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The Fog of Medicine

Pictured: Medicine. In space!

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…)

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Is “harnessing the power of placebo” worthwhile to treat anything?

Placebonex
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.
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On “integrative medicine” and walking and chewing gum at the same time

Walk and chew gum at the same time

I didn’t think I’d be discussing Dr. David Katz again so soon. In fact, when Mark Crislip (who clearly hates me, given how often he sends me links to articles like this) sent me a link to Dr. Katz’s latest article, “Cleaning the House of Medicine“, published—where else?—in The Huffington Post, that home for “reputable” quack-friendly bloviation since 2005, when I first read the article, my first reaction was that Katz must surely be trolling us here at SBM. At first, I wasn’t going to respond to him again. However, Katz’s article represents a very common misconception about science-based medicine that is worth refuting. It is not my intention to be arguing back and forth with Dr. Katz every couple of weeks, but I did think it worth one more round. I think you’ll understand why by the end of this post.

First, however, a brief recap is in order for readers who might not have been following the discussion over the last month or so. It all started a couple of weeks ago, when Jann Bellamy, in response to a special issue of the American Journal of Preventative Medicine edited by Katz and dedicated to making the case for integrative medicine in preventive medicine training, quite correctly discussed how “integrative medicine” is always all about the “potential.” Indeed, after having spent considerable sums of federal grant money studying the “integration” of pseudoscience into medicine with respect to preventive care, the journal couldn’t come up with any concrete examples how integrative medicine adds anything (other than quackery) to medicine. Dr. Katz, who is well-known in the world of quackademic medicine for his infamous 2008 speech in which he asserted that physicians need to use a “more fluid concept of evidence” in evaluating treatments, particularly “complementary and alternative medicine” (CAM), responded with another HuffPo article entitled “Science and Medicine, Fools and Fanatics: The ‘Fluidity’ of Woo“. In lieu of reasonable, science-based arguments, Dr. Katz’ article was little more than a rant that consisted mainly of outrage that mere mortals lacking his awesome academic credentials had had the temerity to question his awesomeness and dedication to science coupled with an accusation that we are just too rigid and simplistic in our thinking to understand the subtle complexities of how different standards of evidence must be applied to complex patients. Steve Novella and I both responded that we understand just fine, explained how doctors do this all the time without using quackery like naturopathy and homeopathy (both of which Katz has advocated), and pointed out his argumentum ad ignorantiam with respect to energy medicine.

There’s where I thought it would end. Unfortunately, I was mistaken. On Friday, Katz launched another broadside at us, couched in the form of an argument that medicine must “clean its own house” before worrying about his quackademic medicine. It’s something I hear often enough that I thought it would be worth responding to, even if Dr. Katz was indeed trolling us.
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We Should Abandon the Concept of “Alternative Medicine”

FALSE-DICHOTOMY-copyIn a recent editorial for the New York Times, Aaron E. Carroll argues, “Labels Like ‘Alternative Medicine’ Don’t Matter. The Science Does.” I agree with this headline thesis, but the details of his argument ironically show the harm that the so-called CAM (complementary and alternative medicine) movement has done.

Carroll starts out well, essentially pointing out that the division between “conventional” and “alternative” medicine, and the division between “Western” and “Eastern” medicine are false dichotomies. Despite this strong start, he muddles his way through the rest of his editorial.

The primary error he commits is to swing from a false dichotomy to a false equivalency, essentially saying that there is no difference between conventional and alternative practice or practitioners. In order to support this contention, however, he has to distort the facts beyond recognition.

In other words, Carroll commits the less-well-known false continuum logical fallacy. Let me explain.

The real differences between SBM and CAM

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NCCIH and the true evolution of integrative medicine

NCCIH and the true evolution of integrative medicine

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly “skeptical,” the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled “Does the Vaccine Matter?” It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. Over at a blog known to many here, the question was asked whether The Atlantic (among other things) matters. It didn’t take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis’ work was represented as meaning we can’t believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled “The Triumph of New Age Medicine.”

Now The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled “The Evolution of Alternative Medicine.” It is, in essence, pure propaganda for the paired phenomena of “integrative” medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It’s the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: “Hey, this stuff isn’t quackery any more! We’re scientific, ma-an!” You can even tell that’s going to be the central message from the tag line under the title:

When it comes to treating pain and chronic disease, many doctors are turning to treatments like acupuncture and meditation—but using them as part of a larger, integrative approach to health.

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A Scientist in Wonderland

Edzard Ernst is one of those rare people who dare to question their own beliefs, look at the evidence without bias, and change their minds. He went from practicing alternative medicine to questioning it, to researching it, to becoming its most prolific critic. I have long admired his work, and I finally met him in person when we were invited to speak at the same conferences. He shattered my stereotype of the stern, formal, self-important German “Herr Professor Doktor.” He was affable, unassuming, and funny; he was even a jazz musician. I wished I knew more about his history, and my wishes have been granted in the form of his new autobiographical book, A Scientist in Wonderland: A Memoir of Searching for Truth and Finding Trouble.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

Edzard Ernst, the early years

Dr. Ernst was born in post-war Germany; his family had suffered greatly during the war and his uncle had been a general in the Waffen SS. He felt slightly ashamed to be German, and as a result he researched and wrote about Nazi health beliefs and medical atrocities so the history of their misdeeds would not be forgotten.

His father was a doctor, his mother an enthusiastic devotee of alternative medicine who subjected him to homeopathy, ice cold baths, and barefoot walks at dawn through wet grass. Early in life, Ernst began to manifest a tendency towards doubt and irreverence, along with an irrepressible sense of curiosity.

Music was his first love. He earned good money when he and his friends spent their summer vacation busking on the beach at St. Tropez, and he had been seriously considering a musical career until his mother persuaded him to study medicine. He earned an MD in Germany, in an environment where alternative medicine was unquestioningly integrated with mainstream medicine. He received hands-on training in acupuncture, autogenic training, herbalism, homeopathy, cupping, massage therapy, spinal manipulation, even leeches. His first job was in a homeopathic hospital where a colleague chose remedies by dowsing with a pendulum. (more…)

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Selling “integrative oncology” as a monograph in JNCI

pancreatic-cancer-diagnostics-l

Sometimes, it’s hard not to get the feeling that my fellow bloggers at Science-Based Medicine and I are trying to hold back the tide in terms the infiltration of pseudoscience and quackery into conventional medicine, a term I like to refer to as quackademic medicine. In most cases, this infiltration occurs under the rubric of “complementary and alternative medicine” (CAM), which these days is increasingly referred to as “integrative medicine,” the better to banish any impression of inferior status implied by the name “CAM” and replace it with the implication of a happy, harmonious “integration” of the “best of both worlds.” (As I like to point out, analogies to another “best of both worlds” are hard to resist.) Of course, as my good buddy Mark Crislip has put it, the passionate protestations of CAM advocates otherwise notwithstanding, integrating cow pie with apple pie doesn’t make the cow pie better. Rather, it makes the apple pie worse.

In any case, over the last three months, Steve Novella and I published a solid commentary in Trends in Molecular Medicine decrying the testing in randomized clinical trials of, in essence, magic, while I managed to score a commentary in Nature Reviews Cancer criticizing “integrative oncology.” Pretty good, right? What do I see this month in the Journal of the National Cancer Institute (or JNCI, as we like to call it)? An entire monograph devoted to a the topic, “The Role of Integrative Oncology for Cancer Survivorship”, touting integrative oncology, of course. And where did I find out about this monograph? I found out about it from Josephine Briggs, the director of the National Center for Complementary and Alternative Medicine (NCCAM) herself, on the NCCAM blog in a post entitled “The Evidence Base for Integrative Approaches to Cancer Care“, in which she touts her perspective piece in the JNCI issue entitled “Building the Evidence Base for Integrative Approaches to Care of Cancer Survivors.” In an introductory article, Jun J. Mao and Lorenzo Cohen of the Department of Family Medicine and Community Health, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania and the University of Texas M.D. Anderson Cancer Center, respectively, line up this monograph thusly:
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The false dichotomies of CAM and “integrative medicine”

Falsedichotomy

A lot of medical specialties have throwaway newspapers/magazines that are supported by advertising and somehow mysteriously managed to show up for free in the mailboxes of practitioners. In my case, I’ve found myself on the subscription list for such papers about oncology, but also general surgery (I’m Board-certified as a general surgeon). When I have to recertify in about three years, it will be as a general surgeon, which was really fun to try to do last time after having specialized as a breast cancer surgeon, and will likely be even more fun next time, when I will be 10 years further out from my general surgery and surgical oncology training. In any case, that must be why, no matter where I end up working, sooner or later I end up receiving General Surgery News (GSN).

As throwaway professional newspapers go, GSN is not bad. However, occasionally it publishes op-ed articles that make me scratch my head or even tick me off with their obtuseness. Lately, apparently, it’s started some blogs. The one in particular that is the center of attention for this post is by Victoria Stern, is called “The Scope” and is billed as “exploring the lesser known sides of surgery.” Of course, it’s a bit odd that some of the first posts on this blog are about work hour restrictions and whether they leave new surgeons unprepared to practice surgery, the debate over breast screening, and what it takes to train expert surgeons, none of which are exactly “lesser known sides of surgery.” Work hour restrictions, in particular, have been discussed in surgery journals, at conferences, and among surgeons ad nauseam, particularly whether we are training a generation of surgeons unable to deal with the rigors of practicing surgery in the real world.
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Lemons and Lyme: Bogus tests and dangerous treatments of the Lyme-literati

Tick

It’s that time of year when every day I can expect to see at least one patient with a concern about Lyme disease. In Lyme-endemic regions such as Western Massachusetts, where I practice pediatrics, summer brings a steady stream of children to my office with either the classic Lyme rash (erythema chronicum migrans, or ECM), an embedded tick, a history of a tick bite, or non-specific signs or symptoms that may or may not be due to Lyme disease. Sometimes the diagnosis is relatively straightforward. A child is brought in after a parent has pulled off an engorged deer tick, and there is a classic, enlarging ECM rash at the site of the bite. More often the presentation is less clear, requiring detective work and science-based reasoning to make an informed decision and a diagnostic and therapeutic plan based on the best available evidence. Depending on the story, the plan may include immediate treatment without any testing (as in the straightforward case described above), immediate testing without treatment pending test results, or waiting as we watch and see how a rash progresses before doing anything. An example of this latter course of action would be when a patient comes in with a pink swelling at the site of a new tick bite. In this case, it may not be clear if the swelling is a Lyme rash or simply a local reaction to the bite, a much more common occurrence. The classic ECM rash (an enlarging, red, circular, bull’s-eye rash at or near a tick bite) typically develops 1-2 weeks after a tick bite, but can occur anywhere from 3-30 days later. It then expands and darkens over another 1-3 weeks before fading. This classic rash is not the most common rash of Lyme disease, however, as it occurs in only about 30% of cases. Instead, the rash may be uniformly pink or red (or even darker in the center) without the target-like appearance, or may be a linear rash, expanding outward from the tick bite site. In the case of a patient who comes in with a vague, pink swelling within a day few days of a tick bite, we will typically wait and see what happens to the rash. If it is a local reaction, it will likely resolve within another few days. With Lyme disease, the rash will continue to enlarge and declare itself as an ECM rash. Another unclear and not uncommon situation is when a patient comes in with non-specific symptoms such as fatigue, musculoskeletal pains, and headache. If warranted by the history and the physical exam, we may in this case order Lyme testing. This may not give us an answer even if the patient has Lyme disease, because results are often negative in the first few weeks of the disease. In this case, if symptoms persist or evolve, we will repeat the testing in another few weeks at which point true Lyme disease will test positive and can then be treated. The good news is that the treatment of Lyme disease, particularly in the early, localized phase of the disease, is extremely safe and effective with a 14-day course of antibiotics. The testing is also relatively straightforward, with very good sensitivity and specificity when performed correctly. And this is where the bad news comes… (more…)

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VacciShield: Pixie dust for an imaginary threat

vaccishield

I know by now I shouldn’t be, but I am still amazed by how readily so many people buy into the seemingly endless array of bogus sCAM nostrums. Many are marketed and hawked for the treatment or prevention of diseases that are poorly managed by science-based medicine. There are countless examples of dietary supplements that are purported to effectively treat back and joint pains, depression, anxiety, autism, chronic pain, and chronic fatigue; the list goes on and on. The lure for these treatments is at least understandable and, although frustrated that scientific literacy and rational thought loses out, I empathize with the desire to believe in them. On the other end of the spectrum is the even more ethically corrupt substitution of safe and effective treatments with products that are not. I encountered what I find to be possibly the most frightening and dangerous example of this recently at my practice. A family new to the area called to schedule a routine health-maintenance visit for their 5-year-old daughter. When our nurse reviewed the medical records the mother had faxed over, she noted that the child was unimmunized and explained to her that she would need to begin catch-up vaccinations. The mother matter-of-factly stated that her daughter was actually fully vaccinated with a vaccine alternative. She had received a series of homeopathic vaccines from a naturopath. I am not going to discuss this egregious example of sCAM here, though it was addressed in previous SBM posts.1,2 Instead I’d like to focus on another part of the sCAM spectrum. Here lies a form of sCAM that, in some ways, is even more difficult for me to comprehend. These are products invented, marketed, and sold solely for the treatment or prevention of fictitious diseases or problems that exist only in the realm of fantasy. (more…)

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