The vast majority of people who don't immunize aren't doing it for religious reasons. There's a growing segment of 'educated' people who have 'researched' the issue and have decided that the risks outweigh the benefits.
Unfortunately there are 'professionals' within the health care system that spout this idiocy, including nurses and chiropractors.
He is saying that teaching a religious doctrine is child abuse. That is just not reasonable.
You may not think it is reasonable, but we have pulled children out of homes before.
Saying that some religious teachings or philosophies are bad is no different than saying that some non religious philosophies are bad
True.
I think a non religious environment can be potentially abusive too. So what? OK, why? At least Dawkins has a rational.
You're misunderstanding me.
The reason children 'get pulled out of homes' in your example is not because the parents are religious, but because the state believes that harm is being done. The focus is on the act (or lack of action) by the parents, not on the fact that the parents are teaching religion to their child.
Dawkins is not advocating against the specific things that can lead to harm, but rather that religion itself is harmful and tantamount to abuse in and of itself. That is unreasonable.
I think a non religious environment can be potentially abusive too. So what? OK, why?
I suspect you think I am saying that a non religious environment is conducive to abuse (compared to a religious one). I am not. I think any environment has a potential for abuse and the religion aspect is a non issue.
You honestly believe that religious people are all abusing their children?
I think a religious environment is potentially abusive, and instilling superstitious beliefs as truth in children is not a good thing.
You think that concept is 'reasonable'? It's staggering that you got modded up.
What about "christian scientists" that deny critical care to their children? What about muslims who teach terrorism. What about "abstenence only" education?
I'm not saying that fundamentalists weren't responsible for the twin towers. I'm saying that painting them as representatives for all religion is offensive. But that is his intent after all...
It is the seeming rational moderate "enablers" that give comfort to the extremists. Religion is nonsense. If you can believe absurdities you can perpetrate atrocities.
It's fine to look at a *specific* act or ideology and debate its merits. He is not. He is not saying 'potentially abusive', or 'more likely to be abusive'. He is saying that teaching a religious doctrine is child abuse. That is just not reasonable.
Saying that some religious teachings or philosophies are bad is no different than saying that some non religious philosophies are bad
I think a non religious environment can be potentially abusive too. So what?
There are plenty of non religious people who perpetrate atrocities. Would it be reasonable to paint Pol Pot or Stalin as model atheists?
He's said that people who teach their kids religion are child abusers.
No, he said that labeling children is close to child abuse.
He ends one of his lectures by saying how religious fundamentalists crashed into the twin towers, and therefore it's time to stop being so respectful of religion.
No he doesn't. You are lying about what he's saying, just like with the child abuse argument he made.
Those are pretty offensive comments to me...
And I find it offensive that you are actively lying about what Dawkins is saying. Pathetic.
And I quote,
"How did September the 11th change you? Well here's how it changed me. Let's all stopped being so damned respectful."
This is from the atheist's call to arms from Tedtalks 2002.
He's said that people who teach their kids religion are child abusers.
From a logical perspective, that is not unreasonable or unheard of. We remove children from "christian scientists" when they refuse critical care.
He ends one of his lectures by saying how religious fundamentalists crashed into the twin towers, and therefore it's time to stop being so respectful of religion.
Religious fundamentalists *DID* crash into the twin towers.
Those are pretty offensive comments to me...
Truth is often offensive to those who refuse to accept it.
You honestly believe that religious people are all abusing their children? You think that concept is 'reasonable'? It's staggering that you got modded up.
I'm not saying that fundamentalists weren't responsible for the twin towers. I'm saying that painting them as representatives for all religion is offensive. But that is his intent after all...
I find a lot of the time he can be callously disrespectful and religiously atheist.
Having seen him many times, the only offense he may have committed is *not* entertaining the rediculous notion that a god exists without any proof.
He's said that people who teach their kids religion are child abusers.
He ends one of his lectures by saying how religious fundamentalists crashed into the twin towers, and therefore it's time to stop being so respectful of religion.
Dawkins holds that to be an intelligent scientific thinker you must hold to both strict naturalism and evolution apriori, which is not so subtly implying that all of the other 53-ish percent of humans living in the United states are basically drooling morons.
Perhaps Dawkins is not implying that these people are unintelligent, but that they are unscientific.
Actually in many of his lectures he implies that religious people are less intelligent. He delights in in the studies that have shown this kind of correlation.
Unfortunately this is severely mitigated by two groups - lawyers and patients.
The original article could equally be titled 'why lawyers hate science' - as the parent says, many judgements against doctors are based on whether something could have been done, not whether there was evidence to support doing it, or even whether it would have been effective.
That is sheer and utter nonsense.
I wish it were nonsense. There was a US case about a patient who had an acute spinal cord injury. There is a controversy about whether or not to give steroids in these cases to reduce swelling and decrease subsequent injury. So far the consensus is that it doesn't help. The ER attending physician therefore did not give steroids. The patient had a bad outcome. The ER attending was found guilty (not sure what the correct term is) because the prosecution found an expert witness who said that it might have helped.
The only "imperative" imposed by the courts is that "reasonable care" be applied? Why is that so terrible? Why is that so onerous? Most medical care is far, far above that relatively low standard.
The difficulty is in defining reasonable. It seems that some lawyers are very good at skewing this definition.
Most physicians practice 'defensive medicine'. That means they do things that are medically unnecessary, solely to protect themselves from frivolous lawsuits. Good medicine alone unfortunately won't protect you from malicious (or vulnerable and wounded) people, looking for someone to blame.
I can tell you a number of cases where the physician was found guilty and they did nothing wrong. The jury just didn't like how things turned out for the patient.
US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient.
Actually one of the big reasons that EM diagnostic evaluation is more aggressive than usual is that (shock) patients actually do have a hint of what is important. That is, if you take a random person who goes to his family doc with chest pain versus one who goes to the ER the former is less likely to have significant coronary artery disease. So its not surprising that if you compare ER with primary care, it is good medicine to be more aggressive with diagnostic evaluations in the ER.
That said, hell yeah as an ER doctor I sometimes practice defensive medicine. If you place me in an environment where people can effectively sue me for what I might make full time in 20 years for a bad outcome that happens despite me practicing medicine that meets the standard of care in my practice environment I sure as hell am going to practice defensive medicine. The fact that I don't always do aggressive diagnostics in every patient is either me being a Pollyanna or perhaps taking my patient's best interests at heart. I'm willing to put my neck on the line somewhat to avoid a CT in a toddler who just has overprotective parents, but your fat, diabetic, smoking, sedentary, litigious ass is just not cute enough to get the my sympathy.
I'm comparing US emergency medicine guidelines with Canadian emergency guidelines. A lot of the US based CME will even directly admit in their lectures that their recommendation is based more on protecting against potential litigation.
I'm not criticizing defensive medicine either. 98% of my charting is done solely to protect myself in case of a law suit. Very little of it is clinically helpful.
I practice mostly in primary care, but I do ER work as well. Most of my EM CME is US based. My comment is not intended as a slam at all, just a realization that we practice medicine in different environments.
(and thanks to my EM training I picked up two subtle acute coronary syndromes recently that my partners missed. Direct admit from clinic to the ICU baby! Sometimes it pays to be aggressive)
I was referring specifically to acute (new onset) back pain. I'm not advocating never investigating back pain.
I think that medicine and physiology is still in its infancy relatively speaking. When I get someone in your situation, I tell them that the tests look normal. That it's good news because it rules out a lot of bad things, but it still doesn't explain the problem. There is a vast range of human experience that we just don't understand or have a good solution for.
There's no good answer to this. There aren't really EBM vs non EBM schools of medicine. The difference is the amount of time you spend keeping up, and how willing you are to change your practice. Newer docs tend to be more up to date than the older ones. EBM is very new phenomenon.
The other problems is that evidence is very often in the eye of the beholder. Many physicians lack the time and ability to evaluate evidence for themselves. They rely on drug reps (shudder) to get their 'evidence'.
Good evidence in medicine is hard to find. Once something is standard of care, it's hard to test it because ethically you can't not offer someone effective treatment to compare. The best studies are placebo controlled, double blind, randomized, controlled trials which are extremely expensive and often sponsored/biased by Big Pharma. Often there are even contradictory studies. A lot of the newest clinical care guidelines boil down to expert opinion.
Re:Evidence based medicine is extremely frustratin
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Why Doctors Hate Science
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· Score: 2, Interesting
I guess I do sometimes prescribe and perform treatments that have little evidence behind them. The problem is that the placebo effect is not necessarily statistically significant. Is it worth taking the gravol to have one less barf over the course of the illness? Maybe...
It's hard for me to recommend anything that has potential to harm, unless I firmly believe that the benefits outweigh the harms. That's the crux of the issue for me.
Many people I see take a number of medications, prescription and non that I may not even know about. There are potential dangerous interactions there that I don't/can't/won't know about. Even non dangerous side effects can be problematic. There is also the fact that medications cost money. I don't want people to waste their money on a treatment that is no better than placebo.
I do prescribe things that are of nebulous benefit, when people are desperate to try something, or to cling to their experience that it works.
It's just not my style to prescribe unnecessarily (in my opinion). If you see me for your cold. I will tell you to rest, take some advil or tylenol, suggest a decongestant and give you a note for work if you need it. If you see my partner, you will get a prescription for cough syrup (most do nothing), painkillers and decongestants. He also has a very low threshold for prescribing antibiotics. The net result is that his patients are extremely satisfied and his visits are quicker. My patients leave somewhat disappointed, often come back (I'm STILL sick!!!) and I have to spend a lot more time educating my patients. The patient populations self select over time and the pill poppers go to him, and the pill averse come to me.
Re:Evidence based medicine is extremely frustratin
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Why Doctors Hate Science
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· Score: 4, Insightful
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
I have considered it. I also consider the fact that every medicine I prescribe carries risks, even if those risks are low. If I don't know whether the risk outweigh the benefits, I don't prescribe, particularly for 'nuisance' illnesses.
I know many physicians who prescribe placebo treatments and tests. I have trouble doing this even though patients find it very satisfying. What I sometimes do instead is tell people what the evidence is and let them decide. I struggle with the ethics of prescribing a placebo.
I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.
This is rule of thumb, and Dr. Merenstein should have known this.
Actually the previous poster is right. Population based studies suggest that more harm than good is done by screening for prostate cancer.
The evidence goes like this. Once you have an elevated PSA, you see the urologist who orders a biopsy. Biopsies and treatments for prostate cancer carry risks like bleeding and infection, urinary incontinence and impotence. Now most prostate cancers will not kill you or cause problems in your lifetime. So investigations and treatments for prostate cancer cause more harm to people than the cancer does. This makes sense in a population, but not to the guy who got a bad cancer.
The current guidelines do not suggest PSA's in all men over fifty, but rather that you discuss the risks and benefits of screening, plus potential harm of further workup of a positive screen vs. the harm of developing prostate cancer. In practice, there is no patient who can actually understand enough of this to truly make an informed decision. Many docs haven't heard of the 'new' evidence and continue screening. The ones who do know of that evidence often ignore it because it's hard to explain, and patients will love you for finding an early cancer, even if it would never have affected them.
As far as your colon cancer screening comment, what you describe is standard of care.
The other thing to consider is that medicine in the US is HUGELY biased by the litiginousness of US culture. US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient. A lot of those investigations are not recommended in socialized health care systems because they are not cost effective, nor do the benefits outweigh the disadvantages.
Evidence based medicine is extremely frustrating
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Why Doctors Hate Science
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· Score: 4, Insightful
I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.
I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?" Very dissatisfying to a lot of patients.
Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.
The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.
EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.
IMHO O-chem as it is taught by most chemistry departments is completely useless for pre-med students. There ought to be a lower level biochemistry course in its stead as a pre-req for pre-meds. Most MDs will NEVER have to worry about organic synthesis and crap like that; they WILL need to worry about metabolic pathways and enzymatic reactions.
Bingo.
I have never used half the crap I took in undergrad. There are two reasons why they include most prereqs.
1)hoops to jump through. 2)most people in 'pre-med' (which doesn't exist in most Canadian universities now) don't get into medicine, so they still need basic science to have some relevant skills in another field.
And as to the article that talks about science leading to research. Many don't like research. To castigate the clinician as mediocre because they don't do research is grotesquely unfair.
Hard core porn exists because it's something we cannot acceptably do, though plenty of people want to. Porn doesn't invent the desire. We have the desire so some people like it. Except that advertising can create the desire in you for something you never even know existed. I went through my entire life, never once wanting a slim MP3 player with a touch screen on it, until the day that I saw one advertised. Suddenly I had to have one.
People are unable to admit that outside influence can control their decisions which is partly why marketing and advertising are so wildly successful in our commercial society. In other words, it's not longer about creating a product to fill a niche. It's all about creating the desire in people for the product in question.
Why wouldn't the exact same principles apply to your pornography argument?
Wrong! Nobody has a right to smoke around someone else without their permission. There is no 'safe' level of second hand smoke, which is proven to be toxic. Nobody has the 'right' to expose you to ammonia gas, or benzene or any other toxic chemical. Why on earth would you make an exception for cigarette smoke?
The 'right' to smoke nonsense is propaganda largely promulgated by tobacco companies.
Again, you obviously don't know the definition of science and faith. from http://www.answers.com/faith&r=67 [answers.com] Faith: Belief that does not rest on logical proof or material evidence.
From Wikipedia [wikipedia.org] on scientific method: It is based on gathering observable, empirical and measurable evidence subject to specific principles of reasoning.
Most people's belief in science is based on 'faith'. Very, very few people have the intellectual capacity or education to truly comprehend or competently discuss the science that they believe in.
The average person who believes in evolution has only the dimmest understanding of the science on which those theories are based.
An astronomer can suggest that the universe is 12 billion years old and people will believe it. Then another astronomer makes another theory that the universe is actually 25 billion years old and people believe that. Ordinary people have no way of understanding the math, physics and other observations on which the theories are based.
A scientist may base his belief on evidence, but the ordinary person is basing his belief on 'faith' that that scientist is right.
The point is NOT the substance/act itself being inherently harmful, but rather an individual's USE of something that is harmful. So, the point is not the game/playing but the use of game/playing? What is then the use of playing computer game? I'm not sure what you mean here. I'm saying that games aren't inherently destructive or problematic, but that some people can play games in a manner that's destructive to themselves. Games are an entertaining diversion to most, but can be 'abused' in a destructive manner.
Food is a wonderful thing, yet there are those individuals who's attitudes and behaviors with respect to food are destructive. It's the destructive behavior that's the 'disorder' not the food itself. Let me try to understand this one: you are probably not saying that that those individuals that have destructive "attitudes and behaviors with respect to food" have disorders, right? If someone has bulemia or anorexia nervosa, they most certainly have a destructive attitude and behavior with respect to food, and these are both recognized mental disorders. There are people who overeat and become unhealthy and obese. This is not a mental disorder, but still a destructive behavior. The label - addiction, disorder etc. - is unimportant. In any of these cases targeting negative behavior is important
Using stimulants like amphetamines to treat certain medical conditions is appropriate. Using them to get high at the cost of your family and career is inappropriate. What about using officially prescribed Prozak/Codein/Morphin at the same cost? Such stuff also happens... It doesn't matter where you get a drug. If you use it inappropriately it's bad. If you use it appropriately it's okay.
Take a look at the DSM IV - the classification book for mental disorders. In order to qualify as a disorder, something usually has to have a significant negative impact on someone's function. So, "disorder" = "significant negative impact", that surely clarifies things, (maybe not on "someone's function", let's say for the sake of agreement on someone's life... is "someone's function" equal to "someone's life"?) No. If you look at the DSM-IV (it's available online) you will see what I mean. Mental illness is a spectrum. Someone who drinks alcohol once a week at dinner is not addicted. Someone who drinks compulsively and gets withdrawal if they stop drinking is addicted. To account for the wide variety of normal and abnormal human behaviors, the medical profession has tried to make criteria to define mental disorders. These criteria aren't perfect, and they often change, nevertheless, they are useful. I said that ONE of the criteria for most disorders is negative impact on function. That means a normal habit, trait or characteristic has changed into something abnormal. That distinction is often made by seeing how it affects someone's life. Are there destructive behaviors that aren't mental disorders? Of course! So what? All I'm saying is that we should recognize destructive behaviors and try to fix them.
I see no difference between compulsive gaming that affects one's life, and compulsive hair pulling that affects one's life. Indeed. I mean insofar as they are both compulsive activities that affect one's life! My point is that you can pluck your eyebrows and that's considered normal. Or you can compulsively pull out your hair and then it's called trichotillomania which is a mental disorder. In both situations you are pulling out hair... nothing wrong with that. But one of them makes you unhappy and impacts your life and that is the distinction I am pointing out.
People are missing the forest for the trees here. The point is NOT the substance/act itself being inherently harmful, but rather an individual's USE of something that is harmful.
Food is a wonderful thing, yet there are those individuals who's attitudes and behaviors with respect to food are destructive. It's the destructive behavior that's the 'disorder' not the food itself.
Using stimulants like amphetamines to treat certain medical conditions is appropriate. Using them to get high at the cost of your family and career is inappropriate.
Take a look at the DSM IV - the classification book for mental disorders. In order to qualify as a disorder, something usually has to have a significant negative impact on someone's function.
I see no difference between compulsive gaming that affects one's life, and compulsive hair pulling that affects one's life.
Medical Specialist Exams have an Oral Component
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The Fallacy of Hard Tests
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· Score: 3, Informative
The hardest part of most medical specialist exams are the orals. Nobody ever complains about the written component. You get a to sit in a room with one or more examiners for a few hours of intense grilling. There is no way to hide any lack of knowledge and your deficiencies are exposed for all to see.
Also the US has a strange system of certifying specialists. After completing residency (usually based on putting in your hours) you can practice medicine under the application 'board-eligible.' Once you've passed your exams, then you can be called 'board certified.'
In Canada, you can't practice at all unless you pass your board (Royal College) exams. The exams are reputedly harder in Canada as well (from those I know who have written both).
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Actually, there was a study that compared the joint problems of joggers and non joggers over decades. Surprisingly, the joggers had fewer problems.
The vast majority of people who don't immunize aren't doing it for religious reasons. There's a growing segment of 'educated' people who have 'researched' the issue and have decided that the risks outweigh the benefits.
Unfortunately there are 'professionals' within the health care system that spout this idiocy, including nurses and chiropractors.
He is saying that teaching a religious doctrine is child abuse. That is just not reasonable.
You may not think it is reasonable, but we have pulled children out of homes before.
Saying that some religious teachings or philosophies are bad is no different than saying that some non religious philosophies are bad
True.
I think a non religious environment can be potentially abusive too. So what?
OK, why? At least Dawkins has a rational.
You're misunderstanding me.
The reason children 'get pulled out of homes' in your example is not because the parents are religious, but because the state believes that harm is being done. The focus is on the act (or lack of action) by the parents, not on the fact that the parents are teaching religion to their child.
Dawkins is not advocating against the specific things that can lead to harm, but rather that religion itself is harmful and tantamount to abuse in and of itself. That is unreasonable.
I think a non religious environment can be potentially abusive too. So what?
OK, why?
I suspect you think I am saying that a non religious environment is conducive to abuse (compared to a religious one). I am not. I think any environment has a potential for abuse and the religion aspect is a non issue.
You honestly believe that religious people are all abusing their children?
I think a religious environment is potentially abusive, and instilling superstitious beliefs as truth in children is not a good thing.
You think that concept is 'reasonable'? It's staggering that you got modded up.
What about "christian scientists" that deny critical care to their children? What about muslims who teach terrorism. What about "abstenence only" education?
I'm not saying that fundamentalists weren't responsible for the twin towers. I'm saying that painting them as representatives for all religion is offensive. But that is his intent after all...
It is the seeming rational moderate "enablers" that give comfort to the extremists. Religion is nonsense. If you can believe absurdities you can perpetrate atrocities.
It's fine to look at a *specific* act or ideology and debate its merits. He is not. He is not saying 'potentially abusive', or 'more likely to be abusive'. He is saying that teaching a religious doctrine is child abuse. That is just not reasonable.
Saying that some religious teachings or philosophies are bad is no different than saying that some non religious philosophies are bad
I think a non religious environment can be potentially abusive too. So what?
There are plenty of non religious people who perpetrate atrocities. Would it be reasonable to paint Pol Pot or Stalin as model atheists?
No, he said that labeling children is close to child abuse.
No he doesn't. You are lying about what he's saying, just like with the child abuse argument he made.
And I find it offensive that you are actively lying about what Dawkins is saying. Pathetic.
And I quote,
"How did September the 11th change you? Well here's how it changed me. Let's all stopped being so damned respectful."
This is from the atheist's call to arms from Tedtalks 2002.
Now who's lying to promote their own agenda?
He's said that people who teach their kids religion are child abusers.
From a logical perspective, that is not unreasonable or unheard of. We remove children from "christian scientists" when they refuse critical care.
He ends one of his lectures by saying how religious fundamentalists crashed into the twin towers, and therefore it's time to stop being so respectful of religion.
Religious fundamentalists *DID* crash into the twin towers.
Those are pretty offensive comments to me...
Truth is often offensive to those who refuse to accept it.
You honestly believe that religious people are all abusing their children? You think that concept is 'reasonable'? It's staggering that you got modded up.
I'm not saying that fundamentalists weren't responsible for the twin towers. I'm saying that painting them as representatives for all religion is offensive. But that is his intent after all...
I find a lot of the time he can be callously disrespectful and religiously atheist.
Having seen him many times, the only offense he may have committed is *not* entertaining the rediculous notion that a god exists without any proof.
He's said that people who teach their kids religion are child abusers.
He ends one of his lectures by saying how religious fundamentalists crashed into the twin towers, and therefore it's time to stop being so respectful of religion.
Those are pretty offensive comments to me...
Dawkins holds that to be an intelligent scientific thinker you must hold to both strict naturalism and evolution apriori, which is not so subtly implying that all of the other 53-ish percent of humans living in the United states are basically drooling morons.
Perhaps Dawkins is not implying that these people are unintelligent, but that they are unscientific.
Actually in many of his lectures he implies that religious people are less intelligent. He delights in in the studies that have shown this kind of correlation.
I mispelled it. It's actually Ovol.
Unfortunately this is severely mitigated by two groups - lawyers and patients.
The original article could equally be titled 'why lawyers hate science' - as the parent says, many judgements against doctors are based on whether something could have been done, not whether there was evidence to support doing it, or even whether it would have been effective.
That is sheer and utter nonsense.
I wish it were nonsense. There was a US case about a patient who had an acute spinal cord injury. There is a controversy about whether or not to give steroids in these cases to reduce swelling and decrease subsequent injury. So far the consensus is that it doesn't help. The ER attending physician therefore did not give steroids. The patient had a bad outcome. The ER attending was found guilty (not sure what the correct term is) because the prosecution found an expert witness who said that it might have helped.
The only "imperative" imposed by the courts is that "reasonable care" be applied? Why is that so terrible? Why is that so onerous? Most medical care is far, far above that relatively low standard.
The difficulty is in defining reasonable. It seems that some lawyers are very good at skewing this definition.
Most physicians practice 'defensive medicine'. That means they do things that are medically unnecessary, solely to protect themselves from frivolous lawsuits. Good medicine alone unfortunately won't protect you from malicious (or vulnerable and wounded) people, looking for someone to blame.
I can tell you a number of cases where the physician was found guilty and they did nothing wrong. The jury just didn't like how things turned out for the patient.
(Big fan of yours by the way!)
US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient.
Actually one of the big reasons that EM diagnostic evaluation is more aggressive than usual is that (shock) patients actually do have a hint of what is important. That is, if you take a random person who goes to his family doc with chest pain versus one who goes to the ER the former is less likely to have significant coronary artery disease. So its not surprising that if you compare ER with primary care, it is good medicine to be more aggressive with diagnostic evaluations in the ER.
That said, hell yeah as an ER doctor I sometimes practice defensive medicine. If you place me in an environment where people can effectively sue me for what I might make full time in 20 years for a bad outcome that happens despite me practicing medicine that meets the standard of care in my practice environment I sure as hell am going to practice defensive medicine. The fact that I don't always do aggressive diagnostics in every patient is either me being a Pollyanna or perhaps taking my patient's best interests at heart. I'm willing to put my neck on the line somewhat to avoid a CT in a toddler who just has overprotective parents, but your fat, diabetic, smoking, sedentary, litigious ass is just not cute enough to get the my sympathy.
I'm comparing US emergency medicine guidelines with Canadian emergency guidelines. A lot of the US based CME will even directly admit in their lectures that their recommendation is based more on protecting against potential litigation.
I'm not criticizing defensive medicine either. 98% of my charting is done solely to protect myself in case of a law suit. Very little of it is clinically helpful.
I practice mostly in primary care, but I do ER work as well. Most of my EM CME is US based. My comment is not intended as a slam at all, just a realization that we practice medicine in different environments.
(and thanks to my EM training I picked up two subtle acute coronary syndromes recently that my partners missed. Direct admit from clinic to the ICU baby! Sometimes it pays to be aggressive)
I was referring specifically to acute (new onset) back pain. I'm not advocating never investigating back pain.
I think that medicine and physiology is still in its infancy relatively speaking. When I get someone in your situation, I tell them that the tests look normal. That it's good news because it rules out a lot of bad things, but it still doesn't explain the problem. There is a vast range of human experience that we just don't understand or have a good solution for.
There's no good answer to this. There aren't really EBM vs non EBM schools of medicine. The difference is the amount of time you spend keeping up, and how willing you are to change your practice. Newer docs tend to be more up to date than the older ones. EBM is very new phenomenon.
The other problems is that evidence is very often in the eye of the beholder. Many physicians lack the time and ability to evaluate evidence for themselves. They rely on drug reps (shudder) to get their 'evidence'.
Good evidence in medicine is hard to find. Once something is standard of care, it's hard to test it because ethically you can't not offer someone effective treatment to compare. The best studies are placebo controlled, double blind, randomized, controlled trials which are extremely expensive and often sponsored/biased by Big Pharma. Often there are even contradictory studies. A lot of the newest clinical care guidelines boil down to expert opinion.
I guess I do sometimes prescribe and perform treatments that have little evidence behind them. The problem is that the placebo effect is not necessarily statistically significant. Is it worth taking the gravol to have one less barf over the course of the illness? Maybe...
It's hard for me to recommend anything that has potential to harm, unless I firmly believe that the benefits outweigh the harms. That's the crux of the issue for me.
Many people I see take a number of medications, prescription and non that I may not even know about. There are potential dangerous interactions there that I don't/can't/won't know about. Even non dangerous side effects can be problematic. There is also the fact that medications cost money. I don't want people to waste their money on a treatment that is no better than placebo.
I do prescribe things that are of nebulous benefit, when people are desperate to try something, or to cling to their experience that it works.
It's just not my style to prescribe unnecessarily (in my opinion). If you see me for your cold. I will tell you to rest, take some advil or tylenol, suggest a decongestant and give you a note for work if you need it. If you see my partner, you will get a prescription for cough syrup (most do nothing), painkillers and decongestants. He also has a very low threshold for prescribing antibiotics. The net result is that his patients are extremely satisfied and his visits are quicker. My patients leave somewhat disappointed, often come back (I'm STILL sick!!!) and I have to spend a lot more time educating my patients. The patient populations self select over time and the pill poppers go to him, and the pill averse come to me.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
I have considered it. I also consider the fact that every medicine I prescribe carries risks, even if those risks are low. If I don't know whether the risk outweigh the benefits, I don't prescribe, particularly for 'nuisance' illnesses.
I know many physicians who prescribe placebo treatments and tests. I have trouble doing this even though patients find it very satisfying. What I sometimes do instead is tell people what the evidence is and let them decide. I struggle with the ethics of prescribing a placebo.
I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.
This is rule of thumb, and Dr. Merenstein should have known this.
Actually the previous poster is right. Population based studies suggest that more harm than good is done by screening for prostate cancer.
The evidence goes like this. Once you have an elevated PSA, you see the urologist who orders a biopsy. Biopsies and treatments for prostate cancer carry risks like bleeding and infection, urinary incontinence and impotence. Now most prostate cancers will not kill you or cause problems in your lifetime. So investigations and treatments for prostate cancer cause more harm to people than the cancer does. This makes sense in a population, but not to the guy who got a bad cancer.
The current guidelines do not suggest PSA's in all men over fifty, but rather that you discuss the risks and benefits of screening, plus potential harm of further workup of a positive screen vs. the harm of developing prostate cancer. In practice, there is no patient who can actually understand enough of this to truly make an informed decision. Many docs haven't heard of the 'new' evidence and continue screening. The ones who do know of that evidence often ignore it because it's hard to explain, and patients will love you for finding an early cancer, even if it would never have affected them.
As far as your colon cancer screening comment, what you describe is standard of care.
The other thing to consider is that medicine in the US is HUGELY biased by the litiginousness of US culture. US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient. A lot of those investigations are not recommended in socialized health care systems because they are not cost effective, nor do the benefits outweigh the disadvantages.
I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.
I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Very dissatisfying to a lot of patients.
Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.
The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.
EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.
IAABP (I am a biology professor).
IMHO O-chem as it is taught by most chemistry departments is completely useless for pre-med students. There ought to be a lower level biochemistry course in its stead as a pre-req for pre-meds. Most MDs will NEVER have to worry about organic synthesis and crap like that; they WILL need to worry about metabolic pathways and enzymatic reactions.
Bingo.
I have never used half the crap I took in undergrad. There are two reasons why they include most prereqs.
1)hoops to jump through.
2)most people in 'pre-med' (which doesn't exist in most Canadian universities now) don't get into medicine, so they still need basic science to have some relevant skills in another field.
And as to the article that talks about science leading to research. Many don't like research. To castigate the clinician as mediocre because they don't do research is grotesquely unfair.
People are unable to admit that outside influence can control their decisions which is partly why marketing and advertising are so wildly successful in our commercial society. In other words, it's not longer about creating a product to fill a niche. It's all about creating the desire in people for the product in question.
Why wouldn't the exact same principles apply to your pornography argument?
Your right to swing your fist ends where the other man's face begins.
Wrong! Nobody has a right to smoke around someone else without their permission. There is no 'safe' level of second hand smoke, which is proven to be toxic. Nobody has the 'right' to expose you to ammonia gas, or benzene or any other toxic chemical. Why on earth would you make an exception for cigarette smoke?
The 'right' to smoke nonsense is propaganda largely promulgated by tobacco companies.
Most people's belief in science is based on 'faith'. Very, very few people have the intellectual capacity or education to truly comprehend or competently discuss the science that they believe in.
The average person who believes in evolution has only the dimmest understanding of the science on which those theories are based.
An astronomer can suggest that the universe is 12 billion years old and people will believe it. Then another astronomer makes another theory that the universe is actually 25 billion years old and people believe that. Ordinary people have no way of understanding the math, physics and other observations on which the theories are based.
A scientist may base his belief on evidence, but the ordinary person is basing his belief on 'faith' that that scientist is right.
People are missing the forest for the trees here. The point is NOT the substance/act itself being inherently harmful, but rather an individual's USE of something that is harmful.
Food is a wonderful thing, yet there are those individuals who's attitudes and behaviors with respect to food are destructive. It's the destructive behavior that's the 'disorder' not the food itself.
Using stimulants like amphetamines to treat certain medical conditions is appropriate. Using them to get high at the cost of your family and career is inappropriate.
Take a look at the DSM IV - the classification book for mental disorders. In order to qualify as a disorder, something usually has to have a significant negative impact on someone's function.
I see no difference between compulsive gaming that affects one's life, and compulsive hair pulling that affects one's life.
The hardest part of most medical specialist exams are the orals. Nobody ever complains about the written component. You get a to sit in a room with one or more examiners for a few hours of intense grilling. There is no way to hide any lack of knowledge and your deficiencies are exposed for all to see.
Also the US has a strange system of certifying specialists. After completing residency (usually based on putting in your hours) you can practice medicine under the application 'board-eligible.' Once you've passed your exams, then you can be called 'board certified.'
In Canada, you can't practice at all unless you pass your board (Royal College) exams. The exams are reputedly harder in Canada as well (from those I know who have written both).