We're Moving!

(by PalMD) Aug 27 2011

For a variety of reasons, I've decided to head back out on my own.  Part of this has to do with my lower output of writing and my inability to share in the duties of maintaining a group site like Scientopia.  Scientopia is a wonderful blog community but I don't feel like I have the time to contribute fairly to the management of this site.  I'm indescribably thankful for everyone who has put so much work into developing Scientopia.

I hope you will follow me over to the new White Coat Underground (expect some bumps along the way).

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Dr. Pal, why do you love Big Pharma so?

(by PalMD) Aug 24 2011

After my recent post attacking the journal Cancer which published a horrid piece on quackery, a twitterer asked me question: "Why do Sci writers go in harder on quacks than pharma?"  (I think this begs the question; I don't believe that we neglect abuses among Pharma, but let's pretend that there is data to support her assertion). She continues, "My problem with selectively trashing these studies is we presume pharma studies better-so our audience does, as well. All quackery should be pilloried yet we selectively pillory the faith healer & homeopath. Why? B/C they're easier targets."

Assuming, once again, that her assertion is true, there are a number of good reasons to focus on blatant quackery above corporate malfeasance.  The pharmaceutical industry, while motivated primarily by profit, is required to go through extensive scientific testing of plausible drugs and devices.  This process is long, expensive, and is frequently successful at actually fighting disease.  There have been many infamous cases of burying data, of inappropriate promotion of drugs, but in general, science has won; sometimes it takes years, and sometimes there is harm done, but eventually, ineffective drugs, or drugs whose risk/benefit ratio is horrible tend to die.  There are of course exceptions, but not many.  The very fact that drugs have been given post-marketing black box warnings or have been withdrawn from the market (sometimes despite the work of bad actors in industry) is a marker of the ultimate success of the system.

This happens because science and medicine is designed to look for faults. Sure, the system can be gamed by dishonest players, but the scientific community is more than willing to toss out a modality that proves itself wanting.  Medical science, while influenced by ideology, is not ruled by it.

So-called alternative medicine and quackery works in a completely different way. Rather than asking a question and accepting an answer good or bad, altmed comes up with an answer and no amount of data will  cause it to be abandoned.  Despite hundreds of years of ineffectiveness, homeopathy is still used.  Despite its utter implausibility and proven inutility, reiki is still practiced.  There are very few if any altmed modalities that have been abandoned because of unfavorable data.  They are ideologies rather than science.

It is science and plausibility that separates quackery from real medicine.   Pharmaceutical companies develop and test hypotheses.  Sometimes they behave badly, but generally they have been successful at helping us live better and  longer.  There is an entire legal infrastructure in place to prevent them from doing ill, and to punish them when they are caught.  This system is far from perfect but it does work.

No system is in place to regulate or punish those who sell snake oil, and since patients are often "true believers" they are unlikely to sue quacks.

It's not a matter of choosing to go after quacks rather than pharmaceutical malfeasance.  We do speak out about it; there is a regulatory structure in place to monitor pharmaceuticals, as imperfect as it may be; and pharmaceutical science is science, whereas quackery is simply immoral, made up practices profiting off the hope of people who hurt.  It deserves every smack-down we can deliver.


3 responses so far

Of douches, online identity, and ethics

(by PalMD) Aug 22 2011

We need to have a little talk, you and me.  There has been a lot going on here on the internet in the last few days, most of which I've been unable to comment on more than briefly due to a vacation far from well-lubricated intertubes.  This evening, let's pull a nice demitasse and see if we can sort out some of this insanity.

Every morning, whether I need it or not

First, a well-respected internet health writer nearly lost his job for his online activities. Whether or not this was a good legal choice by the blogger's employer is nearly irrelevant.  As often happens on the internet, the writer got involved in a heated discussion with some psycho, thin-skinned reader (all simply my opinion of course) who then contacted the state entity by whom Our Hero is employed.  Perhaps not wanting to be linked with the word "douchebag" used in a non-official context, they told Our Hero, "can it or leave."

There are a number of important lessons here.  First, pseudonymity is your (non-legal) right; keeping the pseudonym from being cracked is not.  While outing someone's online identity may, in fact, be "douchey", it's not illegal.  And whether or not one's employer is behaving strictly within the law in firing your profane behind, the trouble stirred up is, in the real world, real, and you will probably lose.  It is therefore wise to remember that what you say online will quite likely be linked to your real name some day.

In addition to any avocational blow-back from internet discussions, there  are ethical concerns, especially to those of us in health care.  During a twitter meet up last night, I made a comment about medical ethics and social media and got a well-justified (though polite) query from a participant wondering what I was talking about.

Before answering her question, though, let's explore a "speech" issue here.  I know nothing---nothing!---about the law.  But what, from a non-legal perspective, makes an online discussion any different than one at a cocktail party?  If I were to call someone a "self-important, ignorant douchebag" at a party, would the target of my derision be justified in calling my employer?  Would my employer even take the call without laughing?  Is it the lasting nature of online writing, the public context that makes it more seemingly "harmful"?  If the exchange had taken place via email rather than on-blog would that have made a difference?

From the standpoint of protecting oneself, no.  If someone chooses to harass you for something you say and your employer decides to take them seriously, you're out of luck unless you have legal recourse, but even if you do, your job, while still technically in existence, may be made impossible to perform.  But what is said on open forums on the internet is enduring and is, at least potentially, available to a wide audience, making a claim of defamation (or whatever legal term is appropriate) more plausible to this lay person.  Still, the whole thing is pretty douchey.

In health care, though, everything changes. When I spent a larger percentage of my time teaching, I would give a yearly lecture to the medical residents about social media and medical ethics.  First there is a legal layer to all communications about patients.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) makes privacy a top concern.  Any "protected health information" (PHI) can be disclosed only under certain circumstances.  For example, if you want life insurance, you will sign a release allowing them access to all of your health information.  You don't have to sign, but they don't have to sell you insurance.  But once given that information, they cannot turn around and give it to your employer, your mom, or the New York Times without your explicit permission.

Doctors like to talk about cases, and HIPPA does not prevent this (once again, I'm no legal eagle), but the case should be discussed for "treatment purposes".   Also, doctors frequently talk about interesting cases simply for educational purposes.  Since there is rarely need to identify the specific patient, privacy is not usually violated.

But with the explosion of social media, these discussions are no longer limited to doctors' lounges.  I regularly field questions from other providers about the appropriateness (not the legality!) of posting certain information on facebook, twitter, and blogs.  For example, a colleague contacted me about posting an X-ray online for discussion with other providers.  The film was edited so that no patient demographics were visible.  This online venue was, however, a semi-public one, not a closed physician-only forum.  The film was unusual enough, and the temporal relationship to the incident close enough that the patient could perhaps be identified.  I recommended he not post it.

There are many subtle pitfalls for health care professionals online.  If I were to say, "I work in a clinic that treats chlamydia," this would differ from saying "I treated a lot of chlamydia in my clinic this month," which is also different from saying, "Last night I treated a horrible case of chlamydia."   Each statement brings me closer to having potentially revealed someone's protected health information.

I have argued in the past (though I can't seem to find the link) that medical ethics should be a pre-requisite for applying to medical school.  Many young doctors have no idea what they are getting into ethically, and some can't handle it.  Social media are the least of these problems, but a significant one nonetheless.  Stressed out medical students and residents want to vent to each other, and it seems natural to do so on facebook and twitter, but it often turns out to be a bad idea both ethically and for one's employment status.

Speech, while free, is not without consequences, and sometimes it's the good guys that get burned.  But we must also consider our own status as being either professionally or socially privileged in such a way that we may behave unethically in our discussions.

5 responses so far

The death of pseudonyms? Not so fast...

(by PalMD) Aug 19 2011

As old as the internet itself is the use of pseudonyms, names that identify individual users but happen to be different from their "real" names.  This practice differs from anonymity in that a unique identity follows the user from blog to board to email.  I blog under a pseudonym, not because I wish to remain anonymous (I am trivially google-able) but because the 'nym has been my internet handle for years.  To change now would confuse me and the people I converse with. There are myriad reasons for pseudonymity and anonymity online, something discussed at great length in many other venues.  There has also been a recent push (putsch?) to rid the internet of these 'nyms.  But I don't see a crisis here.

Google + has made it clear that they prefer "real names" which I'll admit is confusing to me, since I don't know my internet buddies' real names.   Now, one of the first large-scale science blog networks, ScienceBlogs, has announced the end of pseudonymous blogging.  Given that several of there most popular bloggers use 'nyms, this is clearly not an act against the practice itself but some larger business decision (I suspect, as do others, that National Geographic simply bought the network for it's domain name and plans to trash the old ScienceBlogs and replace it with something else, something which will not necessarily be worse.

The blogosphere, especially the science blogosphere, has undergone a lot of change in the last year or two, with network fracturing and new ones forming.  From the perspective of the "back end" of these networks, they aren't simple to run, unlike opening a WordPress or Blogger site, but they offer other benefits.

I'll leave re-hashing the history of structure of blog networks to someone else---my point is that pseudonymity will survive Google+, ScienceBlogs, and whomever else prefers the name on your passport.  Netizens want it, and they will have it, through commercial outlets such as Twitter or on their own via dozens of free infrastructure sites.  Those of us who value choice in naming conventions will simply slip away from Google+, ScienceBlogs, and any other site that fails to offer us what we want.  Our creativity will continue to drive the future of the internet.

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When a "scientific study" is neither

(by PalMD) Aug 18 2011

There is quite a bit of art to the practice of medicine: knowing how to get and to give information to a patient, how to create a sense of worry without creating a feeling of panic, how to use the best available science to help them maintain or return to health. Underlying all of the art is the science: what blood pressure is likely to be harmful in a particular patient? What can I offer to mitigate this harm? This science is developed over years by observation and systematic study. We have a very good idea of what blood pressure levels are optimal to prevent heart attacks in various populations. These data are hard-won. It has taken decades and it continues.

If a researcher were to discover a promising, new blood pressure intervention, they would have a long way to go from bench to bedside. They would have to prove as well as possible that it is safe and effective---and from a science-based medicine perspective, that it is even plausible. If the discovery is a drug that relaxes blood vessels, or a type of exercise, we have good reason to believe it might work and can go on to figuring out if it does work. If the intervention is wearing plaid every day, we have little reason to think this would be effective, and it probably isn't worth the time and cost of looking into it.

The well-respected journal Cancer has just wasted space in the study of wearing plaid. Well, not really; it's worse than that. The article is called, "Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A Randomized Controlled Trial." There is nothing that isn't wrong with this study, and if it weren't published in a major journal, it might even be light comedy.

Tragedy wins the day, however, because cancer is a big deal, and I don't like it when people mess around with cancer.

People with cancer suffer from a number of vague and specific discomforts related to the disease and its treatment. Everything from life-threatening blood clots, to intractable pain and nausea, to depression threaten to kill or disable people with cancer. One symptom common to many illnesses is fatigue, and during chemotherapy, fatigue can be debilitating. This new "study" allegedly investigates an intervention to alleviate fatigue.

Fatigue is one of those symptoms whose study can be difficult and deceptive. It rarely has a single cause, is subjective, and waxes and wanes naturally. Because of this natural variability, it is easy to attribute changes in fatigue to an intervention when if fact we may be observing the natural course of the symptom. My patients with colds often want antibiotics. Without antibiotics, their cold will likely last a week or two; with them, 7-14 days. If I give them antibiotics, they will certainly credit me with curing their cold, but were I to take credit I would be riding nature's coattails.

In the current study, the authors have chosen to ride the coattails of nature but rather than cling to them with medicine, they have chosen "biofield therapy". My spell checker doesn't recognize "biofield" and neither should you. The authors at least acknowledge this in passing:

Biofield therapies are complementary and integrative medicine modalities often used by breast cancer patients,
and have been described as therapies that are intended to affect energy fields that purportedly surround and penetrate the human body for the purposes of healing. (Emphasis mine, PalMD)

I have a big problem with studies built around something that only purportedly exists. What's next, a study of cancer rates in Sasquatch?

This paragraph effectively nullifies everything that follows, but what follows is so horrid and humorous that we can't just stop here.

The "biofield healing" technique chosen for the study? "Energy Chelation". It's almost as if they looked for a term that took all of quackery and combined it into two simple words. Nowhere does it tell us what sort of "energy" is being "chelated"; so I looked it up.

According to the study, the technique was chosen by one of the authors, Reverend Rosalyn L. Bruyere. Is she an oncologist? A physicist?

Rosalyn L. Bruyere is an internationally acclaimed healer, clairvoyant and medicine woman.

You don't need to be a capital-S Skeptic to translate that as "con-artist", although that would simply be an opinion. The real question isn't whether or not she is a con-artist (she may in fact be very sincere despite a website that makes her look like a cult leader) but why in the world any real physician or scientist would take such a person seriously?

Still, I want to know what the hell "energy chelation" is. It's not an easy question to answer, but various searches describe it as a hands-on energy healing technique that, analogous to chelation therapy, "chelate" and remove negative energies from the body. In other words, it's a fantasy spun out of happy thoughts and a juvenile imagination.

The "science-y" bit of the study isn't any better, relying of famously inaccurate "saliva cortisol" measurements, and something called "cortisol variability", which does not appear to be a validated marker of the symptom in question (fatigue). From my reading, I'm unclear that it's ever been validated to measure anything.

For all I know, the editors of Cancer are detoxifying themselves in a sweat lodge to rid themselves of the embarrassment of publishing such dreck. I just hope they remember to drink lots of water---faith healers do not have a great track record for patient safety.

Jain S, Pavlik D, Distefan J, Bruyere RR, Acer J, Garcia R, Coulter I, Ives J, Roesch SC, Jonas W, & Mills PJ (2011). Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A Randomized Controlled Trial. Cancer PMID: 21823103

(h/t Genevra Pittman at Reuters)

16 responses so far

Dear Patient

(by PalMD) Aug 16 2011

I do believe that you are in pain; I can see it in your eyes, your furrowed brow.  I can see it in your hesitant gait, the cautious way you get up and down from my exam table.
But this is the first time I've met you. I don't have your medical records.  I don't know anything about your kidney or liver function, whether or not you have heart disease or diabetes.  You don't know either, which is not unusual.  Many people come to me for the first time without a list of medical conditions or current medications.  We can work it out.

You can expect me to take a thorough history, do a complete physical exam, and request your old records.  But I am not going to give you a prescription for narcotics today.

It's not that I don't believe what you're telling me:  I believe you when you tell me that ibuprofen doesn't work or that you are allergic to it.  I believe you when you tell me that all your other doctors have given you narcotic prescriptions.  But I don't know you yet, don't know your whole medical picture.  Narcotics are potentially beneficial and potentially risky.  Dependence is a disease that is very common, and very difficult to treat.  You should not expect me to take such a risk with your health at this point.

It is possible that your disease, be it chronic pain or opiate dependence or both, does not let you understand that.  You may feel angry, depressed.  You may lose your temper, behave inappropriately.  If I suspect a narcotic use disorder I may offer you a referral to a local expert.

You may not like this, and I may be totally off base, but I have to give the best advice I have, whether you like it or not.  I hope that you will be able to see this as an act of kindness rather than another obstacle in your efforts to get what you think you need.

I will continue to try to help you treat your pain, but I will choose medications for your pain and your other conditions based on what is likely to give the most benefit for the least risk.  Sometimes this treatment may include narcotics, sometimes it will not. All I can do is advise and hope that my advice is good, and that you will follow it to the best of your abilities.

To you health,


5 responses so far

Another (nearly) perfect day

(by PalMD) Aug 15 2011

As a number of Twitter followers have noted, it's Up North time for the Pal Family. Every summer we spend a week together with whomever can make it up here.  This has been a family tradition since my father was young.  The mid-August weather is perfect: cool nights, warm sunny days, although Lake Michigan is a bit on the cool side this month.  The sunsets, though, are lovely.

One of my readers immediately recognized the spot.  The house we're renting is a short walk from the lighthouse and the beach it guards.

The local fishmonger has been in business for many, many decades.  He sends his boats out every day, and his market and smoke house is packed with the catch.  I just rode up there and picked up some smoked whitefish spread and a few filets.  Dinner will be heavenly.

Sleep, however, may be a bit less relaxed.  I walked into the room to say good morning to MrsPal, enjoying her usual vacation sleep-in and she said, pointing to the bed, "What is that?"

She was clearly expecting another of my bland reassurances, but I did not meet her expectations this time.

I don't like this feller one bit.  Nor do I like his buddies, two of whom suffered the wrath of the nearest PalBook (thankfully I wasn't reading on the Kindle).

A few phone calls, professional visits, and loads of laundry later, we seem to be doing just fine.  It's rare that I've rushed to do laundry so quickly, especially given that our room is on the third floor, the machine in the basement.

No one seems to be reacting to any bites, for which I'm thankful, but when we get home, nothing---NOTHING---is coming into our house without passing through the washer and dryer.

7 responses so far


(by PalMD) Aug 10 2011

I finally found a use for Google+.  Science writer extraordinaire Ed Yong (rhymes with "song") wondered aloud (as it were) about the following:

1) Are arachnophobes also scared of scorpions? What about mites? They're not scared of insects, right? Crabs?

2) If they're only scared of arachnids, could you use their degree of fear for classification purposes? Are arachnophobes unknowing closet taxonomists?

3) Some spiders mimic ants very well (http://is.gd/pvriwj). If you showed an ant-mimicking spider to an arachnophobe, and they thought it was an ant, would they suddenly freak out if you then told them it was a spider, or would they be okay? Is it the knowledge that something is a spider, or the spidery appearance that's scary?

Aside from the sheer brilliance of the question,  it made me think back to various arachnid-related issues.  While I was up north last week, I had a number of eight-legged encounters.  This guy, for example, showed up on a piece of felt my daughter was playing with:

It's just a dog tick, but it has a big "ick" factor.  The ick factor would have seismically multiplied had it been attached to PalKid rather than a piece of felt.

It seems to have been a banner year for Dolomedes as well.  These guys were all over the place.  I don't like them.  Not one bit.

Despite my revulsion, "dock spiders" are pretty successful predators, snacking on ubiquitous "water skeeters" (striders), and producing many, many offspring.  In all my years hanging around these guys (despite my attempts to avoid them) I've never been bitten, nor have I met anyone who was bitten.  They just aren't that aggressive when it comes to big, hairy (bipedal) predators.

In my practice, patients frequently come to me with "spider bites".  Clinically, these are usually a red welt that is larger than a typical mosquito bite.  That seems to be the sole criterion for calling something a "spider bite".  I cannot recall how old I was when I first heard this little piece of folk knowledge but it was common knowledge on the elementary school playground.  My mother pooh-poohed such bubbe meisehs; "Spiders are our friends," she would say musically as I cowered in a corner of my room waiting for someone to KILL IT!!!!

Despite this widespread belief, most "spider bites" in my part of the country aren't caused by spiders, and probably aren't bites at all.  (The feared "brown recluse" does not live naturally in my part of the country, although importations have been reported.  They do not generally survive through the winter.) The distinction is important for a few reasons.  First, many of us are guilty of wanton arachnicide propelled by our unwarranted fears.  Second, many "bites" are probably bacterial infections and should be treated properly.  Finally, there's my own bias that we shouldn't assume things that aren't so.

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Happy campers

(by PalMD) Aug 05 2011

This is the first time I've ever tried posting by cell phone, but this being paradise it's the only option available to me.

20110805-124849.jpgHere's my quarters for the week.

20110805-124955.jpgThe views aren't too bad.

20110805-125119.jpgAs camp doctor I don't really have to follow all of the usual rules around here but I thought it important that PalKid take her swim test. She passed rather magnificently, then spiked a fever, puked, and spent the next two days in bed.

But all was not lost. In the way that kids do, she bounced right back. Last night we stayed up late. I wanted to show her the real night sky, just as my father did with me. When I asked her if she wanted to see the Milky Way she said, "Daddy, that's not real."

We fixed that misconception moments later, and she also saw her first four meteors.

The week here is short and full of sore throats and splinters. I can't wait to come back.

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Summer is magic

(by PalMD) Jul 28 2011

Last night it rained.  A lot.  Six inches in some areas, and enough to supply a steady rumble of rain on the roof.  But it wasn't the rain that woke me up: it was an insistent tapping on my arm.

"Daddy.  Daddy. DAADDDDY! I'm scared Daddy."

The rain came with thunder, and the thunder was loud enough to wake my little kiddo.  She does not like thunder.  At all.

"Grumph hrmph," I said, gesturing her into the bed.

When my wife was in the hospital, PalKid slept in my bed as often as not (OK, every night), but to have all three of us in one bed, comfortable and without IV lines was worth the lost sleep.  We lost a lot of family time time this spring.

But August is our month for family.  I don't generally take much time off, and having recently joined a new practice I'm ambivalent about leaving town.  But August is mine.  I spend two weeks away, each in one of my favorite places.

The first is here:

A misty morning

Me, PalKid, and EldestSis will get in the car before sunrise and drive until the road ends.  Once there, I can take out splinters, hug homesick kids, swim in deep, cool waters, and turn off my pager.  And of course, paddle.

That's my paddle and I made it.

A month is what I want; a week is what I'll get, and I'll be thankful for it.  It's a working vacation, but one with a nice cabin, good food, friends...but I'm bringing my own coffee.  I'll drink any coffee, but if I can avoid camp's pishechtz, I'll be much happier (and so will the nurses I'll share it with).

(For those ignorati who think my canoe is tipping over, go study your Omer Stringer and Bill Mason, then get back to me.)

Anyway, despite the pile of work that will await my return, it'll be well worth it.  There is nothing like reaching for your belt and realizing that your pager isn't there and you don't need it.  After a presumably joy-filled reunion of Pal, PalKid, and MrsPal, and a few late nights at the office, we'll head up to Favorite Place #2, my family's summer retreat for many, many decades (I'm fairly certain my dad first went up there sometime in the 1930's and we've rarely missed a summer).

This is the real-deal Up North summer vacation, with bikes, beaches, fudge, and family. The cast changes from year to year, but the setting does not (although, like every other idyllic place, people always complain that "it's not the same anymore").  Maybe we'll drive down to Sleeping Bear Dunes.  Maybe we'll take a ferry to Mackinac Island.  Maybe we'll just sit on the porch reading and watching the sun cross the sky.

For me, summer ends when I cross the 45th parallel heading south.  The trees are still green, the heat is still there, but the air feels heavy and the fun has gone out of it.

10 responses so far

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