Denialism Blog

Author: denialism_bv2x6a

  • Some skills in medicine are harder to teach

    Teaching facts is easy. Medical students eat facts like Cheetos, and regurgitate them like…well, use your imagination. Ask them the details of the Krebs cycle, they deliver. Ask them the attachments of the extensor pollicis brevis, and they’re likely to describe the entire hand to you. Facts, and the learning of them, has traditionally been the focus of the first two years of medical school. The second two years deals with putting facts into action. Teaching medical students and residents is very different from being a school teacher, something with which I have first-hand knowledge and experience. Fetal doctors want to learn…they’re too scared not to. In general, give a med student a book, and she’ll read three, and write a paper before you see her again. But some things in medicine are harder to teach.

    Medical education in America underwent a revolution at the beginning of the 20th century, when texts were written, schools formed, and methods standardized. Now, 20 some-odd years into the evidence-based medicine revolution, medical education is improving once again.

    MarkH describes a method being tested to teach doctors to think under pressure. The big difference between this and the way these things have traditionally been done is that people are measuring them. They are forming hypotheses about learning and testing them. And it’s about damned time.

    My current teaching responsibilities are primarily those of teaching nascent internists how to practice their profession. The facts are (usually) there, but the judgment is not. This is also a field ready for evidence-based evaluation, but some things really do require repetition and mentoring.

    I supervise residents at an outpatient clinic. They see their own patients, and they see patients who either walk in or make appointments for immediate problems. Treating patients you know is one thing—treating a complete stranger is another.

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  • Were the ancients fools?

    Often in the discussion of cult medicines such as homeopathy, acupuncture, and reiki, supporters fall back on “the wisdom of the ancients”. This raises a question. Since “the ancients” had it wrong (i.e. their belief systems could not effectively treat disease), were they just stupid?

    Any of my historian readers already know the answer, but it’s worth going over.

    Our forebears were neither more nor less intelligent that we (unless you go back about 3 or 4 million years—that gets rather dicey). They were literate, intelligent, and damn good thinkers. They just had limits to their ability to investigate their environments.

    Let’s take an example from an English physician living in Paris in the mid-18th century, during the time inoculation against smallpox was spreading, but vaccination had not yet been invented.

    i-aa5bcfa81eb6fcfe8c1013a6ec6a06d7-inoculation.jpg

    By way of background, this new (to Europe) practice actually comprised many different practices, but the basics were the same: take a bit of material from a smallpox pustule, and rub, snort, or inject it into the skin of a healthy person. The healthy person would then develop a (hopefully) mild case of smallpox that would protect them from epidemic smallpox, which had a high rate of mortality and disfigurement.

    Dr. Cantwell, an English physician in Paris, had some concerns about this procedure (translation unfortunately mine):

    It is facts, and not the promise of them, and reason, that must truly interest the public. If they respond to the promises of the Inoculators, inoculation will establish itself despite all that can be said to show the danger and inutility of it. If, on the contrary, the facts directly dispute their promises, the public will be disabused and inoculation fall by the wayside.

    As for my part, I would say that if among the Inoculators there is found even one who responds pertinently to the facts which I allege, I will be the first to swear to my defeat, and will side with these gentlemen. If not, justice demands that one always allow that new facts could be gathered against this method, and they must be rendered public with all pertinent arguments.

    It is not enough to say that of one hundred persons inoculated, only one or two perished in the first forty days. It is a question of knowing FIRST if Inoculation gives lifelong protection from smallpox, and if one can be killed by a natural smallpox infection which may follow the artificial one…. SECOND it is necessary to know, again, if inoculation might accidentally spread smallpox, in the right conditions causing more people to perish of this contagion than would be saved by its application…(emphasis mine)

    Dr. Cantwell was basically one of the earliest opponents of immunoprophylaxis (prevention of disease via inoculation or vaccine). Was he a crank?

    Well, not by this excerpt. He asks the same questions that we do today regarding a vaccine: what is the mortality from the procedure, does it actually protect, and could it possibly spread disease.

    This is very “modern” thinking. It turns out that Dr. Cantwell was both right and wrong in his apprehension about inoculation. There were, of course, no standard practices, and people were hurt, but in general, it tended to save lives during epidemics.

    Thankfully, the much safer practice of vaccination came along, largely building on the knowledge of inoculation, and the discovery of healthy milk maids. (What was Jenner doing hanging out with the milk maids?)

    So, the ancients did indeed possess wisdom; they just didn’t have all the tools to apply it, including statistics, microbiology, and a well-developed germ theory of disease.

    It would be wise to remember that our forebears, though smart, didn’t have the tools we have today. To rely on their intelligence but eschew modern knowledge makes us look like the fools.

  • Morgellons—cranks in search of a disease

    I’m trying to understand “morgellons syndrome”. Based on Morgellons Research Foundation reports, there are a lot of people out there who believe they have this so-called disease. But what is it? I decided to dig deeper on the research end of things. I went to the MRF website, and to MedLine, looking for something, anything, to help me find out more about this problem. I must report that the science doesn’t look good for the morgie boosters.

    First, there has been little legitimate research on morgellons as such. The CDC is doing an epidemiologic study to determine what, if anything, may actually exist.

    The medical consensus is that so-called morgellons is a variant of delusions of parasitosis. It may be, however no case definition exists, and no central registry exists. Each case is treated on its own (and probably should be).

    Since morgellons resembles in every way but name delusions of parasitosis, it is on the morgellons advocates that the burden of proof falls. If they wish to invoke a new diagnosis, they must have a definition, a way of distinguishing morgellons from DOP, and a reasonable hypothesis to investigate. So far, none of these has happened.

    The dermatology literature has treated this phenomenon is a very sensible way. It has been recommended that patients’ feelings and sensations be validated, but that they be told the truth—that there is no evidence of infectious or otherwise primary dermatologic disease. It is sometimes recommended that patients be told that they have a problem with the sensory apparatus in their skin and nervous system, and that medications that act on the nervous system be used. This approach is quite rational, and atypical antipsychotic medications have been used successfully.

    This is in marked contrast to the bizarre approach taken by the morgies. Their “research foundation” has preconceived notions of what is happening—they have formed a conclusion rather than a hypothesis. This is fatal to science.

    Read on….
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  • Why am I here? To bother you, of course

    When I use the word “scientist”, I mean something pretty specific—someone actually doing experiments and publishing the results. Some physicians are scientists. In fact, the MSTP that Mark H is a part of exists specifically to train doctors to do research and bring the results to the bedside.

    Most doctors aren’t scientists, by my definition. But good doctors these days have to be able to read and interpret scientific literature if the wish to practice science-based medicine.

    I think of ScienceBlogs as a community of scientists communicating with the lay-public and other scientists. I’m happy I’ve been allowed to contribute as well, and I think it’s justified. When I see patients, I do so with a head full of knowledge that is based on reading scientific literature. I then have to digest and regurgitate that literature in a form palatable to everyday folks.

    So, now that I’ve justified my existence, it’s time to get back to annoying people.

    Steve Novella over at NeuroLogica recently posted a piece on a new “mystery illness“. These are always fun. Epidemiology is a fascinating field, and has helped discover HIV, hanta virus, SARS, and many other emerging diseases.

    But there is the other kind of “emerging disease”: the folie à news. There have been many descriptions in the past of so-called folie à deux, a shared delusion. In the information age (God, I hate that phrase), the internet and television can bring people with similar delusions closer together to share their “folie”. One of the most recent examples is so-called Morgellons syndrome. This is a disease named by a woman who thought her child had parasites in his skin. The cause has been taken up by a “scientist” at the University of Oklahoma, and by several websites and support groups.

    This “syndrome” differs from emerging diseases such as West Nile Virus in several important ways. Over the next few days, I’ll examine some of the reasons that “Morgellons” is not a real illness. Some of the material will be familiar to readers of my old blog, but I’m buffing it up for a fresh discussion. For the first installment, go below the fold…
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  • Another victim of cult medicine

    This is another one migrated from my old blog. It is the first in a series that generated an unusually large number of comments. Thanks, PalMD

    This particular woo-encounter was non-fatal. A patient came to see me. He’s middle-aged, generally quite healthy, and physically active. After a recent return to physical activity, his elbow began to hurt, so rather than call his internist, he visited a chiropractor. Not surprisingly, the back-cracker was unable to effect a cure. What did he do next? Asked his friend for the name of a “better chiropractor” (which is a bit like trying to find a better wrench to turn a screw). This one took a totally different approach to not helping the patient, but that damned elbow still hurt.

    Like most cult medicine, there is little that chiropractic will not claim as their own. How tennis elbow could possibly be helped by back manipulation is beyond me. One website did, however, give some good insight:

    Not always thought of as a “chiropractic” condition by patients, chiropractic’s conservative approach to elbow pain is often very effective, avoiding more invasive, risky treatment options.

    An excellent example of “hurry up and do nothing”, which is not always bad advice, but is not unique to chiropractic. I guess when all you have is a hammer, and nails are notably absent, a wise chiropractor steps back and says, “abra cadabra!” I’m sure chiropractic cures the common cold as well—whereas the common cold, when left untreated, usually lasts a week to a week and a half, visit the chiropractor and your cold is gone in 7-10 days.

    Anyway, I gave the guy a tennis elbow strap, told him to rest and ice it, and take ibuprofen if he needed it. If he’s patient and follows my advice, he’ll probably save a few bucks. A strap is usually covered by insurance, but cheap anyway. Ice is basically free. And a visit to me is about sixty bucks—and if he gets better, he doesn’t have to return for multiple “manipulations”.

  • How listening to my wife CAN SAVE YOUR LIFE!!!!

    Most of us around here know about internet memes, hoax emails, and other sources of scientific and medical rumor. After all, we’re geeks (or at least, I am). My wife, however, is not. She is a typical (and wonderful) woman, from a particular ethnic group, and particular part of town (and well-educated). I’m a fairly well-known physician, but when we go out to dinner, everyone stops to say “hi” to her—and is introduced to “her husband” for the third time.

    So it isn’t really a surprise that she knows more about the “real world” than I do. I was sitting on the couch reading my feeds, and she was checking her email. She apparently belongs to a mailing list that “everybody” is on. I’m not sure how to reproduce the entire email, so I’ll describe it. It has pictures of an adorable child placing a Tupperware container in a microwave, a refreshing bottle of water, some chemical diagrams, and a headline that reads “Cancer update from Johns Hopkins”. It explains how plastic will poison you with dioxins and other nonsense.

    Now, to most folks reading this, it looks like the internet-equivalent of a cut-out newsprint ransom note. But to a suburban mom…
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  • I'm of two minds about this one

    There’s a new facebook group set up to protest Expelled.

    I am ambivalent for the usual reasons—protest, and you give the reactionary religious cults more publicity, and an illusion of power. Fail to protest, and you appear to consent to their insanity.

    I figure there will be protests either way, so go and chose your way…protest loudly, or protest silently. But please, at least let someone know what you think, even if it’s just your friends or coworkers. I’m not one to keep my mouth shut, so I’m pretty sure I’ll be pissing someone off.

  • More flu woo from Mercola

    OK, I never really liked Joe Mercola, but when I read about this story on his website, I was encouraged. Boy, do I feel like a sucker.

    He started out so well, telling us about the tragic case of a child who died of influenza this year, and how health officials rapidly responded by increasing vaccine availability. Yea! He finally gets it!

    Or not.

    After the reasonably good piece of journalism, Mercola hops back on to the bat-shit insane wagon.

    Joe’s commentary starts thusly:

    This tragic story is, unfortunately, being used for all the wrong reasons; namely to promote the “universal influenza vaccination for all Americans.

    Um, he must have read a different story than I. Unvaccinated girl dies of flu—public health officials respond by trying to prevent a similar tragedy.

    But being unburdened by logic or truth, Mercola has an explanation:

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  • Cults make you stupid

    You don’t have to be stupid to join a cult (although it helps), but once you’re in…

    You see, PZ went to see Expelled    . With some friends. No one of note really, just THE WORLD’S MOST FAMOUS ATHEIST!!!111!

    And which one got tossed at the door? Take that, Dawkins! We grow good atheists right here in the Midwest!

    But really, it’s not just the funniest thing to happen in Minnesota since lutefisk. It shows how cults make you dumb. They discourage independent thought. Followers get their marching orders and, well, march without question. God forbid (irony intended) that you should exercise your own mind and say, “Maybe the Dear Leaders wanted all famous atheists out, not just one.”

    I do wonder about the Rent-a-Cops at the theater. Do the theater owners just throw out everyone they’re asked to? What was it about PZ? What if the KKK had rented out the theater for some white supremicist movie? Would they throw Abe Foxman or Jesse Jackson out?

    Not that arbitrarily tossing some professor out of a movie based on his religious beliefs (OK, lack of them) is the same as tossing out the head of the Anti-Defamation League or a prominent African-American leader.

    Or is it?

  • Flu update

    Continuing my series from WhiteCoat Underground, here is the latest influenza update.

    i-71ff2058c99656a050f7b3ae34ba49f7-usmap10.jpg

    While still widespread, numbers are finally starting to drop. I’m ready to drop myself. It’s been a terrible season—the worst I’ve ever seen. This is probably due, at least in part, to this year’s flu vaccine missing some unanticipated strains.

    For those of you out there who don’t “believe in” flu shots, remember that vaccination isn’t a religion. The anti-vaccination forces are, however, rather cult-like. Here’s some info for you.

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