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Fake diseases, false compassion

Hi,  everybody!  I’m PalMD (although my byline says differently), and you may remember me from such other blogs as WhiteCoat Underground and denialism. The folks around here were kind enough to give me a regular gig dispensing my brand of medical information transfer, and I’m going to start out with a basic question: what is a disease?

Human beings have some pretty powerful pattern-recognition software—so powerful that it can over-perceive patterns, sometimes causing us to confuse randomness for order.  This impacts all aspects of human thought, including medicine.

In the realm of medicine, we define disease as alterations in physiology, anatomy, biochemistry, etc. that causes significant discomfort, disability, or increased risk for same.  OK, really, I sort of cobbled that together, but you get the idea — a disease is a definable alteration in normal function.  A corollary to this is that to define a disease, we must know something about what is normal (a discussion for another time).  A related term is syndrome, which we usually define as  “a set of signs or a series of events occurring together that often point to a single disease or condition as the cause.”  What this effectively means is that we use the word “syndrome” to indicate a set of abnormal findings without a clear cause, and “disease” to indicate the abnormal findings with a putative cause.

(All this verbosity is leading somewhere—I promise.)

“Syndrome” is sometimes a useful place-holder term for a nascent disease.  Sometimes, however, a set of signs and symptoms is simply coincidence that we erroneously recognize as a pattern.

In popular culture there’s a lot of talk about “overmedicalization”, that is, calling things abnormal that are simply slight variations in the wide range of human health.   You’ll find people who argue that treating ADHD with medications is tantamount to abuse (and lost in the hysteria is the real possibility that we are over-medicating some kids). You’ll also find groups that argue that deafness or autism are simply “other”, but not “abnormal” as such.  This, of course, is wrong.  While a deaf or autistic person is just as valuable as a “normal”, and may have just as much to contribute to society, they are very far from normal human health.

And now you have the proper background to approach the problem of fake diseases.

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Posted in: Science and Medicine

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Cholesterol Skeptics Strike Again

I’m really tired of arguing about cholesterol, but I feel obliged to stand up once more to defend science-based medicine from unfair calumny.

Lewis Jones’s article “Cholesterol-shmesterol” in Skeptical Briefs (December 2007) included errors and misconceptions about cholesterol. It was a re-hash of the same kind of misinformation that is being spread by The International Network of Cholesterol Skeptics (THINCS) and that I addressed in an earlier post. THINCS would like us to believe that cholesterol has nothing to do with heart disease; that low cholesterol is harmful and high cholesterol is beneficial; and they demonize statins, even falsely claiming that they cause cancer.

I answered Jones with my own article “Cholesterol Clarifications” in the June 2008 issue of Skeptical Briefs. I said I agreed that cholesterol does not “cause” heart disease, that low-fat and low-cholesterol diets have been promoted way beyond the evidence and that statins are being over-prescribed. The public has a lot of misconceptions, but thoughtful science-based doctors agree that the evidence shows: (more…)

Posted in: Nutrition, Pharmaceuticals, Science and Medicine

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Nobel for HIV Discoverers

The Nobel Prize in Medicine was awarded this week to two French virologists, Françoise Barré-Sinoussi and Luc A. Montagnier, for discovering the AIDS causing virus, the Human Immunodeficiency Virus (HIV). They will share half the prize of 1.4 million dollars, the other half going to three Dr. Harald zur Hausen for discovering the human papilloma virus and its relation to cervical cancer.

The prize comes 25 years after Barré-Sinoussi and Montagnier, working at the Pasteur Institute in Paris, published their paper identifying what was later called HIV. The last quarter of a century has proven their discovery to be a triumph of science-based medicine. The Nobel committee is correct, in my opinion, in waiting such long periods of time before granting such recognition. It reflects that fact that, even in a fast-paced arena of science such as medicine, it takes time for the meticulous process of science to work itself out. It takes decades to garner the perspective necessary to tell the difference between a crucial breakthrough and a false lead.

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A “Shruggie” Awakening – One Doctor’s Journey Toward Scientific Enlightenment

ED. NOTE: Circumstances have dictated an unexpected change of plans; so you’re in for a treat. Dr. Val Jones is starting two days earlier than previously announced. Beginning next week, her posts will appear regularly on Thursday mornings. Harriet Hall’s post scheduled for today will appear on Thursday this week. Be ready; it’ll be the return of the cholesterol “skeptics.” Now, Dr. Val…

Greetings, everyone. I am a proud new member of the Science Based Medicine blogging team, and have committed to one post each Thursday morning. As part of my “grand entrance” onto the skeptical blogging stage, I was hoping to introduce a new noun into our lexicon. I’ve asked permission from Steve Novella and David Gorski, and they’ve given me a wink and a nod, so here goes:

Shruggie (noun): a person who doesn’t care about the science versus pseudoscience debate. When presented with descriptions of exaggerated or fraudulent health claims or practices, their response is to shrug. Shruggies are fairly inert, they will not argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general. They simply aren’t all that interested in the discussion, and are somewhat puzzled by those who are.

I’m sure you’ve encountered shruggies in your daily life. They are quite common – in fact, they may actually be in the majority among healthcare professionals. And I have a confession to make — I used to be one myself.

If you’ll indulge me, I’d like to tell you the story of how I was awakened from my unhealthy indifference toward pseudoscience. (more…)

Posted in: General, Science and Medicine, Science and the Media

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Pitfalls in Regulating Physicians. Part 2: The Games Scoundrels Play

A Few Things that No Doctor Should Do

When a physician is accused of DUI, “substance abuse,” being too loose with narcotic prescriptions, throwing scalpels in the OR, or diddling patients, the response of a state medical board† tends to be swift and definitive. Shoot first, ask questions later. After all, the first responsibility of the board is to the public’s safety, not to preserving the physician’s livelihood. One might therefore expect that a physician accused of using dangerous, substandard treatments would face a similar predicament. As you’ve undoubtedly guessed, such is not the case.

Here on Science-Based Medicine I’ve discussed at least 4 risky and implausible treatments: Laetrile, the “Gonzalez Regimen,” Na2EDTA “chelation therapy,” and intravenous hydrogen peroxide. Any medical board worth its salt ought to recognize each of those as dangerous and sub-standard, and therefore ought quickly to impose serious disciplinary measures upon any licensed physician found using them. Sometimes that is the case, but all too often it isn’t.

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

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Cognitive Dissonance at the New York Times

Humans have the very odd ability to hold contradictory, even mutually exclusive, ideas in their brains at the same time. There are two basic processes at work to make this possible. The first is compartmentalization – the ideas are simply kept separate. They are trains on different tracks that never cross. We can switch from to the other, but they never crash into each other.

When contradictory ideas do come into conflict this causes what psychologists call “cognitive dissonance.” We then typically will relieve cognitive dissonance, which is an unpleasant state, through the second process – rationalization. We happily make up reasons why the two conflicting ideas actually don’t conflict at all. People are generally good at rationalization. It is a supreme intellectual irony that greater intelligence often leads to a greater ability to rationalize with both complexity and subtlety, and therefore a greater capacity to maintain contradictory beliefs.

In fact the demarcation between science and pseudoscience is often determined by the difference between sound scientific reasoning and sophisticated rationalization.

While cognitive dissonance refers to a process that takes place within a single mind, it is a good metaphor for the contradictory impulses of groups of people, like cultures or institutions. I could not help but to invoke this metaphor when reading two editorials published in the same day in the New York Times.

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Posted in: Clinical Trials, Science and Medicine

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A Budget of Anecdotes

Anecdotal evidence. An oxymoron? Or a valid approach to understanding data?

The problem is there are different kinds of anecdotes, used for different purposes, but the purpose of anecdotes is rarely if ever defined explicitly. Anecdotes are used for one purpose by one speaker/writer but interpreted in a different context by the listener/reader. People love anecdotes, especially if the anecdotes are about them or their beliefs. Anecdotes are how patients transmit the particulars of their disease to their health care providers. The medical history, as taken from the patient, is an extended anecdote, from which the particulars of the disease have to be extracted. Anecdotes are how physicians explain disease and treatments. Anecdotes are a tool with which teachers instruct their students. Anecdotes are how CAM proponents validate their particular system, and how skeptics invalidate them.

Anecdotes are useful tools for presenting yourself and your ideas. The convention season is over and is was striking how the candidates attempted to win over voters with anecdotes about their lives rather than the particulars of their policies. Using variations of ‘anecdote’ as a pubmed search term yields little of substance. The predominant theme on medline is to contrast anecdotes with evidence, always to the detriment of anecdotes. Anecdotes have power to influence far greater than evidence.

On The Skeptics Guide to the Universe #165 there was an interview with Ben Goldacre, who noted that there was the popular misbelief that the MMR vaccine was a cause of autism. The belief waned not when the voluminous data on the safety and lack of association with autism and the MMR was released, but when it was discovered that the primary proponent of the MMR/autism link received large sums of money to testify about that MMR/autism link. It was the anecdote about his conflict of interest that invalidated the idea, not the science.

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FDA approval of drugs and transparency in clinical trial results

ResearchBlogging.orgNote: The reason that I am posting today rather than my usual Monday slot is because the article I discuss here was embargoed until last night. Consequently, I asked Harriet if she would trade days with me this week, and she was kind enough to do so.

One thing that science relies on almost absolutely is transparency. Because one of the most important aspects of science is the testing of new results by other investigators to see if they hold up, the diligent recording of scientific results is critical, but even more important is the publication of results. Indeed, the most important peer review is not the peer review that occurs before publication. After all, that peer review usually consists of an editor and anywhere from one to four peer reviewers on average. Most articles that I have published were reviewed by two or three reviewers. No, the most important peer review is what occurs after a scientist’s results are published. Then, all interested scientists in the field who read the article can look for any weakness in methodology, data analysis, or interpretations. They can also attempt to replicate it, usually as a prelude to trying to build on it.

Arguably nowhere is this transparency quite as critical as in the world of clinical trials. The reason is that medications are approved on the basis of these trials; physicians choose treatments; and different medications become accepted as the standard of care. Physicians rely on these trials, as do regulatory bodies. Moreover, there is also the issue of publication bias. It is known that “positive” trials, trials in which the study medication or treatment is found to be either efficacious compared to a placebo or more efficacious than the older drug or treatment it is to replace, are more likely to be published. That is why, more and more, steps are being taken to assure that all clinical trial results are made publicly available. For example, federal law requires that all federally-funded clinical trials be registered at ClinicalTrials.gov at their inception, and peer-reviewed journals will not publish the results of a clinical trial if it hasn’t been registered there. Also, beginning September 27, 2008, the US Food and Drug Administration Amendments Act of 2007 (FDAAA) will require that clinical trials results be made publicly available on the Internet through an expanded “registry and results data bank,” described thusly. Under FDAAA, enrollment and outcomes data from trials of drugs, biologics, and devices (excluding phase I trials) must appear in an open repository associated with the trial’s registration, generally within a year of the trial’s completion, whether or not these results have been published. Although there are some practical issues over this law, for example determining how much information can be disseminated this way without constituting prior publication, which is normally a reason to disqualify a manuscript from publication.
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Posted in: Clinical Trials, Politics and Regulation, Science and Medicine

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Pitfalls in Regulating Physicians. Part 1

I had intended today’s posting to be a summary of a real case faced by a state medical board. It is a case of licensed physicians treating patients with a substandard, dangerous, and unequivocally illegal method. My intent was to use it as an illustration of how difficult it can be for medical boards to discipline such practitioners, even when the treatment involved is obviously, blatantly bad. Only yesterday, I was informed by the pertinent board that because this case has yet to be resolved, I may not discuss it. So be it: I’ll save the specifics for another time. Instead I’ll offer a general example of a dubious treatment as a prelude to Part 2 of this series,† which will attempt to discover some of the reasons that medical boards might, under such circumstances, be ineffectual.

Intravenous Hydrogen Peroxide

Hydrogen peroxide (H2O2) is a highly reactive compound that is caustic to living tissues. It spontaneously decomposes to water and oxygen, a reaction that is greatly accelerated in the presence of peroxidases (mainly catalase), which are ubiquitous in human blood and tissues. It has been used as a disinfectant for superficial skin wounds and in the mouth, and also for fabric and medical equipment. It has been used as a bleaching agent for teeth and hair. When used as an irrigant in surgical fields, in other large wounds, or consumed in any form (including intravenously), however, it has resulted in predictable, catastrophic complications: arterial and venous gas emboli, emphysema, respiratory arrest, strokes, multiple cerebral infarcts, seizures, colonic ulcers, intestinal gangrene, acute hemolytic crises, shock, cardiac arrest, and death.[1-7]

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Posted in: Health Fraud, Politics and Regulation, Science and Medicine

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Trouble in the Library

Anyone attempting a systematic review of the medical literature on sectarian medical systems (“CAM”) starts with a serious disability; the literature itself. The National Library of Medicine still lists abstracts for over 30 “alternative medicine” journals, but more concerning, is my estimate that half or more of the articles on sectarian systems published in standard medical journals range from the erroneous to the fraudulent. If one is conscientious, honest, and wants to produce a realistic review of sectarian systems that reflects reality, one cannot do it.

The problem spills over and beyond boundaries of medical research and practice. Often neglected is a massive literature of the allied professions – nursing, psychology, social work, and others. There are data bases for these professions as well (CINAL, EMBASE, CISCOM, Psychlit.) So not only do physicians and patients deal with a disabled medical literature, other professions also face the same problem in theirs. Little wonder that the “CAM” – “Integrative” movement has been tolerated instead of rejected in the community of health and allied health.

The editor of Research on Social Work Practice sent me a copy of a review of intercessory prayer published in his journal (Hodge DR, A Systematic Review of the Empirical Literature on Intercessory Prayer. Res Soc Work Pract 2007;17(2):174-186.) Intercessory prayer is the prayer offered by others for an ill person, usually not in the person‘s presence. Prayer is usually performed on a regular daily schedule by groups of prayers of one or more religious denominations.

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