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“It’s just a theory”

I am afraid that the experiments you quote, M. Pasteur, will turn against you. The world into which you wish to take us is really too fantastic.

La Presse, 1860

It’s just a theory. Not evolution. Germ theory. Just a theory, one of many that account for the etiology of diseases.

I should mention my bias up front. I am, as some of you are aware, an Infectious Disease doctor. My job is simple: me find germ, me kill germ, me go home. I think there are three causes of disease: wear and tear, genetic, and germs. Perhaps a bit of an exaggeration, but not much. My professional life for the last 22 years has been spent preventing, diagnosing, and treating the multitudinous germs that a continually trying to kill or injure us. It is a fundamentally futile job, as in the end I will be consumed by the organisms I have spend a lifetime trying to kill.

I would have though that the germ theory of disease was a concept that was so grounded in history, science and reality that there would be little opposition to the idea that germs (a broad term for viruses, bacteremia, fungi, parasite etc) cause infections and some other diseases.

Wrong. There are people who deny the validity of germ theory. Add there are people who deny gravity. And evolution.

Opponents of germ theory come in two flavors:

  1. Germ theory deniers.
  2. Those who propose alternative mechanisms of disease.

There is great overlap between the two categories, and the division serves more as a literary device for the sake of exposition than a true description of reality.
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Posted in: Acupuncture, Chiropractic, Homeopathy, Science and Medicine, Vaccines

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“Urban Zen” and homeopathy at Beth Israel Medical Center, or: Dr. Gorski destroys his chances of ever being invited to join the faculty at BIMC or the Albert Einstein College of Medicine

I guess I never really wanted to work in Manhattan anyway. At least, that’s what I keep telling myself.

I mean, why on earth would I want to? What’s the attraction? Living in the heart of it all, all those shows and all those amazing cultural activities, all those world-class restaurants? Being close to Boston, Philadelphia, and other cool East Coast cities, which are all just a quick Acela train ride away? Who cares about those things, anyway?

Apparently I don’t, because I’m about to destroy my chances of working at what has been considered one of the premiere academic hospitals in New York City, specifically Beth Israel Medical Center, an academic affiliate of the Albert Einstein College of Medicine. It’s possible for me to have been ignored when I first included the Albert Einstein College of Medicine and its affliated Continuum Center for Health & Healing in my roll call of shame as a medical center that has not just added woo to its offerings, but actively embraced it. At the time I originally discovered it, though, its offerings seemed limited to fairly mild woo, the usual stuff like acupuncture, what I like to call “gateway modalities” that centers embrace first because they’re relatively tame and commonplace. All too commonly, though, dabbling in gateway modalities leads to the “hard stuff,” outright quackery with zero scientific basis like homeopathy, reflexology, and craniosacral therapy. Such is the pathway an academic medical center follows when it degenerates from science-based medicine to what Dr. R. W. famously dubbed “quackademic medicine,” usually driven by a few famous true believers, which, alas, is exactly what happened at fearless leader Steve Novella’s institution of Yale, thanks to Dr. David Katz and his “more fluid concept of evidence.”

In any case, last week, I realized that I’ve been completely neglecting the aforementioned roll call of shame. Perusing it, I now realize that it’s been over five months since I did a significant update to it. You just know that, given the rate of infiltration of unscientific medical practices into medical academia as seemingly respectable treatment modalities that there must be at least several new additions to this roll of shame. Alas, even today, having been shamed myself by the realization of my failure to keep the list updated, I’m not going to do the full update and revamping that the Roll Call of Quackademic Medicine cries out for. However, that doesn’t mean I can’t do a piecemeal addition here and there. That doesn’t mean I can’t point out new additions as they pop up, even if it takes me a while to find the time to give the list the facelift it cries out for. It doesn’t mean I can’t call out hospitals like Beth Israel when they fall into woo, especially when they dive into quackademic medicine in a big way for cancer patients.
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Posted in: Cancer, Homeopathy, Medical Academia, Science and the Media

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Another take on those “50 Facts About Homeopathy”

You may recall that a week ago fellow SBM blogger Mark Crislip did a truly amusing takedown of an article by a homeopath purporting to provide us with 50 Facts About Homeopathy that supposedly validate the efficacy of this most amazing form of quackery. Not surprisingly, others wanted to get in on the fun, given how outrageously ridiculous and riddled with numerous logical fallacies the homeopath’s article was. Indeed, that’s why prominent Australian skeptic Peter Bowditch, whose website The Millenium Project is always an entertaining read (except that, at only once every one or two weeks, its updates are too infrequent) couldn’t resist getting in on the action with his answer to A Homeopathic Challenge.

Unfortunately, by the time he hit “Fact” #25 Peter was laughing so hard that, try as he might, he just couldn’t continue with his deconstruction. He does, however, promise to finish up the list in a future installment.

Posted in: Homeopathy, Humor

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How State Medical Boards Shoot Themselves (and You) in the Foot

This is almost the final entry (for now) in a series of posts about the pitfalls of regulating physicians who peddle quackery.† In previous entries we’ve seen how quacks have portrayed an illegal and pseudoscientific treatment, intravenous hydrogen peroxide, as legitimate; how a physician who practiced that and other dubious methods eluded definitive regulatory sanctions for years; examples of quacks banding together to form pseudomedical pseudoprofessional organizations (PPOs) and bogus board-certification schemes to establish the appearance of professional legitimacy, for protection from regulatory scrutiny, to garner political clout, to attract funds from interested businesses, to dupe the Accreditation Council for Continuing Medical Education into granting continuing medical education credits (CMEs) for pseudoscientific conferences, and more.

Now we’ll look at several examples of how state medical boards in the U.S. have abdicated their responsibility to protect the public from such practitioners. A few caveats: first, in most cases I can only guess why that has happened. Some of it has probably been due to naiveté, or to political or legal pressures. To some extent it has probably been due to faddism and its close relative, misleading language. Next, the examples given here are by no means exhaustive. Next, a state medical board can only be as effective as the language in the state’s medical practice act allows it to be, and that is determined by legislators (politics), not board members. Finally, state medical boards have not uniformly made the wrong choices regarding quack practices and practitioners.

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Posted in: Health Fraud, Homeopathy, Medical Ethics, Politics and Regulation, Science and Medicine

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51 “Facts” About Homeopathy

Get your facts first, and then you can distort them as much as you please.

—- Mark Twain

I use a Mac, so I know I think different. I also coexist on an alternative parallel world where people live on the same planet as me, but have such a radically different way of thinking that I wonder if we have the same ability to evaluate reality (1).

The best example of different ways of seeing the same thing is homeopathy. Homeopathy is utterly and completely ridiculous with zero plausibility or efficacy. Only therapeutic touch is its rival. Yet homeopath Louise Mclean can suggest there are 50 facts that validate homeopathy (2). These facts were presented as an attempt to counter criticism that homeopathy is only water with no therapeutic effects.

Lets evaluate each fact. There are two parts to the evaluations: whether the fact is true and what, if any, logical fallacy is being used. Deciding on which logical fallacy is being used is not my strong point, feel free to correct me in the comments, and I will add to the text later.
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Posted in: Health Fraud, Homeopathy

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Getting It On with Homeopathy

I have more thoughts on the homeopathy matter than fit in follow-up notes, so here goes.

First, David Gorski recalls the 1994 Pediatrics report on childhood diarrhea treated with tailored homeopathic remedies for each patient. There is more to the story than has been written. I am certain much of this will get back to the authors, but others may benefit from knowing how this group of homeopaths operate.

I recall the paper well, because it was the first journal report that I deconstructed and published (Pediatrics, Oct 1995) as a regular article. I think it was the first time the journal had published a formal rebuttal outside the Letters section. The head of pediatric pharmacy at Valley Medical Center, San Jose, brought the paper to me and asked what I thought if it. Bill London of National Council against Health Fraud and I spent six months discussing it and working over the details.

The paper had so many flaws, that one letter could not contain them. It had five or six end points, several arithmetical errors, graphs with missing data, only one end point reached consensus signficance (barely.)

Each case received a remedy tailored to the age, condition, duration of symptoms, appearance and odor of the stool, the recall of the parent or relative about stool frequency (which depended on how often the child’s diapers were changed, and a number of other qualities, typical of a homeopathic approach to diagnosis. The remedies given were not based on etiology, but based on personal observations, We saw that the remedy was chosen at a snapshot in time, depending on all those factors which varied from hour to hour. So the remedies depended on the time at which the child was brought in for examination and were unchanged throughout the duration of illness. That made no sense at all. Besides, the specific remedies had no data behind them for proof of efficacy, and were chosen on basis of charts and computer references.

One could hardly find anything about the paper that would lend credibility to its conclusion that suggested homeopathy “worked“ better than placebo. The results in our opinion demonstrated nothing more than the variations in the clinical trial system (noise.)
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Posted in: Clinical Trials, Homeopathy, Science and Medicine

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Fun with homeopaths and meta-analyses of homeopathy trials

ResearchBlogging.orgHomeopathy amuses me.

Well, actually it both amuses me and appalls me. The amusement comes from just how utterly ridiculous the concepts behind homeopathy are. Think about it. It is nothing but pure magical thinking. Indeed, at the very core of homeopathy is a concept that can only be considered to be magic. In homeopathy, the main principles are that “like heals like” and that dilution increases potency. Thus, in homeopathy, to cure an illness, you pick something that causes symptoms similar to those of that illness and then dilute it from 20C to 30C, where each “C” represents a 1:100 dilution. Given that such levels of dilution exceed Avagaddro’s number by many orders of magnitude, even if any sort of active medicine was used, there is no active ingredient left after a series of homeopathic dilutions. Indeed, this was known as far back as the mid-1800′s. Of course, this doesn’t stop homeopaths, who argue that water somehow retains the “essence” of whatever homeopathic remedy it has been in contact with, and that’s how homeopathy “works.” Add to that the mystical need to “succuss” (vigorously shake) the homeopathic remedy at each dilution (I’ve been told by homeopaths, with all seriousness, that if each dilution isn’t properly succussed then the homeopathic remedy will not attain its potency), and it’s magic all the way down, just as creationism has been described as “turtles all the way down.” Even more amusing are the contortions of science and logic that are used by otherwise intelligent people to make arguments for homeopathy. For example, just read some of Lionel Milgrom‘s inappropriate invocations of quantum theory at the macroscopic level for some of the most amazing woo you’ve ever seen, or Rustum Roy‘s claims for the “memory of water.” Indeed, if you want to find out just how scientifically bankrupt everything about homepathy is, my co-blogger Dr. Kimball Atwood started his tenure on Science-Based Medicine with a five part series on homeopathy.

At the same time, homeopathy appalls me. There are many reasons for this, not the least of which is how anyone claiming to have a rational or scientific viewpoint can fall so far as to twist science brutally to justify magic. Worse, homepaths and physicians sucked into belief into the sorcery that his homeopathy are driven by their belief to carry out unethical clinical trials in Third World countries, even on children. Meanwhile, time, resources, and precious cash are wasted chasing after pixie dust by our own government through the National Center for Complementary and Alternative Medicine (NCCAM). So while I laugh at the antics of homeopaths going on and on about the “memory of water” or quantum gyroscopic models” in order to justify homeopathy as anything more than an elaborate placebo, I’m crying a little inside as I watch.

The Lancet, meta-analysis, and homeopathy

If there’s one thing that homepaths hate–I mean really, really, really hate–it’s a meta-analysis of high quality homeopathy trials published by Professor Matthias Egger in the Department of Social and Preventative Medicine at the University of Berne in Switzerland, entitled Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy.
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Posted in: Clinical Trials, Homeopathy

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On the ethics of clinical trials of homeopathy in Third World countries

ResearchBlogging.orgI’m on the record multiple times as saying that I reject the entire concept and nomenclature of “alternative medicine” as being distinct from “conventional” medicine as a false dichotomy, when in reality there should be just “medicine.” Indeed, if there is one major theme to which this blog is dedicated it’s that medicine should be as much as possible science-based, a concept that takes into account not just clinical trials, which are prone to all sorts of false-positive results in the case of modalities that have no plausibility from a scientific perspective. In essence, I advocate treating “alternative” medicine the same as “conventional” medicine subjecting it to the same scientific process to determine whether it has efficacy or not, after which medicine that is effective is retained and used and medicine that fails the test is discarded. Where it comes from, the “alternative” or the “conventional” medical realm, matters little to me. All that matters is that it is based on sound science and that it has been demonstrated to have efficacy significantly greater than that of a placebo.

Given that, you’d think I’d be all in favor of subjecting alternative medicine, be it woo or more credible, to rigorous scientific testing. In many cases, you’d be right. My sole caveat is that, when testing alt-med, priority should be given to modalities that have at least a modicum of scientific plausibility, even if a bit tenuous. Herbal remedies would thus be at the front of my line to be tested, while obvious woo whose core principle on which it is based is so utterly ridiculous and scientifically implausible (like homeopathy, for instance) would be relegated to the back of line, if it’s ever tested at all. More implausible modalities that might work (albeit by a method that has nothing to do with the “life energy” manipulation that is claimed for it) like acupuncture would be somewhere in the middle. It’s a matter of resource prioritization, in which it makes little sense to test blatant woo before more plausible therapies are examined. Indeed, it’s arguable whether blatant woo like homeopathy should even have resources wasted testing it at all, given its extreme scientific improbability. Finally, regardless of what modality is being tested in scientific and/or clinical trials, it has to be done according to the highest ethical standards, on adults fully cognizant of or able to be taught about the questions being asked, the issues involved, and the potential risks who are thus able to give truly informed consent.
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Posted in: Homeopathy, Medical Ethics, Public Health, Science and Medicine

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Prior Probability: the Dirty Little Secret of “Evidence-Based Alternative Medicine”—Continued Again

After the previous posting on the Bayesian approach to clinical trial data, several new comments made it clear to me that more needed to be said. This posting addresses those comments and adds a few more observations regarding the unfortunate consequences of EBM’s neglect of prior probability as it applies to “complementary and alternative medicine” (“CAM”).†

The “Galileo Gambit” and the Statistics Gambit

Reader durvit wrote:

A very interesting example, for a number of people, might be estimating the prior probability for Marshall and Warren’s early work on Helicobacter pylori and its impact on gastroduodenal management. I frequently have Marshall quoted to me as a variation on the Galileo gambit, so establishing whether he and Warren would have been helped or hindered by Bayesian techniques would be useful.

This suggestion raises a couple of issues. First, the “Galileo gambit” regarding Marshall and Warren’s discovery is a straw man (as durvit seems to have surmised). (more…)

Posted in: Homeopathy, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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Prior Probability: The Dirty Little Secret of “Evidence-Based Alternative Medicine”

This is actually the second entry in this series;† the first was Part V of the Homeopathy and Evidence-Based Medicine series, which began the discussion of why Evidence-Based Medicine (EBM) is not up to the task of evaluating highly implausible claims. That discussion made the point that EBM favors equivocal clinical trial data over basic science, even if the latter is both firmly established and refutes the clinical claim. It suggested that this failure in calculus is not an indictment of EBM’s originators, but rather was an understandable lapse on their part: it never occurred to them, even as recently as 1990, that EBM would soon be asked to judge contests pitting low powered, bias-prone clinical investigations and reviews against facts of nature elucidated by voluminous and rigorous experimentation. Thus although EBM correctly recognizes that basic science is an insufficient basis for determining the safety and effectiveness of a new medical treatment, it overlooks its necessary place in that exercise.

This entry develops the argument in a more formal way. In so doing it advocates a solution to the problem that has been offered by several others, but so far without real success: the adoption of Bayesian inference for evaluating clinical trial data.
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Posted in: Basic Science, Clinical Trials, Homeopathy, Science and Medicine

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