Science-Based Medicine

When I graduated from Lincoln Chiropractic College in 1956, I had come to the conclusion that chiropractic’s subluxation theory, that misaligned vertebrae can cause organic disease, was not true. When I began my practice in Panama City, Florida, I limited my practice to care of mechanical-type back pain and related problems. Back then, that was not too much of a stretch, since manipulative services were not readily available in medical practices and there were a number of orthopedic and physical medicine texts recommending use of manipulation in the treatment of back pain.

In 1963, I published my book Bonesetting, Chiropractic, and Cultism, renouncing subluxation theory and recommending that chiropractic be developed as physical treatment specialty in the care of back pain. The book was reviewed by the Library Journal (February 1, 1964) and recommended for inclusion in medical and reference libraries. In 1965, I received a letter from the American Chiropractic Association (ACA) informing me that my application for membership in the ACA had been rejected. In the years to follow, I published many articles in an attempt to initiate an effort to change chiropractic from a subluxation-based practice to a legitimate physical treatment method that would fit in with mainstream health care. My suggestions were ignored and I was called a “chiropractic heretic.” Today, I find myself still saying some of the things I said in my 1963 Bonesetting book, still being rejected by most of my colleagues and still voicing opposition to subluxation theory.

There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same affect on the nervous system and general health as a “vertebral subluxation.”
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What do you think would happen if you gave a bunch of “complementary and alternative medicine” practitioners access to a big pot of money — say, up to $10,000 per patient — and let them treat patients virtually without restriction, hampered only by a fee schedule. No utilization review, no refusal based on a treatment’s being “experimental” — none of the usual foils which trip up CAM practitioners in the health insurance field.

Think they’d run up the bill? Yes, they would.

In fact, that’s exactly the scenario playing out in Florida right now with the state’s no-fault auto insurance.
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Here we go again.

In fact, I think I’m starting to see a pattern here among antivaccine organizations. You might remember that in November 2010, the antivaccine group SafeMinds bought ad space in AMC Theaters over the Thanksgiving holiday weekend, one of the heaviest moviegoing time periods of the year. This use of pre-movie time to promote antivaccine propaganda resulted in a campaign by skeptics to try to persuade AMC to see the error of its ways, a campaign that was successful.

Then, a few months later, the the grande dame of the antivaccine movement, arguably the woman who started the most recent incarnation of that hoary old anti-science movement back in the 1980s, Barbara Loe Fisher, decided to start advertising the antivaccine message she promotes through her group, the Orwellian-named National Vaccine Information Center (NVIC) using the JumboTron in Times Square. Unfortunately, despite protests from the American Academy of Pediatrics, promoters of science-based medicine, and skeptics, the ads apparently aired for the full buy.

Then, a few months later (just last month, in fact), somehow the NVIC managed to dupe Delta Airlines, through its video provider In-Flight Media into airing a more subtle “public service announcement” whose antivaccine message was cleverly muted so that it wasn’t so obvious, except to those of us who knew the NVIC (and, of course, the buzzwords used by the antivaccine movement) that its message was antivaccine. Of course, it also didn’t help that the PSA urged viewers to go to the NVIC website, which, as I’ve described many times before, is a font of misinformation, pseudoscience, and antivaccine propaganda. (Just type “NVIC” into this blog’s search box to see.) At least Fisher’s response of crying “repression” in response to the AAP’s complaint to Delta Air Lines was good for a chuckle or two. Unfortunately, the NVIC advertorials aired through the entire buy. Meanwhile, this fall a major dump of antivaccine propaganda was circulating around the country in various film festivals in the form of an antivaccine propaganda movie called The Greater Good, whose manipulativeness and misinformation would make a North Korean propagandists planning state media coverage of Kim Jong-il‘s funeral blush.

Now, it would appear, the NVIC wants to close out 2011 and ring in 2012 with a new round of antivaccine propaganda, this time revisiting Times Square at the heart of the New Years Eve celebration, an effort it’s trumpeting through a press release entitled National Vaccine Information Center (NVIC) Educates One Million Plus in Times Square on New Year’s Eve. Here, Barbara, I’ll fix that for you. It should read “National Vaccine Information Center (NVIC) Mis-Educates One Million Plus in Times Square on New Year’s Eve.”

There, that’s better.
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Labels are a cognitive double-edged sword. We need to categorize the world in order to mentally capture it – labels help us organize our mental maps of the overwhelming complexity of things and to communicate with each other. But labels can also be mental prisons, when they substitute for a thorough, nuanced, or individualized assessment – when categorization becomes pigeon-holing.

We use many labels in our writings here, out of necessity, and we try to be consistent and thoughtful in how we define the labels that we use, recognizing that any sufficiently complex category will be necessarily fuzzy around the edges. We have certainly used a great deal of electrons discussing what exactly is science-based medicine, and that the label of so-called alternative medicine is really a false category, used mainly for marketing and lobbying (hence the caveat of “so-called”).

We get accused of using some labels for propaganda purposes, particularly “antivaccinationist” (often shortened to “antivaxer”). Also “denier” or “denialist”, as in germ-theory denier. Even though we often apply labels to ourselves, no one likes having an unflattering label applied to them, and so we have frequent push-back against our use of the above terms.

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A number of buzz-words appear repeatedly in health claims, such as natural, antioxidants, organic, and inflammation. Inflammation has been implicated in a number of chronic diseases, including diabetes, Parkinson’s, rheumatoid arthritis, allergies, atherosclerosis, and even cancer. Inflammation has been demonized, and is usually thought of as a bad thing. But it is not all bad.

In a study in Nature Medicine in September 2011, a research group led by Dr. Umut Ozcan at Children’s Hospital Boston (a teaching hospital affiliated with Harvard Medical School) reported that two proteins activated by inflammation are crucial to maintaining normal blood sugar levels in obese and diabetic mice. This could be the beginning of a new paradigm. Ozcan says:

This finding is completely contrary to the general dogma in the diabetes field that low-grade inflammation in obesity causes insulin resistance and type 2 diabetes. For 20 years, this inflammation has been seen as detrimental, whereas it is actually beneficial.

Increasing levels of these inflammatory signals might actually be therapeutic in diabetes and obesity. On the other hand, they might worsen inflammatory diseases like asthma and rheumatoid arthritis. Ozcan’s findings are intriguing and might eventually lead to new treatments, but there are no clinical applications as yet.

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I’ve subscribed to Nature for many years now, even though I don’t always read it. Nature is one of the oldest and most respected scientific journals around. It’s been around since 1869 and is said to be the world’s most cited journal. What makes Nature unusual these days is that it’s one of the last of the remaining general science journals and one of the two that still publish original peer-reviewed research in a wide variety of scientific fields. Astronomy, physics, chemistry, medicine, biology, Nature publishes it all. The only other journal of its type that I can think of is Science, which also has a similar high impact factor. In any case, getting published in Nature is a big deal, one that can make a career. Believe it or not, I actually have a Nature publication. True, it’s from the 1990s, and, true, I’m only the fourth author, but it is a Nature publication. Ever since then, I keep telling myself that, one of these days, I’ll manage to find a way to be published again in Nature, although I realize that it’s looking increasingly unlikely that that will happen. Such is the power and cachet of Nature. It’s a name that has provided prestige to some of its spinoff journals, such as Nature Medicine, although of late Nature appears to have diluted the brand name beyond belief.

Nature sells out

All of the above is why I’m very, very disappointed in Nature for having dropped a huge lump of coal into the stockings of supporters of science-based medicine a mere three days before Christmas. Maybe its editors thought that it wouldn’t be noticed right before the holiday season. I don’t know. I do know that I noticed. Basically, Nature sold out to a Japanese pharmaceutical company, which, along with a research institute, bought a supplement in Nature that is in essence an advertorial for its point of view. Don’t believe me? Check out this acknowledgment of the sponsors published in the advertorial:
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The demographic of SBM readers are likely to remember the early Miller Lite beer television commercials where sports personalities debated as to whether the beverage “tastes great” or was “less filling.” In one classic version, New York Mets’ Marv Throneberry breaks the shouting match to level his decision: “I feel strongly both ways.”

My colleagues at Science-Based Medicine have generally been opposed completely to the existence of the NIH’s National Center for Complementary and Alternative Medicine (NCCAM). The primary objection is that the Center awards roughly $125 million per year in taxpayer dollars to studies that are generally not based on a strong scientific foundation or, in some cases, absolutely no scientific basis. On the other hand, the best NCCAM-supported studies have provided fruitful results, if not negative with regard to clinical outcomes.

The recent series of articles by Trine Tsouderos at the Chicago Tribune (1, 2, 3, 4) has reignited a national debate as to whether NCCAM is needed at all. After all, NCCAM was not because of science but because of politics, particularly the efforts of Senator Tom Harkin and Representative Dan Burton. And other NIH institutes, such as the National Cancer Institute, seem to do a much more rigorous and science-based job of funding studies of alternative cancer therapies through their unfortunately-named Office of Cancer Complementary and Alternative Medicine, or OCCAM.

In fact, I have long argued that if alternative therapies are to be investigated rigorously, they should be done so under each of the specific NIH institutes and centers (ICs) that have been established to focus on organ systems (National Institute of Diabetes and Digestive and Kidney Diseases; NIDDK) or a class of related disorders (National Institute on Drug Abuse; NIDA).

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As glands go, we don’t give the butterfly-shaped thyroid that straddles our trachea too much  thought — until it stops working properly. The thyroid is a bit like your home’s thermostat: turn it high, and you’re hyperthyroid: heat intolerant, a high heart rate, and maybe some diarrhea. Turn it down, and you’re hypothyroid: cold, tired, constipated, and possibly even depressed. Both conditions are associated with a long list of more serious health consequences. Between the two however, hypothyroidism is far more prevalent. The mainstay drug that treats it, levothyroxine (Synthroid), is one of the most prescribed in the world.

One of my more memorable pharmacy experiences involved levothyroxine. The store had recently changed its prescription labelling standards: It switched from listing the brand name, to only including the generic name (with the manufacturer in parentheses). Few patients noticed. But one elderly patient, taking Synthroid, was furious, and accused me of making a dispensing error. I assured her that levothyroxine was the active ingredient in Synthroid, and she was getting the exact same product as her last visit — but she would have none of it. Her symptoms had worsened, she said, because the medication wasn’t the same. “I want Synthroid — this levothyroxine stuff does not work,” she screamed at me across the counter. No amount of reassurance would satisfy her — I think we eventually resorted to custom, typewritten labels.

I mention this anecdote not to dismiss the symptoms of hypothyroidism as sensitive to placebo effects — hypothyroidism is a real condition with objective monitoring criteria. But this episode was one of my earliest lessons in understanding how perceptions  can shape expectations of effectiveness — something that I’ll come back to, when we look at the controversies of this common condition. Any the treatment of hypothyroidism is not without its controversies – most of which occur outside the realm of medicine, and can more accurately be labelled pseudoscience. Continue Reading »

There are many medical pseudosciences that persist despite a utter lack of either plausibility or evidence for efficacy. Some practices emerged out of their culture of origin, or out of the prevailing ideas of a pre-scientific age, while others were manufactured out of the imagination of perhaps well-meaning but highly misguided individual practitioners. They were just made up – homeopathy, for example, or subluxation theory.

Iridology belongs to this latter category – a system of diagnosis that was invented entirely by Ignatz Peczely, a Hungarian physician who first published his ideas in 1893. The story goes that Peczely as a boy found an owl with a broken leg. At the time he noticed a prominent black stripe in the iris of one eye of the owl. He nursed the bird back to health and then noticed that the black line was gone, replaced by ragged white lines. From this single observation Peczely developed the notion of iridology.

Peczely’s idea was that the iris maps to the rest of the body in some way, and therefore the flecks of color in the iris reflect the state of health of the various body parts. This basic approach to diagnosis or treatment is called the homunculus approach – the idea that one part of the body maps to the rest of the body, including the organ systems. Reflexology, auricular acupuncture, and even straight chiropractic follow this approach.

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The holiday season is upon us. As a bit of a holiday from science-based writing, I thought I would offer some thoughts inspired by the season and not supported by any scientific evidence.

One of my friends refers to Christmas as “The Feast of St. Dyspepsia.” Holidays are indeed an occasion for over-indulging. People change their routine: they have time off work, they travel, spend too much money, go to parties, skip exercising, eat and drink things they ordinarily avoid, gain weight, and then suffer from post-holiday guilt.

Science and Mom both tell us we will be healthier if we eat our fruits and vegetables, exercise, avoid large quantities of alcohol, get enough rest, avoid stress, and control our weight. I would argue that if we follow that guidance most of the time, an occasional lapse is not likely to matter very much. And the pleasure we experience might even be good for our health.

Now for some heretical words.

Science isn’t everything. Health isn’t everything. Even truth isn’t everything. Humans find value in other things like music and mythology, things that bring great pleasure and help make life worth living.

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