Credit Where Credit Is Due

Here's a couple of websites commenting on the fact that the state of Minnesota, the liberal bastion, has just passed a law designating practitioners of naturopathy as "doctors." I share their concerns. According to at least one interpretation, they'll be able to admit patients to regular hospitals and manage their care. To the extent that it's even imaginable, I find it frightening. On the other hand, in my state of Washington it's been the case for years that, by law, health insurance must cover such crapola as chiropractic, accupuncture, aroma therapy, massage therapy (yes, to the extent that it's the same as physical therapy, I have no problem, but there's all that other therapeutic touch nonsense...), and, of course, naturopathy. Far as I know, homeopathy, too, which is at the very bottom of the barrel, unproven-bullshit-wise. But that's not my point. My point is to give credit when it's due.

Seattle is home to Bastyr University, the mecca of "natural medicine." They claim the mantle of scientific research. And, contrary to what I'd have expected, it seems they actually do it. In the Seattle Times a couple of days ago were the results of a study they announced, on the efficacy of St. John's Wort for treatment of ADHD. It appears to have been an actual double-blind prospective study, and darned if it didn't show exactly what you'd expect real science to show: bupkis. So I congratulate them on being willing actually to subject their stock in trade to the science it requires.

I applaud Bastyr for doing the study and for publishing the results. I assume they'll continue doing so, even though I'd guess someone there must be worried they'll science themselves out of business eventually. We'll see. Meanwhile, it sets a standard for advocates of homeopathy, chiropractic,* Reiki,* accupuncture,* aroma therapy, etc etc ad nauseum to show the same kind of character and honesty and subject their modalities to the same rigorous and reproducible study. Good job, Bastyr.


*What I'd love to see done for those manipulative therapies is a randomized prospective study where the manipulations were divided into "approved" (or whatever you'd call it) and bogus, with neither patient nor provider knowing which was being foisted... er, sorry: provided. It would be tough to do. If you had actual "practitioners" giving the, uh, therapies rightly or wrongly, they could easily have different behaviors with the patients. So you'd need to have neutral people shown what to do for a given diagnosis and then do it not knowing whether they were shown the "real" stuff or deliberately wrong stuff. And although practitioners would object that only by years of training can they learn their craft, I'd think a single intervention for a single agreed-upon diagnosis could be taught. Stick a needle here, or there. Wave your hands there, or here. Crank on this, or that. Be fun to know, wouldn't it?

No Alternative

The world seems to be losing its collective mind, so it shouldn't be surprising that even vaunted medical schools are making "alternative medicine" part of their curricula. Several bloggers have been and are doing a fine job of venting; I come late to the party. (For the record, it's my view that in swallowing the pill, these schools and other hospitals are in it for the marketing. Which is more cynical than the therapies they're touting.)

Many years ago I watched, drop-jawed, the television commercial of a local chiropractor as he stood by a couch-full of young kids. Recommending monthly preventative adjustments for these four- to six-year-olds, he touted the obvious benefits: look how healthy they are. Not, he seemed to imply, a heart attack among them. Nary a stroke. Probably not even a case of colon cancer. And I wondered: is he stupid enough to believe or is he simply a cynical and dishonest charlatan? I got a partial answer a few months later when a woman arrived in the emergency department, acutely paraplegic. Her chiropractor had continued manipulating her increasing and unresponsive back pain until she became paralyzed. The "doctor" must have known about her history of breast cancer, because he was also her husband.

Until that time, because the theory behind chiropractic is so obviously loony, I'd assumed practitioners all knew it and were simply crooks who'd found a surefire way to separate the credulous from their money. (And yes, I acknowledge that manipulation has a place in certain specific anatomic disorders of the back itself. But using it to treat or prevent systemic disease is nothing but laughable. Except that it's not funny.) Stupid, careless, lacking judgment: yes, the man must have been all that. But unless he hated his wife, I had to conclude he believed in what he was doing.

I still haven't figured it out, and I'm sure I never will. Of what do the cerebral lacunae consist in these people? How can (some) otherwise intelligent people (givers and takers) become convinced of the efficacy of whatever woo they wish? Is truth just too hard to take? At some primordial level, is it just that we need to believe in silly stuff? What is it about humankind that pines for magic, for simplicity, for answers that pave over the painful? Why isn't inquisitiveness universal; doesn't skepticism confer survival benefit? Or would we all be jumping off cliffs if we didn't have mythology? Maybe that's it. Maybe too many skeptics have already jumped.

The frailty, the neediness of the human brain, when stacked against the obvious power of it -- the ability to create, to invent, to inquire -- is a probative paradox. It may be a stretch to write my way from anger about alternatives and chafing at chiropractic, to the death of skeptics and skepticism, but in my mind it's of a piece. I have a friend, a brilliant physician and much more of a scientist than most, who tells me he knows, based on his particular faith, exactly into which level of heaven he will enter; as if he's already done a mapquest search and downloaded the directions. Given that there are about six billion people on the planet who believe something else, and with just as much certainty, I find it amazing. And revelatory. It's a need. It's built in. It's human.

My conclusion is that the desire to believe in certain unprovable things at one time was good for us: when the dangers in the world were mostly external -- volcanoes and saber-tooth tigers -- and the need to organize and stay together was clear, supernatural beliefs were of obvious benefit. And now, as society has gotten impossibly complex, and the dangers are mostly human-generated, it's become a detriment. Rather than helping mankind to cleave together and help one another, magical beliefs -- whether on couches or in the clouds -- are causing us to fall upon one another in hate, in fear, in the unreason that comes from a mind blown by the awful realities we have brought upon ourselves.

Magical thinking is who we are, I guess. If it were only that it serves to enrich some at the expense of others, maybe even make some people feel better, what the hell. If they're only hurting themselves, or the willingly deceived, should I let it go? But they are hurting people, and it's pretty clear that eventually it will hurt me. When I see this mainstreaming of stupid, I can't keep myself from thinking of the other side of the same coin: people flying into buildings, blaming hurricanes on gays, invading the wrong countries, laughing as we pee in the pool. The need for crazy-stupid is great; if straws they be, still grasp at them we must. We've gone from flivvers to Ferraris in a sigh and a gasp; from Kitty Hawk fields to the seas of the moon in the eye of a bat; Allan Pinkerton's shoes to spies in the skies: the power of scientific method is obvious to the most casual glance. Yet despite -- or is it because of -- the amazing progress we've seen at the hands of science in less than a lifetime, people willfully and seemingly in increasing numbers simply ignore it at their convenience. Need to ignore it. Demand to ignore it. Demand that I ignore it.

I don't think you should get to pick and choose. Don't believe in evolution? OK, then don't get on an airplane. Earth is twelve thousand years old? Fine. Take back your laptop. Homeopathy makes sense to you? No problem. Put down that cellphone, never avail yourself of GPS. Because if man and dinosaur occupied the same space and the same time, if carbon-dating is bogus, atomic clocks don't work and transplants are impossible. If vaccines cause autism, Rovers aren't on Mars and nothing will happen when I push the button to post this.

Tales From the Right Lower Quadrant, Part four

I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually.

There are several ways to handle an appendiceal abscess, most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of draining the abscess, surgically or by placing drainage catheters into it with Xray guidance. Typically this leads to rapid resolution of the immediate problem, but leaves on the table the question of how -- or whether -- to deal with the offending appendix in the future. But before we get to that, let's talk a bit about draining that abscess.

Mainly risking incredulity and recommending finding another surgeon by the patients' friends, I've on a couple of occasions treated small abscesses only with antibiotics. When a person comes into the office complaining of a month's worth of somewhat annoying illness, and the workup shows mostly swelling in the appendix's homeland with only a small fluid collection, it's seemed reasonable to take a pretty conservative approach. But in most cases, the patient is sicker than that, and the abscess is bigger, so drainage is best. Of course, I've always leaned toward the surgical approach, because it's the most definitive: especially for a large and loculated collection. You can get big drains in there, wiggle your finger around in the hole to break down the septations, and get it done all at once. Radiologists are getting better and braver at approaching intra-abdominal fluid collections, and it's become the preferred approach in lots of situations. The one area that until fairly recently many of them like to avoid, however, is a deep pelvic abscess. I liked it, if the anatomy was just right, because even in busy operating rooms, it seems I could always surprise a person or two with how I did it. Guess it must be an old-timer thing.

When the appendix is long and low-lying, and its tip sits way down in the pelvis, it's not rare for it to rupture by the time its particular form of appendicitis is figured out. That's in large measure because it tends to present with diarrhea, as opposed to most cases, in which bowel shut-down is the norm. The abscess that forms sits on the front of the rectum and bulges inward into it. You can put the victim up in stirrups, spread open the anus, confirm you can reach the abscess, poke a little needle through the rectal wall to prove the pus is there, and then, grossly, ram a clamp through the same point, through the entire thickness of the rectal wall and into the cavity. Pus ensues; fragrant, copious, gratifying pus. Guide a rubber drain into the area, and you're done: no skin incision, no consequences. You'd think poking a hole through the rectal wall into the abdominal cavity would lead to disaster; but it's well walled-off, it drains, it heals, and everyone is happy. The drain falls out in short order.

I drained silly George, and he got well promptly. He followed up as suggested, in the office, and I told him (as I had in the hospital) that I recommended he have his appendix removed after an appropriate amount of time had passed for healing. It's become controversial -- more now than a few years ago. The concern is that left in there, appendicitis will eventually happen again, and it's one of those things passed down from generation to generation of surgeons. It's only quite recently that studies have been done that raise questions about the need (these are all "retrospective" studies, meaning analyses of existing data, rather than "prospective" studies, meaning randomizing current patient to groups who'd have it done and who'd not have it done, and seeing what happens. Prospective studies are better. None have been done; but the papers have, rightly, gotten the attention of surgeons.)

Trained in the dark ages, I've done quite a few "interval appendectomies," and it's interesting how they have varied: in some cases it's as if the person had never had appendicitis. Everything normal, easy as pie. In others, the worm has been plastered to various entrails and exceedingly difficult to remove. Once or twice, it had been so fried by the original infection that there was nothing left but a thread; clearly incapable of causing further trouble. One time the pathology report came back "acute appendicitis with rupture," months after the actual event. But the need for the surgery was not what troubled George. He was worried about having his appendix removed, fearing the loss of it would lead to some sort of future health consequences.

That's not an unreasonable concern, and it's been addressed in many ways. I liked to refer to a study done by the Mayo Clinic (can't find it now. Didn't try real hard.) that compared around 4000 people who'd had appendectomy with the same number of ones that hadn't, similar in all other ways, and found no difference in incidence of health problems over many years of observation. But George brought an article, published in a journal of alternative medicine. It had actual photomicrographs of the appendix, showing lymphoid tissue (well-known.) The article pointed out the appendix's location between the small and large intestine (close enough) and stated that given the location and the lymphoid tissue, it clearly had an immune-surveillance function. There were no data, no studies. Just a conclusion out of thin air. Now this is not really a big deal, and I don't mean to hijack my own post. But it was the first time I'd seen an educated person show a complete lack of ability to judge data. Pretty picture, shiny paper = conclusion must be correct. Imagine. George rejecting reams of scientific and peer-reviewed data in favor of pseudo-data that served his purposes...

I'll finish this series (for now) with another prejudice, for the heck of it: I'm not a big lover of laparoscopic appendectomy. I think laparoscopy is a fabulous innovation, and there are several operations for which the laparoscopic approach is clearly superior to the open one. Appy, in my opinion, ain't one of them. Why? Properly done, an open appy takes fifteen or twenty minutes, uses a small incision that isn't very painful (much less so than the original disease was!) and from which the patient recovers rapidly; often in the hospital only a day or so postop. Admittedly, this isn't always so: appendectomy can be an extremely difficult operation. But we're talking typical, here. Come in to do an appy in the middle of the night, get a crew not so familiar with all the laparoscopic tools of the trade, and you've turned a simple thing into a time- and money-consuming circus. But tool-makers are very talented at marketing (there are some great technologies out there, just waiting for a disease.) High profile, big-ticket lasers gather dust in OR hallways as we speak. But that's for another post, another time.