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Open-Access Peer Review: Increasing the Noise To Signal Ratio

Readers of Science Based Medicine are quite familiar with the distressingly common logical leap made by disgruntled healthcare consumers into alternative medicine. It goes something like this: I had a terrible experience with a doctor who [ignored/patronized/misdiagnosed] me and I also heard something horrible in the media about a pharmaceutical company’s misbehavior [hiding negative results/overstating efficacy/overcharging for medications], therefore alternative treatments [homeopathy/acupuncture/energy healing, etc.] must be more effective than traditional medicine.

Much to my dismay, a similar logical leap is being made about online health information. It goes something like this: Peer reviewing is biased and often keeps innovative research hidden to the world at large, therefore the best kind of peer review is open-access where anyone in the world can contribute.

You may feel free to slap your forehead now.

While I have absolutely no doubt that doctors have their shortcomings, and that some have created less than pleasant healthcare experiences for their patients – the solution to these shortcomings is not to dive headlong into snake oil. Moreover, I agree that the current peer-review process has its flaws and limitations – the solution is not to ask Aunt Enid in Omaha what she thinks of the recent meta-analysis of perioperative beta blockers in patients having non-cardiac surgery.

Peter Frishauf, the founder of Medscape, recently published a webcast editorial predicting that:

“Peer review as we know it will disappear. Rather than the secretive prepublication review process followed by most publishers today, including Medscape, most peer review will occur transparently, and after publication.”

He goes on to describe a Wikipedia-like review scenario where:

“Any user can start an article, link it to related sources, and publish revisions with a click of the mouse. Anyone who reads an article can edit it.”

I know and like Peter very much, and his foresight (that publishing should become open-access), combined with the leadership of editorial heavy-weight, Dr. George Lundberg, led to the creation of the first really successful, quality, free online medical journal. This was no small feat, and a sure victory for global medical education efforts.

But the reason for The Medscape Journal’s success is not the “democratization” of peer review – but the democratization of access to trustworthy information. The quality controls are still in place – and must remain so – otherwise its value as a peer-reviewed journal will be utterly lost. Who should trust the edits of unqualified readers? Should science be determined by popular vote? Should all research be published by journals, regardless of its fatal flaws?

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Posted in: General, Science and Medicine, Science and the Media

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Fecal Transplants: Getting To The Bottom Of The Matter

Many Americans will be introducing more food than usual to their GI tracts on this Thanksgiving Day, and so I thought I’d provide you with a special gastroenterology-related post to complement the mood. If you have already eaten, I might suggest that you come back to this post on an empty stomach. I will be discussing the alternative medicine practice known as “fecal transplantation” and it is rather unsavory.

The idea of transferring stool from one person to another (for the treatment of various GI disorders) was first described in the 1950s. This month the TV show, Grey’s Anatomy, featured the practice in one of their plot lines – which rekindled interest in the therapy, and resulted in an explosion of search engine activity. I figured it was probably my duty, as a member of Science Based Medicine, to offer a rational analysis of the treatment in the hope that the Google gods will serve up my post to a few of the information-seekers out there. I hope to reach them before the snake oil salesmen, wrapped in their mantle of “gentle, natural cures,” convince them that they desperately need a good colon or liver cleanse, if not a fecal transplant.

Like most alternative therapies, fecal transplantation is based on a drop of truth and a gallon of pseudoscience. It is true that the gastrointestinal tract is teeming with hundreds of thousands of bacterial species and pseudo-species, and that without them we would die. It is also true that certain nasty bugs (like clostridium difficile) cause problems when they take up residence within the gut. Antibiotics do upset intestinal flora, much to the consternation of infectious disease specialists. Now, all that being said – the practice of repopulating the gut with another person’s stool requires some fairly grand assumptions about efficacy and safety that are not founded upon any clinical trial data whatsoever.
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Posted in: General, Surgical Procedures

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Canadian Justice: Breast-Fondling Chiropractor Faces “Interpersonal Skills Training”

There is something unexpectedly sinister about this news report from my former home town in Canada. Apparently, a local chiropractor has been using his “medical training” to excuse his sexual misconduct. Here’s the story from the Halifax Chronicle Herald:

During a hearing in July, the woman said the chiropractor would frequently grip her around the ribs and hold tight, sometimes cupping her breasts, while speaking softly over her shoulder.

On other visits, she said, he would have her lie on a table and would undo one side of her johnny shirt, exposing her breast, place a thumb between her breasts and roll her onto her side by pressing the weight of his own body on her.

Dr. LaPierre testified he performed a technique called the Zindler manoeuvre. It involves applying precise, quick pressure to a restricted joint to restore movement. He said he would have explained the procedure to her the first time but not on subsequent treatments…

The second incident involved a woman who complained that in 2006 the chiropractor “massaged” her breast while trying to find the source of her back pain.

Dr. LaPierre said he was using a technique called “matrix repatterning” that required contact with the woman’s sternum. He said he didn’t recall where the rest of his hand was at the time. He determined the woman had a rib out of alignment.

What was the punishment for his behavior?

Dr. Phillip LaPierre must have a female observer present when he examines women for the next five years, must take training on interpersonal skills and must pay a fine and costs totaling $26,000 now that a panel of the Nova Scotia College of Chiropractors has found him guilty of sexual misconduct based on the two complaints.

It’s hard to imagine such a small fee in an American court of law. If a US physician were molesting his patients, I’m willing to bet that the fine would have an additional zero or two at the end.
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Posted in: Chiropractic, Medical Ethics

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Bad Science: Four Things I Learned From Dr. Ben Goldacre

“You cannot reason people out of positions they didn’t reason themselves into.”

– Ben Goldacre, MD

Dr. Ben Goldacre is the author of the popular Guardian column, Bad Science. He has recently published a book by the same name. Bad Science received a very favorable review from the British Medical Journal and although I was tempted to write my own review for Science Based Medicine, I decided to cherry pick some concepts from the book instead. I hope you’ll enjoy the cherries.

Honesty & Placebos

As you can imagine, any good book about bad science must devote at least one chapter to the concept of placebos. We are all quite familiar with placebos, and how squarely the vast majority (and some would argue all) of complementary and alternative medicines fit into that category.  Ben surprised me with a couple of points that I hadn’t considered previously. Firstly, that alerting patients to the fact that you’re planning to prescribe them a placebo does not necessarily negate its effects, and secondly that no matter how skeptical or intelligent you are – all humans are subject to placebo effects.

Ben references a 1965 study from Johns Hopkins [Park et al., Archives of General Psychiatry] in which patients were explicitly told that they were going to receive a sugar pill (with no medicine in it at all) as treatment for their neuroses. The researchers reported substantial improvements in many of the study subjects’ symptoms.

This is the script that the physicians were to use to explain the placebos to the study subjects:

Mr. Doe… we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ‘sugar pills,’ and we feel that a so-called sugar pill may help you too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?

Wow. I was under the impression that the efficacy of the placebo was in the person’s belief that it was a legitimate medicine/therapy. Perhaps it only matters that the prescribing physician believes it might help? Perhaps snake oil salesmen are wasting their time on linguistic and pseudoscientific mental gymnastics?

Of course, the “gymnastics” do help. Other research has shown that the more complex the associated placebo ritual, the more potent its effects (such as piercing the skin with fine needles in many different locations). Nonetheless, I was surprised that an honest and accurate description of a placebo does not necessarily negate its effects.
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Posted in: Book & movie reviews, General, Herbs & Supplements, Science and the Media

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Wyeth vs. Levine: Should Drug Label Standards Be Determined By Juries?

It is with some degree of trepidation that I enter the fray on the Wyeth vs. Levine case. I’ve been watching the media frenzy about the lawsuit with interest – mostly because (for the first time in a while) I think that the pharmaceutical company is in the right on this one – and that most journalists (and even medical journal editors) have missed the salient points.

I think that a close review of the case is instructive in two ways. It shows: 1) the dangers of making legal decisions based on the perspective of the victim (a risk of harm equal to 1 in 20 million is unacceptable to that one person who suffered the consequence, but tolerable to the other 19,999,999 others) and 2) that a simple case of medical malpractice has made it all the way to the US Supreme Court because (as I discussed in my last post) a democratization of knowledge (juries reading a drug label) was believed to democratize expertise (how a physician would understand the label).
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Posted in: Pharmaceuticals, Politics and Regulation, Public Health

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Science Fiction Writing Contest – At Medgadget.com

Attention science fiction buffs: it’s time to put pen to paper (er… keys to keyboard) and create a fictional account of some aspect of the future of medicine. This is Medgadget’s third annual science fiction writing contest.

You could win a Palm Tungsten E2 handheld with Epocrates loaded on it – and the glory that only this honor can bestow. Please go to the Medgadget blog for contest rules.

You have only 2 weeks to submit your entries. Good luck…

I’m one of the judges this year!

Posted in: Announcements

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Knowledge Versus Expertise: The View From Consumer Land

“The internet, in democratizing knowledge, has led a lot of people to believe that it is also possible to democratize expertise.”

- SBM Commenter, yeahsurewhatever

I’ve spent the last few years of my life in Internet “Consumer Land,” doing what I can to bring accurate health information directly to patients. Of course, I have been surprised by the push-back, and the demand for misinformation. When I first left full time clinical work, it never occurred to me that people would prefer to read falsehoods when provided a clear choice between truth and error. I guess I was pretty naïve.

Journalist Lesley Stahl provided me with some helpful insights during a recent conference. She explained that the Internet has catalyzed a new method of information transfer – speed trumps accuracy, the line between pundits and journalists is blurred, and anyone who can get to a microphone can become an “expert.” Gone are the days of careful sourcing and fact-checking. And gone is the public trust in “mainstream media.”

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Posted in: General, Health Fraud, Humor, Public Health, Science and Medicine, Science and the Media

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When Further Research Is NOT Warranted: The “Wisdom of Crowds” Fallacy

Most scientific research studies have at least one thing in common: the conclusion section ends with, “further research is warranted.” I’d say it’s about as common as the “talk to your doctor” disclaimer in TV ads for pharmaceutical products. And in a way, they both serve the same purpose. They’re a “CYA” move.

What does “further research is warranted” mean in plain English? I think it can be roughly translated: “My research study is not of the size or scope to fully explain all the phenomena described in this article. Therefore, draw conclusions beyond the data and study methods at your own risk. And yeah, my work is important and cool – so people should study it further.”

Of course, the first two sentences are reasonable – we should always remember not to draw conclusions beyond the information provided by the data we’ve collected (even though that’s about as challenging as getting a beagle not to eat a table scrap in an empty room). The real problem is the third sentence. Is the research promising enough to require further investment? How are we to know if further research is indeed warranted? I would argue that it should not be based solely on the subjective opinions of the researchers nor the popularity of the research topic to the general public. (more…)

Posted in: Clinical Trials, General, Science and Medicine

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Disintegrating Integrative Medicine: Lessons From Baking

Suppose I were to bake you a cake and my ingredient list included the following:

  • Eggs
  • Milk
  • Butter
  • Sand
  • Flour
  • Baking Powder
  • Vanilla
  • Melamine
  • Sugar
  • Chocolate icing

What is the problem with the ingredient list? It has integrated inedible and poisonous items into the very fine basic ingredients that make a good cake. This is the exact same problem that the medical profession faces with the “integrative medicine” movement. Insofar as it espouses and promotes well-vetted, healthy ingredients, it is a boon to patients. But when inordinate emphasis is placed on placebos (“sand”) or when dangerous practices (“melamine”) are inserted into the prescription for our patients’ “health and wellness,” that attractive-appearing cake becomes a recipe for disaster.

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Posted in: General, Science and Medicine

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A New Blog Is Born

Although I haven’t been with you long, dear readers of SBM, I have an important announcement to make.  I have a brand spankin’ new blog: Getting Better With Dr. Val. I used to blog at “Dr. Val and the Voice of Reason” at Revolution Health – so essentially this is a URL change. You can read the press release here.

If you’ve never read my “regular” blog – it’s an interesting blend of medical expert and celebrity interviews, true stories, health news, cartoons, and Washington policy and advocacy news. It’s written for both lay and professional readers and offers to educate and entertain.

Thank you for enduring this public service announcement. And now back to your regular scheduled programming… (see you Thursday morning!)

Posted in: Announcements

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