Practicing Family Medicine

We Must Consider all Perspectives to Propel Medical Science: another shot at Practiced Evidence Based Medicine

2010-08-31T16:57:00.001+03:00

I am reading a book by Richard D. Moore, M.D., Ph.D. called the high blood pressure solution: a scientifically proven program for preventing strokes and heart disease.
The theme of the book (which I will not discuss here) is that the main cause for essential hypertension is an imbalance in the Potassium Sodium ratio in the cells of our bodies that is caused by disproportionately high sodium to potassium in our western diets.
In the chapter titled ‘why haven’t you heard of these developments?’, he discusses his explanation for the current prevailing medical practice philosophy. The main philosophical position he addresses is the under-play of the effect of diet while over using drugs. He sees one of the main reasons for this erroneous philosophical positions is what he calls the 'golden triangle'; the unholy alliance between the medical schools, the drug companies, and the politicians. He describes the history of the development of this alliance as he had firsthand experience with the detrimental effect of this alliance.

He has a section titled: the confusion of empiricism with science.

Here is a long quote:

Part of the problem is that many in academic medicine confuse empiricism-just collecting and analyzing facts- with science. But although empiricism is part of science, this alone isn't science. It is just taking measurements and doing statistical analysis of the results. Some think that is all there is to science. But as quantum physicist Roland Omnes says:
Statistical methods are a valuable tool to accelerate the discovery of empirical rules, but it would be a mistake to assume that they are sufficient to attain the consistency afforded by the full scientific methods.

The approach Dr. Moore used to come with a cure for hypertension is what is deficient in the medicine we are applying: the use of the largest possible perspective and taking in all possible points of view and then testing them against nature. Yes, this would include empirical/evidence based testing. Dr. Moore used the following six points of view to come up with this treatment: anthropology, vegetarianism, animal studies, clinical studies, drug studies, and biophysical research. The second step is to ignore all authorities other than Mother Nature. He particularly warns against experts/authorities in minutiae that lack the perspective to see the big picture.
Needless to say that this is what is needed to propel medical practice. The only science is the one that considers all possible perspectives weather or not are hard to assess empirically.

Leonardo's Call for Holistic Reasoning

2010-06-17T04:25:00.000+03:00

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Leonardo used the term "abreviators" to describe the reductionists of his time:

The abbreviators of works do injury to knowledge and love ... of what value is he who, in order to abbreviate the parts of those things of which he professes to give complete knowledge, leaves out the greater part of things of which the whole is composed? .. oh human stupidity!... You don't see that you are falling into the same error as one who strips a tree of its adornment of branches full of leaves, intermingled with fragrant flowers or fruit, in order to demonstrate that the tree is good for making planks.

I read this quote in Fritjof Capra latest book: the science of Leonardo.These are Capra's own comments:

Reducing the beauty of life to mechanical parts and valuing trees only for their lumbar is an eerily accurate characterization of the mind-set that dominates our world today.

As illustrated in my previous post, Leonardo relied on detailed observations of nature and of his many experiments. Yet, he kept the whole in his mind. In this era of medicine this is what we need. We need not learn more and more about less and less. Instead, we need to step back, and have a deeper look into how things are inter connected. Omeprazole effects on the incidence of pneumonia and Clostridium difficile collitis is a call to step back and connect things.

FORA.tv - Fritjof Capra: The Science of Leonardo

We needs Laws and not just rules

2010-06-15T00:12:00.003+03:00

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This post is another step in my effort to give my opinion in how should medicine evolves.
Recently, I started learning about medical nutrition from a naturopathic approach. Before falling into preconceptions, you must realise that naturopathy as a philosophy started with
Hippocrates, as he states:

It is only nature that heals and wherever and whenever possible nature should be given the opportunity to do so.

A modest way to address naturopathic philosophy is to trust our body's innate capability to heal itself and only intervene when it is deemed necessary.
Having said this, this post is not to advocate for or defend the naturopathic medicine philosophy. But, there is an intriguing point that naturopathy has that we should look seriously into.
Naturopathy has a Law called the Law of cure that collect dispersed facts into one simple Law that once well understood can be applied in treating most of not all conditions. This Law is stated by Lindlahr (1913) as

Every acute disease is the result of a cleansing and healing effort of nature.

You may not agree with this Law. However, the effort to decipher nature’s Laws is to be respected. In the medicine we practice we do not have a superseding Law, all what we have are dispersed rules. Rules as appendicitis is treated by surgery and those with suspected MI need to chew an aspirin pill. Having rules and not Laws is a sign of immaturity of the science of medicine. All mature sciences as astronomy, physics and chemistry have Laws. Yes, we should not come up with Laws just for the sake of it. However, we should at least try to come up with Laws. I think one of the main hinders to the advancement of medicine is that we do not seek the discovery of Laws.

For advancement of medicine I am proposing to:
1. Focus research to finding nature’s Laws, the Laws that govern health and disease.
2. Train physicians in the proper applications of these Laws to real life situations.

EBM wrongly Instated Epidemiological and Statistical Laws as Clinical Laws

2010-06-15T13:42:00.001+03:00

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Having thought deeper in how I have been practicing, I realised that there is an overarching Law in practice Medicine. This contradicts with what I eluded to in my previous post. The overarching Laws in today’s practice are the Laws of evidence based medicine. These are Laws of statics and epidemiology. For example, I believe I have been practicing under these two Laws:

Randomised controlled trials are to be meticulously applied.
Our clinical decisions should be based on randomised controlled trials whenever possible.

As the title of this post suggest, I don't believe that evidence based medicine (EBM) should be or is capable of having the stature of a Law. Yes, EBM offers the best available tools for us to discover natures Laws. The Laws of nature, if true are 100% correct. Unlike statistics, Laws have no confidence intervals. We should be 100% confident in Laws.

Evidence Based Medicine: Why I Became Weary of Those Who use This Term?

2010-06-10T08:03:00.004+03:00

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In short, in an effort to make Evidence Based Medicine (EBM) an arching philosophy of practice, EBM had to include evidence that is considered poor by EBM own criteria. The scope of EBM must be narrowed to only be a research paper analysis tool. Unless we do this, we will continue to undermine the quality work produced by McMaster group and many others.
After limiting the scope of EBM, we should come with new and practical tools that allow us to be conscientious, explicit and judicious when making decisions about the care of individual patients. Along this journey, we will probably come with new fancy names to describe this philosophy of practice. These names will not include EBM.

Evidence Based Medicine (EBM) has transformed medicine in a good way. Yet unfortunately, EBM is becoming a buzz word and is often use inappropriately. I am in the process of writing my view of how the evidence in medicine should evolve; in details. But, this is taking more effort than I anticipated. So, for the time being, I thought of writing this short post with some of my thoughts on the matter.

To start, I think the main fault for the inappropriate use of EBM principles falls on those who actually proposed EBM. McMaster researchers that coined the term EBM, described EBM as a method to systematically analyze published research, and to combine this analysis with patient evidence to make clinical decisions . (Oxman et al. 1993) Patient evidence is patient's clinical history, examination, and investigations.

They, then, published a series of articles that outlined how to analyse published research. (Oxman et al. 1993)
To fend off criticism, Sackett et al. (1996) published an editorial titled: evidence based medicine: what it is and what it isn't, that clarified their stance. They defined EBM as:

the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. In this editorial, authors stated that EBM is practiced by integrating individual clinical expertise with best available external evidence.

One of the main criticism to EBM ,as initially proposed in 1992 and 1993, was its undermining of clinical expertise. To clarify (or may be slightly modify) their stance they now ask to combine the analysis of research papers with “clinical expertise" which is more encompassing than “patient evidence" as with their initial proposal.

Therefore, a flood of so called evidence based guidelines started to appear. These guidelines would propose recommendations that are based on best evidence as per EBM criteria. But, as this is often lacking, the “clinical expertise” of experts is often used. So, clinical expertise of these experts would be combined with clinician own clinical expertise to come with clinical decisions. However, external clinical expertise is considered poor evidence as per the criteria laid out by EBM proponents. (This just does not sound right. Especially, as for younger physicians like me who are practicing away from research centres, had their expertise developed by using these same guidelines.)

I believe that Sackett et al. should have backed off by limiting EBM to being a tool to analyse research papers. As I will detail in my upcoming post, EBM does not offer the appropriate tools to apply evidence to individual patients. That is, EBM does not offer the tools to combine individual patients' evidence with external evidence. EBM proponents just assume that clinicians would combine these two sources of evidence would happen in a proper manner. But, this doesn’t always happen. Many are using their poor understanding of what EBM as an excuse for bad clinical decisions.

You may or may not agree with me. But, I had to write this post; as sadly, I am becoming wearier of those that use the term EBM than those who don't. Those who don't shout out EBM to support their opinion must think deeper and be more explicit in supporting their decisions.

Oxman, A.D., Sackett, D.L. & Guyatt, G.H., 1993. Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA: The Journal of the American Medical Association, 270(17), 2093-2095.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS., 1996. Evidence based medicine: what it is and what it isn't. BMJ (Clinical Research Ed.), 312(7023), 71-72.

Vitamin B12 level Drops Progressively as Diabetic are on Metformin

2010-05-21T15:47:00.003+03:00

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This study is uncomforting. We all agree that the true reason for treating diabetes is to reduce or eliminate its complications. And here, evidence shows that the treatment we give to reduce these complications can cause them!

In this study 19% of 196 diabetics on Metformin 850mg TID had progressive drop in their vitamin B12 levels. This study also assessed folic acid levels. With folic acid there was a non-significant trend for lower levels.

Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomised placebo controlled trial -- de Jager et al. 340: c2181 -- BMJ

Organophosphate Linked to ADHD in A Pediatrics Article: so Naturopath were right all along

2010-05-19T10:00:00.002+03:00

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This study compared the level of organophosphate pesticides’ metabolites urinary levels with ADHD symptoms. As these metabolites increased, the prevalence of ADHD increased.

Naturopaths have the attitude to avoid all toxins. They proclaim that low levels of toxicity that does not cause acute illness causes chronic ailments due to the chemical reactions of these toxins with our proteins. Homotoxicology is a science that claims is able to remove these toxins through conjugation reactions that bind these toxins to administered drugs lending these toxins harmless, or at least less harmful.

Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides -- Bouchard et al., 10.1542/peds.2009-3058 -- Pediatrics

Coenzyme Q10 and Vitamin D Lower Blood Pressure, But What Does This Mean?

2010-05-16T22:33:00.001+03:00

Coenzyme Q10 lowered 16.6/8.2 in three studies and 13.5/10.3 in others.
Ca 1200 plus 800 vitamin D lowed systolic BP by 13.1 mmHg

You may know that the maximum dose of most antihypertensive doesn't lower BP beyond 15-20 mmHg of systolic blood pressure. And even more important is that just lower BP is not enough as one medicine, Atenolol lowers blood pressure but does not reduce mortality: which is our true goal for treating hypertension.

Another controversial point, is do we consider asymptomatic high blood pressure a disease or a risk factor? My approach as many others is to consider asymptomatic high blood pressure a risk factor for diseases as strokes and heart attacks and then try to manage the overall risk. This means showing that supplements as Co-enzyme Q10 and vitamin D lowering blood pressure does not go far with me.

Having said this there are two points that may change how I manage hypertension:

1. This review article suggests that replacing people with low normal vitamin D lowers their blood pressure. Could low vitamin D be a cause for high blood pressure? Recall that we do not know the cause of over 90% of hypertensive people.

2. Statins that are commonly used in hypertensive people lowers Coenzyme Q10, which when given as a supplement reduces blood pressure. This shows that the way we look at cardiovascular risk reduction needs revision.

Complementary and alternative medicine approaches to blood pressure reduction: An evidence-based review -- Nahas 54 (11): 1529 -- Canadian Family Physician

We Do Need our Stomach's Acidity

2010-05-11T20:18:00.000+03:00

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I discussed the issue of acid suppression and nutritional deficiency in a previous posts. The link between PPI use and pneumonia was previously outlined. This new study outlines the association between acid suppression and nosocomial Clostridium difficile infection.

The push to use NSAIDs for knees OA and just give gastric protection instead of using non-gastric toxic drugs should be questioned.

Arch Intern Med -- Abstract: Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infection, May 10, 2010, Howell et al. 170 (9): 784

Vitamin B12 as a Medicine to Treat Recurrent Aphthous Ulcers

2010-05-10T11:27:00.003+03:00

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I ran by this study published January 2009 in The Journal of the American Board of Family Medicine. It shows the usefulness of the use of vitamins as drugs.This was proposed in the 1960s by Linus Pauling and form the start of an alternative approach to heath named orthomolecular medicine. (check my previous post)

Regarding the study, 58 participants were randomized to either recieve vitamin B12 1000ug sub-lingual a day or placebo. A significant number in the treatment group reached 'no aphthous ulcer status' (74.1% vs. 32%; P<0.01)

Effectiveness of Vitamin B12 in Treating Recurrent Aphthous Stomatitis: A Randomized, Double-Blind, Placebo-Controlled Trial -- Volkov et al. 22 (1): 9 -- The Journal of the American Board of Family Medicine

Time to Rethink our Scientific methodology: Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events

2010-05-01T08:44:00.003+03:00

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Many saw this coming. Long-acting beta-2-agonist causing increased mortality only when not combined with cortisones did not make sense. Myself as others did not voice this oxymoron. We really need to rethink how we think.

This meta-analysis induced 12 studies. The conclusion is as follows:

pooled data show that the use of long-acting β-agonists, with and without concomitant inhaled corticosteroids, was associated with a significant increase in risk for asthma-related intubations and deaths. The magnitude of risk was, in fact, higher for trials with controlled concomitant corticosteroid use (OR 8.2) than for trials with no corticosteroid use at all (OR 2.2)

You can find the full text at:
Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events

Are We Seeing The World in Reverse

2010-04-04T09:21:00.000+03:00

I am browsing Hoffer and Prousky (2006) book: Naturopathic Nutrition: a guide to Nutrient-rich food & nutritional supplements for optimum health. Here is the world in reverse:

Gastritis -> damage to stomach lining -> reduced acid production -> poor digestion -> nutritional deficiencies

We need gastric acids to digest meat. It is expected to be hard release vitamin B12 from undigested meat. More, vitamin B12 needs healthy stomach parital cells to release intrinsic factor.

So by chronically giving acid reducing pills, we are exacerbating the problem!

The sequence is convincing, isn’t it?

There are tests that can check for the presence of reduced acid production and other tests that assess the quality of meat digestion.

I will be writing more on reduced gastric acidity. I just need to finish my health informatics dissertation.

Orthomolecular Medicine: My Search for a New Paradigm

2010-03-23T23:06:00.004+03:00

Dr. Linus Pauling (1901-1994) Photo by Dick Willoughby

The future is here. It's just not evenly distributed yet.
William Gibson

Family medicine as a discipline is young. It was an outcry to the practice of medicine in the third quarter of the last century. One of the main chores we took among ourselves is to focus on prevention. I think we must admit that we lost our way.
Being satisfied by the primary or secondary prevention of statins is a proof of this. Statins at their best provide less than 5% absolute risk reduction for important outcomes.
I am becoming more skeptical. A less skeptical person may see a half full cup; half full and not half empty. But, to see a 5% full cup; %5 full instead of 95% empty is beyond logic.
Using William Gibson’s quote and what Roger Martin (check my post) call for, and most of all luck, I was lead to explore orthomolecular medicine.
Orthomolecular medicine has a very simple philosophy. Our body has the innate capacity to cure itself. For this to happen, our cells need to do their jobs. For our cells to do what is expected from them, we need to provide them with all what they need of nutrients.
That's it. Simple yet powerful.

Linus Pauling the American chemist and molecular biologist with two Nobel prizes is the person who coined the term “orthomolecular”. Orthomolecular medicine has been practiced since the mid of the last century. But, it is a surprise that most of us have not heard of it. The way orthomolecular medicine provides nutrients to our body’s cells is through the use of orthomolecular diet and nutrients principally vitamins.
Orthomolecular physicians/practitioners would strike you by their use of mega-doses of vitamins. They realize that our cells need different amounts of nutrients during health and illness. They also correctly realize that our current diets just don’t provide all what our cells needs.
Orthomolecular medicine should not be considered a type of alternative medicine, as it uses the same scientific methodologies used in mainstream medicine. The only problem is that orthomolecular medicine is alienated. Pubmed does not index the orthomolecular medicine journal!
Orthomolecular medicine practitioners use nutrient, mainly vitamins, to maintain health and to cure (yes cure) illnesses.
I hope I have triggered your curiosity. If so you really need to read Hoffer and Saul book “Orthomolecular Medicine For Everyone: Megavitamin Therapeutics for Families and Physicians”. Dr. Hoffer is a Canadian psychiatrist who passed away last year at the age of 92. It seems that orthomolecular medicine physicians/practitioners live longer because they practice what they preach.

A Welldell Berry Quote Against Reductionism

2009-08-26T12:28:00.005+03:00

Here is the quote without any commnets:

Reductionism (ultimately, the empirical explanability of everything and a cornerstone of science), has uses that are appropriate, and it also can be used inappropriately. It is appropriately used as a way (one way) of understanding what is empirically known or empirically knowable. When it becomes merely an intellectual "position" confronting what is not empirically known or knowable, then it becomes very quickly absurd, and also grossly desensitizing and false.

Gases, Prebiotics, Probiotics and Irritable Bowel Syndrome

2010-01-20T02:57:00.006+03:00

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This is an un-sanitary topic. Yet, for those who have an illness as irritable bowel syndrome (IBS) is a life quality issue. For the same level of colonic distension, pain and discomfort is worse for people suffering from IBS.

Lately, I started reading on prebiotics and probiotics. This led me to read on our gut microbiota. Some consider our gut micorbiota an organ. Yes, an organ that we did not learn about while in medical school.(Gibson 2004)
Above picture is for the 1908 Noble prize in medicine winner Ilya Ilych Mechnikov who started the interest in the gut microbiotia and its connection to health.
Gut microbiota is the bacteria and other micro-organisms living in our gut. Number of their cells is 10 times our cells. They are not all parasitic or pathogenic, rather most are symbiotic. They feed off of use and offer many health benefits. They even feed us. They produce short chain fatty acids that our enterocytes feed on. (Bixquert Jiménez 2009) This is an area of active research and most of the benefits are shown on animal models. For a handful of reasons (big corporations is one) I don’t see this science advancing fast enough. Having said this, there are studies on humans showing some benefits in certain disease entities.
Let go back to gases:

I think we all agree that gases are mainly produced by these bacteria fermenting the food we eat. And, you probably noticed that some foods produce gasses more than others. But, this is not all of it. Lumping all our gut’s bacteria together (as with IBS bacterial overgrowth theory) is as lumping all mammals together. You agree with me that elephants and tigers are quite different. There are 400-500 known species in our gut. (Jimenez 2009) These have undefined number of strains or subspecies.
Lactobacillus and bifidobacterium are two genera that tend not to produce gas when fermenting carbohydrates. (Spiller 2008) And, the more we have of these the less we should have of gas producing ones as clostridia. Therefore, if we can increase non-gas producing bacteria we could reduce gas. There are different methods we can alter our gut bacteria, two have been shown to increase bifidobacterium: prebiotics, and probiotics.
The easiest to explain is probiotics: Just ingest live bifidobactirum, especially that at least some of its strains can bypass the harsh environment produced by gastric acid and bile salts. Live bifidobactirum are found in probiotics capsules and are added to dairy products as with Danon’s Activia yogurt. A study sponsored by Danon, showed if those with constipation predominant IBS eat two servings of Activia yogurt, they would have less gas. (Guyonnet et al. 2007) Something worth noting, we should be down to strain specific when describing probiotics. For example the tested Danon strain was:

Genus: Bifidobacterium
Species: animalis
Strain: DN-173 010

The other method to increase good bacteria is to feed them. Some types of complex carbohydrates that are not digested by humans reach our colon and are fermented by bacteria. It is found that eating certain types of complex carbohydrates preferentially promotes the growth of Bifidobacteria. Inulin and transgalacto-oligosaccharides are two prebiotics. (Gibson 2004) Lactulse, although not food exerts prebiotics effect. There are no properly conducted studies that show any clinical benefits of prebiotics with bloating in IBS. The opposite is true, there are studies that showed worsening of bloating with lactulose. (Spiller 2008) Therefore, prebiotics and foods that alter gut microbiota in a positive way need further investigation which will probably be hampered by reduced funding. Big corporations (surprisingly!) can patent probiotics strains clinical use which probably encourages funding into probiotics and not prebiotics research.

Bixquert Jiménez, M., 2009. Treatment of irritable bowel syndrome with probiotics. An etiopathogenic approach at last? Revista Española De Enfermedades Digestivas: Organo Oficial De La Sociedad Española De Patología Digestiva, 101(8), 553-564.

Gibson, G.R. et al., 2004. Dietary modulation of the human colonic microbiota: updating the concept of prebiotics. Nutrition Research Reviews, 17(2), 259-275.

Guyonnet, D. et al., 2007. Effect of a fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double-blind, controlled trial. Alimentary Pharmacology & Therapeutics, 26(3), 475-486.

Spiller, R., 2008. Review article: probiotics and prebiotics in irritable bowel syndrome. Alimentary Pharmacology & Therapeutics, 28(4), 385-396.

Therapeutics Education Collaboration: a Must Listen to Podcast for Any Family Physician

2010-01-16T09:52:00.002+03:00

If you are family physicians you must listen to the therapeutics education collaboration podcast. This podcast in excellent to perfect on all dimensions:
The presented information, the show notes, the style and the audio qualtiy. Superingly, many podcast don't even come close to this quality.

The two primary hosts are a pharmacist Prof. James McCormack and family physicians Dr. Michael Allan.
I will leave you with this you-tube video for Prof. James McCormack

Integrative Thinking for Preventive Medicine

2010-01-16T12:53:00.002+03:00

It is time for a new paradigm in preventive therapy. RCTs and meta-analyses are not suited for complex interventions as primary prevention. For primary prevention we need to eat well, exercise regularly, and sleep well. I do not believe that family physicians are trained enough in these areas. More, I do not believe that the science in these areas has reached where it is supposed to be.

It is a shame that over 70 years after the death of Dr. Alexis Carrel his observation holds true till today:

Medicine is far from having decreased human sufferings as much as it endeavors to make us believe. Indeed, the number of deaths from infectious diseases has greatly diminished. But we still must die in much larger proportion from degenerative diseases.

Roger Martin the dean of Toronto’s Rotman School of Business has a suggestion that I think is worth trying in medicine. You can find his suggestion in his book ‘The Opposable Mind: How Successful Leaders Win Through Integrative Thinking’

1. Have a good stance. A stance is how we think of the word, and what we value. Thinking high of RCTs can be thought of as a stance. Refusing to accept any reductionist science to guide preventive medicine is another stance. Always being open to different ideas is another stance.

2. Use abductive reasoning along with adductive and inductive reasoning. You may need to read the book to understand abductive reasoning. My understanding is to use our current knowledge to come we with new and imaginative solutions. Abductive reasoning is imagining the possible.

Blind Men and an Elephant: are Drug Preventive Strategies Missing the Elephant?

2009-09-08T00:22:00.001+03:00

You probably know the blind men and an elephant fable. If not this is a Jain version of it:

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Six blind men were asked to determine what an elephant looked like by feeling different parts of the elephant's body. The blind man who feels a leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.

Wikipedia

Each of these six men is correct. Yet, their conclusions are useless to say the least.

The question I would like to raise: are preventive treatments using drugs as aspirin, statins, warfarin, and ACE inhibitors missing the elephant?

These blind men are one tool of perception: vision. Scientists use different tools to perceive reality. These tools evolve. Nowadays, we have electron microscope and PCR. Before using these tools scientist were blind to existing facts. This fable shows that being a 100% correct does not assure understanding reality. The outcome of randomized controlled trials can be 100% correct and still derail us from reality.

If you have read some of my previous post, you probably know where I am going with this. This is another criticism to using reductionist science in preventive science.

Researchers as Weston A. Price and Daphne Miller noticed the dramatic preventive effect of particular diets. Price went further in connecting the quality of the soil to the quality of fruit, vegetables, milk, and meat. To understand reality we must always consider the possibility of the presence of a striking reality that our perception is not to seeing. This strategy should prevent overplaying findings, as overplaying the effect of saturated fat on heart disease.

Miller, D., 2008. The Jungle Effect: A Doctor Discovers the Healthiest Diets from Around the World--Why They Work and How to Bring Them Home, William Morrow.

Price, W.A., 2008. Nutrition and Physical Degeneration 8th ed., Price Pottenger Nutrition.

Scientific Writing Style Should not be Hypnotizing

2009-09-07T19:14:00.001+03:00

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Scientific articles writing style tires to emphasize the presented data and not the presenter of the data. This requires a peculiar writing style known to those who read scientific articles. One rule is never to use the first person.

This style is supposed to aid in the impartiality of presented data. However, this writing style is exploited. Drug companies study how to present data to clinicians in ways that would support drug companies interests. More, everyone, including scientific papers' writers, is biased. In complying with scientific writing, this bias is purposely hidden.

Any reader needs to judge the accuracy and usefulness of what he or she reads. So why no ease up the rules of scientific writings and allow for enjoyable reads?

Aiming for blood pressure targets lower than 140/90 mmHg is not beneficial

2009-08-25T01:04:00.002+03:00

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This is the conclusion of a newly published Cochrane review. Data that support targeting lower targets with drugs just does not exist. As expected from a Cochrane review, they looked at patients’ relevant outcomes as total mortality, myocardial infarction, stroke, congestive heart failure, major cardiovascular events and end-stage renal disease.

You can read physicians comments on EvidenceUpdates.

This review makes me pounder the question whether ‘experts’ that come with guidelines are ‘why not’ person or ‘do no harm’ person?

I end with author’s conclusions:

Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients.

An Old Known Fact: Degenerative Diseases are Increasing

2009-08-28T16:06:00.001+03:00

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Medicine is far from having decreased human sufferings as much as it endeavors to make us believe. Indeed, the number of deaths form infectious diseases has greatly diminished. But we still must die in much larger proportion from degenerative diseases.

Alexis Carrel, 1873-1944

I started reading the 1939 published book: Nutrition and Physical Degeneration by Weston Price. Price is a Canadian born American dentist, who closed his practice and travelled the world in search for the reasons of rocketing dental degenerative diseases. His book details the findings of his research.

Alexis Carrel is the 1912 Nobel prize winner in physiology or medicine.

Randomized Controlled Trials are not Always Necessary, Observation May Suffice

2009-08-01T23:03:00.002+03:00

I just listen to an interview with Professor Sir Michael Rawlins, Chair of UK’s National Institute for Health and Clinical Excellence. You can find it on itconversations. He goes over very interesting topics. Two of which are deciding on what services should a public health service provide and evaluating evidence.

In evaluating evidence, he raise the point to the needless divide between using observation and using randomized controlled trials (RCTs). Both are needed methods for evaluating evidence. However, RCTs can be unnecessary and even unethical to do. He mentions the example of ganciclovir used to treat cytomegalovirus retinitis in AIDS patients. Where although observational study showed efficacy, RCT was carried out. after a year the benefit was shown, but the non-treatment arm got blind! (I need more time to dig up this study) This is an article commenting on Sir Rawlins views.

Knowing What Must be Done Does Away with Fear

2009-06-03T05:10:00.005+03:00

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I have learned over the years that when one’s mind is made up, this diminishes fear; knowing what must be done does away with fear
- Rosa Parks

This is another marvelous quote cited in the book I am reading: Iconoclasts, a neuroscientist reveals how to think differently; by Gregory Berns. The book tries to find what make up iconoclasts. Berns defines iconoclasts as people who do things others say cannot be done.

Over multiple chapters, Berns describes the deleterious effects of fear on innovation. Fear not only prevent people from taking actions but can also change their perception. If perceptions are faulty, the actions taken based on these perceptions will most likely be faulty.

How does this relate to family medicine?

One of the main types of fears Berns describes in his book is the fear of the uncertainty. In practicing family medicine this fear is a fact of life. Rosa Parks states that knowing what to do go away with fear. I can rephrase this for practicing family medicine:

knowing about most illnesses diminishes fear; knowing clinical approaches for different patients’ presentations go away with fear.

Many of family medicine text books and articles do focus on algorithms to approach the problems patients come with. However, if we consider how people (including physicians) actually think, we would end up with slightly different texts. In psychology, people first categories problems and then device their decisions and actions based on these categories. Experts categories are different than novice categories. Experts categories are more detailed. Here are examples:

lay person: Diabetes
novice physicians: Diabetes type I, Diabetes type II on oral hypoglycemic and Diabetes type II on insulin
experts: young Diabetics on oral hypoglycemic, old diabetes on oral hypoglycemic, diabetics on two injections per day of mixed insulin, diabetics on extended release insulin and a fast acting insulin, and so on.

Having texts and articles that address all these categories is not practical. However, addressing a category level called ‘basic’ category is worth it. Basic category is the word people use when asked: what is this? If I point to a coffee table and ask you to name it: will you say a table ,or a piece of furniture, or a coffee table? If you guessed a table, then you are right. Table is a basic category is this context. Basic categories will differ according to the level of expertise. If a carpenter is asked to name the coffee table; s/he will probably call it a coffee table and not just a table.

Basic categories as ‘table convey enough differentiation compared to the more general category: furniture. A table is quite different than a couch which is also furniture. Table also has enough specificity when compared to ‘coffee table’. ‘Coffee table’ is more specific, but this added specificity is not always needed. (Lamberts & Shanks 1997)

All experts acquire basic categories naturally; with practice. Experts have mature categories compared to novice. Having text books and articles that address basic categories may speed family physicians transition from novices to experts.

At the end _however we classify illnesses_, in family medicine we should focus on patients’ presentations and having well thought of, evidenced based approaches to go away with the fear of uncertainty.

Lamberts, K. & Shanks, D., 1997. Knowledge, Concepts, and Categories MIT Press ed., The MIT Press.

When We Mistake What We Can Know for All There is to Know

2009-06-16T00:30:00.002+03:00

The problem is that once science has reduced a complex phenomenon to a couple of variables, however important they may be, the natural tendency is to overlook everything else, to assume that what you can measure is all there is, or at least all that really matters. When we mistake what we can know for all there is to know, a healthy appreciation of one’s ignorance in the face of mystery like soil fertility gives way to the hubris that we can treat nature as a machine.
Michael Pollan, 2007

These nicely crafted words are by Michael Pollan in his book: the Omnivore’s Dilemma: a Natural History of Four Meals. Michael Pollan was describing what happened to the health of plants when we reduced what they need to Nitrogen, Phosphorus, and Potassium (NPK). We started providing plants with NPK only (through synthetic fertilizers). Michael Pollan states: once we reduce complex phenomenon to a couple of variables, however important they may be, the natural tendency is to overlook everything else. This is exactly the problem with the misapplication of evidence based medicine (EBM). There is the tendency to overlook everything else. EBM is a very good tool for evaluating studies. These studies happen to follow the reductionist paradigm. We should never allow reductionism to overcast our thoughts. We should not allow EBM to overlook everything else and assume there is nothing else to know.

Do not let Evidence Based Medicine Set Your Expectations: Stay Curious

2008-12-30T18:45:00.004+03:00

In design, designers use design principles to predict what works for users and what does not work for users. These predictions are based on different types of studies. Yet, it is always advised to test the products or the designs that are based on these studies and predictions with users. This means designers must always keep open eyes, open minds and high curiosity.

open eyes, open minds and high curiosity are traits that all of us physicians need to have to deliver good health care. Most of us still keep them. But, Evidence Based Medicine (EBM) movement unintentionally undermines such traits. EBM has not only set up high quality treatment guidelines but also set up our expectations.

I think that we should adopt designers method of principles use in practicing medicine. Even though we apply EBM 'principles' we should still test the results on our patients. Testing will usually means having attentive ears. If an EBM treatment is given, ask patients, in details, about the effects of this treatment. By comparing what patients say with what EBM tell us we test these principles in real life.