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Fighting Against Evidence

For the past 17 years Edge magazine has put an interesting question to a group of people they consider to be smart public intellectuals. This year’s question is: What Scientific Idea is Ready for Retirement? Several of the answers display, in my opinion, a hostility toward science itself. Two in particular aim their sights at science in medicine, the first by Dean Ornish, who takes issue with large randomized controlled clinical trials, and the second by Gary Klein, who has a beef with evidence-based medicine.

These responses do not come out of nowhere. The “alternative medicine” meme that has taken hold in the last few decades (a triumph of slick marketing over reason) is all about creating a double standard. There is regular medicine which needs to justify itself with rigorous science, and then there is alternative medicine, where the rules of evidence bend to the needs of the guru or snake oil salesperson.

We have been hearing arguments from alternative medicine proponents for years now for why the strict rules of science need to be relaxed or expanded. Andrew Weil has advocated for the use of “uncontrolled clinical observations,” (also known as anecdotes). David Katz advocates for a “more fluid concept of evidence.” Dr. Oz went as far as advocating outright medical relativism, saying. “You find the arguments that support your data, and it’s my fact versus your fact.”

Dean Ornish

I can now add Dean Ornish to the list of gurus who want to change the rules of evidence to suit their needs. He is the founder and president of the Preventive Medicine Research Institute, and a long-time advocate of alternative medicine.

His answer to the question of what concept needs to be ditched from science is the large randomized controlled trial. He writes:

It is a commonly held but erroneous belief that a larger study is always more rigorous or definitive than a smaller one, and a randomized controlled trial is always the gold standard . However, there is a growing awareness that size does not always matter and a randomized controlled trial may introduce its own biases. We need more creative experimental designs.

He then launches into a discussion of the potential weakness and biases inherent in doing large trials. His specific observations are mostly valid, it is the conclusions he draws that are suspect.

Ornish is partly committing the Nirvana fallacy, or making the perfect the enemy of the good. No scientific study is perfect. Large clinical trials are very difficult to run, and compromises are often made for practical reasons. There are limited resources, and when studying people you have to consider the inconvenience to the study subjects.

The goal is to design the best study possible, not necessarily the perfect study. Further, multiple studies are often necessary, making different compromises, so that the strengths and weakness of the various trials will complement each other. In the end we grind our way slowly to a reliable answer.

It is easy, however, to point at the limitations and conclude that science is hopeless (the nihilistic approach) or that anything goes (the alternative medicine approach).

Ornish is claiming that smaller studies can be more rigorous because you can dedicate more time and resources to each subject. Really large trials compromise by spending fewer resources on each subject.

But, Ornish glosses over the fact that with smaller studies you sacrifice statistical power. It is odd to argue that smaller studies are better, or that we should abandon the large clinical trial. A more reasonable conclusion is that, with each trial, we make the compromises that make the most sense.

In general studies are powered just enough to be able to demonstrate the anticipated or likely effect size. Overpowering a study is a bad idea, but so is underpowering a study.

Further, small detailed studies can be complementary to larger simpler trials. So Ornish is also making a false choice fallacy.

Ornish’s odd recommendations perhaps make sense in light of the example he presents:

That’s just what happened in the Women’s Health Initiative study, which followed nearly 49,000 middle-aged women for more than eight years.

However, the experimental group participants did not reduce their dietary fat as recommended—over 29 percent of their diet was comprised of fat, not the study’s goal of less than 20 percent.

It seems he is whining a bit about a large clinical trial that did not show the results he liked. It’s OK to point out the weaknesses in the trial (although I think Ornish protests too much). It’s a radical overreaction to recommend ditching large clinical trials.

Gary Klein

It’s rare to see a logical fallacy stated so overtly. Klein could not have crafted a better example of the Nirvana fallacy if he tried:

But we should only trust EBM if the science behind best practices is infallible and comprehensive, and that’s certainly not the case. Medical science is not infallible. Practitioners shouldn’t believe a published study just because it meets the criteria of randomized controlled trial design. Too many of these studies cannot be replicated. Sometimes the researcher got lucky and the experiments that failed to replicate the finding never got published or even submitted to a journal (the so-called publication bias). In rare cases the researcher has faked the results. Even when the results can be replicated they shouldn’t automatically be believed—conditions may have been set up in a way that misses the phenomenon of interest so a negative finding doesn’t necessarily rule out an effect.

Really – unless science is infallible and comprehensive, we should ditch it? Unless we have perfect knowledge of everything we should behave as if we know nothing?

This attitude is not new. It is common in the alternative world. It just usually isn’t stated so boldly.

Again, Klein points out legitimate problems with the institution of science in general, and evidence-based medicine in particular. Yes – there are biases, there are publication issues and failure to replicate. We spend a great deal of time on SBM pointing out and discussing all the various challenges to rigorous science.

Klein and others, however, want to throw the baby out with the bathwater – to ditch scientific evidence, rather than work toward improving it. All of the problems with science in medicine have potential solutions, and we are making progress.

Klein also falls for a very common myth about EBM:

EBM formulates best practices for general populations but practitioners treat individuals, and need to take individual differences into account.

Here he clearly demonstrates that he is not familiar with EBM (and therefore is not in a position to recommend its demise). EBM absolutely recognizes that evidence needs to be applied to individual patients, and that practitioners need to combine the best evidence with their own clinical experience and judgments. This is nothing but a false accusation based upon ignorance of EBM.

Klein goes further, saying that advances in surgical techniques do not need placebo controlled trials, therefore we don’t really need placebo-controlled studies.

He then concludes:

Worse, reliance on EBM can impede scientific progress. If hospitals and insurance companies mandate EBM, backed up by the threat of lawsuits if adverse outcomes are accompanied by any departure from best practices, physicians will become reluctant to try alternative treatment strategies that have not yet been evaluated using randomized controlled trials. Scientific advancement can become stifled if front-line physicians, who blend medical expertise with respect for research, are prevented from exploration and are discouraged from making discoveries.

This is a profoundly naïve position. Preventing practitioners from essentially experimenting in an uncontrolled way on their patients is a good thing. Best practices and the standard of care exist for a reason – and they are not only based upon the best evidence, but also expert analysis and experience.

Adherence to best practices strongly correlates with better outcomes. Over-reliance on experience and judgement in deciding on treatments can be counterproductive.

Further, experimenting needs to be done within a strict ethical and scientific framework. You cannot, for example, ditch the standard of care in order to go exploring.

Conclusion

Doing clinical science is complex and difficult. The institutions of science are also imperfect and need continuous revisions.

There is a disturbing tendency to point out the challenges of rigorous science as a means of arguing for the abandonment or loosening of the rules of science and evidence.

This very approach is a logical fallacy, however. Limitations with science do not imply that anything works or is better. Further, science may have challenges but it is still the best game in town. Its problems are not insurmountable – they can be improved or fixed.

For example, journals can give more space to publishing replications, human trials should be increasingly registered so that negative studies cannot be hidden, and we need to lower the “publish or perish” pressure in academia to help encourage fewer more rigorous trials and reduce the flood of preliminary studies that are unreliable.

There are plenty of thoughtful solutions. Abandoning rigorous evidence is not one of them.

Posted in: Clinical Trials, Science and Medicine

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79 thoughts on “Fighting Against Evidence

  1. goodnightirene says:

    Have these people heard of Ben Goldacre, MD? He has written an entire book on how to improve SBM by improving the ways studies are done and how they are published. But at no point does he recommend anything like these altie docs.

    http://en.wikipedia.org/wiki/Bad_Pharma

    What worries me is that so many doctors are buying this crap. I can no longer see someone and assume that he or she is reliably following SBM or even EBM. Actually my large regional medical/teaching institution is committed to best outcomes based on data, and is fairly good about making adjustments as formal recommendations occur, but that hasn’t stopped them opening a spa type of pseudo medicine “clinic” for “complementary” care. I guess one can thus be assured that the acupuncture needles will be sterile–though that won’t keep them out of your lung.

  2. Andrey Pavlov says:

    Ornish and Klein are clearly out of touch with reality and definitely out of touch with the cutting edge of clinical science research. You’d think that to actually write something like this you’d want to make really damned sure you actually knew what was going on at the forefront of clinical science since, after all, that is precisely what they are lambasting.

    Derek Angus out of UPitt gave a presentation at the American Thoracic Society conference almost a year ago wherein he outlined the problems with RCTs in general, specifically to critical care research, and posited new study designs that would allow us to take advantage of the clear and obvious benefits of RCTs but allow us to adapt them better to critical care research. A new study design that actually merges the best parts of small studies with the best parts of large studies in an iterative process to allow us to update trial designs, implementation, and collect large amounts of data without sacrificing statistical power.

    Perhaps Ornish and Klein should actually learn a bit about how medical science is actually advancing rather than bloviate from their own limited knowledge base whilst flinging logical fallacies at us.

    1. David Gorski says:

      It’s not just Ornish and Klein pulling a special pleading fallacy. It’s NCCAM as well:

      http://scienceblogs.com/insolence/2014/01/16/quoth-dean-ornish-and-nccam-your-randomized-clinical-trials-cant-study-my-cam/

      Still, the first time around I only saw Ornish’s piece, this time around I browsed the list of the articles of which scientific concepts should be retired and was shocked at how bad several of the articles were. Some are pretty good, but too many of them attack straw men. For example, there is a a psychologist named Athena Vouloumanos arguing that biology should abandon the concept that natural selection is the “only engine of evolution” because epigenetics means that Lamarck wasn’t as wrong as he has been portrayed. Never mind that no evolutionary biologist says that natural selection is the “only” engine of evolution; I don’t think that even Darwin said that. Natural selection is important, but it’s surely not the whole picture, and evolutionary biology has long acknowledged that. Never mind that epigenetics does not vindicate Lamarck. She’s also clearly into the woo a bit, because she repeated a common line that woo-meisters like to invoke when invoking epigenetics that epigenetics means that diet and exercise can be used to produce traits that might be passed on to our children. Ugh.

      It was even more awful a piece than Ornish’s piece on clinical trials.

      1. Sullivanthepoop says:

        Obviously natural selection is not the only engine. I have seen directed mutagenesis in a lab. It is hard to say how much epigenetic changes play a role in evolution because it is hard to know how and if the changes are kept over large periods of time and many generations. It seems like bacteria use epigenetics to change behavior among a population so it could definitely be important for the formation of multicellular organism. I am sure we will have a lot of new information about epigenetics and its role in evolution over the next couple decades.

      2. Andrey Pavlov says:

        Never mind that no evolutionary biologist says that natural selection is the “only” engine of evolution; I don’t think that even Darwin said that.

        Actually Darwin was indeed quite poignantly aware of this even when writing Origins. Which is why he wrote another book on sexual selection just a few years later.

        It is amazing to me how people who are otherwise highly educated, even in biological sciences, but are not evolutionary biologists can get things so wrong. They see a “gap” in what they think the theory says, somehow assume nobody else who actually does evo bio for a living has thought of it, and then writes it up like an indictment of the paradigm. Invariably they are not the first to think of it and it has already been addressed by legitimate evolutionary biologists.

    2. Dr Robert Peers MBBS [UniMelb] says:

      This whole discussion is, to me, very very sad. Dr Ornish is a very good man, who tried–many years ago–to see if a very low-fat, high fibre diet would help heart disease. I guess he got this diet from Nathan Pritikin. Ornish’s studies, available on PubMed, do seem to be quite scientific and impressive–better myocardial perfusion, some plaque regression on serial arteriography, rapid reversal of angina, and [he claims] up to 40% lower total cholesterol [although the Pritikin web site gives different figures for a similar diet/exercise regimen: total and LDL cholesterol down by 23%, triglycerides by 43%, insulin by over 40%, etc.].

      I admire and respect any medical school product who bravely sets out to do what he did–see if diet actually works. But now he has ruined everything, by putting his head on the chopping block, by questioning the value of RCTs.

      By the way, I was NOT aware, previously, that he practised “alternative medicine”–is that really true, does he sell or prescribe supplements, for example? Or do his critics actually regard his nutrition and exercise lifestyle focus as intrinsically alternative, just because it’s obviously alternative to what we learn in medical school [i.e. which drugs to give for diseases that we don't understand, and don't yet know how to prevent].

      It is true that he has long advocated meditation, and uses wooey words like love and spirituality–but if you see his Preventive Medicine Research Institute web site, and find his free paper there, titled “Statins and the Soul of Medicine”, you will soon see what he really means, in this stirring defence of his regimen. I think it was in the American J of Cardiology. He obviously deeply cares about his patients, and is painfully aware that if they are depressed or lonesome, or can find friends only in a cigarette packet, they will not stick to his regimen.

      This is a beautiful paper–I was very moved by his final sentence, after showing that his rigorous diet looks as good as statins, so why don’t we docs at least do BOTH? “I think that the soul of medicine is what is at stake here, and we should set out to reclaim it.”

      Think what this means: if we could just get most family physicians to study and recommend a Mediterranean diet [as good as his, and more edible--and at least twice as effective as statins (M de Lorgeril, 1994)], and have Every Doctor A Dietitian, our patients would soon see that we are now wearing two hats: a Medical Hat and a Health Hat.

      We could give a good opinion on both Health and Medicine, and the public might see that we do this better than naturopaths, and gradually return to the fold.

      Indeed, the scariest thing for CAM would be to face stiff competition from a new-style medical profession that routinely offers scientific diet, as well as–or even instead of–partial chemical remedies that have little impact on nutritional diseases. NOT to offer preventive diet may one day incur the wrath of medical licensing bodies, if they move to requiring docs to learn nutrition and apply it.

      As I see it, Dr Ornish knows his diet is good, but cannot figure out why large dietary intervention studies [low-fat etc.] can’t match his results. Then he falls into the trap of attacking the trial design, inviting a severe counter-attack. But look at this–he may be RIGHT about the {obvious] difficulty in getting 50,000 folks to follow instructions , in the Billion Dollar Iowa Women’s Study.

      Looks like those women lost little weight, and maybe didn’t eat much less saturated fat. But I would be more concerned that they did not increase their GRAIN, NUT and LEGUME intake. And here’s why:

      1. Long term fatty diet appears to increase heart risk by only 15% or so [sayeth Aussie researcher Prof Peter Clifton--but no ref given by him]. High dietary fat-to-oil ratio [low Poly/Sat Ratio] creates polyunsaturate-depleted cell membranes, directly causing insulin resistance [Dr M Tom Clandinin, Alberta, 1988] and also cellular oxidation and secondary low-grade inflammation [R C Moraes, about 2001]. The result will be diabetes years later, but with only mild vascular risk.

      2. Cochrane says low fat diet lowers vascular risk only about 15%–but that is actually half as good as statins, while Medi diet leaves statins far behind [up to 72% reduced risk], perhaps because it is low fat, PLUS has nuts and legumes in it. Nuts alone reduce heart risk by 50% in the Nurses’ Study at Harvard [W Willett].

      3. Backing up Clifton’s point, a 10-20 year observational study in London, published in 1977 by Prof Jerry Morris, showed very little vascular risk [over this 10-20 year time frame] from the fattier diets among the 340 middle-aged men–but a truly remarkable protective effect from eating cereal fibre [cereals and whole grain bread]. “The advantage of a diet high in cereal fibre cannot be explained.”

      4. So what the hell is in these grains and nuts [and in the Medi diet legumes, too], that does the trick? The vital ingredient may be the seed sugar myo-inositol [or just "inositol" also found in citrus fruits]. Cancer researcher Dr A M Shamsuddin, perhaps curious about the role of platelets in cancer metastasis, and knowing his inositol had numerous anti-cancer effects, has found that inositol significantly inhibits platelet aggregation–as good as aspirin? See PubMed.

      5. This totally unexpected anti-thrombotic effect of grains, nuts and legumes [these also have inositol] is precisely what we need to prevent the clot that kills you, in the coronary or brain artery. And unlike aspirin, it may continue to protect diabetics [aspirin loses its effect in diabetes].

      6. Given that fatty diet seems not to be a great risk factor for vascular disease, what DOES cause it [apart from smoking]? I study the foetal origins of adult disease, and long ago observed that fatty MATERNAL diet makes the offspring anxious [now confirmed in animal studies]. It’s a maternal cortisol epigenetic effect on the foetal brain.

      7. OK, so does anxiety cause heart disease? Friedmann though so in the 1970s, and there are studies that say yes–especially on panic disorder and sudden death. Google ANXIETY HEART to see this stuff. But an Australian review [S Bunker et al.] a few years ago says no–but says look out for depression [2-4 fold increase in risk].

      8. Emerging evidence [e.g. insulin resistance and inflammation in depression] suggests that anxiety precedes and underlies depression, and that what converts anxiety to depression is our old friend fatty diet. If this is the case, then we can expect inflammation-induced plaque instability and rupture, plus worse thrombotic tendency than one sees in pure anxiety.

      9. Very strict low fat diet–certainly in my experience–reverses depression rapidly, but leaves the underlying anxiety untouched. So if anxiety alone does not increase heart risk, why does such a diet NOT reduce risk by more than 15%? Maybe, by middle age, the depressed subject has a lot of atherosclerosis, which maintains risk despite a reduction in plaque inflammation and thrombotic risk.

      10. The above inositol may be needed, to really cut risk properly–and the typical amount in a Medi diet [about 1.5-2.0 gm/day] seems to do this.

      11. The same inositol has strategic anti-anxiety properties, by inhibiting serotonin 2A receptors [INOSITOL LEVINE]. A full effect needs about 5 gm/day, which requires supplement. This means both stress axis reduction and an end to sympathetic nerve overactivity–a lower pulse rate, increased heart rate variability, lower blood pressure, and less risk of fatal arrhythmia.

      12. Dr Ornish’s abundant grains, nuts and legumes –like in the Medi diet–provide enough inositol to get the strong Morris anti-platelet effect, even if anxiety is only partly reduced.

      13. That’s ENOUGH!!! By the way, two large intervention studies that did NOT reduce vascular risk [in high-risk diabetics] failed to exploit the known protective effects of grains and legumes, simply by leaving them OUT. The Anglo-Dutch-Danish ADDITION study used intensive drug treatment in newly screened diabetics, and completely failed. And the NIH’s huge LOOK Ahead study, aiming only at weight reduction in overweight diabetics, bombed out totally.

      14. Maybe they should have studied old stuff like Jerry Morris–or Nathan Pritikin?
      So let’s take it easy on Dr Ornish, re-focus on his superb early studies, show some RESPECT for A DOCTOR WHO IS A DIETITIAN, and whose pioneering work should be replicated in larger studies, preferably using the more yummy Medi diet. So be nice to him, and encourage him to come around on RCTs, and keep going, and prove his point in proper scientific fashion. He remains a hero to me.

      1. WilliamLawrenceUtridge says:

        The best of intentions does not a valid scientific conclusion make. Ornish may love and adore his patients, but that’s not the same thing as proof that his diet works.

        As for why patients choose statins (and rest assured, patients choose for the most part) over the huge time and effort to completely change how they eat – it’s easier. Simple as that. Diet and exercise are far more difficult, and require far more effort on a day-to-day basis, than a simple pill, irrespective it’s adverse effects.

        Doctors can’t follow their patients around all day, every day, to ensure they eat healthy and exercise. You don’t need a magical diet to improve your health – just a better one than what most North Americans have. But that’s hard work.

        1. Dr Robert Peers says:

          William, you will have to try harder. Why do I refer to improved myocardial perfusion, plaque regression, rapid remission of angina etc., in the very first paragraph of my post–do you have a suggestion for how Dr Ornish got these groundbreaking results, without statin drugs, solely by means of his good intentions?

          Does he sit there radiating energy fields, or smiling sweetly?

          If you can summon up the requisite level of attention and concentration, find and read his very good RCT, and other studies, via PubMed, by entering …Ornish d and diet heart study.

          If you are not familiar with PubMed, just Google his name, plus diet heart study. I suggest that you read, learn and inwardly digest published evidence, before making impulsive thoughtless comments on a science based web site.

          By the way, my own patients have no trouble following my low fat, inositol rich diet, and we rarely see a coronary or stroke at our clinic. Other patients, at non-preventive clinics, often give up their statins within a few months….see that Ornish paper for graph and ref…mostly because they don’t feel any benefit. My patents stick to the diet, because it reduces anxiety and depression quite markedly, and they notice much better libido, stamina and immunity. You don’t get that from statins. So there.

          1. Sawyer says:

            This entire discussion you’ve started is what is known as the “moving the goalposts” fallacy. Dr. Novella’s original critique of Ornish was that he gave a very sloppy answer about the value of randomized controlled trials. That’s what the rest of us are talking about. You launched off on a dozen different tangents and no one can possibly respond to all of them. Please stop committing this fallacy, as it never leads to a productive discussion.

            Maybe if the practitioners of pseudomedicine started employing some basic communication standards we’d take their stances on science more seriously.

          2. Mie says:

            Yes, what you don’t get from Ornish are properly designed trials with proper control groups. Instead, you get basically descriptions of how plant-based diet rules the universe. Never mind the well-known issues with compliance, the lack of proper control groups, the lack of acknowledgement of contradictory results (see e.g. the issue of weight loss and Gardner et al 2007, “Comparison of the Atkins, Zone, Ornish …) etc. etc. , that is, issues

            One cannot help but wonder whether this has something to do with Ornish “trash-talking” large trials …

          3. WilliamLawrenceUtridge says:

            So there

            Oh snap, you showed me, what with your anecdotes and what not. Now I’m convinced.

  3. windriven says:

    What is it about success that so frightens some people? The careful, deliberate processes of science are to be found at the foundations of nearly every improvement of the human condition in the last century.

    I suggest that these who eschew the hard structures of science are small of mind and timid of spirit rather like the backwoods preachers who cling to a biblical god whose hand moves the sun around the earth. They cling to the magic of unseen forces impervious to the inquiries of science. And I suspect this is all grounded in a fear that science increasingly discloses that they (and we) just ain’t that special.

    Moreover, they obsess with small ball. Science based medicine has transformed the human condition, all but eliminating some diseases that have plagued mankind for millenia, extending not only life but the quality of life throughout that extended span. And yet they wish to mince around the edges whining that homeopathy works ‘because I’ve seen it work’ or suggesting that if one holds their mouth just so and the moon is in the seventh house that acupuncture is almost as good an anti-emetic as phenergan. Well pardon me but who gives a sh|t?

    If we followed the directives of these dufuses air travel would be a risky business, the internet would be erratic and ‘augmented’ with tin-can telephones, some cars would have airbags and seat belts while others had crystal energy fields. I mean really, what the ___?

    If this is the quality of thought to be found in the best ‘public intellectuals’ then we are truly in a period of frighteningly precipitous intellectual decline.

  4. rork says:

    “In general studies are powered just enough to be able to demonstrate the anticipated or likely effect size.”
    Consider powering for a somewhat smaller effect that is still of a size that you would accept the cost to obtain that benefit. Have early stopping rules (sometimes “interim analysis”) to protect against the chance of the effect being larger than that. There are several even fancier tricks, maybe I can hint at one: have allocation to treatment arms depend on data up to that point in time. Power hit is small, but you hope to treat more people with what works. Another: reassign to the other treatment after some “failure” if you can get additional data out of the patient that way. Some loss there if long-term followup is key. Trial design may be starting a golden age, but it’s complicated.

    “that practitioners need to combine the best evidence with their own clinical experience and judgments.” That latitude, in the hands of the worst doctors, would frighten me nearly as much as Klein. For better docs it’s useful. It’s not clear where the line between reasonable and heresy is.

  5. nyudds says:

    Early this year, Dr. John Ioannidis spoke at Harvard about the shortcomings of scientific research and other things. We all know of his statistical prowess in finding validity vs. bias, casting doubt on many research results and methods. His remarks seem appropriate to this thread:

    “Why science, if flawed, is still the best alternative”
    At the end of his week-long visit to Harvard, Science-ish asked Ioannidis whether he ever tired of poking holes in science, whether all his work has caused him to lose faith in the scientific process. With wide eyes, he exclaimed, “I remain as enthusiastic about science as ever!” He went on to describe all the benefits of science, why it is “the best thing that can happen to humans”: the value of rational thinking, of evidence over ideology, religious belief and dogma. “We have effective treatments and interventions and useful tests we can apply. We have both theoretical and empirical evidence that science is beneficial to humans and it’s a wonderful construct of thinking. . . Science is beautiful because it’s falsifiable.”

    “There’s plenty of room to apply the very same (scientific) tools to the way science is done,” he added. “The question is: can we get there faster and more efficiently without wasting effort?”
    http://www2.macleans.ca/2014/01/17/when-science-isnt-science-based-in-class-with-dr-john-ioannidis/

    No, science isn’t perfect, but it is ‘way ahead of whatever is in second place. Actually to be more accurate, I’m reminded of the short conversation between England’s Queen Victoria and her aide during the first England vs. USA America’s Cup Race: The schooner America passed the Royal Yacht three times and dipped its ensign, The Queen asked who won the race. The aide replied that the America had won. The Queen then asked who came in second. The aide replied, ” Your Majesty, there is no second.”

    1. Harriet Hall says:

      There is a video online of the talk Ioannidis gave on this subject at the Trottier Symposium in Montreal recently. See http://www.mcgill.ca/science/events/trottier-symposium/october29
      Title: Improvements in Reproducible Research.
      Well worth watching.

      1. Sawyer says:

        It’s so bizarre seeing what Ioannidis really has to say about medicine after hearing his work bastardized hundreds of times by the quacks. He needs to win some kind of Princess Bride award – “You keep cited Ionnidis. I don’t think he means what you think he means!”

        And what a lineup in that video! Eugenie Scott, Michael Specter, and Tim Caulfield.

        1. Sawyer says:

          Argh! Citing, not cited.

  6. Frederick says:

    So basically, since sciences have flaws, to repair it, instead of improving and “repairing” those flaws, We created MORE flaws. That about as logical as damaging your suspension to ‘repair’ you braking system that does not work properly on you car.

    Funny how alter-med anti-science always seems to picture scientists as “mad scientist” , and yet offering “solutions” that will let every doctor experiment on his patients without control. So a free ticket to every doctor to become mad doctors,

    Absurd exaggeration here, but somehow following what That klein says : A doctors has 5-6 patients with Common cold, there is no cure to it really, BUT he want to try new things, huuum he wonder if electroshock as ever been tested to cure it. So i guess in this new perfect world of uncontrolled experiment and no standard of care, because you know, science is evil, That Mad Doctor will be allowed to try it! and his patient become so much convince it worked, he’ll do it again!

    I guess those man know what they are saying, the know it is stupid and they also know real medicine work better. They just probably don’t care, they have no real ethic, and they also Know that if they can bend the rigorous laws of science to make those alter-med seem to work, They gonna make a tons of money, them and their friends too. Friends like herbal product company and Homeopathy comp. Like Boiron, ( the french verb “boire” ( drink) at the 3rd person plural is “nous boirons” ( we drink) , always found that funny) Burzynski and all that bunch of good people.

    They love to see wild conspiracy? well you have one right there

  7. Science is under attack. The scientific method is more and more seen as a ballast, rather than a strenght.
    Unfortunately, putting “tolerance” and “integration” over “accuracy” and “evidence” seems more common among the intellectual elites.

  8. Ed Stockly says:

    It’s interesting that Dr. Ornish is considered an “Alt-med” advocate. His diet very closely matches the current guidelines for nutrition and weight loss. He recommends a high carb diet, based on whole grains, and very little meat or animal fats.

    It’s no surprise he’s rebelling against Random Controlled Trials, because every time his diet (or any other diet, really) has be studied with a low-carb high-fat (Atkins-like) diet, they have done no better, and frequently worse.

    What puzzles me is how after numerous RCTs the USDA hasn’t significantly modified its advice and various medical associations are only begrudgingly making small changes their recommendations, all but completely ignoring the growing body of evidence.

    1. rork says:

      To really say A beats B, you might have to think hard about the endpoint that matters. Weight 1 year out? All cause mortality? Something else?

      1. Ed Stockly says:

        @Rork, There usually is not enough ‘all cause mortality’ to track in RCTs. What you can do, however is look at the criteria for each study, and see how the various diets do. Or you can apply the same criteria to every study where applicable. (Not all studies will report every variable).

        The criteria I believe are most important are:

        Risk factors for chronic disease (LDL; HDL; TG; BP)
        Body fat percentage
        Total weight

        In every category LCHF does as well or better than every other diet in every RCT study.

        No wonder Dr. Ornish rejects the RCT model. It doesn’t give him the results he knows it should.

        ES

        1. AngoraRabbit says:

          Ed, you do understand, don’t you, that the reason the high fat diet “works” isn’t the mechanism that Atkins claimed (high glucagon and low insulin). What is happening is that the protein/fat have a high satiety factor. When intake is carefully controlled, the decline in weight corresponds is explained by the corresponding reduction in caloric intake. It works not because of the low carb magic, but because the person is simply eating less (and doesn’t realize it). It’s a gimmick, as are most diets that don’t involve a real change in daily behavior (nod to Andrey). Most diets don’t work well in RCT, so I wouldn’t take that as a point in any diet’s favor. :)

          1. Andrey Pavlov says:

            Thanks for noticing Angora. Very edifying to hear you agree.

          2. Sawyer says:

            Abort, abort!

            Stockly may have some interesting things to say about the science of RCTs, but we’ve noticed on another skeptical forum that he will turn every single conversation into a debate about LCHF diets. Seriously, we could be talking about the flu vaccine and he’d somehow tie it in to the USDA ignoring the evils of carbs. I would suggest just letting his comments slide and stick to the main topic.

            Sorry for the preemptive strike Ed, but we have way too many trolls here already.

            1. windriven says:

              Thanks for the heads up. I really do wish David would institute a Troll’s Wall of Shame here. We’ve had so many really amusing ones – and a few so starkly crazy they’re a little frightening. It would be a useful learning tool for new skeptics and for fence-sitters who don’t understand the techniques used by trolls to make quackery look reasonable.

              1. CHotel says:

                But how would we decide whether FBA or Stan gets top billing?

              2. Frederick says:

                There is some good trool in the other topic :-) the one about mister O’Alkaline, There’s one who is guaranteed to go on that wall :-) .

            2. Ed Stockly says:

              @Sawyer — “Sorry for the preemptive strike Ed, but we have way too many trolls here already.”

              No so much a preemptive strike, but more of a ad hominem, no?

              “Seriously, we could be talking about the flu vaccine and he’d somehow tie it in to the USDA ignoring the evils of carbs.”

              Look at the comments about flu vaccine, I’m certainly not there, but, in this case, we’re talking about a high carb, low-fat diet advocate who rejects scientific evidence that disagrees with his position. How is discussing the findings of the very studies he’s rejecting not germain? Plus, as for the USDA, I don’t see much daylight between Ornish’s position on diet and theirs, and to get there both have to ignore the RCTs, which Novella is rightfully criticizing Ornish for.

              1. Sawyer says:

                Very well, it’s an ad hominem. Regardless, I do not want 1000 comments on this thread about how LCHF diets are the best thing in the world since sliced bread (whoops, that analogy doesn’t work with you guys, does it?)

                You have made your viewpoints very clear on the SGU forums and anyone here is welcome to check them out. Scientifically valid or not, your arguments on this topic have proven very unfruitful for most of us interested in health and medicine. Please make those arguments somewhere else and anyone curious will find them eventually.

              2. Ed Stockly says:

                @Sawyer “Very well, it’s an ad hominem. Regardless, I do not want 1000 comments on this thread about how LCHF diets are the best thing in the world”

                And I don’t want ad hominems and other logical fallacies to pollute a discussion on a skeptics’ website, but we can’t always get what we want.

                “You have made your viewpoints very clear on the SGU forums and anyone here is welcome to check them out.”

                Yes. But here, the discussion is more about Dr. Ornish rejecting the validity of RCTs (and epidemiological studies) because they don’t support his pre-defined conclusions, which, I argue, is exactly what the USDA and RDs do. The fact that’s it’s studies that support the effectiveness of LCHF diets is related but not central to that issue.

                >>Scientifically valid or not, your arguments on this topic have proven very unfruitful for most of us interested in health and medicine. Please make those arguments somewhere else and anyone curious will find them eventually.

                You speak for everyone? If a comment on a post generates a thread with thousand comments, then, obviously someone is interested.

          3. Ed Stockly says:

            @Angora “you do understand, don’t you, that the reason the high fat diet “works” isn’t the mechanism that Atkins claimed (high glucagon and low insulin).”

            Well, that’s not an accurate representation of Atkins’ claims, but it’s really not relevant to this discussion.

            The RCTs in question are interventions and RCTs are the best way to judge which intervention is the better one, based on various criteria.

            “It works not because of the low carb magic, but because the person is simply eating less (and doesn’t realize it).”

            Even if that explains everything (which I would dispute) how is that a problem? Isn’t the bottom line that the RCTs (upwards of 20 to date) all show that in every criteria measured (weight; BFP; risk factors for CVD) that the LCHF Atkins-like strategy is consistently as good or better than any other diet?

            “Most diets don’t work well in RCT, so I wouldn’t take that as a point in any diet’s favor”

            No. Many diet interventions do quite well in RCTs. For some things, like CVD risk factors, dietary modification is actually better than statins.

            1. AngorAta Rabbit says:

              I can’t tell if Ed and I are saying the same thing or talking past each other. I think we are saying something different. A lot of diets “work” early on and including RCT, because the person is paying attention to what they put in their mouth, whether it’s all grapefruit, Atkin’s high protein/fat/lowCHO or Ornish high complex CHO. When careful measurements are made of what the patients are doing, what emerges is that the mere action of paying attention to what one eats means that fewer calories are entering.

              That ought to be well and good, except one then has to worry about long-term compliance as opposed to short term compliance. And many of these gimmick diets are just that – the person gets bored w/grapefruit or can’t bear to adhere to the limited menus or won’t make the time to cook, and the weight comes back on. At any rate, I totally agree, Ed, that dietary modification is far better than meds. The sad part is that it is hard to get people to make the change, short term or long term. Hence the statins. I am only semi-joking when I say that most nutritionists think we should become psychologists, because it’s really about trying to change behavior.

              The other issue is that many of these diets claim to be working by some unique magic principle. The more sensible ones tend to focus on blunting postprandial glucose spikes and thus blunting insulin elevations, such that less triglycerides are made and more TAGs are burned. Honestly, whatever their inventors say, that’s really what both diets are about.

            2. Mie says:

              “For some things, like CVD risk factors, dietary modification is actually better than statins.”

              No, not really. E.g. LDL: intensive statin therapy gives the best results in LDL lowering, better than diets – when looking at the evidence as a whole.

              And when we extend the scrutiny into CVD end point data … Well, that’s a whole different story. Consider e.g. mortality (quite a significant end point, don’t you think?):

              http://www.ncbi.nlm.nih.gov/pubmed/15824290

              1. Ed Stockly says:

                http://www.ncbi.nlm.nih.gov/pubmed/15824290

                >>>No, not really. E.g. LDL: intensive statin therapy gives the best results in LDL lowering, better than diets – when looking at the evidence as a whole.

                Statins lower LDL, but do not significantly improve LDL particle size, nor do they increase HDL significantly. In addition, they don’t lower blood pressure or do anything for metabolic syndrome or T2 diabetes.

                The study you provided did not include LCHF diets which are more effective than “usual” at reducing all of those CVD risk factors.

              2. windriven says:

                @Ed Stockly

                The real test is in outcomes. If you have good long term studies that indicate meaningful outcome improvements, I’d like to see them. In the meantime I’ll stick with Lipitor and a nice boule of Country French.

    2. Angora Rabbit says:

      Ed, the problem with Ornish is that he exaggerates the benefits of his diet and exaggerates the harms of diets that he opposes. He is not looking at the real effects of food with a balanced and critical eye. A lot of professional nutritionists agree that he jumped the shark years ago. Which is sad, because he does himself harm by continuing to make those exaggerations.

      Yes, a lot of the dietary suggestions looked good on the surface, and were supported by epidemiology (read, circumstantial) data. Hence the need to do the real trial. And those results are very frustrating to people like Ornish because the findings are not supporting his empire (and do not underestimate his financial loss if the data show him “wrong”!) But we are talking about real people with real health needs, and hence we must do the interventional trial. And if we don’t see the health benefit of dietary practice X in the RCT, then we have to ask what is really going on, and what was the epi study really pulling out with its statistical associations.

      Re: USDA, the complexity there (and my colleagues have worked on Pyramid, My Plate, etc) is that USDA does not answer just to nutrition professionals. They answer to “stakeholders” that include industry lobbies such as the beef council, corn and soy producers, milk marketing board, apple producers, etc etc. None of them want to be the small sliver on the plate, and all will invoke their congressmen to influence the outcome. I mean, the meat people adored My Pyramid because their small segment was at the near top, and therefore the most important! It is so politicized; science, sadly, is only one component.

      1. Ed Stockly says:

        @Angora
        “the problem with Ornish is that he exaggerates the benefits of his diet and exaggerates the harms of diets that he opposes.”

        No argument there, but I say the same things about the USDA, RDs, and their positions.

        “And those results are very frustrating to people like Ornish because the findings are not supporting his empire (and do not underestimate his financial loss if the data show him “wrong”!) ”

        True, and again, I would argue that the same thing applies to the USDA.

        “Re: USDA, the complexity there (and my colleagues have worked on Pyramid, My Plate, etc) is that USDA does not answer just to nutrition professionals. They answer to “stakeholders” that include industry lobbies such as the beef council, corn and soy producers, milk marketing board, apple producers, etc etc. ”

        Yes, yes, yes. Of course, when I say that, I’m accused of being a consipracy-theory-believing troll.

        And what do those “stakeholders” have to do with the scientific validity of the various theories of diet and nutrition.

        “It is so politicized; science, sadly, is only one component.”

        Exactly.

        1. goodnightirene says:

          The main problem with the Ornish diet is that it is too rigid for most anyone to stick with over time. It is so low fat (no nuts even) that there it is just not going to appeal enough to most people to stay with it. Doesn’t mean they might not pick up better eating habits, but that won’t help reduce weight unless they eat fewer calories. Well-controlled studies of diet are nearly impossible to do as they would require locking people up and feeding them specific things for long periods of time (perhaps prison?) in order to make valid comparisons. Ornish, et al, just want to sell books, videos, supplements, etc.

          People continue to make the mistake that there is some ONE TRUE DIET that will grant and maintain optimum health when in fact there are any number of ways to eat things that grow and walk–hence the many varied (and healthy) cuisines of the world.

          @ Angora Rabbit

          Nice to see that you worked on My Plate and thanks for reminding everyone that there’s more to gov’t recommendations than good science. I like My Plate and find it much better than Pyramid, but it still makes a few political compromises (not your fault no doubt :-) ).

          1. Horatio Poindexter says:

            I think the strict version of the Ornish diet ( the one that’s hard to stick to) is the heart disease reversal diet. One would presume that patients placed on this were in the last chance saloon so might have the motivation to stick to it. The mediterranean diet might be a better bet for most people.

        2. WilliamLawrenceUtridge says:

          Ed, I will point out that you are proving Sawyer to be exactly right. He made a nice and accurate prophecy, and you fulfilled it.

          Consider that not everyone else is interested in your tangent into the fat content of diets, and further that the evidence to support your position obviously is suggestive at best, not convincing, otherwise it would be scientific mainstream.

          1. Ed Stockly says:

            @ WilliamLawrenceUtridge “Consider that not everyone else is interested in your tangent into the fat content of diets”

            Of course, and just as I don’t read comments I’m not interested, anyone not interested in my comments should skip them.

            “and further that the evidence to support your position obviously is suggestive at best, not convincing, otherwise it would be scientific mainstream.”

            Do you see the logical fallacy in that statement?

            1. WilliamLawrenceUtridge says:

              I don’t see a logical fallacy. I see an indication of a lack of consensus, which means the data is unconvincing. See, I’m never going to bother arguing specifics with you. I don’t have the interest or time, and I’m going to defer to the experts. I will merely note that when people come up with a widely-divergent reorientation of all the scientific research on a topic, often they are selective in their quotation and citation of said research, often leave out studies that don’t support their points, and often treat speculations as conclusions. If you didn’t have to do this, if your beliefs were based on a foundation of intellectual bricks, each of which were reliable, solid and generally-agreed upon, you wouldn’t be proposing a new theory. You would be reflecting the scientific mainstream.

              Put another way, even if you are correct, your correctness is not based on adequately convincing data. You are asserting correctness without enough data to convince a genuine expert like Angora Rabbit. If you want to prove that you are correct, you will need to construct each of the individual data bricks required. Until then, you can’t expect skeptics to simply take your word for it.

              1. Ed Stockly says:

                @ WilliamLawrenceUtridge
                “Put another way, even if you are correct, your correctness is not based on adequately convincing data. You are asserting correctness without enough data to convince a genuine expert like Angora Rabbit. ”

                Well maybe you should read carefully what Angora said. We agree on most things. Plus, Angora points out that the USDA guidelines, which are the basis for dietary practices in the US, and much of the world, are shaped by politics and various stake-holders.

                I believe that the assumption that the guidelines are based solely on the best science available is a big part of the bias in diet and nutrition.

                It’s one standard to say that the studies aren’t good enough because they don’t convince scientists .

                It’s a different standard to say the studies aren’t good enough because they don’t convince “stake-holders” who have influence over the political organization that establishes the guidelines.

  9. Davdoodles says:

    “But we should only trust EBM if the science behind best practices is infallible and comprehensive….”

    I wonder what mental gymnastics Klein practices to convince himself both (a) that this codswallop is true for EBM and yet (b) it is not also true for his favorite woo.
    .

    1. Frederick says:

      That’s a fallacy that to people who are scared of sciences always do. That we are not in a perfect world , so we can’t trust science. But they trust in some pseudo-science/spiritual way of thinking, which is also imperfect, double standard.

  10. bgoudie says:

    I was rather disappointed in many of the people who were part of that list. From an argument stressing the need to return to mind-brain duality, to one on including the line “It’s entirely more rational—and less steeped in storybook logic—to work with the possibility that time predates matter, and that consciousness is less the consequence of a physical, cause-and-effect reality than a precursor.” there was considerable drift into the realm of fuzzy thinking.

  11. chet says:

    Dealing with this kind of topic is very complicated. People have their own interpretations and beliefs that is why opinions are not all the same.

    1. goodnightirene says:

      Thanks, Chet, but we deal in evidence here, not opinion–well that too, but they are different, although sometimes facts do confirm opinion. :-)

    2. windriven says:

      chet, as Irene pointed out, this isn’t an issue of opinion. Opinion finds its way into these pages but when it does it is clear that it is opinion. Evidence is nearly the polar opposite of opinion in that evidence requires no belief; it is what it is. It is only complicated when opinion and evidence are confused.

      It is my opinion that Bergenost is superior to Havarti. It is a fact that at STP 1 liter of water is heavier than 1 liter of nitrogen.

      There is a postmodernist virus sweeping through academia that causes infected minds to abandon reason and embrace what can only be characterized as silliness. I wonder how long we will have to wait for a graduate studies program in applied alchemy at Harvard? A commenter in another thread already claims credentials in Esotericism.

      I mean, really? 21st century. Mars landings. Hypersonic flight. Worldwide internet. Heart transplants. And … naturalistic fantasies and good intentions are better care than EBM??? Stupidity on that scale should be illegal.

  12. Morris Goruk says:

    I had bought a cook book by Ornish and was very disappointed because there had not been any hint that it was vegetarian only, the recipes needed exotic herbs and tasted bad. In fact the promo had suggested that D.O. being from Texas enjoyed a big steak now and then. It has also been rumored (maybe only malice) that D.O. was an animal rights activist and so his dietary view may be ideological.

  13. oldmanjenkins says:

    Dean Ornish and Gary Klein are using the same canard that ID/Creationist apologists use. “If you can’t answer my ridiculously narrow inflexible question then your entire position is false.” As Dara Ó Briain said “Science knows that it doesn’t know everything or else it would stop.”

  14. I love this.

    “Practitioners shouldn’t believe a published study just because it meets the criteria of randomized controlled trial design…”

    It’s almost like Klein is suggesting some sort of review be applied to a studies…

    1. WilliamLawrenceUtridge says:

      Oh snap. Virtual fist bump =)(=

  15. AJLecter says:

    Author Nicholas G. Carr’s contribution, “Anti-Anecdotalism,” has thrown me into a state of permanent cringe.

  16. Garett says:

    You may want to do a little more background on Gary Klein before lambasting his position. He isn’t some quack with a Blog. He’s a PhD psychologist and one of the top experts in decision making. He has quite extensively studied physician decision making and he’s an expert on the topic. His writing comes from a place of recognizing the limits to human information process and decision making, and he is simply arguing that in some instances, particularly in situations that require flexible-like thinking, focusing too rigidly on certain facts is problematic. This same type of work is what led to Daniel Kahneman’s Nobel prize winning work on decision making. He isn’t advocating for throwing out all scientific evidence as you say; his point is that we recognize that at the end of day that evidence has to be applied by human beings who are subject to the same biases regardless if you are a janitor or a physician. However, these biases do not doom us to flawed thinking and we can avoid them with practice and effort. Klein’s point is that all of the evidence in the world won’t help physicians if they are sabotaged by flawed decision making and the effort should be on limiting those biases.

    1. windriven says:

      @Garett

      “You may want to do a little more background on Gary Klein before lambasting his position. He isn’t some quack with a Blog.”

      Shall we not take the man at his words?

      “But we should only trust EBM if the science behind best practices is infallible and comprehensive, and that’s certainly not the case. ”

      That is among the most destructive, delusional, frankly idiotic assertions I’ve read in some time. Let’s play with his words and see where it takes us.

      We should only trust driving if the science behind traffic management is infallible and comprehensive, and that’s certainly not the case.

      In the meantime we should … walk?

      Science, almost none of it, is infallible. The suggestion that we trust only the infallible leaves my mouth agape. Well let’s all just ask the effing pope because, last I checked, he’s the only man alive (outside of psychiatric institutions) who claims infallibility.

      Now I will admit that very bright people sometimes say incredibly stupid things. But I’m not aware of Klein having made any effort to walk back this statement – are you?

      1. Garett says:

        I would argue he’s pointing more to unquestioning trust. For example, a physician might say, “You can’t have X because no studies have shown this.” I doubt that many physicians would say such a thing but it helps make the point. Expert decision making is a mix of knowledge and some of these more intangible “intuitive” like processing that integrates various pieces of information from many different sources. Focusing on the knowledge to the exclusion of some of these other cues may produce worse outcomes. All I think he’s saying is that if physicians aren’t willing to be open minded and willing to consider alternative possibilities that such rigid decision making processes will produce undesirable outcomes.

        To go off your traffic management example, he would argue that incessantly insisting on a specific traffic management pattern because of the results of evidence might be bad if you continuously observe that the pattern is producing undesirable outcomes (e.g., more crashes). Well, the evidence says it should work so should we keep applying it until it starts working or acknowledge the cues in the environment suggesting something different? The former is a rigid decision process and the latter is a more flexible method. I think all he is arguing is that if we focus too much the facts and figures in treating patients we’ll miss out on some important environmental cues that could produce better decisions in the long run.

        1. windriven says:

          I’m not entirely sure that this explanation is more satisfying, Garett. It is a complete misunderstanding of EBM that EBM excludes any therapy not supported by bulletproof RCTs.

          A patient presents with s. aureus bacteremia. The typical starting point according to EBM, I think, would be a beta lactam antibiotic. Depending on response and susceptibility profile demonstrated in the cultures, treatment might move to a cephalosporin or even IV vancomycin. There is a good deal of clinical judgment involved.

          “All I think he’s saying is that if physicians aren’t willing to be open minded and willing to consider alternative possibilities”

          And here is the tricky part, Garett. If one’s starting point is SBM or even EBM, that open mindedness is likely to adhere to explanations and treatments with scientific plausibility – extrapolations perhaps from current knowledge and practice – but grounded in science and evidence. If we are to discard EBM until it is perfect then isn’t mysticism as valid an approach as any other?

          1. Garett says:

            I would agree 100% that the decision making (DM) process you describe is sound, especially the scientifically plausible piece. Based on what I know about Klein, I would say he’d agree 100% with this too. Maybe it boils down to differences in terms. SBM means something different to readers of this blog than it does to Klein. I’m willing to be that when he says SBM he means excessively rigid DM processes that do not follow what you stated. He’s not advocating mysticism but is saying that if, as a physician, you try something that is theoretically plausible but not yet studied and it works, why not continue? That is exactly what you say above.

            I think he’s talking about the physician who avoids that type of thinking because they treatment hasn’t been tested and found to be “tried and true.” Plenty of times practice outpaces science and if the practice works we wouldn’t abandon it simply because there isn’t currently evidence for precisely how it works assuming scientific plausibility of course. But then one might ask, who decides what is “scientifically plausible”? I think the key is to understand which extrapolations are justified and which are a step too far beyond the state of the science, and becoming good at that type of thinking requires practice (that’s how experts become experts). My point is that at the end of the day, I think if you sat down and talked with Gary Klein he would agree with everything you said above.

            1. Sawyer says:

              I wonder if part of the fault here lies not with Klein but with Edge for providing questions that are way too broad. If you look at some of the other responses, you’ll see people with very different interpretations as to what an idea being “retired” means. Some respondents are picking ideas that they consider completely wrong. Others are pointing to concepts that are technically valid but are oversimplified or easily mischaracterized by the public. Maybe Edge needs to start going for depth rather than breadth?

              And since no one has pointed it out yet, A LOT of the responses to the Edge survey tend to look like branding and PR rather than a real scientific discussion. I get an “I’m really smart and you should buy my new book” vibe from a few in particular.

            2. windriven says:

              I’ll make a point to find some of his work and incorporate it into my reading (but goddamit there’s so much to read and so little time!).

              Taking your input and Sawyer’s observation below, I must admit that it isn’t appropriate to assess a person’s position on the basis of a couple of poorly chosen sentences.

  17. Should we be disappointed in The Edge for allowing itself to be infiltrated by these alternative thinkers? I suppose it’s inevitable since The Edge is seen, rightly, as a bastion of science that those who seen validation by the intellectual community would attempt to insert themselves.
    As for Ionnidis – I wonder if his efforts are constructive in a larger sense. It’s true he has brought attention to important issues re publication bias and reproducibility, but he may have inadvertently given the media and CAM practitioners an opening to further question the framework of science. Time will tell.

    1. Sawyer says:

      My money is on his work paying off in the end, but it may be 20 or 30 years for that to happen. I’m guessing that when a more bombastic, more emotional, and less rigorous scientist publishes a paper showing 99% of published research is wrong, CAM connoisseurs will start citing the newer findings and abandon the “argument ad Ionnidis”. They don’t have the same quality filter the rest of us have, so they don’t have any reason to stick with John’s work. Once their attention wanes then real scientists, journal editors, and funding agencies can start using his discoveries to make improvements to their fields.

  18. Stephen S. Rodrigues, MD says:

    These circular arguments all are flawed, biased and deceptive. This is mostly because your truths are getting twisted together.
    The truths are;
    1. The infallible laws of nature which can not be broken.
    2. Your personal truths; how we define a word or how we witness at any particular moment in time.
    3. Finally, how each of us interact in society as individuals, mostly by choice and thus heavily biased as in religious beliefs.

    These arguments here are an attempt to make a belief or observation an infallible law. Which is impossible! One should not be able to hold a belief up to the standards of natural laws.

    Read Goldacre, Feldman, Bronowski and Sheldrake.

    If the modern scientific methods in medicine are a way to find truth beyond doubt then a pill would cure and a surgery would fix 100% of the time. The failures of this method will have to cared for like humans did 5000 -10000 yrs ago … plain old tried and trues Alternatives!!! I like needles!

    1. Sawyer says:

      “Read Goldacre, Feldman, Bronowski and Sheldrake.”

      SSR, I question if you even understand what the word “read” mean at this point. Are you randomly tearing pages out of these author’s books before you read them? Ben Goldacre and Jacob Bronowski’s work is diametrically opposed to your nonsense versions of science or medicine. If you think they are on board with your fantasy universe, some remedial English classes may be in order.

      1. Stephen S. Rodrigues, MD says:

        My take away from these gents;
        Goldacre refers to how humans (researchers) lie and deceive for an agenda.

        Bronowski refers to how human’s will believe an idea is absolute and used that partial truth to cause people to suffer by ignorance or by malice.

        Sheldrake notes that modern medicine has put all of the eggs into a dogmatic methodology, money, time and faith. Then it disavows any modality that can not fit into that paradigm.

        1. weing says:

          “Bronowski refers to how human’s will believe an idea is absolute and used that partial truth to cause people to suffer by ignorance or by malice.”
          Sounds a lot like your idea of acupuncture.

        2. windriven says:

          Top ten, Roodrigues. No more lies, no more magic. Show us what you’ve got.

        3. Jon Brewer says:

          Researchers lie? And they’re found out, stripped of their license, and their work is retracted and put in the same place as Mein Kampf: Valuable for historical purposes (especially to make sure this doesn’t happen again), but citing it uncritically will get you laughed out of the room. But they still get time in the MSM. Exhibit A, the antivaccine movement.

          1. Stephen S. Rodrigues, MD says:

            As per Robert Feldman … all humans have the capacity to lie, and deceive and do on a regular basis.

            Most of the games we play in the “Games of Life” are deeply rooted in human emotions and beliefs.

      2. Jon Brewer says:

        That’s the lulzy part. Alties didn’t get the whole point of Goldacre’s work. No, just because Vioxx causes heart attacks doesn’t mean garlic and olive oil cure AIDS or magic water suddenly has amazing healing properties.

        Seriously, though, I always find it interesting when they talk about different standards of evidence. There has to be a term for that. Could someone help me? ;)

    2. weing says:

      “If the modern scientific methods in medicine are a way to find truth beyond doubt then a pill would cure and a surgery would fix 100% of the time. ”

      What a steaming pile of horse manure. Do you have any actual evidence to support such a claim?

    3. windriven says:

      Jabber, jabber. Top ten, Roodrigues. No more lies, no more magic. Show us what you’ve got.

  19. Peter H Proctor, PhD,MD says:

    Old concept and how clinical medicine originally developed. As for its respectability– I have a rather thick book on Clinical Trials sitting on my desk. In it is an entire chapter on single-patient trials. Sometimes, that is all you got.

    It helps if the patient has a chronic disease whose symptoms have not alleviated for a while and if symptoms come and go with treatment, ideally-blinded. Even better if the patient has physically or radiologically-verifiable improvements going on and off treatment. Effectively, the patient is acting as his own control…

  20. Kevin says:

    We tend to lose sight of what science really is. We have those like Ornish and Kline who are want science to agree with them and then we have those that play the “I’ve got more study citations than you do so I am right”. And then there are those that see a study that fits what they want to hear and go blindly with it. And the one’s that really get me are the ones that say “There is no study that shows what you are saying is true therefore it is false”. None of this is science.

    Science is not perfect. We of course have to keep doing studies. We also have to keep critiquing the studies and never think that a study “proves” something, it just shows evidence of some hypothesis.

    1. @Peter H Proctor, PhD,MD

      In a lot of clinical in-office situations, the patient is the control!!! Exactly, they are the test case, data collector, the analyst, the experimenter and experimentee and final assessor.

      We the professionals want to be correct in spite of the people we are attempting to help. That idea needs to die.

      1. WilliamLawrenceUtridge says:

        While patients might have an idea for what to do when it comes to joint and muscle pain (i.e. a hot bath), you really think the average patient has the background to treat liver failure, re-attach a severed limb, set a dislocated shoulder, cure cancer, remove an inflamed appendix, correct congenital defect to the heart, manage type I diabetes, manage the consequences of type II diabetes, etc.? Not to mention, patients are often the source of their problems – obesity and most cases of lung cancer for instance.

        You may have a skewed pespective because you deal primarily with mild and self- limiting conditions such as idiopathic muscular pain. Yes, those can be dealt with using the basic knowledge held by a patient – “it hurts but feels good to press here, so I’ll press here or get someone else to do so.”

        Really, what patient knows enough, based on their symptoms, to pick even an antibiotic?

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