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Health And The Value Of Open-Mindedness

Three recent sto­ries lead me to my open­ing topic for the year: The value of open-mindedness. This char­ac­ter­is­tic — a state of recep­tive­ness to new ideas — affects how we per­ceive and process infor­ma­tion. It’s a qual­ity I look for in my doc­tors, and which I admire espe­cially in older people.

Piece #1 — On the brain’s matu­rity, flex­i­bil­ity and “cog­ni­tive fitness”

For the first piece, I’ll note a Dec 31 op-ed piece that appeared in the New York Times: This Year, Change Your Mind, by Dr. Oliver Sacks, the neu­rol­o­gist and author. In this thought­ful essay, he con­sid­ers the adult brain’s “mys­te­ri­ous and extra­or­di­nary” power to adapt and grow: “I have seen hun­dreds of patients with var­i­ous deficits — strokes, Parkinson’s and even demen­tia — learn to do things in new ways, whether con­sciously or uncon­sciously, to work around those deficits.”

With appro­pri­ate and very-real respect, I ques­tion Sacks’ objec­tiv­ity on this sub­ject — he’s referred some of the most out­stand­ing (i.e. excep­tional) neu­ro­log­i­cal cases in the world. And so it may be that his care­ful reports are per­fectly valid but not rep­re­sen­ta­tive; for most of us, the adult brain’s capac­ity to estab­lish new cir­cuitry for lan­guage learn­ing or music appre­ci­a­tion may be lim­ited. What his sto­ries do show is that unimag­in­ably strange things hap­pen in our brains, at least occa­sion­ally. And maybe we should just accept that and take notes (as he does so care­fully), and keep an open mind.

Finally, he writes:

…all of us can find ways to stim­u­late our brains to grow, in the com­ing year and those to fol­low. Just as phys­i­cal activ­ity is essen­tial to main­tain­ing a healthy body, chal­leng­ing one’s brain, keep­ing it active, engaged, flex­i­ble and play­ful, is not only fun. It is essen­tial to cog­ni­tive fitness.

I’m inspired by the notion of keep­ing a fluid, active mind. It’s not easy to keep abreast of new data, and to read the lit­er­a­ture crit­i­cally. While some peo­ple become more with­drawn in adult­hood, rest­ing on com­fort­able rou­tines and reli­able sources, I choose the oppo­site: read­ing blogs, scan­ning Twit­ter, check­ing out lec­tures on YouTube, watch­ing new TV shows, lis­ten­ing to my kids and stu­dents.

Paper #2 — On an incred­i­ble effect of known placebos

Another curi­ous Decem­ber story, Place­bos with­out Decep­tion: A Ran­dom­ized Con­trolled Trial in Irri­ta­ble Bowel Syn­drome, appeared in the strictly on-line jour­nal PLosONE. The arti­cle is per­haps more defin­i­tive, as it is more puz­zling: the inves­ti­ga­tors observed that when peo­ple with irri­ta­ble bowel syn­drome (IBS) took placebo drugs in a clin­i­cal trial, even though they knew they were receiv­ing a placebo and not real med­ica­tion, they felt sig­nif­i­cantly bet­ter than those patients who didn’t receive the open-label, placebo treatment.

As a reader and sci­en­tist, I can­not under­stand this obser­va­tion except to say most likely it’s an exper­i­men­tal fluke. But the study’s sta­tis­tics were strong, and the trends inter­nally con­sis­tent, ren­der­ing it likely that what the inves­ti­ga­tors reported could be repro­duced. The patients’ symp­toms are highly sub­jec­tive in IBS, although they can be debil­i­tat­ing and costly. My con­clu­sion, try­ing to be open-minded about a result that seems improb­a­ble if not impos­si­ble, is that maybe there are things we don’t really under­stand about how “med­i­cine” affects humans.

The eth­i­cal impli­ca­tions of this find­ing — that “place­bos work” — are inter­est­ing, if it’s true (which I wouldn’t con­clude based on this one study reported in PLoS, or any­where). For now what I’d say is the results are intrigu­ing. I’m curi­ous to see if these results are repro­duced, and how the eth­i­cal impli­ca­tions will be ironed out in our mod­ern med­ical community.

Story #3 – On the ques­tion­able effects of echinacea

The third arti­cle, pub­lished in the Dec 21 Annals of Inter­nal Med­i­cine, con­sid­ers the poten­tial of echi­nacea in treat­ing the com­mon cold. The results of a 4-armed, ran­dom­ized study involv­ing 719 patients with symp­toms of an acute res­pi­ra­tory infec­tion (“a cold”) were incon­clu­sive, at best. A skep­tic might say of the trial, spon­sored by the National Cen­ter for Com­pli­men­tary and Alter­na­tive Med­i­cine (NCCAM), that it proves once and for all that echi­nacea is ther­a­peu­ti­cally use­less. Another reader, per­haps versed in the flower-derived substance’s pur­ported effects in other and ear­lier cul­tures, might charge that the inves­ti­ga­tors chose the wrong prepa­ra­tion, derived from roots of the E. angus­ti­fo­lia and E. Pur­purea species, or that the researchers picked the wrong dose to observe an effect of the drug on the dura­tion and inten­sity and bio­log­i­cal effects of a com­mon cold.

I’ve never tried echi­nacea and have no finan­cial or other par­tic­u­lar inter­est in this com­pound. But hav­ing read the arti­cle a few times, I’m dis­ap­pointed, even unset­tled by the results. After so many stud­ies, many of which are ref­er­enced in the Annals paper, and now this costly, NIH-sponsored find­ing of what’s essen­tially no effect, it’s hard to say that echi­nacea is help­ful to any­one. At the same time, I don’t think there’s suf­fi­cient infor­ma­tion to say that it doesn’t work in pre­vent­ing or reduc­ing the inten­sity of an upper res­pi­ra­tory tract infec­tion, or that it doesn’t work in some indi­vid­u­als who have symp­toms like a runny nose and sore throat.

Accord­ing to the ACP Internist (where I am a contributor):

…The study’s lead author, Bruce Bar­rett, MD, PhD, told USA Today that echinacea’s sup­port­ers would prob­a­bly con­sider the find­ings pos­i­tive but that those who oppose it for the com­mon cold would con­sider the study “the nail in the cof­fin.” The direc­tor of the study’s pri­mary fund­ing source, the National Cen­ter for Com­ple­men­tary and Alter­na­tive Med­i­cine, told USA Today that the cen­ter doesn’t plan to sup­port future sim­i­lar research, since exist­ing data make clear that Echinacea’s ben­e­fit for the com­mon cold, if any, is “very modest.”

Still, we don’t know if echi­nacea might work bet­ter as a tea pre­pared from dried roots or some­how oth­er­wise ingested by peo­ple who are sick, as opposed to the pill com­pound that was given to par­tic­i­pants in the Annals study, or if an extract com­pounded from a dif­fer­ent com­bi­na­tion of Echi­nacea flower species might do the trick.

So if a doctor is open-minded and her patient wants to try tak­ing echi­nacea tea for a blos­som­ing cold, she might tell the patient that there’s not much evi­dence based on pub­lished tri­als of the herb, and that in fact so far the echi­nacea data aren’t sup­port­ive of a mean­ing­ful effect in any patient group. At the same time, there’s prob­a­bly lit­tle risk of try­ing echi­nacea, in that it seems to have few unto­ward effects. And the patient and physi­cian might then observe what hap­pens, and draw lim­ited if any con­clu­sions based on that person’s indi­vid­ual, n=1 expe­ri­ence with echinacea.

A closed-minded doc­tor might tell her patient that echi­nacea isn’t worth try­ing, in any form. In her mind, she con­sid­ers the sub­stance is a sort of nat­ural or home-remedy that has no role in mod­ern med­i­cine. She might even feel it’s a waste of her time to dis­cuss the alter­na­tive treat­ment with her patient, and per­ceive the patient as being unco­op­er­a­tive if he or she tries tak­ing it against her advice.

Patients’ atti­tudes vary, as do their doc­tors, and given a choice of physi­cians patients prob­a­bly choose doc­tors whose per­sonal philoso­phies roughly align with their own.

For now what I’ll say is this: I respect it when a doc­tor admits uncer­tainty, and is will­ing to try some­thing of low cost and low tox­i­c­ity, for which the evi­dence is thus-far unclear. (Of course, if we extend this argu­ment to a dis­cus­sion of more costly and poten­tially toxic drugs — like new can­cer treat­ments, we’d need to weigh more care­fully the poten­tial harms of a treat­ment against the unproved ben­e­fit.) In prin­ci­ple, though, I like the approach of an open-minded doc­tor, who rec­og­nizes the lim­i­ta­tions of pub­lished data, and is will­ing to explore an unproved approach to a prob­lem in a way that’s trans­par­ent: as long as the doc­tor doesn’t sell the echi­nacea, and is hon­est with the patient about the lack of evi­dence to sup­port its use, it seems okay.

How much bet­ter it is to approach infor­ma­tion with an open mind, to take it in and con­tem­plate its ram­i­fi­ca­tions, than to sim­ply say “no, that’s impos­si­ble.” As far as my doc­tors are con­cerned, I hope that’s their atti­tude, too.

*This blog post was originally published at Medical Lessons*

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