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Archive for July, 2011

CAM: The Beer Goggles of Medicine

It is summer, the kids are off, and time to write dwindles in the face of sun and golf. Nonsense knows no season, and in my readings this week I came across the phrase “the undeniable power of the placebo.” I will do my best to deny that power at least three times before the I crow my conclusion.

One of my first entries for SBM, back in the mists of time, was the Placebo Myth [0], where I argued that the placebo has no clinical effects, has clinically irrelevant alleged physiology and at most leads to a slight change in perception on the part of the patient that they have less pain. Essentially placebo does nothing. It has no power.

Two studies this month continue that argument: demonstrating that placebo has no practical benefit and the crowing in the media mistakenly trumpets that it does. The headline on Medscape [1] reads “Placebo Effects Modest in Treating the Common Cold.” How modest?

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Posted in: Clinical Trials, Science and Medicine

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Consumer Reports drops the ball on alternative medicine

Ever since I was a teenager, I’ve intermittently read Consumer Reports, relying on it for guidance in all manner of purchase decisions. CR has been known for rigorous testing of all manner of consumer products and the rating of various services, arriving at its rankings through a systematic testing method that, while not necessarily bulletproof, has been far more organized and consistent than most other ranking systems. True, I haven’t always agreed with CR’s rankings of products and services about which I know a lot, but at the very least CR has often made me think about how much of my assessments are based on objective measures and how much on subjective measures.

Until now.

I just saw something yesterday on the CR website that has made me wonder just how scientific CR’s testing methods are, as CR has apparently decided to promote alternative medicine modalities by “assessing” them in an utterly scientifically ignorant manner. Maybe I just haven’t been following CR regularly for a while, but if there’s an article that demonstrates exactly why consumer product testing organizations should not be testing medical treatments; they are ill-equipped to do so and lack the expertise and knowledge. The first red flag was the title, namely Hands-on, mind-body therapies beat supplements. The second red flag was the introduction to the article:

A new survey of subscribers to Consumer Reports found that prescription drugs generally performed better than alternative therapies for 12 common health problems. But hands-on treatments such as chiropractic care and deep-tissue massage, as well as mind-body therapies such as yoga and meditation, held their own, especially for certain conditions. Far fewer said that dietary supplements helped a lot.

Prescription drugs helped the most for nine of the conditions we asked about: allergies, anxiety, colds and flu, depression, digestive problems, headache and migraine, insomnia, irritable bowel syndrome, and osteoarthritis.

But chiropractic care performed better than drugs for back pain, and deep-tissue massage beat drugs for neck pain. Massage was as also as good as drugs for fibromyalgia. Those hands-on therapies also scored near the top for osteoarthritis as well as for headaches and migraines.

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Posted in: Science and the Media

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Varicella Vaccination Program Success

One of the basic human “needs” is the desire for simplicity. We have limited cognitive resources, and when we feel overwhelmed by complexity one adaptive strategy is to simplify things in our mind. This can be useful as long as we know we are oversimplifying. Problems arise when we mistake our schematic version for reality.

In this same vein we also like our narratives to be morally simple, so there is a tendency to replace the complex shades of gray with black and white. This is perhaps related to cognitive dissonance theory. We have a hard time reconciling how someone can be both good and bad, or how a good person can do bad things. So there is also a tendency to see people as all good or all bad. We can transcend these tendencies with maturity and wisdom, but that takes work.

A good example of the desire for simple moral clarity is the anti-vaccine movement. Their world is comprised of white hats and black hats (guess which one they perceive themselves as wearing), as evidenced by the blog posts and comments over at Age of Autism. There is a certain demand for purity of thought and message that seems to be getting worse over time in a self-reinforcing subculture. Many now see their struggle in apocalyptic terms.

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Posted in: Vaccines

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Angell’s Review of Psychiatry

Marcia Angell has written a two-part article for The New York Review of Books: “The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry.” It is a favorable review of 3 recent books:

and an unfavorable review of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR. It paints a disturbing picture of psychiatry. It raises a number of serious concerns but it borders on psychiatry-bashing, a sport that I deplored in a previous post. (more…)

Posted in: Book & movie reviews, Neuroscience/Mental Health

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On the Orwellian language and bad science of the anti-vaccine movement: “SmartVax” versus “MaxVax”?

If there’s one thing that’s true of the human race, it’s that when it comes to persuasion language is has power. Words have power. Just ask the advertising industry or politicians, who rely on their skills manipulating language to persuade for their very livelihood and authority. In the specific bailiwick of this blog, Science-Based Medicine, many of us have spent considerable verbiage describing how advocates of unscientific modalities rebranded as “complementary and alternative medicine” (CAM) and/or “integrative medicine” (IM) are incredibly skilled at the manipulation of language and renaming of terms in order to make them sound more persuasive, particularly to make it sound as though their modalities are scientifically supported or that it’s just another “alternative” to SBM. In fact, Kimball Atwood has made a special study of the language of CAM, even going so far to do an amusing feature that he used to call the Weekly Waluation of the Weasel Words of Woo. Indeed, the very name “integrative medicine” is a masterful term that makes it sound as though they’re just “integrating” the best of scientific medicine and “traditional” or “alternative” medicine when in fact what is happening all too often is the “integration” of quackery with medicine or, as I sometimes like to call it, “integrating” fake medicine with real medicine. Unfortunately, my definition of “integrative medicine” doesn’t appear to be winning, although I was gratified that I got several Tweets during our panel at TAM9 quoting my line about integrating quackery with medicine.

The anti-vaccine movement has been pretty good, albeit not as masterful as, say, Andrew Weil, when it comes to manipulating language to its own end. Who can forget three years ago, when the meme started spreading throughout the anti-vaccine movement that it’s “not anti-vaccine but rather ‘pro-safe vaccine’” and started demanding that the government and pharmaceutical companies “green our vaccines.” The reason is obvious; even anti-vaccine activists know that it’s a public relations loser to be explicitly anti-vaccine, which is Jenny McCarthy and the anti-vaccine groups that participated in her “Green Our Vaccines” rally did their best to downplay and hide their radical anti-vaccine base. They failed. (The signs about vaccines as “weapons of mass destruction” rather undercut the “pro-safe vaccine” message. I’ve dealt with this fallacy before in depth, explaining why it is appropriate to call them “anti-vaccine,” even as they strenuously deny that they are. More recently, the preferred narrative has been “too many, too soon,” which leads me to another term coined by the group SafeMinds and promoted on—where else?—Age of Autism.

Now, the SafeMinds/AoA approach is being dubbed “SmartVax.”
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Posted in: Public Health, Science and the Media, Vaccines

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Asthma, placebo, and how not to kill your patients

A number of years ago I was walking along Lake Michigan with a friend (a fellow medical resident) when she turned to me and said, “are you wheezing?  Do you have asthma?”  I had always been physically active and assumed my breathlessness while walking down the trail was due to the thirty extra pounds of pizza and doughnuts I’d acquired during residency.  But she was right: I was wheezing and breathless and it didn’t feel good at all.  I made an appointment with one of the hospital’s lung docs who took a good history, did a physical, and ran some pulmonary function tests.  And I did have asthma.  And it felt much, much better when I used proper medication, a feeling confirmed by my improving lung function tests. (Not too surprisingly, the asthma got even better when I lost 40 lbs and started treatment for my acid reflux.)

I still get mild asthma symptoms from time to time, especially when I get sick, but for many others, the picture isn’t so pretty.  Asthma kills at least a quarter of a million people every year around the world.   If you’ve ever worked in an ER and seen a kid with a bad asthma attack, you’ve earned a healthy respect for the disease.  If you’ve ever watched your own kid gasping for breath, begging you to make it better, you’ve learned to fear it.

As our understanding of asthma has improved, so has our ability to treat it (an ability that is strongly linked to a patient’s socio-economic status.  Mortality has been rising despite the discovery of better treatments.  Wait: let’s pull this out of the parentheses…)…  Asthma deaths and hospitalizations are largely preventable, and disproportionately affect Black and Hispanic Americans. We know how to treat the disease asthma, but don’t know how to treat the people who are affected most. (more…)

Posted in: Science and Medicine

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

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Salt: More confirmation bias for your preferred narrative

Judging by the recent press reports, the latest Cochrane review reveals that everything we’ve been told about eating salt, and cardiovascular disease, is wrong:

The New York Times: Nostrums: Cutting Salt Has Little Effect on Heart Risk

The Daily Mail: Cutting back on salt ‘does not make you healthier’ (despite nanny state warnings)

Scientific American: It’s Time to End the War on Salt

Sometimes it’s possible to completely miss this point. And that’s what’s happened here.

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Posted in: Science and Medicine

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Behavior and Public Health – To Nudge or Legislate

As health care costs rise and great attention is being paid to the health care system in many countries (perhaps especially the US), the debate is heating up over how to improve public health. Many health problems are greatly increased by the lifestyle choices individuals make – smoking, weight control, and exercise to name a few. The problem is that it is notoriously difficult to change behavior.
There are different ways to approach the challenge of improving lifestyle choices to reduce chronic illness. We can take actions aimed at the individual or aimed at society. These actions can be gentle or passive (the so-called “nudge theory”), or they can be more draconian, such as banning certain activity. We can, of course, do all of these things simultaneously, and may need to in order to have a significant impact.

Affecting Individual Behavior

A common criticism of mainstream physicians is that they do not have much impact on the lifestyle of their patients. This is largely true – although there is no convincing evidence that any practitioners have a significant impact on lifestyle. This is mainly the result of the fact that it is extremely difficult to get people to change their behavior.

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Posted in: Public Health

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Antidepressants and Effect Size

Antidepressant drugs have been getting a bad rap in the media. I’ll just give 3 examples:

  • On the Today show, prominent medical expert :-) Tom Cruise told us Brooke Shields shouldn’t have taken these drugs for her postpartum depression.
  • In Natural News, “Health Ranger” Mike Adams accused pharmaceutical companies and the FDA of covering up negative information about antidepressants, saying it would be considered criminal activity in any other industry.
  • And an article in Newsweek said  “Studies suggest that the popular drugs are no more effective than a placebo. In fact, they may be worse.”

Yet psychiatrists are convinced that antidepressants work and are still routinely prescribing them for their patients. Is it all a Big Pharma plot? Who ya gonna believe? Inquiring minds want to know:

  • Are antidepressants more effective than placebo?
  • Has the efficacy of antidepressants been exaggerated?
  • Is psychotherapy a better treatment choice?

The science-based answers to the first two questions are clearly “Yes.” The best answer to the third question is “It depends.” (more…)

Posted in: Neuroscience/Mental Health, Pharmaceuticals

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