WhiteCoat Underground

I did a silly thing.  I accepted an invitation to write over at ScienceBlogs.  It isn’t because of my leviathan ego, or the free massages they offer, but because it seems like a great opportunity for someone who loves science, medicine, and writing.

I doubt I can maintain two blogs at once (although over there I won’t be burdened by solo work…I have a great pair to work with), so please adjust your feeds to point to the new site.

I plan to continue posting basically the same mix of topics, but as an added bonus, you the Anti-Denialist Brothers, who probably know more about how people and groups aim to deceive you than anyone around.

See you over there!

Denialsim, defined in detail elsewhere, is an interesting phenomenon. It makes use of uniquely human qualities such as our intelligence, our pattern-recognition abilities, and our tendency to over-estimate how well we understand things. In the past, most “science”, including medicine, relied on similar human qualities. It was based on observation mixed with superstition and other non-evidence based ways of understanding the world. Many of these systems were internally consistent, but ultimately failed to accurately describe the real world.

The gradual transition of medical science (the use of evidence is used to evaluate medical practice) has revolutionized medicine. We no longer rely on the glorified shamanism that existed before the mid-20th century.

This also means that medicine has become a true “profession”; it isn’t something you can just “pick up”, hang up a shingle, and practice out of your front room. I’ve taken to calling practices that aren’t evidence-based “cult medicine”. This is because many of the practices have charismatic advocates who encourage followers to dedicate their beliefs and their money to non-mainstream (and ineffective) health practices. Cult medicine is full of folks who have simply decided what they think medicine should be.

Denialists also like to indulge in “should-ism”. AIDS, the WTC attacks, the moon landings are events they have difficulty explaining, so rather than getting educated or asking an expert, they ask themselves. They develop (often) internally consistent explanations of phenomena based on their own interpretations of facts, and their own preconceptions of what “should” be true. Partly because no one believes them, they close ranks, and feel conspired against (although to be fair, that thought pattern may begin before the conspiracy theory).

The patterns seen with denialism and cult medicine are very similar. Whether it’s the CIA-Zionist conspiracy to blow up the WTC towers as causus belli, or the Big Pharma/AMA/FDA conspiracy to suppress the “truth” about vaccines, denialists “deny” reality in favor of their own paranoid, Byzantine ideas.

It’s up at Tangled up in Blue Guy.  His blog is new to me, and I likey.  He talks about my former home (San Francisco), and my favorite song.  How could it be bad?

Hmmm…let’s see…

The hospital kept paging me all night.  I have a whole bunch of patients in house, most of them in training for hospice.  One is a sweet little old lady who fainted at home and said, “I’m fine, please don’t bring me to the hospital.  I feel fine!”  Needless to say, EMS came, she was brought to the ER, where a tube was placed in every orifice, and she became quite delirious.  I will (hopefully) discharge her today before anyone else tries to “help” her.

It’s still the tail-end of flu season, so the office and clinic are bursting at the seams.

It’s pouring cold rain outside, the sky an oppressive grey typical of this part of the country.

And my third patient this morning said to my assistant, “Can you please tell the doctor his fly is open?”

I think it’s time for a vacation.

I am often asked my opinion of chiropractic care. My usual answer (based on evidence) is that it can be somewhat helpful in the treatment of low back pain. That’s it. Any further claims are complete and utter bullshit. Many chiropractors practice ethically, and recognize the correct scope of their abilities…many do not. (more…)

A recent commenter advocated quite voceferously for chiropractic, specifically citing its supposed benefit in hyertension, one of the leading causes of morbidity and mortality in the U.S.  In evaluating this claim, a few things need to be kept in mind.

First, there is no plausible explanation for why “adjusting the spine” should have any effect on arterial hypertension.  This is important not just scientifically, but mathematically.  For a rigorous treatment of this issue (stick with it) please see Kimball Atwoods series on the topic of prior probability. 

Second, the few studies that have been done are, to say the least, unimpressive.  PubMed and OVID MedLine both give under 30 hits for “chiropractic AND hypertension”.  The searches lead to a number of pilot studies, but no studies of adequate power to measure a true effect.  A particularly interesting study from a well-respected hypertension program ⁽¹⁾. A pilot study is not powerful enough to show causation, but is simply a “proof of concept” used to show whether or not an idea is even worth pursuing.  Most of the other studies are from fringe journals.  The citation he gave from the Journal of Clinical Hypertension was, unfortunately, not available to me in full text, but does not appear to relate directly to chiropractic treatment of hypertension.

The evidence does not support the use of chiropractic to treat hypertension—ever.  Hypertension is a complex, dangerous, and heterogeneous set of diseases, the treatments for which are quite well understood.   All the wishing in the world won’t change that.  The use of chiropractic for hypertension is a dangerous idea whose time will likely never come.

References:
¹ Bakris G, Dickholtz M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B.Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study.J Hum Hypertens. 2007 May;21(5):341-2.

In a confluence of stupidity, the crank “journal” JPANDS is hosting an article by Andrew Schlafly, their general counsel, and founder of the bizarre neo-fascist Conservapedia.  The editorial sounds like much of JPANDS’s crap, with a strong emphasis on paranoia about doctors being in any way held accountable for their actions by governing bodies.  In this case it’s some incoherent rant about the Texas State Medical Board.  But what really caught my eye was the very last paragraph (emphasis mine):

The testimonies by the victims of the TMB’s abuse of power that day were tragically compelling. The leftist mindset at the face revealed its ideological pattern in its types of victims: a physician who does not take insurance, a veteran, a father dedicated to his family, and a physician persecuted for expressing a harmless but politically incorrect sexual joke to a female patient. The veteran was a fighter pilot who survived many missions for the United States over NorthVietnam, only to be shot down and destroyed as a physician by theTMB.

Up to that point, I had trouble putting together what Schlafly was trying to say, but the last paragraph pretty much says it all.  It’s not about medical boards;  it’s about the evil liberals.  Want to see some more of his writing?  Here are some titles (punctuation left out to save space. The first link will give you the list of links.  It makes for, um, interesting reading: 

Classical liberalDrinking LiberallyGodless liberalHollywood valuesLast wordismLiberal activistsLiberal artsLiberal Arts collegeLiberal BiasLiberal celebrity obsessionLiberal Behavior on ConservapediaLiberal ChristianityLiberal deceitLiberal DemocratsLiberal denialLiberal EliteLiberal FalsehoodsLiberal Fascism
Liberal friendshipLiberal GlossLiberal gradingLiberal hate speechLiberal HypocrisyLiberal hysteriaLiberal ideologyLiberal IntellectualismLiberalism and artLiberal labelsLiberal Lies About the American RightLiberal logicLibera MindLiberal MythsLiberal obfuscationLiberal PartLiberal quotientLiberal supremacistLiberal StyleLiberal toolsLiberal tricksLiberal valuesMassachusetts LiberalProfessor values

This guy has a serious bee in his bonnet about the vast liberal/athiest conspiracy to destroy all that we hold dear.  I feel much safer knowing he’s looking out for me, both as a doctor and as an American. </snark>

This story came up recently among some folks I know, so I’m reposting it. –PalMD

I’ve been fortunate enough to have excellent health, despite poor diet and lack of exercise. I’ve never really been confronted by my own mortality. In my business, however, I am surrounded by others’ tragedies. (more…)

But this time it was non-fatal. A patient came to see me. He’s middle-aged, generally quite healthy, and physically active. After a recent return to physical activity, his elbow began to hurt, so rather than call his internist, he visited a chiropractor. Not surprisingly, the back-cracker was unable to effect a cure. What did he do next? Asked his friend for the name of a “better chiropractor” (which is a bit like trying to find a better wrench to turn a screw). This one took a totally different approach to not helping the patient, but that damned elbow still hurt.

Like most cult medicine, there is little that chiropractic will not claim as their own. How tennis elbow could possibly be helped by back manipulation is beyond me. One website did, however, give some good insight:

Not always thought of as a “chiropractic” condition by patients, chiropractic’s conservative approach to elbow pain is often very effective, avoiding more invasive, risky treatment options.

An excellent example of “hurry up and do nothing”, which is not always bad advice, but is not unique to chiropractic. I guess when all you have is a hammer, and nails are notably absent, a wise chiropractor steps back and says, “abra cadabra!” I’m sure chiropractic cures the common cold as well—whereas the common cold, when left untreated, usually lasts a week to a week and a half, visit the chiropractor and your cold is gone in 7-10 days.

Anyway, I gave the guy a tennis elbow strap, told him to rest and ice it, and take ibuprofen if he needed it. If he’s patient and follows my advice, he’ll probably save a few bucks. A strap is usually covered by insurance, but cheap anyway. Ice is basically free. And a visit to me is about sixty bucks—and if he gets better, he doesn’t have to return for multiple “manipulations”.

This is rich. This is really rich. Mercola is speaking out against the one thing that keeps him in business: the scientific illiteracy and credulity of Americans. He bemoans ignorance that leads to beliefs such as “the Sun revolves around the Earth”, or the bird flu panic. Then, presumably with a straight face, he invites you to join his “inner circle”, further perpetuating ignorance, and relieving you of the inconvenience carrying around twenty-five bucks that was burning a hole in your pocket (that’s per month).

His “inner circle” includes access to such venerable titles as, “The Psychology of Vaccine Injury Awareness, Plus Excerpts from the Book The Sanctity of Human Blood Vaccination Is NOT Immunization”, and, “Ancient Dietary Wisdom for Tomorrow’s Children”.

Want to avoid ignorance? How about reading the newspaper? Joining a book club? Reading reliable online health resources? Avoiding quacks and cranks?

The New England Journal has just released a new study that adds to our knowledge of HIV prevention, albeit not in a positive way. It is another example of how science works. Pseudoscience, such as that preferred by HIV denialists and creation cult followers, doesn’t require logic or scientific method. Negative results are usually explained away under various excuses. Not so with this study. Lets go over it, shall we? (more…)

The New York Times is reporting the virtual elimination of meningitis due to Haemophilus influenzae type B (Hib) in Uganda.  This follows an aggressive vaccination program against the bacterium, which also causes pneumonia, ear infections, and epiglotitis, a deadly throat infection. 

This was a planned vaccination campaign, with the purpose of eliminating a disease, and it worked.  About 5000 children used to die every year in Uganda from Hib meningitis, and tens of thousands more are sickened.

I’m curious to see what idiotic arguments the anti-vaccination cults come up with for this one.  Guesses anyone?

It’s up over at Happy Jihad’s House of Pancakes, but you have to bring your own maple syrup.

My blog traffic has been picking up quite a bit, and while wordpress allows me to get an idea of where traffic is coming from, I’m curious to see where folks may have heard of this blog.  If you feel like it, please let me know how you came to read my rants.

(According to wordpress, much of my traffic comes from ScienceBlogs, especially Respectful Insolence, from Science-Based Medicine, and from wordpress itself.)

As I’ve mentioned before, I’m an internist. After finishing my residency, I could have hung out a shingle and started to practice. But I chose to become boarded in my specialty by taking the internal medicine board exam, a two-day long headache-inducing, sitzfleish-requiring, circle-filling extravaganza. Why would I bother? The board exams don’t change my ability to open an office, bill my patients, and buy my house. But being “board-certified” in my specialty confers a certain legitimacy. It says that the powers that be in my specialty have tested me and found me likely to be competent, or at least knowledgeable. My hospital will only allow me to be on staff if I am board certified. Still, there are plenty of physicians out there who aren’t boarded; I just don’t refer to them. If they couldn’t pass their boards, or couldn’t be bothered to try, I’d rather they didn’t see my patients.

So who could object to this process of conferring legitimacy to doctors? (more…)

I appear to be having spam filter issues.  Sorry, folks, I’m trying to keep up with them.

Others have written about the so-called autism epidemic, and have deconstructed the numbers that make up the myth. I wanted to personalize it a bit with some material from my mail bag. A retired educator who was tasked by the county to assess students writes:

When I was working, I was exposed to many parents of autistic children who were convinced of the link between vaccinations and autism. I met one parent who had all her mercury fillings removed from her own teeth and put her son through “chelation therapy“. I also think that the 1 in 150 children have ASD is partly due to the expansion of the parameters. What we used to call a “language learning disability” - a not too uncommon one– has now been lumped into ASD. Also, Aspergers was separate at one time. True, autism is more prevalent but some of these kids are just nerdy. The NYTimes had an article about these kids which I cut out many years ago and gave them a name which I can’t remember. ( I could say that about a lot of things.)…[Found it.] The term is ‘dysemia’ which apparently also refers to a kind of blood disorder but also is defined as ’social dyslexia’. I just call it nerdy.

The experience of a single educator gives a snapshot into the harm done by the mercury militia and anti-vaccine cults.  It also gives a front-line view of the changes in diagnostic criteria, enumerated elsewhere.

Now that the mercury connection is completely debunked, and thimerosal is no longer used in most routine vaccines, the antivax cults are grasping  for reasons to hate vaccines, despite their clear benefit.  Rescuing the public from cultist lies is a constant battle, but thankfully we are well armed—with truth.

I just lost a close family member to cancer. She was old, she had been ill a long time; it still hurts. But in her dying, she made some wise choices. She was a very bright woman, and retained her mental capacities right up until the end. This gave her the opportunity to decide how she would approach death. She chose to enroll in hospice… (more…)

Once again, JPANDS, the mouthpiece of the AAPS, has it all wrong. The contradictory missions of the AAPS often lead to humorous juxtapositions of policy. For example, the AAPS wants the physician-patient relationship unsullied by any outside forces—unless that relationship pisses them off. They intervened in the Terry Schiavo case, they wish to make abortion illegal—in other words, they’re libertarians, unless AAPS disapproves of your decisions… (more…)

I recently gave you a short primer on the immunology of vaccines. It’s time now for another short, oversimplified primer, this time on the immunology of HIV. We’ve addressed this a bit in this space before, but I’d like to focus on the immunology, given the amount of immuno-woo out there.

HIV denialists form a persistent little cult, and one of their newest leaders is Gary Null. Despite their small size and dearth of academic heavy-weights, they are quite loud, and can affect health policy.

Let’s delve into the immunology, and, once again, please forgive the over-simplification… (more…)

My residents sometimes complain about all the patients who come to see them with the common cold. After all, what can they do? As we all know, there’s no cure for colds. They are caused by a large assortment of viruses, and no treatments have been consistently found to reduce the duration or severity of a cold. But patients come to you to feel better. They don’t usually care about rhinovirus ecology. And a physician is an expert. They can help figure out whether you have a simple cold or something more ominous. So I tell my residents to suck it up and make people feel better.

But what can be done? Patients hate it when we send them away with nothing more than a “feel better, good luck.” Patients want to feel better, and often enough they want antibiotics.

Let me share a few secrets with you: (more…)

From  Science-Based Medicine, Kimball Atwood gives us a wonderful addition to the literature deconstructing  “CAM”.  You are required to read the entire piece before you engage in enjoyable weekend activities, but here is a quick peek.  Atwood has a suggestion for a new definition of “CAM”:

A spectrum of implausible beliefs and claims about health and disease. These range from the untestable and absurd to the possible but not very intriguing. In all cases the enthusiasm of advocates vastly exceeds the scientific promise.

OK.  Have a great weekend.  Don’t take any wooden nickles, or any homeopathic remedies!

At least, it might be if you’re not in a medical field, but bear with me. The latest issue of JPANDS, the crank journal from the fringes of medicine, has a new editorial (OK, the whole issue is editorial—not a single piece of original research to be found). As usual, the mouthpiece of the uber-quack organization AAPS, is complaining about policies that only affect doctors behaving badly. This time it’s “physician codes of conduct”, or the policies of behavior that hospitals set forth for doctors who wish to practice within their walls.

For those of you who aren’t in the field, let me give you some background… (more…)

I guess I’m going to start reading a new carnival.  I’ve been included in the latest Tangled Bank, up at Archaeoporn.  Don’t be fooled by the name—there’s no actual porn.  It’s a good read all the same.

But according to NewsTarget (or whatever-the-hell they call themselves now), and Joe Mercola, there is a conspiracy between oncologists and sunscreen manufacturers. (I’m not going to link to them this time—it gives me a rash).

The premise set forth by the quacks is that sunscreen lowers vitamin D levels, and contain toxins, both of which will lead to…um…something bad. Or at least, something worse than skin cancer, which is clearly caused by sun exposure. It has been proved beyond any reasonable doubt that sun exposure causes cancer, and that sunscreens can help prevent this… (more…)

We doctors order a lot of lab tests, often more than the evidence would indicate is necessary. The invention of machines to run multiple labs at once led to an explosion of laboratory evaluations. Tests were often named after the machines the ran on, and the number of parameters measured: SMA-7, SMAC-10, etc.

Today, the names have changed, but the tests are very much the same. It is not unusual for a physician to order “routine labs” that include a comprehensive metabolic panel (which measures about 19 different data points, depending on the machine), complete blood count (which can produce about 14 different data points), and more. Sometimes these tests are warranted, sometimes not… (more…)

OK, so no scientist with an intact cerebral cortex take the Answers Research Journal seriously. Still, it’s hard to ignore. If this is the best shot the Creationist cults can do at making their point then I don’t think the NIH is going to be sending them a lot of money any time soon. From the same edition as the article that was subject to my last rant is an article that defies description. OK, it doesn’t really defy description: it is a bloviating screed of pseudoscientific religious drivel. Let me ’splain… (more…)

I know that politics requires compromise, but scientific truth should be a bit more immutable. By way of Historiann, I learned of McCain’s sucking up to the anti-vaccine militia. Orac has covered this in detail, but this is the kind of thing that should get everyone up in arms. It isn’t clear to me what McCain thinks he has to gain from pandering to such a small constituency. I can see why he would suck up to theocratic fascists and the like, as they can really get out the vote, but what do anti-vaccine activists have to offer him?

I do have a few ideas:

1. It never hurts to suck up to anyone, and the only people he’ll piss off are a few scientists and doctors, most of whom don’t care what he says.
2. There is a great deal of overlap between theo-fascists and anti-vaccine wackos. (I didn’t make that up—see my previous posts on vaccination, or ask me for links).
3. He has truly drunk deep of the Kool Aid.

Hopefully Clinton and Obama will stay on the good side of this one. If it’s “Obama and Mercola ‘08″ I may have to vote for a write-in (or wait for the benevolent reign of our new robot overlords).

I’ve been stung by Andrea. She meme-tagged me with an interesting one:

• Go to page 123 of the nearest book.
• Find the 5th sentence.
• Write down the next 3 sentences.

So, I’m sitting in my lab, and one of my medical students left a copy of “Harrison’s Manual of Medicine” (AKA “Baby Harrison’s”) sitting on the counter. Page 123 just happens to be interesting:

The disease smallpox is caused by one of two closely related double-strand DNA viruses, V. major, and V. minor. Both viruses are members of the Orthopoxvirus genus of the Poxviridae family. Infection with V. Minor is generally less severde, with low mortality rates; thus V. major is the only one considered as a potential bioweapon.

I’ve studied the history of smallpox as a hobby (yes, I know, I need to get a life). It’s a nasty, nasty disease. It’s also one of the great success stories in public health, having been eradicated by vaccination by the late 1970s. As both my readers know, I’m a big fan of vaccination; however, this is not one of the vaccinations I feel should be given to everyone.

Over the last 10 years or so, there has been talk of smallpox being used as a bioweapon. Although the virus has been eradicated as a human disease, there are probably stores of it in the U.S. and Russia. It’s not known what other stores may exist. Smallpox is very contagious, easy to distribute, and ugly. That being said, the smallpox vaccine is not as benign as most of the vaccines that are recommended. It has a comparatively high rate of side effects, some of them quite bad. Targeted vaccination has been recommended by some—military personnel, first responders, lab workers, etc. This seems logical.

And the meme moves on.

I’ll try tagging some notables and see if they nibble:

Terrasig,  N.B., OWW, apgaylard, and The Lord.

Oh, and genewitch volunteered, so he can spread it to a few others.

References

Smallpox as a Biological Weapon Medical and Public Health Management. Donald A. Henderson, MD, MPH; Thomas V. Inglesby, MD; John G. Bartlett, MD;Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Peter B. Jahrling, PhD; Jerome Hauer, MPH; Marcelle Layton, MD; Joseph McDade, PhD; Michael T. Osterholm, PhD, MPH; Tara O’Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, PhD; for the Working Group on Civilian Biodefense. JAMA. 1999;281:2127-2137. http://jama.ama-assn.org/cgi/content/full/281/22/2127

As my child approaches school age, I worry about school board battles a little bit more. I hate politics, but I can see myself forced to get involved at some point. And I find myself wondering, what is it about some Evangelical Christians? Why is their faith so weak? Is God testing them? I ask this because of their constant griping about “equal time” for Creationism in public schools. Given that science classes are supposed to teach science and not religion, it’s pretty much a no-brainer; and after the smack-down they received in Dover, you’d think maybe, just maybe, they would have learned their lesson. But these soldiers for Christ carry on, betraying their ultimate lack of faith in the Bible and their God.

Lack of faith? But they’re fighting so hard for their faith! Whatever could you mean? (more…)