You’ve got to hand it to the folks at Matrixx Initiatives. They managed to convince millions of Americans to paint the inside of their noses and throats with a toxic heavy metal that is ineffective in its stated benefit and destroys the nerves responsible for the sense of smell.

Matrixx marketed Zicam as a cold remedy. There is no evidence that Zicam has any effect on colds, but there is decades of data showing that zinc, the purported active ingredient, can damage the sense of smell. Indeed, since 2006, Matrixx Initiatives has been forced to pay $12 million dollars to 340 people who claimed that Zicam destroyed their sense of smell. Hundreds more lawsuits are still pending.

So how did Matrixx manage to convince Americans to apply a toxic heavy metal to sensitive internal tissues? They called it a homeopathic remedy and that allowed them to avoid having to prove that Zicam was effective or even safe. And, they relied on the gullibility of the American public and its current love affair with all things “natural.”

The Obama Administration is working to close the legal loophole that allows companies to market “natural” remedies without proving that they are effective or even safe. In the meantime consumers can become less gullible. The first step is to understand how we know whether a substance works. Answering the question goes far beyond giving the substance to individuals and asking them about their perceptions.

The study of drug efficacy and safety is pharmacology. Pharmacology can be roughly divided into two areas: pharmacodynamics, how the substance acts on the body and pharmacokinetics, how the body acts on the substance.

Here are some basic questions that must be answered to find out how the drug works on the body:

How does the drug work? What is the active ingredient? What effect does the active ingredient have on the body?

What is the dose-response? In other words, as the dose of drug increases, does the response increase?

What is the ED50, the dose that produces a response in 50% of subjects, also known as the median effective dose?

What is the maximum effect that can be produced by the drug, also known as efficacy?

What is the therapeutic window? For every drug, there exists some concentration which is just barely effective and some dose which is just barely toxic. Between them is the therapeutic window where safe and effective treatment will occur.

In addition, we need to know how the body interacts with the substance.

How does it enter the body?

How is it removed from the body?

Does it have effects on other parts of the body besides its stated therapeutic effect?

What did the makers of Zicam know about their product before they put it on the market? The only thing that they knew is that the active ingredient is zinc. They did no testing that would tell them the mechanism of action, the dose response or even the effect of the zinc on other tissues of the body. Therefore, at no time did they have evidence that the drug was either safe or effective, yet they sold it anyway.

Determining drug efficacy and safety is complex. It is absolutely imperative to study the pharmacodynamics and pharmacokinetics of a substance before anyone can claim that it is effective or safe. As the case of Zicam illustrates, when it comes to “natural” remedies, these questions have not even been asked, let alone answered.

In an industry noted for greed, sharp tactics and lack of social conscience, the drug company Genzyme has managed to set a new standard for depravity.

Yes, depravity. Genzyme’s latest strategy for amassing outsize profits, proudly described by company executives in today’s Boston Globe, is, in my judgment, nothing short of morally depraved.

Genzyme, as its name implies, has pioneered the use of genetic engineering techniques to create and manufacture drug treatments. The greatest potential of genetically engineered drugs lies in treatment for so called “orphan” diseases, those they afflict very few people, not nearly enough to form support groups, charities and public advocacy groups that pay for treatment. Although many companies have had success in creating novel, highly effective treatments for orphan diseases, they find it hard to profit from such treatments, because demand is very low.

Orphan diseases, by their very nature, are often difficult to diagnose and require sophisticated medical equipment and training to even identify. The chances of an orphan disease being diagnosed in the third world, let alone being treated, are extremely remote. Genzyme’s new corporate strategy is to search the third world for children suffering rare diseases, provide the technology and equipment to make the diagnosis and then attempt to force the government of the third world country into paying for the extraordinarily expensive treatment by diverting money that would otherwise be used to provide basic medical care for large numbers of people.

The idea is pure genius. By identifying a specific child who will die without treatment, by informing the child’s family that a lifesaving treatment exists, but will be withheld without full payment the drug company is able to exert far more pressure on the specific government than they could by a simple announcement that 1 or 2 children in any given third world country might benefit from the treatment.

The Globe details how this technique works in practice. Consider Tania, the Costa Rican girl, who is dying of the rare genetic disease Gaucher’s. Tania’s family did not know what was killing her, and they would never have known, if it were not for Genzyme’s efforts to find and identify Tania, and inform her family of the treatment that could save her life, the drug Cerezyme, at the cost of $160,000 per year:

Genzyme created divisions within the company to find overseas patients …

Costa Rica was part of this plan, a nearby country whose government, though poor, dedicates much of its budget to healthcare. Company executives began flying to the region and meeting with the person most likely to diagnose a Gaucher patient: Dr. Manuel Saborio Rocafort, who runs the only medical genetics department in Costa Rica. So when Saborio heard about Tania, not only did he know that he should test her for Gaucher disease, but he had the testing kit ready: Genzyme had provided it.

But Genzyme did not go to the trouble and expense of finding and diagnosing Tania in order to save her life. Their avowed corporate strategy involves letting her die, unless Costa Rica will pay the full $160,000 per year for Cerazyme. Absolutely no discount is allowed.

Lest anyone doubt that this is a deliberate corporate strategy, consider:

In Genzyme’s new glass Kendall Square headquarters, the president of the firm’s international group, Sanford Smith, keeps a brass gong outside his office. Every time a foreign government agrees to pay for one of the company’s drugs, he takes out a mallet and rings it.

Presumably, they rang the gong for Tania when Costa Rica agreed to pay the full price, the only price at which Cerezyme can be obtained. Yet the Costa Rican government is not without misgivings:

The Costa Rican healthcare system has survived paying for Tania’s medicine. What worries its leaders is the precedent. Energized by Genzyme’s success, more companies have developed high-tech drugs for other rare diseases. Genzyme’s pricing approach has become the standard for similar drugs…

It is difficult to imagine a corporate practice that is more ethically and morally depraved: deliberately identifying third world children whose lives can be saved by extraordinarily expensive drugs, refusing to provide those drugs at a discount or for free, and then ringing a brass gong to announce that another third world country has been blackmailed into diverting a large share of its healthcare budget to one child, and away from simpler medications and strategies that could save thousands of lives.

The executives responsible for this strategy should be ashamed.

There’s nothing worse than doctors who refuse to learn from their own mistakes.

The latest pronouncement from the American Medical Association opposing publicly funded healthcare (single payer) is foolish on its face, but it unforgivable when turns out that it is merely a recapitulation of a thoroughly discredited policy of the past. The fact that it is not in line with the views of the vast majority of American physicians makes it worse, and goes a long way toward explaining the increasing irrelevance of the organization.

The support for reform of the healthcare system has never been greater. The AMA, in a move supremely out of step with the majority of Americans, not to mention the majority of American physicians, has declared their opposition. According to The New York Times:

…[I]n comments submitted to the Senate Finance Committee, the American Medical Association said: “The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”

The wording is rather ironic. Forty years ago, the AMA declared its opposition to creating a public health insurance option people over age 65, complete with dire predictions of the destruction of American medicine. That public health insurance option is known as Medicare, and far from destroying American medicine, it ushered in a golden age for American physicians.

The current opposition to healthcare reform, like the opposition to Medicare, is consistent with the AMA’s sad and sordid history of vociferous opposition to any attempt at healthcare reform. Truman first proposed universal compulsory health insurance in 1948. As Robert Ball explains:

The AMA’s opposition approached hysteria. Members were assessed dues for the first time to create a $3.5 million war chest-very big money for the times-with which the association conducted an unparalleled campaign of vituperation against the advocates of national health insurance. The AMA also exerted strict discipline over the few of its members who took an “unethical” position favoring the government program.

But AMA is no longer the force in American medicine that it was in the past. In the 1960’s, at the height of opposition to Medicare, the AMA claimed at least 70 percent of American doctors as members. Today, the AMA represents only a third of American doctors, most of them elderly. Almost 90 percent of doctors over age of 70 are members, but fewer than 35 percent of those aged 30 to 49 belong to the AMA

Its decline in membership and influence can be traced to its political positions and financial arrangements. Indeed, the majority of American physicians favor a national healthcare plan:

Of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program, while 32 percent said they opposed it …

“Many claim to speak for physicians and represent their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support national health insurance,” said Dr. Aaron Carroll of the Indiana University School of Medicine, who led the study…

The Indiana survey found that 83 percent of psychiatrists, 69 percent of emergency medicine specialists, 65 percent of pediatricians, 64 percent of internists, 60 percent of family physicians and 55 percent of general surgeons favor a national health insurance plan.

The AMA is opposed to healthcare reform? Who cares? They don’t represent American physicians and they don’t represent the American people. The represent the worst of American medicine, a dying breed that deserves to fade into ignominy.

From MSNBC:

Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.

Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine…

Imagine how many people could have received real medical treatment with that money. Imagine how much real medical treatment we could buy with the tens of billions of dollars that American waste each year on alternative health mumbo jumbo.

Blogger and alternative health advocate Catherine Morgan has attempted to address my claim that alternative health is pseudoscience. She writes:

Not surprisingly, Dr. Amy takes a hard line against alternative health practices, but is alternative medicine just pseudoscience? I don’t think so. Just because something can not be “scientifically” proven today, doesn’t mean it won’t be proven in the future. For example, most people believe that when they die they will go to heaven, but there is no “scientific” proof of heaven. Does that mean heaven doesn’t exist? And at one time, before there was proof that the world was round, everyone believed it was flat. Was it flat just because the science wasn’t available to prove it wasn’t? No. Science may not be able to prove that Reiki or Acupuncture (or any other alternative modality) actually works, but that isn’t proof that it doesn’t work either. Let’s face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next. … Even Einstein was wrong sometimes. The only thing we know for sure, is that no one knows everything.

That paragraph is a “greatest hits” of faulty reasoning, including basic flaws in logic, invocations of religious faith, and, my personal favorite, grandiose comparions with Galileo or Einstein (for some reason it is always Galileo or Einstein), while failing to realize that Galileo and Einstein always supplied scientific proof for their claims while their persecutors and detractors were the ones who insisted that scientific proof wasn’t necessary.

Here’s the comment that I left:

“Just because something can not be “scientifically” proven today, doesn’t mean it won’t be proven in the future.”

1. That statement reflects a very serious misunderstanding about the state of knowledge of alternative remedies. It’s not simply that alternative remedies have not yet been scientifically proven to work; the reality is that alternative remedies have been scientifically proven NOT to work…

2. It is the MORAL obligation of advocates of alternative health to be SURE that an alternative treatment is safe and effective before they recommend it. It is morally wrong to advocate a treatment, and to accept money for the treatment if you don’t have proof that it works.

“And at one time, before there was proof that the world was round,
everyone believed it was flat. Was it flat just because the science
wasn’t available to prove it wasn’t? No.”

That statement offers more support for my view, not yours. Simply put, that statement means that what people “believe” about something is completely unrelated to reality. So the fact that alternative health advocates “believe” that alternative health works tells us absolutely nothing about whether it works.

“Let’s face it, even when things are scientifically proven one day, they are often scientifically dis-proven the next.”

That’s not true, either. What is reported (often erroneously) in the media changes from day to day, but what the scientific literature shows does not change in that way. That’s why it is absolutely critical to read scientific papers if you want to know about scientific phenomena.

Alternative health is the medical equivalent of astrology. Just like astrology, it is nothing more than pseudoscience.

Ms. Morgan replies:

…Even though I’m not a scientist, I don’t believe my post reflects a “serious misunderstanding” of alternative remedies.

I’m interested in how you reconcile your strong belief in scientific fact with the placebo effect? If science has proven that a mind/body connection exists in medicine…Is it really that far fetched that alternative medicine might have some benefits as well?

And my response:

I’d like to ask you some ethical questions, and I hope you will take the time to reply.

May I ask why you have not reviewed the scientific literature on alternative health remedies? Isn’t that like writing a book review recommending a new book without having read it?

Don’t you think you have a moral obligation to read all possible evidence on something that has the power to seriously harm people before suggesting that they should risk their health and wellbeing by believing in it?

Let me try to address the question you asked me.

“I’m interested in how you reconcile your strong belief in scientific fact with the placebo effect?”

Why should I have any difficulty reconciling scientific fact with the placebo effect? The placebo effect IS a scientific fact. It was discovered, described and measured by scientists.

Contrary to what alternative health advocates like to claim, scientists are very much aware of the mind-body connection. (Think psychosomatic illness, for example.) Scientists know that it is absolutely imperative to subtract the placebo effect from any evidence that a substance works.

The placebo effect is “psychosomatic.” You can evoke the placebo effect by feeding someone dirt and claiming it is medicine. So when alternative health advocates invoke the placebo effect to show that an alternative treatment “works” they are essentially saying that the alternative treatment is equally effective as feeding someone dirt.

How can alternative health practitioners ethically justify charging people money for a treatment that is no more effective than dirt?

I’ll let you know if there is a further response.

Alternative health is nothing more than a giant scam to separate the scientifically illiterate from their money. The best and simplest example of this phenomenon is the use of herbs and supplements.

Devotees of alternative health like to pretend that herbs and supplements are better because they are “natural,” because they are pure, and because they are not produced by Big Pharma. Nothing could be further from the truth.

First, “natural” is hardly synonymous with beneficial or even harmless. Earthquake, hurricanes and lightening strikes are all “natural” and quite harmful. More to the point, some of the most toxic substances known to man, like the paralytic poisons tetradotoxin and curare, are natural animal and plant products. Anyone who wonders whether “natural” equals beneficial need only contemplate tobacco, opium and cocaine.

Second, even if the active ingredient of an herb or supplement is harmless, it is mixed with contaminants in its natural state. As MSNBC explains:

Lead in ginkgo pills. Arsenic in herbals. Bugs in a baby’s colic and teething syrup. Toxic metals and parasites are part of nature, and all of these have been found in “natural” products and dietary supplements in recent years.

The risks are not simply theoretical:

Millions of Americans take vitamin, herbal or other dietary supplements. Annual sales exceed $23 billion, and more than 40,000 products are on the market. Tens of thousands of supplement-related health problems are handled by U.S. poison control centers each year, according to a report in the New England Journal of Medicine in 2002.

Until last year, supplement makers were not required to report problems to the FDA, and even now they must report only serious ones. The agency estimates that more than 50,000 safety problems a year are related to supplement use.

Because of vigorous lobbying efforts by supplement manufacturers, herbs and supplements are exempted from the rules that apply to medication. Therefore, there is no way for a consumer to be sure that a given herb or supplement contains any active ingredient, or contains too much or too little of the active ingredient. There is no testing to be sure that harmful contaminants are not present. Manufacturers simply grind up leaves and sell them to gullible people, and neither the manufacturers nor the consumers have any idea what’s in them.

Third, and most ironic, the herb and supplement industry is a financial bonanza for … Big Pharma. Sure, the labels on the products are decorated with butterflies and rainbows, but the producers are none other than Bayer, GlaxoSmithKline and Wyeth.

Little herbal stores are only “what the consumer sees when they’re shopping,” while the large companies that supply them are mostly invisible, Silverglade said.

The industry’s little-guy, granola image has been a great marketing asset, allowing it to tap into Americans’ frustration with big medicine, big prices and big risks. Supplement makers are dwarfed by leading pharmaceutical firms, whose drugs command sales in the tens of billions of dollars. Yet the reality is that natural remedy makers constitute a sizable business that doesn’t have to play by the same rules as companies that make prescription or over-the-counter medicines.

In the final analysis, herbs and supplements represent the trifecta of the gullibility of lay people. The active ingredients themselves don’t actually work, the herbs and supplements often don’t contain the active ingredient or contain poisons, and the consumer is paying Big Pharma for the privilege of being scammed.

Herbs and supplements, like all of alternative health, depend on scientific illiteracy. The executives of Big Pharma are laughing all the way to the bank. Not only do they profit from legitimate pharmaceuticals, all of which require major financial investments to develop and assure safety and quality, but they are raking in money from herbs and supplements, without any research, without any quality control, and without any evidence that they work.

What makes a good doctor?

There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient’s signs and symptoms, the ability to identify the patter, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.

Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.

Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient’s situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don’t read the book. In other words, their signs and symptoms can vary from “textbook” descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.

Yet if there is one thing that contemporary American doctors lack, it is time. That’s because the people who “manage” healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients “processed.” That’s not what it means to be efficient in the practice of medicine, though.

In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That’s because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.

How have doctors become less efficient? All the evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomittant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are “processed” faster, but medical care has arguably gotten worse, not better.

The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.

Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster. And that’s not efficiency.

My favorite part of practicing obstetrics was the moment of delivery, helping mom lift the baby to her chest and calling out, “It’s girl!” or “It’s a boy!” It was always a privilege to be part of the deeply personal moment when parents met their newborn child, and to share their joy and excitement.

Although parents are anxious to establish that the baby has ten fingers and ten toes, and is healthy in every way, the announcement of gender is often equally important. The knowledge of gender immediately begins to shape the way the parents view the baby.

You’d think that figuring out the gender would be simple, and it usually is, but once in my career I delivered a baby and could not tell whether it was a boy or a girl. I said nothing about the gender and the tension and distress of the parents were palpable.

The baby was born with a condition known as ambiguous genitalia. It’s just what it sounds like: external genitals that appear to be a cross between male and female. How does it happen?

For the first 7 weeks of development, every embryo appears to be female. In the absence of male hormones like testosterone, the baby will continue to have female external genitals. In boys, the testicles begin producing male hormones and the external genitals undergo further development. The clitoris enlarges into the penis, and the labia fuse together in the middle to become the scrotum.

It is possible for a baby to be a true hermaphrodite, having both ovaries and testes, but that condition is very rare. Ambiguous genitalia are usually caused by an inherited hormone problem that interferes with the development of the genitals. The baby is either a boy or a girl because it has either testes or ovaries, but the external genitals look like a combination of both, making it difficult to identify the gender simply by looking.

I had never seen a case of ambiguous genitalia before that night, but like every obstetrician I had read about it. And one of the things that I had read was that if there was any doubt about the gender, the doctor should not attempt to guess. According to a variety of studies, more psychological damage could be done by the doctor wrongly assigning gender and then having to change it, than by admitting that you didn’t know and consulting an expert to make the diagnosis.

Talk about an awkward situation! As the baby’s shoulders were being born I started to call out, “It’s a …” and stopped. I was stunned into silence. The baby appeared to be a girl with a very enlarged clitoris that looked like a penis, but I wasn’t sure. Mindful of what I had read, I didn’t want to guess. I asked the nurse to call the neonatologist to the room and I showed the baby to the parents. Not surprisingly, they were even more stunned than I was. I pointed out that the baby was healthy, with all other body parts intact, and I explained that the baby almost certainly had a treatable hormone problem, but the parents were distraught.

The neonatologist arrived within minutes and carefully examined the baby. He announced that the baby was a girl and that a treatable hormone problem had cause virilization (male appearance) of the external genitals. Ultimately the baby was diagnosed with congenital adrenal hyperplasia (CAH) the most common cause of ambiguous genitalia. CAH has effects in addition to ambiguous genitalia. It also leads to serious kidney problems, so it is very important that it be diagnosed and treated immediately.

After some time with mom and dad, the baby went to the newborn intensive care unit for a complete evaluation. Replacement of the appropriate hormones was started, and because the virilization of the genitals was mild, no surgical treatment was needed. The clitoris shrunk back to normal size and the baby did very well.

The parents, on the other hand, took a little longer to recover. The entire experience was deeply disturbing to them as it would be to any parents. And I never forgot it.

“Listen to your patient, he is telling you the diagnosis.”

Those are the words of William Osler (1849-1919) often called the Father of Modern Medicine for his contributions to the development of medical education. I first heard them from the chief of surgery at the beginning of my internship. It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than you might think. That’s because most patients are simultaneously offering a lot of extraneous information, and some patients are not completely honest in the information they offer.

In fact, the patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

I suspect that this problem is at the root of many errors of diagnosis. It is obviously much more difficult to diagnose a problem if the patient has an unusually constellation of symptoms. However, the biggest stumbling block is that the doctor believes that if the symptoms make no sense, the patient must be telling the story wrong, or have some other reason for the symptoms such as depression or medication seeking behavior.

That’s the biggest advantage I have when approached by a friend or relative for help with a difficult medical problem. It can sometimes be much easier for me to figure out the diagnosis than it is for the doctor they are seeing. That’s because I start out by believing them, because I know them, and I don’t waste valuable time pondering whether they are honest or reliable reporters of their symptoms.

Recently a friend called me about unusual symptoms his father-in-law was having. The relationship between our families has extended through several generations, and I knew his father-in-law well. He is a distinguished emeritus professor with a piercing intellect and ongoing curiosity and engagement with the academic world. As he approached and passed his 80th birthday, he was afflicted with slowly progressive muscle weakness. He became wheelchair bound and continued to weaken even further. Ultimately, he was barely able to muster the energy to move.

His impressive team of doctors was stymied by the symptoms and took the easy road. They concluded that he was weak because he was old. There was nothing to be done.

His son-in-law called because his children were convinced that something was going on besides normal aging, but did not know what tests and investigations to insist upon. That’s where my advantage came in. I listened to his story and believed him because I knew him and I knew them. I started from the premise that the story must be true and went from there.

Whenever an elderly person develops a global symptom like fatigue or confusion, the first place to look is at their medications. As people become older, they are put on ever increasing numbers of medications to treat various unrelated ills. Often, some of those medications will interact to produce unusual side effects. In addition, as people age, the ability of the kidneys or liver to break down the medication and remove it from the body diminishes. Because the medication stays in the body longer, it has a chance to build up to toxic amounts. A dose of medication that was conservative 10 years before may have slowly become an overdose.

Since whole body muscle weakness is certainly a global symptom, I asked for a list of his medications, and then I went down the list looking for generalized muscle weakness as a rare side effect. I hit the jackpot almost immediately. Pravachol, a statin (cholesterol lowering drug) he had been taking for decades, is known to cause generalized muscle weakness in rare circumstances by damaging muscle cells. The chance of this unusual side effect is increased in the elderly and is further increased in people with diminished kidney function, which happened to be present in this case as well.

I was so excited that I called my friend right away to tell him. I promised to do further research later in the evening, but in the meantime, he started investigating the rest of the list for unusual interactions between drugs. Sure enough, he found that another medication on the list was known to interact with Pravachol to increase the risk of generalized muscle weakness.

We had the diagnosis: Pravachol induced myopathy exacerbated by age, decreased kidney function and interaction with another drug. My friend called his father-in-law’s doctors first thing the next morning, and the Pravachol was discontinued. Recovery began almost immediately. He now feels better than he has in years and has begun to walk again.

The professor called me recently to express his gratitude. He thought I had made an incredible diagnosis. Frankly, I am a bit embarrassed. I didn’t really diagnose anything. He had been recounting the symptoms of statin induced myopathy in detail for months, if not years. All I did was listen.