Science-based medicine rests on twin pillars that are utterly essential to the development of treatments that are safe and efficacious. Both of these pillars depend on science, but in different ways. The first of these is, of course, the basic science that provides the hypotheses to test about the mechanisms behind the diseases and malfunctions that plague the human body. This basic science suggests ways of either correcting or alleviating these malfunctions in order to alleviate symptoms and prevent morbidity and mortality and how to improve health to increase quality and quantity of life. Another critical aspect of basic science is that it also provides scientists with an estimate of the plausibility of various proposed interventions, treatments and cures designed to treat disease and improve health. For example, if a proposed remedy relies upon ideas that do not jibe with some of the most well-established laws in science, such as homeopathy, the concepts behind which violate multiple laws of physics and chemistry, it’s a very safe bet that that particular treatment will not work and that we should test something else. Of course, the raison d’être of this blog derives from the unfortunate fact that in today’s medicine this is not the case and we are wasting incredible amounts of time, money, and lost opportunities in order to pursue the scientific equivalent of fairy dust as though it represented a promising breakthrough that will save medicine, even though much of it is based on prescientific thinking and mysticism. Examples include homeopathy, reiki, therapeutic touch, acupuncture, and much of traditional Chinese medicine and Ayurveda, all of which have managed to attach themselves to medical academia like kudzu.
Of course, basic science alone is not enough. Humans are incredibly complex organisms, and what we consider to be an adequate understanding of disease won’t always result in an efficacious treatment, no matter how good the science is. Note that this is not the same thing as saying that utter implausibility from a scientific basis (as is the case with homeopathy) doesn’t mean a treatment won’t work. When a proposed treatment relies on claiming “memory” for water that doesn’t exist or postulates the existence of a “life energy” that no scientific instrument can detect and the ability to manipulate that life energy that no scientist can prove, it’s a pretty safe bet that that treatment is a pair of fetid dingo’s kidneys. Outside of these sorts of cases, though, clinical trials and epidemiological studies are the second pillar of science-based medicine, in particular clinical trials, which is where the “rubber hits the road,” so to speak. In clinical trials, we take observations from the laboratory that have led to treatments and test them in humans. The idea is to test for both safety and efficacy and then to begin to figure out which patients are most likely to benefit from the new treatment.
Parenting an infant can be totally overwhelming. One of the earliest challenge many face is learning to deal with periods of intractable crying. I often speak with sleep deprived parents when they’re looking for something — anything — to stop their baby from crying. They’ve typically been told by friends of family that their baby must have “colic” and they’ve come to the pharmacy, looking for a treatment. Colic is common, affecting up to 40% of babies in the few months of life.
While distressing, colic is a diagnosis of exclusion — that it, it is given only after other causes have been ruled out (hunger, pain, fatigue, etc.). The most common definition for colic is fussing or crying for more than 3 hours per day, more than 3 days per week, for more than 3 weeks. These criteria, first proposed by Morris Wessel in 1954, continue to be used today. However, scientific evidence to explain the cause is lacking. Ideas proposed include:
- changes in gastrointestinal bacteria/flora
- food allergies
- lactose intolerance
- excess gas in stomach
- cramping or indigestion
- intolerance to substances in the breast milk
- behavioural issues secondary to parenting factors
Despite its intensity, colic resolves on its own with no interventions. By three months of age, colic has resolved in 60% of infants. By four months, it’s 90%. It sounds harmless and short-lived, but colic’s ability to induce stress in parents cannot be overstated. Parents may be angry, frustrated, depressed, exhausted, or just feel guilty, ascribing their baby’s cries to some parenting fault. (more…)
Like most people who grew up after April 22, 1970, I think it is important to be as environmentally responsible as possible. Like many I fail miserably much of the time, but at least I feel guilty about it. Recycling offers the opportunity to feel good about my environmental impact with little effort, since the garbage collection infrastructure in Portland makes recycling easy.
Some products are best extensively reprocessed before reused. Urine, as an example. There are proponents of topical and/or drinking urine as a treatment/cure for nearly any illnesses. The kidneys are mostly responsible for fluid and electrolyte balance and I realize that normal urine is mostly water, salts, urea and a smattering of other very dilute molecules. I have the urine tox screen to prove it. Urine is not a particularly noxious body fluid, but it is not high on my list of liquids to drink under normal circumstances.
Urine is mostly water but not an optimal source of water if it is your only source for fluids. Urine drinkers love to mention the occasional trapped earthquake victim who survives, in part, from drinking their own urine. For the first several days the urine would be dilute enough to keep people reasonably hydrated, as humans cannot concentrate urine as well as, say, a camel. So I can see where consuming urine for a short period of time would delay progressive dehydration and death. A couple days of drinking urine neat, shaken not stirred, would be harmless and, if there were no alternative sources of water, beneficial. I do suffer from the societal taboo that piss is icky, and for aesthetic reasons urine is not something I would want to consume, even when it is referred to as its more common designation ‘Coors Light’. (more…)
One of the themes of SBM is that modern health care should be based upon solid scientific ground. Interventions should be based on a risk vs benefit analysis using the best available scientific evidence (clinical and basic science).
As an extension of this, the standard of care needs to be a science-based standard. Science is (or at least should be) objective and transparent, and without such standards there is no way to have meaningful quality control. Without the filter of science there is no limit to the nonsense and magical thinking that can flow into the health care system. Increasingly we cannot afford the waste of fanciful and ineffective interventions, and even if limited resources were not an issue – individual patients deserve better.
It is for these reasons that we oppose the attempts by proponents of so-called complementary and alternative medicine (CAM) to erode or eliminate the science-based standard of care in medicine. Proponents differ mostly on how open they are about this goal, but there is no escaping the reality that at the heart of the very concept of CAM is at least a double standard – one in which the science-based bar for inclusion is lowered for some favored modalities.
In 1983, Ted Kaptchuk, the senior author of the recent “albuterol vs. placebo” article, and soon to become the long-time Second-in-Command of the Harvard Medical School “CAM” program, published The Web that Has No Weaver:
The book received rave reviews:
A major advance toward the synthesis of Western and Eastern theory. It will stimulate all practitioners to expand their understanding of the causes and treatment of disease.
–Paul Epstein, MD, Harvard Medical School
A lucid and penetrating exposition of the theory and practice of Chinese medicine. While the book’s rich detail makes it of great use to practicing healers, it is in its entirety very simply written, enjoyable reading for the layman…it brings a demystifying balance…Instructive, profound, and important!
Professor Martin Schwartz, University of California, Berkeley
…demystifies Oriental medicine in a remarkably rational analysis…
—Science Digest, Nov. 1982
…an encyclopedia of how to tell from the Eastern perspective ‘what is wrong.’
Dr. Kaptchuk has become a lyricist for the art of healing…
Although the book is explicitly detailed, it is readable and does not require previous knowledge of Chinese thought…
The 2nd edition was published in 2000, to more acclaim:
…opens the great door of understanding to the profoundness of Chinese medicine.
—People’s Daily, Beijing, China
…weaves a picture…that is eminently understandable from a Westerner’s point of view…adds a valuable analysis of the current scientific understanding of how the therapies work and their effectiveness.
Ted Kaptchuk’s book was inspirational in the development of my acupuncture practice and gave me a deep understanding of traditional Chinese medicine…
Dr. George T. Lewith
…a gift for all who share an interest in deep understanding of healing. This new edition is essential reading…
—Michael Lerner, President, Commonweal
Even Edzard Ernst, still in his foggy period, called the 2nd edition “a brilliant synthesis of traditional and scientific knowledge…compulsory reading…”
“I don’t want to give my child any drugs or chemicals for their ADHD,” says a parent. “Instead, I’m thinking about using caffeine. Sound strategy?”
It may be dispensed by a barista and not a pharmacist, and the unit sizes may be small, medium and large, but caffeine is a chemical and also a drug, just as much as methylphenidate (Ritalin) is. Caffeine is even sold as a drug — alone and in combination with other products. But I regularly speak with consumers who are instinctively resistant to what they perceive as drug therapy — they want “natural” options. Caffeinehas been touted as a viable alternative to prescription drugs for ADHD. But is caffeine a science-based treatment option? This question is a good one to illustrate the process of applying science-based thinking to an individual patient question. (more…)
“CHEMOTHERAPY DOESN’T WORK!!!!!”
“CHEMOTHERAPY IS POISON!!!!”
“CHEMOTHERAPY WILL KILL YOU!!!!”
I’ve lost count of how many times I’ve come across statements like the ones above, often in all caps, quite frequently with more than one exclamation point, on the websites of “natural healers,” purveyors of “alternative medicine.” In fact, if you Google “chemotherapy doesn’t work,” “chemotherapy is poison,” or “chemotherapy kills,” you’ll get thousands upon thousands of hits. In the case of “chemotherapy kills,” Google will even start autofilling it to read “chemotherapy kills more than it saves.” The vast majority of the hits from these searches usually come from websites hostile to science-based medicine. Examples include Mercola.com, the website of “alternative medicine entrepreneur” Dr. Joe Mercola and NaturalNews.com, the website of Mike Adams, where you will find cartoons like this one, which likens the administration of chemotherapy to a Nazi death camp:
Every so often, there’s a bit of misinformation that starts spreading around the Internet that shows up in enough places that our readers take notice and e-mail us about it. What happens is that these in essence become “requests.” We at SBM are, of course, happy to consider all requests and sometimes will actually take them on, particularly when doing so will be educational about the mission of this blog, namely discussing science-based medicine and providing much needed critical analysis to the pseudoscience that is, alas, becoming more and more common in medicine. A frequent topic of this blog is, not surprisingly, the anti-vaccine movement, which is arguably the most dangerous (to public health, at least) pseudoscience movement currently in existence. The misinformation about vaccines that anti-vaccine activists spread through websites, podcasts, radio, TV, and other media is protean, and it’s difficult to keep up with it all.
Which is probably why I hadn’t heard this bit of misinformation about the HPV vaccine from an anti-vaccine group I hadn’t heard of before (or at least didn’t remember) called SANE Vax. (I include the “Inc.” because SAFE Vax, Inc. itself insists on using it frequently in all its press releases.) If you’ve been in the biz a while, as I have, you can tell right away from the very name of this website exactly where its creators are coming from. Here’s a hint. It’s not the mission that the website claims that it is, which is stated thusly:
Back in February, Mark Crislip and I both deconstructed an article written by Dr. Reynold Spector that appeared in the March/April issue of Skeptical Inquirer (SI), the flagship publication for the Committee for Skeptical Inquiry (CSI). The article was entitled Seven Deadly Medical Hypotheses, and, contrary to the usual standard of articles published in SI, it used a panoply of spin, bad arguments, and, yes, misinformation to paint a picture of seven horrifically deadly “medical hypotheses,” most of which, even if the reader accepted Dr. Spector’s arguments at face value in a worst case scenario, weren’t actually all that deadly at all, with the alleged deadliness of the others being in dispute. In addition, Dr. Spector painted a picture of medical science that is not nearly rigorous enough. While we at SBM would probably agree that much of medical science is insufficiently rigorous, given how so-called “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) has found a prominent place in medical practice in all too many academic and private medical centers, Dr. Spector got it so wrong that he wasn’t even wrong when he conflated preliminary, hypothesis-generating studies with the big, randomized, phase III clinical trials necessary to achieve FDA approval for a new drug or device. This latest article by Dr. Spector seemed to be of a piece with his previous article in the January/February 2010 issue of SI entitled The War on Cancer A Progress Report for Skeptics, which was so negative in its assessment of scientific progress against cancer that for a moment I was wondering if I were reading NaturalNews.com or Mercola.com.
Unfortunately, Seven Deadly Medical Hypotheses itself is not yet online on the CSI website; so readers without a subscription to SI cannot at the present time judge for themselves whether Mark and I were too harsh on Dr. Spector, but our criticisms, along with that of SBM partner-in-crime Harriet Hall, did have an impact. Seemingly genuinely stunned at the level of criticism leveled at an article published in SI, SI’s editor Kendrick Frazier, to his credit, invited several responses to Dr. Spector’s article, which Harriet Hall, Mark Crislip, Carol Tavris, Avrum Bluming, and I eagerly provided. These letters were originally scheduled to be published a couple of issues ago, along with Dr. Spector’s response. Unfortunately, publishing in dead tree media being what it is, Harriet Hall and I were disappointed to find that the latest issue of SI still didn’t contain our rebuttals. Fortunately, Mr. Frazier has posted this material online for your edification, although, again, I wish he had also published the original article as well.
As most readers of the blog know, I am mostly an Infectious Disease doc. I spend my day diagnosing and treating infections and infectious complications. It is, as I have said before, a simple job. Me find bug, me kill bug, me go home. Kill bug. It is the key part of what I do everyday, and if there is karmic payback for the billions of microbial lives I have erased from the earth these past 25 years, my next life is not going to be so pleasant. I will probably come back as a rabbit in a syphilis lab.
It is always fun when my hobby, writing for SBM, crosses paths with my job. This month the Annals of Internal Medicine published “Oseltamivir Compared With the Chinese Traditional Therapy Maxingshigan–Yinqiaosan in the Treatment of H1N1 Influenza. A Randomized Trial.”
I though big pharma was good at coming up with names I do not know how to pronounce. If someone could provide a pronunciation guide in the comments, it would be ever so helpful, so I will not have to embarrass myself when this entry becomes a Quackcast. Dr. Hall wrote about this article on Tuesday, and I have avoided reading her post until this one is up, so there may be overlap in what is discussed. (more…)