February 8th, 2008 by Dr. Val Jones in Expert Interviews, News
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Much to the dismay of scientists, policy makers, and health care administrators, good medical decision making is not always black and white. I understand and sympathize with our desire to distill complex disease management issues into specific, easily measured variables. But unfortunately, the human body is exceedingly complex, and willfully resists reductionist thinking.
The recent ACCORD trial (which was designed to quantify the value of aggressive glucose management in a diabetic population) actually demonstrated a higher mortality rate in the intensive treatment group. What? That’s right, people were more likely to die if they had been randomized to the group that used all means necessary to keep blood sugars in a near normal range.
Now, this does NOT mean that it’s a bad thing for diabetics to keep tight control of their blood sugars, but it MAY mean that if they have to take high doses of multiple drugs to get them to that aggressive goal, the negative drug side effects may collectively outweigh their benefits.
I spoke with Dr. Zachary Bloomgarden, a renowned diabetes expert, to discuss his interpretation of the trial results. Here is a snippet from our interview:
My feeling is that this study shows that there is an art to medicine, and that patients can’t be managed via cookbook methods to treat their disease. If a person can control their blood sugar to an A1c of 6.0 without using too many medications, then that might be a good goal for him or her, but if you have to take high doses of several pills to get to that same goal (and therefore experience all the unfavorable additional side effects from taking them like weight gain, fluid retention, and potential arrhythmias) then it might not be appropriate in that case.
Ultimately, it takes a personalized approach by an experienced physician to determine the best treatment plan for an individual patient. One size doesn’t fit all – that’s part of my
take away from this study. We still
certainly want all people with diabetes to do as well as they can with blood
sugar as well as blood pressure, cholesterol, and the myriad other markers of
control of the disease.
And so my plea is that in our race to ensure “quality care for all” in this country, we take a moment to consider that real quality may not be about getting every patient to the same blood test target, but to get every patient to a primary care physician who can apply evidence based recommendations in a personally relevant way. Cookbook medicine is no substitute for good clinical judgment. Let’s invest in our primary care base, and make it financially viable for them to spend the time necessary to ensure that their patients are on individually appropriate therapeutic plans. I hope our next President will appreciate the critical role of primary care in a healthy medical system.
Addendum: a like-minded fellow blogger weighs in on the study
.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 7th, 2008 by Dr. Val Jones in Uncategorized
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Valentine’s Day is one week from today. Since I’m a bit of a blog geek (ok, my husband calls me the “bloginatrix” – go ahead, you can laugh), I can’t think of a better way to spend MY Valentine’s eve than with Dr. Anonymous and 3 other lady bloggers: Crzegrl, Chronic Babe, and Emergency Em on a special Blog Talk Radio feature show! The idea for the show came up when I was complaining to Dr. Anonymous about the fact that most of his guests were male, and that the conversations inevitably degenerated into viagra and cialis debates by the end of the full hour. I suggested that a little bit of estrogen should be added to the testosterone-focused show, then the ladies in the chat room piped up with an enthusiastic, “Let’s have a lady’s night – we’ll call it Estrofest!” And the rest is social networking history.
So please mark your calendars – join me for “Estrofest” on a special Valentine’s Day radio podcast on the Dr. Anonymous show, 9-10pm EST, February 14th. You can call in and chat with us ladies, or just listen in to what we think about medicine, dating, and life in the blogging fast lane. I’m going to do my best to keep this PG-13, but with fellow guests like crzegrl, I’m not sure it’ll be entirely within my control.
Hope to see you at the show!
P.S. Don’t fall for the pressure of Hallmark et al… you can be “romantic” any night of the week… postpone your Valentine’s Day plans with that special someone, and join us at Estrofest!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 7th, 2008 by Dr. Val Jones in True Stories
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This (hat tip to KevinMD) is one of the worst cases of attempted personal injury fraud that I’ve heard of:
It was a very busy weekend afternoon in the ED when a city bus accident occurred. What a disaster. Rarely is anyone really injured but everyone on board almost always winds up coming into the ED. The city encourages it so things can be documented and people are like “Cha-Ching!”, lawsuit! So, this particular time, about 5 people were brought in on back boards (we were lucky to get so few!) As the 3rd year resident started interviewing them one at a time (since all were stable and ambulatory (walking) at the scene), one of the patients said, “Hey Doc, that guy over there was not even on the bus at the time of the accident! He jumped on board afterwards and started complaining of back and neck pain!” The resident could have gone over and confronted him angrily (who would blame him) but instead chose a different approach. He calmly went through all the other backboarded patients, clearing them all clinically out of their cervical collars. He simply ignored the man suffering from “Allstate-itis”. The funny thing is that 2 hours went by and everyone just ignored him (although I think he was triaged at some point – damn EMTALA). All manner of stuff was going on around him. His stretcher was parked right next to the nursing station yet it was like he did not exist! Finally, the guy called the resident over and said, “Hey Doc, isn’t someone going to check me out and do x-rays?” He replied, “Well, you weren’t even on the bus so in my mind, you are already checked out!” Knowing the jig was up, the man sat up, took his C-collar off, and left the ER. I guess he was thinking, “Oh well, maybe next time I’ll hit the jackpot!”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 5th, 2008 by Dr. Val Jones in Quackery Exposed
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So my last post stimulated some interesting discussion amongst friends and colleagues. Some applauded the late night supplement “smack down,” and others felt it was too harsh. Still others who don’t read my blog regularly complained that it was unfair to pick on the supplement industry without also pointing out the flaws of Big Pharma. Well, here’s to equal opportunity smack downs – where things “applied directly to the forehead” are as fair game as anti-psychotics, IT mishaps, healthcare professional SNAFUs, and misguided policies resulting in unanticipated harm to patients.
But let’s not forget the happy stories, the unlikely triumphs, and the snatching of victory from the jaws of defeat. We can laugh at ourselves, cry with our friends, and mourn the loss of the lonely. Medicine is full of a broad array of emotions and perspectives, captured here for you in this blog.
And now, back to bunnies and puppies…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 5th, 2008 by Dr. Val Jones in Quackery Exposed
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The financial burden of snake oil
Prickly snake oil seeds are taking root in the soil of our broken healthcare system. Consumer discontent and feelings of helplessness are the manna of charlatans – and they are growing fat in our lean times. Unprecedented opportunity for promotion via the Internet, coupled with chronically short audience attention spans and generalized patient exhaustion (from the treadmill of life) are creating the perfect climate for the spread of pseudoscience.
I must admit that I had turned a blind eye to the whole pseudoscience movement until fairly recently. I figured it was harmless enough – placebos that might engage peoples’ minds in a more optimistic view of disease. But little did I realize that this tumor on the face of medicine would become life threatening to the advancement of science and truth.
Take for example the money that Americans spend on weight loss supplements – 1.3 billion dollars per year, and yet the American Academy of Family Physicians has found no evidence to support the use of a single one. That’s more money than the World Health Organization’s annual budget, and more than Great Britain spends on cancer research in a year. The supplement industry in general rakes in 20 billion dollars a year, which is more than the total amount spent by the US government in the wake of hurricane Katrina.
And what do snake oil salesmen think of this colossal waste of resources? Why, they’re touting it as a new era of enlightenment of course. They weave in “all natural” products, “mindfulness” practices, and “detoxification” programs into a comprehensive feel-good message that is a soothing balm to anxious souls. In reality they are leading the public down a garden path towards a false wellness nirvana, fleecing them as they go, and sowing seeds of mistrust for science-based medicine.
The rise of snake oil salesmen
The strongest potion in the snake oil salesman’s repertoire is the placebo. Placebos are treatments that work based solely on the power of suggestion. A so-called placebo effect occurs when a patient’s symptoms are altered in some way (i.e., alleviated or exacerbated) by an otherwise inert treatment, due to the individual expecting or believing that it will work. If a snake oil salesman is to become truly successful, he must build a case for his wares through anecdotes and testimonials. To obtain these, he must be a master of the power of suggestion, cultivating a small number of “true believers” from which to conjure evidence for the effectiveness of his oil. He need not convince the majority, a small minority of passionate believers will do. As Mark Twain writes, “The most outrageous lies that can be invented will find believers if a man only tells them with all his might.” Therefore, a common denominator with many snake oil salesmen is charisma and charm.
Once the charlatan has developed his small but passionate following, and some miracle cure anecdotes, he will then start playing the role of a victim. He will look for individuals who are willing to challenge his pseudoscientific claims, and then cry out to his loyal followers that he is being persecuted. He will use racism imagery to describe an illusionary bias against himself and the “good” that he is trying to do for those who are open-minded and willing to forsake “paternalistic” science. His followers will be further emboldened to carry the banner of this “downtrodden hero” as they continue to fall for his under-dog psychology.
The snake oil salesman, of course, will not gain traction with key opinion leaders in medicine, so he is left to draw from the Hollywood celebrity pool to further evangelize the masses. Medical leaders will roll their eyes and ignore his obvious pseudoscience, much to the detriment of the general public who have a hard time discerning science from pseudoscience. The charlatan then points to the medical profession’s silence as “proof” that they cannot deny his claims, further convincing susceptible listeners.
Then years later as snake oil salesmen realize that there is further strength in numbers, they gather together to form the first snake oil union. They create a continuum of oily treatments, gathering anecdotes and testimonials from one another in pseudoscientific “meta-analyses” to further strengthen their assault on science and reason. They find wealthy donors and benefactors who are impressed by their growing numbers, and match them with cash-strapped academic centers who will desperately accept funds for any vaguely scientific purpose. The snake oil team now has won a respectable platform from which to grossly inflate statistics about public use of “alternative medicine” (lumping “prayer” into the list of therapies which, combined together, would have you believe that over 60% of Americans are using alternative therapies like homeopathy).
Snake oil goes mainstream
Now that the very same snake oil that medical experts didn’t wish to dignify with a response is being promoted by academic centers, we are obligated to fund research into the potential therapeutic uses of these placebos, wasting countless millions in government funding to study implausible therapies. With a critical mass of snake oil believers, few dare to challenge the wisdom of this approach, and have become passive observers in a downward spiral that is harming the credibility of the very centers founded to promote objective scientific inquiry.
Can good science separate the wheat from the alternative chaff? Yes, but the problem is that few people seem to care about truth any more. While the American Academy of Family Physicians demonstrates that no single weight loss supplement is recommended for public use, the public is spending 1.3 billion dollars per year on these very supplements. Why? Maybe the AAFP is not reaching the public with their message, or maybe people are simply unable to resist the sweet lure of false promises?
Nonetheless, there is a growing movement in medicine to reclaim scientific territory stolen while we shrugged passively at the snake oil lobby. Blogs like Science-Based Medicine and Respectful Insolence are uniting physicians who believe in the importance of objective scientific inquiry as the foundation for the best therapeutic decision-making.
As the healthcare budget crunch looms, further pressure will be placed on providers and pharmaceutical companies to demonstrate the efficacy of their treatments in order to be eligible for coverage. This will be a boon to scientific medicine, as therapies that actually work will (by budgetary necessity) be preferentially selected for reimbursement. While Big Pharma undergoes further scrutiny, they will also turn to science to demonstrate the utility (or lack thereof) of their drugs. Therefore, those in search of truth will not be completely thwarted by pseudoscience.
Yet patients are free to pay out-of-pocket for any number of alternatives to scientifically proven medicine. I predict that further healthcare access limitations will drive more people to look for placebos than ever before, much to the detriment of those who have diseases that are treatable or curable through proven therapies. I worry far more about missed therapeutic opportunities than the dangers of the snake oil itself.
So my final advice is this: eat a well-balanced, calorie controlled diet, engage in regular exercise, stay within a healthy weight range, sleep well, participate in loving relationships, don’t smoke, do drugs, or drink in excess. At least 60% of your medical problems will be prevented if you do these things. You do not need to waste your money on supplements and snake oil – put that money into a savings account that you can access in case you become seriously ill and your insurance doesn’t cover all the best, evidence based care that you need.
Do not tithe to the snake oil salesman. Resist the dulcet tones of the false promises. Save your money to do good, and listen to your own voice of reason.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
