White Coat Underground

A crank is a crank

Sat, 07 Nov 2009 18:19:44 -0500

I'm told that mathematicians and physicists get a lot of mail from folks with "big discoveries". These discoveries are often of the "Einstein was wrong and I figured out the Theory of Everything" variety. Many of us refer to these folks as "cranks", a catch-all, derogatory term for people who, through their own arrogance and ignorance, think they have, despite little education or work, disproved ideas that have taken lifetimes to assemble.

Enter the anti-vaccination cranks. Immunoprophylaxis---the manipulation of the immune system to prevent disease---is centuries old, and over those centuries has become more refined and sophisticated. We have moved from inoculating people with smallpox pus to using recombinant DNA to create safer vaccines. We have moved from the Royal Experiment, in which a few prisoners were inoculated and counted, to sophisticated epidemiologic methods of evaluating the burden of disease and the efficacy of vaccination. We have eradicated some diseases, and could, with adequate commitment, eliminate more though mass vaccination programs. In the two centuries since smallpox vaccination became an accepted technique, biology, medicine, and epidemiology have become modern, science-based fields that allow for creation of methods and materials to prevent disease, and the means to evaluate their efficacy.

But human beings are superstitious animals. Like the ancients, we use our personal experiences to create generalizations about how the world works, generalizations that often fail when examined in a more rigorous manner. If we get a flu shot, and then get sick, we blame the flu shot, despite the flu shot's inability to cause a rhinovirus infection.

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A pox on your house? How fighting one disease brought back another

Thu, 05 Nov 2009 17:06:54 -0500

Some were surprised to read that after a pro basketball player swatted a bat out of the air, he had to have rabies vaccinations.

This is not a surprise to many medical folks who have had to give rabies prophylaxis after bat exposures. Most of the few human rabies cases in the U.S. are transmitted by bats, although raccoons are more often diagnosed with the disease. Because rabies is fairly easy to transmit and nearly always fatal to humans, we are very aggressive about prevention. Rabid wild animals can have unusually aggressive behavior and can transmit rabies to humans and to their pets. With human populations mixing more and more freely with wild animal populations, the risk of rabies exposures increases. We're obviously not about to hold down every wild raccoon and vaccinate them, but humans, being rather clever animals, have found a way to vaccinate animals in high-risk areas.

One program aims to create a "vaccine barrier" in the Appalachians by dropping oral rabies vaccines into these areas either by plane or by hand. The program is aimed primarily at raccoons but other animals are affected as well. The vaccine itself is fiendishly clever, but, as the CDC reports, is not without some unintended results.

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Cruel and unusual

Wed, 04 Nov 2009 13:46:33 -0500

No matter how you feel about incarceration, it's a dangerous business. Inmates have high rates of serious transmissible diseases which aren't turned into the warden when they are released. Around 2.5 million people are held in American correctional facilities. HIV rates for imprisoned men 1.6% and for women is 2.4% (compared to about 0.4% among Americans as a whole). About 4.5% of inmates reported sexual victimization. Of the facilities that provide hepatitis B vaccination, 65% target "high risk" groups only. Tuberculosis rates are also very high. This is just a sampling of the horrifying health conditions in jails and prisons.

Prisons are a set up for the transmission of infectious diseases, and when prisoners are released, they return these infections to the public at large. This is one of the many reasons to pay better attention to health care in prisons.

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"Mind affects body": what a new Science placebo study tells us

Wed, 04 Nov 2009 13:23:24 -0500

As I've written before, the placebo effect is a rather messy phenomenon. It usually refers to the difference in outcomes in a study that are not due to the intervention but to multiple other variables associated with being in a study. More colloquially, "placebo" often means a positive effect seen from the administration of a biologically inert substance. There's a bit of a buzz brewing about a recent brief communication in Science. The report used fMRI to look for physiologic correlates to pain responses that were attenuated by an inert substance. (For the purposes of this discussion, I'll assume that the fMRI technique used is valid.) According to the authors:

Placebo analgesia is a prime example of how psychological factors can influence pain perception (1). It refers to a situation where the administration of an inactive treatment has a pain-relieving effect, presumably because of the participant's belief in the analgesic effectiveness of the treatment.

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Dear Bigot

Tue, 03 Nov 2009 20:38:37 -0500

Thank you for polluting my in box with a hateful, lie-filled chain letter. It took me all of ten seconds on the internet to find the truth behind your lie and thereby discover what a tool you are. I'm sure it would have seemed natural to you that because we share an ethnic identity I would give you a pass on this one---I won't. My wife and I are not raising our daughter in a household of hatred, but of love. She will learn to love and respect everyone, and even to reach out to those, who like you, may not at first seem deserving of such a precious gift.

My daughter is surrounded by people of many backgrounds and religions, and has learned a respect for different beliefs. She may not always feel that way, but when she feels afraid of something different she asks questions rather than lashing out at the unknown. This is the difference between compassionate intelligence and loathsome stupidity.

My daughter is a better person than I am. She would likely embrace you, loathsome correspondent, as a human being worthy of respect and love, regardless of background and beliefs.

I'm not there yet.

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Faith healing in health care reform---blogs had the story first

Tue, 03 Nov 2009 14:17:40 -0500

The mainstream media is finally catching on to a disturbing story--the insertion of faith-healing and other non-scientific practices into health care reform. Health bloggers have been on this story for a while, showing us that Senate Bill 1679 currently contains language that would require support for faith healing practices:

The essential benefits provided for in subparagraph (A) shall include a requirement that there be non-discrimination in health care in a manner that, with respect to an individual who is eligible for medical or surgical care under a qualified health plan offered through a Gateway, prohibits the Administrator of the Gateway, or a qualified health plan offered through the Gateway, from denying such individual benefits for religious or spiritual health care, except that such religious or spiritual health care shall be an expense eligible for deduction as a medical care expense as determined by Internal Revenue Service Rulings interpreting section 213(d) of the Internal Revenue Code of 1986 as of January 1, 2009.

This, and other language, would protect such services as Christian Science healing as valid, reimbursable medical practices. Why should anyone have a problem with that?

As I pointed out previously, it takes away important resources needed for real medical practices, and my violate the Constitution. But there are more important ethical reasons to be cautious about such language.

Religious healing practices are nonsense. They are not based on science but on mystical, vitalistic nonsense, and while one cannot object to people doing it on their own dime, to give these practices the same legitimacy as, say, blood pressure monitoring and treatment is unconscionable and immoral. When the government decides to require that faith healing be treated like any other modality, it lends legitimacy to useless and often harmful practices. How are we to protect children from their deluded parents if health insurance actually pays for neglect?

We cannot allow codification of faith healing and child neglect. This is a deal-breaker. It is not impossible to believe that if this language were retained, we could see homeopathic hospitals and Scientology psychiatry wards.

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What do we need most during a flu pandemic? Zombie quacks!

Mon, 02 Nov 2009 19:16:41 -0500

One of my dear readers just left the internet equivalent of a flaming bag of turd on my bloggy doorstep:

Everybody should read this article by Dr. Russell Blaylock http://articles.mercola.com/sites/articles/archive/2009/11/03/What-We-Have-Learned-About-the-Great-Swine-Flu-Pandemic.aspx
These are the facts folks, all information is derived from Center for Disease Control and Prevention, the National Institutes of Health, the National Institutes of Allergy and Infectious Diseases and the New England Journal of Medicine.

Whenever stamping out the flaming bag of poo, it's wise to remember ones shoes may become sullied. Still, how can I resist?

Before we explore the link kindly given by our reader, let's look at the messenger. He recommends reading Dr. Russell Blaylock. Who is this man?

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Swine flu is killing a different set of folks---young folks

Mon, 02 Nov 2009 08:08:57 -0500

This is not a normal flu season (if you hadn't heard). Normally, summer sees a return of flu cases to a low baseline, but not this year---this year we saw a bump in cases around April, with a consistent trickle of cases throughout the summer, and significant outbreaks at summer camps and military bases. And now, from that "higher low point" we are seeing an early, rapid rise in flu cases. Some of this is likely attributable to an increase in reporting---people are worried and going to the doctor for illnesses that they would normally ignore. But that isn't likely to be the bulk of reported cases.

Flu visits, from the CDC

An "influenza-like illness" (ILI) is usually defined as a fever of 37.8 or above (100 degrees Farenheit), plus either sore throat or cough, without another explanation, such as strep throat. Many ILIs are not influenza, but during the flu season, the sets of ILI and actual flu increasingly overlap; that is, more ILIs are due to actual flu when there is a lot of flu in the community, making this a useful marker of flu activity. We can't test everyone, so we have to make an educated guess, and the fact that ILI rates are soaring above anything we normally see, combined with samples from surveillance sites, confirms that we are seeing flu rates far above what would normally be expected.

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Donors choose---this is it, folks

Fri, 30 Oct 2009 14:35:30 -0500

This is the penultimate day of our Donors Choose challenge to fund needy Michigan classrooms. We have fully funded 13 separate projects and scooped up matching funds from the Gates Foundation and Hewlett-Packard.

You have all been terribly generous, but I have to ask one final favor. A generous reader just gave $100 to a project to create an outdoor science classroom focusing on gardening. It's a terrific project and that single donation has brought the project within $300 of being fully funded. If you, dear readers, could kick in even a few small donations (in the 1-5 dollar range) I think I could find a way to get this project funded before the end of the drive.

This is the last you'll hear from me until next October. If you could kick in a buck or two and get the word out on twitter, it would be very exciting.

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Next!

Fri, 30 Oct 2009 13:57:15 -0500

Getting my swine flu shot

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The anti-vaccination movement is morally bankrupt

Wed, 28 Oct 2009 16:02:33 -0500

A hat-tip to my buddy Abel over at TerraSig for keeping this story alive and inspiring me to chime in. --PalMD

It's no secret that I find the anti-vaccination crowd to be abhorrent. The public's health is the first victim, followed closely by individual patients and parents struggling with individual health decisions. I cannot fault patients for making bad decisions---the anti-vaccination movement has a very effective propaganda arm. Folks like Jenny McCarthy have a large audience and make no secret of their desire to see infectious diseases increase in others:

I do believe sadly it's going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it's their f___ing fault that the diseases are coming back. They're making a product that's s___. If you give us a safe vaccine, we'll use it. It shouldn't be polio versus autism.

These folks are so focused on their own quasi-religious delusions that they can no longer properly evaluate reality. That would be fine if they lived in isolated caves away from electronic media. But they don't.

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Service

Tue, 27 Oct 2009 21:28:28 -0500

The young resident presented the patient in the usual dry terms we use for such things.

"The patient is a 42 year old woman recently hospitalized for cirrhosis due to alcohol use. Her cirrhosis has been complicated by esophageal varices, encephalopathy, and refractory ascites."

In other words, the woman has drunk herself nearly to death.

"Is she still drinking?" I asked.

"She says not. She says she stopped about six months ago when she first got sick."

"What did GI say? Did they refer her for transplant evaluation?"

"No," she said, a bit disappointedly, "they said she wasn't a candidate."

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Donors choose---almost there!

Tue, 27 Oct 2009 13:28:25 -0500

You guys are great. Large donations continue to trickle in, but really, we can live quite well off of small donations. It would be really cool if we finished off the drive with a bunch of micro-donations, in the 1-10 dollar range. These small donations add up really quickly.

A Story to Tell is $97 away from being fully funded, allowing the teacher to buy a laptop and printer.

Inner City Soccer Team is a bit more of a challenge with $376 to go. There is no reason we can't get this done before the end of the week.

So let's do it---a buck here, a buck there, and soon enough...

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Are you a 99214 with 250.02, 401.1, and 272.2?

Mon, 26 Oct 2009 22:28:59 -0500

When I see a patient at the office, I spend time developing trust, forming a therapeutic alliance, thinking through their physical complaints, examining them, and applying the best evidence to formulating a plan for maintaining their health. It's a lot of fun.

Less fun is the part where I try to get paid. To bill an insurance company, I must use numeric diagnostic codes that best fit what I'm seeing, and I must pick a code representing a level of service, that is, how hard I worked.

The diagnostic codes are referred to as ICD-9 codes, and the service codes are called E/M codes. Not all ICD-9 codes are easily billable. For example, if a patient comes to see me for anxiety or depression, I can't bill for it. I can bill for "malaise and fatigue" (780.7), but not for generalized anxiety disorder (300.02) (supposedly it's possible, but, like the Loch Ness monster, it's always a friend of a friend of a friend who saw it).

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Donors Choose---final days

Mon, 26 Oct 2009 13:20:24 -0500

We have some very generous readers. We've managed to fully fund 12 out of 14 proposals from needy Michigan classrooms. We can probably pull off funding the final two projects this week, and although our readers have been quite generous in the size of individual gifts, I'd love to see a bunch of micro-gifts, in the 1-10 dollar range.

Remaining Projects

A Story to Tell: The teacher is trying to get a lap top and printer for her kids. That's it. She's ~~$148~~ $123 away from getting it.

Inner City Soccer Team: Aside from the benefit of athletics, these kids are isolated in an economically and ethnically homogenous community and the teacher wants them to be exposed to a bit more of the world. $450 left to go.

There are other projects as well, but these are the final two of the 14 original Michigan classroom projects. We have a few days. Let's get some micro-moolah flowing.

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