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Is U.S. cancer care “in crisis,” as the Institute of Medicine proclaims?

Americans love to fight, traditionally. All real Americans love the sting and clash of battle…When you, here, everyone of you, were kids, you all admired the champion marble player, the fastest runner, the toughest boxer, the big league ball players, and the All-American football players. Americans love a winner. Americans will not tolerate a loser.

General George S. Patton, Jr. was famous for his flamboyance and aggressiveness going on the attack, among other things. He was also known for a number of pithy quotes made throughout his lifetime, particularly during World War II, such as the one above in which he declared how much Americans love to fight. I sometimes wonder whether he was more correct in that assessment than he knew in that we seem to view almost everything through the lens of war and a crisis that calls for a war. In medicine, for instance, we have the “war on cancer” and the “war on obesity.” We have a propensity for likening problems and their solutions to war, where the goal is to destroy the enemy.

Similarly, but less dramatic (although only slightly so), we have various crises. Indeed, Americans seem to love to compare problems to crises as much as they love to compare them to war. Of course, the two are closely related, as a crisis of some sort is a necessary prelude to a war. We can argue about the definition of a “crisis,” but one thing is certain. No matter how one defines it the word “crisis” implies an urgent problem and further implies that something must be done now—or at least very soon—to prevent the catastrophic consequences of that problem, which usually involve a breakdown of a current system. It was with these thoughts in mind that I approached the Institute of Medicine (IOM) consensus report released last week, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. It’s a behemoth of a report, weighing in at 360 pages, and it does indeed paint a picture of some very serious problems in cancer care that should be addressed. It is subdued in that it doesn’t engage in that oh-so-American tendency to declare “war” on every problem, but is cancer care “in crisis”? Of that, I’m not so sure, but it’s definitely got problems. But, as I’ve said, the system’s had problems for a long time, as the IOM itself documented in its 1999 report Ensuring Quality of Cancer Care, which concluded that “for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.” The report also recommended steps to improve cancer care and the evidence base for cancer care, and to overcome barriers of access to high-quality cancer care. As the introduction to the current report states:

These recommendations led to a number of efforts targeted at improving the delivery of cancer care. The Secretary of the U.S. Department of Health and Human Services (HHS) established the Quality of Cancer Care Committee to work on issues identified in the report. A number of organizations used the report to develop core indicators of quality of cancer care and recommendations for improving the quality of cancer care, including the Agency for Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF), and the National Dialogue on Cancer (a collaboration organized by former President George H.W. Bush and Senator Dianne Feinstein, now known as C-Change). In response to the report, the American Society of Clinical Oncology (ASCO) undertook a national study of the quality of care delivered by oncologists, called the National Initiative on Quality Cancer Care (ASCO, 2013). In addition, the Cancer Quality Alliance, a diverse group of stakeholders committed to advocating for improvements in the quality of cancer care, used this report and several other IOM reports to develop five cancer case studies depicting a vision for high-quality cancer care and a blueprint for action to realize that vision (Rose et al., 2008). The report provided major input into quality of cancer care legislation drafted by the Senate Health, Education, Labor, and Pension Committee

Not to blow my own horn (too much, anyway), I happen to be involved with two major quality improvement initiatives, one national through the American College of Surgeons Committee on Cancer and another statewide initiative seeking to improve the quality of breast cancer care throughout the state, not just at the two NCI-designated comprehensive cancer centers in the state and the several large health systems but at community hospitals as well. After all, most cancer care in this country does not occur at the 41 NCI-designated comprehensive cancer centers. It is clear to me that, since 1999, there has been a sea change in the attitudes of physicians regarding outcomes tracking to improve quality and adherence to evidence-based guidelines for the better. Physicians in the past were all too frequently wedded to a view in which a physician’s autonomy and every decision was unquestioned (and the choice of the word “his” was intentional, given how male-dominated the profession was) and they viewed attempts to persuade them to adopt evidence-based guidelines as intolerable infringements on their god-like autonomy. Today, they are much more receptive to following the guidelines, particularly in oncology. (Unfortunately, when it comes to the CDC’s recommended vaccine schedule we’ve seen an example of a physician who still follows the old-school, haughtily dismissing the recommended schedule because he thinks his clinical experience trumps expert, evidence-based guidelines. But I digress.)

Here’s a typical example of how the report is being discussed in the press:

Cancer treatment has grown so complex, many U.S. doctors can’t keep up with new information and are offering incorrect treatment, failing to explain options and leaving patients to coordinate their own care, according to a report released on Tuesday by the Institute of Medicine, part of the National Academy of Sciences.

The 315-page report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” identifies a long list of reasons for the crisis, including a growing demand for cancer care as more people receive a diagnosis and a shrinking oncology workforce.

“Probably on average the quality of care is not bad, but we know there are people who are not getting the (highest) standard of care,” said Dr Patricia Ganz, who chaired the institute’s panel that wrote the report and is a professor at the Schools of Medicine and Public Health, University of California, Los Angeles. “Patients need to be asking, Is my doctor giving me appropriate treatment?”

On its web page for the report, the IOM even includes a video designed to zero in on the issues discussed in the report:

The first thing I noticed about this video is that it does indeed touch on a number of prominent problems with the cancer care system, but that most of the problems discussed are in reality problems with the entire health care system that tend to be magnified in cancer care. The IOM identifies six items that it used as a conceptual framework on which to drape its solutions:

  1. Engaged patients
  2. Adequately staffed, trained, and coordinated workforce
  3. Evidence-based cancer care
  4. A learning health care IT system for cancer
  5. Translation of evidence into clinical practice, quality measurement, and performance improvement
  6. Accessible, affordable health care

The IOM also articulates ten goals for its recommendations:

  1. Provide patients and their families with understandable information about cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs.
  2. Provide patients with end-of-life care that meets their needs, values, and preferences.
  3. Ensure coordinated and comprehensive patient-centered care.
  4. Ensure that all individuals caring for cancer patients have appropriate core competencies.
  5. Expand the breadth of data collected in cancer research for older adults and patients with multiple comorbid conditions.
  6. Expand the depth of data collected in cancer research through a common set of data elements that capture patient-reported outcomes, relevant patient characteristics, and health behaviors.
  7. Develop a learning health care information technology system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings.
  8. Develop a national quality reporting program for cancer care as part of a learning health care system.
  9. Implement a national strategy to reduce disparities in access to cancer care for underserved populations by leveraging community interventions.
  10. Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste.

I don’t think I’ll be able to address all the issues, because each of the six items in the conceptual framework and goals have several recommendations to achieve them and the discussion would quickly balloon beyond the already prodigious verbiage of a typical one of these posts. (Also, I’m trying to make like Harriet and keep my posts a bit brief, at least under 4,000 words for a change.) So I’ll basically pick and choose, since a lot of these principles and recommendations are related. Let’s start with the issues that are basically the same issues that plague all of medicine, for instance an adequately staffed and trained workforce, a better IT system, and accessible, affordable care. All three of these are clearly interrelated, and tend to boil down to money, perverse incentives in the reimbursement system, and systemic inefficiencies. For example, if we want an adequately staffed, trained, and coordinated workforce, it’s going to require cash. From somewhere.

Fortunately, there are some actions that can be taken legislatively, and recommendations to change the system so that reimbursement for team-based care is more favorable are appreciated. Of course, recommendations for a shift to team-based care will conflict with recommendations to improve the number of trained providers, because team-based care can be quite inefficient. Multidisciplinary tumor care groups often see far fewer patients in a day because each patient is seen by all the specialties on the same day. For example, such systems can make it hard for surgeons to see enough patients to generate enough cases to generate enough revenue be financially viable. As long as surgeons are paid by the procedure, this will be a problem. Also, multidisciplinary teams require a significant infrastructure to maintain, and that doesn’t come cheap. Come to think of it, two of these goals (better IT, an adequately staffed and trained workforce) will likely conflict with making cancer care more affordable. True, it’s argued that this won’t be the case because better coordination of care, better cancer IT, and better staffing will reduce costs, but the evidence is rather thin to support these assertions.

In the case of IT and a better electronic medical record (EMR), certainly there would be benefits, as described in the report and greatly touted in the video, where one of the patients complained that lack of coordination between her doctors led to her being overdosed with an antihypertensive medication. The problem with coordinating care in the US is that there is no single unified health system, nor is there a single, unified medical record. Large health systems have common medical records, but that only helps if a patient is receiving all of his or her care in a single health care system. EMRs from different health care systems often don’t talk to each other. Transferring data from EMRs can be a nightmare. Worse, many of the existing EMRs are not exactly what one would call “user friendly.” Indeed, the EMR I’m stuck using can best be described as “user hostile.” After five years, I can honestly say that I still don’t fully understand much of it, and I’m not exactly computer illiterate. In fairness, I will point out that I haven’t put the time in to learn all the ins and outs of the system, but that brings up another point, namely that the up-front costs, in terms of money and time to implement an EMR, are enormous. Between lost productivity and the costs of implementation and maintenance, many private practices can’t afford it. Worse:

To make matters tougher on physicians, today’s EHRs are not really designed to “optimize speed of throughput for the clinician,” Haughton says. In many instances, a quick handwritten note in a patient’s chart is all that’s needed to record the encounter. Today’s EHRs, however, with their quality reporting and meaningful use integrations, make it challenging for doctors to complete their notes swiftly. They must enter, and often re-enter again and again, patient data that are not immediately germane to the medical issue at hand. Thus, it can take physicians a significantly longer time to input their notes into an electronic record than it took with their old paper processes—thereby increasing practice costs after EHR implementation.

Moreover, the advantages of adopting a health IT, for cancer or any other disease, are blunted if the systems can’t communicate with each other. Politically, it might never be possible to have a single EMR as there is an inherent distrust of the government having too much of our health information, something that would be facilitated by a single, unified EMR.

Of course, the EMR is only part of the better health IT so I don’t want to dwell on it too long. The overall recommendation was to have a “learning IT,” but I think that my brief discussion of EMRs is quite relevant, because this is what the IOM’s vision for a “learning health care system” includes:

Science and Informatics

  • Real-time access to knowledge – A learning health care system continuously and reliably captures, curates, and delivers the best available evidence to guide, support, tailor, and improve clinical decision making and care safety and quality.
  • Digital capture of the care experience – A learning health care system captures the care experience on digital platforms for real-time generation and application of knowledge for care improvement.

“Digital capture of the care experience” is, basically, the EMR. However, the IOM goes beyond that in wanting this digital capture to be able to be fed into a system that can track outcomes and be used for “real time” care improvement and improved clinical decision-making. This is a very tall order that would require considerable allotment of resources. The IOM states that many of the elements necessary are already in place, but if they are I can’t see them, and I’m involved in quality initiatives in my own institution, with the American College of Surgeons, and with our statewide collaborative. Data are not entered into our databases in anything resembling “real time,” despite our best efforts. I’d love to see such a system, although I’m perhaps a bit more skeptical of the claimed benefits for it; indeed, it would be highly useful to have such a system for all of medicine, not just cancer. Also in fairness, the IOM does recognize the difficulties and challenges involved in

Of most interest to me are the IOM recommendations regarding evidence-based oncology. Ironically, it’s hard not to point out that the evidence base for a lot of the health IT recommendations being able to do what they are claimed to be able to do is currently thin to nonexistent, but in terms of actual treatment there has been a major initiative over the last 14 years to improve the adherence to evidence-based guidelines in treating cancer patients. Although this has largely been fairly successful, the IOM points out that there are areas where current oncology practices fall short, particularly in the elderly, for whom the evidence base supporting some common treatments is disappointingly thin.

However, the IOM does make a good point that cancer care has become more complex in the last 14 years. That is arguably true, with the proliferation of genomic tests for various cancers, the attempts to administer “personalized” cancer treatment (or, at it’s now more often called “precision oncology“). Few diseases, or classes of diseases (which is what cancer really is, a large class of diseases) require as many specialties to treat it. Nearly every patient with a solid tumor (as opposed to hematologic malignancies) can expect to be treated—or at least seen—by a minimum of two specialties (medical oncology and surgical oncology) and most see a third specialist as well (radiation oncology).

Once the province of surgeons and local-regional therapies, cancer treatment has evolved rapidly in recent decades. Systemic treatments emerged in the 1950s and 1960s, initially as relatively nonspecific chemotherapies with limited efficacy in some human cancers. Empiricism dominated oncology drug development in this era, rather than an understanding of tumor biology. In recent years, researchers have developed treatments targeting specific molecular aberrations (e.g., imatinib for chronic myelogenous leukemia, trastuzumab for breast cancer). Molecularly targeted treatments have pervaded Food and Drug Administration (FDA) approvals in oncology in the past decade and have improved patient outcomes for many cancers. These agents commonly require a test to assess the drug target in the patient’s tumor. As such, companion diagnostic testing (e.g., estrogen receptor [ER] and human epidermal growth factor receptor-2 [HER2] in breast cancer, anaplastic lymphoma kinase [ALK] and epidermal growth factor receptor [EGFR] in non small-cell lung cancer) has increased in importance. The sheer number of targeted agents has increased the educational burden for cancer care clinicians and the financial burden for the healthcare system. In the near future, the implementation of genome-based diagnostics will likely alter both our ability to deliver precision medicine and the complexity of cancer treatment (IOM, 2010, 2012b; NRC, 2011).

Indeed, even the surgical treatment of breast cancer has become more complex. When we do a sentinel lymph node biopsy, for instance, what findings lead us to go back and take the rest of the lymph nodes? Should we do breast-conserving surgery or a mastectomy? When should neoadjuvant chemotherapy be given to shrink the tumor, and how do we predict the likelihood of success?

In any case, the recommendations of the IOM are on more solid ground here, and include requiring researchers evaluating the role of standard and novel interventions and technologies used in cancer care to include a plan to study a population that mirrors the age distribution and health risk profile of patients with the disease, as well as recommending that the National Cancer Institute should build on ongoing efforts and work with other federal agencies, the Patient Centered Outcomes Research Institute, clinical and health services researchers, clinicians, and patients to develop a common set of data elements that captures patient-reported outcomes, relevant patient characteristics, and health behaviors that researchers should collect from randomized clinical trials and observational studies. And, of course, the IOM is big on comparative effectiveness research (CER), which basically involves doing research that compares the effectiveness of two existing treatments. One problem with CER, however, as I’ve pointed out before, is that it sometimes takes so long to do clinical trials that by the time the results of CER studies are published their results might very well no longer be relevant to cancer care because the standard of care has moved to something different than the treatments being compared. So, yes, I like CER, too. However, I don’t know that its power is as great as its adherents claim.

I’m also very impressed with the IOM’s recommendations for improved palliative care and increased emphasis on palliative care. Five years ago, my mother-in-law was diagnosed with a recurrence of a particularly nasty form of breast cancer. This recurrence was in the form of widespread metastatic disease, clearly incurable. If there’s one thing that resonates with me it’s the deficiencies in palliative care in this country, particularly with respect to home care and home hospice. Once my mother-in-law was in inpatient hospice, the care she received was excellent, but while she was still at home the burden fell nearly entirely on my wife and her sister, with very little guidance. If there’s a gap in US cancer care, it’s there. I learned more than I ever had before about the “real world” during those months.

Finally, one very important part of the IOM report is its emphasis on patient-centered care. I’ve written about patient-centered care on multiple occasions before (for example, here), and I definitely believe that we do not always study the patient outcomes that matter to patients. The video above featured a woman who saw a “famous” oncologist about her cancer who recommended a very aggressive course of therapy even though she had stage IV (and therefore incurable) disease, and a man with stage I prostate cancer whose first doctor recommended very aggressive surgery. Neither, we’re told, were asked what they wanted or what they valued. Although I like to think that this sort of paternalism and “go for cure no matter what” attitude is becoming less prevalent, it still exists in a lot of oncology. That’s why it’s hard not to agree that patient-centered care is important. However, I always raise one caveat. The decisions and the trade-offs patients decide to accept should be informed by the science. The options presented to the patient, and their cost in terms of potential complications and impact on the patient’s ability to go about his daily activities and in essence live his life, must be based on science. The key is that we, as clinicians, must make sure that the patient has accurate, up-to-date, science-based information upon which to base his or her choice.

Let me just finish by pointing out that, my skepticism towards parts of this report notwithstanding, the IOM has demonstrated once again the difference between science- and evidence-based medicine and CAM. SBM rigorously questions everything about how it does everything and is continually trying to improve. Nothing is off the table, and we discuss our deficiencies and failures openly. I can’t help but contrast that to certain other areas of “medicine” frequently discussed on this blog. Even if I don’t agree with everything in the IOM report and suspect that the use of the word “crisis” was a means of getting attention more than an accurate description of the situation, the IOM itself deserves plaudits for its work in this area.

Posted in: Cancer

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103 thoughts on “Is U.S. cancer care “in crisis,” as the Institute of Medicine proclaims?

  1. Harriet Hall says:

    When the doctor has to take time to enter data into the computer, it takes up valuable time and diverts attention away from the patient. The clinic where I recently had a “health maintenance” annual checkup has found a workable solution. An assistant (I think she was a nurse) dealt with the computer while the doctor dealt with the patient. At the end of the visit, I was handed a 4-page printout of “Harriet Hall’s Care Plan.” It listed my vital signs, current medications, instructions for tests and referrals, and general information about the clinic (services, hours, phone numbers, how to make appointments, etc.). It also included brief comments about what I had discussed with the doctor. This system is efficient and patient-friendly, but it has the drawback of requiring an additional staff member in the exam room. It is probably more costly, but if it saves enough valuable physician time and improves accuracy and thoroughness, it might actually reduce costs in the long run: this could be tested.

    1. windriven says:

      Interesting, Dr. Hall. My internist enters the data herself. It is quick and unobtrusive, perhaps because of well thought out ergonomics for the equipment and good touch typing skills. I suspect there will be lots of refinements over the next few years.

    2. weing says:

      Wow. An emanuensis. I wish I could afford one.

      1. WilliamLawrenceUtridge says:

        Perhaps Sandra Courtney is available, she is an experienced medical transcriptionist. And if you’ve a bent for fraud, she will believe literally anything.

        1. weing says:

          As long as it’s nonsense.

  2. Carl says:

    I’m probably ahead of the world, but maybe we will eventually have good enough voice recognition stuff to have a computer figure out when the doctor says something relevant, and the doctor just hits a button on the tricorder to confirm that they are telling the patient to take a pill or whatever. They could do it on the fly, or the computer could queue up everything and the doctor could just check it all off to confirm at the end.

  3. duggansc says:

    I work for a company that does voice recognition software for EHRs. It’s getting better, but it’s surprisingly tricky to figure out the context of what’s being said, particularly when doctors are jumping around fields. One of the next steps involves expert systems to catch simple mistakes that could have large consequences (to use a somewhat extreme case, imagine if a doctor recorded several entries regarding the spread of infection in the left leg and then accidentally puts down his recommendation to amputate the right leg. Or somehow his prescription for 15 mg of medication gets misheard as 50 mg), and to request more information in cases where the doctor only provided the basic details (for example, if the doctor says they see a rash on the patient’s left leg, the EHR should probably note that he should state the type of rash and more specific location). *wry grin* And, of course, all this while dealing with a wide range of accents and background noise.

    On a side note, I read an interesting article on the reduplication of information. We have seen in the field several cases of people cutting and pasting past history into a note and modifying things that have changed with mistakes sticking around because each shift assumed that the doctor before them made that measurement or notation. It can get even more complicated if abbreviations or codes within a hospital change over time, making the history seem to say things that it isn’t actually saying. Some companies push back by forbidding copying and pasting, but human ingenuity always seems to prevail for finding an easier way…

  4. rork says:

    I do not trust doctors to say whether filling out EMR is good or not, if they are just telling us stories about what they think. They are just bellyaching, unless they have data that I care about.

    Docs are used to doing mostly high-value stuff with the dumb stuff often done by others. Is it the case that they could enter some data directly and save on some staff and have that be a win overall? That’s the question. I’m ready for some experiments where actual care providers do work with the goal of reducing staff.

    In the lab it is simpler. Try figuring out which 50 patient samples you should pull from a collection of 50000 samples in the freezers to do a certain experiment, without a computer system holding a description of the samples. You’ll be more interested in populating such a database after that, I assure you, even if it costs you time doing some boring things every day.

    1. David Gorski says:

      Out of curiosity, have you ever actually used an EMR? Because the usability thing is not a trivial complaint, as any health care provider who’s worked with, for example, Citrix, knows. It’s a massive time suck. I still can’t figure out why software vendors can make lots of other forms of software user-friendly but when it comes to EMRs, they’re pretty much all user-hostile to one degree or another. Sure, you can point out that some docs don’t want to take the time to learn it, but more and more docs never knew anything other than an EMR because EMRs were there when they were in medical school. Usability is still a problem.

      1. windriven says:

        it takes time to get these things right. When Microsoft released the first tablet devices in 2002 the world groaned. When Steve Jobs released the first iPad a few years later he was a genius.

        EMR will get nothing but better.

      2. rork says:

        No I haven’t used EMRs, but I sure did not mean to say usability is not a problem, or that docs aren’t allowed to complain about that. I have designed, built, and populated laboratory information management systems for proteomics labs. This goes to mouse @#7 too: it took me and 2 operations engineers years to build, fail, and rebuild what we needed. It’s better if the designer is in fact a user, and is painfully aware of the usability issues. I was.

        1. Oh, I misunderstood, then. Sorry. Personally, I’d suggest, in this case, that’s it better to have an experienced designer working closely with a group of users. But, I was a graphic designer/web designer, so obvious bias there.

  5. For record keeping, I’d expect a combination of the method HH mentioned and better interface/information design would help. Our pediatrician office and doctor has the nurse who does blood pressure, etc update the patient records and write in complaint, then the doctor finishes the form.

    But, watching folks work with those system make me suspect that many of them are not user-friendly or efficient. It’s a shame.

  6. Rork “I do not trust doctors to say whether filling out EMR is good or not, if they are just telling us stories about what they think. They are just bellyaching, unless they have data that I care about.”

    When I worked in ecommerce, I never heard my coworkers say, “I don’t trust the user to say whether the shopping experience is good or not.” It’s true, you can’t trust the user to tell you what’s wrong with the interface, but if a good percentage of users hate it, then that a reliable sign that the interface should be looked at from a usability, time to complete task perspective.

    I suspect that one problem is that usability is only one factor, maybe not even a very big one, when purchasing these huge systems.

    1. duggansc says:

      Of course, as with many other large systems, part of the problem is that the client is not the user. EHRs are sold to hospitals. They pay the bills and thus make the specifications. Unfortunately, that means that doctors aren’t always involved in the design. And of course, by the time they realize the usability issues, they’re stuck with it because almost every EHR uses a file format incompatible to that of its competitors to ensure lock-in. The Microsoft analogy is very apt.

      1. Young CC Prof says:

        Our institution went shopping for a new learning management system last year, and it was a little surreal. The administration and the vendors are talking bells and whistles, while the faculty (the ones who actually took an interest in the process, anyway) wanted to know things like reliability, uptime, ease of integration with our registration system, and how many mouse clicks it would take to change a single student’s grade.

        The demos were kind of like car shopping. Except we couldn’t see the prices on any of the cars, and we didn’t know how much money was in the budget, anyway. We were fairly sure we couldn’t afford a new car, though, and we’d have to buy one that was a few years old. “Ah,” says the dealer, “I’ll take you for a test drive in this one! I’ll drive, you get in the backseat.” And then you go on a test drive where you can’t take the wheel, can’t kick the tires and can’t look under the hood. You go to another car dealership, same thing happens. Then someone asks you which car you want.

        Moral: Even when you ask the users what they want, the users often can’t provide useful feedback at the time the information is needed.

  7. DugganSC – Yes, good point.

  8. angorarabbit says:

    I’d like to hear what users think of Epic EHRs. I attended our university’s graduation when they awarded the Epic founder and CEO an honorary doctorate, and she made much hay that she never actually finished that computer science master’s degree. I have many friends who are ex-Epic employees as the installs are so grueling; one became a city cop because it was less stressful*. Our airport’s security screening area has adverts telling Epic employees to come work for us instead because the conditions are so much better. So I’ve oft wondered if the software is as bad as the company itself to work for. The comparison to Microsoft is apt – they are building a massive campus just south of here.

    *and after they learned of her work experience they shifted her out of the patrol car and over to run their computers.

    1. Marcus says:

      I had some experience using Epic as a student. For reasons that I can’t quite specify, I never really took to it. I’m currently using the VA’s system (CPRS) and, at least in my experience, it’s been better.

    2. weing says:

      I’ve heard Epic is good. Currently using Allscripts. You know the saying about the other guy’s grass being always more potent or greener. I think these companies bribed some politicians to force us to adopt their inferior products so that they could get rich. Were there studies done to show how we were able to see more patients in less time with more comprehensive care by using the EHR? I bet the drug companies could learn something from these guys.

      1. weing “Were there studies done to show how we were able to see more patients in less time with more comprehensive care by using the EHR? I bet the drug companies could learn something from these guys.”

        As a patient (and parent of a patient), It’s been a lot easier since our doctors got EMR. It has eliminated all the schlepping around to get releases of paper test results or imaging or things faxed, doctors missing previous test results or health history from other doctors, because we didn’t have them in hand and having no way to get at them during the appointment. It’s just a ton easier and it really seems more accurate/reliable.

        Not that I don’t sympathize what a pain it must be to work with an inferior product. I personally believe there is a special place in hell for people who design bad forms or interfaces for a captive user.

        1. weing says:

          @mtr,
          I am not a luddite. I started using a DOS based system in 1993. They have improved since then but they are still far off from what we need. They slow me down tremendously. Too many clicks, too much waiting between clicks, my mind and the patient are already several clicks ahead and the damn cursor is in seizure mode. I think I’m developing ADD from it. IT says it can’t run any faster. There’s all sorts of security software running in the background that slows the system down. It is a bottleneck.

          1. @weing – I don’t get it. The thought that you were a Luddite didn’t even occur to me when I was writing that comment. and I believed your complaints were valid. Either I’m being clueless or you’re being touchy. I’m often clueless, so apologies for any offense.

          2. weing says:

            @mtr,
            It must be me. Been playing first person shooter games too much. Tends to make me pugnacious. Gotta get the new Grand Theft Auto.

          3. @Ha – no worries either way then.

    3. MadisonMD says:

      Angorarabbit. You must live very close to me. I use Epic daily. It is OK. Some notes are very difficult to read– housestaff and students get used to pulling in all kinds of extraneous information. Sometimes it is hard to use. Nothing can be done in a patient chart outside of an ‘encounter.’ But overall, it is better than paper and several other EMRs I’ve worked with in the past.

  9. Shoot, my above comment was in response to Angorarabbits story on former Epic employees. Not just general hilarity.

  10. Self Skeptic says:

    I read the report.

    The “crisis” referred to in the IOM report is financial. See the section beginning on page 2-15,”Unsustainable Cancer Care Cost,” and Chapter 8. It’s no news that the health care industry is currently consuming more than 17% of the US GDP, and that this is problematic. If US health care costs were in line with other developed nations, which have equal or better outcomes, they would be almost halved. The usual argument offered by the US health care industry (including doctors, insurance companies, pharmaceutical companies, and other beneficiaries) is that the US is picking up the tab for research, for the rest of the world, and that accounts for the discrepancy. But the pharmaceutical business only reinvests 12% of its profits in research, and it seems likely that claims by other parts of the industry (including academia) are similarly skewed.

    As the SBM bloggers know, the opportunities for making money offering marginally effective cures to the sick are very tempting, and there’s little evidence that academic doctors are not swayed, consciously or unconsciously, by them. (I know this is not a frequent topic at SBM blogs; maybe considering the excessive financial burden of medicine in the US, it should be?) There is abundant evidence that clinical guidelines, care pathways, reviews, and the primary medical evidence itself, are not scientifically rigorous in many (most?) cases. Much of this is probably due to the almost insurmountable difficulty of adequately controlling variables in clinical research, compared with laboratory science, but some of it is surely due to high careerist and/or financial stakes, coupled with self-regulation.

    I keep wondering when the SBM blogs will follow Ben Goldacre’s example, and start including the task of of putting mainstream medicine’s house in order. (Granted it is a Sisyphean task, but so is complaining about non-mainstream quackery.) It would require applying critical thinking to the field in which the bloggers are currently employed; but failing to do that falsifies the claim that “Science-Based Medicine” is being offered here.

    1. David Gorski says:

      I keep wondering when the SBM blogs will follow Ben Goldacre’s example, and start including the task of of putting mainstream medicine’s house in order. (Granted it is a Sisyphean task, but so is complaining about non-mainstream quackery.) It would require applying critical thinking to the field in which the bloggers are currently employed; but failing to do that falsifies the claim that “Science-Based Medicine” is being offered here.

      Ah, yes. The old, “Why do you concentrate on quacks so much when mainstream medicine has so many conflicts of interest and problems?” ploy. It’s not as though we haven’t heard this tired old trope many, many times before.

      Actually, we do include the task of putting mainstream medicine’s house in order. You obviously haven’t read our critiques of mainstream practices, issues and conflicts of interest that affect the objectivity of research, issues that affect the science in bad ways (just search for “Ioannidis” on SBM and you’ll find how much most of us are admirers of his work), etc., etc. While it is true that these are not the main concern of SBM and therefore garner less verbiage than issues of quackademic medicine, alternative medicine, and the like, we do cover them and not infrequently. If you don’t see that, you obviously aren’t a regular reader.

      Here’s the thing: There are plenty of people and groups that already work on those problems, and they include, for instance, Ben Goldacre. They are very good at it; many of them are far more prominent than us. In contrast, there are precious few people and groups that pay attention to the sorts of issues that we at SBM pay attention to. We’ve chosen our primary niche because it is an underserved niche and a problem that is largely unrecognized among our colleagues. It is the issue where we think we can have the most impact. However, we do not limit ourselves to that niche.

      1. I’m not sure that it was nessacarily a ploy. I’ve often wondered why SBM didn’t focus on mainstream medicine more. I guess I’m being self serving as a patient, I feel like I’m okay at identifying many of the quack therapies that you all cover as questionable. But I find myself much more uncertain about how to deal with inconsistent recommendations and confusion when dealing with mainstream medicine. I hoped more article focused on mainstream medicine might help me.

        Hearing your rational, the editorial choices makes more sense to me, now. I was under the mistaken impression that Goldacre was also focused on CAM. I’ll have to check out his work, see if that’s helpful.

        1. David Gorski says:

          I can usually tell by the tone and writing style whether it’s a trope or not. Sometimes I’m wrong, but I doubt it in this case, particularly since this is, as far as I can tell, the first time this guy has commented here, which makes me wonder if it’s just a drive-by comment. We’ll see soon enough.

          In any case, we can only do so much. There are only a handful of us, and most of us have demanding full time day jobs. How, for example, Steve does all he does I have no idea. I find just blogging here, editing here, and blogging at my not-so-super-secret other blog, along with my occasional speaking engagement to be quite a lot. So we have to focus. We can’t do everything. There is no inconsistency.

          Ben does focus on CAM, or at least he did. Lately he seems to have shifted his focus more toward “conventional medicine” and the pharmaceutical industry.

          1. You may be a better judge on an intentional trope than me. I try to cultivate pollyanna expectations that are crushed repeatedly each day as I see perfectly normal people, just asking innocent questions revealed as people who obviously had an agenda all along.

            Regardless – I just found myself in agreement that there is a compelling need for improvement in some areas of conventional medicine in the U.S. and that it’s be good to hear more about it from folks who’s analysis I find enlightening.

            The problem with being good at what you do is that everyone wants to give you their top priority job.

            I appreciated hearing your reasoning, though.

    2. duggansc says:

      Dr. Gorski has covered the issue of SBM addressing modern medicine concerns as well, so I’m just going to put in that the fact that health care is simply more expensive in the United States is indeed a major issue (there’s a decent and entertaining breakdown at http://www.upworthy.com/his-first-4-sentences-are-interesting-the-5th-blew-my-mind-and-made-me-a-little-sick-2?g=3 FWIW). There are some aspects of cost of research (as pointed out in the above video, many countries have the government pick out the “best” provider of a given technology and giving them the contract while in the United States, it’s kind of catch-as-catch-can with sometimes seemingly very little accountability if a given company is bad at their job) but overall, costs are simply higher, and it’s entrenched enough that no one can really step out and say “Alright, enough is enough. It only costs us $X to provide this care including overhead and doctors do just fine on $Y salary, so we’re going with that” because a lot of the qualified works would simply go with the companies that are still offering the higher salaries. There’s a bit of a parallel with engineering. Within the United States, engineers, including software engineers, receive a very high salary upon exiting college, usually at least $60k without experience. Compare that to the situation in the U.K. (at least according to engineers I’ve talked to from there) where engineers are considered tradesmen and a starting salary for an engineer isn’t really all that different from that of a bricklayer.

      I honestly don’t think we’re going to reach a solution unless either a) the government steps in and forces lower pricing (unlikely because it’s very contrary to how the average citizen feels our country works) or b) some hospital starts offering care at affordable prices and gradually everyone has to follow that model (again, unlikely short of government intervention because, frankly, a lot of qualified workers won’t work for you because they could make more money elsewhere and a lot of consumers will equate “cheaper” with “worse”. That’s not even getting into the fact that there are a lot of forces in place to maintain status quo from people profiting from the situation to unions who don’t want their salary reduced). The more likely case is somewhere in between with the government offering subsidies for companies who make steps to cut costs, but unfortunately, lobbyists will likely neuter any such bill to the point where it makes things worse. Just look at how biofuel subsidies are handled.

      So yeah, complicated problem, but expense is indeed a huge thing that will need a lot of patching.

    3. weing says:

      “There is abundant evidence that clinical guidelines, care pathways, reviews, and the primary medical evidence itself, are not scientifically rigorous in many (most?) cases.”

      References, please. In case you haven’t noticed, non-mainstream quackery has penetrated into Academia and Integrative Medicine divisions in hospitals. We can’t even get at the low-hanging fruit. I agree. We need a new Flexner to come around and purge our medical schools and hospitals of everything that is not science-based. We could then start with comparative effectiveness studies.

      1. pmoran2013 says:

        We shouldn’t be too sensitive concerning allegations that we are not as solidly science-based as we like to think. Our very own, former “Gold Standard” of evidence for medical efficacy (the RCT) has taken some serious hits in recent decades.

        Who would have thought homeopathy and many other unlikely methods could have produced as many positive studies as they have? We have had to downgrade that kind of evidence by invoking prior plausibility as an essential factor for their interpretation.

        Then, even within our own research, where plausibility is not often a major concern, we have had Ionnadis demonstrating how much of it has been delivering wrong answers, and why. Some of us like to invoke that to counter positive CAM research, when it is also a deeply disturbing comment on our own scientific pretensions.

        And in the practical application of the research we have had to too often change our minds as to the effectiveness and safety of once widely used methods.

        So let’s be prepared to wear our own lumps, if we are going to dish it out as much as we do. Relatively speaking we are streets ahead of CAM, the main difference being the dependence of the latter on anecdotal evidence. That is not necessarily invalid in all respects. It is simply usually open to too many different interpretations.

        1. weing says:

          “And in the practical application of the research we have had to too often change our minds as to the effectiveness and safety of once widely used methods.”

          But we do change. That is not at all a bad thing. Science is self-correcting. It does not claim we have all the answers. Only the way to get them.

      2. Self Skeptic “There is abundant evidence that clinical guidelines, care pathways, reviews, and the primary medical evidence itself, are not scientifically rigorous in many (most?) cases.”

        weing “References, please.”

        Sorry weing – You probably know all this and don’t have time to listen to redundancy. But I’m using your request for references as a jumping off point for others who might be looking for info.

        I listening to this Goldacre guy yesterday on TED talking about prescription drug research.

        http://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe.html

        Urgh. That was kinda depressing.

        Then I listened to Gawande talking about how broken processes increase cost and lowers health benefits and a proposed solution, checklists.

        http://www.ted.com/playlists/70/what_doctors_worry_about.html
        Which slightly more interesting than depressing also good points.

        I think Harriet Hall had a post on checklists awhile back, if someone’s interested they can search.

        1. Harriet Hall says:

          “I think Harriet Hall had a post on checklists”
          Not me. Steven Novella: http://www.sciencebasedmedicine.org/checklists-and-culture-in-medicine/

          1. Damn, here I was congratulating myself on my wonderful memory*. :)

            Thanks HH.

            *Not.

        2. weing says:

          @mtr,

          You should read Goldacre’s book. The shenanigans of the pharma industry have made it very difficult for us. We need comparative effectiveness studies. I particularly liked his idea of using the EHR to enter our patients into such studies and using this database for outcomes analysis.

          1. duggansc says:

            Oof… that goes straight into what I said above about how every EMR/EHR is specifically engineered with a different file format to prevent records from being migrated. You’ll get the same issue trying to collate data, I suspect.

          2. @weing – Maybe I should. But, I found just the TED talk pretty darn depressing. As a patient, it just makes me feel helpless because I don’t see anyway that I can influence the situation.

            (Or I maybe hitting that 3rd day post cortisone shot mood swing)

            It is good to see that doctors are thinking about it and discussing possible solutions, though.

    4. WilliamLawrenceUtridge says:

      Why don’t you follow Ben Goldacre’s example and start on the task of putting mainstream medicine in order? Blogs are free, feel free to start one.

  11. weing says:

    @duggansc,

    There is a requirement of interoperability of the EHRs in order to qualify for meaningful use next year.
    http://www.informationweek.com/healthcare/interoperability/ehr-interoperability-a-hot-topic-at-hims/240150443

  12. Self Skeptic says:

    A.
    MTRoared said, “…I feel like I’m okay at identifying many of the quack therapies that you all cover as questionable. But I find myself much more uncertain about how to deal with inconsistent recommendations and confusion when dealing with mainstream medicine. ”

    Yes, you hit the nail on the head. It’s easy to spot CAM, and not to use it (unless you count an occasional massage for a sore muscle). But when it comes to mainstream medicine, it’s not at all easy to tell which things work well, and which have been overhyped, either for financial gain (=financial COI), or misplaced enthusiasm (=non-financial COI). Similarly, one can’t tell which interventions are very safe, and which aren’t, due to the risks having been incorrectly evaluated.

    B.
    Weing said, “References, please.” in response to my sentence “There is abundant evidence that clinical guidelines, care pathways, reviews, and the primary medical evidence itself, are not scientifically rigorous in many (most?) cases.” It seems that Goldacre’s book “Bad Pharma” has been cited. I suspect that careerist pressures and ambitions in academia also play a role.

    At the recent 7th Peer Review Congress, organized by BMJ and JAMA, there were two sessions about bias, including a talk about spinning conclusions in abstracts in the medical literature. See summary of the conference topics here:
    http://www.peerreviewcongress.org/2013/Final-Program.pdf
    Note especially:
    “Impact of Spin in the Abstract on the Interpretation of Randomized Controlled Trials [/color]in the Field of Cancer: A Randomized Controlled Trial
    Isabelle Boutron, Douglas G. Altman, Sally Hopewell, Francisco Vera-Badillo, Ian Tannock, Philippe Ravaud (FRANCE, UNITED KINGDOM, CANADA)”

    An open access paper by these authors is available here, in PLoS:
    http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001308
    “PLoS Med. 2012;9(9):e1001308. doi: 10.1371/journal.pmed.1001308. Epub 2012 Sep 11.
    Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study.
    Yavchitz A, Boutron I, Bafeta A, Marroun I, Charles P, Mantz J, Ravaud P.
    Source
    INSERM, U738, Paris, France.
    Abstract
    BACKGROUND:
    Previous studies indicate that in published reports, trial results can be distorted by the use of “spin” (specific reporting strategies, intentional or unintentional, emphasizing the beneficial effect of the experimental treatment). We aimed to (1) evaluate the presence of “spin” in press releases and associated media coverage; and (2) evaluate whether findings of randomized controlled trials (RCTs) based on press releases and media coverage are misinterpreted.
    METHODS AND FINDINGS:
    We systematically searched for all press releases indexed in the EurekAlert! database between December 2009 and March 2010. Of the 498 press releases retrieved and screened, we included press releases for all two-arm, parallel-group RCTs (n = 70). We obtained a copy of the scientific article to which the press release related and we systematically searched for related news items using Lexis Nexis. “Spin,” defined as specific reporting strategies (intentional or unintentional) emphasizing the beneficial effect of the experimental treatment, was identified in 28 (40%) scientific article abstract conclusions and in 33 (47%) press releases. From bivariate and multivariable analysis assessing the journal type, funding source, sample size, type of treatment (drug or other), results of the primary outcomes (all nonstatistically significant versus other), author of the press release, and the presence of “spin” in the abstract conclusion, the only factor associated, with “spin” in the press release was “spin” in the article abstract conclusions (relative risk [RR] 5.6, [95% CI 2.8-11.1], p < 0.001). Findings of RCTs based on press releases were overestimated for 19 (27%) reports. News items were identified for 41 RCTs; 21 (51%) were reported with "spin," mainly the same type of "spin" as those identified in the press release and article abstract conclusion. Findings of RCTs based on the news item was overestimated for ten (24%) reports.
    CONCLUSION:
    "Spin" was identified in about half of press releases and media coverage. In multivariable analysis, the main factor associated with "spin" in press releases was the presence of "spin" in the article abstract conclusion."

    Spin in press releases, although bad, isn't as worrisome to me as spin in article abstract conclusions. Unfortunately, writers of medical review articles are often not skeptical about spin in abstracts, especially if it comes from a field's dominating experts. This compromises the evidence base of guidelines and care pathways, even if the authors were not themselves involved in financial or non-financial COIs.

    Finally, elite mainstream press like the WSJ and the NYT tend to be naively accepting of medical PR from respectable universities. So it's a buyer-beware situation for the public.

  13. Chris says:

    All the more reason to get yourself down to your local medical school library to read the actual paper and not just abstract.

    Also, never believe press releases: http://bad-pr.tumblr.com/

    And more from the above blogger: http://www.merseysideskeptics.org.uk/tag/bad-news/

  14. Chris says:

    By the way, the editors of this blog and their long time readers are very much aware of the disconnect between the abstract and the papers. The editors have written many articles to that effect on this blog, and their own personal blogs (some that some readers have followed for almost a decade).

    Even if some of their long time readers are not medical care professionals, we are not stupid.

  15. Self Skeptic says:

    @pmoran,
    Nicely said. Thanks for commenting.

  16. Self Skeptic says:

    @Chris Yes, I agree people who are going to depend on a result, comment on it, or cite it, should always read the whole paper carefully. But I doubt that busy doctors do much of that; you can see from Dr. Gorski’s comment above that his time and effort is already fully committed. It takes a couple of hours to read a paper and analyze the data critically. I’m beginning to doubt that even the peer reviewers are doing a thorough job. Maybe that accounts for so many papers getting into journals with conclusions in the abstracts, that aren’t supported by the data.

    1. weing says:

      According to the article below from 2004 it’s easier for the doctor to just skim the relevant literature to keep up. It would only take him/her 29 hours a day of skimming to keep up.

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC521514/?report=classic

      1. Self Skeptic says:

        @weing,
        Ha, great citation! Thanks, I’d never seen it.
        Evaluation of sample articles found that the time spent evaluating individual articles ranged from 0.18 minutes (for an article quickly deemed irrelevant) [24] to 39.5 minutes [25], with the exception of 1 outlier (taking up to 133 minutes to evaluate one citation [26] that represented 34 abstracts from a conference). No articles required formal critical appraisal and detailed summarization. The average times per article spent by the 5 physicians were 1.82 minutes, 1.83 minutes, 3.88 minutes, 4.03 minutes, and 14 minutes, with an overall average of 5.16 minutes. Sources of variation among the 5 physicians include levels of experience processing articles for clinical references, reading pace, format in which articles were read (electronic or print), and decisions regarding how much information was clinically relevant. One outlier spent considerably more time evaluating articles and summarized more information. Average time per article was 2.89 minutes, if this outlier was excluded.

        Extrapolating this estimate to 7,287 articles per month, this effort would require 627.5 hours per month, or about 29 hours per weekday, or 3.6 full-time equivalents of physician effort. If excluding the outlier (i.e., basing estimates only on physicians with higher thresholds for clinical relevance), the estimated effort would be 351 hours per month or 2 full-time equivalents of physician effort.

        So even at an average of 5 minutes per article (which is of course only enough time to skim it, not read it and think about whether its stated conclusion is true) it can’t be done. It’s the worst for primary care, of course. No wonder people specialize: not just higher pay, but a lot less to know. On the plus side, it seems to change slowly. On the minus side, when guidelines are wrong and doctors follow them, a huge number of patients get mistreated.

        I think this problem of not being able to actually read the literature tells us two things;
        1) the system of rewarding people by how many articles they publish is counter-productive, as it causes people to publish even when they don’t have anything important to say, and the few important things gets drowned in the noise.
        2) Letting papers get published with exaggerated conclusions stated in the abstracts is really, really bad. Again, the most likely explanation is that it is a problem of too many papers, and too-busy medical academics with no time to do thorough peer review. Once standards for publishing get low, it’s hard to make them more rigorous. But the alternative is to keep publishing articles that are misleading. I wonder if it would be possible just to get people to tighten up on the abstracts and conclusions? But they’d still have to analyze the arguments and data, to figure out that they’re exaggerated, and that takes time.

        1. Self Skeptic says:

          Oops, I tried to use quote tags but it didn’t work. The quote is 2 paragraphs,
          “Evaluation of sample articles…equivalents of physician effort.”

        2. Chris says:

          Take note that one of this blog’s authors has this particular medical blog:
          http://edgydoc.com/puscast/

  17. Self Skeptic says:

    @duggansc,
    The Upworthy video of John Green is great! Thanks for posting the link.

  18. Chris says:

    See http://www.sciencebasedmedicine.org/?s=abstract

    It gets covered. Including some very choice words for the peer reviews.

    1. Self Skeptic says:

      Good! Glad to hear it.
      I’ll look forward to reading thoughtful critiques of non-CAM mainstream medicine, here at SBM, in the future.
      Here’s a blistering example from another source, looking at the system from the outside. (I’ve noticed that SBM prides itself on not pulling punches, so I won’t worry that the tone is too aggressive.) The comments are good, too.
      http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/#postComment

      BTW, the comments are good on that 2009 Val Jones post (your second link). Evaluating science by the prestige of the researcher, the institution, or the journal is a very bad habit, though a common shortcut/timesaver in medicine. A lot of superficially plausible, but inadequately demonstrated, ideas get propagated that way. It’s the opposite of science.

      1. David Gorski says:

        I’ll look forward to reading thoughtful critiques of non-CAM mainstream medicine, here at SBM, in the future.

        They already exist, and you would have found them if you had bothered to look. However, they are not our main focus at SBM (and likely never will be) because that is not the niche we have chosen. Complain about it all you like, I don’t really care that much. Enough to make this comment, but not much more. I’ve already explained in detail why we have the emphasis we do.

        1. Self Skeptic says:

          Thanks, I appreciate that you’ve registered my opinion. I was talking to Chris, who thinks that SBM is thoroughly covering the other serious issues in mainstream medicine, despite your previous explanation of why you are focused on debunking CAM. Maybe this comment of yours will help explain SBM’s agenda a little more clearly, to those who were perhaps confused by its title.

          1. Chris says:

            “Thanks, I appreciate that you’ve registered my opinion. I was talking to Chris, ”

            Total fail. You do not get to decide who responds to your comments on a public blog. Are you new to this thing we call the “internet”?

          2. David Gorski says:

            Look, you’re not the first person who’s shown up here imperiously taking us to task for not blogging about what you think we should blog about. I don’t have a lot of patience for such people anymore, having dealt with them over the years. My response tends to be on the order of: You don’t like our blog? You don’t think we write enough about mainstream medical misadventures? Fine! Don’t read it. Of course, if you had bothered to click on the tab above “About the Science-Based Medicine blog” (see, it’s right there at the top of the page), you’d get a brief description of our mission and some posts that hit what SBM is and why it’s different than EBM.

            But, seriously, you seem to be here more to whine about what we don’t write about. As I said before, we write about what we right about. You clearly leapt in here as a newbie and started complaining, and the content of your complaints demonstrated to me that you don’t really know what we’re about or why. That’s not surprising. As I said, I’ve seen your kind in the comments many times before.

      2. Chris says:

        It is really bad form to tell a blogger what to write. It is even worse when you tell him what to write without bothering to see if your desired content was already on the blog.

        1. Self Skeptic says:

          @Chris,
          Hmm, then it must also be bad form to tell a commenter what to write. But that means I shouldn’t tell you not to tell me not to tell the blogger my opinion about his opinion about…geez, it’s late. Sorry I annoyed you. Thanks for the links. Did you notice I followed up on your comment about reading the whole paper?G’night.

        2. David Gorski says:

          Heh. After realizing that some of what he wants is on this blog, he’ll complain that there’s not nearly enough of what he wants for his liking. Then, if we were to try to write more about what he wants, he wouldn’t be satisfied until we wrote about nothing but mainstream medical deficiencies and misadventures. Then, if we did that, he’d complain that we were far too easy on mainstream medicine. You see, as the old Elton John song goes, I’ve seen that movie too.

      3. Chris says:

        “Here’s a blistering example from another source, looking at the system from the outside. ”

        So you have decided that the actual medical doctors who write this blog would benefit from a journalist’s perspective. How insightful of you, especially when you have proven that you have not even bothered to read the archives of this blog.

        I have a very special child. The birth of this child is why I am no longer an aerospace engineer, firstly due to the seizures he had on his second day of life. This child is the reason that the numbers “911″ were dialed from our phone more often than I can calculate. Plus the reason we have figured our way around multiple hospitals, including the Mayo Clinic in Minnesota.

        Do not deign to tell me how to think. Do not even think that you can comprehend what it takes to deal with real medical issues. Do not even think you can understand what it takes to get a PhD or a medical degree. I know a bit of what it takes since I have dropped out of graduate school twice (usually due to financial issues, but I know what it takes to be in graduate school).

        From my perspective, you are looking at superficial issues. Things that those of us who deal with real medical issues feel are minor annoyances, but do not count when reality set in. Because, what really matters in the end? A dead or a live child? Just this past week a high school kid in are area died suddenly from the reason my son had surgery. My kid had his condition diagnosed because he had a heart murmur during a “well child checkup” when he was fourteen years old, that I thought I would have to pay for since insurance had decided they don’t happen after age four (our family doctor told me he was overdue for a tetanus shot!). Shouldn’t all kids get that? Shouldn’t we find those heart murmurs before they are fatal?

        Come on. You seem to want to be an expert, you tell us what medicine should do. Tell us exactly why we should listen to a journalist or to you. Because I am a mother of a special needs kid, and I think you do not know anything.

        1. Self Skeptic says:

          @Chris
          I’m sorry to hear about your child. I hope you are finding support and comfort, here and elsewhere. I also have sick family members, and they have suffered from mistakes in mainstream medicine, too. I think most people have some experience with this, by my age. I’m in my late 50′s, and I’m a PhD scientist in a medically relevant field. I am disturbed by the lack of rigor in the medical literature, and I feel it contributes to mistakes like those my family experienced.

          Perhaps we should get to know more about each other, before criticizing each other’s responses.

          You’re welcome to ignore me from now on. But I’ll answer the substance of your criticism, in case others are interested.

          The SBM bloggers have been opinionating for years. (I’ll speak of them as a group, to avoid unfairly singling out any individual.) The site cultivates a confrontational style. I stop by once a year or so, to see if their agenda is evolving beyond its focus on CAM. So far it hasn’t, which is kind of interesting in itself. I wouldn’t worry about their feelings being hurt by criticism. They like to argue and provoke; if not, the site would have a more kindly and moderate tone. As “pmoran” put it, they heavily dish it out, so it behooves them to gracefully take their lumps, in turn.

          I’m aware of their occasional, lukewarm, acknowledgements of systematic problems in mainstream mediciine. But as Dr. Gorski has repeatedly confirmed, the focus of the site is to debunk CAM, not to critique mainstream medicine.

          I’m not sure why you (or Dr. G) object, when I suggest that CAM is a side-issue, compared with insufficiently rigorous science being frequently hyped in the medical literature. That’s the bigger problem, because in my opinion, the sheer number of (mostly unimportant or untrue) publications, coupled with deceptive abstracts, risks distracting doctors from doing those things current medicine really can do, thoroughly and well. (There are greater distractions, I’m sure, like bureaucracy, and stressful cultural mores. But I’m a scientist, so I’m focused on that – seems appropriate, at SBM.)

          Let’s look at abstract spin, as an example. A common type of abstract/conclusion hype is to draw unwarranted generalities from the data. If a “thought leader” does it, and it is propagated without correction, it goes on to distort textbook teachings, which influences the standardized care that everyone gets. The idea that a condition “typically” is limited to a certain age group, for example, often gets generalized into a failure to recognize it, in other cohorts.

          A book that details other such cognitive errors is Jerome Groopman’s “How Doctors Think.” Detailed thought about one patient’s illness is now often slighted. I think this may be due to its association with the despised terms “anecdotal.” Perhaps not coincidentally, this habit neatly fits with the trend to maximize “productivity” by minimizing the time spent on each patient. That is, in a nutshell, perhaps the biggest problem with guidelines, algorithms, and “care pathways,” also known as “cookbook medicine.” A new book by two Harvard docs bluntly tackles this issue, with special emphasis on care pathways: “When Doctors Don’t Listen,” by Wen and Kosowsky. It is written for the public, but has been widely discussed in medicine.

          Well, that’s enough. (Too much, one might say. But I am writing in response to specific comments that were made to me.)

          Again, I’m sorry I’ve annoyed you, and I’m sorry to hear about your family’s medical challenges.
          Best wishes.

          1. WilliamLawrenceUtridge says:

            This site can have a confrontational style because many of the subjects are pure nonsense (hello homeopathy!) and because so many show up in the comments to lecture about how ignorant we are and how they have the One True Answer to all disease (then shortly thereafter reveal they don’t know what the kidney does, or how the immune system works, or how actual medical treatment occurs, or that they have a curiously unskeptical attitude towards Joe Mercola, or Gary Null, or (Dog forbid) anything posted at whale.to.

            If you read the “about” page, you’ll see why it focuses on CAM – because it’s about science-based medicine, as a correction for evidence-based medicine, which places prior probability too low on the evidence hierarchy used to assess potential treatments (and the result of such a low emphasis on prior probability results in patent nonsense or highly unlikely treatments, like homeopathy and herbal medicine, having precious research funding or patient resources wasted when it could go towards something meaningful like comparative effectiveness research). I’m sorry this blog isn’t exactly what you want it to be – perhaps you would like to submit a guest post, to show us how it’s done, or start your own blog? Or publish in the peer-reviewed literature? As Bad Pharma showed us, there’s a tremendous amount of criticism of medicine in the peer-reviewed literature, and some of it is discussed here. But really, it sounds like as a reader you aren’t a good match for this blog. It’s a big internet, perhaps some google searches might turn up something more to your tastes.

          2. David Gorski says:

            I’m aware of their occasional, lukewarm, acknowledgements of systematic problems in mainstream mediciine. But as Dr. Gorski has repeatedly confirmed, the focus of the site is to debunk CAM, not to critique mainstream medicine.

            Straw man. The primary focus of this site is to explain and promote science-based medicine. If you had bothered to read what science-based medicine is compared to evidence-based medicine, you’d know that. The infiltration CAM just happens to be the most egregious case where science-based medicine matters, which is why CAM and “integrative medicine” tend to be the primary focus of this blog.

            Again, one notes that the “blog about what I want you to blog about” complaint is guaranteed to irritate bloggers, particularly when the person making it doesn’t understand (either unintentionally or willfully) what the blog is about and that the blog does not infrequently touch on the topics that he considers so important and woefully neglected.

          3. Chris says:

            “I also have sick family members, and they have suffered from mistakes in mainstream medicine, too. I think most people have some experience with this, by my age. I’m in my late 50′s, and I’m a PhD scientist in a medically relevant field. I am disturbed by the lack of rigor in the medical literature, and I feel it contributes to mistakes like those my family experienced.”

            Then write your own blog.

          4. Chris says:

            By the way, many years ago when we first got a modem I remember reading some advice on a Compuserve discussion group. The advice was to actually lurk for a while in the group to learn the “lay of the land.” This means you should have searched this blog for its articles and read some of them first.

            Also, I am not perfect, and neither are you. Unfortunately bad things happen, often times it is due to honest errors. Like the things that were very wrong for my health insurance forms on Thursday morning (I suspect that even though I have been married for over thirty years some new marriage laws in my state made the medical practice switch my marital status to “Unknown” because I do not share dear spouse’s last name… it has lots of vowels and my step-mother took ten years to spell it right and never learned to pronounce). And then there is both incompetence and fraud (every hear of Andrew Wakefield?).

            So before you go off and start your own blog (the “Anti-Science Based Medicine blog?), here are a couple of more articles to read:

            http://www.sciencebasedmedicine.org/the-science-of-clinical-trials/
            http://www.sciencebasedmedicine.org/when-conventional-doctors-betray-science-based-medicine-for-money/

            And remember, at least there are ways to govern real medicine, something that seems to not happen with many alternative medicine places. Is there a way to report adverse effects for acupuncture or homeopathy?

          5. Chris says:

            Oh, and on mistakes… I have recently been informed that I have been spelling my sister’s last name wrong since she got married fourteen years ago. Aargh.

  19. duggansc says:

    @Self Skeptic (in case the reply thread doesn’t unwind itself):
    I think that kind of gets into what was said before about how expert systems are going to be at the forefront of medicine. We already have news readers, book websites, and TV recorders that do a pretty good job of recommending items people might like based on their past interests. I suspect it won’t be long before we start getting programs that can accurately sum up papers and check for whether it’s a case of 5 papers for and 5 against such that you really need to read in more details.

    Of course, human cognition isn’t always so great… I was up in arms a bit recently when a news site took an article about a school board suggesting that a book contained too much obscenity and one member claimed they didn’t like the book, and ran a summary of “School board bans black book for lacking literary merit!”

    1. Self Skeptic says:

      @duggansc,
      It would be nice if computers (or humans) could cut through the jungle for us. I’m afraid there’s a bit of a GIGO problem with both analyzers.

      The 5 papers vs. 5 papers problem has that too. I think people are already on to that, and that the literature is suffering from a lot of article-spam. Nothing really rigorous peer review couldn’t theoretically solve, but that is being overwhelmed. Maybe it’s just too time-consuming and unrewarding, in these speedy times. It’s hard to get people to focus on quality, once the pendulum has swung into the territory where only quantity counts. I’m just hoping it really is like a pendulum, and it comes back again to the middle. (Or is the this the new middle?)
      Oh well. Thanks for stimulating thoughts.

    2. “We already have news readers, book websites, and TV recorders that do a pretty good job of recommending items people might like based on their past interests.”

      I think we have systems which convert this idea of related interests into a tractable problem. i.e. “People who bought X also bought Y” However I’m not entirely convinced that these solve the problem very well or that they even need to in order to have value.

      On the other hand evaluating a group of medical papers doesn’t a) sound easily converted into a tractable problem and b) probably requires a significantly more accurate result to be useful.

      1. Self Skeptic says:

        @Jonathan Graham,
        Yes, I agree. Sometimes there’s no substitute for human discernment. I wonder how we could make it easier for people to apply themselves to the task.

  20. pmoran2013 says:

    WLU: “But really, it sounds like as a reader you aren’t a good match for this blog. It’s a big internet, perhaps some google searches might turn up something more to your tastes.”

    I cannot agree with this attitude towards visitors, WLU. If medical scepticism is not having the impact it desires, as per one recurring theme on these pages, closing ourselves off to differing viewpoints may not be helpful to understanding why. We can learn something useful from almost anyone.

    I have myself defended Quackwatch and SBM for their focus on CAM, but I am having increasing trouble accepting the latter’s greater “egregiousness”, when recent mainstream errors and other systemic problems have the potential to adversely affect thousands of people, while constituting an arguably more serious betrayal of public trust. We should be horrified at the likelihood that this kind of thing might continue. We may pat ourselves on the back for being able to uncover our mistakes and trying to do something about them , but who would expect less of us?
    . .
    Meanwhile, and contrary to the fears of some concerning an imminent slippery slope back into medical Dark Ages, CAM will become a declining threat to people’s lives, or at least reach a level where we can do little more about it a free country populated by persons of differing intellects and inclinations..

    I see some signs already of CAM subsiding into such a grumbling undercurrent.. The public is not as generally gullible as we like to think. It will eventually dawn on most people, even parochial elements of America, that after some decades of intense examination and moderate popularity CAM has failed to contribute to medical knowledge in any important way. Meanwhile the mainstream continues to make small, sometimes major gains, mainly by virtue of its seamless integration with advancing technology.. Who can possibly argue otherwise? — they can try, but they would have to find a “major gain” first.

    This, by the way, should be our theme for the future. Show CAM up for the passe thing that it truly is while also giving it some credit for reminding us of the human side to medical interactions. By giving some CAM propositions like those of homeopathy the time we do we may be inadvertently helping to perpetuate them. Their proponents like to create the illusion that they are engaged in legitimate scientific controversy, when the parsimonious conclusion is that they are all simply exploiting that “human side” to medical interactions to the fullest degree..

    1. David Gorski says:

      I cannot agree with this attitude towards visitors, WLU. If medical scepticism is not having the impact it desires, as per one recurring theme on these pages, closing ourselves off to differing viewpoints may not be helpful to understanding why. We can learn something useful from almost anyone.

      I would remind our readers that this “attitude” towards certain specific visitors did not magically appear overnight. It evolved. It was—shall we say?—earned over a long period of time by some of those certain specific visitors through their persistent use of fuzzy pro-CAM arguments, tone trolling, and straw man arguments. Indeed, in the beginning we bent over backward to be respectful and inviting until, after many moons, it finally dawned on us that the same attacks kept coming no matter how “civil” and “inviting” we tried to be. Human patience can only last so long.

    2. WilliamLawrenceUtridge says:

      Well Pete, you’re going to get a rather similar reply – feel free to set up a comments section on your website, and treat them however you want. The reality is, a commenter showed up and essentially complained for the website not being exactly what he wanted to read. What is the reasonable response? “Oh, I’m sorry, please let me focus on whatever topic is most important and relevant to you, in total exclusion of what I, a volunteer, want to write about, am interested in, and am an expert in.” Is that what should have been said?

      When I have a question, I pose it politely in the comments (and will often have it answered). When I have a suggestion for a topic, I e-mail it to the editors and suggest that perhaps it might be an area of interest for one of them – and then don’t whinge if they decline to write about it.

      I don’t show up with a chip on my shoulder the size of my self-entitlement, demanding the blog adhere to my standards and demands. When people point out I could have used the search feature, I don’t move the goalposts to justify my original compliant and try to cover up the fact that the blog in fact does contain criticisms of mainstream medicine.

      Mainstream medicine does have problems, and numerous posts on SBM address them, but that is not the exclusive focus of the blog. However, generally even in these cases, the blog focuses on doing what it does (second*) best – summarizing the medical literature and adding their own interpretations and explanations. Which points to a much better place to look for such criticisms – the medical literature itself.

      Unlike so many commenters, the complaint wasn’t a fallacy-filled rant, if it was, would have engaged and politely pointed out how wrong and stupid s/he was. Instead, it was a non-fallacy-filled rant that was still wrong, entitled and self-righteous, with a keen lack of awareness of the purpose of this blog – which I pointed out. But overall, I made the point I thought most salient and relevant – nobody is forcing you to read things you don’t like reading about, and nobody is forcing you to not write your own blog popularizing important areas of medical research. It’s a free internet, there is the IP, feel free to avail yourself of it. And, to my tremendous disappointment Peter, the same to you. Perhaps the comment stung a little because it hit you in an already bruised area, but perhaps that’s an indication that nobody here is keen to listen to you yet again make the same accommodationist point.

      *First-best is criticizing CAM.

    3. “I see some signs already of CAM subsiding into such a grumbling undercurrent.. The public is not as generally gullible as we like to think”

      I think everyone is that gullible. It’s part of the human pattern matching machinery.

      Skepticism, rationalism, whatever you want to call it isn’t like the orbits of the planets or the speed of light. You can’t just disseminate skepticism into a population. You can disseminate it’s results i.e. Homeopathy is nonsense, acupuncture doesn’t work

      Rationality is a discipline. Expecting a society to sort of naturally wake up and become more rational is no more realistic than expecting them to wake up being able to bench press 180, Mistrusting your instincts is no different than forcing yourself to go to the gym. Your mind needs to say “yes” even though your body says “no”.

      “It will eventually dawn on most people, even parochial elements of America, that after some decades of intense examination and moderate popularity CAM has failed to contribute to medical knowledge in any important way.”

      Why today? Homeopathy and Chiropractic medicine have been around over 100 years. Skepticism surrounding them has been around almost as long. Is there some statute of limitations linked to the swearing in of the first black president of the United States?

      1. pmoran2013 says:

        I sort of agree with much that you say, Jonathan. But I can
        point to a number of signs that what I say about CAM’s inevitable
        decline from recent peaks is true, and it IS relevant to SBM
        appearing to have a sound sense of proportion in relation to how it
        invests its efforts. The fact is that we do regard imperfections in
        mainstream medical processes as proper matters to discuss here. So
        I am not sure what all the fuss is about. Those imperfections are
        also very relevant to CAM use. Rightly or wrongly the potential CAM
        user sees little harm from their own personal, judicious (?) use of
        CAM and they already know that it may not work for them (sceptics
        will find this out if they actively LISTEN to them rather than
        switch on “sceptic mode” the instant they open their mouths ). So
        they see little downside and only upside to trying it out. It is
        NEVER a truly “scientific” decision and most CAM users won’t even
        pretend that it is. Don’t judge this by the few extremists who come
        here trying to argue it out for various reasons. No, it is all to
        do with where people with unmet medical needs are prepared to
        invest their trust, and this is why evidence that the mainstream
        has widely using treatments of dubious safety and effectiveness is
        so damaging. It is frankly highly disturbing to me that the mere
        suggestion that we give more thought to these matters provokes the
        kind of reaction it has. Are we sure that these matters are going
        to be dealt with adequately in other circles? If so where?

        1. David Gorski says:

          It is frankly highly disturbing to me that the mere suggestion that we give more thought to these matters provokes the kind of reaction it has.

          Then be disturbed. (We all know how easily disturbed you are anyway.) It is frankly highly disturbing to me that certain commenters (who really should know better and in fact did know better in the not-so-distant past) continue after years to repeat the same tropes about SBM and this blog despite its having been patiently explained to them many, many times where they go wrong, instead opting to call people “extremists” because they think we’re too hard on CAM and not hard enough on conventional medicine. However, unlike you, I’m learning to get over my being disturbed, as there is no sign that these sorts of self-righteous attacks obviously intended to distract attention from criticisms of CAM while at the same time (conveniently enough) painting SBM bloggers as hypocrites are likely to abate any time soon. :-)

        2. “It is NEVER a truly “scientific” decision and most CAM
          users won’t even pretend that it is.” I don’t know what
          “scientific” means in this context but I think the more important
          question is: “Is it rational?” Is it rational to spend $12 on
          oscillococcinum to treat influenza? I’d argue “no”. The probability
          of it treating anything in controlled conditions is near zero and
          the probability of it treating anything when someone takes it is
          even less (as you are constantly being bombarded with ‘weak’
          homeopathic doses of all sorts of things). Framing the question
          that way aren’t you essentially arguing that consistently engaging
          in an irrational act will result in rationality? If that is your
          hypothesis (H) then people leaving CAM is an expectation (E) which
          validates H right? It also means that ~E must validate ~H. In other
          words if you are rational and the use of CAM stays the same or
          increases then you are forced to believe that there is something
          effective about CAM. Which is essentially the
          “If-they’ve-been-doing-this-for-so-long-there-must-be
          something-to-it-fallacy”. “Don’t judge this by the few extremists
          who come here trying to argue it out for various reasons.” Don’t
          assume that’s my criteria. What I see are not just the nutcases but
          the number of integrated medicine centers showing up. How the
          nursing college that was across the street from the hospital I grew
          up at is now a Naturopathic college. How the homeopathic section of
          my supermarket has grown from a shelf into a half-aisle. How I have
          to couch my words around my circle of friends to avoid
          confrontations because some of them are friends with, married to or
          go to chiropractors, naturopaths or homeopaths.

          1. Where did all my line breaks go?

        3. Once more, this time with line breaks…

          “It is NEVER a truly “scientific” decision and most CAM users won’t even pretend that it is.”

          I don’t know what “scientific” means in this context but I think the more important question is: “Is it rational?” Is it rational to spend $12 on
          oscillococcinum to treat influenza? I’d argue “no”.

          The probability of homeopathy treating anything in controlled conditions is near zero and the probability of it treating anything when someone takes it is
          even less (as you are constantly being bombarded with ‘weak’
          homeopathic doses of all sorts of things).

          Framing the question that way aren’t you essentially arguing that consistently engaging in an irrational act will result in rationality

          If that is your hypothesis (H) then people leaving CAM is an expectation (E) which validates H right? It also means that ~E must validate ~H. In other words if you are rational and the use of CAM stays the same or increases then you are forced to believe that there is something effective about CAM.

          Which is essentially the “If-they’ve-been-doing-this-for-so-long-there-must-be
          something-to-it-fallacy”.

          “Don’t judge this by the few extremists who come here trying to argue it out for various reasons.”

          Don’t assume that’s my criteria. What I see are not just the nutcases but the number of integrated medicine centers showing up. How the nursing college that was across the street from the hospital I grew up at is now a Naturopathic college. How the homeopathic section of my supermarket has grown from a shelf into a half-aisle. How I have to couch my words around my circle of friends to avoid confrontations because some of them are friends with, married to or go to chiropractors, naturopaths or homeopaths.

    4. Andrey Pavlov says:

      Well, there isn’t much for me to add to what Dr. Gorski, WLU, and Jon Graham have already said. But I’ll try.

      To sum up we have the point that “being nice” simply hasn’t worked and certainly doesn’t attain the goals you are envisioning, that this is a volunteer blog which nobody has the right to dictate what is written about, and the very valid point that things like homeopathy have been with us for well over 100 years with almost the entirety of it demonstrably false with heaping helpings of skepticism and mainstream derision along the way.

      So yes, what are you trying to get at? Why should we not address CAM? I actually just watched a really great old video of Larry Weed giving grand rounds discussing the medical record back in 1971 and he hit on some very salient points and he followed them up in 2009 in an interview. The key takeaway from the interview:

      One reason is that medical education is fundamentally incompatible with the underlying philosophy of the POMR. Medical education seeks to instill medical knowledge and “clinical judgment.” In doing so, medical schools give students a misplaced faith in the completeness and accuracy of their own personal store of medical knowledge and the efficacy of their intellects. What is done to students in medical school is the antithesis of a truly scientific education.

      What’s the relevance you may ask? Unlike you we see (and I experience) the erosion of the skeptical edifice you seem to think is turning some sort of tide. Medical students – who are generally the folks that become physicians – are taught a plethora of facts. Most of them can regurgitate them to you at the drop of a hat and most of those don’t really understand what the hell it is that they are regurgitating and why it is that way. So when CAM makes it into med school lectures, what do you think ensues? Where do you think that tide will turn if we actually do churn out a generation of physicians who had CAM “integrated” into their medical education when they don’t actually know how to think but are merely mechanics, aping the thoughts and actions of those who taught them? When the likes of David Katz at Yale – Yale! – school of medicine go on about changing the standards of evidence?

      You try to make the claim that giving them the time of day validates them. And indeed that does happen, which is why we here generally think the NCCAM shouldn’t exist. However it is one thing to study credulously and another to lambaste. Whilst Dawkins made it clear that debating a creationist looks better on their CV than his, that doesn’t mean that he doesn’t continue to demonstrate that fallaciousness of their claims. Or PZ Myers or Jerry Coyne or Aron Ra. Yes, it is a manufactroversy but the reality is that ignoring them simply does not work. You do realize that this blog is vastly younger than anything that could be construed as the “modern” CAM movement and the concept of “integrative medicine”? That is a reaction to what happens when we do ignore CAM. We even have a word for it – shruggie – to describe the problem of sitting idly by and assuming that rational discourse will win the day, even when utterly ignoring the irrational agents.

      Sorry Peter, but you are simply wrong in this. And you clearly do not understand the realities of the gullibility of the human mind and how that operates on an unconcsious level. The best way to teach good science is by learning from the mistakes of bad science. The best way to teach good medicine and critical thinking in medicine is by learning from bad medicine – what we tend to call CAM.

      The simple reality is that there are places that deal with the failings of modern medicine ad nauseum but very few that deal with the insidious cognitive traps of CAM. Jon Graham said it well. Skepticism and critical thought is not something a person or a population simply wakes up to one day, but an active and ongoing process very much like building and maintaining muscle mass.

      And you still haven’t even broached my thought experiment. I’m sure I’ve managed to annoy you a fair bit and you probably don’t want to give us all another show like you’ve done in the past, descending into a copious lack of professionalism. So ignore me if you must, but the reality is you can’t address my thought experiment because it undermines the last ephemeral vestiges of a leg your argument has to stand on.

      In the meantime, it is certainly poor form to be siding with those trying to tell someone else what they should and shouldn’t write about. One would think by now you would understand at least that.

  21. pmoran2013 says:

    Andrey: “You try to make the claim that giving them the time of day validates them. ”

    Huh? And I asked you once what your thought experiment was, as I was finding it difficult to find within long post after long post of this kind of nonsense.

  22. I do agree that this new format makes it difficult to keep track of and find comments. I did explicitly ask it a number of times, however.

    The brief version is that you claim that acupuncture may be the “optimal” placebo delivery device. I have been stressing that this is entirely ephemeral and based on the cultural context. I used the example of my fiance who is deathly afraid of needles (to the point I find it comical) and asked you if you think that acupuncture would be an “optimal” placebo delivery mechanism for her. I further expounded and gave the thought experiment of snapping my fingers and magically making everyone in the US and Australia understand – the way that you and I do – that there is nothing intrinsically unique to acupuncture (which you have admitted) and that it was all an elaborate placebo delivery mechanism and nothing more. That yes, they could experience relief from pure psychological factors with the needle placement and even their use being not at all relevant (in fact, the study you linked me to demonstrated that actually inserting the needles decreased the effect size!). Do you think then that acupuncture would “work” by whatever contrived definition you want to use? Do you think it would still remain and “optimal placebo delivery mechanism?”

    The other thought experiment was to simply ask if you felt that acupuncture would work well in WWII era United States (with the implicit assumption you knew about the rampant anti-Asian sentiment in the US at the time, complete with internment camps).

    In other words, your study you asked me to read demonstrates it is not the optimal deliver for placebo (since actually inserting the needles decreased effect size) and that the entirety of the effect lays within the cultural perception of what people think it is, rather than what it actually is.

    So what do you think Peter? If we were actually able to do my thought experiment would you still think acupuncture “works”? And how about that effect size you keep prattling on about? You know, the one that is all over the map and actually shows a decrease when needles are inserted (sort of undermining part of your ongoing thesis that the reason for the efficacy of acupuncture is because it is so “extreme” as to insert needles into the skin that people perceive there must be more benefit).

    1. pmoran2013 says:

      Andrey: “The brief version is that you claim that acupuncture may be the “optimal” placebo delivery device.”

      That comment arose partly because sham acupuncture seems able to produce much larger effect sizes than are observed with other placebos (short of sham operations, however) and partly for theoretical reasons related to its complex mixture of influences. .

      In answer to your subsequent question, you may have noted that I have often referred to acupuncture as having apparent effectiveness “in certain populations”. That qualification is necessary because of the great number of factors (probably including cultural) that can be shown to affect responsiveness to placebo influences and that are also likely to affect responses to the various non-specific influences that a program of acupuncture may also exert.

      Indeed, one of several reasons why I do not support acupuncture for routine use for any condition within the mainstream is that we cannot yet predict how cost-effective it would be in the usual mainstream medical practice population. I have said this several times here.

      We still need to think about what the all evidence means.

      SBM chooses to overlook the “complex intervention” aspect of acupuncture, yet its more evidence-based proponents do think of it this way. SBM has no therapeutic concept that permits a treatment to “work” little a bit this way and a bit that way, or differently in different patients.

      Yet the actual truth in terms of potential patient benefits may lie herein, very awkwardly for something that might have genuine but limited medical usefulness (“in some patient populations”) but which doesn’t fit neatly into any respectable, mainstream, conceptual slot.

  23. Kevin Bond says:

    Regardless of what causes cancer, there is a single cure for all of its forms -

  24. DT35 says:

    @ Dr. Moran: “I see some signs already of CAM subsiding into such a grumbling undercurrent.”

    What are these signs and where do you see them?

    1. pmoran2013 says:

      DT35 “What are these signs and where do you see them?”

      There are patchy signs of resistance in mainstream institutions: the English doctors pushing for the NHS to stop funding homeopathy, the prominent Australian university stopping its chiropractic program because it considered that field as “insufficiently evidence-based”.

      Our local media has changed its tune over the last ten years. The weekend newspaper supplements are no longer full of infomercials from naturopaths and chiropractors and uncritical endorsements of CAM. You can still find regular articles on “Detox” and other pretty harmless lifestyle flummery but there is no implication that CAM has a significant role in serious illnesses.

      Likewise the Current Affairs programs on TV still refer to unproven methods of treatment of arthritis, headache, back pain etc but they are far less one-sided and gung-ho with their presentations. A major TV presenter was sacked after he was strongly promoting the microwave therapy of cancer being given by a local quack after a review of his records showed no benefit but some harm.

      Look at films. The New Age is now the subject of mockery and the treatment of other forms of CAM is edging close to the same.

      But the most dramatic turn-around can be seen within an “alternative” cancer group that I monitor. It is now possible on that to talk favourably of mainstream treatment without being howled down or (in my case) booted off completely.

      Such a retrenchment was inevitable. CAM exploded onto the scene a couple of decades ago with extravagant claims that here was the answer to cancer, viral illnesses, heart disease, psychological disorders — you name it. It is obvious to all but the seriously self-deluded (and therefore unreachable) that none of these have been fulfilled. The claims are in consequence now generally more modest, and that is a good thing. I can largely live with that, , feeling as I do that CAM is probably of some aid to patients who for a variety of reasons may not be well-served by the mainstream,

      In my view it is unrealistic to expect CAM use to cease in the short or medium term. That would only happen if the mainstream found entirely effective and safe treatments for remaining unresolved medical problems.

      1. the English doctors pushing for the NHS to stop funding homeopathy, the prominent Australian university stopping its chiropractic program because it considered that field as “insufficiently evidence-based”.

        Funny that because it was exactly the likes of us that led to such things. Specifically the Aussie chiro school was a direct result of the Friends of Science in Medicine. Of which I am a member, as is Dr. Atwood, Jann Bellamy, Dr. Gorski, Dr. Hall, Dr. Crislip, and is affiliated with the Institute of Science in Medicine which Dr. Novella is is Board Chairman (and everyone else listed is a member as well, save me).

        The claims are in consequence now generally more modest, and that is a good thing. I can largely live with that

        Well, I suppose we can all be glad that you think we are essentially done. We disagree and continue to do our work on the matter.

  25. That comment arose partly because sham acupuncture seems able to produce much larger effect sizes than are observed with other placebos (short of sham operations, however) and partly for theoretical reasons related to its complex mixture of influences

    The problem is that you are still left holding the bag with a host of highly variable, very equivocal, and mostly very poorly done studies. With better studies showing smaller effect sizes and, I’ll say this ad nauseum because it bites you in the ass and you refuse to acknowledge it, that the meta analysis you linked to demonstrated smaller effect size with needle insertion. Which undermines your theoretical reasons and certainly calls into question the entire notion of acupuncture.

    In answer to your subsequent question, you may have noted that I have often referred to acupuncture as having apparent effectiveness “in certain populations”. That qualification is necessary because of the great number of factors (probably including cultural) that can be shown to affect responsiveness to placebo influences and that are also likely to affect responses to the various non-specific influences that a program of acupuncture may also exert.

    Ah yes. You have. A handy little cop out. Notice that “certain populations” is not definable in any sense accept one – gullibility. Unlike other medical interventions that work, where “certain populations” can be identified by genetic or other surrogate markers, your “certain populations” can be changed at the whim of a cultural change. If “Eastern Mysticism” suddenly was out of vogue your entire argument crumbles to dust in an instant.

    I think any reasonable and rational person could not consider something to “work” if the only basis by which it “works” is because people happen to be gullible enough to believe it works. Because then it “works” in exactly the same way and to the same extent that homeopathy, reiki, or any other random thing I can dream up on a whim “works.” Which is to say, not at all.

    Indeed, one of several reasons why I do not support acupuncture for routine use for any condition within the mainstream is that we cannot yet predict how cost-effective it would be in the usual mainstream medical practice population. I have said this several times here.

    But you’ll consider our work done because it isn’t quite as malicious as false cancer cures and be willing to turn a blind eye rather than uphold standards. How on earth can you justify not using it in medicine but seem to think it is ok for charlatans and the deluded to go ahead and do it. That is irrational and unjustifiable.

    Indeed, one of several reasons why I do not support acupuncture for routine use for any condition within the mainstream is that we cannot yet predict how cost-effective it would be in the usual mainstream medical practice population. I have said this several times here.

    No, we explain it as more mundane psychological effects with a large portion of study artifact and reporting bias/error in play.

    SBM has no therapeutic concept that permits a treatment to “work” little a bit this way and a bit that way, or differently in different patients.

    What a crock. Of course we do. Have you read any of the posts here about personalized medicine? But when the difference is what someone happens to be gullible about, that is simply not a good enough basis for which to say something “works.” By definition it is the way by which it tricks, not works.

    Yet the actual truth in terms of potential patient benefits may lie herein, very awkwardly for something that might have genuine but limited medical usefulness (“in some patient populations”) but which doesn’t fit neatly into any respectable, mainstream, conceptual slot.

    Wow. You really are descending into the ridiculous language of CAM apologists. We don’t decry it because we don’t have a slot it can fit into (which is just a fancier way of saying we aren’t “open minded” enough) but because it doesn’t have genuine medical uselessness. Something cannot be useful if it relies on a violation of medical ethics in order to be implemented. It cannot be useful if its mechanism is based on trickery and gullibility (intentional or not).

    What SBM does require is a single uniform standard. Not the double standard you are not-so-implicitly proposing.

    1. pmoran2013 says:

      Andrey: “With better studies showing smaller effect sizes and, I’ll say this ad nauseum because it bites you in the ass and you refuse to acknowledge it, that the meta analysis you linked to demonstrated smaller effect size with needle insertion. Which undermines your theoretical reasons and certainly calls into question the entire notion of acupuncture.”

      Are you referring to this? “Thus the limited available data suggest that skin penetration or no skin penetration does not seem to make a big difference.”

      That is a counterintuitive finding, both theoretically and when taking into account the number of studies that do show small differences when skin penetration is compared to non-penetrating controls, in other kinds of comparisons.

      From the point of view of eliciting pure placebo responses then the thought that the skin is being penetrated would be all that matters. However, I agree you would expect stronger responses if the sensation was also authentic.

  26. Kevin Bond says:

    Everybody in the U.S. and the rest of the world can rest assured – the PCK can solve any cancer care crisis. What is PCK – the Personal Cancer Killer – the only escape to complete freedom. PCK is a devastating weapon of unlimited power against any cancers and infectious diseases on Earth – a discovery that can change the life of humans on the planet. We humans are not helpless against cancers and infectious diseases any more – we can strike back with a devastating force. Nature has provided us the enormous power of being as healthy as Gods, we just gotta activate it and become completely independent of any vaccines, drugs, doctors, hospitals, clinics,surgeries (especially the awful mastectomy), any kinds of therapies (but not cure), etc. Doing the Immunizer (PCK), all of us – kids and adults – can be any bugs and cancers killers and enjoy the perfect health all the time, all our lives (much longer than usual), regardless of age, environmental and occupational exposure and lifestyle (like smoking, diet, sexx life, stress, sexual orientation, obesity, etc.).
    Any cancers and infectious diseases on Earth can be wiped out immediately (everybody being his/her own Jesus) by doing an exercise (incredible as it nay seem) – the Immunizer – just a simple exercise for a minute a day for kids and adults as the full prevention of any diseases – from the common cold to cancer. If done for 3 – 4 minutes a day, the immunizer will guarantee a very fast recovery from any viral and other infections and any forms of cancer at any stage. No killer viruses, bacteria, germs and cancers on Earth got any chance against the tremendous power of the immunizer – they just die the moment they touch you.
    The price to disclose the Immunizer to the whole world is 2,25 Trillion US Dollars.
    Further details of the incredible Immunizer are availsble upon request.

  27. Oh yes, and I should add, before you try and say that the FSM and ISM are much more tone-neutral than SBM (and actually I would certainly agree that they are! In reading much of what comes out of the FSM, I find myself constantly feeling it is too tepid) check out the wikipedia article on the FSM (I didn’t realize it had one till this morning):

    A critical review from the University of New England in 2013 was published in the Journal of Creative Approaches to Research concluded that FSM contradicts the literature in their viewpoint of complementary medicine and its use, and manifests ideology and power within their discourse. They found that their style of language promotes their own beliefs to suppress alternate voices. This leads to FSM having an inaccurate understanding of complementary medicine and patients because they have an interpretive bias originating from and ideological perspective. In conclusion, the author states that ‘Their underlying desire to maintain power overrides and potential positive outcomes from within their view of complementary medicine, and contributes to a discourse that presents as diatribe.

    Funny that. When someone has a belief not based in science (aka CAM) any criticism is immediately considered “too strident” and “ideologically based.” Which is exactly the point that Dr. Gorski has been trying to drive home and one that I have as well – how much do we “tone it down?” There simply is no level, short of packing up shop and going home and shutting up that will obviate any criticisms of stridency and “being mean.” So what level is acceptable?

    The answer, it would seem, is the level that Peter Moran decides. Well, as has been pointed out, Peter Moran can have his own blog and be as nice as he wants to over there.

  28. Kevin Bond says:

    You are completely wrong, my friend. You just cannot believe the PCK is at all possible, that’s all.

  29. @pmoran:

    No, that is not what I was referring to. I don’t have the reference handy and am actually running very late in the morning to get to clinic so I don’t have time to dig it up. But it was in reference to the meta analysis you linked me to a week or two ago and directed me to read the discussion. In that one, it demonstrated the heterogeneity of the data and when pooling the best studies they could find found a significant decrease in effect size when the needle actually penetrated the skin. They were comparing sham to real, so in both cases the subject would have anticipated the needle penetrating. Yet when it actually did the effect size was smaller.

    Now, I agree with you on the theoretical principles involved here and that more dramatic interventions do and should elicit more dramatic placebo responses and placebo effects. But this data is yet more evidence that there is simply no consistent placebo effect and that the responses vary wildly as we would expect from something contingent on that “certain population” who is gullible and likes the Eastern mysticism thing. In other words, it completely undermines your thesis that there is a significant effect to be exploited (specific or not) and particularly the notion that acupuncture itself is particularly good at exploiting it.

    One of the whole points of SBM is that when you have a large amount of equivocal data that jumps all over the place and even the best of studies have heterogeneity to the point where good meta analyses of these best studies are showing effects all over the place means that we are chasing ghosts rather than real effects. The only possible salvage here is that your “certain populations” are genuinely experiencing profound placebo effects, but that said population is indeed quite rapidly changing, diverse, and ephemeral. And don’t forget that most of the people that would be in such studies are already likely a self-selected population in that they would be interested in pursuing acupuncture as a study modality. In other words, these highly equivocal results with effects all over the place are most likely being studied in a population that is a priori much more likely to be that “certain population” than the general population and we would expect to be the best case scenario. And even that is very, very disappointing in the results. So we must assume that in general population it woudl be substantially worse.

  30. pmoran2013 says:

    Andrey: “They were comparing sham to real, so in both cases the subject would have anticipated the needle penetrating. Yet when it actually did the effect size was smaller.”

    I wondered if you had got tangled up by that. If this is the comparison you were referring to, don’t you realise that this shows the opposite of what you were claiming in your last post? It is entirely consistent with the “complex therapeutic influences” theory of acupuncture (or of any other method having similar characteristics), if actually penetrating the skin increases responses in the sham arm, thereby reducing differences between sham and real.

    It is also predictable that there would be heterogeneity between studies regarding the strength of responses to sham , depending upon the study population (as we are both agreed) and what expectations were either aroused or dampened within the study participants, and whether practitioners who may be anxious to vindicate acupuncture may unconsciously or unconsciously cue patients when they are not getting “the real deal”.

    Apart from that we still don’t know what might be possible in individuals under particularly favourable conditions.

    I don’t deny that you have a makeable hypothesis (that nonspecific influences are generally weak), but that is not nearly as strongly supported by the evidence as you think, or is mostly expounded on SBM. That the evidence is mixed is indicated by the wide diversity of opinion on this matter within the science-based camp.

    1. Andrey Pavlov says:

      @pmoran:

      Firstly I want to say that the new comments section on this site have been making it rather difficult for me to keep up with the comment threads. I do not know if you are having the same trouble, but even though I sign up for the email alerts and have the comments feed in my RSS reader, I still miss comments. Like this one. So I apologize for fragmented responses, later comments that appear as if I didn’t read what you wrote (this right here being a prime example), and if I don’t respond at all it may well be because it simply was never noticed by me.

      There are also a couple of comments you wrote after I sent my last one via mobile phone where I apologized in advance for the “hit and run” – I am trying to track those down, but once again having trouble doing so. I was out of town and in a place with no electricity let alone internet or cell phone connection, so I fear they may have somehow been lost. I am also a little pressed for time so I probably won’t be able to get to those comments this morning, but I will endeavor to find them again.

      All this preamble merely to say that I am genuinely not trying to engage you in bad faith and leave your comments hanging.

      If this is the comparison you were referring to, don’t you realise that this shows the opposite of what you were claiming in your last post?

      No, I don’t see that. But let me try and figure it out…

      It is entirely consistent with the “complex therapeutic influences” theory of acupuncture (or of any other method having similar characteristics),

      Yes, I agree with this…

      if actually penetrating the skin increases responses in the sham arm, thereby reducing differences between sham and real.

      But you’ve lost me here. The sham arm does not include penetrating the skin. Either this is a typo on your part or you are trying to say that in the studies the “sham” arm may have actually had skin penetration thus closing the gap between the two groups.

      This would indeed make my point a little less strong, but it would harm your overall claim even more. If you have evidence that studies have been botched in such ways then there is even less leg to stand on when it comes to any effect in acupuncture because the study designs would be abysmal rather than just poor.

      Additionally, it still doesn’t quite fit your claim but it does mine. The meta analysis demonstrated that any needle penetration decreased effect size when compared to no needle penetration. Now, if there is actually any consistent signal with needle penetration in terms of effect size (part of your claim about acupuncture being an “optimal” placebo delivery mechanism) then we would expect that the aggregate data demonstrate a smaller gap between sham and verum acupuncture, but not a reversal of effect size.

      There are only two reasonable conclusions from finding this reversal. The most likely, IMO, is that there really is not much signal and a lot of noise such that random variation led to this finding since so many attributes were studied (in other words something was bound to be significant by chance, and since they were looking in both directions that chance doubled with the possibility it may be a negative association). The other is that many, if not most, people actually really don’t like the sensation of the needle penetration and in both the sham and verum arms most people felt nothing and the few that did in the verum arms did not like the feeling of the needle thus lowering the effect size.

      In any case, my main thesis is still supported – that acupuncture, like all placebo based therapies, is simply highly variable, with ephemeral effects, the size or even existence of which can vary in size (and even be negative) at a whim.

      So saying that acupuncture “works” would be like saying that an airplane where the wings sometimes fall off at random times and is occasionally a submarine “works.” Oh sure, you could talk about how when it does fly it works beautifully and that for some people, who don’t have the option of flying on a Boeing or who have tried to fly with Jetstar but it simply didn’t work out for them for some reason or other, managed to actually get to Sydney on occasion, or at least as far as Byron Bay if not all the way to Sydney. And some desperate or deluded people convinced that the plane works may try and use it. But no reasonable person would actually say it works.

      It is also predictable that there would be heterogeneity between studies regarding the strength of responses to sham , depending upon the study population (as we are both agreed) and what expectations were either aroused or dampened within the study participants, and whether practitioners who may be anxious to vindicate acupuncture may unconsciously or unconsciously cue patients when they are not getting “the real deal”.

      All of this merely demonstrates why it doesn’t “work.” You can’t predict those who would have a favorable response, studies are all so poorly done it is highly suspect that it is any remotely significant portion of the population, the effect size is highly suspect, and the population can change at a whim depending on prevailing cultural whims. Plus, you even have to throw in aspects that can easily affect outcomes purely through artifact to help explain these findings. I mean, think about it. If the practitioner truly believed sham acupuncture to be verum, suddenly the “cue” would be in its favor. So nothing about “acupuncture” is what really matters – but how much we can sell it to the patient. That not acupuncture working that is gullibility and salesmanship working.

      <blockquote.Apart from that we still don’t know what might be possible in individuals under particularly favourable conditions.

      The problem is that we don’t even know what “particularly favorable conditions” actually are. And we do know that they can change on anything from a population to a local to an individual level. And after so many thousands of studies over decades, if there really was any sort of robust effect in those individuals under particularly favorable conditions, you’d think we’d have some inkling of what that is. Yet the data is simply all over the place. Hell, it could change from session to session. First session patient is all excited, big effect. Next session patient’s dog dies, effect is negligible. Next session patient watched a Japanese samurai movie to feel better about dog, effect is bigger. Four sessions later patient is annoyed that effect only last a short while until next session and effect is smaller. How can that be construed as acupuncture “working?” It can’t.

      It does tell us interesting things about people and the placebo response and the placebo effects. Which should be studied, and are. But directly, not through the guise of a BS modality that can’t really tell us anything useful about what is genuinely interesting.

      I don’t deny that you have a makeable hypothesis (that nonspecific influences are generally weak), but that is not nearly as strongly supported by the evidence as you think, or is mostly expounded on SBM.

      The thing is that the burden of evidence does not lay with me. I say it doesn’t work. That is the null hypothesis. The burden is on you (and acupuncture proponents) to reject the null. In a strictly frequentist analysis without any further analysis, yes that is actually accomplished. But the whole point of SBM is to demonstrate why that is a minimum starting point, but not nearly sufficient. I don’t actually have to find evidence to support that acupuncture doesn’t work. I am merely demonstrating why the evidence that it does is not robust by reasonable scientific standards.

      That the evidence is mixed is indicated by the wide diversity of opinion on this matter within the science-based camp.

      Actually there is very little diversity of opinion on the matter over here. Dr. Crislip may be a little old school and poo-poos placebo effects more than others, but even he has come around with the evidence and admitted they exist. Just that he doesn’t find it worthwhile to explore them in great detail and that he believes that they are small and likely unexploitable. I am a little more open minded than that, but generally tend to agree with him. And I would be willing to bet that any of the other authors here more or less pretty much agree with what I have been writing. The fact that each one chooses to focus on different aspects to a different degree at different times does not indicate that we are of substantially mixed opinion. It is just a reflection of having multiple angles to discuss.

      You seem to think that I have substantially swung around to your viewpoint regarding placebo effects (which is not true) and that I am part of that “diversity of opinion” around these parts. So go ahead and ask Drs. Gorski, Hall, and Novella (and even Crislip) if they disagree with what I’ve been saying. I’d bet they don’t, but I’m happy to stand corrected if they do.

      Lastly, I’ll close with a very brief reference to a different comment made at us by MTR (one of those that I can’t find again). Please pay attention to what she said – very specifically and very clearly that a variety of tacks is necessary and a staunch stance like ours is, often times, greatly appreciated. That is what I have been saying all along. And MTR isn’t the only one around these parts that has made such comments. I have a personal anecdote about exactly this topic that just came up this weekend, but I’ll spare you. Suffice it to say, it is not only useful, but important to not have the wishy washy play nice stance that you advocate. I appreciate stances like yours and it is also helpful, but it is absolutely not sufficient to only have that.

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