First published on on Nov. 20, 2013
In response to the question: What is the biggest misconception people have about alternative medicine?

Defining “alternative medicine” is the chief pitfall in any discussion of the topic. It is a nebulous term.

The National Institutes of Health defines alternative medicine as a “non-mainstream approach [used] in place of conventional medicine” – effectively exiling it to a desert island and emphasizing that it can only be defined by its relation to mainstream medicine. The NIH notes that true alternative medicine is uncommon, because most people combine it with conventional techniques.

More helpful, I think, is viewing alternative medicine as “proto-medicine,” i.e. as techniques that may some day be adopted into conventional medicine if well-conducted clinical trials show a favorable ratio of benefit to harm.

The classic example of an alternative medicine moving into conventional medicine is the heart medicine digitalis. In the 1700s, Dr. William Withering in Shropshire, England heard that a local witch could do something he couldn’t: successfully treat dropsy (which is today called “edema”). Gaining the witch’s cooperation, Withering painstakingly discovered that, among her potion’s dozens of ingredients, the foxglove plant provided the therapeutic effect. He proved this by conducting formal trials of foxglove, whose scientific name is digitalis. All of this took nine years, but Withering, and the unnamed witch, achieved immortality in medical circles, and their work has benefitted untold numbers of patients. Digitalis derivatives remain in use today.

Physicians are (or should be) pragmatic. If something is provably successful, it deserves to be adopted into conventional medicine and to shed its “alternative” label. To make such a jump, a high level of evidence is required. Investing time, energy, or self in an approach that is unsupported by evidence, no matter how “natural” it seems, is an invitation to disappointment, and worse.

First published on on Nov. 18, 2013
In response to the question: If you could change one aspect of the Affordable Care Act, what would it be?

Similar to the old comedy straight-line, “When did you stop beating your wife?” this question has a built-in assumption.  From their first day on the wards, medical students are taught never to ask such questions, because they bias a patient’s response.

Instead, phrasing the question as “What would you do to improve healthcare or its delivery in the United States?” would elicit equivalent answers, without bias.

I’m not saying the ACA is the pinnacle of mankind’s legislative accomplishments.  But it’s clearly not the monstrous cancer that loud voices proclaim it to be.  Let us take the energy directed against the ACA and try turning it positive.  Let’s try to make the Act work, and bring healthcare insurance to the tens of millions of Americans who don’t now have it.

First published on on Nov. 19, 2013
In response to the question: Should the eligibility age for Medicare be raised?

No. Raising Medicare eligibility age across the board would inevitably eliminate healthcare coverage for some people who simply cannot financially afford it. Why would a compassionate nation want to do that?

At the very least, any proposal to increase Medicare’s eligibility age should add means-testing, so that persons who can afford to pay for their healthcare do so.

This will probably be insufficient, however. Healthcare is already so expensive that the percentage of the population older than 65 who can afford to buy insurance is limited (and declining). Means-testing, therefore, may not exclude enough people to appreciably lessen needs for publicly funded healthcare.

Long term, only one strategy makes sense: give people significant financial incentives to eschew unhealthy lifestyles and to adhere to proven plans that reduce disease burden. It would be the healthcare equivalent of good driver discounts in automotive insurance, and, as with driving, it can have huge effects.

Consider, for example, former Vice President Cheney. Had financial incentives kept him from smoking cigarettes from ages 12 to 37, it is quite possible that onset of his heart disease could have been delayed by 10 years. That would have made him age 79 (not 69) when he was faced with the decision to undergo implantation of an expensive heart-assist device – which ultimately required a 5-week hospitalization, most of it in intensive care – and would have made him 81 (not 71) when he needed a heart transplant – too old to be eligible. He might, therefore, have undergone neither of these very expensive procedures, lowering dramatically his consumption of healthcare resources.

Physicians call such deferral of medical problems (and, therefore, costs) “Compression of morbidity” and view it as the ideal for aging. Helping all Americans attain it would be both compassionate and fiscally sound.

Rejected by the New England Journal of Medicine in 2013.

To the Editor:

Dr. Stabler’s review of vitamin B12 deficiency (*) rightfully emphasized laboratory diagnosis, but, consequently, omitted several clinical features that may raise suspicion of its most prominent cause: pernicious anemia (PA).

For example, before Minot and Murphy’s 1926 discovery of liver therapy, PA was a relapsing/remitting disease inevitably ending in death (1,2). Infection, especially dental, could trigger relapses (2). In relapse, cardiomyopathy, nephrotic-type edema, spontaneously resolved hypertension, abdominal discomfort, diarrhea, weight loss, fever, lassitude, and a characteristic grapefruit coloration of the skin (due to pallor combined with hemolytic bilirubinemia) (1,2,3,4) might accompany the anemia and neuropsychiatric dysfunctions Stabler describes.

Also curiously, Minot (4) and others (3) note that northern European patients may have a characteristic phenotype: wide facies, hypertelorism, wide jaw, large earlobes, “a bulky frame,” early graying, and light colored eyes.

These presentations, derived from older literature and now uncommon, are not backed by modern standards of evidence – and never will be. Nevertheless, they should not be forgotten because, when a disease is both serious and curable, any clue that triggers suspicion can be life-saving.

(*) Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013 May 23;368(21):2041-2.   PubMed 23697526

(1) Cabot RC. Pernicious anemia (cryptogenic). In: Osler W, McCrae T. Modern Medicine: Its Theory and Practice. Vol. 4. Philadelphia: Lea & Febiger; 1915:619-659.

(2) Graham D. Addison’s (pernicious) anemia. Can Med Assoc J. 1926; 16: 881-886.

(3) Spivak JL, Barnes HV. Manual of Clinical Problems in Internal Medicine. 3rd ed. Boston: Little, Brown; 1983; 426-431.

(4) Vaughan JM. The gain in body weight associated with remissions in pernicious anemia. Arch Int Med. 1931; 47: 688-697

(5) Minot GR. Case 12342: pernicious anemia: treatment by a special diet. Boston Med Surg Journal. 1926; 195: 429-434.

Some “off-the-record” comments were also submitted with this letter:

Figure 2 in the paper is both pedagogically suboptimal and an inefficient use of page-space.

  • It’s spatially inefficient because it is enormous, and the drawing adds nothing. No one needs reminding of where the brain is, or where the bone marrow lies. The panel for infants and children doesn’t even fit the figure, and it’s unclear if men are infertile, too.

  • It’s pedagogically suboptimal because it’s effectively a list of signs-and-symptoms the reader must memorize. That’s hard to do, and no one does it voluntarily. Physicians learn far more easily from clinical stories.

Thus, I would have dramatically reduced the figure’s size and used the space saved to put some clinical meat around the bones of the list, including:

  • How pernicious evolves clinically over time, and how any organ system can be the presenting one,
  • How subtle changes in personality can be,
  • Vignettes of the incredible cardiac cures that B12 repletion has brought,
  • Expansion of the change in natural history since 1926,
  • The mode of death (which is not anemic).

In summary, changing from pictures to interesting clinical illustrations would, I think, be an improvement over large but fundamentally unhelpful illustrations.

First published on on June 20, 2013

Short answer: Yes, of course.

Longer answer: There is no new thing under the sun. Physicians in the 1920s debated whether they should use telephones to communicate with their patients. We know how that turned out.

The issues debated, then and now, are not too different, e.g. the loss of information and nuance when two people cannot see each other, or when the physician cannot examine the patient. And just as they did with telephones, physicians will have to learn what topics are effectively handled by email and which are not.

Even the vexations are similar. Insurance companies are just as unwilling to pay physicians for email messaging as they are for telephone consultations. Many physicians, however, are already emailing patients. A salaried friend loves it.

As technology evolves, the next debate will ask whether texting is appropriate for physicians. Are 140 characters enough to have a clinically meaningful conversation? Let’s give it a try:

(PT = Patient, MD = Physician)

PT: “Hurting”

MD: “Where?”

PT: “Chest.”

MD: “Describe”

PT: “Squeezing”

MD: “Bad?”

PT: “Elephantweight!”

MD: “Call 911”

< crickets >

MD: “Now”

< crickets++ >

MD: “Hello?”

< ominous crickets >

MD: < expletive >

< anguish >

MD: “Hello?!!”

PT: “Here.”

MD: “Alive!”

PT: “Batterycrumped.”

MD: “Call 911”

PT: “Text 911?”

MD: “CALL 911”

PT: “Ok”

MD: “Now”

PT: “Ok”

< disconnect >

MD: “Yeow.”

All technologies carry their own frustrations.