Angry Doctor

Tuesday, August 15, 2006

Confidence Goods

A letter to the ST Forum today gives me an excuse to rant about the issue of confidence.

Beware of medical tips from sales staff in health stores

I get urinary tract infection quite often and have undergone various tests like urine culture and uroscopy to make sure I don't have kidney stones.

My doctor recommended that I take cranberry extract as it is known to ease the problem.

I visited a GNC store to buy cranberry extract and the staff recommended that cranberry extract, garlic and acidophilus would work even better to kill the bacteria that cause the infection.

I completed the course and went for my urine test but bacteria were still detected in my urine. The doctor mentioned that garlic tablets would kill the effects of acidophilus.

I wonder whether the staff in health stores give the correct information or they just want to make a commission out of the sales.

Can health experts advise us on the adverse effects of medication if taken with the wrong food? I have been told that those taking high blood pressure medication shouldn't take grapefruit due to the acidity in the fruit.

Most people whom I've spoken to aren't aware as the pharmacists just dispense the medication.

Should we take medication as prescribed or must we do our own research on how well the medicine would work for us?

H. Bhaskaran (Ms)

There's UTI, and there's UTI; but let's assume that Ms Bhaskaran had been properly evaluated and that her doctor was correct in advising her to take cranberry tablets for prophylaxis against UTI. There is actually evidence to show that it is effective and cost-effective. I won't post a link here - just google it up and see for yourself.

Now let's move on to the health store staff. There is also some evidence that acidophilus does protect against UTI. Again, I leave you to google that up.

Now the garlic. Garlic kills bacteria. Acidophilus are bacteria. So angry doc was a little surprised to find that there is some evidence that garlic can (under in vitro condition) enhance the action of acidophilus used in the context of candida infection. You can google that one up too.

The interesting thing here is, Ms Bhaskaran concludes that her doctor was correct about the garlic and that the health store staff was wrong.


Because her doctor has an M.B.B.S. from a reputable university? Because he is made to undergo Continuing Medical Education to ensure he keeps up to date with the latest information?

Or is it because he has been right about so many things else before? Or because he wasn't the one who tried to sell her the cranberry, acidophilus, or garlic?

Now if Ms Bhaskaran did do her 'own research' by googling up the topics as I suggested you do above, she will find many websites with information on them. How will she know which ones are just advertisements, and which ones are 'proper' research information?

How do you know whether you can trust your doctor? How do you know whether the medical information you read is correct and unbiased?

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  • Actually this brings up a bigger scope of discussion.

    What do doctors base their opinions on? Research.

    Can we trust the research out there? If you look hard enough you will find that there are research papers that get contradictory results all the time! Most doctors don't even read research papers! They just follow what they hear at CMEs or the Clinical Practice Guidelines.

    Of course the CPGs are created after the "experts" have gone through all the relevant research papers out there to make a recommendation. But there is still going to be those who don't agree with the CPGs. As it is some of the things in the CPG in USA is different from the CPG in Singapore for various conditions.

    So it isn't just how do you believe your doctor. But also how does your doctor believe what he believes?

    By Blogger Dr Oz bloke, At August 15, 2006 8:06 pm  

  • Oz Bloke, your post omits the fact that there is such a thing as the 'quality' of research. There are bad research and robust, good research.

    The 'experts' collating the CPGs (and evidence-based medicine) recognise this fact and evidence and recommendations are classified into different levels accordingly.

    Doctors are taught how to read and interprete research papers at the undergrad and post-grad levels, so unless the raw data making up the studies are fake to begin with, we can tell the difference between good and bad research, be it in the design, methodology, bias, sample size or study duration.

    I don't think it is a given that 'most' doctors do not read research papers. About 40% of doctors are specialists, and they have to keep up-to-date by reading journals and papers (heck, they need to produce papers themselves!), so if 17% of the 60% of non-specialist doctors read papers, we already have 50% of doctors reading papers.

    Undeniably, we cannot read every journal and paper out there, so CPGs do have their place. CPGs may differ, but I doubt they often contradict each other outright, or disagree on basic tenets.

    Of course, even the experts collating the CPGs cannot possibly read every paper out there, but then CPGs do not claim to be the truth, but just guidelines based on the best available evidence.

    At the end of the day, I need to assume that epistemologically, the information I base my practice on, imperfect though they may be, bear a relation to reality, or else my practice has no meaning.

    By Blogger angry doc, At August 15, 2006 9:42 pm  

  • My approach is be honest with the patient if faced with a question for which you don't know the answer. We all know that study results, no matter how credible it appears on face value, is not fool-proof. Doctors can also be duped (look at Vioxx).

    Most questions regarding alternative medicine, herbal cures & supplements, I admit to the patients that I do not know enough to give an answer to.

    Even questions on safety of long-term medicines, I need to let them know that nothing is 100% in Medicine - this approach is especially important when dealing with knowledgable patients. For the most part, they understand where I am coming from.

    By Blogger aliendoc, At August 15, 2006 11:33 pm  

  • I am actually a huge fan of Vioxx and its family. Now there are a whole load of elderly rheumatology patients who will be in all kinds of agony (or in all kinds of confusion and constipation) because it's been taken off formulary.

    Most of the patients who were on Vioxx long term were about 80 years old. So I am not sure how reliable the study is that showed how Vioxx was related to heart disease.

    By Blogger tscd, At August 16, 2006 3:58 am  

  • I liked Vioxx too. Thing is, we still have to rely on guidelines which are based on studies which may or may not be reliable as time goes on & new discoveries are made about certain drugs or modes of therapy etc. A few years ago, there was also some hoohaa over an anti-congestant phenylpropanolamine which had been used for years, and yet was withdrawn by the FDA because of some study which showed an increased risk of stroke or something like that (I forget the details). I asked the opinions of some ENT experts at a conference I attended & they were quite upset over this because this had been a previously very effective drug.

    And with the media & the easily available material on the Internet, it doesn't make it easier for the doctors to give what we hope is correct information to our patients.

    Which goes back to angrydoc's question about who to believe :)

    By Blogger aliendoc, At August 16, 2006 4:47 pm  

  • the grapefruit thing is because grapefruit juice has CYP450 inhibitors and not because of the acidity, isn't it?

    By Anonymous Anonymous, At August 16, 2006 7:34 pm  

  • Yes, the grapefruit juice inhibits CYP450 1A2. Hope Angry doc and address that, otherwise lemons, oranges and other citrus will soon become no-nos as well.

    By Anonymous Anonymous, At August 18, 2006 9:49 am  

  • I dunno... you should probably ask your doctor. :)

    By Blogger angry doc, At August 18, 2006 5:17 pm  

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