Carlyle said “a lie cannot live.” It shows that he did not know how to tell them.
— Mark Twain
There is an infamous hoax from last century called The Protocols of the (Learned) Elders of Zion, an anti-Semitic text purporting to describe a plan to achieve global domination by the Jewish people. Despite the fact that the Protocols is a work of fiction, there have been and still are folks who believe it to be real, from Hitler on down. (Or is that “on up”? Can one be lower than Hitler? And have I already committed a breach of Godwin’s Law?)
Inventing apparently legitimate information is a useful propaganda device not limited to anti-Semites. Having people appear evil or uncaring using their own words is far more effective than calling them evil and uncaring.
There are many in the community who suffer from a variety of complaints that I cannot diagnose, and, as people do not like uncertainty about their health, they will find someone who will give them a diagnosis. Not infrequently they will come upon the idea of chronic Lyme disease.
The Institute of Medicine report is a frequent ‘rebuttal’ to science based/real medicine. The argument is usually phrased something to the effect that since medicine can be dangerous, SCAM’s are legitimate. Of course, one does not follow the other. It is the equivalent of saying since you are old, bald and pudgy, I am young, have a full head of hair, and are thin. If every doctor and hospital were to vanish tomorrow like an episode of the Outer Limits, SCAM’s would be just a ineffective.
Despite the flawed logic of the comparison, I have always had an affinity for the estimates that 44,000 to 98,000 were (note the deliberate use of the past tense) killed each year in hospitals. There may be methodological flaws in the estimate but the ballpark figure is probably correct.
Naturopathy is an unusual chimera. It is basically a collection of old fashioned medical superstitions presented under a veneer of highly speculative, quasi-scientific assertions. But given its popularity, it is important, from time to time, to evaluate specific claims made by this particular non-science-based belief system.
A reader informed me that he was advised to seek the advice of a naturopath for treatment of his seasonal allergies. Since naturopaths claim to be “doctors plus”, I was curious what they would recommend. Would it be standard allergy treatment with antihistimines and other proven medications along with some sort of vitalistic mumbo-jumbo? It turns out I was half-right.
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…)
For most of human history, doctors have killed their patients more often than they have saved them. An excellent new book, Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and Our Difficulty Swallowing It, by Druin Burch, MD, describes medicine’s bleak past, how better ways of thinking led to modern successes, and how failure to adopt those better ways of thinking continues to impede medical progress.
The moral is not that doctors once did foolish things. The moral is that even the best of people let themselves down when they rely on untested theories and that these failures kill people and stain history. Bleeding and mercury have gone out of fashion, untested certainties and overconfidence have not.
Burch’s conversation with his rowing coach epitomizes the problem:
“I want you to keep your heart rate at 85% of max for the next hour and a half.”
“Because it’s the best way to improve your fitness.”
“How do you know?”
“Because I’ve done it before and it worked. Because that’s what the people who win the Olympics do. I know, I’ve trained some of them.”
“But has anyone actually done an experiment?”
“What on earth are you talking about?”
This book is Burch’s answer to his coach’s question. Medicine’s “beautiful idea” is that we should test all hypotheses and beliefs using the kind of tests that are reliable for determining the truth. Instead of going by tradition, authority, theory, common sense, or personal experience, we now have effective tools to find out for sure whether a treatment really works. (more…)
Science-based medicine is, among other things, a tool. Science helps us sequester our biases so that we may better understand reality. Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools. Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).
Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts. But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas. Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict. They can also arise when we as physicians are constrained in our actions by outside forces.
On SBM we have documented the many and various ways that science is abused in the pursuit of health (or making money from those who are pursuing health). One such method is to take a new, but reasonable, scientific hypothesis and run with it, long past the current state of the evidence. We see this with the many bogus stem cell therapy clinics that are popping up in parts of the world with lax regulation.
This type of medical pseudoscience is particularly challenging to deal with, because there is a scientific paper trail that seems to support many of the claims of proponents. The claims themselves may have significant plausibility, and parts of the claims may in fact be true. Efforts to educate the public about such treatments are frustrated by the mainstream media’s lazy tendency to discuss every study as if it were the definitive last word on a topic, and to site individual experts as if they represent the consensus of scientific opinion.
Recent claims made for low dose naltrexone (LDN) fit nicely into this model – a medical intervention with interesting research, but in a preliminary phase that does not justify clinical use. And yet proponents talk about it as if it is a medical revolution.
In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1
Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”
The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.
In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3
Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4
A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6
There is a trend in the media when presenting a contentious topic to provide balance. For topics not founded upon objective facts this serves the media well; provide both sides of the argument, and let the viewer decide. The problem is that not every issue is evenly balanced, particularly in science. Covering the discovery of a new extra-solar planet by giving equal airtime to astronomers and astrologers, for example, would be the height of absurdity, yet this is precisely how the media approaches scientific topics with frightening regularity. You need look no further than the coverage of evolution, or 2012, or global climate change (that list should derail the comments nicely) for excellent examples of the same type of false balance in mainstream media outlets.
It was with trepidation, then, that I waited to see how PBS’s Frontline handled the topic of vaccination. I was pleasantly surprised. “The Vaccine War” introduced the most common concerns expressed about vaccination, and then presented the evidence addressing each concern in turn clearly and concisely. It gave airtime to some rather prominent anti-vaccine personalities, but the bulk of the program was dedicated to the data, the science, the evidence, and where answers are available it did not hesitate to present them baldly and clearly. “The Vaccine War” was not a comprehensive review of every perspective, every theory, every vaccine and study, but it did provide a fair discussion balanced by the science.
My first clue that Frontline had acquitted itself well was when Dr. Jay Gordon, pediatrician to Jenny McCarthy’s son, tweeted his opinion of the show:
PBS show about vaccines. Don’t bother to watch it.” (more…)
The American Society of Bariatric Physicians recently invited me to speak at their continuing medical education (CME) conference on obesity in Seattle. They got my name from Stephen Barrett of Quackwatch and asked if I could speak about questionable weight loss treatments like HGH, MIC (methionine, inositol and choline), and the HCG Diet. I seized the opportunity to discuss how to evaluate any medical claim, with examples from alternative medicine as well as from weight loss. My title was “Questionable Evidence for Questionable Treatments.” I talked about some of the things that can go wrong in clinical trials and why simply finding reports of positive randomized controlled trials (RCT) is not enough. I advocated rigorously science-based medicine and recommended the SBM website.
Several people came up afterwards to express their thanks and their agreement, but some of the questions from the audience were rather hostile. One man said he was a military doctor and he was using and teaching acupuncture (which I had criticized as a bad example of “tooth fairy science” in my talk). I asked for his opinion of battlefield acupuncture and he just said “No comment.” A couple of people thought science wasn’t enough and thought it was okay to prescribe questionable treatments when there was no proven effective treatment. I responded that I had no objection as long as the patient was told the facts and not given the false impression that the questionable treatment had been tested and shown to work.
I was glad for the chance to meet some of the ASBP members. I had never met a bariatric physician and was interested to learn about their practices and philosophies. I had never really thought about the fact that most obese patients had associated diseases like hypertension and diabetes, so their overall management could be very complex. I attended the whole obesity course: some of what I heard was educational, some of it was questionable, and some of it was frankly disturbing. (more…)