Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, January 30, 2008

Why do Doctors Fall for CAM?

Medical training is, by definition, steeped in science. Given this as a starting point, there is a great deal of puzzlement about why doctors -- supposedly intelligent and scientific to begin with -- turn to forms of "alternative medicine" that require magical thinking to buy into their purported mechanisms of action. This is not intended as a snarky "What makes them turn to the dark side" essay, but an honest attempt to understand the relative roles of emotion and logic in medicine.

I'm going to begin by giving these physicians the benefit of the doubt by assuming that their "conversion" to CAM principles is intellectually sincere, and not purely for the monetary gain of producing a cash-only practice, independent of insurance constraints. Granted, such a practice shift is virtually certain to produce a financial windfall. Still, I'd prefer to believe most doctors are above such base and cynical motivations.

I'm also going to assume that the primary motivator is not the emotional one of acceptance into the warm, fuzzy, welcoming world of CAM. Without doubt there is a large, passionate population eager to welcome such physicians with open arms. Praise for "having such an open mind" and being so "different from all those other doctors who just won't listen to reason" is powerful, and its emotional effects should not be underestimated. While just being liked probably isn't reason enough to endorse magical thinking, it is still a very real and important secondary benefit.

What I'd like to address specifically is the physician who, after many years of conventional practice, decides that one or more of the magically based alternative modalities are in fact true and correct. Why? What could make a rational person suddenly believe things that make no sense when thought about rationally?

If you practice medicine long enough, you will see things you cannot explain. Cancers that go into spontaneous remission; documented infertile women becoming pregnant; asthma, arthritis, psoriasis that spontaneously improve or abate completely. I do not deny that these and other phenomena defy our scientific understanding. When out patients say to us, "How did this happen?" we are forced to answer -- if we are being honest -- "I don't know."

I don't know.

Difficult words to utter; more difficult still to live with, especially as an inquiring, curious, scientific physician. Dealing with uncertainty can be downright painful; a pain known as cognitive dissonance. Because doctors are human, they can't be blamed for trying to deal with the discomfort of not knowing. Along comes a knowledgeable, reasonable patient experiencing one of these inexplicable events who discloses that they have utilized alternative medicine; perhaps homeopathy or Reiki. Neither physician nor patient can figure out what else could have "caused" the miraculous result, and so two skeptics are converted. The doctor goes on, cautiously perhaps, to utilize the new modality. A combination of confirmation bias and the fallacy of correlation and causation turn him into a true believer. The same process can occur more quickly when the physician has a close emotional relationship with the patient, such that the "miraculous healing" is experienced as a spiritual awakening. In fact, an article on Quackwatch has this to say about what they call the "conversion phenomenon":
Many individuals who [embrace alternative medicine] undergo a midlife crisis, painful divorce, life-threatening disease, or another severely stressful experience. The conversion theory is supported by a study of why physicians had taken up "holistic" practices. By far the greatest reason given (51.7%) was "spiritual or religious experiences."
Far from gaining a new "faith" in alternative medicine (that requires magical thinking), I believe that these physicians have lost their faith. Faith that science and rational thinking are the best way to understand the physical world around us, including the human body. How easy it is to relieve the pain of not understanding by giving in to the idea that there are answers after all; energy fields; water with memory; the "mind-body connection." That there is also an enormous, enthusiastic, welcoming community -- cult-like -- merely reinforces all the new "paradigms."

For what it's worth, I happen to have a deep faith and a rich spiritual life. But despite that -- or because of it? -- I am not willing to give in to the idea that magical explanations must be accepted when scientific ones cannot be produced. I believe in a soul, but I do not accept neurosurgeons flaunting PET scans claiming they have found it. Humans may indeed have sacred energy fields that cannot be measured, but how arrogant of Reiki practitioners to claim they can manipulate them! Faith and science surely interface in the art of medicine, but not via alternative medicine paradigms. Reiki is as inappropriate in an ICU as a geologist barging into synagogue on Simchat Torah complaining as we read the Genesis creation story from the Torah that it's a bunch of scientific bunk. If nothing else, I have faith that although science may not YET know the answers, rational thinking is the only way they can be eventually found.

Sunday, January 27, 2008

Sour Cream Mushroom Sauce

  • 1 Copy of TBTAM's recipe for Mushroom Strudel, printed out before she corrected the typo, so that it reads "3 cup" sour cream instead of "1/3 cup"
  • 1 shitload of sour cream
  • all the other ingredients in the recipe
  1. Decide to make TBTAM's Mushroom Strudel for Super Bowl party
  2. Agree that Darling Spouse's suggestion to do a test run ahead of time is a good idea
  3. Mix dough and refrigerate overnight
  4. Saute chopped mushrooms, salt and pepper in butter
  5. Decide that sweet vermouth will work just as well the dry called for in the recipe, because you forgot to double check before going to the liquor store, which is closed on Sundays
  6. Decide that onion and some garlic will have to do for the shallots, because you forgot to pick up shallots as well
  7. Cook mixture for awhile; notice how quickly it gets mushy; wonder how much liquid left constitutes "mostly evaporated"
  8. Add 3 cups of sour cream to mixture and let cool
  9. Notice how that much cold sour cream cools mixture down pretty quickly
  10. Roll out 1/4 of dough as thin as possible
  11. Decide that TBTAM really meant to roll it out into an oblong instead of a "round", the better to jelly roll it with the filling
  12. Notice that 1/4 of mushroom mixture is one helluva lot for that amount of pastry
  13. Try to roll it up; just try
  14. Log onto internet; re-check recipe; discover that no, she didn't really mean 3 cups of sour cream, because now it reads "1/3 cup"
  15. Wonder what to do with pan 3/4 full of mostly-sour-cream and mushroom mixture
  16. Taste it
  17. Discover that it still tastes wonderful, even though there's no way you're going to be able to use it as a pastry filling
  18. Serve it over baked chicken and rice you were making for dinner anyway
  19. Enjoy
  20. Accept compliments from Darling Spouse on delicious sauce
  21. Thank your lucky stars that you bought literally twice as many mushrooms as you needed so you can try again tomorrow with the right amount of sour cream and the other 3/4 of the dough
  22. Thank TBTAM for delicious recipe
Thank you, TBTAM.

Friday, January 25, 2008

The Hypochondriac

Beverage alert: swallow before reading.

34-year-old man, confirmed hypochondriac, presents with less than twenty-four hours of sore throat and fever. No cough; no nasal symptoms.

Vital signs:
  • Weight: 151
  • Temp: 99.7
  • Pulse: 84
  • Resp: 12

Ears with pearly TMs bilaterally; throat somewhat injected, but without exudates or lesions; nose clear, pink turbinates, no discharge; lungs clear; heart regular without murmurs or gallops.

I go to palpate his neck for enlarged lymph nodes and as I do, I ask, "Does it hurt here?"

His response: "Should it?"

Monday, January 21, 2008

Sex or Religion?

Upon reuniting with an old friend from many years ago, significant revelations were made and assorted responses provoked. Can you match the responses with the revelations?

Response group A:
  • Really?
  • I'm not surprised.
  • Whatever makes her happy.
Response group B:
  • What?!?
  • You're kidding!
  • How did her parents take it?
Here were the two revelations:
  1. That she had converted to Christianity (from Judaism) and was now an Episcopalian minister.
  2. She was a lesbian.
Personally, I find it intensely amusing that Response Group A was to her sexual orientation, and Group B was the response to religion. Interesting times we live in, eh?

Saturday, January 19, 2008

Human Nature

This is my contribution to the Panda-Graham debate about Social Justice, whatever that is. They are never going to be able to come to any agreement because they are beginning with two completely different assumptions about "human nature," a phrase I would argue means even less than "social justice."

Consider the following statement:
Deep down inside, we're really all the same.
Sounds like an innocuous, self-evident statement with which everyone can agree. The problem is that it's wrong. Of course as humans, we all have the same "basic needs" for food, sex, approval and so forth, but the values, morals and experiences we bring to the task of meeting those needs are so different both from person to person as well as from culture to culture that in too many ways to count, we are NOT all fundamentally "the same."

Some people are fundamentally trusting (and therefore trustworthy) and believe, like Anne Frank, that people are really good at heart. Others, perhaps those who failed to master basic trust in infancy, do not think their needs will be met unless they take what they need. Others live in a culture where getting away with whatever you can is the accepted norm; one who works harder than he needs to is a naive patsy.

I think what that statement really means is that deep down inside, we believe everyone else is really like us. Not like we think we are, or what we'd like to be, or what we tell ourselves we are, but how we really really really are, deep in our hearts. (I came to ponder this phenomenon, by the way, when a patient with a drinking problem said to me, "Doesn't everyone like to have three or four beers after work to relax?" Er, no; but it showed me that's what HE wanted.)

Take the following example: walking down the street, you see a wallet fall out of the pocket of a man walking ahead of you. Do you pick it up, run after him and give it back, or do you pick it up and slip it into your own pocket? (Or do you leave it there and just walk by?) How much does the risk of getting caught play into your decision?

Now, instead of answering the question, "What would you do?" in this situation, answer this one: "What do you think most people would do?" I submit that your answer to that second question is what reveals your true character.

What this means is that when Panda says,
We are, most of us, potential freeloaders...
he is really admitting that given the opportunity (and with no risk of being caught) he would take the money and run. Although granted, much of what Panda writes is so over the top it's hard to know how much of it he really means and how much is just the posturing of a blog persona. Still, as one of his commenters puts it:
...the view of life one gleans from the ER is truly confined to the ER....Generalizing to the world from one’s narrow workview in the ER is a dangerous and very strangely skewed view of humanity.
Graham, on the other hand, is young and idealistic; here's his core statement (my term):
I believe that for the most part, [people] do the best they can based on their circumstances.
What this says to me is that Graham does the best he can, based on circumstances of course. There are plenty of people Panda never sees who somehow manage to stay out of the ER; who have no insurance but manage to pay me out of pocket, even though they wait far longer than they should to come in. Panda is a victim of what I call the Denominator Effect (probably the subject of a future post): he doesn't realize how skewed his patient population is, and he doesn't believe that other kinds of patients exist. Oh, he'll acknowledge it intellectually, but deep down inside he doesn't really *believe* it.

Because Panda and Graham, who are so different from one another, each believe that everyone is just like him, they will never -- by definition -- be able to agree. Each is right, but only to his own way of thinking. Human nature, you know.

Thursday, January 17, 2008

Trekker Beverage Alert

What happens when a bored trekker becomes completely enchanted with lolcats (I can has cheezburger):


Despite having issued fair warning (in the post title), I do have a new policy of reimbursing readers for keyboards, monitors and other computer equipment ruined by spewing liquids. Just email place of purchase, original purchase price and sales clerk's mother's maiden name to:

Tuesday, January 15, 2008

Another Nail in the Coffin of Correlation and Causation

Surprise: Zetia doesn't reduce heart attacks and strokes, even though it lowers cholesterol. The whole "cholesterol hypothesis" turns out to be exactly that: merely a hypothesis that now appears on its way into the stack labeled "Disproved."

It turns out that statin drugs like Zocor (simvastatin) and Lipitor (atorvastatin), the first drugs that meaningfully reduced cholesterol with a reasonable side effect profile (a patient asked me about cholestyramine last week; I asked if she really wanted to eat four packets of sand a day) can lower cholesterol significantly while also markedly reducing the risk of heart attacks and strokes. When I began reading evidence that it also had an impact on reducing the risk of Alzeimer's dementia, though, I said to myself, "There's probably more going on here than just cholesterol lowering."

Turns out to be exactly right.

Statins lower cholesterol. Statins decrease the risk of cardiovascular disease. Both of these are observations. Making the jump to "Lowering cholesterol lowers the risk of cardiovascular disease" turns out to be an error of confusing correlation with causation. The rooster crows and the sun comes up. Let's make even more noise; oh wait: it's midnight and the sun didn't come up? Something wrong with that formulation.

Now, of course, aren't all those "Cholesterol goals"' in the P4P schemes rendered meaningless? If I get someone's moderately elevated cholesterol down to "goal" with Zetia instead of a statin, have I really done them any good? Apparently not, but I can still get rewarded for it. If this doesn't highlight the perils of P4P, I don't know what does.

(I expected Orac to weigh in first on correlation-causation angle, though Dr. Centor has beaten him (and me) to it. On the other hand, I thought the good Dr. Centor would be the one jumping on the "Quality" issues. Ah well; the unexpected is what makes life interesting.)

Sunday, January 13, 2008

Joining the Crowd

I wouldn't be able to call myself a "Member of the Blogosphere" if I didn't link this, courtesy of Orac:

Too awesome. Now I've got the refrain in my head also:
"PCR, when you need to know who the daddy is (Who's your daddy?)"

Saturday, January 12, 2008

Name Calling

Cranky Prof has a mini-rant at the end of her latest post, about being called "Mama" by people other than her own spawn, but when she moved on to her annoyance at her given name being used by health care professionals, I realized something about my own practice.

I always tried to be good. I remembered what I was taught as a med student about treating patients respectfully by not using their first names until invited to do so. All through residency I was good, never using patients first names until invited to do so. I did notice that relatively few older patients seemed overly upset when nurses and aides and other little chippies running around the hospital used their first names without permission; almost like it wasn't worth the effort to take offense, although they certainly had every right.

When I began my practice, I was good. My default address form to my patients was Mr./Ms. Lastname. I would then introduce myself by my first and last name, without the "Doctor;" I figured it was assumed, although sometimes I would add, "I'm the doctor."

As a young whippersnapper, it worked just fine. I was nice and polite, and none of my patients had reason to be cranky about me, at least not about any promiscuous use of their first names.

What about children, though? It would have been terribly stilted to call for "Miss Droolmeister" when she was there for her four month checkup. So of course I always called kids by their first names. And teens. Not their parents, of course, but with younger patients it felt perfectly appropriate.

Then from time to time, I found myself uncomfortable calling people Mr. Smith or Ms. Jones. Can you guess who? Yep; people much younger than I. College kids. Folks in their twenties (once I was well into my thirties.) I finally realized that it was ok to use first names with people younger than I, both because younger generations tend to be less formal, and because etiquette has always allowed it. Given that I always know how old patients are before I face them (name and date of birth are at the top of every page of the chart, even if I don't sneak a peek at their registration form, which I usually do) it's easy enough. Here's how the greetings break down (not that I consciously decided to do this; I do what feels right, and am only now codifying it):
  • More than 20 years younger than I (ie, young enough to be my kid): "Hi, John; I'm Dr. Dino."
  • Less than 20 years younger than me: "Hi, Jane; I'm NumberOne Dino."
  • Older than me: "Hi, Mr. Dinkleheimer; I'm NumberOne Dino."
  • Usually patients up to about 10 years older than me will say, "Please call me Shlomo."
Finally, I realized that the pool of people who fell into the category of "younger than I" was getting bigger and bigger every year. Talk about a "duh" moment; as I get older, more people are younger than I.

I also notice is that things bother me less and less as I get older, like being called by my first name by some young chippie in the dentist's office. No offense intended to CrankyProf and others who get all bent out of shape at the indignity of inappropriate familiarity, but I find it just doesn't bother me nearly as much as it used to. I must be getting old.

Friday, January 11, 2008

MS Website Slams CAM

(Just auditioning for a job as a headline writer.)

I have a cousin with MS who sent me the link to this really cool site, Multiple Sclerosis Sucks. Go check it out; it's great. What's really refreshing is to read about MS from the view of the patient-scientist. Here are some of the more interesting pages I've read on the site so far:
'Nuff said.

Wednesday, January 09, 2008

Just Click on It

It doesn't even matter that it's all in Dutch; just click here and wait to see what happens. (Thanks, MG.)

Monday, January 07, 2008

An Immodest Proposal

I have an idea that's sure to piss off general internists and family docs alike (a sure sign that I'm on to something?): how about if we limit internists to the care of hospital and facility inpatients, and reserve the care of outpatients for the FPs.

Dr. Centor, an academic hospitalist, is obviously excellent at what he does -- in the hospital. He goes out of his way to point out that he doesn't do office care. And much of what he says about internists in offices are, by definition, second hand. If general internal medicine is failing as an outpatient endeavor, the rise of the hospitalist movement seems to be tailor-made as the natural venue for the practice of internal medicine.

I practice exclusively in the office; I don't do hospital or nursing home care. To be sure, there are loudly vocal FPs castigating me as "not a real doctor" for having given those up. Certainly they aren't going to accede to my proposal without a significant fight. But outpatient medicine has its own skill set that includes preventive care, chronic disease management (of multiple concurrent diseases), minor procedures like skin biopsies and lump/bump removal, and acute management of the worried patient with a self-limiting condition, as well as complex diagnostic challenges, among other things. Why not concede that arena to me and my colleagues?

There is a great deal of confusion about the difference between Family Practice and General Internal Medicine. Patients are confused; hell, practitioners are confused. Much of the time, we end up admitting that there really isn't any difference. So why not let Internists concentrate on the "sicker" patients they supposedly excel at caring for -- in the hospital. And let the Family Practitioners specialize in what we do best: keeping people healthy, and out of the hospital.

Let the fur fly...

Thursday, January 03, 2008

Sayings of a Jewish Buddhist

I have a patient who always sends me great stuff. Thanks, SG:

Be here now.
Be someplace else later.
Is that so complicated?

Drink tea and nourish life;
with the first sip, joy;
with the second sip, satisfaction;
with the third sip, peace;
with the fourth, a Danish.

Wherever you go, there you are.
Your luggage is another story.

Do not wish for perfect health, or a life without problems.
What would you talk about?

The journey of a thousand miles begins with a single Oy.

There is no escaping karma.
In a previous life, you never called, you never wrote, you never visited.
And whose fault was that?

Zen is not easy.
It takes effort to attain nothingness.
And then what do you have?

The Tao does not speak.
The Tao does not blame.
The Tao does not take sides.
The Tao has no expectations.
The Tao demands nothing of others.
The Tao is not Jewish.

If there is no self, whose arthritis is this?

Breathe in. Breathe out.
Breathe in. Breathe out.
Forget this and attaining Enlightenment will be the least of your problems.

Let your mind be as a floating cloud.
Let your stillness be as a wooded glen.
And sit up straight.
You'll never meet the Buddha with such rounded shoulders.

Deep inside you are ten thousand flowers.
Each flower blossoms ten thousand times.
Each blossom has ten thousand petals.
You might want to see a specialist.

Be aware of your body.
Be aware of your perceptions.
Keep in mind that not every physical sensation is a symptom of a terminal illness.

The Torah says, Love your neighbor as yourself.
The Buddha says, There is no self.
So, maybe we're off the hook.

Wednesday, January 02, 2008

What CAM and Vanity Publishing Have in Common

What do "Complementary and Alternative Medicine" (CAM) and "Vanity Publishing" have in common? Quite a lot, as it turns out.

Some quick definitions to bring the non-writing and the non-medical public up to speed on each other:

The central tenet of legitimate publishing is "money flows to the author." Individuals and companies that make their money charging authors for anything from "reading fees" to "editing services" to actually producing books are not legitimate publishers. They are scammers preying on ignorant and/or gullible authors who, holding a book in their hands with their name on it, don't really understand what publishing is all about.

Medicine as defined in this day and age is the application of science to the diagnosis and treatment of disease. Of course there is an "art" to medicine, mainly because the science is incomplete. CAM refers to individuals who prey on ignorant, gullible and/or desperate patients who do not understand medicine, offering magical thinking cloaked in the trappings of scientific medicine (calling themselves "doctors," for example.)

One fascinating similarity is that outside their respective fields, neither is considered much of a big deal:

In general, non-physicians don't see the harm in allowing stupid people to spend money on things like homeopathy, Reiki, supplements and chiropractors, and don't understand why physicians are so up in arms over the issue. Deaths from curable conditions treated with fake medicine are chalked up to the tragedy of stupidity. They may not even believe or understand what's wrong with CAM in the first place. It makes you feel better; isn't that what medicine's all about?

Non-authors and people not involved in publishing couldn't care less about vanity publishing. What difference does it make if an author is published by Random House or Publish America? It's a free country; if people want to spend their money self-publishing their books to call themselves "published authors," so what? Good people are victims of fraud. Tough; it happens. If someone who actually writes something with legitimate potential has his career destroyed before it begins because of a Lulu ISBN, who cares? A book is a book, isn't it?

Muddying the water is the fact that under specific and limited circumstances, some versions of both CAM and vanity publishing have their uses. Certain kinds of yoga and relaxation exercises have been shown to improve well-being in patients undergoing cancer chemotherapy, for example. Some people with highly personal or technical books who need a small number of them for sentimental or professional purposes ("back of the room" books after a lecture, or a family biography) can have them produced beautifully by a company like Lulu. Problems arise when, ignoring limitations, these scenarios are used by the unscrupulous to validate other, less appropriate contexts of their false promises.

Another important similarity is that many "consumers" of both CAM and vanity publishing don't consider themselves victimized at all. They are a large part of the problem, and explain why both forms of fakery continue to flourish. Many patients with vague symptoms, ill-served by busy doctors, find "relief" in the arms of the homeopaths, the chiropractors and other quacks, and then spread the word like religious zealots. Likewise, discouraged by both the rigor as well as the seeming randomness of the legitimate publishing industry (including literary agents) plenty of people have turned to what is essentially self-publishing, where they are the ones primarily responsible for selling their books through signings and "author events." They see nothing wrong with having to purchase their own books at 50% off the cover price and then re-selling them themselves. They consider themselves legitimate, published authors and no one can convince them otherwise.

Flying equally under the radar of both groups are the forces trying to warn and protect the other, hoping to transform the ignorant and gullible into the knowledgeable and savvy:
Still, it's difficult for each group to get all worked up about the travails of the other. So why should they? Here's why: People shouldn't be allowed to defraud others out of their hard-earned cash with false promises -- whether of legitimate publishing or rational health care.

Tuesday, January 01, 2008

New Year's Wish

An image more powerful than the mere words, "Peace on Earth:"

Said best by lolCats.