(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.

(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)
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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.”

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.

(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.

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.

Beware

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.