And now for something completely different.
Yes, it's about time for that, isn't it? I've probably beat the Tribeca Film Festival story into the ground, even for me, having spent the last week blogging about it. Scratch that. There's no "probably" about it.
I frequently write at length about the quackery that is homeopathy. One reason I do this is because it is one of the most perfect forms fo quackery there is. There is about as close to no chance that it could work as there can be, and the only reason I don't call homeopathy completely impossible is because I have a hard time calling anything completely impossible. However, it's about as close to impossible as one can imagine, as, for homeopathy to work, multiple well-established laws of physics and chemistry would have to be not just wrong, but spectacularly wrong. Moreover, homeopathy is based on two principles that have zero basis in science. The first is the so-called law of similars, which states that to relieve a symptom you use a substance that causes the symptom in healthy volunteers. No basis in science and medicine. The second is the law of infinitesimals, which states that diluting a remedy (with vigorous shaking between serial dilutions, a process that homeopaths call "succussion", to "potentize" it) makes it stronger. Of course, it's more common than not that homeopaths dilute their remedies far more than Avogadro's number, such that it is incredibly unlikely that there is even a single molecule of remedy left, barring carry over from serial dilutions. Basically, most homeopathic remedies are water or ethanol, depending on what was used to dilute them. Actually, many of them are not even that, because the final dilution is often pressed into sugar pills. Homeopathy is, as I said, the perfect quackery. It can't work, and it doesn't work.
Over the many years that I've been writing about homeopathy and other alternative medicine, one question that's come to mind on many occasions is simple: How on earth can a physician come to believe that something that is this obviously quackery and this obviously doesn't work actually does work? Naturopaths, I can understand. They are steeped in a world view that is part prescientific and part pseudoscientific. Homeopathy is part of their training—a major part. They have to know homeopathy to pass the NPLEX, the naturopathic licensing examination. Physicians, on the other hand, are trained in evidence- and science-based medicine, or at least they should be.
So it was with interest that I read Edzard Ernst's post on The Making of a Homeopath. Part autobiographical, given Ernst's experience before he became a skeptic of alternative medicine, part fictional, the story helps to explain why someone trained in medicine could fall for the pure pseudoscience that is homeopathy.
The story begins:
After he had finished medical school, our young and enthusiastic doctor wanted nothing more than to help and assist needy patients. A chain of coincidences made him take a post in a homeopathic hospital where he worked as a junior clinician alongside 10 experienced homeopaths. What he saw impressed him: despite of what he had learnt at med school, homeopathy seemed to work quite well: patients with all sorts of symptoms improved. This was not his or anybody else’s imagination, it was an undeniable fact.
This is why placebo controls are so important for any treatment designed to relieve symptoms. Basically, any treatment or intervention, effective or not, will produce an apparent improvement in symptoms due to placebo effects. That's why personal clinical experience can be so misleading, something many physicians have a hard time accepting. Ernst then explains how this can happen, using the example of an otherwise healthy young woman suffering from infertility:
Our young physician was not convinced that he could help his patient but, in the end, he was persuaded to give it a try. As he had been taught by his fellow homeopaths, he conducted a full homeopathic history to find the optimal remedy for his patient, gave her an individualised prescription and explained that any effect might take a while. The patient was delighted that someone had given her so much time, felt well-cared for by her homeopaths, and seemed full of optimism.
Months passed and she returned for several further consultations. But sadly she failed to become pregnant. About a year later, when everyone involved had all but given up hope, her periods stopped and the test confirmed: she was expecting!
Everyone was surprised, not least our doctor. This outcome, he reasoned, could not possibly be due to placebo, or the good therapeutic relationship he had been able to establish with his patient. Perhaps it was just a coincidence?
There's no "perhaps" about it. It was very likely coincidence, particularly given that it was a year later that the woman finally became pregnant. However, news of this anecdote provided by this seeming success of homeopathy spread, leading the young doctor to see several other young women with fertility problems, ten to be precise. The results were as follows:
The doctor thus treated several infertile women, about 10, during the next months. Amazingly most of them got pregnant within a year or so. The doctor was baffled, such a series of pregnancies could not be a coincidence, he reasoned.
Naturally, the cases that were talked about were the women who had become pregnant. And naturally, these were the patients our doctor liked to remember. Slowly he became convinced that he was indeed able to treat infertility homeopathically – so much so that he published a case series in a homeopathic journal about his successes.
In a way, he had hoped that, perhaps, someone would challenge him and explain where he had gone wrong. But the article was greeted nationally with much applause by his fellow homeopaths, and he was even invited to speak at several conferences. In short, within a few years, he made himself a name for his ability to help infertile women.
One more time: Personal clinical experience can be very misleading. It's not just how anecdotes can make it seem as though ineffective treatments "work." It's also how good such anecdotes make physicians feel. Think about it. Why do people go into medicine? One reason that it is profoundly rewarding to help patients. Being able to help a fellow human being overcome an illness, to relieve suffering, to cure a disease, all of these things make a doctor feel very, very good. Helping our fellow human beings is a powerful reward. I've felt it myself after a particularly difficult operation to remove a breast cancer. Saving lives and removing suffering, it's what we as physicians are about. Homeopathy can make it seem as though that's what we are doing is the same. When there are no controls, we can easily confuse regression to the mean or the normal clinical course of, say, infertility with an actual therapeutic effect.
Ernst schools us on why:
But there are other, even simpler and much more plausible explanations for our doctor’s apparent success rate: otherwise healthy women who don’t get pregnant within months of trying do very often succeed eventually, even without any treatment whatsoever. Our doctor struck lucky when this happened a few times after the first patient had consulted him. Had he prescribed non-homeopathic placebos, his success rate would have been exactly the same.
As a clinician, it is all too easy and extremely tempting not to adequately rationalise such ‘success’. If the ‘success’ then happens repeatedly, one can be in danger of becoming deluded, and then one almost automatically ‘forgets’ one’s failures. Over time, this confirmation bias will create an entirely false impression and often even a deeply felt conviction.
I am sure that this sort of thing happens often, very often. And it happens not just to homeopaths. It happens to all types of quacks. And, I am afraid, it also happens to many conventional doctors.
This is how ineffective treatments survive for often very long periods. This is how blood-letting survived for centuries. This is how millions of patients get harmed following the advice of their trusted physicians to employ a useless or even dangerous therapy.
I would go even further than this. It happens to all doctors at one time or another. In particular, it happens to surgeons. We tend to remember the good outcomes and forget the bad. It's not that we do this intentionally. It's just that confirmation bias is part of human nature. It's how our brains are wired, every bit as much as how we tend to confuse correlation with causation. While it's true that correlation can often indicate causation, more often it does not. In fact, if there's one thing that Ernst doesn't emphasize enough, it's just how much this happens not just to quacks, but to doctors who like to think of themselves as science- and evidence-based.
It's a two-way street. Both the doctor and the patient get something out of alternative medicine, particularly in the case of chronic disease or chronic symptoms for which conventional medicine doesn't have a treatment that does what the patient wants and completely eliminates his symptoms. The patient derives hope and seeming temporary relief due to placebo effects. In addition, because so many alternative medicine modalities practically require "personalization" or, more specifically, for the practitioner providing treatment to pay more attention to the patient, the patient also gets a human ear to listen to him.
But what does the doctor get out of this? First of all, he gets something he can offer patients other than the unsatisfying options that conventional medicine provides him. For patients with, for instance, chronic pain this is a fantastic thing, as patients will tell him they feel better even in the case of using homeopathic remedies due to placebo effects and regression to the mean. Also, as Ernst points out, even in the case of "hard" endpoints like a successful pregnancy after treatment for infertility, there are a lot of conditions that improve on their own a lot more frequently than people tend to believe. Another perceived reward doctors receive for using alternative medicine comes from how medicine is practiced today. Today, everything is about productivity, about RVUs. In primary care, doctors seldom have the time to be complete doctors of the old-fashioned variety who can spend time with their patients because it's not financially viable to do so. Alternative medicine allows a way out, and, because it's not reimbursed by insurance, physicians can charge whatever the market will bear to prescribe it.
Ernst is quite correct to conclude, as he does, that "health care professionals need to systematically learn critical thinking early on in their education." However, in the US at least, medicine itself needs to change the features in it that reinforce the use of alternative medicine, such as the hamster wheel schedule that so many primary care doctors must adhere to in order to support themselves.
- Log in to post comments
More like this
Here is a (not at all serious) explanation, why people fall for alternative medicine.
Over here in the UK, rumour has it that GPs have about 7 minutes on average for regular appointments. The other side of free of charge is that the service tends to get rationed like this.
If someone with an annoying but not serious condition visits a wizard instead of a GP, talks about the problem for 20 minutes, gets 20 minutes of attention and a personal guarantee that this particular mix of xyz is helping, they might just forget about the times they are hurting and remember those occasions they feel better.
Trouble is if the wizard is not prepared/interested in escalating more serious issues to a proper doctor and just keeps selling xyz..
Desperate people do desperate things, and once in a while, one of the desperate things they do seems to work.
Homeopathy is one of the desperate things some of these people try. Many of Orac's other regular blog topics involve other desperate things that desperate people try. What sets homeopathy apart from these other things is that any reasonably intelligent layman should know that homeopathy cannot work--Avogadro's number is something they teach in high school chemistry classes. That's unlike most other forms of woo, where you need to have a background in medicine to understand why the alleged treatment won't work.
Treatment of infertility is an especially tricky business. I have heard anecdotal reports of couples who, after months or even years of infertility treatments, give up and decide to adopt a child--and shortly thereafter, she becomes pregnant.
I have heard anecdotal reports of couples who, after months or even years of infertility treatments, give up and decide to adopt a child–and shortly thereafter, she becomes pregnant.
This is a really good examply of the post’s thesis. This happens occassionally, but that’s why it gets talked about. It is not the rule, by any means. It happened to an aunt of mine, and our whole family went around for years blabbing about it and assumming it was absolutely true that if you attempt to adopt after years of infertility, you will get pregnant. We totallly ignored all the childless people who had tried this and not succeeded, of course.
Vodka Diet Guru, #2:
"Over here in the UK, rumour has it that GPs have about 7 minutes on average for regular appointments. The other side of free of charge is that the service tends to get rationed like this."
The fee-for-service model in the United States results in average appointment durations with general practitioners which are even shorter than that, somewhere closer to 5 minutes. Patient load is still high, but GP's are further encouraged to rush patients out the door in order to bill more visits per day.
And I'm not trying to imply that GP's are greedy for those big insurance bucks -- reimbursement rates from both public (Medicare/Medicaid) and private insurers drop lower and lower every year, forcing most practitioners to join major hospital networks just to keep their doors open.
Why not go to a quack who faces far fewer expensive regulatory requirements (if any at all), can use whatever bogus diagnostic criteria he/she wishes, dispense useless snake oil (or water) directly out of his/her office at a huge markup, and spend far more time (with much lower overhead costs) grifting patients out of their cash, perhaps at an hourly rate?
So much better and more caring than those money-grubbing "allopathic" doctors who just want to rush you in and out of the office to get that sweet (read: horribly low, oftentimes below break-even) insurance payment.
Well, when your state government has a "board of homeopathic and integrated medicine" ( http://www.azhomeopathbd.az.gov/ ), it's pretty damn depressing to try and convince parents that the homeopathic teething tablets they just spent $10 on at the local pharmacy are junk. This may just be my increasingly sour demeanor, but I feel I'm getting more comments from parents about taking their kids to the chiropractors, homeopaths and naturopaths then ever before. I've got all the accountability, and they have all the time and easy profits. There is a strong feeling of burnout right now.
Dr. Hickie,
Watch the hell out for burnout. I don't wish that to you because I've been on burnout in the distant past and was on the verge of one very lately. An ex-colleague of mine told me that my mental health was more important compared to any jobs and I do agree but it may be more difficult to solve the situation considering the particular job that you have.
Alain
I have heard this as well, but am also pushed (by the same person, in large part) to perform well as a graduate student.
It is an interesting dilemma; how to protect one's mental health in graduate school when so many of one's mental health problems seem to be symptoms of being in graduate school. (That, at least, is what I gather from my relationships with other grad students.)
The doctor thus treated several infertile women, about 10, during the next months. Amazingly most of them got pregnant within a year or so. The doctor was baffled, such a series of pregnancies could not be a coincidence, he reasoned.
Naturally, the cases that were talked about were the women who had become pregnant. And naturally, these were the patients our doctor liked to remember. Slowly he became convinced that he was indeed able to treat infertility homeopathically – so much so that he published a case series in a homeopathic journal about his successes.
In a way, he had hoped that, perhaps, someone would challenge him and explain where he had gone wrong. But the article was greeted nationally with much applause by his fellow homeopaths, and he was even invited to speak at several conferences. In short, within a few years, he made himself a name for his ability to help infertile women.
No mention of examining or treating male factor, huh? Why is that, when MFI is responsible for around a third of all infertility?
Also: http://humrep.oxfordjournals.org/content/18/9/1959.full The majority of women conceive within 6 cycles of well timed sex. 92% are pregnant after 12 months.
Bravo, brave homeopath.
I HATE these quacks who prey on/exploit those who are truly desperate to have a child. You have NO idea.
Almost forgot...
Happy National Doctors' Day, Orac!
It is an interesting dilemma; how to protect one’s mental health in graduate school when so many of one’s mental health problems seem to be symptoms of being in graduate school. (That, at least, is what I gather from my relationships with other grad students.)
Can't easily change the system and that impose an additional cognitive workload. My basic answer to this (and it's very basic) is figure out what I can change and what do I have to accept as it is. Second, I work on myself to accept the thing that I can't change or sidestep while, in the absence of management, I decide how I can change things or situation for the better of my health (mental or otherwise). After that process, I take it up with the person involved (if a person is involved) and finally, I call for backup from higher up or move out.
Make it difficult to hold a job for any length but then, that's the basic process of keeping my sanity intact or as close to. Give me more leadership and more power, I can solve more problems and/or issues.
Alain
Chris Hickie says (#6),
...I feel I’m getting more comments from parents about taking their kids to the chiropractors, homeopaths and naturopaths then ever before.
MJD says,
I'm not saying anything about your practice Dr. Hickie but technologies (e.g., automation) may be dehumanizing medicine to such an extent that some parents will embrace the alternative.
As an example, here's a pharmaceutical virtual tour that is free of the most important element in medicine - people.
https://www.youtube.com/watch?v=SHJWfLl9p8w
@ Med-Health Pharma facility,
Enhance the human experience by allowing people to earn a good salary for dispensing your product line and discard the automation when applicable.
@ JP:
You may be right because graduate school involves a great investment of time, sacrifice of other goals and relationships ( sometimes) and a great deal of uncertainty concerning the eventual outcome.
A prof of mine who studied depression, social cognition and attribution ( amongst other topics) would ask- "Are you sure you really want this?" because it was so risky especially in faltering economies and with changing occupational outlooks.
HOWEVER you always have what you learned and in the future, you may find it useful in ways you cannot possibly fathom right now. also you learned how to persist in making an effort despite impediments.
I have found this to be true hundreds of times.
In your case, being a professor or writer are only two options amongst many because you have studied languages that are important in both international affairs and commerce. Not many people are experts in these tongues as well in the English speaking world.
I know a young Chinese man who studied English to become a lawyer but wound up being a translator for corporations and he really loves it.
I think the main reason some docs embrace quackery is a psychological need to feel superior and more enlightened than their peers. This is why the uniting philosophy they embrace is one of opposition- they reject natural treatments like vitamin K as long as mainstream medicine embraces it.
They can pat themselves on the back themselves on the back for being "open minded" while simultaneously rarely having any responsibility for treating patients. This is why there are no "holistic" ICU doctors or neurosurgeons. You will never find a functional medicine doctor in the hospital on the nights and weekends- if you find them there at all.
They cater to the richest 1%, peddling their books, and supplements, all to serve their need to feel special.
Although I think that the wealthiest people do pay for woo-fraught doctors et al I think that a great part of their audience is the middle class who can't afford to waste money on nonsense. Their sales tactics were especially despicable during the Great Recession.
Often anti-vax mothers complain how expensive the autism protocols/ supplements/ special diets are. TMR actually has a charity- Team TMR- to help parents pay for woo-ful treatments.
Unfortunately, I also know of a woo-meister who targets minority groups through their religious establishments.
Yeah, I kind of wish people had been more upfront about that at the beginning, but at the same time, with a degree in liberal arts, it was pretty much a choice between grad school and crappy jobs all through my twenties, and at least grad school is interesting.
At this point I've invested so much time and energy that I might as well finish and at least get the letters behind my name.
My buddy Vlad did score a tenure track position in Austin, so yay, go team!, etc.
OP at #1
Why did I not know of these before? You have just provided me hours of lunchtime entertainment. I thank you, from the bottom of my skeptical heart.
@janet
I know BAHFest! from reading SMBC, whose author (Zack Wienersmith) is one of its initiators.
I've kept coming across a Pamela Wible, MD, regarding physician burnout and suicide. Now one would, think that this is good as the suicide rate for physicians is well above the average. Indeed, a few years ago Dr. Wible was getting good press regarding her thoughts on physician burnout and suicide, but now her pitch seems to be we should start cash-only practices and push whatever woo works (http://www.idealmedicalcare.org/blog/create-your-ideal-clinic-dr-wible-… ) , and oh, take my course for only $2500 (https://beahappydoctor.com/sales ).
I think she's found a niche capitalizing on burned out physicians that leads them to the woo.
"I frequently write at length about the quackery that is homeopathy. One reason I do this is because it is one of the most perfect forms fo quackery there is."
Maybe you haven't seen this yet:
http://www.quantummansite.com/catalog/
@ TroubleMaker
Oh, Orac's seen QuantunMAN. The blinking box has the most refined woo-sensor algorithms known to Man or Astroman. In fact, I wouldn't be surprised if there's some quantum magic involved in the circuitry. Lest ye be scolded by the host for not using the search field: Try this from 2013: http://tinyurl.com/jqhwkrx
I think she’s found a niche capitalizing on burned out physicians that leads them to the woo.
Yeah...she look to me that she want to solve the problem by herself and got too far for her sanity which is a management problem. Possible recommendation for my statement is go as far as she can using SBM and get backup where needed: https://www.ncbi.nlm.nih.gov/pubmed/26529871 (this article touch this).
Alain
Meant this one instead: https://www.ncbi.nlm.nih.gov/pubmed/26529870 and yes, I got a package in the mail from them: http://www.physicianleaders.org/news/journals/plj
Alain
My first alternative physician hire had turned to complementary - alternative medicine because he had had diabetes and cancer, not doing well with conventional medical practices.
He changed his practice after success with that.
My mother’s doctor found a small growth somewhere inside her chest (or abdomen, I can’t recall where, and don’t know the exact details) and wanted her to come back in a month to see if it had grown. On her return visit, my mother became worried because the doctor was bringing in other doctors to look at the latest results. To her relief, the growth seemed to have disappeared on its own. My mother happened to mention this to her chiropractor. His response: “Can I use your story in an article I’m writing and let people know how chiropractic adjustments removed this growth?”
She hasn’t returned to him since. (to my relief!)
@ sadmar
Yeah, thanks. I figured he probably had (although I didn't realize it had been around that long). I was really just making a joke since, as crazy as homeopathy is, this QuantumMAN stuff seems like pretty much the platonic ideal of absolute woo.
The woo practices for infertility are many and varied. They know a good audience when they see one. Having fallen for them myself I will tell you, when you are desperate to have a child you will do most anything. I hated the advice I got. I don't know how many versions of the 'if you just stop trying you'll get pregnant! it worked for my sister/cousin/friend" I was subjected to. Or eat this, or exercise more, or see this practitioner, or take these supplements, or even well you need to have sex this way. Some people went way into the TMI zone. It wasn't until I stopped all the nonsense and went to a real fertility specialist that I got pregnant. And then it took the better part of a year. Yes, in general if you have no major problems most women will be pregnant within a year. If you have problems (in my case anovulation) or male factor infertility then skip straight to the specialist. That's what I tell everyone now. If you've been trying to a year, skip to a specialist. He'll do the same workup as your OB, but he'll know what to do with it. And the first thing he will test is your male partner. That might solve your problem right there.
Troublemaker:
Mentioned in a recent thread.
http://scienceblogs.com/insolence/2016/03/18/truthkings-not-so-truthful…
QuantumMAN!
Why am I suddenly thinking of Scott Bakula?
"Today, everything is about productivity, about RVUs. In primary care, doctors seldom have the time to be complete doctors of the old-fashioned variety who can spend time with their patients because it’s not financially viable to do so."
I don't want to belittle the difficulties of balancing patient care and maintaining a viable practice (i.e. generating revenue). Lord knows it's hard enough to do as a surgical specialist, let alone as a PCP, but I don't think we need to accept this idea as fact. The reality is that it does not usually take more than a few minutes to formulate a plan for a patient based on his or her given presentation. This is what I physicians are trained to do, and most docs are exceedingly efficient at this. The majority of the face-to-face time during the visit is dedicated to explaining to the patient the "why" of what we do, and to make sure to the patient feels "heard." This is an issue of patient expectation, no more, no less. Even though docs complain about decreased time spent with the patient, I haven't seen data to suggest that those same docs feel like they're rendering worse care (I'm sure there are surveys out there to this effect, but that's not the thrust of the issue, from what I've seen). I invite any doc to think back on how they were trained when they saw patients in clinic--residents presented the patient they just saw to the attending. The attending clarified pertinent details, and then formulated a plan in mere minutes (if that). Depending on the institution, the resident returned to the patient and explained the plan. The attending would come in to shake hands and confirm the plan, and then on to the next patient. No one was short-changed, and everyone was functioning to the "top of their license." This can be duplicated by using mid-level providers (i.e. PAs and NPs) to the same effect. The only obstacle would seem to be patient expectation. If there isn't enough face time with an MD, the tired refrain of "the doctor barely spent any time with me" is quickly heard. In my opinion, that's an issue of patient expectation rather than shortcomings in the system itself.
I have friends in primary care, internists and family practitioners, who would beg to differ.
@Orac
With which part?
QuantumMan needs a hecka big dose of EneMan: http://tinyurl.com/zx62tou
@Orac
And, FWIW, I have friends in primary care, internists, and family practitioners who would agree. So what?
There's a woomart in my city (TCM and acupuncture) that specialises in infertility and claims to have a 90+ success rate. Of course they recommend you start treatment before trying to conceive. And of course they support people using IVF etc. The sales and marketing info heavily implies that their treatments are evidence based and endorsed by actual fertility specialists. Tempted to report them to consumer affairs given that practitioner boards are worse than useless.
@ TroubleMaker:
Actually, I think Orac was the first person to uncover QuantumMAN, in a post even earlier than the one I linked.
QuantumMAN's may be a useful reference for discussing homeopathy, though rather than a platonic ideal of woo, it's more hyper-woo. Nobody knows what to make of it. But for the fact the site has a functioning PayPal link where people can pay the listed prices for the remedies, it would be indistinguishable from a Landover Baptist-type parody site. Even with the active PayPal known, and the operators IDed as veteran scammers who relocated to Hawaii after being chased out of Florida and Utah, some folks still think it has to be a joke.
A thread about QuantumMAN on reddit includes this hypothesis:
In short, the more ridiculously funny, the more efficient the algorithm for separating rubes from their money. Just a hypotheis, min d you, but the thought kinda puts a damper on the quantum-powered comedy that I doubt even the best writers for The Onion could generate. "Heaven's Gate™ (Aphrodisiac) -Your quantum rocket to sexual bliss!." "Tiger Tail™ Male Stimulant; supercharges your male G-Spot while reversing autoimmunities to your prostate!" complete with photos purported to be dripping ejaculate. Quantum Chiropratic, available for cats via the QuantumVET™ Tricorder Plus.
[Factoid: QuantumMAN's creators previously ran The Hydroceutical Corporation, which trademarked the phrase "A quantum incubator form miracles," for use branding "over the counter health care products derived from water programmed or 'encoded' with information." So QuantumMAN is homeopathy without water beamed from outer space.]
But seriously, I'm wondering what we can learn about the appeals of 'mainstream' homeopathy by comparison to QuantumMAN. I don't have any formulated thoughts about this, just a vague open question. For example, how did we get to a place where makers of zinc lozenges – which definitlely have something in them, however worthless – employ the rubric of 'homeopathy' to market them, when classic homeopathy has nothing in it, especially when the retail pharmacies are full of other products with worthless ingredients presented as not-homeopathic? Classic homeopathy claims to have ingredients, and has established an elaborate labeling ruse to appear more-than-water, but when you dig below the surface you get the acknowledgement that it's water-memory-of-energy – i.e. QuantumMAN w/o the entertainment value of the computer graphic display of the theatrical download/upload routine. ???
@ Chris H. #33
I actually have an EneMan. The photo you linked shows the color as a nice pale blue, but mine is more a yucky dusty aquamarine.
Yes, it was again Orac who brought Eneman to the attention of the larger world back in 2004. [http://tinyurl.com/j3x4bqe] At the time, he had an EneMan clock, EneMan calendars, and EneMan tree ornaments.
My envy knows no bounds...
I still have the clock and EneMan Christmas tree decorations lying around my office at work. I think. Now you make me wonder if I still have the clock. Dammit. I'm going to have to go and look when I get to work tomorrow morning.
Ahhh...EneMan and Hitler Zombie posts. Those were a lot of fun to read. But realizing that I do remember those posts shows how long I've been reading RI....
Orac and Sadmar--I do have an EneMan as well (via ebay, alas never got one as drug rep swag)--I just couldn't get a good picture of him with my phone. I have never seen the clock--does it always "run fast"?
Back to the topic at hand: "Paleo Cardiologist"/quack/anti-vaccine loon Jack Wolfson gives a fairly detailed telling of his departure from allopathic medicine in the paleo cardiologist book. Between his father (a physician) dying (with Wolfson blaming modern medicine in part for his death), dissatisfaction with the cardiology group he was with (not clear if it was a competency or productivity issue) and somehow falling in love with one of the most vicious, uncaring chiropractors I have even seen--he went full woo. I find it hard to believe he wasn't doing well financially before he went to the dork side. However, I do know physicians who become embittered when they work for a group and then (after 3-7 years) are told to either "buy in" as a partner (often at a substantial cost) or leave the group. It's the private practice equivalent of tenure in some ways, though with more of a financial shakedown.
And Chim (#30 and #34)--there are lots of studies you can find online showing levels of physician burnout are at record levels. Many physicians are retiring as soon as they feel it is financially viable. Also (and to me this is the most telling of all) a company named SEAK which markets non-clinical career to physicians has grown immensely in the last decade. I remember in the early 2000's getting their mailing and it was a tri-fold brochure about the 1-2 seminars a year for doctors seaking non-clinical careers. Now their mailing is many pages thick (it's like a community college catalog) with many seminars in many places each year. SEAK wouldn't be doing so well if there weren't physicians looking to escape the worsening grind of what surrounds trying to provide good patient care.
Dr. Hickie,
I also think about the learning curve (MBA, change management skills and probably epidemiology too) needed to effect some changes in the current health care structure by applying for an appropriate position needed to make those changes.
No wonder physicians are burning out. IMO, it's an occupational health hazard...
Alain
@CH #40
I don't disagree with your concerns over physician burnout and the increasing difficulties of providing quality care as perceived by physicians. I certainly see it around me quite a bit. I do, however, take exception to the idea that it's all about productivity and RVUs, and that more time with the patient is the cure. I also admittedly chafe at the idea that spending more time with the patient is the only way to be a "comprehensive" physician. I just think this is a commonly used trope: docs just want more time with their patients, and if we can just go back to the way things used to be, all would be well. Admittedly, I'm reading a lot into a few lines of text from the original post, but the reliance on the trope of "things were better back then" in this instance is becoming a pet peeve of mine. My comment was a bit of venting on my part, and a long-winded description of an alternative option to "doc spends more time with patient," the point of which was ultimately that patient expectation has to change too, especially as we try to find ways of providing quality care at lower costs. Certainly, not all docs will feel this is what they signed up for, and that time with the patient is what they do want more of, but the days of seeing a few patients a day and spending all the time they need with them are over. We all (patients and docs) need to adapt. You can't have us see fewer patients (and be compensated for it) and still make sure everyone has access to care. There aren't enough docs to go around for this.
With the exception of comment #/19, I haven't seen so far, a comment addressed to me regarding physician burnout and patient expectations but I'll make my 0.02$ suggestion after asking a question:
Regarding patient education, is it common practice to have a qualified personnel (nurse, psycho-educator or social worker) educate patient on the proper monitoring of their health (especially in chronic disease cases), medication and lifestyle in hospital and clinics over the US of A?
Alain
I've never had this, but I go to University Health Services, which is free for students.
It all seems to fall upon my psychiatrist. He does, it seems, spend about as much time as he wants with patients, to the point where I've waited 20-30 minutes past my scheduled appointment time, but I don't mind too much.
I imagine the reimbursement situation might be different at UHS; probably one earns a salary, I imagine, or something similar. He only works there on Mondays, in any case, and works in Psychiatric Emergency Services the rest of the time, where one receives a lot of attention, I can tell you.
Thanks you very much JP,
That echo somewhat my experiences in psych services but here, it's far from the same in any other services, case in point:
Last Wednesday 23 of March, I was riding the city bus when it crashed into 3 cars. I was at the far back in the bus and didn't witness anything except me falling and injuring myself (whiplash + injured nose). Adrenaline kick-in so I feel not bad at first and I stay there for assistance to other peoples. Then the pain kick-in so I ask one of the cop for 1 minutes of attention for two questions (didn't witness anything, do they need me to take my declaration. Answer: nope. Second question was about my pain and he summoned two firefighter to take care of me and followup with the paramedics and then, the machine kick-in).
At the hospital, I get a quick look over (5 minutes max) from the ER physician and she order xrays for me. Given that my pain at the time was 4 over 10 in the spine (my headache was more troublesome at 7/10 but still manageable; ain't the first time at this pain threshold), I was a very obedient patient in a jungle of patient seriously in pain and crying. I could see with a lot of intensity that the ER physician was very anxious to the point of being frazzled (my impression, I could be wrong). Same with the clinical staff so when I had some demand, I made sure to profusely thanks everyone involved in my care and have as little demand as possible (two, the small canister to pee and when my spine pain hit 8 over 10 over the whole length but that was due to my immobilized neck). Had I could read the xrays, I would have done so to alleviate the ER doctor's workload. Turnaround time was very fast still for such a workload because 15 minutes after the xrays done, I was out of the hospital with the vetting of the ER doc. She and they all did an excellent job in my case and I need to remind myself to bring a Thanks you card for them.
Alain
@Alain: first, let me say that I hope you are doing well after the injuries. Whiplash can be very painful.
Second: it depends on the MD's office. I've had my doctors (in the US, in New Jersey) spend 15-20 minutes each visit - after the exam - going over the exam and asking questions, discussing lifestyle changes (i.e. keep not smoking, eat better, exercise more). I've also had them spend 5 minutes total. Some offices do use NPs, CNMs, etc to do additional counseling. It all varies, and I don't honestly think there is any common base to it.
OTOH, I've never been shy, since I became a nurse, to ask what I don't know. And, because I *am* a nurse, I don't need a lot of the information others might. I certainly can guess that with my current MD, if I wasn't a nurse, I would need more time with her or someone else who would discuss my exam, etc. (she's the 5 minutes in and out type0.
MI Dawn,
Key point is education. My psychiatrist trust me to research all the medication I take and he's very much the in-and-out type (some meeting barely lasted 15 minutes out of an allotted time of 30) despite taking care of me every 2 months (I'd extend that to 6 months if it was me).
Alain
Yeah, we were meeting about once a month when I was just trying to get over the depression from the summer, although when I first started seeing him we were meeting every week. Back to once every one or two weeks now, for the time being. Although I'll be flying out West to visit my family in the middle of the month for a few weeks; I imagine we'll just keep up via phone and email, he's very responsive.
Re: the ER: the first time I was in the hospital, I ended up there via the regular ER, where I was not having a very good time or being a very good patient; I was seriously freaked out. They were doing all kinds of EKGs and exams, and I was thrashing around and stuff so much that they had to put me in an updated version of a strait jacket (slightly less menacing).
Good time. /sarcasm
MI Dawn,
The ER doctor prescribed me some anti-inflammatory (sp?) painkillers but I didn't need them. Two Tylenol (out of 3 prescribed) was all I needed to be pain-free when I hit the 8/10 pain level (about 15 minutes before the xrays).
Alain
JP,
umm....straight jacket. I have yet to wear one but if I can spare it, I will :)
Alain
@Alain:
Well, it's one more life experience under the belt. I believe this intake method is referred to as "kicking and screaming."
Zoloft, it's a helluva drug. Who knew?
@Alain: actually, JP's spelling is correct for the US (though it's also commonly seen as one word: straitjacket). They are for use in dire straits. Your Canadian spelling may differ... :)
TBH, I only saw one used once in all my years of hospital nursing, and the patient was seriously scary. Took 6 big security guards to take her down, and she was a little bit of a thing (about 5' tall and maybe 100 lbs dripping wet). Of course, part of the reason it took 6 is that we didn't want to hurt her. Amazing what some illegal drugs will help someone do.
I'm 5' 4'', and I was about 100 kilos (lots of muscle) the last time I checked, but I've been losing weight again.
In all fairness (to myself), I was more-or-less meek as a lamb once I was quite thoroughly sedated. I had some weird dreams in that hospital bed, though, let me tell you.
Most excellent Dr. Hickie: 'Does the Eneman clock always run fast?' made my day. Thank you, Thank you. <3 <3
JP: Based on the experiences of every depressive I've ever met, the effects of any given anti-depressant (tolerance, side-effects, and mood-dive-limiting) vary widely from one individual to the next, despite the sometimes only minute chemical differences. Finding the 'right' med is often like the shrink throwing darts blindfolded in the general direction of a target until one Rx finally hits and sticks. Zoloft kept me out of the ER in '92, but ten years later, I couldn't res-start it without wanting to claw out of my own skin. I could take Wellbutrin OK, but it didn't staunch the depression. Celexa, same problem as the Zoloft. Finally got Lexapro, helped w/o hurting anything but the libido after a survivable adjustment period; still taking it. Which means nada for anyone else. Who knew what would be a helluva drug for you? Nobody, methinks. (And <3 <3 to you, too)
Alain #43: Short answer, "No." (and all sympathies for your injuries... take care of yourself, my friend...)
Because some physicians may have somewhat loose understanding of professional integrity and will embrace anything they can possibly sell to attract more clients. Quackery sells and they don't want to miss out on this extra income without having second thoughts that it actually undermines the medical profession and blurs the line between medicine and nonsense.
Dr. Chim: Docs (in general) do need to spend more time with patients than they're now allowed to do because they don't ask enough questions, don't listen, and too often miss crucial diagnoses as a result. The problem is decoding the patient's presentation, not knowing what to do about it. There's only so much of the diagnostic responsibility you can delegate to a PA or ARPN.
That said, the 'human side' of 'comprehensive care', while absolutely crucial, should not be dumped entirely or even primarily on physicians. If old-school PCPs used to do that, the reality is that nobody does it now. And you're absolutely right that someone other than an MD should be responsible: but I'll add it should be someone who's specifically trained for skill in patient interaction. That won't be cheap either, but it will be more efficient than having the doc do it. The only patient expectation that should change is that it's the doctor who has to do everything. What gets done shouldn't be an expectation but a demand.
And how, exactly, would you get 'patient expectations' on the nature of medical interactions to change? Wave your hand, and tell them "expect less". Like that's going to work? How much do you think it would cost to train the adult population of the U.S. to effectively monitor their own health, perform their own checks on the Rx they receive, and develop the knowledge, cognitive and psychological skills to interact effectively with physicians who treats their bodies like a car mechanic treats a Volkswagon?
It's blindered and false to say 'there aren't enough docs to make sure everyone has access to quality care." There isn't enough money – and like the number of docs, that's a social policy choice that can be changed, not a force of nature we just have to live with. Step back and look 'big picture'. Primary care in the U.S. is a clusterf*** because it's too driven by profit motive in the insurance companies and large medical groups. PCPs have been proletarianized, and like other labor sectors have long experienced, they've been subjected to forced speed-ups under Taylorist regimes. Read some labor history. Unless doctors organize, it's only going to get worse.
And back to economics, lets compare the costs of fixing the delivery system by returning the 'human element' – in any fashion – to the costs of not fixing it: over-burdened ERs, too many cases winding up with specialists, too much human time lost to preventable illness and recovery, or death... Oh yeah, and too many people turning to woo because the quacktitioners appear to give a sh!t...
The productivity pressures have crossed the line into absurdity. It is impossible to see the patient, do some education, enter the scripts into the puter, enter the note, return phone calls, fight through press 1 press 2 menus, review labs, write arguments on prior auth forms, complete disability forms, in the time allowed. No time is given for calling other MDs about shared patients. No time is given for trying to improve work flow issues.
The people who survive seem to be the ones who give patients Adderall and benzos without asking too many questions. Or the ones who radiate confidence and decisiveness.
The money saved by squeezing MD time goes into somebody's pocket. It is not going into building and maintaining a culture of wise patient care, like it once was.
It is depressing to hear that the same productivity crunch is happening in the UK.
When I read "QuantumMAN" I keep hearing that goofy condom commercial: "Trojan MAN!!!"
@sadmar
"And how, exactly, would you get ‘patient expectations’ on the nature of medical interactions to change?"
By necessity, essentially. The same number of physicians cannot and will not have the time to do everything as they are expected (and want?) to do now. Mid-level providers and nurses will have to do more of this work. My concern was that no matter how well this is done, patients often evaluate their experience entirely on the time spent with the doc, and complain accordingly. This is the expectation that needs to change. The doc is supervising, but s/he does not need to do everything, and that includes a long meandering conversation taking a detailed history themselves--this is med-student-level work.
"It’s blindered and false to say ‘there aren’t enough docs to make sure everyone has access to quality care.'"
Incorrect. Current and future physician shortfalls are well documented. Access will decline; this is a function of supply and demand. Read some economics, to parrot your condescending phrasing right back at you.
"Primary care in the U.S. is a clusterf*** because it’s too driven by profit motive in the insurance companies and large medical groups."
This is pure cynicism, bordering on platitude. These are sources of strain on the system, but they are not the only ones. Expectations in this country need to change if we are to make progress in our medical system. It's the third rail of any discussion on the topic, but in order to get more people access to at least a minimum standard of care, others will have to do with less. No system in the world has access for all its citizens without some form of rationed care.
Physicians are being asked to spend more time with patients to give a more "comprehensive experience" (whatever that means), at the same time they are being told to see more patients in order to allow for better access. These two things, as it stands now, are incompatible with each other. Fewer docs seeing fewer patients means longer wait times to be seen and, by definition, less access to care. My suggestion was that well-supervised mid-level providers can help bridge this gap, but that can only happen with an acceptance on the part of patients that they may not get all the face time that they would want with the doc. That's it. I've consulted my astrologer on this, and he agrees, so I'm not sure how you can argue otherwise.
I dunno, my psychiatrist seems to enjoy taking histories and finds it valuable, nay, necessary to his work.
He did major in literature, though.
He did major in literature, though.
A boon and a bane...When I was working on the meta-analysis (https://www.ncbi.nlm.nih.gov/pubmed/21833294) I was dumbfounded on the number of badly (sometime, really badly) written publications I encountered and read in full (around 2000) including once catching one which had left & right brain reversed (coordinates were right but the brain regions was mistaken...or so I hope, could be that all the coordinate were wrong...) and now, I think about the neurolinguistics of taking a detailed exam so this is why I didn't intervene since my last comment (I'm too overkill) but it leave me to wonder how long your history would be if your MD would have majored into neurolinguistics.
Al
Goodness, I have somehow never heard of this field!
It turns out that I did leave something out during all the history-taking, which is that I have indeed what might be called manic episodes as a teenager. I remember one particularly fire-fueled one where I had a bunch of my work in an art show, was generally walking around in a very good mood and ranting about the intelligence of whales and how we are all children of the sun/stars.
It didn't seem relevant, I guess, since it hadn't happened, really, since I went away to college; depression had been much more prevalent. And it wasn't anything that required hospitalization, just something that seemed to fall more into the general rubric of being moody and "artistic."
Probably should have brought it up. I also recently found out that my favorite uncle has been diagnosed with Bipolar I, which is something I should perhaps mention. (It explains a lot.)
Oh well, twenty-twenty hindsight and all that.
I don't think my shrink has ever published anything, but I could be wrong. I did see, for a while, a psychiatrist who had published quite a bit on borderline personality disorder, but somehow we didn't really hit it off and he also left after a while for private practice. My current shrink apparently knows him; they used to work together when the publishing psychiatrist was a resident, I think.
The main sticking point was that he kept going on at me about how I shouldn't drink at all, and this right before I was about to leave on a trip for Poland.
Let it be known that I had more than a few drinks that summer in Krakow. And I made a lot of friends!
Dr. Chim:
With which I wholeheartedly agreed, despite my lack of credentials in astrology.
Holy planets in alignment, I agreed with that too!
What I also said, and you seem to have either missed or ignored, is that: 1) Training up mid-level providers to do the job won't be easy or cheap, as current PA/APRN curriculla are no more qualifying for it than MD training. And, more importantly, 2) The insurance companies and medical groups aren't going to hire those mid-level providers in the quantity necessary to fill the gaps left from Taylorizing primary care. They're just going to keep the speed-up on you. And yes, if you don't get that, you need to read labor history.
Now, IF we did have those mid-level providers doing a god job of filling the functions old-school PCPs did, new-gen PCPs are too squeezed to do, which MDs aren't trained for and aren't efficient uses of an MDs time and expertise – yeah, patients would still whine for awhile, but without cause, and eventually they WOULD come around, change their expectations, and everything would be peachy keen. But you seem to want them to magically and instantly change those expectations first. "By necessity"? Oh, my... (something's burning...)
Well, I guess we can just expect Birdie to be voted in to the White House along with a D-Soc Congress, single-payer to become the law of the land, with funding suitable to train and hire all the new mid-level providers you and I both want, drawn from higher taxes on the 1% and diversion from the imperialist-war budget. Because 'necessity'.
Economics? Uncle Milty, and other Rand-worshipping Chicago school d-bags? I don't think so, or rather, been there, heard that, laughed hard, and banged my head against solid objects harder. All abstract models, ridiculous assumptions about human behavior, and no, you know, empirical facts like those damn historians have to use. If you want to see the absences of necessity and rationality, watch The Big Short, which shows how economics actually worked (and still works) on Wall Street, yielding effects the Freidmanites averred were absolutely impossible. History, doc. Try it; you'll like it. :-)
Goodness, I have somehow never heard of this field!
Language is an approximation of what we think (I could be wrong but being autistics, this is how I feel and Vin diesel was right, words haven't been invented yet for how he feel sometime wrt his enemy in FF7, it just need to be studied but I opened a way too big can of worm right now...)
Think about the different languages and alphabet (Russian & English & Chinese & Japanese), this is linguistics territory and the neuro counterpart add complexity.
Al
Agreed. I find that I rarely think in language, except when I actually want to say something; it's usually more of a free flow of feelings and memories and images, if I'm consciously "thinking" at all, which often enough I'm not. (Just being there, I suppose, when I'm not thinking.)
I do find that there are things that I can express in Russian or Polish which English simply isn't as well (or at all) equipped to express.
There is a Russian (mixed with German) saying, "pit' na brudershaft," for example. I suppose the English would be "to drink to brotherhood," but it's not really a saying we have or a thing that exists to as great an extent in our culture.
Sure we need to begin revising our expectations: upward
We need to expect progress, not regress.
We need to expect that one parent working 40 hours a week can provide a middle-class standard of living for their spouse and two children.
We need to expect that doctors be treated like professionals rather than proles, and that our health care dollars will pay their salaries and expenses, rather than feather the nests of middlemen.
We need to expect that college is a ticket to a good job rather than an undischargable mortgage-sized debt, forever hanging like an albatross around the neck.
We need to expect that 300-foot yachts, subscriptions to Alcor, and expensive quack immortality treatments, are the stuff of bad sci fi comedy rather than the birthright of spoiled sociopaths while the rest of us go hungry.
We need to expect that public water supplies won't give children brain damage.
We need to expect progressive taxation in order to pay for these things, because in the end, taxes are the price tag for civilization, and wealth is as wealth does.
And we can start right now by expecting that our votes are going to matter, and by making damn sure that everyone we know gets to their polling place, and exercises their right and duty to elect public officials who will work for all of us rather than for spoiled sociopaths.
On a more theoretical note, about confirmation bias:
Humans remember events that are emotionally consistent with their emotional state at the time of recall. Very often this translates to people building various narratives out of memories that are consistent with their long-term emotional traits. Very often it translates to editing the memory to match one's current emotions.
Many people have had this experience: They go on a vacation that turns out to be one painful or unpleasant experience after another, but shortly after they get back home, they "remember" that it was "really great!" The two days they spent calling their bank after their wallet got stolen, or praying on their knees before the toilet-god, were "no big deal really" (I have never understood people who think that puking is "no big deal"). What's going on is that memory is edited by the filter of emotions.
When the subject matter is one's preferred hypothesis about this or that, the emotional memory-editing is called confirmation bias.
Agree completely, titmouse, #57. I have to work harder to support more people to keep a practice going and pay more for all the things I am mandated to have (computers, EHRs, etc). None of this creates less work for me and a lot of it doesn't even help improve patient care.
the average length of time a PCP spends with a patient remains about 20 minutes or so.
http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-…
@KR
Well, I can't say that I don't feel more than a little bit vindicated in my comments after reading that study. A couple of highlights:
-"Increasing length of visits should be expected to exacerbate the anticipated physician shortage in coming years, and may increase problems with access to care."
-"The use of care managers, or other nonphysician extender personnel, might allow for physicians to spend more time with their patients, as these personnel are able to oversee other work that would have been previously performed by physicians and limited the amount of time for physicians to interact with their patients."
Ahem.
If we could just go back to the 1980s before managed care ruined everything and EMRs reduced productivity by 50% or so, things would be cheaper and doctors would have more time.