by Dr. Iain Corness
Is EBM good for you?
The practice of
Medicine is a fascinating story that has unfolded over thousands of
years. “Healers” have been part of most societies, and in ancient China,
for example, you paid the doctor to remain well, not for treatment of
your ailment. Now there’s an incentive bonus for you!
Then there are different kinds of
“medicine” given such names as “conventional”, “alternative” and
These different ways at looking at
the same subject (making you well) can be quite confusing, and for me
much hangs on the term EBM, which stands for Evidence Based Medicine.
Mind you, it has also always been
the case where people like to throw stones at conventional clinical
medicine. Claims of over-servicing, over-prescribing and downright
fraudulent practices are thrown about, citing someone whose
uncle/friend/mother (delete that which is inappropriate) suffered at the
hands of “bad” doctors who misdiagnosed the illness and the patient
Now, there are certainly some “bad”
doctors out there, just as there are “bad” lawyers, “bad” real estate
agents, “bad” mechanics and just about any profession you would like to
think of. But they’re not all “bad”.
And me? I am a conventionally
trained British/Australian style medical practitioner who has spent a
lifetime practicing EBM. Practices that have been proven to work. Call
it “good” medicine, if you like.
I am also proud of my final exams
taken in the Royal Colleges of Physicians and Surgeons in London. I have
the honor to have my name listed in the ‘great book’ with luminaries
such as Hunter, Jenner and Lister. I am also indebted to my tutors
during the 12 months of ‘pre-registration’, where you apply your
knowledge under the supervision of accredited specialists. An arduous
road, but one that is a safeguard for you, the general public.
The ‘powers that be’ are also
ensuring that we keep up to date with a process called Continuous
Medical Education (CME). That medical education continues through to
today, with CME lectures being attended by my hospital’s doctors, and
myself. Fortunately for me, the slides are in English.
Those ‘powers that be’ also try to
ensure that we prescribe drugs that are efficacious, that have been
tested, and the evidence points to this. It is not anecdotal evidence,
but true scientific evidence shown by research in many countries, with
hundreds of thousands of patients. It is following that type of evidence
that I can recommend with all good faith that 100 mg of aspirin a day is
“good” medicine. I also know that if you are prescribed a ‘statin’ drug
it will lower your cholesterol levels. They have been tested.
I am also the first to admit that
we have sometimes managed to get it wrong. The Thalidomide story still
has living examples of this. However, the medical world-wide network is
cohesive enough to ensure that this drug was withdrawn. It is the checks
and balances system that has kept conventional medicine afloat.
I am often asked my opinion on
“alternative” medicine, and I try to avoid direct confrontation over
this. If devotees have found that they can diagnose tumors by looking at
patient’s auras through their third eye in the middle of their
foreheads, then I am genuinely pleased, in fact delighted, provided that
they have subjected the method to scientific scrutiny.
If various groups can actually cure
cancer, epilepsy, halitosis or lock-jaw by inserting dandelions into a
fundamental orifice, then again I am delighted. This is a medical
break-through, but as such, must be subjected to medical scrutiny. If
the method stands true scientific examination (not to be confused with
anecdotal ‘evidence’) then it will be adopted by everyone, complete with
thanks to those clever people who picked the dandelions in the first
place. Ignore the claims that “Big Pharma” is suppressing cancer
treatments. If someone has the answer, they will be multi-millionaires
As far as the majority of ‘folk’
remedies is concerned, I work on the principle that if you ‘think’ it is
doing you good, then it probably is. But don’t ask me to endorse
something that has not been scientifically tested.
When the ‘alternative’ group spends
more time proving their methods, instead of complaining about
non-acceptance, EBM practitioners will give them more credence.
Falling off the bed
Ever turned over in bed and the room
began to spin? And you were sober? It could have been Benign Paroxysmal
Positional Vertigo (BPPV).
This is a very distressing condition,
and much more common than you imagine. If you have it, after you move in a
particular way, you feel that the room spins around you and you cannot stop
it. It is like being so drunk that when you lie down on the bed the spinning
rotation is so bad you grip the edges of the bed to stop falling off? That
is what BPPV is like – but without the hangover the next morning!
The symptoms of BPPV include the
dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that
bring on symptoms will vary, but are almost always produced by a rapid
change of position of the head. Getting out of bed or turning over in bed
are common ‘problem’ motions. Because people with BPPV often feel dizzy and
unsteady when they tip their heads back to look up, BPPV is sometimes called
‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can
bring on the symptoms. It also tends to be recurrent. So until you read
further, don’t look up or get your hair washed!
To understand BPPV, you have to
understand the workings of your inner ear. You have three semi-circular
canals aligned in different directions, which act like spirit levels (the
builders type, not the three fingers on the glass barman type) which have
cells with fine hairs bathed with fluid as your head moves in different
directions. The movement of the fine hairs sends electrical impulses to the
brain to tell it (and you) which way is “up”.
However, with BPPV, the natural
movement inside the semi-circular canals is disrupted, so the fine hairs
send the wrong signals to the brain, and being unable to work out which way
is really “up” the sufferer falls over, totally unable to save themselves
from hitting the floor. Debilitating and embarrassing! Ask anyone who has
The commonest cause of interruption to
the normal ebb and flow in the semi-circular canals is produced by something
we have called “ear rocks”. These are made up of crystals of calcium
carbonate, and we medicos call these ear rocks “otoconia”. Imagine these
rocks to be like sugar crystals in the bottom of your coffee cup. These now
swish around every time you move your cup, and likewise your “ear rocks”
swish around every time you move your head.
However, it is not all that simple (it
never is, is it?) as the commonest cause of BPPV in people under 50 is head
injury. In older people, the most common cause is degeneration in the
semi-circular canals of the inner ear. BPPV becomes much more common with
advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’,
which is a fancy word we use when we don’t know!
Viruses can be accused too, such as
those causing vestibular neuritis, minor strokes such as those involving
anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease
are significant but unusual causes. Occasionally BPPV follows surgery, where
the cause is felt to be from a prolonged period of lying on the back with
the chin raised (for the anaesthetic tubes to slip down your throat), or ear
trauma when the surgery is to the inner ear. The simple situation is that we
can make the diagnosis, but it can be harder for us to exactly pinpoint the
cause. To make it even harder, an intermittent pattern is common. Your BPPV
may be present for a few weeks, then stop, but then come back again.
Is there any treatment? Yes there is,
if ear rocks are the cause. Treatment usually consists of a series of
maneuvers you are put through which are designed to move the ‘ear rocks’
around till they no longer cause problems. These are demonstrated by the
Ear, Nose and Throat (ENT) specialists and usually result in around a 90
percent cure rate. The most common is called the Epley maneuver or the
particle repositioning or canalith repositioning procedure, but have your
ENT specialist show you how to do this.
The will you make in the
living not in the after-life?
I’m sorry, but I
have it on good authority that you can’t take it with you. And that’s
the reason why I’m not going. But to cover all eventualities, I have
made out a will. And so should you. That’s your dying will – but you
need to make another, and that’s called your “Living Will”.
However, there is confusion in the
minds of many people, as to what a “Living Will” actually is and what it
covers. First off, it is not euthanasia. I repeat, it is not euthanasia.
Borrowing from the Mayo Clinic in the US, it states on their website
“This written, legal document spells out the types of medical treatments
and life-sustaining measures you do and don’t want, such as mechanical
breathing (respiration and ventilation), tube feeding or resuscitation.”
The important words to note are “life sustaining” and “resuscitation”.
Neither of these concepts imply medically assisted suicide.
Once again from the Mayo Clinic,
“Injury, illness and death aren’t easy subjects to talk about, but by
planning ahead you can ensure that you receive the type of medical care
you want, to take the burden off your family of trying to guess at what
you’d want done.”
Remember that we are talking about
terminal situations here. Not situations from which it would be
reasonably expected that you will recover and still have a good quality
of life. A fractured hip when you are 90 is a serious situation, but
provided you are healthy otherwise, then it would be expected that you
would recover. You might need a stick for a while, but you would still
be able to have a beer with your mates or whatever your pursuits were
before the incident. In other words, the expectancy of a reasonable
quality of life is there.
However, if you are in the terminal
phase of metastatic cancer, which has progressed despite treatment, the
future quality of life is not there. Artificially prolonging life under
that situation is then covered by the Living Will.
As an example, note the following:
The Living Will is made while of
sound mind. It is not something you scribble out while lying in God’s
waiting room. An example of a Living Will. “Being of sound mind and
understanding all the implications, I ask that this document be brought
to the attention of any medical facility in whose care I happen to be,
and to any person who may become responsible for my affairs.
“This is my ‘Living Will’ stating
my wishes in that my life should not be artificially prolonged, if this
sacrifices my Quality of Life.
“If, for any reason, I am diagnosed
as being in a terminal condition, I wish that my treatment be designed
to keep me comfortable and to relieve pain, and allow me to die as
naturally as possible, with as much dignity as can be maintained under
“As well as the situation in which
I have been diagnosed as being in a terminal condition, these
instructions will apply to situations of permanently unconscious states
and irreversible brain damage.
“In the case of a life-threatening
condition, in which I am unconscious or otherwise unable to express my
wishes, I hereby advise that I do not want to be kept alive on a life
support system, and I do not want resuscitation, nor do I authorize, or
give my consent to procedures being carried out which would compromise
any Quality of Life that I might expect in the future.
“I ask that you are sensitive to
and respectful of my wishes; and use the most appropriate measures that
are consistent with my choices and encompass alleviation of pain and
other physical symptoms; without attempting to prolong life.”
Now those are only examples. The
Bangkok Hospital Pattaya has a pro forma Living Will, which was also
repeated in the Pattaya City Expats website, I believe.
The take home message is that a
Living Will is not euthanasia, and that you must lodge it, before you
need it! The responsibility is yours, as nobody else can say any
procedure was what you wanted (or didn’t want), if in the terminal stage
of your life.
Lies, damned lies and then there is statistics
Will you live forever?
I’m sorry to disappoint you, but statistically you have a 100 percent chance
of dying. Yes, forget about “health” medications, statistics will prove it.
Did you know, for example, that everyone dies within six months of their
birthdays? They do, either before or after (do the math). Did you know that
95 percent of all the people who died in Pattaya last year wore shoes? The
statistics would then have you believe that shoes were the greatest killer
of mankind (not sure where that puts flip-flops).
A couple of years ago, the Cancer
Council of Australia produced a sober warning message (at this time of year
anyway), “Quit drinking to cut cancer risk.” The Cancer Council went on
further to proclaim, “New evidence reveals the extent of alcohol’s
contribution to cancer.”
Now, having been photographed with the
odd glass of wine in my hand on more than one occasion, I was immediately
interested. Should I go on the wagon tomorrow? (“Today” was being a bit
soon, I thought.)
I continued reading, “Cancer Council
Australia has revised dramatically upwards its estimate of alcohol’s
contribution to new cancer cases and issued its strongest warning yet that
people worried by any link should avoid drinking altogether.”
It appeared that the cancers involved
were bowel and breast and the figures indicated that these were nearly
two-thirds of all alcohol-related cancers, overtaking those of the mouth,
throat and esophagus.
More chilling news was that the
Convener of the Public Health Association of Australia’s alcohol expert
group, said he would write to the Australia and New Zealand Food Regulation
Ministerial Council, to request it mandate health warnings on bottles. (It
may be of interest to you that in Thailand there is an anti-alcohol group as
well as the anti-smoking lobby).
Now there are many individuals
predicting the end of the world, as well as Scandinavian teenagers, so how
great a threat was this really? The group media release went on, “New
evidence implicating alcohol in the development of bowel and breast cancer
meant drinking probably caused about 5.6 percent of cancers in Australia.
This was nearly double the 3.1 percent figure it nominated in its last
assessment, in 2008.”
Using their own figures we are looking
at 94.4 percent were not caused by alcohol.
So now we are getting to the
nitty-gritty of all this. If we accept that they have managed to “prove”
(beyond reasonable doubt) that alcohol does indeed “cause” 5.6 percent of
cancers, what does this mean? Since breast and bowel cancers are only two
thirds of the alcohol-related cancers (their mathematics, not mine), this
means that together they make up 3.7 percent of the cancers in Australia.
Let’s split the figure and make it 1.85 percent each. I remain somewhat
underwhelmed, I am afraid. These figures can be read to suggest that 98.15
percent of breast cancers are not related to alcohol ingestion, and
similarly the figures for bowel cancer.
Now don’t get me wrong here. I am not
advocating we all get smashed every night, and indeed I do not think we
should drink alcohol every day. However there are greater risks from alcohol
intake than breast or bowel cancer. Liver damage for starters.
So if you are a person who likes a
drink or three and would like to check your liver function we do have a GI
and Liver Center that would be happy to check for you. Telephone 1719 for an