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Answering another criticism of science-based medicine

In the three and a half years that the Science-Based Medicine blog has existed, we contributors have come in for our share of criticism. Sometimes, the criticism is relatively mild; often it’s based on a misunderstanding of what SBM is; but sometimes it’s quite nasty. I can’t speak for the rest of the SBM crew on this, but I’ve gotten used to it. It comes with the territory, and there’s little to do about it other than to skim each criticism as it comes in to see if the author makes any valid points and, if he doesn’t, to ignore it and move on. Indeed, there’s enough criticism being flung our way that I rarely respond directly anymore. Exceptions tend to be egregious examples, incidents that spark real problems, such as when Age of Autism blogger and anti-vaccine activist Jake Crosby tried to paint me as being hopelessly in the thrall of big pharma, which resulted in the anti-vaccine horde who read that blog to try to get me fired by sending complaints to the Board of Governors at my university and the dean of my medical school. Other examples tend to be what I call “teachable moments,” in which the mistakes made in the criticism provide fodder for making a point about SBM versus alternative medicine, “complementary and alternative medicine” (CAM), or “integrative medicine” (IM)—or whatever the nom du jour is.

File this next one under the “teachable moment” variety of criticism directed at SBM.

A pain researcher takes Steve and me to task

In order to stoke my massive ego (if you don’t believe I have a massive ego, just ask my critics), I have a Google Alerts set to my name. One thing I learn from these alerts is that there are a lot of people out there named David Gorski, few of them doing medicine and not all of them particularly reputable. The other thing I learn is that I’m actually mentioned on the web and in the blogosphere more times than I ever would have imagined possible a few years ago. More importantly, I’m quickly aware of criticisms directed my way. So it was that I found out about an article by someone named Stewart B. Leavitt, MA, PhD entitled A Burgeoning Klatch of Science Skeptics, which managed to attack both Steve Novella and myself in a manner that’s so off-base that it presents said “teachable moment,” much as an earlier criticism by Steve Simon provided such a moment.

You know right off the bat that Dr. Leavitt is going to go far off base when his opening paragraph contains the passage:

As it turns out, skepticism regarding modern science, including the field of pain medicine, is somewhat of an international movement. Its mantra might be “Stop the B.S.” (with the irreverent logo at right); yet, there is an apparent danger of skepticism becoming close-minded cynicism falling into the trap of contempt prior to investigation that might preclude truly objective analyses of research.

The community of skeptics, worldwide, serves an important function in modern society, as they always have. It was probably skeptics who asked, “What makes you think the Earth is flat — where’s your proof?” When it comes to healthcare, skeptics at their best evaluate medical treatments and products in a scientific light, promoting the highest standards and traditions of scientific inquiry; however, at their worst, skeptics may merely be naysayers, stirring up the pot of already-established evidence to draw attention to themselves.

This is the classic confusing of skepticism with nihilism or cynicism. In my experience, sometimes skepticism and cynicism are conflated intentionally by opponents of SBM in order to dismiss skepticism as nothing more than a cynical “Dr. No” approach in which claims are reflexively rejected without consideration, but sometimes (and perhaps more frequently) the two are conflated through ignorance because the difference between the two is not understood. I rather suspect that Dr. Leavitt does not understand the difference. (At least, I will give him the benefit of the doubt.) And this criticism can be true to a point: As skeptics we have to be very careful to avoid falling into the trap of cynicism, of rejecting claims without giving them a fair hearing. Indeed, most of us have said as much ourselves on this very blog on multiple occasions, particularly how we ourselves have to try to avoid falling into the trap of motivated reasoning, which is wielded to great effect by proponents of pseudoscience to protect themselves from having to change their minds about cherished views. On the other hand, how many times do clinical trials of pseudoscience like, for example, homeopathy have to fail and how often do we have to point out that the principles by which homeopaths claim homeopathy works violate well-established laws of physics and chemistry before we’re allowed the shorthand of provisionally rejecting homeopathy until its proponents produce data compelling enough to make us question the laws of physics as currently understood?

I won’t take on Leavitt’s criticism of Steve Novella (much). After all, Steve is more than capable of taking care of himself, having been in the skeptic biz at a higher level several years longer than I have. I do note, however, that, although Leavitt links to both Steve’s blog and SBM, he does not directly link to the posts that he cites, making it difficult to see what is being said in context. For example, Leavitt cites Novella as saying:

I have become thoroughly convinced of the axiom that there is no claim so absurd that it cannot attract flocks of true believers. The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility.

An excellent quote, succinctly summing up the situation. It comes from a post in which Steve deconstructed an example of pure health supplement quackery. In the context of Steve’s post, it makes perfect sense. Yet Leavitt dismisses this as an “emotive” appeal. Similarly, he is very unhappy when I say things that he views as similarly emotive, in particular, when I refer to the “integration” of alternative medicine modalities into medicine as “quackademic medicine” and refer to “integrative medicine” as “integrating quackery with medicine.” I’ll be the first to admit that I came up with these sorts of pithy phrases (aside from “quackademic medicine,” whose origin I cannot claim, as much as I would like to) to make a point in a memorable way that can be easily repeated. This is how one communicates complex topics in a sound bite world, and it worked at TAM in that my point about “integrating quackery with medicine” was Tweeted and re-Tweeted rather extensively.

Of course, it is rather amusing to note that Leavitt dismisses our appeals as “emotive,” while he himself denigrates skeptics using language at least as emotive as ours, describing us, in essence, as cynics who “posture” and preach to the choir in the proverbial echo chamber, such as meetings like TAM, which Leavitt describes as:

The most recent TAM brought together skeptics from around the world and a long list of guest speakers and panelists. Workshops included: Defending Evolution, Skeptical Activism , Advancing Skepticism Online, Investigating Monster Mysteries, Raising Skeptics, and others. And, among the sessions discrediting UFOs and paranormal phenomena were the usual attacks against “alternative therapies” in healthcare and pain management.

Note the dismissive tone about sessions including the “usual attacks” against “alternative therapies.”

More telling is Leavitt’s attempt to contrast the type of skepticism that he claims he promotes, which he characterizes as “healthy skepticism” and “educated skepticism,” with our skepticism. He begins with a nonsequitur:

Along with that, however, we have acknowledged that it is far easier to criticize science — asking tough questions, pointing out flaws or weaknesses — than it is to do good science. Therefore, we were somewhat dismayed by the writings and posturing of the self-proclaimed community of professional skeptics.

So what if it’s easier to criticize science and to point out flaws or weaknesses than it is to do good science? Even if true, this observation on Leavitt’s part serves no other purpose besides denigrating critics of CAM. As someone who does what I like to think is good science myself and has been funded by the NIH, the Department of Defense, and the Conquer Cancer Foundation of ASCO, I find Leavitt’s comment profoundly insulting. His argument boils down to, in essence, a claim that if you don’t do pain research science you aren’t qualified to criticize bad CAM research about pain treatments. From my perspective, though, good science is good science, and bad science is bad science. It doesn’t matter who is doing the criticism; what matters is whether the criticisms are valid. In fact, Leavitt’s use of language is as clever as that of the CAM proponents we routinely discuss. His skepticism is “healthy” and “educated.” Left unspoken is what our skepticism must be—presumably by contrast “unhealthy” and “uneducated”—while Leavitt also characterizes us as “posturing.”

Logical fallacies and false dichotomies on parade

After the warmup, Leavitt gets to the meat of his objections, or so it would appear:

For example, their diatribes against CAM and integrative therapies — which actually can be vital modalities for effective pain management — seem guided more by emotional arguments than a systematic study of all available evidence. Hence, when Novella writes (as noted above), “The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility,” we wonder if he also is describing how a credulous community of skeptics approach their subjects of scorn.

And, when Gorski asserts that “integrative medicine is all too often in reality nothing more than ‘integrating’ pseudoscience with science, quackery with medicine,” we might assume he has solid evidence to justify such claims; but, if so, he is keeping it secret. And, his far-reaching denigration of NCCAM, the Bravewell Collaborative, and unnamed medical schools adds emotive impact to arguments that might have no basis in fact.

Leavitt amuses me in this passage. His first criticism of Steve is a deftly executed tu quoque argument, in which he seems to concede that the default mode of human psychology is to think with our emotions (which it is, by the way) but turns it around to accuse skeptics of the same thing. Here’s the difference, though. Skeptics know that the default mode of human thought is to think with our emotions, to leap to conclusions first and then to try to find evidence to justify our opinions. Skepticism, science, and critical thinking are all methods designed to try to minimize that very human tendency and to minimize the effects of the cognitive quirks we all share that mislead us, including confusing confirmation bias, confusing correlation with causation, regression to the mean, and placebo responses.

I’m further amused that Leavitt would think that I don’t provide solid evidence to justify my claims. Once again, he doesn’t directly link to the post from which that quote comes, which is entitled The ultimate in “integrative medicine,” continued, which described a cooperative agreement between Georgetown University School of Medicine and the Bastyr University, the latter of which is a school of naturopathy. Clearly, Leavitt doesn’t support the notion that much of naturopathy is quackery and pseudoscience. Even if that’s the case and he disagrees, Leavitt reveals pure laziness in his statement, given that I’ve written copiously, logorrheically even, about this issue, providing numerous examples. For example, here are a few:

  1. The ultimate in “integrative medicine”: Integrating the unscientific into the medical school curriculum
  2. The ultimate in “integrative medicine,” continued
  3. A University of Michigan Medical School alumnus confronts anthroposophic medicine at his alma mater
  4. An open letter to NIH Director Francis Collins regarding his appearance at the Society for Integrative Oncology
  5. “Integrative” oncology: Trojan horse, quackademic medicine, or both?
  6. The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work
  7. Cancer Treatment Centers of America and “naturopathic oncology”
  8. NCCAM Director Dr. Josephine Briggs and the American Association of Naturopathic Physicians
  9. Surprise, surprise! Dr. Andrew Weil doesn’t like evidence-based medicine

As I particularly glaring example selected from the posts above, I submit that the “integration” of anthroposophic medicine with real medicine at my alma mater is the integration of quackery and pseudoscience with medicine.

I’ve also provided multiple lines of evidence on my other blog, and my fellow SBM bloggers have written about this issue, in particular Kimball Atwood. Gratifyingly, we’re even starting to have some success, as the Cochrane Reviews editors have been showing signs of starting to “get” SBM.

Then, after stating that neither Steve nor I have taken the time to study the issues of “integrative medicine” in depth, Leavitt concedes:

Admittedly, the comments above from Gorski and Novella are mere snippets of their voluminous writings, described out of context. Readers can themselves visit the blogs of these skeptics (linked above) to decide the merits of their arguments. For example, we find using words like “pseudoscience” and “quackery,” as they do, to be rather slanderous and empty invectives.

In other words, Leavitt admits to quoting us out of context and then just links to our blogs in general, all the while not providing a single concrete example of our committing the offenses of which he accuses us. These tactics are disingenuous at best and intellectually dishonest at worst, particularly given that Leavitt never bothered to link directly to the posts from which he extracted our comments out of context. Basically, this gambit allows Leavitt to give the appearance of being fair while misrepresenting our arguments and trying to paint us as emotion-driven, biased, and “uneducated” about CAM. Think of it this way. It’s asking a lot—and I do mean a lot—for anyone to visit two blogs that have been in existence for several years, each with thousands of posts, and to try to evaluate the core of the voluminous arguments there. What will happen is that without guidance regarding where to start even the small minority who click on links in a blog post will be quickly overwhelmed by the volume of verbiage and tend simply to accept Leavitt’s characterization without too much investigation.

Leavitt concludes with a false dichotomy:

The lesson in all this is that our understanding of “healthy skepticism,” as advocated in these Pain-Topics UPDATES, may have an objective of “stopping the B.S.,” but it is not necessarily bent on “spoiling anyone’s fun.” And, it is not a close-minded approach that encourages contempt prior to adequate investigation.

Skepticism in pain research should drive a search for truth that recognizes and acknowledges the boundaries of uncertainty. Unfortunately, a great deal of research in the pain field seems driven by political agendas and hidden self-interests, so educated skeptics have much work ahead. We hope our readers are up to the task.

There are two problems here. (Actually, there are more than that, but I’ll concentrate on two.) First, as I said, it’s a false dichotomy. Either you accept Leavitt’s dismissive definition of skepticism, or you’re necessarily “spoiling someone’s fun.” And make no mistake, Leavitt is a pretty credulous fellow. For instance, he has made a holiday “wish list” for “holistic care” that includes a number of pseudoscientific alternative medicine modalities—is that an oxymoron?—including acupuncture, ayurveda, energy medicine (healing touch and reiki), and traditional Chinese medicine, among others. About homeopathy, Leavitt says, “Homeopathy is a therapeutic modality practiced worldwide, it is very popular among some patients, and it has withstood the test of time,” while expressing disappointment in a study of homeopathy for rheumatoid arthritis showed no therapeutic effect and trying to attribute the negative result of the study to its being underpowered. In yet another example, Leavitt critiques Edzard Ernst’s recent review of acupuncture systematic reviews, and while much of what he writes in this particular post is not unreasonable, he can’t help but drop bombs of credulity on the science, saying, for example, that “comparing acupuncture to a molecular entity, such as a drug for pain, may reflect a Western bias regarding how medical treatments are expected to work” and citing an acupuncture proponent who concludes that “it is probably no coincidence that many positive trials of [acupuncture and related techniques] have come from China where the techniques have been practiced for centuries; whereas, studies conducted in other countries often use divergent forms of acupuncture that also may be hindered by poor or improper technique, such as using only a limited number of sites or incorrect acupoints.”

Leavitt then concludes about acupuncture:

Considering the multitude of patients worldwide who have benefitted from acupuncture in one way or another, it still appears premature to broadly dismiss it as being of little or no value for pain relief.

This is yet another appeal to popularity devoid of science.

Finally, I can’t help but cite one last example in which Leavitt discusses “biofield therapies” (reiki, healing touch, etc.):

Although many traditionally-trained practitioners may remain skeptical, significant numbers of patients apparently seek biofield therapies, often without telling their healthcare providers, and the techniques have been used over millennia in various cultures to allegedly heal physical and mental disorders. In general, complementary and alternative therapies are used by 38% of adults and 12% of children in America, and it is a $34 billion per year business; so, these approaches cannot be easily ignored. The customary caveat — more research is necessary to arrive at definitive conclusions — would seem very appropriate regarding biofield-based therapies for pain. However, as the 16th Century Swiss physician Philipus Aureolus Paracelsus advised, “The art of healing comes from nature, not from the physician. Therefore the physician must start from nature, with an open mind.”

I submit that this more than approaches being so open-minded that one’s brains fall out. It embraces such unskeptical open-mindedness and gives it a big, sloppy kiss on the lips. Basically, what we have here is an appeal to popularity plus an argument from ignorance; i.e., that something is likely to be true simply because it hasn’t been proved false or, equivalently, that something is likely to be false because it hasn’t been proved true. Of course, for modalities like energy healing and homeopathy, it’s a fallacy to say that we don’t know. Basic science, such as physics, can tell us with a high degree of probability that homeopathy can’t work, for instance.

Dr. Leavitt’s straw man caricature of skepticism versus positive skepticism

Near the end of his post, Leavitt defines skepticism as “encouraging contempt prior to adequate investigation.” At the risk of sounding “contemptuous,” I am going to say that this is a fetid load of dingo’s kidneys. It’s a favorite straw man characterization of skepticism by the credulous, be they believers in the paranormal, alternative medicine aficionados, evolution denialists, or other promoters of pseudoscience. Personally, in response to such arguments, I like to cite the writings of Michael Shermer regarding positive skepticism:

This brings me to the larger issue of two forms of skepticism, negative and positive. Stephen Jay Gould began his foreword to my 1997 book, Why People Believe Weird Things, by noting: “Skepticism or debunking often receives the bad rap reserved for activities — like garbage disposal — that absolutely must be done for a safe and sane life, but seem either unglamorous or unworthy of overt celebration.”…

Positive skepticism, however, involves much more than the negative disposal of false claims. In fact, the word “skeptic” comes from the Greek skeptikos, for “thoughtful.” According to the Oxford English Dictionary, “skeptical” has also been used to mean “inquiring,” “reflective,” and, with variations in the ancient Greek, “watchman” or “mark to aim at.” What a positive meaning for what we do! We are thoughtful, inquiring, and reflective, and we are the watchmen who guard against bad ideas in order to discover good ideas, consumer advocates of critical thinking who, through the guidelines of science, establish a mark at which to aim. “Proper debunking is done in the interest of an alternate model of explanation, not as a nihilistic exercise,” Gould concludes. “The alternate model is rationality itself, tied to moral decency —the most powerful joint instrument for good that our planet has ever known.”

In other words, not only is “negative skepticism” not cynicism, but it’s actually a good thing. Indeed, skepticism is far more than just the debunking of claims. It’s the application of the best of human reason, including science, logic, and critical thinking to claims. When properly done, skepticism represents the highest intellectual aspirations of humankind. As Shermer points out, skepticism keeps the borders of science from moving too far into the realm of pseudoscience and non-science, and for every Copernicus, Newton, and Einstein, there are hundreds, if not thousands, of cranks and quacks whose ideas never pass scientific muster because they are nonsense. It might be some day that a CAM modality such as homeopathy or energy healing will pass scientific muster. Unlikely, but possible, and if and when that day comes I will examine the evidence and, if appropriate, change my mind to embrace what I formerly considered pseudoscience. That’s what skepticism really is. Moreover, science-based medicine is not an attempt to turn medicine into a pure science; rather it is the philosophy that science should inform and guide medicine.

To conclude, I realize that I perhaps cite this too often and that some might be offended by its language, which some might consider NSFW, but Tim Minchin put it best in his beat poem Storm:

Science adjusts its beliefs based on what’s observed
Faith is the denial of observation so that Belief can be preserved.
If you show me that, say, homeopathy works,
Then I will change my mind
I’ll spin on a…dime
I’ll be embarrassed as hell,
But I will run through the streets yelling
It’s a miracle! Take physics and bin it!
Water has memory!
And while its memory of a long lost drop of onion juice is Infinite
It somehow forgets all the poo it’s had in it!

You show me that it works and how it works
And when I’ve recovered from the shock
I will take a compass and carve “Fancy that!” on the side of my cock.

And I will, too. Well, except perhaps for the part about the compass and carving. We wouldn’t want to go too far, now, would we? On the other hand, one wonders how rapidly Dr. Leavitt will abandon beliefs that he possesses that are not supported by science. Apparently not very quickly. After all, he remains “open-minded” to energy healing, acupuncture, and other unscientific forms of medicine and shows no sign of changing.

Posted in: Basic Science, Clinical Trials, Science and Medicine

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34 thoughts on “Answering another criticism of science-based medicine

  1. Diane Jacobs says:

    >”Basic science, such as physics, can tell us with a high degree of probability that”….

    Did the rest of this sentence get chopped off some how?
    Thank you for the careful sift in this post. Much appreciated.
    Diane

  2. BillyJoe says:

    Diane,

    ”Basic science, such as physics, can tell us with a high degree of probability that”

    Read it this way:

    ”Basic science, such as physics, can tell us, with a high degree of probability, that”

    Or more clearly:

    ”Basic science, such as physics, can tell us that with a high degree of probability”

  3. phayes says:

    “Basic science, such as physics, can tell us with a high degree of probability that”

    So high a degree of probability in fact that CTs of such ‘modalities’ are utterly futile¹ – (not even) pathological science. Jaynes wrote that “it is a major scandal that orthodox methods continue to be taught at all to young statisticians, economists, biologists, and medical researchers”. Add to that the major scandal that they’re (apparently) taught so very little about what modern science does know² and I suppose it’s not really surprising that they don’t realise what enormous fools they’re making of themselves by doing their CTs of reiki or homeopathy or whatever and writing such nonsense.

    ¹ http://www-biba.inrialpes.fr/Jaynes/cc05e.pdf
    ² http://blogs.discovermagazine.com/cosmicvariance/2010/09/23/the-laws-underlying-the-physics-of-everyday-life-are-completely-understood/

  4. woo-fu says:

    Along with that, however, we have acknowledged that it is far easier to criticize science — asking tough questions, pointing out flaws or weaknesses — than it is to do good science. ~Leavitt

    Gosh–and here I’ve been thinking asking tough questions and pointing out weaknesses was actually a major part of good science!
    ;)

  5. woo-fu says:

    Dr. Gorski,

    when I first landed on the SBM blog, I had difficulty at times figuring out if there was simply an agenda against CAM rather than a spirit of true scientific inquiry. And I embarrassed myself over the confusion in my comments on at least a few occasions. However, as I worked my way through the majority of posts and comments, I determined that what I mistook for “closed-mindedness” at times was more accurately a reflection of extreme frustration and burn-out over trying time and time again to explain the same scientific points and the same logical fallacies.

    The more I have been able to participate in discussions, the more I realize that the majority here are truly dedicated to educating the public. If I have a major disagreement, most posters and commenters are willing to talk it out until we reach some level of mutual understanding, even if we were frustrated or hot-headed at the outset of the discussion. Teachable moments are priceless as long as people are willing to learn.

    Thank you for your contribution.

  6. Ed Whitney says:

    Any time you see people bring up a “flat earth” analogy, you can be certain that they are not exactly scholars of history. The myth that “everyone once thought that the earth was flat” was invented by Washington Irving, and received additional energy later in the 19th century when American nativism capitalized on (1) the idea that humanity dwelled in darkness until the discovery of America, which invented the world anew, and (2) the idea that the Catholic Church was the promulgator of this notion about the shape of the earth, and that therefore hostility to Irish immigration was well justified. The flat earth myth served both purposes very well, and generations of American schoolchildren were taught some version of it. This was not the case in Europe.

    Anyone who has studied Ptolemy’s Almagest or Dante’s Divine Comedy knows that they knew perfectly well in the middle ages that the earth was round. They assumed that the sun went around the earth, of course, but that is a different matter. But the model of concentric circles of the moon, planets, and fixed stars had to have a circular earth in the middle in order to be constructed at all.

    There are many ways to recognize a charlatan; science provides some, and history provides others.

  7. cervantes says:

    Come on Ed, the analogy is valid even if its historical basis is questionable. That’s just a pedantic quibble.

    BTW, regarding Columbus, of course mariners knew the earth was round, but Columbus was still wrong — he thought he could get to India by sailing west because he thought the earth was only 2/3 its actual size. If he hadn’t blundered onto an unanticipated continent, he and his crew would indeed have starved. So he was just a lucky fool, after all.

  8. Calli Arcale says:

    The flat earth myth served both purposes very well, and generations of American schoolchildren were taught some version of it. This was not the case in Europe.

    The flat earth myth exists on the eastern side of the Atlantic as well, though I acknowledge it may have been exported there at some point. At any rate, I saw it promulgated, regrettably, in an episode of my very favorite TV show, the quintessentially British sci-fi drama “Doctor Who”. The story was “The Masque of Mandragora”, and our heroes find themselves in 15th Century Italy (in other words, shortly before the time of Columbus). There is an exchange at one point where an Italian prince (Guiliano) tentatively confesses to our heroes that he believes the world might actually be round. The major subtext of the entire story is the struggle for dominance between science and knowledge and superstition and tyranny; Guiliano seems to think his belief is heretical and that he’d be in serious trouble if people found out he thought the world was round.

    The serial aired in 1976, so the “flat earth myth” was active in England at that time. It seems reasonably likely that the scriptwriter (Louis Marks) grew up like most of us, with the idea that the Earth was not believed to be round prior to the Renaissance, so it had to have been in play in Great Britain at least by the 1950s, and probably earlier. I would be surprised if under the curricula of the day Marks had not been made to read The Divine Comedy and other such classics, but perhaps like many schoolchildren, he didn’t really pay much attention.

  9. Chris says:

    Ed Whitney:

    The flat earth myth served both purposes very well, and generations of American schoolchildren were taught some version of it.

    Not in Stilwell Elementary School in Ft. Ord, California during the early 1960s. Perhaps it was due to they actually spending money on science education as a reaction to Sputnik, but I did read about science. I remember learning that the Greeks had measured the circumference of the earth and that fog was like a cloud (which there was lots of near Monterey Bay).

    Of course, I also vividly remember reading in the same third grade text that the sun was going to explode. That scared me, so I asked my mother about it. She glanced at the book and reminded me that it was still billions of years away.

    Though, in retrospect, it could have been that I had a really good third grade teacher. The back of the room had jars of preserved sea critters on the shelf, since she like that stuff. We also went on a field trip to the little museum that eventually became the Monterey Bay Aquarium.

  10. nybgrus says:

    @woo-fu:

    And thanks for your contributions here. I think your story illustrates quite nicely the point the Dr. Gorski was making regarding Leavitt’s lack of direct linking – anyone picking up this entire blog would be overwhelmed and, as you found out the hard way, take some serious time investment and effort to really figure out. Not that it actually took you all that long really, but you came here reasonably open minded. If you were led here having Leavitt’s piece as your only primer into it, I doubt you would have likely stuck through reading a number of posts, let alone the comments. Hopefully you’ll be around for a while.

  11. weing says:

    “In general, complementary and alternative therapies ……, and it is a $34 billion per year business; so, these approaches cannot be easily ignored. ”

    That is exactly why we are not ignoring them. What a colossal waste of resources and tremendous opportunity cost! It is imperative that Americans become aware that this is in fact all quackery and channel the money into real science where something good may come out of it. Leavitt is trying to silence the little boy from pointing out that the emperor in fact has no clothes. What is his motive? So that he is not seen as a dupe who fell for the BS of the con men in the story. What an ego! Can’t admit he’s wrong.

  12. I had the same reaction as woo-fu initially and felt like this post and a comment that Dr. Atwood left on my blog were two items instrumental in helping me to realize that there is not an anti-CAM agenda here, and that the goal here is to promote critical thinking and education.

    Not that I would have minded an anti-CAM agenda persay, but I would enjoy such an agenda for purely emotional reasons related to negative personal experiences with it. I prefer to think rationally about these things and most books and websites that are more emotionally driven tend to get stale after a while.

    Whenever I post a comment, I always worry a bunch of people will jump on me and correct some minor thing that I did mean but just did not articulate well. But, corrections help me improve so I continue to put myself out there.

  13. ebohlman says:

    Calli: I’m sure that if Louis Marks were still alive (he died a little short of a year ago) he’d wave away your objection by claiming that the flat-earth belief in San Martino was the result of FUD deliberately propagated by Hieronymous’s cult rather than being the normal state of the population.

  14. Toiletman says:

    You have been financed by the Department of Defense? O.o

  15. So high a degree of probability in fact that CTs of such ‘modalities’ are utterly futile¹ – (not even) pathological science.

    Which we have also been arguing for years (although pathological science is entirely apropos), e.g.,

    Homeopathy and Evidence-Based Medicine: Back to the Future Part V

    Of SBM and EBM Redux. Part II: Is it a Good Idea to test Highly Implausible Health Claims?

    Of SBM and EBM Redux. Part III: Parapsychology is the Role Model for “CAM” Research

    And, just to demonstrate that this has been a theme for about a decade,

    Prior Probability: the dirty little secret of “Evidence-Based Alternative Medicine.” Talk given at the 11th European Skeptics Congress. London, September 5-7, 2003

    (You’ll have to take my word for the final two years).

  16. ebohlman says:

    Toiletman:

    You have been financed by the Department of Defense? O.o

    A substantial number of soldiers, sailors, air(wo)men and Marines have two X chromosomes, and thus are susceptible to breast cancer, namely the condition that Dr. Gorski specializes in treating. The DoD, by any reasonable measure, has a justified interest in making sure that they don’t prematurely lose the services of such well-and-expensively trained personnel because of breast cancer; it costs (both directly and indirectly) real money to, say, replace a 20-year NCO.

    You aren’t the sort of person who refers to the gender integration of the armed forces as a “social experiment”, now are you?

  17. phayes says:

    Yes – I have been paying attention :) – but I don’t think I’ve seen the implausible hypotheses Catch-22 effect (described so clearly and thoroughly by Jaynes in the pdf I linked to) mentioned here. In fact I haven’t seen it mentioned anywhere else in the skeptosphere either (except by myself) and when I have brought it up its implications don’t always seem to have been appreciated, or at least haven’t had the impact I expected.

  18. David Gorski says:

    You have been financed by the Department of Defense?

    The Department of Defense has a number of health-related and cancer-related research funding programs. For example, here’s the breast cancer program:

    https://cdmrp.org/files/2011/bcrp/bcrp_reftable.pdf

  19. daedalus2u says:

    phayes The issue has been brought up on SBM, perhaps not so explicitly as in the very nice paper you linked to.

    “But the example also shows clearly that in practice the situation faced by the scientist is so complicated that there is little hope of applying Bayes’ theorem to give quantitative results about the relative status of theories. Also there is no need to do this, because the real difficulty of the scientist is not in the reasoning process itself; his common sense is quite adequate for that. The real difficulty is in learning how to formulate new alternatives which better fit the facts. Usually, when one succeeds in doing this, the evidence for the new theory soon becomes so overwhelming that nobody needs probability theory to tell him what conclusions to draw.”

    “At present we have no formal theory at all on the process of “optimal hypothesis formulation” and we are dependent entirely on the creative imagination of individual persons like Newton, Mendel, Einstein, Wegener, Crick. So, we would say that in principle the application of Bayes’ theorem in the above way is perfectly legitimate; but in practice it is of very little use to a scientist.”

    The post where the idea of prior plausibility was discussed is this one:

    http://www.sciencebasedmedicine.org/index.php/h-pylori-plausibility-and-greek-tragedy-the-case-of-dr-john-lykoudis/

    Where I attempted to re-frame it as a lack of prior implausibility. A potential treatment has sufficient prior plausibility to test depending on how much data there is that it is incompatible with it. If there is no data that is incompatible with an idea, then the idea is not implausible.

    No correct idea can ever be implausible because correct ideas are always compatible with the data. The problem that I have in trying to get my nitric oxide physiology ideas considered fits exactly with a problem the author of the cited work had:

    “Indeed, in the course of writing this Chapter, the writer found himself a victim of this phenomenon. In the Ph. D. thesis of G. L. Bretthorst (1987), reported in Chapter 21 below and more fully in Bretthorst (1988), we applied Bayesian analysis to estimation of frequencies of non-stationary sinusoidal signals, such as exponential decay in nuclear magnetic resonance (NMR) data, or chirp in oceanographic waves. We found (as was expected on theoretical grounds) an improved resolution over the previously used Fourier transform methods.”

    “If we had claimed a 50% improvement, we would have been believed at once, and other researchers would have adopted this method eagerly. But in fact we found orders of magnitude improvement in resolution. It was, in retrospect, foolish of us to mention this at the outset, for in the minds of others the prior probability that we were irresponsible charlatans was greater than the prior probability that a new method could possibly be that good; and we were not at first believed.”

    I experience this all the time with people who consider themselves to be skeptics. They find my claims about nitric oxide to be implausible but are not able to articulate where any of them are actually incompatible with any data. I have looked at much more data regarding nitric oxide than have any of my critics, and haven’t been able to find any incompatibilities of my hypothesis with any reliable data. I understand why people find it implausible, I don’t blame them, I simply don’t know what to do to convince them otherwise.

  20. Calli Arcale says:

    ebohlman — I have to admit, though, that it was a cracking good story. “Masque of Mandragora” remains one of my all-time favorites, with the flat Earth thing being pretty much the only real annoyance I had with it. Glad to hear you’ve clearly seen it too. ;-)

  21. Harriet Hall says:

    @daedalus,
    ” I simply don’t know what to do to convince them otherwise.”

    I think you do know. You know that throughout medical history others have developed plausible hypotheses that fit all the data but that turned out to be false when tested. You know how science works. Skeptics only require the same kind of evidence that science requires before it integrates a new idea.

  22. phayes says:

    @daedalus2u

    No, I’m afraid that’s not it – explicitly or inexplicitly. I wish people would grok this “positive results floating *all* the implausible hypothesis boats” effect not least because it pains me to see rational friends and acquaintances promising to change their minds about homeopathy if e.g. the CT of homeopathic essence of dangerous power tools yields 10 regrown fingers in the treatment group and none in the control, or about psi if the n=~2000¹ parapsych. retrocausality experiment is done and confirms Bem, or if…

    ¹ IIRC that’s the number Wagenmakers et al suggested would be needed.

  23. Chris says:

    ebohlman:

    A substantial number of soldiers, sailors, air(wo)men and Marines have two X chromosomes, and thus are susceptible to breast cancer,

    Don’t forget that even those with a Y chromosome can get breast cancer. A carpenter who has done quite a bit of work on our house spent about a year dealing with his breast cancer.

  24. daedalus2u says:

    Harriet, you are right, I do know how to convince them, I simply don’t have the resources to acquire the data to do so. Acquiring the resources before people are willing to accept that my idea has plausibility is not something I know how to do. But I am coontinuing to work on it.

  25. daedalus2u says:

    phayes, I see how you think my reply was not related to what you said, and you are partially right. You are considering treatment modalities that are accepted by some even though they are inconsistent with much data. The example of homeopathy and psychic abilities are good for that. You are correct that no amount of low power trials could convince any scientist that homeopathy or psychic abilities are real.

    I understand that this is because the low power trials don’t address the data in the literature that would have to be wrong for homeopathy to be correct. Psychic abilities require action at a distance. Successful low power trials don’t overcome the centuries of observations of no action at a distance, one of the foundation observations on which physics is based.

    Adding a thousand or ten thousand low power trials don’t change the data that was used to formulate the “no action at a distance” hypothesis. Even extremely high powered trials don’t change that data.

    After there were some high powered trials, 10 out of 10 regrown amputated fingers would be very high powered data. It would not convince me because it is more likely to be trickery or fraud than for homeopathy to be correct. Even if I did the trials myself I would not believe homeopathy to be correct. My faith in my own experimental abilities is not so high as to negate the collected wisdom of centuries of scientists. I would doubt my own observations. New data doesn’t change the Bayesian analysis that includes the old data, it just adds new data to it.

    One of my goals in posting here at SBM is to get people to focus on data and consistency with data and to get people to consider prior plausibility to be a consequence of compatibility with prior data and not their feeling that something “seems plausible”. I do this because I am trying to push my nitric oxide stuff.

    Every correct ideas is plausible, even if we think that correct ideas is wrong. If we think a correct idea is not plausible, what is wrong is our thinking and our analysis of the idea and its prior plausibility. People are mostly hung up on trying to make new ideas compatible with old ideas, not new ideas compatible with old data.

    My problem is that as I try to convince people that I am right, I bring every more data to bear on the issue and low-and-behold, nitric oxide physiology is even more important than I had said before. When at first I thought NO was involved in at least a few pathways, later I found it to be dozens, hundreds and now more than thousands. There is essentially no pathway in physiology that is not more than a few steps away from control via NO signaling. I actually understand why that is, why evolution configured physiology to be that way. It pretty much had to, it wasn’t possible for another signaling molecule to take the place of NO, or for other pathways to evolve independent of NO signaling.

    I appreciate that to people not aware of the importance of NO in physiology, this seems to be even more implausible as the number of pathways multiplies. Even though they know of no data inconsistent with what I am saying, the idea that so many things could be coupled is hard to accept. It is much easier to default to someone on the internet is wrong.

    I have essentially the opposite problem. There is so much compatibility of my nitric oxide hypothesis with the data in the literature that a few negative low powered clinical trials would not diminish its prior plausibility. My concern is that poorly done low powered trials would be negative and would slow its acceptance even more. People sometimes ask me what experiment could I do that would disprove my idea. It is like asking what experiment could be done that would prove homeopathy. There is such a consilience with vast amounts of data in the literature that there isn’t room in the literature for my nitric oxide idea to be completely wrong. Just as there isn’t room in the literature for homeopathy to be correct.

  26. phayes says:

    “You are correct that no amount of low power trials could convince any scientist that homeopathy or psychic abilities are real.”

    I would’ve been if I had but I didn’t and that was rather the whole point old bean. Never mind, at least you got there in the end (or middle) and apparently quite independently of anything I’d said…

    ;-)

  27. Scott says:

    Just to be clear, the two big problems with your NO stuff are:

    1. Given the sheer number of things you claim are caused by NO, even if one assumes that the prior probability of each is 90%, the prior probability of all being correct approaches 0.

    2. You typically present them as proven fact despite admitting that the proper testing has not yet been done.

    And that’s all I will say on the matter.

  28. nybgrus says:

    daedalus:

    If you have noticed in our interactions I have always respected your opinions, but indeed thought them a bit far fetched. The reasons for me are twofold. Firstly, because I know the first step to losing yourself in science is to lose a foothold on the stuff you do know. And I just don’t know enough to comfortably jump over to your unified theory of NO since, even if it were 99% right (I think you will admit nothing can be 100% right), I would simply lose my footing and bumble around. Secondly, it is because your claims seem to rally around NO producing bacteria and how adding them to the mileu would improve just about anything. My issue here is not that NO is not involved with just about everything. I don’t think there is the typical sCAMster fallacy of the one leaf to cure all disease, no matter how disparate the etiology. I am actually quite aware that NO is involved in just about every physiological process. My issue is that I feel the regulatory processes would be necessarily complex and jumbled – not because they need be, but because evolution doesn’t breed efficiency but merely adds and substracts in whatever manner works to solve the immediate problem. So whilst I may agree with you that NO physiology is vastly important, and that it does indeed play a role in many (if not a vast majority or all) physiological processes, I am simply not convinced that there is one convenient way to address the dysregulation issues – or even that they can be addressed. You yourself have commented that the body is not designed to be homeostatic to a “perfect” setpoint. It is just a lot of independent but interlinked control circuits that operate in whatever way is “good enough” to let the organism (us) survive. So even defining what proper NO regulation would be becomes problematic, compounded by orders of magnitude because of how many interconnected control mechanisms are involved, and then further compounded by how best to actually effect an “appropriate” change in NO regulation once that has been defined. Never mind that each independent control mechanism would have different effect sizes and thus targeting “optimal” NO regulation is further more difficult.

    At least, that is my take based on my knowledge so far (which I freely admit is limited, especially on the topic of NO specifically). But that is what makes me very leery that taking a bath in a NO bacteria soup would have a generally positive effect or that such an effect would even last a clinically significant amount of time.

    I do think you are a bit on the nutty side, daedalus, but don’t take that as an insult. I too am a bit nutty, and I think the most interesting people who are the smartest and best contributors to humanity have all been a bit nutty as well. It is just hard to distinguish that sort of nuttiness from the normal variant of troll nuttery we oft see here (save for degree, of course). I can tell you obviously aren’t a libby or jeremiah, for instance, and I love reading what you write, but I am just not able to confidently jump over to your NO theories is all. Keep plugging away at it though. I truly do hope you are vindicated some day :-)

  29. nybgrus, what a lovely explanation of your concerns. I wish I could bottle the essence of that comment. I think it would be the cure of all blog commenting disease.

  30. nybgrus says:

    As usual, you are much too kind Michele. Thank you :-)

  31. daedalus2u says:

    nybgrus, I pretty much agree with you. NO physiology is too complex for any non-physiological intervention to “work” without bad side effects. That is why there aren’t any (essentially). SNP can be used in patient for blood P control, but it requires constant monitoring. Nitroglycerin isn’t a NO donor and what it does is really complicated and does have side effects.

    It is precisely because physiology evolved that all the NO pathways have to work together and have to be “in sync”. Keeping the NO pathways “in sync” can’t be done artificially, it can only be done by the evolved pathways that do it. That is the only reason that these bacteria will work, because physiology evolved with those bacteria present and taking the bacteria away perturbs physiology in the characteristic direction of high stress. Physiology can tolerate some of the perturbation, but it mimics stress and chronic stress causes chronic (and characteristic) problems.

    The idea that basal NO is extremely important isn’t my original idea. I just found the physiological mechanism that regulates it (sweating delivering NH3 to a biofilm of these bacteria) and appreciated that since there is no threshold for changes in the basal level of a signaling molecule to change the output of signaling pathways that use that signaling molecule (a result shown with estrogen changing the sex ratio of turtles) that applies to NO also. In the case of NO, NO is used as a global control parameter. NO is what couples cells together so that the cells work together “in sync”. Screw up NO signaling and you screw up cells working together “in sync”.

  32. daedalus2u says:

    Scott, you are doing the Bayesian calculation wrong. What you want to calculate is the odds that I am wrong = the odds that the null hypothesis is correct.

    (prior odds of null hypothesis) X (Bayes factor) = (posterior odds of null hypothesis)

    The way to calculate that with Bayesian statistics is to take the prior odds of the null hypothesis, multiply it by the Bayes factor and you get the posterior odds of the null hypothesis (the null hypothesis being that NO is not involved in lots of pathways).

    The Bayes factor is the P(the data given the null hypothesis)/P(the data given the alternative hypothesis).

    For pathways that it is known that NO is involved in them (regulation of steroid synthesis), assume P(null hypothesis) =0.2 (a very modest value) and P(hypothesis that NO is involved) = 0.8. This makes the Bayes factor =0.2/0.8 = 0.25, that is with increased data that NO is involved in signaling pathways, the smaller the odds that the null hypothesis that NO is not involved is correct.

    If we assign a prior probability of one in a million to the idea that NO is involved in many pathways, we have

    prior odds of null hypothesis = (a million to one)

    So then we calculate the P of the null hypothesis after applying the data from the literature that NO regulates steroid synthesis, we have

    (a million to one) X (0.25) = (250,000 to one)

    If we apply the next paper from the literature that NO is involved in regulation of O2 consumption by mitochondria, and generate a similar 0.25 Bayes factor then we have

    (250,000 to one) X (0.25) = (62,500 to one)

    We apply this 98 times more and we end up with the probability of the null hypothesis =

    (a million to one) X (0.25)^100 = (6 times 10e -55 to one).

    Those are not bad odds. Of course I have a lot more than 100 pieces of data, more like tens of thousands. When about a thousand pieces of data all fit together I come to the conclusion that it is perverse to withhold provisional assent. I have looked for data that doesn’t fit and haven’t found any. I haven’t looked at all data, but I have looked at a great deal and I have not tried to cherry pick only data that supports my idea. Without knowing what I know, you can’t appreciate that.

    I appreciate that other people are not there yet. Abandoning the p value approach and adopting a Bayesian approach is difficult for some people, even people at SBM. I am prepared to be wrong if the data says I am wrong, but it would take extraordinary data to counter the tens of thousands of pieces of data from the literature. I am not making an extraordinary claim. I am just claiming something that is consistent with a lot of data in the literature. That is an ordinary claim, not an extraordinary claim.

  33. nybgrus says:

    daedalus:

    I agree with you in general, though I am not entirely sold on the NO bacteria co-evolution theory (not to say I am dismissing it entirely).

    The question that I would then have is how would we actually change that and maintain it? I have recently had a number of conversations about politics, economy, science, and obesity and all hinge on one thing – it is the entirety of the lifestyle and culture that leads to the problems described in the aforementioned areas. So, if the argument is that our naturally co-evolved biofilm of NO bacteria is off kilter, thus causing the effects you describe (which I think are at least partially correct if not entirely), then what is causing that to be off kilter? My guess would be it would be factors of our everyday lives and the way we do our tasks of daily living. So to replenish the NO bacteria would be fleeting and effect minor changes at best, since without global change in the myriad behaviours and actions leading to the decrease in the first place they would simply be removed back to the pathologic state we started with. How quickly that would happen is anyone’s guess since what is actually causing it to happen is largely unknown and likely itself complex and multifactorial. So even doing large studies to demonstrate the fleeting efficacy of NO bacteria replenishment would be difficult, let alone finding a way to make that effect long(er) lasting.

    At least, those are my thoughts spitballing of the top of my head.

  34. daedalus2u says:

    nybgrus, the bacteria have a doubling time of ~10 hours compared to 20 minutes for the bacteria that cause odor. It is trivial to wash them off faster than they can proliferate. If you wash every couple of days, you are washing them off faster than they can develop a biofilm. If you use agents on the skin that kill bacteria (deodorants and antimicrobials) in the niches they need to be in (places where humans have hair), they won’t be there when needed to produce NO/NOx.

    If you do replenish them (as with a culture of them in sufficient numbers), they remain alive on the skin actively metabolizing ammonia into NO and nitrite and are there to actively regulate the NO/NOx level when physiology calls on them to do so (by releasing NH3 via sweating). They can live on the human body long term (years) surviving only on natural secretions. They are not displace by other bacteria except following their removal either by antimicrobials or by bathing.

    I have instrumental data showing NO from these bacteria in vivo (human). I have instrumental data showing that some of the NO these bacteria produce is absorbed, in vivo (human). I have instrumental data showing a spontaneous physiological effect known to be mediated through NO coincident with instrumental data of spontaneous NO production by these bacteria in vivo, human, on multiple occasions.

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