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Boundaries

Vacation then taxes have consumed my focus the last two weeks, and I have had little time to devote to issues of infectious diseases, much less SBM, so I will instead meander around a more philosophical terrain.  I feel guilty when I do not have a substantive, data driven post evaluating a paper or essay in detail, but some weeks there just is not the time.

Being involved with SBM has been, like all intellectual endeavors, a process rather than result. I keep experimenting with conceptual frameworks with which I can understand the differences between a SBM approach and a SCAM (supplements, complementary and alternative medicine) approach. Nothing clarifies thoughts quite like writing them down. Or maybe not.

The motto of the blog is “exploring the relationships between science and medicine” but it is often more about non-overlapping boundaries* than relationships. We are often separated more by Berlin walls than Venn diagrams.

There are perhaps four boundaries that separate science-based medicine from those who prefer SCAMs. More if you are a splitter; I am a lumper by nature. At work I am an Occam kind of guy.

One boundary separates reality from fantasy. Reality is defined by the description of the natural world provided by the sciences. This blog keeps pounding away at the wall, with remarkably little effect. Be it anti-evolution, anti-vaccine or any other non-reality-based world view, they appear immune to the facts.

It is weird, and it took me a long time to realize that for many people facts are just not important. For 30 years I have worked in medical teaching institutions where facts are important. I see a patient where the intern has treated a methicillin susceptible S. aureus bacteremia with a short course of IV vancomycin and then changed the patient to oral clindamycin. I see a similar case or two at the start of almost every academic year. I go though all the permeations of S. aureus infections and the antibiotics used to treat them, going through all the clinical trials to justify my conclusions. Just the facts ma’am.

And when we are done the intern will not do THAT again. Trust me. No one wants to sit through me talking about S. aureus more than once in a career. But in medicine the facts change what we do. Eventually. That never seems to be the case in the SCAM world. It took me years to understand that although my blog entries often focus on the facts of a topic, reality as I understand it, for many, if not most in the SCAM community, facts do not matter. Facts only serve to support a predetermined world view, not alter it.

This month an article was published by the CDC looking at whether autism is caused by too many vaccines in too short a time, the “too much too soon” hypothesis. Dr. Gorski covered it a few days ago.

From basic principles one would not expect the paltry number of antigens in vaccines to be associated with autism, and the study suggests there is NO relationship between the number of vaccines and the development of autism.

I was looking forward to an essay at Age of Autism with the title: “We were wrong. Too many too soon is a failed hypothesis.” I should also look forward to an end to global warming and increased Medicare reimbursements.

To my knowledge, those who are the topics of this blog never change their beliefs as a result of high quality medical studies, which is hard to do even if you are not emotionally invested in the concepts studied. The longer I practice medicine the more effort it takes to practice differently based on new information. In the SCAM world they are immune to reality-based change, which, in the case of anti-vaccine proponents, is a curious phraseology.

Another boundary is philosophical/political/moral. It is a weird wall that separates us. I can understand the wish to be free to make your own decisions about your health care. What I can’t wrap my head around is the conspiratorial nature of many of the comments on this and other blogs. That there is a cabal of Government, pharmaceutical companies and doctors conspiring to hide the truth from people. And we do it because we are not only greedy, profiting from the medical-industrial complex, but we have evil motives. We are bad guys.

It is a world view that I overheard on vacation. I was wandering around a jewelry shop in Santa Fe and I overheard a customer telling the poor cashier that “they know what causes cancer and how to cure it, but there is too much money in the status quo.”

I do not know how common that world view is, which to my mind is as fantastical as the precepts of homeopathy, but it is a loud one. The conspiracy is always the last refuge of those who cannot accept the findings of science, as Orac points out:

They would never publish a study showing vaccines cause autism.

Sure they would. That’s what the CDC does. That is what they have done and always will do.

I do not comprehend the conspiratorial approach to the world. I tend to see most people in health care, real and alternative, as doing what they think is the right thing for people. I do not see SCAM proponents as evil, just misguided. They certainly do not see SBM in the same way.

Another boundary is in understanding that the fundamental flaws in thinking that define human behavior, the logical fallacies, apply to everyone all the time: me, you, all of us. Most of the time proponents of SCAMs fail to comprehend my favorite observation by Richard Feynman:

“The first principle is that you must not fool yourself and you are the easiest person to fool.”

It is odd that those us of at SBM may have the adjective “arrogant” applied to us, but I think we are just the opposite. We are all too aware of the numerous ways we can think poorly and be fooled. That ability seems lacking in proponents of SCAM.

So often when reading a study that allegedly demonstrates efficacy of one SCAM or another there are flaws that allow the researcher or the patient to fool themselves. It is remarkable how often these flaws go unnoticed.

The final boundary is not realizing that the usual standards by which we evaluate the medical literature do not apply when evaluating the alleged effects of SCAMs. The rules of engagement are slightly different for reality- than for fantasy-based interventions.

Studies of the effects homeopathy or reiki or acupuncture are not evaluations of a therapeutic intervention that has an effect on an anatomic structure or a physiologic process. They are best seen as elaborate psychological evaluations of the reaction of people to complicated artificial rituals. They are medical equivalent of the Stanford prison experiment where patient and doctor follow explicit and subtle cues to behave as if something is occurring that could alter a disease.

When evaluating nonsense in a clinical trial, are you doing science? Yes, just not good science. If the principals you are studying are based on fantasy, like homeopathy or chelation, it is mummery of science; it is tooth fairy science.

I was struck this week by a quote of one of the TACT investigators and their inability to recognize in TACT tooth fairy science combined with methodological flaws, as the flaws were noted by skeptics:

“Although skepticism has an important role to play in critical debates, it is easy to overplay that hand. The people you mention seem to have a very naïve view of science, very far removed from the messy realities of daily work of people doing science. It is also important to remember that even the most hard core scientists can have some pretty eccentric views when they venture outside their narrow field of expertise. What does that imply about science and the people who wish to guard its borders?

There has been a project in philosophy to identify firm demarcation criteria that will allow for a distinction between science and pseudoscience. While some useful work has resulted, the overall attempt failed. Gets into some deep waters, but the harder the philosophers tried to find that electrified fence that marked off “real science” from the rest of human thought, the more they undermined the borders of science itself. Interestingly, “real scientists” rarely worry about whether they are doing science. They consider the question uninteresting, leaving it for the philosophers, sociologists and (now) the bloggers!”

For three years as a fellow I tried being a “real scientist”, involved with investigating the interactions of Candida and endothelial cells and what made the former adhere to the latter. I was involved in a clinical trial using anti-endotoxin antibody to modify the course of sepsis. I was the Peter Principal personified. It is with good reason I am a clinician.

In those days I never worried whether I was doing science, because Candida and endothelial cells are tangible, as are endotoxin and antibodies.

I did not try to generate adherence negative Candida mutants with N-Ray’s; I used UV. I did not suppress bacteria in the endothelial cultures with homeopathy, I used antibiotics. I did not try to alter the pathophysiology of sepsis by altering qi, I tried to inactivate bacterial endotoxin.  I kept within the bounds of reality.

The question is not whether “real scientists” are doing “real science” but are they doing good science: careful evaluation of complex, and real, phenomena where potential biases and flaws are known and controlled for.

When you study a real intervention against a real phenomena, you need not worry quite as much about the potentially confounding issues raised by fantasy. When you are studying nonsense as if it were real, those potentially confounding biases become of paramount importance.

What skeptics recognize are “the messy realities of daily work of people doing science” especially as they apply to the scientific evaluation of fantasy-based therapies. Just as the best investigator for psychic powers is a magician, not a physicist, the best critic of a study of nonsense is a skeptic. We are experienced in recognizing the errors that most people either do not consider or fail to apply to themselves.

It is an ongoing curiosity how real scientists become blind to the confounding flaws and even reality when they study SCAMs.  So many, where read carefully, are all sound and fury signifying nothing.

There many boundaries between SBM and SCAM. They all seem thicker and taller than when I started blogging years ago. Then I thought all that people needed to know was the difference between reality and fiction.  A wee bit of education. Let them know why this SCAM or that is nonsense and they would say “oh, I see” and we could all move on. Naïve and simplistic, I know. But that is the story of all my intellectual endeavors. The more I know, the more complicated it becomes.

Sisyphus had it easy.

*no way am I going to say Non-overlapping magisteria ; je déteste ça.

Posted in: Science and Medicine, Uncategorized

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48 thoughts on “Boundaries

  1. brianbuch says:

    As one who has stepped rather deeply into the Popperian morass, the statements about “demarcation” are true so far as they go. There are indeed murky areas that “demarcation” doesn’t deal with well. That’s not the same as saying there’s no way to distinguish evidence-based investigation from woo. It’s as if to say that the human visual system can’t always distinguish blues from greens. Yes, that’s true, but grass (even the KY variety) is green, and the sky is blue on a nice day, not green. It’s a move as old as Plato to use the difficulty of defining a category in a precise and unambiguous way as a way of denying the usefulness of categories.

    Thanks, Mark, for all you do.

    Brian

  2. BillyJoe7 says:

    Mark: “It is weird, and it took me a long time to realize that for many people facts are just not important”.

    I have been living with such a person for 25 years. You are sort of right, but it seems to me that it’s not really a matter of cold hard facts being not important, but a matter of warm soft feelings being what is important. The emphasis is on the positive, not the negative. They don’t think “facts are not important”, they think “feelings are what’s important”. Feelings are what connects them to people and facts don’t come into that scenario. If your friend Sharon is into organics and it gives her meaning and purpose, well that’s just great. You’ll gladly listen to her tell you all about it and share her excitement and you’ll even have fun helping her out in her garden. Facts just don’t come into it. It’s all about friendly relationships with people who feel good and make you feel good.

    Well, actually, come to think of it, perhaps that’s exactly what you meant.

  3. BillyJoe7 says:

    BTW, I was unable to reset my password (refused to this user!), so I had to re-register, which is why my user name is slightly different. I’ll never remember the password though.

  4. windriven says:

    “Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.”
    ― John Adams

    “I couldn’t care less about evidence and proof and assurances. I just want God. I want God inside me. I want God to play in my bloodstream the way sunlight amuses itself on water.”
    ― Elizabeth Gilbert, Eat, Pray, Love

    “You just can’t fix stupid.”
    - Ron White

  5. windriven says:

    @Dr. Crislip

    ” [T]axes have consumed my focus the last two weeks…”

    One CPA is worth ten gobbets o’ pus. ;-)

  6. Badly Shaved Monkey says:

    Dr Crislip

    I’d be very grateful for a quick version of that lecture to which you alluded on the topic of MRSA.

    Thanks

    BSM

  7. goodnightirene says:

    I guess it’s okay if the average person just doesn’t care about facts. I know lots of people like BillyJoe’s significant other, and have tolerated them with varying degrees of success–it’s when the conspiracies take over that I begin to stop returning their calls. I have had such people say outright that they neither understand nor care about science–as if it’s a language only spoken in the remotest rain forest of Brazil and has no impact on their own lives.

    It is quite another thing, though, when major medical institutions set up “integrative” departments and when formerly respected journals publish rubbish. It has got to where I can no longer rebut my more credulous friends with, “well, a real doctor would never tell you to do that”, because I am likely to hear that my friend is, indeed, seeing someone with MD after her name.

    Shruggie doctors and medical school boards are who need to stop allowing Tooth Fairy Science to get a toehold. Journals must stop pandering to post-modernism as well. There is no point in being so broad-minded that your brains fall out. Who said that, anyway–I don’t wish to take credit where it is not due?

  8. elburto says:

    What I can’t wrap my head around is the conspiratorial nature of many of the comments on this and other blogs. That there is a cabal of Government, pharmaceutical companies and doctors conspiring to hide the truth from people. And we do it because we are not only greedy, profiting from the medical-industrial complex, but we have evil motives. We are bad guys.

    What I love about the conspiracymongers is their complete inability to comprehend the world beyond the tips of their noses.

    I see it here all the time, “Doctors order unnecessary tests so they can earn more money” or “Doctors push branded drugs on people so that they can get more kickbacks”. Not to mention “The FDA do X, Y and Z”

    When I point out that the first two could only be relevant in countries that practice for profit medicine, and the third is only applicable in one country, I am accused of everything from “not getting it” to “promoting death”.

    What’s hilarious though, is when notAmericans spend so much time hanging around quackpot havens like Rense/Prisonplanet/Whale.to/Natural News etc, that they become completely separated from reality.

    The funniest, by far, was the British woman claiming that the FDA have made it illegal to prescribe generics, that drug companies don’t make generics, that her GP made her have extra tests in order to make more money, and that they will never, ever prescribe anything that eVIl BiG pHARMa can’t patent.

    So, this is in the UK, where not only do patients not pay for tests, but where doctors are salaried. Also, prescription fees are flat. You pay roughly £8 for any item, whether it’s a new wonderdrug in a ninety day pack, or a short course of antibiotics. Anything administered in hospital is free of charge.

    Also, the generics thing – the NHS provides branded drugs only when there is no alternative. Generics make up the vast majority of prescriptions, but rarely, if all of the generics for $drug are out of stock, a branded pack will appear in it’s place.

    Also, the whole thing is distinctly not a profit-making enterprise. It’s funded by public monies, so whoever’s supplying the cheapest generic during the buying process, will sell the most units. This means that any given drug, let’s say tramadol, can show up in the system produced by five or six pharmaceutical companies. I can get a bag of repeat prescriptions with five drugs made by eight companies!

    And the FDA thing is rib-smashingly funny. Mentioning the MHRA to UK conspiracy-mules (infected by their US counterparts) gets silence. Tumbleweed. Is that not truly amazing?

  9. mousethatroared says:

    Elburto “I see it here all the time, “Doctors order unnecessary tests so they can earn more money” or “Doctors push branded drugs on people so that they can get more kickbacks”. Not to mention “The FDA do X, Y and Z”

    When I point out that the first two could only be relevant in countries that practice for profit medicine, and the third is only applicable in one country, I am accused of everything from “not getting it” to “promoting death”.”

    Are you implying that U.S. doctor’s DO routinely do those things? Meaning the pharmashill gambit is legit, as long as you are accusing the U.S.

  10. mousethatroared says:

    U.S. medical system…that is.

  11. windriven says:

    @goodnightirene

    “Shruggie doctors and medical school boards are who need to stop allowing Tooth Fairy Science to get a toehold.”

    Bingo. And your comment on journals as well. But just how can we get that done?

  12. mousethatroared says:

    @BillyJoe – What are the “facts” associated with organic versus conventional gardening?

    “Insecticide use and risk of rheumatoid arthritis and systemic lupus erythematosus in the Women’s Health Initiative Observational Study.”

    http://www.ncbi.nlm.nih.gov/pubmed/20740609

    Personally, I’m a “if the bugs like it, I dig it up and burn it.” kinda gardener.

  13. Jacob V says:

    I was having a FB message discussion today with a friend about CAM, science and what evidence is. This was her last response which seems to be where many people are when it comes to having even a basic understanding of the scientific method.

    “And I have seen vast evidence of natural prevention and cures, VAST. So you see, the “sides” is of perspectives. What we choose to see and accept.”

    Not that she made a valid point, but the argument does seem more or less over after that.

  14. windriven says:

    @Jacob V

    “[B]ut the argument does seem more or less over after that.”

    It needn’t be. It oughtn’t be.

    You need to point out that the “vast evidence of natural prevention and cures” that she has seen are called anecdotes. That doesn’t make them bad or wrong. Many solid lines of scientific inquiry start out in just that way; an action took place that appeared to correlate with an immediate or future result.

    Scientists start out with a conjecture like that and build a hypotheses that can be tested. Those last four words are what separates the “vast evidence of natural prevention and cures” that your friend has seen and science. Rigorous testing is what separates coincidence from data.

    If your friend believes in these natural preventions and cures she should be eager to test the validity of her observations. If not, then the argument is over because what you have is a refractory and petulant child uninterested in anything but her own prejudices.

  15. WilliamLawrenceUtridge says:

    Indeed, to truly understand why CAM is such a flawed system requires a relatively solid grasp of the scientific method at a granular level (i.e. why the specific components of randomization, control, good record keeping, adequate n, statistical tests, dropouts and proper reporting are all necessary) as well as some specific medical information (notably what “cured” means and how this is different from symptom improvement). An appreciation of fallacies, how the human mind can fool itself, is also very helpful. To do a proper job as a skeptic requires considerable knowledge.

    You could always try recommending R. Barker Bausell’s Snake Oil Science, as it does a good job of at least explaining the first part. A Socratic approach might also work (how do you know they got better because of the CAM treatment and not just normal healing? Why can CAM not be tested? If Pfizer tried that method, would you take their drugs? If not, why is it acceptable for “natural” remedies? Is death due to smallpox “natural”, and if so, why is it preferred to vaccination?). But overall, the best I think we can do is to shift the fencies.

  16. Kiiri says:

    Thanks for the great post Dr. Crislip. I also enjoy your Rubor, Dolor, Calor, Tumor blog as well. Links on that page led me here and I am glad! Fight the good fight! If even one child gets fully vaccinated because their parent listened to reason and science above all of the CAM proponents it will be worth it. As an epidemiologist working in local public health I have seen way too much troubling data on the rise of VPD that scare all of us working to prevent outbreaks. It is important to arm rational thinkers to help dissuade their friends from pursuing foolishness over science. Thanks!

  17. elburto says:

    @mtr – on the off-chance that you’re actually serious (surely not?), the operative word is “could“.

  18. BillyJoe7 says:

    Michelle,

    “@BillyJoe – What are the “facts” associated with organic versus conventional gardening?”

    Well, it doesn’t matter does it…if it feels good.

  19. mousethatroared says:

    Yes – Elburto, I was serious. Because I can’t read people’s minds on the preferred emphasis on words.

  20. mousethatroared says:

    ^ That is why I asked, to clarify your meaning.

  21. mousethatroared says:

    @BillyJoe – To many of us facts do matter in our friendships when safety is involved and they don’t so much when it’s not. I have friends that I humor on many of their somewhat wooish approaches because I can’t see a way that they are dangerous. But they are willing to listen to me when I do see a safety issue and say, “wait I’m concerned about this, I think you need to see a standard doctor for this.”

    The safety issue does tie into my first response – I think the facts actually suggest that some forms of organic gardening (which focuses on resistant plants and site specific plant selection to avoid the use of pesticides) are safer for the gardener than conventional gardening. So going along with the organic gardening friend may be a win win.

  22. elburto says:

    @mtr – You’re sort of proving my original point.

    OK, my entire comment referred to generalised statements like “Doctors do X for money” and “Doctors prescribe branded drugs for kickbacks”. Yes? The context was the giveaway.

    I’d said that the the vast majority of conspiracy fiends could not see past the ends of their noses, and thought up elaborate plots (and this is the important bit) without ever taking into account the fact that their theories could only work in a country with a for-profit system.

    Their country, the USA. Which means that their fevered imaginations have dreamed up a plot that wouldn’t work in most of the world, because they’re so stupid that they think that American systems/customs/rules apply everywhere.

    I then clarified even further, by mocking notAmerican woo-peddlers who’d spent so much time reading the deranged ramblings of various US-based crackpots that they regurgitated their theories wholesale.

    I paid special attention to one fellow Brit who vomited out the nonsense about ordering tests/prescribing drugs to make money, completely failing to grasp that if doctors here did that, they’d bankrupt the entire system in weeks.

    To recap,

    Statements like “Doctors do…” or “Pharmacists do…” are nonsensical because practises are not global, and medical professionals are not part of a hivemind. However, US,based conspiracy theorists do not realise that a world exists outside their borders, and formulate their wild theories based on their own ignorance.

    Now do you get it? I mean, why would I suddenly start accusing doctors of being pharma shills. after spending (too many) years here arguing the exact opposite with trolls?

    Context is always key.

  23. weing says:

    @elburto,

    re “Doctors prescribe branded drugs for kickbacks”. Are you saying that this is possible or actually a fact in the US because of our for profit system? I practice in the US. I mostly prescribe what the patient can afford, which usually means it is on the list of $10 dollar for 90 day supply. I have no control over what meds show up on that list. The kickbacks would be in those determining the content of those lists. I may be wrong, but I don’t think they are usually doctors. Also these lists, or formularies are not confined to the US. I understand all countries have a list of medications covered. My point is, the kickbacks you are talking about, are going to the list makers and not confined to the US.

  24. mousethatroared says:

    elburto -”Statements like “Doctors do…” or “Pharmacists do…” are nonsensical because practises are not global, and medical professionals are not part of a hivemind. However, US,based conspiracy theorists do not realise that a world exists outside their borders, and formulate their wild theories based on their own ignorance.”

    IME – U.S. based conspiracy theorists (that we see here) are basing their wild theories on inaccurate information about the U.S. medical system…I’m not really sure why it is more offensive for them to be equally inaccurate about the world at large, but hey! Whatever floats your boat.

    Elburto “Now do you get it? I mean, why would I suddenly start accusing doctors of being pharma shills. after spending (too many) years here arguing the exact opposite with trolls?”

    I don’t really get it. I’m not that familiar with your past comments. I was confused by what seemed like a turn-around, but I thought maybe you saw the U.S. medical system as a corrupting influence, or something. Thanks for trying to clarify.

    Honestly, it doesn’t seem that I can have a civil discussion with you, so it’s probably best if I leave it at that. Perhaps weing will have more luck.

  25. Alia says:

    well, over here doctors were accused of getting kickbacks (often in the form of “medical conferences” in nice hotels in warm places) from Big Pharma. The thing is – over here you can get generics cheaply (symbolic $1 or a fraction of the full price) – their cost is partially or fully covered by the insurance, but for brand name products you often have to pay the full price. So the pharmaceutical companies try to persuade doctors to prescribe their brand-name version. Each patient going to the pharmacy with their prescription has the right to demand a cheaper generic version – but not all of them know it and some believe that generics are not so good.

  26. weing says:

    @Alia,

    “The thing is – over here you can get generics cheaply (symbolic $1 or a fraction of the full price) – their cost is partially or fully covered by the insurance, but for brand name products you often have to pay the full price. ”

    Where is here? In the US, not all generics are so covered by insurance plans. The default mode for the pharmacists is to give the generics. A lot of patients want brand-name versions. I guess they watch too much TV. Do you know what a pain it is to print out prescriptions and manually write “Brand medically necessary” because the patient wants it instead of just electronically transmitting the prescription?

  27. mousethatroared says:

    @weing – I always ask for the brand name – Synthroid, because my endocrinologist recommended it. She said that switching to generic would mean I’d have to retest my TSH levels and she thought that her patients on the brand name seemed to maintain more stable levels (At least this is what I understood her to be saying. I may have misunderstood). I actually didn’t know that (or if) it was any extra trouble for the doctor. They just seem to send it through the computer as usual. Occasionally (maybe once a year), the pharmacists rolls their eyes at me, though. I dislike being caught between my doctor and my pharmacist, but I guess I trust my doctor more.

    The rest of my medication are generic or not generic available. I guess I don’t care that much, but none of them are advertised on TV.

    As an aside, I always find the TV ads for medication somewhat terrifying. Sure they start out sounding good, but then they leave you with a list of side effects from here to kingdom come. No wonder people are increasing afraid of medications.

    The worst is the animated commercial for the anti-depressant (can’t remember which one) that features a creepy blanket with eyes that follows people around, very disconcerting.

    I always wonder if those commercials are really that effective. But you doctors would know, you all are the ones getting the requests from patients. I suppose if people were commonly creeped out by the commercials, you would hear about it.

    sorry, ramble (avoiding mopping floors)

  28. the bug guy says:

    I had a good example the other day in a person who stated, “It is virtually impossible to overeat on meat and fat.” As far as I could tell, he was a paleo diet supporter who stayed much more on the carnivore end of the spectrum.

  29. Sastra_ says:

    I like your 4 boundaries: reality vs. fantasy; philosophical/political/moral; awareness of fundamental flaws in thinking; consistency of standards. There’s a lot of insight there.

    I’d like to share a boundary — or a difference — which I have noticed when talking to my alt med friends. I’ve been trying to think this one out for a while. It doesn’t just apply to SCAM I think; it also applies to religion. It has to do with how you frame diversity. How do you approach different ideas?

    The two models are 1.) the Diversity Smorgasbord and 2.) The Diverse Problem-Solving Group.

    The Diversity Smorgasbord is one where different ideas, different identities, different experiences, different types of people and different ways of seeing things are all celebrated and acknowledged. The more diversity the better! It’s like a table with many foods. There is no right or wrong –it’s not a cooking contest. These are values, moral commitments, and individual expressions. No judging. You simply take what you need and leave the rest. Different kinds of people prefer different kinds of things.

    If you bring critique or debate into a Diversity Smorgasbord, then at best you don’t “get it.” At worst you are a bigoted monster who doesn’t allow people the right to be who they are and make their own choices. You insult people at a very deep level. Your win is their loss.

    The Diverse Problem-Solving Group values diversity for a different goal: universal consensus. Everyone is trying to solve a problem or answer a question. Is the lake polluted? Does God exist? Is there such a thing as Human Energy Fields and can they be used to cure disease? These are fact questions, not moral values. In this group there is debate; there are rules; there is a right and wrong. Focus on the issue and be consistent. If you “lose” your argument you technically “win” because you learned something: it’s not a zero-sum game. The value of diversity is for its checks and balances. Everyone is better at catching the mistakes of others than they are of their own mistakes.

    If you bring the “no judgment” Diversity Smorgasbord into a Diverse Problem-Solving Group you end up privileging a view and the people who hold it. You can do an end run around the 4 boundaries: reality vs. fantasy; philosophical/political/moral; awareness of fundamental flaws in thinking; consistency of standards. Homeopathy is now just another way of trying to see what works for you — instead of a hypothesis to be tested and discarded if necessary. There is progress in the Diverse Problem-Solving Group because we learn from mistakes. There is no progress in a system of medicine which can’t detect mistakes without mixing that up with prejudice and “attacking” people by telling them they are wrong.

    Keep in mind that as much as the alties hate mainstream medicine and villify it, they love it when mainstream doctors play the Diversity Smorgasbord approach: “modern medicine is fine for some things, but alternative medicine is fine for other things. I don’t use it myself, but I would never try to discourage people who believe in it from doing so. That’s narrow, intolerant, and disrespectful. It’s all good.” (Sort of like the ‘Good Atheist’ trope)

    I think one of the big differences between a SBM approach and a SCAM approach is WHERE they place medicine when it comes to diversity. They don’t really put it in the scientific Diverse Problem-Solving Group category. They think it belongs in the same category as identities, tastes, preferences, and personal choices. They want it in a Diversity Smorgasbord.

    And if so, that might explain why their boundaries are different than ours. In order to share their divisions, we wouldn’t need to think alt med works. We’d just need to think that there are many equally fine ways of finding truth for every individual.

  30. Sastra_ says:

    BillyJoe7 wrote:

    BTW, I was unable to reset my password (refused to this user!), so I had to re-register, which is why my user name is slightly different. I’ll never remember the password though.

    Same here. It took a lot of trial and error to figure out my user name is gone for good. *grumble*

  31. pmoran says:

    My journey in science has gone the other way. At the margins many matters seem less obvious than they once seemed, that is, less well supported by all the facts.

    Many years ago I first switched on to the fact that most science is actually based upon rather arbitrary statistical judgements, tuned to specific practical purposes. Astronomers like very low P values i.e. very “significant” ones, because they are seeking near-absolute truths about the universe, ones that can be built upon.

    Medicine cannot set its standards that high. It merely needs a reasonably reliable guide to the effectiveness and safety of practical medicine. Clinical studies of “astronomical” size would make already outlandishly expensive clinical studies prohibitively ponderous and costly. We hope that the replication of the results of studies with lower levels of statistical significance will allow reasonably reliable decision-making.

    That works most of the time. We know of a number of examples where it has failed. It can not guarantee truth for several reasons gone into by Ionnanidis in his unfortunately named “Why Most Published Research Studies Are Wrong”.

    The boundary between clinical effectiveness and non-effectiveness is further shaken if we consider evidence for the placebo responsiveness of many conditions.

    The most we can say about CAM is that after taking ALL scientific knowledge into account , most of its methods are most unlikely to have any intrinsic efficacy, even when they seem to be able to produce statistically significant results in what was once our “Gold Standard” of evidence.

    Another matter: we love to make pronouncements such as “all of medicine should be held to the same standard”. Which standard would that be? We know that a considerable proportion of everyday medical practice is based upon low-level evidence. Where are we drawing our own boundaries?

    I know I seem to some to be taking an anti-sceptical stance. That’s not so. I strongly believe that more we understand ourselves, our own science, and our own limitations, and the more we display that, the more authoritative, persuasive and well-directed our voice will be in those areas where we crave influence.

  32. Alia says:

    @weing – I’m on the other side of the pond, in Europe. We don’t have insurance plans, we have one universal state insurance, which covers everyone who works on a contract, as well as all children and retired people. And if you do not belong to any of the groups, you can still pay a monthly fee to the state insurer and get insurance. Not all generics are covered by insurance, that’s a fact, but if you suffer from a chronic, serious or life-threatening condition, you will get medicine cheaply (although it may be not the newest generation out there, that’s true).
    On the other hand – we do not see commercials for prescription drugs, that’s forbidden (not sure about professional medical magazines, though). So patients cannot really influence their doctors in that way. The biggest fight is over OTC, herbal and supplement market, when it comes to commercials.

  33. windriven says:

    @Sastra_

    “If you bring the “no judgment” Diversity Smorgasbord into a Diverse Problem-Solving Group”

    This gave me a serious case of cognitive dissonance. I think there may be a powerful point here but I’m apparently too dim to capture it.

    You characterize the Diversity Smorgasbord as entirely non-judgmental except that it judges those who judge (and it judges them harshly). And you characterize the Diversity Problem-Solving Group as judges who systematically dissect and judge. I got lost when you brought the two groups together. If you could take a moment to lead me back to your path I would appreciate it.

    For what it is worth, I look at the wooies differently. Those of my acquaintance who embrace unscientific claptrap tend to embrace it in many of its manifestations (sCAM, ghosts, gods, etc.). I tend to believe that they do this because they intuit that apprehending reality coldly would force them to confront issues like mortality in ways that would discomfort them.

  34. windriven says:

    @pmoran

    “Medicine cannot set its standards that high. It merely needs a reasonably reliable guide to the effectiveness and safety of practical medicine. ”

    Might part of this owe to the relative youth of medicine as a truly scientific field of study? For instance, Crick and Watson only elucidated the double helix structure of DNA in 1953. We have learned an immense amount in the intervening 60 years but I suspect that what we have learned barely scratches the surface.

    I further suspect that 60 years hence medicine will be closing in – at least in a few areas – on the levels of certainty that are enjoyed in some areas of chemistry and physics today.

  35. Sastra says:

    windriven wrote:

    You characterize the Diversity Smorgasbord as entirely non-judgmental except that it judges those who judge (and it judges them harshly). And you characterize the Diversity Problem-Solving Group as judges who systematically dissect and judge. I got lost when you brought the two groups together. If you could take a moment to lead me back to your path I would appreciate it.

    Ok. The two groups shouldn’t really come together because they’re dealing with different things: one is about appreciating lots of different views and the other is about figuring out which view is correct. The conflict comes when someone tries to insist that something which belongs in one group belongs instead in another. They treat a value claim like a fact claim. Or they treat a fact claim like a value one. And they insist that they’re doing it correctly.

    For example, imagine someone telling a person that they are WRONG to enjoy country western music. Country music is objectively bad. Anyone who does country line dancing is a loser. This would be an example of someone bringing a Problem-Solving mentality into what is simply a matter of taste. The proper attitude to take would be that you don’t like country music yourself, but it’s okay if someone else likes it. Otherwise, you’re being ‘judgmental’ and bigoted.

    Now imagine someone telling someone else that there is no objective right or wrong when it comes to science. Different people do science in different ways. “Western science” is simply one way and it’s not necessarily better. Personal experience is good, too. There are many equally valid ways of learning things and individual choice has to be respected.

    This would be an example of someone bringing a Smorgasbord mentality into what is a matter of problem-solving through reason. The proper attitude to take would be to agree to submit your personal experience and ‘other ways of knowing’ to rigorous objective analysis. Otherwise, you’re not being judgmental enough. Judgment isn’t a bad thing if that’s the actual goal. This person is treating an empirical matter (let’s all figure out what is true) as if it were an issue concerning identity (let’s all figure out what is true for ourselves.) They’re mixing up the objective or inter-subjective with the purely subjective.

    From what I can tell people who believe in claptrap seem to be placing said claptrap into some hybrid area where it’s both empirically true that there are ghosts … but if someone believes in ghosts it’s bigoted for someone else to try to rationally or scientifically show them they are wrong. It’s a “choice” which needs to be respected. They’re using a Diversity Smorgasbord framework for what really belongs in a Diverse Problem-Solving Group and trying to get a free ride for an empirical claim.

    The underlying danger of doing this is more than just never getting anywhere in discovering or uncovering what the truth is. There is also a strong implication that those who don’t believe in claptrap refuse to do so as a matter of their own taste. They don’t WANT it to be true. And the claptrap is almost always something very, very nice.

    Thus, alties end up framing us SBM advocates as folks who “choose” to endorse SBM because we hate the idea of people making their own choices and healing themselves and others through natural means. We automatically become the bullies who charge onto the dance floor and cry “Losers!” It not only shuts down debate — but it does so by demonizing the opposition.

  36. windriven says:

    @Sastra

    Thank you for expanding on your idea. It was the bringing the two groups together that I struggled with and I now understand that was not your intent.

    I would place myself squarely in the Diversity Problem Solving group but I would never find myself telling someone else that their choice of musical genre is ‘bad’. Artistic taste is inherently subjective.

    When my daughter was in her late teens she assured me that Eminem was a powerful and evocative poet. This came as something of a surprise to me as my analysis was that Eminem was a misogynistic, self-absorbed poseur. I did not, however, verbalize this to my daughter who had listened to far more Eminem than I had. Instead, I suggested that she print out the lyrics to two or three of his songs that she felt best exemplified his poetic prowess and we would analyze them together. Oddly enough when I asked her about it a few days later she had decided that perhaps Eminem was not actually a moosical genius. Go figure.

    I guess my point is that perhaps I am not as good an exemplar of the Diversity Problem Solving group as I would have thought. Perhaps there is another group that better fits me and many of the critical thinkers that I know.

    You said: “but it does so by demonizing the opposition”, and here I think you touch on an important point. I have certainly been guilty of demonizing not just the purveyors of woo but consumers as well. As the anecdote about my daughter suggests, I know it is not productive to directly attack someone’s beliefs. But that hasn’t stopped me from ripping woo-guzzling morons a new one from time-to-time. It is essential, I think, to first attempt to educate.

    Unfortunately, some people cling to superstition regardless of logic. Ignorance the most easily cured frailty. I try to chip away a little at my own monumental ignorance every single day. But there is a difference between ignorance and stupidity; ignorance is superficial and fixable but stupidity runs right to the bone.

  37. Sastra says:

    windriven wrote:

    I would place myself squarely in the Diversity Problem Solving group but I would never find myself telling someone else that their choice of musical genre is ‘bad’. Artistic taste is inherently subjective.

    No. My explanation wasn’t clear enough. The two-versions- of- diversity model has to do with how ideas are classified, not people. This isn’t about which group you belong in. It’s about which group you would place something like ‘homeopathy’ in.

    Is homeopathy a fact claim — a proposed medication which will help cure various ills and which may or may not work? Then it needs to be evaluated in a Diverse Problem-Solving Group to see if it does work. Is homeopathy a personal preference, a choice which expresses the kind of person you are? Then it’s in the Diversity Smorgasbord and it doesn’t matter if a homeopathic remedy is scientifically demonstrable as long as you feel it’s right for you.

    I agree that artistic taste should be placed in a Diversity Smorgasbord. But homeopathy is not art, it’s a hypothesis and should be evaluated under different standards. The value of the distinction I’m making is that we aren’t dividing people up into “types.” The alties and the SBMs could in theory agree 99% of the time on classification for other ideas. But they’re making a mistake when it comes to medicine. They’re attaching their self-image to a factual claim and I think this is why they are so hostile to criticism. If we’re all in a Diverse Problem-Solving Group then they should be happy to throw out what doesn’t work so we can all go on together to discover what does heal. But if alternative medicine is something people “choose” to believe in due to their sensitive, caring nature, then attack the idea and you attack them.

  38. Badly Shaved Monkey says:

    They’re using a Diversity Smorgasbord framework for what really belongs in a Diverse Problem-Solving Group and trying to get a free ride for an empirical claim.

    It’s too long for a t-shirt slogan and the t-shirt would need a lengthy footnote printed on the back to explain what Diversity Smorgasbord and Diversity Solving mean, but otherwise I think that’s a very neat summary of the entire problem with SCAMsters’ claims.

  39. Narad says:

    Astronomers like very low P values i.e. very “significant” ones, because they are seeking near-absolute truths about the universe, ones that can be built upon.

    Perhaps you’re thinking of HEP. In astro, significance is generally at the 2 σ or 3 σ level; I don’t think I’ve ever seen a p-value quoted over thousands of articles.

  40. BillyJoe7 says:

    “if alternative medicine is something people “choose” to believe in due to their sensitive, caring nature, then attack the idea and you attack them”

    I can arrest to that.
    No matter how dispassionately I attack her ideas, she cannot help but feel it as a personal attack.
    It’s a no win situation. :(

  41. DugganSC says:

    Regarding the perception of SBM-type people from the “woo” people, my impression has been that they tend to view us as kind of like that kid in school who went around explaining exactly how everything worked to the people around him. 95% of the time, he was right. 5% of the time, he was full of shit, whether because he had the wrong facts in hand or because he was so convinced that he knew everything that he tried to generalize other experience over or outright made up stories. And, frankly, he was annoying nearly 100% of the time. I was one of those kids, so I’ve got some experience in that area. They know that we know a lot of things. They also know that we sometimes get things wrong and we get a fiendish glee out of squashing dreams with blunt truths (honestly, how many of us can say they haven’t read an article here, then immediately fired up Facebook, and made pointed comments on the entries about THC curing cancer, or how much someone’s chiropracter is helping their back pain?).

    Of course, there’s also the “misguided shill” viewpoint where they’re convinced that we’re the ignorant/indoctrinated ones, parroting the lies of Big Med, Big Pharma, etc, but honestly, that’s usually invoked at the level of the conspiracy theory people who think that Big Pharma is sitting on the fact that marijuana cures all ills, and that Bill Gates released mosquitoes filled with genetically engineered malaria to try to get rid of poor people (and yes, I know someone on Facebook who believes both of those things).

  42. pilotgrrl says:

    SCAM is a religion. Those who claim to be the most like the founder of their brand are often the biggest braggarts, the first to cast stones, and the least like the founder of their brand. Sound familiar, anyone?

  43. mousethatroared says:

    moderation? what’d I do?

  44. geo says:

    “When you study a real intervention against a real phenomena, you need not worry quite as much about the potentially confounding issues raised by fantasy. When you are studying nonsense as if it were real, those potentially confounding biases become of paramount importance.”

    I don’t know about this. If implausible treatments are able to produce the sort of evidence of efficacy that might be seen as convincing for plausible treatments, then I see that as reason to raise our standards. While there are areas where we can rely on such clear and objective evidence that there is less room for bias, confounding factors, etc, there are many areas of what is considered to be mainstream medicine (eg: Coyne’s recent posts here) where these problems can seriously distort our understanding as to what is ‘real’ phenomena.

  45. BillyJoe7 says:

    geo,

    I think he’s talking about individual trials, not evidence from multiple trials or systematic reviews. Implausible treatments can produce a positive result even in a well conducted trial. This is because clinical trials set their p = .05, meaning that 1 in 20 trials of non-efective treatments will produce a positive result.

  46. BillyJoe7 says:

    Michelle,

    “moderation? what’d I do?”

    Sometimes it’s just random.
    Your post is doomed to be unread by anyone save the moderator.
    I suggest you post the bugger again.

  47. mousethatroared says:

    Yeah, you’re right BillyJoe – but the moment has passed….just take my word for it – it was earth shatteringly brilliant (or not).

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