February 14th, 2008 by Dr. Val Jones in Uncategorized
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Happy Valentine’s Day folks – hope you have some great plans tonight with your significant other… but if not, [insert hopeful grin], why not join me, crzegrl and Jenni from Chronic Babe at the Dr. Anonymous show tonight (Feb 14th from 9-10pm EST)? We’re going to be talking about gender differences in medicine, romantic patient stories, and the importance of good relationships. There’s a live chat feature, a call in number, and a video feed of our host, Dr. Anonymous.
I hope to see a few of you there in the chat room or calling in! If you can’t make it, check out the podcast link tomorrow on Dr. Anonymous’ website.
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.
February 2nd, 2008 by Dr. Val Jones in Opinion
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I must have a really trustworthy face. No matter where I go, absolute strangers ask me for directions, they request that I watch their belongings, hold their place in line, they even ask me to help with their kids. I am continually astonished by the uninvited inquiries that I receive walking down the street, on the train, or even in foreign countries. I guess people think I’m both harmless and likely to know how to help them. They are right about the first part, and not quite as right about the second.
Just a couple of days ago I was settling into a train seat when the woman in front of me peaked over the head rest and asked if I’d mind watching her bags while she left to go to the restroom. I happily agreed to do so, wondering what I’d actually do if someone tried to take her bag. And as I mused about how on earth I’d won her absolute confidence without even making eye contact, I began to think about the idea of trust. How do patients decide whom they trust with their medical care?
I’d like to think that trust is earned – and many times it is – but there’s also something more primitive about it than that. Without knowing a person for long enough to judge his or her character, we often draw conclusions nonetheless. How successful are we at these snap decisions? Well, we might be quite good at it. I was amused to find an online test where you may judge the sincerity of a person’s smile just by looking at a 4 second video clip. Some of the models were asked to smile convincingly, and others were told a joke or were caused to laugh by some genuine means. Most people figure out which smile is contrived and which is natural most of the time. See how you do.
And so, when it comes to finding a primary care physician, or a doctor that you trust with your medical care, should you rely on your gut instincts or is there a better way to assess their competency?
I’ve wrestled with the idea of online physician ratings for a couple of years. Part of me thinks that it’s impossible to capture all the qualities of a good physician in some simplified form filled out by non-medical professionals. But another part of me wonders if a large collection of different experiences might add up to an opinion trend that’s on the mark. Whether or not you’re a fan of physician ratings, they are here to stay. Perhaps the best we can do is offer as many ratings as possible so that the average might provide high level, helpful information. Revolution Health has a free physician rating tool. Check it out.
How do you know whom to trust? Do you rely on your instincts or the referral of someone you know? Would online physician ratings be helpful, harmful, or simply limited in their utility?
Let me know… and if you see me on the street, yes, I’d be happy to watch your bags.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 1st, 2008 by Dr. Val Jones in True Stories
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For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.
Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:
Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.
Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.
So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.
Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.
How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.
There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?
This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.
I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 27th, 2008 by Dr. Val Jones in Humor, True Stories
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I spent the weekend with 6 nieces and nephews, ranging in
age from 6 weeks to 13 years. One four-year-old niece was particularly
interested in engaging me. I tried to warn her that I was terribly boring and
that I wasn’t good at playing with dolls. But she remained unfazed by my
late-night protestations.
“Auntie Val would you like some ice?” She said, presenting
one melting ice cube to me in her warm hand.
“Hmm… no, not really, thanks.” I mustered a smile hoping
that she wouldn’t feel rejected.
The little girl went on, “Well, my bed is full of soft
blankets so you should put on your jammies and we can go to sleep there. It
will be a lot of fun.”
“Ah… well, that’s very kind of you to offer, but I think I
need my teddy bear to fall asleep. Uncle Steve is my teddy bear.” I pointed at
my husband sitting next to me on the couch.
The little girl replied matter-of-factly, “No he’s not. He’s
your cake.”
“Um… well, that’s an interesting way to look at it.” I
replied awkwardly.
“You know, if you kiss uncle Steve then you’ll be married.”
She went on.
Steve immediately kissed me on the cheek and smiled
triumphantly.
“No, you have to kiss her on the lips, uncle Steve.” The
little girl put her hands on her hips.
“Uh… well… Honey, would you like to marry me again?” I asked
sheepishly.
“Why yes I would…” and Steve gave me a peck on the lips.
Then the girl squealed with glee and ran around the coffee
table one and a half times.
Does this buy me a second honeymoon?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
