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Reporting back on my Grand Rounds experience at FSU

Last Thursday, I had the distinct privilege and honor to be invited to speak at Grand Rounds at the Florida State University College of Medicine in Tallahassee. Ray Bellamy, who is on the faculty there and is also the husband of our very own Jann Bellamy (who is herself is the founder of the Campaign for Science-based Health Care), invited me down to give a talk on “complementary and alternative medicine” (CAM) and “integrative medicine” (IM). Although I’ve spoken to skeptics’ groups, such as local groups or even to workshops at The Amazing Meeting, and to medical students’ groups, this represented the first time I had been invited to speak in front of a large group of medical professionals, not all of whom necessarily agreed with our viewpoint here at SBM. So it was with some trepidation that last Wednesday I braved the trip to Tallahassee, with the unfortunately requisite connection in Atlanta that necessitated my practically running from one end of that massive airport to the other in order to make my connection to the little puddle jumper of a jet that took me to Tallahassee. Whether or not my talk was a success or not, readers can judge for themselves, as it’s been posted online on the FSU Grand Rounds page. (Just scroll down to November 10 and then hit the link. Unfortunately, it appears that you’ll need Microsoft Silverlight to get the video to work.) I haven’t watched the whole thing yet, but I encourage you to do so and tell me how good (or bad) I was and why. I want to get better, and I won’t rest until I’m as good at communicating medicine as Neil deGrasse Tyson or Richard Wiseman, for instance, is at communicating science.
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Posted in: Medical Academia

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Defining what a “physician” is

The very concepts of “complementary and alternative medicine” (CAM) and “integrative medicine” (IM), the former of which “complements” science-based medicine with quackery and the latter of which “integrates” pseudoscience-based with science-based medicine are all about slapping a veneer of scientific legitimacy onto something that has failed to achieve such legitimacy through actual basic, translational, and clinical science. The reason I start out by saying this is to emphasize that CAM/IM is all about using language to persuade that pseudoscience is actually science-based. It’s far more about marketing than accurately communicating concepts. In CAM, everything is “holistic,” and doctors “care for the whole patient,” while “Western medicine” is “reductionistic” and “allopathic.” At the very heart of this language is a false dichotomy: That you must either embrace pseudoscience or that you somehow can’t provide care as compassionate and caring as what the quacks supposedly provide, nor are you able to provide for the emotional needs of your patients. There are two false dichotomies, actually, in that there is also the not-so-subtle implication in CAM that you can’t be truly “holistic” without—you guessed it—embracing the pseudoscience that is at the heart of many CAM/IM modalities.

This use and abuse of language for propagandistic purposes in CAM/IM is not limited to just these examples. In fact, the misuse of language infuses the whole enterprise of CAM/IM to the point that its adherents, not content with being mere “practitioners,” are trying to claim the very title of “physician” for themselves. I learned this from John Weeks, the main force behind the Integrator Blog, a blog dedicated to issues of CAM and IM. He’s the one who first let me know about Andrew Weil’s attempt to put together a board certification in IM. In particular, his reporting on the reaction of CAM/IM practitioners, both physicians and non-physicians, to this initiative by Andrew Weil was most illuminating to me. What was most telling was how further propagandistic use of the language focused on “dominance” by MDs, which in this case struck me as actually being closer to the truth than the usual CAM-speak is. In any case, Dr. Weil’s initiative does indeed appear to be more about taking control of CAM for physicians, his high-minded language about “establishing standards” notwithstanding.

This time around, Weeks has provided me with an education about how alternative/CAM/integrative practitioners now covet the title of “physician”. In the process, he also uses and abuses language in the same way that Andrew Weil and CAM/IM advocates do. This time around, it’s all about co-opting the title of “physician” for non-physician CAM practitioners. It’s bad enough to me when actual physicians are seduced by the pseudoscience of CAM, but this effort appears to be an intentional strategy designed to confuse the public by proclaiming as physicians practitioners who lack the essential skills to be a physician, such as acupuncturists, chiropractors, homeopaths, and naturopaths.
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Posted in: Chiropractic, Homeopathy, Naturopathy, Politics and Regulation

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The Greater Good: Pure, unadulterated anti-vaccine propaganda masquerading as a “balanced” documentary

I’ve heard it said (actually, I’ve said it myself) that if you don’t have the science and evidence to back up your point of view, in order to persuade someone, make a movie. At least, this seems to be the philosophy of a number of cranks who have produced movies promoting pseudoscience over the last five years or so. The first one of these movies that really caught my attention was an anti-evolution, pro-”intelligent design” creationism documentary narrated by Ben Stein and released in 2008, Expelled: No Intelligence Allowed. The movie was pure creationist propaganda, complete with Ben Stein visiting Auschwitz and Dachau, the better to try to link “Darwinism” to the Holocaust.

Movies promoting religious pseudoscience such as intelligent design creationism are not the only kinds of pseudoscience propaganda films. Indeed, medicine is rife with them, and Wally Sampson has referred to this particularly pernicious genre of documentary as “medical propaganda films.” During the existence of this blog, we’ve reviewed a few such films (or at least written about what we could find out about them without paying for the DVD). For example, I’ve written about The Beautiful Truth, a paean to the Gerson protocol for cancer, complete with coffee enemas, and reviewed Simply Raw: Reversing Diabetes in 30 Days, a film dedicated to the claim that you can cure almost everything (including not just type II but type I diabetes) with a raw vegan diet. Harriet reviewed The Living Matrix: A Film on the New Science of Healing, a movie promoting “energy medicine” quackery. There’s even a film out now praising Stanley Burzynski and his highly dubious “antineoplaston” therapy that I’ve been meaning to review. I finally found a free copy of it to watch, and perhaps I’ll get to it before the end of the month. In the meantime, there’s a documentary people have been begging me to check out called The Greater Good that has been making the rounds of various film festivals and will be debuting at the IFC Center in New York on November 18. The very fact that Joe Mercola has hosted the movie streaming on his website in celebration of what he and Barbara Loe Fisher have dubbed “Vaccine Awareness Week” should tell you all you need to know about the movie.

I’m going to tell you more, though, because I’ve actually managed to sit through the whole thing. The things I do for my readers! To give you an idea of what you’re in for (in case the video is no longer available by the time that you read this), here’s the trailer:

The first thing I noticed about The Greater Good is that it’s slick and very well produced—considerably better produced, I think, than Expelled! The only aspect of it that I found annoying (besides the sheer quantity of anti-vaccine misinformation, pseudoscience, talking points, and distortions, all of which were plenty annoying) was the little animated segments. (Well, the little animated segments and any segment featuring Dr. Bob Sears.) However, given the sheer mass of anti-vaccine propaganda contained within this documentary, quibbling about a stylistic element like that is rather like quibbling about the arrangement of the deck chairs on the Titanic.

The documentary is structured, as many documentaries are, around three families, the better to provide the human interest “hook” for the rest of the story. Interspersed with segments about each family are interviews with various experts. Perhaps I should say two experts arrayed against a whole lot of “experts,” because defending vaccines we have real experts like Dr. Paul Offit; Dr. Melinda Wharton of the CDC; Dr. Norman Baylor, who is Director of the Office of Vaccines Research and Review in the FDA’s Center for Biologics Evaluation and Research; and Dr. Mark B. Feinberg, Vice President for Medical Affairs and Policy for Merck Vaccines and Infectious Diseases at Merck & Co., Inc. Arrayed against them we have a whole lot of anti-vaccine pseudoexperts, such as Barbara Loe Fisher, grande dame of the anti-vaccine movement and founder of the Orwellian-named National Vaccine Information Center (NVIC); Dr. Bob Sears, a pediatrician known for his non-science-based “alternative” vaccination schedule, who of late appears to have ceased mere flirting with the anti-vaccine movement and thrown his lot in with it; Dr. Lawrence Palevsky, a “wholistic” pediatrician; Dr. John Green III, who is described as a “specialist in clinical ecology and nutritional medicine“; and several trial lawyers known for representing parents suing for “vaccine injury,” lawyers such as Clifford Shoemaker, Kevin Conway, and Renee Gentry.
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Posted in: Science and the Media, Vaccines

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Pox parties taken to the next (illegal) level

Normally, we don’t post on weekends on this particular blog, mainly because most of our readership visits during the week and we don’t have enough bloggers to cover the weekend reliably anyway. However, occasionally something happens that’s so bizarre, so worrisom that we can’t wait until Monday. I don’t even care if I’m late to the party after Tara, Mike the Mad Biologist, The Biology Files, Todd, and probably several others whom I’ve missed.

Regular readers of this blog and anyone who’s ever followed the anti-vaccine movement more than superficially have probably heard of pox parties. These are, yes, parties where parents who don’t want to vaccinate their children against chickenpox, hoping for “natural immunity,” expose their children who have never had chickenpox to children with active chickenpox in order to intentionally infect them with the disease. (Thanks, Mom and Dad, for a couple of weeks worth of misery and intense itching and a small chance of serious complications!) Although there might have been a weak rationale for such activities back before there was a vaccine for chickenpox, today pox parties are about as dumb a concept as I can think of and only make sense in the context of equally idiotic anti-vaccine pseudoscience, and apparently, as is the case with many idiotic things, has co-opted Facebook and other discussion forums as a means of getting like minded (if you can call what is behind this a “mind”) together for purposes of inflicting misery on their children. One such page even has a Quack Miranda-style warning:
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Posted in: Vaccines

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CAM practitioners react to Andrew Weil’s proposal for a board certification for integrative medicine. It isn’t (all) pretty.

About a month ago, I discussed a rather disturbing development, namely the initiative by Dr. Andrew Weil to set up something he was going to call the American Board of Integrative Medicine, all for the purpose of creating a system of board certification for physicians practicing “integrative medicine” (IM), or, as I prefer to call them, physicians who like to integrate pseudoscience with their science, quackery with their medicine. Harsh? Yes. Accurate? Also yes. Unfortunately, many medical centers, both academic and community, are hopping on the IM bandwagon while more and more medical schools are “integrating” pseudoscience into their curricula. While one might expect Josephine Briggs of the National Center for Complementary and Alternative Medicine (NCCAM) to be cozy with IM, depressingly, even current director of the National Institutes of Health, Francis Collins, seems to have fallen into the trap.

As was admitted by Dr. Weil and his colleagues, this decision to create a board certification in IM was a huge about-face in that Weil had always argued that IM should be infused into all specialties of medicine. What happened, of course, is that once again marketing won out over idealism. Dr. Weil was concerned that there were lots of physicians and practitioners out there claiming to practice “integrative” medicine, many of whom had no qualifications in the field. At this point, the wag in me can’t resist pointing out that, given that IM “integrates” pseudoscience with science and that there really are no standards, scientific or otherwise, to guide IM practitioners (mainly because so much of IM is rank pseudoscience), why would this matter? The answer, again, comes down to branding and turf protection.

All of this is why seeing the reactions to Dr. Weil’s initiative from members of the “complementary and alternative medicine” (CAM) and IM community is very instructive. Fortunately, John Weeks of the Integrator Blog has come through again, quoting over twenty different people, including physicians, naturopaths, chiropractors, journalists, and other IM practitioners in an article entitled, appropriately enough, Integrator Forum: 20 Voices on Weil/U. Arizona and the American Board of Integrative Medicine. Yours truly is even mentioned (disparagingly, of course).

Uncharacteristically (for me), I’ll cut to the chase and tell you the results before I show you some of the quotes (with, of course, my own translation of what the IM-speak really means). Basically, physicians practicing IM tend to love what Dr. Weil is doing. All other practitioners (chiropractors, naturopaths, etc.) hate it. Of course, that’s not a big surprise given that Weil’s plan would in essence cut out all non-physician IM practitioners from being able to call themselves “integrative physicians” or, at the very least, to relegate them to a lower, non-board-certified rung in the practice hierarchy, which, I suspect, was the point all along. Andrew Weil wants IM to be “respectable,” and to him it will only become so if the riff-raff (i.e., non-physicians) are excluded.
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Posted in: Politics and Regulation, Science and Medicine

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“And one more thing” about Steve Jobs’ battle with cancer

I’ve written quite a bit about Steve Jobs in the wake of his death nearly four weeks ago. The reason, of course, is that the course of his cancer was of intense interest after it became public knowledge that he had cancer. In particular, what I most considered to be worth discussing was whether the nine month delay between Jobs’ diagnosis and his undergoing surgery for his pancreatic insulinoma might have been what did him in. I’ve made my position very clear on the issue, namely that, although Jobs certainly did himself no favors in delaying his surgery, it’s impossible to know whether and by how much he might have decreased his chances of surviving his cancer through his flirtation with woo. However much his medical reality distortion field might have mirrored his tech reality distortion field, my best guess was that Jobs probably only modestly decreased his chances of survival, if that. I also pointed out that, if more information came in that necessitated it I’d certainly reconsider my conclusions.

The other issue that’s irritated me is that the quackery apologists and quacks have been coming out of the woodwork, each claiming that if only Steve Jobs had subjected himself to this woo or taken this supplement, he’d still be alive today. Nicholas Gonzalez was first out of the gate with that particularly nasty, unfalsifiable form of fake sadness, but he wasn’t the only one. Recently Bill Sardi claimed that there are all sorts of “natural therapies” that could have helped Jobs, while Dr. Robert Wascher, MD, a surgical oncologist from California (who really should know better but apparently does not) claims that tumeric spice could have prevented or cured Steve Jobs’ cancer, although in all fairness he also pointed out that radical surgery is currently the only cure. Unfortunately, he also used the failure of chemotherapy to cure this kind of cancer as an excuse to call for being more “open-minded” to alternative therapies. Even Andrew Weil, apparently stung by the speculation that Jobs’ delay in surgery to pursue quackery might have contributed to his death, to tout how great he thinks integrative cancer care is.

Last week, Amazon.com finally delivered my copy of Walter Isaacson’s biography of Steve Jobs. I haven’t had a chance to read the whole thing yet, but, because of the intense interest in Jobs’ medical history, not to mention a desire on my part to see (1) if there were any new information there that would allow me to assess how accurate my previous commentary was and (2) information that would allow me to fill in the gaps in the story from the intense media coverage. So I couldn’t help myself. I skipped ahead to the chapters on his illness, of which there are three, entitled Round One, Round Two, and Round Three. Round One covers the initial diagnosis. Round Two deals with the recurrence of Jobs’ cancer and his liver transplant. Finally, Round Three deals with the final recurrence of Jobs’ cancer, his decline, and death.

Before I start, a warning: I’m going to discuss these issues in a fair amount of detail. If you want “medical spoilers,” don’t read any further. On the other hand, one spoiler I will mention is that there was surprisingly little here that wasn’t reported before; the only difference is that there is more detail. However, the details are informative.
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Posted in: Cancer, Nutrition, Science and the Media

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More Breast Cancer Awareness Month pseudoscience from (who else?) Joe Mercola

I have mixed emotions regarding Breast Cancer Awareness Month. On the one hand, I look forward to it because it provides us with a pretext to get out science-based messages about breast cancer and to highlight a lot of the cool science that we do at our cancer center. On the other hand, the quacks see an opportunity in Breast Cancer Awareness Month to spread their message too. That message, not surprisingly, generally involves attacking science-based modalities for the detection and treatment of breast cancer and promoting their “alternative” methods. For example, last year, Christiane Northrup promoted thermography as somehow being better than mammography for the early detection of breast cancer. It’s not. Yet there she is this year again, still promoting the same nonsense. In years past, I’ve seen people like Dennis Byrne promoting a link between abortion and breast cancer, a link that is not supported by science. I’ve seen the likes of Mike Adams claiming that Breast Cancer Awareness Month is nothing more than a conspiracy by the male-dominated “cancer industry” to keep women down and misinformation about “myths” of breast cancer while likening the “cancer industry” to Nazi extermination camp commanders and chemotherapy to Zyklon-B. I kid you not about that last part. Indeed, during October, I frequently get to look forward to images like this one (click for a larger image):

Or this one:
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Posted in: Basic Science, Cancer, Clinical Trials

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Steve Jobs’ medical reality distortion field

As I pointed out in my previous post about Steve Jobs, I’m a bit of an Apple fan boy. A housemate of mine got the very first Mac way back in 1984, and ever since I bought my first computer that was mine and mine alone back in 1991 (a Mac LC), I’ve used nothing but Macintosh computers, except when compelled to use Windows machines by work—and even then under protest. Indeed, as I searched for jobs at various times in my life, I asked myself whether I could accept a job at an institution that didn’t permit me to have a Mac in my office, such as the V.A. Fortunately, I never had to make that choice. All of this explains why I paid a lot of attention to Steve Jobs and also why his death saddened me and, relevant to this blog, the clinical history of the cancer that killed him fascinates me.

It’s often been said that there was a sort of “reality distortion field” around Steve Jobs. It was a part joking, part derogatory, part admiring term applied to Jobs’ talent for persuasion in which, through a combination of personal charisma, bravado, hyperbole, marketing, and persistence, Jobs was able to persuade almost anyone, even developers and engineers, of almost anything. In particular, it referred to his ability to convince so many people that each new Apple product was the greatest thing ever, even when that product had obvious flaws. Unfortunately, as more news comes out about how Steve Jobs initially dealt with his diagnosis of a neuroendocrine tumor of the pancreas (specifically, an insulinoma) back in 2003 and 2004, it’s become apparent that Jobs had his own medical reality distortion field, at least in the beginning right after his diagnosis of a rare form of pancreatic cancer, that allowed him to come to think that he might be able to reverse his cancer with diet plus various “alternative” modalities.

In the immediate aftermath of Steve Jobs’ death, I summarized the facts about Jobs’ case that were known at the time. In particular, I took issue with the claims of a skeptic that “alternative medicine killed Steve Jobs.” At the time, I pointed out that, although it was very clear that Steve Jobs did himself no favors by delaying his initial surgery for nine months after his initial diagnosis, we do not have sufficient information to know what his clinical situation was and therefore how much, if at all, he decreased his odds of survival by not undergoing surgery expeditiously. To recap: Did Steve Jobs harm himself by trying diet and alternative medicine first? Quite possibly. Did alternative medicine kill him? As I’ve argued before, that’s impossible to say, and any skeptic who dogmatically makes such an argument has taken what we known beyond what can be supported. Regular readers know that when I see a story that looks as though “alternative medicine” directly contributed to the death of someone, I usually pull no punches, but in this case I had a hard time being so definitive because the unknowns are too many, with all due respect to Ramzi Amri, a Research Associate at Harvard Medical School who in my opinion also went too far. I did, however, point out that I’m always open to changing my opinion if new evidence comes in. Jobs was always incredibly secretive about his medical condition, so much so that it didn’t even come out in the press until after it had happened that he had undergone a liver transplant in 2008 for metastatic insulinoma in his liver, just as his cancer diagnosis in 2003 remained secret for 9 months, not being revealed until he sent an e-mail to Apple employees announcing that he had undergone surgery.

It turns out that, with the imminent release of a major biography of Steve Jobs, more information is finally trickling out about his medical history. For instance, Jobs’ biographer Walter Isaacson is going to appear on 60 Minutes this Sunday, and apparently he is going to say this:
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Posted in: Cancer, Nutrition, Science and the Media

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Steve Jobs’ cancer and pushing the limits of science-based medicine

Editor’s note: There is an update to this post.

An Apple fanboy contemplates computers and mortality

I’m a bit of an Apple fanboy and admit it freely. My history with Apple products goes way back to the early 1980s, when one of my housemates at college had an Apple IIe, which I would sometimes use for writing, gaming, and various other applications. Indeed, I remember one of the first “bloody” battle games for the IIe. It was called The Bilestoad and involved either taking on the computer or another opponent with battle axes in combat that basically involved hacking each other’s limbs off, complete with chunky, low-resolution blood and gore. (You youngsters out there will be highly amused at the gameplay here.) Of course, it’s amazing that nothing’s changed when it comes to computer games except the quality of graphics. Be that as it may, this same roommate was one of the first students to get a hold of the new Macintosh when it was released in early 1984. I really liked it right from the start but only got to play with it occasionally for a few months. After using a Macintosh SE to do a research project during my last year of medical school, I have used the Macintosh platform more or less exclusively, and the first computer I purchased with my own money was a Mac LC back in 1990 or 1991. Today, I have multiple Apple products, including my MacBook Air, my iPhone, and my old school iPod Classic, among others. Oddly enough, I do not have an iPad, but that’s probably only a matter of time, awaiting software that lets me do actual work on it.

All of this is my typical long-winded way of explaining why I was immensely saddened when I learned of Steve Jobs’ death last week. Ever since speculation started to swirl about his health back 2004 and then again in 2008, capped off by the revelation that he had undergone a liver transplant for a rare form of pancreatic cancer in 2009, I feared the worst. Last week, the end finally came. However, there is much to learn relevant to the themes of this blog in examining the strange and unusual case of Steve Jobs. Now, after his death five days ago, which coincidentally came a mere day after the launch of iCloud and the iPhone 4S, it occurs to me that it would be worthwhile to try to synthesize what we know about Jobs’ battle with cancer and then to discuss the use (and misuse) of his story. Of course, this is a difficult thing to do because Jobs was notoriously secretive and I can only rely on what has been published in the media, some of which is conflicting and all of which lacks sufficient detail to come to any definite conclusions, but I will try, hoping that the upcoming release of his biography by Walter Isaacson in couple of weeks might answer some of the questions I still have remaining, given that Isaacson followed Jobs through his battle with cancer and was given unprecedented access to Jobs and those close to him.

In the meantime, I speculate. I hope my speculations are sufficiently educated as not to be shown to be completely wrong, but they are speculations nonetheless.
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Posted in: Cancer, Medical Ethics, Nutrition, Science and the Media, Surgical Procedures

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The wrong way to “open up” clinical trials

Science-based medicine rests on twin pillars that are utterly essential to the development of treatments that are safe and efficacious. Both of these pillars depend on science, but in different ways. The first of these is, of course, the basic science that provides the hypotheses to test about the mechanisms behind the diseases and malfunctions that plague the human body. This basic science suggests ways of either correcting or alleviating these malfunctions in order to alleviate symptoms and prevent morbidity and mortality and how to improve health to increase quality and quantity of life. Another critical aspect of basic science is that it also provides scientists with an estimate of the plausibility of various proposed interventions, treatments and cures designed to treat disease and improve health. For example, if a proposed remedy relies upon ideas that do not jibe with some of the most well-established laws in science, such as homeopathy, the concepts behind which violate multiple laws of physics and chemistry, it’s a very safe bet that that particular treatment will not work and that we should test something else. Of course, the raison d’être of this blog derives from the unfortunate fact that in today’s medicine this is not the case and we are wasting incredible amounts of time, money, and lost opportunities in order to pursue the scientific equivalent of fairy dust as though it represented a promising breakthrough that will save medicine, even though much of it is based on prescientific thinking and mysticism. Examples include homeopathy, reiki, therapeutic touch, acupuncture, and much of traditional Chinese medicine and Ayurveda, all of which have managed to attach themselves to medical academia like kudzu.

Of course, basic science alone is not enough. Humans are incredibly complex organisms, and what we consider to be an adequate understanding of disease won’t always result in an efficacious treatment, no matter how good the science is. Note that this is not the same thing as saying that utter implausibility from a scientific basis (as is the case with homeopathy) doesn’t mean a treatment won’t work. When a proposed treatment relies on claiming “memory” for water that doesn’t exist or postulates the existence of a “life energy” that no scientific instrument can detect and the ability to manipulate that life energy that no scientist can prove, it’s a pretty safe bet that that treatment is a pair of fetid dingo’s kidneys. Outside of these sorts of cases, though, clinical trials and epidemiological studies are the second pillar of science-based medicine, in particular clinical trials, which is where the “rubber hits the road,” so to speak. In clinical trials, we take observations from the laboratory that have led to treatments and test them in humans. The idea is to test for both safety and efficacy and then to begin to figure out which patients are most likely to benefit from the new treatment.
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Posted in: Clinical Trials, Science and Medicine

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