When an article is published in a medical journal, the authors must disclose any conflicts of interest. This is important, because even if they think owning stock in the drug company won’t influence their scientific judgment, we know that subtle biases can creep in to somehow affect the findings of studies. It has been shown that studies funded by drug companies are more likely to get positive results for their drug than studies funded by independent sources. Andrew Wakefield, author of the infamous retracted Lancet study suggesting a relationship between MMR vaccine and autism, was severely chastised for not disclosing that he received money from autism litigators and expected to earn a fortune from his own patented products if the MMR vaccine could be discredited.
I was recently contacted by an acupuncturist who plans to critique an article I wrote. It was a commentary in the journal Pain that accompanied a systematic review of systematic reviews of acupuncture by Ernst et al. For details of Ernst’s and my articles, see my previous post. He challenged my statement that I had no conflicts of interest to report. He apparently thinks I should have said I have a conflict of interest in that I am anti-CAM and anti-acupuncture. When he writes about my article, he plans to attack me for not declaring this alleged conflict of interest and he plans to set a good example with a conflict of interest statement of his own, divulging that he makes his living practicing acupuncture, has financial investments in it and many personal relationships, that his self-identity and prestige are dependent on his belief in acupuncture’s efficacy, and that he is biased towards constructivism and away from positivism. (I think this is a fancy way of saying he favors experience over the scientific method.) I agree that he has conflicts of interest, but was I wrong to say I had no conflicts of interest? I don’t think so. (more…)
Some of our readers have complained that we pick on alternative medicine while ignoring the problems in conventional medicine. That criticism is unjustified: we oppose non-science-based medicine wherever we find it. We find it regularly in alternative medicine; we find it less frequently in conventional medicine, but when we do, we speak out. A new book by Dr. Peter Palmieri is aimed squarely at failure to use science-based medicine in conventional practice.
Dr. Palmieri is a pediatrician who strives to provide the best compassionate, cost-effective, science-based care to all his patients. Over 15 years of practice in various settings, he observed that many of his colleagues were practicing substandard medicine. He tried to understand what led to that situation and how it might be remedied. The result is a gem of a book: Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. Its lessons are important and are not limited to pediatrics: every health care provider and every patient could benefit from reading this book.
The chapters cover these subjects:
- How doctors mishandle the most common childhood illnesses
- How doctors succumb to parental demands
- How they embrace superstition and magical beliefs
- How they fall prey to cognitive errors
- How they order the wrong test at the wrong time on the wrong patient
- How financial conflicts of interest defile the medical profession
- How doctors undermine parents’ confidence by labeling their children as ill
- A prescription for change
Before we had EBM (evidence-based medicine) we had another kind of EBM: experience-based medicine. Mark Crislip has said that the three most dangerous words in medicine are “In my experience.” I agree wholeheartedly. On the other hand, it would be a mistake to discount experience entirely. Dynamite is dangerous too, but when handled with proper safety precautions it can be very useful in mining, road-building, and other endeavors.
When I was in med school, the professor would say “In my experience, drug A works better than drug B.” and we would take careful notes, follow his lead, and prescribe drug A unquestioningly. That is no longer acceptable. Today we ask for controlled studies that objectively compare drug A to drug B. That doesn’t mean the professor’s observations were entirely useless: experience, like anecdotes, can draw attention to things that are worth evaluating with the scientific method.
We don’t always have the pertinent scientific studies needed to make a clinical decision. When there is no hard evidence, a clinician’s experience may be all we have to go on. Knowing that a patient with disease X got better following treatment Y is a step above having no knowledge at all about X or Y. A small step, but arguably better than no step at all. (more…)
Lest some of our readers imagine that the authors of this blog are mere armchair opinion-spouters and keyboard-tappers for one little blog, I’d like to point out some of the other things we do to spread the word about science and reason. Steven Novella’s new course about medical myths for “The Great Courses” of The Teaching Company is a prime example: more about that later.
First, some examples of the kinds of things we have been doing: (more…)
… animals are divided into (a) those that belong to the emperor; (b) embalmed ones; (c) those that are trained; (d) suckling pigs; (e) mermaids; (f) fabulous ones; (g) stray dogs; (h) those that are included in this classification; (i) those that tremble as if they were mad; (j) innumerable ones; (k) those drawn with a very fine camel’s-hair brush; (l) etcetera; (m) those that have just broken the flower vase; (n) those that at a distance resemble flies.
– Jorge Luis Borges (1899–1986)1
Not too long ago, I came across a disease taxonomy proposed by a certain East-West Medical Research Institute (EWMRI), that includes the kind of fantastic afflictions — such as “running piglet” disorder — fit for the best Borgesian list.
This obscure institute, located at Kyung Hee University in Seoul, Korea, is one of the 800 WHO Collaborating Centres designated to carry out various activities in support of the Organization’s programs. With the collaboration of China, Japan, Vietnam, Australia, and the US, this center is working to incorporate medieval Asian disease nomenclature to the 11th version of the International Classification of Disease (ICD-11).
I have frequently said that science can only provide data to inform our decisions but can’t tell us what we “should” do; that it can determine facts but not values. I stand corrected. A persuasive new book by Sam Harris, The Moral Landscape, has convinced me that science can and should determine what is moral. In fact, it is a more reliable guide than any other option.
Several recent books have looked at morality from a scientific viewpoint. Animals have been shown to exercise altruism and to appreciate fairness. Human cooperation has been shown to offer a survival advantage to individuals and groups. Game theory has demonstrated the success of the tit-for-tat strategy. In The Science of Good and Evil, Michael Shermer argues that evolution has produced in us a moral sense that is not a reflection of some “absolute” morality but that constitutes a worthy human project that transcends individuals. He posits a pyramid of morality that becomes more advanced as it is applied to larger in-groups, from self to family to community to all living creatures. He amends the Golden Rule to specify that we should treat others not as we want to be treated but as others want to be treated. (more…)
The Internet is a wonderful new medium for communicating ideas and information in a rapid and interactive way. Many articles are followed by a “comments” section. Like so many things in this imperfect world, comments are a mixed blessing. They can enhance the article by correcting errors, adding further information, and contributing useful thoughts to a productive discussion. But all too often they consist of emotional outbursts, unwarranted personal attacks on the author, logical fallacies, and misinformation. They provide irrational and ignorant people with a soapbox for promoting prejudices and false information.
To illustrate, let’s look at the responses to something I wrote about a weight loss product called Isagenix that is sold through a multilevel marketing scheme. To quote the website,
The Isagenix cleanse is unique because it not only removes impurities at the cellular level, it builds the body up with incredible nutrition. Besides detoxing the body, Isagenix teaches people a wonderful lesson that they don’t need to eat as much as they are accustom to and eating healthy choices are really important and also a lot of the food we are eating is nutritionally bankrupt. [errors are in the original]
I didn’t set out to write an article about this. It started when I received an e-mail inquiry about Isagenix. I posted my answer on a discussion list and it was picked up and published on the healthfraudoz website. Sandy Szwarc approved of it and kindly reposted it on her Junkfood Science blog.
As I write, the comments on the healthfraudoz website have reached a total of 176. A few commenters approved of what I wrote, but the majority of commenters tried to defend Isagenix. Their arguments were irrational, incompetent, and sometimes amusing. (more…)
Spring is here. I don’t say that because of the warmer weather, the blooming tulips in my back yard, or the current effect of the earth’s axial tilt on the Northern hemisphere. No, in my somewhat warped world of the pediatric ICU seasons are marked by illnesses and injuries with an annual rhythm. Fall begins with a spike in cases of bronchiolitis, Summer with a near-drowning in a swimming pool. Winter has arrived when seasonal influenza reappears. And Spring, well, Spring has several harbingers, including auto vs bicycle accidents, falls from windows, and snakebites.
Sure enough, this week we admitted our first child of the year bitten by a venomous snake who, like most people unfortunate enough to be envenomated by a North American pit viper, has done very well. This child fell prey not only to our local limbless fauna, but also to one of several common myths or misunderstandings about snakebites that place the victim, rescuer, or both at higher risk for injury and complications. This post will explore some of the more common mistakes people make during North American snakebite encounters (being limited to snakes native to North America, the following does not necessarily apply to snakes from other areas).
File this post under Science-Based-You’re-Not-Helping-Please-Don’t-Do-That.
Myth #1: You Need to Know the Species / Kill the Snake
North America has around 120 species of snake, over 20 of which are venomous. With so many species, it may seem important to ID the snake so the docs in the ED can give the appropriate anti-venin. Fortunately, that isn’t the case. (more…)
As 2009 comes to an end, it seems that everyone is creating year-in-review lists. I thought I’d jump on the list band wagon and offer my purely subjective top 5 threats to rational thought in healthcare and medicine.
Of course, it strikes me as rather ironic that we’re having this discussion – who knew that medicine could be divorced from science in the first place? I thought the two went hand-in-hand, like a nice antigen and its receptor… and yet, here we are, on the verge of tremendous technological breakthroughs (thanks to advances in our understanding of molecular genetics, immunology, and biochemistry, etc.), faced with a growing number of people who prefer to resort to placebo-based remedies (such as heavy-metal laced herbs or vigorously shaken water) and Christian Science Prayer.
And so, without further ado, here’s my list of the top 5 threats to science in medicine for 2009 and beyond: