Stupid Until Proven Intelligent - MD & DC Relations

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Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.

Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.

I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.

I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.

MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”

He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”

Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.

The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."

Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.

I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.

Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.

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1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.

Uncientific America - A Pluto Moment

Image by the mad LOLscientist via Flickr

The LA Times (what not the NY Times) has an article about Chris Mooney & Sheril Kirshenbaum's new book, Unscientific America. The article, by Lori Kozlowski, Bringing science back into America's sphere laments the pitiful state of America's understanding of science.

The "demotion" of Pluto from a planet is used as a metaphor for what people know about science. It seems that the Pew Research Center did a study about what the public understands when it comes to science. They found that 60% knew that Pluto had been reclassified. On the other hand 54% thought that antibiotics kill viruses and 46% knew that electrons are smaller than atoms.
Given how little the public knows about science Kozlowski writes:

It is exceedingly rare that science does anything that reaches almost everybody anymore. So, when you get your moment to put it all before everybody, you don't want it to be a Pluto moment.

If science is going to be a candle in the darkness (as the late Carl Sagan subtitled his great book: The Demon-Haunted World) then it needs to go viral. It has to grab the imagination of the public. In the preface to The Demon-Haunted World, Sagan relates how he had a limo driver ask why science guys, like Sagan, didn't work on finding the secret to unlimited power that supposedly powered the mythical island of Atlantis. This event was one reason why such a serious scientist, as Sagan, would write popular books. He wanted to make science interesting to the masses.

Kozlowski then talks about how so many people erroneously believe that vaccinations cause autism. These people are often well to do and educated. In a book that is similar to Sagan's Michael Shermer, in
"Why people believe weird things: Pseudoscience, Superstition, and Other Confusions of Our Time" writes:

In day-to-day life, as in science, we all resist fundamental paradigm change. Social scientist Jay Stuart Snelson calls this resistance an ideological immune system: 'educated, intelligent, and successful adults rarely change their most fundamental presuppositions.' ... That is, the higher the IQ, the greater the potential for ideological immunity.

Maybe Mooney & Kirshenbaum have figured out how to break though ideological immunity and to make the excitement of the discoveries of science go viral. I'll have to add their book to my list to read.

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You can only do the best you can do

Image by hbp_pix via Flickr

This weekend I helped supervise triage at the NYC Half Marathon. It was to say the least a HOT day. The vast majority of people I saw were with a little support, and salt able to leave my area under the own power. A few were not able to and went to the hospital. It's rather nerve racking to stand by as those who do the next level of care take over. It gets worse when they get carted off to the hospital and one is left without knowing what is going on. You run the event though your mind, was there something I could have done better, could I have gotten to the athlete sooner, etc. And then you hopefully come to the conclusion, as I did, that lacking a finish line in an ER I did the best and I know those I handed the athlete off to, likewise did their best. In the end the athletes recovered and you can only do the best you can do.

Diet

Image by Getty Images via Daylife

If you have not seen it Time has a great series on eating, diet etc. titles The Way We Eat.

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Biking & Bones

Recent studies, discussed in a NYTimes blog have found that cycling is a risk factor for low bone density or osteopenia. This finding is actually not unexpected. Bone mass is in part determined by the amount of load / force applied to the bone. Thus, as noted in the blog runners, weight lifters and triathletes have higher bone mass than cyclists (keep in mind that triathletes do a significant amount of running too).
These findings stress the importance of weight bearing exercise and especially for females. Swimming and cycling while both great exercises do not put adequate stress on bone to stimulate bone deposition thus predisposing the swimmer and cyclist to osteopenia and osteoporosis.

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Vaccines: "Wading through the Confusion"

I was invited last year to participate in a webcast about vaccinations. This was conducted by the California Department of Public Health. They invited me because they had searched the web and found an article that I did with Randy Ferrance, DC, MD on vaccinations for Dynamic Chiropractic in February of 2005: What's Good for the Goose Is ... Ethics and Vaccinations

Here is a link to the webcast on vaccinations. It is a 60 minute program. We taped about hours of material which were edited down to this.

I think the production team headed by Lars Ullberg (he's the on camera moderator) did a great editing job.

Other members of the panel were:

• Ken Reibel is a journalist with a autistic son who blogs at Autism News Beat An evidence-based resource for journalists
• Frankie Milley (and her husband Bob) lost their only child Ryan Wayne Milley, to Meningococcemia/Meningococcal Meningitis on June 22, 1998 - she started meningitis advocacy group for meningitis a vaccine-preventable disease called Meningitis Angels
• Mark Sawyer, MD from the San Diego County Immunization Branch, and a pediatrics professor at the University of California, San Diego,
• Rahul K. Parikh, MD is a physician and writer in the San Francisco Bay Area.
• S. Michael Marcy, MD, UCLA Center for Vaccine Research
• David G. Amaral, PhD is an autism researcher from the UC Davis MIND Institute
• Kristine Sheedy, Ph.D., Associate Director for Communication Science, National Center for Immunization and Respiratory Diseases, CDC Atlanta, GA
• Jamie Betters, a parent of small children
  

A few of the panelists have written papers on the topic of immunization which I think are very important. Citations below:

• Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. Immunization attitudes and beliefs among parents: beyond a dichotomous perspective. Am J Health Behav. 2005 Jan-Feb;29(1):81-92. pubmed record
• Amaral DG, Schumann CM, Nordahl CW. Neuroanatomy of autism. Trends Neurosci. 2008 Mar;31(3):137-45. pubmed record
  
• Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen VL, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 2007 Sep 27;357(13):1281-92. Marcy SM is one of the et al pubmed record
• Parikh RK. Fighting for the reputation of vaccines: lessons from American politics. Pediatrics. 2008 Mar;121(3):621-2. pubmed record
  

There are a lot of web sites that present theories or vitriol regarding vaccinations. The link to the video also links to other valuable web sites on vaccinations.

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What does it take to put an ugly fact through the heart of a beautiful hypothesis?

NPR yesterday did a piece on treating fractured vertebra and so did the NYTimes This is hot news because two papers appeared in the New England Journal of Medicine that compared vertebroplasty to placebo and found them comparable.

The great problem is that the treatment is perceived by both doctors and patients as effective. This treatment provides opportunity for discussion about a huge problem for health care reform. When common knowledge suggests a treatment is effective but the data show, in a compelling way, that the treatment (which has risks and financial costs) is no better than placebo should insurance pay for the treatment?

The fear of some is that because a treatment does not appear to be clinically effective "big brother" will say, "we won't pay." I understand the fear that some all powerful insurance company will get to decide what is and is not effective. But is this bad, per se? I do not think so. Both doctors and patients have for years mistakenly believed that various treatments that aren't effective actually are. I've blogged on this before, see Treatments That Don't Work.

I recently read a great paper whose title I love: What does it take to put an ugly fact through the heart of a beautiful hypothesis? (1) The title is from a quote by Thomas Huxley who lamented "The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact." The point in this article is that our modern history of health care is full of beautiful hypotheses, that some treatment is effective, slayed by a ugly fact, research showing the treatment to be ineffective. The problem is that although the hypothesis, that the treatment is effective is dead, the belief in the effectiveness of the treatment isn't dead. Both doctors and patients alike have resurrected these treatments that ugly facts have slayed like the zombies in the classic Night of the Living Dead.

Another quote from Haynes (1) paper from Max Planck, renowned physicist

‘‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.’’

However, it seems that while opponents of the new scientific truth die they unfortunately are capable of infecting a new generation that because of truthiness will accept these slain hypotheses.

Truthiness, is defined by Merriam-Webster as:

Truth that comes from the gut, not books
The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true.

For more on truthiness and the danger it poses for patients see my article in Dynamic Chiropractic, The Dangers of Truthiness

As Prof. Dov Cooperman of the University of Maryland wrote in a letter to the editor of Newsweek: "...our society is more than happy to accept spin and cant because we have come to believe that all expertise is bias, that all knowledge is opinion, that every judgment is relative. I see this daily in my university classroom. Many of even my best students seem to have lost the ability to think critically about the world. They do not believe in the transformative power of knowledge because they do not believe in knowledge itself"

Unfortunately I see it everyday in my classroom and hear it from many of my professional colleagues too.

My final quote from Haynes (1): Samuel Johnson, the 18th century poet and critic

‘‘The chains of habit are too weak to be felt until they are too strong to be broken.’’

The habits that are so problematic are a lack of critical thinking skills and reliance upon the "wisdom" of others (i.e. dogma), unsystematic and uncontrolled observation, and just truthiness.

For more information on critical thinking I recommend the Foundation for Critical Thinking.

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1. Haynes RB, Haynes GA. What does it take to put an ugly fact through the heart of a beautiful hypothesis? Evid Based Med. 2009 Jun;14(3):68-9. Pubmed link