biomarkers-vs-outcomes rants

Bio-markers and Bio-plausible not bio-promoting

Sometimes when my patients and I discuss a treatment option, I might get a little rant going about how researchers and health professionals and also patients are confusing bio-markers with actual health outcomes. This is especially significant when trying to evaluate whether a treatment is (1) evidence-based medicine and (2) whether the evidence is actually useful evidence.

There is a long but very interesting article co-published by ProPublica and The Atlantic, which everyone interested in health should read:
When Evidence Says No, But Doctors Say Yes, by David Epstein, published 2/22/2017. This article is primarily about how bio-plausible (it just makes sense!) treatments keep getting recommended to patients despite in-depth quality evidence showing that they aren’t useful.

I am very interested in this in general, but considering my particular pet peeve of biomarkers being confused for outcomes, this paragraph stuck out:

In 1997, a Swedish hospital began a trial of more than 9,000 patients with high blood pressure who were randomly assigned to take either atenolol or a competitor drug that was designed to lower blood pressure for at least four years. The competitor-drug group had fewer deaths (204) than the atenolol group (234) and fewer strokes (232 compared with 309). But the study also found that both drugs lowered blood pressure by the exact same amount, so why wasn’t the vaunted atenolol saving more people? That odd result prompted a subsequent study, which compared atenolol with sugar pills. It found that atenolol didn’t prevent heart attacks or extend life at all; it just lowered blood pressure. A 2004 analysis of clinical trials — including eight randomized controlled trials comprising more than 24,000 patients — concluded that atenolol did not reduce heart attacks or deaths compared with using no treatment whatsoever; patients on atenolol just had better blood-pressure numbers when they died.

I’m diverging from the topic of the article to point this out, because it is very important when weighing your options.

A colleague asked the Facebook hivemind what questions she, as an accompanying advocate, should ask the physician/surgeon of a friend who had debilitating back pain about a proposed surgery. Many people chimed in that in addition to her already proposed “risks, alternatives, and physician experience” and etc., she should absolutely ask about the expected result of the surgery. This goes for medications and nutritional changes and physical therapies as well. What are you trying to achieve? What can you expect to achieve?

A lot of interventions (medications, nutritional changes, exercises and physical therapy… anything you change in order to make a difference) have been tested against whether they make a difference in bio-markers because it is too costly and risky to see if they make a difference in actually important things like quality of life, mobility and individual agency, and duration of life. They’ll therefore conflate a biomarker known to be involved in the outcome, such as LDL cholesterol or blood pressure, with the outcome of Not Dying Suddenly From A Heart Attack or Permanent Disability After A Stroke. Again, the reason is that it’s often too costly or too difficult/unethical to get permission to run a study long enough to find out; but that means that there’s lots and lots and lots of treatments out there that make your numbers look pretty without addressing the cause for those numbers to be “off.” They also confuse people as to whether the biomarker is the cause of an outcome, or just related to the outcome. Things like LDL cholesterol can be a predictor of cardiovascular disease but don’t necessarily cause CVD!

This doesn’t even get into the difficulty of studying one particular outcome, like cardiovascular disease or skin cancer, while ignoring all other outcomes, like autoimmune disease, diabetes, other types of cancers, infection, and all sorts of other things that can make life difficult or make life end. Or being so focused on reducing the biomarkers of one disease (blood pressure as an indicator of CVD) that you take risks with other diseases (blood pressure medications making diabetes mellitus type II more common) which can increase mortality or reduce quality of life.

It’s a very tricky balance. It’s not something that you can just figure out by finding the one right study.

That’s why it’s important to find clinicians who will work with you holistically –as a whole complex person– to figure out which risks are the real risks, which biomarkers are worth chasing down into pretty, non-threatening ranges, and which interventions are actually helpful versus which ones are just to cover everyone’s behind.

social-justice Uncategorized

Social Determinants of Health

Need justice, have umbrella, willing to march!
Coming together to ensure mutual security and wellbeing, rain or shine!

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.

As a part of my education in East Asian medicine and Naturopathic medicine, we looked at not only individual determinants of health (your behavior, your choices, your genes and your upbringing) but the social determinants of health (Are you persecuted by your government or by fellow citizens? Do you have freedom of movement, of the ability to better yourself, to accumulate wealth for security?)

This political climate calls upon us to clarify our values and to look at how our actions influence others, and our role in upholding, ignoring, or resisting our social norms and government codes.

To that effect, I want to share these documents about how we can make sure our Representatives in government truly represent our interests, and how to resist without undermining your cause.

Indivisible Guide: A PRACTICAL GUIDE FOR RESISTING THE TRUMP AGENDA, Former congressional staffers reveal best practices for making Congress listen.  This is both a guide translated into many languages and in both written and audio format, and a community for support.

198 Methods of Nonviolent Action: Practitioners of nonviolent struggle have an entire arsenal of “nonviolent weapons” at their disposal. Listed below are 198 of them, classified into three broad categories: nonviolent protest and persuasion, noncooperation (social, economic, and political), and nonviolent intervention.

mental health

Where’s the negativity coming from?

[google search] how do I block my lawn
Full credit to XKCD, the artist/author Randall Munroe
I was just doing a meditative/spiritual practice about connecting with whatever our version of The Everything (commonly called God, or in this leader’s Sufi practice, Allah). I was getting stuck, because as the exercise was about taking responsibility for what mistakes I have made about a situation that doesn’t sit right, I then pray for Forgiveness from The Everything.

I was stuck, because (1) I’m struggling with my connection to, opinion of, relationship with Divinity and therefore the corollary of (1a) does The Everything have the power to bestow forgiveness? and also stuck on (2) why do I deserve forgiveness?

When you don’t trust that there is love and forgiveness for you and that you deserve it, it can then seem as though everything out there sees the lack of worth that you feel.

Then I calmed myself down, went over to the internet for a little distraction, and saw that the author of XKCD is also feeling inundated with judgement.

Clearly from the alt-text, he’s aware of the desire to just shut down that perception, to avoid it and get even further away. No comment on whether that works or not.

I don’t have a solution to this. I think you can work with a strong sense of your own worth to mitigate that, for an internal locus of control, or belief and trust in a higher being that has the power and inclination to forgive, for an external locus of control.  Maybe starting with behavior modeled by parents and mentors loving and forgiving our mistakes and helping us to acknowledge them safely and empowering us to move forward.  Not that all of us receive that modeling…

think that, but it seems I don’t know that or feel in my core.  Like many of us (evidenced by webcomics), I struggle.

What does this have to do with acupuncture, or even the general practice of medicine?  How do I dare to reveal my struggles with self-worth here in the open?

Firstly, just as I was heartened to see that I’m not alone by reading a webcomic, I want to let you know that you’re not alone.  I don’t –and can’t– understand your full lived situation, but I understand what it is to struggle with guilt, remorse, being cut off from or cutting myself off from loving connection with others, and the actual physical heartache that comes from facing that lack.

But secondly, the lineage of acupuncture I was drawn to (Worsley 5 Element, if you’d like to look it up) isn’t just about relieving back pain or quelling nausea. (It does that too, of course. Acupuncture is powerful.)  This style of acupuncture is about finding how we are vulnerable, and gently and persistently removing blocks to that connection with The Everything, with our worth, with our deserved love.

And oh, my dears, we do deserve love. And we deserve forgiveness when we realize our mistakes.  And we deserve a space where the grass supports us under our feet, and doesn’t echo the blame and shame we feel about our various mistakes.

Though it is difficult to manufacture forgiveness for myself (unless I wronged me), I can be a part of transmitting your deserved forgiveness, and standing as a conduit for your connection to The Everything and with your own sense of peace and safety. We humans can do that for each other.


Big Medicine

Electra Allenton, ND, MSOM, LAcTwice recently, I’ve been given a gift of someone’s medicine.  It’s not what you’re probably thinking.  In today’s troubles with an opioid epidemic, with ADHD medication sharing or selling on school campuses, and things like that, being given medicine sounds very strange.  I’m not talking about pharmaceutical drugs, though.

I’m talking about plant-based medicine that heals as much through history and meaning as it does through phytochemicals.

I am talking about relationship and communication, fostered through our less intellectualized senses like smell and taste and touch, between humans and humans and between humans and our world.


Those waters are still troubled, but we’re coasting along.

Electra Allenton, ND, MSOM, LAcDear ones, I’m ready to go!  How about you?

For anyone looking back…back…back through time at this blog post, I want to give you some context.  It is November of 2016.  Last week, Donald J. Trump became our president-elect.  There’s almost no one in the country who hasn’t had an emotional response, whether it’s elation at having the sense of being heard and seen, or fear at what drastic changes will come.  Everyone’s relative sense of safety has shifted for better or worse.  And, our country is remarkably polarized.

My clinic is in Portland, Oregon.  I’ve lived in Portland on and off since 2001, and I’ve lived in quite a few places in the United States and in the world.  I am a white, cis-female, neurotypical human being. But even though I am these things, I want to assure you –whoever is blessing me by reading my post here– that I am doing my best to seek training and experiences so that you are safe in my care.  You’ve maybe looked around my website to get a sense of who I am and what I offer to my patients.  I want to, straightaway, tell you my core values:

I value quality of life.

I value informed autonomy and agency – a.k.a. independence –
within an interdependent society.

I value a strong and resilient sense of self.

I believe these things are the root of healthy self-esteem, healthy relationships and the basis of a secure place in society.

I’m currently starting up my practice, but once it’s rolling smoothly I hope to donate some of my net income (after my professional bills are paid but before I get paid) to charities that will support vulnerable people in our country. There are so many to choose from that I haven’t decided yet, but I think the ACLU reflects my values pretty well.  They are also generous in lending lawyers to other organizations who defend the vulnerable among us.

I look forward to meeting you, and hope I can be a bridge to your becoming whole!