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A new Croakey project: Naked Doctor, profiling overdiagnosis and overtreatment

Up to $3 billion of public money is wasted each year under Medicare, according to estimates by Dr Tony Webber, who headed the Professional Services Review for more than six years.

His article in today’s Medical Journal of Australia – which has drawn widespread media coverage – argues that poor policy (such as the Medicare Safety Net, “one of the most poorly thought-through pieces of health legislation”) and the practices of a “minority of unscrupulous and greedy practitioners” are responsible for this waste.

General practice management plans (GPMPs) and team care arrangements (TCAs) “have created opportunities for a bonanza for some practices”, he says. Obstetricians and ophthalmologists receive particular mention. Webber also questions the repeated use of procedures and investigations by some gastroenterologists and cardiologists in patients “whose clinical condition appears not to warrant them”.

Webber says maladministration does not only occur with the MBS and the PBS. “On several occasions I came across significant cost-shifting between the states and the federal government. Medicare was being used to subsidise state health budgets. Private radiology and pathology services were used for public inpatients, Medicare benefits were used to fund staff specialist study tours and to buy essential equipment. This is against the provisions in the Council of Australian Governments National Health Care Agreement. When this was pointed out to officers in the DoHA, I was told not to say anything.”

Webber says that while most health professionals are motivated and ethical, colleagues feel let down by a system that often does not deliver a timely or cost-effective service with proper controls. “Many doctors I have spoken to are disillusioned by the inappropriate claiming and practice they are aware of,” he says.

Meanwhile, with impeccable timing, Brisbane GP and writer Dr Justin Coleman today launches a new project at Croakey, the Naked Doctor, which aims to encourage discussion and awareness of the opportunities to do more for health by doing less. It is a compilation of articles, books and other works that highlight overdiagnosis and overtreatment.

Coleman is a GP who works in Aboriginal and Torres Strait Islander health in Brisbane. He holds a Masters in Public Health, and is President of the Australasian Medical Writers Association. You can also find him on Twitter.

Naked Doctor is a work in progress. Comments and suggestions are welcomed.

Below are two items: an introduction to the project; and Naked Doctor’s first entries (some articles are from subscriber-only journals; if you are unable to access an article, please leave your details on the bottom of this post or email Croakey asking for a copy).

***

Introducing the Naked Doctor: When is ‘no action’ the best action?

Justin Coleman writes:

The modern doctor seems to have an intervention for every occasion. He or she wears a magician’s coat of surprises, each more incredible than the last. Hidden pockets contain pills, scalpels and lasers, with sophisticated medical tests providing the performance instructions.

At its finest, the medical method is impeccable; type I diabetes was a rapid death sentence prior to insulin and accurate blood sugar tests. Sometimes, though, the heavy clothing creates it own problems. Tests point to the wrong diagnosis, treatments cause harm and the promised magic fails.

Some failures are a consequence of bad luck and random variation. But the closer we study these problem areas—applying the scientific method—the more we find predictable patterns emerging. Many tests and interventions fail because they should never have been used in the first place.

The Naked Doctor probes the places in medicine that would be better stripped bare. Places where the correct option is to do nothing. The ‘doctor’s bag’ accompanying a home visit before the second world war contained no medication which would be considered of any use today, and quite a few dangerous poisons. The physician would have been of more use turning up empty handed—or, given the lack of latex gloves and infection control, perhaps not turning up at all. The modern example of cancer screening via whole-body CT scanning offers as much protection as the emperor’s new clothes, and the guileless emperor would be better off naked.

Naked Doctor’s old anatomy professor Norm Eisenberg used to claim ‘only half of the stuff we teach you in this medical course is true. The problem is, we don’t know which half!’

Luckily, various health professionals and journalists around the globe dedicate themselves to steadily peeling back the covers. Naked Doctor exposes their disrobing of over investigation and overtreatment. We invite you to watch, and to contribute.

***

Naked Doctor: the list

Over-intervention unveiled

Start at home with our very own Melissa Sweet who introduced the over-intervention theme to Crikey readers. A systematic approach is needed to balance the all-powerful “give us more” lobby.

Speaking of which, Melissa does give us more; in her non-Croakey spare time, she sums up our ‘less is more’ theme at Inside Story.

Sharon Beglee at The Daily Beast pens a neat appraisal of situations where saying ‘No’ to a test or procedure can potentially save your life. Some thoughtful doctors are voting ‘No’ when it comes to their own health—and Sharon names names.

Sharon also dispels four health care myths in the Scientific American, although it’s doubtful much dynamite is required to explode myth 4: The US has the best health care system in the world.

In 2010, Archives of Internal Medicine started a column ‘Less is More: How Less Health Care Can Result in Better Health’. Section editor Deborah Grady maintains the impressive article list. Naked Doctor recommends a pleasurable browse through the less-is-more garden, plucking full-texts at whim. Discover that doctors themselves think their patients get too much care, and find out the interventions voted ‘top 5’ for superfluities to avoid in general practice and paediatrics.

Josh Freeman, physician educator, Kansas US, writes a lovely blog mixing medicine with social justice. A number of articles discuss the inequities of spending money on treatments that don’t work. He scrutinises the money spent on MRIs and suggests patient advocacy organisations don’t necessarily have the population’s interests at heart.

Shannon Brownlee discusses a study by cardiologists Grace Lin and Rita Redberg, who designed three theoretical cases where evidence suggests non-intervention was the correct treatment. They found that their cardiologist colleagues would almost always recommend surgical intervention. Surprise! Maybe author Upton Sinclair had it right when he said: It is difficult to get a man to understand something when his salary depends upon his not understanding it.

Blogger Dr Jay Parkinson wonders if Lindsay Lohan and Steve Jobs received the worst health care in America…by which he means the most health care. The more famous you are, the more care you get and therefore the more can go wrong. A certain M. Jackson springs to mind. Jay deplores the relative lack of interest in preventative health.

Former BMJ editor Richard Smith teaches ten lessons about the world delivering the wrong care to the wrong places. When North America has 250 times Africa’s number of health workers per percentage of global disease burden, then modern clinical medicine is as out of control as the banks and is unaffordable globally.

He points out the Victorians eventually couldn’t live with the difference between rich and poor, and we got income tax with substantial transfers of wealth within countries. We now need such transfers between countries. Less over here, more over there; them’s fightin’ words, Dr Smith!

Croakey readers will be familiar with Dr Gary Schwitzer’s HealthNewsReview.org which is often relevant to our theme; could Gary himself be a closet Naked Doctor? One blog here covers disease-mongering, the ancient alchemic art of creating something out of nothing.

Chris Del Mar’s BMJ editorial provides a cogent argument for avoiding antibiotic prescription for colds, sore throats and ear infections. Unfortunately, patients expect doctors to intervene, and even when they don’t, doctors expect that their patients expect intervention. Confused? Paul Little explains the concept here.

Pharmed Out is a Georgetown University project educating healthcare professionals about pharmaceutical marketing practices. Grab a ‘No Drug Reps’ certificate for your waiting room or play Drug Ad Bingo in your spare time.

Departing boss of the US Medicare and Medicaid system, Dr Donald Berwick, lists ‘overtreatment’ as the first of five reasons for the very high 20-30 percent of US health spending he calls waste that yields no benefit to patients.

In a world where dental undertreatment is the norm, dentists are not immune from the temptation to overtreat when the patient can afford it. Many experts think it doesn’t make sense to operate in the early stages of decay…yet a majority of practitioners are inclined to do so. Just say Aaaaargh!

***

Revealing what lies behind the screening

We live in testing times. The National Cancer Institute provides a wordy but interesting overview of the hazards of cancer screening.

Two former ‘track favourites’ for cancer screening—mammograms and PSA tests —seem to be running off the pace in 2012, although both still have plenty of backing. The controversy provides insight into the pros and cons of screening tests.

Med Page Today is a hardworking site which covers medical news for clinicians and is prepared to call bad behaviour when spotted. In Arithmetic stings when well people seek medical care, Dr George Lundberg gives a simple maths lesson, demonstrating the large number of false positives generated by even an accurate test for a rare condition. The increase of well people seeking medical care lowers the prevalence of all diseases and increases the rates of false diagnoses.

Patients referred for MRIs by physicians who owned their own MRI machine were almost twice as likely to have no pathology on review by an independent radiologist. Nothing beats the moolah as an incentive for ordering a test. Do private hospitals also see dollar signs when over treating patients with dementia?

***

Books that bare all

Overtreated: Why too much medicine is making us sicker and poorer
Shannon Brownlee, 2007, US
Find out about Roemer’s Law ‘A built hospital bed is a filled hospital bed.’ Discover the ‘Limits of Seeing’, where high tech scans make us as transparent as jellyfish, but just as often cloud the diagnosis. And read the last chapter ‘Less is More’, which would have made a great title for this Croakey page, if only Naked Doctor had thought of it first.

Testing Treatments: Better research for better healthcare
Imogen Evans, Hazel Thornton, Iain Chalmers, Paul Glasziou
With the addition of Queensland’s Paul Glasziou, this second edition discusses how to ensure research into medical treatments best meets the needs of patients. The chapter Earlier is not necessarily better covers a Naked Doctor pet theme of the benefits and harms of screening tests.

Overdiagnosed: Making people sick in the pursuit of health
H. Gilbert Welch, Lisa Schwartz and Steve Woloshin
As a society consumed by technological advances and scientific breakthroughs, we have narrowed the definition of normal and increasingly are turning more and more people into patients. Well worth a read: but why take Naked Doctor’s word for it, when you can read the BMJ book review by Croakey regular and fellow sceptic Ray Moynihan.

Ten questions you must ask your doctor
Ray Moynihan and Melissa Sweet
Ray and Melissa would make their mothers proud and their GP nervous. Their approach to keeping the bastards honest is patient-driven quality control at its best. I just hope they book longer consultations. There is little doubt that a dose of healthy scepticism is just what the doctor ordered. Indeed, the Naked Doctor orders scepticism twice daily, taken with a glass of water and a grain of salt.

House of God
Samuel Shem
Shem’s classic 1978 novel has the narrator as an intern admitting his hospital’s most important benefactor and secretly ordering no investigations or treatment. The patient’s rapid improvement underlines the thirteenth and final law taught to the intern by his wise mentor, the Fat Man: The delivery of good medical care is to do as much nothing as possible. Another Naked Doctor favourite is his tenth law; If you don’t take a temperature, you can’t find a fever. Indeed!

Disclaimer: Reading House of God as an intern was Naked Doctor’s original inspiration for a career-long interest in avoiding overtreatment. He does still own a thermometer and uses it discretionally.

***

Naked Doctor welcomes suggestions for inclusion on this list, but is responsible for the final decision about which entries are included.

 

 

 

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  • 1
    William
    Posted January 16, 2012 at 9:35 pm | Permalink

    I think you blew it when you mentioned that you based your career on ‘The House of God’ – Most of us did but then we grew up.

    I don’t question that there is over diagnosis and over investigation but your implication that this is simply all about self serving doctors is something of an oversimplification. Again whilst this is undoubtedly a factor where does the influence of defensive practice in the face of a litigious society, a pack mentality media starving for the next Dr Death story, increasing demand from patients etc etc etc.

    Somewhat bizarrely I see that the Naked Doctor works in ATSI health – just what they (the most under served population in the country with disgraceful outcomes) need, I am sure, a doctor with a conspiracy theory….

    I spend a fair amount of time seeing patients or examining cases where patients have suffered from lack of investigation and diagnosis – exactly how will Croakey be reconciling itself with the inevitible effect of this initiative that is to increase the risk of this occurring.

    This is tiger territory Melissa – and the first time a patient tells me they don’t want their potentially life threatening symptoms investigated because of what they read on ‘The Naked Doctor’ you’ll be the first to hear about it.

    Get a grip…

  • 2
    chazzai
    Posted January 16, 2012 at 10:44 pm | Permalink

    William, I don’t think there’s an implication that it’s all about self serving doctors. But I am constantly faced with a situation whereby more faith is placed (by the patient) on investigation and treatment than the reality warrants. Perhaps the most blatant would be a request for a script for antibiotics or “a blood test for everything.” Combine this societal attitude with a doctor’s natural fear of missing diagnoses and consequent anger from patients, and you get a situation where more tests and treatment occur than what would occur in a perfect world where we get the balance just right to get the maximum benefit and minimal harm to the most people.

    I spend a huge amount of time trying to engage patients in a discussion about how to proceed and guide people through the decisions that need to be made to balance benefit and harm.

    The first time a patient is not amazed by being told that there may be some downsides to immediate testing or screening, and can take more control of their healthcare because of what they read on ‘The Naked Doctor’ you’ll be the first to hear about it!

  • 3
    William
    Posted January 16, 2012 at 11:24 pm | Permalink

    I think you have a dim view of your colleagues. I also think that this is very much a view from general practice. For those of us that are involved with delivering invasive and high risk investigations as well as low risk simple ones, this sort of discussion goes on every day. You are not the only person who spends time having conversations with patients explaining the advantages and disadvantages of proceeding with an investigation. And I don’t find patients ‘are amazed’ at all…

    I’m actually at my desk revising a paper relating to patients who present with chest pain. The pretest probability that they are having a heart attack is ~10% but if they are discharged from the ED (in less than 4 hours as the government wants) they want to be told that the probability they’ve had a heart attack is <1% (in fact they want it to be 0% but no diagnostic system will be perfect)…In order to active this you need to do blood tests…heaps of them… 2 per patient in a cohort of ~800 (remember 90% of them haven't had a heart attack)…how will The Naked Doctor distinguish this from shameful over investigation…and how would Medicare see this as anything other than a shocking waste of money???

    This just smells of another witch hunt but then that seems to be the only thing Croakey is interested in these day. What a disappointing beginning to the the New Year… three articles and all complete tripe…c'mon Croakey surely you can do better than this.

    I feel my subscription to Crikey withering by the day…

  • 4
    gremar
    Posted January 17, 2012 at 5:34 pm | Permalink

    My worry about this whole process is that it based on opinions expressed by the former director of the Professional Services Review process. My experience of this process suggests that the whole thing was pretty much a kangaroo court and many of the decisions were based on opinion rather than real facts. Whilst it is likely that some medicos are rorting the system it is extremely unlikely that this is a major problem either financially or medically. Of course there is considerable waste of money in the widening use of medically unnecessary investigations, but further enquiry would suggest that much of this is the result of bureaucratic and legal interference in Medicine. As stated above it does seem to be a true witch hunt and is very likely to do more harm than good to the medical services of this country

  • 5
    Gavin Mooney
    Posted January 17, 2012 at 8:57 pm | Permalink

    This ‘Naked Doctor’ initiative surely has to be welcomed by those who recognise that what ever good medicine (like any other profession) does it can do better which does not mean doing more. There are all sorts of incentives on doctors which can influence them in what they do.

    For example, doctors are affected by inducements by drug companies. In this context I note the following in the NY Times today: “To head off medical conflicts of interest, the Obama administration is poised to require drug companies to disclose the payments they make to doctors for research, consulting, speaking, travel and entertainment.

    Many researchers have found evidence that such payments can influence doctors’ treatment decisions and contribute to higher costs by encouraging the use of more expensive drugs and medical devices.”

    Unfortunately particularly with fee for service medicine, more is preferred by the doctor to less. What we need to try to establish is what is optimal and whatever that is it is not the same as maximising services or treatments.

    What is optimal (and I am an economist) has to be considered within some limits of resources that this society is prepared to devote to health care. What we need alongside the Naked Doctor is a wider public debate about what we as a society want from our doctors but then the Naked Doctor may help to stimulate that debate.

    For William to describe this as ‘another witch hunt’ is most unfortunate. Many doctors know they need help in providing optimal care and the information from the Naked Doctor will help them.

    On Medicare rorting more generally, the system is very clearly such that rorting is possible. We may need to think of a different system – but that is another story.

  • 6
    William
    Posted January 17, 2012 at 10:45 pm | Permalink

    Oh I don’t think so..A ‘witch hunt’ is generally considered to be a campaign against a ‘perceived’ enemy with little regard to guilt or innocence. I think this just about fits the bill…

    I am struggling with the concept (as I do on a daily basis) to understand how an economist can inform clinicians how to deliver best medicine. To inform me how much it costs? Sure. Whether the budget balances? Sure. Whether the system can deliver it? Sure. But what constitutes best medicine – I don’t think so.

    Finally, do you seriously think that The Naked Doctor is a going to be a legitimate and valuable source of information to assist ‘many doctors’ in providing ‘optimal care’??? You can’t be serious, surely.

  • 7
    Jon Hunt
    Posted January 18, 2012 at 11:57 am | Permalink

    I had a patient come in today asking me what I felt about the need for an operation which he has been told would “fix” the problem. He works in medical IT, and along the way has been told by various practice managers that surgeons don’t make any money just talking about things. So, perhaps wisely, he wanted another opinion about whether he really needed the op or not. Its been a month now and the symptoms are settling on
    their own so I thought that waiting another month or two wouldn’t hurt.

    I have had three or four patients recently who have unfortunately had various forms of malignancy treated with what I would think was expensive radio/chemo/surgery, only to
    have recurrence a few months later. In the meantime their lives have of course been pretty miserable.

    It’s very easy, with the medicare system, to charge for whatever you want. Any consult is a “B” whether its just a quick immunisation, or a script or not. Care plans are easy money for not doing much else. Often it is patient who is told to have one so they can get their dentistry work performed at a reduced price.

    I think it’s quite sensible to look at the cost effectiveness of all this. It is of course mainly an ethical argument, whether the population is happy paying for expensive chemotherapy treatments for a few, or subsidising dental work (which incidentally I think should be included in medicare at any rate, given dental problems can have life threatening complications, even if this is rare). This isn’t about best medicine, it’s about the best medicine we can afford.

  • 8
    William
    Posted January 19, 2012 at 5:29 am | Permalink

    Thanks Jon. At last some sensible discussion.

    What you say makes perfect sense. What concerns me are comments but the likes of Mooney and others that this sort of initiative will

    ‘…be welcomed by those who recognise that what ever good medicine…does it can do better which does not mean doing more.’

    This just seems to have be reduced very simplistically to a statement that medicine is expensive, some of it doesn’t lead directly to an improved outcome, therefore that is waste and would be stopped.

    Unfortunately, anecdotes that ‘my patient/daughter/granny didn’t take advice but everything turned out OK so they were right’ just add fuel to the fire of this (potentially) dangerous movement.

    Medicine isn’t an exact science – not everybody will die in the 12 months following a heart attack, but the treatments we give significantly reduce the probability that they will…some acute appendices would settle with conservative management, but the others can kill you so they need to come out, etc etc etc. There are many, many , many examples of waste in the delivery of public and private healthcare but this line of attack (the ‘less is better’ lobby) is too simplistic and unfortunately being driven by those who, frankly, don’t know enough about what they are talking about.

    What is desperately needed here is some sensible discussion about how we might make the delivery of medicine better aligned with evidence, more appropriate and accountable (see http://wp.me/p25FwE-m)

    These concepts are poorly understood by the well meaning Mooney, Sweet et al who know more about the bottom line than medicine, although one would think that The Naked Doctor should know better…

  • 9
    William
    Posted January 19, 2012 at 5:33 am | Permalink

    Sorry, shocking typos…(mod please delete my last post if you wish)

    Thanks Jon. At last some sensible discussion.

    What you say makes perfect sense. What concerns me are comments by the likes of Mooney and others that this sort of initiative will

    ‘…be welcomed by those who recognise that what ever good medicine…does it can do better which does not mean doing more.’

    This just seems to have been reduced very simplistically to a statement that medicine is expensive, some of it doesn’t lead directly to an improved outcome, and therefore that is waste and should be stopped.

    Unfortunately, anecdotes that ‘my patient/daughter/granny didn’t take advice but everything turned out OK so they were right’ just add fuel to the fire of this (potentially) dangerous movement, but just don’t cut it.

    Medicine isn’t an exact science – not everybody will die in the 12 months following a heart attack, but the treatments we give significantly reduce the probability that they will…some acute appendices would settle with conservative management, but the others can kill you so they all need to come out, etc etc etc. There are many, many , many examples of waste in the delivery of public and private healthcare but this line of attack (the ‘less is better’ lobby) is too simplistic and unfortunately being driven by those who, frankly, don’t know enough about what they are talking about.

    What is desperately needed here is some sensible discussion about how we might make the delivery of medicine better aligned with evidence, more appropriate and accountable (see http://wp.me/p25FwE-m)

    These concepts are poorly understood by the well meaning Mooney, Sweet et al who know more about the bottom line than medicine, although one would think that The Naked Doctor should know better…

  • 10
    Gavin Mooney
    Posted January 19, 2012 at 6:24 am | Permalink

    William notes that I wrote: ‘…be welcomed by those who recognise that what ever good medicine…does it can do better which does not mean doing more.’ In retrospect it might have been better if there had been a ‘necessarily’ between the ‘not’ and the ‘mean’.
    William goes on: “What is desperately needed here is some sensible discussion about how we might make the delivery of medicine better aligned with evidence, more appropriate and accountable” At last I agree with something from William although I would want to add ‘within available resources’.

    He continues: “These concepts are poorly understood by the well meaning Mooney, Sweet et al who know more about the bottom line than medicine, although one would think that The Naked Doctor should know better…” Beyond finding this mode of debate unhelpful, I think Mooney at least (and I suspect Sweet and the Naked Doctor – but they can speak for themselves) do understand these concepts.

    My understanding is this. I think what lies behind the ideas of the Naked Doctor is a recognition that the resources that any society will devote to medicine and to health care are finite so that if we can cut back on some activity which can be replaced by one which does more good, then let’s do it. That is the economist’s notion of opportunity cost: the benefit foregone in the best alternative use of the resources. This is summed up in the idea that medicine is about doing good; economics about doing better.

    We want to do the best we can with the resources available and I think the Naked Doctor can help in this task but it is not easy. Doing the best requires that we define what is good. Using resources better means again defining good.

    Apart from the likely benefits of identifying where less may be better, I would hope that the Naked Doctor might stimulate a positive useful debate on the question: what is the good of health care and medicine? And also, who should define that good?

  • 11
    William
    Posted January 19, 2012 at 2:27 pm | Permalink

    ‘This is summed up in the idea that medicine is about doing good; economics about doing better.’

    Meaning that medicine can only get better with the help of economics? I beg to differ. The practice of medicine was being improved long before the notion of the ‘health economist’ was even thought of.

    You seem to be back tracking here…

    ‘In retrospect it might have been better if there had been a ‘necessarily’ between the ‘not’ and the ‘mean’.’

    and, to some extent here…

    ‘I think what lies behind the ideas of the Naked Doctor is a recognition that the resources that any society will devote to medicine and to health care are finite so that if we can cut back on some activity which can be replaced by one which does more good, then let’s do it…’

    You are entitled to think what you want, as am I. It might be better if we weren’t left ‘thinking’ about what ‘lies behind’ The Naked Doctor (and his sponsor Croakey) and have it better explained in the first place…

    I make no apologies for my interpretation of the original article and the lack of confidence inspired by comments such as…

    ‘The modern doctor seems to have an intervention for every occasion. He or she wears a magician’s coat of surprises, each more incredible than the last’

    and…

    ‘Reading House of God as an intern was Naked Doctor’s original inspiration for a career-long interest in avoiding over treatment’

    Anyway I’ve said my bit…I’ll watch with interest.

  • 12
    Sue Ieraci
    Posted January 19, 2012 at 4:23 pm | Permalink

    Justin, you start with the premise “The modern doctor seems to have an intervention for every occasion. He or she wears a magician’s coat of surprises, each more incredible than the last. Hidden pockets contain pills, scalpels and lasers, with sophisticated medical tests providing the performance instructions.”

    But here’s where I think you’re wrong – the modern doctor uses more common sense and reassurance than most people give them credit for. On the other hand, it’s the “alternative” practitioners who have a remedy for every visit, and want you to “keep cominig back for adjustments” – essentially forever.

    It’s very fashionable to knock “modern medicine” as being paternalistic and in the arms of “Big Pharma.” But paradoxically, as orthodox medicine has become less paternalistic, people are flocking in droves to the “alternatives” – who always express certainty and always offer therapy – commonly sold to you themselves, at a mark up from Big sCAMa.

    Let’s hear some real analysis about what motivates people to seek different types of health care, and what types of service deliver value for money.

  • 13
    LJG..............
    Posted January 19, 2012 at 5:42 pm | Permalink

    Mr Naked Doctor – do you actually READ all of the articles you quote -> Steve Jobs actually did NOTHING but go on a “special diet” FOR NINE MONTHS after he was diagnosed with his pancreatic neuroendocrine tumour.
    Exactly what you would have prescribed.
    Your friend doesn’t actually know whether the diet didn’t work and the cancer grew or the doctors convinced Steve to intervene with western medicine at that point in time.
    It’s a very poorly researched article if he doesn’t even know the full facts and a poor example of the perils of Western Medicine when the patient starts the treatment by doing b-gger all for the first 9 months.

  • 14
    Bert Giorgio
    Posted January 23, 2012 at 8:59 pm | Permalink

    Italian association Slow Medicine (www.slowmedicine.it; Facebook Group: Slow Medicine Italia) works in this same field and shares your objectives… Thak uou for the blog!

  • 15
    Levy Paul
    Posted January 24, 2012 at 8:07 am | Permalink

    A great blog!

    I referred to it here, in this post: http://www.runningahospital.blogspot.com/2012/01/shamans-knew.html

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