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“Sense and nonsense” about alternative medicine in USA Today

Sometimes, between blogging, a demanding day (and night) job doing surgery and science, and everything else, I embarrass myself. Sure, sometimes I embarrass myself by saying something that, in retrospect, I wish I hadn’t. More often, I embarrass myself by letting things slide that I shouldn’t. For instance, when friends send me a prepublication copy of their books, I should damned well read them, don’t you think? So it was that Paul Offit sent me a copy of his latest book, which just hit the bookstores and online outlets this week, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, and I haven’t finished it. Oh, I’ve read a good chunk of it, but it’s not a huge book (around 335 pages); so I should have finished it by now, particularly since it’s quite good. My failure to properly read and plug the book aside, I’m glad to see that the book’s getting attention in a large media outlet, namely USA Today, in an article by Liz Szabo Book raises alarms about alternative medicine. There’s also a companion piece How to guard against a quack. I figure that the least I can do is to plug Dr. Offit’s book and the USA Today story in which he is featured, just as Harriet plugged his recent speaking appearance.

It’s also nice that Steve Novella and I were both interviewed. Now, excuse me while I get back to doing what I really should have had finished a month or two ago: Reading Dr. Offit’s excellent book.

Posted in: Book & movie reviews, Cancer, Health Fraud, Herbs & Supplements

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Progressive Mythology

In their book Science Left Behind: Feel-Good Fallacies and the Rise of the Anti-Scientific Left, Alex Berezow and Hank Campbell counter allegations of a Republican war on science by pointing out how political progressives are equally anti-science. According to Berezow and Campbell, progressives hold opinions that are not based on physical reality, and claim that their beliefs are based on science even when they are not.

I try to stay out of politics, but anti-science attitudes should be discouraged wherever they are found, and the mythology of progressives as described by Berezow and Campbell is very much like the thinking of alternative medicine:

  1. Everything natural is good
  2. Everything unnatural is bad
  3. Unchecked science and progress will destroy us
  4. Science is only relative anyway

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Posted in: Book & movie reviews, Politics and Regulation

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Doves, Diplomats, and Diabetes

In the past I have criticized evolutionary medicine for its tendency to rely on unverifiable “Just-So Stories,” but a new book has helped me appreciate what the best kind of evolutionary thinking can contribute to our understanding of medicine. Doves, Diplomats, and Diabetes: A Darwinian Interpretation of Type 2 Diabetes and Related Disorders by Milind Watve investigates diabetes from an evolutionary perspective, suggesting how it might have originated, why it persisted, and how it is related to survival advantages. Watve develops well-reasoned hypotheses that can be tested by examining their expected consequences. He believes it is impossible to understand metabolism without understanding behavioral ecology, and he makes a good case.

A reassessment of the evidence concerning Type II diabetes (T2D) reveals a number of paradoxes. Elevated blood glucose is the defining feature of T2D but controlling it doesn’t prevent all the complications of diabetes, and it doesn’t appear that elevated blood sugar could produce all the pathological changes of diabetes.  Insulin resistance is believed to be central to a cluster of deadly diseases in humans, but in other animals it has no adverse effects on health and even increases lifespan. Studying diabetes from an evolutionary perspective can shed light on such paradoxes. (more…)

Posted in: Basic Science, Book & movie reviews, Evolution

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Adventures on the Alimentary Canal

I write about a lot of depressing subjects, and sometimes a change of pace is welcome. Mary Roach, billed as “America’s funniest science writer,” has followed up on her earlier explorations of cadavers (Stiff), sex (Bonk), the afterlife (Spook), and survival on spaceships (Packing for Mars) with a new book entitled Gulp: Adventures on the Alimentary Canal.

Forget all that mythology about diet, detoxification, and 10-year-old hamburger accretions in the bowel. The reality of human digestive physiology is far more interesting and has the extra-added attraction of being true. And in Roach’s hands, often howlingly funny.  She is a hands-on investigative reporter who is ready to try anything; among other adventures she inserts her entire arm in a cow’s stomach. Her highly entertaining odyssey takes her to Igloolik to eat narwhal skin, to a dog food tasting lab in Missouri, to Minnesota to observe a fecal transplant, and to strange and exotic outposts at the cutting edge of science, populated by colorful characters. (more…)

Posted in: Basic Science, Book & movie reviews, History

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Worms, Germs, and Dirt: What Can They Teach Us About Allergies and Autoimmune Diseases?

Whipworms in the intestine

Whipworms in the intestine. Click to enlarge.

Humans evolved in an environment where they were exposed to animals, dirt, and a variety of pathogens and parasites. Our immune systems evolved to cope with that environment. Now most of us live in a different environment, with safe drinking water, flush toilets, food inspection, immunizations, and public sanitation. This means that we are far less likely than our ancestors to die of infectious diseases or to harbor intestinal worms. But it seems that the cleaner we get, the more likely we are to suffer from allergies and autoimmune diseases. One hypothesis is that our immune systems evolved to require early challenges by parasites and pathogens in order to develop properly. A hygienic environment fails to give our immune system the exercise it needs, resulting in imbalances and malfunctions.

The hygiene hypothesis was first proposed to explain observations like these:

  • Hay fever and allergies were less common in large families where children were presumably exposed to more infections through their siblings.
  • Polio attack rates were higher in high socioeconomic groups than in lower ones.
  • Allergies and many other diseases were less common in the developing world.

Investigation of these and other phenomena is contributing to a better understanding of the immune system, which is a good thing. At the same time, it has led some people to deliberately infect themselves with intestinal worms in an attempt to cure their allergies and autoimmune diseases, which may not be such a good thing. These treatments are far from ready for prime time, are risky, and they have a high yuck factor. The very idea of deliberately infecting yourself with worms is unpalatable, and finding wiggly live creatures in your stool or passing a 20 foot tapeworm are not generally considered to be pleasant experiences.  (more…)

Posted in: Book & movie reviews, Epidemiology, Evolution

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Beyond Informed Consent: Shared Decision-Making

Happy New Year to all our readers! Today marks the completion of 5 years of SBM and the beginning of year 6. My contributions, at one a week, have now reached a total of 260. My first post on this blog, 5 years ago, was a review of an important book about science and alternative medicine, Snake Oil ScienceThis year I’d like to start with an important book about communicating medical science to patients, Critical Decisions,  by Peter A. Ubel, M.D.

I was wrong about informed consent. I thought informed consent was a matter of explaining the risks and benefits of treatments to patients so they could decide what they wanted to do.  That was naïve, simplistic, and misguided. Ubel’s book has radically changed my thinking about how doctors should interact with patients.

Paternalism in medicine is dead. Patient autonomy rules. We respect the right of patients to determine their own treatments, even if their choices seem unwise to us. Patients should do what they want. But there’s a problem: patients may not know what they really want. Emotions and unconscious and irrational forces influence their medical decisions. Preferences can change from one moment to the next, and they can shift with subtle changes in how treatments are described and how the issues are framed. Doctors need to develop a better understanding of what is going on in their patients’ minds, of how the way they present treatment options can inadvertently influence patients, and of how they can participate with patients in a process of shared decision-making. It’s possible to provide direction without paternalism. (more…)

Posted in: Book & movie reviews, Medical Ethics

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Storytelling in Medicine

We can’t stress often enough that anecdotes are not reliable evidence; but on the other hand, patient stories can serve a valuable purpose in medical education. Hearing how a disease affected an individual patient is more powerful than reading a list of symptoms in a textbook and is far more likely to fix the disease in the student’s memory. When I think of Parkinson’s disease, the first thing that comes to mind is my first patient with Parkinson’s and how he responded to levodopa; and the first thing that may come to many people’s minds is Michael J. Fox. Of course, we must realize that they may not be typical examples; but putting a face to a diagnosis serves as a memory aid and a hook to hang the rest of our knowledge on.

In his new book, The Power of Patient Stories: Learning Moments in Medicine, Paul F. Griner, MD relates more than 50 stories that distill the wisdom he has developed over a 58-year career of practicing medicine and teaching young doctors. He describes them as “stories that provided a learning moment for me.” It’s interesting to see how much medicine has changed over his professional lifetime and yet how cases from the 50s and 60s are still highly relevant. Ethical dilemmas and lessons about medical practice come alive under his pen. Each story is followed by incisive questions and exercises that engage the reader and challenge him to think about the issues. (more…)

Posted in: Book & movie reviews, History, Medical Academia, Medical Ethics

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Fun With Statistics

Statistics is the essential foundation for science-based medicine.  Unfortunately, it’s a confusing subject that invites errors and misunderstandings.  We non-statisticians could all benefit from learning more about statistics as well as trying to get a better understanding of just how much we don’t know. Most of us are not going to read a statistics textbook, but the book Dicing with Death: Chance, Risk, and Health by Stephen Senn is an excellent place to start or continue our education. Statistics can be misused to lie with numbers, but when used properly it is the indispensable discipline that allows scientists:

 …to translate information into knowledge. It tells us how to evaluate evidence, how to design experiments, how to turn data into decisions, how much credence should be given to whom to what and why, how to reckon chances and when to take them.

Senn covers the whole field of statistics, including Bayesian vs. frequentist approaches, significance tests, life tables, survival analysis, the problematic but still useful meta-analysis, prior probability, likelihood, coefficients of correlation, the generalizability of results, multivariate analysis, ethics, equipoise, and a multitude of other useful topics. He includes biographical notes about the often rather curious statisticians who developed the discipline. And while he includes some mathematics out of necessity, he helpfully stars the more technical sections and chapters so they can be skipped by readers who find mathematics painful. The book is full of examples from real-life medical applications, and it is funny enough to hold the reader’s interest. (more…)

Posted in: Book & movie reviews, Science and Medicine

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Now that Burzynski has gotten off in 2012, Burzynski The Movie will spawn a sequel in 2013

About a year ago, I became interested in a physician named Stanislaw Burzynski who has been treating cancer with compounds that he calls “antineoplastons” for over three decades without, in my opinion, ever having ever produced any compelling evidence that antineoplastons have significant anticancer activity. Although I had been vaguely aware of Burzynski and his activities, it was the first time that I had looked into them in a big way.

Having found very few skeptical, science-based takes on Burzynski and having noted that the Quackwatch entries on Burzynski (1, 2, 3) were hopelessly out of date, I wrote a trilogy of posts about him, starting with a review of an execrably bad movie made by a simultaneously credulous yet cynical independent writer, producer, and director named Eric Merola whose primary business, appropriately enough, is mainly marketing. The movie was Burzynski The Movie: Cancer Is A Serious Business, a “documentary” (and I’m being polite here) that I characterized at the time as a bad movie and bad P.R. In brief, I saw this movie as a hagiography, a propaganda film so ham-fisted that, if she were still alive, it would easily simultaneously make Leni Riefenstahl blush at its blatantness and feel nauseated how truly awful it was from a strictly film making standpoint. It was also chock full of highly dubious science, in particular Burzynski’s latest venture, which is to sell “personalized gene-targeted cancer therapy” similarly lacking in oncological insight, so much so that I observed at the time that it was as though Dr. Burzynski read a book called Personalized Cancer Therapy for Dummies and decided he is an expert in genomics-based tailoring of targeted therapies to individual cancer patients. Finally, I completed the trilogy by pointing out that lately Burzynski has been rebranding an orphan drug that showed mild to moderate promise as an anticancer therapy.
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Posted in: Book & movie reviews, Cancer, Clinical Trials

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Bad Pharma: A Manifesto to Fix the Pharmaceutical Industry

“There is no medicine without medicines” write Ben Goldacre in his new book Bad Pharma. To Goldacre, an author, journalist and physician, this cause is personal. The title, a reference to both his first book, Bad Science, as well as the pharmaceutical industry’s nickname Big Pharma, is a bit of a misnomer. While the focus is pharmaceutical companies and their actions, there are a number of enablers in the health care system – medical journals, regulators, and even medical professionals, all of whom have put the industry’s needs ahead of good medicine. According to Goldacre, the damage is pervasive and deep, right to the roots of modern medicine. These problems know no borders, and affect us all. Despite the different health care systems that exist worldwide, we all depend on for-profit pharmaceutical companies to develop and market new medicines. These companies collectively wield enormous clout, due in part to the remarkable success of medicines over the past several decades. The global pharmaceutical market will probably top $1 trillion (yes, 12 zeros) this year. And Goldacre argues the industry is not only compromised, it is broken. And over 400 pages, he defends the following paragraph:

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques that are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their forty years of practice after leaving medical school, doctors hear about what works ad hoc, from sales reps, colleagues and journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are, too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all. These are ongoing problems, and although people have claimed to fix many of them, for the most party they have failed; so all of these programs persist, but worse than ever, because now people can pretend that everything is fine after all.

We all have our own biases, and I should disclose mine. I’m a pharmacist who has seen HIV go from a death sentence to a chronic disease, thanks to newly developed drugs. I’ve watched cancers like leukemias be effectively cured, thanks to medication. And I’m amazed that surgeries like double-lung transplants, impossible in the past, are now a reality, thanks in part to drug treatments. Yet I’ve also spent more than a decade reviewing the efficacy and safety of prescriptions drugs. Regrettably few are truly innovative. Many are approved with lingering questions about long-term safety and effectiveness. The value some offer can be questionable. I’ve also seen tremendous harms caused by drugs – from individual patients who have suffered horrible adverse drug reactions to population-level disasters like the Vioxx (COX-2) debacle. And I haven’t ignored the countless fines levied on pharmaceutical companies for bad, and sometimes even criminal, behavior. With its repeated capacity for self-sabotage, the pharmaceutical industry is its own worst enemy. My colleagues who work in the pharmaceutical industry agree. They’re smart, honest people that genuinely want to help get good treatments to patients. They’re embarrassed by what they see. So while I have no doubts about the astonishing track record of innovative new drugs that have transformed medicine, I also have no illusions that drug companies always behave in ways that support science-based medicine. And I think there is the potential for the industry to do much better. So how do we get this? (more…)

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