Peer-review is a critical part of the functioning of the scientific community, of quality control, and the self corrective nature of science. But it is no panacea. It is helpful to understand what it is, and what it isn’t, its uses and abuses.
When the statement is made that research is “peer-reviewed” this is usually meant to refer to the fact that it has been published in a peer-reviewed journal. Different scientific disciplines have different mechanisms for determining which journals are legitimately peer-reviewed. In medicine the National Library of Medicine (NLM) has rules for peer-review and they decide on a case by case basis which journals get their stamp of approval. Such journals are then listed as peer-reviewed.
Increasingly there is a cultural trend toward health care freedom and empowerment. This trend is partly a reaction to the paternalism of the past, and reflects an overall change in attitude by the public toward all institutions and authority. Within medicine there has also been a move toward the partnership model of practice – where patients are well-informed full partners in the decision-making process. But this trend has also been fueled by providers who want the public to have the freedom to choose their unconventional treatment, even if it does not meet reasonable standards for evidence or even ethics.
In addition the public must deal with an increasingly free health care market with an expanding array of products, and claims to back them up. The internet has served to facilitate and accelerate this process.
Therefore public education about common health matters is more important than ever. Part of the mission for this blog is to improve public health education, to correct common misconceptions, help put recent research into proper perspective, and to counter false or misleading propaganda or marketing claims. There seems to be an intense need for such correction, and mainstream media and the internet are full of misinformation. News outlets are a mixed-bag, sometimes providing helpful information, but more often emphasizing unusual or dramatic health risks while ignoring far more important but less interesting ones.
The public is often left to fend for themselves in the marketplace of medical devices and health aids. Current regulations in most countries are inadequate to prevent grossly misleading claims in advertising and to provide adequate evidence for safety and effectiveness for products on the market. So it is helpful for consumers to be aware of the red flags for dubious devices to watch out for.
I came across this ad for The Rebuilder, which purports to be a treatment for painful neuropathy. About 2.4% of the population has some kind of peripheral nerve damage (neuropathy), which means there are about 7.2 million Americans with neuropathy. In most cases there is no cure (although there is effective treatment for some of the symptoms of neuropathy) so it is not surprising that neuropathy is a common target for questionable treatments and devices.
The ad is full of misleading or unsupported claims and blatant misinformation and provides an excellent example of the many features of quackery marketing to look out for.
The internet is arguably the ultimate expression of democracy and the free market. For the cost of internet access anyone can pull up a virtual soap box and preach to the world. There are no real gatekeepers, and the public can vote with their search entries, clicks, and links. Every point of view can be catered to and every special interest satisfied. Type in any obscure term or concept into Google and see how many hits you get (“banana farming” yielded 1,470,000 hits).
There is potentially a downside to this as well, however. Because there are websites fashioned for every opinion and perspective no one has to venture far out of their intellectual comfort zone. Virtual communities of like-minded individuals can gather and reinforce their prejudices, and to varying degrees keep out contrary opinions. This is harmless when dealing with aesthetic tastes, but can be stifling to intellectual discourse.
On the other hand defining the mission, scope, and character of a blog, website, or forum is necessary to some degree. Every site does not have to be a free-for-all. If biologists want a forum to politely discuss biological topics in a collegial fashion they have the right to create a virtual space in which to do that, and whoever owns and operates the site has the right to mandate whatever rules they wish. Allowing political activists to overrun the site and hijack the conversation would be counterproductive. Like most things a healthy balance probably works best.
There is general agreement that the US, and the West in general, is in the midst of an obesity epidemic. Even if you think this is alarmist or overstating the situation, the data clearly shows a steady expansion of the American waistline. Weight loss is a multi-billion dollar industry and is an active area of research, and yet all the self-help books, low-carb diets, and whole grain foods do not seem to be translating into successful weight loss for the public. Why is this?
From my perspective the failure of the weight-loss industry and public health measures is due to a failed approach – focusing on factors that have a small overall effect on weight loss while neglecting those that have a huge impact.
From an individual perspective, weight loss is simple (although not easy). It is a matter of calories in vs calories out – you cannot escape this equation. This means eating less and moving more. Simple, basic strategies to help reduce caloric intake seem to be the most effective. This means portion control, and limiting calorie-dense foods. The latter requires knowing how many calories are in food you are likely to consume (that Starbucks Mocha Breve has 580 calories). Limiting total caloric intake also means keeping track of how much you eat – which is deceptively difficult to do. Most people fail on diets because they simply underestimate their total caloric intake.
People with HIV are living longer on the latest anti-retroviral therapy. This is something any infectious disease specialist knows from their own clinical experience – but it’s reassuring (I would even argue necessary) to have objective data to support experience. A study published in the latest issue of Lancet provides this objective data. (Lancet. 2008 Jul 26;372(9635):293-9.)
The press release from Bristol University, academic home of the lead author, says:
Professor Jonathan Sterne of Bristol University’s Department of Social Medicine and Professor Robert Hogg of British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University, Vancouver, Canada and colleagues from The Antiretroviral Therapy Cohort Collaboration (ART-CC) compared changes in mortality and life expectancy among HIV-positive individuals on cART.
This collaboration of 14 studies in Europe and North America analysed 18,587, 13,914, and 10,584 patients who started cART in 1996-99, 2000-02, and 2003-05 respectively.
A total of 2,056 patients died during the study period, with mortality decreasing from 16.3 deaths per 1000 person-years to in 1996-99 to 10.0 in 2003-05 – a drop of around 40 per cent.
Potential life years lost per 1000 person-years also decreased over the same time, from 366 to 189 — a fall of 48 per cent. Life expectancy increased from 36.1 years in 1996-99 to 49.4 years in 2003-05, an increase of more than 13 years.
In response to my NeuroLogica blog post on Monday, David Kirby wrote a response in the Huffington Post and Dr. Jon Poling (father of Hannah Poling) wrote an open letter to me, placed in the comment section and posted at Age of Autism. It seems only polite that I respond to their kind attention.The primary focus of my original post (which I further developed yesterday) was that the media is focusing too much attention on what celebrities and politicians are saying about the controversy surrounding the discredited notion that vaccines are a significant cause of autism. Over the past year Jenny McCarthy (now joined by her boyfriend Jim Carrey) has become the major spokesperson for a movement that, at its core, is anti-vaccine and is dedicated to the scientific opinion that vaccines are toxic and cause autism. Recently actress Amanda Peet joined the fray, professing her belief that vaccines are safe, are not associated with autism, and that parents who do not vaccinate their children are “parasites” for depending on other parents who do. (She later apologized for that remark, calling it “divisive”.)
While I appreciate Amanda Peet’s support, I feel strongly that scientific questions should be handled by the scientific community. Celebrities are great when they support causes – but when they second guess the scientific community and decide to advocate for their own scientific conclusions, they are more likely to cause harm than good. (more…)
I sometimes lecture on science-based medicine to my colleagues and one of the most common questions I get is how to deal with a patient who expresses belief in unscientific treatments. The dilemma for the physician is that professionalism requires that we do not confront patients regarding their personal beliefs. We are there to inform and advise, not preach. And yet proper medical care is often hampered by unscientific beliefs on the part of patients.
David wrote previously about a case he reviewed in which a woman with a very treatable early stage of breast cancer opted for “alternative” treatment rather than the standard treatment, which carries a > 93% good outcome. As a result her cancer progressed horribly – but she clung to belief in CAM despite its obvious failure in her case. This story highlighted the fact that giving patients proper medical advice sometime requires confronting their false beliefs.
Unscientific and bizarre medical practices are in vogue and are increasingly infiltrating the medical system through a combination of misguided political correctness, stealth, and apathy. This is exacerbating the dilemma for science-based practitioners who are caught between the imperative to do the right thing in accordance with evidence-based guidelines and the default respect for the patient and the desire to maintain a therapeutic relationship.
In my experience, however, these two goals do not have to be mutually exclusive. An uncompromising but non-judgmental approach works very well.
The National Institute of Mental Health (NIMH) supports doing a study on the effects of oral chelation therapy in autism. The proposal is highly controversial, is drawing criticism from many scientists, but has popular support among parents who believe this type of therapy might help their children with autism. The proposal raises many questions about the ethics of biomedical research.
Chelation and Autism
Chelation therapy is a legitimate FDA approved treatment for heavy metal poisoning. The drugs used for chelation, such as disodium EDTA, bind to heavy metals so that they can be removed from the body. Chelation drugs can be given either orally or intravenously. The treatment is somewhat risky because it can also remove needed electrolytes, like calcium, from the body or causes shifts in the electrolytes that can cause arhythmias and changes in brain function. There are reported cases of cardiac arrest and death due to chelation.
Chelation therapy has a long history of quackery – not for its intended use but for other uses for which there is no evidence. The classic example of this is the use of chelation therapy to treat atherosclerosis to prevent heart disease. This claim persists despite the utter lack of evidence for efficacy and the fact that all proposed mechanisms have been shown to be flawed or false.
Savvy consumers are familiar with the classic scam of the “bait and switch” – in practice if not the term itself. My wife and I ran across it when we were shopping for our first car. We needed a bargain and so we were attracted to the ads that promised a new Colt for only $9,000 (that’s the bait). Of course when we got to the dealership they were all out of Colts with the configuration advertised, but they had plenty of others that had different options that cost several thousand dollars more (that’s the switch).
It’s a basic and very successful form of deception, and so even though there are laws against such practices it is impossible to eliminate in all its various and more subtle forms. It even permeates scientific, political, and other intellectual endeavors – anytime a more palatable idea or claim is put forward to represent the less acceptable truth.
Science, however, requires transparent honesty to function properly, and therefore scientific practitioners must vigilantly guard against the cognitive bait and switch. Generic intellectual virtues incorporate this vigilance – they include the need to unambiguously define terms, to make claims as specific and operational as possible, and the use of valid logic. Beware of any claims that subtly violate these rules because they are probably setting you up for a bait and switch.
The purveyors of unscientific medical claims have become as expert at this classic deception as the slickest used-car salesman – in fact they have left the hawkers of dubious transportation in the dust.