Regardless of what you feel about the ethical question, we need to know if the laws we pass to achieve our goals actually work, or if they don’t work, or even have unintended consequences. Having an admirable goal is not enough; when you make actual decisions (practice decisions, policy decisions, healthcare decisions for you and for family) you want to know that those decisions are having the desired effect.
When I was pregnant, I obediently took the iron pills and prenatal vitamins prescribed by my obstetrician. And I prescribed them for every pregnant patient I took care of as a family physician. I never questioned the practice. It seemed intuitively obvious that it was a good thing; we know pregnancy makes extra nutritional demands and depletes iron stores. It never occurred to me to question what I had been taught, because it seemed perfectly logical. I did question other things I was taught that didn’t seem so logical. In my internship, we were ordered to do episiotomies on every patient (the rationale was that it made birth less traumatic for the baby and prevented uncontrolled perineal tearing in the mother). I was severely chastised for omitting an episiotomy on a patient who begged me not to do one. She had had several babies and was stretchy enough to deliver easily without an episiotomy. In this case, my common-sense clinical judgment was vindicated by further research in the years after my internship; new evidence showed that routine episiotomies were of no benefit, practice changed in response to the new evidence, and episiotomies are no longer done routinely.
That was a long time ago. I have long since learned that even the most reasonable assumptions can be wrong. I happened to be right about episiotomies, but I might just as well have been wrong; and the only way to know whether a belief is true is to test it in controlled scientific trials. As Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” It turns out that routine multivitamin and iron supplementation is not supported by any convincing evidence from scientific studies. And practice is changing. Recently, when one woman asked her OB what she should do about prenatal vitamins he pulled his wastebasket out from under his desk and said “put them there.” (more…)
Bill Maher (right) expresses admiration for HIV quack Samir Chachoua (left), who claims to be able to cure people of HIV and cancer using milk from arthritic goats.
I know I must be getting older because of Friday nights. After a long, hard week (and, during grant season, in anticipation of a long, hard weekend of grant writing), it’s not infrequent that my wife and I order pizza, plant ourselves in front of the TV, and end up asleep before 10 or 11 PM. Usually, a few hours later, between midnight and 3 AM one or both of us will wake up and head upstairs to bed, but not always. Sometimes it’s all Friday night on the couch.
Last Friday was a bit different. It wasn’t different in that I did fall asleep on the couch sometime around 10 PM. However, unlike the usual case, when I woke up around 1:30 or 2 AM to head upstairs I was stone cold wide awake, feeling like Alex in A Clockwork Orange, eyes held wide open. So I did what I do when insomnia strikes. I popped up the computer and checked my e-mail and Facebook. Immediately, I saw messages asking me if I had seen Real Time With Bill Maher that night and, oh boy, I really should watch Maher. Apprehensive but curious, I fired up the DVR and watched.
And, shortly after the monologue, was totally appalled by this;
Funny, how the segment hasn’t yet been posted to Bill Maher’s YouTube page, as many of his interviews are. If he ever does post it, I’ll switch out the video above for the “official” source. Somehow, though, I doubt that the video will ever be posted, the reason being that it contains an embarrassingly fawning 10 minute interview with “Dr.” Samir Chachoua, better known (at least to skeptics) as Charlie Sheen’s HIV quack. Somehow, when Charlie Sheen was on The Dr. Oz Show a couple of weeks ago, other things were going on and I didn’t blog about it. Fortunately, Steve Novella did. Now, with Sheen’s very own quack who failed him being fawned over by Bill Maher, it gives me a chance to take down three birds with one stone: Bill Maher, Dr. Oz, and, of course, Sam Chachoua. Sadly for Bill Maher, America’s Quack Dr. Mehmet Oz comes off looking a lot better than he does, and that’s saying something. (more…)
Note this special guest post submitted by Maddaz A. Hatter, D.D.S. Thanks Dr. Hatter!
Also, on an almost-completely-unrelated note, skeptical dentist, haberdasher extraordinaire, and sometime-guest-blogger Grant Ritchey recently moderated debate between SBM regular Clay Jones, and pediatrician-who-has-yet-to-be-coerced-into-blogging-with-us Raymond Cattaneo, about the pros and cons of firing families who refuse to vaccinate according to the recommended schedule. I’m told Clay wins the debate through a swift blow to the throat, but it happens at the very end so you’ll have to listen to the whole thing! Located at the Prism Podcast via this tasteful and refined link.
In England during the 1700s and 1800s, felt hats – very fashionable at the time – contained trace amounts of mercury, and many of the workers in the hat factories that produced them succumbed to mercury poisoning over time. Symptoms of mercury poisoning include dementia and other neurological complications, from whence came the term “Mad as a Hatter.” We’ve known for quite a while that quicksilver in large enough quantities does not do a body (or brain) good.
This brings up a point. It seems that a recurring theme at Science Based Medicine is that we are always defending what legitimate health care providers want to put into a human body to prevent, cure, or manage disease, or to improve health or quality of life. Conversely, we critique those who want to put things in us that are of no demonstrable benefit or which may cause harm. To wit: vaccines – good, coffee enemas – not good. Fluoride (at appropriate doses) – good, colloidal silver – not good. This is an ongoing tug-of-war that will likely continue until our sun supernovas and consumes our planet, after which all arguments will probably be moot.
Do you take a vitamin or dietary supplement? Over half of all American adults do, making this a $30 billion dollar business. Many of us even take supplements in the absence of any clear medical or health need. I’m often told it’s a form of nutritional “insurance” or it’s being taken for some presumed beneficial effect – like Steven Novella outlined in yesterday’s post on antioxidants. We love the idea of a risk-free magic bullet that improves our health and wellness. Especially one that avoids what are presumed to be toxic, unnatural drugs. Supplements are marketed as safe, natural and effective, and there is no question that messaging has been effective.
I used to take supplements. For me it was multivitamins. But as I’ve taken a closer look at the evidence for supplementation, my personal behaviors changed. The primary reason is a lack of evidence. There is no evidence to suggest that vitamins offer any health benefits in the absence of deficiency. The balance of evidence suggests that routine multivitamins are unnecessary for most people. Vitamins should come from your food, not from supplements. More generally, looking at the broader category of supplements that range from probiotics to herbal remedies, there is little evidence to support most of them. With a few exceptions, the research done on dietary supplements is unconvincing and largely negative. If you don’t supplement, you don’t seem to be missing out on any tremendous health benefits.
Antioxidants are better-acquired through food than pills.
Antioxidants are now an iconic example of premature hype making its way into marketing and the public consciousness long before the science is adequately understood. There are multiple lessons to be learned in this story, and a new study just emphasizes those lessons further.
A brief history of antioxidants
One of the unavoidable consequences of metabolism (burning food for energy) is the creation of oxygen free radicals, or reactive oxygen species (ROS). These are molecules that are highly reactive. They essentially contain oxygen with an extra electron, which can react with another molecule, breaking bonds and causing damage.
As you might expect, the body has natural antioxidants which react with ROS to form benign molecules.
In the 1990s it became increasingly apparent that oxidative stress was playing an important role in cell damage, even sometimes triggering apoptosis, or programmed cell death. Many degenerative diseases, like Alzheimer’s disease, were shown to be driven in part by oxidative stress. In addition, it seemed that ROS play a role in aging.
I don’t know of any evidence that the mind has ever cured a disease, so I would have been prejudiced against this book just from its title, and Dr. Gorski’s post prejudiced me even more. But I was willing to give it a fair trial. The publisher sent me a review copy of the book and I read it. I was expecting to hate it, but I was pleasantly surprised. I enjoyed reading it. I found it fascinating. I found myself agreeing with much of what Marchant says, and I was intrigued by some of the recent research she reports that I was not yet aware of. Preliminary studies, to be sure, but thought-provoking. The book challenged me to think more deeply about placebos, alternative medicine, and patient comfort. (more…)
This is exactly the sort of cover story you don’t want to see about your city in TIME.
One aspect of science-based medicine that is not covered frequently on this blog, aside from vaccines and antivaccine pseudoscience, but perhaps should be, is the intersection of SBM and public health. Unfortunately, living as I do in southeast Michigan right now, I’ve been on the receiving end of an inescapable lesson in what happens when the government fails in its mission to enforce science-based public health issues. I’m referring, of course, to what has become known worldwide as the Flint water crisis. The Flint water crisis has become so famous that unfortunately it now has its very own Wikipedia page. That is not an “honor” I like to see for my state, and I’m sure the residents of Flint, which is an hour’s drive north of where I live, would agree. This crisis provides an unfortunate illustration of what can easily happen when multiple layers of government fail in a science-based public health task as basic as providing clean water to the citizens they ostensibly serve.
For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply.
I was born and raised in Detroit. My parents didn’t move to the suburbs until I was ten years old, and I stayed in southeast Michigan until I graduated from medical school and ended up in Cleveland for my surgical residency and, ultimately, my PhD work. From there I bounced to Chicago and New Jersey. Then, in 2008, nearly twenty years after I had left my hometown, I ended up back in the Detroit area. The point of this story is that my roots in the Detroit area run deep. Michigan is my state, for better or for worse, which is why I get annoyed when bad things happen here. I particularly become outraged when a preventable tragedy occurs here, one that science told us how to prevent but the government went ahead and did anyway. It’s a horrific tale of how science was basically ignored because of politics, and legitimate scientific concerns about a policy that changed the water source for an entire city were downplayed, derided, and even denied by state officials at every level of government. The story has now gone international. Indeed, our state and the city of Flint are featured on the cover of this week’s TIME Magazine. (more…)
I often get called on to be a diagnostician. The referring doctor is uncertain what is going on in the patient, often a fever of unknown origin, and they call me to help figure it out. Sometimes I do, sometimes I don’t.
Making the correct diagnosis is not easy, even after 35 years. The classic phrase is the fog of war, but the fog of medicine is equally confusing. In retrospect sometimes a diagnosis becomes clearer, but in real time? It is so easy to be wrong and so difficult to be correct.
I remember the first case of my career. A patient developed neutropenia (low white count) from a sulfa antibiotic and over the next two weeks went into multi-organ system failure and died. At autopsy it was discovered that he had miliary tuberculosis. I totally missed the diagnosis, despite all the tests, including liver and bone marrow biopsies before he died.
A decade later a case was presented at conference about a patient with a fever who went into multi-organ system failure and died. At the time of the conference I had zero recollection of the case from a decade earlier, but knew this was a case of miliary TB based on the data presented, although it was far from a textbook case. After the conference the presenter let me know that it had been my case, the one I had missed years ago.
I was ten years wiser in my medical career and more aware of the subtleties and variations of disease presentation. Experience has made me a somewhat better diagnostician. Or so I hope. Making the diagnosis of a common presentation of a common disease should be simple, but patients rarely read the textbooks and we are more likely to see an uncommon presentation of a common disease, a common presentation of an uncommon disease, and most dreaded, an uncommon presentation of an uncommon disease. (more…)
Complaints to Florida legislators about these and similar incidents prompted the introduction of a bill that would have, among other things, criminalized any
verbal or written inquiry by a . . . physician, nurse, or other medical staff person regarding the ownership of a firearm by a patient or the family of a patient or the presence of a firearm in a private home . . .
As finally passed by the legislature and signed by Governor Rick Scott, the 2011 Firearm Owners Privacy Act subjects physicians to disciplinary action for making “verbal or written inquiry” into a patient’s firearm ownership when the physician does not “in good faith believe” such inquiries are “relevant to the patient’s medical care or safety of others.” The Act included amendments to the Florida Patient’s Bill of Rights and Responsibilities, adding similar provisions. (The Act also applies to health care facilities, but here we will discuss only its effect on physicians and their patients.) Physicians may not enter any information regarding firearm ownership into the patient’s medical record if they know this information is not “relevant to the patient’s medical care or safety, or the safety of others.” They may not “discriminate” against a patient “based solely on the patient’s Second Amendment right to own firearms or ammunition.” Finally, physicians must refrain from “unnecessarily harassing” a patient regarding firearm ownership during an examination. (more…)