December 19th, 2007 by Dr. Val Jones in Book Reviews
No Comments »
Have you ever been surprised and confused by what seem to be conflicting results from scientific research? Have you ever secretly wondered if the medical profession is comprised of neurotic individuals who change their mind more frequently than you change your clothes? Well, I can understand why you’d feel that way because the public is constantly barraged with mixed health messages. But why is this happening?
The answer is complex, and I’d like to take a closer look at a few of the reasons in a series of blog posts. First, the human body is so incredibly complicated that we are constantly learning new things about it – how medicines, foods, and the environment impact it from the chemical to cellular to organ system level. There will always be new information, some of which may contradict previous thinking, and some that furthers it or ads a new facet to what we have already learned. Because human behavior is also so intricate, it’s far more difficult to prove a clear cause and effect relationship with certain treatments and interventions, due to the power of the human mind to perceive benefit when there is none (placebo effect).
Second, the media, by its very nature, seeks to present data with less ambiguity than is warranted. R. Barker Bausell, PhD, explains this tendency:
1. Superficiality is easier to present than depth.
2. The media cannot deal with ambiguity, subtlety, and diversity (which always characterizes scientific endeavors involving new areas of investigation or human behavior in general)
3. The bizarre always gets more attention than the usual.
I really don’t blame the media – they’re under intense pressure to find interesting sound bites to keep peoples’ attention. It’s not their job to present a careful and detailed analysis of the health news that they report. So it’s no wonder that a research paper suggesting that a certain herb may influence cancer cell protein expression in a Petri dish becomes: herb is new cure for cancer! Of course, many media outlets are more responsible in their reporting than that, but you get the picture.
And thirdly, the scientific method (if not carefully followed in rigorous, randomized, placebo-controlled trials) is a set up for false positive tests. What does that mean? It means that the default for your average research study (before it even begins) is that there will be a positive association between intervention and outcome. So I could do a trial on, say, the potential therapeutic use of candy bars for the treatment of eczema, and it’s likely (if I’m not a careful scientist) that the outcome will show a positive correlation between the two.
There are many reasons for false positive results (e.g. wrongly ascribing effectiveness to a given therapy) in scientific research. “Experimental artifacts” as they’re called, are very common and must be accounted for in a study’s design. For fun let’s think about how the following factors stack the deck in favor of positive research findings (regardless of the treatment being analyzed):
1. Natural History: most medical conditions have fluctuating symptoms and many improve on their own over time. Therefore, for many conditions, one would expect improvement during the course of study, regardless of treatment.
2. Regression to the Mean: people are more likely to join a research study when their illness/problem is at its worst during its natural history. Therefore, it is more likely that the symptoms will improve during the study than if they joined at times when symptoms were not as troublesome. Therefore, in any given study – there is a tendency for participants in particular to improve after joining.
3. The Hawthorne Effect: people behave differently and experience treatment differently when they’re being studied. So for example, if people know they’re being observed regarding their work productivity, they’re likely to work harder during the research study. The enhanced results therefore, do not reflect typical behavior.
4. Limitations of Memory: studies have shown that people ascribe greater improvement of symptoms in retrospect. Research that relies on patient recall is in danger of increased false positive rates.
5. Experimenter Bias: it is difficult for researchers to treat all study subjects in an identical manner if they know which patient is receiving an experimental treatment versus a placebo. Their gestures and the way that they question the subjects may set up expectations of benefit. Also, scientists are eager to demonstrate positive results for publication purposes.
6. Experimental Attrition: people generally join research studies because they expect that they may benefit from the treatment they receive. If they suspect that they are in the placebo group, they are more likely to drop out of the study. This can influence the study results so that the sicker patients who are not finding benefit with the placebo drop out, leaving the milder cases to try to tease out their response to the intervention.
7. The Placebo Effect: I saved the most important artifact for last. The natural tendency for study subjects is to perceive that a treatment is effective. Previous research has shown that about 33% of study subjects will report that the placebo has a positive therapeutic effect of some sort.
So my dear readers – if the media wants to get your attention with exaggerated representations of research findings, and the research findings themselves are stacked in favor of reporting an effect that isn’t real… then how on earth are we to know what to make of health news? Luckily, R. Barker Bausell has explained all of this really well in his book and I will attempt to summarize the following principles in the next few posts:
1. The importance of credible scientific evidence
2. The importance of plausible scientific evidence
3. The importance of reproducible scientific evidenceThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in Uncategorized
No Comments »
It’s time for the 4th annual Medical Blogger awards… nominate your favorites at MedGadget:
This competition
is designed to recognize the very best from the medical blogosphere,
and to highlight the diversity and excitement of the world of medical
blogs.
The categories for this year’s awards will be:
— Best Medical Weblog
— Best New Medical Weblog (established in 2007)
— Best Literary Medical Weblog
— Best Clinical Sciences Weblog
— Best Health Policies/Ethics Weblog
— Best Medical Technologies/Informatics Weblog
— Best Patient’s Blog
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in True Stories
5 Comments »
For more than a decade, I successfully avoided a visit to the orthopedist for a chronic elbow problem. Today I reluctantly decided, on the advice of a friend and orthopod, to go to the hospital and find out once and for all what could be causing my elbows to lock during certain exercises.
The process took 4 hours, all told. I registered at the clinic, then proceeded to the radiology suite to wait for some X-rays. There was a long line of legitimate-appearing X-ray candidates before me – some in casts, others in slings, still others limping pitifully. I was just fine and pain free, feeling a bit guilty – as if I might be wasting resources.
I glanced at the films as I put them in a folder to take back upstairs to the clinic – they looked perfectly normal. “Oh, boy.” I thought, “young Caucasian female complaining of elbow locking for 15 years, now with normal X-rays.” I bet the orthopedist is going to roll his eyes at me. I was escorted to an examining room where I sat on a table across from my normal X-rays, clipped on a light box.
A trim and athletic gentleman in his mid 60’s introduced himself to me. He had crystal blue eyes and short white hair… and disproportionately large hands (kind of the way Michelangelo’s David does). I was sure that I was the healthiest person he’d see that day. He glanced at my totally uninteresting elbow X-rays, took a deep breath and raised a skeptical eyebrow as he asked me to describe my difficulty.
“Well, when I’m at the gym, my elbows lock at about 15 degrees from full extension during certain exercises. It’s always during the eccentric phase of muscle contraction, and usually during a lat pulldown or seated row. If I rotate my forearm there’s a snap and the discomfort disappears and I can resume the exercise.”
He was impressed by the specificity of my description, and asked me to demonstrate the problem. I felt a little bit silly, but attempted to keep a straight face. Seeing that we were not going to be able to reproduce the problem without counter weight, the good doctor jumped in to simulate the exercise by pulling on my arm. I pulled back, and we soon realized that he was unable to apply a force strong enough to trigger the problem. In fact, I pulled the poor man off balance and nearly dropped him on the floor.
After a few more maneuvers he concluded that he had no idea whatsoever what the problem might be. He told me that since the X-rays were normal there was probably nothing to worry about, and that I might consider avoiding lifting weights in “clanky gyms filled with smelly, sweaty people.”
He dictated his note in front of me, highlighting my excellent health, unusual strength, and completely benign X-rays. He seemed to relish the whimsy of the fact that he was no physical match for me (a smallish blond woman) and added that I was unlikely to be damaging my elbows at the gym.
His advice, as I had anticipated, was to “stop doing the things that trigger the locking” and to consult him if I developed any neuropathic pain or effusions. He added that I reminded him of his daughter.
Well, it was an amusing interaction – but somewhat unsatisfying. It made me think of all the times that I wasn’t sure what was wrong with my patients, and how disappointed they were when I had to tell them this. Medicine is an inexact science at times – and the best that we can do is rule out the really bad stuff, and shrug when the rest remains unclear.
Have you had a problem but couldn’t find a diagnosis? Do tell…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 15th, 2007 by Dr. Val Jones in Health Policy, Opinion
5 Comments »
More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).
In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):
Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.
Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).
“We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.
While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.
What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?
I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”
My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.
My mother said tersely, “I hope I die in Europe.”
My father replied, “Whether you’re old or young, it’s nice to be alive.”
But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?
This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 14th, 2007 by Dr. Val Jones in Humor, True Stories
3 Comments »
My sister Vicki lives in Grand Rapids, Michigan with her husband, three children and
an alarmingly large and slobbery Saint Bernard named Gilbert. Several Christmases ago she decided to teach her then 5 year old son, Harrison, about Christmas tree decorating. She took him to a Christmas tree farm and helped him select a tree. They hauled it back to the house and my sister managed, with no help whatsoever from Gilbert, to set it up in a nice corner of the living room. The tip of the tree reached the ceiling and its full figured branches spread from icy window to window.
Vicki and Harrison spent hours and hours winding lights, tinsel, ornaments, paper angels and popcorn strings around the tree. Little Harrison couldn’t wait to see the final product, with glittering lights and a magical star to top off their fine work. They decorated into the early evening, and the living room grew dark as the sun set over the snow covered neighborhood. At last it was time to plug in the tree lights.
As Vicki plugged in the lights for the first time, Gilbert roused himself from his resting place in front of the fireplace and shook off his drowsiness. Harrison held his breath in eager anticipation of the twinkling display that he had helped to create. My sister turned off all the overhead lights.
As the plug entered the outlet, the tree lit up with thousands of tiny glittering lights. Harrison
marveled at his glorious creation. “Mom, it’s the most beautiful tree in the world!”
My sister sat down on the couch and hugged her son tightly in her lap as they relaxed and enjoyed the view. Suddenly, Harrison’s eyes fixated on one of the branches.
“Mom… look! There’s an icicle on the tree!!”
My sister squinted and followed the direction of Harrison’s pointing finger.
Sure enough, there was a glassy, 5 inch long, icicle-appearing object perched in a tree branch in the middle of the tree.
Harrison’s raised his voice with glee: “Mom! It’s a Christmas MIRACLE!!”
The little boy broke free of his mom’s grasp and ran up to the tree to inspect the icicle at close range. As he reached out his hand to clasp it, his look of amazement turned to horror. The icicle was in fact a long
string of dog drool that had flicked off of Gilbert when he shook himself out of his sleep.
“Ewww!!!” Harrison screamed. My sister slowly realized what had happened and started laughing
uncontrollably. Gilbert wanted to get in on the fun and began barking and running in circles. He became tangled up in the extension cord and pulled the tree right out of the tree stand. At that moment, Vicki’s husband returned from shopping with the other 2 children. As he turned on the lights he found my sister
trapped under an unraveling Christmas tree, a hysterical child frantically wiping his hands on paper towel, and a barking, drooling Gilbert in the midst.
“What happened here?!” he shouted, attempting to rescue Vicki from underneath the tree.
“It’s a Christmas miracle” was her muffled cry.
And this story will be in our family for a long time to come.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
