A really snazzy new invention allows doctors to see inside their patients’ hearts as never before: the CT angiogram. It produces gorgeous 3-D video images of the beating heart in action. It allows us to see the blood flow through the heart’s chambers and it shows any plaque in the coronary arteries. Cardiologists are understandably excited about this new tool. Too excited. Some of them are using it indiscriminately and are getting half their income from using it.
On June 29, 2008 the New York Times published an excellent article entitled “Weighing the Costs of a CT Scan’s Look Inside the Heart.” A commenter on this blog has quoted from that article to criticize scientific medicine, and it brings up some important points that deserve a closer look.
With any new technology, the important question is whether it really improves patient outcome or just increases the cost of healthcare. These scans are a huge improvement for visualizing the heart. But are they any better than older diagnostic methods at actually preventing heart attacks or prolonging life? We don’t know yet. Will they cause harm through over-diagnosis? We don’t know yet. Will they cause radiation-induced cancers? We think they might. What’s the risk/benefit ratio? We don’t know yet.
Oprah thinks she knows. She’s urging her viewers to get tested. But she may not be the best source of medical advice. (more…)
King Arthur: Now stand aside, worthy adversary.
Black Knight: ‘Tis but a scratch.
King Arthur: A scratch? Your arm’s off.
Black Knight: No it isn’t.
King Arthur: What’s that, then?
Black Knight: [after a pause] I’ve had worse.
King Arthur: You liar.
Black Knight: Come on ya pansy.King Arthur: [after Arthur's cut off both of the Black Knight's arms] Look, you stupid Bastard. You’ve got no arms left.
Black Knight: Yes I have.
King Arthur: Look!
Black Knight: It’s just a flesh wound.Monty Python and the Holy Grail
I am, I think, in a minority on this blog, in that I do not think there is a placebo effect. Period. None. Zip. Zero. Nada. Zilch.
For analysis purposes, I divide the lack of placebo effect into outcomes that do not occur with objective measurement and those that do not occur with subjective measurement.
Why the dichotomy? Those studies where there have been an active treatment, a placebo treatment and an observation group, have demonstrated no difference between observation and placebo (1). To summarize from the conclusion of the compelling NEJM review:
“We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.”
Savvy consumers are familiar with the classic scam of the “bait and switch” – in practice if not the term itself. My wife and I ran across it when we were shopping for our first car. We needed a bargain and so we were attracted to the ads that promised a new Colt for only $9,000 (that’s the bait). Of course when we got to the dealership they were all out of Colts with the configuration advertised, but they had plenty of others that had different options that cost several thousand dollars more (that’s the switch).
It’s a basic and very successful form of deception, and so even though there are laws against such practices it is impossible to eliminate in all its various and more subtle forms. It even permeates scientific, political, and other intellectual endeavors – anytime a more palatable idea or claim is put forward to represent the less acceptable truth.
Science, however, requires transparent honesty to function properly, and therefore scientific practitioners must vigilantly guard against the cognitive bait and switch. Generic intellectual virtues incorporate this vigilance – they include the need to unambiguously define terms, to make claims as specific and operational as possible, and the use of valid logic. Beware of any claims that subtly violate these rules because they are probably setting you up for a bait and switch.
The purveyors of unscientific medical claims have become as expert at this classic deception as the slickest used-car salesman – in fact they have left the hawkers of dubious transportation in the dust.
Dr. Sampson’s droll post on Thursday written from the point of view of an advocate of unscientific “alternative” medicine modalites (these days known as “complementary and alternative medicine”–abbreviated “CAM”–or “integrative” medicine), coupled with Dr. Atwood’s most recent contribution to his ongoing series on how the mish-mash of a little valid herbal medicine mixed with a whole lot of woo otherwise known as the “profession” of naturopathy is pushing for greater legal legitimacy, depressed me mightily. The posts depressed me because they are but more evidence of just how effective advocates of non-science-based medicine have been over the last several years at twisting the linguistic landscape to their advantage and winning. Indeed, I’ve written about this before on this very blog, including my (in)famous list of medical schools that have embraced CAM and my lament about a medical school that has even gone so far as to “integrate” so-called “integrative” medicine into every aspect of its curriculum from day one of the first year. These disheartening trends accompany and draw succor from the $120 million a year budget of that center of woo in the heart of the National Institutes of Health, the National Center for Complementary and Alternative Medicine, the equal amount of money coming yearly from, alas, the National Cancer Institute, and, of course, the financial clout of the Bravewell Collaborative.
Things are not looking good for science-based medicine in academia right now. I say this in particular because I just learned of a press release issued three weeks ago by Andrew Weil and his University of Arizona Program in Integrative Medicine that, as Emeril Lagasse would say, “Kicks it up a notch,” but not for the better.
The press release begins:
When politics and science collide, shenanigans are likely to ensue. Politics is often antithetical to science because the former is about persuasion and value judgments while the latter is about objectivity and transparency. Science cannot function properly under the yoke of political ideology.
The infiltration of unscientific and anti-scientific practices and ideas into mainstream medicine is primarily an act of politics and ideology trumping science. The latest example of this comes from the Department of Health and Human Services (HHS) who put out a press release on June 16th declaring that: “HHS Secretary and Chinese Minister of Health Sign Memorandum of Understanding on Traditional Chinese Medicine Research.” The press release states:
“Many Americans incorporate alternative medical practices into their personal health care and are interested in the potential of a variety of traditional Chinese medicine approaches,” Secretary Leavitt said. “This project will advance our understanding of when and how to appropriately integrate traditional Chinese medicine with Western medical approaches to improve the health of the American and Chinese people.”
This statement is so common among the political apologists for unscientific medicine that is has become almost a cliche. The first claim in Secretary Leavitt’s statement is that “Many Americans incorporate alternative medical practices into their personal health care…” This is misleading and irrelevant. The primary problem is with the use of the term “alternative medicine” without providing any kind of definition. This is a false category because the modalities that are generally included in so-called CAM do not necessarily have anything in common except for the fact that they lack adequate scientific justification to be considered part of mainstream medicine. That is, except for those treatments that CAM proponents sneak into this category to misleadingly inflate its apparent size and impact – like exercise, nutrition, physical therapy, etc. These modalities can be scientific (depending upon how they are applied) and have no place under the CAM umbrella.
Critics of “conventional” medicine delight in pointing out how much harm it causes. Carolyn Dean, Gary Null, and others have written extensively about “death by medicine.” A typical statement (from Mercola.com) says:
A definitive review and close reading of medical peer-review journals, and government health statistics shows that American medicine frequently causes more harm than good. The number of people having in-hospital, adverse drug reactions (ADR) to prescribed medicine is 2.2 million. Dr. Richard Besser, of the CDC, in 1995, said the number of unnecessary antibiotics prescribed annually for viral infections was 20 million. Dr. Besser, in 2003, now refers to tens of millions of unnecessary antibiotics. The number of unnecessary medical and surgical procedures performed annually is 7.5 million. The number of people exposed to unnecessary hospitalization annually is 8.9 million. The total number of iatrogenic deaths shown in the following table is 783,936. It’s evident that the American medical system is the leading cause of death and injury in the United States. The 2001 heart disease annual death rate is 699,697; the annual cancer death rate, 553,251.
To show what’s wrong with this reasoning, let’s substitute “food” for “medicine.” (more…)
I approach this week’s topic with a bit of trepidation, even though I’ve been meaning to discuss it ever since this blog started. Over the weekend, I decided I had put it off long enough.
Why, you might ask, would I approach this topic with trepidation? A reasonable question, and I will give what I hope to be a reasonable answer. For one thing, this topic forces me to drift to areas more political than I normally like and is likely to provoke some angry reactions. More importantly, though, I’m about to discuss a medical organization that is steeped in an utterly toxic brew of bad science and extreme ideology. So what? you might ask. Well, there are some fairly prominent physicians that belong to this organization, including Ron Paul, among others, and you never know who in my own place of employment or referral base might also belong. For all I know, one of my bosses might belong. I sincerely hope this isn’t the case (or if it is they just don’t know about the organization’s extreme views), but you never know, and what I’m about to write is going to be harsh indeed because articles from the journal published by this organization are often cited by cranks and pseudoscientists. Sometimes they even make their way into the mainstream press as though they were legitimate scientific studies. Make no mistake, though, when it comes to medical science, this organization deserves every harsh word that I am about to write because it is a major booster of antivaccinationism, HIV/AIDS denialism, and the now discredited hypothesis that abortion causes breast cancer, while on its pages it regularly attacks the very concept of evidence-based medicine and peer-review. That it is an organization of physicians is all the more appalling.
The group to which I refer is the Association of American Physicians and Surgeons (AAPS), and its journal is the Journal of American Physicians and Surgeons (abbreviated JPANDS, because “JAPS” has some rather obvious negative connotations). It is not an exaggeration to say that the AAPS, through its journal JPANDS, is waging a war on science- and evidence-based medicine in the name of its politics.
The “Safety of Naturopathic Treatment”
In their nationwide effort to convince lawmakers to pronounce them primary care physicians, “educated” naturopaths have repeatedly claimed that their “natural” treatments are “safer and gentler” than those offered by medical doctors. The Alliance Legislative Workbook, a website that for several years provided strategies and “talking points” for ND-activists seeking state licensure, made this assertion in 2001:
Malpractice insurance rates [for licensed NDs] are generally less than $4000.00 per year, indicating the safety of naturopathic treatment as assessed by insurance companies. Master Insurance Trust reports that of the naturopathic physicians for whom MIT provides liability insurance, there have been only four incidents reported to the company for follow-up. However, nothing has been paid in either settlements or judgements on any of these items. “While this pooling of physicians is much too small to base actuarial considerations, this claims experience is clearly superior.” (Jeffrey D. Brunken, Program Manager, MIT, Letter dated May 21, 1990.)
Jury Verdicts Northwest, a legal database which records court cases in Washington and Oregon, the area of the country with the largest number of naturopathic physicians, shows no judgments for malpractice against N.D.s since the database was started in 1983. One in five M.D.s is sued each year in the US (AMA).
Why is malpractice so much lower among naturopathic physicians?
Naturopathic methods are less likely to cause injury than orthodox methods. Prudent dietary and lifestyle changes, for instance, are unlikely to cause harm. Naturopathic physicians by philosophy and training use the least invasive means to treat and prevent disease. This results in less injury to patients. Naturopathic physicians also have excellent diagnostic and referral skills. There is no significant history of complaints against naturopathic physicians resulting from a missed diagnoses, the most common cause for suits in a general practice. From insurance data, it appears that naturopathic physicians as a group know the limits of their methods and refer patients to other practitioners or specialists when appropriate.
One of the criticisms of modern medicine is that doctors prescribe too many pills. That’s true. Patients and doctors sometimes get caught up in a mutual misunderstanding. The patient assumes that he needs a prescription, and the doctor assumes that the patient wants a prescription. But sometimes patients don’t either need or want a prescription.
I’ll use myself as an illustration. I get occasional episodes of funny, blurry spots in my visual field that gradually expand to a sparkling zigzag pattern and go away after 20 minutes. They are typical scintillating scotomas, the aura that precedes some migraines. I am lucky because I never get the headache. My doctor said we could try to prevent my symptoms with the same medications we use to prevent migraine, but there was no need to treat them from a medical standpoint. Nothing bad would happen if we didn’t treat. I told her I didn’t want them treated. They are a minor annoyance; I can carry on with my normal activities, even reading, throughout the episodes, and I have no desire to take pills with potential side effects and with the cost and the hassle of remembering when to take them.
If it had been a typical patient and a typical doctor, the sequence of events might have been very different. The patient might have been more frightened by the strange phenomenon than I was. (I thought the weird tricks my brain could play on me were fascinating and fun to watch, not scary.) The patient might have desperately wanted those threatening symptoms to go away without understanding how insignificant and non-threatening they really were. The doctor might have assumed the patient wanted them to go away. The pills might have been offered and accepted with little thought. (more…)
Several people have been sending me either links to this paper or even the paper itself:
Young HA, Geier DA, Geier MR. (2008). Thimerosal exposure in infants and neurodevelopmental disorders: An assessment of computerized medical records in the Vaccine Safety Datalink. J Neurol Sci. 2008 May 14 [Epub ahead of print]. (Full text here.)
A few have asked me whether I was planning on deconstructing this study, given that antivaccinationists have apparently been promoting it as “evidence” that it really, truly, and honestly was the mercury in vaccines after all that caused autism. In actuality, I really didn’t feel the need to bother to do a full deconstruction because a new blogger called EpiWonk did a three part take-down that eviscerated this latest bit of “science” from Geier père et fils so thoroughly and with a much greater knowledge of epidemiology than I could ever muster, that I saw no need. Add to that a four-part takedown on the Pathophilia blog, and there was really no need for me to write a detailed deconstruction of my own. Unfortunately, since this study appears to be rearing its ugly head again and again in the blogosphere, I think it’s worth directing you to these discussions. I had been meaning to to this anyway, but had gotten side-tracked by numerous other topics. To make up for my lapse, here we go:
- New Study on Thimerosal and Neurodevelopmental Disorders: I. Scientific Fraud or Just Playing with Data?
- New Study on Thimerosal and Neurodevelopmental Disorders: II. What Happened to Control for Confounding?
- New Study on Thimerosal and Neurodevelopmental Disorders: III. Group-Level Units of Analysis and the Ecological Fallacy
Meanwhile, the Pathophilia blog also has a multi-part deconstruction of the latest Geier study from a different viewpoint:
- IRB Approval of Geier Autism Study: Yes or No?
- I’ve Been Sucked Into the Thimerosal-Autism-Geier Vortex
- Young-Geier Autism Study: What the—? (Part 1)
- Young-Geier Autism Study: What the—? (Part 2)
- Young-Geier Autism Study: What the—? (Part 3)
- Young-Geier Autism Study: What the—? (Part 4)
Ow! That’s gonna leave a mark!
Enjoy! And the next time an antivaccinationist points to this particular study, send ‘em over to see EpiWonk and Pathophilia.