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Archive for July, 2008

A Guide for Confronting Patients

I sometimes lecture on science-based medicine to my colleagues and one of the most common questions I get is how to deal with a patient who expresses belief in unscientific treatments. The dilemma for the physician is that professionalism requires that we do not confront patients regarding their personal beliefs. We are there to inform and advise, not preach. And yet proper medical care is often hampered by unscientific beliefs on the part of patients.

David wrote previously about a case he reviewed in which a woman with a very treatable early stage of breast cancer opted for “alternative” treatment rather than the standard treatment, which carries a > 93% good outcome. As a result her cancer progressed horribly – but she clung to belief in CAM despite its obvious failure in her case. This story highlighted the fact that giving patients proper medical advice sometime requires confronting their false beliefs.

Unscientific and bizarre medical practices are in vogue and are increasingly infiltrating the medical system through a combination of misguided political correctness, stealth, and apathy. This is exacerbating the dilemma for science-based practitioners who are caught between the imperative to do the right thing in accordance with evidence-based guidelines and the default respect for the patient and the desire to maintain a therapeutic relationship.

In my experience, however, these two goals do not have to be mutually exclusive. An uncompromising but non-judgmental approach works very well.

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Posted in: Medical Ethics

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Should I Take a Multivitamin?

I’ll start with a confession. I used to do something irrational. I used to take a daily multivitamin, not because I thought there was good scientific evidence to support the practice, but for psychotherapy. I tried to eat a healthy diet and worried about it. By taking a pill, I could stop worrying.

Then I found out that higher intake of vitamin A was associated with an increased risk of hip fractures in postmenopausal women like me, and I stopped. (High doses of vitamin A also cause births defects and are contraindicated in pregnancy.) Now I only take supplemental calcium and vitamin D, not on general principles but because of personal risk factors.

We’re being bombarded by advice to take vitamins and various other supplements. Health gurus like Andrew Weil recommend that everyone take vitamins (which they just happen to sell). The orthomolecular followers of Linus Pauling want us to take megadoses of vitamins. Ray Kurzweil tells us we should take vitamins to make us live longer; he takes 250 vitamin and supplement pills a day and thinks he will live forever. (You can read about his ideas in his book Fantastic Voyage: Live Long Enough to Live Forever.) Who should we believe? (more…)

Posted in: Herbs & Supplements, Nutrition

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When “investigative reporting” becomes anti-vaccine propaganda

Introduction: The following is the text of a letter that I mailed to Bob Sliva, General Manager of WXYZ-TV in Detroit in response to arguably the most biased and incompetent “investigative report” about mercury, vaccines, or autism that I have ever seen. I sent the letter by snail mail, because I was always taught that that gets a station manager’s attention far better than e-mail. My plan was to allow the three days until today for the letter to arrive and then to publish the text of my letter here on SBM as an open letter. After I mailed my letter, I worried that no one would bother to look at links that they had to type in themselves, which is why I wanted to post this as an open letter whose link I could then e-mail to the station.

I also worried that maybe I had been insufficiently polite and persuasive, given that one is always urged not to be too insulting or strident when writing to a media outlet. After all, if I were too strident, Mr. Sliva would find it easy to write me off as a biased crank. I also worried that maybe I should have e-mailed Mr. Wilson first. On the other hand, Mr. Wilson is a serial offender. In 2003 and 2004, he did a series on mercury, vaccines, and autism that credulously parroted all the pseudoscience, distortions, and misinformation that we’ve come to expect from the anti-vaccine movement. About two weeks before the “Green Our Vaccines” rally, my routine monitoring of the anti-vaccine underground turned up references to a story that Wilson was working on about the rally and the thimerosal issue. Believers in the myth that vaccines cause autism described Wilson and his earlier report in glowing terms, which sent up huge red flags to me. The original links no longer function, but, thanks to the Wayback Machine, I was able to find the transcripts of the original reports (1, 2, 3, 4, 5). This “reporting” (if you can call it that) somehow garnered an Emmy Award, showing that an award, even a normally prestigious one, is no guarantee of anything resembling scientific accuracy in reporting.

However, it was Mr. Wilson’s comments and behavior after a post by a friend of mine, Dr. Peter Lipson, that made me realize that dealing directly with Wilson was a waste of time and that I was right to go straight to the General Manager. I’ll show why in an addendum and will also add references to sources that refute Wilson’s one-sided and credulous reporting. It’s funny how such a pit pull of an “investigative journalist” who goes after politicians and others with such tenacity can’t find it in himself to ask even a mildly probing question when interviewing “luminaries” such as Boyd Haley or parents with no scientific background repeating anti-vaccine talking points. In any case, here follows the text of the letter that I sent to Bob Sliva, the Vice President and General Manager of WXYZ-TV:

July 9,2008Bob Sliva
Vice President/General Manager
WXYZ-TV
20777 West Ten Mile Road
Southfield, MI 48037

Dear Mr. Silva:
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Posted in: Neuroscience/Mental Health, Science and the Media, Vaccines

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Science, Reason, Ethics, and Modern Medicine Part 1: Tu Quoque and History

Several weeks ago I argued here that a physician’s primary ethical obligation is to science and truth. In retrospect I probably should have put it a slightly different way: a physician’s primary ethical obligation is the same as everyone else’s. It is to honesty and integrity. For physicians, however, that means being true to real medical knowledge, among other things, and real medical knowledge comes from science. That is what this and the next several posts will be about.*

First, a little Tu Quoque

After reading some of the comments that followed my posting of two weeks ago, I reluctantly thought to add a few words about the medical profession’s view of physicians selling drugs. It felt tiresome to have to address the issue, because it is beside the point. The series was about “naturopathic medicine,” not about modern medicine. If readers who understand the point will excuse the interruption, I’ll quickly attempt to explain why by posing two extreme possibilities: If MDs are entirely innocent of the relevant breach of ethics, what would that have to do with naturopaths selling drugs? But if MDs are entirely guilty, two wrongs don’t make a right—demonstrating the same irrelevancy.

That is why the ”you should talk” sneer is known, in debate, as the tu quoque (“you too”) fallacy. It’s funny how parents seem to recognize it when faced with children who, in seeking permission to engage in dubious activities, invoke the parents’ own sordid histories or the equally irrelevant, alleged prerogatives of other people’s children. Yet the same parents appear to forget it in other contexts.

I was also weary and wary of those who would draw me into a strawman debate pitting the medical profession against any group of sectarian health advocates. I have only a small sense of “solidarity” with the group of people who have MD degrees, and even less so with organized medicine. My first allegiance, as I’ve explained elsewhere, is to science and reason. Those modes of inquiry, together with their obvious bearing on the integrity of all claims about nature, are the bases for my objections to naturopathy and to pseudoscience in general. The medical profession per se is related but not central to the issue. While thinking about these things, it dawned on me that a discussion of why that is might be useful. (more…)

Posted in: Medical Ethics, Science and Medicine

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Cavalcade of Quackery: A Pantomine Horse

Last week I received the news release below that Steve Zeitzew, an orthopedic surgeon at VA Hospital Los Angeles and UCLA, sent to the Healthfraud list. It was sent to me by our colleague Liz Woeckner, President of the nonprofit research protection advocacy organization Citizens for Responsible Care in Research (CIRCARE) http://www.circare.org/
Ms. Woeckner sent it on with a cryptic comment, wondering if this action was a quid pro quo for the Chinese granting less than a dozen FDA “inspection stations” in Chinese cities. The latter is supposed to be an attempt to control the impurities and adulterants of Chinese herbal products.

But before proceeding, read for yourselves:

Monday, June 16, 2008 Contact: HHS Press Office

HHS Secretary and Chinese Minister of Health Sign Memorandum of Understanding on Traditional Chinese Medicine Research .

HHS Secretary Mike Leavitt today signed a memorandum of understanding with Chinese Vice Minister of Health Wang Guoqiang to foster collaboration between scientists in both countries in research on integrative and traditional Chinese medicine. The signing marks the opening of a two-day traditional Chinese medicine Research Roundtable at the National Institutes of Health (NIH). The roundtable features scientific presentations by researchers from China and the United States. Topics include the synthesis of Western medicine and traditional Chinese medicine, criteria for evaluating traditional Chinese medicine practices, and the application of modern scientific tools such as proteomics (the study of proteins) to the study of traditional Chinese medicine. “Many Americans incorporate alternative medical practices into their personal health care and are interested in the potential of a variety of traditional Chinese medicine approaches,” Secretary Leavitt said. “This project will advance our understanding of when and how to appropriately integrate traditional Chinese medicine with Western medical approaches to improve the health of the American and Chinese people.” The memorandum of understanding and the establishment of the international collaboration will aid in furthering scientific research on traditional Chinese medicine. Participants in the roundtable include a delegation from the Chinese State Administration on Traditional Chinese Medicine, academics from U.S. universities, and scientists and researchers from NIH, Indian Health Service and the Food and Drug Administration (FDA). Thirty-six percent of Americans use some form of complementary and alternative medicine (CAM), according to the 2002 National Health Interview Survey. In the United States, traditional Chinese medicine is an alternative medical system that is considered a part of complementary and alternative medicine. Integrative medicine combines mainstream medical practices with alternative medical practices. Traditional Chinese medicine involves numerous practices including acupuncture, tai chi, and herbal therapies. In 2007, NIH’s National Center for Complementary and Alternative Medicine (NCCAM) supported nearly $20 million in research on traditional Chinese medicine practices. Secretary Leavitt was joined at the signing by FDA Commissioner Andrew von Eschenbach, M.D., and NCCAM Director Josephine P. Briggs, M.D. The roundtable, which was coordinated by NCCAM, National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine and the Fogarty International Center, is being held in advance of the Fourth Session of the United States-China Strategic Economic Dialogue, which began today in Annapolis, Md.

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Posted in: Acupuncture, Clinical Trials, Herbs & Supplements, Science and Medicine

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Should We Study Chelation for Autism?

The National Institute of Mental Health (NIMH) supports doing a study on the effects of oral chelation therapy in autism. The proposal is highly controversial, is drawing criticism from many scientists, but has popular support among parents who believe this type of therapy might help their children with autism. The proposal raises many questions about the ethics of biomedical research.

Chelation and Autism

Chelation therapy is a legitimate FDA approved treatment for heavy metal poisoning. The drugs used for chelation, such as disodium EDTA, bind to heavy metals so that they can be removed from the body. Chelation drugs can be given either orally or intravenously. The treatment is somewhat risky because it can also remove needed electrolytes, like calcium, from the body or causes shifts in the electrolytes that can cause arhythmias and changes in brain function. There are reported cases of cardiac arrest and death due to chelation.

Chelation therapy has a long history of quackery – not for its intended use but for other uses for which there is no evidence. The classic example of this is the use of chelation therapy to treat atherosclerosis to prevent heart disease. This claim persists despite the utter lack of evidence for efficacy and the fact that all proposed mechanisms have been shown to be flawed or false.

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Posted in: Clinical Trials, Medical Ethics, Neuroscience/Mental Health, Vaccines

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Are Cardiologists Ordering Too Many CT Angiograms?

A really snazzy new invention allows doctors to see inside their patients’ hearts as never before: the CT angiogram. It produces gorgeous 3-D video images of the beating heart in action. It allows us to see the blood flow through the heart’s chambers and it shows any plaque in the coronary arteries. Cardiologists are understandably excited about this new tool. Too excited. Some of them are using it indiscriminately and are getting half their income from using it.

On June 29, 2008 the New York Times published an excellent article entitled “Weighing the Costs of a CT Scan’s Look Inside the Heart.” A commenter on this blog has quoted from that article to criticize scientific medicine, and it brings up some important points that deserve a closer look.

With any new technology, the important question is whether it really improves patient outcome or just increases the cost of healthcare. These scans are a huge improvement for visualizing the heart. But are they any better than older diagnostic methods at actually preventing heart attacks or prolonging life? We don’t know yet. Will they cause harm through over-diagnosis? We don’t know yet. Will they cause radiation-induced cancers? We think they might. What’s the risk/benefit ratio? We don’t know yet.

Oprah thinks she knows. She’s urging her viewers to get tested. But she may not be the best source of medical advice. (more…)

Posted in: Science and Medicine

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Death by “alternative” medicine: Who’s to blame?

One of the more annoying duties I used to have several years ago at our cancer center was to “show the flag” at our various affiliates by attending their tumor boards. I say “annoying” not so much because the tumor boards themselves were onerous or even uninteresting but rather because traveling to them used to cut into my already limited time for research, given that these tumor boards were always scheduled on days on which I didn’t have to be in clinic or the operating room. In other words, they always took place on my research days.

One of our affiliates was a nearly an hour and a half drive away, and many of them were close to an hour away. When you add up travel time and the tumor board, that’s easily more than three hours eaten up, all too often right in the middle of the day. In actuality, though, several of the tumor boards themselves were quite good, one of which being the aforementioned one that required nearly a 90 minute drive to reach. (It helped that they served a really nice breakfast there, too, but they also have really stimulating discussion about various cancer cases.) One of the weird things about these tumor boards is that I was viewed as–and I quote–the “outside expert.” This was particularly disconcerting the first year I had the job. There I was, fresh out of fellowship, being looked up to as the “expert” by physicians, many of whom who may have been in practice for 10, 20, or even 30 years. Somehow I managed to muddle through without making too big a fool of myself. These days, years later, I almost even feel as though, for breast cancer at least, I am worthy of the appellation of “outside expert.” Experience does matter, I guess.
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Posted in: Health Fraud

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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4

The “Science” and Ethics of “Natural Medicines” (and Nutrition) cont.

This is the continuation of a discussion concerning the explicit claim of “naturopathic physicians”* to being experts in the use of “natural medicines,” defined as “medicines of mineral, animal and botanical origin.” Last week’s post established that the cult has chosen to profit from the “retail selling of medications,” as evidenced by the relevant Position Paper of the American Association of Naturopathic Physicians (AANP) and by that organization’s having made a deal with a drug company to make profits for both itself and its members.

The Position Paper observes that such selling “could be construed as a conflict of interest on the part of the physician.” That is true, if embarrassingly understated: anyone representing himself as a physician, who both recommends and sells the same medications for a profit, has conflicting interests. The conflict undermines his claim to offering responsible advice regarding those medications, and as such is a breach of medical ethics.

The AANP’s deal with MotherNature.com was even worse: by promoting such peddling in a formal, institutional fashion, NDs and their national organization went beyond the already widespread problem of practitioners hawking drugs. It is unclear whether the deal still exists, by the way: MotherNature.com was a victim of the “dot com” bust of a few years ago. It has since been resurrected, but a quick perusal of its new website fails to reveal the old AANP relationship. Nevertheless, I have seen no evidence to suggest that the AANP has changed its view of that sort of deal.

Are NDs Truly “Learned Intermediaries” in the Use of “Natural Medicines?”

This entry discusses the other part of the claim of expertise: that, aside from their conflicting interests, NDs have real knowledge of “natural medicines.” It will become clear during the discussion that the purported naturopathic expertise in nutrition—another standard claim—is also under review. I will include or cite abundant evidence for my assertions, because I’ve found that a predictable response of representatives of the highest levels of “naturopathic medicine” is to flatly deny them. I apologize again for including excerpts from previously published material.

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Posted in: Book & movie reviews, Health Fraud, Herbs & Supplements, Medical Ethics, Nutrition, Politics and Regulation

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The Placebo Myth

King Arthur: Now stand aside, worthy adversary.
Black Knight: ‘Tis but a scratch.
King Arthur: A scratch? Your arm’s off.
Black Knight: No it isn’t.
King Arthur: What’s that, then?
Black Knight: [after a pause] I’ve had worse.
King Arthur: You liar.
Black Knight: Come on ya pansy.King Arthur: [after Arthur's cut off both of the Black Knight's arms] Look, you stupid Bastard. You’ve got no arms left.
Black Knight: Yes I have.
King Arthur: Look!
Black Knight: It’s just a flesh wound.Monty Python and the Holy Grail

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I am, I think, in a minority on this blog, in that I do not think there is a placebo effect. Period. None. Zip. Zero. Nada. Zilch.

For analysis purposes, I divide the lack of placebo effect into outcomes that do not occur with objective measurement and those that do not occur with subjective measurement.

Why the dichotomy? Those studies where there have been an active treatment, a placebo treatment and an observation group, have demonstrated no difference between observation and placebo (1). To summarize from the conclusion of the compelling NEJM review:

“We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.”

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Posted in: Science and Medicine

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