Pictured: Medicine. In space!
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…)
A few years ago, an Ocala, Florida, pediatrician, as part of a routine visit, asked a patient’s mother whether she kept firearms in the home. She refused to answer, feeling the question constituted an invasion of her right to privacy. The pediatrician then terminated the relationship and told the mother she had 30 days to find a new doctor for her child. In another incident, a mother reported she was separated from her children while medical staff asked them whether their mother owned firearms. And, according to a Florida legislator, he was told to remove firearms from the home during an appointment with his daughter’s pediatrician.
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…)
While some parts of the world are concerned with eating, because of food insecurity, the “worried and well-fed well” are increasingly obsessed with so-called “clean eating.”
This is nothing new, but like every cultural phenomenon, it seems, has increased partly due to the easy spread of misinformation over the internet. If you are anxious about your health, and who isn’t to some degree, your anxiety is fed by a steady diet of pseudo-experts, con-artists, and internet personalities telling you about all the things you eat that adversely affect your health.
This phenomenon is increasingly being recognized as a health issue among experts. In 1996 Dr. Steven Bratman proposed a formal disorder he calls orthorexia nervosa. He writes:
For people with orthorexia, eating healthily has become an extreme, obsessive, psychologically limiting and sometimes physically dangerous disorder, related to but quite distinct from anorexia.
Three years ago I wrote about an experimental treatment for chronic fatigue syndrome (CFS): rituximab (brand name Rituxan). I was concerned that doctors who offered it, like Andreas Kogelnik, were jumping the gun by offering it before the evidence was in, and that they might be putting patients at risk.
A correspondent who has been following the CFS forums asked me to revisit this issue. She sent me links to forum posts indicating that Dr. Kogelnik is treating CFS patients with the drug, that they are not being enrolled in clinical trials, that information about results is not available, and that at least one patient may have developed a life-threatening side effect. I want to stress that I don’t have any evidence that those statements are true. These are only posts on a forum, and I have no way to verify the information. I tried to get more information from Dr. Kogelnik’s clinic, but was unsuccessful. Nevertheless, even if everything in those forum posts is false, I think the issue is serious enough to bring it to the attention of the public again. My purpose is to provide accurate information about rituximab and to get people to think about the principles involved, not to make claims or accusations or cast any blame. (more…)
It’s a seldom mentioned aspect of my professional history that I used to do a lot of trauma surgery in my youth. I did my residency at a program that included a county hospital with a busy trauma program where I saw quite a bit of vehicular carnage and an urban hospital (which has since closed) where I saw a fair amount of what we in the surgery biz call gun and knife club action. During my time as a PhD student, I moonlighted as a flight physician for the local helicopter rescue service, Metro Life Flight, where I took care of patients with everything from cardiac disease requiring transfer to the Cleveland Clinic to near-drownings during the summer at the Lake Erie resorts, particularly Put-in-Bay, to obstetrical transfers (which terrified me) to, of course, the unfortunately copious run-of-the-mill vehicular trauma. I saw the sort of tragedy that could result. Then, in the late 1990s, as I did research for my surgical oncology fellowship in Chicago, I also moonlighted as a trauma attending at a local suburban level II trauma center.
At that point, I realized that trauma was not my thing, as I couldn’t see myself at my present advanced age doing the sort of physically and emotionally demanding work that required fast decisions. It stressed me out too much; which is part of the reason why I went into surgical oncology in the first place. However, I have an appreciation for those who do do trauma. I also realize that trauma is, in a way, the “purest” form of surgery in that it involves taking a body broken by mechanical forces and trying to repair it, all the while keeping the patient alive until the repairs can heal. I will, however, miss the enjoyment I get hearing presentations on tree stand falls during hunting season.
I don’t mention my youthful flirtation with trauma surgery so much because I think it’s something so fascinating that I must tell it. (If that were the case, I’d have been mentioning it much more frequently in my blogs and social media than I have before.) Rather, it lets you know why I was so distressed when this story was forwarded to me a few days ago. It’s a Reuters report entitled “Injuries soar after Michigan stops requiring motorcycle helmets“:
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…)
One of the most satisfying parts of being a health professional is the opportunity to help people make better health decisions. In between the emails suggesting I’m a paid lackey of the Pharmaceutical-Industrial Complex™ for not endorsing coffee enemas, vitamin C, or homeopathy, I do receive the occasional note thanking me for my advocacy, or for writing about a subject in a way they found helpful. I’m also sent questions – too many to answer, but occasionally opening my eyes to new “concepts” in alternative medicine. And while I spent years working in a pharmacy with a huge “holistic” health section, containing products that, if they worked, would have defied one or more laws of physics or chemistry, I can still be surprised at novel alternative-to-medicine approaches to health care. Last week I was sent a questions about hydrogen peroxide – not for first aid use (where it may not be as useful as thought), but for oral consumption, as some sort of health “cure-all”. I was baffled, but the concept does exist – and the Big Pharma Overlords apparently don’t want you to know about it. There must be a rule 34 of alternative medicine – if it exists, there is an (inappropriate) alternative medicine use for it. The active ingredient in hair bleach and teeth whitening strips is no exception. (more…)
The public fight over the human papillomavirus (HPV) vaccine is still raging. The debate partly reflects the underlying logic of health prevention measures, which is essentially a statistical game of risk vs benefit. Unfortunately thrown into the mix are ideological opponents to vaccines who are distorting the facts at every turn.
Notice that I said this was a “public” fight, because it is not a serious scientific dispute. There is sufficient evidence to confidently conclude that the HPV vaccines currently available are safe and effective. All medical interventions will contain some risk, it is never zero, but vaccines in general, and the HPV vaccine specifically, have minimal risks and clearly prevent disease.
In addition there is a social angle to the HPV vaccine in that it is given to children to prevent a sexually transmitted disease.
The science of the HPV vaccine
What’s the best route to this happy outcome?
Doctors used to insist “once a C-section, always a C-section.” Today it is standard practice to allow vaginal births after C-section (VBAC) for appropriately selected patients. The American Congress of Obstetricians and Gynecologists (ACOG) has issued a Practice Bulletin to guide obstetricians in determining which patients are appropriate candidates for VBAC.
We frequently hear criticisms of practice guidelines like these. The doctors who write the guidelines are accused of conflict of interest, turf protection, and biased evaluation of the evidence. For those who believe doctors put profits before patients, this should be an eye-opener. It would presumably be in the best financial interests of obstetricians to do as many C-sections as possible, since they can charge more for them than for vaginal births. It would have been easy for the ACOG to put a spin on the data to make repeat C-sections look like a better choice. The fact that they offer VBACs despite their conflict of interest makes me think that their evaluation of the evidence was probably fair and unbiased.
So just how safe is VBAC? What are the pros and cons? What does the evidence say? (more…)
We frequently write about placebo effects here on Science-Based Medicine. The reason is simple. They are an important topic in medicine and, at least as importantly, understanding placebo effects is critical to understanding the exaggerated claims of advocates of “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine” (i.e., integrating pseudoscience with science). Over the years, I (and, of course, others) have documented how CAM advocates have consistently moved the goalposts with respect to the efficacy of their pseudoscientific interventions. As larger and better-designed clinical trials have been done demonstrating that various CAM therapies without a basis in science—I’m distinguishing these from science-based modalities that have been co-opted and “rebranded” as CAM, such as exercise and nutrition—have no specific effects detectable above placebo effects, CAM advocates move the goalposts and claim that CAM works through the “power of placebo” and do their best to claim that “harnessing” that “power of placebo” is a justification to use their treatments. It turns out, however, that when placebo effects are examined rigorously there’s just not a lot of there there, so to speak. Results are underwhelming, and trying to “harness the power of placebo” without an intervention that actually impacts the pathophysiology of disease can even be dangerous. That’s not to say that learning to maximize placebo responses (whatever they are) while administering effective medical treatments isn’t important; rather, it’s to point out that, by themselves, placebo effects are not of much value.
Unfortunately, none of this has stopped what Steve Novella refers to as the “placebo narrative” from insinuating itself into lay discussions of medicine. That narrative proclaims in breathless terms (as Steve put it) the “surprising power of the placebo effect” without putting it into reasonable perspective or even really defining what is meant by “placebo effect.” First, as we have tried to explain time and time again here, there is no single “placebo effect.” There are placebo effects. Second, the only really correct reference to “the placebo response” or “placebo effect” is the outcome measured in the placebo arm of a clinical trial. The problem is that, all too often, discussions of placebo responses conflate the placebo effect measured in a clinical trial with all the other various placebo effects that add up to the response that is measured in that trial. Those effects include reporting biases, researcher biases, regression to the mean, conditioning, and many other components that contribute to what is measured in the outcome of a clinical trial. Another common misconception about placebo effects is that they are somehow “mind over matter,” that we can heal ourselves (or at least reduce our symptoms) through the power of will and mind. This is not true. Placebo effects are not the power of positive thinking.