The purpose of this blog is purely educational. It does not advise any reader to forgo medical treatment for any condition. It describes methods that have not yet been proven effective through widespread scientific testing. Readers who are concerned about their health are advised to contact their physician.

Wednesday, December 19, 2012

Are you allowed to know about "energy healing"?

Recently I participated in a vigorous debate on a sceptical blog about the merits of energy healing. The participants wanted me to learn about the importance of science-based medicine, but what I learned instead was a lesson about the human propensity to develop lynch mobs. All it takes is a group of passionate, like-minded individuals, a single outlier, and a few maliciously inclined, self-righteous people who shout "let's go get 'er!" for the pitchforks and the torches to come out. It was a sobering lesson. I got the distinct feeling that if this were the Middle Ages some of the people there would have cheerfully burned me and my ilk at the stake and felt good about themselves for doing it too.

The issue at hand was whether "energy healing" is real. I cited studies on my side of the debate; they cited studies on theirs. The studies I most relied on were Dr. Bengston's studies with mice, in particular the ones described in his paper "The 'Laying on of Hands' in Transplanted Breast Cancer in Mice." For the uninitiated, this paper refers to four studies in which mice injected with a fatal form of breast cancer were treated with a form of energy healing. They should have all died within 27 days, but instead 87.9% of them survived and recovered. But the kicker is that a large percentage of the control group also survived. According to Dr. Bengston, once the first two control mice died, he peeked in on the surviving controls, and then they too went into remission. Thinking that there was maybe a field effect, in a subsequent experiment he also used outside controls, housed in a different building. Those controls died on schedule.

According to the sceptics, the survival of the control mice made all the experiments invalid. The whole point of using controls is that it is their death that makes the experiment viable. Even though the remotely housed control mice died, for the sceptics they "didn't count". The fact that Dr. Bengston did multiple experiments at several accredited institutions didn't count. It is supposed that several separate sets of lab technicians at different institutions using different sets of mice all somehow made fundamental errors; or that all these different sets of mice, obtained from Jackson Labs and bred to be used in cancer research, were all somehow defective; or that the cancer, usually virulently fatal, simply did not take in any of the experiments. What are the odds?

On their side they quoted as most authoritative a science fair experiment, conducted by 9-year-old Emily Rosa, in which Therapeutic Touch practitioners were shown to be unable to detect the presence of a human energy field. Emily was helped to write up the experiment by Dr. Stephen Barrett of Quackwatch and her parents, and the paper was published in the Journal of the American Medical Association. This one study is supposed to prove, to everyone, for once and for all, forever and always, that energy healing in all its forms is bunk.

The sceptics just know that energy healing cannot possibly work. From their perspective for someone to suggest to cancer patients that something like Reiki might improve their quality of life is, in the absence of gold-plated, double-blind studies, a heinous lie. Never mind that many hospitals already have Reiki programs or that Dr. Oz's colleague, Dr. Sheldon Marc Feldman (Chief of the Division of Breast Surgery in New York-Presbyterian Hospital/Columbia University Medical Center), followed in his footsteps in inviting Reiki practitioners into his operating room, and found Reiki to be helpful to patients. Dr. Oz's recommendation on his show that Americans should try Reiki just proved to the sceptics that he had "gone over to the Dark Side."

"It's just not scientific!"

From the sceptics' point of view energy healing at best only works because of the placebo effect. People just "think" they feel better; they don't "actually" feel better. The sceptic says so. They just imagine that their mobility has improved or that their knee no longer hurts. The sceptic says so. Healer and client are seen as locked in a mutual dance of self-deception. All because in the sceptic's mind energy healing could not possibly exist. It's just not scientific.

Never mind that there are scientists who accept the possibility of energy healing and want to know more. The scientists in "What the Bleep Do We Know?" The scientists in Lynn McTaggart's The Field. Many of the scientists with PhDs who are members of the Society for Scientific Exploration. William Tiller. Rupert Sheldrake, author of The Science Delusion. Even some medical doctors: Larry Dossey, Deepak Chopra, Bernie Siegel, Andrew Weill, and of course Mehmet Oz and his colleague Sheldon Marc Feldman above. All dismissed as having no credibility at all, despite their years of study and their multiple credentials, simply for being interested in phenomena that "real" science doesn't recognize.

So are you allowed to know about energy healing? Yes, you are. Are you allowed to make up your own mind about energy healing? Yes, you are. Are you allowed to try energy healing as an informed, consenting adult living in an ostensibly democratic society? You ought to be. But the sceptics' concern, and here they are being commendably humanitarian, is that you will forgo or delay important medical treatment in favour of "woo", their term for anything not backed by science which conveniently overlooks the fact that a good chunk of medical practice is not backed by science either. The answer is simple: don't forgo or delay medical treatment in favour of "woo". Be a responsible consumer of healthcare. Does that mean don't try energy healing, ever? No, it doesn't.

But there are some sceptics who go one step further to suggest that you should not even be able to try anything they define as "woo". If they had their way, "woo" would not be available for you to try. There would be no Reiki programs in hospitals. Practitioners would be prosecuted. This blog would not exist for you to read because I would not be allowed to write it.

For me, that's going just a bit too far.

Tuesday, December 11, 2012

Why the cost of delivering medical care is bankrupting America - one example

In my previous post I discussed Dr. Marty Makary's book Unaccountable about what goes on behind the scenes in American hospitals. One of the issues he raises is the number of unnecessary or unwarranted procedures that are done on patients. In his aptly numbered chapter 11, entitled "Eat What You Kill", he describes the excesses of a system in which the doctor has become more a salesman than a primary healthcare provider. One result of this business model is that many procedures such as back operations, spinal fusions and angioplasties are done to excess, with huge costs to the system.

To support this Dr. Makary cites a 2012 study, entitled "Appropriateness of Percutaneous Coronary Intervention" (PCI, or more commonly known as angioplasty). The study found that in the space of a little over a year (July 2009 to September 2010), there were altogether 500,154 such operations, of which 355,417 (71.1%) were for acute indications (such as myocardial infarctions and unstable angina) and 144,737 (28.9%) were for nonacute indications, which I imagine means that the patient was experiencing symptoms, but not in distress or imminent danger.

Of the latter group, surgery for nonacute indications, "72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate."

In short, that's almost 17,000 unnecessary operations, and almost 55,000 questionable ones, for a total of 72,000, all in the space of 15 months.

Out of curiosity, I next went on Google to find out how much an angioplasty costs. I found this topic discussed at The numbers varied wildly. One quoted price was this:
About the cost of angioplasty and stenting in the US based on medicare payment: Cardiologist fee: $838 for one vessel, each additional $233 Hospital fee: $10,371-$18,227
Then a man from Texas spoke up and said he paid $101,000.00 and it was worth every penny. Other people chimed in with numbers in the vicinity of $50,000 to $90,000, and people from outside the US gloated that theirs was free (in Canada) or a few hundred euros for the hospital stay (Ireland).

At any rate, the reason I bring these numbers up is to point out that those 72,000 unneccesary or questionable angioplasties from July 2009 to September 2010 cost Americans anywhere between $720,000,000 (if you calculate $10,000 per procedure) and $7,200,000,000 (if you calculate $100,000). That latter figure is $7.2 billion, by the way. Now add in all your unnecessary back operations and spinal fusions at $12,000 a pop, give or take a few thousand, and you have numbers for unnecessary or questionable surgeries that are not just in the stratosphere, but way beyond, hovering somewhere around Jupiter if not out of the solar system altogether. No wonder America is in danger of going bankrupt.

PS: And the true shocker is that according to a recent study angioplasty for these nonacute patients (who had stable angina or narrowed arteries) was no better than optimal medical therapy and lifestyle change. The study found that
getting angioplasty and a stent to hold open a narrowed artery didn’t offer any extra protection against a heart attack, stroke, hospitalization for acute coronary syndrome (the umbrella for heart attack and unstable angina), or premature death ... If you have chronic angina, it’s worth giving medical therapy the old college try. One of the findings from [the study] that surprised even researchers was how effective medical therapy was at relieving angina and improving quality of life. You might be surprised at how well exercise, a better diet, and medications can make you feel. If, after six months to a year, your angina is still bothering you or keeping you from doing activities you enjoy, angioplasty or bypass surgery are reasonable next steps.
If that is indeed the case, then the number for unnecessary angioplasties may be a lot higher than 17,000.

Sunday, December 9, 2012

Iatrogenic disease - part 2

Oh my God. Oh ... my ... God. I am just reading a book, Dr. Marty Makary's Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Healthcare. Dr. Makary is a surgeon and an associate professor at Johns Hopkins. I can't put the book down. My blood pressure must be in the stratosphere. I am reading things that are making my hair stand on end.

Dr. Makary is scathingly honest about his profession. His candor burns like a cauterizing iron. In this book patients die; patients are maimed; mistakes are swept under the rug; surgeons who should never be allowed near patients continue to practice; professional bodies that are charged with overseeing doctors routinely fail to do so; and whistle-blowers who advocate for patients get fired or drummed out of the profession.

The scale of the problem is huge. In his introduction, and later in his chapter 8 (entitled "Impaired Physicians"), Dr. Makary writes of attending a conference where a renowned Harvard surgeon asked his audience if any of them had a colleague who they knew should not be performing surgery -- in an audience of thousands, every hand went up. He calculates that if only 2 per cent of America's doctors are impaired, that's 20,000 unsafe doctors, who altogether see about 10,000,000 patients a year. He calls this "a public health crisis".

As an intern at Harvard, Makary trained under a surgeon who was referred to behind his back as Dr. Hodad. "Hodad" stood for "Hands of Death and Destruction". Dr. Hodad had impeccable credentials, an unimpeachable presence, and a splendid bedside manner. His patients adored him and had no idea that his incompetence was the reason for their long hospital stays and their post-surgical complications.

Hospitals have no reason to rein in such surgeons, Makary tells the reader, because post-surgical complications add dollars to their coffers. The greater the number of procedures that need to be done, the longer a patient needs to stay, the more money a hospital makes: about $10,000 on average for each complication. Incompetence only becomes an issue if the patient who dies as a result is famous and the story gets wide-spread public airing, causing the hospital major embarrassment. There is a culture of omerta. Makary relates the story of a heart surgeon, one of four in a well-known hospital, who had "six consecutive deaths during routine bypass surgery". Soon after the sixth death, he was about to operate on yet another patient, when the patient asked the anasthesiologist, "Is my surgeon a good surgeon?" Thinking quickly on his feet, the anasthesiologist replied, "He is one of the four best heart surgeons we have here", and the patient luckily didn't ask how many there were. This young doctor was routinely protected by the other heart surgeons, who attributed the deaths of his patients to "extenuating patient circumstance".

Makary's point is that patients have no way of knowing whether they are in the hands of a competent doctor or a Dr. Hodad. Medical students who barely pass, or who have untreated substance abuse or psychiatric problems, also become doctors and receive a license to practice -- with little or no accountability. Doctors with known substance abuse problems may not be allowed to drive their cars, but they are still allowed to wield scalpels and prescribe potentially lethal drugs. Makary writes:
After we doctors graduate from medical school, the government, via state medical boards, pretty much gives us a pass to do whatever we want.... After ... I got my license based on a 70-per-cent-or-higher passing score on my board exam, I was literally licensed to do anything in medicine -- perform brain surgery, prescribe chemotherapy, remove varicose veins, or do electric-shock therapy for psychiatric disorders ... I can legally do anything.
The issue is not only a small percentage of incompetent physicians, but also the "Wild West" attitude endemic in the culture and practice of medicine. Much has been written about the conditions under which young doctors are trained: brutal work hours; little sleep; inadequate support; even psychological abuse. The conditions are such that it is often impossible for them to deliver even adequate care. Makary writes about one night when he was an intern at D.C. General Hospital, trying to handle twelve emergency cases all at once. He called his chief resident for help and got shouted at for his pains. He then did his best on his own, with the help of a medical student, but two of the patients died. He mentions other cases where patients died because the intern on duty was spread too thin. So when he also cites a study claiming that one in four hospitalized patients experience some kind of harm due to medical error, the surprise is not that the number is so high, but that it is so low.

Makary quit his medical training after one of his own patients came to grief despite his best efforts to prevent her having the entirely unnecessary procedure that harmed her. He says:
I felt disillusioned. It seemed as if, despite all the book knowledge I had gained, nearly half of the patients I saw in the clinics had problems for which modern medicine had nothing to offer except phony names for diseases we didn't understand. The other half .... seemed to be sick because they were obese, smoking or not taking care of themselves -- preventable problems.
He switched to the Harvard School of Public Health, where he learned a whole new perspective on disease, and later returned to medicine because he missed the contact with patients, resolving to practice medicine as he thought "it ought to be practiced -- with honesty".

The economic angle

The book also takes aim at the business model of medicine, in which doctors are encouraged to perform ever more procedures to generate income for the hospital, and in which the CEOs of children's hospitals are compensated to the tune of millions of dollars. As an example of the business attitude that pervades healthcare he quotes an email sent by a hospital administrator to the surgeons in his department, which reads, "As we approach the end of the fiscal year, try to do more operations. Your productivity will be used to determine your bonus." He points out that doctors and hospitals profit from prescribing chemotherapy, that doctors receive commissions, royalties and consulting fees from using prosthetics and surgical implants. Between paying for errors, unnecessary procedures, and excessive compensation under what Makary calls the "eat what you kill" model, it is little wonder that the U.S. is staggering under the costs of delivering healthcare to its citizens.

Parts of the book deal with solutions, which is just as well, because otherwise it would be an infuriating and depressing read. The larger perspective Makary attained at the Harvard School of Public Health allows him to provide suggestions for systemic improvement. He advocates salaries for doctors rather than payment per procedure; transparency about patient outcomes; public access to information; changing the workplace culture of hospitals to privilege teamwork over hierarchy and safety over profit. He especially highlights the importance of teamwork: in the interest of patient safety, everyone who works at the hospital, regardless of where they are in the hierarchy, should be able to speak up, just as anyone on the Honda assembly line is allowed to shut it down if they spot a problem.

After lambasting his profession for most of the book, Makary reveals at the end that he is optimistic about the future. The culture is changing; the medical students he now works with are more into openness and honesty with patients and are less willing to put up with hazing and shenanigans than his generation was. New technologies such as interactive patient records and video cameras in the operating rooms aid transparency. The internet has revolutionized the ability of patients to obtain information so they can ask more knowledgeable questions. There is a light at the end of the tunnel. My blood pressure back to normal, I was pleased to read that the new generation of medical students is open even to alternative therapies.

And in the meantime, until the system is thoroughly reformed, Dr. Makary offers patients a list of questions to ask their doctors on his website,