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Archive for 2012

Adventures in defending science-based medicine in cancer journals: Energy chelation

My co-bloggers and I have spent considerable time and effort over the last four years writing posts for this blog (and I for my not-so-super-secret other blog) bemoaning the infiltration of quackademic medicine into what once were bastions of evidence- and science-based medicine. We’ve discussed at considerable length reasons for why this steady infiltration of pseudoscience into medical academia has been occurring. Among other potential explanations, these reasons range from the ascendence of postmodernism in areas where it really doesn’t belong; to a change in our medical culture to a more “consumer”-oriented, “keep the customer satisfied”-sort of model in which patients are often referred to as “clients” or “customers”; to the corrosive influences of moneyed groups (such as the Bravewell Collaborative) and government agencies (such as the National Center for Complementary and Alternative medicine, a.k.a. NCCAM); to the equally corrosive influences of powerful woo-friendly legislators who use their position and influence to create such agencies (such as Senator Tom Harkin and Representative Dan Burton) and otherwise champion “complementary and alternative medicine” (CAM) and “integrative medicine” because they are true believers in quackery; to cynical legislators, like Senator Orrin Hatch, who champions such government programs supporting pseudoscience because he represents a state that is home to the largest concentration of supplement manufacturers in the United States and is consequently a master at bringing any initiative to regulate the supplement industry more tightly to a screeching halt.

As a result of our efforts and the need for a counterweight to the quackery that has infiltrated so much of academia, SBM has become fairly prominent in the medical blogosphere. Our traffic is good, and we have a number of “thought leaders” who regularly read what we write. We’ve even caught the attention of Dr. Josephine Briggs, director of NCCAM, and our founder Steve Novella was even invited to appear on The Dr. Oz Show for “balance.” All of this is something that we are justly proud of. On the other hand, I can’t help but keep things in perspective. While our traffic as a blog is quite respectable and we have become prominent in the skeptical and medical blogosphere and even, to some extent, in academia—we’re particularly gratified at the number of medical students who are regular readers—compared to the forces arrayed against SBM in academia and the media, we have to face facts: We are truly a tiny voice in the wilderness. For instance, we average around 9,000 to 16,000 visits a day. Compare that traffic to the many millions who used to watch Oprah Winfrey and still watch her protégé Dr. Oz or to health media and product empires of people like Andrew Weil and Deepak Chopra, and you get the idea.

All of this is why I started looking for opportunities to respond more directly to incursions of pseudoscience into medical academia. Occasional SBM contributor Peter Lipson provided me with just such an opportunity last summer when he sent me a link to a brain-meltingly bad study about the use of CAM in cancer that shows just how bad a study can be and still be published in what I used to consider a reasonably good cancer journal. I say “used to consider,” because the fact that this journal accepted a study this ludicrous indicates to me that its peer review is so broken that I now wonder about what else I’ve read in that journal that I should now discount as being too unreliable to take seriously. Maybe everything. I don’t know. What I do know is that seldom have I seen such a bad study in such a good cancer journal. Studies like the one about Tai Chi in fibromyalgia or placebo acupuncture applied to asthma don’t even come close.

Soon after this study appeared online ahead of print, James Coyne contacted me and asked me if I wanted to be co-author on a letter to the editor of the journal. Honored by Dr. Coyne’s request, I immediately said yes (of course), and together with Dr. Christoffer Johansen at the Survivorship Unit of the Danish Cancer Society, we submitted our letter to the editor. To my surprise, given the utter failure of past efforts to publish letters to the editor about studies of this sort, our letter was accepted for publication. Last week, the study in question saw print, and our letter was published online ahead of print, along with the response of the authors. All are instructive and, to me, show just what we are up against in trying to prevent pseudoscience from creeping into academia.
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Posted in: Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Medical Academia

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Placebo Again.

Medicine is simultaneously both easy and hard. As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Sometimes it is just that simple. A lot of the time it isn’t. I may not be certain what the infection is, or even if the patient has an infection, or allergies and/or antibiotic resistance limit therapeutic options, the host has co-morbidities that limit effectiveness, and the patient has no financial resources for the needed treatment.

I am lucky, since most infections are acute, make people feel terrible, and require a relatively short course of therapy during which the patient feels better. I rarely have to worry about compliance with the treatment plan; it is the rare patient, usually a heroin user or a particularly irascible old man, who will not follow through with their antibiotic course. I do not have to worry about chronic or symptomless diseases like diabetes or hypertension or the complications of obesity where long term compliance often limit therapeutic success. Long term it is difficult for many people to stick with their therapeutic plan, much less their diet and exercise resolutions.
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Posted in: Acupuncture, Medical Ethics, Science and Medicine

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Night of the living naturopaths

Colorado’s “degreed” naturopaths (NDs) are nothing if not persistent. Starting in 1994 they have tried seven times to convince legislators that the Colorado’s public needs protection from what “traditional” naturopaths (traditionals) do, and that the best way of providing that protection, they claim, is to bestow licensure on the guys with the college degrees. The irony in this is that the NDs could well be the more dangerous practitioners.

Legislators have been largely sympathetic to the concerns of the more numerous traditionals who fear the loss of their right to work as naturopaths. The NDs have tried neutralize these opponents by reassuring them they could continue to practice naturopathy, but the traditionals don’t buy that. And they won’t easily forfeit the title of “naturopath” to which they believe to have more claim.

So what we have here in Colorado is near 20-year turf war between two types of naturopaths: the NDs who seek legislation to transform naturopathy into a protected guild, and the traditionals who are happy with the status quo. There is no love lost between these groups. Legislators repeatedly advise them to resolve their differences before asking for licensure again, but they haven’t gotten close to détente.

Colorado NDs have made no secret of their economic motivations. Before the 2011 legislative session, the Colorado Association of Naturopathic Doctors (CAND) was reinvigorated by the passage of the Patient Protection and Affordable Care Act which has this “non-discrimination” provision:

(a) Providers- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. [Sec. 2706]

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Posted in: Naturopathy, Politics and Regulation, Public Health

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What Is Traditional Chinese Medicine?

One of the themes of science-based medicine is to be suspicious of any form of medicine that is not science-based. In other words, beware of dodgy qualifiers placed before “medicine,” such as: “alternative”, “integrative”, or “complementary” – those that imply that something other than science or evidence is being used to determine which treatments are safe and effective. I would also include “traditional Chinese” medicine in the dodgy category.  A recent article defending Traditional Chinese Medicine (TCM) provides, ironically, an excellent argument for the rejection of TCM as a valid form of medicine. The authors, Jingqing Hua and Baoyan Liub, engage in a number of logical fallacies that are worth exploring.

Their introduction sets the tone:

Traditional Chinese medicine (TCM) has a history of thousands of years. It is formed by summarizing the precious experience of understanding life, maintaining health, and fighting diseases accumulated in daily life, production and medical practice. It not only has systematic theories, but also has abundant preventative and therapeutic methods for disease.

It may be trivially true that TCM has a long history, but it is hard to ignore that the placement of this statement at the beginning of a scientific article implies an argument from antiquity – that TCM should be taken seriously because of this long history. I would argue that this is actually a reason to be suspicious of TCM, for it derives from a pre-scientific largely superstition-based culture, similar in this way to the pre-scientific Western culture that produced the humoral (Galenic) theory of biology.

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Posted in: Acupuncture, Energy Medicine, Science and Medicine

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An Owner’s Manual for the Heart

In writing about science-based medicine, we give a lot of attention to medicine that is not based on good science. We use bad examples to show why science is important and how it is frequently misapplied, misinterpreted, misreported, or even wholly rejected. It’s a pleasure, for a change, to write about a straightforward example of the best of science-based medicine in action. The book Heart 411 is such an example.

The medical literature is a jungle of conflicting and complicated studies. It’s difficult for novices and even for sophisticated non-specialists to navigate. It’s useful to have experts as guides who can apply their knowledge, experience, and judgment to analyze the data and put everything into perspective. I can’t imagine anyone more qualified as guides to “matters of the heart” than the authors of this book. Heart surgeon Marc Gillinov and cardiologist Steven Nissen practice at the Cleveland Clinic, which has been ranked as the number one heart hospital by U.S. News & World Report for the last 15 years and is currently ranked 4th best hospital overall. They have treated more than 10,000 heart patients over 30 years of clinical practice and have also done extensive research and published hundreds of articles in peer reviewed journals. Their book contains everything they would like their patients to know about the prevention, diagnosis, and treatment of  heart disease.  It amounts to an owner’s manual for the heart.  (more…)

Posted in: Book & movie reviews, Science and Medicine

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Legislative alchemy (briefly) revisited: Naturopathy in Vermont and colloidal silver

A couple of weeks ago, Jann Bellamy wrote about “legislative alchemy” in the new year, in which CAM mischief works its way into state legislatures. Specifically, she mentioned the case of legislators in Vermont trying to declare in law that naturopaths are primary care physicians, who can serve as a patient’s medical home without supervision by real doctors.

Rosemary Jacobs, whose life was altered irrevocably when she developed agyria due to colloidal silver noticed another aspect of this new proposed law:

I recently learned that Vermont licenses naturopaths, NDs, as physicians and that they have a state sanctioned formulary, a list of drugs they can prescribe and administer to patients. To my horror, the 2009 formulary includes “colloidal silver preparations” to treat eye infections and “silver” which they can administer intravenously.
http://www.vtprofessionals.org/opr1/naturopaths/info/Naturopathic Physician Formulary 20091211.pdf [pdf download]

I was horrified because of the danger this poses to patients, the incredible ignorance it shows on the part of naturopaths, and because NDs had, without my knowledge, been licensed in Vermont to administer prescription drugs and other strange substances like silver and tin, do physical exams and order the same diagnostic tests that MDs order.

How had this happened without my knowledge? I have been following alternative medicine for 15 years and warning people about the danger of ingesting silver, an alternative “remedy”, because I don’t want anyone else disfigured by it like I was over 50 years ago.

Silver drugs were used by medical doctors before the advent of antibiotics. Although they didn’t work, they permanently turned many people blue and gray. The condition is called argyria. It was formerly common, and is well documented and understood by scientists.

If NDs had known as much about medicine as I, an educated consumer, do, they would have searched the medical literature before including anything in their formulary. If they had done that, they would have seen that: there are no studies showing that ingesting silver in any form or amount offers benefits; colloidal silver does not treat eye infections; taking silver internally or putting it in your eye can result in permanent discoloration.

Colloidal silver is nonsense. There’s no evidence that it is good for anything. Rosemary also revealed to me something I didn’t know before, namely that there’s another woo-friendly Senator that I didn’t really know about: Bernie Sanders, who, according to her, helped naturopaths become players in the medical marketplace.

Posted in: Legal, Naturopathy

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Reassessing whether low energy electromagnetic fields can have clinically relevant biological effects

It is with some trepidation that I write this, given that I realize this post might lead to charges that I’ve allowed myself to become so open-minded that my brains fell out, but I think the issues raised by what I’m about to discuss will make our readers think a bit—and perhaps spark some conversation. Because I’m in a bit of a contrarian mood, I’ll take that risk, although it’s possible I might end up with the proverbial egg on my face. As our regular readers know, the issue of the health effects of radiation from mobile phones has been a frequent topic of this blog. The reasons are obvious because fear mongering claims not based in science are frequently made in the lay press and in books (for example, Disconnect by Devra Davis) and, unfortunately, also by some physicians and scientists. Moreover, like homeopathy, the issue demands a discussion of prior probability and plausibility based on basic science alone, but the issues are a bit less clear-cut. Whereas the tenets of homeopathy clearly violate multiple laws of physics and chemistry, it is possible, albeit very unlikely, that radio waves might produce significant biological changes.

There’s also sometimes a maddening dogmatism on the part of some physicists that it’s “impossible” that long term exposure to radio waves could possibly cause cancer because such electromagnetic waves do not have anywhere near enough energy to cause ionization and thereby break chemical bonds. While it is certainly true that such radio waves can’t break chemical bonds and the likelihood that the radio waves from cell phones can cause cancer appears very low based solely on physics considerations, all too often the arguments made based on physics considerations alone use a simplistic understanding of cancer and carcinogenesis as their basis. It’s not for nothing that I have referred to such arguments as being based on a high school or freshman level of understanding about cancer—or just an outmoded understanding that prevailed a decade or two ago but today no longer does. Bernard Leikind, for instance, argued and famed skeptic Michael Shermer accepted that, because the radio waves used in cellular communications are too low energy to break chemical bonds and do not produce significant heating compared to other sources, “cell phones cannot damage living tissue or cause cancer.” Note the implicit assumption: That it is somehow necessary to “damage” living tissue in order to cause cancer. That’s an assumption that is arguably quite simplistic and ignores knowledge we’ve gained about epigenetics and how potential metabolic influences might cause cancer. Cancer is associated with characteristic cellular metabolic abnormalities, and determining which is responsible for the formation of cancer, metabolic abnormalities or gene mutations, has become a “chicken or the egg”-type of question.

I do not in any way believe that cell phone radiation actually is a cause of cancer because, unlike the case in homeopathy, where multiple well-established laws of physics would have to be overturned for homeopathy to work, I find the argument that a causation is “utterly impossible” far less persuasive than some physicists do when it comes to cell phone radiation and cancer. Even dismissing the “impossibility” argument, however, clearly such a link is at the very least incredibly implausible on physics considerations alone, as I have pointed out time and time again. Add to that the nearly completely negative epidemiological data in which only one group of researchers has been able to produce apparently “positive” studies, and my personal conclusion is that we probably already have enough data to reject a connection between radio waves and cancer and don’t need any more new large epidemiological studies; following up long term results on the ones already under way should be sufficient. That is not the same thing as arguing that radio waves have no significant biological effect, which is what, in essence, the argument from physics is based on. In fact, the inspiration for the rest of this post came from a meeting I had last week with a scientist and that scientist’s talk for our cancer center’s weekly Grand Rounds. What I learned did not demonstrate that cell phones cause cancer or even that they might cause cancer. Not even this scientist claimed his results were consistent with cell phone radiation causing cancer; in fact, he quite clearly stated they were not. However, what I learned from him cast some doubt (to me, at least) on the assumption that radio waves cannot have profound biological effects. In fact, ironically enough, this scientist is proposing the use of amplitude-modulated (AM) radio waves to treat cancer. I’m not yet convinced by any stretch of the imagination that this researcher is on to something, but his findings made me think about the perils and pitfalls of declaring something “impossible” solely on basic science considerations, because he has some very intriguing results that I can’t find a compelling reason to dismiss.

And, at least as of now, there’s no known physical mechanism that can explain his findings. Leaving aside the possibility of fraud or some sort of systematic bias that is not apparent in the methods sections of the papers I’m about to summarize, either he’s found something new and potentially promising, or he’s somehow very, very wrong.
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Posted in: Basic Science, Cancer, Clinical Trials

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Podcast Interlude

I’m traveling this week, checking out pharmacy practice internationally, and looking for signs of science-based medicine. Instead of a post, here are the links to two podcasts I recently recorded that will be of interest to SBM readers. Sit back, press play, and enjoy.

Point of Inquiry: Dispensing Skepticism

I recently spoke with Karen Stollznow for the Point of Inquiry podcast. This discussion focused on the role of the pharmacist and the need for science-based pharmacy practice. We touched on a lot of issues including the changing role of the pharmacist, the ethical responsibilities of pharmacists when it comes to products like homeopathy, what compounding pharmacies do, what generic drugs are, what an expiry date means, what pharmacists think about vitamins and other supplements, and more. You can listen to the podcast here.

Skeptically Speaking: The Common Cold

I was recently the guest of Desiree Schell on Skeptically Speaking, where we spent an hour discussing the prevention and treatment of the common cold. You can listen to the podcast, and I’ve compiled a long list of related links and references on cold treatment for your reading pleasure too.

 

 

 

Posted in: Announcements

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Aspirin Risks and Benefits

A new review published in the BMJ once again opens the question of the risks vs benefits of daily aspirin as a prevention for heart attacks and strokes. The reviewers looked at nine randomized trials involving over 100,000 patients and found that aspirin is effective in reducing heart attacks and strokes, but also increases the risk of gastrointestinal bleeding and that in some patients this risk outweighs the benefit.

This is an old and enduring controversy, and one with significant public health ramifications. Aspirin is an anti-platelet agent – it inhibits platelets, the cell fragments in the blood that are the first line against bleeding, from aggregating (clumping together). Platelets aggregate in order to quickly stop bleeding from damaged veins or arteries. But they can also aggregate around cholesterol plaques in arteries, causing a large thrombus (blood clot) that can block off the artery, or that can break off and lodge in a downstream artery (an embolus) and cause a stroke or heart attack.

By inhibiting platelet aggregation daily aspirin reduces the risk of forming a thrombus or embolus, and thereby reduces the risk of heart attack or stroke. Of course, the real story is always more complex than our straightforward explanations. There is some research to suggest that the anti-inflammatory effects of aspirin may also be important to their role in reducing vascular risk. The relative contribution of anti-platelet and anti-inflammatory effects have not been fully teased out. Further, the anti-inflammatory effects of daily aspirin may have non-vascular benefits, like reducing the risk of some cancers.

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Posted in: Public Health

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Visceral Manipulation Embraced by the APTA

Many years ago, when I was a naïve and gullible teenager, I read about a home treatment for constipation that involved rolling a bowling ball around on the abdomen. I was intrigued, thought it sounded reasonable, and might even have tried it myself if I had been constipated or had had a bowling ball to experiment with. Many decades later, with the advantages of a medical education and experience in science-based medicine and critical thinking, I encountered a treatment that reminded me of the bowling ball: visceral manipulation (VM), a practice developed by a French osteopath and physical therapist, Jean-Pierre Barral. This time I was far more skeptical. VM may be more sophisticated than a bowling ball, but its effectiveness and safety are equally dubious.

Visceral manipulation (VM) will probably be unfamiliar to most of my readers, but its promoters say it has been adopted by osteopathic physicians, “allopathic” physicians, doctors of chiropractic, doctors of Oriental medicine, naturopathic physicians, physical therapists, occupational therapists, massage therapists and other licensed body workers. Its origin follows the path of many other alternative health systems. Like chiropractic, ear acupuncture, iridology, EMDR, and others, it was developed by one individual based on his personal observations and experiences without any kind of proper testing. Like the others, it started with a single patient: in Ignaz von Peczely’s case an owl with a spot on its iris, in D.D. Palmer’s case a janitor whose hearing allegedly improved after something was done to his back, in Barral’s case a patient who said he had felt relief from his back pain after going to an “old man who pushed something in his abdomen.” From a single case they extrapolated to a general belief about disease causation and a whole diagnostic and/or treatment system.

How is VM Done?

A video shows Barral demonstrating his skills.  He “listens with his hands” to detect tension (elsewhere the perception is designated as a thermal phenomenon). His diagnostic process begins by “listening with the hands” on the top of the patient’s head to determine the lateralization or general area of the problem. Then his hands “listen” to the areas of concern to further localize the problem.  In this demonstration he detects something in the stomach which he says could be from decreased acidity or emotional tension. Then he listens to the skull repeatedly with both hands, does something simultaneously to the neck and abdomen, and finally he is satisfied that his hands are telling him that he has corrected the problem. (more…)

Posted in: Energy Medicine, Science and Medicine

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