Pliny's Confusion

I was talking to some people about healthcare reform the other day and I ended up asking them a couple of questions:

1): Did they think it was ok for MD's to publish research while being payed by pharma companies?

Answer - resoundingly - absolutely not!

Why, I asked? It's an obvious conflict of interest, was the general reason.

Follow-up question 1a): Is it a problem when you have a conflict of interest in medicine?

Well, DUH! was the gist of the responses.

1b): So how is a private insurance company whose financial performance is governed by limiting their payouts from client fees, not a conflict of interest too?

grrrrrr

Ok let's move on.

2: How is a private insurance bureaucrat determining the services you receive better than a governmental employee?

GD Commie!

Pliny is confused...

On the Subject of Nazis

If I lived a thousand years I cannot imagine forgetting walking past a pile of eye glasses stacked by the thousands. Piles of shoes, human hair. Mute testimony of the deaths of millions. More than the gas chambers or the ovens, those eye glasses haunt me most of all. A last set of indignities by a culture that wasn't satisfied to merely kill. But to exterminate. To separate any last 'useful' materials from the flesh about to be obliterated. Taken from the faces of the damned moments before death. That's what made it real to me - the glasses. That and the tattooed forearms. Humans made inventory. Evil beyond evil. So you'll have to forgive my bluntness.

Stupid people are the unfortunate but inescapable bane of democracy. One hopes that stupidity doesn't drown out common sense but with the rapid ability of the Internet to rally imbeciles to almost any degree of ire needed to disrupt discourse, it remains to be seen which will win the day. None are more stupid than those who cannot tell the difference between concerned citizens debating the best way to reform healthcare and the Nazis. Civility cannot be extended to such types. The idiot women who yelled Sieg Heil to the Jewish man talking about state run healthcare in Israel may be the new poster child for some one who should be too dumb to vote. That and all the old people railing against state run healthcare out one side of their mouths while praising Medicare out of the other side. My GUT, what do they think Medicare actually is? It's ok to oppose nationalized healthcare but it should be for real reasons. I lament that in all likelihood when the final chapter is written about the USA it will say that it failed because its citizens were too apathetic to be bothered with taking the time to learn the truth and thereby granting proxy to those who would control them through manipulation of information.

I just wish that these 'concerned citizens' had the sense to understand that going to rallys with no other agenda than to disrupt, grand lies in the media, intimidation with guns, creating a sense of victimization where none actually exists and demonizing their opponents in the most vile ways actually WERE tactics used by the Nazis during their rise to power. Goebbels talked about the power of the 'big lie' to inflame and motivate the masses. One imagines that he would have loved the Internet.

Cancer

Talking about medical issues in a blog is hard for the most part because a lot of a physician's experiences are derived from single encounters with a particular patient. A surprising number of our most cherished and/or educational career moments can be traced to a single incident. Of course one has to be careful in talking about these times because of patient confidentiality. Like a spy huge parts of my career are hidden from even those most dear to me. Their only clue to my day being a look in my eyes that my wife has long since learned to recognize. So I've tended to shy away from exact clinical experiences because of this with few exceptions. But a recent experience has reminded me about the importance of articulating some of what we learn through more trial and error than we would like. As events unfold that if all goes well, will finally take me away from the bedside for good, I'm feeling a certain nostalgia. So tonight I'm writing about a part of my experience with caring for patients with cancer although I hope none of you ever need to benefit from any of this. I'm not going to talk anything about the treatment of cancer - just some thoughts on how we treat people with cancer.

Few words are as paralyzing as cancer (I knew how terrible AIDS had become when a young man I had been asked to see turned out to have AIDS. He asked if we should do some other tests because maybe it was cancer or something else). The moment a physician says that word anything that follows becomes nothing but static in your ears. The ultimate in betrayal, our own body conspiring to kill us. Just enough of us left in it to make it harder to kill. The word has seemed more like a death sentence than a condition to most people even today when the range of treatments is so much better and improves all the time.

As a general surgeon, I've seen more than my share of patients with cancer and had to break the news to many of them. It's never gotten any easier nor do I ever expect that it will. Many of the people I've seen over the years came to me late in their disease when I was asked by some other doctor to either implant a catheter for treatment or perform what are called palliative procedures; surgeries not intended to cure but to reduce suffering or prolong life for some period.

Ironically these brave souls, whom I could neither treat nor help with any clinical means taught me more about my chosen profession than the ones that I could treat successfully. These experiences have taught me some lessons about caring for patients with a diagnosis of cancer and have opened my eyes to some of the disservices done to them. Not just the ones done by the medical profession either. What follows in no particular order of importance are some of the things I've seen and ways I've tried to combat these problems for what it's worth. I share this here because most of these things apply to everyone not just medical professionals. Many of these items are most germane to those individuals who aren't likely to survive their condition but also apply to those who are. And many may provide comfort to those left behind.

Cancer patient: It's subtle but I always try to avoid labeling a person as a diabetic, a cancer patient, an asthmatic and so on. Every time we do this it gives the condition center stage instead of acknowledging that a human being, made up of many parts with many descriptors happens to also have a condition. It's all part of how we tend to define things by how they end rather than remembering a life well lived. Cancer may consume a life but we should never let it consume the living.

'There's nothing more we can do'; Our healthcare system isn't one. It's an acute care system; a very good one at that, but it isn't designed or really equipped all that well to deal with dying patients. Yes we have hospice programs and the like and the people who perform that service are wonderful but it doesn't serve the needs of all patients as much as it serves the needs of care givers. One of the things I seen over the years is that when a patient is diagnosed with a terminal illness, many of their physician care givers stop seeing them since they have nothing more to offer. Not true. Physicians, in my experience, can do a lot. Patients with terminal disease need the comfort often of nothing more than simple acknowledgment and attention. Over the years we had our patients who were dying come to the office routinely for scheduled exams just to sit down and talk with them. It's amazing how often they would eventually open up and tell you what they were thinking, what they feared, and what they wanted from their own death and their family. We became their liaison with the living. It may have been one of the most important duties for which I was never trained. Families would see that dad or mom, sis or brother was not being abandoned and started to come in with them and use our office to talk about things that needed to be said while there was still time. It didn't make them live longer but it allowed them to die much easier. The families also came to trust us more and listened to what needed to be done when the time came. There is a lot we can do - even when there is no hope - there can be peace. Guilt drives family members to insist on inappropriate efforts at the end of life as a display of how much they care. I've seen that little terminal family drama play out far too many times. It harms not just the patient but the families that remain. Usually it just prolongs suffering rather than extends life in any case. The time from when the certainty of death is apparent until the end, can be used to purge that guilt and mend fences and physicians can help with this. Partly it's because we are seen as sort of a disinterested bystander. We have nothing to gain one way or the other so our motivations tend not be questioned. A mediator comes in handy a lot of the time and a doc can do that pretty well. There's nothing magical or saintly in doing any of this it just takes common sense and a little empathy. This is why I have been maddened by these dreadful lies coming from opponents to healthcare reform about counseling services to those near the end of their lives. It's the opposite of death panels - it is compassion for those who need it most. Those poor souls feeling lost because they are losing what little control over their own destinys they previously enjoyed. Opposing that is plain evil, in its most apathetic form.

Isolation: As a resident I started to notice that dying patients didn't get touched. I guess we all thought death was contagious or something. Patients with cancer suffer terribly from this neglect. I can recall the relief I've seen in the eyes of the dying when you shake or pat their hand. A lot of the reason that we had people come in to the office for an exam is because it was the only time they ever had any physical contact with another human being. Some guy in a white coat listening to their lung sounds was the only contact many of them had. That was its only purpose. I don't believe in therapeutic touch but I do in Humanitarian touch.

Isolation takes other forms as well. People don't talk and the patient feels like they shouldn't. They have a lot they'd like to say but don't want to be a burden. Can you be a burden to those who love you? Being a stoic in my experience is just a lost opportunity to make someone understand how much they mean to you at a time when hearing that may make all the difference in the world. I learned these things by listening to the dying. Most of the time they did all the talking except when it was time to bring in their family members and get them talking. Then I'd leave them in my office as long as they needed. Neutral territory.

Dying at home; A colleague of mine found out that fewer of my patients with terminal illnesses died in the hospital than any other service. He asked me why and my answer was simple - peaceful deaths do not always occur in the hospital. People at peace with what was coming and with those they loved tended to die in the comfort and embrace of their own homes. On more than one occasion I had to leave the hospital to pronounce a patient of mine dead, so that paramedics would not have to transport them to the hospital. I will never forget one particular time. A fine elderly man's (I'd been caring for him about a year) lovely wife called me to tell me he had passed and asked if I could prevent the paramedics from taking him. I drove over to his house and found him at rest in his recliner surrounded by his family - lifeless but looking at peace at last. What possible good could have come from his last breath in a hospital escapes me. Many if not most would prefer to die at home. Only fear of pain and a greater fear of being a burden keep them from asking. They shouldn't have to ask.

Pain: Politics has no place in suffering. Some with agendas claim that all pain is manageable. In the words of my most famous mentor "that's a bunch of bullshit!" Most pain is manageable, not all. I've worked with those in pain for 2 decades and given boatloads of meds to treat pain. It isn't always enough. How many prescriptions for large bottles of narcotic pain elixirs have been given to patients by their doctor in the last weeks of life with explicit instructions to "never take all of it at one time because it would kill you"? Quite a few I would guess. Of course they'd never suggest any illegal acts and been 'shocked' if the patient dies of an overdose but there it is. One of medicine's dirtiest secrets - the law promotes suffering.

I count myself fortunate to live in the first state to fix that to some degree. For some the ultimate release from their feelings of helplessness is to choose the time, manner and location of their death. This is one thing that I am an absolutist about; No book, no creed, no belief, no pundit will ever convince me that this is wrong. This is not an academic debate to me. I have attended the deaths of quite a few fellow humans and see nothing noble in any of the suffering I have seen. Having options preserves some measure of autonomy - control in at least one final way to those who have lost all other controls. Many (possibly even most) won't use the option but having it there does provide comfort.

Death is a failure; It has always amazes me how doctors and nurses come to think of every death as a failure. Considering that we all die that results in a failure rate of 100% in time. I don't know why but I've never felt that way. Don't get me wrong; I fight for my patients to the extent of my abilities and those of anyone else who can contribute but sometimes it's not enough. That's part of the reason they abandon the dying - get over it, this isn't about us. Tending the dying and relieving their suffering is no failure at all.

Prayer: I put great stock in prayer and ritual for the sick. I don't believe it does anything concrete but if it provides comfort to the suffering then I'm for it. I've performed surgery while a native American shaman chanted over the patient. Fine by me - it isn't about what I believe but what comforts the sick. We forget that it isn't about us sometimes.

The most sacred duty of a physician is to alleviate suffering. That suffering can be clinical, emotional, social, familial. We are uniquely positioned to help with all of that and the patient with cancer needs all that we can bring to bear. Oh well, enough ranting for one night. Be well all.

Friday Potpourri

Some closing thoughts for the week.

Where are the Christian Leaders?

As one who is often told that I could not possibly be moral because of my philosophy of life, I find it interesting that many of the Christian commentators seem to be mute about healthcare reform. Why is it that I am driven to ask, "Am I my brother's keeper?" but I don't hear so much from those who put a lot more stock in the text from which that comes. Yes, I know all about the self-levitating boot straps that have become a staple of modern conservatism, but here, would seem to be an opportunity for Christians to provide the kind of moral leadership we are told only they can provide. Other than telling Arlen Spector that he will burn in hell, I mean...

Seriously, this would seem to be a common ground for empathetic beings of all stripes. It would be a great way to help the less fortunate.

On the subject of boot straps

Maybe this helps explain the extremist's who don't want too much science in the classroom. Rudimentary physics education would pretty much rule out the mechanics of lifting oneself up by bootstraps - outside of a cartoon that is.

Freedom in Action and Deed

Irony is my forte but even I am overwhelmed with it this week. People clamoring because of perceived threats to liberty, carry guns into town hall meetings with the President while holding a threatening sign - and don't get shot or sent to the gulag. People can pop up like those mechanized vermin from Wack-A-Mole shouting slogans they got from some right-winged website and disrupt discussions of a critical issue yet they too are free to say what they want - even if it's hateful nonsence.

While on the subject of contrasts

Right wing dissenters disrupting town hall meetings might benefit from remembering that the last time they were in power, people were ejected from President Bush's get togethers for simply wearing protest t-shirts let alone packing iron. So much for socialism I guess...

Something else for Glen to cry about

Glen Beck has the freedom to say what he likes. Americans have the freedom to show their disdain for his views through voting with their wallets. thecolorofchange.org has organized a boycott of Beck's sponsors because of his comments about Obama. Corporate sponsorship of hate speech is an iffy business model, as a number of companies have already realized. So as to not have the reputation of all reptiles besmirched, Geiko has pulled its ads. Freedom of speech does not obligate the rest of us to amplify anyone's voice to Nigel's setting of 11. Say what you like, but do it on some lonely street corner.

A Rove by any other name would smell as foul

Carl Rove got outed in writing as a liar (say it isn't so!) by the justice department no less . Apparently several thousand pages of documents prove that he lied about having no real role in the attorney firing scandal. Again I am shock. Rove's defense and denial consists of referring people to his own testimony on his own website because that certainly is where the truth can be found. Not a good week for Fox commentators, so we have that going for us.

Spinal dissolution

The Phylum Cordata took a huge blow this week. News has arrived that the end of life counseling has been deleted from the healthcare bill. Instead of telling Sara Palin, et. al., to 'shut your lying pie holes', our leaders have once again caved to lies. I guess throwing yourself on the ground and screaming like a two year old really IS a viable means to restore Republican relevance.

Alternate Universes

As a surgeon I would like to move to the alternate dimension that President Obama mentioned when he claimed that surgeons get 30-50,000 for a lower limb amputation. Cause I don't get any where near that much for any surgery I perform. FYI Mr. President; Surgeons just love having a lawyer tell them they make too much money...

Cheney's big promotion?

Coming close on the heals of Discovery's Shark Week, the evil one was active again as he prepares his memoirs (called the Necronomicon, I believe) Take care Mr Cheney. While you bash your old boss, remember the fate Dante imagined for those who betray their benefactors. Maybe Satan will give Brutus some time off...

W

Former President Bush. FYI, when Cheney's memoirs come out saying that you listened less to him and more to the public in your second term, the great great majority of Americans will think that is a good thing...

Rush Limbaugh, Sara Palin, Glen Beck: the Modern Voice of Holocaust Denial.

Is this the scene that Rush, Glen and Sara imagine? It's the 1940's and a kindly Nazi doctor in an SS uniform sits down with a nice Jewish family to discuss the government's plan to exterminate their entire family and all of their friends and business associates, after seizing their possessions or working them to death as slaves. The government mandated options are many; death by firing squad in a Polish forest, asphyxiation in the back of a specially prepared van, or zyclon B from a shower head. Comparative effectiveness research has shown the zyclon B to be the most efficient option for the State run program. Or they can opt to work for Werner von Braum in a cave making V2 rockets until they die of starvation or illness along with 40,000 similar 'patients'. Other options are available but all have a common end point unless the Allies reach them first. Are you people insane, stupid or plain evil?

Yes, I can see how a neocon could see that as equivalent to a family practice physician sitting down with his elderly patients and openly discussing with them what they would want done if they got really sick. Deciding medical contingency plans for 'what if' situations. The same thing that's done now just doctors could be payed to help their patients with the resources and information they need to make informed decisions. BTW, no of those options involve gas of any kind, save anesthesia should surgery be required.

To equate the systematic state and culturally supported extermination of millions to informed medical consent is unforgivable. Unforgivable. Forgive my bluntness, but to use the Holocaust metaphorically in such way is either criminally stupid or evil in the extreme. Which are you Sara, Rush, Glen? I feel dirty even having to point out the difference. Your voices no longer have the capacity to spur meaningful debate for you have gone so far off the political reservation that no one who believes in true democracy and debate can reasonably listen to a word you say.

Dr Arthur Caplan, a well known bioethicist wrote far more eloquently than I ever could. His essay is a must read in my opinion.

http://www.msnbc.msn.com/id/32372258/ns/health-health_care/

Time to boycott and denounce these people once and for all.

PAC Up Some Troubles, Then Just Smile, Smile, Smile...

Soft money, soft money your power is great;
your ability to cloud facts can ruin any debate.

One PAC, two PAC say whatever you like;
before long network flunkies will repeat it into their mike.

No one will track back to the black well from which the untruth sprung,
they'll be too busy interviewing your slick pundit with lies on his tongue.

It's not exactly lying, well I guess that it is;
But don't blame us, for that's show biz!

Websites, emails and snail mail can deliver your bile,
your messages calculated to make the public, your opponents, to revile.

They spend their time answering the foul vitriol you produce;
giving you time the next talking points to deduce.

Matters not in the slightest whether they are right or are wrong;
Only matters if an irate public joins in with your song.

Just call Limbaugh and beg him to add in his brass,
though his services could be duplicated far cheaper by a hand up a mannequin's ----

The public feigns ire that such tactics are wrought;
while hiding that copy of the Enquirer they have just bought.

Not solutions, but stories is all that matters,
And wasted energy spent leaves our nation in tatters.

A medalled hero, by a fat coward and liar, can be denounced;
So that by one with no record, the hero, in an election can be trounced.

Call yourselves friends of liberty and champions of truth;
Then toast your success in back rooms sipping gin and vermouth.

To bad you're not as good at solutions as you are at spewing hate;
won elections not solved problems is how your efforts we will rate.

Send sheep to town meetings, democracy to disrupt;
Then look for new soldiers whose views you can corrupt.

Say nonsense enough times and common wisdom does it become,
proving time and again that yes the public really is just that dumb.

Soft money, soft money from the wealthy and powerful do you flow;
and we eat it up as they add to our doubts and make them all grow.

The rich get far richer while the rest fall further behind;
but those ill got riches lead to more pronouncements even further refined.

Soft money, soft money, like a magician's deft hand do you distract our attention,
from problems real and too numerous to even bother to mention.

It may be true that indeed nothing need be feared but fear itself,
but when fear is bought and sold in such volumes hard to remember much else...

LIARS!

LIARS!

I think most of the tiny segment who read this blog know that I prefer civil conversation but there are times when enough is enough. I despise liars. In my profession it is intolerable to lie considering the stakes involved. Wish it were so in politics.

There are many questions that need careful debate and consideration before we set on a healthcare reform plan. But liars are setting the agenda.

Case in point: Representative Earl Blumenauer (D, Oregon 3rd) added an amendment to the healthcare reform package being discussed in Congress. It was an addition that was universally favored by healthcare professionals and advocates of the elderly Simply stated it allows for reimbursement to clinicians when they have end of life discussions with patients in their offices. This is important legislation for a number of reasons.

As a physician I have seen the havoc wrought to patients and families when end of life issues don't get hammered out before it's too late. A lot of suffering and heartache is the result when the wishes of a patient are not known and respected. A lot of futile and expensive care gets provided to those who would not have wanted it if someone had bothered to have the conversation with them when they were alert. Physicians are not required to provide futile care but in the end it sadly is seen as far easier just to do it rather than trying to explain the subtleties of futility in endless depositions and to armies of lawyers over the next several years.

All hospitalized patients are required to have a 'code status' determined in writing when admitted as part of the metrics used to determine 'quality of care'. In the absence of information it is an American legal presumption that people would prefer to try everything to live unless otherwise recorded. This contrasts to Great Britain where just the opposite is presumed.

What Earl Blumenauer's amendment does is finally pay clinicians to provide counseling services to patients so that they can make informed and prudent plans for unfortunate contingencies should they arise. This is a very good thing. It gets the need for these conversations out in the open where it needs to be. I know from 20 years of experience that having these conversations helps both the patient, their families and their care givers. It results in more appropriate and humane treatment of the elderly. (There is a fine line between preserving life and prolonging suffering that all clinicians know too well. We have seen far too many people on the wrong side of that line.)

It's also a good sign that emphasis is finally being shifted toward true healthcare rather than our system of sick care. Caring for the overall needs of the individual rather than just trying to patch them up when ill or injured is a laudable goal that has been hampered by a lack of financial support. As the old saw goes, "an ounce of prevention...". Valuing the important work of counseling patients is an important part of healthcare reform.

It is not euthanizing the old. To say that it is - is a lie. And a particularly hateful and crass one at that.

All around the country ads and emails are flying claiming that this is a plan to euthanize the old. That is a lie. The people that started this rumor are liars.

Absent a plan of their own, or beholding to special interests who line their pockets, the opponents of reform efforts have nothing to offer but lies. Do yourself and everyone else a favor - call them out as liars.

As I said, there are plenty of issues to debate about healthcare but lies and liars have no place at the healthcare table. In 3 years the baby boomer generation starts reaching Medicare age. Unless something other than neocon bashing or insurance industry pandering gets done before then, the country will be on a slope to bankruptcy.

Return to Sender! Some CAM Ruminations

Returning to the roost: Pliny says I think I CAM...

Me and my big mouth suggesting an exercise where we have to take an opposite point of view on a topic from where we would normally find ourselves. I am hosed since others have already accepted the challenge and been quite true to its intent so here goes.
____________________________________________________________

Complementary and Alternative Medicine (CAM) is a broad-ranged group of beliefs, professions, cultural models and philosophies that generally fall into one of five recognized categories:

1. Whole Medical Systems (naturopathy, Chinese medicine, etc.),
2. Mind-Body medicine (prayer, meditation, etc.),
3. Biologically-based practices (herbalism, vitamins, antioxidants, etc.),
4. Manipulative or Body-based practices (osteopathy, chiropracy), and
   
5. Energy Medicine (Reki, touch, magnets, etc.)
   

Generally these practices fall outside of the range of options used by (and recognized by) most Western trained clinicians.

Obviously the full range of CAM options is beyond the scope of a single discussion so for now I am going to limit my comments to herbal remedies. In a later post I will talk about what CAM practices can teach western clinicians about caring for the sick. First, some general operating principles that I use in studing these claims.

Why limit the discussions of CAM to scientific practices? Many would take issue but this is a reasonable approach due to the reality of the medical market place. Medicine is held to a high standard in our society and the stated ideal for the healthcare system is the use of scientifically vetted best practices. Payment and professional liability are determined in this way for physicians so it seems both logical and fair that any complements to medicine be judged the same way particularly when we are considering paying for these services at the societal level. How can we have a double standard for those who provide healthcare services? To hold physicians to a higher level than that applied to chiropractors for example would be unfair and a tacit acknowledgment that the two professions were not comparable in clinical utility. Some defenders of CAM imply that using science as a benchmark is unfair but what other standard is reasonable? Why should medicine be held to an objective standard when others are not? Others may point out that there is more to healthcare than objective outcomes. While true, this in no way eliminates the need for objective measurement of outcomes of any therapies in addition to consideration of subjective patient experience.

Many adherents of CAM point out that some previously discounted alternates have reached more mainstream acceptance (group counseling and meditation for example) suggesting that many of today's fringe beliefs may yet be vindicated. Perhaps, but this kind of thinking ignores the considerable differences between today's medical science and that of even 50 years ago. Medical science of today incorporates a far greater understanding of biochemistry, molecular biology and physiology that makes it less and less likely that huge gaps in basic science understanding will be discovered. With the ability of naturalistic models to account for the so much of the range of observed phenomena it becomes less likely that any mysterious lifeforces or novel forms of energy will be discovered. If they exist in the gaps of our knowledge they are becoming tiny indeed.

Based upon purely scientific criteria for success the overwhelming majority of CAM practices fail to demonstrate clinical efficacy in controlled trials. Controlled trials are imperfect but they remain our best method for identifying true effects that can be reproduced in future patients. Fortunately for the practitioners of such, the public doesn't seem to mind and billions of dollars are spent each year on CAM. Even ignoring the danger of delaying or interfering with proven and effective treatment through the use of these practices, some are down right dangerous in themselves. Spinal manipulation for example has been proven to result in neck injuries and damage to the carotid arteries resulting in stroke in some patients, without a single study demonstrating its clinical utility.

Professor Sprout to the Rescue!

Herbal remedies are an area of CAM which has been proven to have clinically demonstrable effects - though not always the desired ones. There is no doubt that naturally occurring chemicals in plants, etc. have physiologic effects and this is in fact the wellspring from which the modern field of pharmacology arose. Penicillin, digitalis, atropine, all these substances and many others were discovered from the chemical analysis of folk and herbal remedies. No one one disputes that fact and others probably are out there waiting to be discovered.

What is often ignored by the herbal remedy community is HOW these discoveries were usually made - through the study of toxicology - i.e. the study of poisoned people. Certainly true of digitalis and atropine (belladonna anyone?) That as they say is the rub. Below are some cautions suggested to those who use herbal remedies.

The problem with herbal remedies is not that they don't do something. The problems are these:

1. Herbal remedies contain multiple active ingredients
2. The pharmacological effects of these preparations aren't always the advertised outcome
   
3. Herbal remedies are unregulated
4. Herbal remedies interact with other medications
   

Multiple agents in the preparations

As said before; herbal remedies do have biologic effects. But many preparations include more than one biologically active ingredient. Why is this concerning? Imagine the following. In your medicine cabinet there is a drug that may help you. Instead of finding it and taking the one drug, you just grab a handful of many of the drugs in the cabinet including the one of interest. Would you be surprised if the effect was somewhat different from what you hoped? Probably not. But that in essence is what happens with unregulated herbal remedies. There are a lot of things in herbal preparations that may be active beyond what it's being taken for. (Many of the people who rant about the dangers of vaccinations turn right around and down a handful of unregulated pharmoactive agents without a second thought. )

The pharmacological effects of these preparations aren't always the advertised outcome

Related to the above, but with the additional concern that people often incorrectly perceive that taking herbal preparations is not taking a medication. They are. Drugs of any kind - herbal or from Glaxo affect a wide range of the body's processes. And because they are unregulated these undesirable effects may be recognized only after many people have been harmed.

Herbal remedies interact with other medications

Some agents in common herbal remedies interfere with aspirin or coumadin, for example, used to either treat blood clots or reduce the risk of stroke or heart attack. Some increase the anticoagulant effect of the drugs (increasing the risk of bleeding) and some reduce it (counteracting the desired effect). Often the ingredient that has this effect is not the primary agent in the preparation.

Lack of regulation

The FDA can be a pain, of that there is no doubt. Pain or not, regulation of medications is what separates a medication from snake oil. Controlled trials of drugs often (nothing is perfect) discover hidden effects before they reach the market. It adds to cost, its adds to delays but it improves safety. When taking unregulated medications (which have not been shown to have any of their claimed effects via clinical trials) you are taking a risk. certainly one that you should share with your care givers so that they are aware of the drug's presence. You are agreeing to participate in an unregulated trial of a drug when you buy them.

Why trials are so important beyond simple safety.

Science is a very unforgiving discipline. It cares nothing for our pet theories or for what sounds reasonable. It only deals with demonstrable facts. Take the antioxidant issue. Oxygen free radicals exist, are a byproduct of metabolism, and are very reactive (White Blood Cells use them as one of their ways to kill bacteria, for example). Substantial investments in enzyme infrastructure exist to combat the effects of O2 free radicals. It makes logical sense that getting rid of these guys is a good thing. It is not entirely crazy to theorize that they are involved in some of the processes of aging from a purely chemical perspective. But just because it sounds reasonable doesn't make it true. (There in lies much of America's problem ;) and much of why CAM is so popular). Only through controlled trials of antioxidants can we learn whether our common sense musings have any basis in demonstrable science. You can of course gobble blueberries until you look like violet from Willy Wonka, but it may not be helping you. Just a thought.

Many of these agents may be useful. But for safety's sake they should be isolated and studied individually in controlled trials. Herbal remedies may be beneficial but this must be confirmed through the same kinds of testing as we use for antibiotics. My advise is avoid drugs as much as you can and take only those that specifically address a well described clinical need be they herbal or not.

Revealed Truth

I had a dream last night and apparently channeled some latent race memories from millions of years before the dawn of man. I don't know what they mean but clearly someone or something felt compelled to force my hand into writing this. It's a good thing that this is only fiction! Any similarities to any real phenomena is purely coincidental and the product of a fever dream.

--------------------------------------------

L Ron Hubbard's books collected dust in the cupboard,
he couldn't even give them away,
A third rate pulp hack,
far from riches was his track,
the need for a regular job would come any day.

But to him it then occurred,
if vast and easy sums were to be procured,
And apparently of misery there was a dearth,
not filled merely by publishing Battlefield Earth,
Along with the recurrent revenues he would need,
for which there was nothing better than a new creed.

Though they raised no complaints,
much was lifted from the Latter Day Saints,
Why they did not seem to care,
perhaps they realized it was only fair,
With a generous helping of bad scifi,
he was ready to offer answers to the why.

Dianetics was his book,
its rehash by some for wisdom was mistook,
Hollywood lemmings swallowed the hook,
leading their fans to take a look,
Once in, perhaps too embarrassed to ask why,
until Hubbardology had bled them dry.

Seems with thetans are we all crusted ,
If his wild theory could be trusted,
they all arrived on galactic DC-8's,
He'd tell us more after he emptied the collection plates.

All started with the evil Xenu,
millions of years on earth called Teegeeack before we knew,
had deposited thetans in an active crater,
blasting them with H-bombs would come later,
Belt and suspenders one may suppose,
Not sure why lava wasn't enough, but with thetans who knows.

In Xenu's employ did psychiatrists conspire,
To betray the Thetans through a plan the evil one did sire,
The poor old Thetans all fell for their ruse,
which explains some of the behavior of Tom Cruise.

Like fundamentalists killing them wasn't enough,
as tormented souls Xenu kept it rough,
They scattered about in the mist,
understandably quite pissed,
not sure quite what to do,
til someone came along they could cling onto,

And cling, that they did,
the great religions could not rid,
every poor depressed human soul,
the weight of thetans took its toll.

They'd been programmed with all other creeds,
and responsible for planting all of their seeds,
till a misogynist writer discovered,
what no one before had uncovered,
the wall of fire did he survive,
then his bank account began to thrive.

For he had a device,
available for a really hefty price,
that would drive those old thetans away,
or at least go infest some Catholics by the way,
Though a great deal did it cost ya,
when not auditing could be used to strain pasta.

Of course this detail was not told,
til all your money, the faith, had bankrolled,
and feeling very glum,
one may feel it best to remain mum.

Gather enough into your cell,
you might nick enough from them to finally drink from the well.
If the newbies can be duped,
then maybe one's costs could be recouped.

Another creed was hardly needed,
appeals to reason went unheeded,
Antiquity of idea was not to blame,
Anyone could see it was completely lame.

A Great spiritual ponzi scheme,
every con man's wildest dream,
L Ron did not live long enough to know,
how truly large his made up faith would finally grow.

No doubt offended some of his lot,
Mostly those unable to appreciate my bon mot,
But don't look for Pliny with lawyers or to hurl your scatology,
for I'm off trying to found the newly revealed creed of Plinyology...

To Be, But Not to Do... Should that be the question?

No Man is an island, entire of itself...

(John Donne)

While I take my medicine I'd like to post the following for your consideration: Is a reasonable model of morality that there should be no limits to be whatever you are or care to be, only limits on what you do as that alone reasonably impacts others?

Must Make Pain Stop!

I am slowly making progress through the scientific purgitory of CAM. The experience may dissuade me from ever suggesting any kind of similar activities in the future so you all have that going for you...