Wednesday, December 22, 2010

0 Part 5: Critique of Chicago Tribune's "Chronic Lyme Disease: a dubious diagnosis"

[ Ed. - This is part 5 of a multi-part critique of the Chicago Tribune's article, "Chronic Lyme Disease: a dubious diagnosis".]
"Bernard Raxlen, the doctor who received an award at the 2008 Turn the Corner Foundation gala, has faced four disciplinary cases before the Connecticut medical board in the past decade."
Structural nitpick: This statement would be better incorporated into the first page of this article, as well as the following paragraph.
"The current case initially involved charges that Raxlen told a Massachusetts woman with fatal Lou Gehrig's disease that she had a Lyme infection and treated her with an illegal drug from Germany. After years of legal wrangling, what remains are charges that Raxlen, as a psychiatrist, failed to diagnose and treat the patient for severe depression or refer her for such an exam and failed to consider any diagnoses other than Lyme."
This is the second time that Dr. Raxlen's and his disciplinary record is being mentioned in the same article, with a repeat of information offered earlier. The reader at this point might get the impression that Dr. Raxlen has repeatedly been charged with the same kind of actions when the article is just restating the case.

But at least in this section, there is more information than the reader had before when Dr. Raxlen was first mentioned on the first page or section of this article: the patient was treated with an illegal drug from Germany and failed to consider any diagnoses other than Lyme. 

This doesn't look good for Dr. Raxlen. Even if a doctor can diagnose and treat Lyme Disease and its coinfections, doctors have the responsibility of ensuring their patients are not suffering from other conditions concurrently and offer differential diagnoses and treat anything that comes up. If it is beyond their expertise, they have an obligation to acknowledge their limitations and refer the patient to a specialist who knows more about their condition.

Dr. Raxlen has failed on more than one count here to fulfill the role of a good doctor - and as a psychiatrist, failed to offer the diagnosis of depression when he specializes in its treatment. Whether or not Dr. Raxlen diagnosed the patient with Lyme Disease correctly or incorrectly became moot in the end - he was found guilty of not diagnosing the patient with a condition that falls within his area of expertise.

On the issue of Lyme Disease which is neuroborreliosis, it is possible the patient suffered depression due to an infection in their CNS/brain, in which case treating it with antibiotics would have been the right course of action. But even if this had been the case, a dual diagnosis could have been made and the depression treated.
"In an interview, Raxlen said the patient did have Lyme disease. He said the relationship between Lyme and Lou Gehrig's disease "is unclear." (Last year, experts on ALS wrote in a journal devoted to the disease: "There is no convincing evidence that ALS can be caused by Lyme disease.")"
 Which experts? Which journal? What evidence has been presented where that ALS can be caused by Lyme Disease, convincing or not?
"Raxlen said he is proud of his medical record. Charges of patient harm have been repeatedly dismissed. He has been sanctioned twice for lesser charges related to his failure to turn over patient records to the medical board or insurers. Charges in 2003 related to a Lyme patient's suicide were dropped entirely. "
If charges of patient harm have been repeatedly dismissed, doesn't this mean Dr. Raxlen wasn't guilty of the actions of which he was accused? Who filed the charges of patient harm in the first place? Was it the patient, the patient's family, another doctor, or an insurance company? Doesn't it make a difference who filed the charges?

Due to Dr. Raxlen being a psychiatrist, the odds of his being held accountable for a patient's suicide are considerably higher than being a doctor in another area of specialization. Given that the authors did not mention this charge earlier, the authors seem to be trying to add emotional punch to the weight of Dr. Raxlen's record by mentioning the suicide now.

'"I've never been reprimanded for my clinical judgment," Raxlen said.

Stacey Sobel, executive director of the Turn the Corner Foundation, says it's a shame Raxlen and other doctors in the movement have been disciplined. "We look at them as doctors who are trying to help Lyme patients," she said."'
This second paragraph doesn't make sense to readers. Why would the executive director say it's shame Raxlen and other doctors in the movement have been disciplined? In light of what Dr. Ryser did - which sounds egregious compared to Dr. Raxlen - is there a point where Sobel would agree that being disciplined is the right course of action and not a shame to have happen?

 Why have these doctors been disciplined? What have they done to help Lyme patients?

The authors neither explain the full extent of the actions and charges made against these doctors, nor do they describe how they have helped Lyme Disease patients.

So far, all they have done is inform the reader that Dr. Ryser and Dr. Raxlen have treated patients who were diagnosed with Lyme Disease and these doctors have been accused of charges and considered for disciplinary action. So far, they have pointed out one man, Bransford, who conned people out of their money and admitted so in court.

But none of this has established whether or not Chronic Lyme Disease is possible or not. It has only pointed out that there are doctors out there who have been disciplined who happened to diagnose patients with Lyme Disease and there are charlatans who exploit people who are sick. Nothing new that the public hasn't heard about or been outraged about before - and also nothing that is really particular to a diagnosis of Lyme Disease, chronic or otherwise.
"While they have lost the scientific battle so far, chronic Lyme activists are winning politically. In recent years, they have persuaded politicians in 13 states to introduce Lyme-friendly bills, many of which prevent medical boards from disciplining doctors for treating Lyme with antibiotics long-term."
What scientific battle have the Chronic Lyme activists lost so far? What do Chronic Lyme activists think about Lyme Disease and why? What scientific arguments do they have in support of Chronic Lyme and why are they valid or invalid?

Why would Chronic Lyme activists be able to persuade politicians in 13 states to introduce Lyme-friendly bills? What persuasive arguments do the activists present to state legislature? What kind of evidence do they present that convinces legislature to pass bills which prevent medical boards from disciplining doctors for treating Lyme with antibiotics long-term?

[ Mention of different states which passed legislation omitted for brevity; not germane to discussion. ]
"It can be an uphill battle getting politicians to side with science when sick patients testify that long-term antibiotic treatment helped them, said infectious disease physician Dr. Jeffrey Parsonnet, who testified against a New Hampshire doctor-protection bill.

"It is all focused on either siding with the big, rich doctors with their BMWs or this poor person who is suffering and misdiagnosed," said Parsonnet, a professor of medicine at Dartmouth Medical School."
Using Carl Sagan's Baloney Detection Kit,  Dr. Parsonnet is being interviewed here in the role of being an expert who is helping the authors build their straw man by using ad hominem attacks.

Dr. Parsonnet is not arguing the case for science, and is not stating any facts about why he thinks politicians are not siding with science when it comes to sick patients testifying about long-term antibiotic treatment. Instead, Dr. Parsonnet attacks "big, rich doctors with their BMW's" - presumably indicating "the Dr. Rysers of the Lyme Disease world" - and mentions the "poor person who is suffering and misdiagnosed" to gain sympathy for the patient.

Taking a step back from this, though, many doctors are rich and own BMW's. The country doctor who charges $40 a visit is a relic of the past. The median salary for an anesthesiologist is $336,865 per year, and only a tiny percentage earn less than $200,000 annually. That should buy a fair bit of BMWs, possibly one for the year. The median salary for a family physician is lower, at $167,327., and only a tiny percentage earn less than $130,000. per year. Doctors as a general rule are not exactly getting low salaries, and specialists, surgeons, and anesthesiologists are at the top of the payscale.

Physician car ownership and tax brackets don't even support the goal of the authors of the article - what the authors want is to complete their position piece showing that doctors are treating a disease that might not/never exist(ed) and charlatans who take advantage of sick patients.

The point Dr. Parsonnet should be getting into - if any at all - should be his proof of whether or not Lyme Disease can persist and how doctors can be ethical in their treatment of patients who are suffering; how doctors can look at all possible diagnoses of their patients including ones which are less well-understood or known.

"The biggest boon to the chronic Lyme movement came when Connecticut Attorney General Richard Blumenthal launched an antitrust investigation of the Infectious Diseases Society of America panel that set Lyme treatment guidelines in 2006. The panel was made up of some of the world's top experts in Lyme disease.

But Blumenthal, soon to be a U.S. senator, said the society undercut its credibility by empaneling doctors who consulted for insurers and had financial interests in drug companies and Lyme disease diagnostic tests. A spokeswoman for the Infectious Diseases Society of America (IDSA) said the panelists did not benefit financially from the guidelines, which recommend generic drugs and lab tests.

Because of a 2008 agreement between Blumenthal and the IDSA, a new panel considered evidence submitted by all sides. Panelists were screened by an independent ombudsman to ensure they had no significant financial ties to Lyme disease."
Who was this independent ombudsman? What does "had no significant financial ties to Lyme Disease" mean? What if that included doctors who received a significant portion of their income from treating patients with Lyme Disease and coinfections, including infectious disease doctors who would be bound to see many Lyme Disease patients? In this way, wouldn't those who had the most experience with Lyme Disease be out of consideration for considering evidence?
"In April, the panel released its report. It agreed with the 2006 panel: The evidence for chronic Lyme disease was weak, and long-term antibiotic treatment was dangerous and ineffective."
Who was on this panel that was selected? Why did they agree with the 2006 panel? To what degree did they agree - were there any inconclusive decisions or questions on any section of the guidelines? Why is the evidence for Chronic Lyme Disease weak? What is the evidence that was given to the panel?

None of these questions are addressed or answered in the course of this article. The authors present the basic history of what has happened with the treatment of Lyme Disease guidelines without further investigation into the science and research of Borrelia bacteria.
"As is often the case in this era of dubious medicine, the scientific review did not put the issue to rest. Instead, the panel's decision was a call to arms for chronic Lyme advocates."
Why didn't the scientific review put the issue to rest? Why was it a call to arms for Chronic Lyme Disease advocates? Did the advocates have any evidence that conflicted with the panel's that could be considered scientifically valid? Did the panel have any other agendas which did not involve their financial gain from Lyme Disease related services or products which could have influenced their decision?

"On a popular blog for Lyme sufferers, Ashley van Tol wrote that "infecting the committee members with Lyme sounds great because we are pissed off."

After acknowledging that would not be "realistic or appropriate," van Tol went on to urge readers to make their voices heard, because personal stories are more powerful than scientific guidelines.

"In a competition between posting the IDSA guidelines or your Lyme story," she wrote, "it is going to be you that they choose to read about."
The authors have taken one quote (which Ms. Tol later stated (online in a comment in response to the article) was a misquote) of one Lyme patient and used it to represent the sentiment of all Lyme patients. By using one (mis)quote which characterizes a Lyme patient as wanting to infect others - even with a retraction - the authors are painting Lyme patients as angry and vengeful. By adding the additional note about a patient saying personal stories are more powerful than scientific guidelines, the authors are able to support their platform they've been promoting all along: Chronic Lyme Disease is not about science or proof, but about the stories that people tell others about their experience.

And this is a problem, because right here both sides of the argument - one against the idea that Chronic Lyme Disease exists and one invested in it - are not demonstrating their scientific knowledge in this article, which is one of the few things anyone outside of both sides of the argument with any power to change things might be willing to try to understand and hear.


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