Dick Boggs

When I was a medical school junior, we had a rotation on the Neurology service at LA County Hospital. One of my classmates was planning a career in neurology but the reason it was so popular with the students like me who were interested in surgery was that we got to do tracheostomies. A number of patients with severe neurological lesions would require respirators or had trouble with airway secretions requiring a tracheostomy. This was our one chance to do surgery, even a minor procedure as things go. It was good practice and I later did a lot of tracheostomies, some quite difficult and rushed.

Our resident was a very interesting guy named Dick Boggs. He was tall and looked a lot like Orson Welles did when he was young and making “The Third Man.” Boggs was quiet and aloof but let us do trachs and work up any patient we wanted to. I had some very interesting cases. One was a woman who showed all the signs of alcoholic neuropathy, which is very similar to diabetic neuropathey. It was a popular rotation for juniors. Boggs was popular among the residents and was elected the president of the Interns’ and Residents’ Association, which under his leadership took on some of the characteristics of a union.

At the time, intern and resident pay was very low and, aside from a new dormitory that was built for single house staff, we were on our own. I was married with one child, born in March 1965, so I was really on my own. My wife quit her job as a teacher in January 1965 and I was working after hours doing histories and physicals at private hospitals for $7 per hour. Fortunately, my tuition was covered by scholarship but living expenses were tight. We lived on $200/month contributed by our parents, $100 from my father and the same from Irene’s parents. Half of that went for the rent of our two bedroom house in Eagle Rock, near Pasadena. I’m spending some time on details to emphasize what Boggs accomplished for us all.

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Does this sound familiar ?

The science community is now closing in on an example of scientific fraud at Duke University. The story sounds awfully familiar.

ANIL POTTI, Joseph Nevins and their colleagues at Duke University in Durham, North Carolina, garnered widespread attention in 2006. They reported in the New England Journal of Medicine that they could predict the course of a patient’s lung cancer using devices called expression arrays, which log the activity patterns of thousands of genes in a sample of tissue as a colourful picture. A few months later, they wrote in Nature Medicine that they had developed a similar technique which used gene expression in laboratory cultures of cancer cells, known as cell lines, to predict which chemotherapy would be most effective for an individual patient suffering from lung, breast or ovarian cancer.
 
At the time, this work looked like a tremendous advance for personalised medicine—the idea that understanding the molecular specifics of an individual’s illness will lead to a tailored treatment.

This would be an incredible step forward in chemotherapy. Sensitivity to anti-tumor drugs is the holy grail of chemotherapy.

Unbeknown to most people in the field, however, within a few weeks of the publication of the Nature Medicine paper a group of biostatisticians at the MD Anderson Cancer Centre in Houston, led by Keith Baggerly and Kevin Coombes, had begun to find serious flaws in the work.
 
Dr Baggerly and Dr Coombes had been trying to reproduce Dr Potti’s results at the request of clinical researchers at the Anderson centre who wished to use the new technique. When they first encountered problems, they followed normal procedures by asking Dr Potti, who had been in charge of the day-to-day research, and Dr Nevins, who was Dr Potti’s supervisor, for the raw data on which the published analysis was based—and also for further details about the team’s methods, so that they could try to replicate the original findings.

The raw data is always the place that any analysis of another’s work must begin.

Dr Potti and Dr Nevins answered the queries and publicly corrected several errors, but Dr Baggerly and Dr Coombes still found the methods’ predictions were little better than chance. Furthermore, the list of problems they uncovered continued to grow. For example, they saw that in one of their papers Dr Potti and his colleagues had mislabelled the cell lines they used to derive their chemotherapy prediction model, describing those that were sensitive as resistant, and vice versa. This meant that even if the predictive method the team at Duke were describing did work, which Dr Baggerly and Dr Coombes now seriously doubted, patients whose doctors relied on this paper would end up being given a drug they were less likely to benefit from instead of more likely.

In other words, the raw data was a mess. The results had to be random.

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Global Warming and acupuncture

It looks as though the sun is entering a new dormant period, similar to the Maunder Minimum which led to the Little Ice Age.

This will almost certainly end the global warming hysteria in a few years. The people who continue to cling to this sort of hoax, will be looking for the Next Big Thing. I don’t mean to imply that the earth did not warm over the past century. The Little Ice Age ended about 1850 so a warming trend is expected following such an event. The hoax is the contrived evidence that humans are responsible. I was skeptical about that from the first. The forces involved are too large. If humans affected climate, it probably began with the development of agriculture. Perhaps we have had no ice age in the past 10,000 years because of the effects of agriculture and forest changes. I have previously discussed this and nothing has changed my mind.

The next question is what will replace global warming as the religion of the bored classes ? There are signs that it may be “New Age” medicine. This sort of thing is common in certain circles and has considerable similarity to the global warming arguments.

The Center for Integrative Medicine, Berman’s clinic, is focused on alternative medicine, sometimes known as “complementary” or “holistic” medicine. There’s no official list of what alternative medicine actually comprises, but treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors. The term integrative medicine refers to the conjunction of these practices with mainstream medical care.

Here we have what may become the replacement for AGW in the minds of the exquisite privileged class. It has all the requirements.

1. America is corrupt and inferior ? Yes. (See the comments)

2. Capitalism is corrupt and inferior ? Yes

3. Only the truly intelligent and sensitive can appreciate it ? Well.

You might think the weight of the clinical evidence would close the case on alternative medicine, at least in the eyes of mainstream physicians and scientists who aren’t in a position to make a buck on it. Yet many extremely well-credentialed scientists and physicians with no skin in the game take issue with the black-and-white view espoused by Salzberg and other critics. And on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.

That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.

But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.

No doubt the author would prefer that people died too young for chronic disease to affect them.

A well-known science blog states the case for scientific medicine.

Speaking of bad ideas, in contrast to his previous article, in which he managed at least to get the gist of what Ioannidis teaches but merely spun it in what I considered to be an annoying fashion, the entire idea behind Freedman’s new article channels the worst fallacies of apologists for alternative medicine. The whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way), it’s making patients better because its practitioners take the time to talk to patients and doctors do not. In other words, it’s a massive “What’s the harm?” argument. Yes, that’s basically the entire idea of the article boiled down into a couple of sentences. Deepak Chopra couldn’t have said it better. Tacked on to that bad idea is a massive argumentum ad populum that portrays alternative medicine (or, as purveyors of quackademic medicine like to call it, “complementary and alternative medicine” or “integrative medicine”) as the wave of the future, a wave that’s washing over medicine and teaching us cold, reductionistic doctors to care again about patients and thus make them better. Freedman even contrasts this to what he calls the “failure” of scientific medicine. I kid you not. Worse, Freedman makes this argument after having actually interviewed some prominent skeptics, including Steve Salzberg and Steve Novella, in essence, missing the point.

I expect to see more and more of “alternative medicine” because it appeals to the scientific illiterate and it damns another traditional source of authority, scientific medicine. Global warming hysteria attacks capitalism and prosperity. Alternative medicine is also going to be useful to Obamacare as a way of cutting reimbursement for traditional care. There are assumptions that it is cheaper. It may be cheaper per session, although is also uncertain, but there is no end point to such treatment. Who can say when the treatment is enough if it cannot be measured ? The theory that it is cheaper will be a powerful wind behind it. Watch for more and more about it in the left leaning media.

A Very Modern Christmas

The hospital is dotted with Christmas trees: plastic green triangles, some tall and some small, in lobbies and resident rooms and offices. The lights twinkle, golden tinsel glitters, and little angels top the trees. And yet, every posted sign or printed document reads, “happy holidays!”. Easier that way, I suppose. Covers the lot.

Shopping in the neighborhood, I notice that rows of neat little Christmas trees, in shades of pale gray, are standing upright in oblong concrete planters lining the sidewalks. In summer, the planters hold flowers in every color imaginable. Now, in winter, the Christmas season, bright lights are strung around the oddly ethereal trees, shocking pink and blue and purple to contrast with the dove gray branches and silvery bows. From a distance, it looks like an 80s dance floor.

We will have our annual Christmas potluck lunch at work next Monday and food from every corner of the planet, seemingly, will grace the table. Freshly made hummus and pita, spicy fragrant curries and rice, baba ganoush sprinkled with pomegranate seeds, sesame noodles and eggrolls, home made Filipino Pancit, southern fried chicken, red beans and rice, pierogies, baked ham and chicken and salad and cookies and cakes. Well, that’s some of what we had last year I think. We’ll see about this year. The potluck menu rotates because, in a busy teaching hospital like ours, the staff rotates a lot too. It’s a very nice event and a chance to catch your breath during a busy work day, wish others well and a Merry Christmas, and remember just why it is that you chose to practice medicine. You wanted to help people and you wanted to do it in an environment that is warm and nurturing.

Smart Phones and Medicine

Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a “person-centered health system” for patients with numerous moles and pigmented skin lesions who could forward images for evaluation.

Semin Cutan Med Surg. 2009 Sep;28(3):203-5. Mobile teledermoscopy–melanoma diagnosis by one click?

More data just means more data. Someone – or some thing – has to interpret all of the information generated by new technologies. Too bad we are creating a health care system with all the responsiveness of a snail on downers.

Model that we are creating: A federal bureaucrat commissions a study, to be vetted by a centralized board, to be further vetted by a state panel, to be implemented by a local health care provider, and zzzzzzzzzzzzzzzzzzzzzzz….

Model real-life Millenials will someday use for medical diagnostics: “There’s an app for that.”

I’m exaggerating for effect so don’t get too hung up on the potential accuracy of the prediction. You get the point.

Yell at me in the comments or whatever.