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Cochrane is Starting to ‘Get’ SBM!

This essay is the latest in the series indexed at the bottom.* It follows several (nos. 10-14) that responded to a critique by statistician Stephen Simon, who had taken issue with our asserting an important distinction between Science-Based Medicine (SBM) and Evidence-Based Medicine (EBM). (Dr. Gorski also posted a response to Dr. Simon’s critique). A quick-if-incomplete Review can be found here.

One of Dr. Simon’s points was this:

I am as harshly critical of the hierarchy of evidence as anyone. I see this as something that will self-correct over time, and I see people within EBM working both formally and informally to replace the rigid hierarchy with something that places each research study in context. I’m staying with EBM because I believe that people who practice EBM thoughtfully do consider mechanisms carefully. That includes the Cochrane Collaboration.

To which I responded:

We don’t see much evidence that people at the highest levels of EBM, eg, Sackett’s Center for EBM or Cochrane, are “working both formally and informally to replace the rigid hierarchy with something that places each research study in context.”

Hallafrickin’loo-ya

Well, perhaps I shouldn’t have been so quick to quip—or perhaps that was exactly what the doctor ordered, as will become clear—because on March 5th, nearly four months after writing those words, I received this email from Karianne Hammerstrøm, the Trials Search Coordinator and Managing Editor for The Campbell Collaboration, which lists Cochrane as one of its partners and which, together with the Norwegian Knowledge Centre for the Health Services, is a source of systematic reviews:

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Posted in: Clinical Trials, Energy Medicine, Medical Academia, Science and Medicine

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Coming to an emergency room near you in 2030?

I’ve frequently lamented what might happen if the current trend towards quackademic medicine continues unabated, and quackery becomes fully “integrated” with science-based medicine as a co-equal. Interestingly, this concept has provided fodder for several comedians. For example, the first comedy sketch I discovered on this theme was homeopathic e.r. Then a couple of years ago, Mitchell and Webb brought us the British version of essentially the same idea (but done so much better), namely Homeopathic A&E. What I didn’t realize is that predating both of these was…Holistic E.R. (Embedding disabled, unfortunately.)

This sketch comes from an old sketch comedy show known as Almost Live!, which I had never heard of before, but if this sketch is any indication, it was brilliant. Favorite bits from Holistic E.R.: The part about vitamin C, the use of visualization, and, of course, the crystals. Sadly, with the way academic medicine is being infused with quackery such as energy healing, homeopathy, and even anthroposophic medicine at my medical alma mater, I could see this happening within my lifetime.

Posted in: Homeopathy, Humor, Medical Academia

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CAM In Medical Schools

A recent US News and World Report article on the incorporation of complementary and alternative medicine (CAM) into US medical schools credulously repeats the pro-CAM marketing hype. There is no evidence that the author, Meryl Davids Landau, spoke to a single critic of CAM, or is even aware that such criticism exists. The result looks more like marketing copy than serious journalism.

She begins:

Now that nearly 40 percent of American adults swear by some form of complementary and alternative medicine, or CAM—from nutrition and mental relaxation to acupuncture, magnet therapy, and foreign healing systems like traditional Chinese medicine and Indian ayurveda—a growing number of medical schools, too, are supplementing medication with meditation.

There is much to deconstruct just in this first paragraph. The entire article in an argument from popularity. This is a game the pro-CAM community has been playing for years. People are using CAM because it’s popular; medical schools should teach it because people are using it; the government should research it because of all the interest in it; and CAM should be popular because it’s being researched and taught in medical schools. CAM is like Paris Hilton – famous for being famous.

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Posted in: Medical Academia, Science and the Media

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The Hazards of “CAM”-Pandering

Steven Salzberg, a friend of this blog and Director of the Center for Bioinformatics and Computational Biology at the University of Maryland, is on the editorial boards of three of the many journals published by BioMed Central (BMC), an important source of open-access, peer-reviewed biomedical reports. He is disturbed by the presence of two other journals under the BMC umbrella: Chinese Medicine and BMC Complementary and Alternative Medicine. A couple of days ago, on his Forbes science blog, Dr. Salzberg explained why. Here are some excerpts:

The Chinese Medicine journal promotes, according to its own mission statement, studies of “acupuncture, Tui-na, Qi-qong, Tai Chi Quan, energy research,” and other nonsense. Tui na, for example, supposedly “affects the flow of energy by holding and pressing the body at acupressure points.”

Right. What is this doing in a scientific journal?… I support BMC…But their corporate leaders seem to care more about expanding their stable than about maintaining the integrity of science. Chinese Medicine simply does not belong in the company of respectable scientific journals.

Forming a scientific journal whose goal is to validate antiquated, unproven superstitions is simply not science, whatever the editors of Chinese Medicine claim.

BMC should be embarrassed to be publishing journals that promote anti-scientific theories and otherwise muddy the literature. By supporting these journals, they undermine the credibility of many excellent BMC journals. They should cut these journals loose.

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Posted in: Acupuncture, Clinical Trials, Energy Medicine, Herbs & Supplements, History, Homeopathy, Medical Academia, Pharmaceuticals, Science and Medicine, Science and the Media

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A University of Michigan Medical School alumnus confronts anthroposophic medicine at his alma mater

I graduated from the University of Michigan Medical School in the late 1980s. If there’s one thing I remember about the four years I was there, it’s that U. of M. was really hardcore about science back then. In fact, one of the things I remember is that U. of M. was viewed as being rather old-fashioned. No new (at the time) organ system approach for us! Every four weeks, like clockwork, we’d have what was called a concurrent examination, which basically meant that we were tested (with multiple choice tests, of course) on every subject on the same morning. The medical curriculum for the first two years had been fairly constant for quite some time, with a heaping helpin’ of anatomy, histology, biochemistry, and physiology in the first year and the second year packed full of pharmacology, pathology, and neurosciences. Nowhere to be found was anything resembling “energy medicine” or anything that wasn’t science-based!

Of course, back in the 1980s, the infiltration of quackademic medicine into medical schools and academic medical centers hadn’t really begun in earnest yet, although the rumblings of what is now called “complementary and alternative medicine” (CAM) and, more frequently these days, “integrative medicine” (IM) were starting to be heard in East Coast and West Coast schools. Even there, though, the incipient CAM movement was viewed as fringe, not worthy of the attention of serious academic physicians. Indeed, in the late 1980s, even at what are now havens of quackademic medicine if someone had suggested that diluting substances until there is nothing left, as in homeopathy, or waving your hands over a patient in order to channel the “universal source” of energy into a patient in order to heal a patient, as in reiki, had any place in scientific medicine, he’d have been laughed out of medical school–and rightly so.

Not so today, unfortunately. Although the problem of infiltration of quackademic medicine into academic medical centers goes way beyond this example, I can point out that faith healing based on Eastern mystical beliefs instead of Christianity is alive and well and ensconced in academic medical centers such as the University of Maryland School of Medicine Center for Integrative Medicine, where reiki masters are roaming the halls of the University of Maryland R. Adam Cowley Shock Trauma Center and Bonnie Tarantino, a Melchizedek practitioner, holographic sound healer, and an Usui and Karuna Reiki Master holds sway. Meanwhile, all manner of woo, such as acupuncture, homeopathy, craniosacral therapy, reiki, and reflexology are offered. Truly, you know that when an academic medical center has gone so far as to offer homeopathy, reflexology, and reiki, it’s all over as far as academic credibility is concerned, and it has become a center of quackademic medicine. Sadly, even a hospital where I trained, MetroHealth Medical Center, has succumbed to the temptation to add the quackery that is reiki to its armamentarium. That aside, I had never expected that my old, hardcore University of Michigan would go woo in such a big way.

I was wrong.
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Posted in: Faith Healing & Spirituality, Homeopathy, Medical Academia, Religion

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Of SBM and EBM Redux. Part IV, Continued: More Cochrane and a little Bayes

OK, I admit that I pulled a fast one. I never finished the last post as promised, so here it is.

Cochrane Continued

In the last post I alluded to the 2006 Cochrane Laetrile review, the conclusion of which was:

This systematic review has clearly identified the need for randomised or controlled clinical trials assessing the effectiveness of Laetrile or amygdalin for cancer treatment.

I’d previously asserted that this conclusion “stand[s] the rationale for RCTs on its head,” because a rigorous, disconfirming case series had long ago put the matter to rest. Later I reported that Edzard Ernst, one of the Cochrane authors, had changed his mind, writing, “Would I argue for more Laetrile studies? NO.” That in itself is a reason for optimism, but Dr. Ernst is such an exception among “CAM” researchers that it almost seemed not to count.

Until recently, however, I’d only seen the abstract of the Cochrane Laetrile review. Now I’ve read the entire review, and there’s a very pleasant surprise in it (Professor Simon, take notice). In a section labeled “Feedback” is this letter from another Cochrane reviewer, which was apparently added in August of 2006, well before I voiced my own objections:

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Posted in: Clinical Trials, Homeopathy, Medical Academia, Science and Medicine

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Of SBM and EBM Redux. Part IV: More Cochrane and a little Bayes

NB: This is a partial posting; I was up all night ‘on-call’ and too tired to continue. I’ll post the rest of the essay later…

Review

This is the fourth and final part of a series-within-a-series* inspired by statistician Steve Simon. Professor Simon had challenged the view, held by several bloggers here at SBM, that Evidence-Based Medicine (EBM) has been mostly inadequate to the task of reaching definitive conclusions about highly implausible medical claims. In Part I, I reiterated a fundamental problem with EBM, reflected in its Levels of Evidence scheme, that although it correctly recognizes basic science and other pre-clinical evidence as insufficient bases for introducing novel treatments into practice, it fails to acknowledge that they are necessary bases. I explained the difference between “plausibility” and “knowing the mechanism.”

I showed, with several examples, that in the EBM lexicon the word “evidence” refers almost exclusively to the results of clinical trials: thus, when faced with equivocal or no clinical trials of some highly implausible claim, EBM practitioners typically declare that there is “not enough evidence” to either accept or reject the claim, and call for more trials—although in many cases there is abundant evidence, other than clinical trials, that conclusively refutes the claim. I rejected Prof. Simon’s assertion that we at SBM want to “give (EBM) a new label,” making the point that we only want it to live up to its current label by considering all the evidence. I doubted Prof. Simon’s contention that “people within EBM (are) working both formally and informally to replace the rigid hierarchy with something that places each research study in context.”

In Part II I responded to the widely held assertion, also held by Prof. Simon, that there is “societal value in testing (highly implausible) therapies that are in wide use.” I made it clear that I don’t oppose simple tests of basic claims, such as the Emily Rosa experiment, but I noted that EBM reviewers, including those employed by the Cochrane Collaboration, typically ignore such tests. I wrote that I oppose large efficacy trials and public funding of such trials. I argued that the popularity gambit has resulted in human subjects being exposed to dangerous and unethical trials, and I quoted language from ethics treatises specifically contradicting the assertion that popularity justifies such trials. Finally, I showed that the alleged popularity of most “CAM” methods—as irrelevant as it may be to the question of human studies ethics—has been greatly exaggerated.

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Posted in: Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Medical Academia, Medical Ethics, Science and Medicine

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The Good Rewards of Bad Science

All the world sees us
In grand style wherever we are;
The big and the small
Are infatuated with us:
They run to our remedies
And regard us as gods
And to our prescriptions
Principles and regimens, they submit themselves.

Molière, The Imaginary Invalid (1673)1

The passage above is part of a burlesque doctoral conferment ceremony, where the French playwright Molière (1622-1673) mocks the unscrupulous physicians of his time. “All the excellency of their art consists in pompous gibberish, in a specious babbling, which gives you words instead of reasons, and promises instead of results,” he writes. In Moliere’s plays doctors never cure anyone; they are put on stage just to display their own vanity and ignorance.2 The Spanish painter Francisco de Goya (1746-1828) also took on the same issue by painting in 1799 a well attired jackass taking the pulse of a dying man, in a pose that accentuates the large gem on his hoof.


Image 1. De qué mal morirá (Of what illness will he die?) by Francisco de Goya is held at the Biblioteca Nacional, Madrid, and The Metropolitan Museum of Art, New York.

But if the asinine doctors of Molière and de Goya’s time never cured anyone, it is because they held prescientific views, and believed that disease was caused by imbalances in “humors,” and by malefic influences of the Heavens. Even the most educated among them treated illnesses in good faith by purging, bloodletting and enema at astrologically auspicious times. In contrast, current physicians who for the sake of funding embrace and endorse unscientific views and practices under the guise of CAM or integrative medicine, do so knowing that they often contradict the established principles of physics, chemistry, and biology. Therefore, in addition to promoting “snake oil science”3 (as R. Barker Bausell calls it), these physicians are also guilty of bad faith. Most of this takes place at large academic centers, where funding seems to outweigh the concern for science. As Val Jones, MD, writes in 2009′s Top 5 Threats To Science In Medicine:

Often referred to by David Gorski as “Quackademic” Medical Centers – there is a growing trend among these centers to accept endowments for “integrative” approaches to medical care. Because of the economic realities of decreasing healthcare reimbursements – these once proud defenders of science are now accepting money to “study” implausible and often disproven medical treatments because they’re trendy. Scientists at these centers are forced to look the other way while patients (who trust the center’s reputation that took tens of decades to build) are exposed to placebo medicine under the guise of “holistic” healthcare.

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Posted in: Acupuncture, Medical Academia

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Of SBM and EBM Redux. Part III: Parapsychology is the Role Model for “CAM” Research

This is the third post in this series*; please see Part II for a review. Part II offered several arguments against the assertion that it is a good idea to perform efficacy trials of medical claims that have been refuted by basic science or by other, pre-trial evidence. This post will add to those arguments, continuing to identify the inadequacies of the tools of Evidence-Based Medicine (EBM) as applied to such claims.

Prof. Simon Replies

Prior to the posting of Part II, statistician Steve Simon, whose views had been the impetus for this series, posted another article on his blog, responding to Part I of this series. He agreed with some of what both Dr. Gorski and I had written:

The blog post by Dr. Atwood points out a critical distinction between “biologically implausible” and “no known mechanism of action” and I must concede this point. There are certain therapies in CAM that take the claim of biological plausibility to an extreme. It’s not as if those therapies are just implausible. It is that those therapies must posit a mechanism that “would necessarily violate scientific principles that rest on far more solid ground than any number of equivocal, bias-and-error-prone clinical trials could hope to overturn.” Examples of such therapies are homeopathy, energy medicine, chiropractic subluxations, craniosacral rhythms, and coffee enemas.

The Science Based Medicine site would argue that randomized trials for these therapies are never justified. And it bothers Dr. Atwood when a systematic review from the Cochrane Collaboration states that no conclusions can be drawn about homeopathy as a treatment for asthma because of a lack of evidence from well conducted clinical trials. There’s plenty of evidence from basic physics and chemistry that can allow you to draw strong conclusions about whether homeopathy is an effective treatment for asthma. So the Cochrane Collaboration is ignoring this evidence, and worse still, is implicitly (and sometimes explicitly) calling for more research in this area.

On the other hand:

There are a host of issues worth discussing here, but let me limit myself for now to one very basic issue. Is any research justified for a therapy like homeopathy when basic physics and chemistry will provide more than enough evidence by itself to suggest that such research is futile(?) Worse still, the randomized trial is subject to numerous biases that can lead to erroneous conclusions.

I disagree for a variety of reasons.

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Posted in: Acupuncture, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Herbs & Supplements, Homeopathy, Medical Academia, Medical Ethics, Science and Medicine

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