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Integrative Medicine is the Butt of a Sokal-Type Hoax

In 1996, Alan Sokal got a bogus paper published in the journal Social Text. It was a parody full of meaningless statements in the jargon of postmodern philosophy and cultural studies. The editors couldn’t tell the difference between Sokal’s nonsense and the usual articles they publish.

Now a British professor of medical education, Dr. John McLachlan, has perpetrated a similar hoax on supporters of so-called “integrative” medicine. He reports his prank in an article in the British Medical Journal (BMJ).  

After receiving an invitation to submit papers to an International Conference on Integrative Medicine, he invented a ridiculous story about a new form of reflexology and acupuncture with points represented by a homunculus map on the buttocks. He claimed to have done studies showing that

responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes.

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Posted in: Humor

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The “decline effect”: Is it a real decline or just science correcting itself?

‘Tis the season, it would seem, for questioning the scientific method.

You might recall that back in October, I was a bit miffed by an article in The Atlantic entitled Lies, Damned Lies, and Medical Science and expressed my annoyance in one of my typical logorrheic posts. Then, a mere couple of weeks later, Steve Simon wrote a rather scathing criticism of the very concept of science-based medicine, which I ended up answering, again in my usual inimitable logorrheic fashion. Unfortunately, these things often come in threes. Well, maybe not always threes. It’s not as though this “rule” is anything like the count for the Holy Hand Grenade of Antioch, where “Four shalt thou not count, nor either count thou two, excepting that thou then proceed to three. Five is right out.” Except that five isn’t always right out when it comes to these sorts of criticisms of science and/or science-based medicine.

But enough of my pathetic attempt to channel Mark Crislip. The third count in articles expressing skepticism of the scientific method and science-based medicine comes, for purposes of my discussion, in the form of an article in The New Yorker by Jonah Lehrer entitled The Truth Wears Off: Is There Something Wrong With the Scientific Method? Unfortunately, the full article is restricted only to subscribers. Fortunately, a reader sent me a PDF of the article; otherwise, I wouldn’t have bothered to discuss it. Also, Lehrer himself has elaborated a bit on questions asked of him since the article’s publication and published fairly sizable excerpts from his article here and here. In any case, I’ll try to quote as much of the article as I think I can get away with without violating fair use, and those of you who don’t have a subscription to The New Yorker might just have to trust my characterization of the rest. It’s not an ideal situation, but it’s what I have to work with.
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Posted in: Clinical Trials, Science and Medicine, Science and the Media

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Of SBM and EBM Redux. Part II: Is it a Good Idea to test Highly Implausible Health Claims?

Review

This is the second post in a series* prompted by an essay by statistician Stephen Simon, who argued that Evidence-Based Medicine (EBM) is not lacking in the ways that we at Science-Based Medicine have argued. David Gorski responded here, and Prof. Simon responded to Dr. Gorski here. Between that response and the comments following Dr. Gorski’s post it became clear to me that a new round of discussion would be worth the effort.

Part I of this series provided ample evidence for EBM’s “scientific blind spot”: the EBM Levels of Evidence scheme and EBM’s most conspicuous exponents consistently fail to consider all of the evidence relevant to efficacy claims, choosing instead to rely almost exclusively on randomized, controlled trials (RCTs). The several quoted Cochrane abstracts, regarding homeopathy and Laetrile, suggest that in the EBM lexicon, “evidence” and “RCTs” are almost synonymous. Yet basic science or preliminary clinical studies provide evidence sufficient to refute some health claims (e.g., homeopathy and Laetrile), particularly those emanating from the social movement known by the euphemism “CAM.”

It’s remarkable to consider just how unremarkable that last sentence ought to be. EBM’s founders understood the proper role of the rigorous clinical trial: to be the final arbiter of any claim that had already demonstrated promise by all other criteria—basic science, animal studies, legitimate case series, small controlled trials, “expert opinion,” whatever (but not inexpert opinion). EBM’s founders knew that such pieces of evidence, promising though they may be, are insufficient because they “routinely lead to false positive conclusions about efficacy.” They must have assumed, even if they felt no need to articulate it, that claims lacking such promise were not part of the discussion. Nevertheless, the obvious point was somehow lost in the subsequent formalization of EBM methods, and seems to have been entirely forgotten just when it ought to have resurfaced: during the conception of the Center for Evidence-Based Medicine’s Introduction to Evidence-Based Complementary Medicine.

Thus, in 2000, the American Heart Journal (AHJ) could publish an unchallenged editorial arguing that Na2EDTA chelation “therapy” could not be ruled out as efficacious for atherosclerotic cardiovascular disease because it hadn’t yet been subjected to any large RCTs—never mind that there had been several small ones, and abundant additional evidence from basic science, case studies, and legal documents, all demonstrating that the treatment is both useless and dangerous. The well-powered RCT had somehow been transformed, for practical purposes, from the final arbiter of efficacy to the only arbiter. If preliminary evidence was no longer to have practical consequences, why bother with it at all? This was surely an example of what Prof. Simon calls “Poorly Implemented Evidence Based Medicine,” but one that was also implemented by the very EBM experts who ought to have recognized the fallacy.

There will be more evidence for these assertions as we proceed, but the main thrust of Part II is to begin to respond to this statement from Prof. Simon: “There is some societal value in testing therapies that are in wide use, even though there is no scientifically valid reason to believe that those therapies work.”

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Posted in: Chiropractic, Clinical Trials, Energy Medicine, Health Fraud, History, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine

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Good Idea, Bad Execution: Dosing Errors, A Preventable Harm

We spend a lot time at SBM discussing different elements of the art and science of medicine, and how we believe that practice can be improve. Yet our science-based intentions can be thwarted at the last possible moment – in the form of dosing errors. The workup may have been comprehensive, the diagnosis could be correct, the most clinically and cost-effective intervention chosen, and whammo. An overdose or underdose, possible toxicity, and a failure to achieve the desired outcome. It’s a completely avoidable, but often overlooked aspect of the practice of medicine.

In my last post, I noted how cough and cold products for children have largely been withdrawn from the market due to their lack of efficacy, and the risks related to toxicity. Today’s post is going to dive a little more deeply into factors that can contribute to toxicity in the pediatric population. Let’s start with a vignette that may be familiar to parents:

The new father is wakened from a blissful, deep sleep by a crying child. Once Dad realizes when and where he is, and the source of the crying, he silently curses the short duration of action of the acetaminophen liquid he gave his child at bedtime. It has probably worn off already, and the fever is back.  Stumbling into his child’s room in the dark, he can feel the heat radiating off his body.  He fumbles around for the Tylenol, and something to measure it with. He can’t find the dropper bottle, but finds a bottle of syrup. It’s hard to measure the dose in the dark, and the medicine cup he finds is hard to read. “I think the dose is a teaspoon..that’s 5mL”.  He pours the medicine into his child’s throat, tucks him back into bed, and both are back asleep within minutes.

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Posted in: Science and Medicine

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Cell Phones and Behavior

Cell phones continue to be a focus of epidemiological studies and public concern, despite the fact that so far there is no compelling evidence of any health risk from cell phones. Concerns are likely to be sparked anew with the report of a study linking cell phone use to behavioral problems in children.

The study, by Divan, Kheifets, Obel, and Olsen, is a follow up of a prior study which showed a correlation between cell phone use in pregnant women and behavior problems in their children. They sought to replicate this study with a larger data set and taking into consideration more possible confounding factors. They found:

Results The highest OR for behavioural problems were for children who had both prenatal and postnatal exposure to cell phones compared with children not exposed during either time period. The adjusted effect estimate was 1.5 (95% CI 1.4 to 1.7).

Conclusions The findings of the previous publication were replicated in this separate group of participants demonstrating that cell phone use was associated with behavioural problems at age 7 years in children, and this association was not limited to early users of the technology. Although weaker in the new dataset, even with further control for an extended set of potential confounders, the associations remained.

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Posted in: Public Health

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New Recommendations for Calcium and Vitamin D Intake

 A Walmart ad in my local newspaper trumpets “75% of all Americans don’t get enough Vitamin D” and offers to sell me Maximum Strength Vitamin D3, 5000 IU capsules to “promote bone, colon and breast health.” Meanwhile, the Institute of Medicine (IOM) tells me that “the majority of Americans and Canadians are receiving adequate amounts of … vitamin D” and that no one should take more than 4000 IU a day.  Apparently Walmart and the IOM aren’t talking to each other.

The media have been giving the impression that vitamin D is a new wonder drug. They have told us that we aren’t getting enough sunlight, that a large percentage of us suffer from vitamin D deficiency, and that low levels of vitamin D are associated with cancer, multiple sclerosis, peripheral vascular disease, diabetes, rheumatoid arthritis, Parkinson’s and Alzheimer’s disease, and other conditions. Low levels of vitamin D have been linked to higher overall mortality (but so have high levels of vitamin D!). The anti-vaccine folks have been telling us (without any controlled studies) that vitamin D supplements are better than vaccines for preventing influenza. There’s no good evidence that raising vitamin D levels with supplements actually prevents any of these conditions, but many people think it should, and doctors have increasingly been measuring blood levels and prescribing high dose supplements. Is this just another passing fad like the enthusiasm for vitamin C, or are we belatedly recognizing a serious deficiency problem?

I’ve had a lot of inquiries about “is this information trustworthy?” and “how much vitamin D should I be taking?” I’ve been telling people that I didn’t know, that recent findings will soon result in new recommendations, and I’ve been eagerly awaiting the new guidelines. Now we have them, thanks to the IOM. They are not what most of us anticipated. Since so many doctors had been advocating higher levels to prevent things like cancer, I thought official recommended intake levels would go up; instead, they went down.

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Posted in: Nutrition

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Death by “alternative” medicine: Who’s to blame? (Revisited)

(NOTE: There is now an addendum to this post.)

(NOTE #2: The videos of Robert O. Young’s interview with Kim Tinkham have been removed, as I predicted in this post that they would be. Fortunately, I downloaded copies before he managed to do that. Part 6 appears to be still there–for now.)

(NOTE #3: It was announced on the Facebook page Caring for Kim that the subject of this post, Kim Tinkham, passed away on December 7, 2010 in the late afternoon. Although it was not revealed what kind of cancer she died of, Tinkham almost certainly died from metastatic breast cancer. Quackery appears to have claimed another victim.)

I hate stories like this. I really do. I hate them with a burning passion that makes it hard for me to see straight when I first find out about them.

In fact, you might even say that stories like this are a major part of the reason why I do what I do, both here and elsewhere. They’re a major part of the reason why I’ve recently branched out into public speaking, something that used to terrify me beyond belief but that lately I’ve become at least competent at–sometimes even not bad at all. Sadly, the story I’m about to tell is one I’ve told before, most recently at the Lorne Trottier Science Symposium, where I gave a talk on cancer cure “testimonials,” although at the time I gave the talk the story’s outcome, although predictable, was not yet known.

Now it is.

The woman to whom I refer is named Kim Tinkham, who was diagnosed with breast cancer over three and a half years ago. Regular readers may recall that Kim Tinkham achieved fame not long after that when she was featured on The Oprah Winfrey Show in an episode about The Secret, an episode I discussed posts entitled The Oprah-fication of Medicine and On the nature of “alternative” medicine cancer cure testimonials. I don’t want to discuss the utter nonsense that is The Secret in any detail here. However, for those unfamiliar with this particular bit of New Age woo, it’s important to point out that The Secret’s “Law of Attraction” takes the germ of a reasonable idea (namely that one’s attitudes and wishes influence whether one gets what one wants in life, something that’s been known for millennia) and goes off the deep end of woo by proclaiming that, in essence, you can get anything you want by wanting it badly enough and thinking positive thoughts. Basically “The Secret” is that you have the power to “attract” good to yourself by thinking happy thoughts (hence “the law of attraction,” which, according to Secret adherents always works). It’s an idea that resonates in so much of “alternative medicine,” such as German New Medicine or Biologie Totale. Of course, the implication of “Secret” thinking is that, if you don’t get what you want, it’s your fault, an idea that also resonates with so much “alternative” medicine, where a frequent excuse for failure is that the patient either didn’t follow the regimen closely enough or didn’t want it badly enough.

Basically, The Secret is what inspired Kim Tinkham to eschew all conventional therapy for her breast cancer and pursue “alternative” therapies, which is what she has done since 2007. Before I discuss her case in more detail, I’m going to cut to the chase, though.

This weekend, I learned that Kim Tinkham’s cancer has recurred and that she is dying. On Saturday, a reader of my other blog sent me an e-mail that informed me:
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Posted in: Cancer, Faith Healing & Spirituality, Health Fraud, Science and the Media

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Sky Maul

The worst part of flying is the take off and landing. Not that I am nervous about those parts of the trip, it is that I am all electronic. Once I have to turn off my electronic devices, all I am left with is my own thoughts or what is in the seat pocket in front of me. Since there is nothing to be gained from quiet introspection, I am stuck with either the in-flight magazine or SkyMall. I usually choose the latter. SkyMall, for those of you who do not fly, is a collection of catalogs bound in one volume. I have occasionally purchased products found in SkyMall and thumb through it with mild interest.

This time one product caught my eye, the Aculife home acupuncture/acupressure device. I had never noticed the ‘health’-related products in SkyMall before, usually looking for electronic gadgets that I really do not need. I was curious. How many other products besides Aculife are in the catalogue? According to the interwebs, about 100,000,000 Americans fly every year and well over half a billion people world wide. A lot of people can potentially look at SkyMall, including the occasional skeptic.

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Posted in: Acupuncture, Science and Medicine

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CAM and the Law Part 3: Malpractice

It is with some trepidation I venture into the next subject in this series — malpractice law. This is a touchy subject for healthcare providers, for obvious reasons. Regardless of the flaws in the system, however, malpractice law is one of the mechanisms put in place by government to regulate the practice of medicine. Like the other such mechanisms touched on so far, licensure and scope of practice law, malpractice laws apply to alternative medicine practices in ways that are broadly similar, but sometimes subtly and significantly different, from how they apply to scientific medicine. 

So far, alternative practitioners are sued for malpractice relatively infrequently compared with physicians, presumably because they represent a much smaller fraction of the care provided, they tend to be utilized by those with an ideological bias in favor of their approaches, and they are not viewed as nearly as rich a target for litigation. But this may change if the political and cultural winds blow in the direction of greater utilization of alternative medical approaches. 

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Posted in: Legal, Politics and Regulation

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