Vol. 136 November 15, 2015 “By Degrees”

November 15, 2015

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“If a frog is placed into a pot of boiling water it will immediately try to jump out; but if it’s placed into a pot of cool water that’s gradually heated until boiling, it will stay put and never try to jump out.” (1)

Fall is here in New England. There’s a snap in the air as we shuffle through the leaves waiting to be raked up. It is a most beautiful time of the year when many of our thoughts turn to hunting. A noble sport, a timeless match-up of human endurance, skill, and patience against the stealth and quickness of wild game. Of course, the human often has the advantage of a gun. Except for the occasional cow, horse, or large dog that gets mistaken for a deer there are few accidental hunting deaths. That is because hunters are familiar with their guns, know how to handle them, and respect them. Not so much for toddlers.

“Toddlers in America this year have been shooting people at the rate of once a week.” (2)

That’s only 52 a year. Not a really big number. But if you add on 2 parents, 2.18 siblings (on average), 4 grandparents, and maybe at least one lovely teen age baby sitter per toddler, you get up to over 500 devastated people per year. Now THAT number might be big enough to get our attention.

Last week’s Miami Herald reported that a 3 year old who was looking for an iPad in his father’s dresser drawer found a loaded Smith & Wesson pistol instead. The .40 caliber bullet struck him between the eyes. The father worked as a fitness attendant, not usually considered a high-risk or dangerous occupation, so presumably he had the gun for self-defense.

Statistics show that people who have guns in their homes for self defense (”home protection”) are actually shot more often than intruders are. For every gun used to wound or kill in self-defense, four are involved in accidental shootings. (3)

Self-reported use of guns for self defense are grossly exaggerated. On examination most “self defense” use is actually  “threatening or intimidation” use.

In one study over 1/3 of parents who reported that their son had not handled a household gun were contradicted by the child.

By a margin of more than 3 to 1, Americans would feel less safe, not safer, when others in their community acquire guns.

Nearly one-half of gun deaths in U.S. are suicides. Suicides are often impulsive acts, and once the trigger is pulled the act is over.

75% of the guns used in crime are handguns.

An American teenager is more apt to die from a gun shot wound than from all natural causes.

Enough statistics. We all know that the debate about “gun control” is not a rational one anyway.

How about a musical contribution instead of quoting more statistics?  In the tradition of Pete Seeger, a singer of many protest songs, including the still relevant  “The Banks are Made of Marble”, Mark Erelli  (4) has just released “By Degrees” . Screen Shot 2015-11-14 at 9.56.03 AM Click below to watch Mark Erelli’s quietly powerful music video about gun violence in America..

1.Edward Scripture, The New Psychology (1897): “The original 1872 experiment was cited in: Sedgwick, “On the Variation of Reflex Excitability in the Frog induced by changes of Temperature,” Stud. Biol. Lab. Johns Hopkins University (1882): 385. “in one experiment the temperature was raised at a rate of 0.002 °C. per second, and the frog was found dead at the end of 2½ hours without having moved.” 2. Washington Post, Christopher Ingraham, Oct 14, 2015
3. Brady Center to Prevent Gun Violence
4. Full disclosure: Mark is my favorite son-in-law…OK, my only son-in-law.

Vol. 135 November 1, 2015 “He, She, or It?”

November 2, 2015

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People tend to confuse sexuality and identity, and often want to conflate these things, but being transgender has nothing to do with sexuality.

— Norman Spack, Director Emeritus and Founder of the GeMS Program, Boston Children’s Hospital

Last week one of our five-man book-and-lunch club started our monthly gathering with, “Before we start can you tell me if an infant with unclear genitalia is called transgender?” It quickly became clear during the ensuing conversation that most of us not only knew someone with gender identity issues, but also that we (all over 60 y.o) had blurry, often overlapping, and quite different understandings of gender definitions and terms.  I suspected that we might not be the only ones confused, and thought that researching a blog on the subject might be clarifying for me and others.

What’s the difference between“transsexual”  and “transgender”?
“Transsexual” was coined by a German surgeon in the 1930’s for people (usually males) who wished to have sexual reassignment surgery (SRS) and change from male to female (M2F, MTF). “Transgender” was coined in the 1960’s, was much more about who the person thought they should be rather than about sexual orientation, and was not usually associated with the desire for SRS. In 1979 Christine Jorgensen rejected “transsexual” and insisted on “transgender” (even though he/she underwent SRS). Transgender seems to be the most PC term today, and transsexual, still implying an interest in SRS, is considered to be a subset of transgender. There is a World Professional Association for Transgender Health  as well as a blue/pink/white striped Transgender Pride flag that “will always be correct, no matter which way you fly it.”Screen Shot 2015-11-01 at 5.17.07 PM

A over-simplified, and not always correct, way to remember the differences is:
“Transsexual usually implies sexual orientation, ‘who you go to bed WITH’.
Transgender usually implies gender orientation, “who you go to bed AS?’ ” (1)

An excellent illustration of the complex interplay of these two terms is the Amazon Prime video “Transparent” for which Jeff Tambour won a 2015 Emmy for Lead Actor (a term, by the way, that is now often used for both male and female). In the series of 12 episodes we met several transgender characters, some of whom appeared to have had SRS and hormone therapy and some who have not.

What’s the difference between cross-dressers, drag queens, and transvestites?
Transvestites  are people who like to dress and act like those of the opposite sex. In the 1970‘s “cross dressers” was coined by such people who disliked the implications of fetishism or homosexuality in being called “transvestite”. Cross dressers can be private and have any kind of sexual orientation (J. Edgar Hoover?). Drag queens are theatrical cross dressers who are mostly male homosexuals with great pride in their flamboyant entertainment value.

Is a hermaphrodite the same as an infant with ambiguous genitalia?
Rarely an infant may be born with genitalia that appears to be neither clearly male or female (now called “intersex”). It is important for physicians and family to quickly forge ahead in checking chromosomes, internal anatomy, external physical appearance, parental wishes, and other factors to decide quickly which sex the child shall be raised as. Surgically, it is much easier to create a functional female than a male, but many factors are involved. Even rarer is the hermaphrodite who is born with both male and female genitalia. Unlike lesser species, these human hermaphrodites can not self-impregnate, but can apparently have a future career in adult porn.

In recent years our recognition of and services for gender identity confusion in children has increased. In 2007 Boston Childrens Hospital started a Disorders of Sexual Development and Gender Management Service (GeMS). Since then that multi-disciplinary team of 12 professionals have evaluated and treated over 160 pre-pubertal teen agers for gender identity confusion; 75% of whom lived within 150 miles of Boston. (1)  GeMS considers gender identity confusion as potentially life-threatening because of the higher than expected suicide rate among those adolescents not treated. Evaluations are initiated in “gender non-conforming” children  as soon as 10 or 11 years of age. Puberty is delayed by hormonal therapy, and later the child’s gender appearance can be changed to match the child’s mental gender identity through hormones and surgery.

Even a cursory review of these terms, what they used to mean and what they mean today, suggests many PC/sensitivity potholes dotting the road of their practical use. One Boston suburb middle school teacher started the first day of school this fall with a request to her class to indicate “by which pronoun each wished to be called”.  In addition to the grammatically traditional gender neutral terms like “it”, “one”, and “they”, invented gender neutral pronouns exist and include “zhe” and “zher” and “zhem”. (2000). The medical term “gender identity disorder”, disliked by many because it implies a disease condition, is being replaced with “gender dysphoria”.

References: 1. Norman Spack, MD TED talk

Vol. 134 October 15, 2015 Supplements Are Not Harmless.

October 16, 2015

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“The belief is that they [dietary supplements] are entirely safe,
but now science says that they’re not.”
– Pieter Cohen, MD, Harvard Medical School

A recent study of 63 hospitals from 2004 to 2013 estimated that over 20,000 ER visits and 2000 hospital admissions annually in the U.S. were due to adverse effects of dietary supplements. Adverse events included allergic reactions, excess doses, unsupervised ingestion by children, or other events (e.g., choking). Cases involving death, intentional self-harm, drug abuse, or withdrawal were excluded.  Adverse effects commonly involved cardiovascular adverse effects from weight-loss or energy herbal products among young adults, unsupervised ingestion of micronutrients (iron) by children, and swallowing problems associated with micronutrients (multi-vitamins) among older adults. (1)

The supplements listed included orally administered herbal products (Echinacea, Coenzyme Q10, Gripe Water, etc.), complementary nutritional products (fish oil, body building protein , chondroitin/glucosamine, etc), vitamins and minerals (including calcium and iron), and topically administered herbal or homeopathic products. Energy drinks and herbal tea beverages were excluded from the study.

In the U.S. there were more than 55,000 dietary supplements on the market in 2012, and about half of all adults reported having used at least one dietary supplement in the past month. 150 million people in the U.S. take supplements, including children’s vitamins. In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, which equaled one-third of the total out-of-pocket expenditures for prescription drugs.

  • Weight loss supplements or herbal energy products led the list of supplements with adverse effects in this study.
  • More than half of emergency department visits for supplement-related adverse events involved female patients.
  • Sexual-enhancement products or bodybuilding products were implicated in 14% of emergency department visits for supplement-related adverse events among male patients; there were too few cases among female patients to calculate a reliable estimate.
  • 20% of ER visits involved children who took supplements without supervision.
  • Most ER visits for unsupervised ingestion of supplements by children involved multivitamins (34%), iron (12%), supplements for weight loss (11%), and supplements for sleep, sedation, or anxiety (9%). Child-resistant packaging is not required for dietary supplements other than those containing iron (the amount of iron in the usual bottle can be lethal to small children) , but despite such packaging, iron supplements were the second most commonly implicated type of supplement in unsupervised ingestion by children.

Although the numbers of ER visits and hospitalizations were less than the 5% of the ER visits that have been reported for pharmaceutical products, dietary supplements are unregulated and marketed under the presumption of safety. The FDA is actually BARRED from regulating dietary supplements by the Dietary Supplement Health and Education Act of 1994. (Wouldn’t you like to know the history of that particular bill, or at least, the lobbyists involved?)

When you or someone you know has a good effect from a supplement (like taking glucosamine for knee pain) it natural to think that anyone with knee pain should take it, and that every physician should know about this “miracle supplement”. In medicine that kind of anecdote is called a “case report”.  Case reports can lead to studies of a large number of people, called “statistical studies”. Results of those studies can be persuasive, but the truly scientifically skeptical physician will wait for the results of an organized, randomized, double-blind study with controls (people who don’t get the supplement). Such organized, controlled studies have not found a whole lot of benefit, if any, from taking dietary supplements, especially vitamins, but that is the subject for another whole blog… or two.


1. Emergency Department Visits for Adverse Events Related to Dietary Supplements
Andrew I. Geller, M.D., et al, N Engl J Med 2015; 373: 1531-1540; October 15, 2015

Vol. 133 October 1, 2015 What Year Is This? 1984??

October 1, 2015


“Have you seen the video? You must see the video?” -Carly Fiorina on CNN


I must admit that the Republican Presidential debates have been occasionally entertaining as the non-Trumps gradually reveal a little of their own personalities in trying to counter his H-U-G-E one. But sometimes the posturing for a sound bite or a differentiating headline has so grossly distorted the facts that alarm bells go off in my head. Wait, you say, isn’t that normal for a political campaign? Of course it is, but as a physician I can’t help but cringe watching rabid political attacks based on distorted, misleading, and even deliberately misstated “medical information”.

“Planned Parenthood is profiting from selling baby parts obtained from abortions”.

  1. The 1988 Fetal Tissue Transplantation Panel, appointed by President Reagan, after reviewing decades of research stated that there was no evidence that the possible use of fetal tissue for medical research had ever helped persuade a woman to have an abortion.
  2. Only a few Planned Parenthood affiliates in three Western states have arrangements to provide fetal tissue from abortions to researchers.
  3. Permission for donation of fetal tissue cannot be sought from a woman until after she has decided to end the pregnancy.
  4. By law, the fetal tissue can not be sold for profit. A sum of $30 to $100 may be reimbursed to the health care providers/facility (not to Planned Parenthood, not to the patient) to cover costs of tissue recovery.
  5. By law, there is no federal reimbursement for the abortion procedure itself.
  6. Use of the unique characteristics of fetal tissue has allowed successful research for decades in the development of life-saving , disease-preventing vaccines. “Virtually every person in the country has benefitted from research using fetal tissue.” (1)

“Use of fetal tissue is unethical.”

  1. Just today the pediatric neurosurgeon running for President answered a question in New Hampshire about Planned Parenthood with, “Tearing babies apart? Is that what you mean? The medical ethics of selling body parts and manipulating babies in order to preserve certain body parts? It’s illegal.” Besides mixing “legal’ in with “ethical’, two different concepts, Dr. Carson has also apparently forgotten that he participated in a 1992 medical research study using tissue from aborted fetuses. (2)
  2. “The research use of fetal remains is ethical.” said Reagan’s 1988 panel.
  3. The Committee on Pro-Life Activities of the National Conference of Bishops has written “it may not be wrong in principle for someone unconnected with an abortion to make use of fetal organ from an unborn child who died as a result of an abortion.” (3)

“Planned Parenthood is in the abortion business.”

  1. Three per cent (3%) of the 10.6 million services delivered annually by Planned Parenthood were related to abortion procedures in 2014. That does represent over 320,000 abortions, so I can understand why believers in “zero abortions” might be upset, but Planned Parenthood services are much broader:
    42% for sexually transmitted disease tests (including HIV tests),
    34% for contraception services,
    11% for pregnancy tests,
    and 9% for cancer screening and prevention.
  2. “The inconsistent or incorrect use of contraception accounts for nearly half of unintended pregnancies and half of those end in abortion.” (4)
  3.  78% of the people served lived at or below the 150% federal poverty level.
  4. “We strongly support Planned Parenthood not only for its efforts to channel fetal tissue into important medical research but also for its other work as one of the country’s largest providers of healthcare for women, especially poor women.” (5)

“Have you seen the video? You must see the video?” -Carly Fiorina on CNN

  1. The Video” of Planned Parenthood physicians describing how they obtained fetal tissue is a heavily and deceptively edited compilation of 30 months of taping obtained by actors who misrepresented themselves and asked leading questions.
  2. “The Other Video” and pictures of a bucket of dead baby parts being sorted out by a technician has nothing to do with Planned Parenthood and is from “stock footage” from an anti-abortion organization.

I have no association with Planned Parenthood, and I am not an advocate of abortion as “a means of contraception”.
I am dismayed when information about a major health care provider and a valuable medical research resource is so distorted in such a believable fashion for political means.

In New Hampshire Dr. Carson decried political correctness and likened it to “group-think in Nazi Germany”.  In our present state of political polarization, demand for political correctness, a discouraged middle-class, growing fear of foreigners and scapegoating of immigrants, and even a popular, narcissistic candidate with a distinctive hair style, could “It” happen here?

1.  NEJM 373:10, September 3, 2015 , p.890
2.  Boston Globe, Oct. 1, 2015, B4
3.  Biomedical Politics 1991
4.  Guttmacher Institute 2014
5.  Editors of the NEJM, Sept. 3, 2015



Vol. 132 September 15, 2015 BUGS: Can’t Live Without Them, Can’t Live With Some of Them

September 16, 2015


 “Germs make us sick, but everyone focusses on the harm.
And it’s not that simple, because without most of these organisms,
we could not survive.”
– Martin Blaser, MD; Professor of Microbiology, NYU School of Medicine

Bacteria (bugs) on and in our body outnumber our own cells by about 10 to 1. They only comprise 1-3% of our total body mass or up to about 3 pounds. but they essentially make life possible, as well as occasionally cause us great harm. That bacterial crowd, with its companions of fungus, protozoa  other one-celled critters, is called a microbiome (“microbes that share our body space”). We inherit about 23,000 genes from our parents. Our microbiome contains 4 MILLION, and they are always working.

The National Microbiome Project funded by NIH for $115 million and completed in 2012 confirmed many associations between our bacteria and both health and illness. By our bacteria I mean “our” bacteria. Each person develops a unique microbiome starting with maternal bacteria received during birth. By age three years our microbiome is stable, but can be altered by antibiotics, what we eat, and sanitation practices. The “microbiome fingerprint” of an individual’s stool is distinct and can correctly identify a second stool from that same individual a month later 80% of the time.

Most of the bacteria we live with reside in our intestines. Roughly 70-80% of our feces is made up of bacteria living peacefully in our gut helping us to digest food, absorb sugar, protecting us from auto-immune disease, and maybe even to communicate with our brain. Certain groups of gut bacteria in mice have been shown to affect the blood-brain barrier, to make it more open, “to leak”, which has spurred some researchers to study the effect of gut bacteria on mental health. Associations between obesity, diabetes, and auto-immune diseases like Crohn’s and Irritable Bowel Syndrome (IBS) and the gut microbiome in laboratory mice have already been made.

Some gut bacteria in mice have been found to have two different, interchangeable physical shapes which can sense the environment (the kind of food passing by) and change from one shape to the other, just like a silicon chip. Crohn’s disease was long thought to be an infections disease, but is now considered a non-infectious inflammatory disease. In fact, the absence of one particular bacteria in mice reproduces Crohn’s disease symptoms in them. Human clinical researcher of the microbiome is flourishing.

Balance within our microbiome is important. Clostridium difficile, a pathogen when it overgrows in our gut when competing bacteria are knocked out by prolonged use of antibiotics, can cause debilitating diarrhea, dehydration, malnutrition, and even death. “Clostridial clusters”, a group of non-pathogens, on the other hand can detect sugar in the gut, increase insulin sensitivity, and may protect against the development of diabetes. The recently developed treatment of performing fecal transplants from healthy people to patients with C. difficile infections might be more readily accepted if we called them “microbiome transplants”.

What’s New?
Antibacterial soaps containing triclorsan have been found to be no more antibacterial than soap and water after 40 years of study reviewed by the FDA. Because of recent concerns about the effect of triclorsan on hormone levels and the growth of drug-resistant bacteria in lab animals, the FDA will require manufacturers to prove that their anti-bacterial soap or cleanser is better than soap and water or change its claims or cease its sale by 2016. Anti-bacterial solutions (Purell) are effective because they contain alcohol.

A recent study of the treatment of acute appendicitis with antibiotics alone (24 hours of high dose IV and then 10 days of oral antibiotics) has shown that in selected cases that non-operative treatment is as successful as surgical treatment. Long-term follow-up of these patients remains to be done.

The microbiome of the subway was studied in 2013 by Weill Cornell Medical School investigators who collected and analyzed hundreds of DNA samples from the underbelly of New York City. The good news is that very few samples had the DNA of disease-causing bacteria, and only 1% was identifiable as human bacterial DNA. The more striking fact is that “48% of the DNA found did not match any known organism”. Now, the investigators say that’s because our databases of genomes are incomplete, but I think that there is a Stephen King novel waiting to be written there.

1.  Scientific American, June 2012,, The Ultimate Social Network, Jennifer Ackerman
2.  Scientific American, Feb, 2015, Innovations In, The Microbiome
3.  Weill Cornell Medicine, Vol. 14, No. 1
4.  New Yorker, Oct. 22, 2012 p.32, “Germs Are Us” by Michael Specter
5.  Microbes can be used to identify individuals, Boston Globe, May 18,2015, B4

Vol. 131 September 1, 2015 Current, Recurrent Controversies

September 1, 2015


“Anachron’s Law:
There is no myth which is so irrational that no one will believe it.
Anachron’s Corollary:
There is no truth which is so obvious that everyone will accept it.”
George Hammond

“How Much Is That Pill In The Window?”:
It costs either $2.6 BILLION or $1.4 BILLION to develop a new drug depending on which report you believe… the Tufts Center for the Study of Drug Development (supported in large part by drug companies) or Jeffery Avorn, MD of the Division of Pharmacoepidemiology and Pharmoeconomics of Harvard Medical School. The discrepancy is important since the high price of drugs is becoming a hot topic in this pre-election year. Read this NEJM article to get a glimpse of the smoke and mirrors used in such calculations (how to calculate capital costs?, what is a “self-originated” drug?, how much of R&D costs are covered by public tax money (NIH grants)?, what are R&D and what are marketing costs?, etc.). (1)

  • 80% of new compounds fail to meet expectations and are abandoned during development. This, of course, raises the calculated cost of developing the successful ones.
  • Both reports agree that the time required for new drug approval by the FDA has decreased to the point where it as fast as, or faster than other countries.

“Gadar” is faulty :
Ten years of research has not appreciably advanced our understanding of what makes people gay according to a “state-of-the-art” review of research into sexual orientation held every five years in a remote location. This year’s conference was held at the University of Lethbridge in Western Canada. The sharp dichotomy between nature (genetics) versus nurture (cultural) causes, the focus of numerous “twin studies” in many countries over many years, has been significantly blurred. The search for the “gay gene” has been tempered by the realization that at least 150 genes are involved in determining “something as simple as your height.” (2)

A new concept, the “environment of the womb”, has recently received greater research interest, but data remains inconclusive. The “environment of the womb” swirls with all sorts of different, and changing, levels of hormones and proteins for 9 months, and researchers  continue to look for its effects on the fetus – “epigenetics”. “Genes are the ingredients of grandma’s apple pie. Epigenetics is the recipe of how she actually makes it.” (2)

The scarce support of sexual orientation research is due in large part to societal controversies  (hence the remote locations for conferences to reduce easy access for “Spotlight Investigative Teams” roaming for hot topics). I wonder if such research is even worth it at all. Any research conclusion will likely be ignored by those people with the strongest negative opinions about sexual orientation because many have clearly shown no acceptance of scientific evidence about anything.

“Low-T” is another manufactured diagnosis:
Despite the lack of scientific evidence showing any benefits, 2.2 million men were prescribed testosterone in 2013 for “age-related hypogonadism”, a brand new diagnosis limited to aging men and apparently coined in response to a demand for testosterone prescriptions. Most of the men are 40 to 64 years old, and one-third of them had never had their actual testosterone blood level checked prior to the prescription. The authors of this report suggest that direct-to-consumer marketing for the improvement of “low-T symptoms” is a major reason for this wide-spread, increasing usage. The FDA has identified a “weak signal” that testosterone usage has adverse cardiac effects, and is concerned … so they have… “recommended some drug label revisions”. (3)

“Lingering Lyme”:
The CDC notes that one in five patients treated for Lyme disease may develop a persistent syndrome of fatigue and other symptoms known as “post-treatment Lyme syndrome”, and no one knows what causes it. It is NOT cured by continuous long-term antibiotics. There is new laboratory animal evidence that some of the organisms causing Lyme go into a “dormant state” when under antibiotic attack. They are NOT resistant to the antibiotic. The cell metabolism function that is attacked by the antibiotic just shuts down temporarily when the antibiotic is present, and so the organism survives. The researchers found that reintroducing the same antibiotic in the lab animal after a time off antibiotics subsequently killed these “persister” organisms. This is a new direction of inquiry in Lyme disease, but not everyone believes in “persisters” and “pulsed antibiotics”. They won’t believe, and shouldn’t, until all four of Koch’s postulates  for establishing a link between a disease and an organism are met. (4)

“Water, Water Everywhere…but not needed”:
The persistent myth that 8 glasses of water will keep you healthy was apparently initiated by readers of a 1945 Food and Nutrition Board recommendation that people need 2.5 liters of water a day. BUT, the readers ignored the next sentence that read “most of that quantity is contained in prepared food” … like fruits, vegetables, juice, coffee, tea, and even beer. Prospective studies have failed to find any benefit on skin elasticity, kidney function, “healthy appearance”, disease-free state, or mortality in those healthy people who increase their water intake. A recent study using a urine osmolality of 800 mOsm/kg (a measure of concentration) as the “normal” value in children concluded that more than half of 4,000 symptom-free, healthy children were “dehydrated”! It would seem that we should throw that particular “normal” standard out the window … or at least into the crapper. (5) Water is good for you, but, let’s face it, you really don’t need take a water bottle with you in the car when you go to pick up the mail.

1. “The $2.6 Billion Pill – Methodologic and Policy Considerations”, Jeffery Avorn, MD, NEJM 372;20, May 14, 2015 .
2. “What Makes People Gay?- Revisited” , Neil Swidey, Boston Globe Magazine, August 23, 2015,
3. “Testosterone and ‘Age-Related Hypogonadism’ – FDA Concerns”, NEJM 378;8, Aug 20, 2015
4. “Lingering Lyme”, Scientific American, Sept. 2015, pg.17
5. “The Persistent Health Myth of 8 Glasses of Water A Day”, Aaron J. Carroll, MD, NY Times, Aug. 25, 2015, pg. A3

Vol. 130 August 1, 2015 Medical Diagnosing Websites

July 31, 2015


Have you ever gone on the internet
to seek a diagnosis for your symptoms?


Fifty million people did so on iTriage last year. Healthline.com

gets 6.5 million visits a month. WebMD’s “symptom tracker” gets 4 million visits a month.

Are they any good at making a diagnosis for you? Do they give good triage advice?

A recent study by Harvard Medical School faculty says “not too bad”, BUT “seeker beware”. (1)
There is significant accuracy variability between the websites. The authors identified 143 websites offering diagnoses in response to symptoms entered by the user. They submitted 45 standard sets of symptoms from “patients looking for a diagnosis” (entered by non-professionals) to each of the 43 websites directed at general medicine/primary care “symptom tracking”. The “patient’s” symptoms entered were in one of three categories (unlabeled and unknown to the website): 1) symptoms require urgent medical evaluation, 2) symptoms should be evaluated by a medical professional by appointment, and 3) self-care without medical evaluation is all that is recommended (the classic medical triage decision tree).

On average, half of the websites listed the correct diagnosis first. 58% listed the correct diagnosis in the top three. However, the range of correct number of #1 diagnoses varied from 5% to 50% between websites. Not unlike a medical professional’s diagnostic decision-making, the software on these websites correctly identified common diseases more frequently than uncommon ones. (The old medical student saw is true: “When you hear hoofbeats think of horses, not zebras.”)

A more comforting result of the study was that 80% of the symptoms needing urgent evaluation and care were identified correctly. The flip side was that two-thirds of the patients that could have been served well by self-care alone were instructed to seek a medical evaluation. As one web-designer physician remarked, “We try to neither unduly alarm nor inappropriately reassurance users.” The software behind the triage advice on these websites (“should I see a doctor or not”) is highly risk-adverse in suggesting so many medical evaluations for minor symptoms. This may not prove so useful to people using the websites to avoid a visit and the payment of a deductible.

The triage accuracy was comparable to that found in studies of nurse practitioner telephone triage which ran about 60-70% compliant with physician in-person recommendations. Of course, the symptom tracking websites do lack perceptions of patient anxiety, tone of voice, urgency of speech, and other subtle, but important clues (especially to pediatricians), of the nature of the situation. Perhaps as a practicing pediatrician I put too much stock in those kind of clues in assessing a patient by telephone, but I suspect that they do improve the person-to-person triage decision-making. At least, the symptom tracking websites were better than just entering symptoms into a Google.

Which symptom tracking website was the best? DocResponse.com got the highest score, but offers no pediatric content. Healthychildren.com by the American Academy of Pediatrics is the site to go to for that. MEDoctor had the worst results. e-Patient Dave, a respected non-medical patient care advocate, recommends trying 2 or 3 websites with the same symptoms.

The traffic to these kind of websites and their popularity with patients may spawn a new word in the lexicon of medical practice; “cyberchondriac”

1. BMJ 2015:351, July 8, 2015

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