Dr. Jay Gordon is a pediatrician to a particular subculture of pseudoscientific celebrities, such as Jenny McCarthy. He lends his MD cred to this community. He also appears, in my opinion, to be a shameless self-promoter – one of those pop professionals (Dr. Oz, Dr. Phil) who has sold his soul for some easy celebrity.
Regardless of his motivations, he has been spouting arrogant nonsense about vaccines for years, essentially arguing that his clinical gut feeling and anecdotal experience trump the actual science. This is exactly the wrong approach to science-based medicine.
In a recent open letter on his website, he adds to the anti-vax chorus advising not to get the H1N1 (swine flu) vaccine. It’s almost as if this crowd wants to maximize the morbidity and suffering from this somewhat preventable disease. I know this is not literally true, but their ideologically motivated and confused actions will have the same effect.
I know we have been focusing on the vaccine issue extensively, but this is crunch time and the anti-vaccine forces are relentless. We are now facing a regular seasonal flu spiked with the H1N1 pandemic. Our best weapon against morbidity and mortality caused by the flu is information, and yet the public is being barraged with misinformation designed to encourage poor choices and thereby result in maximal morbidity and mortality.
I confess I was never impressed with FDR’s famous quip, “All we have to fear is fear itself,” – I think there is plenty else to fear. But his sentiment is very appropriate to the current situation – fear mongering around the seasonal flu and H1N1 vaccines is what we have most to fear.
And of course, as is almost always the case, accurate information is complex and requires a nuanced understanding. This creates uncertainty, which is easy to exploit to manufacture unreasonable fear.
The anti-vaccine fear mongers are playing every card in the deck. They are arguing (falsely) that H1N1 is not severe enough to warrant getting the vaccine, that the vaccine does not work anyway, and that there are unacceptable or unknown risks to the vaccine. In the most extreme cases, bizarre conspiracy theories are brought to bear, but I will not discuss these here as anyone compelled by such fantasies is likely beyond the reach of any information I could provide.
Two recent studies concerning the prevalence of autism in the US have been getting a lot of attention, because they indicate that autism prevalence may be higher than previously estimated. This, of course, fuels the debate over whether or not there are environmental triggers of autism.
One study was conducted by the CDC but has yet to be published. The results were announced ahead of publication by the US Health and Human Services Secretary Kathleen Sebelius to the autism community. She reports that the new prevalence of autism spectrum disorder (ASD) is now estimated at 1% or 100 in 10,000 children. This is an increase over the last few years. In 2002 the prevalence was estimated to be 66 per 10,000.
The second study was published in the journal Pediatrics and is a phone survey of 78,037 parents. They asked if they had any children who had ever been diagnosed with an ASD. Here are the results:
A recent editorial in PLOS Medicine discusses the need for transparency in the medical literature, specifically with regard to comparative effectiveness research (CER). The editorial makes many excellent points, but also puts into clear relief the double standard that is consciously being fabricated by proponents of non-science-based medicine.
I wrote previously about another editorial that took a very different approach. Speaking for The Kings Fund, Professor Dame Carol Black said.
“The challenge is to develop methods of research that allow us to assess the value of an approach that seeks to integrate the physical intervention, the personal context in which it is given, and non-specific effects that together comprise a particular therapy.”
The editorial essentially defended the use of CER and other forms of evidence to bolster the evidence base for so-called CAM (complementary and alternative medicine) in order to promote its use.
As you can see, Science-Based Medicine is now back online and fully functional. We have moved to a new host and a faster dedicated server. It seems that our problem was just that we outgrew our previous host.
Sorry for the inconvenience and thank you for your patience. We will now resume our usual schedule of postings.
As many of you have probably noticed, the science-based medicine site has been having connection problems for the last week, and was in fact down for most of Friday. We are actively working on the problem and hopefully will have it fixed soon. The site is functioning now, but remains very slow.
Thanks for your patience, and sorry for any inconvenience.
Kevin Trudeau has made millions of dollars selling dubious medical products. He started his snake-oil salesman career selling coral calcium through infomercials. Trudeau claimed that this magical form of calcium could cure cancer and whatever ails you. The Federal Trade Commission (FTC) investigated Trudeau, who was making millions off his claims, and found that he was being, let us say, less than honest. As a result the FTC banned Trudeau from selling health products through infomercials.
But Trudeau is tenacious and creative – an innovator. Prior to getting into infomercials he was small time – he was convicted for writing bad checks and credit card fraud and spent some time in prison. I always find it interesting that convicted con-artists seem to hit upon such well-guarded secrets. Dennis Lee claims to have found the secret of limitless energy, if only he were not attacked by Big Oil and a corrupt government. Kevin Trudeau claims to have found the cures for just about everything, but The Man is trying to shut him down.
Undeterred by the FTC ban, Trudeau decided that even though he could not sell health products he could sell information – that was protected under free speech – so he started selling books through infomercial, including Natural Cures They Don’t Want You To Know About. Trudeau claimed he went from writing bad checks to discovering not only hundreds of natural cures but uncovering a government and Big Medicine conspiracy to keep this vital information from the public.
The marketing of so-called CAM or integrative medicine continues. These terms are just that – marketing. They are otherwise vacuous, even deceptive, and meant only to conceal the naked fact that most medical interventions that hide under the CAM/integrative umbrella lack plausibility or credible evidence that they actually work.
Medicine that works is simply “medicine” – everything else needs marketing.
The essence of the editorial can be boiled down to this – proponents of integrative medicine are disappointed that scientific research has not validated their failed modalities. Therefore they want to weaken the rules of evidence so that they can get the results they desire.
Perhaps the biggest hurdle to broader acceptance of the need for a consistent scientific basis for medical interventions is the attitude that worthless treatments are harmless. I often have the experience, after reviewing the evidence showing lack of efficacy for a specific intervention, of getting the head-tilt and shrug along with some variation of the dismissive attitude, “Well, if people feel better, then what’s the harm?” In my opinion, ethics and intellectual honesty indicate that we have to do better than that.
The “what’s the harm” refrain is so tired and overused that it prompted a website by that name, documenting direct harm caused by unscientific treatment modalities. This is a helpful reminder that any intervention that actually does something (has biological activity) must also contain some risks. But this site also has significant limitations. First, it is anecdotal. But also it emphasizes direct harm, while the indirect harm of unscientific methods (for example by delaying definitive treatment) likely vastly outweighs the direct harm. However, indirect harm is extremely difficult to quantify.
A recent survey of 599 primary care physicians and 600 psychiatrists found that:
The adjusted response rate was 47%, respondents were similar to non-respondents, and physicians commonly prescribed the drugs examined. The average respondent accurately identified the FDA-approval status of just over half of the drug-indication pairs queried (mean 55%; median 57%). Accuracy increased modestly (mean 60%, median 63%) when limited to drugs the respondent reported having prescribed during the previous 12 months. There was a strong association between physicians’ belief that an indication was FDA-approved and greater evidence supporting efficacy for that use (Spearman’s 0.74, p < 0.001). However, 41% of physicians believed at least one drug-indication pair with uncertain or no supporting evidence (e.g., quetiapine [Seroquel®] for dementia with agitation) was FDA approved.
These results are interesting, but deserve to be dissected a bit further. Taken at face value they indicate that physicians need better education regarding the FDA indications and (more importantly) the evidence-base for commonly prescribed drugs. This is an uncontroversial recommendation, and I personally strongly advocate more thorough physician continuing medical education.
Of course, at SBM we have to also dissect the weaknesses of any study we examine. This was a voluntary survey with a 47% response rate, which opens the door for significant responder bias. The survey does not broadly represent different specialties and therefore its relevance beyond primary care and psychiatry is uncertain. The details of the study may also have greatly influenced the outcome.
For example, one of the drug-indication pairs was gabapentin for diabetic peripheral neuropathy. Gabapentin is not specifically indicated for diabetic neuropathy, but it is indicated for post-herpetic neuralgia. Both conditions are forms of neuropathic pain, and it is highly scientifically plausible for a treatment of one condition to also be effective for the other. In fact, there is strong evidence that gabapentin is effective for diabetic neuropathy, and it is commonly prescribed for this condition (in fact insurance companies often require that it is first line treatment as it is now available generically and is therefore less expensive than newer drugs that are indicated specifically for diabetic neuropathy). In other words, this was one of the easiest mistakes to make.