Science/Technology blog

I have a question for any students in the audience today. Are you ready? Here it is: what is the most important part of the medical history?

The medical history, by the way, is what physicians document when they meet a patient for the first time. The doctor asks a series of questions and the answers are shaped into a narrative that documents the details of the clinical situation in order to deduce what exactly is wrong with the patient and maybe even correct the problem. The medical history is recorded in this order:

Chief Complaint

History of Present Illness

Allergies

Medicines

Past Medical History

Family History

Social History

Review of Systems

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I know we’re all used to seeing creationists dishonestly quoting something written by scientists, but folks I’m about to show you one of the most egregious examples you will ever see of it. This is as bad as Morris and Whitcomb’s famous distortion of Ross and Rezak’s paper on the Lewis overthrust, where they literally quoted a paragraph and stopped just before the sentence that began, “However…..”, to give the impression that the authors were saying the exact opposite of what they actually said. Go read this post by Sal at UD and you will see the following quote:

Charles Darwin, perhaps medicine’s most famous dropout, provided the impetus for a subject that figures so rarely in medical education. Indeed, even the iconic textbook example of evolution–antibiotic resistance–is rarely described as “evolution” in relevant papers published in medical journals. Despite potentially valid reasons for this oversight (e.g., that authors of papers in medical journals would regard the term as too general), it propagates into the popular press when those papers are reported on, feeding the wider perception of evolution’s irrelevance in general, and to medicine in particular.

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I’m confused again about what appear to be mutually conflicting statements.

The Discovery Institute’s favorite creationist neurosurgeon Dr. Michael Egnor two months ago on Pharyngula:

Perhaps a fable (not a just-so story!) will illustrate. Imagine that you, P.Z., were a student in 1925. You would study Darwinism fairly intensively as a high school student, undergrad, and med student (it’s a hypothetical!). In high school you’d read Hunter’s ‘A Civic Biology’ (unless you lived in Dayton, Tennessee), which taught the Darwinian superiority of the Nordic races and the need to eliminate the lesser races. In college you would take courses on Eugenics (thousands were offered), and learn the application of dog breeding to humans. As a medical student you would be steeped in Eugenic practices. You might do a term paper on Darwin’s lament in the ‘Descent of Man’ (ever heard of the book?) that the smallpox vaccine was regrettable because it enabled the ‘weak’ to breed, noting that ‘no breeder would ever breed from his worst stock’. You would then go off to practice medicine, and join the Eugenic frenzy. Fifty thousand Americans, tagged ‘feeble minded’ and manifestly poor breeding stock, were sterilized involuntarily. Your Darwinian-Eugenic work would be mainstream medicine, endorsed by all the big guys, except the ‘anti-science’ types like Chesterton and the Catholics, who kept bleating about human dignity, and your only interruption would be those pesky Germans who kept visiting, and learning from you. Darwinism was absolutely indispensable to Eugenics, and to American medicine (and some continental European medicine) in the first half of the 20th century…

Darwinism was the indispensable basis for Eugenics. I teach in the medical ethics course in my medical school. I make sure the students learn about Eugenics, and where it came from. I have a particular distaste for your ideological ancestors.

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I have talked about funding a couple of times (here and here), and I get the impression from the comments about those posts that my views are at the minimum somewhat iconoclastic. Basically, while I would prefer the government to give more to research, at the moment I don’t think that the primary issue is that the government isn’t giving enough.

In this area, The Health Care Renewal Blog has a great post on the funding problems facing researchers in medical schools. Here’s a clue — they don’t have to do with the government’s but rather the medical school’s priorities:

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Over the last year or so, the US FDA has grown tougher on withdrawing prescription and over-the-counter drugs that have not met the modern burden of proof for safety and efficacy that was officially required by the 1962 passage of the Kefauver-Harris amendments to the 1906 Federal Food and Drug Act (WaPo overview from June 2006 here). This legislation not only gave us the modern structure of preclinical and clincal trials, but it also required that drugs sold previously between 1938 and 1962 had to meet this standard of proof of safety and effectiveness.

But, it didn’t make financial sense for these companies to be required to submit to the full battery of preclinical and clincal tests required of new drugs. So in 1966, the National Academy of Sciences convened a special group to assess the existing clinical literature on 4,000 of these drugs and the FDA took their recommendations to keep or ban these agents in 1968 by forming the Drug Efficacy Study Implementation (DESI). Very common drugs like aspirin and acetaminophen were “grandfathered” in under this literature review process.

Not well-appreciated was that the FDA did ultimately require companies selling these drugs to conduct prospective clinical trials within some ill-defined timeframe. Drugs like phenobarbital for epilepsy and chloral hydrate for sedation and alcohol withdrawal are two examples of drugs that continue to be sold as “unapproved” drugs. However, there was little financial incentive for a drug company to support such trials and the FDA had for many years a rather relaxed attitude toward these agents. But, as the FDA notes:

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Phil Plait of Bad Astronomy writes eloquently on debating pseudoscientists:

Debunking fringe theories is usually not trivial. For example, Richard Hoagland has been making his (mistaken) claims about Mars for literally decades. The breadth and depth of his claims is astonishing! It would take forever to debunk everything he says, as it would for most pseudoscience theories. And every time you debunk one thing, they pop up with another claim, instantly ignoring that you just destroyed their last argument. This is another reason most scientists don’t bother debunking wacky theories.

… I took on the gist of the claims, and I don’t bother with the hundreds or sometimes thousands of minor details. Destroy the foundation of their theories, and all the little claims flutter to the ground as well on their own.

But then, inevitably, the issue of a debate comes up. Nearly every major (in the loose sense of the term) pseudoscientist has challenged me to a debate at one time or another. Both McCanney and Hoagland have publicly called for me to debate them on, for example, the “Coast to Coast AM” radio show. In almost every case, I have refused.

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Well, well, well, well.

I hadn’t expected it. I really hadn’t. After just shy of three weeks since I first made my challenge to Dr. Egnor to put up or shut up regarding certain claims of his that the “design inference” has been “of great value” in medicine and results in “the best medical research,” I had pretty much given up trying to get an answer out of him. I had come to assume that either (1) Dr. Egnor had been either unaware of my challenge (although I tended to doubt it, given how many echoed it, or (2) he was simply ignoring it in favor of posting some amazingly bad reasoning. To refresh your memory, I will point out that, intrigued by Dr. Egnor’s assertions about how useful the “design inference” was to medicine and biology, I asked him on numerous occasions:

1. Explain, specifically, how the design inference is “of great value” in medicine. Please support your description with concrete examples, preferably documented in the biomedical peer-reviewed literature that show how the design inference makes one a better physician or contributes to treatments for disease.
2. Explain, specifically, how the design inference has been of “enormous help in scientific research in general and medical research.” Please support your description with concrete examples documented in the biomedical peer-reviewed literature that show “best medical research” that is based on the “search for patterns recognizable as design.” In other words, show us examples of medical research either based on or strongly influenced by the design inference, and how the design inference led to or facilitated the discovery of a better treatment for a disease or a better understanding of the pathophysiology behind a disease.

Those are two pretty reasonable questions, if I do say so myself, given how, with the supreme confidence of a surgeon who regularly cuts into people’s skulls to operate on their brains, Dr. Egnor had repeated his assertions of how useful the “design inference” supposedly is for science. And, after nearly three weeks, Dr. Egnor has finally responded with a post over at the Discovery Institute Whine Blog entitled, Orac’s Challenge: Do Scientists ever use the Design Inference in Biology? (Hmmm…let me think…)

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A recent study in The Archives of General Psychiatry suggests that 25 percent of all Americans diagnosed with depression are actually just dealing with the normal disappointments of life, like divorce or the loss of a job. Their sadness is being treated like a medical condition. They were given drugs, when what they really needed was support:

The study also suggested that drug treatment may often be inappropriate for people who are experiencing painful — but normal — responses to life’s stresses. Supportive therapy, on the other hand, may be useful — and may keep someone who has been through a divorce or has lost a job from going on to develop full-blown depression.

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Doug Farrago, MD, is a private practice doc in Maine who has been publishing the print medical satire journal, Placebo Journal, since 2001. Doug does it all, including spoofing drug company adverts, collecting humorous doc stories, and generally poking fun at drug reps, HMOs, and lawyers.

About two years ago, Doug started sending out e-mails of the Placebo Gazette, a rather bloggy and somewhat more serious newsletter of issues facing docs and medicine in general. Imagine my surprise in Placebo Gazette #81 where Dr Farrago threatened to start writing a blog:

The Detroit Free Press did an article on doctors who blog. It is starting to spread, so much that we will be doing it here at the Placebo Journal in the near future. It wasn’t a flattering piece for us physicians as the critics are questioning the ethics of those that do this sort of thing. They bring up patient privacy and liability risks. These are good points. As the editor of the Placebo Journal, I am acutely aware of this issue. Our medical stories, which are all true, come from around the country. The stories are not time sensitive so they can be 1 month old or 50 years old. We print stories about funny things that happen on our job. It may be about patients, about administrators, about doctors, etc. The only rules we have is that it has to be true, be confidential, and there can be no compromise of care. It is my opinion that unless physicians can commiserate about our lives, then we are relegated to the slow burn that is spreading across our profession. By understanding that others walk in our shoes and have similar experiences, we can feel a little better about ourselves. It is highly therapeutic. It is also good to laugh. It is funny when a rude doctor’s toupee gets blown across from a disconnected ventilator tube. It is funny when a medical student flips off her glove (fresh from a rectal exam) and turns around to see some splatter across her chief resident’s face. It is funny to see a potato used as a contraceptive device. It is hilarious to make fun of HMOs, pharmaceutical companies and lawyers. I need this and per the popularity of my magazine, so do other docs, nurses and even patients!

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Physicians from around the world urged Elsevier Group PLC., the publisher of The Lancet medical journal and other scientific and medical journals, to cut its links to weapons sales, calling on the editors to find another publisher if Reed Elsevier refused to stop hosting arms fairs.

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