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California Bill AB 2109: The Antivaccine Movement Attacks School Vaccine Mandates Again

Of all the preventative treatments ever developed through science- and evidence-based medicine, vaccines have arguably saved more lives, prevented more illness and disability, and in general alleviated more suffering than any single class of treatments or preventative measures throughout history. Given the obvious and incredible success of vaccines at decreasing the incidence of infectious diseases that used to ravage populations, it seems incredible that there would be such a thing as an antivaccine movement, but there is. Indeed, when I first encountered antivaccine zealots on the Usenet newsgroup misc.health.alternative about ten or twelve years ago, as a physician I really had a hard time wrapping my head around the fact that such people existed. No doubt the same is true of many physicians, who take the scientific evidence for the safety and efficacy for vaccines for granted. However, I am a cancer surgeon, and I do not treat children; so until I discovered antivaccine rhetoric on the Internet I was blissfully ignorant that such views even existed. Other health care professionals knew better. Pediatricians, nurses, and any health care professionals who deal with children and the issue of vaccinations know better, because they face antivaccine views on a daily basis. It is because of the incredible importance of vaccination and the danger to public health the antivaccine movement represents that we at Science-Based Medicine write so frequently about vaccines and the antiscientific, pseudoscientific, and misinformation-packed fear mongering about vaccines that is so prevalent today.

The success of vaccination campaigns has recently been endangered by a number of factors, in particular the antivaccine movement. Because of various groups opposed to vaccination, either for philosophical reasons or because they incorrectly believe that vaccines cause autism, neurodevelopmental disorders, sudden infant death syndrome, and autoimmune diseases, among others, one of the most potent tools for encouraging high rates of vaccine uptake, school vaccine mandates, have come under attack. Alternatively, increasing numbers of parents have taken advantage of religious or philosophical exemptions in order to avoid the requirement to have their children vaccinated prior to entry to school. As a result, of late some states with lax vaccination requirements have begun to try to tighten up requirement for non-medical vaccine exemptions. The arguments used by the antivaccine movement against such legislation are highly revealing about their mindset, in particular their attitude towards issues of informed consent, which I will discuss a bit. But first, here’s a little background.
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Posted in: Politics and Regulation, Public Health, Science and the Media, Vaccines

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Keeping the customer satisfied

One thing about blogging once a week or so compared to my other blogging gig, which is usually close to every day, occasionally more often, is that I really can’t cover everything I want to cover for this blog. Even more so than at my not-so-super-secret other blogging gig, I have to pass on topics that could be fodder for what could be excellent to even awesome posts—or, self-congratulating hyperbole aside, at least reasonably interesting to the readers of this blog. When that happens, I can only hope that one of my co-bloggers picks up on it and gives the subject matter the treatment it cries out for. Or, sometimes, such subject matter just has to be dealth with elsewhere by me—or not at all. Even a hypercaffeinated blogger like myself has limits.

Sometimes, however, I actually get a second chance. In other words, I get a chance to revisit a topic that I passed by. Usually, this happens when something new happens that gives me an excuse to revisit the topic. So it was last of week, when I was perusing the New York Times by an oncology nurse named Theresa Brown. Her article was titled, appropriately enough, Hospitals Aren’t Hotels. It will become very apparent very quickly why in a moment. But first, let’s sample Brown’s article a bit, because it brings up an issue that is very pertinent to science-based medicine:
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Posted in: Clinical Trials, Diagnostic tests & procedures, Epidemiology

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An antivaccine tale of two legal actions

I don’t know what it is about the beginning of a year. I don’t know if it’s confirmation bias or real, but it sure seems that something big happens early every year in the antivaccine world. Consider. As I pointed out back in February 2009, in rapid succession Brian Deer reported that Andrew Wakefield had not only had undisclosed conflicts of interest regarding the research that he did for his now infamous 1998 Lancet paper but that he had falsified data. Then, a couple of weeks later the Special Masters weighed in, rejecting the claims of autism causation by vaccines made in three test cases about as resoundingly as is imaginable. Then, in February 2010, in rapid succession Andrew Wakefield, the hero of the antivaccine movement, was struck off the British medical register, saw his 1998 Lancet paper retracted by the editors, and was unceremoniously booted from his medical directorship of Thoughtful House, the autism quack clinic he helped to found after he fled the U.K. for the more friendly confines of Texas. Soon after that, the Special Masters weighed in again, rejecting the claims of autism causation by vaccines in the remaining test cases. Then, in January 2011, Brian Deer struck again, publishing more damaging revelations about Wakefield, referring to his work as Piltdown medicine in the British journal BMJ.

This year, things were different.
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Posted in: Politics and Regulation, Science and the Media, Vaccines

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Help a reader out: Abstracts that misrepresent the content of the paper

Earlier this week, a reader of ours wrote to Steve and me with a request:

First off, I just want to say thank you for everything you gentlemen do. I find that your sites are extremely helpful when trying to figure out what level of information is BS, and what is real.

In short, I was wondering if either of you two would be able to refer me to a scientific or psuedo-scientific article where the abstract completely misrepresents the article or the conclusion doesn’t fit the analysis/data. The reason is that I’m writing is that I’m currently in my third year at [REDACTED], and currently I’m working on my seminar paper so I can graduate. I decided to look at whether there is a reasonable fair use argument in the reproduction of an entire scientific article and at what instances prior precedent would allow it. Inherent in the argument is that a scientific paper can’t be properly excerpted without losing vital information (or that an abstract does not adequately describe the entire paper), so complete reproduction of the article is necessary to properly convey the point.

Sincerely,

A Reader

So…at the risk of being too blatant, I’ll just say that our readers are very informed and scientifically knowledgeable (excepting the odd troll, of course). Can you help another reader out and provide references that fit this reader’s request? I can think of one, but I don’t think it’s as blatant as what he has in mind. Please list your references below. Heck, we might even be able to get a post for SBM out of this if there are some interesting papers that fit the description above.

Posted in: Basic Science, Medical Academia

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A surprising article about “integrative” medicine in The New England Journal of Medicine vs. “patient-centered” care

The New England Journal of Medicine (NEJM) is published on Thursdays. I mention this because this is one of the rare times where my owning Mondays on this blog tends to be a rather large advantage. Fridays are rotated between two or three different bloggers, and, as awesome as they are as writers, bloggers, and friends, they don’t possess the rabbit-like speed (and attention span) that I do that would allow me to see an article published in the NEJM on Thursday and get a post written about it by early Friday morning. This is, of course, a skill I have honed in my not-so-super-secret other blogging identity; so if I owned the Friday slot I could pull it off. However, the Monday slot is good enough because I’ll almost always have first crack at juicy studies and articles published in the NEJM before my fellow SBM partners in crime, unless Steve Novella managed to crank something out for his own personal blog on Friday, curse him.

My desire to be the firstest with the mostest when it comes to blogging about new articles notwithstanding, as I perused the table of contents of the NEJM this week, I was shocked to see an article that made me wonder whether the editors at NEJM might just be starting to “get it”—just a little bit—regarding “integrative” medicine. As our very own Mark Crislip put it a little more than a week ago:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

Lately, though, I’ve been more fond of a version that doesn’t use fancy words like “instantiate”:

If you integrate fantasy with reality, you don’t make the fantasy more real. You temporarily make your reality seem more fantasy-based, but reality always wins out in the end.

The part about the cow pie needs no change, although I think ice cream works a bit better than apple pie. Your mileage may vary. Feel free to make up your own metaphor inspired by Mark’s.

In any case, in the Perspective section, I saw three articles about “patient-centered” care:
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Posted in: Cancer, Diagnostic tests & procedures, Medical Academia, Medical Ethics

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Dr. Oz revisited

We here at SBM have been very critical of Dr. Mehmet Oz, who through his relentless self-promotion (and with more than a little help from his patron Oprah Winfrey) has somehow become known as “America’s doctor.” Back in the early days, when he was the regular medical expert on The Oprah Winfrey Show, Dr. Oz was at least tolerable. Much of what he discussed was reasonably science-based and even sensible, mainly advice to eat better and get more exercise, which is what most primary care doctors tell their patients every day. True, he did “integrate” some non-evidence-based therapies in with the evidence-based therapies, which was not good given how a typical viewer wouldn’t be able to tell where the science-based advice ended and the magical thinking began, but for the most part, even on Oprah’s show, he kept his woo somewhat in check. At least, there were boundaries beyond which he wouldn’t pass, even though Dr. Oz’s wife is a reiki master and he has been a fan of reiki (gaining fame for inviting reiki masters into his operating room during cardiac surgery) since at least the 1990s. More recently, Dr. Oz has testified in front of NCCAM patron Senator Tom Harkin’s committee to promote “complementary and alternative medicine” (CAM) or, as its advocates like to call it now, “integrative medicine.” He’s also been the Medical Director for the Integrative Medicine Program at New York-Presbyterian Hospital/Columbia University Medical Center since 2001. (How he does his TV show, holds a job as a professor of surgery at Columbia University, and holds positions as Clinical Trials of New Surgical Technology, Attending Surgeon, and Director, Clinical Perfusion Services at the same hospital, I’ll never know. He must have the most understanding partners ever.)

Be that as it may, even after Dr. Oz landed The Doctor Oz Show, for the first half of his first season he kept it fairly straight and science-based. However, two years ago the mask began to slip when Dr. Oz first aired a credulous feature about reiki under the title Dr. Oz’s Ultimate Alternative Medicine Secrets. Not long after that, Dr. Oz featured a man who is in my opinion arguably the foremost promoter of quackery on the Internet, Dr. Joe Mercola, along with the master of quantum quackery, Dr. Deepak Chopra. It was at that point that one could rightly say that Dr. Oz had “crossed the Woobicon.” Since then, it’s been one thing after another, beginning in earnest about a year ago. For instance, in January 2011, Dr. Oz featured Dr. Mercola again in a completely credulous portrait that painted him a “brave maverick doctor,” only without a hint of irony. A couple of weeks later, he featured a yogi who advocated “detoxing” and a faith healer from my old stomping grounds in Cleveland. Then, just when I thought Oz couldn’t go any lower, he featured psychic scammer John Edward.

Finally, back in April 2011, Dr. Oz’s producers apparently figured out that there was a problem with Dr. Oz’s image, except that they saw it as an opportunity to gin up a little controversy on the show. They invited our very own Dr. Steve Novella on the show as the “skeptic” who criticizes Dr. Oz. I very much admire Steve for going into the lion’s den, where, he knew in advance, he would be the underdog and the audience would be against him. Steve acquitted himself well, and after his appearance, I have to admit, I pretty much stopped paying attention to Dr. Oz for several months. He basically faded into the background of quackery, a prominent voice “integrating” quackery with medicine, pseudoscience with science, in the apparent belief that mixing fantasy with reality somehow improves medicine. Personally, I prefer Mark Crislip’s take and will steal his statement about “integrative medicine”:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

I just learned last week that Dr. Oz, while trying to make the cow pie taste better, is only continuing to succeed in making the apple pie taste worse. Witness an episode from last week featuring a long segment entitled Dr. Mercola’s Most Radical Alternative Cures, or, as the banner on the segment calls it, “Radical Cures Your Doctor Thinks Are Crazy.” Not surprisingly, Dr. Mercola has been bragging about his fourth appearance on Dr. Oz’s show yet again. (Video: Part 1 and Part 2).
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Posted in: Cancer, Energy Medicine, Science and the Media

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SANE Vax adopts Dr. Hanan Polansky’s “microcompetition” as its own. Hilarity ensues.

One of the hallmarks of science as it has been practiced for the last century or so is that scientists share their discoveries in the peer-reviewed literature, where their fellow scientists can evaluate them, decide if they’re interesting, and then replicate them, usually as a prelude to building upon them. While the system of publication and peer review in science is anything but perfect (and, indeed, we have discussed many of its shortcomings right here on this very blog), I tend to like to view it in much the same way Winston Churchill characterized democracy:

Many forms of Government have been tried and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of government except all those other forms that have been tried from time to time.

I would rephrase this as:

Many forms of evaluating science have been tried and will be tried in this world of sin and woe. No one pretends that peer review is perfect or all-wise. Indeed, it has been said (by me) that peer review is the worst form of evaluating science except all those other forms that have been tried from time to time.

As mainstream medicine has become more scientific over the last century in the wake of the Flexner Report, physicians and medical researchers have similarly come to view publication in the peer-reviewed literature to be a very important component of communicating and evaluating medical discoveries. It’s not as though this is even a particularly high bar to pass, either. After all, many are the absolutely execrable papers that I (and my partners in crime here at SBM) have discussed over the last four years, nearly all of which were in peer-reviewed journals, some very prestigious. After all, if papers on “energy chelation” can find their way into decent journals and the likes of Mark and David Geier can publish in the peer-reviewed literature, while someone like Christopher Shaw can get cringe-worthy confusions of correlation with causation published, I don’t take seriously the whines of cranks who claim that they can’t publish in the peer-reviewed literature for one reason or another.

That’s why I view being published in the peer-reviewed literature as a minimum, but by no means sufficient, requirement good science. It’s also why, whenever I see a new claim, my first reaction is to see if (1) the person making the claim has published on it and (2) there are publications in the peer reviewed literature that support the claim. The first criterion helps me judge whether the person is a serious scientist; the second, whether there is any plausibility to his ideas. Sure, it’s not a foolproof scheme, but it is helpful.

I only wish antivaccinationists would do the same. That they don’t explains why they seem to be embracing someone named Dr. Hanan Polansky.
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Posted in: Basic Science, Cancer, Vaccines

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The Bravewell Collaborative maps the state of “integrative medicine” in the U.S., or: Survey says, “Hop on the bandwagon of ‘integrative medicine’!” (2012 Edition)

Earlier today, Steve discussed a new report hot off the presses (metaphorically speaking, given that it’s been published online) from the Bravewell Collaborative. Naturally, given the importance of the issue, I couldn’t resist jumping in myself, but before you read the blather I have to lay down, you really should read what Steve wrote about it. It’s that good. (Also, he’s our fearless leader, and I wouldn’t want him to be…unhappy about my having muscled in on his usual day to post.) Have you read it? Good. Now we can begin…

One of the most common (and potent) strategies used by promoters of “complementary and alternative medicine” (CAM)–or, as its proponents like to call it these days, “integrative medicine” (IM)–to convince the public and physicians either to use it (or at least to remain a shruggie about it) is in essence an argumentum ad populum; i.e., an appeal to popularity. Specifically, CAM/IM apologists like to use the variant of argumentum ad populum known as the “bandwagon effect,” in which they try to persuade patients and physicians that they should get with the CAM/IM program because, in essence, everyone else is doing it and it’s sweeping the nation in much the same way New Coke did in the 1980s. (Admittedly, CAM/IM apologists are, unfortunately, much better at sales than Coca-Cola was.) Not coincidentally, this is one type of method of persuasion much favored by Madison Avenue when selling cars, clothing, music, movies, food, beer, and nearly every other product–like Coca-Cola. I say “not coincidentally” because what CAM proponents are doing, more than anything else, is selling a lifestyle, a brand, a belief system, and, of course, many, many products whose value reminds me, more than anything else, of the aforementioned New Coke. In using this appeal to popularity, CAM/IM proponents try to portray stodgy physicians (you know, like pretty much every one of us at this blog) who insist on plausibility, science, and evidence to support the use of drugs and treatments as hopelessly behind the times, dogmatic, out of touch, and in general no fun to be around at all, particularly at parties.
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Posted in: Medical Academia, Science and the Media

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Does massage therapy decrease inflammation and stimulate mitochondrial growth? An intriguing study oversold

If there’s one form of so-called “complementary and alternative medicine” (CAM) that I find more tolerable than most, it’s massage therapy. The reason, of course, is that, whatever else anyone claims about massage, there’s no doubt that it feels good. Indeed, I’ve sort of come around to Kimball Atwood’s way of thinking. Back when he and I were on a panel together at TAM9, Kimball said something somewhat surprising, namely that he’s not sure we even need to test massage in randomized clinical trials because we all know that it feels good and if it feels good it can certainly be helpful at the very least to improve patients’ quality of life. Unfortunately, there’s a lot of woo in massage these days, and massage therapists who buy into the woo aren’t satisfied with simply using the rationale that massage feels good to recommend it to patients. They just can’t resist going beyond that to infuse massage therapy with every bit as much woo as any chiropractor or acupuncturist infuses into his respective specialty. For instance, some of the claims for massage include:

  • Decreases muscle pain & tension.
  • Rejuvenates the body and mind and lifts the spirit.
  • Relieves anxiety, stress and tension.
  • Relaxes muscles.
  • Alleviates headaches.
  • Hastens healing.
  • Increases ranges of motion.
  • Facilitates removal of waste and inflammation by-products.
  • Stimulates the immune system.
  • Eases symptoms related to fibromyalgia.
  • Promotes relaxation and comfort.
  • Reduces nausea in pregnant women.
  • Accelerates weight gain in premature infants.
  • Helps premature infants become more active and aware.
  • Increases energy and alertness.
  • Enhances morale and attitude.

Of course, there’s little doubt that a good massage probably can relax muscles, promote relaxation and comfort (which seems like the same thing to me), and enhance morale and attitude. I’d even be willing to concede that massage, properly administered, can probably also alleviate headaches (tension headaches, anyway) and increase range of motion in joints. But facilitate the removal of waste and inflammation byproducts? Stimulate the immune system (the all-purpose meaningless claim)? Hasten healing? Not so much.

All too often massage therapists ruin a perfectly good massage by imposing pseudoscientific and quack claims on it, such as claims that they are stimulating acupressure points or their adoption of the language of “energy healing.” Our own assistant editor, Paul Ingraham, a former massage therapist, has covered massage therapy claims thoroughly on PainScience.com.

So it was with a bit of trepidation (but also more than a bit of interest) that I took a look at some links that readers sent me about a week ago (too late, alas, for me to write about this last Monday). These links were to news stories with titles like Scientists Uncover Why Massage Heals Sore Muscles and Massage Reduces Inflammation And Promotes Growth Of New Mitochondria Following Strenuous Exercise, Study Finds. My first impression, actually, was that this was somewhat counterintuitive in that one might predict that deep kneading of muscles might actually cause a bit of inflammation and that it’s the counterirritation effect that leads to the perceived reduction in the amount of pain. Yet, according to the press release issued by McMasters University, whose contents were mirrored in many news stories, a study claiming state-of-the-art methods is concluding that massage is reducing inflammation:
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Posted in: Basic Science, Clinical Trials, Science and the Media

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Does thinking make it so? CAM placebo fantasy versus scientific reality

Last week, I discussed a rather execrable study. Actually, the study itself wasn’t so execrable, at least not in its design, which was a fairly straightforward three-arm randomized clinical trial. Rather it was the interpretation of the study’s results that was execrable. In brief, the authors tested an “energy healing” modality known as “energy chelation” versus a placebo (sham “energy chelation”) and found, as is so often the case in studies of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) that both modalities did better than no treatment on the primary outcomes but that the “real” treatment (if one can call energy chelation “real treatment”) produced outcomes that were statistically indistinguishable from the “sham” treatment. Not surprisingly, the next move on the part of the researchers was to do a bunch of comparisons, and, as is so often the case (particularly when one fails to correct statistically for multiple comparisons), they found a couple of secondary endpoints with barely statistically significant differences and trumpeted them as meaning that their “energy chelation therapy” has “significant promise for reducing fatigue.” They then argued that the study was also ” designed to examine nonspecific and placebo elements that may drive responses.”

Which brings us to the “power” of placebo.

As I was contemplating what I wanted to discuss this week, I thought about the study that Drs. Coyne, Johansen, and I objected to, but then I also thought about Dr. Crislip’s post last week and post I did about a month ago in which I noticed how lately CAM apologists seem to be—shall we say?—retooling their message in the wake of negative trial after negative trial of their implausible treatments. Gone (mostly) are claims of powerful specific effects and efficacy from treatments such as various “energy healing” modalities, acupuncture, homeopathy, and the like themselves, to be replaced by claims that physicians should embrace CAM because it’s “harnessing the power of placebo” to produce “powerful mind-body healing.” It’s a powerful message that has sucked in people who normally would be considered skeptics, such as Michael Specter, who, as I described, apparently bought into the message sufficiently that when Ted Kaptchuk was making the media round right before the holidays he happily published a fairly credulous interview with him entitled, The Power of Nothing: Could Studying the Placebo Effect Change the Way We Think About Medicine? (My answer: Very likely no.) Even Ira Flatow of Science Friday fell hard for Kaptchuk’s message, declaring at the beginning of the interview that Kaptchuk’s irritable bowel syndrome study is evidence that “placebos work even when patients are in on the secret.” (It’s not.)

That skeptics and scientists find the idea that the mind has the power to heal the body, often referred to as “self-healing” or “mind-body healing,” so seductive should probably not be surprising. After all, who wouldn’t want to be able to cure themselves simply by willing it to be so? It’s a concept that, like so many concepts in CAM, goes far back into ancient times and stretches forward to today in ideas like The Secret, which goes quite a bit beyond the whole idea of “mind-body healing” or healing yourself because you wish it to be so, and declares that you can have virtually anything you want simply by thinking the right thoughts. In fact, to me it appears that the “powerful placebo” is being drafted in the service of supporting what are, at their core, mystical beliefs far more than science. I’d like to elaborate on that idea a bit more than I did last time I discussed this isssue, where I concluded by writing:

In the end, all too much of the rebranding of CAM as placebo and the selling of placebos as some sort of powerful “mind-body healing” strikes me as being much like The Secret, in which wishing makes it so.

Let’s take a look at just how far this goes.
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Posted in: Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Religion

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