Letters
From the November 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.
Alternative medicine
"When patients want 'alternative' care," (July/August ACP-ASIM Observer, p. 1) illustrates the confusion of the ACP-ASIM Ethics and Human Rights Committee. While it may be true that alternative treatments such as chelation and high-dose vitamins are "perplexing" to both patients and physicians, so, to me, is the strategy of treating classic angina pectoris with angiography and a coronary stent in a 47-year-old nondiabetic, normotensive patient without any information on his cholesterol levels.
In this case, the evidence-based approach would mandate that we first discern the patient's lipid profile and consider him for secondary prevention of coronary disease using simvastatin and prazastatin, not just any "HMG-Co-A reductase inhibitor." At the same time, the patient should be started on medical therapy, beginning with sublingual nitroglycerin for classic angina pectoris.
The article states that "chelation therapy can be harmful, and that there is no evidence of its effectiveness." This may be true, but the "harmful" effects of chelation therapy should be compared with the adverse events of angiography and stenting. Perhaps we would find that the $13 billion spent on "alternative medicine" is cost-effective when compared to the billions spent in the United States (but not the United Kingdom) on what has come to be accepted as "conventional" medicine.
Bertrand M. Bell, FACP
Bronx, N.Y.
The articles on "alternative medicine" in the July/August ACP-ASIM Observer had several accuracy problems. The first article on chelation therapy listed the Office of Alternative Medicine (OAM) as one source of information about chelation. The OAM is unreliable because it is staffed by advocates of dubious methods. As evidence, its Web page lists proponents of alternative medicine like chiropractic and homeopathy associations, but it does not list the National Council Against Health Fraud (NCAHF). Users seeking information on chelation are referred to a guild of chelation therapists.
Members of the NCAHF have the facts on chelation. The major danger from chelation therapy with EDTA therapy is no longer renal toxicity, as so little EDTA is typically used that it is relatively nonrenotoxic. The real danger is that chelation acts as a strong oxidant.
In 1958, Saul Green, PhD, published EDTA's oxidation of epinephrine, acting through iron. (The mechanism is summarized in the January 1993 issue of the Bulletin of the New York State Medical Association.) In addition, EDTA's mutagenic and carcinogenic potential was demonstrated more than 15 years ago. In "therapeutic" concentrations, EDTA has been used to produce DNA breaks for experimental purposes. (See Dervan et. al in the March 1985 "Proceedings of the National Academy of Sciences.") Even worse, EDTA has potential as an oxidant to damage vascular endothelium, thus adding to the patient's pathological burden rather than reducing it.
Even if EDTA worked as advocates claim, it would cost nearly twice as much as bypass surgery and several times more than angioplasty. Simple pharmacology calculations show that to remove only 10% of calcium in atherosclerotic plaques, patients would require four-hour daily infusions for two years—at a cost of $50,000. (See the Winter 1997-98 issue of The Scientific Review of Alternative Medicine.)
As to the "free radicals" that chelationists worry about, chelation actually produces them. Even if chelation worked the way that advocates claim, a one-month course could remove only 1/7,000th of a lifetime exposure. Talking to patients about these factors and alternative medicine in general does not require kid gloves or "respect for the patient's world view."
The article did not list the only North American medical journal devoted to scientific inquiry about these methods, The Scientific Review of Alternative Medicine. It also did not list the approximately 10 books on aberrant clinical methods published by Prometheus books (see www.prometheusbooks.com/ for a list) or mention the AMA's "Reader's Guide to Alternative Medicine."
In the accompanying article on the physicians at the University of Arizona ("Giving doctors another view of alternative medicine," p. 18), no indication was given that these two physicians' actions were erroneous or that their practices were substandard and bordered on cult behavior. One physician stated that before administering a homeopathic remedy to patients, she tries it on herself. What does she expect to discover from taking a substance that has no pharmacologically active ingredient? Even by the dictates of homeopathy's founders, the preparation would produce no pharmacological effect. Conducting an experiment in which n=1 will not change this.
The physician also said that she relies on her observations of herself. There is an admonition in medicine against self-diagnosis, self-medication and treating one's own family. The reason is obvious: We are the worst observers of ourselves. Does any internist need that concept explained? The other physician quoted in the story is shown examining the ear of a patient while holding an otoscope incorrectly. These are examples of the "medicine for the 21st century."
The coverage of alternative medicine in the medical press has been particularly frustrating. It adopts the popular press' methods of presenting alternative medicine practitioners or patients as the subjects of the story and presents, for balance, a "skeptic's" viewpoint in five lines. That kind of presentation provides not balance but bias.
Wallace I. Sampson, FACP
San Jose, Calif.
Editor's note: Dr. Sampson is immediate past board chairman of the National Council Against Health Fraud and editor of The Scientific Review of Alternative Medicine.
Distress
I read the front page of the July/August ACP-ASIM Observer with great distress and no small amount of nausea. The lead article was about unionizing, where the only real bargaining chip we would have is to strike and harm our patients, and the second article concerned an ethical response to "alternative care." ("Physicians and unions: a good match?" and "When patients want 'alternative' care," July/August ACP-ASIM Observer, p. 1.)
I will return to farming or to research before joining a union, and my contempt for most of "alternative care" is limitless. Any modality of "medical care" that relies on uncontrolled, unblinded therapies is quackery and fraud, and we should treat it as such. Chelation therapy is an egregious example of a specious, worthless procedure that should be restricted immediately except for cases of heavy metal poisoning, for which it was designed.
John T. Bakos, ACP-ASIM Member
Houston
Nurse practitioners
Not only have nurse practitioners and physician assistants invaded the turf of fully qualified practicing physicians, but public opinion seems to be in their favor. ("More on NPs," July/August ACP-ASIM Observer, p. 2.) Nurse practitioners and nurse specialists are nurses that practice nursing more intensively than a registered nurse. This is not the same medical practice as carried out by a physician. A similar analogy applies to physician assistants.
Munir E. Nassar, FACP
Pittsford, N.Y.
Pro regulation?
I want to add my voice to the recent letter sent by two Fellows of the College. ("Private contracting," September ACP-ASIM Observer, p. 3.) ACP-ASIM is so timid in its relations with government that one gets the feeling that it "loves regulation." Please pass the word on: no guts, no glory.
Edward A. Cohen, ACP-ASIM Member
Chicago
Physician-assisted suicide
I was disappointed with a recent President's Column. ("Attacking physician-assisted suicide at the expense of patient care," September ACP-ASIM Observer, p. 14.) ACP-ASIM President Harold C. Sox, FACP, attacks the Lethal Drug Abuse Prevention Act (H.R. 4006; S. 2151) as a piece of legislation with no redeeming qualities. Dr. Sox refers to the bill as "very troubling legislation" and states that "... it's difficult to recall any other proposed legislation that has had so much potential to harm patients."
It is unfortunate that our leadership did not apply the same harsh criticism to Oregon's Death with Dignity Act. Thanks to the silence of the College and other organizations, physician-assisted suicide now has a foothold in the United States, and it may soon expand beyond Oregon.
After reading the text of the Lethal Drug Abuse Prevention Act (http://thomas.loc.gov/), I feel that it is an honest and thoughtful attempt by our elected officials to prevent the widespread practice of assisted suicide in the United States. These officials are trying to prevent the same tragedy that has occurred in the Netherlands.
Dr. Sox offers no specific alternative plan for fighting assisted suicide. He simply states, "The best way to eliminate physician-assisted suicide is by providing excellent end-of-life care. ..." If ACP-ASIM was truly dedicated to eliminating physician-assisted suicide, it would do and say much more than this.
Kenneth J. Simcic, FACP
San Antonio, Texas
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