White Coat Underground

My friend Janet has a piece up about what qualifies one to be a philosopher, a piece which is remarkably brief but says much. She points out that get a position at a university, there are certain requirements, but that one can be “off the books”. Anyone can call themselves a philosopher, and if enough of us assent to their claim, well, then they’re a philosopher, no matter how muddled their thinking may or may not be.

In medicine, we have a similar problem—the problem of assent. To become a primary care doctor (a category which includes internists and family physicians) the “official” training is rather rigorous—four years of university, four more of medical school, three or four years of post-graduate training. After that, one would be wise to take board exams and become “board certified”. Then, to practice, one must become licensed—that’s the easiest part of all.

But quacks have a big advantage here. Licensing is easy. If you’ve completed the basic requirements, you can practice, no matter how bad you are, no matter how much you fail to practice in a manner that most doctors would recognize as “competent”.

I’ve been made aware of a local “integrative medicine” practice that exemplifies this problem. They claim to treat all manner of ills. They claim to be “holistic”, treating the “whole patient” rather than…well, I’m not sure.

But they don’t even examine the patient. I’ve spoken to people who have dealt with them, and I’ve called them myself and they acknowledge that their practice (which is a cash practice) asks questions, recommends lab tests and treatments, but does not do a real physical exam. They refer out for that.

This is the height of hypocrisy. To claim to offer a better alternative to real medicine, and then fail to do the most basic thing, this should be criminal.

But it’s not. There is no insurance fraud—they don’t take insurance. The doctor is licensed, and will remain so unless a patient complains. And the patients will never complain. We have given our assent to these quacks—we have granted them the status of “physician” although they don’t merit it by any other standard.

It’s our fault, and we deserve the care we get.

Comments

#1 Russell
August 23, 2009

One of the major dimensions in which people vary with regard to their health is the degree to which they take matters into their own hands. I suspect these “integrative practitioners” are preying on those who fall on the side of wanting continual attention from health care professionals. (I likely err in the opposite direction. When a dog nipped me recently, I determined from its owner that it had had its shots, I knew that I had had a tetanus booster in the last few years, so I walked home and cleaned and dressed the small wound myself.)
#2 Whitecoat Tales
August 23, 2009

Ha! In July I had multiple patients present as “transfer of care” from chiropractors who had been acting as PCP’s. Reading their ‘documentation’ was depressing. My preceptor had me call one to see if they’d ever done any sort of a physical exam and the chiropractor said “nope just x-rays.”

It’s our fault, and we deserve the care we get.

I’m not sure I can agree there. People just don’t know. I’ve had so many patients talk to me with a very straight face about what their alt-med ‘practioner’ had told them their problem is. They’re shocked when I tell them things about evidence, or what education their alt-med practioner actually has. Public perception has so legitimized these things, and the average layperson just doesn’t have the background to know what they aren’t getting.
#3 Brodie209
August 23, 2009

I have a project for science class due on Moday. The project is to find an article about science to read to the class. I was wondering if I could maybe use this article to read to my class? Is that ok? I thought I should ask first. So do you think that would be ok?
#4 PalMD
August 23, 2009

@Brodie209

There’s no need to ask an author’s permission to read an article to a class. It’s ur funeral : )
#5 Kim
August 23, 2009

I wish I’d bookmarked it, but someone (I think KevinMD?) had posted a link to an article about how physical exams are becoming a lost art…presumably due to the need to get a patient in and out so quickly. It was actually a surprise to me to learn via the discussion that physical exams of adults even happen, other than examining a specific injury.
#6 D. C. Sessions
August 23, 2009

It was actually a surprise to me to learn via the discussion that physical exams of adults even happen, other than examining a specific injury.

Ah, here it is late summer again and it’s time to train another crop of ski patrol candidates (yes, this is relevant.)

One of the things we pound into them, and I do mean with the proverbial cluehammer, is to do a thorough physical examination on the hill. Never mind the cold, never mind the inevitable time pressure, never mind. DO IT!

Why? Because every year we have at least one, usually several, cases where someone’s initial complaint is a wrist or an arm. Basic protocol: field stabilization and transport. Except …

On doing a general exam, that “arm injury” turns out to also involve some very sore ribs on the right side. A deep breath discovers sharp pain in the lower-right chest. Abdominal palpation discovers tenderness and possible rigidity in the upper right quadrant.

Obviously the details vary year to year. It’s pretty common to find that the patient is disoriented, perhaps with uneven pupils. It’s pretty common to find that the patient has severe point tenderness in the cervical spine. Or the symptoms may be as above.

Is it serious? Don’t ask me — we almost never hear back. I do know that we can’t afford to ignore the possibility that it might be. And, yes, all of the above examples are from actual incidents.
#7 Tony P
August 23, 2009

I’ve noted something about M.D.’s that always seems a clear indicator if they’re any good at it.

If they’re a Jesus freak I steer far clear of them.
#8 Mu
August 24, 2009

You should have that tattooed on your chest, so the ER personnel knows to turn you over to the proper atheist intern to avoid offending your sensibilities, just in case the attending physician somewhere found a god in 20 years dealing with emergencies.
#9 rob
August 24, 2009

great. so you’re saying the “degree” i created in MS Paint using comic sans is no good?
#10 Eddie Vos
August 25, 2009

Peter, are YOU qualified to give nutritional advise? For some time now you chose not to answer my question here: http://scienceblogs.com/whitecoatunderground/2009/04/take_vitamins—its_magic.php on what base without evidence in support: “a typical American diet provides far in excess of what is needed. Far in excess of what you need??

Since you don’t want to correct or back-up that statement –that will cause harm in anyone believing you–, why not tell us what qualifies you to talk about micronutrients? How many years of the American Journal of Clinical Nutrition are on your book shelf? As you know, it’s one of the top 10 medical journals on the planet. On that blog I gave you some data about just one nutrient –needed for 16 known reactions– in which a typical diet may be low, and where genetic and drug impediments affect what “you” need.

Doctors who have typically less knowledge about nutrients than their secretaries [an old saying] and believe [like dogma] that a typical diet has “far in excess of what you need” for optimal health and that don’t consider ‘vitamins’ to be ‘magic’ cause whitecoat harm. Many doctors are great fixing things that are broken but they should stay out of the PREVENTION of diseases that have nutritional components since their education does not allow them to be qualified [think heart disease, diabetes, Alzheimer's and cancer].

About your current heart blog, did you know that MOST cells in the heart are NOT muscle cells but fibre building cells and that most of that fiber, collagen, is turns over (is replaced) in about 3-4 months, and that sufficient vitamin C, copper, B6 and another 3 B vitamins are needed to make ‘healthy’ x-linked collagen? The typical US diet is deficient in about all of the components to make optimal heart structure.
#11 Eddie Vos
August 25, 2009

Follow up about ‘typical American diet’ from today’s AHA’s scientific statement: In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans’ average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans’ diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients.
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.109.192627v1
#12 PalMD
August 25, 2009

You do realize that the next sentence starts “Although data are limited…”
#13 PalMD
August 25, 2009

Context:

The effects of excess intake of sugars on nutrient adequacy
are of concern. The association between added sugars and
micronutrient intakes were examined with data from
NHANES III. Although the trends were not consistent for all
age groups, reduced intakes of calcium, vitamin A, iron, and
zinc were observed with increasing intake of added sugars,
particularly at intake levels that exceeded 25% of energy.
Largely on the basis of these data, the Dietary Reference
Intakes report on macronutrients suggests that no more than
25% of energy should be consumed as added sugars104;
however, as discussed below, these recommendations were
not consistently supported by subsequent literature. More
importantly, the Dietary Reference Intakes approach to nutrient adequacy, based on the intake of selected individual nutrients, was subsequently superseded by an alternative construct, discretionary calories, which considers recommendations for all nutrients in the context of energy balance.

[...]

These authors concluded
that there was no clear evidence of micronutrient dilution or
of a threshold at which a quantitative
#14 Eddie Vos
August 25, 2009

Dear medical doctor PAL, you must have flunked reading. There were 3 questions that you chose to divert by suggesting the evidence is not conclusive and selecting some convoluted out of context cut and paste above while you earlier asked me if I even knew folate was added to some US food stuffs. Average [i.e typical] US diets contain 22 tea spoons [355 kcal/d] of added white sugar and are you suggesting that despite of that we get an EXCESS of all the micronutrients we need.

I asked you for Evidence on which you Base your Medicine stating that “a typical American diet provides far in excess of what is needed.”

I asked you how many years of issues of AJCN you have on your self .. or, alternatively, have you ever read a copy of that important journal. Not reading the journal regularly makes one miss the essence of clinical nutrition.

The question to you also was what makes you (or any typical other regular MD) expert about micro-nutrient intakes for optimal health?

You can argue with the AHA or the significance of the 3 NHANES’s but if indeed the data would be limited [it is not], that would not support your bold statement of a a far excess of micronutrients in typical US diets.
#15 MonkeyPox
August 25, 2009

So, how many threads you gonna hijack you stoopid twit of a troll?
#16 Eddie Vos
August 26, 2009

All I ask for is an explanation by Dr. PAL for his non science supported statement that will harm people from sub-optimal micronutrient intakes who believing him. So far, he has not taken responsibility for that opinion.

People that deal with science calling others “stoopid twit of a troll” should be prevented posting on self respecting blogs.
#17 MonkeyPox
August 26, 2009

I’ve got an idea—rather than making demands, why don’t you cite actual evidence for your unfounded assertion? So far you’ve cited an article whose conclusions didn’t support your hypothesis…idiot.
#18 Eddie Vos
August 26, 2009

I am not communicating with someone calling me an idiot and other such names while hiding behind a fake name. Rather than posting 2x on this blog and once on another just today calling others stupid, try contributing some science instead and do so under your real name if you want to be taken seriously.

This has NOTHING to do with MY assertions, it’s the medical assertions of internist Dr. PAL that need support.
#19 terrifiedtabetic
August 26, 2009

Dude, I’m no scientist, but you come around here, throwing out charges about stupid shit you don’t seem to understand, you’re gonna get skool’d. Srsly, you mentioned one paper, and apparently it doesn’t support ur assertion that this nation of fatties is deficient in anything. So instead of being an annoying asswipe, why don’t you actually show what data ur working from, eh?

Oh, and I can’t be sure with teh intertubes and all, but i’m pretty sure you smell like old socks. Try showering.
#20 MonkeyPox
August 26, 2009

It’s worse than you think, t. That dude is a THINCS.

And guess what…he’s an engineer! LOLOLOLOL
#21 Eddie Vos
August 26, 2009

With 20 references regarding nutrition, statins and heart disease on Medline, at least the Journals take my writings seriously. I can’t help those who bravely but anonymously insult the person with toilet talk.
#22 terrifiedtabetic
August 26, 2009

HAHAHAHAHA!

An argument from authority???? Based on some stupid ass letters???

Sane people: “support your claim with evidence”
Eddie: “No! Respect my nutsack!!!”
#23 PalMD
August 26, 2009

Whoa.

Let me remind folks that I only rarely censor comments, so comment at your own risk.

Remember, the internet’s a rough place…wear a helmet.
#24 Eddie Vos
August 26, 2009

Why should I want to wear a helmet talking medicine or science? Clearly, a moderator can censor for personal insults, personal attacks and trash talk. Look at the BMJ criteria for posting. All it takes is the moderator / blog master putting rules: “removed for inappropriate slander and/or gutter talk.” Any of the words in what was said by Terrified or Monkey is cause for removal. Not only that, you’ve got their email addresses to warn and then block but that’s probably of little use in these to cases. Best, E.
#25 PalMD
August 26, 2009

Perhaps the “internets” are a new thing for you, Eddie. Really, invest in a good helmet.

If your going to toss unfounded assertions around, folks are gonna come after you, and if you ignore them, they’re going to up the rhetoric.

Shit happens…and usually because it’s provoked.
#26 Isis the Scientist
August 26, 2009

About your current heart blog, did you know that MOST cells in the heart are NOT muscle cells but fibre building cells and that most of that fiber, collagen, is turns over (is replaced) in about 3-4 months, and that sufficient vitamin C, copper, B6 and another 3 B vitamins are needed to make ‘healthy’ x-linked collagen? The typical US diet is deficient in about all of the components to make optimal heart structure.

HA HA HA!

You’ve got yourself quite the nutter here, Pal. I’m going to go and rest. I fear my heart may fall apart from lack of “fibre”-type tissue. What my heart REALLY needs is more collagen!
#27 PalMD
August 26, 2009

Well, you know…engineers..structure…yada yada yada.

Dude still hasn’t cited any evidence about vitamin deficiencies, just a “Respect mah authoriteh! Prove me wrong!!”
#28 Eddie Vos
August 27, 2009

You won, I’m gone. I’m not up to the likes of Monkey and Terrified and yourselves that chose not to take responsibility for their statements. I have better things to do than to revisit this blog and get insulted by the anonymous. Have a happy life and hopefully you’ll clean up the site in the company of like minded souls. E.V.
#29 Eddie Vos
August 27, 2009

To Isis and only since the page is still open: type in ” myofibroblast heart ” on Medline but you probably know all that already. Signed, HAHA nutter.
#30 PalMD
August 27, 2009

I thought you were “leaving and never coming back”. Wha happen??
#31 Cashmoney
August 27, 2009

Dear DrPal, thanks for “cleaning up the site” by getting rid of the selfimportant nutters like Vos
#32 antipodean
August 27, 2009

Eddie seem to be a spectacularly successful letter writer. No actual scientific output. Just a lot of letters to every medical journal in the world. As he says, about 20 of these have slipped through and been published.
#33 rini6
August 29, 2009

The fact that the “complementary” practice that you mention doesn’t examine patients is actually hilarious (or sad.)

Isn’t the idea of treating the “whole” person predicated on actually examining said person??? I do not want to overgeneralize, but there are some alternative practices out there that actually do not head the basic premises upon which much alternative/holistic medicine thought is based. They prescribe pills for every problem. They order technical and expensive tests and the are completely impersonal. The difference between these practitioners and allopathic physicians? Nothing that they do is based on any sort of placebo controlled study.