Wednesday, February 29, 2012

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.

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 irrefutable, 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. Patients 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 worthwhile 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.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Labels: alternative medicine, evidence-based medicine, guest post, Peter A. Lipson, White Coat Underground

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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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Wednesday, February 29, 2012

Think like a doctor, part III

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