Archive for: January, 2009

Generic drugs rock! (Except when they don't)

Jan 30 2009 Published by under Medicine

A patient broke the news to me. There is a massive recall of generic drugs made by a single company, Ethex Corp, a subsidiary of KV Pharmaceuticals. The company makes many of the popular generic drugs that I prescribe every day, such as generic extended-release metoprolol.
This is a really big deal, and I'm pretty angry that I had to rely on a patient to tell me. Generic medications have revolutionized the affordability of essential care, and are usually a good thing. Also, insurance companies push them, and hard, offering incentives for their use, and penalties for using branded drugs. Because the U.S. has a pretty good quality-control system, this is usually not a problem. After all, we don't live in China where some guy can open a little factory and start cranking out bogus pills. Of course, KV and Ethex can have their factories anywhere they wish, and who knows what happens there?
A news search on the web brings up mostly hits from law firms looking to file dubious suits on behalf of "victims", but they've got it wrong. Patients aren't victims because they have headaches and tummy cramps---none of these symptoms are likely to have anything to do with these poorly manufactured drugs. We are all victims of a lousy system that allows crappy drugs to sneak into an otherwise very good supply of generic medications. We are victims because of the inconvenience caused. Thankfully, there isn't likely to much in the way of injury, but who knows?
And that's the problem. If I have to wait for a patient to give me the information, we have a big, huge, horrible problem here. Who knows what's going on with our drug quality control? Not me, and I'm a doctor.

10 responses so far

Alternative medicine---back to basics

Jan 29 2009 Published by under Absurd medical claims, Medicine

A long time ago (in blog years) I wrote a series on alternative medicine over at my old WordPress blog. It's time to dust off the old post and get back to some basics.
What is alternative medicine, anyway?
That's a great question. I know it is, because I asked it. I get this question almost daily. The secret answer is that there is no such thing as alternative medicine. You don't believe me? Why not--I am a doctor.
There are several ways to define alternative medicine, and sometimes it is contrasted with "complementary medicine". CM refers to treatments that "complement" traditional medicine, while AM refers to treatments that stand in the stead of mainstream medicine. CAM is a broad category used to refer to both.
So what's my problem? How can I say that there is no such thing?

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23 responses so far

Low back pain---the scourge of Homo sapiens

Jan 29 2009 Published by under Medicine

It started a few weeks ago---a dull ache in my lower back, more on the right, worse with sitting for prolonged periods of time. I did my usual stretches, although not as much as I should have. The pain waxed and waned, until a few days ago, when the pain escalated suddenly, preventing me from standing up straight, and making even a trip to the bathroom an unwelcome adventure. Two nights ago, I lay in bed awake, pillows wedged at strategic points, hoping to find some comfort, any comfort.
And then all hell broke loose. My back spasms loosened up a bit last night, so I got a few essential things done---and felt sudden burning pain shooting down my right leg, accompanied by numbness, tingling, and weakness. I writhed on the floor in pain, with even more drama than usual. Around 1:00 a.m., Mrs. Pal said, "Hey, I hear there's a pain clinic open's over in the guest room." I rifled through the medicine cabinet and tried various tablets searching for relief.
I ended up laying on the floor of the guest room, legs on a pillow, sleeping fitfully. I was so desperate that I actually saw my doctor.
What is this low back pain stuff anyway?
First of all, it's common. When people come to see their primary care physician for other-than regularly scheduled visits, low back pain is one of the most common complaints (ranking anywhere between first and fifth, depending on the survey). This is a common problem. The good news is that most of the time it gets better spontaneously. The bad news is that while it's healing, there is significant lost work, and significant suffering.
There are many causes for low back pain, but quite often the cause isn't so important. It's useful to divide low back pain into two broad categories: benign causes, and not-so-benign causes. As physicians, we look for "red flags" that point toward the not-so-benign causes, which probably make up less than 5% of all back pain.
In evaluating the patient with low back pain, three questions form a useful framework:

    Is there evidence of systemic disease?
    Is there evidence of neurologic compromise?
    Is there social or psychological distress that may contribute to chronic, disabling pain?

The first two help detect back pain caused by other underlying systemic disease. The last is a prognostic question. People who answer "yes" to the third question are at risk of prolonged back problems and possibly substance abuse if the underlying psychosocial problems are not addressed.
Some of the conditions discovered by the first two questions include infections of the spine, cancers affecting the spine, and other serious neuroanatomical spine problems.
But, as I said, most back problems not due to other serious diseases respond very well to conservative therapy, regardless of the cause.


The picture above is one example. See where the red bit is pushing on the yellow bit? That's probably somewhat like what's happening in my back at this very minute. An intervertebral disk is prolapsed, pushing against a nerve root, causing pain, tingling, numbness, and weakness in my leg. It's possible that surgery could be of some use, but even fairly dramatic injuries such as this one usually heal up with time (and pain control and physical therapy). In fact, imaging is rarely needed (but, at least in the U.S., often obtained).
The evidence would suggest that since I don't have weight loss, fever, incontinence, or other concerning symptoms, I should take some pain medication, go to physical therapy, and try not to do anything stupid.
I've definitely got the first two covered.

16 responses so far

Skeptics' Circle # 104

Jan 29 2009 Published by under Carnivalia

It's up and ready for visitors at Space City Skeptics. Go and read.

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PalCast Update

Jan 28 2009 Published by under Narcissistic self-involvement

I love my podcast. A lot. I have great guests lined up. Really.
But I also have a dead computer (I'm using a hospital PC right now). My laptop has all the "stuff" I need for the podcast, so please don't give up! When it's back out again (hopefully this weekend), I'll let you know.
That is all.

7 responses so far


Jan 28 2009 Published by under Absurd medical claims, Medicine

ResearchBlogging.orgIt's hard to hide severe back pain. When I stand up, I look like a question mark. The visibility of the problem, combined with the general goodness of my fellow human beings, leads to lots of unsolicited advice. Folks have given me great advice (take some NSAIDs, stretch, and don't lay in bed) and some questionable advice (go to the chiropractor, get some acupuncture). My colleagues and I have written a lot about acupuncture. It's sort of a "gateway CAM", in that it has a patina of plausibility. But the evidence of its efficacy has pointed toward it being an elaborate placebo.
To help settle the question, the British Medical Journal (BMJ) has published a systematic review (which is different from a meta-analysis) of studies of acupuncture that were as well-controlled as possible. Much of the acupuncture literature suffers from lack of proper controls, as it's difficult to blind either the subject or practitioner to pointy needles in flesh. But it can be done, to a certain extent, with "sham" acupuncture, and the current review aimed, "to analyse all trials of acupuncture for pain that had two control groups consisting of placebo acupuncture and no acupuncture." This type of systematic is especially important for implausible medical claims. If you do enough studies, you can always find "positive" results---a key question is do the positive results reflect reality. A well-done systematic review can help determine what the preponderance of the data mean.
So, what did they find?

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7 responses so far

Sleeping with dogs

Jan 28 2009 Published by under Absurd religious wingnutery

Look, the Pope gets to make the rules---it's his club and he gets to decide who plays and who doesn't. The Vatican does not claim to be democratic. That being said, all decisions rest on him, and him alone, and cannot be blamed on "the will of the people". The buck really does stop with Papa. So when he invites rabid anti-semites back into the fold, it's a reflection of his personal beliefs. Catholicism, and Christianity in general, places a premium on forgiveness---it's some good shit for the soul, and the story of Pope John-Paul II reconciling with his would-be assassin is truly heart-warming.
Contrast that with Benedict (the former heir to Torquemada) who has reached out to unrepentant anti-semitic holocaust deniers. This kind of act is symbolic, but what message is he trying to send? Catholics are all one big happy family? Hey, they invented excommunication for a reason. These guys, like Richard Williamson, are completely unrepentant. Even with the ex-excommunication, he is still spouting typical holocaust denial tripe:

"I believe that the historical evidence . . . is hugely against 6 million Jews having been deliberately gassed...I believe there were no gas chambers."

Gee, I really don't fucking care what you believe, you sick, demented fuck. But I do care that Il Papa has invited you back up into the treehouse. That shit makes baby Jesus weep. It also makes me wonder what Benedicts goal is here. But, hey, it's his club, he can do what he wants. Viva Il Papa, right or wrong.
This may sound a little radical, but perhaps Catholics should be speaking out against their Dear Leader?
(Yes, my back still what?)

11 responses so far

Incoherent rant #37

Jan 27 2009 Published by under Medicine, Narcissistic self-involvement

Now, both of my readers may note that: 1) the number "37" appears to be randomly assigned, and 2) "incoherent" would appear to be redundant. But let me explain.
Many, many years ago I injured my back. It got better. Until 3 a.m. this morning. Since then, I have been a walking question mark, except when I'm laying on the X-ray table or floor trying to find a flat surface from which I might just have a chance to get up again. It's both humiliating and humorous to hobble through an enormous American hospital holding onto the walls. Normally, I stride rapidly from room to room, down tunnels and hallways. Today, I limp---when I'm lucky.
There's a couple of things about severe low back pain. First, it almost always gets better all by itself. Second, it makes me really short-tempered. If I were to take a little bit of cyclobenzaprine, I'd be even crankier, so I've eschewed that particular muscle relaxant in favor of other pharmaceuticals.
I've been listening to a bunch of right-wing wackaloons lately, and their stultifying dishonesty makes my skin itch. They bitch and moan about how Obama stole the election by coercing votes from the downtrodden, by enrolling the illiterate, and by some other ill-defined shenanigans. They conveniently forget that Bush won his first election by fiat, and the second by borderline voter fraud. The fact that turnout was the highest in recent history and the margin was sound seems to be lost on them. Sore. Fucking. Losers. (Damned medication again).
But worst than the right-wing wackaloonery of the conservatiariat is the re-emergence of the (so-called) intellectual libertarians. These folks are very well-read when it comes to their favorite political philosophers, and like to go on about Spooner this, Bakunin that, Rand the's really quite erudite---AND FUCKING IRRELEVANT TO REAL LIFE! Some of these folks are textual originalists, believing that any law passed after the consitutional convention is unconstitutional, or that the Constitution itself is a tyrannical document. Lovely. Fucking anarchist pigs.
It reminds me of my late nights in Ann Arbor discussing post-modernist and critical/Marxist interpretations of, well everything. It was fascinating, but had nothing to do with the real world.
In the real world, we have a Constitutional government, which is made up of millions of citizens who disagree about all sorts of things, but who live by the law and the founding documents. Many of these citizens are struggling, looking for work, homes, food, jobs. When another libertarian crawls out from some survivalist cave and denounces government involvement in anything, they reveal how little they are able to empathize with real people, people who live among other people, who are stuck with the world (approximately) as it is, and not as some Randian "paradise".
Hey, reading Heinlein was fun...IN 7TH GRADE! In the real world, citizenship isn't contingent on "service" or even literacy. Individuals are citizens because the Constitution designates them as such, and no one can take that away.
OK, look, I know this is an uncharacteristically frank rant, but dammit, my back is killing me and I'm cranky, and feeling less than tolerant of intellectual game-players who are busy publicly masturbating while America burns.
Here's my invitation for you: join the real world, with real people in it, or shut the fuck up.
(yeah, i'll regret this when the pain and medication wears the fuck what!)

44 responses so far

Medical Weblog awards---the news is good

Jan 26 2009 Published by under Medicine

Blog buddy and all-around great guy lucite box of diodes, Orac of Respectful Insolence, has won "Best Health Policies/Ethics Weblog of 2008", sponsored by According to the website:

Orac of Respectful Insolence has been chosen as the Best Health Policies/Ethics Weblog of 2008. As one of the members of Science Blogs, Orac attempts to bring sanity to the world full of medical quackery. His efforts at exposing the dangers of alternative medicine, pseudoscience, and evolution deniers have made Orac one of the most recognized online activists against medical fraud and pseudoscience.

I couldn't have said it better myself.

One response so far

Morning Report #1

Jan 26 2009 Published by under Medical ethics, Medicine, Morning report

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. --PalMD
Mrs. M is an 89 year old woman who resides in a nursing home who was admitted with confusion and lethargy. She has a past medical history significant for stroke, coronary artery disease, depression in the distant past, and no history of dementia. She has lost significant weight over the last 12 months. She participates in social activities with her fellow nursing home residents, but prefers to spend time alone. She is a retired registered nurse and a widow.
On the day of admission, her nurse found her to be much sleepier than usual, and when she spoke, she wasn't making a great deal of sense. An ambulance was called and she was brought to the emergency department.

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23 responses so far

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