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.

Adapted from RationalWiki
Chiropractic is the theory and practice of correction of “vertebral subluxation processes” to treat and cure disease. It was developed in the late 19th century, just before the development of modern medical education in the United States.
Chiropractors subscribe to the theory of “vertebral subluxation”. This differs from the medical definition considerably. An orthopaedic (real) subluxation is a painful partial dislocation of a vertebral body. A “chiropractic subluxation” is an asymptomatic misalignment or a “vertebral subluxation complex” thought to be a cause of disease. The mechanism posited is usually the blocking of nerve impulses from spinal roots, or some such nonsense. Such a subluxation has never been proven to exist.

Lest you think that this unproved hypothesis has died away, in July 1996, the Association of Chiropractic Colleges issued a consensus statement that:

Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

This hypothesis has never been tested, and ignores significant anatomical reality, such as the fact that much of the nervous system does not pass through “subluxations” in any way. This especially applies to the autonomic nervous system that “influences organ system function”.

According to the American Chiropractic Association:

The ACA Master Plan, ratified by the House of Delegates in June 1964 (Amended June 1979, June 1989, July 1994 and September 2000), and will govern future policies of ACA as quoted:
“With regard to the core chiropractic principle, which holds that the relationship between structure and function in the human body is a significant health factor and that such relationships between the spinal column and the nervous system are highly significant because the normal transmission and expression of nerve energy are essential to the restoration and maintenance of health.

That’s basically a re-statement of subluxation theory without the “s” word. It’s also patent bullshit.

So the chiropractors haven’t given up the absurd theory behind their “profession”—but does it work despite the poor theory? After all, outcomes are what count.

For back pain, there is evidence that chiropractic therapy may be as effective back exercises plus anti-inflammatory medications. Chiropractic has also been found to be slightly more effective than simply handing a patient a book about back care. In some studies, chiropractic did cost more overall. Specifically, a study comparing outcomes of acute low back pain treated by orthopedic surgeons, primary care physicians (PCP), and chiropractors found similar outcomes, but less cost from PCPs.

While 50-60% of patients who seek chiropractic care do so for back or neck pain, a significant number are treated for other problems. There is no evidence to support the use of chiropractic outside the realm of minor musculoskeletal complaints. Chiropractors who make any claims beyond low back pain are either dishonest, ignorant, or both. There is some evidence that (rarely) chiropractic care can cause stroke, carotid artery dissection, and other life-threatening problems.

Chiropractic may have a place in the treatment of low back pain—or it may not. Chiropractors are basically glorified massage therapists—except many massage therapists have better training, and know the limits of their profession. Chiropractors who discourage real medical care, vaccinations, and medications, or sell herbs and other potions out of their offices should be ashamed of themselves.

But of course, they have no shame.

————

References

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.

I did my training in a large city that attracts lots of young people from my home town. They tend to form an informal network there, and people keep loosely in touch.

So, I wasn’t surprised when a doctor I knew called me.

“Do you remember K.?” he asked.

“Sure, why?” I responded cautiously.

“She’s in the hospital with a big liver tumor. You might want to go see her.”

Ugh.

K. was always a vivacious girl (now a woman of 30). She was known for her smile. I was happy to be able to see her again after so many years, but not under these circumstances.

I walked into her hospital room. Her parents were there, and she was lying in her bed, recovering from a massive surgery. We chatted a bit, caught up on mutual friends, but she was pretty doped up and I let her rest. I spoke with her folks, let them know that I pretty much lived in the hospital, so if there was anything they needed, etc.

The prognosis for a tumor like hers is horrible, and she knew it. But, given her age and her attitude, she was not going to let her story end there.

She researched the latest treatments, went to specialty centers, enrolled in experimental protocols. But the tumor came back.

We spoke occasionally. We had never been close, but I thought maybe I could provide a unique ear for her–someone who wasn’t afraid to talk about illness and pain; someone who cared, but wasn’t a close friend or family member. Someone who was less likely to cry or pull away out of pain or emotional discomfort.

As the disease progressed, she moved back home. We spoke on the phone from time to time. She had a falling out with a close friend–she was dying, her friend was getting married and moving on with her life, and they couldn’t seem to communicate across that divide.

When I was home for the holidays I stopped by to visit her. She was thin. Very thin. But that smile still lit up the small room. She had given up futile treatments by then, and she knew she was dying. Abdominal pain and nausea we constant companions, but she found significant relief with marijuana.
We sat on the couch and talked about it…about pain, about pot, about friends. Then she looked at me and said, “You’ve seen people die of liver cancer?”

“Yeah.”

“What’s it like? To die of liver cancer? What happens?”

She didn’t need my tears, she needed my knowledge. I took a sip of water and a deep breath.

“Well, most of the people I’ve seen slip into a coma. We give them whatever pain medicine they need. As the liver fails, it can’t process toxins. Eventually, you’ll probably fall asleep and not wake up.”

We talked like that for a while. I realized that despite our not being close friends, I was in a unique position. It is a kind of intimacy that isn’t quite a doctor-patient relationship and isn’t quite a regular friendship. It’s a relationship built on a horrible reality, that both people understand, but from very different perspectives.

I hugged her goodbye, and the next morning headed home.

She did OK for a while. A local massage therapist donated her time to help bring her physical comfort. Her family was wonderful. But some things are inevitable.

A few months later, I heard she died.

Death was inevitable, but she found a way to make it less horrible for her than it could have been. It’s a lesson I can’t forget.

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?

The study starts with an interesting hypothesis. It has been observed that HIV is more easily acquired in the setting of other sexually transmitted diseases, among these genital herpes (HSV-2). We know how to reduce the incidence of HSV outbreaks in patients previously infected with the virus. This study looked at high risk women with HSV, gave half of them appropriate prophylaxis, and half of them placebo. The end point studied was new infection with HIV.

Despite the use of effective HSV prophylaxis, there was no difference in HIV acquisition rates between the two groups of women. This doesn’t rule out any benefit, but per the authors’ analysis, the study design should have picked up any moderate or strong preventative effect of the medication.

The results are disappointing—it would have been nice to be able to give a cheap, well-tolerated drug to at-risk individuals to prevent HIV, but in this case, it didn’t help.  This doesn’t mean that preventing STDs will not prevent some cases of HIV.  The results indicated that in similar populations (at-risk East African women), prevention of herpes outbreaks with standard medications didn’t reduce HIV infections.  No further extrapolations can be made.

This is the difference between science and bullshit. Science evaluates a hypothesis, and if it is not supported after repeated tests, the hypothesis is rejected. Pseudoscience just makes excuses and moves the goalposts.

References

Watson-Jones, D., Weiss, H.A., Rusizoka, M., Changalucha, J., Baisley, K., Mugeye, K., Tanton, C., Ross, D., Everett, D., Clayton, T., Balira, R., Knight, L., Hambleton, I., Le Goff, J., Belec, L., Hayes, R. (2008). Effect of Herpes Simplex Suppression on Incidence of HIV among Women in Tanzania. New England Journal of Medicine DOI: 10.1056/NEJMoa0800260

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? The AAPS, that’s who! (Up at the top left is a picture of an ignorant ass, in case you were wondering.) In the latest edition of my specialty newspaper is a letter from an executive at this quasi-medical association:

Recertification Wastes Time and Money

I want to express my opposition to the concept of maintenance of certification in the field of internal medicine (“ABIM Proposes Comprehensive Internist Concept,” Dec. 15, 2007, p. 1).

I agree with others who have noted that it would further fracture the practice of internal medicine.

The article says that this program would not bring in any additional dollars to the Maintenance of Certification Program, but that statement begs the question of just how much money the ABIM is generating from the program. There is no reason, in my opinion, for this program other than to bring in a stream of revenue to the ABIM.

When I was certified by the ABIM in 1977, it was for life. The purpose of an internal medicine residency was to train physicians in interviewing patients, performing a competent physical examination, constructing a differential diagnosis, making appropriate use of the available laboratory tests, and then prescribing appropriate treatment. The process of evaluating a patient and constructing a differential diagnosis has basically not changed, just as human anatomy and physiology have not changed.

What has been changing continuously, and this was true even before 1977, is the range of diagnostic tests and treatment modalities that are available. What one is required to study for a maintenance-of-certification examination could be obsolete long before the next one. And what is most pertinent for a physician to know for his particular practice depends upon his patient population and the services that he chooses to offer.

If a physician is not a highly trained professional with knowledge of scientific principles, cramming for an examination periodically is not going to help. If he is such an individual, the examination is just a way of stealing his money and his time that could be better spent in activities of greater value.

The very concept of the need to be continuously recertified is an insult to the profession of medicine. Lawyers, engineers, and other professionals are continuously learning as they perform their jobs. They continually receive feedback from the outcome of their work in the real world. They are continuously monitored by their colleagues, their patients or customers, and other oversight agencies. If they are not more knowledgeable about their particular job than anybody else, then they don’t belong in that job in the first place, and recertification will not help.

Physicians are being sufficiently demeaned by lawyers, insurers, and bureaucrats of every description. Professional societies should be working to enhance the integrity and standing of the profession, not contributing to its demise.

Jane M. Orient, M.D.

Executive Director, Association of American Physicians and Surgeons

Tucson, Ariz.
Internal medicine news, Issue 5, Page 12 (1 March 200
http://www.internalmedicinenews.com/article/S1097-8690(08)70244-0/fulltext

The recertification process is an expensive pain in the ass (pictured above). But medical science changes daily. This process insures that your doctor is at least nominally up to date in their field. Remember, a doc is free to practice even if they aren’t boarded, so really, the only reason to object to the concept is sloth or incompetence. If you want to be judged to be in my league, then take the damned test.