How do you know? Fact, fiction, alternative truth?

Humanity has explored many ways of knowing, from trusting deities and their 'earthly conduits,' to seeking out experts, to looking for evidence and statistics, to believing what one feels is 'right.' I am fascinated by epistemology (the investigation of how we know things, of what distinguishes justified belief from opinion) and the psychology of choice, but I am even more interested in what we can do to promote critical thinking.

 

How do you raise children to question the statements that they hear?

How do you inspire patients to develop their health literacy and explore how probabilities are presented to them?

How do you convince policy-makers to consider value rather than throughput in their decision-making?

Can we convince health 'experts' to include effectiveness, the risks, and costs of various interventions when they write guidelines?

Apparently the heat from climate change has fried our leader's critical-thinking brain centres, and we now find ourselves awkwardly in an era of supposed "alternative facts." We know that fighting firmly held personal beliefs (even if we consider them lies and delusions) with facts is not effective; however, if you a reading this then you are already probably a bit skeptical, and you can explore the resources below to help with your own decision-making.

 

HERE ARE A HANDFUL OF PUBLICLY-AVAILABLE TOOLS TO HELP:

 

1) A book: Know Your Chances - Woloshin, Schwartz, Welch - FREE Online via PubMed

Every day we are bombarded by television ads, public service announcements, and media reports warning of dire risks to our health and offering solutions to help us lower those risks. But many of these messages are incomplete, misleading, or exaggerated, leaving the average person misinformed and confused. Know Your Chances is a lively, accessible, and carefully researched book that can help consumers sort through this daily barrage by teaching them how to interpret the numbers behind the messages. . . The book's easy-to-understand charts will help ordinary people put their health concerns into perspective.This short, reader-friendly volume will foster communication between patients and doctors and provide the basic critical-thinking skills necessary for navigating today's confusing health landscape.

[some other books about overtesting, overtreatment, and being skeptical in medicine are listed HERE]


2) A video: How to spot fake news

This video highlights the need to be skeptical and question headlines on social media or on other sites; it's sometimes hard to tell if a story is fake. If something seems shocking or strange, it's a good idea to ask around and do a bit of google-sleuthing. Checking the date, the source, and asking a skeptical friend can help you figure it out.
 

3) A website: Testing Treatments Interactive

The TTi site contains learning resources to help people recognise and understand Key Concepts, and how use them to evaluate treatment claims. These are categorized by concept, target learning group (kids, undergraduate students, etc), and the format (videos, websites, cartoons, etc). The book is also free and available in audio, PDF, or HTML format.

4) A guide: 12 Questions to Ask: How to Evaluate Health Information on the Internet

The National Institutes of Health has put together a great tool to help patients and caregivers check the reliability if information from the internet. These 12 straightforward questions can help you decide if what you are reading is useful - or useless.

Do you have other tips for getting to the truth? 

Source: https://www.amazon.ca/Know-Your-Chances-Un...

FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

Families, doctors, nurses, patients, people all:

Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

There are things you can do to lower your risks, robustly backed by the evidence: 

  • Avoid smoking
  • Exercise regularly
  • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
  • Reduce radiation exposure by avoiding unnecessary medical imaging tests
  • Avoid excesses of alcohol
  • Wear sunscreen
  • Consider a pap test
  • Only take supplemental hormones if medically required
  • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

  • Eating whatever you want
    • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
  • Using money to enjoy experiences that are important to you 
    • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
  • Focusing on treatments that have been shown to be effective through scientific study
    • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
  • Working through the difficult task of coming to terms with having cancer, whether treatable or not
  • Receiving palliative care (which improves quality of life and can actually extend life!)

Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

--

Learn more about Tackling cancer treatment myths, from clean eating to cannabis

Source: https://www.theguardian.com/science/blog/2...

The answer to everything wrong in health care

TOP Alberta has released a beautiful infographic Evidence Summary: The Benefits of Continuity in Primary Care, and the document also serves as an overview of the 112 publications they reviewed.

It speaks for itself. Maybe the title of this post is a bit grandiose, but as a shameful hypocrite [I have very little continuity in my clinical practice, something I'm working to remedy] I cannot underscore how important this idea is.

Every physician, nurse, administrator (yes, you!), health policy person, and their uncle needs to not only know this but act on it. Continuity is what we need.

It's not a fad. It's something that we used to have. And it has slowly been eroded, without too many people noticing, as we kept focussing on the newest technology and the latest pharmaceuticals as if they would solve everything.

In BC, the essential nature of continuity has been recognized particularly with the work of Marcus Hollander and was implemented in the GP for Me/Attachment Initiative. Unfortunately (some might dispute this), changing physician incentives to try to encourage more attachment hasn't made much of a difference for patients. So while we know that we need continuity, we don't know how to 'make' the system or the providers do it.

It's a perfect storm for patients: Can't find a GP, or if you can it's hard to build a relationship with them because they are so busy/unavailable/don't have enough time to spend with you; the GP doesn't know all the details of your care as pharmacists/naturopaths and others expand their scope and don't communicate with the GP; the medical records at the hospital or from the specialist in the other city don't link with those of the GP so no one knows what is going on; when a referral or requisition is sent, there is no confirmation that is was received so it might be that you are just waiting, or it might be that it has been lost and you will never hear back about the appointment; when a home care support worker or nurse comes, it is a different person each day and they don't know you or your needs, and they aren't allowed to do the things you need help with most.

Health care really is about caring for people, and how can we do this when we do not build robust and lasting relationships?

The review did not cover provider satisfaction but personally and in BC studies so far, physician satisfaction is improved by continuity with patients. However, this is not how most young graduates are practicing; Yet another great reason that we need to look more into this.

Is it too good to be true? Before we rush ahead and try to force the "magic pill" of continuity, we need to know more about why it's being eroded, and if we can save it, then how?

 

Source: http://www.topalbertadoctors.org/file/top-...

Is it worth it? The role of Health Technology Assessment (HTA) and using evidence with patients

"These are my people," I thought to myself on the long plane ride West, destined for home to a verdant explosion of nature after three days in snowy Ottawa. Maybe it was the season, but I think it was more the people around me that reignited my enthusiasm for change in health care.

In April, I was invited to Ottawa to be a part of the Canadian Agency for Drugs and Technologies in Health (CADTH) symposium closing plenary on the subject of Health Technology Assessment (HTA), a term that I had (embarrassingly!) not really heard of until receiving that invitation.

Despite feeling woefully out of place as a mere clinician, surrounded by successful policy analysts, clever researchers, health economists, and seasoned advocates, I had an incredible time. As I milled about taking in various presentations and getting my feet wet as part of a panel on Disinvestment, I found myself suddenly realize: everyone around me "gets" it.

What a gift: when you are asked to share your passion, say whatever you want to say, and know that the people listening are listening and nodding "yes" to some of the things that fall out of your mouth?

As I think more and more about how I can have a positive impact on the health and well-being of people, I think about the role of HTA in policy change, and about how evidence belongs to everyone. Being a bit camera-phobic I was reluctant to highlight this 8 minute video, but it was an honour that I do not wish to squander and I hope that some of what I said resonates with you too.

The 2017 CADTH Symposium is Apr 23-25, with the theme "Measuring Value in Theory and the Real World." If you are a student or patient group representative, you may be eligible for a travel scholarship. Check it out!

No strong proof that flossing your teeth has medical benefit

This is the third in a series of "no evidence" posts I've made recently, with the first two being "No evidence that N95 respirators are better than surgical masks" and "No benefit to locked mental health wards."

Today's serves as another example of where something seemed like a good idea but... "sURpriSe!!!!" maybe it isn't. 

Certainly, the evidence is lacking to support the bullying that goes on in dental chairs around the world.
"Are you flossing?"
"Yes....."
"Are you sure?"
"Uhhh....." *guilty face*

Personally, as a reluctant flosser, and as a person who questioned the risk/benefit return of having wisdom teeth extracted, I feel a little bit vindicated here. I was always curious 1) if I asked the dentist to guess whether I was flossing or not, could they tell? and 2) Does flossing really do anything useful?

I can't lie to my dentist... how could they do their job if I did? So when asked "have you been flossing?" I usually tell them "no" or "yah but just for 2 months" if I had been doing so, in a phase of thinking I should probably try to stick with flossing. 

Last time I was feeling contemplative in between wafts of chemical smells and *wizzzzzzzes* of the drill in the neighbouring stall, I told my dentist and hygenist that if they could show me solid evidence of benefit of flossing, then I would do it. The hygienist listed a bunch of benefits and I went home to check it out. All the PubMedding in the world didn't find anything to back up her statements. Since they couldn't produce a strong reason for me to do it, so I decided to stop.

Flossing is not fun, it creates waste, and I can think of better things to do with 5 minutes a day. In fact, with those 5 minutes today, I can bring you this article in The Journal of Clinical Peridontology, which found:

The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal. All investigated devices for inter-dental self-care seem to support the management of gingivitis, however, to a varying extent.

The paper did find that  inter-dental brushes (IDBs) are effective in removing plaque. These brushes I have tried and they look like little pipe-cleaners that you shove between your teeth. It feels about as good as it sounds!!! Ow.

I may wait for the randomized controlled trial (RCT) proving that those angry little bristles decrease caries (cavities) before attempting their use again, as "plaque removal" is but a surrogate marker for other things.

Further to the lack of advancement of evidence-based practice in dentistry, one periodontist. Dr Ghilzon, when interviewed by the CBC said:

I would say if you know how to floss I would continue just in case it does make a difference

When the CBC talked to Matthew J. Messina, a dentist and spokesman for the U.S. dental association, they pressed him. He acknowledged weak evidence, but he blamed research participants who didn't floss correctly.

It seems Dentistry is eons behing medicine in terms of evidence gathering let alone application. Whether employing patient-blaming, citing anecdotes, or declining to accept the value of evidence, Dentistry is set to follow Medicine in suffering the same "just in case" approach that dooms patients to overtesting and overtreating and promotes ignorance of the harms of intervention.  

See the original CBC article here.

Source: http://www.cbc.ca/beta/news/health/dental-...

No benefit to locked mental health wards: 15yr study

A once 'sound' idea is now in question.

A 15-year study has concluded that there is no benefit in locking up many mentally ill patients.

Looking at about 350k cases, the researchers selected 145 738 cases, matched for propensity around suicide attempts. In open units, elopement and suicide attempts were less frequent than in locked units.

An open-door policy could be preferable for those with depression, anxiety or psychosis, as it promoted a better therapeutic atmosphere and more positive health outcomes

Even if this large study is imperfect, it gives us a perfect illustration that what seems sensible or logical does not necessarily result in the expected outcome. Although it makes sense that locking people up should not only help them stay put but also keep them safe,, that seems not to be the case.

Counterintuitive? Yes. But brains and bodies often do not conform to the rules of logic. This is in part due to the fact that we have only a superficial understanding of the complexity of our behaviours and physiology. 

How else are we hurting people when we think we are helping them? 

The full article is in Lancet Psychiatry

Source: http://www.radionz.co.nz/national/programm...

No evidence that N95 respirators are better than surgical masks

From NinjaCat14 on  Deviant Art  I can't make this stuff up!

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2695252...

Other Blogs: Less Is More | An index of evidence-based, “less-medical” patient care

More "Less is More"!

Dr Bill Cayley Jr has started a Wordpress Blog, "Less is More EBM" to review studies that explore situations in which less involved/invasive/expensive/difficult/novel/etc. care is actually best for patients.

He writes, "This index is currently a personal (and extremely part-time!) project aiming to catalog literature documenting when “less is more” in a searchable and accessible format." It has just started, but there are already insights on papers about overuse of arthroscopy, the best treatment for paediatric upper respiratory infection, and creative solutions for low resource areas (eg. mosquito nets instead of mesh for hernia repair).

It's great to see interest booming. More people are writing books and blogs, talking at conferences, changing the care they deliver, and asking questions of their health care provider. The movement – still known by many names, a few of which are highlighted in the glossary – is growing!

If you are particularly interested in blogs, look at the left sidebar column, and under 'Similar Blogs' you'll find others writing about similar issues as you'll find on this site. Check 'em out!

Source: https://lessismoreebm.wordpress.com/

BMJ Blogs: Six proposals for EBM’s future

Dr Paul Glasziou is a Professor of Evidence-Based Medicine at Bond University in Australia. He speaks and writes mainly about the translation of health research into clinical practice.

His latest contribution to the BMJ Blog is a look at the future of evidence-based medicine (EBM). As its era fades into another, it becomes apparent that there is still a huge gap between what research tells us and what doctors and patients wind up doing.

Sometimes the known evidence is biased, of poor quality, or doesn't actually have any relevance for our patient. Sometimes, we have strong evidence about what is clinically 'correct' but we have forgotten to remember that each patient is an individual, with unique goals and life circumstances. Sometimes, we get so caught up in chasing the potential benefits of something that we fail to realize it could be causing more harm than good.

Read Dr Glaszious' Six Proposals for EBM's future, as he tackles these tough issues and helps to guide us back to a place where research improves care.

Source: http://blogs.bmj.com/ce/2015/03/27/six-pro...

VIDEO: How To Become Gluten Intolerant: The lighter side of medicalization

You are going to have to watch this genius video to understand. When the human condition becomes a medical condition, it can be very very funny.

JP Sears (@AwakenWithJP) explains that "being gluten intolerant is a fantastic opportunity for you to assert your dominance in the life everyone around you, which helps improve your life."

His video contains amazing tips on how to achieve the gluten intolerant lifestyle, among them:

Give expert medical advice. Once you take your gluten free vows, you'll need to have an automatic understanding that every medical condition in caused by gluten. Depression: it's always caused by gluten. Obesity: that's 100% gluten. Every single case of cancer is caused by gluten. I swear, gluten's what killed Gandhi. . . 

Seclusion makes gluten healthier. Understand that when no one's around, you somehow become less gluten intolerant. How does this happen? Well, based on medical evidence that's yet to be discovered, there's a direct correlation between how many people are around and how gluten intolerant you are."

See for yourself, and become enlightened in the ways of the gluten free: 

Being gluten free used to be a luxury only reserved for those who are intolerant to gluten. With this cutting edge gluten educational video, you can become gluten intolerant too, whether or not you're actually intolerant to gluten.

Source: http://devour.com/video/how-to-become-glut...