elfs | The Jury, Episode 4: The Rather Ordinary Doctor L.

The afternoon session sits us all down with the big guy: Doc L, the doctor treating Miss T. He introduces himself as a Doctor of Osteopathic Medicine and Surgery (D.O.), with a 41-year practice. He talks to us of diatheramy and sclerotherapy, and I have to confess that I'm feeling bamboozled. I'm trying hard, and so far succeeding, in not looking this stuff up, in not "forming my own opinions" about the procedures he's describing, but instead taking what's said in the courtroom at face value. I know in this era that there's a gigaton of data about this kind of thing. I could ask Orac: he's a font of data about woo. Is sclerotherapy woo-ey? I have this fretful feeling that it is. That there's no real scientific evidence to back it up. I don't know, and it infuriates my network-born instincts that I'm not allowed to know.

Doc L talks about how his practice is "everything from dandruff to fallen arches." Cute. Sounds practiced. Uses the word "allopathic." Well, score one for him. "A Doctor of Osteopathic Medicine and Surgery is a full doctor. We are not limited. Not like them." We'll learn who Doc L believes is "them" shortly.

Landry goes on for some time, making the case with Doc L that Miss T was benefiting from his therapy. A line of questioning straight out of one of those textbooks. My discomfort is that there's no corroboration. No physical therapy was ordered, no neurology studies, nothing. It's all about the ligaments, which he asserts can only be healed primarily by an irritation technique: he introduces a foreign substance ("sterilized dextrose" or "cod liver oil"-- the last makes the woo-meter tick hard!) and that causes the ligament to grow defensive tissue to protect it against the substance. He makes the comment that skin grafts and bone grafts work the same way-- an assertion I would contest. Introducing growing tissue and spanning the gap sufficient to encourage growth is different from irritating the tissue to encourage defensive growth. Doc L says he looked at the head CT scans, skeletal X-rays, and abdominal ultrasound, but asserts (and I underlined "asserts") that none of them can tell you about ligament failure. (He later admits, under cross-examination, that he never actually saw the films, only the radiologist's reports.) The only way to do tissue density of ligaments is to assess the turgor with a needle; no visualization technique will give you an insight into the status of strained ligaments.

This therapy is his life's mission: it worked for his father, and his mother, and he went into osteopathic medicine to bring this technique to the world. The woo meter goes up another tick.

But he does say that he didn't start this procedure until two years after the accident. Instead, he concentrated on the traditional sports medicine treatments: pain relievers, muscle relaxants, ice, massage to break up swelling and move blood in and out of the injured portion, physical therapy of the injured parts to restore range of motion. He testifies that Miss T is "hypermoble," meaning she has more elastin than collagen in her ligaments, and so has less protection against this kind of soft-tissue damage.

He makes an interesting case against the current three-point seat belt, recommending a four-point instead, although he admits he doesn't have one. We get a show-and-tell, with a full-sized plastic model of the spine ("Gave 'em a bit of a start at the security checkpoint" -- really? Like they don't have personal injury cases come through here constantly?) as Doc L points to where the ligaments are, what the injections are like, and so forth. As he twists and bends the model spine, several members of the jury tense visibly.

I wrote in my notes, "Are there any EBM [evidence-based medicine - Elf] studies that back it up? Double blind, placebo, that sort of thing?" A few lines later I write, "Koenig delivers!" Because he does. His first line of attack upon standing up is a 2007 meta-study concluding that all the studies to date have shown no conclusive evidence that the procedure works at all. The doctor says he's not surprised: it depends upon the skill of the practitioner, and the substance used. My problem with his response is that the same is true of surgery, but if this procedure is fifty years old good grief you would think the docs would have figured out what works and what doesn't? Woo meter plus one. He goes on to diss the "other" members of his profession: chiropractors on the one hand-- "We have significant disagreement about what really goes wrong with the spine"-- and orthopedic specialists on the other-- "They're surgeons. That's what they do. Surgeons love to do surgery. ... I am not a fan of surgery, nor would I recommend it. In this case, I mean." Woo meter climbs once more.

Koenig then goes on to attack a different aspect of practice: the doctor's use of his own hand as an instrument of diagnosis, specifically his use of turgor. I find this a weak line of attack: the hand is a perfectly valid tool, and an experienced hand with a needle is probably better than a machine for determining the turgor of at least some conditions.

Koenig's last line of attack is to the documentation, specifically that his own objective assessments of Miss T's conditions do not match her subjective assessments. Doc L isn't surprised: he might see full range of motion but she might continue to report pain. And indeed, her reports do show "full range of motion" and "within normal limits."

Landry gets back and talks about the procedure. It's painful. No patient would go through it unless they absolutely have to. I write in my note, "What an evolutionary mess we are." A minute later Doc L mirrors my sentiment theologically: "I don't know why our Creator would create us so messed up. To make such marvels as our body, and then not give this one important part of us the ability to heal." His final point is that all of his treatments have been necessary and reasonable for the injuries she has sustained as a result of the auto accident.

The jury gets to ask its questions. Someone asks the obvious: even with the sclerotherapy can Miss T expect to see restoration to full health? Doc L answers no, of course not. But she will see significant improvement and that's what's important. He wants to try and restore her limbs to their pre-injury state, he says. He says he has no reason to believe that Miss T is a "malingerer" or is "being untruthful" about her subjective state.

After that, we're all free to go on our own recognizance.

I'm reminded of a quote I read once:

Cardiac physicians are fitness freaks. They exercise and eat right. They know the consequences of a heart attack. Oncologists, in contrast, are usually eat-drink-and-be merry types. They know the consequences of cancer. They'd rather have a heart attack.

I don't know why my brain thinks that's relevant right now, but I wrote it down.