Category Archives: Complementary and Alternative Medicine

Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

(In which I answer several random questions submitted to me by readers. -PB)

Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties.  Your thoughts?

I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty.  By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency.  If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t.   A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.

Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.

Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.

But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?

No.  Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job.  The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties.  The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig.  You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.

The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.  As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.

The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed.  It is in this specialty where mid-level providers particularly excel and for which most are hired.  What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts?  Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.

Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely.  If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.

The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork?  Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.

But what about Primary Care?  Surely mid-level providers are suited for primary care?

You only say that because you don’t understand primary care or are confusing it with something else.  Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties.  To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival.   With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address.  In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one.  I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker.  Realistically, however, I could train a high school student to do most of her job.

Now, it is true that primary care physicians see a lot of minor complaints.  Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey.  In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention.  Can a mid-level provider handle these?  Of course.  But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”

Primary Care, in other words, is not just about minor complaints and it is not urgent care either.

What About Urgent Care?

Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman.  With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course.  If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.

Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work?  Sure you can.  But these things are worth what they are worth.  The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one.   This is why, by the way, residents love moonlighting at Urgent Care Clinics.  Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.

What about Complementary and Alternative Medicine?  Can’t I go to Chiropractic School or something like that if all I want to do is primary care?  My Chiropractor advertises himself as “Primary Care” so I was just wondering.

Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.   On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.

Take your typical chiropractor, for example.  He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department.  Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed.  He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody.  More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors.  He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.

The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.

No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman.   Likewise if you really care about your long-term health.

Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level.  To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.

Defending the Pie

(The pie is a metaphor. I’m only mentioning this because the last time I mentioned pie, I received several irate emails, the gist of which were that pie is not to blame for the collapse of society. -PB)

Primary Snake Oil

The silliest thing about the practitioners of Complementary and alternative medicine is that they don’t know when to leave well enough alone. Currently, with the exception of the occasional over-enthusiastic chiropractor who breaks somebody’s neck or tears an important artery that he has never even heard of, Complementary and Alternative Medicine is a low-risk enterprise, the business model of which is to take a panel of essentially healthy patients with predominantly psychosomatic complaints, stroke their egos a little, mumble either some pseudo-scientific rigmarole or some whacky Eastern nonsense, and send them on their way totally cured and none the wiser. The worst that could happen is the patient still feels bad but, since lawyers have yet to work out a way to demonstrate in court that your qi was irreparably damaged by your acupuncturist, as long as the needles are reasonably sterile and there is really nothing in your homeopathic pills but sugar and a one-in-one-billion chance of one molecule of sheep spleen, you are as a CAM practitioner (if you will pardon the expression) shitting in high cotton.

It is with great interest therefore that I read about naturopaths and chiropractors, among others, trying to pass themselves off as primary care physicians. I see the usual billboards in my town from the chiropractors advertising themselves as the complete medical solution for the entire family and there is even a small subset of back-crackers billing themselves as pediatricians. Naturopaths, for their part, are even recognized as Primary Care Physicians in some states (particulary in the Northeast) and are attempting the usual inroads elsewhere. Leaving aside the obvious, that chiropractors and naturopaths are physicians in the same way that I am a Starfleet Admiral, it is puzzling that, with such a good racket going, the witchdoctors would be trying to sneak into a job for which their training is inadequate and which opens them up to all of the hassles of real medicine like deadly earnest malpractice suits (not to mention suffocating government control, and declining reimbursements).

Suppose you used a chiropractor or a homeopath as your primary care provider. In the best of circumstances, and loosely following the mid-level model for delivering primary care, the CAM practitioner would be a low-level gatekeeper, assuming they knew their limitations which is not usually the case. The typical education model for a CAM practitioner with an advanced degree in his modality, also known as lipstick on a pig, leans heavily on their own particular flavor of snake oil and throws in just enough of the traditional medical curriculum to say, “See, nobody here but us scientifically trained doctors,” but not enough where anybody should feel confident that they would even know when to refer to a real physician.

Even if you came across the rare naturopath or chiropractor who knows that he is selling hokum and is therefore keenly aware of his limitations, if he wanted to be a primary care physician he would do nothing but add another layer of expensive and completely useless medical care to an already overdoctored society. Except for the rare public service of calling 911 like any good Samaritan would if somebody showed up at his clinic with chest pain, he is contributing nothing, and the only difference between he and his more adventurous and less self-aware colleagues in that he will quickly refer to real primary care physicians for real medical problems while they might sit on the truly sick patient for a long time before getting spooked, scratching their heads and wondering why the Ginkgo friggin’ Biloba isn’t doing the trick.

Benefit to society: Zero. My neighbor can call an ambulance and most people know when to go to the doctor. Hell, the real trick is getting them not to go. There is, you see, more to primary care than referring to a real doctor or a specialist. Certainly knowing when to call a real doctor shouldn’t be all the credentials you need to label yourself as as primary care provider. You do actually have to treat something and adjusting qi to improve the subjective well-being of your bored patients isn’t it.

For their part, the chiropractors and naturopaths will point to the existing mid-level providers, many with only a couple of years of formal medical training who are also making inroads into the primary care field, and invoke the doctrine of “me too,” reasoning that since they have a fancy four-year degree they are more than qualified to work as primary care physicians. Whatever the qualification of Physician Assistants and Nurse Practitioners however, their training at least follows the rational model of medicine and is not encumbered by snake oil. A Physician Assistant may only have only two years of formal training but all of it is good which cannot be said for CAM practitioners. Chiropractic school may be four years long, for example, but as most of it involves instruction in a completely debunked treatment philosophy as well as desultory clinical years where all the student sees are mostly well patients with the aforementioned psychosomatic complaints, it is not exactly medically rigorous and in no way prepares the practitioner to understand, let alone treat, even the simplest of presentations. Not only is their first instinct is to throw useless woo at medical problems, under the theory that if you have a hammer you nail, but they don’t even know enough to know their limitations which is perhaps the most dangerous character flaw in the medical world.

Sure, anybody can see somebody with a cold or some other minor complaint and the odds are good that nothing they do, provided they don’t get too jiggy with it, will do much harm. But let’s suppose that you have never rotated on a medical service or done your share of critical care. Suppose you have never worked in an emergency department or spent a few sloppy months on the labor and delivery floor. Imagine, if you can, seeing a provider for your family’s medical care who is treating your kids but has never had a lick of formal pediatric training or so little that she has never seen the really bad pediatric diseases that look like a little bit of nothing when they first present. Does your chiropractor, for example, know the odds that a fever in a neonate is some flavor of bacteremia that needs aggressive treatment?. Let us further suppose that while your chiropractor has spent hundreds of hours learning how a little normal misallignment in the spine can cause “dis-ease,” he has never had to recognize appendicitis, pancreatitis, or the first subtle hints of colon cancer. In short, while a lot of primary care is routine stuff, little potatoes that the school nurse would have to work at to screw up, not all of it is and if all you’re barely qualified for is to pass sick patients to somebody else as some kind of completely redundant middleman, maybe you should stick to the entertainment business and leave medicine to those with training.

Seriously now, there are whole groups of trained physicians, radiologists and orthopedic surgeons for example, who have not only legitimate training in general medicine but the legal license to practice any kind of medicine in which they feel comfortable who wouldn’t dream of doing pap smears or treating some kid with an ear infection because they are a little rusty in that kind of thing. Internists do not moonlight as obstetricians even if they have delivered a few babies in medical school and for my part, although I have done six months of surgery rotations in my training as an Emergency Physician, I’m not taking out anyone’s gallbladder anytime soon. I’m not adequately trained and I could not look the patient in the eye and ask for their trust.

Remember, also, that your primary care physician has a minimum of seven years of formal medical training. Your family physician has, in fact, done a lot of inpatient pediatrics, internal medicine, and a few months in the Pediatric and Adult Intensive Care Unit. The only legitimate question is whether a residency-trained primary care physician is over-qualified for many of the patients they see. The purveyor of snake oil doesn’t even rise to the threshold of qualification.

Mid-level providers and physicians practice in the real world of medicine and when confronted as we all are from time to time by the limits of our knowledge or abilities refer to a higher level of care. The Complementary and Alternative Practitioner, in a tacit acknowledgment that his therapies are ridiculous, will always defer to real medicine when he at last realizes that he is an ineffectual bufoon but only after exhausting his repertoire of snake oil. The danger is that there is no higher level of care in complementary and alternative medicine, just a hodge podge of smooth-talking clowns to whom the customer may be sent, and unless the chiropractor or naturopath honestly assesses his abilities (which would preclude him from even wanting to be in primary care) we’ll have a subset of sick patients who need real medical attention but are not getting it. Now, while this may be good from a strictly Darwinian point of view, allowing the oldest and sickest to die before they can become to much of a burden on society, this is not exactly a ringing endorsement of Complementary and Alternative Medicine.

Currently, the only benefit at all from CAM is that it keeps otherwise healthy people with no real medical complaints from clogging a medical system that is already overloaded, in part because of patients for whom nothing really needs or can be done. And it’s fine. I have long passed the stage in my life where I view it as a personal mission in life to cure others of their stupidity. It’s a free country and if you think you have it all figured out, then knock yourself out. The only money you are wasting is yours and you obviously have more of it than you know what to do with. The problem comes when public money and “quasi-public” money from private insurance pools is used to pay for this kind of things which is, I suppose, the Holy Grail of the Complementary and Alternative Medicine practitioner. That is, to get their claws into the the trillion dollar pie, which, unlike most economic pies, is indeed finite and not big enough to feed everybody all they want. For my part, I don’t think we even need to eat the whole pie but should instead save some for later.

The trouble is that when you leave a pie out and turn off the lights, the rats will edge towards it for their share. I’d like to protect the pie from the rats, both in real medicine and most especially from the exotic rats in the world of Complementary and Alternative Medicine.

Evidence Based Medicine? We Don’t Need No Stinking Evidence Based Medicine

The Free Netter’s Ain’t Worth It

I am an educated man. I have an extensive liberal education, a degree in Civil Engineering, a Medical Degree, and am almost done with residency training in Emergency Medicine. Just for fun, I read the kinds of books they forced you to read in your long-forgotten English literature course (not that you actually read them but instead passed the course with the help of CliffsNotes and the professor’s fear of damaging your ego). While not an expert in much, I have a good working knowledge of physics, biology, chemistry and enough of the medical sciences where I at least know enough to understand new concepts as they present themselves and when smoke is being blown up my ass.

On the other hand I am also an ordinary guy and have done my share of regular jobs from fast food to landscaping and a lot of things in between. As I may have mentioned once or twice, I was also a United States Marine Infantryman and consequently know which is the dangerous end of a gun and, while I am today just a stocky suburban dad, at one time could and did endure physical hardships that would make the typical malignant Attending Physician, cock-of-the-walk in the hospital chicken house, weep like a little girl.

I have by no means seen and done it all but I have a pretty good idea how things work. I confess, however, that about one of the major underpinnings of the great structure that supports my beliefs, I have been wrong. Completely and utterly mistaken, so much so that if I could, I would find everyone upon whom I inflicted my totally incorrect theory and humbly abase myself in abject and total apology.

You see, for my whole life I have believed, and defended vigorously, the notion that being educated does not preclude one from having common sense. The conventional wisdom is the contrary of course, and I have heard this wisdom expressed often, especially when I was a Marine. “Yeah, he’s book smart,” went the typical conversation, “But that guy can’t find his ass with two hands and a flashlight…couldn’t pour water from his boot if the instructions were on the heel.”

I’m not saying that educated people are immune from stupidity, just that education does not cause stupidity and I have been a champion, a lion, in the defense of education as a complement and even an enabler of common sense. After all, many of the cool kids at my high school who eschewed the Chess Club are currently living in single wide trailers with women who, despite weighing 400 pounds (181 kg), are still trying to cram themselves into the same revealing clothes they wore in their brief flowering of trailer park beauty, those precious couple of years as fleeting as the tundra blossoms, between their first tattoo and their first illegitimate baby.

And then I read, via Orac at Respectful Insolence, about something called the Complementary and Alternative Medicine Leadership Program, sponsored not by some third rate chiropratic mill but by the American Medical Student Association, a splinter group of the august American Medical Association, who have bribed hundreds of thousands of medical students to join their ridiculous organization by giving them a free anatomy atlas (Netter’s).

I wept.

Suddenly, what I once thought to be the stable soil underneath the foundations of my weltanschauung heaved as if nothing more substantial than wet gumbo clay. Maybe smart people are prone to be booger-eating morons after all. I mean, seriously, here’s a group of American medical students who they tell me are drawn from the very top percentiles for intelligence spending their summer sitting at the feet of homeopaths, acupuncturists, and Reiki healers, soaking up the woo like so many lumps of dry cornbread. And they are buying it. Completely and wholeheartedly. The natural skepticism which is the true birthright of an educated man seems to have skipped a generation.

Take something like Reiki, one of the latest and trendiest of the new age Complementary and Alternative Medicine therapies. The Reiki practitioner claims to produce medically significant effects on a patient by shooting sacred fire out of his appendages. That’s it. That’s all there is to it. Once you strip away the Eastern mysticism and flamboyant Asian ambience it’s just a guy shooting spiritual energy into a patient. I told my Heating and Air Conditioning Guy about Reiki and he laughed.

“Hey, maybe you can get a a Reiki healer to shoot some mystical fire out of his ass to fix your furnace,” he said, “But in the meantime I’m still going to have to charge you a hundred and twenty bucks for the new igniter.”

The Good Lord knows that I embrace the concept of Evidence Based Medicine. A lot of what we do in medicine is marginally effective (if at all) and it is sometimes only tradition and a general sense that something should work (even if it doesn’t) that keeps us doing it. Evidenced Based Medicine is a world-view, a system of thought, that allows us to test everything we possibly can and eliminate these therapies that are ineffective or even harmful. But Reiki? With respect to my colleagues investigating every aspect of medicine, I don’t need a double-blinded placebo controlled study, a meta-analysis, or any other proof except the obvious one that some smarmy guy with a mail-order degree in Eastern mysticism cannot shoot spiritual fire out of his hands. First because there is no such thing as spiritual fire and second because, well, he’s some smarmy little fraud with a mail order degree. As I mentioned in another post, res ipsa loquitor; some things just speak for themselves and while I appreciate the zeal of many in the scientific community to test even things that are obviously ridiculous on a fourth grade biology level, I don’t necessarily need a lot of evidence to suggest that magic fairies and pixie dust are not legitimate treatment modalities.

Which is kind of the point of research into things like Reiki and Homeopathy. What on Earth do you expect to find? Even those who are inclined to believe in this kind of nonsense, when pressed, will admit that for any given Complementary and Alternative Medicine therapy the research is generally incredibly shoddy and, even allowing for a generous confidence interval, a blind eye turned towards the biases of the researchers, charitable peer review, publication in journals that are only one step above the supermarket checkout line variety, a favorable wind, planetary alignment, and an early showing by the groundhog, the positive results are slim, barely detectable, and easily ascribed to a placebo effect; something that is controlled for in real medical research and, if detected taints the entire study. In the world of real medical research, you understand, discovering that your prized medication is no better than a placebo is not greeted with war whoops and fists clenched in triumph.

No high fives, in other words. Back to the old drawing board. Things work the other way in the mystical world of Complementary and Alternative Medicine. The discovery of some insignificant statistical anomaly in a poorly designed and non-reproducible study is greeted with the same enthusiasm by the true believers as the discovery of the structure of DNA and we must now run, not walk, to legitimize their particular brand of fairy dust and use it on everybody. Pulling the same trick in real medicine leads to eventual exposure, embarrassment, ridicule, and even criminal charges. While every medical therapy involves some combination of cost and effectiveness, for Complementary and Alternative Medicine the cost (because Reiki healers do not dispense spiritual energy for free) is not even remotely worth whatever miniscule and highly subjective clinical results can be delivered by what is essentially an entertainment modality and not a medical one. You could, for example probably get the same results watching old Kung Fu reruns as you could with acupuncture. Or, to put it another way, acupuncture won’t work if it’s some bored acupuncture tech named Frank doing it, even if he puts the needles in the right spots. Unless he dazzles you with his mystical dog-and-pony show it’s just some paunchy guy smelling of cheap cologne sticking needles in you.

You know, I cannot help but sympathize with the young AMSA scholars. Medical students are not generally the popular kids in high school or college. The demands of making good grades and navigating the poodle-circus of medical school admissions preclude a normal social life. For my part, I was something of a nerd in high school. I was on the Debate Team, for Mohammed’s sake. Can’t get more uncool than that so I understand full well the appeal to you, oh young AMSA scholar, of going to some retreat with a group of your geeky friends lead by a bunch of people who, as you are the future leaders of medicine, will coddle, stroke, and reaffirm how special you are. It probably gives you the same rush you got from representing Cuba in the Model United Nations. But that’s the thing, isn’t it? Complementary and Alternative Medicine at the medical student level is not about the patient but about the medical student who use it as a positive affirmation of their own values; their open-mindedness and their unshakable belief that some Native American Medicine Man chanting around a sacred fire has something legitimate to teach the medical profession. It’s a way to resist the brutal self-discipline required to put away the fantasies of childhood and deal with the World-As-It-Is rather than how you would like it to be.

It also affords you the opportunity to get close to that awkward but reasonably pretty girl who otherwise won’t give you the time of day but who sent shivers up your spine that time she accidentally brushed by you. Dude, that’s why they have Spring Break. Not that I don’t applaud your motivation, especially if you are into earnest chicks who want to save the world but just admit it and stop with the magic fairies.

Housekeeping Stuff:

1. Congratulations to Graham over at Over!My!Med!Body! for matching into Emergency Medicine. Welcome to the club and no matter what they say, all the other specialists secretly wish that they were the combination of poker player, cowboy, daredevil, scholar, and circus clown that it takes to be an Emergency Physician. I can’t imagine doing any other specialty (even though anesthesiology looked mighty good, details in a later post, when I recently did a two week rotation) and once you get through all of the intern year crap you will enjoy yourself immensely.

2. Your comments are appreciated. Please, limit your links to two (2) as my spam filter is on a hair-trigger. No matter what your comment-the cardioselectivity of various drugs, your groundbreaking economic theories-if you use the words Brittney or Spears anywhere in the comment I think it is automatically shredded.

Rambling Around the Medical Blogosphere

(A roundup of some of the non-seismic events that have been troubling medical bloggers -PB)

Whaddya’ Mean it Doesn’t Work?

I rise in support of the makers of Airborne, an all-natural cold remedy, who are the unfair victims of a class action lawsuit that alleges, among other things, that the product neither works as advertised nor has any legitimate research behind it to back its claims. Developed by a couple of school teachers in the late nineties, this nostrum was promised to do nothing less than cure the common cold and in the process fulfilling the second part of the impossibility trifecta; the first of which was putting a man on the moon and the third, the remote possibility that Whoopi Goldberg will ever make a funny movie. Having been involved in a couple of business ventures myself, I understand the difficulty of marketing a new product in an economy packed to the gills with hundreds of variations of every product you can think of. The spatula section alone at a typical Target, for example, offers a bewildering array of spatulas (spatulae?) each with some carefully researched but ultimately ineffectual angle to attract the consumer. It’s not easy marketing some crap in bottle as the market is currently saturated with the stuff.

Claiming to cure the common cold was a good start because that takes some chutzpah even if it did require a careful strategy to keep the FDA at bay. The teacher angle was pretty good, too. I mean they’re school teachers fer’ Muhammed’s sake. School teachers! Everybody knows they’re smart and that they can do no wrong. They’re, like, untouchable, man! Accusing them of chicanery would be like bludgeoning the Pope with a baby seal. It should have been enough except that the makers of Airborne forgot one important lesson: In this day and age, lawyers are everywhere and if you’re going to sell useless crap to a gullible public, at the bare minimum you’ve got to have some big academic medical center providing cover. They know this in Durham, North Carolina where Duke Integrative Medicine flogs the usual candy-ass Complementary and Alternative Medicine with complete impunity, secure in the knowledge that every brand of snake oil they peddle, from Reiki to Guided Imagery and every breed of utter stupidity in between, bears the august imprimatur of Duke University.

You’re Doing it Wrong

I also rise in support of the New Scotland International School of Medicine, which, as its home page breathlessly informs us, is the Number One Leader in US Medical education. Not bad for a school that just opened its alleged doors a little more than a year ago. Ostensibly a churlish little enterprise taking advantage of some little-known (and perhaps imaginary) World Health Organization loophole conceived by French bureaucrats to legitimaze medical schools in countries ruled by oleaginous fat guys in military uniforms, Stewart University (as it is also known) promises to provide affordable and easily accessible medical training to people who, by virtue of bad grades, poor test scores, lack of a high school education, and other injustices are incapable of gaining admission to more traditional American medical schools.

Is it a scam? What do you think? At the risk of sounding shallow, one look at the nepotic rogues gallery comprising its administration, including the Provost Emeritus whose photograph lools like the last known picture of a Nazi war criminal before he fled to Argentina and the Chief Operations Officer who is a dead ringer for the Girl in the Back of the Bus who smoked cigarettes and let the boys look at her hooters, should be all anybody needs to know. The provost himself is a 32nd Degree Mason and a Member of the Ancient Arabic Order of the Nobles of the Mystic Shrine so, you know, he’s gotta’ be qualified as is the Facilities Director who couldn’t get a date for the prom and decided to get a job with Stewart instead.

Clinical rotations, you ask? Hah! “Clinical rotations,” the eponymous Chancellor informs us, “Are the least concern of a new applicant to medical school.” So apparently yer’ not going to do any. MCAT? College degree? Not required, allegedly, in Burundi or Southern California. A GED will do. That troublesome extra fourth year? Not necessary. The United Nations has decreed it, we believe it, and nothing more need be said. All you gotta’ do is get one of their cut-rate degrees, pass the USMLE Step tests, and finagle your way into the American residency training system with a generic international medical degree and no clinical experience whatsoever.

Oh the seductive allure to those whose dreams of a medical career are otherwise impossible to attain. This school has it all. No admission requirements to speak of. Easy courses taught by a lackluster faculty. Three-year curriculum. Southern California location. One last chance to redeem frustrated dreams, an in-your-face to those who said that your child pornography conviction would forever keep the prize out of your reach. With this in mind I must ask Graham to stop busting down on this little enterprise, this last best hope for those who could be great physicians if they could only get a handle on that, what do you call it, heart-thingy. The fact that this beacon of mediocrity might have to close its alleged doors (if it already hasn’t) would be a great blow to American health care and could be avoided if the school just tried a different marketing approach.

First of all, if you’re going to make a virtue of a weak curriculum, broken-down faculty, and shoddy instruction, you have to protect yourself from your potential critics. The military angle had got to go. The academic left will forgive a lot and tolerate all sorts of assaults on their academic standards but as every single member of Stewart’s executive body is a uniformed, blood-thirsty, baby-killing, My Lai torching, brainwashed, current or former military officer, they are nothing if not a big old fat target. Might as well put a big sign on the alleged doors begging to be shut down. If they’re going to do it right the Chancellor et al need to grow beards, learn how to tell jokes, and give their medical school some whimsical name like the Gesundheit Institute or the Center for Caring. Can’t shut you down if you’re wearing clown suits, home boy, or don’t you watch movies?

Not to mention the school needs to drop the legitimate medical education angle. Nobody’s buying it and it is too hard to fake. Instead, they need to invent some useless crapola and market it to the leftover hippies. I suggest they go au natural and offer degrees in Naturopathic medicine or similar horseshit. It’s not as if there are any standards. You can pretty much make it up as you go along, gleaning whatever you need from head shop catalogues, Wiccan literature, and whatever you can rustle up in the Alternative lifestyles section of your local Barnes and Nobles. Then they need to move to Seattle where they’re into that sort of thing. Give Bastyr University a run for their money.

Complementary and Alternative Medicine Month: Finale (Reposted from 12/6/06)

(No, we’re not in re-runs here at Panda Bear, MD. I was asked to repost this article by a few of you and even though it is in the catagorized archives, I thought I’d just run it again as a finale to CAM month. Enjoy and I swear I will have a new post up tomorrow. -PB)

Keep an Open Mind

So they asked me a lot, when I was interviewing for medical school, what I thought about complementary and alternative medicine particularly the use of traditional practices as adjuncts to Western Medicine.

I’m all for it. There are a lot of traditional practices I’d like to see become a part of modern medicine. Like snake handling. For my money snake handling has everything you’d ever need in an alternative therapy. You’ve got your snakes representing nature, you’ve got your mystical religious overtones, and you’ve got scads of anecdotal evidence and testimonials in prestigious religious journals attesting to it’s efficacy.

For those of you who don’t know, snake handling has flourished in the folkways of the southern United States for more than a hundred years and is a time-honored method of casting out the demons that cause most sickness, at least those that cannot be ascribed to qi or bad karma. I understand that the NIH offers a fellowship that will equip anyone interested for an expedition to the wilds of Louisiana in which strange and magical land they may sit at the feet of ancient masters of this art and learn the secrets of the serpents.

And don’t forget to try Uncle Skeeter’s Gator-Taffy if your expedition passes through Lafayette.

I also would like to see more faith healing employed in the modern clinic. I’ve personally seen the lame walk, the blind see, and the gaseous find relief all from the “laying on of hands” as the technique is described by the learned shaman who practice it. For those of you who are lacking in cultural competence, the faith healer’s art is practiced in tents or, more lately, air-conditioned football ashrams where a large crowd can direct their good karma (or “prayerful thoughts” as it is often roughly translated) towards the patient. The patient, under the power of both suggestion and an Ayurvedic being named “Jaysus,” has his bad chakra forcefully removed, some would say driven, from his body with a precisely placed blow to the forehead.

The Shaman often yells “Come out!” but this is just showmanship, not unlike the way we yell “stat” in the Emergency Department even though we know that we’ll be lucky to get the labs by next Tuesday.

There is some debate whether faith-healing owes it’s effectiveness to the so-called “placebo effect” rather than any demonstrable physiological process but the debate is ridiculous and anybody who challenges this ancient traditional practice is a close-minded bigot. It’s not like they’re sticking needles into people or something lame like that. We’re talking bona-fide healing here, often before a television audience of millions. It would be highly unlikely that something like this could be faked in front of so many highly intelligent television viewers.

I have also heard of another traditional mind-body therapy for psychiatric problems, this one practiced in the deep hearts of our ancient cities. Basically, the patient dials a talismanic number, usually preceded by the mystical “900” or any other Number of Power and ceremoniously asks to speak with a priestess whose name is usually Yolanda or Mistress Debbie. The priestess then diagnosis all kinds of psychiatric and sexual dysfunctions, often times correctly pointing out that somebody close to you is cheating on somebody else close to you and “he needs to show you love, girlfriend…and you are so not fat…besides, he digs big women.”

Sometimes they throw in the winning lottery numbers.

Anyways, with all of my patients, the “P” in SIG E CAPS is “Psychic Hot-line.” I understand medicaid will reimburse for it. It’s not as if we’re asking them to pay for something ridiculous like a visit to the chiropractor.

Finally, for my money, nothing can compare to the healing powers of a good old-fashioned poultice like the kind my grandma used to make out of chicken droppings and mustard greens. It was the sovereign cure for a variety of ailments from lumbago to dropsy. Through years of experimentation, traditional practitioners have developed a wide spectrum of salves and rubs that are pushing the boundaries of our understanding of medicine. Our so-called “evidence based medicine” has nothing to compare to alternating layers of gumbo clay, sassafras bark, and chicken bile covered with brown paper and tied to the offending limb with common twine. It’s so good it’s almost magical. For fever, pepper is often added as it is a hot spice. For chills, it’s not uncommon to add the musk of a nutria as everybody knows this hardy animal can gnaw it’s way through the ice that forms every fifty years or so on the bayou. Beaver semen will do, I suppose, but there is no good evidence to support its substitution and I wouldn’t have that kind of quackery in my practice.

Besides, there’s no room to stock it as my shelves are crammed with homeopathic remedies.

Nothing Much More to Say About Complementary and Alternative Medicine. (CAM Month Draws to a Close)

Everything You Need to Know About Complementary and Alternative Medicine (Part the Third and Last)

(One last time I state the obvious while continuing to marvel that it needs to be explained although judging from my email and comments it does. -PB)

8.You Can’t Have it Both Ways

I have some fundamentalist Christian relatives who believe the Bible to be a literal account of the creation of the world. They’re not wishy-washy Christians who get all mushy around the edges and, in an effort to reconcile science and their weak faith, allow that perhaps “a day to God is a billion years to the rest of us.”  The Bible says the world was created in six days and by golly, it was created in six 24-hour days. God said it. They believe it. If you don’t you’re going to hell. Paleontology? Evolution? The fossil record? All tricks of the Deceiver to lead the faithful astray.

You may think that I dislike people who hold these beliefs, or that I am bothered by what I can only call their profound ignorance, but you would be wrong. I admire their faith and they are as welcome to it as anybody else is to theirs. I’ll even send my kids to one of their private schools if I have the chance because learning math, reading, and writing (something not emphasized in many public schools as they are in the grip of their own peculiar religion) is not strictly dependent on a belief in evolution and we can always do a little deprogramming when they get home.

On the other hand I often find myself in goofy conversations (wrestling with pigs if you know the analogy) where my relatives insist that paleontology is bunk because Carbon-14 dating, apart from being a tool of the Devil, is wildly inaccurate and cannot establish the age of ancient fossils. A little later in the coversation we usually roll around to how someone has found the Ark, a barn-like structure on a mountain in Turkey, that has been positively Carbon-14 dated to the time of Noah. I am not a smart guy and I struggle, yes struggle, with sophisticated intellectual concepts but even I can see the contradiction here, the blatant doublethink required to both believe and at the same time disbelieve something depending on what you are trying to prove.

In much the same manner do the True Believers of Complementary and Alternative Medicine try to eat the proverbial cake and have it, too. The NIH, they proudly point out, studies CAM using the same methods used to study real science. Not only does this establish the validity of quackery in their minds but the very act of a government agency studying their peculiar little beliefs is an act of validation in itself. And yet, when numerous well-designed studies using rigorous statistical methods continue to show that Complementary and Alternative Medicine is nothing more than an expensive and highly detailed placebo, the usual accusations are made that the scientific method is indequate to study qi or spiritual fire shooting from the appendages of the healer. The current meme of the homeopaths, for example, is that independent research of homeopathy is impossible because, through some quantum effect, the beliefs of the investigator influence the actual efficacy of homeopathic remedies.  In other words, only a homeopath who believes in homeopathy can research homeopathic effects.

Which then, is it? Is your particular flavor of quackery a scientifically verifiable treatment modality or is it a religion whose secrets are only available to those who make the leap of faith required to believe it? You can’t have it both ways. If you would enter the arena of science then you have to face the lions.

9. You are not the Pope.

I mean, seriously now. Let’s suppose, for the sake of the argument, that there is spiritual fire that can be channeled from your appendages to cure disease. What makes you think some greasy little sociology major who sat through a couple of motivational seminars is the one who can do it? The Pope, for his part, is the spiritual leader of the world’s one billion Catholics, a deeply pious and theologically sophisticated man, and yet he would be the first to deny that he can work the kind of miracles that are the regular activity of oleagenous Pentacostal preachers and their svelte, holistic counterparts in the alternative medicine world. In other words, how do you verify the claims of your dime-store miracle workers? Has your Reiki healer graduated at the top of his class in Lahore or did he go to a cut-rate Reiki training course in Klamath Falls? How do you know your homeopath is shaking the mixture the right way? If there are several schools of acupuncture with their own meridians (and there are), who’s nailing qi like a big dog and who’s just jabbing you with needles? The fact that many of you don’t even think to ask these questions but accept every smooth-talking healer as the real McCoy indicates a level of gulibility, already incredible, that should be embarrasing for any adult who purports to have any street-smarts.

10. “Holistic” is a marketing phrase.

When confronted by the evidence, the purveyors of Complementary and Alternative Medicine will fight a desperate rear-guard action as they retreat deeper into the interior of their vast, irrational country. Finally, in a last-ditch effort to hold onto even that infertile territory they will rally around the holistic banner, insisting that Complementary and Alternative Medicine treats the whole patient while real medicine does not. If you think about it however, it is real medicine, a profession with both generalists and specialists that is treating the whole patient or at least the important, non-entertaining parts. This is why there are so very few Reiki healers doing critical care medicine. Namely because the whole patient is an order of magnitude more complex than can be handled by what is essentially the entertainment committee. Cardiovascular collapse? Sepsis? Rectal bleeding? Please, they’re too busy managing how the patient feels to be bothered with objective disease.

If there’s one thing I’d like every medical student to unlearn its the supposed signficance of the term “holistic.” It’s just a word like “granola,” a clever marketing phrase which is used to disguise a bunch of unwholesome things. When I hear the word “holistic” I reach for my revolver.

Stealth Medicine and Other Topics

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

Everything You Need to Know About Complementary and Alternative Medicine (Part 2)

(In which we address more of the blatantly obvious. -PB)

5. You Can be Fooled

I’m a fairly intelligent guy Not a super-genius or anything like that but I can tease out the truth of most things if given enough time and, when the wind is just right, can tell a hawk from a handsaw.  And yet I am not so confident in my intelligence that I don’t think I can be fooled. Because, for example, I having nothing but a polite interest in automotive technology I am pretty much at the mercy of my mechanic when he describes the repairs needed by our aging pair of automobiles. I trust the guy because nothing he has ever suggested sounds too outrageous and on a couple of occasions he replaced a three-dollar fuse when he could have taken me for an alternator. I am however at his mercy unless I want to study car repair or haul the thing to more than one mechanic.

Consider the typical customer of Complementary and Alternatative Medicine. They are usually fairly intelligent and, by necessity, prosperous enough to pay for something as exotic as a Chakra tuning. But as far as medical knowledge? Not even a clue except for some superficial things and the usual lies and half-truths they have found on the internet. Medicine is an order of magnitude more complicated than auto-repair (although a good mechanic, like a good barber, is worth his weight in platinum) and cannot be casually learned by most people. I can read about engines and have enough of an understanding of their workings to understand what my mechanic is telling me but compared to learning the necessary background to diagnose, treat, and manage disease, this does not require too much effort. When it comes to medicine, the public who undeniably have a huge interest in the subject naturally gravitate towards explanations that simplfy things a tad and don’t require quite the intensive science background.

It’s just human nature. We prefer the simple explanations that do not require complicated and often non-linear thinking. Acupuncture, for example, is billed as redirecting the flow of mystical energy in the body by the use of needles. It jibes pretty well with what most people learned watching those poorly animated Saturday morning cartoons where, instead of incurring the expense of animating the characters, every important action is mediated by some kind of force field or power ray shooting out of Captain Planet’s hands. Thus there is a natural tendency of the public to accept Acupuncture, seeing as it jibes with their world-view. Or consider Homeopathy whose founding principle, that like cures like, is not only appealing to the ear and the heart but also sounds strangely like some of the dim knowledge the public has about the action of vaccines. If they had a more detailed understanding of the immune system it wouldn’t sound so good but who has the time to read a boring old immunology textbook when American Idol is down to the final four?

Intelligent as they are I have to laugh at the typical consumer of Complementary and Alternative Medicine who, while open-minded to a fault, deride speaking in tongues, Christian faith healing, and other barbaric customs of the uncouth rubes infesting the backwoods but pay good money to have some charlatan extract bad Chakra. The difference between some sweaty little televangelist and your local purveyor of Complementary and Alternative Medicine is nothing but style and body mass index and you are being robbed just as surely as if you are sending money for prayer intercession to the Reverend Jimmy Swaggert. You can be fooled, especially when it comes to religion. What, after all, is the standard orthodoxy of open-mindedness, non-judgmentalism, and self-absorption but a religion? It preaches that belief is a substitute for reality and that to even question its central belief, that self-created reality trumps the real kind, is to be an infidel.

The denizen of a mouldering single-wide trailer in Sisterboff, Arkansas sending money to an oily television preacher so Jesus can reveal the winning lottery numbers is philosophically no different than a fit, professional woman swallowing her homeopathic remedies. One has a faith in her dimly understood religion, the other in her poorly understood notion of science. Both are being played for suckers.

6. Quantum Physics, The Last Refuge of Scoundrels

Quantum physics describes the relationships between energy and matter at the subatomic level where the principles of classical physics (momentum, acceleration, velocity, etc.) do not apply. In particular it addresses the relationship between the orbital shells of electrons and photons. It is not a goofy, mystical endeavor that exists outside the realm of the rational world and in fact, while classical physics cannot explain quantum phenomena, quantum physics explains classical physics which results from the cumulative effects of quantum properties.

Quantum mechanics no more explains Reiki, Homeopathy, or Acupuncture than do magic pixies. Or to put it another way, if you were to posit quantum effects as a mechanism for your particular quackery du jour as is common among the purveyors of complementary and alternative medicine you may as well use it to bolster your belief in just about anything at all, no matter how ridiculous. To be sure the field of quantum physics is expanding and there is much to be learned. But it is not expanding towards Ayurvedic Medicine or Homeopathy. Physicists are hard at work trying to reconcile quantum physics with relativity, not proving the existence of Chakra. So sorry. Like I said, you can be fooled and your Homeopath desperately clinging to quantum theory knows less about it than he does about medicine. It’s just part of the con; his attempt to mix enough scientific chatter into a his otherwise nonsensical duckspeak so you will buy it.

7. Political Correctness Does Not Apply to Medicine

The ancient Chinese did not have advanced medical knowledge which allowed them to live long, healthy lives. And they did not, as has been suggested, have diseases unique to their own culture against which their indigenous medicine was effective but which does not work against the white man’s diseases. It is probably true that the Han Dynasty Chinese did not have too much colon cancer, for example, but then the average lifespan back then was around thirty and to live past sixty represented either an exceptionally privileged or lucky life. I am 43 and I have no health problems nor have I ever had any. But let’s see how I do in another twenty years when all of those bacon and eggs have had a chance to work their magic. Who knows what diseases I will get? Whatever they are they will all be the result of a life lived well beyond genetic usefulness and this potential smorgasbord of morbidity is only to be made possible because Western medicine can extend my life long enough for it to happen. In ancient China (or Europe, or Meso-American, or Africa) I would have been dead or decrepit by now and my predictable decline would have been ascribed to old age or maybe Utapu, the God of Rectal Fire. Not only that but the disease that finished me would have been poorly decribed and my long life into the forties would be testimony to the benefits of keeping my qi in order.

This is not to say that the ancients didn’t occasionally stumble upon some legitimate medicine. Surgeons for the Roman Legions, for example, used silver staples to close wounds no doubt having observed that silver had some antiseptic properties. But they still had no idea of germ theory so anybody who would prefer the Legion’s medicus vulnerarius over a modern trauma surgeon is an idiot.

Political correctness is an apologia by the guilt-ridden children of the baby-boomers for the current but by no means permanent economic, political, scientific, and miltary superiority of the West. It is an angst-ridden, completely irrational philosophy that has as its central theme that only Western man has ever behaved in a violent, selfish, or self-destructive manner. It constructs an artificial worldview and is an insubstantatial foundation on which to anchor medicine, a science which like all practical endeavors should be as rational as possible.

Everything You Need to Know About Complementary and Alternative Medicine (Part 1)

(Just belaboring the obvious again. Some things should speak for themselves but judging from my angry email defending Complementary and Alternative Medicine, this is not the case. Rather than respond publicly to private emails I thought I would address some of the major themes of my critics. -PB)

1. The Imperfections of real medicine do not validate your kooky theories.

You, oh purveyor of snake oil, may exhaust yourself pointing out the flaws in medical science. You may grimly list the horrific side effects of many of our therapies and gleefully highlight the lack of evidence for quite a few things done in the real medical world. You may even solemnly condemn our general inability to really cure much of anything but, apart from making yourself really tired and giving me a crick in my neck from nodding in agreement, all you will have demonstrated is that real medicine is an imperfect business which is not a huge revelation to anyone who has spent more than an hour in a nursing home, a hospital, or any other place where you can find incredibly sick people who, despite our best efforts, often remain incredibly sick and die after being flogged by the mightiest weapons in the medical arsenal. A darn shame but it does not follow that the solution to our limited medical knowledge is pixie dust, magical gnomes, or spiritual energy streaming from your fingertips.

On the other hand, while medicine is imperfect you’d have to be a moron or totally brainwashed into your particular CAM cult to not recognize the tremendous advances in medicine even over the last twenty years to say nothing of the huge leap from the days of snake oil at the turn of the last century. That’s the point of modern medicine. It advances. Expanding knowledge leads to to increasingly sophisticated and effective therapies. It’s Complementary and Alternative Medicine that is perfect. Everything you need to know about acupuncture for example, was elucidated a thousand years ago well before those wily Chinese had even the foggiest notion about germs or cardiac physiology. They so totally nailed it that no new research needs to be done. It’s all about qi and the meridians along which it happily flows and is so perfect as to be impervious to debate, refutation, or criticism. While we plod along with our feeble attempts to expand medical knowledge acupuncturists ply their needles in service of a perfect medical philosophy that was ossified in the Dark Ages.

2. The complexity of your kooky theory does not validate it.

For thousands of years Astrology was considered a legitimate science and the best minds of those distant ages devoted their lives to deriving horoscopes and divining the effects of the stars on our lives. They wrote books, developed complicated theories, and tried to apply the principles of Astrology in every aspect of life including medicine. And yet today if you proposed endowing a Chair of Astrology at your Alma Mater or incorporated horoscopes in your medical practice I have no doubt that even the most laissez-faire of liberal academics, grimly keeping their minds open in the face of every other stupidity under the sun, would at last have their fill and laugh in your face with all the pent-up rage of a politically correct bureaucrat forced to shuck and jive to ideas he knows to be ridiculous. Clearly astrology is ridiculous despite the vast amounts of intellectual energy that have been (and still are) devoted to it.

In the same vein, I have no doubt that Ayurvedic Medicine has been beaten to death by the learned men of India for thousands of years in the same manner that Astrology was dissected in the West. I also have no doubt that there is a massive body of Ayurvedic scholarship collecting dust in libraries from Duluth to Calcutta. But as it’s a system of medicine based on a highly imperfect understanding of physiology, more religious than scientific, and Indians who used it pretty much dropped like flies from diseases that it took Western medicine to defeat, except for historical interest all of that intellectual activity is as useless as trying to divine the future from the entrails of birds. You can learn Sanskrit to really get into the source material but you’re wasting your time. The initial premise is wrong and, like a house built on weak foundation, no matter how much you spend on the bathrooms it’s still going to collapse.

3. Complementary and Alternative Medicine is parasitic, not symbiotic.

Suppose I were to actually build a house. Along with a foundation it would require framing of the walls and floors, siding, wiring, glazing, plumbing and a dozen other skilled trades coordinating their efforts. The practitioners of Complementary and Alternative Medicine would be like your Aunt Mildred telling you how to hang the toilet paper in the finished bathrooms and then trying to claim credit as an essential part in the construction. Complementary and alternative medicine only exists because real medicine does all of the heavy lifting leaving a risk-free environment in which it may ply its patent remedies. At best it’s an afterthought, something that legitimate hospitals add to their services to attract the kook money. At worst it’s a cynical ploy to fleece a little extra from the desperate, many of whom are dying and will gladly pay for another straw to grasp. In no way is it an essential part of medical therapy except that it provides entertainment to the patients and their families while medicine and nature run their courses.

4. Placebo Medicine is not Medicine.

Millions of dollars are wasted every year on shoddily constructed studies trying to demonstrate efficacy of Complementary and Alternative Medicine. The results have been disappointing and entirely predictable. Generally, if you ignore poor study design and spin the data just so, CAM is shown to be occasionally but not reliably slightly, and we’re talking slightly, more effecitive than placebo. These results are naturally touted as a both a huge victory for kook-dom and as a justification for continuing to charge large sums of money for therapies that are so close to placebo in their effectivness that you should wonder why the opposite conclusion isn’t derived. In other words, maybe if your treatment modality is so iffy, requiring as it does to be viewed through squinted eyes in dim light at a distance of several hundred feet to show even a trace of effectivness, maybe you need to reassess your career goals. Call me a cynic but something that is slightly better than placebo could also be called next to useless. Certainly not worth spending a lot of money on unless it carries a big disclaimer saying, “For Entertainment Purposes Only.”

Complementary and Alternative Medicine Month Continues

This Ain’t no Party, This Ain’t no Disco, This Ain’t no Fooling Around

It’s a grim business, medicine I mean. For all the hype it’s nothing more than a futile struggle with death, a battle lost in the early stages by some, a bit later by others, but lost all the same in the end. If you’re lucky you make it to fifty with no Past Medical History until one day your cholesterol is noted to be a little high or you get a little rectal bleeding and things are never the same again. Then you get a little winded and wake up one morning to discover that it’s been ten years since your bypass and all of a sudden your feet seem to be swollen most of the week and you’re urinating all of the time. Your couple of pills a day have become a plastic pill organizer and your Past Medical History, once easily checked as “none” on all of the forms, is now spread through several different computer systems and thick files in various specialist’s offices. You get older and sicker. Your quality of life diminishes with each passing year and you gradually forget what it was like to sprint up a flight of stairs or run to catch a bus. Eventually simple things like getting out of a car or making it to your bedside commode become the major ordeals of a pain-filled day and you are rushed to the hospital every month for fear that you may have at last suffered the Big One, the final event that will put you out of reach of the medical profession’s best efforts to wrest a little more time for you.

In the end, the Reaper who has been waiting in the cool shadows just beyond the incandescent glare on the emaciated ruin of your body gently reaches through the crowd frantically trying to restart your heart and politely claims you as his own.

That’s how it goes. Your physicians are natural pessimists and can see the end for all but the youngest of their patients. We do what we can, of course, and it is our privilege to occasionally snatch you away from death but this is not done without a cost. Our treatments are crude, our understanding of physiology imperfect, and we do not yet have the knowledge or the sophisitication to precisely target your disease leaving the rest of your body unscathed. Every therapy yet devised has a dark parcel of side effects and adverse outcomes. When you start your long march through the medical world the risks of these therapies are relatively benign. We put you on an innocuous little blood pressure pill and warn you that it may cause a persistant but otherwise harmless cough. A few years later you become light-headed from the medications that are absolutely essential to control your potentially lethal cardiac arrythmia and your physicians debate whether to take you off of blood thinners lest you fall and suffer a catastrophic bleed in your brain. Time goes by and to save you from pancreatic cancer the surgeons shell you out like you were some kind of mammalian oyster.

At no time however, will your physicians ever promise a magic cure, a therapy that will definitively fix the problem with no ill effects leaving alone the precarious balance of your fantastically complicated body. At best they will promise good results with minimal and easily tolerated side effects. At worst the therapies they will reluctantly propose are almost as bad as the disease they will ameliorate and the subject of, for example, chemotherapy or a risky aortic repair is broached with dread to a patient who must be made to understand that real medicine is not as it appears in the popular media.

At a philosophical level, leaving aside the utter ridiculousness of Reiki healers shooting sacred energy from their fingers, this is the difference between real medicine and Complementary and Alternative Medicine whose practitioners, as they don’t treat real pathology, have never developed humility in the face of disease. It is easy, for example, for your acupuncturist to promise a perfect cure because they’re not really treating anything, just some nebulous mumbo-jumbo like a dysfunction of your ability to receive pure qi from the heavens. Side effects? None, of course. It’s perfect medicine because, despite being based on a completely imaginary idea of physiology that has no relation whatsoever to the way things actually are, it can magically target your imaginary complaint.

All medicine is a metaphor of course. We speak of proton pumps and “watershed strokes” as a way to explain complex structure and pathology that would be otherwise too cumbersome to describe. Ideally however you would want your metaphors to closely match what they purport to represent. Refining these metaphors is the purpose of medical science and the appropriatness of a therapy depends on the level to which it coincides with the most reasonable description of the underlying dysfunction. Almost all of complementary and alternative medicine is based on metaphors which were either, as is the case with Homeopathy fabricated from whole cloth, or in the case of Acupuncture and Ayurvedic medicine develped at a time when it was impossible to know any better. “Meridians” make sense when your knowledge of the body is based on religious superstition and mysticism. Once you discover the true function of blood vessels and nerves, however, it is time to put away your belief in qi, a spiritual construct that as a metaphor for disease has no basis in real physiology. The metaphors are diverging. Acupuncture stands still with its feet firmly planted in a time when people routinely died in their thirties from diseases that modern medicine has eliminated. It still exists because real medicine provides the practitioner of Complementary and Alternative Medicine a risk-free environment in which to operate as well as a steady stream of customers who cannot accept the truth, namely that we all die, our health fails, and, as there is no evolutionary disadvantage to it, we seem to be genetically programmed to wear out.

So you see, to practice real medicine is to create problems. Fifty years ago the majority of my multiply co-morbid and incredibly sick patients would have died in their fifties from the first of the many conditions which they have today accumulated. No amount of Acupuncture, homeopathy, or Reiki would have got them through their first heart attack just as no amount can now treat the hundreds of petty ailments which have become the bread and butter of the quacks.

Snake oil is something of an American tradition but it is only recently that its purveyors have had the benefit of physicians to do their heavy lifting.

Kicking Off Complementary and Alternative Medicine Month

(November is going to be Complementary and Alternative Medicine month here on Panda Bear, MD. My recent posts on the subject have generated a lot of interest, quite a few visits, and a bunch of angry email so I believe there is some interest in the subject out there. I apologize to you, oh my long-suffering readers, who would like to read more about residency and medical school but as I have categorized all of my previous articles on that subject and I have recently thrown you plenty of red meat on the subject of Emergency Medicine I ask for your indulgence as we explore the inroads of the lunatic fringe into the medical profession.-PB)

If Wishes and Buts Were Candies and Nuts We’d All Have a Merry Christmas

No one thinks rationally anymore, not even the well-educated. While I don’t necessarily expect critical thinking from the unwashed, higher education, while of no practical value to the legions of college graduates sporting their polyurethane diplomas, should at least teach people to think critically or there is no point to it and it becomes just a four year interlude where you learned a bunch of trivia and borrowed a lot of money to party with sorority girls. Certainly you should ask for your money back if you graduated without the intellectual skill to distinguish something that you want to be true from something that is. And you should ask for a refund if you have been awarded a diploma in any field without obtaining the fund of knowledge to recognize the difference between something that could be possible and something that can’t possibly be.

Take Homeopathy, a medical therapy which relies on the imaginary property of water to retain the memory of a substance which it has diluted to a point where not a single atom of the substance remains. People often ask me if my experience with Emergency Medicine, the most practical and hard-nosed of the medical specialties, has left me cynical about the possibility of finding some validity in Homeopathy and other equally ridiculous Complementary and Alternative Medicine therapies. Actually, by the time I had finished the eighth grade I had a sufficient background in chemistry and biology to recognize that these things cannot possibly work. How much education do you need, for example, to definitively state that spinal manipulation cannot possibly obviate the need for vaccinations (as many of our chiropractic friends believe) or that spiritual fire cannot possibly, a la Saturday morning cartoons, stream out of the fingers of Reiki healers? It’s not even as if we’re arguing some subtle point about the energy state of an electron shell or an obscure ion channel in yer’ fucking spleen. This is literally third grade stuff and the fact that many prestigious medical centers lack the institutional courage to point it out should make you cringe in shame, either at their gullibility or their venality.

“Well, we’re just being open-minded,” is the formula used to justify spending large sums of money to investigate therapies that even my ten-year-old son could instantly recognize as not only impossible but also somewhat ridiculous. I guess I’ll just have to be closed-minded because if you asked me for money to investigate the healing properties of magical gnomes I would turn you down. Gnomes, like Reiki, Homeopathy, faith healing, and ayurvedic medicine are ridiculous at face value. The extent that they are investigated highlights one of the biggest problems with Complementary and Alternative Medicine, not that it is mostly ridiculous (which it is), takes money from the gullible including those who really can’t afford it (which it does), or even that it sometimes delays the effective treatment of health problems (which I see regularly), but that it has the potential at a time when we should be looking for ways to economize on medical care to suck up even more public money with nothing to show in return except the enrichment of a pack of charlatans.

As many of my regular readers know I have a deep skepticism for much of what we do even in the practice of real medicine and believe we waste vast sums on only marginally effective and oftentimes inopportune therapies. It is not unusual in our system, for example, for a nonagenarian patient teetering on the edge of death to be followed by six specialists as well as a primary physican, have undergone batteries of repetitive tests and redundant imaging studies, and been the recipient of scores of procedures, many of them of dubious benefit as it relates to decreasing their morbidity or mortality.  There is also no question that cognitive medicine, the art of deliberating and arriving at the optimal and usually the simplest treatment regimen for a patient, is playing second fiddle to procedural medicine. I confess that I sometimes fantasize about being a primary care physician if only so I could sit down with my masively polypharmic and polyiatric patients to make sense of everything being done to them, much of it harmful or of only limited use.

No need to make the problem worse by invoking qi, karma, and magic pixies as therapies except if you believe that everyone should have an equal opportunity to steal money from the public.  In other words, the answer to the oft-cited rational for patients turning to CAM, that they have exhausted all that real medicine can offer, is not to keep feeding their delusions that they’ll live forever or can achieve health without effort but to have the economic courage to tell them that nothing more needs or can be done and that medicine cannot solve most of their problems. In other words, we need to continue to make medicine as rational as we possibly can, eschewing treatments and practices that are ineffective or ridiculous despite what the public wants. More importantly, medicine shoud be a minimalistic pursuit where we have the common sense to limit what we do instead of continuing to expand our scope so that everything under the sun, including the great spiritual void in the hearts of those who dabble in Complementary and Alternative Medicine, becomes a medical problem.

The desire to spread the tentacles of Complementary and Alternative Medicine to real patients, those who have real diseases and not nebulous emotional complaints, has the potential to suck even more money into health care, money that is going to be thrown away as surely as we throw it away keeping the living dead warm in the ICU.

Res Ipsa Loquitur

Integrative Medicine

The term “integrative medicine,” like the words “holistic” and “natural,” is a mealy-mouthed euphemism for such a broad range of ideas, most of them utter tripe, that it means nothing. Although it once must have meant something to somebody, now it is just another marketing phrase to make people feel good about buying swill. Pleasantly scented swill, no doubt, but swill just the same. This is not to say that medicine shouldn’t be integrative. In fact, many would argue that medicine has become so specialized and sub-specialized that it is a little too integrative. A hospitalized patient, for example, is usually escorted through his Big Hospital Adventure by a small platoon of doctors and other health care professionals. There’s the hospitalist who admitted him, the cardiologist who was consulted because of chest pain, the nephrologist fretting over his decreasing renal function, and the usual gaggle of physical therapists, nutritionists, and pharmacists all integrating their talents for his benefit. Under the aegis of this team however are now added homeopaths, bio-feedback experts, Chinese herbalists, and other purveyors of Complementary and Alternative Medicine. Add an Ayurvedic healer, an acupuncturist, and a couple of circus freaks and now we’re talking integrative, baby!

Originally devised as a marketing ploy to lure desperate cancer patients into for-profit hospitals, integrative medicine has now found its way into primary care where the wealthy and bored can experience the ultimate in egocentric boutique medicine. Take a therapy like Reiki, proudly offered at such notable medical centers like Sloan-Kettering and Duke. Oh my learned colleagues, physicians and inheritors of a profession that has but recently lifted itself from superstition and snake oil, do you really want to be associated with practioners who purport to heal by shooting mystical Japanese spiritual energy out of their fingers? I ask because when you strip away all of the glitz and the pretense, that is exactly and in totality the therapeutic modality of Reiki. Sounds ridiculous because…well…it is ridiculous.

Or suppose I invited an Astrologer to join the faculty and offer medical advice to your patients? Or a faith healer? You’d no doubt protest and mutter darkly about primitive superstition not having a place in medicine and you’d be right.  But what, pray tell, is the difference between something like Ayurvedic medicine, one of the usual suspects in integrative medicine, and astrology or faith healing? Nothing, really, except that you’d be embarassed to consult an astrologer and Christian faith healing, as you reject religion in medicine, is prima facie unacceptable while Hindu faith healing gets a free pass. The fact that we even have to have a debate on the validity of Ayurveduc medicine, homeopathy, and other obviously ridiculous treatment modalities is, in itself, ridiculous and I can only shake my head and wonder at the powerful hold of quackery on my learned colleagues in the Ivy League where this kind of thing flourishes. When you are incapable of asking for proof of the existence of chakra, qi, or mystical fire flowing from the appendages of charlatans, maybe you have become a tad too open-minded. So open minded that you no longer have the conceptual tools to distinguish the right from the wrong, the good from the bad, or the reasonable from the ridiculous.

It’s not difficult. Generally, if someone claims to shoot mystical fire or diagnose Hindu humors he should have an uphill struggle convincing the educated. Skepticism should be your first position but that would require a little too much common sense, not to mention being a little judgemental which is the only remaining sin among the over-educated elites. It is in this manner that that prestigious medical centers succumb to a form of blackmail. If they Reject Eastern mysticism and other completely laughable medical therapies they risk losing their street cred’ among their lesser-educated but more institutionally powerful peers.

Why Chiropractors are Idiots, Your Stinking Well-Being, and Other Topics


On the same shift I saw two very sick patients, both of whom were under the care of chiropractors before they decided to pay us a visit in the Emergency Department. The first was an old woman with a one week history of dyspnea, chest pain, and a cough. Her chiropractor had diagnosed her with a “displaced rib,” and had been dilligently popping it back into place every day for the previous week. After a simple set of vital signs revealing low blood pressure, a slow heart rate, and a slightly low temperature, not to mention a chest x-ray which showed a huge unilateral pleural effusion, it was not hard to come up with the diagnosis of pneumonia with sepsis.

“He [the chiropractor] said she didn’t have a fever and she wasn’t coughing anything up,” said the sister.

A little knowledge is a dangerous thing. I’m sure chiropractors study a little bit about infectious diseases somewhere in their four years of training but that’s not the same thing as recognizing a constellation of symptoms and responding appropriately.

The second patient was a 70-year-old man who finally came in after a week of ineffectual adjustments for “muscle aches” and general malaise which had evolved, by the time we saw him, into a vague intermittant chest pain related to exertion but which the chiropractor insisted, apparently, was some kind of subluxation. The EKG told the true story, an evolving myocardial infarction. My patient would have probably died if his son hadn’t raised the alarm and insisted his father see some real doctors.

Is this kind of dangerous ignorance typical of all chiropractors? Probably, although some are probably quicker to push the panic button than others. Sending a patient to the Emergency Department costs them nothing after all, and you can always get the patient back if he lives. I note with interest that some people consider chiropractors to be primary care and that many chiropractors would like this recognition for themselves. The problem is that, their laughable primary treatment modality aside, chiropractors are not qualified to be primary care physicians because they know nothing about it. There are, of course, incompetent medical doctors but they tend to stand out. Incompetence seems to be the norm among chiropractors, at least from my perspective and from some of the patients I see.

Look, it’s not rocket science.  Chiropracty is based on treating imaginary defects of the spine, called subluxations, by manipulation. These so-called defects, which are also common in people who are not sick, are believed by chiropractors to cause disease and dysfunction of organs.  Again, this is an example of a little knowledge being dangerous. Chiropracty was invented at a time when physicians were just beginning to understand the role of nerves and particularly those of the autonomic nervous system.  The metaphor proposed by David Palmer, the father of chiropracty, to explain disease might have sounded credible 100 years ago but it no longer fits with objective reality. It is only a dogged faith among its practitioners and the credulity of its patients that allows it to survive. And survive it does like an old painted whore, displaying a new wig and a few new trinkets, but still an old painted whore.

Now, as to whether a visit to a chiropractor makes you feel better, I don’t care. Lots of things make people feel better including having their back cracked. When I was a young Marine on the island of Okinawa, the local barbers provided a vigorous back and neck cracking after a haircut. Did it make me feel good? You betcha.’ A medical specialty? No way. I understand you can get the same thing nowadays with a happy ending but I don’t believe it requires a medical degree. The point being that not everything that feels good or makes us happy is medicine. Endorphins, those magical happy chemicals that along with placebos and quantum mechanics are the last refuge of qauckery, are over-rated. Feeling good is not the same thing as being well, an important concept that gets obscured in the expanding dust cloud from the stampede to well-being.

Sounds Like a Personal Problem

Strictly speaking, your well-being is not a medical problem except for the part of it that is effected by your real medical problems; a difficult concept for many in the Complementary and Alternative Health community to grasp.  Improving your health improves your well-being but not the other way around. To believe it does would be to say that vigorously wagging a vicious dog’s tail will improve its disposition. You might feel good about it but he’ll still sink his teeth into your ass.

The tail does not wag the dog which is why most of Complementary and Alternative Medicine, as it focuses on well-being, is so ridiculous. Medicine is by necessity reactive. We treat objective medical problems, either early in their course as is the case with primary care, or late in the game in the more overtly reactive medical specialties like interventional cardiology and Emergency Medicine. Your well-being, as it is dependent on hundreds of factors most of which are decidely non-medical is your own business, more of a personal problem really, and not something that needs to be or even can be addressed by your doctor. This is why the largest consumers of Complementary and Alternative Medicine are people who are not really sick but only playing at it. They have a vague disquietude about the course of their increasingly materialistic and spiritually bankrupt lives which manifests as nebulous symptoms, eagerly interpreted and accepted as perturbations in their qi or an unbalanced chakra, and then healed by some combination of cheap Eastern mysticism and dime-store science.  Complemenatary and Alternative Medicine provides them with an alibi, not therapy, in much the same way that recycling and shopping in trendy organic coops gives the same patients an alibi for their increasingly materialistic lifestyles.

Imagine trying to throw some Ayurvedic therapy at the typical census of patients in the Emergency Department. It just won’t work with sick patients who have subjective complaints resulting from objective medical problems. All the chanting in the world is not going to cure a yeast infection or diagnose meningitis unless if helps steady the hand holding the spinal needle. (Because it does feel kind of creepy sticking a long needle into somebody’s back the first twenty times you do it). Your well-being, your opinion of your disease, your spirituality, and your ability to laugh and spread happiness and sunshine are completely useless in the face of a real disease.  This is why there are no Complementary and Alternative Medicine emergency departments. That is, because their patients self-select for credulity. To open up your CAM practice to random patients with real complaints would put the lie to most of what you do, not to mention opening you up to all kinds of legal jeopardy for practicing fake medicine.

A Reader Writes: “Hey, Panda, I notice you’re not posting as much. Are you losing interest in your blog?”

Well, no. But I have a real job now and I don’t have the time I once had. While it’s true that I don’t work as many hours now as I used to during my two intern years (new readers will have to do a little digging in the archives for an explanation), when I am at work I am really working and I no longer have the odd hour or two here or there that I managed to squeeze in while I was working longer hours but not technically working all the time. I mean, call was usually pretty busy when I was doing it but I still managed, by sacrificing a little sleep (which would have been interuptted anyways and not worth much), to knock out what I hope were interesting articles that you folks enjoyed reading.

As an aside, my pet peeve are people who send me private emails saying that this or that particular article was not as interesting as previous articles. Hey, I’ve got close to 200 articles on this blog (search the newly catagorized archives) and if you think it’s easy filling every paragraph with completely new and mind-numbingly original ideas than you need to get yer’ own blog and have at it. I do what I can.

But I digress. The point is that while I work fewer hours now and fewer total days per month, my schedule is kind of screwy and as I find myself frequently out of sync with my family’s schedule, it’s hard to find time to write. I enjoy it, of course, and as I feel almost obligated to keep churning out what some of my kinder critics refer to as the usual crap I will keep writing and I beg your indulgence, oh my faithful readers, as well as your patience. And if you have any questions about the whole medical career shooting match go ahead and email them to me.

In the meantime, you may as well peruse the selection of blogs on the right sidebar. I don’t just put anybody on that list. Every blog listed there has some quality that makes it stand out, in my mind, from the crowd and they are all, in their own way, a little subversive.

I include Kevin, MD on the left sidebar because he is an institution as is the Student Doctor Network. Over!My!Med!Body! is well written, informative, and a good way to keep up with what The Man is teaching medical students. It’s sort of the anti-Medschoolhell.

Ask Yer’ Uncle Panda….

Say Uncle Panda, I notice you haven’t written about chiropractors. What do you think about them and chiropractic in general?
Chiropractors serve a useful role in society, particularly when it comes to taking some of the pressure off of used car salesmen who would otherwise have the market cornered on chicanery. Nobody likes to be the only crook in town you understand, and if chiropractors are good for the self-esteem of used car dealers I’m all for ’em. Other than that there’s not much use for chiropractors except to keep second-rate strip malls in business as they make that long descent from shopping mecca to consignment stores and karate studios.

On one hand you have the straight chiropractors who preach a strange religion where manipulating the spine can take the place of vaccines and cure all manner of diseases from cancer to your Aunt Dottie’s lumbago. On the other are the so-called “reform” chiropractors who confine their practice to musckuloskeletal complaints. Six of one, a half dozen of the other. Despite the occasional studies showing that it has a slight advantage over placebos in the relief of chronic pain and other fuzzy symptoms, chiropractic is a lot of sound and fury signifying little or nothing. For the money people spend and the effort they put into it (chiropractic school is four years, after all) I guess I’d want a little more than a slight improvement over a placebo. Just for my self-respect, you understand.

The basis of chiropractic is the theory that misalligned vertebrate (called “subluxations”) are responsible for disease. The old school chiropractor will shoot a plain film of your spine and use this as a basis for manipulating it back into position despite the overwhelming evidence that not only do otherwise healthy people have asymptomatic misalignments in their spines but there is no way to change the alignment anyway short of orthopaedic surgery.

But do what you want. I don’t care.

Hey Uncle Panda, I’m considering Emergency Medicine but I’m concerned that it’s just glorified primary care. What say you?

That’s ridiculous, at least from my perspective. As many of you know, I did a year of Family Practice and while I disliked it intensely, it at least gave me a taste of primary care. Emergency Medicine is nothing like primary care.

Here’s what I saw on a recent shift: Two acute MIs (one with significant ST elevations), one acute pancreatitis with nausea and projectile vomiting, a baby with meningitis and CSF that looked milky when I did the lumbar puncture, a motor vehicle accident with bilateral tibia fractures, a tylenol overdose, vaginal bleeding that turned out to be an incomplete abortion, a couple of strokes, a severe COPD exacerbation, a third nerve palsy (which I diagnosed without an MRI, thank you very much) and the usual minor stuff which, although minor, was still more “urgent” than the usual primary care fodder.

People go to their family doctor for diabetes management. They go to the Emergency Department for diabetic ketoacidosis or when their foot is rotting off as a consequence of distal peripheral neuropathy. That’s the difference. I think I see more truly sick patients in one week in the Emergency Department than I did in a year of clinic in family medicine where, on the rare occasion when somebody was really sick they got sent to the Emergency Department.
Now, it’s true that a lot of our patients could be better served at an Urgent Care. On the other hand one of our biggest source of customers are the local Urgent Care clinics, many of which are staffed by midlevels who have the good sense to drop back and punt.

I think a lot of folks don’t really understand primary care which is the long-term management of chronic conditions and not something we do in the Emergency Department, even if we wanted to which we don’t. We refer to primary care almost as much as they refer to us.

The truth is that you get so used to really sick patients that it begins to seem like primary care.

I am not busting down on primary care and Family Practice in particular. Primary care is neither easy nor quick. That’s why residency-trained physicians need to do it. The reason mid-levels do it is because nobody else will and because, cobra-like, they have mesmerized the Family Practice physicians who are their natural prey into accepting them as equals.

How long does it take to write an article for your blog and where did you learn to write so well?

Some articles write themselves and some I have to sweat over for days. I do experience periodic writer’s block and can go a long time without a decent idea (like the past couple of weeks). I suppose I could always write about how much residency blows but I don’t want to be a one trick pony. Besides, that would be like playing a crowd for cheap laughs. It’s too easy.

I also write most of my articles late at night when I should be sleeping. I hope that you, oh my critics, appreciate this when I don’t provide footnotes and an exhaustive bibliography. I just don’t have time. And I blog for fun so while I feel a responsibility to my readers to provide interesting articles, I do have a real job and to be honest, I make more moonlighting for half an hour than I do from the advertisments on my blog for a month.

In other words, this blog is a labor of love and not a money-maker so sometimes responsibility trumps fun.

I am flattered that many of you think I am a good writer. Let’s just say I’m working on it. I have pretty good role models who include Herman Melville, Mark Twain, Anthony Burgess, George Orwell, Charles Dickens, and Joseph Conrad to name a few. People ask me what I think about the Da Vinci Code. I didn’t read it. I don’t read crap. Period. I used to, of course, but after I discovered Robert Graves I have never looked back.

Read the first page of “Bleak House” or “1984” and compare it to the typical offering at Barnes and Noble and you will see what I mean. Most writing, like most popular culture, is excruciatingly bad. Almost painful to read. I’m probably not too much better but at least I can see where I need to go. One day I will have time to really write something meaningful but not right now.
Paradoxically, the rest of my tastes are completely plebian.

A Quick Note


My hit counter tells me that I’ve had 100,000 unique visits to this blog in the last six months. Add that to the 120,000-or-so visits before I started using Sitemeter and that’s not bad for sixteen months of blogging. Readership is growing and I like to think it’s because I have a lot of well-written articles on interesting subjects which offer a unique insight into the world of medical training that you will not find anywhere else.

It’s either that or the doggy-porn but I’m not complaining.

CAM and Academia

Part of what passes for being open-minded in academia these days is the inability call “bullshit.” This is also known as being so open-minded that your brain either falls out or flaps listlessly in the breeze like a ratty pair of underwear on a line. There is, apparently, very little under heaven, no matter how ridiculous, that some earnest academic, frightened of giving offense, will not either embrace or tolerate even though somewhere, deep down in his crocadile brain a little voice must be shouting at him to grow a spine.

This is because the ethos of the ivory tower is anti-Western, anti-Judeo-Christian, and almost anti-intellectual, at least in the sense that reason and disciplined thinking are subordinate to the latest political fads that periodically sweep through our highly impressionable, somewhat provincial academic community. This is why people who will scoff at traditional religion and impune it’s adherents will never-the-less become extremely reverential when discussing Buddism, Hinduism, and any other religious practice which doesn’t carry the baggage of morality against which they have been conditioned to rebel.

(In regards to Islam, the militant variety of which is antiethical to every principle of liberal Western thought, they are silent either out of fear or because the anti-American strain that pervades it is convenient to their political beliefs. In the the screwy world of academia, you can have liberal, pro-choice professors actively supporting groups like the Taliban who treat women like property, execute dissenters, and would merrily burn their universities to the ground if given the chance.)

The point is that while acupuncture, homeopathy, and other faith-based healing practices will be embraced tightly, faith healing, snake handling, and speaking in toungues, also known as Traditional American Medicine (TAM) will be ridiculed as absurd by the same people who will credulously clap their hands and burn joss to nightmarish asian gods. How some sweaty pastor of a secretive congregation in Arkansas casting out demons through his traditional practice of medicine is different than some svelte intellectual with equally shoddy academic credentials pushing homeopathy or acupuncture is not exactly clear from a strictly rational point of view.