American College of Physicians: Internal Medicine — Doctors for Adults ®



From the September ACP Observer, copyright 2006 by the American College of Physicians.

Questioning alternative remedies

It was sad to see an otherwise reasonable summary of low-back pain (Special Focus: Low-back pain, ACP Observer, June 2006) contaminated by a section on unscientific complementary-alternative treatments. It is especially disheartening to see such information in an ACP publication.

The authors warn against high velocity or thrusting spinal manipulation, suggesting a belief in benefits from ordinary spinal manipulation. I always thought that old-fashioned massage was what helped patients. Spinal manipulation as touted by chiropractors is a HOAX. As for acupuncture and acupressure, they should be categorized as placebo, and there is no good data on Devil's claw. And homeopathic gel? Is there any proof that any homeopathic remedy was any more than a placebo?

The ACP needs to distance itself from these unscientific therapies or it will lose creditability with its Members.

— Carl E. Bartecchi, FACP
Pueblo, Colo.

Editor's note: Since, many patients use complementary-alternative treatments, it is important for physicians to know what is out there, what patients are using and which treatments may be supported by some study data. For example, there are approximately 50 randomized studies on spinal manipulation in the literature, as well as many meta-analyses and systematic reviews. Regarding acupuncture and acupressure, the most recent Cochrane review of acupuncture and dry-needling for low back pain found 35 randomized, controlled trials in six different languages. Although the effects are small, acupuncture used as an adjunct to conventional therapies appears to relieve pain and improve function more than the conventional therapies alone. Still, particular vigilance is needed in following patients who are using any complementary-alternative treatments as not all have been rigorously studied.

Organ transplants: what's behind the numbers?

Your recent article on organ transplantation ("Organ donation: balancing patient duties and public health," June 2006 ACP Observer, p. 5), notes that 90,000 people in the U.S. are waiting for organ transplants, mostly kidney, liver, lung and heart. This figure has been widely used, frequently in an effort to stimulate donations. But how many of these people are real transplant candidates? If there were a plethora of organs, would they all be acceptable as recipients?

Some years ago, I was closely involved with the National Marrow Donor Program. Their waiting/search list was made up of patients who would likely receive transplants as soon as a suitable matching donor was found as well as patients who had become too ill to tolerate a transplant. In the latter case, even if a donor was found, the treating physicians did not proceed with a transplant because the patient likely wouldn’t tolerate it.

Is this situation true with solid organ transplants? Even if the true number is lower, it would not diminish the need for organ donors.

— Paul R. McCurdy, FACP
Springfield, Va.

P4P not the answer

It was upsetting to see that the American Board of Internal Medicine's ("Health plans partner with ABIM on incentive programs," ACP Observer Weekly, July 11, 2006) has joined forces with insurers in pay-for-performance schemes.

On the contrary, ABIM should be encouraging doctors not to fall for yet another scheme to control physician reimbursements. Pay-for-performance has little to do with patient care and physician education. Doing the best one knows how and keeping up with new knowledge is what we are about. It is a personal and ethical responsibility that we undertake when we decide to become physicians.

As recruitment for internists is on the decline and more practicing internists are refusing to see new Medicare patients, has it not occurred to ABIM or the College to say what is wrong? Why are doctors unhappy and leaving practice, or not choosing internal medicine? Could it be that they are working longer hours, making difficult decisions about patients and told that their labors deserve less reimbursement?

ABIM and the College should not be supporting pay for performance. It should be encouraging all physicians to tell payers that enough is enough. Pay the docs a decent wage.

— John G. Paty, Jr., FACP
Hixon, Tenn.

RLS: Disease mongering?

Your recent piece on insomnia (Special Focus: insomnia, July/August, 2006 ACP Observer) was surprising to see in an ACP publication based on PIER and meant to educate healthcare professionals and policy makers. Our major concern is the completely one-sided response to the question, "RLS: 'disease mongering' or real concern?". Instead of a debate or even a review of the evidence about RLS (restless legs syndrome), PIER simply quotes an expert clinician who dismisses the possibility of disease mongering out of hand. RLS, he asserts, is "not uncommon" and is often overlooked and underdiagnosed.

Earlier this year, we reviewed how the news media covered RLS during GlaxoSmithKline's disease awareness campaign preceding FDA approval of its drug, Ropinirole (PLoS-Medicine). RLS is a great example of a larger phenomenon called disease mongering—expanding disease definitions to increase the market for a treatment beyond patients for whom there is clear evidence of benefit. Disease mongering may be perpetrated by anyone with a financial interest: pharmaceutical companies, device manufacturers, physicians (or researchers) specializing in the disease, and advocacy groups (often industry funded). We concluded that the media abetted disease mongering efforts by uncritically citing exaggerated prevalence estimates; ignoring concerns about overdiagnosis and overtreatment; and failing to report potential conflicts of quoted sources. Unfortunately, the PIER segment did not do much better (e.g., failing to consider overtreatment, and not noting that the expert quoted is part of a GlaxoSmithKline funded RLS group).

All sorts of forces are conspiring to turn healthy people into patients and expose more and more people to medical interventions. Some—people with more severe symptoms—generally stand to benefit. But for those with mild symptoms (eg, occasional need to move their legs to feel comfortable), the balance of risk and benefit may well fall on the side of harm. Physicians (and their patients) need balanced, evidence-based, transparent resources to help inform treatment choices. That’s what PIER and the ACP Observer are supposed to do. But didn't.

— Steven Woloshin, MD, MS and Lisa M. Schwartz, MD, MS
Dartmouth Medical School, Hanover, N.H.

Editor's note: Far from dismissing controversy about RLS, the intention of the article in Special Focus: Insomnia was to bring this issue to the attention of readers and to highlight that there is now an FDA-approved medication—ripinirole—to add to the treatment options for this condition. While space limitations precluded publishing all of the evidence, data exists on the prevalence of RLS and the criteria for diagnosis and treatment. A summary of the evidence, including the results of randomized controlled trials of newer agents, can be found online in PIER.


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