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What will January 20th do for science-based medicine?

Make no little plans; they have no power to stir men’s blood.

—Daniel Burnham

Politics is deadly to science-based medicine, and while I don’t often go for politics, the last eight years have seen subtle and not-so subtle predations on the practice of medicine. Will the new administration be able to promote the kind of change we need? Let’s review some of the challenges facing the Obama administration.

Ethical apocalypse

Bush’s evisceration of the Constitution of the United States has affected health care professionals. The military has likely always used psychologists to assist with interrogations, but the last eight years has seen a huge increase in the number of secret charges, unconsitutional imprisonment, and “forceful” interrogations. Military psychologists have been put in the position of choosing between what their country demand of them, and what their ethics and responsibilities to other human beings requires…

More…Additionally, the (now former) administration worked tirelessly to push through so-called “conscience clauses” during the waning days of their power. Given the challenges of the Mid-East, the economy, and other crises, it’s hard to imagine why they would think this should be a priority, but apparently giving health care providers legal protection to advance their own needs above those of their patients seemed like a good idea at the time.
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Reality is unfair

This space has often hosted musings on the nature of scientific knowledge, on how medical science is based in methodological naturalism (MN), rather than supernaturalism.  MN requires that our acquisition of knowledge about the natural world be based on natural phenomena.  The reason for this should be quite obvious:  the natural world is the only one that exists, for all intents and purposes, and explanations must be based on natural processes.  Can you name any supernatural processes?  Can you measure them?  Of course not.

This bothers adherents of alternative medical practices.   Since science doesn’t support their ideas, they would like to carve out exceptions to natural laws.   Remember, we know quite a bit about the universe.  We don’t understand exactly what matter is yet, but we can measure it and experience it without ambiguity.  We know the universe has matter/energy; we understand pretty well the primary forces of electromagentism, gravity, small and weak nuclear; and there are probably a few other things whose effects we can measure even if they aren’t completely understood (dark energy, dark matter).

All of modern medicine works in ways consistent with our understanding of the universe.  Even when we don’t completely understand something, it does not behave contrary to these laws.  A beta blocker has never caused someone to levitate.  No one has been revivified by electricity, a la Dr. Frankenstein (“That’s Frahnkensteen!“).  Human bodies follow natural laws, and natural explanations are the ones that have explanatory power.

Since these natural laws explain what we see in the clinic and lab, what are the altmed gurus to do?

They have three main strategies, each of which is conveniently described by a logical fallacy. (more…)

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Put your fears in perspective

I’m having a helluva Sunday.  My father-in-law’s in the hospital,  it’s 2 degrees out with a wind chill of 40 below, my clothes all smell like latkes, my daughter is having a melt-down, and I screwed up the .xml file for my podcast. The last part reminds me of something—science is hard, and when we step out of our areas of expertise, it’s easy to make some pretty silly mistakes.

If you don’t understand the basics of a subject, it’s easy to form conclusions that seem logical, but these same conclusions seem silly to those who have a deeper understanding of a subject.

With may damned podcast, I’m writing xml files based on templates—little thinking is involved.  I’m looking at other people’s code and inserting my own details, hoping it works.  If I actually understood the syntax of xml files, I could write a correct one based on a solid understanding of the specifics of the subject.

Medicine is one of those areas in which we all feel we should be experts.  After all, we all have a body, and we figure that our bodies follow a logic that we can plainly see—if you prick us, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die? It all seems so logical.

Colons are full of poop. Poop is yucky. Therefore, cleaning out a colon is good.

Except that it’s not true. The human body is rather complex, and the study of the aggregate of all human bodies living together (e.g. public health) is more complex still.

Since the world of cult medicine hasn’t bothered to learn real science,  they often rest on what sounds “right”.  Like poop being yucky, this is often based on a sliver of fact that is horribly misused due to ignorance.

One of the more popular canards propagated by cult medicine leaders and their followers is that modern medical care kills.  Rather than exploring what the data are and what they mean in order to find a problem and correct it, they manufacture a problem out of whole cloth and come up with non sequitor solutions.

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Credulous medical reporting

Science and medicine reporting is hard. In this space and otherswe’ve dealt with some of the problems that arise when “generalist” reporters try to “do” science and medicine. And now, CNN has shut down its science unit. Given the increasing complexity of medical and scientific knowledge, this is very bad news.

As a fine example of poor medical reporting, let’s look at a local business magazine. The article, called “The Fatigue Factor”, is about fibromyalgia, and manages to get it wrong from the very beginning.

Some medical reporting is destined to be bad simply because the topic is too complex for a generalist reporter. But sometimes, a reporter succumbs to journalistic sloth. In this story, for instance, if the reporter had spoken to a recognized local expert rather than a self-proclaimed expert, she would have written a much different article.

Let’s start with the headline:
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Posted in: Science and Medicine, Science and the Media

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H. influenzae—it ain’t the flu, but it’s still pretty cool

I’ve been thinking about an interesting organism lately, an organism that illustrates some basic principles in science-based medicine.

The organism is called Haemophilus influenzae (H flu), a gram-negative bacterium discovered in the late 19th century. H flu has a great story, both in historic and modern times.

The brilliant microbiologist Richard Pfeiffer isolated H flu from influenza patients in the late 1800′s (hence its name) and for many years, it was believed to be the cause of the epidemic illness, and when the flu pandemic of 1918 hit, researchers worked tirelessly to develop anti-sera against H flu.

But some things weren’t adding up. As thousands died of the flu, doctors were isolating H flu from victims, but also other virulent bacteria such as Streptococcus pneumoniae. Influenza was decimating military camps, and was seriously degrading our ability to fight in WW I, so military bases were a focus of research. Doctors looked for H flu in patients, but could not find it consistently. For example in Camp Dodge, Iowa, an autopsy series showed H flu in only 9.6% of victims.

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Posted in: Science and Medicine, Vaccines

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The science of purging, or the purging of science?

It’s Thanksgiving in the U.S., one of my favorite holidays.  Thanksgiving habits get set down early in life, and the while I may find your lima bean casserole execrable, to you it’s just not Thanksgiving without it.

And speaking of excrement, you can expect to see adds encouraging you to “detox” from all of your holiday excesses.  Outside the field of substance abuse, what the hell is “detox” anyway?  “Detoxification” is apparently the pinnacle of modern health care, if you believe the dozens of adds on late-night TV.

For me to explain to you why even the very idea is laughable, I have to teach you a bit of human biochemistry—just a little, I promise. My scientific readers will find this grossly oversimplified, but hopefully they will forgive me.

Detox sounds so simple, but in fact, human biology is more complex and beautiful than is dreamt of in the quacks’ philosophies.
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NCCAM: the not-even-wrong agency

The National Center for Complementary and Alternative Medicine (NCCAM) is a government agency tasked with (among other things), “[exploring] complementary and alternative healing practices in the context of rigorous science.” In this space we have talked about NCCAM quite a bit, but I have to admit that I don’t think about them very much. The other day, though, I was reading though JAMA and I came across a study funded by the agency. The study, which showed that Ginkgo does not prevent Alzheimer’s-type dementia, was pretty good, so I cruised on over to NCCAM’s website to see what else they’ve been up to.

A quick glance at NCCAM’s front page:

    “Ginkgo Evaluation of Memory (GEM) Study Fails To Show Benefit in Preventing Dementia in the Elderly”
    “CAM and Hepatitis C: A Focus on Herbal Supplements ‘No CAM treatment has yet been proven effective for treating hepatitis C or its complications.’”
    “Selenium and Vitamin E in Prostate Cancer Prevention Study, ‘selenium and vitamin E supplements, taken either alone or together, did not prevent prostate cancer.’”

It seems that NCCAM is finding out something we already strongly suspected:  improbable medical claims are usually wrong.  Since that’s not how they see things,  and since I don’t believe that there is such a thing as alternative medicine, I was curious how they defined CAM.

CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses. Some health care providers practice both CAM and conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies–questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.

The list of what is considered to be CAM changes continually, as those therapies that are proven to be safe and effective become adopted into conventional health care and as new approaches to health care emerge. emphasis mine, ed.

The list of NCCAM studies appears to fall into three broad categories.

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Posted in: Clinical Trials, Politics and Regulation, Science and Medicine

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Does alternative medicine have alternative ethics?

Kimball Atwood has an interesting series of posts on the ethics of alternative medicine which I strongly encourage you to read.  He does a great job examining the ethical implications of certain alternative medicine practices, and has a terrific dialog with Peter Moran, a frequent commenter here.   At my other online locale, I make frequent forays into the morass of medical ethics, with an emphasis on specific clinical scenarios.  Today, though, I’d like to take a step back and examine the nature of medical ethics as they apply to so-called alternative medicine.

First, and perhaps most important, I am not an ethicist.  I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics.  What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.

Ethics are not static.  They are not a divine gift bestowed on each of us as we don our white coats.  They are a living part of our specific cultures, and of the profession we serve.  Some of the modern principles of medical ethics are newer than others.  Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today.  Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician.  These ethics must be mutable, as the profession itself is ever-changing.  Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.

Alternative medicine poses real challenges to the principle of medical ethics.  First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics. (more…)

Posted in: Medical Ethics, Science and Medicine

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Breast cancer and migraines–what is risk, anyway?

ResearchBlogging.orgOne of the questions most often asked in the medical literature is “what is the risk of x?”  It’s a pretty important question.  I’d like to be able to tell my patient with high blood pressure what their risk of heart attack is, both with and without treatment.  And risk is a sexy topic—the press loves it.  Whether it’s cell phones and the “risk” of brain cancer, or vaccines and the “risk” of autism, risk makes for cool headlines.  Take this one for example:

Migraines cut breast cancer risk 30 percent: study

What does this mean?  Should I tell my wife to go out and find some migraines?  I have a feeling one or more of my colleagues will give a more detailed critique of this study, but I’d like to talk to you a bit about what we mean by “risk”.

Risk, in the most basic sense, is a causal association.  If, for example, I find that members of the “Thunderstorm-lovers Golf Association” have a higher incidence of being struck by lightning than golfers who don’t belong to this odd club, I may have stumbled upon a measurable risk.  There is both a measurable association, and a plausible reason to causally link the associated variables.   If I find that members of the National Association of Philatelists have a higher incidence of heart disease than other folks, I may or may not have stumbled on a risk.  Is there a reason that philatelists should have more heart disease?  Is it a coincidence?  Is it worth investigating further?  Is there a confounding variable, e.g. are philatelists in general older, and did I fail to control for this?

Then there is the question of the degree of risk.  How strong is the risk observed?

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Posted in: Science and Medicine, Science and the Media

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Do physicians really believe in placebos?

ResearchBlogging.orgIn a previous post, I argued that placebo is an artifact of certain clinical interactions, rather than a treatment that we can exploit. Apparently, there are a whole lot of doctors out there who don’t agree with me. Or are there?

A recent study published in the British Medical Journal is getting
a lot of enk (e-ink) in the blogosphere. As a practicing internist, I have some pretty strong opinions (based in fact, of course) about both this study and placebos in general.

The Study

The current BMJ study defines placebo as “positive clinical outcomes caused by a treatment that is not attributable to its known physical properties or mechanism of action.”  I’ve got a lot of problems with this definition, but we’ll get to that later.  It also allowed physiologically active medications to “count” as placebos.  Oops.

The study surveyed internists and rheumatologists practicing in the U.S. They tried to control negative responses to the term “placebo” thusly (from the Methods section):

Because the term “placebo” and behaviours surrounding its use can be contentious, we devised a series of non-judgmental questions beginning with broad questions that avoided the term “placebo” and then gradually gained more specificity, culminating in items whose responses used a clear definition of a “placebo treatment.” By constructing a series of items in this manner we allowed respondents to describe their attitudes and experiences as accurately as possible.

The first set of three items began with a hypothetical scenario in which a dextrose tablet was shown in clinical trials to be superior to a no treatment control group (thus establishing its efficacy as a placebo treatment). To avoid biasing responses these three questions did not use the term “placebo,” “placebo treatment,” or “placebo effect.”

I know a lot of doctors.  They tend to be fairly bright.  I don’t think any of them would be deceived by this scenario.  When you read “dextrose pill”, you think “placebo”.  It might as well be the same word.

Respondents were then asked to indicate which of several treatments they had used within the past year primarily as a placebo treatment, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself; and how they typically described placebo treatments to patients. By asking these five questions both without the term “placebo” and then using the term, we aimed to assess physicians’ practices as accurately as possible.

All docs would recognize this as a placebo scenario.  However, the definition above is rather problematic.   Is a placebo “a treatment whose benefits derive from positive patient expectations and not from the physiologic mechanism of the treatment itself”?

The validity of this study hinges on the answer to this question.

Placebo—I do not think it means what you think it means

The concept of placebo, and the way it is used in this study are both problematic.  First, we have an elephant in the exam room.  When we observe a so-called placebo effect, we are very susceptible to the post hoc ergo propter hoc fallacy.  Just because the patient’s condition changes doesn’t mean we have done anything to cause that change.  In fact, due to the remarkably inexact human pattern-recognition software, we are likely to attribute a change in a patient’s condition to something, and if we don’t know what that something is, we may label it “placebo”.  So the very concept of placebo may be an artifact of our way of thinking, a label to place on a co-incidence, rather than a “thing”.  We may have wrongly reified a rather fuzzy concept.

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