Monday, October 7, 2013

The Reluctant Hypnotist

The most frequent criticism skeptics receive is that we are not open-minded. I’m sure this is true to some extent but contrary to popular belief, it is not a quality that defines us.  Sure, there are closed-minded skeptics just as there are many non-skeptics who are closed-minded to the value and validity of the scientific method. 

Most of the skeptics I’ve come across are actually what I like to think of as reservedly open-minded, which simply means that they defer acceptance of a belief until after they’ve been presented supporting evidence.  The only exception might be in matters of absolute implausibility based on a preponderance of scientific knowledge, past experience and logic (things like telepathic weight-loss, proven systems for winning the Mega-Lotto and the efficiency of government programs come to mind). 

Many other issues – those that seem to straddle the realms of possibility and unlikelihood – are downright intriguing to skeptics.  For me, one such issue is hypnosis.  I find the topic of hypnosis so intriguing, in fact, that I’ve actually dabbled in it.  I want to share my experiences and offer a rational explanation for what I witnessed.

A few summers ago, I was working as a pediatric hospitalist in South Texas in the midst of an epidemic of viral meningitis.  Nearly every day I was charged with admitting one or more children who presented to the hospital with high fever, chills, vomiting, a stiff neck and the worst headache of their lives.

The treatment for viral meningitis is “supportive”:  pain relief, rest and IV hydration in most cases. The majority of children feel much better after a few rather miserable days. Physicians also give intravenous antibiotics until they’re quite certain that the patient doesn’t actually have bacterial meningitis which is a life-threatening condition.  The only sure-fire way to distinguish viral from bacterial meningitis is to analyze the cerebro-spinal fluid (CSF) which bathes our brain and spinal cord. And the only way to do that is to do a lumbar puncture or spinal tap.

I’ve done hundreds of spinal taps in my life (most of them on infants) but I’ve never had one done on me.  I’m sure it hurts at least a little and, depending on how it’s done, sometimes it hurts a lot. With the exception of newborns, we try to eliminate the pain by using local anesthetics. But the injection of lidocaine to numb up the area stings in and of itself, and the sensation is augmented in a child or teenager who is ill to start with besides being terribly anxious. So we often must resort to providing some form of sedation (you really don’t want a child writhing and jerking when you’re about to insert a needle in their lower spine).

Sedation requires a much higher level of care.  You need adequate monitoring capabilities and more staff in order to quickly recognize and deal with any potential adverse effect from the sedative. You also must have the capability to provide life supportive measures should the child have a complication from the sedation.  In our hospital in South Texas the policy required placing these children in the intensive care unit.  Yet the ICU was often full and we were sometimes short-staffed. So what was one to do?

I was pretty convinced that if I could gain the complete trust of my young patients and succeeded at reducing their anxiety I’d be able to mitigate some or most of their pain.  So I decided to give hypnosis a chance.

My first experience with hypnosis was in high school when a stage hypnotist held a show at our school.  I was pretty darn impressed (but then again, I was a very gullible lad).  Still, I didn’t quite know what to make of the whole thing.  Were the participants on stage actually entering a different state of consciousness or were they just being driven to “play along” with the hypnotist’s suggestions due to some psychological prerogative of being the center of the show, not wanting to disappoint the audience, the hypnotist, or maybe both?  

In college, my studies (including a class titled, Altered States of Consciousness) did little to shed light on the issue.  Interestingly, I started gaining a clearer understanding about the phenomenon from the entertainment world, most recently from Derren Brown (if you don’t know who Derren Brown is, you just have to watch some of his videos which are everywhere on the internet).

So that summer, I decided to resort to hypnotism as an adjunct to local anesthetic in performing spinal taps on any child who was old enough to be able to listen to me and understand what I was saying.  I developed an “induction script” (the series of phrases designed to help subjects enter “trance”) that I felt comfortable with and refined and calibrated it for my purposes.  

The first patient I tried it on was a bright teen-aged girl.  She listened to my script, closed her eyes and lay perfectly still as I spoke to her in my best hypnotist voice.  When I decided to “test” the depth of her trance by suggesting that one of her arms was getting lighter and lighter, as though a bunch of helium balloons were tied to her wrist, her arm began to drift up in the air, at which point her mother (who was sitting quietly in the procedure room) leaned forward wide-eyed and  let her jaw drop.
The procedure went so smoothly that it was an absolute joy. When I was finished I asked the child if she had experienced much pain.  She said, “I didn’t feel a thing.”

My second patient was an extremely anxious boy who was the son of a high-ranking county official. The nurses had struggled to draw blood work and insert an IV because he was so terribly scared by the entire experience of being in the hospital. I honestly didn’t think my hypnosis would work at all with him.  But to my surprise, and to his mother’s utter delight, he too remained comfortable for the entire procedure and later told me, “That was great!”

Over the next few weeks I performed nearly two dozen lumbar punctures under hypnosis.  Most of the patients had extremely pleasant experiences. I was not able to provide comfort in one case.  Overall, I was very happy with the ability to comfort my young patients.  Some of the parents were skeptical at first but thrilled by the end result.  Nurses volunteered to assist me with the procedure, intrigued by the whole process.  None of my patients required ICU stays for sedation.
Let’s be clear. This is complete anecdotal experience, but will I perform hypnosis on the next child or teenager that needs a lumbar puncture?  Absolutely.

This is how I see it.  As a hospitalist, I was providing care to patients who in most cases I had never met.  Along with the anxiety sparked by the child’s illness and by the intimidating surroundings, there was the added apprehension that neither the family nor the child knew me.  So, how could they know if they should trust me?

Hypnosis, in my opinion, goes a long way in such a setting to establish trust.  I clearly communicated to the parents and the children that patient comfort and relief from pain were my utmost priorities.  This in itself was very reassuring.  I listened, answered questions and deliberately did not rush (the process of hypnosis does have a cost in terms of physician time, but is well worth it and may actually save a lot of time in the long run).

So do I believe that hypnosis is a true altered state of consciousness?  I’m still not sure.  I think that for most individuals it is simply a state of great relaxation, of extreme serenity and trust, and of heightened suggestibility.  To me, hypnosis is just an extension of good bed-side manners.  It is an explicit expression and demonstration of concern that requires an investment of time and patience. 
Besides benefitting the patient, hypnosis is a boon to the physician as well.  It helps to establish a cooperative and trusting relationship.  It creates a sense of goodwill and calm that is highly therapeutic for all involved.  And it helps you care more deeply for the patient, which is always a good thing.

And what about those stage hypnotists?  Is that stuff for real? I believe very different psychological mechanisms may be at work there.  I can’t say that I’m very concerned or impressed by them anymore (except for Derren Brown – he is beyond impressive; he’s outright fascinating, but of course he’s not technically a stage hypnotist).

As I was saying, skepticism is not a position of closed-mindedness.  In fact, it is frequently a position of absolute fascination and appreciation for the wonders of the universe.  It is a devotion to pursuing the truth wherever it may lead us.  But the pursuit of the truth is not likely to be fruitful when we leave the path of plausibility. And the truth does not require the investment of faith; it does not require us to believe first so that we may experience the truth first-hand; it does not demand that we forfeit thoughtfulness and a questioning, critical stance; it does not require the sacrificing of objective evidence in favor of subjective validation.

Call me the reluctant hypnotist;  just another soul trying to make sense of the utter complexity of the world we are part of, meagerly equipped with a fallible mind that is prone to error, easily seduced by the siren-song of false prophets but fortunately tied to the mast of a steady ship with the ropes of reason, empiricism and questioning. 

 Am I closed-minded?  I’ll let you decide.

Tuesday, August 13, 2013

The Delusion of Dilution: When Pharmacists Recommend Homeopathy

You’re awakened just after midnight by a scream.  You pull on a robe, step through the darkened hallway and tiptoe into the bedroom of your three-year old.  He’s sitting up in bed, clutching his ear, sobbing.  As you try to comfort him he settles into a plaintive wail.
“It hurts, Mommy.”
That’s when you realize you’re all out of pain medication.  You pull on a pair of jeans and a sweatshirt to make a run to the 24-hour pharmacy.  When you get there, you notice a kindly-looking man in a starch-white smock behind the counter.  He doesn’t appear particularly busy, so you decide to ask him for advice. After relaying your son’s symptoms, he nods, walks around the counter and leads you down an aisle stocked with brightly colored boxes of medicine.
“Try these,” he says, as he hands you a small box of ear drops.
Not what you expected, you think.  But you’re glad.  In fact, you’re only too happy to shell out twelve bucks to relieve your child’s pain.
What you don’t know is that the drops the pharmacist gave you will not work.  In fact, they couldn’t possibly work because they contain no medicine at all.  What you don’t realize – what he didn’t tell you – is that the “medicine” he gave you is a homeopathic preparation.
Anyone who’s read my book, Suffer the Children knows that I hold no punches in holding my profession of pediatrics accountable when its practitioners stray from accepted standards of care. I’ve strongly criticized physicians for exposing children to potential harm by missing basic diagnoses, by excessively prescribing unnecessary medications and needless laboratory tests, and in some instance, by putting profit above patient care.
In this article, I will turn my attention to a non-scientific philosophy of healing created by the German physician, Samuel Hahnemann in the late 18th century. Normally I don’t fret too much about this subject, but lately I’ve noted a worrisome trend.  I see more and more families who are “prescribed” homeopathic remedies by pharmacists, often for the treatment of diarrhea or teething, and more frequently to relieve ear pain due to infection.  Almost always, the family is unaware that the medicine they purchased is homeopathic.
When I ask my patients’ parents what their understanding of homeopathy is, many answer that it’s “natural” and involves herbs and such.  Actually, that’s not true at all.  If you read the list of ingredients on homeopathic preparations, you’ll often find the names of highly toxic materials such as lead, mercury and sulfur.  But don’t worry if you’ve taken these in the past:  they don’t really contain these ingredients at all (I’ll explain in just a bit).
Actually, homeopathy is based on a couple of fundamental precepts.  The first, known as the “law of similars” holds that a substance that is able to create a particular symptom holds the key in treating a disease in which the symptom is present.  This is sometimes knows as “like treats like”.  So something that makes you sneeze, according to homeopathy, would be a good choice for the treatment of hay-fever. As long as it is prepared in accordance to the second law:  “the law of infinitesimals”.  This law holds that the more dilute a substance is, the more effective it will be.
How dilute?  Let’s take the example of the earache drops that are commonly recommended by pharmacists and advertised on the web page of the largest national franchise pharmacies.  Here’s what the box says:

Active Ingredients

Pulsatilla 30C, Chamomilla 30C, Sulphur 30C, Calcium Carbonate 30C, Belladonna 30C, Lycopodium Clavatum (Club Moss) 30C
Inactive Ingredients

Citric Acid, Water (Purified), Sodium Benzoate, Vegetable Glycerin

The “30C” following each of the active ingredients reveals their supposed dilution.  In homeopathy, an “X” represents a dilution of one part active ingredient in 10 parts of water.  A “C” is one part active ingredient in 100 parts of water.  To achieve a 30C dilution, we start with one part of the active ingredient, drop it in 100 parts water and shake real well.  Then you get an aliquot of that suspension, put in another 100 parts of water and stir well.  Repeat the operation 28 more times. 
Basic chemistry tells us just how much we can dilute a substance and still retain the original ingredient.  The prominent physicist, author and debunker of pseudo-science, Robert Park Ph.D. calculated that to retain a single molecule of the original substance, a 30C dilution would need to be dissolved in at least 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000 molecules of water (see the excellent article on which corresponds to a volume 30,000,000,000 times the size of our planet.
Modern practitioners of homeopathy don’t dispute these calculations. They agree that none of the active ingredient is likely to be present at such dilutions but they claim their medications are effective nonetheless because the water retains a memory or essence of the original substance.  This is sheer nonsense.

Join me in celebrating the launch of my medical suspense, The Art of Forgetting
August and September, 2013 

It may be hard to believe that pharmacists, who are educated in basic chemistry, biology, pharmacokinetics and pharmacodynamics would buy into the claims proposed by homeopathy (and most don’t), but I’ve learned that a good education and even intelligence does not necessarily render an individual immune from irrational beliefs.
A couple of years ago, I wrote a letter to the executive directors of two major pharmacy chains to ask if they endorsed the use of homeopathy and whether it was company policy for pharmacists to recommend homeopathic products.  I never received a reply, which I guess should be no surprise.  As is so often the case, the best way to protect consumers from this type of fraudulent practice is through education, and I hope I’ve done my small part with this article.
In truth, if I had been alive in 1795, I’d have gladly chosen Hahnemann’s nostrums over the leeching, purging and blood-letting that was rampant in the day – homeopathy doesn’t work, but at least it doesn’t outright kill you. But the year is 2013.  The world has changed dramatically.  Homeopathy has not.  So I’ll take the cold, objectiveness of science over the warm fuzziness of pseudoscience every time.  In the end, nothing is as soothing as rationality.

Thursday, July 4, 2013

Much Ado About Foreskin: A No-Sweat Approach To The Circumcision Decision

There are few pediatric topics that fuel as much passionate debate (among physicians and laypeople alike) as to whether healthy newborn boys should be routinely circumcised. One camp argues that the procedure is essential to avert potentially catastrophic illnesses whereas the opposition go as far as calling the procedure a wanton violation of human rights.
Claims from the most ardent advocates on either side can be strident and silly, which is not helpful to parents caught in the middle. Much of the controversy, I believe, stems from the fact that circumcision is the only elective surgical procedure that is performed on neonates. Unfortunately, a policy statement from the American Academy of Pediatrics and its recent revision have neither doused the flames of controversy nor imparted clarity on the debate.

Circumcision is the only elective surgical procedure performed on neonates.

For many well-meaning parents, the entire issue is befuddling and adds unnecessary stress to what should be a joyful time. To the anxious parent, I’d like to offer a simple message: relax! The choice you make is not likely to have a major impact on your child’s health one way or the other. And your child, I assure you, will not be asked his circumcision status on his application to Harvard. To stress the point, I am told that there have been great men who have made significant contributions to human society and lived healthy lives well into their nineties both with and without their foreskins.

What I do advise parents to do is to become aware of the issues involved so that they can be comfortable with whichever decision they settle on. Know why you chose what you chose.
Part of the reason this issue is mired in controversy is that it is colored by religious and cultural considerations. If you wish to circumcise your child for religious reasons, this article is not for you. You already know the reason behind your choice, and presumably, you are comfortable with it.  Go in peace. But please do not misinterpret this as my supporting the procedure for religious reasons. It’s just that the reason for your choice is outside the purview of this particular article. On the other hand, if you are interested solely on the potential health benefits of circumcision, please read on.

The best place to start in making sense of the debate is to glance at the policy statement from the American Academy of Pediatrics (available in its entirety here: The Academy proposes that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure… Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure.”  This is a more enthusiastic endorsement of the procedure compared to the 1999 position that stated that there were some potential health benefits to circumcision “yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child.”

So, what are these health benefits?  The AAP cites a reduction in the rate of urinary tract infections, penile cancer and some sexually transmitted diseases (STDs) including HIV infection. That sounds pretty impressive, but what the AAP statement does not specifically address is whether the risk of these diseases needs to be addressed in the newborn period or whether the procedure is the most effective way at preventing these conditions. Let’s break them down one by one.

Urinary tract infections

About 1% of uncircumcised boys will develop a urinary tract infection in the first year of life (UTIs in older boys are much rarer). Boys that are circumcised have only a 1 in 1,000 risk of developing a UTI in the same time period. Some people look at this data and are impressed by the fact that circumcision imparts a 10 fold reduction in UTI. Others look at the same numbers and conclude that a 1% risk is not so bad for a condition that can be readily treated with a course of oral antibiotics.  To be clear, a UTI in the first 3 months of life does carry additional risks and typically requires hospitalization.

The prevention of urinary tract infections in the first 3 months of life is, without a doubt, the single most compelling argument in favor of routine circumcision in the newborn period.

The prevention of urinary tract infections in the first 3 months of life is, without a doubt, the single most compelling argument in favor of routine circumcision in the newborn period. But to analyze whether a surgical procedure is warranted we must consider a statistical tool known as the Number Needed to Treat (NNT) which asks, ‘how many patients must undergo a treatment in order to prevent a single case of the disease we’re trying to prevent?’  According to a study published in the Archives of Diseases in Children in 2005, the NNT for preventing UTI is 111.  That is, 111 boys must be circumcised in order to prevent 1 case of UTI. Another way of phrasing it is to say that 110 out of every 111 boys circumcised will not derive a benefit from the procedure in terms of UTI prevention. But that one baby who will be spared a UTI may avoid possible hospitalization and multiple interventions.

Penile cancer

I wish I could tell you I was an expert on cancer of the penis but I most certainly am not. I’ve never seen a case of cancer of the penis and I’ve never met anyone who’s had the condition or even one who knows of someone who’s had the condition. That’s because this is an extremely rare form of cancer. (Thus my lack of personal expertise.)

But here are the facts.  According to the American Cancer Society, in the United States penile cancer is extremely rare, affecting only 1 in 100,000 men and accounting for about 1% of all cancers. The cancer arises from the foreskin (the tissue cut off by circumcision) 21% of the time, and from the head of the penis 48% of the time. The remaining 31% of these tumors arise from the shaft of the penis and are likely not influenced by whether the individual is circumcised or not.
Penile cancer is a disease of older men, with the prevalence rising abruptly after 60 years of age, with a peak in incidence at age 80. In 2005, 310 men died of this disease in the United States representing a mortality rate of 24.8% among sufferers of this condition. This number reflects a frequent delay in diagnosis due to a reluctance to seek care for the disease. With early treatment, cancer of the penis is highly treatable.

The NNT to prevent cancer of the penis has been calculated to be 909.  That is, 909 boys must be circumcised to prevent a single case of invasive cancer of the penis many decades later.  Look, there are plenty of things to worry about when your baby is born – cancer of the penis ain’t one of ‘em!

Sexually transmitted diseases/HIV

Studies in countries where heterosexual HIV is epidemic (the United States is not one of those countries) have demonstrated a lower rate of HIV in men who are circumcised. However, the link between HIV and circumcision in developed countries is not nearly as clear cut. Some studies have found no difference in rates of HIV among men based on their circumcision status whereas others found a mild association. 

One thing is clear: the likelihood that a man will develop STDs including HIV in the United States is related to his sexual practices including the number of partners he has and whether he engages in high-risk sexual activity. Public health interventions that reduce high-risk sexual behaviors are going to be far more effective at reducing HIV in the United States than circumcision will ever be.

But to follow through with number needed to treat analysis, all we can say is that the NNT varies dramatically by region. In Uganda, the NNT for HIV prevention via circumcision is 55. In Canada, on the other hand, more than 5,000 circumcisions must be performed to prevent a case of HIV infection (

Anatomical variations

Many parents are just not comfortable with the appearance and the perceived need for special care of the uncircumcised penis, particularly if the father of the baby is circumcised.  They are alarmed when the foreskin cannot be retracted past the head of the penis (a completely normal situation in the first few years of life, known as physiologic phimosis) and they sometimes complicate matters by unnecessary manipulation of the foreskin leading to a painful and urgent condition known as paraphimosis, where the skin gets stuck behind the head of the penis.

These conditions can be easily handled and prevented with simple care, though many doctors contribute to this problem by dispensing misguided advice (read Forcing the tissue in Why Doctors Believe Weird Things:

Risks of circumcision

In the hands of an experienced surgeon, the risks of circumcision are quite low. The rate of immediate complications ranges from 0.2% to 10%.  The most commonly reported problem is bleeding. Rare catastrophic complications include amputation of the penis, kidney failure and overwhelming infection.  Late complications include meatal stenosis (a narrowing of the opening of the urethra) and, among some men, the report of an alteration in the sensitivity of the penis, particularly in the act of sexual intercourse.

Certainly, another downside to the procedure is the pain associated with it. In years past, this was brushed away with the breezy argument that babies do not perceive pain the way older children do, and wouldn’t it be best to have a painful procedure done when the child will not remember it (and can’t fight you off quite as effectively)?  It goes without saying that infants do perceive pain, and the sensation of pain in the newborn period interferes with sleep and feeding and may even modulate the perception of pain later in life.

Putting it all together

Circumcision is a common and generally safe procedure in the newborn period.  It is the only elective procedure that is performed in neonates. The most compelling medical reason to have the procedure performed is to reduce the likelihood your baby will experience a urinary tract infection in the first year of life.  Other health benefits are minimal or less well established and can be addressed with more effective strategies and interventions. At a minimum, some of the purported health benefits involve issues that probably don’t need to be dealt with in the first 48 hours of life when other challenges, such as the successful establishment of breast feeding, are far more important.

If you've decided you’d like to have your baby circumcised, I advise the following: 

1. Understand your reasoning in reaching this decision and be sure you’re comfortable with your choice. Almost always, this is best achieved by having a frank discussion with your baby’s doctor.

2. Decide on the most appropriate timing to establish your goals.

3. As with any procedure, select a practitioner that is experienced in performing the procedure and who is able and available to deal with the odd complication. 

4. Discuss the method of pain control selected by the surgeon. General anesthesia is only used in older children due to the higher risk of complications with its use in newborns. But all babies deserve some form of pain control during and after and surgery. 

5. Be sure you understand and are comfortable with all post-operative care.

And whatever choice you make, don’t sweat it. It’s unlikely that it will have a major, lasting impact on your child’s health either way.