Saturday Case Study—updated

A 28 year old woman consults a plastic surgeon about a scar on her face left over from a childhood accident.  As part of a preoperative workup, she has some blood drawn.  Her pregnancy test is negative, and she is found to be anemic, with a hemoglobin of 8.1 g/dL (normal 12.1-15.1).  She is sent to you for further evaluation.

She comes to the office a little worried.  You take a detailed history. She is of Armenian ancestry. Among the pertinent positives and negatives: she has no family history of anemia.  She has an IUD in place and has very light periods.  She eats a balanced diet which includes a moderate amount of red meat.  She has had no chest pain, no fatigue, and no shortness of breath and plays soccer regularly in a local league.  She has not observed any blood in her stool.  She has had no recent infections that she recalls.  She drinks a moderate amount of alcohol.  She has a history of an anxiety disorder since childhood with occasional panic attacks and episodes of abdominal cramping and migraine.  She has occasional constipation alternating with diarrhea.

I invite you to ask a few questions to round out the history, then I will add the physical exam findings.  I would prefer that you not pipe in with proposed diagnoses until we complete the case.

Update:

In response to the very reasonable questions below:

  • She has no common symptoms of gastric reflux (heart burn, acid brash, etc.)
  • She is not light-headed when standing.
  • She plays soccer twice a week, and has noticed some fatigue near the end of a game.
  • Family history: grandfather with heart disease, grandmother with diabetes, great aunt and cousin with familial Mediterranean fever
  • Her medications include the above-noted IUD, calcium with vitamin D, a multivitamin, and a “energy enhancer” pill that she started a few weeks ago.
  • There have been no hair or skin changes
  • No overt bleeding other than her normal menses
  • She tried eliminating a few foods to prevent migraines, but soon tired of the effort and did not find a connection
  • She has not noted any sensory disturbances

On physical exam:

Heart rate is 92, blood pressure is 110/58, weight is 106 lbs.

She is thin, muscular, and in no distress.

There is mild pallor of her conjunctivae.

Her heart rate is regular and there is a 1/6 systolic murmur at her left sternal border

Lungs are clear

There is no abdominal distention, no organomegaly.

Her labs are in progress, but you ran to the microscope and made this peripheral smear:

Update 2:

Relevant lab results (first round):

Liver function tests (including LDH and bilirubin) normal. Basic metabolic panel normal. MCV 68 (low). Folic acid normal. Vitamin B12 150 (low).  Iron 10, TIBC 454, ferritin 2.

In the way of the boards: her laboratory results are consistent with an iron deficiency anemia.

Next: Differential diagnosis.  Iron-defiency anemia must have a cause.  What studies do you want to see (within my ability to produce them)?

Update 3:

To finish off answering your questions:

  • The energy supplement’s main ingredient is “guaranine”
  • Tissue transglutaminase IgA 122 U/mL (serum IgA levels within normal limits.

Final Update:

The patient has celiac disease, confirmed by a biopsy of her duodenum.  Her anemia and her abdominal discomfort resolved on a gluten-free diet.

Nooooooo!!!

Yesterday afternoon I started sneezing.  Damn warm winter and early spring! Here come the allergies!

By the time I got home I was tired.  My throat was a bit itchy.  As the evening went on I felt as if someone had crawled inside me and taken a sledge hammer to my bones.  I gobbled some naproxen and benadryl and lay on the bed staring at the ceiling fan.  I blinked, trying to find the frequency that would “freeze” the fan, until blinking became painful.

Eventually I drifted off into a dream-haunted sleep, one where the little bone crushing dybbuks were thankfully absent.

I sit in a small room with sick people every day all day.  In the last few years, I don’t think I’ve missed a day due to illness.  I’ve been lucky.

But a few days ago I took a plane ride.  Two and a half hours stuffed into a metal cylinder, cheek to jowl with strangers.  Ugh.

But I suppose I shouldn’t complain.  I speak to people every day waiting for their cancer surgeries, recovering from their heart attacks, living with busted spines.  Suffering is relative (unless it’s your own).

 

Should I lick this?

Originally posted October 14, 2010.  A little weekend repost. –PalMD

When I lived in Northern California, I would often hear stories about people scouring the back country for psychedelic toads.  In popular imagination, these toad wranglers would then gather around bonfires and with great ceremony and earnestness, they would lick hapless bufoids until they (the humans) fell into ecstatic trances—and then vomited profusely. These stories, often parroted by local media, would end with the news that toad licking had finally been outlawed by the state.   The truth, as usual, is quite a bit more complicated.

Bufotenin, one of many molecules secreted by the skin and parotid glands of some toads of the genus Bufo, is classified by the DEA as a Schedule I drug.  This is the same class as heroin, mescaline, cannabis, and other drugs the DEA feels have a high potential for abuse and little or no therapeutic value.  Bufotenin is also present in certain mushrooms, so I wouldn’t swear that is was outlawed because of a pandemic of toad licking.

But many toads are toxic.  While there are few reports in the literature about poisoning due to toad licking, there are plenty of reports of accidental toad poisoning.  Toads are a food product in parts of Southeast Asia.  There have been many reports of accidental toad poisoning in rural Laos, especially when toad skin and toad eggs are part of a meal.

But there’s more than one way to get killed by a toad. A traditional Chinese herbal medicine called ch’an su *, which has been sold as an aphrodisiac, topical anesthetic, and a heart medicine, has been responsible for poisonings both in Asia and the U.S. (one of the versions sold in the U.S. was “marketed” as a topical medication, but was taken internally, perhaps for the hallucinogentic affects).  

Some of the chemicals present in toad venom are closely related to cardiac glycosides such as digoxin, a potent naturally-derived heart medication, and intoxication with toad venom closely resembles digoxin poisoning.  In fact, blood tests in victims are often positive for digoxin.  Given the similarities to digoxing poisoning, investigators have tried treating toad poisoning in a clever way. Digoxin (and toad) poisoning requires intensive medical care.  Even with close care, a patient can die of fatal heart arrhythmias.  But a couple of decades ago, an antidote was developed for digoxin poisoning.  Sheep are injected with digoxin and anti-digoxin antibodies are then isolated from their blood.  These antibodies are then chopped up so that only the “Fab” portion is present.  When given to a patient with digoxin toxicity, the Fab binds to circulating digoxin, preventing it from binding to other receptors in the body, and allowing it to be harmlessly excreted by the kidney.

Given how closely toad poisoning and digoxin poisoning resemble each other, and that toad toxins are similar enough to digoxin that they show up as digoxin in toxicology tests, it seems reasonable to think that the same antidote may work for both poisons.  This has been tested in several cases, with apparently good results (there data are limited by the small number of patients).

Cardiac glycoside poisoning is very dangerous.  It would appear that poisoning by sources other than regular medications has a high fatality rate.  Given this, it would seem reasonable to treat suspected toxicity with digoxin immune Fab.  The only catch is cost and availability.  If a kid in New York eats some Chinese toad venom, any hospital can administer the antidote.  If a woman in a small Laotian village eats a bad batch of toad soup, the cure may not be available.  The cost may also be prohibitive.  Each vial costs around $700, and it wouldn’t be unusual to give 10 vials.

It may be hard to prevent toad poisoning among rural Laotians without solving societal problems of poverty and hunger.  But in this country we can easily avoid consuming potentially deadly herbal remedies.

*(a special shout-out to my buddy David Kroll who may be interested in this bit of history, if he doesn’t already know it).

(more…)

Death smells like vanilla

She lay in bed, her breathing erratic; she would breathe in deep and fast, then exhale slowly, as if she’d just hit her first cigarette of the day.  In place of a cigarette was a tube, about a quarter of an inch wide. It was stained brown, and every few minutes a bucket attached to the wall would make a hissing sound, and brown sludge would course from the tube into the bucket.  Presumably, the tube went down to her stomach.   The brown sludge, being contained in tube and bucket, didn’t convey a smell or any other hints as to what it might be.

Another tube was in her nose, making a faint, continuous hissing noise.  It also had a bit of a brown stain, just on the tips that sat inside her nose.  It ran from her nose to another wall outlet, just next to the sludge bucket.

The third tube ran out from under her blanket, across her exposed thigh, and over the side of the bed.  It ran into a large, thick plastic bag filled with something that looked like urine, but with white flecks forming a cloudy layer at the bottom of the bag.  That tube also had spots of brown sludge, but not exclusively, as the oral tube did.

She seemed to produce a lot of brown sludge.  A bedside commode had a bit in it, and that one did have an odor, a faintly sweet but strongly fecal smell.  More powerful was another bit of sludge on a shelf by the window.  In between flowers in various stages of wilt; between cards, some with the neat hand of an older person, some in the large scrawl of a grandchild; next to pictures of someone who must be her, but without tubes and beautiful; on that shelf was a small styrofoam bowl filled something that looked like cooled beef consomme.  It was brown, of course.

From that small bowl, a powerful scent flowed around the dying flowers, past the cards and toward the dying woman.  The consomme wasn’t beef, but vanilla.

People think of vanilla as subtle; it’s synonymous with “bland”.  But not this vanilla.  The hospital-grade vanilla flows thickly through the room, around the sludge bucket, the commode, the still-living body.  It attaches itself to other smells, sometimes accenting them, hopefully but rarely overwhelming them.  It shares every room filled with brown sludge and grief.

That pleasant scent, the one that defines bland, attaches itself to something else, becoming something else.  It becomes part of the smells of dying, of suffering. It becomes cloying, suffocating,  insufferable.  Outside the woman’s room, it may be subtle, but it hints of what is behind the door—tubes, brown sludge, sunken cheeks, uneven breaths.

 

Are you a 99214 with 250.02, 401.1, and 272.2?

Yeah, it’s a recycled post. So sue me. –PalMd

When I see a patient at the office, I spend time developing trust, forming a therapeutic alliance, thinking through their physical complaints, examining them, and applying the best evidence to formulating a plan for maintaining their health. It’s a lot of fun.

Less fun is the part where I try to get paid. To bill an insurance company, I must use numeric diagnostic codes that best fit what I’m seeing, and I must pick a code representing a level of service, that is, how hard I worked.

The diagnostic codes are referred to as ICD-9 codes, and the service codes are called E/M codes. Not all ICD-9 codes are easily billable. I treat a lot of anxiety and depression, but since I’m not a psychiatrist, I can’t really bill for it. If a patient comes to see me for anxiety or depression and that’s what I bill for, I probably won’t get paid. I can bill for “malaise and fatigue” (780.7), but not for generalized anxiety disorder (300.02) (supposedly it’s possible, but, like the Loch Ness monster, it’s always a friend of a friend of a friend who saw it).

Once I’ve pigeon-holed a patient into a set of diagnoses for billing purposes, I’d better make sure that there is a diagnosis code to “match” with any tests I order, or the patient will get a big bill. If I think a blood count is necessary, but I forget to write “anemia” (285.9), the insurance company won’t pay for it.

In determining how I’m allowed to bill for a visit, I have, for a returning patient, five choices: 99211-99215. The level is determined by the number of “elements” I document, or something like that. These five E/M codes are determined by my documentation. I must document a “chief complaint” as any physician should, and then…well then it gets tough. I make notes in a chart based on a standard format used by physicians for decades, but parsing out what code is born from it is difficult. In determining the code, I must consider three parts of my note: history, physical exam, and medical decision making (remember, it’s flu season, and I’ve got a lot of patients waiting…).

Included in “history” are several items, including past medical problems, medications, and a “review of systems” in which a doctor must document having tried to obtain information on 14 separate organ system. It’s not clear to most physicians how much needs to be present for a particular billing level.

Physical exam is easy though. Sort of. I mean, we all do them every day, but the coders divide exams into categories based on how many organ systems were examined. These levels range from problem-focused (one area examined) to comprehensive (9 organ systems examined).

Medical decision making takes into account how much thinking you had to do, how much data you had to review, and how much risk there was. How is this determined, and how do you combine these three elements to get a code?

This helpful tool should clear things up.

If I want to get paid for my work, then while seeing patients and making complex medical decisions, I have to look over what I’ve written and attempt to apply some sort of complicated and nonsensical flow sheet. If I choose wrongly, payment can be denied, or worse, I can be charged with fraud.

And this doesn’t even begin to address the “incentive” systems that require me to enter individual patient data into various data bases in order get paid fully for my services.

So why would anyone want to practice medicine in the States?

Any real health care reform has to address this insanity.

Lie to me

Once upon a time we used to let drug reps feed us, bring us tchotchkes, and generally use our time.  The staff liked the free food, and our patients liked the free drug samples.  But we didn’t like how it made us feel.  The pharmaceutical companies have stopped giving out pens and such, and we have stopped allowing them to bring us lunches.  There are a few samples which are still useful, especially respiratory drugs which aren’t available as generics.  To this, we give in, and we do allow reps to stop by the office with samples, occasionally taking a bit of our time.

Studies show that these interactions affect prescribing patterns.  I’m not happy about it, but it’s hard to get some drugs for my patients.  The reps know me well enough to know that I don’t like to be detailed and that I’m pretty easily annoyed.  They’re tenacious beasts though.  A new one stopped by today.

She was trying to get me to prescribe a drug called Glumetza (Santarus, Inc.).  It’s a diabetes drug.  In fact, it’s a really good diabetes drug.  Not only is it a good diabetes drug, but it’s laughably cheap, although not under that name.

Glumetza is metformin—a drug also branded as Glucophage—in an extended release form.  Metformin costs about 4.00 USD per month.  The extended release version costs about 10-15 USD per month.  Glumetza costs about 250 USD per month.  This must be some sort of uber-metformin, right?  At that price it better lower your sugar and wipe your ass for you.

And that’s basically what it claims to do.  One of the problems with metformin is that it can cause some stomach upset, especially diarrhea.  In nearly all patients, this wears off in a few days, and when it doesn’t, changing to the extended release form (10-15 USD/mo, remember?) usually does the trick.  What does Glumetza claim?

Unlike immediate-release metformin, GLUMETZA uses a special advanced polymer technology that delivers the medicine slowly and steadily over several hours.5 This delay in the release of the medicine may result in fewer stomach-related side effects, such as nausea, in the 1st week of taking the medication.4

I don’t doubt that the company has a proprietary drug delivery system.  But what about the other claims?

The footnotes point to:

  1. The Glumetza package insert
  2. An inaccurate citation, but allows me to track down a journal article about extended-release metformin, not Glumetza specifically
  3. A patent summary
  4. A study that compared Glumetza, extended-release metformin, and immediate release metformin.  What did it find? We’ll get to that.
  5. A footnote leading nowhere.

Footnote 4’s study found that:

Even with a 1,000-mg q.d. starting dose, the overall incidence of gastrointestinal adverse events during the 1st week of dosing was low and comparable among treatment groups (Table 3). There was a higher incidence of nausea in the immediate-release metformin group than in the extended-release metformin groups (P = 0.05). In addition, there were more adverse events of nausea and diarrhea causing treatment discontinuation in the immediate-release metformin group than in the extended-release metformin groups. The overall incidence of adverse events considered possibly or probably related to the study drug was similar for all treatment groups; the only such events reported for >5% of patients in any treatment group were gastrointestinal events.

In other words, all forms of metformin were well-tolerated.  Even so, there was a measurable difference between the immediate release form and the extended release forms.  There was no convincing evidence that Glumetza was better than the cheaper, generic extended release metformin.  The discussion tries to be convincing, but the data don’t back any other conclusion:  Glumetza is different than generic metformin—it costs more money.

The lesson here isn’t that medicine is bad.  Metformin is a terrific drug, and cheap.  But the marketing of predictable and high-priced knock-off drugs does nothing to contribute to our health.  And plenty of physicians and patients fall for the not-so-cheap marketing.

Clusters

Lot’s of young people from the Detroit area move to Chicago, and I was one of them.  As a medical resident I worked with a fellow Michigander, an attending physician I’d known when we were younger.  One day he called me.  Did I know this woman from home? -Of course, sort of, why? -Because she’s in the hospital with something bad, and we have to find out what it is.

That story is long, and has a sad ending with bright moments in between.  But shortly after he called me again.  Did I know another talented young woman from back home? -Yes, better than the last, in fact. I was afraid to ask why.

She had something really bad, and that story ended badly, with few bright spots.  Some day I’ll dredge up the piece I wrote about it, but she was someone I knew only passingly well, but developed what was, at least to me, an unusual relationship, one between a person facing death and one who had seen a lot of it.  I’ll never know how she viewed it, of course, but I hope the friendship gave her some comfort.

A number of people from that particular part of town developed malignancies when young.  At least that’s what they say.  Many suspect a common factor, aside from geography and ethnicity, one that may explain this cluster of diseases. It’s never, to my knowledge, been investigated.

Disease clusters are a tough nut to crack.  Randomness does not describe a system where events are scattered evenly, but one in which there are voids and clusters without any unifying cause. It is the job of epidemiologists and public health officials is to figure out which clusters have a common cause and which are due to chance alone.

There is a cluster in the news right now.  In an Upstate New York community, several young women have begun to experience involuntary movements similar to the symptoms of Tourette’s syndrome. The tics that have been shown on TV are fairly complex tics, with stereotypic gestures and utterances.  The story has regained headlines because activist Erin Brockovich has become involved.

It has been reported that local neurologists have diagnosed the cases as “conversion disorder”, that is involuntary physical manifestations of psychological stressors.  Epidemiologists approach cases like this in various ways, identifying cases, commonalities, common exposures, etc.  They have to figure out if each individual case is physiologically similar, and if there may be a common cause, what it could plausibly be.  It’s a lot of work.

In this case it seems unlikely that Brockovich will turn up a valid environmental cause.  It seems more likely the underlying connection will be social, that is, a non-physical transmission of a disorder.  Disorders have been spread this way before, and will be again.  It doesn’t make them less real.  These young women are suffering, but from the evidence available, it appears their suffering is likely connected by knowledge rather than a traditional pathogen.  As they hear of someone else with symptoms, they begin to experience it themselves.

We don’t know exactly what makes people susceptible to such things, but they are very real.  The fact that they are not based on chemical exposures or bacteria makes them no less a problem.  But without the tedious gumshoe work of the public health community, it’s easy to blame something more sinister, like a landfill, or power lines, or foods.  These hypotheses, if found to be wanting, distract from the real cause, and real solutions.

And everything that creepeth upon the Earth

Courtesy Alex Wild Photography

Image courtesy of Alex Wild, click image for link

Not all hallucinations are disturbing, but most probably are.  They can be categorized by which sense is involved or by cause.  Schizophrenics often experience auditory hallucinations, hearing voices that are not actually present.  Many people can experience olfactory hallucinations, usually smelling foul odors that no one else can detect.  These are often caused by specific problems in the brain or nose.  A classic cause is seizure in the temporal lobe of the brain.

Visual hallucinations aren’t that common and usually aren’t associated directly with mental illness as auditory ones are.  Most of the time, visual hallucinations are caused by chemicals such as drugs, or by withdrawal from drugs.  Sometimes they are caused by specific brain disorders.  A classic cause of visual hallucination is delirium tremens, or acute alcohol withdrawal.  Victims often have disturbing visual hallucinations (one of my favorites being skeletons fighting with swords on the IV pole, although in that case, the patient wasn’t all that disturbed by it).

As if that weren’t enough, alcohol withdrawal is often accompanied by an additional type of hallucination called formication (from Latin formica ant). This is a tactile hallucination usually described as a feeling of bugs crawling on the skin.  It’s rarely pleasant.

Delusions differ from hallucinations.  Rather than being a sensory problem, they are a thought problem.  People with delusions believe something that is demonstrably false and cannot be convinced otherwise.

Which brings us to what is surely not the end of the story of “morgellons syndrome”.  Over the last few years, patient advocacy groups have militated for further investigation of this putative skin disease.  The disease is characterized by a variety of symptoms, most of which are cutaneous and include itching, sores, and foreign substances arising out of wounds.  Most physicians view this as a variant of delusional parasitosis, an illness where people believe they are infested but no proof of infestation can be found.

Patients typically have a pattern of skin lesions indistinguishable from damage done by scratching, and the fibers and other substances, when analyzed, have been found to be common substances such as clothing fibers.  Even a brief perusal of morgellons advocacy websites will demonstrate the hostility with which this analysis is viewed. Sufferers believe they are truly stricken—and they are. But the enemy is within rather than without. Their brains have convinced them that their skin is crawling with various sorts of things and they cannot be convinced otherwise.

A few years ago, the CDC decided to investigate what they have labelled “unexplained dermatopathy”.  This week, the results of their study were published in PLoS ONE.

The investigators focused on Northern California, where there seemed to be many case reports.  They sifted through charts and invited those who described the syndrome to join the study.  What they found was that cases were rare, but were associated with significant disruption in quality of life.  They also found a significant incidence of neuropsychiatric disorders.  A remarkably large percentage of patients had hair samples testing positive for drug use, but the specific drugs are not reported, nor is the validity of the hair sampling technique.

In sum, there was a set of patients who reported disturbing skin sensations and wounds, who were disproportionately unhappy and may have been using drugs.  But which way does the arrow of causation go?  Does a mystery disease cause people to become depressed and use drugs, or does psychiatric disease and/or drug use cause a delusional syndrome? Delusions and hallucinations caused by psychiatric disease and substance use are well-documented.  The other way ’round is a bit murkier.

Some clues are found in the study.  Many cases began around the same time the internet picked up on morgellons suggesting a folie a deux/plusiers —a shared delusion (this also suffers from a correlation vs. causation problem).  Also, the skin changes among patients were diverse, too diverse to be easily explained by a single non-psychiatric cause. Pathology findings most commonly showed skin changes due to sun exposure and trauma such as scratching.  Finally, the “fibers” and other objects emerging from the skin were found to be common substances like threads from clothing and were not emerging from the skin but rather were enmeshed with skin debris.

This will not be the last word on this particular variant of delusional parasitosis.  The definition of a delusion is a fixed, false belief, one that is not dislodged by data or knowledge.  The inability to accept the diagnosis is part of the illness itself.  The challenge to clinicians will be to treat these patients delicately, with respect, acknowledging their real distress and attempting to guide them toward proper treatment.

References

Pearson, M., Selby, J., Katz, K., Cantrell, V., Braden, C., Parise, M., Paddock, C., Lewin-Smith, M., Kalasinsky, V., Goldstein, F., Hightower, A., Papier, A., Lewis, B., Motipara, S., Eberhard, M., & , . (2012). Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy PLoS ONE, 7 (1) DOI: 10.1371/journal.pone.0029908

Think like a doctor, Part III

In Part I we discussed the history of medicine as a science. In Part II we addressed the role of compassion. This is the third part of the series.

Meridians of so-called Traditional Chinese Medicine

In 1994, I first put my hands on a human cadaver.  When we first received it, the head and hands were wrapped.  The rumor was that this would help us to adjust to the humanity of the thing more gradually.  When we did uncover the hands, the nails were painted, giving the meat a sudden, undeniable humanity.

Over the months, my friends and I slowly dissected this person, finding nerves, veins, arteries, muscles.  At the same time we learned the microscopic anatomy.  We learned how chemistry drove the smallest units of muscles, causing the whole to contract and lift an arm. We learned how specialized channels in the gut could be poisoned, causing cholera patients to dehydrate and die in hours.

We learned how the immune system could be taught to fight influenza; the mechanism by which common antibiotics poisoned cell wall formation in bacteria; the horridly complicated function of the smallest functional unit of the kidney called the nephron.  We stood on the shoulders of giants. I loved it.

The first two years of medical school is an intimate visit with the inanimate.  Living patients are scarce; the knowledge the human machine is the focus.  We stayed in the labs until the middle of the night examining our cadaver, looking into microscopes and comparing what we saw to pictures in books.  We traced out biochemical pathways on chalkboards.  Never did we see anything corresponding to a meridian or to the four humors, or any other pre-scientific medical ideas. They were clearly a fiction, one dreamed up by our ancestors to explain something insanely complicated.

In the third year, when we did finally see patients regularly, it all came together—slowly.  It’s a medical aphorism that patients don’t always read the textbooks.  Their diseases may not follow expected patterns.  And the addition of real human desires and fears complicates everything.

It takes years to learn how to use medical knowledge to help real people, but you can tell immediately how comforting a word or gesture can be.  During that period of perceived incompetence, while you learn how put book knowledge into practice, we reach for things we already—hopefully—know: how to comfort people.

So-called alternative medicine seems attractive at this point because it purports to focus on the compassion, the relief of symptoms. Let’s look into why this is a false compassion.

During my third year internal medicine rotation, some of the nurses were practicing “therapeutic touch” on our patients. Since none of us knew what this was, we asked them to stop doing things to patients without an order.  Soon after, a remarkable article showed up in the Journal of the American Medical Association.  A young girl, with the help of her parents and a well-respected physician, conducted a study on therapeutic touch showing its underlying theory to be fictitious.  The alleged energy fields being manipulated by practitioners could not be found to exist.

This was a revelation for me.  It brought it all together: the lack of alternative medicine findings in biology or anatomy, the mystical nature of altmed, the claims that the effects could not be measured by “traditional, scientific means”.  I came to realize that there was no such thing as alternative medicine.  There was only medicine shown to work, and everything else.

I did go through my “shruggie” phase—after all, if acupuncture makes my patient feels better, than what’s the harm? (In the case of acupuncture, one of the harms may be hepatitis C.)

What I found, though, is whatever good may have come from some altmed practices, it didn’t even compare to the harm. Patients were taking buckets of supplements, undergoing potentially harmful procedures, and turning away from medicine proven to work.

This whole process took me years.  The rhetoric of alternative medicine is seductive; the truth of real medicine beautiful but messy. How can we teach people to sort out real medicine from everything else?  For a layperson, there is no sure way, but here are some hints for laypeople and for doctors who haven’t thought much about it.

  • If a claim goes against the basic rules of nature, it’s probably bunk. Homeopathy, where substances are diluted beyond existence, claims to treat all manner of problems, but for this to be true, we would have to overturn our basic understanding of the universe.  Unless the data are close to unrefutable, I’ll stick with the model of the universe we already have.
  • If a treatment relies on an energy or pathway in the body that cannot be seen in the anatomy lab or detected in some other way, it doesn’t exist.  So-called energy fields purported to run through the body have never been detected.  Meridians of qi have never been detected.  Subluxation complexes of chiropractic have never been detected.  Therefore, they are unlikely to exist.
  • If someone claims that their healing method can’t be measured by modern science, they are wrong.  It is nonsense on its face.  If someone claims an effect, then it is measurable. For example, if someone says that reiki treats a disease, then it should be easy enough to create a study where one group gets fake reiki and the other gets “real” reiki.  There.  You’ve measured it. There is no medical intervention that cannot be measured in some way.
  • If someone is charging you an exorbitant price for something seemingly simple, it’s probably a rip-off.  Energy bracelets, crystals, special supplements, sea salts—none of these things contain anything special, nor should they cost a lot of money.  Most real doctors prescribe medicines and interventions that they don’t directly profit from (directly being the key word).  Some specialties, such as dermatology and ophthalmology may sell items directly related to their practice, but most other specialties do not.  As an internist, there is nothing I can think of that I could ethically sell to my patients.
  • If a practitioner tells you not to go to regular doctors, then they are trying to kill you, whether they know it or not.
  • If a practitioner claims to have special tests that no one else has access to, such as mouth swabs for toxins or special tests for Lyme disease, something is fishy.
  • If a practitioner claims there is a grand plot by pharmacy companies or “mainstream medicine” to hide a cure, they are either criminal or crazy.  Real doctors want to help people, and real cures are very, very profitable.
  • If a practitioner is a “brave maverick”, bucking the stodgy power structure of traditional medicine then he is more likely a dangerous rogue and believes his intuition is smarter than science.
  • Older is not better.  Just because something is ancient doesn’t make it good. In fact, the opposite is usually true, as ancient medical beliefs are usually pre-scientific and fictitious.
  • If it sounds too good to be true, it probably is.  This is an old rule, but useful.  If some drug or procedure really makes you live longer, or cures a horrible disease, it will eventually be available everywhere.  Patients and doctors will demand it.  But most of these claims never pan out.

This is just a few hints, not a comprehensive list.  And certainly, these don’t work all the time.  A cancer specialty center will probably have new tests that aren’t available everywhere, but this is the exception.  Web sites like What’s the Harm, Quack Watch, and Science-based Medicine have lists of questionable practices and make useful references.  But the easiest thing to do is to find a doctor you trust and run things by them.  Patient come to me all the time with ads from the paper or printouts from websites.  I explain to them what the context is and whether it’s worth while to follow up on them.

Medicine has spent the last century-and-a-half maturing into a real science.  We know that human body is part of the same universe as everything else, made of the same “star stuff”.  Understanding and improving medicine requires a scientific approach to a real, physical problem. The practice of medicine requires a thorough dedication to science and a deep well of compassion.  With either missing, we do our patients a disservice.

Think Like a Doctor, Part II

In Part I we discussed the history of medicine as a science. This is Part II in a series.

It is during a surgery rotation when a medical student perhaps feels least competent. Not only is there an enormous amount of book learning, there are the physical skills that take years to develop.  Most of the time you pull on a retractor and answer questions, record vitals and pull out drains. My instructor, who in the OR hurled Spanish invectives like scalpels and called every med student, “Pullgoddamyou”, was gentle as a kitten with conscious patients. When I was in his office an elderly woman came in for a superficial biopsy. He had treated her for years and she trusted him.  After spending time talking to her and calming her, he numbed up the area and went to work. But the patient was tearful, from the pain and also from the knowledge that the biopsy was not going to give her good news.  I reached up an took her hand, then quickly released it, uncomfortable with my spontaneous act of intimacy.  Dr. Gruff looked at me and said, “No!  Hold her hand!  That is compassion, that is being a doctor!”

Compassion can be learned, or at least a simulacrum of it. Hopefully it comes naturally to most doctors, but for those who is does not, and cannot be taught, there are specialties that don’t involve much patient care.  Radiology, pathology, and a few others involve very little patient interaction, but are essential to the modern practice of medicine.  While the surgeon waits, hands folded in the OR, the pathologist quickly prepares slides and calls up with an answer that can be the difference between a small biopsy or a radical cancer surgery.  Sitting in the barber’s chair one day, the barber asked me to take a bottle of wine to a radiologist.  His wife had gone in for minor surgery and the radiologist had discovered an early cancer on a routine x-ray, saving the woman’s life.

I’d guess that most people, when thinking of a doctor, think of their own doctor, a primary care physician or an OB/GYN.  Hopefully this is someone they’ve come to trust, someone who can give them the tools to stay as healthy as possible and to treat them with compassion when they fall ill.  This part of medicine: this rapport, this compassion, is essential to good patient care.  A patient who likes you, and who you in turn like, is more likely to trust in and benefit from your advice.

But compassion is not enough.   In medicine, compassion unguided by science can be dangerous.  When you have strep throat, do you seek out a compassionate clergy or friend with no medical knowledge, or a doctor?  The doctor knows that untreated, strep can lead to abscesses, rheumatic fever, and can (but does not usually) cause permanent damage.  She knows that strep is easily killed by certain antibiotics and not by others.  She knows when the sore throat is more likely to be a virus and should be treated with hot tea and chicken soup rather than drugs.

Physicians are daily witnesses to the power of compassion, and like any power, compassion can corrupt. A compassionate act often has immediate and satisfying results. Treating hypertension gives neither the physician nor the patient immediate satisfaction.  It is the reduction of the risk of heart attack and stroke, a benefit that accrues over time, that makes treatment worthwhile.  But doctors like anyone else would love to see an immediate reaction, something unlikely in a patient with a disease without symptoms.  Patients are rightly skeptical about treating a disease which causes no discomfort.  It is up to the physician to work with the patient to help them understand the importance of treatment, to use their rapport to help the patient understand the benefit.

Sometimes the doctor and the patient unconsciously conspire to gain immediate satisfaction where none should medically exist.  Of the two, the physician should know better.  When doctors recommend unproven or implausible treatments with the idea that it may make the patient feel better they enter a folie a deux. We know how to treat high blood pressure with diet, exercise, and medication.  It might not make you feel better immediately but it will save your life.  Compassion will help bring the patient around. But how about adding on some hypnosis or acupuncture?  These feel more “real” to the doctor and the patient, but are no more real than a sugar pill.  If there is any benefit to these, it is through the same mechanism the doctor uses in the exam room: a hand on the shoulder, a cocked ear, a smile.  It is compassion without the benefit of actually treating the disease.

There is nothing wrong with compassion. In fact it is necessary to get the most benefit out of the patient-doctor collaboration.  But it is not, in itself, powerful enough to cure infection, to prevent strokes and heart attacks.  Compassion plus medical science is good doctoring.  Compassion plus no science is charlatanism.

In Part III, how to spot the difference.

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