Three recent sto?-ries lead me to my open?-ing topic for the year: The value of open-mindedness. This char?-ac?-ter?-is?-tic a?? a state of recep?-tive?-ness to new ideas a?? affects how we per?-ceive and process infor?-ma?-tion. Ita??s a qual?-ity I look for in my doc?-tors, and which I admire espe?-cially in older people.
Piece #1 a?? On the braina??s matu?-rity, flex?-i?-bil?-ity and a??cog?-ni?-tive fitnessa??
For the first piece, Ia??ll note a Dec 31 op-ed piece that appeared in the New York Times: This Year, Change Your Mind, by Dr. Oliver Sacks, the neu?-rol?-o?-gist and author. In this thought?-ful essay, he con?-sid?-ers the adult braina??s a??mys?-te?-ri?-ous and extra?-or?-di?-narya?? power to adapt and grow: a??I have seen hun?-dreds of patients with var?-i?-ous deficits — strokes, Parkinsona??s and even demen?-tia — learn to do things in new ways, whether con?-sciously or uncon?-sciously, to work around those deficits.a??
With appro?-pri?-ate and very-real respect, I ques?-tion Sacksa?? objec?-tiv?-ity on this sub?-ject — hea??s referred some of the most out?-stand?-ing (i.e. excep?-tional) neu?-ro?-log?-i?-cal cases in the world. And so it may be that his care?-ful reports are per?-fectly valid but not rep?-re?-sen?-ta?-tive; for most of us, the adult braina??s capac?-ity to estab?-lish new cir?-cuitry for lan?-guage learn?-ing or music appre?-ci?-a?-tion may be lim?-ited. What his sto?-ries do show is that unimag?-in?-ably strange things hap?-pen in our brains, at least occa?-sion?-ally. And maybe we should just accept that and take notes (as he does so care?-fully), and keep an open??mind.
Finally, he writes:
a?|all of us can find ways to stim?-u?-late our brains to grow, in the com?-ing year and those to fol?-low. Just as phys?-i?-cal activ?-ity is essen?-tial to main?-tain?-ing a healthy body, chal?-leng?-ing onea??s brain, keep?-ing it active, engaged, flex?-i?-ble and play?-ful, is not only fun. It is essen?-tial to cog?-ni?-tive fitness.
Ia??m inspired by the notion of keep?-ing a fluid, active mind. Ita??s not easy to keep abreast of new data, and to read the lit?-er?-a?-ture crit?-i?-cally. While some peo?-ple become more with?-drawn in adult?-hood, rest?-ing on com?-fort?-able rou?-tines and reli?-able sources, I choose the oppo?-site: read?-ing blogs, scan?-ning Twit?-ter, check?-ing out lec?-tures on YouTube, watch?-ing new TV shows, lis?-ten?-ing to my kids and stu?-dents.
Paper #2 a?? On an incred?-i?-ble effect of known placebos
Another curi?-ous Decem?-ber story, Place?-bos with?-out Decep?-tion: A Ran?-dom?-ized Con?-trolled Trial in Irri?-ta?-ble Bowel Syn?-drome, appeared in the strictly on-line jour?-nal PLosONE. The arti?-cle is per?-haps more defin?-i?-tive, as it is more puz?-zling: the inves?-ti?-ga?-tors observed that when peo?-ple with irri?-ta?-ble bowel syn?-drome (IBS) took placebo drugs in a clin?-i?-cal trial, even though they knew they were receiv?-ing a placebo and not real med?-ica?-tion, they felt sig?-nif?-i?-cantly bet?-ter than those patients who didna??t receive the open-label, placebo treatment.
As a reader and sci?-en?-tist, I can?-not under?-stand this obser?-va?-tion except to say most likely ita??s an exper?-i?-men?-tal fluke. But the studya??s sta?-tis?-tics were strong, and the trends inter?-nally con?-sis?-tent, ren?-der?-ing it likely that what the inves?-ti?-ga?-tors reported could be repro?-duced. The patientsa?? symp?-toms are highly sub?-jec?-tive in IBS, although they can be debil?-i?-tat?-ing and costly. My con?-clu?-sion, try?-ing to be open-minded about a result that seems improb?-a?-ble if not impos?-si?-ble, is that maybe there are things we dona??t really under?-stand about how a??med?-i?-cinea?? affects humans.
The eth?-i?-cal impli?-ca?-tions of this find?-ing — that a??place?-bos worka?? — are inter?-est?-ing, if ita??s true (which I wouldna??t con?-clude based on this one study reported in PLoS, or any?-where). For now what Ia??d say is the results are intrigu?-ing. Ia??m curi?-ous to see if these results are repro?-duced, and how the eth?-i?-cal impli?-ca?-tions will be ironed out in our mod?-ern med?-ical community.
Story #3 a?? On the ques?-tion?-able effects of echinacea
The??third arti?-cle, pub?-lished in the Dec 21 Annals of Inter?-nal Med?-i?-cine, con?-sid?-ers the poten?-tial of echi?-nacea in treat?-ing the com?-mon cold. The results of a 4-armed, ran?-dom?-ized study involv?-ing 719 patients with symp?-toms of an acute res?-pi?-ra?-tory infec?-tion (a??a colda??) were incon?-clu?-sive, at best. A skep?-tic might say of the trial, spon?-sored by the National Cen?-ter for Com?-pli?-men?-tary and Alter?-na?-tive Med?-i?-cine (NCCAM), that it proves once and for all that echi?-nacea is ther?-a?-peu?-ti?-cally use?-less. Another reader, per?-haps versed in the flower-derived substancea??s pur?-ported effects in other and ear?-lier cul?-tures, might charge that the inves?-ti?-ga?-tors chose the wrong prepa?-ra?-tion, derived from roots of the E. angus?-ti?-fo?-lia and E. Pur?-purea species, or that the researchers picked the wrong dose to observe an effect of the drug on the dura?-tion and inten?-sity and bio?-log?-i?-cal effects of a com?-mon??cold.
Ia??ve never tried echi?-nacea and have no finan?-cial or other par?-tic?-u?-lar inter?-est in this com?-pound. But hav?-ing read the arti?-cle a few times, Ia??m dis?-ap?-pointed, even unset?-tled by the results. After so many stud?-ies, many of which are ref?-er?-enced in the Annals paper, and now this costly, NIH-sponsored find?-ing of whata??s essen?-tially no effect, ita??s hard to say that echi?-nacea is help?-ful to any?-one. At the same time, I dona??t think therea??s suf?-fi?-cient infor?-ma?-tion to say that it doesna??t work in pre?-vent?-ing or reduc?-ing the inten?-sity of an upper res?-pi?-ra?-tory tract infec?-tion, or that it doesna??t work in some indi?-vid?-u?-als who have symp?-toms like a runny nose and sore throat.
Accord?-ing to the ACP Internist (where I am a contributor):
a?|The studya??s lead author, Bruce Bar?-rett, MD, PhD, told USA Today that echinaceaa??s sup?-port?-ers would prob?-a?-bly con?-sider the find?-ings pos?-i?-tive but that those who oppose it for the com?-mon cold would con?-sider the study a??the nail in the cof?-fin.a?? The direc?-tor of the studya??s pri?-mary fund?-ing source, the National Cen?-ter for Com?-ple?-men?-tary and Alter?-na?-tive Med?-i?-cine, told USA Today that the cen?-ter doesna??t plan to sup?-port future sim?-i?-lar research, since exist?-ing data make clear that Echinaceaa??s ben?-e?-fit for the com?-mon cold, if any, is a??very modest.a??
Still, we dona??t know if echi?-nacea might work bet?-ter as a tea pre?-pared from dried roots or some?-how oth?-er?-wise ingested by peo?-ple who are sick, as opposed to the pill com?-pound that was given to par?-tic?-i?-pants in the Annals study, or if an extract com?-pounded from a dif?-fer?-ent com?-bi?-na?-tion of Echi?-nacea flower species might do the??trick.
So if a doctor??is??open-minded and her patient wants to try tak?-ing echi?-nacea tea for a blos?-som?-ing cold, she might tell the patient that therea??s not much evi?-dence based on pub?-lished tri?-als of the herb, and that in fact so far the echi?-nacea data arena??t sup?-port?-ive of a mean?-ing?-ful effect in any patient group. At the same time, therea??s prob?-a?-bly lit?-tle risk of try?-ing echi?-nacea, in that it seems to have few unto?-ward effects. And the patient and physi?-cian might then observe what hap?-pens, and draw lim?-ited if any con?-clu?-sions based on that persona??s indi?-vid?-ual, n=1 expe?-ri?-ence with echinacea.
A closed-minded doc?-tor might tell her patient that echi?-nacea isna??t worth try?-ing, in any form. In her mind, she con?-sid?-ers the sub?-stance is a sort of nat?-ural or home-remedy that has no role in mod?-ern med?-i?-cine. She might even feel ita??s a waste of her time to dis?-cuss the alter?-na?-tive treat?-ment with her patient, and per?-ceive the patient as being unco?-op?-er?-a?-tive if he or she tries tak?-ing it against her advice.
Patientsa?? atti?-tudes vary, as do their doc?-tors, and given a choice of physi?-cians patients prob?-a?-bly choose doc?-tors whose per?-sonal philoso?-phies roughly align with their??own.
For now what Ia??ll say is this: I respect it when a doc?-tor admits uncer?-tainty, and is will?-ing to try some?-thing of low cost and low tox?-i?-c?-ity, for which the evi?-dence is thus-far unclear. (Of course, if we extend this argu?-ment to a dis?-cus?-sion of more costly and poten?-tially toxic drugs — like new can?-cer treat?-ments, wea??d need to weigh more care?-fully the poten?-tial harms of a treat?-ment against the unproved ben?-e?-fit.) In prin?-ci?-ple, though, I like the approach of an open-minded doc?-tor, who rec?-og?-nizes the lim?-i?-ta?-tions of pub?-lished data, and is will?-ing to explore an unproved approach to a prob?-lem in a way thata??s trans?-par?-ent: as long as the doc?-tor doesna??t sell the echi?-nacea, and is hon?-est with the patient about the lack of evi?-dence to sup?-port its use, it seems??okay.
How much bet?-ter it is to approach infor?-ma?-tion with an open mind, to take it in and con?-tem?-plate its ram?-i?-fi?-ca?-tions, than to sim?-ply say a??no, thata??s impos?-si?-ble.a?? As far as my doc?-tors are con?-cerned, I hope thata??s their atti?-tude,??too.
No comments:
Post a Comment