More on UpToDate

Following recent blog posts on “UpToDate dependence” by intueri, Kevin M.D., Caseblog and myself considerable discussion ensued on medical library lists and blogs about not only the addiction but also the cost of feeding the doctors’ habits. It’s something medical libraries grapple with every year or two when renewal time rolls around.

Medical information specialist David Rothman predicts:

As time passes, UpToDate will have more and more well-designed, well-maintained, effectively-marketed, affordable competitors. The competition will bring subscription costs down to a more reasonable level.

(Can’t wait for it to happen!).

The Krafty Librarian believes UpToDate’s business tactics are heavy handed and its prices are---well, pricey. I knew individual subscriptions were steep (I’ve got my own) but the institutional subscriptions, it seems, are through the roof:

Apparently there are some institutions starting to consider eliminating institutional access leaving their physicians to pay for the product on their own. UpToDate bases their prices on the institution's total number of outpatient and inpatients. No wonder some very big and successful institutions are rethinking the cost of UpToDate. It is not unheard of for small community hospitals to pay $10,000 -$15,000 for online access. I have heard of larger institutions paying $80,000 - $100,000 for access (which of course can't be used at home).

Emphasis mine on that last phrase! That’s a huge downside, particularly when UpToDate’s competitors provide home access for no additional cost! Why is home access important? Because home is where you do background reading, underappreciated but every bit as important as point of care reading. UpToDate has a wealth of background reading content in the form of pathophysiology, detailed disease descriptions, tutorials and case studies, but I suspect the background content is vastly underutilized since most use of UpToDate is at the point of care (to look up diagnostic algorithms and the latest treatment recommendations) when there’s insufficient time for in depth reading.

Dr. Thomas E. Brittingham, master clinician and director of the third year Medicine clerkship at Vanderbilt knew the importance of background reading and, in his letter to students at the beginning of the rotation, said this:

Dr. Carl Moore, Chairman of the Department of Medicine at Washington University, tells me that he finds it necessary to read medicine for 3-4 hours every day, 365 ¼ days yearly. If he finds it so necessary to read in order to remain competent, we probably need to read too in order to become competent. Half of your evenings are unscheduled so that you may have the opportunity to read about the patients you have seen. Read and think extensively about their disease problems….

Read and think extensively. You don’t have time to do that at “the point of care.” And it’s not just for junior medical students. It’s part of life long learning. Of course, back in the days of my medical clerkship point of care reading like we have now didn’t exist. So what’s the ideal reading routine for doctors today? I think it’s a combination of point of care and background reading. At or shortly before the patient encounter use point of care resources to determine the best and most current evidence for treatment decisions. Then go home and read in more depth about the pathophysiology and clinical features in the patients you encountered that day.

When woo meets mainstream medicine

---it gets my attention, especially when the mainstream embraces or teaches it uncritically. My mission: expose it. The latest is the Maine Medical Center Family Practice elective, Integrative Medicine focus:

The integrative medicine portion of the rotation takes place both in the Family Practice Centers and in the offices of complementary and integrative medicine practitioners in the community. This aspect includes opportunities to observe patient care and provider/patient interactions and has the potential for complementary therapy treatments. Learning experiences may include integrative medicine consults, mind/body medicine, homeopathy, manual therapies, acupuncture and nutritional and botanical medicine.

Long QT and Brugada syndromes

I’ve posted many reviews on the cardiac channelopathies. This one recently published in the Texas Heart Institute Journal is open access full text and nicely summarizes the relevant basic electrophysiology.

Review of Hemochromatosis

Topic review from Seminars in Liver disease.

Venlafaxine (Effexor) induced hyponatremia

This study in the Australian and New Zealand Journal of Psychiatry sought to evaluate the incidence and mechanism of venlafaxine induced hyponatremia, which was defined as a plasma Na concentration of less than 130 mmol/L. A 17.2% incidence of hyponatremia was noted. Hyponatremia invariably developed within days of the start of therapy and was associated with failure to suppress vasopressin secretion during conditions of low osmolarity. Fluid restriction during continuation of drug treatment was effective. The authors recommend electrolyte testing in all patients over 65 within 3-5 days of starting venlafaxine.

Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is closely related to the class of selective serotonin reuptake inhibitors (SSRI) which are known to cause hyponatremia. Should we be monitoring electrolytes in patients taking SSRIs?

Distrust in mainstream pharmaceuticals linked to rise in woo

We’re seeing it all over, and across all disciplines. The result is a double standard. Doctors rally behind the cause of evidence based medicine for prescription drugs, yet fail to object when their patients utilize unproven herbs and vitamins. The American Medical Student Association through its Pharmfree campaign holds the drug companies to the most rigorous of evidentiary standards yet promotes numerous implausible and non-evidence based complementary and alternative modalities.

Now we’re seeing it in the field of psychiatry according to this recent Wall Street Journal report.

Now, spurred by the growing disenchantment with antidepressants, an increasing number of people are seeking treatment for depression, anxiety and eating disorders from naturopaths, acupuncturists and even chiropractors. At the same time, more traditional psychiatrists are incorporating massage and meditation in their practices.

The treatments go beyond needles and spinal manipulation. They include Emotional Freedom Techniques -- tapping on the body's "energy meridians" as the patient thinks about upsetting incidents -- and craniosacral therapy, which involves a gentle rocking of the head, neck, spine and pelvis. In cranial electrotherapy stimulation, a AA-battery-powered device sends mild electrical currents to the brain. (The procedure has its roots in ancient Greek medicine, when electric eels were used.)

Single payer system seen as a giant HMO

Kevin M.D. had an interesting take on national health care plans after reading this report revealing the regulatory nightmares and access restrictions of Britain’s NHS.

It’s ironic that the proponents of a national health care system in the U.S. try to bolster their arguments by citing the evils of managed care, that monster we all love to hate. But national health care, in whatever form it may ultimately arrive here will, likely as not, be a system of heavy managed care under multiple layers of intrusive government bureaucracy---everything we hate about managed care and much more.

Don’t forget that Hillary Care was, in large part, modeled after an elaborate managed care scheme proposed by the Jackson Hole Medical Group. Managed care organizations were influenced in the 1990s by the Jackson Hole model. Although Hillary Care died in 1994, its anticipation in the early 90s may have spurred the subsequent wave of managed care in the U.S.

LDL reduction matters

Given recent enthusiasm for the pleiotrophic effects of statins as well as controversy regarding the appropriate goal for LDL cholesterol reduction, a paper in the American Journal of Cardiology (AJC) entitled Low-Density Lipoprotein Cholesterol Reduction: The End Is More Important Than the Means seems timely. The paper reviews multiple lipid lowering trials which show that the more one lowers LDL cholesterol the greater the cardiovascular risk reduction, regardless of the means used to do it.

Moreover, it cited this meta-regression analysis which raised questions about the pleiotrophic effects of statins, concluding:

The pleiotropic effects of statins do not seem to contribute an additional cardiovascular risk reduction benefit beyond that expected from the degree of LDL-C lowering observed in other trials that primarily lowered LDL-C.

Multiple means of LDLC reduction, whether via statins, ileal bypass surgery, diet or binding resins were associated with similar reductions in risk for a given degree of LDLC reduction.

The AJC paper also synthesized the strong data from multiple trials in support of newer aggressive LDLC targets (70mg/dl) for secondary prevention and confirmed the safety of such reductions. Until very recently, clinical studies suggested that statins failed to address a significant portion of the total cardiovascular disease burden, in as much as their use was associated with a relative risk reduction of only about 30%. This was largely due to the fact that when targeted to the less aggressive LDLC goals of the past statin drugs failed to address the cardiovascular risk associated with the metabolic syndrome. More recent data cited in the AJC review, however, suggest that event rates approach zero for LDLC reductions in primary and secondary prevention populations to levels of 57mg/dl and 30mg/dl, respectively.

All this being said, I do believe statins have beneficial pleiotrophic effects related to anti-inflammatory and other properties. I suspect these effects may be of relatively greater importance in the near term in situations such as acute coronary syndrome. With long term use LDLC reduction assumes greater importance.

Perioperative beta blockers: not so fast!

The initial enthusiasm for perioperative beta blockers was soon tempered by conflicting studies. In an effort to address the controversy the American College of Cardiology (ACC) issued guidelines last year which were somewhat more conservative than previous recommendations. Their class I recommendation was restricted to those patients who were already taking beta blockers and patients undergoing vascular surgery who had had ischemia demonstrated on preoperative testing. A class IIa recommendation was given for all other patients undergoing vascular surgery in addition to certain other high risk patients.

But now we must ask whether the guidelines are evidence based. The MaVS trial, the largest blinded RCT published at that time, demonstrated no benefit from perioperative metoprolol. The study, published last fall in the American Heart Journal, was composed of patients undergoing vascular surgery, a group that would be expected to uniquely benefit from beta blockers.

According to an editorial in the same issue “Larger and even more convincing trials are in the process of publication, demonstrating no impact of beta-blockade on perioperative events.” One of these, the DIPOM trial, was presented at the 2004 American Heart Association scientific sessions.

The editorial writer believes that poor quality studies combined with initial “belief” in the protective effects of beta blockers led to premature endorsement. An appeal to pathophysiology might help explain a lack of observed effect. Most ischemic cardiac events, particularly in this era of revascularization, are caused by rupture of a vulnerable (and often non hemodynamically significant) plaque, a process not mitigated by beta blockers. The relatively few patients with severe epicardial coronary disease who are susceptible to acute increases in myocardial oxygen demand might benefit.

As discussed in the editorial, these pathophysiologic considerations have fuelled interest in the use of statin drugs for perioperative cardiac protection. Early evidence suggests a strong protective effect. At least one larger trial is in progress. While it may be too early to recommend routine perioperative use of statins it is probably safe to say that patients with coronary disease already taking statins should continue them through the perioperative period.

Are perioperative beta blockers evidence based? It would seem that the answer is a cautious no. Should the ACC guideline be followed? There is strong pathophysiologic rationale for the class I indication. Patients already taking beta blockers should probably have them continued as seamlessly as possible perioperatively. The hemodynamic stress of surgery combined with the hemodynamic stress of beta blocker withdrawal might put patients at risk for ischemic events. Those undergoing vascular surgery who demonstrated ischemia on preoperative stress testing are more likely to have severe epicardial coronary artery disease and be susceptible to hemodynamic stress which would be mitigated by beta blockers.

The editorial’s pessimistic view of perioperative beta blockers is summarized by--

Where did the evidence-based guidelines process go wrong? The most readily apparent answer is in the reliance of small and in some cases unblinded trials, which had sparse absolute differences in event rates. When this is encountered in a systematic review, it should be realized that by random error, if a handful of events occurred in the opposite group by chance alone, then the significant result could not have been found. Thus, based on an intuitive and expected effect with beta-blockers, the ACC/AHA guidelines process has produced recommendations that almost certainly will be reversed.

For now, pending further results from clinical trials, I intend to follow the ACC guidelines for the class I indication, consider statin use in high risk patients, and continue statins perioperatively, when possible, in those patients already on statins. I also look for statins to emerge as the “next beta blockers” for perioperative treatment in the coming years.

You just can't turn your back on patients

A study on heart failure medication compliance published recently in the Annals of Internal Medicine concluded:

A pharmacist intervention for outpatients with heart failure can improve adherence to cardiovascular medications and decrease health care use and costs, but the benefit probably requires constant intervention because the effect dissipates when the intervention ceases.

The Quackometer knows

My Internet research on Yoga and quackery led me to the Yoga Journal. While the journal may not be an authoritative source on Yoga it seems to be a pretty good reflection of its popular promotions and claims. So I decided to run it through the Quackometer, which gave it a rating of 9 canards (out of a possible 10) and this description:

This web site has more quackery than my village pond. It is throwing in some scientific jargon and may be doing this to give an appearance of knowledgablity. It shows no sceptical awareness and so should be treated with a suspicious mind. It also looks like this site is trying to sell stuff. Buyer Beware!

Are you UpToDate dependent?

Can you make it through hospital rounds or a day in clinic without consulting UpToDate? Do you rely almost entirely on UpToDate to research topics or patient encounters, without going to primary sources? Do you feel you’d be unable to practice competently without it? Do you consider it your “peripheral brain” (translate: substitute for thought)? If you answered yes to any of these questions you may be UpToDate dependent. The habit can be darned expensive as Maria points out in a recent intueri post (h/t to Kevin M.D.).

Surveys and testimonials suggest that UpToDate dependence may be widespread. In one study, abstracted on the UpToDate website, over 90% of users thought UpToDate was “integral” to their decision making. Most usage was in association with patient encounters and 50% of usage was in the presence of the patient. Interestingly, most non-use of UpToDate was associated with lack of familiarity with the resource. Comments submitted to the website include “Can’t be without it”, “In time of need, I turn to UpToDate” and “Essential for my practice.”

Now I’m not here to criticize UpToDate. I love UpToDate and have my own personal subscription. It is a wonderful resource and, other than perhaps the cost, I find no fault with it. The problem is UpToDate dependence, which is symbolic of the larger problem of over reliance on “look up” resources. Although look up resources are essential to the practice of evidence based medicine, over reliance becomes a problem when their use supplants knowledge of basic science, acquisition of medical knowledge, background reading and clinical judgment. These essential skills and attributes help safeguard against an overly formulaic approach to patient care and result in fewer mistakes when patients do not follow the usual scripts.

The problem is symptomatic of growing attitudes which de-emphasize basic science in medical curricula and diminish the importance of medical knowledge as well as an agenda to restrict accredited CME to activities directly related to physician “behavior”.

This topic dovetails with a recent series of Med Rants posts on basic science in the medical curriculum, particularly as it relates to the USMLE Step 1 exam. Medical students sometimes complain about the basic science minutia they are forced to learn. DB, the author of the posts, tends to be in sympathy with their view, pointing out that all too often medical school basic science courses merely “teach for the test”. He suggests that the basic science content should be more focused on clinically relevant material.

I don’t know what the Step 1 exam looks like these days, or what DB has in mind for the curriculum. I suspect I would agree with his vision for medical education although I’m concerned that the de-emphasis on basic knowledge along with uncritical teaching of pseudoscience may reflect a dumbing down of medical education.

What principle, coach?

Notre Dame head football coach Charlie Weis had a thing or two to say after losing his malpractice suit against doctors at Mass General.

Weis, former Patriots assistant coach, said had he won, he would have donated any damages to a charity for people with special needs. " Our family decided to retry this case based on principle, not money," he said. (TED FITZGERALD/ASSOCIATED PRESS).

Well, if there’s a principle here I wish the coach or his attorneys would tell us what it is.

From the Boston Globe via Kevin M.D.

Yoga: Is it woo? Is it religious?

Hey, it’s only exercise! That’s the usual rejoinder I hear. A commenter, expressing astonishment that I would regard Yoga as woo, goes on to make my point by making a woo based Yoga claim:

And, unlike most gym type workouts, it stimulates the parasympathetic system rather than the sympathetic system, which is useful for the majority of people that are under chronic stress and therefore in sympathetic overload. A gym workout for someone in chronic stress is counterproductive as lifting weights or running on a treadmill further stimulates the sympathetic system, the stress/cortisol response and all that that entails.

It’s woo on two levels. First, there’s no evidence that Yoga somehow uniquely activates the parasympathetic nervous system. Secondly, traditional “gym workouts”, carried out over enough time to condition the cardiovascular system do in fact increase parasympathetic tone, as evidenced by the slower heart rates of conditioned individuals.

I plan to parse the religious and pseudoscientific underpinnings of Yoga in future posts.

ARDS and ALI following transfusion

Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are well recognized complications of transfusion but it has been unclear which particular blood products put patients at risk. This retrospective cohort study in Chest confirmed that ARDS and ALI follow blood product transfusion and identified the highest risk for platelet and plasma transfusions.

Background: FDA advisory on transfusion related acute lung injury (TRALI).

An important electrocardiographic differentiation in patients with acute STEMI

When examining the electrocardiogram, look at how the injury current distorts the second portion of the QRS for an important prognostic sign (American Heart Journal).

In anterior infarction does the S wave in V2 and V3 fail to dip below the isoelectric line? In inferior infarction is the ST takeoff (J point) greater than half way up the height of the R wave? These electrocardiographic findings indicate a worse outcome, in particular poor results from reperfusion efforts via systemic thrombolysis or catheter intervention.

Teaching woo to kindergartners

A while back I noted that an up and coming generation of kids will be better prepared for the mandatory woo they’ll encounter in med school because it’s now being taught in undergrad. Today I found something even more astounding. Woo, namely Yoga, is being “integrated” into the curriculum of public schools, starting in kindergarten! The integration encompasses multiple content areas of the curriculum as stated in Yoga for Kids Tools for Schools:

Curriculum Integration: All basic curriculum areas are addressed, as well as classroom management, test preparation, fitness, and environmental and multicultural education.

But it’s more than just physical education and relaxation. In this report from WTVJ channel 6, Miami, kids are being taught some fascinating immune system woo:

Some of the yoga poses have actual health benefits, according to DeWitt. "The Tarzan thymus tap in particular, where they're tapping their chest and tapping the glands in their bodies, that helps stimulate and helps the immune system function better," she said.

Although yoga has been catching on in many school systems it is not without controversy. According to an MSNBC report, some parents are concerned that teaching it in the public schools violates the establishment clause:

Tara Guber and her staff demonstrate a typical session where she teaches the teachers in her home in Los Angeles. When Guber created a yoga program five years ago for a public elementary school in Colorado, she never fathomed her proposal would provoke a crusade by some who argued that yoga's Hindu roots possibly violated the separation of church and state.

But proponents of Yoga in the public schools argue that it is merely a form of exercise, or that it is scientific. Well, that's not only woo but another example of a common guise under which Eastern religions are repackaged for the West. We’ve seen this sort of repackaging not only of Yoga but also of other traditions such as Zen Buddhism (as illustrated by the writings of Alan Watts).

Perhaps the best example, and one which provides precedent for an establishment clause challenge, is Transcendental Meditation, a tradition based on Maharishi Mahesh Yogi’s brand of Hindu faith. For a time TM was promoted in the West as the “Science of Creative Intelligence” (SCI) and introduced into the New Jersey public schools. With support from the Spiritual Counterfeits Project, teaching of “The Science of Creative Intelligence” was challenged in court. On December 12, 1977 the U.S. District Court of New Jersey ruled that due to the religious underpinnings of SCI its teaching was in violation of the establishment clause of the First Amendment. The New Jersey public schools were thereby enjoined from teaching TM.

I wonder if the case might provide precedent for an establishment clause challenge against the teaching of Yoga in public schools. For that matter, given the religious origins of many forms of woo taught in medical schools, at least those that receive government funding, there may be basis for legal challenges at that level as well.

Another malpractice trial blogged in real time

But this time the blogging was done by an outsider, not the defendant. A malpractice action brought by Notre Dame head football coach Charlie Weis over complications following gastric bypass surgery was decided in favor of the defendants. Attorney blogger Eric Turkewitz reports on the verdict and provides links, including one to the sports blog which provided real time coverage.This, by the way, was the retrial of that case which was declared a mistrial after defendant doctors rushed to the aid of an ill juror.Turkewitz’s take on the verdict?

Nationwide, approximately 2/3 of all malpractice verdicts favor the defendants. This occurs because, generally speaking, it is usually the most difficult of cases that go to verdict, and due to juries favoring physicians over patients according to a recent Michigan Law Review study.

Glycemic control in sepsis---the jury is still out

Despite recent enthusiasm for intensive glycemic control for septic patients and the provision for intensive glucose control in the Surviving Sepsis Guidelines and the IHI sepsis bundle, patient selection and target glucose range are unclear. Better answers await the results of two currently ongoing large trials. This topic was recently updated in Advances in Sepsis.

Low ICU staffing levels increase the risk of ventilator associated pneumonia

The study was just reported in Critical Care. It’s always been intuitive to doctors and nurses that staffing ratios affect patient outcomes. Now with this study, alongside another one showing a mortality hazard associated with low nurse to patient ratios, evidence is being marshaled to back up our intuition. This evidence also favors the judicious use of ambulance diversion despite the Institute of Medicine’s silly mandate from last year.

A little self congratulation

Today is blogiversary two for Notes from Dr. RW and I almost forgot. Perhaps this would be a good time to reflect on a few things that have occurred to me in two years of blogging.


Go with the flow and don’t be rigid.
Although the “Notes” set out to be a clinical blog I find that I have ventured into the politics of medicine more than originally intended. As such it has become a mix of about 50% clinical content and 50% miscellaneous ranting. Not that there’s anything wrong with that. Blog about things that stoke the fire in the belly, I say!

When people disagree with you, don’t sweat it.
Detractors go with the territory in blogging. It would be boring if everyone agreed with you. Besides, detractors help you sharpen your arguments by pointing out the weaknesses.

Don’t take things too seriously.
The demise of several blogs in recent months generated a lot of discussion about blogging safety issues. Blog smart and exercise reasonable care but don’t obsess over the hazards or it’ll drive you crazy.

Keep blogging in perspective.
If it quits being fun or is taking too much of your time, slow it down!

Thanks to all the loyal readers and supporters!

Musings on Dr. House and the disruptive physician

Frederick Turton, M.D., chair of the Ethics and Human Rights Committee of the American College of Physicians, just can’t bring himself to watch the television medical drama House. Why? He’s apparently uncomfortable with the notion that the most brilliant diagnostician around could also be a disruptive physician.

Read it here in Internal Medicine News.

New York Times profiles Avandia researcher Steven Nissen as Naderesque

Wow. How many self respecting doctors and researchers would be flattered by that characterization? It would raise all sorts of questions about one’s scientific objectivity and rigor. But maybe it’s true. The NYT notes this:

In some media interviews, though, he was less guarded. On the ABC television program “Nightline,” Dr. Nissen predicted that the deaths caused by Avandia could “dwarf” the carnage of Sept. 11, 2001.

Wait a minute. Not even his own meta-analysis showed a statistically significant increase in death. Dr. Nissen, you’re feeding the media hype. This issue needs objective scientific discussion, not demagoguery.

The American Board of Internal Medicine is up to something

---but at this point it’s hard to know just what. Given my concern and skepticism about the way the American College of Physicians (ACP) and the American Board of Internal Medicine (ABIM) are redefining internal medicine, this post by Retired Doc naturally caught my eye. He writes:

The American Board of Internal Medicine (ABIM) is proposing still another piece of sanctified paper for internists to strive for and jump through hoops to obtain.

According to a news article in the July 1, 2007 issue of Internal Medicine News, ABIM's Board of Directors has approved the concept and is moving forward awaiting the report of a committee, due in Feb. 2008, charged with the development of requirements.This certification is to be optional and is called a Recognition of Focused Practice.

The Internal Medicine News article is linked here. As much pleasure as I’d probably derive from shooting the proposal down I can’t, really, because the article is so vague. Whether this piece of obfuscation is the work of Internal Medicine News or of ABIM is difficult to say, but it makes little sense.

While the concept of focused practice could take several forms a major area for “focus” is, oxymoronically, “comprehensive internal medicine.” Aside from the obvious contradiction in these terms, what about the existing certification exam? Isn’t it supposed to be comprehensive? What’s different, then, about the special recognition? The ABIM seems to think there’s a difference but they don’t tell us what it is:

In the meantime, the ABIM Board of Directors has endorsed the idea that comprehensive internal medicine is a form of practice that is different from what is recognized by the underlying general internal medicine certificate.

It sounds pretty nebulous to me. There’s nothing new in the tradition of internal medicine about comprehensive care. It’s part of what general internal medicine has always been about.

Stay tuned. I’ll be here to comment further once the ABIM spells out what hoops are to be jumped through and what it all means.

What is an outstanding internist?

Robert M. Centor, MD (better known as DB to many of us) shares some insights in his 2007 Presidential Address to the Society of General Internal Medicine. Hint: don’t expect to find the answer in performance measurements or report cards. Watch the video here.

After a long hiatus

---the Medscape Roundtable is back. For this edition Robert Centor, MD (DB) is joined by three new participants: Therese Polick, RN, Nicholas Genes, MD, PhD and Graham Walker. (Don’t worry, Pennie Marchetti, MD, Roy M. Poses, MD and I will be back soon!).

The topic this time is How Do You Treat VIP Patients? I confess. I opted out of this Roundtable because I couldn’t imagine doing anything interesting or controversial with the topic. After all, you treat everybody the same, right? Surprisingly, though, each participant came through with a unique and insightful slant. Go and see.

American College of Physicians Diabetes Portal

Extensive collection of resources for clinicians and patients.

Medical Progress Today’s conflict of interest symposium—Michael Weber, M.D.

Like me, Dr. Weber seems to believe that the outrage concerning conflict of interest in the medical profession is selective. In his contribution to the conflict of interest symposium he challenges the popular notion that government funded research is the answer. In many ways researchers beholden to the government and engaged in the fierce competition for career enhancing grants from the NIH and the VA are more conflicted than the “free agents” of industry funded research.

Washington Post article on med school woo misses the point

I’ve often fumed and ranted about how mainstream medical institutions--- journals, hospitals and medical schools---embrace quackery. Although it may serve no purpose other than to vent my spleen I try and do my meager part in the battle against pseudoscience by exposing it when I see it in hopes that some how, some day, the thought leaders of mainstream medicine will catch my outrage.

The deplorable trend is increasing, and the latest report comes from the Washington Post. Unfortunately the article, linked by Kevin M.D. and the WSJ Health Blog, seems to miss the point (italics mine):

While CAM and conventional medicine have long held each other at arm's length, major medical schools have begun to incorporate information about these non-conventional techniques into their curricula. The idea is that doctors need to know about CAM -- if only to keep up with what their patients are already doing to heal themselves.

Unfortunately that doesn’t seem to be the only reason medical schools are introducing CAM into their curricula. Not by a long shot. I’ve been monitoring this trend for a good while now and have cited example after outrageous example of promotion of pseudoscience and quackery by medical schools. If my compelling anecdotes aren’t convincing, survey data published in the journal Academic Medicine indicate that the teaching of CAM in medical schools is overwhelmingly promotional and uncritical. That’s what the Washington Post article left out.

Is conventional medicine a cult?

Journalist and health crusader Mike Adams recently blasted conventional medicine with a tirade entitled The false gods of scientific medicine revealed: It's a cult, not a science. I would have dismissed the article (pointed out by Science Blogger Mark Hoofnagle) as just another piece of anti-science trash but for something that piqued my interest in a certain way.

Let me explain. I have long puzzled over some activist groups which criticize the pharmaceutical industry for its corrupting influence on science but are silent (or worse yet, promotional) concerning the implausible and unproven claims of alternative medicine. Adams’s article may help resolve the inconsistency. It reinforces an idea I considered before when I tried to reconcile the American Medical Student Association’s Pharm Free campaign with its promotion of quackery: that the purveyors of pseudoscientific woo share a common mindset with anti-Pharma activists. As I posted on this subject about a year ago:

That suggests a common thread in the AMSA’s seemingly contradictory positions: the notion that Big Pharma is leading a medical-industrial conspiracy to suppress research in (and the integration of) alternative methods.

Adams’s depiction of mainstream medicine as a cult certainly has a conspiratorial flavor. (And if you wonder whether or not he pushes woo, decide for yourself after you take a gander at his web site).

So, let’s examine some of the claims in the article. From the opening paragraph:

…what passes for "science" today is a collection of health myths, half-truths, intellectual dishonesty, self delusion, fraudulent reporting and wishful thinking.

Though Adams engages in a bit of hyperbole here I’ll meet him half way and acknowledge that there are some shortcomings in the application of conventional medical science. The problem is, aside from a few testimonials his arguments for his own incredible health claims amount to little more than bashing mainstream medicine with exaggerated and often baseless statements, such as:

This is how doctors have come to believe the incredible: That food has nothing to do with health, that antioxidants will kill you, that herbs interfere with drugs, and that only drugs can treat or cure disease.

These straw man positions have been advanced many times before. It would be amusing, I’m sure, to see Adams try and provide evidence that doctors believe food has nothing to do with health or only drugs cure disease.

Adams goes on---

Mainstream media stories that parrot the cult-like beliefs of conventional medicine are the singing of the church choir, and the altar boys getting sodomized in the back room by high priests are like the public being chemically assaulted by pharmaceuticals. (A kind of "medical violence" perpetrated against the general public.)

And there’s this:

All drugs get an automatic thumbs up, no matter how ludicrous the underlying science, while all natural therapies are automatically and routinely criticized by skeptics who equate their own lack of understanding with proof that something mysterious can't possibly work. They say homeopathy can't work, for example, simply because they can't find any mechanism to explain how it could work.

Well, not quite. Many drugs have been rejected by mainstream science, based on clinical trials. As for homeopathy, the “mechanisms” that have been purported have no plausible basis in chemistry or physics.

Rather than pick apart the rest of the article I’ll jump down to this little gem:

Cholesterol drugs, for example, may artificially lower cholesterol numbers, but they completely ignore the root cause of elevated cholesterol. This is why cholesterol drugs have been scientifically proven worthless in preventing heart attacks or other fatal cardiovascular events.

One little problem with that. It disregards the overwhelming evidence proving cholesterol drugs quite effective in preventing heart attacks and other fatal cardiovascular events.

The piece concludes with:

After the collapse of Western medicine, real health care will inevitably end up returning to its roots: The healing power of nature.

The irony of that statement is that all too many of today’s “natural” healing claims are based on anything and everything but an understanding of nature.

By the way, Hoofnagle’s post does a good job of debunking Adams’s claims about chemotherapy and biomarkers.

Texas medical board plans to fingerprint doctors

This will include new applicants and currently licensed physicians. KTVT channel 11, Dallas, Fort Worth reports:

The call for mandatory background checks comes in the wake of a CBS 11 investigation which uncovered that a registered sex offender was honored by the Texas Legislature as their “Doctor of the Day” twice over the past two years.

Given the flood of applications to practice in Texas following tort reform, this will be quite a task.

Management of heat stroke

This topic is timely and of increasing importance, what with global warming and all. Critical Care has a nice review. Good studies are in short supply, but it appears that the management, in terms of optimal cooling methods and hemodynamic support may differ between classic heat stroke and exertional heat stroke.

By the way, in applying published literature to treatment, Google calculator may come in handy.

Pacemaker information for patients and physicians

There’s a huge repository if information here.

Radiopaedia---an open radiology resource

This site is relatively new and appears to be a wiki of sorts.

Psychiatrists arise!

Shame people into saving the planet! I thought psychiatrists were supposed to be about the business of relieving mental anguish. Not necessarily so when it comes to environmental concerns, says Dr. Steven Moffic, Professor of Psychiatry at the Medical College of Wisconsin in a MedGenMed video editorial:

Therefore, instead of using psychiatric insight and techniques to reduce excessive anxiety, shame, and guilt for global warming these emotions will need to be increased in the unconcerned. This kind of 'help' runs counter to our usual goal of not making people feel worse!

Practicing doctors’ reactions to Avandia controversy predictable

Many will be switching patients to insulin according to a survey. What’s this going to do to the problem of insulin resistance and the metabolic syndrome?

Prescription fish oil

Prescription fish oil (Omacor) is approved in the U.S. for treatment of patients with very high triglyceride levels. In some other countries it is also approved for secondary prevention following myocardial infarction.

A review of prescription omega-3 fatty acids in the American Journal of Health-System Pharmacy addresses both indications as well as issues relating to safety, tolerability, drug interactions and the use of non-prescription (supplement) forms of fish oil.

Takotsubo cardiomyopathy

Here is a presentation of 4 cases and literature discussion in the Texas Heart Institute Journal. It’s one of the brain-heart conditions I discussed here.

Where did you get your MD?

---asks emergency physician Edwin Leap.

So here is our announcement. Attention patients and families of patients, regulators, government officials, commentators, angry bloggers, and reporters: I am the physician. That makes me the expert. I realize that we live in the age of polls, surveys, empowerment, and self-help. I realize that the opinion of the masses generally matters more than the opinion of the educated. But as one of the educated, as one of those who considers his opinion more valid than many others, let me say what most physicians are too nice to say. Medicine is not a democracy.

Read the rest.

PharmaGossip with some suggestions in the wake of the Avandia controversy

Acknowledge that your drug is not "God's Gift to Diabetics"
- Start proper mortality studies earlier
- Don't bully medics who raise legitimate concerns
- Don't promote the hell out of product and deny any issues exist.

Well said.

Is this hospitalist program in trouble?

Whether you’re job hunting or evaluating your own program, watch out for these red flags. From Today’s Hospitalist.

Fibrate review

Why are they so controversial after 40 years? What is their role today? Some answers are here in a review from Pharmacotherapy.

Whither the routine electrocardiogram?

Electrocardiograms were once performed on virtually all adult hospital admissions. Although that changed in the era of cost containment there may be legitimate indications for screening electrocardiography. This company promotes screening for kids and young adults. Kevin recently linked to this skeptical piece concerning the practice. Indeed, given the rarity with which a cardiac channelopathy would be detected and appropriately acted on in a healthy population one has to wonder about cost effectiveness.

On the other hand how good is the stethoscope (or, more to the point, the thing between the ear pieces) in those assembly line style athletic pre-participation school physicals? To address that concern, investigators have looked at not only EKGs but also routine limited echocardiography as part of pre-participation screening (Clin J. Sports Med.). By doing echos at $7.34 a whack (no doubt utilizing volunteers and loaner equipment) they were able to detect a sufficient number of abnormalities to conclude it was useful. More importantly they demonstrated very poor performance of physical examination. (By the way, here’s a nice review of the topic from Clinics in Sports Medicine and here’s the AHA 2007 update).

There is some evidence that silent electrocardiographic abnormalities are quite common in older folk and that such abnormalities portend mortality and functional decline. A more liberal strategy for admission electrocardiograms may be warranted in adult hospital admissions.

Update from Kevin here.

Where the grass is greener

Best places to practice, according to Medical Economics.

Varied reactions to the Avandia meta-analysis

---were cited in a report from DOC News. Despite widespread criticism of the meta-analysis lead author Steven E. Nissen thinks he’s had the last word:

"We're in a very tough quandary here in that we don't have the data that definitely answer the [heart attack] question," he says. "We just have the meta-analysis, which is all we're ever going to have because it looks like RECORD isn't going to give us the answer either."

And Dr. Sidney Wolfe, director of the Public Citizen Health Research Group implies that Avandia is useless with this statement:

"A diabetes drug is only important or effective if it prevents cardiovascular problems, and Avandia doesn't prevent them; if anything, it makes them worse," says Wolfe, who has called on the FDA to withdraw the drug, or at the very least issue a "black-box" warning about the heart attack risk.

Well, Dr. Wolfe, if prevention of cardiovascular disease is the only standard, what do you want to do about insulin?

When we’re forced to play insane quality games we make more mistakes

Of course we already knew this. Here’s even more evidence from the current issue of Chest.

Inventors of perpetual motion machine keep the world waiting

Orac has been following this story closely. Why doesn’t this get published in a reputable journal? And why don’t the independent observers come forward? Says Orac:

It must be that nasty conspiracy by the oil, coal, and natural gas companies whose livelihoods would be threatened by the Orbo. Yes, that's definitely it.

Ah, yes. Another example of financial conflicts of interest and the suppression of open science by evil industry.

Eastern religion is often sterilized for Western consumption

---and marketed as health methodology, science, self help or, as in the case of this recent Medscape article, stress management. The article, innocuously titled “Stress and the Mind”, reminds us that stress results from a mismatch between what we expect and what the environment delivers; that we can help reduce this stress by adjusting our own attitudes and expectations; that we should count our blessings and cultivate altruism.

Well, there are no overtly religious themes there. At first glance it sounds like nothing more than sage advice. But, on closer inspection, the article appears to be a promotional piece for Vedanta, an ancient branch of Hinduism. One of the problems with the piece is a lack of full disclosure. Although the article has a link to the vedantausa page (which itself appears to be almost stripped of religious references---one has to go deep into the website to find them) and, for purposes of attribution, an acknowledgement of Swami A. Parthasarathy there is no author information and there are no references (this may be a site error---the links don’t work!).

In Medscape of all places.

Scientology implicated in stabbings

---according to this report from the Sidney Morning Herald.

THE young woman needed psychiatric care, and she knew it. She tried to get help twice, but her Scientologist parents had a religious objection to psychiatric intervention.

Read the rest.

The American Medical Student Association flunks the Quackometer test

I’ve cited many examples of quackery promotion by the AMSA before, but have not subjected the organization to any sort of quantitative analysis. So, I decided to plug their url into the Quackometer and this is what I found:

This web site is using lots of alternative medicine terms. It is full of scientific jargon that is out of place and probably doesn't know the meaning of any of the terms. It shows no sceptical awareness and so should be treated with a suspicious mind.

Now the Quackometer, mind you, is an experiment in whether quacky web sites can be identified by automation. Take that for what it’s worth. But its “reading” on AMSA pretty well matches my own observations.

It's been a good week (nonmedical)

I had some time off last week, so my wife and I joined the RW sibs in our home town (and the place we generally converge for family reunions), St. Louis. In addition to family time the trip afforded me an opportunity to visit some old haunts and play with my Sony Cyber-shot, some results of which are shown. I could have spent an entire day or two grabbing images of the architectural wonders of my beloved St. Louis, but I tried the patience of my family just to get these. (They'd probably think I was being dorky).

Above is the view looking east down Market Street. Union Station is on the right. The building on the left in front of the Arch is the St. Louis Civil Courts building.

Below is Aloe Plaza, across Market Street from Union Station.

Finally, a shot of my kid bro showing off atop the steps of Brookings Hall on the beautiful campus of his alma mater, Washington University.

Introducing the Quackometer

Boy am I gonna have some fun with this.

The latest buzz on hospital medicine

---with hospitalist thought leader Bob Wachter. You can access his podcast interview at the SHM national meeting here. Interesting how his projections on the number of future hospitalists keep increasing.

When medical ingenuity outpaces bureaucracy

The government is not, and should not be, the final arbiter of medical progress. This is particularly true in the field of electrophysiology. Dr. Wes drives the point home as he comments on a New York Times article about government scrutiny of the profusion of devices and ablation procedures for atrial fibrillation:

The field of electrophysiology has a history of far-exceeding regulatory capabilities in the bureaucracy of government. Look at radiofrequency catheter ablation. If we hadn't moved from DC shock to radiofrequency energy sources, many, many more people would have been harmed during catheter ablation procedures. Doctors did this because it was safer for patients and less anxiety-provoking for them during the procedure - not because of governmental regulations.

Patient empowerment: can it go too far?

In the last 30 years or so we have moved from medical paternalism to medical consumerism. An About.com article entitled Are You an Empowered Patient...or a Pain in the Neck? addresses some unintended consequences. (Via Kevin M.D.).

Among the questions asked are Do You Bring in Pages of Printouts from the Internet?

If so, you could be interfering with the effectiveness of your visit. One of two things may happen: Your doctor may spend most of your appointment time reading through your printouts, or your doctor may decide that he/she doesn't have time to even look at the printouts at all, and ignore them completely.

I would add that if Internet homework presented at the appointment is to be anything more than a distraction it needs to be evidence based. But evidence based patient participation, as I demonstrated before, is arduous and requires a certain degree of skill. How many patients can do it?

Exchanging anecdotes: Sicko versus Dead Meat

Kurt Loder’s critical review of Michael Moore’s Sicko makes the case that the film is unbalanced and non-evidence based:

Unfortunately, Moore is also a con man of a very brazen sort, and never more so than in this film. His cherry-picked facts, manipulative interviews (with lingering close-ups of distraught people breaking down in tears) and blithe assertions (how does he know 18,000* people will die this year because they have no health insurance?) are so stacked that you can feel his whole argument sliding sideways as the picture unspools.

Moore and others clamor for universal access. But as Loder illustrates, in socialized healthcare systems this access is often merely access to waiting lists. That point is also well made in the 2005 documentary Dead Meat which portrays Canada’s system in a negative light.

When it comes right down to it, the two films constitute an exchange of anecdotes. A balanced view of the controversy might require viewing both.

Neuromuscular disorders in the ICU

Acute Neuromuscular Weakness In The Intensive Care Unit was reviewed in a recent issue of Critical Care Medicine.

Katrina charges against nurses dropped

---in exchange for their testimony in the continuing grand jury proceedings against Dr. Anna Pou. Via Forbes.

Forensic scientist tests DNA in her husband’s underwear

---to prove infidelity.

A state forensics scientist who said she tested DNA in her husband's underwear to find out whether he was cheating could be disciplined if investigators determine she violated the use of state equipment.

Her findings? “Another female. It wasn't me.”

P4P for patients

That’s what the Healthy Americans Act, S.334, cosponsored by Senators Bob Bennett (R-Utah) and Ron Wyden (D-Ore.) seems to offer. Patients would have financial incentives to lead healthy lifestyles.

Healthy behavior incentives are working in other countries around the world. For example, in Switzerland, where only 11 percent of GDP is spent on health care and everyone is required to purchase his own private health plan, competition has led to innovative incentives. Some plans offer lump-sum cash awards for those who stay healthy; others penalize unhealthy habits or behaviors.

People respond to incentives, and if there are incentives for individuals to stay healthy, we will make a significant difference in driving down health care costs. The Healthy Americans Act promotes personal responsibility and prevention by offering discounted premiums for participation in wellness programs and by rewarding providers for helping their patients stay healthy.

How are doctors reacting to the Avandia meta-analysis?

The July 1 issue of DOC News tackled that question. Doctors are reporting a range of actions:

Therein lies the dilemma for physicians: How should they advise the legions of patients calling with rosiglitazone questions? On one end of the spectrum, clinicians are watching and waiting. On the other end, they are taking all their patients off rosiglitazone, sometimes switching them to pioglitazone, and sometimes taking them off all TZDs. Physicians taking a middle-of-the-road position are discontinuing rosiglitazone only in patients with the highest cardiovascular disease (CVD) risk and more closely monitoring those who stay on the drug.

Some physicians are asking patients to make the decision. But how well can patients parse the evidence? How many patients can appreciate the methodological and statistical issues surrounding the meta-analysis and evaluate them in light of other evidence about TZDs and alternative treatments?

Dr. Curt Furberg of Wake Forest University seems to go a step beyond his editorial opinion in NEJM by suggesting that all patients be switched from Avandia.

"If my wife were on a TZD, I'd switch her," Furberg says. "You don't gamble when treating patients. You play it safe."

The blogosphere’s reaction to the Google health Advisory Council

Is it a case of sour grapes? The Open Medicine Blog wonders.

U.S. versus Canada in treatment of survivors of cardiac arrest

Survival of cardiac arrest due to ventricular arrhythmia not due to a transient or reversible cause is a slam-dunk indication for an implantable defibrillator. However, almost twice as many eligible patients in the U.S. receive this treatment as do those in Canada according to this report from CMAJ:

In Canada, 3793 patients survived to discharge after a cardiac arrest; 628 (16.6%) of these were implanted with a cardioverter defibrillator before discharge. The implant rate rose steadily from 5.4% in 1994/95 to 26.7% in 2002/03. In the United States, 23 688 (30.2%) of 78 538 such survivors received an implantable cardioverter defibrillator before discharge.

Scrubs for Sicko

Some healthcare workers are campaigning to promote the film.

AMSA teams with Michael Moore, lauds Sicko

From an AMSA press release:

Members of the American Medical Student Association (AMSA) joined nurses, survivors of the private health insurance industry, Michael Moore, and members of Congress in a historic hearing on the negative health impacts of the for-profit private insurance industry.

Here’s the rest.

Tinea pedis

Med Rants has done some research on treatment. One important reason to treat is the fact that many cases of lower leg cellulitis derive from tinea pedis.

Tips for cost effective inpatient medicine

In response to a reader's request DB of Med Rants posted these suggestions.