Shame on you, New England Journal of Medicine

(by PalMD) Jul 25 2011

For specialists in internal medicine, the New England Journal of Medicine is one of the journals you really read.  It's not a free throwaway journal or bathroom reading---it's where you find good original research, interesting case studies, cogent editorials.  Usually.  More or less.

Right now it's "less".  A few days ago I posted my review of a recent study on placebos.  I found it interesting but somewhat problematic. It's real benefit seems to have been that it has sparked substantive and vigorous discussions about placebos.   To save you from reading my entire review, the study basically took asthmatics and gave them either real medicine, fake medicine, "sham" acupuncture, or nothing at all.  All the patients reported feeling at least somewhat better, but only the patients treated with real medicine had significant improvement in measured lung function.  Another way to state the findings might be "the placebos and the real medicine all made the patients feel better.  Oh, and only the real medicine made actually better." I have a problem with this presentation as you will read below.

What we've learned about so-called placebos over the years is that "placebo" is not an intervention like a medication or a surgery.  It is an artifact of observation.  A certain amount of change can be expected any time you study a group of people.  "Placebo" is simply all of the change that can't be explained by the primary intervention.  Taking the asthma study as an example, simply enrolling people in the study and doing nothing else caused them to feel a bit better.  But treating them with real medicine caused them to feel better and get significantly better physically.    The bit of "better" that was seen simply by enrolling is referred to as placebo effect, and is a mix of various factors, such as patients' being cared for, regression to the mean, desire to please researchers, and other effects not due to a "real" intervention.  It is likely that a good deal of placebo is subsumed in standard care: if you go to the doctor for a broken leg, being cared for and listened to makes you feel better, but setting the bone and placing the cast does most of the work.  Good doctors maximize our ability to make people "feel" better along with treating the underlying illness.

The current object of my ire is an editorial published in the Journal to accompany the asthma study.  It was written by an anthropologist named Danial Moerman who completely misreads the study, the meaning of placebo, and what a disease actually is.  He first fails to understand that there were actually four interventions:

They found that three of the interventions — active albuterol, sham albuterol, and sham acupuncture — were all equally effective in controlling asthma symptoms, as judged by patient-reported improvement.


The fourth intervention was “no treatment,” in which patients were told to wait for several hours and then return home. Waiting had no effect on either subjective asthma symptoms or lung function.

Perhaps I misread the results and the graphs, but it appears to me that the "do nothing" group did in fact report feeling better, just not as much as the other groups.   The importance of this lies in the fact that part of the placebo phenomenon is simply being cared for or enrolled in the study (in this case it also involved repeated lung function testing).  If this were subtracted out in some way, we might find a much less significant effect.   But we are still speaking of "subjective" improvement, an important factor, but not one nearly as important as being able to breathe better.

Professor Moerman, perhaps being used to dealing with less concrete ideas, misses the importance of objective vs. subjective outcomes in medicine.  Holding a cancer patient's hand can make them feel better, a lot better in the short term than chemotherapy.   But it won't shrink a tumor.  Moerman thinks we have it the wrong way 'round:

It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor's or the patient's perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.

First, I hate it when people misuse "begs the question", but that's not important.  What's important is that he's asked the wrong question.  It's not whether subjective or objective is most important, or whether a "patient-" vs. "doctor-centered" care (whatever that means) is the best model.   In medicine, we assess both how a patient feels, and how well they are doing physiologically.  We do this in the exam room and we do this in our research.  We (meaning doctors and medical scientists) don't think one is "more important" than the other; we know that any intervention is a balance between changing physiology and making a patient feel better.  Reading this editorial makes me think of Columbus "discovering" America: it was already here, the folks living here obviously knew it, and he really had no idea where he was anyway.

Another example of his profound ignorance is his complete lack of understanding of common medical conditions:

For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson's disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.

None of the conditions he mentions above are what he thinks they are.  There is nothing "subjective" about the cognitive dysfunction of schizophrenia or the tremors and stiffness of Parkinson's disease.  And there are drugs and other physiologic interventions that improve both the way patients feel and objective measures of how they are doing.

It's not so much Moerman's ignorance that disturbs me: anyone can be ignorant.  But this piece of idiocy was published in one of the world's most respected medical journals.   Well, his ignorance really does disturb me too.  He closes with a false dichotomy:

Do we need to control for all meaning in order to show that a treatment is specifically effective? Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”

As a physician and a patient, I'm unwilling to settle for "no negative side effects over the short or long term."   There are no such things as "side effects"; only "effects", some of which we desire, some of which we do not, so risk can only be minimized, never eliminated.   The precept is "First, do no harm", not "Do nothing and hope for the best."


Moerman, Daniel E. Meaningful placebos—controlling the uncontrollable. N Engl J Med 365(2):171-172 (2011). DOI:10.1056/NEJMe1104010.

8 responses so far

Asthma, placebo, and how not to kill your patients

(by PalMD) Jul 21 2011

A number of years ago I was walking along Lake Michigan with a friend (a fellow medical resident) when she turned to me and said, "are you wheezing?  Do you have asthma?"  I had always been physically active and assumed my breathlessness while walking down the trail was due to the thirty extra pounds of pizza and doughnuts I'd acquired during residency.  But she was right: I was wheezing and breathless and it didn't feel good at all.  I made an appointment with one of the hospital's lung docs who took a good history, did a physical, and ran some pulmonary function tests.  And I did have asthma.  And it felt much, much better when I used proper medication, a feeling confirmed by my improving lung function tests. (Not too surprisingly, the asthma got even better when I lost 40 lbs and started treatment for my acid reflux.)

I still get mild asthma symptoms from time to time, especially when I get sick, but for many others, the picture isn't so pretty.  Asthma kills at least a quarter of a million people every year around the world.   If you've ever worked in an ER and seen a kid with a bad asthma attack, you've earned a healthy respect for the disease.  If you've ever watched your own kid gasping for breath, begging you to make it better, you've learned to fear it.

As our understanding of asthma has improved, so has our ability to treat it (an ability that is strongly linked to a patient's socio-economic status.  Mortality has been rising despite the discovery of better treatments.  Wait: let's pull this out of the parentheses...)...  Asthma deaths and hospitalizations are largely preventable, and disproportionately affect Black and Hispanic Americans.  We know how to treat the disease asthma, but don't know how to treat the people who are affected most.

We understand that asthma is not just a tightening of the airways but also an inflammation that can cause long-term damage.   Not only can we treat asthma, but we have objective ways of measuring how well our patients are doing.   It's easy and inexpensive to measure airway obstruction and response to medications.  We know what works.
For this reason, a new study in the New England Journal of Medicine seems both wise and foolish.

(I thought I was so on the ball.  I really did. But while I was busy riding my bike, playing with my kid, and looking at rentals with my wife, David Gorski and my other medical blogger pals were out in Las Vegas at TAM discussing the very study I wanted to tell you about.)

The study, called "Active albuterol or placebo, sham acupuncture, or no intervention in asthma," was done for reasons that are not clear to me. It may have been done not to test the effectiveness of asthma therapy but to look at what a "placebo" might really be or do.  At least, I think that was the idea.  When reading the abstract and full text, it's not actually clear why the study was done.  At first it seems as if it were done to see why asthmatics treated with placebo improve:

In prospective experimental studies in patients with asthma, it is difficult to determine whether responses to placebo differ from the natural course of physiological changes that occur without any intervention.

Why ask such a question? We know that poorly-treated asthma is deadly, and well treated asthma much less so.  Why do we care about placebo effects here?  The authors explain further:

Placebo effects (i.e., benefits resulting from simulated treatment or the experience of receiving care) are reported to improve signs and symptoms of many diseases in clinical trials and in clinical practice. On this basis, the accepted standards for clinical-trial design specify that the effects of active treatment should ideally be compared with the effects of placebo. Despite this common practice, it is unclear whether placebo effects observed in clinical trials (or those that presumably occur in clinical care) influence both objective and subjective outcomes and whether placebo effects differ from the natural course of disease or regression to the mean.

In other words, the authors want to know what placebos actually do to real people, and they chose asthmatics because they are easy to study (there are symptom-assessment tools for subjective data and spirometry for objective data).   This makes asthma both the right and wrong choice for the study.  It's an excellent model to assess the affect of placebo, but one in which the use of placebo is hard to justify on an ethical basis.

Not surprisingly, they found that "doing something" worked better than doing nothing.  More specifically, they found that any placebo will make a patient feel subjectively better than doing nothing at all.   They also found that all three placebos (sham acupuncture, fake inhaled medicine, and simply being enrolled in the study without treatment) improved objective measures of lung function, but not nearly as much as real medicine (in fact, not much at all).

In other words, simply attending to a patient makes them feel better.  But to get a significant objective improvement (in asthma at least) you must also give them real medicine.  Real medicine comprises both active medications and attending to the patient.  There is no separate "placebo" that can be given to treat asthma effectively.

This is actually a quite beautiful study.  It demonstrates that "placebo effect" is not the same as a real treatment, that real treatment always includes whatever benefit placebo provides, and that placebo is mostly an effect on subjective rather than objective measures of health.  You can't fix asthma with placebo, only with real treatment.  But we've already known that from decades of studying asthma.  So what other justification is there for doing this study?

Our research has important implications both for the treatment of asthma and for clinical-trial design in general. Many patients with asthma have symptoms that remain uncontrolled, and the discrepancy between objective pulmonary function and patients' self-reports noted in this study suggests that subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care. Indeed, although improvement in objective measures of lung function would be expected to correlate with subjective measures, our study suggests that in clinical trials, reliance solely on subjective outcomes may be inherently unreliable, since they may be significantly influenced by placebo effects. However, even though objective physiological measures (e.g., FEV1) are important, other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians. Although placebos remain an essential component of clinical trials to validate objective findings, assessment of the course of the disease without treatment, if medically appropriate, is essential in the evaluation of patient-reported outcomes. (Emphasis mine, PalMD)

This is folly.  First, we have a huge literature on quality of life metrics in asthma.  Huge.  And we also know that objective changes in asthma are what save patients' lives.  Yes, I care how my patient feels, but it is not more "clinically relevant" than how they are actually doing physiologically.  Both are important, but not equal.  And the idea that comparing active treatment to placebo is not ideal is not new to researchers.  It's simply that following the natural history of the disease as a "control" is not usually appropriate (cf. Tuskegee syphilis experiment).

No good clinician would consider treating an asthmatic with placebo.  Improper treatment of asthma leads to debility and death.  This study chose mild asthmatics, but I still feel very uncomfortable with the ethics of the study design.  Rather than using a disease we know how to treat to study placebo, we should be finding ways to get treatment to the millions of people who aren't getting it.


Wechsler ME, Kelley JM, Boyd IO, Dutile S, Marigowda G, Kirsch I, Israel E, & Kaptchuk TJ (2011). Active albuterol or placebo, sham acupuncture, or no intervention in asthma. The New England journal of medicine, 365 (2), 119-26 PMID: 21751905

7 responses so far

Friday night family follies

(by PalMD) Jul 15 2011

A couple of nights ago, a small, warm body crept into bed between me and MrsPal.  Our sneaky snuggler has been mostly keeping to her bed, but once in a while her fears get the better of her.  And sometimes, my fears get the better of me.

A few months ago as my wife lay in a hospital bed trying not to choke on her own vomit I got a call from a friend.

"Pal?  Someone from the breast center just called on MrsPal's phone.  They won't talk to me.  What should I do?"

A few days before her infamously complicated surgery, MrsPal took care of her yearly boob-squishing, but the results hadn't come back before she went under the knife.  As she lay in her hospital bed not recovering, the results became available---sort of.  There was no way I was going to disturb her with anything; we were too busy trying to keep her alive.

I called up the breast center, but predictably they wouldn't tell me anything (and I wasn't about to try to explain that we have documents on file for just such a situation; it would have taken too long).  So I called a breast surgeon and asked her to take a look at the films.  There was a mass that had been stable for years, but now it had new calcifications and more films were needed to get a better look.  As my already fragile stomach dropped further I explained my dilemma, and asked if we could get away with waiting a while.  She felt we probably could.

I didn't tell MrsPal about it.  I kept the mail to myself.  It may have been the wrong decision, but she was so fragile I didn't think she could handle another blow.  But I failed to cover all my bases: once she finally came home, a registered letter came from her OB/GYN with the details. I explained to her my conversation with the surgeon and we agreed to wait a little while longer while she got her strength up.  Her birth mother died of breast cancer, and in the last year or so, two of her friends have had bilateral mastectomies. This was not a great wait.

She finally got her follow up study yesterday, and I called the surgeon back: it all looks benign, no need to worry.  And I didn't.  I thought of my little kiddo who loves cuddling between us, who doesn't deserve any more fear and worry.  I thought of my wife, and how she's finally dodged a bullet.  And I slept.

10 responses so far

The "hCG diet": a fraud literally without substance

(by PalMD) Jul 14 2011

Back in the 1950s, a British endocrinologist named ATW Simeons had an idea: a human pregnancy hormone called hCG (human chorionic gonadotropin) could help people lose weight without feeling hungry.  His idea was to put obese patients on a 500 kcal a day diet (in contrast, you probably eat about that much or more at each meal) and give injections of hCG which was supposed to blunt their hunger.  According to his writings, his results were not reproduced by anyone else, which, rather than make him doubt his own hypothesis, hardened his belief that only he could do it right.  Several studies in the 1970s effectively discredited his work, but in the 90's, famous shill and convicted felon Kevin Trudeau published a book that helped revive the hCG diet craze.

hCG has a number of clinical uses mostly related to fertility medicine.  It's also used as a biomarker for pregnancy (it's what we detect on home pregnancy tests) and for certain tumors.  Despite many negative studies in the 70s, hCG has made a spectacular return as a diet fad.   Not only does it not aid in weight loss, but as an active hormone, it may have other unintended effects (for example, it's not known if it can contribute to tumor formation or growth, but it is produced by a number of different tumors).

So put yourself in the shoes of a convicted felon like Kevin Trudeau: you want to continue to sell a weight loss scam, but you want to avoid getting sued if you happen to cause a tumor.  How can you still market the hCG diet without the hCG?  Homeopathy!

A product called KetoMist Spray (not, as far as I know, connected to Trudeau in any way) is purportedly a homeopathic dilution of hCG, that is, there is no hCG in it.  Using it, in conjunction with a 500kcal diet, should be no different than using, say, a spray of water.  The FDA recently came down on so-called homeopathic hCGs  because they are not FDA-approved drugs, nor are they in the "Homeopathic Pharmacopoeia", a list that allows fake drugs to be sold as real drugs.

But hucksters are endlessly clever.  KetoMist appears to skirt the FDA regulations by a bit of sleight-of-hand:

What is in each bottle?
Each bottle contains the 'Energy Profile' of HCG in multiple potencies (6c / 12c / 30c) imprinted onto a solution of Steam Distilled Water (80%) and Kosher Corn Alcohol (20%). If you want to know more about homeopathic remedies, search online - there is a ton of info on homeopathy.Since an 'energy signature' cannot be listed as a physical ingredient (for what should be obvious reasons) it isn't on the 'ingredients list' on the label, but it IS on the label.

In other words, KetoMist "contains" the  same homeopathic ingredient which was banned, but it's called an "energy signature", hoping to avoid the wrath of the FDA and to separate more husky consumers from their money.

hCG does not contribute to weight loss, and ultra-dilute hCG isn't even real---there is no hCG in it.  It's all, in my opinion, more fraud, but if consumers read the fine print they will see the truth:


A tiny but truthful Quack Miranda Warning inserted  at the bottom of the webpage specifically refutes all of the claims in big, bold print above.  But humans are endlessly hopeful, and looking for that miracle.  This isn't it.


Miller R, & Schneiderman LJ (1977). A clinical study of the use of human chorionic gonadotrophin in weight reduction. The Journal of family practice, 4 (3), 445-8 PMID: 321723

Young RL, Fuchs RJ, & Woltjen MJ (1976). Chorionic gonadotropin in weight control. A double-blind crossover study. JAMA : the journal of the American Medical Association, 236 (22), 2495-7 PMID: 792477

Bosch B, Venter I, Stewart RI, & Bertram SR (1990). Human chorionic gonadotrophin and weight loss. A double-blind, placebo-controlled trial. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 77 (4), 185-9 PMID: 2405506

Stein MR, Julis RE, Peck CC, Hinshaw W, Sawicki JE, & Deller JJ Jr (1976). Ineffectiveness of human chorionic gonadotropin in weight reduction: a double-blind study. The American journal of clinical nutrition, 29 (9), 940-8 PMID: 786001

Rabe T, Richter S, Kiesel L, & Runnebaum B (1987). [Risk-benefit analysis of a hCG-500 kcal reducing diet (cura romana) in females]. Geburtshilfe und Frauenheilkunde, 47 (5), 297-307 PMID: 3609673

4 responses so far

Mid-week meanderings

(by PalMD) Jul 13 2011

Wednesday again and it's been three days since my last bike ride.  I treated myself to a new bike this year, upgrading from the used bike I bought about eight years ago.  I'm not a serious road biker and probably never will be, and serious mountain biking is pretty much laughable around here so I went and got myself a hybrid, and all of you hybrid haters can kish mir in tuchas. I kept the old bike attached to the trail-a-bike for PalKid, but the new one is all mine.  Wouldn't you know, PalKid decided this was a good time to figure out how to ride a two-wheeler, so now we get to go for actual rides together, rather than my simply pulling her along.  She isn't fast, but she keeps going.

Since it was the best way to get around as a kid, I rode a lot.  I rode to middle school every day, as long as it was 40F or above, about 2 miles each way.  I expanded my commuting significantly when I lived in San Francisco as a twenty-something, with a 15 mile round trip commute (in the flatter part of town).  When I wasn't commuting, I would ride over the Bridge to Marin and head out into the headlands or ride up Mt. Tam.  Riding over the Golden Gate and looking back at the City is something everyone should do at some point in their lives.

Med school and residency were a biking low.  I would ride around Evanston just to get around, but mostly when I traveled I was on the El or in a car.   When I moved back here, getting a bike felt like getting younger---getting a good bike felt like getting younger still.  I was happy to find this past weekend that my I can still do some serious riding.  Pulling the kiddo has probably been a good work out, because 14 miles up and down the small hills around here felt awesome.  All those little voices in the head (the pestering "get this done" ones, not the "redrum redrum" ones) just fade away when I'm pumping up a hill, or better yet, coasting down with the wind in my face.

Plenty of people ride in the winter around here but I'm fairly certain they all have the "redrum redrum" voices, so I have to get it in while I can.   We don't generally get a lot of snow around here, but the last few years have been wetter, and I'm thinking about snow shoes for a winter activity.  I understand that they can give you quite a work out.

Meanwhile, on the home front, poor PalKid.  She did not like having Mommy sick in the hospital.  She gave up sleeping in my bed fairly shortly after MrsPal came home from the hospital and is really bouncing back, but now she's terrified of tornadoes.  We don't get a lot of tornadoes around here.  The sirens did go off early this spring when a nasty storm was approaching, and poor little PalKid came down to the basement in four layers of clothes, snow boots, and an armful of dolls.  Now she "hears" sirens every day.

She'll get through this, but meanwhile it's affecting our bike riding.  We've told her that tornadoes only happen "out in the country", so now I can't get her to come for a ride with me "out in the country."  Oops.


9 responses so far

Wednesday wackiness

(by PalMD) Jul 06 2011

So it's the middle of the week (a short week here in the US) and it looks like it's time for a little chat.  First, go read Sister Isis on the Dawkins's idiocy.  In case you weren't keeping up, the basic story is that Skepchick Rebecca Watson (of whose work  I am a bit of a fan) openly wrote about an uncomfortable incident in the greater context of sexism in the skeptical community.  Famed biologist and atheist Richard Dawkins responded to her in a horridly sexist, belittling, "get back to the kitchen and STFU" manner.  And now there seems to be a bit of an imbroglio in the skeptical movement.  Thank God; it's about time.

We all may suffer from the incredulity of privilege.  Just as we don't often notice the air we breathe until it's taken from us, we don't often notice the "isms" that we swim in.  Patriarchy, like racism, anti-Semitism, Islamophobia, homophobia, undergirds everything in our society (some would argue that patriarchy is actually the basis for all other -isms).  It is so much a part of our society that even outrageous acts can seem normal.  When you step back and look objectively (skeptically, if you will) at gender and society, you can see that ours is a culture that views women as sex objects first and people last, in which sexual violence is a normative cultural tool used to control women.  To you who are unfamiliar with this view, it helps to read a bit from those who are more familiar with it.

Feminism is both radical and obvious.  It overturns many of our basic assumptions, assumptions that are so much a part of our society that we see them as fundamental truths.  But it's really, really obvious once the veil is lifted.  And for those of us who benefit from cultural assumptions such as patriarchy and homophobia, we may have little occasion to notice something is wrong.  But we are drunk on it, deceived into complacency.  Those who value justice because it is right, who value human rights for all humans because it is simply right, we must all speak out whenever we can.

In my work I am confronted daily by sexual violence, financial entrapment in relationships, and other horrors, horrors people are easily blinded to and blinded by.  We blame the victim either because it may benefit us to eschew change, or because we are relieved it wasn't us---this time.

One of my hesitations about being labelled a fervent skeptic is that the community is often skeptical of everything except its own beliefs.  It houses the same sexism, racism, and other societal norms as any other community---skepticism, which at its best can help to remedy these, is simply not immune to human foibles.  It is not enough to promote skeptical thinking, a value of empiricism over faith.  We must use these tools to root out some of the most irrational "memes" we encounter.  Which is more harmful, Creationism or racism?  Which is less rational?  Why must we fight one and not the other?

Brava, Rebecca.  Hopefully, the skeptical community isn't dominated by porn-surfing nerds ignorant of the real world.  We all should apply our thinking skills to everyday problems, not just our pet inconveniences.

35 responses so far

In Congress, July 4th, 1776

(by PalMD) Jul 04 2011

I've taken to reposting this every July 4th.  It's worth re-reading this remarkable document from time to time, especially given recent notable events (same-sex marriage legalization in NY, the Arab Spring, Michele Bachmann's meteoric rise to the head of the kakistocracy).

It does, for example, give special importance to representative government; that is, in fact, one of the main purposes of the document. It does not call for a "right" to toss away any government someone disapproves of but lays out specific grievances and makes its declaration through the representatives of the people, not by mob action. It also gives an interesting historical perspective into our founding documents as living documents.  Certain political elements would have us see our founding documents as immutable and mute with regards to modern problems, but just as we no longer speak of "merciless Indian savages" or of African Americans as 3/5's human, we cannot ignore conflicts not foreseen by the Framers.

The document's wording was very carefully developed and has specific meaning to those who wrote it at the time and their descendants. If you've never read it, or haven't for a long time, give it a try.

The unanimous Declaration of the thirteen united States of America

When in the Course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. -- That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, -- That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. -- Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected, whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice by refusing his Assent to Laws for establishing Judiciary Powers.

He has made Judges dependent on his Will alone for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our people and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the Consent of our legislatures.

He has affected to render the Military independent of and superior to the Civil Power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For quartering large bodies of armed troops among us:

For protecting them, by a mock Trial from punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing Taxes on us without our Consent:

For depriving us in many cases, of the benefit of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies

For taking away our Charters, abolishing our most valuable Laws and altering fundamentally the Forms of our Governments:

For suspending our own Legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large Armies of foreign Mercenaries to compleat the works of death, desolation, and tyranny, already begun with circumstances of Cruelty & Perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince, whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free people.

Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these united Colonies are, and of Right ought to be Free and Independent States, that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. -- And for the support of this Declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.

2 responses so far

A challenge to homeopaths

(by PalMD) Jul 03 2011

It's re-post day again.  I thought I'd give you this to chew on with your high-sodium BBQ.  Originally posted May 20, 2010. --PalMD

Dana Ullman, a Huffington Post blogger who never fails to bring the stupid, has now gathered all the idiocy he can find, put it in a wheelbarrow, and dumped it into his latest piece up at HuffPo. In this piece, he calls on readers to stop all medications (except, presumably, the voodoo potions he approves of). A lawyer probably got to him before posting because he inserted an asterisk after this idiotic piece of advice recommending consulting your doctor first.
Which is it, Dana? Do the doctors have it all wrong, or should we consult them before "unplugging"? Dana suggests that this "unplugging" will allow us to better heal ourselves.

Sadly, many of us are so arrogant that we think that we are smarter than our own bodies. We think that we can do better than what nature has provided us. The idea that we can or even should "conquer" nature is so 19th century. Some people today actually think that our bodies are not very smart and that we could and should overcome its weaknesses by the use of pharmaceutical agents that can rid the body of its symptoms

The fact of the matter is that our symptoms are our body's best efforts to defend and heal ourselves from infection, environmental assault or any type of stress. Drugs that suppress our symptoms may provide short-term benefits, but they usually inhibit our own self-healing and self-regulating functions.

Let's take a real example. About 75 million American adults have high blood pressure (hypertension). Hypertension kills at least 15/100,000 Americans yearly (the rates differ significantly by ethnicity). Hypertension kills primarily by causing heart attacks and strokes. It also causes kidney failure and peripheral artery disease. Hypertension generally takes years to kill, and during these years, it almost never causes any symptoms. According to Ullman, "symptoms are our body's best efforts to defend and heal ourselves...". Apparently, our bodies are not quite as "wise" as he supposes.
The nice thing about hypertension is that it is easily treated and its consequences easily prevented. Diet and exercise often help lower blood pressure, and a number of medications are available for those who cannot achieve a goal blood pressure for whatever reason.

While I wait for phone calls from my patients who have stopped taking their meds on Ullman's advice, I'd like to hear from him.

Dana, how do you, as a "homeopathic expert", suggest we treat hypertension? Since it is not always preventable or treatable with diet and exercise, and has no wise, healing symptoms, how would you, in your practice, approach this common disease?

24 responses so far

Will finding sex partners online make you sick?

(by PalMD) Jul 01 2011

Today seemed like a good day for a repost.  This piece gets lots of hits, albeit probably not what the searcher was hoping for.  --PalMD

To people who grew up before the internet, the debate about whether Craigslist should be allowed to post “erotic services” must seem bizarre. But meeting people online, whether for romance, friendship, collegiality, or anonymous sex is becoming not only common, but has lost its novelty. This isn’t going anywhere. The most compelling argument I’ve heard for asking Craigslist to abandon its lucrative paid sex ads is that it helps perpetuate an oppressive and violent sex trade, one that essentially enslaves women and turns them into chattel for the profit of others. That’s pretty damned compelling.

But should those of us who care about public health focus only on the "sex work” section of online bulletin boards? People meeting not only for romance but also for consensual, sometimes anonymous sex has become increasingly common. Like the bath houses of the 1970s, could online sex encounters possibly encourage the risk of sexually transmitted infections?

Data from before the late 1990s are hard to find, since broadband internet services were not widely available. In 2000, a study of a small syphilis outbreak among men who have sex with men (MSM) found that the men who had syphilis were much more likely to have met partners in an online chat room than men without syphilis. This made notification of contacts (for control of the outbreak) more difficult. Of note, when public health authorities launched an informational campaign about the phenomenon, gay online chat rooms were flooded with anti-gay hate messages, perhaps interfering with effective outreach.

Since that initial report, further studies seemed to confirm that meeting sex partners online conferred an increased risk for sexually transmitted diseases, especially among men who have sex with men. A more recent study from the journal Sexually Transmitted Infections aimed to clarify this risk.

The authors combed the records of a sexual health clinic in Denver for patients with a history of chlamydia or gonorrhea confirmed by laboratory testing. They then looked for a history of having sex with someone met online (this was a question asked of all the patients). Neither the group with these infections nor those without were more likely to have met sex partners online, arguing against what has become common knowledge. Earlier data suggested any effect might be more prominent among MSM, but while they found MSM to be significantly more likely to find sex partners online, there was no significant difference in infection rates between MSM and other groups.

The authors discuss possible weaknesses of this study, but there a few critical problems left undiscussed. Chlamydia and gonorrhea are not terribly rare in men who have sex with men, but left out were syphilis, HIV, and HPV infections. These infections have been implicated in earlier reports of online sexual behavior. While it is encouraging that sexual encounters that originate online may not be a unique risk factor for gonorrhea and chlamydia, these other diseases can be pretty devastating.

If the internet may increase the risk of STIs, it may also give us unique opportunities to reach out to people at risk. There are services that allow you to anonymously email a sexual partner to inform them of “bad news”. Internet sites that are used for finding sexual partners sometimes have links to websites with sexual health information (although how effective this might be at mitigating risky behavior is a big unknown).

Ten years ago, not many Americans had internet access, and even fewer had broadband access. Human ingenuity inserted sex into online interactions early, and increasing penetrance of the internet into our lives may increase the frequency of risky sexual encounters. In And the Band Played On, journalist Randy Shilts reported the difficult work of teasing out the origins of the AIDS pandemic, including the sociopolitical challenges of telling a despised minority that some of their behaviors were risky. Studies like the one one on chlamydia and gonorrhea will hopefully help flesh out the interaction between internet hook-ups and health risks so that we can better target at risk groups for preventative education.

Selected References

Klausner JD, Wolf W, Fischer-Ponce L, Zolt I, & Katz MH (2000). Tracing a syphilis outbreak through cyberspace. JAMA : the journal of the American Medical Association, 284 (4), 447-9 PMID: 10904507

Mary McFarlane, PhD; Sheana S. Bull, PhD, MPH; Cornelis A. Rietmeijer, MD, MPH (2000). The Internet as a Newly Emerging Risk Environment for Sexually Transmitted Diseases JAMA, 244 (4), 443-446 DOI: 10.1001/jama.284.4.443

Kim AA, Kent C, McFarland W, & Klausner JD (2001). Cruising on the Internet highway. Journal of acquired immune deficiency syndromes (1999), 28 (1), 89-93 PMID: 11579282

McFarlane M, Bull SS, & Rietmeijer CA (2002). Young adults on the Internet: risk behaviors for sexually transmitted diseases and HIV(1). The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 31 (1), 11-6 PMID: 12090960

Centers for Disease Control and Prevention (CDC) (2003). Internet use and early syphilis infection among men who have sex with men--San Francisco, California, 1999-2003. MMWR. Morbidity and mortality weekly report, 52 (50), 1229-32 PMID: 14681596

A A Al-Tayyib1, M McFarlane, R Kachur, C A Rietmeijer1 (2009). Finding sex partners on the internet: what is the risk for sexually transmitted infections? Sexually Transmitted Infections, 85, 216-220 DOI: 10.1136/sti.2008.032631

2 responses so far

July is Coming

(by PalMD) Jun 29 2011

July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart.  Every year around this time medical bloggers (among others of course) discuss the "July Phenomenon".  Today's post is not about the "July Phenomenon", something that may exist in some contexts but is likely dwarfed by other problems in medical education.

Rather than re-hash the debate on whether July in the most dangerous month to be in a hospital (it probably isn't), I'd like to give a little advice to newly minted doctors.  The rest of you are welcome to read it too.  This applies mainly to internal medicine, but I'm sure much of it crosses over into other specialties.

  1. Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  And remember that your senior resident and attending physician are there to help you, whether they act like it or not.  Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.
  2. Listen to the nurses and ancillary staff.  They spend much more time with the patient than you do, they've seen many years of interns come and go.  They can help you, but if they sense you don't respect them or that you aren't caring for their patients well, they will hurt you.  They will do whatever they can to help their patients, and they will not care if they make you miserable in the process.  They will often know more than you do.  If you don't trust what they tell you, verify it.  You do posses a different sort of knowledge, one that you can combine with theirs to help your patients.
  3. Read up on your cases.  You may not have a lot of time for formal reading and studying.  Read up on the diseases your own patient has, and soon you will have an impressive breadth and depth of knowledge.  Listen on rounds, especially when your colleagues are presenting their patients and you'll get more bang for your buck.  Teach the medical students if you have them and you'll learn even more.
  4. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't.
  5. Don't abuse substances other than caffeine.  Even caffeine isn't that good, but if you are susceptible to substance abuse, the stress of internship can be dangerous.  Be honest with yourself, and if you develop a problem, seek help from your program.  You'd be surprised how much help you can get.
  6. Eat well and exercise.  Even if it's only taking the stairs (three down, two up), exercise will help you.  You'll need it.  Try to avoid all the crappy free food at conferences.  Go for the healthy choices at the cafeteria.
  7. Wash your hands.  If a patient asks you if you did, don't be offended.  Thank them for the reminder and do it again.  If you can, wash them in front of the patient so they can see that you care enough to do it.  Remember that certain pathogens, such as C. difficle, sporulate and will not be killed by topical alcohol solutions but must be physically scrubbed off.
  8. Learn to live with uncertainty.  In the hospital you get used to having information at your fingertips.  You can order stat labs, get X-rays and other studies quickly.  You can't do that in the clinic.  Not every patient will present classically.  It is more common for an common disease to present uncommonly than an uncommon disease to present commonly.  Dig?
  9. Trust no one.  Patients will come up from the ER "pre-packaged", work up done, diagnosis made.  Don't believe it.  Verify it for yourself.  Start from the beginning, because leaning on others' workups simply perpetuates errors.
  10. Corollary: examine every patient yourself, and do it right.  The exam can be focused, but do it.  If your resident or student says that the skin is intact, turn the patient over and search for bed sores.  Listen to the lungs.  Check the mouth for thrush.  Be confident in your skills, skills which will improve every day as you use them.
  11. Senior residents, remember the interns are the interns, not you.  Let them do their work.  Let them answer their own questions.  While they are pre-rounding, do your own pre-rounding, checking labs, checking in on patients.  This way, when you pimp the intern on Mr. Smith's potassium and she doesn't know it, your team will realize that not only are you on top of things, but you're watching them,  both to help and to make sure they stay on task.
  12. Wikipedia is not a valid medical reference. I'm sorry I have to even say this.
  13. Ars longa vita brevis.  Enjoy the art.  Medicine is interesting.  It's fun.  And there are no bad patients.  It's just as important to learn how to manage a drug-seeking sociopath as it is to treat an acute MI.  There is always something to learn, even if that "something" is that you don't want to be a gerontologist.

OK, folks.  Go for it.



13 responses so far

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