dras knowledge

Friday, January 30, 2004

screening tests, the Bird machine, HUAM, and sickness

Preventive medicine and screening tests have been a bane for years. Bladder tumor markers (CA 27.29, CA 19-9, etc.) are routine in many circles without, I think, really having shown their worth. Bone density studies are everywhere done more frequently than routine. There's even professional consensus that every expecting couple get genetic workups so they can prepare for what might be wrong with their unborn. How much of all of this is the result of aggressive product marketing, and how much is based on a scientifically demonstrated health benefit?
I was a Medicare home health case manager for three years a decade ago. The heyday of home health. It didn't take me long to understand that it probably cost Medicare more to keep a sick person at home than institutionalized. A very expensive program to take care of some of the nation's chronic and elderly, disproportionate to that which our society can afford. Even though outcomes effected on some individuals are epic, I suggest many payors are concluding that many such programs directed toward prevention do not cost less overall in the short, or the long run. Especially in cases when things like virtual colonoscopy are promoted as essential for prevention.

If preventing malady often fails society's cost-benefit ratio, diagnosing and treating the sick are close behind. The treatment of the those with a diagnosis of exclusion is part of the enigma. These used to be easy to pick out until we opened up disease categorizations to accept more of the possible candidates. I am convinced that two-thirds of the nations population has AASM defined, clinically significant obstructive sleep apnea deserving of a home machine or one or more out-patient ENT procedures. Don’t we all know someone who has chronic fatigue, polycystic ovary, Raynaud's, polymyositis, and maybe a few more, all at the same time? As a clinician, I am ashamed I have to approach diagnoses of Lupus, bleeding disorders, and even such as myasthenia gravis with skepticism as to the person's true extent of dissability. It is disheartening to know there are those few clinicians and patients who use some of these diagnoses to game the system for money.

Again, we must not forget we live in a capitalistic society. I am a respiratory therapist by training. When we look at the history of my chosen profession we see we used to be orderlies, and sometimes "oxygen techs." One of the single greatest influences in our evolution to a legitimate licensed health profession was the invention and marketing genius of Dr. Forrest Bird. He invented the fluid valve ventilator and marketed it in the highly successful Bird Mark VII ventilator. This device wasn't necessarily intended to breathe for the apneic, but was used to rehabilitate compromised pulmonary function. Studies showed that postoperative patients, who used the "Bird Machine" as we called it, were much less likely to develop atelectasis, pneumonia or other pulmonary complications. In the 1970's and early 1980's every hospital had dozens of these devices used as part of standing orders for nearly every surgical and pulmonary patient. These technical treatments became the property of us newly recognized respiratory techs/Respiratory Therapists. One wonders how much society could have saved on machines, therapists, and resultant nosocomial infections and other complications had we understood that simple breathing exercises, self-practiced by the patient, were even more effective in achieving the desired outcomes. The use of the Bird Mark VII has fallen into antiquity. Lucky for me, respiratory therapists are still useful.

This is one example. There are other similar stories including BMT's for breast cancer and HUAM for high-risk pregnancy, and I've lost count of the examples in the pharmacy industry. All may have been based on noble ideals and good science. But we cannot ignore the monetary influences that made them widely accepted despite a lack of good clinical evidence. The difficult trick is knowing when something truly is "latest and greatest" or merely a marketing hyped fad. Healthcare is an industry, and any industry's biggest influence is money. I suspect in the case for virtual colonoscopy, anything but a definitive "no" by the scientific community is a "must do" to the marketing spinmasters

Tuesday, January 20, 2004

Are there Conflicts of Interest in Medicine?

I worked with a pulmonologist who would not carry a pen or rx pad with a commercial logo on it. He did not have medication samples in his office.

I am regularly fed by, and acquire my CEU's from, medical service and pharmaceutical companies. HMO's own doctors, Big Pharm sponsors clinical trials, commercial industry grant money to research universities.

Who is to say when any of these potential "conflicts of interest" will or will not influence a clinician to choose one intervention or care over another.

The language of Alernative Medicine: CAMspeak

"Detoxify" is a GREAT word. It is an absolutely necessary word because it is a SAFE word for the supplement industry. What else can we actively do without expressly implying that we are diagnosing, treating, or preventing disease? "Neutralize" infers a measurable chemical (ie acid-base) imbalance, "cleanse" infers identifiable impurities. We can't use "treat", "cure". "Correct", "benefit", or "restore" aren't even as safe as "detoxify" when it comes to skirting FDA regs for a supplement.

Here's a fun game. Compress some kind of organic matter into a pellet. Package it. Then for the label, choose a word from a, then b, then c, to make a 3 word statement about the amazing benefits of your product.

a. energize, detoxify, balance, empower, vitalize
b. life-force, cell-action, mind-body, auto-immune (create your own, but hyphenated words are better.)
c. processes, function, behavior, activity

Cold lasers, part 1

Not only does "cold" laser sound innovative and cool from a marketing standpoint, this is also called "laser acupuncture," a term that I think just beats all.
The Low-level laser refers to the use of red-beam or near-infrared lasers with a wavelength between 600 and 1000 nm and Watts from 5-500 milliwatts, this is too low to produce heat, hence: "cold" laser.
The Mircolight 830 has had FDA 510(k) PMA approval for over a year. According to the FDA letter, the "MicroLight 830 Laser is indicated for adjunctive use in the temporary relief of hand and wrist pain associated with carpal tunnel syndrome." http://www.fda.gov/cdrh/pdf/k010175.pdf
There were actually quite a number of comparative clinical studies on "low level laser" treatment on a MEDLINE search several months ago, also there was one reported to the FDA (see link). However, none of them really reported outcomes when compared with standard treatments for carpal tunnel. Of course, there's many studies for "cold" laser in the treatment of other things as well, including fibromyalgia, low back pain and sprain ankle. Outcomes have been very mixed. There seems to be serious investigation, but the technology doesn't look to be breakthrough for any medical indication. Do a google search, and I suspect where you find it is where it will ultimately end up.

Monday, January 19, 2004

Do all Mormons do multi-level marketing?

An associate lost an LDS friend by being critical and skeptical of the "Young Essential Oils" they were peddling. The following is my sincere reply.-dr

I have heard this story. When you hear things like this, about all you can do is sigh, shake your head and admit to the existence of nuttiness. It's also a reminder to be aware of what's going on around you. Part of my involvement on this list is just that. I want to be aware of things in order to be wary of them, and to pass the wisdom along to family and neighbors.

I'm not the guru of LDS apologetics, but I know stories like this are used to insinuate, slander, or otherwise put the Church as a body in poor light. I can attempt to put the LDS ties in the story in a little perspective. I live in a suburban, almost rural area between SLC and the "Sunset" mentioned in the story. There's over 25 acres of orchards and alfalfa bordering my property on 3 sides. Nevertheless, I am within a 5 minute walking distance of three LDS meetinghouses. Two host three separate congregations on Sunday, the other hosts two. Each with over 50 families. My point is, community and church and barely separable. Now consider that all the leaders, teachers, and ministers in the LDS church (outside regional general authorities) are volunteer laymen, with full time occupations outside Church responsibilities. It is amazing all things work as well and consistently as they do. But with tens of thousands of parish leaders in different capacities, we can expect to occasionally see things that are corrupt, non-Christian, and plain not right.

Included in the LDS cannon of scripture are inspired writings of Joseph Smith called the Doctrine and Covenants. In this, "priestcrafts" are spoken of. The admonition is for leaders and members to be wary of Church authority being used for anything outside the strict definition of the calling. Specifically, to exercise any kind of power over another, or to get personal gain. It is inferred that these priestcrafts will be common.

I cannot be a judge of other men. Sometimes I suppose someone in cognitive dissonance can rationalize all kinds of behavior to themselves and others as being "right." The banner I raise says that our Father in Heaven, above all else, is concerned with our spiritual salvation. Temporal matters are a distant second, just ask Job. I often preach to the list that one shouldn't look to medical clinicians to address their spiritual needs. Closer to home, I preach one shouldn’t trust to Church leaders to advise on their medical, political, business, and other temporal questions. I suspect local leaders that advise in these matters in the capacity of their leadership position, are loosing their focus on the priority and are in danger of forfeiting salvation.

It is unfortunate you see the nuttiness. Please spend a week, or an hour, in my neighborhood (we'd love to host you) and I'm sure you'd see first-hand a very different picture of the Church and community.

Friday, January 16, 2004

Chiropractic manipulation, personal account

I actually had some kind of extreme neck manipulation done once. Several years ago at a health fair, I was running a booth next to a chiropractor and got to gabbing with him. He seemed eager to preach so I talked about some long-term back pain I had due to working the floors (wards) at the hospital. He suggested I needed my neck worked on but he couldn’t do it; that there were few chiropractors around that could do it. He did say that his partner taking over the booth in the afternoon could do it. When he arrived, I lay prone on his health-fair table and underwent several minutes of what felt like a nice neck massage. He asked if I could be completely relaxed, then suddenly it was like Bruce Lee finishing off Bolo. A few seconds later my head was similarly "manipulated" in the other direction. The popping felt and sounded like a crepitus knee, but it was not uncomfortable. In fact, I jumped up off the table with my head and shoulders feeling lighter than air and better than they had in months! The cool thing was, it took several more weeks of lifting patients up in bed before I even started to notice my upper back again. I've long since abandoned floor work, and my back problems have gone away.

Despite my developing wisdom, skepticism and cynicism, my attitudes about this have not changed. I understood there was serious risk to the neck procedure as was explained by this guy's partner, but I trusted he knew what he was doing and the chances for adverse effects were small. I'd do it again if my back ached, provided it was this same guy.

Thursday, January 15, 2004

God and Medicine

The Deseret Morning News of this week ran an article mirroring a recent Newsweek story on how medical clinicians use religion in their practice to benefit their patients. -dr

Dear Editor:

I enjoyed the local perspective on the recent Newsweek topic: God and Health as presented by Ms. Jarvik in the Religion and Ethics section of the Morning News. When considering this subject, some obvious red-flags should not be ignored. There are dangers in matriculating the two very different concepts of faith based spirituality and religion, and the empirical science of medical practice. Both may play an important part in healing and health, but allowing or believing science and religion to be interchangeable opens the door to pseudoscience, mysticism, charlatanism, and fraud.

Many concepts in so-called alternative medicine require a belief in life-force, energy-pathways, and other ideals that are not, and perhaps can not, be demonstrated scientifically. They, therefore, require faith. Any medical practitioner using treatments based on these concepts is imposing their own faith-based (religious) ideals upon their patients, a serious breech of ethical practice. It becomes more serious when the practitioner expects society (Government programs or private insurance) to pay for treatments that rely on religious-like concepts. In essence, this becomes state sponsored religion. Easy to see how important it is to keep our practice of medicine and our practice of religion separate, and to know the difference.

Some would argue that using scientific clinical studies to "prove" the benefits of intercessory prayer is to tempt God. My comment would only be that society's limited resources would be better applied toward more practical investigation, like a cure for cancer or aids. Physicians graduate from medical school, not a ministry, not a seminary. Few if any are set apart by clergy as ministers of religious rites. We are foolish to expect our doctor to address our spiritual ailments along with our physical ones. We are wrong to look to our healthcare system to fill our spiritual needs.

Thursday, January 08, 2004

Beyond the science of legitimate medical care

This writ started out as a blantent and sharp bashing of Chiropractic. But, that entity should not be singled out as the target of my rants -dr

As soon as Chiropractic philosophy establishes itself as a religion it will have my deepest respect. Call it religion, or call it philosophy, but do not call it medical science and do not equate it to society's general perception, definition and understanding of health and medicine. A spirit or etheral connection to health and wellness may some day become understood. Until such time we, your health-care industry, are soberly obligated to act based solely upon our observations from nature.

My intent is not to bash Chiropractic, or any other alternative treatments. None of them should be sold or infered as being qualified health care treatment along side those that are based on empiric understanding. Inferring directly or indirectly that correcting energy flows in the body, balancing Qi, or whatever, is just as valid as giving antibiotics or NSAIDs is not right.

....what can be done when the proven therapies don't work? Few will deny that empiric textbook medicine doesn't have all the answers for what makes us sick, or well. I'm convinced that there is a mind-spirit connection to being and feeling healthy. But no one should sell any philosophy or theology about this connection in the quise of medical science. Especially when it is done to promote sale of a product, or solicit money for "treatment." This is healthfraud.

Monday, January 05, 2004

Jay Gould and Leon Festinger

I learned this concept of 'reification' from reading "The Mismeasure of Man" by the late Stephen Jay Gould.
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Maybe I'm off base, but I thought I remembered "Mismeasure..." in discussions about IQ tests carrying test-maker biases, and therefore not representing a valid representation of intelligence. (Thus my comment in not commenting.)

I probably should look it up. Did it cause you to change some of the beliefs you had about humankind? Is it going to challenge my trust that there is order in the universe?

Perhaps instead I'll remain content with the current post-modernistic ideal of not necessarily having to be well-read or learned to be credible, valid, or of worthy opinion. What a wonderful time we live in.

At any rate, I'll file away "reification" with another favorite (and alt-med related) term: "cognitive dissonance" [Leon Festinger]

Friday, January 02, 2004

Why I need to know why I'm sick

To name something makes it real by giving it identity. (Learned that from several fiction-fantasy novels.) Perhaps saying "I don't know what's causing your symptoms" is like saying "there's nothing wrong with you." Not understanding why you feel the way you feel, and not being able to identify what is causing you to feel the way you feel is very uncomfortable for most people. Hence, our current epidemic of diagnosis' of exclusion. Cause and effect is an easy concept for us to accept and understand. It is obvious that the scientific application of medicine often falls well short in reliably assigning cause and effect to explain the diagnosis and cure of much of what ails us. We want answers, and alternative medicine, like astrology, does not have a problem in coming up with causes and effects.

There are a couple other reasons why I think people turn to so called CAM.

We are told we are sick, could be sick, or are otherwise in less than optimal health. This traditional ploy of the supplement industry (take any on-line health evaluation test) is more and more prevalent in the over-the-counter and prescription drug industries, and is creeping into a growing fad of the preventive health industry.

We also feel we have the right to good health. It is not fair or right that I am sick, may become sick, or am in any way disabled, and someone should be doing something about it.

Health is an obsession in our society. I have friends that cannot speak two sentences in conversation without mentioning one of their own chronic maladies. We all know people who at any opportunity proudly recite their (or a family members) medical history.

To the many who seem to unreasonably fixate on health and wellness I would say: Find religion, find a hobby, join a book club, buy a new puppy. I'm not suggesting that "there is nothing wrong with you," or to ignore your health and not attempt to control symptoms or chronic disease. I'm only suggesting there is too much happiness to be found in life, even when health problems seem to impact even every minute of it.