Monday, May 20, 2013
Is your doctor relying on bad information?
When I was a medical student, my friends and I wore white coats so stuffed with reference books we could barely move. When we were taking care of patients, a trip to the library simply wasn't practical, and that whole internet thing wasn't really up and running yet. Now my pocket contains only my smart phone.
Sure, I know more than I did then, but I also know that I am fallible. I like to look things up, and from my phone I can access a world of medical information. Certain resources have become more popular than others, but there is no way to gauge the quality of these resources other than relying on my opinions and those of my colleagues. Online references are a tempting but risky resource for doctors.
Two of the more widely-used resources are UpToDate and eMedicine. UpToDate is just that: a resource of practical medical knowledge that is updated frequently by experts. It's also very expensive (about $500/year last time I checked). eMedicine from Medscape is free, and usually quite reliable. Last week, though, I stumbled upon a something disturbing.
Moraxella catarrhalis is a common bacterium causing disease in humans. It causes sinus infections, bronchitis, ear infections, especially in children, but in adults it can be quite deadly. It's a serious bug. Thankfully, it's usually pretty responsive to antibiotics. But here's were eMedicine loses me:
Numerous different antimicrobials have been employed to treat M catarrhalis infection (see below). In addition, among the medicinal plants, garlic, cinnamon, and avocado leaves have all been found to be antagonistic to M catarrhalis.
This makes it seem as if antibiotics and medicinal plants are on equal footing here: They are not. M. catarrhalis can cause serious, life-threatening illness. There is no reason to think that avocado, garlic, or any other plant can be used in place of or even as an adjunct to antibiotics.
Most doctors know this. Many patients who stumble upon this information may not, leading to delay of therapy. I'm going to be keeping an eye on Medscape products looking for similar problems, but the real lesson here is that even with the entirety of medical knowledge in the palm of your hand, the guidance of a professional is important in interpreting and using this knowledge.
A reader pointed me to the study that was likely the source of the claims about treating M. cat with avocado, etc. As expected, it is an in vitro look at the effect of these substances on the bacteria. In my into to microbiology course, we would often grow out cultures of various bacteria, setting, for example, a slice of garlic on the medium to see if it would inhibit growth (we also did much more sophisticated versions of this experiment. While interesting, these studies say nothing about the clinical utility of these substances. The human body is very different from a Petri dish. For these plants to be used as treatments, they would have to be "weaponized," creating a way to deliver useful doses of the plant without, for example, having the putative active ingredients destroyed in the acidic environment of the stomach.
When researching antibiotics, candidate substances are identified either by computer modeling or good old-fashioned trial and error in the lab. After that comes years of testing to see if there is a way to make it useful in human beings. The study authors' conclude that (emphasis mine): "Garlic, cinnamon and avocado leaves extracts represents alternative source of natural antimicrobial substances for use in clinical practice for the treatment of cases of M. cattarhalis."
This is irresponsible and just plain wrong. The study doesn't lead us to conclude anything about clinical practice and to claim otherwise is bad science and bad medicine.
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 at Forbes. His 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.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, 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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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.
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.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.