New ACS Breast Cancer Screening Guidelines

CDR711008-750The American Cancer Society now recommends starting breast cancer screening at age 45 in women with average risk, no longer recommends clinical breast exams at all (a usual part of the annual physical exam), and has increased the breast cancer screening interval to every 2  years after age 54. This change in guidelines follows an exhaustive 2-year review of available evidence, and reflects a decrease in the previous recommended, and, compared to the United States Preventive Task Force recommendations, which most of us family physicians are guided by, aggressive screening, starting yearly at age 40. Read on here. 

New York Times article, 10/20/15:

Updated screening guidelines from the American Cancer Society:

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Supplements Cause 23,000 Yearly Visits to the ER

Loretta-Marron-smallAh, supplements: the bane of many physicians’ existence. The New England Journal of Medicine (NEJM) published a study today  that supplement (over the counter dietary, herbal, and/or homeopathic) use accounts for tens of thousands of ER visit a year and thousands of annual hospitalizations.

Over-the-counter dietary supplements are considered by many to be safe and natural. The truth is, no one but the manufacturer knows what’s in that bottle of melatonin pills you’re taking for sleep every night. Supplements do not require FDA approval, and are thus not subject to safety and efficacy testing requirements. Whereas standard prescription and over-the-counter medications are FDA-regulated, supplements are not. Additionally, the FDA can only take action against dietary supplements after they have been proven to be unsafe: 

Under the 1994 Diet Supplement Health and Education Act (DSHEA), a variety of products such as vitamins, minerals, herbs and botanicals, amino acids, enzymes, organ tissues, and hormones can evade the usual controls if they are sold as diet supplements. Under the DSHEA, the manufacturer doesn’t have to prove to the FDA that a product is safe and effective; it is up to the FDA to prove that it isn’t safe, and until recently there was no systematic method of reporting adverse effects (required reporting is still limited to serious effects like death).

Proprietary Blend = “whatever we feel like putting in this product.”

It can take months or years for the FDA to catch up to companies making libelous statements or adulterating their products. doTerra and Young Living essential oils were marketed as cures for malaria, until the FDA finally slapped them on the wrist. In the past year, major retailers such as Walmart, GNC, Target, and Walgreens, have been found to be adulterating the supplements they were selling. DNA testing of 44 randomly-selected over-the-counter products found product substitution in 30 of the products tested and only 2 companies had products without any substitution, contamination or fillers. You are essentially playing Russian Roulette with your body every time you purchase and consume any supplement. 

usps-221x300Part of the appeal of supplements and vitamins is easy access. When Aunt Ruth tells you that Vitamin C saved her from the flu last year, all you have to do is go to the store and pick up a bottle. No expensive doctor’s visit, no prescriptions, no insurance company issues, no other hoops to jump through. Come to think of it, you don’t even have to leave your house to get your vitamins and herbals: there are plenty of sellers online, including Amazon, and you can’t beat that Prime shipping speed.

And it’s safe, because it’s over the counter! Right?! Well, wrong. Aside from the fact that that ginkgo biloba in your bottle might actually be some random weed or grass, supplements are not safe. Garlic, gingko, ginger, and St. John’s wort, among many other products, increase your risk of bleeding. Imagine being on the operating table with a baffled surgeon wondering why you are gushing blood–you didn’t report being on blood thinners! Patients who consume supplements may have excessive and unexpected intraoperative bleeding. Or imagine that the surgeon is trying to sedate you, and having a difficult time: some supplements prolong or counteract effects of anesthesia. This is some scary stuff.

Totally-Fake-News-Diet-Scam-Acai-BerryIt is partially due to the belief that supplements are completely safe and innocuous that patients often neglect to report the supplements that they are taking to their doctors. This is not a minor issue. According to a recent review in Frontiers of Pharmacology, 80% of the world’s population, or over 4 billion people, rely on supplements as their primary source of medical care.

We have been fooled by the supplement industry to believe that their products boost the immune system (false and biologically impossible), that supplements help get rid of toxins (detox is a fake construct, your body does it just fine on its own), that we can’t get all required nutrients in food (just not true), and that taking supplements leads to optimal health (all it does for patients is produce costly urine and line the wallets of Big Alt-Med.)

Yes, some supplements do work. They are often cheaper and, as noted above, more convenient to access than prescription medications, but the argument that they are safer is wrong. Additionally, Dr. Harriet Hall, AKA the SkepDoc, a retired family practice physician and personal hero, went through all the entries in the Natural Medicines Comprehensive Database a few years ago, and found that only 5% of these supplements were rated “effective”. Of these 5%, the majority are also available as prescriptions or have been FDA-approved as over-the-counter medications.

True-Skeptic-ID-CardThe NEJM study is based on nationally representative surveillance data obtained from 2004 through 2013 from 63 emergency departments, examining 3667 cases. Weight-loss and energy products caused the most events, including palpitations (the feeling of your heart beating in your chest), chest pain, or fast heart rate, and over half of these events were in young adults aged 20-34 years. Overall, supplements were found to be the cause of an estimated 23,000 emergency department visits in the United States every year.

Read the original study here.

ABC News Story, which the American Medical Association reported on, here.

OTHER SOURCES: (source of the quote about the DSHEA)

Posted in alt med, alternative medicine, analysis, article, blog, critical thinking, debunk, dietary, DSHEA, editorial, emergency room, essential oils, FDA, Harriet Hall, herbal, hospitalization, in the news, logic, medicine, NEJM, nutrition, primary care, public health, science, science-based medicine, skeptic, skepticism, study, supplements, vitamins | Tagged , | Leave a comment

TV Review: “Adam Ruins Everything”

Image 14.10.15 at 20.39Spoilers for the end of this blog post: “Adam Ruins Everything” is awesome TV. It fills the snark-shaped void of “Penn & Teller’s Bullshit!,” while encouraging debate and promoting awareness. Adam Conover is a stand-up comedian and philosophy major, who has said of his new TV program,

I don’t want anyone to think that this show pretends to present absolute certainty. I’m totally happy to have people respond. If an article comes out that says, “Here’s what Adam Ruins Everything gets wrong about engagement rings,” whatever it is, I welcome that article. If I find that argument has a ton of merit, maybe we’ll do a follow-up if we have a second season.

Image 14.10.15 at 20.40Spoken like a true scientist. Adam is presenting the best-available evidence, and his sources are always prominently displayed on screen. He engages his viewers to fact-check and google everything, an attitude that forms the basis of healthy scientific inquiry. All the show’s sources are also available on the show’s website here.

I am a proud debunker and skeptic, and frequently start sentences with “well, actually, the evidence(/research/data) shows…”. Naturally, then, I love “Adam Ruins Everything.” Adam’s approach to destroying preconceived notions is at turns gleeful and diabolical, and his clever rants draw comparison to John Oliver and Jon Stewart.

The show originated as a series on, and retains a frenetic, sketch-show energy. Adam’s writing team includes both comedy writers and research staff, who maintain the show’s balance between education and entertainment. Of his approach, Adam says,

” I really saw through (Jon Stewart’s) show the power that comedy could have as a mode of communication and that comedy can do more than make people laugh. It can also teach and enlighten people and open people’s minds and sort of inspire people to think more deeply about the world.”

Episode 2 contains a spot-on segment on Tylenol, the FDA, and over-the-counter medications, and I only hope that he continues to apply his skeptical eye to the medical world. Most everything he covers is relevant to day-to-day life, from credit card fraud, to the TSA, to tipping at restaurants. He also pushes the boundaries of the world we have grown comfortable with–what The New York Times terms ‘feel good liberality’–for example, donating to food drives and buying Tom’s shoes.

Image 14.10.15 at 20.40 (1)Watch full episodes (if you own a cable subscription) here. The show can also be found in parts and full on Youtube ( I mention that but won’t link to the full episodes, since I am not sure that the source is official and authorized.)

“Adam Ruins Everything” is a show to satisfy your inner geek. It deserves a broad audience, six seasons, and a movie.

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Article Review: “ACUPUNCTURE: poor evidence, poorer journalism”

This new blog post, Acupuncture: poor evidence, poorer journalism, highlights some of the important issues in dealing with pseudomedicine today. It is a reaction piece to an article published this morning by The Guardian, a long-running and well-respected U.K. daily newspaper.

Author of the post, Dr. Edzard Ernst, is an MD and PhD, former University of Exeter Chair of Complementary Medicine, and has written 48 books, including Trick or Treatment? Alternative Medicine on Trial. His research is focused on the critical evaluation of alternative medicine. Though Dr. Ernst is based in the U.K., he addresses points that are universally relevant to skeptical inquiry and medicine.

Essentially, The Guardian published an article that is pro-acupuncture based on little evidence, no critical awareness, and containing misleading information. The Guardian also makes the same tired assertions that alt-med-ers rely on: according to the article, the U.K. ‘lags behind’ countries like Germany in its support of acupuncture. However, as Dr. Ernst astutely points out,

The UK also lags behind Germany in the use of leeches and other quackery. The ‘ad populum’ fallacy is certainly popular in alternative medicine…

Dr. Ernst’s conclusions match those of the science-based medicine world: acupuncture research is mostly of poor quality; the effectiveness of acupuncture has not been proven for a single condition; there have been serious adverse effects; and acupuncture as a modality of treatment is not cheap. 

Shame on The Guardian for publishing this. Thank you to Dr. Ernst and other tireless promoters of science-based inquiry for continuing to shed a light into the dark, murky corners of pseudoscience.

Here is Dr. Ernst’s post .

This is the original Guardian article . I am encouraged by the number of skeptical comments and posters asking “where is the evidence?”

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Here, Let Me Fix That For You: ASPARTAME!!


The meme above is making the rounds today on FaceBook. And, really, aspartame is like the basic b**** of alt med: get a new target already, you guys. The largest study done to date of 500,000 patients proved no conclusive link between consumption of aspartame-containing beverages and increased cancer risk. Even the American Cancer Society agrees that aspartame fears are played out, and states that no health problems have clearly been linked to aspartame use.

The FDA regulates aspartame use. FDA regulation means products are tested for safety and approved, and an acceptable daily intake (ADI) is set. An ADI is customarily set at a level hundreds of times lower than the smallest amount that might have caused health concerns, as demonstrated in studies done on lab animals.

For aspartame, the ADI is set at 50 miligrams per kilogram of body weight: a 165-pound adult would have to drink more than 19 cans of diet soda a day to reach this limit.

Aspartame is one of the safest and most studied food additives in the world. A meta-analysis from 2007 and an updated one from 2o12 again found no link to cancer. JAMA  (the Journal of the American Medical Association) published a review back in 1985 with the same conclusion. The only people who need to avoid aspartame are those with the genetic disorder phenylketonuria (PKU), as they are unable to process phenylalanine, a component of aspartame, and accumulated high levels of this chemical cause brain damage.

So the meme is a complete fallacy. Not suprising, given the source (which I am not going to link to here): Cancer Truth is one of the many alt med sites that masquerades as news, but lacks appropriate sourcing and any base in real science.

The logical fallacies present include appeal to emotion (sugar-coated poison!), burden of proof (the meme claims that several animals will not eat aspartame, which is…not true. It’s been tested–and there I go with anecdotal evidence, which of course is part of this meme, too.) Overwhelmingly this is a bandwagon fallacy–an appeal to popularity, and nothing is more popular than continued, blind aspartame denouncement. I would argue that the texas sharpshooter fallacy is also present here: the meme cherry-picks data that suits its argument, finding a pattern that fits the presumption. And, finally, vilifying the FDA: the big “Them,” because every good conspiracy theory needs a big, bad evil.

So here, I fixed the meme:



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LGBT Health: We’re Still Here and Medicine Needs to Catch Up.

English: Rainbow flag flapping in the wind wit...

I am currently sitting in a large lecture hall at the Gay and Lesbian Medical Association (GLMA)’s yearly conference. I came here hoping for guidance on treating my transgender patients (more on those issues in an upcoming post), to reconnect with my residency roommate, and because I have been a GLMA member since medical school. LGBT (lesbian, gay, bisexual, and trans) issues have always been an important part of my life: this is my community, after all. Due to my involvement in various organizations, my resume essentially reads super-gay, and there is nothing I could (or would) do to change that.

Stern doctor  When I started to interview for medical residency, I was warned that programs might have a problem with my resume. My philosophy was that I wouldn’t go somewhere I wasn’t fully accepted. Let this, then, serve as my official middle finger to Cheyenne, Wyoming, and Milwaukee, Wisconsin, where the residents and faculty felt compelled to express to me that they might be “too conservative” for my ‘kind’. They would give me these concerned looks and I wondered if they actually thought that I was planning to march my own one-person Pride parade down the center of their quiet town while shouting about gay rights. (Push me far enough in a repressive residency program, and who knows what would have happened, I guess. But these programs confused my visibility with an affront to their personal beliefs.) Extend that middle finger to my med school faculty and peers, who acted worried for me because I was too ‘out’ and ‘open’: f*** them for shaming me and trying to control my sexuality.

Hate is NOT OKAY.

Hate is NOT OKAY.

That is something that is never, ever, ok; but talk to any LGBT medical professional, and you are sure to hear at least one harrowing story of closeting and/or behavior-monitoring. I once had an openly gay faculty advisor tell me that I ought to tone myself down, or I would have to accept that I would experience adversity. I know he meant well, but it broke my heart a little that someone who was claiming to be out and proud would encourage such a harmful message:’ be gay, but not *too* gay.’

My mother used to say something similar to me. Once I came out to her, she would occasionally pause what she was doing, look over at me sadly, and ask why I insisted on making life harder on myself.

shutterstock_204374473After a decade-plus in LGBT advocacy, I find myself asking the same questions I was asking at the beginnings of my medical career: Why is there such a dearth of health information for and about queer populations? Why are we still invisible in the scope of medicine and social welfare? Why is health care access, especially in rural areas, so notoriously terrible for LGBT-identified individuals? And, finally, why do people still believe and propagate myths and misconceptions about the LGBT community?*

Those of us who are treating trans patients today are still considered cutting-edge, and we struggle to find appropriate, relevant, and useful information. It’s this huge, glaring black hole in medicine, and is total bullshit.

Healthcare is greatly influenced by societal standards and norms, and this conference itself is a good example: I go to a couple of medical summits a year. Most of them are well-represented, well-attended, and supported by pharmaceutical industries, with free breakfasts, lunches and dinners. At this conference, every attendee has been identified in the directory, and everyone here has put forth an incredible effort. We number in the hundreds and not the thousands, and it is achingly clear that the medical community at large still treats us as a fringe group. I haven’t seen one pharmaceutical drug rep, and I’ve had to buy my own damn food.

professional-ignorance-1LGBT health is an area of medicine where physicians can still get away with claiming ignorance: ‘I don’t know enough about those people, so I can’t possibly treat them.’ Medical school training is complicit in this; I have yet to hear of a curriculum in which LGBT care is fully integrated and not an outlying topic, consisting of a couple of off-hand lectures. And we do nothing to stop this behavior and culture.

Being openly gay is not sufficient when the underlying message is that there’s a right and wrong way to express your sexuality as a medical professional. Too much gayness, and the conservative medical community gets uncomfortable, which is unfathomable. I was explicitly told that it was not ok for me to divulge my sexuality to my patients, yet heard colleagues talk about their hetero partners to patients on a daily basis. I would be asked by patients on a regular basis if I was married or had any children, and I was forced to confabulate, either pretending to be straight or pretending to be too busy to date. It’s prime time we stop catering to the middle-aged, cis white heterosexual male physician, and acknowledge that turning a blind eye to LGBT care is just as, if not more, harmful than blatant homophobia.

Aww...what a nice...wait, never mind, you did it all wrong.

Aww…what a nice…wait, never mind, you did it all wrong.

When a baker refuses to make a cake for a lesbian couple out of religious/moral/ethical/other b.s. principle, it makes national headlines. Why, then, do we flatly accept that some doctors will not see gay patients, and that most doctors do not prescribe trans hormone therapy?

Censorship Logo 2Even my queer-literate family practice residency program presented roadblocks. My friend and I attempted a research project on health care access for rural LGBT-identified individuals. I completed a comprehensive literature review of all studies done up to that point on LGBT healthcare, and found many troublesome aspects (which is why I can rant ad-lib on queer visibility in the medical field without any external sourcing), including a lack of visibility in the community, several confirmation and selection biases, and a general disinterest of the medical world in LGBT care. It took several drafts of our initial project proposal to get IRB approval.

By the last draft, ‘LGBT’ in any form was all but gone. We were told more people would be receptive to our study if we ‘kept it vague’ (read: don’t be too gay), if we focused on rural populations in general (read: don’t be too gay and no one cares about gay health anyway), and if every participant gave informed consent (read: participating in a gay study is dangerous and scary for people and we need them to sign off to make sure that they’re super-extra-ok with it).

The research program director refused us approval at first because we wanted to leave anonymous questionnaires for patients to fill out in the rooms before or after regularly-scheduled doctor appointments. His concern was that older patients might be offended by the content, and that children could accidentally read the forms. Let me emphasize here that we were not displaying pornographic images or using any curse words or coded language. We even buried the ‘gay’ questions among 13 total in an innocuous survey. What was so offensive? Apparently, it was the fact that we would dare to ask patients if they ever had an HIV test, what they considered themselves to be (gay/straight/other), and who (m/f/other) they had had sex with in the past two years. Oh, and this happened in 2014.


My alma mater in 2007.

In 2006, I remember doing an icebreaker activity with other med students during my first week of medical school during which we were asked various yes/no questions, and moved around the room accordingly. Most of these questions were verbal, but a handful were written down and anonymous, and we could chose to publicly acknowledge our answers or not. I paraphrase the anonymous questions here: “1. I have shoplifted in the past-yes/no. 2. I have cheated on an exam-yes/no. 3. I have knowingly lied to someone-yes/no. 4. I identify as gay or lesbian-yes/no.”

Why was sexuality included under questions about moral and ethical integrity? And do you really think anyone decided to ‘out’ themselves that day? (Both these questions are rhetorical; if you can’t see what’s wrong with this survey, read again. If you think any LGBT medical students wanted to be stigmatized that day, try again.)

This exercise set the tone for our academic medicine years: I was the only ‘out’ member of our med school class, and became, entirely by default, the president, secretary, and treasurer of our Gay-Straight Alliance (GSA). There were other LGBT-identified people in our class, naturally, but they chose the arguably safer, quieter road.

Additionally, my med school banned the GSA during the second week of my first year there. Their reasoning was that we were religion-funded, and a gay-straight alliance flew in the face of the Boards’ beliefs. Why they chose my year to put their foot down I will never know. We saved our GSA, through lobbying with the American Medical Student Association (AMSA), and by having our small club become a chapter of GLMA, but the effects were devastating. It took a couple of years for students to get interested in joining again without feeling that they would be stigmatized. In a field such as medicine, where internalized homophobia is rampant, further poisoning of the well is calamitous.

For those who sense that my experience was unique, this Harvard Pediatrician wrote about being gay in medicine in the 70s and 80s. We have made huge strides–the experiences of the generation before mine are shocking and abysmal–but we still have quite a way to go. Especially when med schools admit that they just don’t care about us. 

full-list-gay-pride-2015-europe-mainAs we become more visible-as ‘gay marriage’ has become just: ‘marriage’, and we engage as a nation in conversations about transgender individuals, we need to continue to encourage our friends and allies to get involved. Gay rights are human rights, and none of the caring, thoughtful, and excellent physicians I see in this room belong on the fringe.

*In regards to my earlier questions about the dearth of health information, invisibility, and rural care access: I realize I barely touched on these. I plan to come back to them. This is now Day Two of a conference that is much more triggering to my past experiences than I could have imagined. If I sound angry in my post, it’s because I am. I am tired of being nice and invisible, and hearing other doctors be as complacent in this behavior. Imagine the experience, too, of someone who is more visibly different: I am a cis-gendered white female with more privilege than many. And being queer in medicine has still been a battle.

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Critical Thinking: Regression to the Mean

The alt-med world runs on anecdotes, a general disdain toward mainstream medicine (right back atcha!),  and the power of the placebo effect (a bandwagon alt-med practitioners have jumped on recently, as science continues to disprove their therapies). If I had a dime for every time a patient told me that they took a homeopathic remedy and got better, I could pay my student loans off in full.

But interesting things happen when you take a sugar pill and experience healing: one is the placebo effect (which is much more than ‘mind over matter,’ and includes variables such as the patients’ faith in the cure and in the physician, and the physician’s confidence in the cure) and the other is a phenomenon called regression to the mean, AKA the regressive fallacy.

In statistics, regression is the tendency of a variable to move away from extreme values and toward the mean, which represents the mathematical average of some variable in a population. Sir Francis Galton (a statistician who was also the founder of Eugenics, which was…not great) coined the phrase “regression to the mean” in his 1885 study entitled “Regression Toward Mediocrity in Hereditary Stature.” He recorded the average heights of sons of very tall and very short patients, and found that the sons tended to be tall and short, respectively, but not as tall or as short as their parents. The concept has been proven time and again in statistics, and is an important addition to science.

Regression to the mean comes into play in medicine because you are most likely to seek treatment for illness when you are at your sickest (i.e., when your condition is at an extreme). You take a remedy, and get better, forgetting that even the most insidious disease waxes and wanes, getting alternatively better and worse, and that every illness has natural fluctuations. You attribute your recovery to the remedy.

The regressive fallacy actually falls under post hoc ergo propter hoc thinking (Event A happens after Event B, therefore Event A must have caused Event B).

Copper + Jesus = still nothing. Sorry.

The truth is that you were likely to get better, treatment or no treatment. But if you do a therapy and feel improvement, you will naturally attribute this to the remedy, no matter how wacky it is. We humans are great at finding patterns among things that are not connected. This is where alt-med really digs in to anecdotal evidence and testimonials: “it worked for me.” We also experience a selection bias here, since those who get worse or die after treatment do not self-report in the way that those who improve do. Alt-med testimonials are invariably positive.

Regression to the mean makes it difficult to determine whether a remedy is actually effective, especially when the evidence consists of testimonial from someone taking it while they are ill.

This is why scientific rigor is so important in development of new medications: laboratory trials, double-blinded, randomized studies, full transparency of how studies are conducted so others can reproduce the results, etc.

Next time, try taking your feet out of the bath. The water will still turn brown. Why? Iron rusts. And that chlorine smell? There is salt (Na+Cl-) in the water, and a positive-charged battery in the bath. This causes an extraction of negative ions, emitting chlorine gas. SCIENCE!

The fact that the alt med world requires testimonials to provide strength to their therapy–see here for homeopathy, here for Reiki, here for acupuncture, all Google-searched within seconds, should be enough to shed a dubious light on their practices. The plural of anecdote is not data, and never will be, no matter how much better your Aunt Mildred’s rheumatoid arthritis felt after a detox foot bath.

On a personal note, regression to the mean is rampant in osteopathic manipulation therapy. As the graph earlier in this post indicates, low back pain experiences a natural cycle of fluctuations. In the beginnings of my career as a D.O., when I was still practicing hands-on therapy, I would see the same chronic pain patients over and over, and it was always a variation on the same story: “I felt better a couple of days after my last treatment with you, but then the pain came back,” “your treatment felt great but now my back hurts again.” I was unable to present my patients with good evidence for what I was doing and how I was influencing their pain. I relied on personal testimonial and feelings, which turns out to be about as scientific as it sounds. I became convinced after a while that a lot of what I was doing was no more than therapeutic touch, in the sense that patients feel as though they are getting better treatment when there is physical contact between them and the provider.

Essentially I was practicing placebo, which is (justifiably so) an ethically dubious practice in mainstream medicine. I plan to write more about placebo in the future, as it is a fascinating social and medical concept, and another favorite of the alt-med folk. Dr. Ben Goldacre’s Bad Science has an excellent chapter on the placebo effect.

Image result for bell curveRegression to the mean is a fascinating phenomenon that presents itself everywhere on a daily basis, and serves as a reminder that we are human and fallible. Be wary of any phenomenon that cannot be reproduced on further testing, of any treatment where effects cannot be accurately tested, and of medical ‘facts’ presented without documentation. The burden of proof lies with those who make extraordinary claims, no matter what they might tell you.


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