From deep in the heart of the Midwest: A belated politically correct Holiday greeting

I did say that blogging would be light or nonexistent over the holidays, but a friend forwarded this to me, and I thought I'd share with you, since I actually have high speed Internet access (briefly):

With with the holidays fast approaching, please accept -- with no obligation, implied or implicit, on behalf of the wisher or wishee -- my best wishes for an environmentally-conscious, socially-responsible, low-stress, non-addictive, gender-neutral celebration of the winter solstice, practiced within the traditions and/or within the religious or secular belief(s) of your choice and with respect for the traditions and/or religious or secular beliefs of others or for their choice to not practice traditions and/or religious or secular beliefs at all; and for a fiscally-successful, personally-fulfilling, medically-uncomplicated recognition of the onset of what is generally accepted as the new Gregorian calendar year, but with due respect for calendars of other cultures whose contributions to society have helped make America great*, and without regard to the race, creed, color, age, physical ability, sexual orientation, political affiliation, or choice of computer operating system of the wisher.

DISCLAIMER

By accepting this greeting you are accepting the terms of the greeting and all responsibility associated with it. This greeting is subject to clarification and/or revocation at any time at the discretion of the wisher. This greeting is non-transferable without the express written consent of the wisher. It implies no promise by the wisher to actually implement any of the wishes for him/herself or for others. This greeting is warranted to perform as expected within the usual application of good tidings for a period of one year or until the issuance of a subsequent holiday greeting, whichever comes first. Warranty is limited to replacement of this greeting or issuance of a new greeting at the sole discretion of the wisher, who assumes no responsibility for any unintended emotional stress this greeting may bring to those not caught up in the holiday spirit.

By accepting this greeting you agree to subscribe to annual updates at a cost completely arbitrary to the wisher at the time of renewal. Failure to subscribe - in effect, failure to renew this greeting -will result in forfeiture of the original greeting, loss of your parents' homes, euthanasia for your and your neighbors' pets, and prosecution in a kangaroo court of law comprised of the wisher's closest friends and paid business associates, convened by the wisher at a location deemed most inconvenient to you. Reading of this disclaimer constitutes your acceptance of the greeting. Oh, and I almost forgot...this disclaimer supersedes all local, state and federal laws previously enacted to prevent such disclaimers from superseding all local, state and federal laws.

* This does not imply that the United States of America is necessarily greater than any other country, or that it is the only America in the western and/or eastern hemispheres.

Merry Christmas and Happy New Year

There will be only sporadic (or, more likely, no) blogging from now until January 3 (unless I decide to use Instant Blog Post during my absence). Like many, my wife and I are going home to visit family. I'm guessing most people have better things to do this time of year than to read my ramblings anyway.

Thanks to all who've started reading regularly. I hope it's been worth your while. I can't believe I've actually accumulated some regular readers in less than two weeks. I'll pick up where I left off after I get back and try to make it even more worth your while to check me out. Here are a few topics/ideas in my queue. (Yes, this is a blatant plug so that, hopefully, you'll want to check back here; if you've been reading from the beginning, you'll know I can be as blatant as any blogger in self-promotion.) A very partial (and ever-changing) list:

• Clinical trials
• The Nazi biomedical vision and how it led to Auschwitz
• Battling quackery in conventional medicine
• How alt-med purveyors scare patients away from chemotherapy and radiation therapy
• What is a scientific "theory"?
• Hate speech laws
  
• Why Creationism is not science
• Holocaust "revisionism" versus Holocaust denial
• Stem cell research
• Conspiracy theories in alternative medicine
• Do Holocaust deniers really believe what they say about the Holocaust?
• Logical fallacies loved by pseudoscientists and Holocaust deniers
• Levels of medical evidence
• Treating chronic pain versus the "War on Drugs"
• Why ineffective alternative medicine is not "harmless"
• How and why alternative medicine is misrepresented in the media
• How clinical trials are spun in the media and by drug companies
  

It may well take me months to get through these and the other ideas I have floating around in my fevered brain. Interspersed with these will very likely be my usual random commentary on anything that happens to strike my fancy, commentary on specific alt-med and conventional therapies, as well as perhaps some pieces on how science is done in the "real" world--if you can call my lab the "real" world. Eventually, I may start making the occasional political post, in order to get a shot at the Weblog Awards (which, sadly, don't have an award category for medical or science blogs, as I pointed out early on when I started blogging). In the meantime, if you've just discovered Respectful Insolence (a.k.a. Orac Knows), feel free to check out the archives and see if you like what I've been doing so far. Given how new this blog is, they aren't (yet) extensive.

Merry Christmas and Happy New Year to all.

Best CDs of 2004 (IMHO, of course!)

I know people tend either to love or to hate year-end best-of lists. If you hate them, skip this post.

I love music. Over the last 15-20 years, I have accumulated a large collection of CDs, and my 40 MB iPod is totally filled to bursting with tunes ripped from my CD collection. (Damn it, Apple, can't you come out with a 60 MB iPod that doesn't cost $600?) The 40+ GB of AAC files in my iTunes library on the iMac in my office stream over our LAN to my lab and that of my partner, where researchers listen to whatever they want from it all day. The secretaries are even starting to ask for the password to access to my collection over the network. Given my love of music, my music collection, it shouldn't be surprising that I'm a music critic wannabe, particularly given the ego that comes with being a surgeon. Naturally I have to conclude that people will be interested in the sorts of music I like. (Whether that is true or not, who knows? It doesn't really matter, though, does it, as it's my blog.) I also think you might be surprised at what sort of music this surgeon in his early 40's listens to. Certainly it's very different from any of my colleagues of similar age (or even younger).

Against all hope, 2004 was a great year for new music. In fact, a couple of years ago, I had almost given up on new music and started to concentrate my CD-buying habits on filling in the gaps in my collection and to the joys of discovering Frank Sinatra. (I think it must be mandatory in this country that, upon hitting 40, you muststart to appreciate Sinatra. It seems to be the law, particularly around where I live. I did, even though I had never given him a second thought up before last year. Wonderful stuff, particularly the 1950's era stuff.) However, this year, I've found a lot that I've really liked. Here are my picks for the best albums of 2004 (I'm hoping to get through them all again in my car during the many hours of driving I'll be doing through the snow over the next week and a half):

1. Funeral (The Arcade Fire). Soaring, melodic, elegiac, at times bombastic, this gem was made during a winter in Montreal, and it's infused with all of the sadness its title implies, tempered with hope and gorgeous melodies. I expect big things from this band. This one has not left my car CD player even once since I bought it a couple of months ago. Buy it. Buy it now. You won't regret it.
   
2. Secret Machines (Secret Machines). Clearly inspired by Led Zeppelin, but not slavish in their devotion, Secret Machines released a pummeling, tuneful debut full-length CD of 1970's style hard rock, updated for the new millenium. Best tunes: "Nowhere Again" (catchy, clever, and heavy) and "Sad and Lonely" (their most obvious homage to Zep).
   
3. Antics (Interpol). Not as dark and not as obviously mining the darkness of their chief influence Joy Division, Interpol's sophomore effort is their best yet. They're starting to develop their own voice.
   
4. How To Dismantle An Atomic Bomb (U2). Not quite as good as their comeback All That You Can't Leave Behind, but still damned good. Vertigo starts things off with a rousing rocker, and things continue from there. U2's above average efforts are better than most bands' absolute best, and this is no exception.
   
5. Hot Fuss (The Killers). OK, a couple of critics I've read say that these guys sound like Duran Duran. I just don't hear the resemblance. What I do hear is brooding, slick rock with amusing lyrics. I only wish the pretty boys in Duran Duran had sounded like this.
   
6. Hopes and Fears (Keane). Hailed by the British press as the next Coldplay, these guys can stand on their own without comparisons. Their brand of piano-based pop-rock is timeless.
   
7. Franz Ferdinand (Franz Ferdinand). Buoyant 1980's new wave-style dance rock, played straight ahead, with addictively catchy melodies.
   
8. American Idiot (Green Day). A concept album from those punk-pop Clash wannabes Green Day, who seemed to have been washed up before this??? Unbelievably, against all expectations otherwise, it actually works. In fact, the "Jesus of Suburbia" medley and "Boulevard of Broken Dreams" almost make me take back all those snide comments I used to make about these guys.
   
9. Blue Cathedral (Comets On Fire). Mind- (and ear)-melting acid psychedelic rock that defines the word heavy, done in the style of Blue Cheer and other heavy acid jam-rockers from the late 1960's and early 1970's. I didn't think anyone even made this kind of music anymore. But Comets On Fire does. Thank heaven. They even added an organ. Careful, or you'll melt your speakers.
   
10. Heroes to Zeros (The Beta Band). I fell in love with the Beta Band when they were featured in the soundtrack of High Fidelity (perhaps the most effective tune placement ever in a movie). They've had a couple of misses since then, but this album is highly listenable, a mixture of electronica, pop, and random jamming.
    

And the best rereleases of the year were, without a doubt:

Left of the Dial (Various artists). An awesome collection of 1980's alternative rock that ranges from hardcore punk to the electronic, to rather pop-sounding stuff, all of which made its home on college radio stations during the 1980's (hence the name) and some of which made it to the mainstream, producing big stars (like R.E.M. or Depeche Mode, for instance). It's a four CD set, and it's worth every penny.

London Calling [The Legacy Edition] (The Clash). London Calling is one of my all-time favorite albums, bar none, and arguably one of the top ten (or even top five) best rock albums ever recorded. This mammoth rerelease includes previously unreleased demos (The Vanilla Recordings) and a DVD on the making of the album, in addition to pristine remastered sound.

And, CD's I want to buy that might have made the list if I had bought them before today:

1. Seven Swans (Sufjan Stevens)
2. Bows + Arrows (The Walkmen)
3. Good News for People Who Love Bad News (Modest Mouse)

I promise not to subject my readers to these things too often, but sometimes the inner music critic in me must come out. Perhaps a few weeks (or months) from now, I'll talk about some of my favorite bands. (Godspeed You Black Emperor!, anyone?)

Anti-science on the march

There has always been an anti-intellectual, anti-science strain in American opinion and politics. Unfortunately, such tendencies, which were on the rise in the 1990's, appear to have worsened over the last few years. Worse, they are influencing federal policy more than in a long time. (They were always an influence on state and local policies, depending on the part of the country; for instance, efforts to get intelligent design or creationism taught in science classes.) Although I'm most familiar with fundamentalist attacks on evolution and on the attacks by alternative medicine practitioners on conventional medicine and biomedical science, it isn't limited to that. A nice summary is here.

Awesome Bioethics blog

For those interested in bioethics, there's a wonderful blog here.

Is it just me...

...or does anyone find this a wee bit exploitative?

Weird stuff doctors get from pharmaceutical representatives

Doctors get all sorts of weird little things from pharmaecutical representatives. I've gotten foam brains emblazoned with drug names; foam red blood cells with the Procrit logo; hats; all manner of pens, some shaped like various body parts (like bones, emblazoned with the logo of an orthopedic surgical supply manufacturer); all sorts of Beanie Babies and various plushes; a cup with a battery-powered stirrer; calendars; etc.

Perhaps no pharmaceutical company knick-knack is stranger than objects featuring a "superhero mascot" created by Fleet Pharmaceuticals and dubbed EneMan. (Yes, he is shaped very much like an actual Fleet enema.) EneMan is supposed to promote screening for colorectal cancer. How exactly he does this, I'm not sure, given that taking an enema before a Hemoccult test would probably cause false negatives. I guess it's supposed to remind people to get their sigmoidoscopies and colonoscopies, tests that do require a colon cleanout beforehand. Believe it or not, there are actually poor slobs out there who are hired to don an EneMan suit and go around promoting screening for colorectal cancer or pushing EneMan-related objects on doctors. I saw one of them myself at the American College of Surgeons Meeting in Chicago in 2003. I pity that guy. He did, however, give me some cool EneMan stuff.

I first discovered EneMan a couple of years ago, when Fleet Pharmaceuticals mailed me a calendar called EneMonths. These calendars are truly works of kitsch high art. The 2004 (or maybe it was the 2003) EneMonths calendar with EneMan was vaguely creepy, as many of the photos pictured EneMan with small children doing all sorts of "fun" things. (In fact, a couple of the photos were extremely creepy. One featured EneMan and a bunch of five or six year old kids, all with milk mustaches, the implications of which still haunt me to this day.) Unfortunately (or fortunately, depending upon how you look at it), I lost that calendar. The 2005 calendar features EneMan traveling the world. Perhaps I'll scan and post some pictures from it after the holidays. Over the last couple of years, though, they've started sending me EneMan Christmas tree ornaments every year, some of which are pictured above. (The one with the Santa hat and reindeer antlers is my favorite.) My wife wasn't too thrilled with my suggestion that we put a couple on the tree this year; so they sit on my shelf as pictured above. I also have an EneMan clock, which I forgot to take a picture of. One of my sisters thinks these things are hysterically funny and wants me to get them whenever I can. I'm usually happy to oblige.

I still don't understand how something like EneMan is good P.R. or sells enemas, though. I guess the minds of pharmaceutical company marketing people are still beyond me.

Scared of Santa

Nothing says Merry Christmas like a photo of sweet little toddlers screaming at Santa. Check out the Scared of Santa photo gallery.

Delaying cancer death...

It would appear that terminally ill cancer patients probably can't hold on just a few more days or weeks in order to see an important event, like a holiday, a birthday, a wedding, or the birth of a child. Despite all the anecdotes, I had always sort of suspected that this phenomenon was probably exaggerated or nonexistent, but now there's some hard evidence that it probably is. Investigators at The Ohio State University (BTW, that's its proper name--take it from someone who lived in Ohio for eight years, don't leave out the "The" with a capital "T") looked at 300,000 cancer deaths over 12 years and were unable to find evidence of unusually high death rates around birthdays, Christmas, and Thanksgiving.

Money quote from Dr. Donn Young, one of the investigators:

I think the most important thing for all of us to take away from this is the notion of attending to what is important.

In other words, don't put off what is meaningful in life. Do it now, before it is too late.

Amen. No doubt we'd like to believe that we have at least a little control over our own death and might be able to hold it off a little while by sheer force of will, but the sad truth is that we probably do not.

Unbelievable, Part II

I can't believe that my little blog managed to pass the 1000 hit mark in only 9 days! (The blog has been in existence 11 days, but I didn't figure out how to add a site meter for a couple of days.) OK, I know that, compared to the big boys, it barely registered, but a guy's got to start somewhere.

I thought it would take at least a couple of months.

If this keeps up, I might get a swelled head thinking that there are a few hundred people out there who are actually interested in what I have to day. Naahhh. I'm a surgeon. By definition I have a swelled head. It's what people in the insurance biz call a preexisting condition.

Stats:

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	Average Per Day	132
	Average Visit Length	3:06
	Last Hour	2
	Today	20
	This Week	925
PAGE VIEWS
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	Last Hour	4
	Today	39
	This Week	1,787

Awful creationist propaganda

PZ Myers posts on some really bad creationist propaganda a reader sent to him. It's not bad because he and I both know creationism is not science. It's bad because it's a badly written, poorly drawn piece of comic book propaganda that uses weak and fallacious arguments against evolution. As Myers points out, it's a type of creationist propaganda that is common, showing "brave" creationist students questioning a dogmatic "evolutionist" biology teacher and supposedly tearing his arguments apart and revealing him to be a fool. I've come across the source of this particular piece before, The Truth for Youth. (Its comic about the dangers rock 'n' roll is one of the most hysterically funny pieces of fundamentalist fear-mongering I've seen in a long time.)

I'm not going to deconstruct it in detail, as Myers is a developmental biologist and has done so far better than I ever could. However, I would quibble with him on one thing. He's a bit too nice of a guy. He warns students not to try to use the arguments found in this comic on a biology professor (particularly on him), because doing so will result in their humiliation in front of their class. I'm not so sure that a little humiliation, as long as it isn't taken to an extreme (respectful humiliation, anyone?), isn't just the thing to teach such a student a little life lesson. On the other hand, given that surgical education still includes the "pimp" session, where the professor asks purposefully hard questions in order to show off and show the student's limitations (often humiliating him/her in the process), maybe this viewpoint is simply a primitive remnant of my having survived a less enlightened training method.

When not to treat (random thoughts)

The Cheerful Oncologist posts a nice piece about "When Is No Treatment the Right Treatment?" It's a difficult question that surgical oncologists have to face as well. His example is a man with lung cancer who has recently rapidly deteriorated with little hope for long-term survival. Should he get chemotherapy? Are the risks (immunosuppression, etc.) worth the rather meager benefit?

It's a really, really tough question.

We surgeons face this question as well, although probably much less frequently than medical oncologists do (another reason I don't think I could do medical oncology). One of the more common oncologic problems that force us to consider such choices is malignant bowel obstruction in a patient with a known metastic solid tumor. Do we operate to try to relieve the obstruction, even knowing that bowel obstruction in a patient with a metastatic solid tumor is usually a pre-terminal event? It's usually a fairly easy decision if the patient has widespread metastatic disease in multiple sites and isn't likely to live more than a few weeks. On the other hand, if disease in the abdomen is the only known site of disease, it can often take a somewhat indolent course, meaning that the patient might live as long as a few months. In fact, the mean survival for a patient operated on for malignant bowel obstruction is around five or six months. If no operation is done, the patient will spend those remaining months never being able to eat again. He will have to live out his days on intravenous nutrition, with either a tube sticking out of his side (called a gastrostomy tube) to drain the backed-up intestinal fluid from his stomach and thus keep him from constantly vomiting or (worse) a tube in his nose to do the same thing (which sometimes happens in the case of patients with such widespread intraabdominal disease that using endoscopy to put a gastrostomy tube in is not safe. Some patients in this situation will opt to forgo intravenous fluids and nutrition, in which case they will die of dehydration within hours to days.

Of course, the question then becomes: Are the potential benefits of surgery worth the risks in these patients? As is the case for chemotherapy, the risks of surgery are substantial. Overall, explorations related to malignant bowel obstruction carry around a 10% mortality rate and a 30% rate of major complications. In older, sicker patients, these risks will be higher, sometimes much higher. Worse, the rate of success is relatively low. In the case of obstructions from benign causes (adhesions from previous surgery, for instance), success, as measured by the chance of the patient's leaving the hospital able maintain his hydration and nutrition by oral intake alone, will be very high. In the case of a localized tumor obstruction (an obstructing rectal cancer, for instance, with no disease detectable elsewhere in the abdomen), success will still be pretty high, but not nearly as high as for a benign obstruction. In the case of more extensive intraabdominal disease (called carcinomatosis), the chances of getting the patient out of the hospital able to eat and drink enough to survive are fairly low. Worse, if there are significant complications (not uncommon), the patient may linger in the hospital, spending his brief remaining time away from home and family, suffering numerous pains and indignities, and ultimately dying in the hospital or (if he's lucky) getting sent to a good hospice.

Given these realities, a less interventionalist approach is usually better. Certainly, any patient with a previously treated solid tumor who develops a bowel obstruction should be considered for surgery. If no cancer is seen in the abdomen on imaging studies, there is still a substantial chance that this might be a benign obstruction, particularly if the patient has undergone prior surgery and therefore might have adhesions. In general, these patients should be given the benefit of the doubt and operated on, unless they are poor surgical risks. Patients with known intraabdominal disease who develop an obstruction should probably be treated with more circumspection. For good operative candidates, a good general rule is: "Everybody deserves one chance." If the abdomen is the only known site of disease, a tendency is err on the side of operating to see if anything can be done (unless the patient is a bad surgical risk) is a reasonable policy, because it really sucks not to be able to eat and to have to have a tube sticking out of one's stomach or nose for the rest of one's life. (Giving the patient the ability to eat for a few months is a wonderful thing if it can be accomplished with low enough risk; it should not be underestimated in its effect on quality of life.) However, if the patient has widely metastatic disease to multiple organs, it's usually better to put in a gastrostomy tube, because these patients are not likely to live very long no matter what is done. Finally, for patients with advanced disease and a recurrent bowel obstruction, reoperation is seldom indicated (IMHO). The success rate is just too low for recurrent obstruction to justify it, except in very select cases (very healthy patients, low volume disease on imaging studies, for instance--quite uncommon).

Of course, there are surgeons who believe that huge operations to debulk intraabdominal solid tumors, followed by intraabdominal chemotherapy, will prolong survival. They will even publish and present what appear to be impressive results. To me, it's still unclear whether this is simply selection bias, in which the patients they choose to operate on tend to be healthier people with less extensive disease, who are more likely to live longer anyway. The only exception is ovarian cancer, for which there is good evidence that debulking improves chemotherapy responsiveness. I'm tend to be of the opinion that, as of now, such procedures should not be done except in the context of a clinical trial.

In all cases, however, one must keep in mind the principle of always considering foremost what the patient wants. For this, Dr. Hildreth's four principles are an excellent set of guidelines to keep in mind. In the case of surgery, I would add an additional principle: Even if the surgery goes perfectly, consider how long the patient will be in the hospital versus his life expectancy. If the operation is likely to keep the patient in the hospital two weeks if things go perfectly (and a month, or even more, if they don't) but he is likely only to have two or three months more to live, is it worth it to operate? In this case, as always, it's probably a good idea to defer to the patient's desires when possible.

Top ten urban legends of 2004

...are listed here.

Understanding alternative medicine "testimonials" for cancer cures

No doubt you've seen it. The alternative medicine cancer "testimonial." They sure can sound convincing. A chipper-looking person claims that this treatment "cured" his cancer. These testimonials almost always include some or all of these elements: First, the cancer patient is lost and suffering at the hands of "conventional" doctors, who either cannot or do not wish to understand and who cannot do anything for him. Then, when all hope seems lost, the patient discovers an alternative medicine "healer" or treatment. It is not infrequently described in quasireligious terms, like a revelation or something that brings the patient out of the darkness and into the light. Naturally, there is resistance from the patient's doctors, family, and/or friends, who warn against it, with doctors warning of dire consequences. Often, they describe themselves as "being sent home to die." But the patient "sees" that the treatment "works" in a way that medical science cannot and survives. Infused with fervor, the patient now wants to spread the word. Often, the patient is now selling the remedy. Perhaps you've seen such testimonials or heard them on the radio and thought: "Gee, this sounds great. I wonder if it works."

The answer is: Almost certainly not.

I thought I'd discuss these alternative medicine "testimonials," as they are one of the most visible and highly abused methods of selling alternative medical therapies. I will concentrate on breast cancer as the prototypical example, but many of the same comments apply to other diseases and treatments. In future posts, I'll compare testimonials with anecdotes and other types of medical evidence, and try to explain minimum standards for medical evidence.

But first, some terminology: The treatment of breast cancer is divided into two phases, locoregional control (treatment of the disease in the breast and the axillary lymph nodes) and systemic control (prevention of distant metastases). Surgery and radiation therapy are modalities for local control; chemotherapy and hormonal therapy, for systemic control. Adjuvant therapy is one of these modalities administered after surgery. Adjuvant radiation therapy will improve local control and lower the rate of recurrence in the breast. Adjuvant chemotherapy and hormonal therapy will improve systemic control and decrease the rate of development of metastases, which are usually what kill patients.

The reason breast cancer testimonials sound so convincing is that most lay people don't know a lot about the disease, particularly that surgery alone "cures" many breast cancers. Early stage cancers are cured by surgery alone more often than not, and a significant minority of patients with even large tumors and multiple positive lymph nodes can be expected to have long term survival with surgery alone. In the case of a lumpectomy, the local recurrence rate in the breast is in the 30-40% range. Radiation can reduce it to less than 10%. That means that women who forgo radiation are still more likely than not to avoid local recurrence in their breast, particularly if their tumor is small. As far as distant metastases, chemotherapy and hormonal therapy improve survival, but the effect is small in patients with early stage cancers and becomes more impressive with more advanced operable tumors. Because many breast cancer patients will do well with surgery alone, clinical trials with large numbers of patients are needed to find true treatment effects due to adjuvant therapies.

These facts help to explain breast cancer survivors who have undergone surgery but decided to forego chemotherapy and/or radiation therapy in favor of "alternative" medicine (Suzanne Somers, for instance). When such patients are in a good prognosis group, where recurrence is uncommon, or have a more advanced tumor but are lucky enough not to recur, often they attribute their survival not to the primary surgery, but rather to whatever alternative therapy they have decided to take, even though it almost certainly had nothing to do with their survival. To them, it was the alternative medicine that "saved" them, not good old-fashioned surgery. In contrast, women who opt for alternative therapy and then recur obviously don't provide good testimonials to sell alternative medicine, which is why you almost never hear about them.

Some might ask: Why do patients fall for this? It is not a matter of intelligence. In my experience, women who pursue alternative therapy are, more often than not, intelligent and/or highly educated. Instead, they do not possess the scientific knowledge or enough critical thinking skills to separate truth from nonsense in medicine. It also seems to be a question of human nature. The diagnosis of breast cancer is devastating emotionally. Formerly self-assured women feel themselves losing control of their lives. Unfortunately, our system of medicine reinforces this feeling of loss of control, as it is all too often impersonal and even disrespectful of patients. Patients find themselves going to multiple doctor's visits, where all too often they have to wait for hours in crowded waiting rooms to see their doctors, who then, thanks to the demands of managed care, often only spend 5 or 10 minutes with them discussing a life-threatening disease. They deal with voicemail hell trying to reach their doctor when they are having problems and endure other indignities. They often conclude from this that the system does not respect their time or them and that they are considered nothing more than a number, a disease, or money. In contrast, alternative practitioners often provide the human touch that is too often missing from modern medicine. They take the time to listen to the patient and make her feel good about herself and her decision, all too often giving erroneous information about chemotherapy and radiation therapy. When a woman makes a decision to choose alternative therapy, she often sees herself as "taking control" of her treatment from uncaring doctors whose treatments, she is told, do not treat the root cause of her disease. Understandably, she may feel liberated and back in control. In addition, many testimonials have religious overtones as well, where lost, suffering women misguided by conventional doctors and without hope find a savior (their "healer") and/or enlightenment (the "alternative" therapy) that leads her out of the darkness and into the light of health. Her ignoring the reportedly dire warnings of doctors (unbelievers) is validated. Filled with quasireligious (or explicitly religious) fervor, they want to convert the doubters. Depending upon a woman's background and beliefs, this religious appeal can be as powerful as the desire for regaining control.

That religion and spirituality should play such a large role in alternative medicine testimonials should not be surprising, given how much of alt-med is infused with New Age "spirituality" about living "energy flows" and connections with the earth. Consider, for instance, the concepts behind traditional Chinese medicine (TCM). These concepts are mostly based on a non-Christian religion (Taoism) particularly the emphasis of TCM on the need to correct "imbalances" between different kinds of spiritual "energies" in order to restore health. These concepts powerfully influence more of alt-med than just TCM. Sometimes, fundamentalist Christians, who would normally be very suspicious of such non-Christian concepts, manage find a way to infuse their brand of alt-med with their Christian religion (particularly faith-healing, which fits in well with alt-med spirituality) or to downplay inconvenient Eastern or pagan spirituality that underlies much of alt-med. (For examples of what I'm talking about check this and this out.)

Even doctors, who are trained to have the knowledge and critical thinking skills to know better, are not immune to falling under this spell. Case in point, Dr. Lorraine Day was Associate Professor of Orthopedic Surgery at UCSF and Chief of Orthopedic Surgery at San Francisco General Hospital in the 1980's. She made a name for herself through dire warnings of AIDS spreading through aerosolized blood during trauma surgery (although, as far as I can tell from PubMed, she never published any studies in peer-reviewed journals to support her claims other than this interview). In the early 1990's, she developed breast cancer. Her website and this annotated transcript of one of her informercials tell her tale. In brief, in 1993 Dr. Day underwent an excisional biopsy that showed a ~2 cm breast cancer, with tumor extending to the margins. She underwent what sounds like a re-excision lumpectomy, refusing the addition of axillary dissection, the standard of care at the time. She then started an alternative medicine regimen of diet manipulations and prayer. Nine months latter, she developed a small "bump" near her previous site, which (she claims) grew to the size of a grapefruit in only three weeks. She even posted a picture. (I have to point out that I've never seen a breast cancer--recurrent or primary--even a really nasty one, that looked like this or that grew that fast. Invasive breast cancers usually start ulcerating through the skin long before they stick out like that.) The mass was, according to her, partially removed surgically, after which she was "sent home to die," suffering many other physical symptoms in the process. She "cured" herself with a regimen that included various dietary manipulations and prayer. Dr. Barrett has posted a very nice analysis of Dr. Day's story and a deconstruction of her infomercial, concluding that the second operation most likely cured her and that the grapefruit-sized mass was not recurrent cancer. Given that Dr. Day has refused to release the pathology report for her last operation after having released her first pathology report and part of her second report (leaving out the part that tells whether the residual cancer had been completely excised with clear margins at her second operation), I tend to agree with Dr. Barrett's assessment. Very likely the last pathology report shows no breast cancer (in which case the second operation cured her) or a recurrent cancer that was completely excised (in which case the third operation cured her). Of course, Dr. Day could easily prove all us doubters wrong by releasing the last pathology report, but she does not.

I mention this case not to trash Dr. Day, but rather to demonstrate that even highly trained and educated doctors, who should be able to evaluate alternative medicine therapies dispassionately, can become their biggest boosters. Even if Dr. Day could prove that she cured herself exactly as described, I would still ask her why she never did a clinical trial to see if her result could be generalized to others, instead of using her story to sell Barley Green and her books and videos. That would be what a real academic surgeon would do. If her recovery was as miraculous as she claims, it would not take very many patients or very long to show its efficacy. Unfortunately, Dr. Day appears to take a dim view of even honest criticism and is not above threatening her critics with the wrath of God.

Never forget that alternative medicine testimonials exist largely for one purpose: To sell a product. Most of them are advertisements They are no more "unbiased" than pharmaceutical advertisements. In fact, they are worse, because at least the pharmaceutical companies have to be able to back up their claims with science and disclose potential adverse reactions in their ads. No such requirements exist for most alternative medical treatments, mainly because most of them claim to be supplements rather than medicines. The other problem with testimonials is that they don't rise even to the lowest level of medical evidence, the anecdotal report. Anecdotal reports in medicine require a careful documentation of symptoms, lab tests, diagnoses, exact courses of treatment, and a patient's response to treatment. Testimonials almost never present these elements in sufficient detail to judge whether the treatment actually did anything. There's just no way of telling truth from exaggeration or fiction.

So, in conclusion, be very skeptical of alt-med testimonials. If you look at them closely, you will often find that the patient did have significant conventional treatment (such as surgery); that the story is vague (often omitting, for example, the stage of a cancer); that there is no data, just other testimonials; or that the data mentioned either comes from alt-med websites selling a product rather than peer-reviewed medical journals or is a nonsequitur from peer-reviewed sources. Also remember that conventional medicine is not above misusing testimonials in advertisements. Treat them with the same degree of skepticism. Look for the scientific and clinical evidence, not stories of great cures, regardless of the type of testimonial. If there is one principle I hope to impart here, it is that the claims of conventional medicine and alternative medicine should be treated the same and that they should be held to the same standard of scientific and clinical evidence. I do not differentiate between the two when considering evidence, nor should you. I hope to expand upon this principle in the future.

Living forever

Do you think this guy will really live forever? The problem is, I think I may be older than he is and probably won't get to see him die first...

But he does have these testimonials, so it must work, right? (This is sneaky way of introducing tomorrow's post.)

Gollum mentally ill?

The British Medical Journal seems to think so...

Big post tomorrow. (Too big, in fact. I'm going to see if I can whittle it down some today.)

Assisted suicide

An excellent piece on the myths used to argue for assisted suicide is here. He says it better than I could. The another good (albeit older) piece comes from Thomas Szasz, Emeritus Professor of Psychiatry at SUNY Upstate, who calls assisted suicide an oxymoron.