Science-Based Medicine

One of the questions most often asked in the medical literature is “what is the risk of x?”  It’s a pretty important question.  I’d like to be able to tell my patient with high blood pressure what their risk of heart attack is, both with and without treatment.  And risk is a sexy topic—the press loves it.  Whether it’s cell phones and the “risk” of brain cancer, or vaccines and the “risk” of autism, risk makes for cool headlines.  Take this one for example:

Migraines cut breast cancer risk 30 percent: study

What does this mean?  Should I tell my wife to go out and find some migraines?  I have a feeling one or more of my colleagues will give a more detailed critique of this study, but I’d like to talk to you a bit about what we mean by “risk”.

Risk, in the most basic sense, is a causal association.  If, for example, I find that members of the “Thunderstorm-lovers Golf Association” have a higher incidence of being struck by lightning than golfers who don’t belong to this odd club, I may have stumbled upon a measurable risk.  There is both a measurable association, and a plausible reason to causally link the associated variables.   If I find that members of the National Association of Philatelists have a higher incidence of heart disease than other folks, I may or may not have stumbled on a risk.  Is there a reason that philatelists should have more heart disease?  Is it a coincidence?  Is it worth investigating further?  Is there a confounding variable, e.g. are philatelists in general older, and did I fail to control for this?

Then there is the question of the degree of risk.  How strong is the risk observed?

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It is with some degree of trepidation that I enter the fray on the Wyeth vs. Levine case. I’ve been watching the media frenzy about the lawsuit with interest – mostly because (for the first time in a while) I think that the pharmaceutical company is in the right on this one – and that most journalists (and even medical journal editors) have missed the salient points.

I think that a close review of the case is instructive in two ways. It shows: 1) the dangers of making legal decisions based on the perspective of the victim (a risk of harm equal to 1 in 20 million is unacceptable to that one person who suffered the consequence, but tolerable to the other 19,999,999 others) and 2) that a simple case of medical malpractice has made it all the way to the US Supreme Court because (as I discussed in my last post) a democratization of knowledge (juries reading a drug label) was believed to democratize expertise (how a physician would understand the label).
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A new study published in the Archives of Pediatrics and Adolescent Medicine shows a positive correlation between counties in California, Oregon, and Washington with greater precipitation and a higher incidence of autism. While the results of this study are interesting, it needs to be put into proper context. Also of note, the authors had presented early results from this data previously.

Correlation is not Causation

This type of study is a correlational study, which means it asks whether or not there is a statistical correlation between two variables – in this case the rate of autism and the amount of precipitation.  This type of data is extremely useful to medical science, but it has known limitations, which can be summarized by the statement that correlation is not causation.

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My valued colleague, Dr. Antonio Baines, recently invited me to speak for his graduate course in Toxicology.  Dr. Baines’ course is one of the most highly-regarded graduate classes at North Carolina Central University for M.S. students in Biology and Pharmaceutical Sciences.  Antonio asked that I discuss the pharmacology and toxicology of herbal and non-botanical dietary supplements but pretty much gave me free reign as to the mechanism by which I would do so.

In the past, I have often introduced herbal supplements to students who already know a bit about drug and toxicant action by taking the example of the anticancer drug, taxol (Note: Little “t” taxol was the name originally given to this chemical by its co-discovers but the corporate sponsor used it as a registered trademark for the brand name, big “t” Taxol, and the USAN proposed the use of the cumbersome paclitaxel as the generic name.).  As I noted in my previous post, taxol is an anticancer drug isolated from the bark of the Pacific yew tree, Taxus brevifolia, and was the first compound shown to kill cancer cells by promoting microtubule polymerization (and preventing depolymerization).

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Some people think circumcision is mutilation; others want one even if they don’t know what it is. When I was working in an Air Force hospital emergency room one night, a young airman came in requesting a circumcision. I asked him why he wanted one. He said a couple of his friends had had it done, and he’d heard it was a good idea, and he was going to be getting out of the Air Force pretty soon and wanted to have it done while Uncle Sam would still foot the bill. I examined him: he had a neatly circumcised penis without so much as a hint of any foreskin remnant. I’ve always wondered what he thought we were going to cut off.

The subject of circumcision evokes strong emotions. Some people think of neonatal circumcision as a religious duty or a valuable preventive health measure; others think it is the epitome of child abuse. I have no strong feelings either way. I’m not sure what I would have decided if I’d had sons; fortunately my children were both daughters so I didn’t have to decide. I’m going to try to stand back and look at the scientific evidence objectively. What are the medical benefits and risks of circumcision? Continue Reading »

I guess I never really wanted to work in Manhattan anyway. At least, that’s what I keep telling myself.

I mean, why on earth would I want to? What’s the attraction? Living in the heart of it all, all those shows and all those amazing cultural activities, all those world-class restaurants? Being close to Boston, Philadelphia, and other cool East Coast cities, which are all just a quick Acela train ride away? Who cares about those things, anyway?

Apparently I don’t, because I’m about to destroy my chances of working at what has been considered one of the premiere academic hospitals in New York City, specifically Beth Israel Medical Center, an academic affiliate of the Albert Einstein College of Medicine. It’s possible for me to have been ignored when I first included the Albert Einstein College of Medicine and its affliated Continuum Center for Health & Healing in my roll call of shame as a medical center that has not just added woo to its offerings, but actively embraced it. At the time I originally discovered it, though, its offerings seemed limited to fairly mild woo, the usual stuff like acupuncture, what I like to call “gateway modalities” that centers embrace first because they’re relatively tame and commonplace. All too commonly, though, dabbling in gateway modalities leads to the “hard stuff,” outright quackery with zero scientific basis like homeopathy, reflexology, and craniosacral therapy. Such is the pathway an academic medical center follows when it degenerates from science-based medicine to what Dr. R. W. famously dubbed “quackademic medicine,” usually driven by a few famous true believers, which, alas, is exactly what happened at fearless leader Steve Novella’s institution of Yale, thanks to Dr. David Katz and his “more fluid concept of evidence.”

In any case, last week, I realized that I’ve been completely neglecting the aforementioned roll call of shame. Perusing it, I now realize that it’s been over five months since I did a significant update to it. You just know that, given the rate of infiltration of unscientific medical practices into medical academia as seemingly respectable treatment modalities that there must be at least several new additions to this roll of shame. Alas, even today, having been shamed myself by the realization of my failure to keep the list updated, I’m not going to do the full update and revamping that the Roll Call of Quackademic Medicine cries out for. However, that doesn’t mean I can’t do a piecemeal addition here and there. That doesn’t mean I can’t point out new additions as they pop up, even if it takes me a while to find the time to give the list the facelift it cries out for. It doesn’t mean I can’t call out hospitals like Beth Israel when they fall into woo, especially when they dive into quackademic medicine in a big way for cancer patients.
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You may recall that a week ago fellow SBM blogger Mark Crislip did a truly amusing takedown of an article by a homeopath purporting to provide us with 50 Facts About Homeopathy that supposedly validate the efficacy of this most amazing form of quackery. Not surprisingly, others wanted to get in on the fun, given how outrageously ridiculous and riddled with numerous logical fallacies the homeopath’s article was. Indeed, that’s why prominent Australian skeptic Peter Bowditch, whose website The Millenium Project is always an entertaining read (except that, at only once every one or two weeks, its updates are too infrequent) couldn’t resist getting in on the action with his answer to A Homeopathic Challenge.

Unfortunately, by the time he hit “Fact” #25 Peter was laughing so hard that, try as he might, he just couldn’t continue with his deconstruction. He does, however, promise to finish up the list in a future installment.