European View on ADHD

In alt.support.attn-deficit 00doc wrote:
Steve Harris wrote:

But I'll debate you. You start.

Been there - done that. You had nothing.

If my views on this matter are so irrational, you should
have no
problem demolishing them in a short time.

I did - quite a while ago. In can understand why your would
want to forget the experience.

I tried a newsgroup google for this, but couldn't find it. Were you
posting with a different pseudonym then?

--
Chris Malcolm +44 (0)131 651 3445 DoD #205
IPAB, Informatics, JCMB, King's Buildings, Edinburgh, EH9 3JZ, UK
[http://www.dai.ed.ac.uk/homes/cam/]

In alt.support.attn-deficit 00doc wrote:
Chris Malcolm wrote:

Turns out they start to feel empowered
make and their own treatment decisions
- and - guess what? They don't
do as well as their doctors.

I just read a paper in a medical journal which
said the complete opposite.

The link you give is not really on point. It gives an
anecdote about a patient that researched her disease and
successfully contradicted her docs and then goes on to
give
more anecdote and opinions about how docs can use on-line
resources to help educate patients - hardly what we are
talking about (in fact, pretty much the opposite). It is
an
editorial abstracted from a talk and not an original
study.

I never suggested it was any grander than that. I simply
said I'd read
something in a medical journal which said the opposite.
Which it does.

Most people take the word "paper" int his setting - writings
in medical journals - to mean original research reports.

Most people doesn't include my own paper-writing community. We call it
a paper whether it reports the results of research in an archival
journal, reviews other research in an edited book chapter, or proposes
an interesting idea in a conference proceedings. I don't happen to
know any paper publishing medics well enough to know their own usage
of "paper", but my usage of "paper" applies to the paper publishers I
know in several other academic fields. Maybe it's different in the
medical field, or in the US, but I suspect "most people" above to be a
misleading exaggeration, like saying "most of the US voted for Bush".

And
it doesn't say the opposite. I said that people who do
research and this the important part - and then decide
they know more than their docs and so make treatment
decisions apart from them, and often contrary to their
advice, tend to do worse.

I agree with the "tend to do worse", but think there are important
exceptions where they do a lot better.

You posted a study about docs using the Internet to help
educate their patients.

See the difference? Being arrogant, assuming you know more,
and working at cross purposes to the doc - bad. Using the
Internet as a tool to help you work with the doc - good.

I do, and I agree. I just don't want to obscure those cases where the
doc's advice is bad and the "arrogant" patient discovers this.

There are much better papers of that genre and point of
view on the
BMJ web site.

Not exactly. Surely, as you mention, there is a lot of
literature on what types of information is out there, who
looks at it, how they find it, what they do with it, etc.,
etc. But there is not much that shows an outcome - whether
they do better or worse for their efforts.

I agree.

The reason I counterposed the contrary anecdotal
editorial is that they ignore the well-educated searcher
who already
has a background of medical knowledge and is a
sophisticated web
searcher, e.g., the profs who attend university health
centres, and
whom the docs in university health centres are well used
to.

You seem to be using some kind of pseudo-terminal which breaks lines
of more than about 55 chars in two. It makes rather a mess of your
quotations. The recommnded email and newsgroup standard is to accept
72 char lines.

How many of those are around? It is not a matter of ignoring
anyone - it is just that you are describing a rare beast -
too rare to change the outcome of any realistic population
based study.

I agree. But I think doctors should be prepared to admit the existence
of rare beasts when they meet them, rather than insist that they don't
exist. In fact, if they did that, they might find that some allegedly
rare beasts weren't quite as rare as they thought. For example, I find
it very difficult to believe that I have been so extraordinarily lucky
as not only to enjoy outcomes to a number of injuries and disorders
which I was told very firmly by doctors and consultants were either
impossible or extremely unlikely, in cases varying from broken bones
to endocrine disorders, but also to have met a few other patients in
the same boat.

In cases
where a particular topic is developing fast, such as
diabetes, it's
not unusual for the sharp edge of research to be a few
years ahead of
the consensus diagnostic and treatment guidelines, those
in turn to be
a few years ahead of the textbooks, and those in turn to
be a few
years ahead of most docs.

Eh - I think you are overstating the case. Sure there is
always new science that takes a while to percolate down but
it tends to be the esoteric tid bit here or the marginal
advance there. If you restrict the discussion to true nuts
and bolts - what I do do with this clinical situation types
of information - the changes are not all that fast.

Generally speaking you're right. As I pointed out I was talking about
those specific cases where new evidence requires a substantial
revision of diagnostic or treatment procedures. In those cases the
natural time lags of the system can become significant. And there are
cases where institutional conservatism of the kind Kuhn describes is
added to those time lags.

If you choose to disagree with me here please give examples
of "cutting edge" technologies that measurably and
significantly improve patient management that are in
research settings but have yet to come down to common
clinical practice - diabetes is a good example of your own
choosing - go ahead and use that.

Ok. I'll give you a head start. You tell us the current diagnostic
criteria for T2 diabetes, and the recommended treatment for those who
fall just within the criteria. Pointers to authoritative web pages are
fine.

These are the kind of cases where a proficient web
searcher with the
time of a chronic disorder to play with can become
usefully better
informed than the doc, and the doc can usefully guide the
web
searching of the patient, to the benefit of both.

Again - you are discussing the exception not the norm.

Exactly. My point is the annoying habit of many doctors, and those
responsible for advising them, to use the norms, or averages, in a
one-size-fits-all system of medicine.

"The doc usefully guiding the web searching of the patient"
is a completely different subject. It is the exact opposite
situation. I don't see why you are having trouble with this
distinction.

I'm objecting to the tendency for medicine's search for efficiency and
cost-effectivness to end up with Procrustean one-size-fits-all
diagnoses and treatments. For example, the tendency prescribe pills
rather than lifestyle changes to those who have had a heart attack,
because research shows that most people will take pills, whereas most
people won't change their diet and exercise habits.

I'll give you an example of a personal friend who greatly benefitted
from going contrary to all medical advice. He was an obsessive
marathon runner in his thirties with very painfully knackered knees.
Everyone he consulted told him he'd totally and irretrievably
knackered his knees, and nothing short of surgery would give him the
slightest chance of ever running again, and even with the best outcome
of surgery, marathons were pretty likely gone for good. He refused to
accept this, and after a lot of research started by resting his knees
totally. After a year of total rest, the pain fianlly went. He then
started a programme of very gentle walking. After two more years of
carefully ramping up the walking he was able to start gentle running
without pain.

I last met him after he had just returned from a Himalayan marathon
run, with not the slightest trouble from his knees.

I agree that he's a statistically insignificant rare beast. He
wouldn't be so annoyed with doctors if at least one had said to him,
"There's no record of anyone recovering from such damage. It might
just be possible, but only if you're prepared to follow a heroically
obsessive regime for years. Are you willing to have a go?"

--
Chris Malcolm +44 (0)131 651 3445 DoD #205
IPAB, Informatics, JCMB, King's Buildings, Edinburgh, EH9 3JZ, UK
[http://www.dai.ed.ac.uk/homes/cam/]

Chris Malcolm wrote:
If you choose to disagree with me here please give
examples
of "cutting edge" technologies that measurably and
significantly improve patient management that are in
research settings but have yet to come down to common
clinical practice - diabetes is a good example of your
own
choosing - go ahead and use that.

Ok. I'll give you a head start. You tell us the current
diagnostic
criteria for T2 diabetes, and the recommended treatment
for those who
fall just within the criteria. Pointers to authoritative
web pages are
fine.

You didn't answer my question.


Again - you are discussing the exception not the norm.

Exactly. My point is the annoying habit of many doctors,
and those
responsible for advising them, to use the norms, or
averages, in a
one-size-fits-all system of medicine.

No - you are using the annoying habit of Internet medicine
bashers of reading too much into what an author says and
then complaining about it. No one ever said there were not
instances where people do well with their own research. No
one advocated a one size fits all strategy. You are fighting
a strawman.


I'm objecting to the tendency for medicine's search for
efficiency and
cost-effectivness to end up with Procrustean
one-size-fits-all
diagnoses and treatments. For example, the tendency
prescribe pills
rather than lifestyle changes to those who have had a
heart attack,
because research shows that most people will take pills,
whereas most
people won't change their diet and exercise habits.

Again - you are charging at windmills. No major organization
or competant physician sees this as an "either or" situation
and all recommend doing both. None advocate a "one size fits
all" approach. It is not the will or the fault of the docs
that people happen to find it easier to take pills than the
eat right and exercise. The docs tend to be delighted when
people are successful with the lifestyle modifations and can
come off of some of the drugs - it just doesn't happen all
that much.


I'll give you an example of a personal friend who greatly
benefitted
from going contrary to all medical advice.

Again - no one ever said it didn't happen. For every
anecdote you can give me I could show you ten patients that
do not follow advice and are the worse for it.

--
00doc

In alt.support.attn-deficit 00doc wrote:
Chris Malcolm wrote:

If you choose to disagree with me here please give
examples
of "cutting edge" technologies that measurably and
significantly improve patient management that are in
research settings but have yet to come down to common
clinical practice - diabetes is a good example of your
own
choosing - go ahead and use that.

Ok. I'll give you a head start. You tell us the current
diagnostic
criteria for T2 diabetes, and the recommended treatment
for those who
fall just within the criteria. Pointers to authoritative
web pages are
fine.

You didn't answer my question.

sigh I don't want to get into a hair-splitting dispute about the
meaning of "is", so let's first establish whether you really do
disagree with me.

First of all I do agree with you that generally speaking where a
patient finds a difference between their doc's advice and advice from
the web, that they'd be much better off following their doc's
advice. That's a very good general rule, but there are important
exceptions. The exceptions are cases where you'd be a fool to follow
your doctor's advice. The simplest case is where the doctor is wrong,
and other doctors would agree with that (where their lawyers,
professional solidarity, etc., permitted). I also agree that good
doctors can make errors in good faith. This correction of error is the
simple obvious exception which I don't want to bother arguing about.

The more interesting exception is where a combination of fast moving
research and the time lags of institutionalised medicine mean that a
doctor who is competently following the proper official diagnostic
criteria and treatment recommendations will offer diagnoses and
treatments which will lead to significantly worse outcomes for the
patient than following advice which the intelligent web-savvy patient
can find, which is supported by good published research, and which is
endorsed by doctors who agree that the official stance is damagingly
out of date.

I suggested that T2 diabetes was such a case.

If you agree with this claim then we don't need to argue.

Again - you are discussing the exception not the norm.

Exactly. My point is the annoying habit of many doctors,
and those
responsible for advising them, to use the norms, or
averages, in a
one-size-fits-all system of medicine.

No - you are using the annoying habit of Internet medicine
bashers of reading too much into what an author says and
then complaining about it. No one ever said there were not
instances where people do well with their own research. No
one advocated a one size fits all strategy. You are fighting
a strawman.

I realise that may be the case, and I don't want to do that. That's
why I have carefully restated my position so that you can agree, or
clarify your disagreement. I'm not a medicine basher. I get on well
with my doctors.

I'm objecting to the tendency for medicine's search for
efficiency and
cost-effectivness to end up with Procrustean
one-size-fits-all
diagnoses and treatments. For example, the tendency
prescribe pills
rather than lifestyle changes to those who have had a
heart attack,
because research shows that most people will take pills,
whereas most
people won't change their diet and exercise habits.

Again - you are charging at windmills. No major organization
or competant physician sees this as an "either or" situation
and all recommend doing both.

US doctors must be very much better than in the UK (I presume you are
a US doctor describing US medical practice). I was recently diagnosed
with high blood pressure and oxygen deficit to the heart at high heart
rates. I saw a cardiologist, and asked four GPs in my local practice
to interpret the recommendations of the cardiologist. These were GPs I
specifically chose because on past experience I considered them good
doctors. None of these four doctors, nor the cardiologist, volunteered
the suggestion that I change my diet or exercise habits. I was
surprised, and asked if they agreed that I could get worthwhile risk
reduction from a change of diet and exercise habits. They all agreed,
and explained that research had shown that so few patients were
capable of making such changes that it wasn't a cost effective
treatment option, whereas most patients would take a pill. They said
they would have made such recommendations if I had been overweight or
unfit.

I still think those doctors are good doctors. I think they have been
pushed by time constraints and efficiency guidelines into the position
they described, which they regret. I'm very pleased if that doesnt
happen in the US.

None advocate a "one size fits
all" approach. It is not the will or the fault of the docs
that people happen to find it easier to take pills than the
eat right and exercise. The docs tend to be delighted when
people are successful with the lifestyle modifations and can
come off of some of the drugs - it just doesn't happen all
that much.

That's exactly what the docs I consulted said to me. The reason I call
that a "one size fits all" approach is that if they'd bothered to
consult my notes they would have discovered that I was one of those
rare beasts who can make and stick to dietary changes, because I had
done so, for other reasons, on two separate occasions, one twenty
years ago, one five. And had stuck to the changes. It was in my
notes in the folder on their desk.

I'll give you an example of a personal friend who greatly
benefitted
from going contrary to all medical advice.

Again - no one ever said it didn't happen. For every
anecdote you can give me I could show you ten patients that
do not follow advice and are the worse for it.

Of course. I've tried to make it as clear as possible that I'm not
arguing about the average, but how the exceptions are dealt with.

--
Chris Malcolm +44 (0)131 651 3445 DoD #205
IPAB, Informatics, JCMB, King's Buildings, Edinburgh, EH9 3JZ, UK
[http://www.dai.ed.ac.uk/homes/cam/]