Navigating the Medical School Admission Obstacle Course. (Real Questions from Real Readers)

(I have received quite a few emails over the past two years asking for advice as well as anwering a lot of questions about the medical school admission process on The Student Doctor Network. I thought I’d publish some of them along with my replies. -PB)

Dear Panda,

I said I spoke Spanish on my AMCAS application when in fact the only Spanish I know is the Taco Bell menu. Was this a bad idea and will it come back to haunt me?

Sincerely,

Nervous in Nebraska

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Dear Nervous,

I also claimed to speak a foreign language. The problem with this is, obviously, that someone who interviews you might actually speak the language and want to bust out with you, his homie, in his native toungue.

So Spanish is definitely out. Although the possibility is remote, I have heard that some members of admission committees (and even some doctors if you can believe it) speak a little Spanish.

I picked “Walloon” as my language and wouldn’t you know it, one of my interviewers was from the Low Countries and started jabbering at me the minute I walked into his office.

That’s when I played my trump card and had a full-blown Grand Mal seizure. They took me to the Emergency Department and I was post-ictal until the end of that particular interview slot. But it’s cool. I had devoted some of my personal statement to how I had fought and overcome epilepsy to achieve my goal of Medical School so I had them in check.

Like I said. You have to think quick and be prepared.

Respectfully,

P. Bear, MD

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Dear Uncle Panda,

In a desperate attempt to make myself more diverse I may have exaggerated some of my extracurricular activities and qualifications. Do medical schools try to verify these things?

Respectfully,

Worried in Wyoming
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Dear Worried in Wyoming,
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They most certainly do check on your qualifications and extracurricular activities. My medical school has an office that does nothing but verify everything you list on your AMCAS application. Fortunately they are kind of short-staffed because of budget cuts so if you play your cards right, delay submitting your application to the last minute, and use a little common sense the odds are that they won’t get around to checking your extracurriculars and qualifications until you are well into first year at which time, possession being nine-tenths of the law, it will be very difficult to dislodge you.

In fact, I listed myself as “Native American” and even described some of the suffering of my people in my personal statement.  I’m not really a Native American except in the sense that I was born here (so technically I am a indeed a native American). One day towards the end of first year I got an irate email from the registrar inviting me to explain to the verification committee how I could possibly make this claim.

As soon as I walked into the registrar’s office I let out a blood-curdling shriek, charged his desk, and touched him with my coup stick…you know…just to establish my tribal cred’.

“We prefer to be called Indians,” I said as I adjusted my loin cloth and sat down, “And I don’t know how those people from Calcutta or Bombay get away with calling themselves Indians either. It’s shameful and I don’t think they’re fooling anybody.”

The registrar politely inquired as to when we they would get my tribal certificate from the Bureau of Indian Affairs who had claimed to have never heard of me.

“I don’t need the white man’s worthless paper,” I replied fixing him with what I hoped was a don’t-give-me-your-small-pox-infected-blanket stare, “Or the white man’s laws, the white man’ unnatural technology, or the white man’s corrupt political system.”

“Hey, is that some of the white man’s coffee? Mind if I get a cup?”

Apparently the North Dakota Sioux in which tribe I may or may not have claimed membership had never heard of me either.

“Did you call my Uncle John Raging Pony? He’s the chief, you know.” Actually my uncle John couldn’t chief his way out of a paper bag. We only call him Raging Pony because he drinks a lot of Malt Liquor. But he lives in North Dakota. In a trailer. With no phone which is not really my problem.

“Oh, and my tribal name is Turgid Ferret.”

The registrar insisted that there was no record as far as they could tell of my belonging to any tribe in the United States.

“Well, there’s yer’ problem Great White Father. Our ancestral homeland straddles the border with Canada. We actually spend most of our time in Alberta. More bison, you understand”

Very pained look from the registrar. I could see he didn’t relish negotiating Canada’s incredibly primitive phone system. Plus he didn’t speak French so talking to the Canadians was going to be a problem. Always pick a third world country for your extracurriculars. It slows the verification process.

“Well, if that’s all I’ll be on way,”I said prying my tomahawk from his desk, “I go now to commune with the spirits of my ancestors over the traditional frothy coffee drink of my people.”

The medical school admission process is tough. You have to be smart and you have to keep your options open.

Glad I could help

Regards,

P. Bear, MD

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Dear Dr. Bear,

What keeps people from making up extracurricular activites?

Respectfully,

Curious in Klamath Falls

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Dear Curious,

What keeps people from making up extracurricular activities?

Nothing. Absolutely nothing.

Yours,

P. Bear MD
Winner, 1998 Noble Prize for Chemistry

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Dr. Panda,

What is the purpose of the essay on the Secondary Application? I mean, I wrote my heart out on the AMCAS personal statement and now I have nothing more to give.

Sincerely,

Perplexed in Paducah

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Dear Perplexed,

The secondary essay gives you a place to explain why you called Mahatma Gandhi a “urine drinking magnificent bastard” in you AMCAS personal statement. It is also a good place to admit that you don’t actually have any kittens and yer’ Grandma who you claimed to have cared for until she “slid gently into a peaceful dream of death” is actually in a third-rate nursing home in the suburbs of Dubuque and you actually haven’t seen her in three years because the smell of “poopy” makes you gag.

They do check these things you know. My medical school had a whole department of “verifiers.”

Glad I could help.

Respects,

P. Bear, MD

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Dear Dr. Bear,

Do medical schools really verify all of the crap we list as extracurricular activities in our AMCAS application? I may have stretched the truth a bit (well, more than a bit) and I am starting to worry.

Respectfully,

Nail-Biting in New York

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Dear Nail Biting,

About six months into fourth year I got called into the Dean of Students office. Apparently they had found out that I hadn’t actually won the Nobel Prize for chemistry.

Thinking quickly, I said, “Nobel prize? Of course I didn’t win the Nobel Prize. I won the Noble Prize. See? Right there. Call my undergraduate institution and ask them about it.”

“Sure, I keep the Harvard registrars phone number in my wallet. Here ya’ go.”

By the time they sorted it out I had graduated.

I didn’t actually go to Harvard, by the way. A few months later I got an angry letter from the Dean of Students saying that there was no record of my having attended Harvard.

“Harvard?” I wrote back, “I didn’t go to Harvard, I went to Harvarads…you know, in St. Croix.” I gave him the phone number of the registrar which was really my cell-phone number. Every call I got for the next three months I always answered (in a thick Jamaican accent), “Hello, Registrars Office, can I help you mon?”

Incidently, if you look closely at my ID badge, between the “M” and the “D” is a tiny “C.” I actually didn’t go to a real undergraduate university but I did attend McDonald’s Hamburger U as an assistant night shift trainee. It said “University of Hamburg” on my AMCAS application so I’m not really lying. Besides, are they really going to call Norway to verify that I went there?

You just have to be smart.

My Best Regards,

Panda Bear, MD

Navigating the Medical School Admission Obstacle Course. (Real Questions from Real Readers)

Nothing Much More to Say About Complementary and Alternative Medicine. (CAM Month Draws to a Close)

Everything You Need to Know About Complementary and Alternative Medicine (Part the Third and Last)

(One last time I state the obvious while continuing to marvel that it needs to be explained although judging from my email and comments it does. -PB)

8.You Can’t Have it Both Ways

I have some fundamentalist Christian relatives who believe the Bible to be a literal account of the creation of the world. They’re not wishy-washy Christians who get all mushy around the edges and, in an effort to reconcile science and their weak faith, allow that perhaps “a day to God is a billion years to the rest of us.”  The Bible says the world was created in six days and by golly, it was created in six 24-hour days. God said it. They believe it. If you don’t you’re going to hell. Paleontology? Evolution? The fossil record? All tricks of the Deceiver to lead the faithful astray.

You may think that I dislike people who hold these beliefs, or that I am bothered by what I can only call their profound ignorance, but you would be wrong. I admire their faith and they are as welcome to it as anybody else is to theirs. I’ll even send my kids to one of their private schools if I have the chance because learning math, reading, and writing (something not emphasized in many public schools as they are in the grip of their own peculiar religion) is not strictly dependent on a belief in evolution and we can always do a little deprogramming when they get home.

On the other hand I often find myself in goofy conversations (wrestling with pigs if you know the analogy) where my relatives insist that paleontology is bunk because Carbon-14 dating, apart from being a tool of the Devil, is wildly inaccurate and cannot establish the age of ancient fossils. A little later in the coversation we usually roll around to how someone has found the Ark, a barn-like structure on a mountain in Turkey, that has been positively Carbon-14 dated to the time of Noah. I am not a smart guy and I struggle, yes struggle, with sophisticated intellectual concepts but even I can see the contradiction here, the blatant doublethink required to both believe and at the same time disbelieve something depending on what you are trying to prove.

In much the same manner do the True Believers of Complementary and Alternative Medicine try to eat the proverbial cake and have it, too. The NIH, they proudly point out, studies CAM using the same methods used to study real science. Not only does this establish the validity of quackery in their minds but the very act of a government agency studying their peculiar little beliefs is an act of validation in itself. And yet, when numerous well-designed studies using rigorous statistical methods continue to show that Complementary and Alternative Medicine is nothing more than an expensive and highly detailed placebo, the usual accusations are made that the scientific method is indequate to study qi or spiritual fire shooting from the appendages of the healer. The current meme of the homeopaths, for example, is that independent research of homeopathy is impossible because, through some quantum effect, the beliefs of the investigator influence the actual efficacy of homeopathic remedies.  In other words, only a homeopath who believes in homeopathy can research homeopathic effects.

Which then, is it? Is your particular flavor of quackery a scientifically verifiable treatment modality or is it a religion whose secrets are only available to those who make the leap of faith required to believe it? You can’t have it both ways. If you would enter the arena of science then you have to face the lions.

9. You are not the Pope.

I mean, seriously now. Let’s suppose, for the sake of the argument, that there is spiritual fire that can be channeled from your appendages to cure disease. What makes you think some greasy little sociology major who sat through a couple of motivational seminars is the one who can do it? The Pope, for his part, is the spiritual leader of the world’s one billion Catholics, a deeply pious and theologically sophisticated man, and yet he would be the first to deny that he can work the kind of miracles that are the regular activity of oleagenous Pentacostal preachers and their svelte, holistic counterparts in the alternative medicine world. In other words, how do you verify the claims of your dime-store miracle workers? Has your Reiki healer graduated at the top of his class in Lahore or did he go to a cut-rate Reiki training course in Klamath Falls? How do you know your homeopath is shaking the mixture the right way? If there are several schools of acupuncture with their own meridians (and there are), who’s nailing qi like a big dog and who’s just jabbing you with needles? The fact that many of you don’t even think to ask these questions but accept every smooth-talking healer as the real McCoy indicates a level of gulibility, already incredible, that should be embarrasing for any adult who purports to have any street-smarts.

10. “Holistic” is a marketing phrase.

When confronted by the evidence, the purveyors of Complementary and Alternative Medicine will fight a desperate rear-guard action as they retreat deeper into the interior of their vast, irrational country. Finally, in a last-ditch effort to hold onto even that infertile territory they will rally around the holistic banner, insisting that Complementary and Alternative Medicine treats the whole patient while real medicine does not. If you think about it however, it is real medicine, a profession with both generalists and specialists that is treating the whole patient or at least the important, non-entertaining parts. This is why there are so very few Reiki healers doing critical care medicine. Namely because the whole patient is an order of magnitude more complex than can be handled by what is essentially the entertainment committee. Cardiovascular collapse? Sepsis? Rectal bleeding? Please, they’re too busy managing how the patient feels to be bothered with objective disease.

If there’s one thing I’d like every medical student to unlearn its the supposed signficance of the term “holistic.” It’s just a word like “granola,” a clever marketing phrase which is used to disguise a bunch of unwholesome things. When I hear the word “holistic” I reach for my revolver.

Nothing Much More to Say About Complementary and Alternative Medicine. (CAM Month Draws to a Close)

Poodle Circus and Other Things (Real Questions From Real Readers)

You seem a little less bitter about residency.  How are things going?

Fine, thanks for asking.  I haven’t had call in about five months and I am gradually starting to forget all about it.  Sleep deprivation has always been my biggest complaint about residency and now that I am getting regular sleep I am pleased to report that I am feeling much better most of the time.  We do not have call in Emergency Medicine and, what’s better, we have a predictable schedule with shifts and conferences clearly layed out.  Oh, I still get tired. Of course I do.  Conferences always seem to fall on a day off or when I am getting off of long night shift and we do in fact work pretty hard. I don’t think there will ever be a resident who isn’t tired most of the time except maybe one of those lazy bastards in Physical Medicine and Rehabilitation.

Not to mention that I feel a lot better about things now that I am actually training for my job.  This is not to say that off-service rotations are not important.  Of course they are.  It’s just that on many rotations the teaching is at a minimum while the work is at a maximum.  There is something to be said for requiring residents to “figure it out themselves” but, and if I’m going way out on a limb here I apologize, doesn’t that sort of defeat the purpose of education?  In other words, if every time I ask an attending a question she snarls and looks at me contemptuously for having the unmitigated gall to not be an expert in a field that I have been exposed to for one week compared to her having studied it for twenty years, well, what’s the point of the rotation?    Whether I can look it up myself is besides the point and my asking for information is not the same thing as being spoon-fed.  I realize that the crusty old-timers are going to snarl and opine that, after crawling to the hospital though snow and broken glass, they had absolutely no supervision and learned it all on their own so I apologize for not being such a fine specimen of prehistoric medical animal.

Medicine is one of the few professions where superior knowledge breeds hostility.  As a Marine infantryman, for example, we never castigated the new guys fresh out of the Infantry Training School for not knowing how we did things in the fleet.  Rule number one is to never bully your subordinates.  You have them at an unfair disadvantage, in the Marines its the Uniform Code of Military Justice, in residency it’s the reluctance of a resident to do anything other than suck it up for fear of being fired.   Either way it reflects poorly on a leader who doesn’t have the empathy to realize this.

Because of the nature of Emergency Medicine residency training we tend to work fairly closely with our attendings for the whole shift.  My program has exceptional attendings all of whom take the time to teach, taking into account of course that we are always extremely busy.  So now that I am being taught the profession instead of just being used as cheap labor to cover call, I naturally feel much better about things.

I assure you however that I occasionally get demoralized and some might even say depressed.  That also seems to be the nature of residency.  You can have a string of good days where you do everything right and feel like you have a pretty good grasp on things only to have a couple of bad shifts, or even a couple of bad patients, where you so obviously show your ignorance and unsuitability for the medical profession that you dread going in for the next shift.  I have had a few shifts like that this week and I am feeling kind of beat down, if you know what I mean.

This is why I laugh at all of the lay people who email me or post snarky comments accusing doctors of being arrogant or having some kind of God complex.  There may be some physicians who have it all figured out to the extent that they always know what to do and never make a mistake but I assure you this is not me and, from discussions with my friends, I am not the only resident who is often humbled by the limits of his knowledge and abilities.  Residency training breeds caution, not arrogance.  If you think your doctor is arrogant it may be because you are, yourself, something of a jackass and cannot handle the fact that patients are not customers, the doctor is not a clerk, and you are not always right. 

I think I want to go to medical school, how hard is it to apply and get accepted?

First you have to get the basics in order which are getting good grades and scoring well on the MCAT.  I don’t have too much advice for that except if you are not incredibly intelligent this is going to require a lot of hard studying in college.  Medical school is pretty competitive and only about half of the college students who apply are accepted.  This might not seem like bad odds at first but you also have to realize that a large number of college freshmen who declare themselves as pre-med discover that they don’t have the right stuff and end up pursuing other careers.  So your odds are pretty good (and I call fifty percent good odds) only once you get through all of the obstacles which include classes like calculus and organic chemistry, the de facto destroyers of medical school dreams at most universities.

It’s not that these classes are incredibly hard, it’s just that the competitiveness of medical school requires that those who make the final cut, the twenty thousand students who matriculate every year, get exceptionally good grades.  When I was working towards my engineering degree, I worked hard but didn’t flinch at a B or even the occasional C.  These are both passing grades and nobody ever asked me about my Grade Point Average when I was applying for engineering jobs.  And there was certainly no GPA requirment for professional licensing as an engineer.  All that was required to sit for the Professional Engineeing Licensing Exam (a test that makes the MCAT look like a pop quiz) was a degree and five years of engineering experience.

But applying for medical school?  You need to get an A most of the time in most of your classes.  Maybe there’s no substantive difference between a 3.7 and a 4.0 GPA but there is a huge difference from an admissions point of view between a 3.2 and a 3.7.  One is an automatic rejection at many medical schools, meaning that your application is automatically shunted into the trash, or at least a big strike against you unless you have an awfully interesting resume (which is how I managed to get in with my GPA).  You definitely have to get very high grades in the BPCM (Biology, Physics, Chemistry, and Math) pre-requisites to even be considered.

The ironic thing is that all you really need to start medical school is the abiity to read and some basic, and I mean basic, biological and scientific knowledge.  In the first couple of days of medical school, for example, you are probably going to cover the equivalent of college semester’s worth of the subject.  You have to understand that college courses, compared to medical school, proceed at a leisurely pace and you will laugh to think that you ever felt college courses to be overwhelming.   The real purpose of the pre-requisuites is not so much to teach you anything but to demonstrate that you have the ability to handle the barrage of material heading your way.  Intelligence aside, if you can’t muster the discipline to do well in college, while you may be able to switch gears in medical school, the conventional wisdom is that you are not worth the risk, especially not when every medical school can find plenty of people who have shown that they can.

I understand that there was once a time when medical school admission was much easier but many matriculants were weeded out in the first couple of years.  As my old professors used to relate, the standard speech to incoming first-years was, “Look to your left…now look to your right.  This time next year both of those people might not be here.”  Now most of the weeding out is accomplished before matriculation and unless you lose that fire, that interest in the profession that keeps even the most jaded medical student slogging through, your chances of not graduating are vanishingly small.  In my class of 100, when all was said and done, only two people didn’t finish.   Several were dropped back a year but they all eventually graduated.

So you see, the big hurdle is getting in, not finishing.  And there are a lot of other hoops to jump through which have nothing to do with grades and make the whole process seem something like a poodle circus.  For the record the requirement for good grades is not a hoop.  It is silly not to have some kind of objective standard of intelligence for people who want to enter what is a highly important, intellectually demanding, and in many ways (as there is a great potential to harm people) a highly dangerous profession.  The real hoops are the nebuluous extracurricular activities that are unofficially offically required by almost every medical school to prove your dedication and your, I blush to call it, moral fitness for the job.

In other words, it is not enough to get good grades and have an inkling that you want to be a doctor because it is a useful, well-paying, interesting career with good job security but you must also prove to the admission committee that medicine is and has been your passion since the second grade and you view it as an almost divine calling to have the opportunity to help your fellow man blah blah blah.  Now, I don’t confess to kow the importance of extracurricular activities to medical school admission.  At some level the members of the admission committee must know that you only went to Zaire to help in a jungle hospital for resume padding.  Maybe American health care is not as advanced as Cuba’s but surely there are not long lines of American residency-trained physicians fighting for visas to practice medicine on the the Dark Continent, Central America, or anywhere else where a young medical school applicant may sojourn for a couple of weeks to demonstrate his commitment to global health care.

In the Pandaverse, if a young medical school applicant mentioned that he had volunteered in Chad the interviewer’s eyes would glaze over and he would ask, “So what does that have to do with practicing medicine in the United States?”  (Hint: Nothing.)

But whatever your feeling about relevance it is understood among the pre-med community that these kinds of activities are required and as the admission community endorses, either overtly or tacitly, this kind of thing you need to put on your frilled ballerina skirt, your ribbons, your muzzle, and jump…I said jump!…jump, poodle through the hoops and count yourself lucky that they haven’t yet lighted them on fire.  The way things are going, it is only a matter of time before an actual medical degree from a Third World country will be a requirement for admission.  Either that or having been intimately involved in the crafting of health care policy for some Brie-eating United Nations Bureaucrat.

Until that day you can probably get by with passing out clean needles to addicts, holding women’s hands at Planned Parenthood while they abort their babies, fetching water for the patients in the Emergency Department, or half a hundred other things that really make no difference and have nothing to do with the practice of medicine.  For my money, the most valuable things you can do are to either shadow a doctor or a resident (to give you a real idea of what is involved) or to get some kind of minor career in the health care industry where you can see if you have the stomach for it.  If you already have such a career then your’re golden because being a Paramedic or a Physical Therapist (for example) speaks for itself about your dedication. 

Research is probably the one thing you can do that will really set you apart from the pack.  Everybody passes out needles.  Hell, there’s nothing to it.  No commitement at all and the self-righteousness you can experience passing out the implements of self-destruction to people who may as well be alien life-forms to you for all you have in common with them is an added bonus.  You also get to practice your faux empathy and it gives you a chance to hate on President Bush for not making Heroin legal.  But the discipline to work for a cantankerous professor, essentially as his bitch, doing his grunt work to have your name on a paper?  That’s what I’m talking about.  It’s difficult and everybody knows it which is why meaningful research as an undergraduate will give your otherwise decent but not spectacular application a boost.

Short of that it’s going to come down to good grades and bogus extracurricular activities of the High School Musical variety, long on talk, short on action, in which you demonstrated some ethereal and hard-to-explain leadership traits.

Any kinds of patients you don’t like?

Naw, I like ‘em all for one reason or another.  The sicker the better.  And I don’t dislike minor complaints either except that sometimes a minor complaint turns into a life-threatening emergency.  Nothing wrong with that actually except if I pick up the chart at the end of a shift.  But the minor complaints, the non-emergent, non-urgent, and sometimes puzzling patients (why on earth did they haul their kids and themselves out of bed at 2AM for a minor cough?) are a large portion of the bread and butter of our specialty and pay the bills, so to speak, that allow us hang around to take care of the two or three patients a shift who are either heading south fast or have arrived and are setting up camp.

(Public Service Announcement: Don’t skip dialysis over the Thanksgiving holiday so you can visit from out of town and eat highly salted holiday foods with your relatives.  I’m just saying…)

But there are, so far, two kinds of patients that annoy me a little.  The first are the drug seekers and frequent fliers who want to jump to the goodies and then get irate if I insist on a history, a physical exam, an assesment, and a plan.  Generally, I am not buying that on each of the thirty times you have presented for your back pain they just gave you some demerol and you were in and out in twenty minutes. 

Lady, the only people who get in and out of here in twenty minutes are the ones heading to the cath lab or the morgue. 

Not to mention that I don’t like being told how I am going to do my job by an amateur (although admittedly an interested one).  I happen to like trying the basic but effective things to break a migraine and 200 milligrams of Demerol is not on the “first do this” list.  I don’t even mind the lies.  Just don’t tell me what to do.  I have the medical degree.  It’s not much but it’s all I’ve got.  

The other kind of patient who annoy me are the ones who are ridiculously impatient.  Now, I understand that a visit to the Emergency Department, particularly a busy one that trains residents, can involve many hours of just sitting around waiting.   The beds are not comfortable and neither are the chairs for the family.  But can’t they get the sense, just by looking around, that we are sometimes insanely busy?  There are not that many doctors. If a trauma or two or a critical patient comes in that’s it for their minor complaint until things settle down again.  I am glad the minor complaints come in, the hospital and the law certainly encourage this kind of thing, but the Emergency Department only functions as your Urgent Care Clinic if there is nobody ahead of you who is sicker.  It’s not first come first served and I sometimes am embarrassed to have to explain it to people.  I apologize for the delay when I finally get around to them because most of my patients are decent people and very understanding but to the minority who are not, if you don’t want to risk the wait then don’t come in with your bogus complaint.  You said you had a problem.  You came to the Emergency Department at 2AM because it couldn’t wait until morning or for an appointment with your own doctor. Consequently, there is a huge prejudice on my part to give you the benefit of the doubt and do a reasonable amount of diagnostic testing and cognitive interpretation. 

Which takes time.  Time for the labs.  Time for the studies.  Hell, time for me to get around to writing up your discharge.  I generally want to get you out as much as you want to go so I can put you in the “win” column but not at the expense of giving you shoddy care.   Don’t keep bugging your nurse.  I have currently and will have in the future a huge incentive to get a disposition on you as fast as possible but a critical patient takes precedence and needs most of my attention until things settle out. 

Poodle Circus and Other Things (Real Questions From Real Readers)

Stealth Medicine and Other Topics

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

Stealth Medicine and Other Topics

Everything You Need to Know About Complementary and Alternative Medicine (Part 2)

(In which we address more of the blatantly obvious. -PB)

5. You Can be Fooled

I’m a fairly intelligent guy Not a super-genius or anything like that but I can tease out the truth of most things if given enough time and, when the wind is just right, can tell a hawk from a handsaw.  And yet I am not so confident in my intelligence that I don’t think I can be fooled. Because, for example, I having nothing but a polite interest in automotive technology I am pretty much at the mercy of my mechanic when he describes the repairs needed by our aging pair of automobiles. I trust the guy because nothing he has ever suggested sounds too outrageous and on a couple of occasions he replaced a three-dollar fuse when he could have taken me for an alternator. I am however at his mercy unless I want to study car repair or haul the thing to more than one mechanic.

Consider the typical customer of Complementary and Alternatative Medicine. They are usually fairly intelligent and, by necessity, prosperous enough to pay for something as exotic as a Chakra tuning. But as far as medical knowledge? Not even a clue except for some superficial things and the usual lies and half-truths they have found on the internet. Medicine is an order of magnitude more complicated than auto-repair (although a good mechanic, like a good barber, is worth his weight in platinum) and cannot be casually learned by most people. I can read about engines and have enough of an understanding of their workings to understand what my mechanic is telling me but compared to learning the necessary background to diagnose, treat, and manage disease, this does not require too much effort. When it comes to medicine, the public who undeniably have a huge interest in the subject naturally gravitate towards explanations that simplfy things a tad and don’t require quite the intensive science background.

It’s just human nature. We prefer the simple explanations that do not require complicated and often non-linear thinking. Acupuncture, for example, is billed as redirecting the flow of mystical energy in the body by the use of needles. It jibes pretty well with what most people learned watching those poorly animated Saturday morning cartoons where, instead of incurring the expense of animating the characters, every important action is mediated by some kind of force field or power ray shooting out of Captain Planet’s hands. Thus there is a natural tendency of the public to accept Acupuncture, seeing as it jibes with their world-view. Or consider Homeopathy whose founding principle, that like cures like, is not only appealing to the ear and the heart but also sounds strangely like some of the dim knowledge the public has about the action of vaccines. If they had a more detailed understanding of the immune system it wouldn’t sound so good but who has the time to read a boring old immunology textbook when American Idol is down to the final four?

Intelligent as they are I have to laugh at the typical consumer of Complementary and Alternative Medicine who, while open-minded to a fault, deride speaking in tongues, Christian faith healing, and other barbaric customs of the uncouth rubes infesting the backwoods but pay good money to have some charlatan extract bad Chakra. The difference between some sweaty little televangelist and your local purveyor of Complementary and Alternative Medicine is nothing but style and body mass index and you are being robbed just as surely as if you are sending money for prayer intercession to the Reverend Jimmy Swaggert. You can be fooled, especially when it comes to religion. What, after all, is the standard orthodoxy of open-mindedness, non-judgmentalism, and self-absorption but a religion? It preaches that belief is a substitute for reality and that to even question its central belief, that self-created reality trumps the real kind, is to be an infidel.

The denizen of a mouldering single-wide trailer in Sisterboff, Arkansas sending money to an oily television preacher so Jesus can reveal the winning lottery numbers is philosophically no different than a fit, professional woman swallowing her homeopathic remedies. One has a faith in her dimly understood religion, the other in her poorly understood notion of science. Both are being played for suckers.

6. Quantum Physics, The Last Refuge of Scoundrels

Quantum physics describes the relationships between energy and matter at the subatomic level where the principles of classical physics (momentum, acceleration, velocity, etc.) do not apply. In particular it addresses the relationship between the orbital shells of electrons and photons. It is not a goofy, mystical endeavor that exists outside the realm of the rational world and in fact, while classical physics cannot explain quantum phenomena, quantum physics explains classical physics which results from the cumulative effects of quantum properties.

Quantum mechanics no more explains Reiki, Homeopathy, or Acupuncture than do magic pixies. Or to put it another way, if you were to posit quantum effects as a mechanism for your particular quackery du jour as is common among the purveyors of complementary and alternative medicine you may as well use it to bolster your belief in just about anything at all, no matter how ridiculous. To be sure the field of quantum physics is expanding and there is much to be learned. But it is not expanding towards Ayurvedic Medicine or Homeopathy. Physicists are hard at work trying to reconcile quantum physics with relativity, not proving the existence of Chakra. So sorry. Like I said, you can be fooled and your Homeopath desperately clinging to quantum theory knows less about it than he does about medicine. It’s just part of the con; his attempt to mix enough scientific chatter into a his otherwise nonsensical duckspeak so you will buy it.

7. Political Correctness Does Not Apply to Medicine

The ancient Chinese did not have advanced medical knowledge which allowed them to live long, healthy lives. And they did not, as has been suggested, have diseases unique to their own culture against which their indigenous medicine was effective but which does not work against the white man’s diseases. It is probably true that the Han Dynasty Chinese did not have too much colon cancer, for example, but then the average lifespan back then was around thirty and to live past sixty represented either an exceptionally privileged or lucky life. I am 43 and I have no health problems nor have I ever had any. But let’s see how I do in another twenty years when all of those bacon and eggs have had a chance to work their magic. Who knows what diseases I will get? Whatever they are they will all be the result of a life lived well beyond genetic usefulness and this potential smorgasbord of morbidity is only to be made possible because Western medicine can extend my life long enough for it to happen. In ancient China (or Europe, or Meso-American, or Africa) I would have been dead or decrepit by now and my predictable decline would have been ascribed to old age or maybe Utapu, the God of Rectal Fire. Not only that but the disease that finished me would have been poorly decribed and my long life into the forties would be testimony to the benefits of keeping my qi in order.

This is not to say that the ancients didn’t occasionally stumble upon some legitimate medicine. Surgeons for the Roman Legions, for example, used silver staples to close wounds no doubt having observed that silver had some antiseptic properties. But they still had no idea of germ theory so anybody who would prefer the Legion’s medicus vulnerarius over a modern trauma surgeon is an idiot.

Political correctness is an apologia by the guilt-ridden children of the baby-boomers for the current but by no means permanent economic, political, scientific, and miltary superiority of the West. It is an angst-ridden, completely irrational philosophy that has as its central theme that only Western man has ever behaved in a violent, selfish, or self-destructive manner. It constructs an artificial worldview and is an insubstantatial foundation on which to anchor medicine, a science which like all practical endeavors should be as rational as possible.

Everything You Need to Know About Complementary and Alternative Medicine (Part 2)

Everything You Need to Know About Complementary and Alternative Medicine (Part 1)

(Just belaboring the obvious again. Some things should speak for themselves but judging from my angry email defending Complementary and Alternative Medicine, this is not the case. Rather than respond publicly to private emails I thought I would address some of the major themes of my critics. -PB)
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1. The Imperfections of real medicine do not validate your kooky theories.

You, oh purveyor of snake oil, may exhaust yourself pointing out the flaws in medical science. You may grimly list the horrific side effects of many of our therapies and gleefully highlight the lack of evidence for quite a few things done in the real medical world. You may even solemnly condemn our general inability to really cure much of anything but, apart from making yourself really tired and giving me a crick in my neck from nodding in agreement, all you will have demonstrated is that real medicine is an imperfect business which is not a huge revelation to anyone who has spent more than an hour in a nursing home, a hospital, or any other place where you can find incredibly sick people who, despite our best efforts, often remain incredibly sick and die after being flogged by the mightiest weapons in the medical arsenal. A darn shame but it does not follow that the solution to our limited medical knowledge is pixie dust, magical gnomes, or spiritual energy streaming from your fingertips.

On the other hand, while medicine is imperfect you’d have to be a moron or totally brainwashed into your particular CAM cult to not recognize the tremendous advances in medicine even over the last twenty years to say nothing of the huge leap from the days of snake oil at the turn of the last century. That’s the point of modern medicine. It advances. Expanding knowledge leads to to increasingly sophisticated and effective therapies. It’s Complementary and Alternative Medicine that is perfect. Everything you need to know about acupuncture for example, was elucidated a thousand years ago well before those wily Chinese had even the foggiest notion about germs or cardiac physiology. They so totally nailed it that no new research needs to be done. It’s all about qi and the meridians along which it happily flows and is so perfect as to be impervious to debate, refutation, or criticism. While we plod along with our feeble attempts to expand medical knowledge acupuncturists ply their needles in service of a perfect medical philosophy that was ossified in the Dark Ages.

2. The complexity of your kooky theory does not validate it.

For thousands of years Astrology was considered a legitimate science and the best minds of those distant ages devoted their lives to deriving horoscopes and divining the effects of the stars on our lives. They wrote books, developed complicated theories, and tried to apply the principles of Astrology in every aspect of life including medicine. And yet today if you proposed endowing a Chair of Astrology at your Alma Mater or incorporated horoscopes in your medical practice I have no doubt that even the most laissez-faire of liberal academics, grimly keeping their minds open in the face of every other stupidity under the sun, would at last have their fill and laugh in your face with all the pent-up rage of a politically correct bureaucrat forced to shuck and jive to ideas he knows to be ridiculous. Clearly astrology is ridiculous despite the vast amounts of intellectual energy that have been (and still are) devoted to it.

In the same vein, I have no doubt that Ayurvedic Medicine has been beaten to death by the learned men of India for thousands of years in the same manner that Astrology was dissected in the West. I also have no doubt that there is a massive body of Ayurvedic scholarship collecting dust in libraries from Duluth to Calcutta. But as it’s a system of medicine based on a highly imperfect understanding of physiology, more religious than scientific, and Indians who used it pretty much dropped like flies from diseases that it took Western medicine to defeat, except for historical interest all of that intellectual activity is as useless as trying to divine the future from the entrails of birds. You can learn Sanskrit to really get into the source material but you’re wasting your time. The initial premise is wrong and, like a house built on weak foundation, no matter how much you spend on the bathrooms it’s still going to collapse.

3. Complementary and Alternative Medicine is parasitic, not symbiotic.

Suppose I were to actually build a house. Along with a foundation it would require framing of the walls and floors, siding, wiring, glazing, plumbing and a dozen other skilled trades coordinating their efforts. The practitioners of Complementary and Alternative Medicine would be like your Aunt Mildred telling you how to hang the toilet paper in the finished bathrooms and then trying to claim credit as an essential part in the construction. Complementary and alternative medicine only exists because real medicine does all of the heavy lifting leaving a risk-free environment in which it may ply its patent remedies. At best it’s an afterthought, something that legitimate hospitals add to their services to attract the kook money. At worst it’s a cynical ploy to fleece a little extra from the desperate, many of whom are dying and will gladly pay for another straw to grasp. In no way is it an essential part of medical therapy except that it provides entertainment to the patients and their families while medicine and nature run their courses.

4. Placebo Medicine is not Medicine.

Millions of dollars are wasted every year on shoddily constructed studies trying to demonstrate efficacy of Complementary and Alternative Medicine. The results have been disappointing and entirely predictable. Generally, if you ignore poor study design and spin the data just so, CAM is shown to be occasionally but not reliably slightly, and we’re talking slightly, more effecitive than placebo. These results are naturally touted as a both a huge victory for kook-dom and as a justification for continuing to charge large sums of money for therapies that are so close to placebo in their effectivness that you should wonder why the opposite conclusion isn’t derived. In other words, maybe if your treatment modality is so iffy, requiring as it does to be viewed through squinted eyes in dim light at a distance of several hundred feet to show even a trace of effectivness, maybe you need to reassess your career goals. Call me a cynic but something that is slightly better than placebo could also be called next to useless. Certainly not worth spending a lot of money on unless it carries a big disclaimer saying, “For Entertainment Purposes Only.”

Everything You Need to Know About Complementary and Alternative Medicine (Part 1)

Complementary and Alternative Medicine Month Continues

This Ain’t no Party, This Ain’t no Disco, This Ain’t no Fooling Around

It’s a grim business, medicine I mean. For all the hype it’s nothing more than a futile struggle with death, a battle lost in the early stages by some, a bit later by others, but lost all the same in the end. If you’re lucky you make it to fifty with no Past Medical History until one day your cholesterol is noted to be a little high or you get a little rectal bleeding and things are never the same again. Then you get a little winded and wake up one morning to discover that it’s been ten years since your bypass and all of a sudden your feet seem to be swollen most of the week and you’re urinating all of the time. Your couple of pills a day have become a plastic pill organizer and your Past Medical History, once easily checked as “none” on all of the forms, is now spread through several different computer systems and thick files in various specialist’s offices. You get older and sicker. Your quality of life diminishes with each passing year and you gradually forget what it was like to sprint up a flight of stairs or run to catch a bus. Eventually simple things like getting out of a car or making it to your bedside commode become the major ordeals of a pain-filled day and you are rushed to the hospital every month for fear that you may have at last suffered the Big One, the final event that will put you out of reach of the medical profession’s best efforts to wrest a little more time for you.

In the end, the Reaper who has been waiting in the cool shadows just beyond the incandescent glare on the emaciated ruin of your body gently reaches through the crowd frantically trying to restart your heart and politely claims you as his own.

That’s how it goes. Your physicians are natural pessimists and can see the end for all but the youngest of their patients. We do what we can, of course, and it is our privilege to occasionally snatch you away from death but this is not done without a cost. Our treatments are crude, our understanding of physiology imperfect, and we do not yet have the knowledge or the sophisitication to precisely target your disease leaving the rest of your body unscathed. Every therapy yet devised has a dark parcel of side effects and adverse outcomes. When you start your long march through the medical world the risks of these therapies are relatively benign. We put you on an innocuous little blood pressure pill and warn you that it may cause a persistant but otherwise harmless cough. A few years later you become light-headed from the medications that are absolutely essential to control your potentially lethal cardiac arrythmia and your physicians debate whether to take you off of blood thinners lest you fall and suffer a catastrophic bleed in your brain. Time goes by and to save you from pancreatic cancer the surgeons shell you out like you were some kind of mammalian oyster.

At no time however, will your physicians ever promise a magic cure, a therapy that will definitively fix the problem with no ill effects leaving alone the precarious balance of your fantastically complicated body. At best they will promise good results with minimal and easily tolerated side effects. At worst the therapies they will reluctantly propose are almost as bad as the disease they will ameliorate and the subject of, for example, chemotherapy or a risky aortic repair is broached with dread to a patient who must be made to understand that real medicine is not as it appears in the popular media.

At a philosophical level, leaving aside the utter ridiculousness of Reiki healers shooting sacred energy from their fingers, this is the difference between real medicine and Complementary and Alternative Medicine whose practitioners, as they don’t treat real pathology, have never developed humility in the face of disease. It is easy, for example, for your acupuncturist to promise a perfect cure because they’re not really treating anything, just some nebulous mumbo-jumbo like a dysfunction of your ability to receive pure qi from the heavens. Side effects? None, of course. It’s perfect medicine because, despite being based on a completely imaginary idea of physiology that has no relation whatsoever to the way things actually are, it can magically target your imaginary complaint.

All medicine is a metaphor of course. We speak of proton pumps and “watershed strokes” as a way to explain complex structure and pathology that would be otherwise too cumbersome to describe. Ideally however you would want your metaphors to closely match what they purport to represent. Refining these metaphors is the purpose of medical science and the appropriatness of a therapy depends on the level to which it coincides with the most reasonable description of the underlying dysfunction. Almost all of complementary and alternative medicine is based on metaphors which were either, as is the case with Homeopathy fabricated from whole cloth, or in the case of Acupuncture and Ayurvedic medicine develped at a time when it was impossible to know any better. “Meridians” make sense when your knowledge of the body is based on religious superstition and mysticism. Once you discover the true function of blood vessels and nerves, however, it is time to put away your belief in qi, a spiritual construct that as a metaphor for disease has no basis in real physiology. The metaphors are diverging. Acupuncture stands still with its feet firmly planted in a time when people routinely died in their thirties from diseases that modern medicine has eliminated. It still exists because real medicine provides the practitioner of Complementary and Alternative Medicine a risk-free environment in which to operate as well as a steady stream of customers who cannot accept the truth, namely that we all die, our health fails, and, as there is no evolutionary disadvantage to it, we seem to be genetically programmed to wear out.

So you see, to practice real medicine is to create problems. Fifty years ago the majority of my multiply co-morbid and incredibly sick patients would have died in their fifties from the first of the many conditions which they have today accumulated. No amount of Acupuncture, homeopathy, or Reiki would have got them through their first heart attack just as no amount can now treat the hundreds of petty ailments which have become the bread and butter of the quacks.

Snake oil is something of an American tradition but it is only recently that its purveyors have had the benefit of physicians to do their heavy lifting.

Complementary and Alternative Medicine Month Continues

Kicking Off Complementary and Alternative Medicine Month

(November is going to be Complementary and Alternative Medicine month here on Panda Bear, MD. My recent posts on the subject have generated a lot of interest, quite a few visits, and a bunch of angry email so I believe there is some interest in the subject out there. I apologize to you, oh my long-suffering readers, who would like to read more about residency and medical school but as I have categorized all of my previous articles on that subject and I have recently thrown you plenty of red meat on the subject of Emergency Medicine I ask for your indulgence as we explore the inroads of the lunatic fringe into the medical profession.-PB)

If Wishes and Buts Were Candies and Nuts We’d All Have a Merry Christmas

No one thinks rationally anymore, not even the well-educated. While I don’t necessarily expect critical thinking from the unwashed, higher education, while of no practical value to the legions of college graduates sporting their polyurethane diplomas, should at least teach people to think critically or there is no point to it and it becomes just a four year interlude where you learned a bunch of trivia and borrowed a lot of money to party with sorority girls. Certainly you should ask for your money back if you graduated without the intellectual skill to distinguish something that you want to be true from something that is. And you should ask for a refund if you have been awarded a diploma in any field without obtaining the fund of knowledge to recognize the difference between something that could be possible and something that can’t possibly be.

Take Homeopathy, a medical therapy which relies on the imaginary property of water to retain the memory of a substance which it has diluted to a point where not a single atom of the substance remains. People often ask me if my experience with Emergency Medicine, the most practical and hard-nosed of the medical specialties, has left me cynical about the possibility of finding some validity in Homeopathy and other equally ridiculous Complementary and Alternative Medicine therapies. Actually, by the time I had finished the eighth grade I had a sufficient background in chemistry and biology to recognize that these things cannot possibly work. How much education do you need, for example, to definitively state that spinal manipulation cannot possibly obviate the need for vaccinations (as many of our chiropractic friends believe) or that spiritual fire cannot possibly, a la Saturday morning cartoons, stream out of the fingers of Reiki healers? It’s not even as if we’re arguing some subtle point about the energy state of an electron shell or an obscure ion channel in yer’ fucking spleen. This is literally third grade stuff and the fact that many prestigious medical centers lack the institutional courage to point it out should make you cringe in shame, either at their gullibility or their venality.

“Well, we’re just being open-minded,” is the formula used to justify spending large sums of money to investigate therapies that even my ten-year-old son could instantly recognize as not only impossible but also somewhat ridiculous. I guess I’ll just have to be closed-minded because if you asked me for money to investigate the healing properties of magical gnomes I would turn you down. Gnomes, like Reiki, Homeopathy, faith healing, and ayurvedic medicine are ridiculous at face value. The extent that they are investigated highlights one of the biggest problems with Complementary and Alternative Medicine, not that it is mostly ridiculous (which it is), takes money from the gullible including those who really can’t afford it (which it does), or even that it sometimes delays the effective treatment of health problems (which I see regularly), but that it has the potential at a time when we should be looking for ways to economize on medical care to suck up even more public money with nothing to show in return except the enrichment of a pack of charlatans.

As many of my regular readers know I have a deep skepticism for much of what we do even in the practice of real medicine and believe we waste vast sums on only marginally effective and oftentimes inopportune therapies. It is not unusual in our system, for example, for a nonagenarian patient teetering on the edge of death to be followed by six specialists as well as a primary physican, have undergone batteries of repetitive tests and redundant imaging studies, and been the recipient of scores of procedures, many of them of dubious benefit as it relates to decreasing their morbidity or mortality.  There is also no question that cognitive medicine, the art of deliberating and arriving at the optimal and usually the simplest treatment regimen for a patient, is playing second fiddle to procedural medicine. I confess that I sometimes fantasize about being a primary care physician if only so I could sit down with my masively polypharmic and polyiatric patients to make sense of everything being done to them, much of it harmful or of only limited use.

No need to make the problem worse by invoking qi, karma, and magic pixies as therapies except if you believe that everyone should have an equal opportunity to steal money from the public.  In other words, the answer to the oft-cited rational for patients turning to CAM, that they have exhausted all that real medicine can offer, is not to keep feeding their delusions that they’ll live forever or can achieve health without effort but to have the economic courage to tell them that nothing more needs or can be done and that medicine cannot solve most of their problems. In other words, we need to continue to make medicine as rational as we possibly can, eschewing treatments and practices that are ineffective or ridiculous despite what the public wants. More importantly, medicine shoud be a minimalistic pursuit where we have the common sense to limit what we do instead of continuing to expand our scope so that everything under the sun, including the great spiritual void in the hearts of those who dabble in Complementary and Alternative Medicine, becomes a medical problem.

The desire to spread the tentacles of Complementary and Alternative Medicine to real patients, those who have real diseases and not nebulous emotional complaints, has the potential to suck even more money into health care, money that is going to be thrown away as surely as we throw it away keeping the living dead warm in the ICU.

Kicking Off Complementary and Alternative Medicine Month