Those who cannot remember the past are condemned to repeat it.
– George Santayana
Science-based medicine is more than a set of methods or certain philosophy of medicine – it is an entire approach to what should be the core questions for any interventionist profession: is it real and does it work?
These are often deceptively difficult questions to answer. Fortunately we have at least a century of experience applying systematic methods to answering these questions within the context of medicine. This is a wealth of history from which to learn, full of cautionary tales and enlightening examples.
However, as Winston Churchill lamented, we tend to forget the lessons of the past leading to, “…the most thoughtless of ages. Every day headlines and short views.”
Part of the mission of science-based medicine (and skepticism in general) is to remember the lessons of the past as they relate to science and pseudoscience, and to constantly remind the public and our colleagues of these lessons.
“Postnatal depression blood test breakthrough” proclaimed the headline. The UK Guardian article then declared:
British doctors reveal ‘extremely important’ research that could help tens of thousands of women at risk.
Here it comes. Readers were going to be fed a press release generated by the study’s authors and forwarded undigested by the media but disguised as writings of a journalist. If only the journo had asked someone in the know about the likelihood of a single study yielding such breakthrough blood test for risk of depression in new mothers.
The story echoed earlier churnalism from Sky News, British satellite television news service:
There is evidence that if you can identify women at risk early you could treat early or introduce measures to prevent or stop the process of the disease.
A study of 200 pregnant women, published in the Journal of Psychiatric Research, found two molecular “signatures” in the genes that increased the risk of postnatal depression by up to five times. One in seven new mothers suffer from depression.
“For every complex problem there is an answer that is clear, simple, and wrong.”
-H. L. Mencken
This approach is not endorsed by the American Academy of Pediatrics.
As I sit in an apartment full of unpacked boxes and grumpy children, only a few days removed from driving 1,600 miles to a 3rd floor walk-up and a better life just outside of Boston, I find the task of writing a post somewhat daunting. But I must admit that this new town is not without the potential for inspiring future musings. In fact, I find myself surrounded by irregular medicine of all shapes, sizes and dilutions.
Next door is a chiropractor who cures Tourette’s syndrome and, according to the pamphlet available outside the clinic entrance, only uses the in-house x-ray machine on select patients who truly need it. A few buildings down from me is an acupuncturist that treats athletic injuries with ear acupuncture and Kinesio-tape while liberally sprinkling references to his practice of “sports medicine” and “orthopedics” throughout the clinic’s promotional material. But at least I was reassured that acupuncture is completely harmless because it is a natural medicine. Finally, a block further down the road, completing my welcome committee of woo is a clinic that uses homeopathy to treat just about every real and fictional condition under the sun. I checked out their website and it’s a good thing that the walls are well insulated or my neighbors would have surely been forced to ignore the sound of my forehead pounding a wooden desk like a flagellant monk hoping for divine intervention.
Yoga is an increasingly popular form of exercise in the US. According to Yoga Journal more than 20 million Americans use yoga as their form of exercise. As a form of exercise yoga is fairly straightforward, involving stretching and holding poses that strengthen muscles. It also carries the generic benefits of any exercise in terms of calorie-burning and cardiovascular health.
Yoga, however, is more than exercise – it also comes with a “spiritual” angle. The term itself refers to a number of practices originating in ancient India meant to strength mind, body, and spirit. For this reason it has become a popular target for marketing the latest health pseudoscience. You will be hard pressed, in fact, to find a yoga class that does not incorporate some degree of outright woo, the only question really is not if, but how much. This is unfortunate because yoga may be an effective alternative for low-impact exercise.
There is some evidence that yoga, for example, is effective in relieving low back pain, although it may not be more effective than usual care. There is a lack of quality studies comparing yoga to other forms of exercise, and so we may just be seeing the generic benefits of exercise. Still, if the classes are fun and they keep people motivated to continue their exercise regimen, that is useful.
Yoga, therefore, fits into a more general phenomenon of marketing a specific intervention as if it has specific benefits, when in fact it only has generic benefits. For example, there are many studies showing that transcendental meditation is effective for lowering blood pressure. However, studies generally compare TM to no intervention, not to other forms of relaxation. The parsimonious interpretation is that TM confers the generic benefits of relaxation, but there is no evidence to suggest it confers any specific benefits.
I do not worry much about being dead although the process of getting there gives me pause. I have witnessed a few unpleasant deaths and I hope to never see the Grim Reaper coming my way.
One of the more awful and pointless deaths occurred early in my career. I had a patient with hepatitis C and cirrhosis. He had low platelets, low clotting factors (many of which are made by the liver), a previously undiagnosed clotting disorder, and a mouth full of bad teeth that were removed all at once when he acquired dental insurance.
Then he started to ooze blood from his extractions. An ooze that did not stop, it was a constant trickle of blood that would not clot. After several visits to his dentist he almost passed out and came to the emergency room. After 4 days he had bled out about half his blood volume, his haemoglobin had gone from 12 to 6. At this point we geared up for transfusions of red cells and clotting factors and he let us know that he was a Jehovah’s Witness and, no thank you, he would not accept any blood or blood products.
For the next week he continued to ooze despite all the interventions we could come up with to stop the bleeding and he remained adamant in his refusal of transfusions of any kind, despite the risk of death. At about a hemoglobin of 2 he had a large stroke and severe muscle pain from ischemia. At 1 he had a large heart attack and died. If you could rank deaths as pointless and horrific, this would be in my top 10. And I was struck at how nonplussed the family was, accepting this completely preventable death matter-of-factly. (more…)
The internet is a fabulous resource of information. It is one of those technological innovations for which you soon can no longer imagine how you lived without it. I certainly cannot imagine a project like science-based medicine prior to the web.
The web, however, is also a tremendous source of misinformation, opinion, and ideology. Also the volume of information, good and bad, can be overwhelming. We therefore are frequently asked the meta-question of how we conduct our research into specific topics, or how can the average layperson do their own research online.
Efficiently and effectively researching a complex topic is complex. It is a skill that needs to be developed, and it is especially difficult without having detailed knowledge of the specific topic ahead of time. Therefore there is no simple answer to this question, but I can offer some tips.
There are two main resources I use when searching a topic, Google and PubMed. They each have their strengths and weaknesses. For the average user, Google (or whichever general search engine you prefer) is likely going to be your first stop.
Mrs. Teasdale: Your Excellency, I thought you’d left!
Chicolini: Oh no, I no leave.
Mrs. Teasdale: But I saw you with my own eyes!
Chicolini: Well, who you gonna believe, me or your own eyes?
Duck Soup. Funniest movie ever.
If I could choose a super power, it would be neither flight nor invisibility, but the ability, like Triad, to separate into multiple people so I could accomplish more. I find that my multiple personality disorder is not all that efficient at getting things done. The Goth cowgirl? Lazy.
So sometimes I have to cut corners. As this post goes live I am at TAM helping with panel discussions and workshops and the only way I can get a post up is to cannibalize my lecture. Dr. Gorski will not let me post the slides and be done with it; those managing editors can be so unreasonable. Full sentences. Proper spelling. Good grammar. Sheesh. Some people.
The topic of my presentation is the cognitive errors that lead people to believe in nonsense and is, or was, a brief tour of the flawed ways in which we think and how the brain allows everyone to be under the false impression that fictions are real. (more…)
It’s summertime, and the living is easy. Forget the solstice. For most of North America, this week is the real start of summer – July 1 in Canada, and July 4 in the USA. Vacation time means breaking out of that those usual routines of work and school. I’m amazed after a few weeks of vacation how much sleep my body will accept if given the opportunity, where it will climb from six to nine hours a night within a week. I try not to change my kids’ habits too much, and one area I’m fairly disciplined with is maintaining a predictable sleep/wake cycle, even when they’re on vacation. I’ve learned, mainly through trial and error, that I suffer the consequences when my own kids don’t get enough sleep, or when their sleep cycle is thrown off. It wasn’t always like this. I remember a period of what felt like years when I had to crawl out of my child’s bedroom on my hands and knees so as to not disturb a child who simply would not fall asleep. And when it finally, mercifully, occurred, it would be a brief respite before the cycle began again. The sleepless nights left us all cranky and exhausted. Admittedly I was fortunate, either due to my successful parenting (but more likely mean reversion) and my kids are pretty good sleepers now. I’m reminded of my good fortune when I speak with exhausted and frustrated parents who have children that cannot sleep and are worried about the causes and consequences of persistent insomnia. As a pharmacist I’m regularly asked about insomnia for both kids and adults as there are a number of over-the-counter products available, and many consumers are understandably apprehensive about seeking out prescription products. Tell someone there’s “natural supplement” for sleep and there’s usually a lot of interest. That’s what I’ve seen with melatonin, a hormone that is sold without a prescription in Canada, the United States, and other countries. It is widely perceived as safe and alternative health purveyors like naturopaths, and even some health professionals, may recommend it for treating sleeping problems in both adults and children. Beyond sleeping, some believe melatonin is a wonder drug with efficacy for diseases ranging from chronic fatigue to cancer to irritable bowel. (more…)
We are not alone. Walt Whitman didn’t know how right he was when he said, “I contain multitudes.” The microbes on and in our bodies outnumber our own cells 10:1. Perhaps that creeps you out. Perhaps that makes you curious to know just who all these billions of creatures are that are using your body for a home and a transportation device.
For just $89 you can learn what’s in your gut, nose, mouth, skin, genitals…or sample anything!
The offer comes from uBiome, a “citizen science startup” that has scientific goals somewhere down the line, but for the moment is happy to just provide a personal service, to sequence your microbiome and tell you how you compare to others. The current utility of this offering is questionable. It’s just not ready for prime time. (more…)
Every so often, the reality of trying to maintain a career in science-based medicine interferes with the fun that is writing for this blog. Basically, what happened is that I spent the entire weekend working on three different grant applications and, by the time Sunday night rolled around, I was too exhausted to write what I had originally planned on writing. Fortunately, one advantage of having been blogging so long and also having blogged under a pseudonym over at my not-so-super-secret other blog is that there’s a lot of material which is pretty damned good, if I do say so myself, that I can draw on for just these situations. Even better, it’s old enough that it’s unlikely that most of you have actually come across it before, which makes it new to you (well, at least most of you). As a special bonus, the jumping off point was a post by an occasional contributor to this blog, Peter Lipson. Actually, I wish Peter would contribute more regularly, but he’s too busy moving on to bigger things at Forbes.
This time around, I’m half-recycling, half-revising a post that was a bit more navel-gazing than usual. However, as the only surgeon on SBM I think it’s actually useful every now and then to discuss the trials and tribulations of practicing science-based surgery. It began when Peter wrote an excellent meditation on a topic that’s always been a difficult issue for me to face as a surgeon, namely how one balances confidence in one’s ability with humility in the face of disease and uncertain science. He started with a spot-on observation:
The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge.