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Archive for March, 2013

It’s a part of my paleo fantasy, it’s a part of my paleo dream

There are many fallacies that undergird alternative medicine, which evolved into “complementary and alternative medicine” (CAM), and for which the preferred term among its advocates is now “integrative medicine,” meant to imply the “best of both worlds.” If I had to pick one fallacy that rules above all among proponents of CAM/IM, it would have to be either the naturalistic fallacy (i.e., that if it’s natural—whatever that means—it must be better) or the fallacy of antiquity (i.e., that if it’s really old, it must be better). Of course, the two fallacies are not unrelated. In the minds of CAM proponents, old is more likely to have been based on nature, and the naturalistic fallacy often correlates with the fallacy of antiquity. Basically, it’s a rejection of modernity, and from it flow the interest in herbalism, various religious practices rebranded as treatments (thousands of years ago, medicine was religion and religion was medicine—the two were more or less one and physicians were often priests as well), and the all-consuming fear of “toxins,” in which it is thought that the products of modernity are poisoning us.

Yes, there is a definite belief underlying much of CAM that technology and pharmaceuticals are automatically bad and that “natural” must be better. Flowing from that belief is the belief that people were happier and much healthier in the preindustrial, preagricultural past, that cardiovascular disease was rare or nonexistent, and that cancer was seldom heard of. Of course, it’s hard not to note that cancer and heart disease are primarily diseases of aging, and life expectancy was so much lower back in the day that a much smaller percentage of the population lived to advanced ages than is the case today. Even so, an implicit assumption among many CAM advocates is that cardiovascular disease is largely a disease of modern lifestyle and diet and that, if modern humans could somehow mimic preindustrial or, according to some, even preagricultural, lifestyles, that cardiovascular disease could be avoided. Not infrequently, evolutionary and genomic arguments are invoked, claiming that the estimated 10,000 years since the dawn of human agriculture is not a sufficiently long period of time for us to have evolved to handle diets rich in grains and meats and that we are “genetically wired” to exist on a diet like those of our paleolithic hunter-gatherer ancestors. For instance, in 2004, James H. O’Keefe Jr, MD and Loren Cordain, PhD wrote an article in the Mayo Proceedings entitled Cardiovascular Disease Resulting From a Diet and Lifestyle at Odds With Our Paleolithic Genome: How to Become a 21st-Century Hunter-Gatherer that asserted in essence, just that. Over the last decade, Cordain has become the most prominent promoter of the so-called “Paleo diet,” having written The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat and multiple other books advocating a paleolithic-mimetic diet as the cure for what ails modern humans. Meanwhile, diets thought to reflect what our hunter-gatherer ancestors ate, such as the Paleo Diet consisting largely of animal and fish that can be hunted and fruits and vegetables that can be foraged for in the wild, have been promoted as a near-panacea for the chronic diseases of aging, such as cardiovascular disease and cancer.

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Posted in: Evolution, History, Nutrition

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Anti-inflammatory drugs: A closer look at the risks

If science-based medicine reflects the application of the best evidence, then we should expect practices to change when new data emerges. In the long run that’s generally true, and the progressive gains we’ve seen in the management of disease reflect this. But in the short run, change can be maddeningly slow, and there are many areas of medicine where we could be doing a better job of applying what we already know to improve outcomes and reduce harms. One area where this is obvious is drug treatments, which can provide remarkable benefits but are also sources of significant harms.

Somewhat problematically, the real world is often the setting where the full extent of harms from treatments are identified. Bringing new drugs to market means tradeoffs: Do you demand larger and longer clinical trials to get as much information as possible about a drug before it’s sold? Or do you approve based on more preliminary, potentially weaker evidence, to meet (potentially) important patient need? There is no set formula or right answer to this questions – it’s ultimately a value judgement exercised by regulators like the FDA, who decide which drugs are allowed for sale (the benefits are assumed, overall, to exceed the harms) or removed for sale (when the opposite is felt to be the case).
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Posted in: Pharmaceuticals

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Burzynski: Cancer Is A Serious Business, Part 2: Like the first Burzynski movie, only more so?

Film producer Eric Merola seems to think that there is a conspiracy of skeptics (whom he calls The Skeptics) who are fanatically hell-bent on harassing his hero, Brave Maverick Doctor Stanislaw Burzynski. According to his latest film Burzynski: Cancer Is A Serious Business, Part 2 (henceforth referred to as Burzynski II, to distinguish it from part 1, to which I will refer as Burzynski I), there is a shadowy cabal of Skeptics out there just waiting to swoop down on any Burzynski supporter who has the temerity to Tweet support for him, any cancer patient being treated by Burzynski who Tweets or blogs about it, and any cancer patient even thinking about going to the Burzynski Clinic. I know this because he’s made it very clear in the promotional materials of his movie that that’s what he thinks and that skeptics were going to be the main target of his “film making” in his latest hagiography devoted to Stanislaw Burzynski. Very clear indeed. And, given how ham-fisted he was in his conspiracy mongering in Burzynski I, I’d be lying if I didn’t admit that I was at least a little concerned, because Merola made an explicit promise to “name names.” So were some other skeptics. After all, Merola isn’t exactly known for intellectual honesty (or even talent) in film making. We expected a heavy duty sliming, and curiosity (not to mention concern over our reputations) made us very—shall we say?—curious about what Merola was going to say about us.

So it was with great interest that I learned that Burzynski II was going to be screened at a film festival in San Luis Obispo last weekend. Its DVD release having been delayed from March 5 to July 1, I had thought that my curiosity about the contents of the movie would probably have to wait, and it will, at least as far as seeing the movie. A review of the movie suggested dark insinuations about Burzynski critics abounded, but that was not enough. Fortunately, a small posse of skeptics, lead by the intrepid Brian Thompson, made posthaste for San Luis Obispo. When the reports and copious handwritten notes in perfect encoded reptilian script came back, however, I was faced with a problem. How does one review or discuss a movie second-hand? How does one report on a movie that one hasn’t seen, about which one has to trust the powers of observation (and not to mention the note taking capabilities) of someone else, no matter how well briefed beforehand about what to look for? I decided that there was only one thing to do, and that’s just to go ahead and do it. I realize that there are likely huge swaths of information missing, but I definitely got a flavor of the movie from Brian’s detailed account plus discussions, and a definite idea of how it is going to be promoted from what was reported to have been said during the Q&A. Then I’ll discuss each of these points, thus inflating the rather thin observations I have from our Skeptics into a real post. Unfortunately, more detail from me will have to wait until the official release of the movie, or until such a time as Merola tries to bring the movie to somewhere in my neck of the woods. (Wouldn’t that be amusing?)

So here are the five things I learned (secondhand) from the Burzynski II screening, thanks to The Skeptics.
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Posted in: Cancer, Clinical Trials, Science and the Media

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Clinical Decision-Making: Part II

This is the second in a brief series of posts about how clinicians think. My purpose here is to elucidate how skeptical principles apply to clinical decision-making, but also as background to provide context to many of the articles we publish here.  In this installment I will review the factors that clinicians consider when deciding what tests to order for screening and when conducting a diagnostic workup.

The gunshot approach

Last week I discussed the “Dr. House” approach to medicine, using that particular TV character as an example of how medicine is often portrayed in fiction. Another aspect of the Dr. House image that is very misleading is his approach to diagnosis, which tends to be very linear. He decides what the most likely diagnosis is, then proceeds to either treat that entity or order a confirmatory diagnostic test. When that diagnosis fails, he then proceeds onto diagnosis B. A string of such failures then culminates in a flash of brilliance that allows him to make the actual obscure diagnosis and cure the patient. This approach is optimized for storytelling and drama, but is not how actual clinicians operate.

At the other end of the spectrum is what doctors often refer to as “the gunshot approach” – test for everything in hopes that you hit something. Another derogatory term that doctors throw around is “a fishing expedition,” referring to a diagnostic approach that amounts to hunting around for any possible diagnosis without having a real justification.

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Posted in: Science and Medicine

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Smoking: The Good News and the Bad News

The principles we espouse on Science-Based Medicine are vitally important, but some of the subjects we address are not so important in the big scheme of things. Homeopathy and electrodermal diagnostic devices don’t actually harm very many people. For today’s post, I’m going to follow the Willie Sutton rule and go where the money is, so to speak.

Smoking is the leading preventable cause of death. No prospective double blind randomized controlled studies have been done, or ever could be done; but a mountain of evidence converging from many avenues has established the health dangers of smoking beyond any doubt. Hill’s criteria of causation have been amply fulfilled.  Smoking causes 90% of all deaths from lung cancer and chronic obstructive pulmonary disease (COPD). It increases the risk of coronary heart disease, stroke, several types of cancer, infertility, stillbirth, sudden infant death syndrome (SIDS), osteoporosis, and premature skin aging (wrinkles). The dangers of second-hand smoke have been amply documented, and where smoke-free laws have been passed there has been a drop in the incidence of heart attacks and of emergency room visits for children with asthma.

Two new studies published in The New England Journal of Medicine reinforce what we already knew and offer both good news and bad news.  (more…)

Posted in: Public Health

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Three myths about Stanislaw Burzynski and The Skeptics

As I finished last week’s post, I promised myself that I wouldn’t write about Stanislaw Burzynski again this week. After all, counting this post I will have done 13 posts so far in 2013, and, counting this one, four of them will have been about Burzynski, and three out of the last five posts (three out of four, really, if we eliminate my blatant self-promotion for the talk I gave to the National Capital Area Skeptics over the weekend). It’s the same sort of thing that I sometimes comment about over at my not-so-super-secret other blog when seemingly all my posts are about the antivaccine movement for days at a time. Still, as Michael Corleone said in The Godfather, Part III (admittedly the weakest of the Godfather movies), “Just when I thought I was out…they pull me back in.” Except, I guess, that I never really was out and, as long as Burzynski’s propagandist is coming after skeptics, myself included, I’ve come to the reluctant conclusion that I can’t be out for a long time.

Besides, with the first screening of the Burzynski sequel, Burzynski: Cancer Is Serious Business, Part II (which I’ll simply call Burzynski II, given Eric Merola’s penchant for long titles with multiple subtitles) at the San Luis Obispo International Film Festival yesterday, it looks as though I will find myself on the receiving end of what, from what I can gather, will be a withering and deceptive campaign of personal attack directed against myself and other skeptics who are critical of Burzynski’s treatments and methods. Like Josephine Jones, I can’t help but admit to feeling a little trepidation over this. Meanwhile, given that the Burzynski movie is now finding its way out into the wild, I thought it would be worthwhile to compare the myth-making about Burzynski in the movie with reality. There are so many myths being perpetuated by Merola and Burzynski, so I thought I’d take on three of the most flagrant ones. At some point, once I know the nature of the attacks against me, I will have to respond to specific allegations. Unfortunately, that might not be possible until after the DVD release in July. However, for now, I hope to make this post a resource that takes on the most blatant examples of exaggeration, cherry picking, and spin likely to be in the movie. Hopefully after that I can leave this topic alone for a while and explore more of the big wide world of science-based medicine and offenses against it.
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Posted in: Cancer, Science and the Media

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Acupuncture and Allergic Rhinitis: Another Opportunity for Intellectual Sterility

You need to keep an open mind.

A common suggestion offered to naysayers of nonsense.

The usual retort concerns not letting one’s brain fall out.

Evaluating SCAM’s is less about having an open mind and more about having standards, a conceptual framework that is used to interpret and analyze new information. One of the benefits of writing and reading topics covered by science-based medicine (SBM) is it has clarified and sharpened the ideas by which I understand the world. Those concepts were nicely summed up by Steve Novella at Neurologica, and I reproduce them here, slightly modified. They should be on stone tablets, not quite commandants, but strong suggestions. The 8 strong suggestions somehow doesn’t cut it however. (more…)

Posted in: Acupuncture, Clinical Trials, Science and Medicine

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Legislative Alchemy: Acupuncture and Homeopathy 2013

Acupuncture, or more broadly, Oriental or Traditional Chinese Medicine, is a

weird medley of philosophy, religion, superstition, magic, alchemy, astrology, feng shui, divination, sorcery, demonology and quackery.

And via the particular form of magic known as legislative alchemy, acupuncture is a licensed health care profession in 44 states and the District of Columbia.

A growing body of evidence demonstrates acupuncture is simply an elaborate placebo. Even the CAM-friendly National Center for Complementary and Alternative Medicine, says

Although millions of Americans use acupuncture each year, often for chronic pain, there has been considerable controversy surrounding its value as a therapy and whether it is anything more than placebo.

Someone should tell the state legislatures. (more…)

Posted in: Acupuncture, Homeopathy, Legal, Politics and Regulation, Traditional Chinese Medicine

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Time for a little blatant self-promotion

I thought I’d take advantage of my prerogative as managing editor of this blog to do a quick bit of blatant self-promotion. I will be in the Washington, DC area later this week, and while I’m there to attend the Society of Surgical Oncology Annual Cancer Symposium, I’ll also be taking advantage to do a little side trip to give a talk for the National Capital Area Skeptics. The talk will take place at the National Science Foundation in Arlington, VA on Saturday, March 9, 2013 at 1 PM. So if you’re in the DC area and want to hear me pontificate about quackademic medicine (and, really, what reader of this blog wouldn’t want to?), mosey on over on Saturday. Full details can be found here.

Posted in: Announcements, Medical Academia

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Clinical Decision Making: Part I

I practice in a university clinic which functions partly as a tertiary referral center, which means we get referrals from other specialists. I also get many referrals for second opinions. Sometimes the entire cause for the patient’s desire for a second opinion, it seems to me, is the simple fact that they did not understand the reasoning of the previous specialist. They were given a diagnosis and a course of treatment, but not an explanation of how their doctor arrived at those conclusions.

I am not being judgmental – different practices are under different pressures and time constraints, and it can be very difficult to gauge a patient’s understanding. Often the physician and the patient are proceeding based upon differing assumptions and narratives that are not expressly stated. The doctor may think they have explained the situation entirely, but simply did not confront misleading assumptions they were not aware their patient had.

This is part of the advantage of engaging the public about health issues and confronting pseudoscience, myths, and misconceptions – you develop a deep awareness of how the general public thinks about medicine.

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Posted in: Science and Medicine

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