Seth's Blog

I have already linked to this 2004 article (“How Ignorant Doctors Kill Patients”) by Russell Blaylock, a neurosurgeon, but after rereading think it deserves a second link and extended quotation.

I recently spoke to a large group concerning the harmful effects of glutamate, explaining it is now known that glutamate, as added to foods, significantly accelerates the growth and spread of cancers. I [rhetorically] asked the crowd when was the last time an oncologist told his or her patient to avoid MSG or foods high in glutamate. The answer, I said, was never.

After the talk, a crowd gathered to ask more questions. Suddenly I was interrupted by a young woman who identified herself as a radiation oncologist. She angrily stated, “I really took offense to your comment about oncologists not telling their patients about glutamate.”

I turned to her and asked, “Well, do you tell your patients to avoid glutamate?” She looked puzzled and said, “No one told us to.” I asked her who this person or persons were whose job it was to provide her with this information. I then reminded her that I obtained this information from her oncology journals. Did she not read her own journals?

Yet, this is the attitude of the modern doctor. An elitist group is in charge of disseminating all the information physicians are to know. If they do not tell them, then, in their way of thinking, the information was of no value.

The incentive structure of modern medicine in action. If you do harm, you are not punished — thus the high error rate. If you do good, you are not rewarded — so why bother to think (“no one told us”)? The similarity to pre-1980 Chinese communism, where it didn’t matter if you were a good farmer or a bad farmer, is obvious. It is a big step forward that the rest of us can now search the medical literature and see the evidence for ourselves.

In this post a contract artist who calls himself Wolverine gives a long list of life-threatening medical errors that happened to him. I hope that he will eventually add dates so that the rate of error becomes clearer [more: all the errors happened within a 14-month period] but even without them the stories suggest that life-threatening errors are common. (As does the effectiveness of surgical checklists.) Medicine is a job where if you make a mistake only the customer suffers not you. Surely this is why the error rate is so high. Wolverine was operated on by a surgeon who, because of a fatal error, had lost his license to practice in California. He changed states, was hired again, and made the same error on Wolverine.

I learned about this from Tucker Goodrich, who has been corresponding with the author and told me something remarkable:

He’s eating a paleo with raw milk diet.  The other transplant patients he knows are all eating the modern American diet and dying of infections; he’s been infection-free for two years.

In April there was a conference in Cambridge, Massachusetts, about how to reduce overtreatment in American health care. Attendees were told:

The first randomised study of coronary artery bypass surgery was not carried out until 16 years after the procedure was first developed, a conference on overtreatment in US healthcare was told last week. When the results were published, they “provided no comfort for those doing the surgery,” as it showed no mortality benefit from surgery for stable coronary patients.

One participant said that overtreatment cost one-third of US health care spending. As far as I can tell, no one said that “evidence-based medicine” underestimates — in the case of tonsillectomies, almost completely ignores — bad effects of treatments. This failure to anticipate and accurately measure bad effects of treatments makes the overall picture worse. Maybe much worse.

Ron Unz makes a very good point — that just one awful drug (Vioxx) sold by just one awful drug company (Merck) appear to have caused hundreds of thousands of deaths:

The headline of the short article that ran in the April 19, 2005 edition of USA Today was typical: “USA Records Largest Drop in Annual Deaths in at Least 60 Years.” During that one year, American deaths had fallen by 50,000 despite the growth in both the size and the age of the nation’s population. Government health experts were quoted as being greatly “surprised” and “scratching [their] heads” over this strange anomaly, which was led by a sharp drop in fatal heart attacks. . . .

On April 24, 2005, the New York Times ran another of its long stories about the continuing Vioxx controversy, disclosing that Merck officials had knowingly concealed evidence that their drug greatly increased the risk of heart-related fatalities. . . .

A cursory examination of the most recent 15 years worth of national mortality data provided on the Centers for Disease Control and Prevention website offers some intriguing clues to this mystery. We find the largest rise in American mortality rates occurred in 1999, the year Vioxx was introduced, while the largest drop occurred in 2004, the year it was withdrawn. Vioxx was almost entirely marketed to the elderly, and these substantial changes in national death-rate were completely concentrated within the 65-plus population. The FDA studies had proven that use of Vioxx led to deaths from cardiovascular diseases such as heart attacks and strokes, and these were exactly the factors driving the changes in national mortality rates.

The impact of these shifts was not small. After a decade of remaining roughly constant, the overall American death rate began a substantial decline in 2004, soon falling by approximately 5 percent, despite the continued aging of the population. This drop corresponds to roughly 100,000 fewer deaths per year. The age-adjusted decline in death rates was considerably greater.

This illustrates how Merck company executives got away with mass murder on a scale that the Khmer Rouge would be proud of. It also illustrates why I find “evidence-based medicine” as currently practiced so awful. Evidence-based medicine tells doctors to be evidence snobs. As I showed in my Boing Boing article about tonsillectomies, it causes them to ignore evidence of harm — such as heart attacks and strokes caused by Vioxx — because the first evidence of harm does not come from randomized controlled studies, the only evidence they accept. It delays the detection of monumental tragedies like this one.

The new Choosing Wisely campaign is centered on lists of “unnecessary” medical tests and procedures. The hope is that these lists will reduce waste in the health care system. I wondered what “unnecessary” meant so I interviewed Daniel Wolfson, who is Executive Vice President and Chief Operating Officer of the American Board of Internal Medicine, located in Philadelphia.

At the heart of my question was: why these procedures and not others? Each list has five items. How were they chosen? Here is how the five items on the American College of Physicians’ list were selected:

The American College of Physicians (ACP) formed a workgroup of eleven experienced internal medicine physicians with specific skills in the assessment of evidence. . . . The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP staff physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1 percent of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care.

I said this sounded like a popularity contest. Mr. Wolfson said, no, the recommendations are based on evidence. “Do you know what a randomized trial is?” he asked. What evidence? I said. It’s not on your website.

Yes, it’s there, said Mr. Wolfson. He pointed me to the “sources” at the end of the ACP list. Here is one of those sources:

2011 USPSTF screening for coronary heart disease with electrocardiography (draft) guideline; 2011 AAFP recommendations for preventive services guideline; 2010 ACCF/AHA assessment of cardiovascular risk in asymptomatic adults guideline.

This is evidence? I said. It’s very vague. At this point Mr. Wolfson ended the interview.

So I continue to think it is a popularity contest. Who knows how the doctors on that “randomly selected internal medicine research panel” made their decisions.

I think the Choosing Wisely campaign is worthwhile, in spite of Mr. Wolfson’s implausible claims (he also said the doctors who created these lists were “courageous”).  Here’s what I would say: The items on these lists are things that many doctors in that specialty think are done too often. The lists are like a free second opinion. 

Michael Ellsberg has an excellent article about the American Dietetic Association’s attempts to make it illegal for anyone they haven’t approved to give nutritional advice. In this document, they are frank that this is their goal. After Ellsberg drew attention to it, it was taken down. I look forward to learning why it was taken down.

The Washington State chapter of the ADA, now called the Washington State Academy of Nutrition and Dietetics, is responsible for taking down the document. The organization has this mission statement:

Empowering the people of Washington to improve health with safe, effective and reliable food and nutrition information.

Our Vision:  Optimize the health and well being of Washington State individuals through food & nutrition.

Our Mission:  Empower members to be Washington State’s food and nutrition leaders.

Long ago, in the civil rights or suffrage movements, for example, empowerment meant removal of barriers. This organization preaches empowerment by creation of barriers. Their empowerment is someone else’s disempowerment.

An organization called the American Board of Internal Medicine Foundation has launched a campaign to reduce the cost of health care by reducing “unnecessary” tests, drugs, and procedures.  A bare-bones website lists them. For example:

Don’t routinely do diagnostic testing in patients with chronic urticaria [hives].

Here is the explanation of that recommendation:

In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.

Not clear.  Are they trying to say the tests are useless (“not associated with improved clinical outcomes”)?

My broad question about the campaign is: What does “unnecessary” mean? This is not explained on the website nor in a Washington Post article about the campaign.

A nearby article on the Post website is about “the downside of mammography”.  It says:

 A study published Monday in the Annals of Internal Medicine adds to a growing body of evidence that the potential risks of routine breast-cancer screening via mammography might in fact outweigh such screening’s benefits.

That’s clearer. It seems to be saying the costs outweigh the benefits. (What are “potential” risks? I thought all risks were potential.) But that doesn’t mean that breast cancer screening is “unnecessary”, it means it is a bad idea.

If the foundation is trying to say that a lot of medicine does more harm than good, then, please, say so. If they are trying to say that a lot of medicine is useless, then, please, say so. Stop being polite.

I contacted the foundation to ask them about this.

Thanks to Bryan Castañeda.

• Where are they now? J. S. Boggs, profiled by Lawrence Wechsler in The New Yorker. Boggs made small paintings closely resembling money (e.g., a $100 bill) that he offered in place of real money. He sold surrounding details (e.g., the receipt) to a collector who would try to get the bill Boggs had drawn from the merchant in order to “complete” the work of art.
• A SLDer (Shangri-La Dieter) loses 80 pounds in 18 months. That’s 1.0 pounds/week.
• More medicine does not equal better medicine.  I agree with every word of this critique by a Glasgow general practitioner named Des Spence. For example, “The prescribing of powerful antipsychotic and potentially addictive stimulant drugs to children is a societal norm. . . . A quarter of US women are taking mental health drugs.” As Spence says, these are signs of a healthcare system biased toward those who make money from it and against everyone else (including children). One way to sum up why this is a mistake: Your health is too important to be left to those who only make money if you are sick.
• Japan: from rice to wheat to rice.

Thanks to Bryan Castañeda.

• All about kefir
• Fraud and waste at a New York hospital. From the comments you can see that the problems have lasted decades.  If someone is always sick, year after year, it means there is something about their sickness (about health in general, actually) we do not understand. Likewise, the decades-long persistence of huge problems at this hospital suggests there is something fundamental about regulation (and perhaps health care) we do not understand.
• This paper about how well blood uric acid level predicts mortality, which appeared in 2004, did not get nearly the attention it deserves. I was shocked by its existence — American medical school professors are almost incapable of good research. Well, it’s from Finland.
• David Healy’s new blog.

Thanks to Bruce Charlton, Jazi Zilber, Melissa McEwen and Alex Chernavsky.

• more health, less profit?
• Long interesting review of Michael Mann’s new book. “The controversy is actually very simple. Mann’s papers give undue focus to a small amount of data.”
• excellent article in The Smithsonian about fermentation. “We’re trying to see if there’s a way to get more of that umami richness and less fishiness.”
• Flaxseed in Human Nutrition (1995 book).
• Spy magazine highlights.

Thanks to Tom George and Mark Griffith.