White Coat Underground

One of the hardest things about practicing medicine is being compassionate and dispassionate at the same time; acknowledging a person’s pain, but standing aside enough to view the problem with a degree of objectivity. This is one of the easiest mis-steps to make in medicine, and is the root of the problem of many so-called alternative medicine practitioners. Take a look at this email from a fan:

I find it interesting and short sighted that you (and many medical providers) require published research in order to be convinced that a new medical condition exists. Have you ever considered that prior to the discovery and research related to PCN (or any drug or any medical condition) didn’t make it a worthwhile treatment??? I am a medical provider and happen to know someone with what appears to be Morgellons and has been belittled and discounted trying to get help with our peers. Shame, shame – on you and most of our peers for being so closed minded.

I know a lot of people with a lot of horrible problems, and I allow that to feed my passion for medicine, but I cannot allow it to distort my view of how the science of medicine works. This will lead me to wrong conclusions, and in medicine, wrong conclusions hurt real people. This is one of the main reasons that it’s a bad idea to treat family members, and for that, I have a brief example.

About a year ago my daughter was on rounds with me at the hospital and we stopped for a cookie. A little while later she started whining and complaining of not feeling well. She started coughing, and complaining of a stomach ache, so I took her home. Her cough got worse and she started wheezing, so I gave her a breathing treatment. Then she got hives, and we gave her some benadryl. (We did call her doctor during all this.) I thought that she was simply getting one of the many respiratory viruses that she loves to catch, but my wife correctly diagnosed her as having a severe allergic reaction.

After the breathing treatment and the benadryl she was fine (it turns out she’s allergic to nuts) but it was remarkable how easily my connection to the “patient” overcame my ability to recognize a common medical problem. Cultivating objectivity is not “closed-mindedness”—it is an essential tool in the practice of medicine. If we allow our passions to rule our thinking rather than inform it, we will injure and kill people.

___________________________

And speaking of allowing our passions to overcome the cold, harsh light of science, the Connecticut legislature has done something rather foolish—-it has decided to take a try at practicing medicine. They have a good model for this in their attorney general, who tried something similar and lost his little battle, all the while claiming victory.

To remind you again of the particulars, the Infectious Disease Society of America publishes guidelines to treating many infectious diseases. These are non-binding, expert recommendations. They recommend against long-term antibiotics for so-called chronic Lyme disease (CLD), where people have a host of vague symptoms and no microbiologic evidence of current infection. The paranoid host of chronic Lyme disease boosters, led in no small part by far-from-dispassionate “Lyme-literate doctors” who stand to benefit financially, lobbied the CT AG to go after the IDSA. He charged them with some sort of “anti-trust” violation, and when his case was shown to be ridiculously hollow, he backed away, having gained nothing (except for future votes). The IDSA agreed to re-evaluate their guidelines, but not to change them.

This having failed the CLD boosters, they turned to the CT legislature. Remember, there is nothing binding about the IDSA guidelines. CLD docs will claim that these guidelines affect what insurance companies will pay for, and they are probably right. Insurance companies don’t like to lose money on disproved, dangerous treatments (or anything else for that matter). In one of the few cases in which I will side with an insurance company, it would be folly for them to waste money on treatments that are not even experimental, just wrong. But this doesn’t make them illegal.

So the legislature has passed a bill which is supposed to protect physicians who treat CLD. Exactly what this means isn’t clear to me. It essentially forbids the state from going after doctors for prescribing long-term antibiotics for Lyme disease as long as they document that they think the patient has it, and their treatment plan.

I’m not sure how that’s any different from the status quo. Currently, there is nothing to prevent a doctor from deciding that a patient has Lyme disease and then treating it however they see fit. The law give a lot of room for quackery. I could, theoretically, decide that a patient has Lyme disease and treat them with long-term antibiotics, mushrooms, or lawn clippings, and the only real consequence would be a malpractice suit. State medical boards are very reluctant to interfere with physician autonomy.

CLD advocates are declaring an important legislative victory, one which accomplishes nothing. It lends neither scientific nor legal status to their putative illness. It does, however, show how passion can be mistaken for compassion; how people’s real suffering can be so compelling that doctors allow themselves to lose their objectivity, succumb to unscientific ideas, and strangely enough, manage to profit from it.

Comments

#1 Rose W.
May 31, 2009

Excellent thoughts regarding passion….and a good reminder for a pre-medical student such as myself.

Thanks!
#2 Kathleen M. Dickson
May 31, 2009

You are a fool.
Why would CDC officer Alan Barbour recommend treating syphilis with Relapsing Fever?
http://www.actionlyme.org/RICOCHRON.htm

Why does IDSA refuse to acknowledge what Pam3Cys does, when Luc Montanier and Anthony Fauci both do?

Kathleen M. Dickson
http://www.actionlyme.org
http://www.relapsingfever.org
#3 Ciaphas
May 31, 2009

I’ve noticed that the CLD people (and others) always seem to miss something very important about what you write. You never deny that they suffer. I’ve seen you accused of it many times but it’s not true.

As a compassionate person you recognize that they suffer and want to help. As a dispassionate doctor you understand that simply throwing up your hands and declaring “it’s all CLD” doesn’t actually get anyone closer to a real solution.
#4 Anonymous
May 31, 2009

Have you evaluate the Igenex test? I hear that it is more accurate than the typical test for Lyme — can you please explain what the difference is between the tests? I was diagnosed with Lyme in October 2006, bulls eye, blood test, fatigue, joint pain, nausea, solar plexus pain, etc. Had 4 weeks of augmentin, but relapsed with a vengeance — had 4 more peaks on the Western Blot in January ’07 than I did in October. I recently had the Igenex test, and it shows that I still have active Lyme (IgM) in addition to the IgG in my system, even after 2.5 years.
#5 Tmccall
May 31, 2009

I feel compelled just to clarify one comment made in your article. The doctor who treats me for lyme disease makes the exact same amount of money as my other doctor for a normal visit -One catch the lyme doctor spends sometimes two hours with me whereas the other doctor might spend 10 minutes tops. So tell me how it is you think they are making so much money – This infuriates me. Most of them have been brought to court with funding out of their own pocket – It appears to me they are the ones doing what they vowed to do when becoming a doctor and that is to treat the patient- By the way its not the nurse that calls back (even when I leave a message for her) – NOPE its the good doctor who is there for me everytime!
#6 Noadi
June 1, 2009

So if your doctor prescribed bloodletting for you would you do it? Just because he’s a caring guy who spends lots of time with you? Do you really put more weight on that than his competence?

Also I don’t think any doc spending 2 hours with a patient for a non-emergency isn’t making more money out of it somehow (unless somehow he has so few patients that there’s no rush on his time).
#7 Bob
June 1, 2009

Dear PalMD,

By way of helping you to calibrate this observation, I’m a highly analytical engineer and a member of American Mensa and the IEEE who has consulted to NASA, Los Alamos, AES Energy, as well as a range of Silicon Valley, financial, and energy enterprises. Translation — I have no time to waste and I’m credible (at least in my opinion . I suffered from the condition tagged “Morgellons” for nearly three years while I learned, somewhat serendipitously, to control (not cure) it.

The absence of knowledge in the medical community as to the reality of this condition is a poor reason to indict it. I would suggest that this reflects a familiar mentality upon which I will not further comment.

There are no ‘bugs’ or other parasites involved as far as I can determine, however, this is doubtless a legitimate pathology, known or otherwise, that is causing misery for a startling number of people. It seems to me that the CDC’s investigation offers some support of this notion. Candidly, I find myself left with little alternative than to speculate that this is just one more example of the “learned” medical community concomitantly knowing both too much and, equally, too little.

“Men are from Mars. Women are from Venus. “Morgellons” exists. — Deal with it!
#8 JP
June 1, 2009

Hi Bob,

I’m a member of the IEEE as well, and I’m a little pissed that you’re using our organization in your appeal to authority. We engineers are not gods, and you’re way outside of your field. Hell, I wouldn’t pay any attention to my thesis committee’s opinion on medicine, and two of them are IEEE Fellows.

If Morgellons is real, which looks like a pretty big if due to the lack of published data, I expect the doctors and scientists of the CDC, NIH, etc., to get to the bottom of it. The members of the IEEE are unlikely to make any meaningful contributions.
#9 KS
June 1, 2009

I truly find it unfortunate to have MDs like you practicing medicine. Lack of passion in your profession makes you a mediocre doctor at best.

Objectivity is certainly important but you are NOT being objective. However, you cannot be objective if you haven’t done your homework. Do your research before taking a position on CLD. There are hundreds of studies (peer-reviewed from respected institutions) that supports that Borrelia can be chronic AND that the currently available diagnostic tests are not reliable. Regarding the latter, you can easily spend a few minutes on the FDA website and review the Lyme Diagnostic Kit Manufacturer applications to the FDA. The data presented clearly shows that early in the disease and in late stage lyme, the diagnostic tests have a very high false-negative rate.

For those who truly spent their time OBJECTIVELY reviewing the data related to CLD, the only conclusion that can be drawn is that science and medicine do not have the answers.

The MDs that are treating patients with long-term antibiotics are truly the objective ones. They have done their research and have seen success with long-term treatment in a majority of their patients. These doctors are actually far more objective than the handful of members at the IDSA, that have established the guidelines.

Regarding alternative health practitioners, let’s give the patient population some credit. Many have been turned away by traditional medical professionals and are desperate to try anything to improve the quality of their lives.
#10 Jimbo Jones
June 1, 2009

Not to mention the fact that mentioning “I’m a Mensa member” is a big red flag. Especially since most meetings are people sitting around a wanking on about how smart they are, and how they know so much more than specialists.

Bob, you’re either lying about your credentials, or a really smart idiot.
#11 amlv
June 1, 2009

So, according to your logic, you were not objective about your daughter, but her Mother, who correctly diagnosed your daughter with a severe allergic reaction, IS objective?

I am a Mother and I am arguably the least objective person when it comes to my children. Maybe you were just downplaying the severity of your daughters symptoms and thinking they were either all in her head or “some virus” that she loves to catch. I see a pattern here.

It seems you are not only objective, but also very insensitive and dangerously arrogant.

I am glad you’re not my doctor.
#12 CyberLizard
June 1, 2009

@amlv, I would be ecstatic if PalMD were my doctor, at least within the areas of his expertise. He never said his wife was more objective. You certainly seem to be reading a great deal into his little anecdote. FWIW (and it’s not much at that) my wife is generally much better at analyzing our children’s illnesses.
#13 Bev
June 1, 2009

I’m glad your daughter is ok from her incident. My daughter at age 13 became acutely ill, and over 9 months was misdiagnosed by over 20 doctors. We were uniformly told that she had “too many symptoms” and should go to therapy for “emotional problems.” (Note: she displayed not one “emotional” problem. She was acutely physically ill, including having partial seizures.) Here is the real issue: Lyme disease is NOT ON THE MAP with doctors– she was a walking billboard for Borrelia, sans the rash, and no doctor saw it. She was misdiagnosed as having juvenile arthritis, migraines, fibromyalia, chronic fatigue, etc. The day that your profession is adequately informed about the dangers and presentations of Lyme (NOT currently adequately done by the IDSA), we should not have to have the “chronic Lyme” conversation because recognition and swift intervention will make it a non-issue. It is the failure of the medical profession to date that there are people like my daughter, now 20, who are still sick because of late diagnosis.
#14 catgirl
June 1, 2009

I think that doctors like you have much more compassion than alt-med pushers. You realize that people are genuinely suffering and you want to find effective ways to help them. People who have Morgellen’s definitely suffer and no one has denied that. The people in the group probably do not all have the same disease. Spending time chasing down a diagnosis that is not supported by evidence only delays the correct diagnosis. It’s a shame that these people have to suffer longer than necessary because someone has convinced them to stop looking for a correct diagnosis.
#15 Mu
June 1, 2009

Bev,

you admit the diagnostic tools are unreliable, but nevertheless claim the doctor is supposed to do a very specific treatment without any way of confirming the diagnosis. They typical late lyme symptoms support a number of diagnosis, often with completely counter indicated treatments. Last week we had a thread where the exact same list of potential symptoms (any 20 out of these 50) was used to advocate either CLD, Mogellons or fibromyalgia, and they would also fit a low level MS and others.
Since you pointed out it’s a quality of life and not a life or death situation, the serious MD will try to narrow down a diagnosis BEFORE doing a shotgun approach of treatments in the hope of catching the right one at some point.
#16 Jo Anne
June 1, 2009

What makes you think these doctors that are willing to treat Lyme Disease and Morgellen’s havent looked for everything under the sun b4 diagnosis and treatment. the patient would want it too. Palmd is the doctor that I would not go back to.
#17 J G
June 1, 2009

PalMD, I am sorry to hear your daughter is allergic to nuts. It can be hard to cope with because nuts can be in almost any commercial product. My own daughter is severely allergic to wheat, milk, eggs, soy, and peanuts, as well as animals, molds, and plants. It took 3 allergists and an anaphylactic episode to diagnose this even though she had the classic symptoms – red, watery eyes, runny nose, and horrible eczema, and finally a trip to the ER with a swollen eye and breathing problems. It was lucky your daughter was diagnosed when she was, because I know by personal experience some doctors scoff at the idea of food allergies. I guess a lot of doctors tend to simply ignore or ridicule things they don’t care to try to understand.
#18 Mu
June 1, 2009

Jo Anne, how do you come up with a diagnosis for each of those (excluding the other) and pick a treatment? I mean, long term antibiotics wouldn’t do diddly against a parasite, and wrack havoc on people with autoimmune disorders.
#19 Josh in California
June 2, 2009

Jo Anne,

How do you treat Morgellons? People who claim to have it claim that it’s new, unknown, and completely un-studied.

So how does a “Morgellons doctor” go about treating something they know nothing about?

And if the claims of those suffering from Morgellons are true (visible fibers moving under the surface of the skin, etc.), why doesn’t anyone take them seriously? Are the fibers only visible to those with the disease? If so, we already have a name for Morgellons, but you’re not gonna like it.
#20 daedalus2u
June 2, 2009

There are very good reasons why close personal relationships interfere with logical thinking. It isn’t a “bug”, it is a “feature”, the feature responsible for the proverb “lucky at love, unlucky at cards”. Of course this is mediated through nitric oxide.

The archetypal mammalian social behavior is maternal bonding. Mammalian mothers have to bond to their infants in order to lactate and provide them with milk. Lactation is extremely energy intensive, so lactation and maternal bonding has to be coupled to energy physiology. This coupling is through nitric oxide. Low NO is a state of stress including metabolic stress and if NO is sufficiently low, then maternal bonding is inhibited. As an aside, this is what makes lactation among the obese so difficult.

The state of “fight or flight” is a low NO state. During a state of “fight or flight” is not a good time to go all lovey-dovey or sappy. That is why the lovey-dovey pathways are also coupled to NO such that they are made less active during times of stress.

There are two fundamental ways of thinking, anthropomorphic-type thinking as with a “theory of mind”, where one emulates the thinking of another individual so as to communicate with them. This is used for social-type interactions including the lovey-dovey ones.

They other way of thinking is with a “theory of reality”, where one tries to emulate reality. The theory of reality neural pathways are activated under conditions of lower NO. These are the neural pathways used to think abstractly about facts, to think logically, to use non-social thinking heuristics. If you are going to calculate the probabilities of card games, this is the part of your brain that you use. If you can’t access it (because you are all lovey-dovey), you are going to lose at cards. Thinking with one’s “theory of reality” is how a science based health care provider works. He/she starts out with facts, manipulates them with logic via algorithmic thought processes tested to be effective in diagnosing and then treating health problems.

When you are all lovey-dovey, you want prospective mates to see that and appreciate that you are under low stress because your mojo is so strong you can afford to be transparently lovey-dovey. What the low stress, lovey-dovey individual “wants” is to give out authentic signals that he/she is all lovey-dovey so that prospective mates can read those signals accurately and reciprocate those lovey-dovey feelings. If you broadcast how you are feeling to people you are playing cards with, they will beat you.

What about in the specific context that PalMD mentions, where his young daughter has an allergic reaction? In the “wild”, a father would be unable to provide any antihistamines or other pharmacological agents to change the course of any immune system reaction. All he can do is try and affect her own neurological regulation of her own physiology. Nitric oxide is highly involved in immune system regulation. Low NO potentiates the immune response by increasing the sensitivity of mast cells to degranulation, and by disinhibiting NFkB. The respiratory burst that immune cells generate when activated lowers NO levels local to that respiratory burst and so potentiates the immune system response locally.

Increasing NO levels (by any method) will tone down an immune response. The local control can still override any global toning down. Getting all lovey-dovey with his daughter does increase her NO levels because he is activating her lovey-dovey pathways too. Increasing NO levels is the mechanism behind the placebo effect.

I suspect that the compulsion for a father to be transparently lovey-dovey with his young daughter may have other evolutionary roots too. Children use their opposite gender parent as their archetypal conceptualization of future mates. There are advantages to being attracted to a mate that is transparently lovey-dovey (as opposed to being deceptive and manipulative or abusive). I think that is the card-playing trade-off; be transparent or be deceptive and manipulative. There is even a name for people who are deceptive and manipulative in relationships, they are called “players”.

It is one’s feelings that are most easily manipulated (not facts and logic), and those feelings are most easily manipulated when one is in a lovey-dovey state. To think clearly and logically, and not be swayed by emotion, one must not be in a lovey-dovey state. One must dissociate from one’s feelings so that those feelings do not interfere with the accurate remembering of facts and the accurate manipulation of those facts to reach conclusions such as is necessary for diagnosis and treatment. Once one learns how to dissociate, it becomes easier the next time. I suspect that some of the traditional training of MDs, the tortuously long hours, is in part to induce dissociation so that the med student can learn how to dissociate in the future.

I remember an analogous experience when I played football in high school. In one game I happened to be on every single team, offence, defense, kickoff, kickoff return, punt and punt return. I never left the field until the end of the game. I was completely exhausted. But by playing when one is exhausted one is forced to not waste effort and motion, and one learns how to be much more efficient in accomplishing what one needs to do. Once one learns how to invoke that state, it can be invoked as needed.

In contrast, quacks and CAM providers generate therapeutic effects by invoking the placebo effect. This is best invoked by being in a lovey-dovey state oneself and inducing it in the patient. A CAM provider will produce a better placebo in a lovey-dovey state than can a SBM provider while in an analytic scientific state. If you want the best placebos, get them from quacks and CAM providers. If you want SBM or EBM, get it from providers who know facts and can think logically. Keep your lovey-dovey relationships in their proper place. Psychotherapy is a place where lovey-dovey relationships can occur, but there are special safeguards to protect both parties in those cases.
#21 antipodean
June 2, 2009

A good physician needs both a heart and a brain.

When practicing medicine she needs to remember to use both of them at once.

PAL is a clear example of just such a physician. I’d be glad to work with him.
#22 Jo Anne
June 2, 2009

Yes, good doctors need to have a heart and brain as well as an open mind wich clearly PALMD is lacking!! Feel sorry for those patients.
#23 antipodean
June 2, 2009

See PAL. It’s all your fault as you don’t have both a brain and a mind open enough that your brain would have fallen out long ago.

Apart from the problems of introducing mind-body dualism into the discussion lets think for a second.

Sometimes being a knowledgeable and compassionate physician means telling your patient things they don’t want to hear.
#24 daedalus2u
June 2, 2009

No! to both Jo Anne and antipodean. The ability to think emotionally and the ability to think logically are two extremes of the human spectrum of how to think. They interfere with each other.

Humans have limited brain capacity and cannot simultaneously use both capacities maximally. By time shifting a single brain can do both tasks but not simultaneously.

There is some pretty good research that the two extremes of the autism spectrum are autism/Asperger’s at one end and schizophrenia/psychosis on the other end. One has trouble understanding what people are communicating, one hears communication that no one has generated.

http://matthewckeller.com/Crespi.Badcock_BBS_2008.pdf

One has too strong a “theory of mind”, and projects their own feelings onto others, the other has trouble understanding feelings at all but can be a whiz at “simple” things like math, physics or medicine.

This results in different trade-offs of type 1 vs. type 2 errors, false negatives vs, false positives. PalMD’s “style” as a health care provider is to try an minimize false positives, to not treat conditions until he has a firm diagnosis based on tested protocols, and “by the book”. Other health care providers may go with their gut and pull stuff out of the air because they “feel” the chakras need alignment.

There is a gigantic difference between having an open mind and making stuff up. If you don’t have a very large background of facts and sufficient training and expertise to fit those facts together logically and coherently so they fit into a single picture of reality, you can’t tell when stuff is just made up. With a theory of reality you can tell when stuff doesn’t fit and so is unknown or even wrong. With a theory of mind all you can tell is if it does or if it doesn’t feel “truthy”.

The whole point of this clinical vignette was that PalMD recognized that he was a lousy doctor for his own daughter! He can’t practice what he considers to be good medicine on his own daughter because his feelings interfere!

It takes great expertise to recognize when one’s performance is unacceptably poor and to figure out the reasons why. I would much rather have a health care provider who knows his/her limits because I will be more confident that they will not try to exceed the limits of their expertise and screw up.
#25 antipodean
June 2, 2009

Good points Daedalus.

You will still find that the art and the science of medicine do require people to shift thinking. I don’t think as you seem to be indaicting that these are polar opposites on a single axis.

You may not be able to do both at once, as you claim. That’s why you need to stop and remember that you do in fact need both a ‘heart’ and a ‘brain’ to be a successful physician. Recognising when one has failed to do that, as PAL has done, indicates a measure of wisdom to me also.