Oh, loneliness and cheeseburgers are a dangerous mix.
– Comic Book Guy

Same can be said of viral syndromes and Thanksgiving. My brain has been in an interferon-induced haze for the last week that is not lifting anytime soon. Tell me about the rabbits, George. But no excuses. I have been reading the works of Chuck Wendig over at Terrible Minds. (Really, really like the Miriam Black books). Writers write and finish what they start and only posers use excuses for not completing their work.

Recently I attended an excellent Grand Rounds on some of the reasons doctors do what they do. Partly it is habit. We learn to a certain way of practice early in our training and it carries on into practice and it is not always best practice. Patients also learn from us and have expectations on what diagnostics or treatments they should receive, and that too it is not always the best practice.

So to educate physicians and patients, the American Board of Internal Medicine (ABIM) started the Choosing Wisely initiative.

Their goals:

Choosing Wisely® aims to promote conversations between providers and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

To do this they asked various medical societies for five or more do’s and don’t’s’. Punctuation humor.

In the world of pseudo-medicine, Choosing Wisely has one win from American College of Medical Toxicology and The American Academy of Clinical Toxicology:

  • Don’t use homeopathic medications, non-vitamin dietary supplements or herbal supplements as treatments for disease or preventive health measures.
  • Don’t administer a chelating agent prior to testing urine for metals, a practice referred to as “provoked” urine testing.
  • Don’t order heavy metal screening tests to assess non-specific symptoms in the absence of excessive exposure to metals.
  • Don’t recommend chelation except for documented metal intoxication which has been diagnosed using validated tests in appropriate biological samples.
  • Don’t remove mercury-containing dental amalgams.

and two fails. One fail for low back pain:

If you don’t feel better after four weeks or so, it might be worth talking with your doctor about other options, including physical therapy, chiropractic care, yoga, massage, acupuncture, cognitive-behavioral therapy, and progressive muscle relaxation.

and the other for choosing a pain reliever:

Staying physically active often helps. Acupuncture, massage, physical therapy, and yoga, might work, too. Chiropractic care might also be beneficial.

Both acupuncture and chiropractic do not meet the four criteria of the organization.

It is also ironic that while the ABIM is striving to improve care with the initiative, many organizations are institutionalizing pseudo-medical therapies in Integrative Medicine Departments that meet none of the Choosing Wisely criteria. What SBM givith, pseudo-medicine taketh away.

So much of what we are for at SBM manifests in what we oppose. That makes Choosing Wisely a nice fit for SBM recommendations. Much of this blog concerns what to avoid but it is not realistic to simply say “read the 2,147 blog entries and you will know what to do”. None of the medical societies have a particular interest in pseudo-medicines and SCAMs. I have always been surprised, as one example, at how little the IDSA does to combat the anti-vaccine movement in the US both on their website and at their meetings.

While SBM is not a medical society, in the spirit of Choosing Wisely I offer the SBM Choosing Wisely. I am going for the top 10, since I cannot stop at 5.

Avoid chiropractic manipulation of the neck

While rare, tears of the vertebral arteries can occur from chiropractic neck manipulation with catastrophic strokes and death. There have been at least 26 deaths following neck manipulate and the American Heart Association review suggests the risk is real. There is no proven benefit for chiropractic manipulation of the neck and there are safer and equal interventions.

The major chiropractic organizations have been aggressive in denying the risk of stroke and death, having little interest in improving patient safety or chiropractic as a profession. I is unlikely that individual chiropractors will be careful and follow the precautionary principle and abandon the procedure

And avoid any x-rays looking for chiropractic subluxations which do not exist. You only get radiation and cost without diagnostic benefit.

Avoid naturopaths as a Primary Care Provider

The 4 year education in naturopathy consists of the extensive study of non-reality based therapies (homeopathy, acupuncture, energy therapy etc.) but little training in real medicine. They usually have none of the post graduate training (internship, residency and fellowships) that prepare MD/DOs to provide competent care. With totally inadequate educations, a lack of supervised post graduate training and an understanding of disease and health that is divorced from known reality, naturopaths are rendered unfit to be a primary care physician.

Avoid any practitioner who sells the pseudo-cure for their pseudo-disease in their front office

It is a gross conflict of interest to sell the herbs, vitamins and supplements to treat the diseases and often pseudo-diseases diagnosed in the CAM clinic. If a provider makes a diagnosis and sells the remedy from their front office, be very suspicious of both diagnosis and treatment, and find another provider

Avoid any acupuncturist who does not use good infection control technique: hand hygiene, gloves and cleaning of the injection site

While acupuncturists deny the need for good technique, the literature is filled with infectious complications from acupuncture and poor technique, from bloodstream infections to infected joints. It is hard to infect a human being, but the average acupuncturist seems to go out of their way to maximize the potential to cause a rare infection.

Avoid any product that can “boost your immune system”

While it sounds impressive, the immune system cannot be boosted. When it is, in medicine we call it the inflammatory response, and is not without risk: stokes, heart attacks, and pulmonary emboli often occur after infections, probably as inflammation increases the rate of clot formation.

Avoid products that…

  • were invented by school teachers or other lone geniuses working in their basement
  • rely on anecdotes to sell their products
  • are being suppressed by big whatever
  • that represent an ancient truth, and/or
  • are promoted in the media but not the medical literature

These are all signs of bogus science.

Avoid any product that “supports” an organ or a physiologic process

Any product that suggests it functions like a truss, bra or jock strap doesn’t. Like boosting the immune system, it is a phrase that, while sounding promising, is a code word for ‘does nothing but we want you to think it does.’

Avoid any product that offer includes the Quack Miranda Warning

“These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”

They use the Quack Miranda Warning as a way of avoiding the fact the claims made for the product are, in fact, not true and that the product does nothing

Avoid homeopathy

Homeopathy is not an herbal product or a supplement. Homeopathic products are literally water and/or a sugar tablet. There is no active product in a homeopathic product. It is nothing that does nothing.

Avoid any practitioner, alternative or legitimate, who uses the phrase “in my experience” in deciding on a therapeutic intervention

Experience is important for any health care provider in diagnosing patients but when it comes to deciding what the best intervention is, experience is unreliable at best and dangerous at worst. “In my experience” is a distillation of all the cognitive biases that make human thought unreliable.

Conclusion: Choosing Wisely in CAM means avoiding it

The interesting aspect about the Choosing Wisely initiative is how many of the recommendations are proscriptive. They are about avoiding the useless, the dangerous and the expensive that do not add to quality medicine. The quality improvement process avoided or ignored by SCAM practitioners.

I wonder if a chiropractor could come up with five standards treatments in chiropractic to be avoided or if naturopaths, homeopaths and acupuncturists could as well. I know they would say avoid vaccines and NSAIDS and most of reality based medicine. But could they come up with five treatments or diagnostics in their own field to avoid? I bet not. We have a few alt med providers who occasionally comment; I look forward to their proving me wrong.

 

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.