going well. There is no user manual for the care of the newborn human that could possibly describe every situation and how to effectively respond to it in each individual child. A trial and error approach is always necessary to some degree, and it tends to result in a lot of sleepless nights, with many parents finding themselves more exhausted than they ever dreamed possible. So it shouldn’t be surprising that parents are a particularly vulnerable population when it comes to the marketing claims of bogus technology aimed at making their lives even the slightest bit easier. (more…)