Archive for: January, 2009

Lipstick on a pig

Jan 26 2009 Published by under Absurd medical claims, Medicine

It's true that words matter, and that we who practice real medicine have often let cult medicine practitioners get the linguistic high ground. We've let them get away with calling non-science-based practices "alternative" and "complementary", without really asking, "alternative to what?" or "does it really "complement, or just distract?" We've often ignored language, and when we don't, we are accused of being pedantic, of focusing on "rhetoric" rather than "real" issues. Language is powerful. There is no such thing as "it's just a word".
Language is even more important in the fight against pseudo-science in medicine. Since evidence consistently fails to show benefit of practices such as homeopathy and acupuncture, language is all their adherents have left. What can you do when your favorite cult practice just isn't showing promise? Call your legislator! Maybe he or she will pass a law making your hobby sound better.
And that's just what is happening right now in Washington state. Let's look at some of the language of the bill.

Sec. 1. INTENT. The legislature intends this act to
8 recognize that acupuncturists licensed by the state of Washington are
9 practicing a system of medicine, and that changing the name of their
10 title to "Oriental medicine practitioners" more appropriately captures
11 the nature and scope of their work. It is further the intent that
12 references in federal law to "acupuncturists" apply to persons licensed
13 under this act as "Oriental medicine practitioners."

So much wrong in such a short piece of writing. First, "acupuncturists...are practicing a system of medicine..." is rather deceiving. What "system of medicine"? Is there more than one "medicine"? As far as I know, there is medicine that works, and is taught in medical schools and practiced throughout the world, and that which does not. Harriet Hall has a nice piece on the history of this so-called ancient bit of wisdom. It's not what you think.

"Oriental medicine practitioners" more appropriately captures
11 the nature and scope of their work.

Really? Why? What is "the Orient"? Are they referring to Edward Said's writings? Are they talking about Camboida? Turkey? Azerbaijan? And what kind of medicine is practiced in "the East"? Do they do things much differently than here? (Answer: They practice the same medicine we do here, to their ability to pay for it.)
The Bill is fascinating, and refers to such time-honored idiocy as "laserpuncture" (originated by Lao Tze as we know that the first laser was developed in the ancient Far East), moxibustion, and cupping. Lovely.
It's been (famously) said that that you can put lipstick on a pig, but it's still a pig. Unfortunately, it's not that simple. Dress a pig pretty enough, and someone's going to ask it to dance. When a quasi-medical practice can't gain legitimacy through science, and it turns to the government for a stamp of approval, it really can become legitimized. It can gain funding and acceptance, despite it's lack of efficacy. Government's should be a little more cautious before throwing their weight behind fringe practitioners of quackery.
That is all.

12 responses so far

Diseases that suck...a quick reminder

Jan 26 2009 Published by under Absurd medical claims

A short time ago, I told you about H. flu, a nasty, but preventable disease. Now, Orac tells us about some unfortunate idiots who chose not to prevent it. Go and read.

3 responses so far

Argumentum ad nauseum---more on conscience clauses

Jan 25 2009 Published by under Medical ethics, Medicine

Sometimes I feel like I'm pounding my head against a wall. I've been wondering why the issue of so-called conscience clauses just won't die, why otherwise intelligent people can't just agree with me just don't get it.
Quick review: some health care professionals wish to be able to deny patients certain types of care, and want to be protected by law for imposing their own morals on others, in violation of basic medical ethics and human dignity (as you can see, I don't have a strong opinion about this one).
Ethical behavior is difficult. It requires empathy---but in a very particular sense. It requires someone to be able to see things through someone else's eyes, to imagine the same events from more than one perspective. Ethics aren't a blunt object used to impose your will; they are a tool to help elucidate the differences between choices, and to solve problems. Ethics, in short, requires a good imagination.
Some of the arguments that people in favor of conscience clauses provide are based on a fundamental misunderstanding of ethics.
A health care provider is not required to provide any service to any person. She has the right to choose whom to serve and how. Within limits.
For example, in the AMA code of ethics, one of the principles says:

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

Remember, ethics provide for the dignity of both persons in a relationship. A physician can't be forced into any relationship...BUT if a physician chooses to deny care to someone, there better be a good reason, and the dignity of a patient must still be respected. So, for example, when a patient calls my office, but I don't participate in their insurance, my secretary informs them of the problem and offers them the numbers of other practitioners. If the same patient comes to see me, and I don't properly check their insurance status, it's too late---I have a deeper ethical obligation, and I need a stronger reason to deny them care. In this case, the reason is that it will cost both me and the patient monetarily to continue the relationship, and we will probably choose together to end it. Ethics is a shared tool, and ethical decisions involve all parties.
Given that ethics provide for the dignity of both people in a relationship, what should we do when a decision appears to inevitably cause a conflict between the needs of both?
This is when we must look at what other duties are implied by the relationship. As a physician I have a responsibility to provide the standard of care to my patients, as far as I am able. If a patient has appendicitis, the standard of care is not for me to remove the appendix, as I'm not competent to do that. The standard of care if for me to send them to the emergency room. If a patient comes to me for contraception, well, I'm competent to provide it, and its provision meets the standard of care. What if I'm morally opposed to it? Personally, I find that abhorrent, but a not-so-horrible second choice is to explain to the patient your general lack of competence in the area (they don't need to know that your incompetence is due to religious beliefs), and to give them a realistic and timely referral.
Let's be clear here: we are talking about "standard of care", not medical necessity. One of my commenters believes that providers (pharmacists in particular) are not required to provide services that are not medically necessary. This is a fundamental misunderstanding. "Medical necessity" is a financial, not medical, concept. An insurance company determines what is "medically necessary" in order to decide what they will or will not pay for. Often enough, what an insurer thinks is not medically necessary is still vital to the patient.
Ethics is hard. It requires imaging a world without you in it, or at least one in which your needs are not paramount. It requires a very "grown-up" perspective. If you can't behave like a grown up, you shouldn't be playing with people's health.

23 responses so far

I can quit anytime...

Jan 24 2009 Published by under Medicine

...or so goes the refrain of the addict. I was going to put up a more substantive, well-researched post, but I wanted to give you a few weekend thoughts to chew on.
I deal with addictions a lot, but the most common and deadly one is tobacco. Tobacco is responsible for millions of serious illness and deaths every year in the U.S., all of which are preventable. But, like other substance use disorders, we don't really know how to talk about tobacco addiction (which is more properly "nicotine addiction"). There is no doubt that nicotine is powerfully addictive, and the health and social consequences of cigarettes are huge. Clearly, almost any rational person would quit smoking once they were told the consequences.
But of course, they don't.
If I have a patient with coronary heart disease, the medical regimen that they need to be on costs about $16.00 per month (aspirin, beta blocker, ACE-inhibitor, statin). Often, patients tell me they can't afford these life-saving medications, but they may still have a $120.00/month smoking habit. Even if they have symptomatic lung disease and peripheral artery disease, they still won't quit. Clearly their behavior is not entirely rational. It often seems like smokers are just not exercising any will-power.
But this is where the "dualism" problem comes in (as DrugMonkey has pointed out in several conversations). Where does will-power come in when discussing addiction? Does it have something to do with the "psychological" rather than the "physical" addiction? Since "mind" is an epiphenomenon of brain, it can be argued that this is an invalid division. All addiction is a "brain" problem. Drugs that cause physical dependence---such as nicotine, alcohol, heroin---cause profound changes to the brain and other parts of the body. Wherever receptors for the drug are present, or where affected brain exerts an effect, these areas are affected by drug dependence. What sense is there in creating a division of the mind and body when referring to addiction?
Part of the reason for doing this is the treatments we have available---support groups and counseling are often thought of as part of the psychological treatment, but of course these interventions cause changes in the brain just as medications do.
Just as important, we are much more comfortable laying blame on people for their inability to control the psychological symptoms rather than the physical symptoms---the physical is seen is being "more" outside the control of the individual.
Does creating sanctions help the addict? Will creating financial penalties (such as higher insurance rates for smokers) help people to quit? Isn't feeling like hell already a sanction that isn't working?
Clearly (to me, at least) since nicotine addiction causes so much suffering and financial loss, we need to treat it comprehensively, based on the evidence when evidence exists. There should be subsidies for anti-smoking programs, including medications such as Chantix. Behavioral treatments---support groups, limiting smoking areas---should be implemented.
There is no easy way to tell which smokers do it "by choice" and which are truly addicted. We need to have a national program to help people quit---and scary statements on the package do very little. This will cost money, but it's a helluva lot cheaper than a cardiac cath or ICU stay for everyone.

28 responses so far

Hospital city

Jan 24 2009 Published by under Medical Musings

I don't have a lot of experience with small hospitals. My medical school's hospital was about two square blocks of buildings, all of them attached, ranging in age from 100 years to 10 years. The were connected by irregular bridges and linked (ex)-fire escapes, and by miles of dim tunnels.
During my residency, the campus covered several square blocks, with buildings linked by more airy bridges (a la Minneapolis) and "secret" tunnels that you could find if you just knew where to look---although getting lost underground was the rule.
My current hospital is---by number of admissions---one of the largest in the country. It's fairly modern, with the buildings ranging from 50 year old to three years old. But it has that sine qua non of all hospitals---a basement city.
My hospital is actually quite beautiful. There are occasional hints of the complexity hidden above and below---signal boosters jut from drop ceilings, oxygen hook-ups slide out from behind panels---but really, it might be confused for any hotel or office building. Until you climb into the basement.

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8 responses so far

xkcd FTW

Jan 23 2009 Published by under humor

Similar to this classic geek comic, xkcd shows the stupidity of the above-average geek.

4 responses so far

Woo-fully ignorant

Jan 22 2009 Published by under Absurd medical claims, Medicine

I've written quite a bit of the need for good health reporting, and I've had the good fortune to talk to some terrific reporters. But bad reporters are easy to come by, which is kind of sad, especially since jobs are getting scarce.
When this article came across my browser, something looked familiar. The Stamford (CT) Advocate has shown up on my blog before. The last time, it was an article about a naturopath preying on immigrants. When I saw a new story pop up, I was sure it would be the same reporter. The article is locked in the archives, so it took some searching, but I eventually found a copy----different reporter, same paper. Hmmm...two horrible stories, two reporters, one paper. It seems the Advocate has an editorial problem. Let's look at the latest story.

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5 responses so far

Experiment--woo woo journal club

Jan 22 2009 Published by under Absurd medical claims, Medicine, Science-y stuff

This is just for kicks, and requires a little work. I recently became aware of a dreadful article that I'd love to share with you, but then I thought, "my readers are pretty damned smart; let's see what they have to say first."
The article in question, "External Qi of Yan Xin Qigong differentially regulates the Akt and extracellular signal-regulated kinase pathways and is cytotoxic to cancer cells but not to normal cells" just seems ripe for feeding into the dewooificator. Now, the full text is behind a paywall, and it wouldn't do for me to share my full text copy with you. I certainly can't prevent readers from participating in academic discourse and sharing the article with each other. Anyway, here's the rest of the citation:
Xin Yana, Hua Shenb, Hongjian Jiangc, Chengsheng Zhangd, Dan Hud, Jun Wangb and Xinqi Wue. The International Journal of Biochemistry & Cell Biology. Volume 38, Issue 12, 2006, Pages 2102-2113. doi:10.1016/j.biocel.2006.06.002.
Thank you in advance for posting your well-thought out comments on this, er, groundbreaking paper.

20 responses so far

Change we can believe in?

Jan 21 2009 Published by under Absurd religious wingnutery, Medical ethics, Medicine

I'm one of those wacky idealists for whom January 20th was a great day. But with those high hopes, I have some fairly high expectations of our new president, one of the first of which is to repeal the Church Amendment, an HHS directive allowing health care providers to abandon proper ethics without consequence.
I've done quite a bit of blogviating about so-called conscience clauses, the rules that would allow health care providers to deny patients care not because it is outside the standard of care but because it bothers the personal beliefs of the provider. In case my previous writings have been unclear let me say right off the bat that conscience clauses are an ethical abomination.
Let's look, though, at how these are being used in the real world. Providers who refuse care based on their own beliefs seem to make decisions that disproportionately affect women. I know, I know, this may seem obvious to some, but let's look a little more closely.
The rules are quite broad and will allow providers to refuse to do nearly anything, including referring to a provider who will provide the treatment. For example:

[The statute] prohibits the Federal government and any State or local government that receives federal financial assistance from discriminating against any health care entity (including both individual and institutional providers) on the basis that the entity refuses to (1) receive training in abortion; (2) provide abortion training; (3) perform abortions; (4) provide referral for such abortions; and (5) provide referrals for abortion training.

Theoretically, the HHS rules should apply to any provider with any set of beliefs, but certain beliefs are mentioned explicitly in the draft rules.
Abortion

the Department proposes to define abortion as "any of the various procedures--including the prescription and administration of any drug or the performance of any procedure or any other action--that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation."


Contraception
(female):

Despite the fact that several conscience statutes protecting health care entities from discrimination have been in existence for decades, recent events suggest the public and people in the health care industry are largely uninformed of the protections afforded to individuals and institutions under these provisions. This lack of knowledge in the health professions can be detrimental to conscience and other rights, particularly for individuals and entities with moral objections to abortion and other medical procedures.

The draft goes on to list state laws that require health plans to give equal coverage to female contraception and emergency contraception ("Plan B"). Condoms, the only "male" form of contraception, are nowhere mentioned.
Sterilization: Sterilization in mentioned no fewer than 28 times in the draft document, although in this case, there is no mention of female vs. male sterilization.
The statues allow for providers to refuse to dispense medications, refuse training programs from setting their own standards for their professions (e.g. it would forbid OB/GYN residencies from requiring abortion training in any way), allow unethical doctors to give false information about abortion and birth control (including that some birth control is equivalent to abortion (sic)), and allows them to refuse to give further information to help a patient find an alternate provider.
It is clear to all but the most muddled of thinkers that these rules are aimed at protecting providers with fringe religious beliefs when they violate the ethics of their professions. It should also be clear that these rules affect women disproportionately. If women cannot obtain birth control, Griswold is meaningless. It is inconceivable to me that in a modern democracy, the federal government can get away with passing laws that clearly discriminate against women. It is less inconceivable that there are doctors out there who would violate our most sacred duties toward our patients to fulfill our own religious needs.

29 responses so far

Ethical implications of death by prayer

Nearly a year ago, a young girl was killed by her parents. She was dying of diabetic ketoacidosis, and her parents provided only prayer. They weren't living on some compound under the thrall of some cult leader. They weren't living in a third-world country far from modern medical care. They were living in the middle of Wisconsin, and had access to any care they might need, but while their child suffered, the parents did the equivalent of nothing. This type of situation has been done to death, but since the parents are about to go on trial, let's review the responsibilities of the state and the parents (but not the law, which is an unsettled and confusing area even if I were a lawyer). In fact, rather than beat up further on the negligent parents who are mourning the loss of their child, let's explore a broad range of ethical issues that this case brings up.

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4 responses so far

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