Recents posts by Drs. Albietz and Gorski have highlighted questions that are recurrent on SBM. We are convinced that medicine should be based on real knowledge, to the extent that it exists, and that physicians should be honest; these are matters of science and ethics. How do we reconcile that with heartfelt, if misguided beliefs of patients, their families, and others? When Dr. Albietz wrote that it might have been better for the chiropractor to visit in the same way that “priests, imams, prayer sessions, rabbis, etc visit children within the PICU,” it was reminiscent of Dr. Peter Moran’s hypothetical “witch doctor.” When he lamented academic medicine’s current dalliances with quackery, it brought to mind the NCCAM, David Katz, Andrew Weil, Bravewell , and their enablers.
Dr. Albietz argued that when talking to credulous patients or their families, taking a hard line against quackery is likely to be counter-productive. Most of us would agree with that. Dr. Gorski described a different scenario: after calling a quack “a quack” when talking to a friend of a friend who is a scientist, he concluded that he had been too “blunt.” Several commenters disagreed, but all would probably agree with Dr. Gorski that “you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.”
Another Case of Foot-In-Mouth Disease
I recently had an experience strikingly similar to Dr. Gorski’s, during which I castigated myself for my rancor even as I was incapable of moderating it. Fellow blogger Dr. Val Jones was a witness!
I noted that “humor” is a designated category at Science Based Medicine, and that I hadn’t made full use of it yet. I hope that the holiday season has put you in the mood for a whimsical look at Christmas – from my “skeptical family” to yours. Enjoy!
My sister Vicki lives in Grand Rapids, Michigan with her husband, three children and an alarmingly large and slobbery Saint Bernard named Gilbert. Several Christmases ago she decided to teach her then 5-year-old son, Harrison, about Christmas tree decorating. She took him to a Christmas tree farm and helped him select a tree. They hauled it back to the house and my sister managed, with no help whatsoever from Gilbert, to set it up in a nice corner of the living room. The tip of the tree reached the ceiling and its full figured branches spread from icy window to window.
Vicki and Harrison spent hours and hours winding lights, tinsel, ornaments, paper angels and popcorn strings around the tree. Little Harrison couldn’t wait to see the final product, with glittering lights and a magical star to top off their fine work. They decorated into the early evening, and the living room grew dark as the sun set over the snow covered neighborhood. At last it was time to plug in the tree lights.
I rather like Late Night with Conan O’Brien. Unfortunately, I seldom get to watch, mainly because I usually show up at work sometime between 7:00 and 7:30 AM, and I don’t like watching more than a few minutes of video on my computer.
However, Hugh Laurie, star of House, was interviewed by Conan and revealed himself to be not unlike me in that he’s definitely a booster of reason and science in medicine over irrationality and dubious “complementary and alternative medicine” (CAM) therapies. In fact, his attitude towards CAM appears to be not at all unlike that of the character he plays on House. Check out the interview. (If you want to watch, the relevant part of the interview begins at about 23:50 into the show.)
For those who might have problems playing Internet video, I’ve found a transcript:
Science and medicine reporting is hard. In this space and otherswe’ve dealt with some of the problems that arise when “generalist” reporters try to “do” science and medicine. And now, CNN has shut down its science unit. Given the increasing complexity of medical and scientific knowledge, this is very bad news.
As a fine example of poor medical reporting, let’s look at a local business magazine. The article, called “The Fatigue Factor”, is about fibromyalgia, and manages to get it wrong from the very beginning.
Some medical reporting is destined to be bad simply because the topic is too complex for a generalist reporter. But sometimes, a reporter succumbs to journalistic sloth. In this story, for instance, if the reporter had spoken to a recognized local expert rather than a self-proclaimed expert, she would have written a much different article.
Let’s start with the headline:
Dr. Olivier Ameisen is a prominent French cardiologist who believes that the muscle-relaxant drug baclofen relieves the cravings of alcoholism. This is indeed an interesting, and as yet unsettled, scientific medical question. Dr. Ameisen has decided to take his personal scientific opinion directly to the public in his book – Le Dernier Verre (The Last Glass). The result has been a surge of interest among alcoholics for this new “miracle cure” for their affliction.
Increasingly the medical community is caught between two opposing imperatives. There is the desire to make medical information freely available and the process of medical research transparent. On the other hand, the public is best served when new ideas in medicine are put through the mill of science before they become part of medical practice. As we enter headlong into the information age these two imperatives are increasingly at odds.
Problems arise when a new treatment, syndrome, intervention, or concept in medicine is promoted to the public prior to undergoing a reasonable degree of scientific vetting. What is the point, after all, of spending tremendous resources on medical research if proponents are going to bypass the process altogether to market their modalities and promote their ideas directly to the public?
Note: This article was originally published in Skeptic magazine. Space limitations resulted in omitting some of what I wanted to say. I’m taking advantage of having a blog to publish the entire article as originally submitted.
On an episode of Mythbusters, Adam Savage was shown a video clip that contradicted his memory of something he had said. He responded, “I reject your reality… and substitute my own.” He was joking. Unfortunately, the world is full of people who reject reality and who are not joking.
James Randi tells a story about a TV program that featured Uri Geller doing his standard trick of bending a key. Afterwards, the program’s host said it couldn’t possibly have been a trick because Uri had “never touched” the key. The host was then shown the recorded program, which proved that Geller clearly had the key in his hands, for two-and-a-half minutes. Instead of admitting having been wrong, the host exclaimed, “Well, that’s not how it happened.”
One of my own ancestors was a pro at this kind of thing. I’ll call her Aunt S (for stubborn). She had once tried tinned sardines, hated them, and refused to ever touch sardines again. One day she came into my grandmother’s kitchen when she was frying up some large fresh sardines a friend had brought her. Aunt S ate some, proclaimed them tasty, then asked, “What kind of fish were those, Mary?” My grandmother told her they were sardines. She protested, “No they weren’t! I don’t eat sardines!”
I’ve been thinking about an interesting organism lately, an organism that illustrates some basic principles in science-based medicine.
The organism is called Haemophilus influenzae (H flu), a gram-negative bacterium discovered in the late 19th century. H flu has a great story, both in historic and modern times.
The brilliant microbiologist Richard Pfeiffer isolated H flu from influenza patients in the late 1800′s (hence its name) and for many years, it was believed to be the cause of the epidemic illness, and when the flu pandemic of 1918 hit, researchers worked tirelessly to develop anti-sera against H flu.
But some things weren’t adding up. As thousands died of the flu, doctors were isolating H flu from victims, but also other virulent bacteria such as Streptococcus pneumoniae. Influenza was decimating military camps, and was seriously degrading our ability to fight in WW I, so military bases were a focus of research. Doctors looked for H flu in patients, but could not find it consistently. For example in Camp Dodge, Iowa, an autopsy series showed H flu in only 9.6% of victims.
BLOGGER’S NOTE: The incident described in this post is true, although somewhat embellished to protect the names and identities of the innocent, if you know what I mean. This conversation occurred a few years ago at a large national cancer meeting.
The question caught me by surprise.
While attending a large national cancer meeting, I was having brunch with a friend, a colleague with whom I used to work when I was doing laboratory research, someone whom I hadn’t seen in a long time. She and her husband had brought along two of their oldest and dearest friends, whom they had known for decades, as well as another of my former coworkers from my old lab. We were idly chatting away and eating, when one of the occupational hazards of being a doctor presented itself. Tthe conversation drifted to medical topics. And then it came.
“What do you think of Dr. Gonzalez?”
Editor’s Note: This is a guest post solicited by Dr. Hall, who describes Dr. Albietz thusly: He’s a skeptical young pediatrician who works in a PICU and recently had a chiropractor come into the PICU to consult on a child with intractable seizures. He was sort of coerced to allow this at the parents’ request and against his better judgment. His hospital had set a precedent of letting alternative practitioners have temporary privileges in cases like this. He was torn between his academic integrity and doing the most humane thing for the patient and family.
“Primum non nocere.” First, do no harm. It is a guiding principle of medicine, and one which is next to impossible to achieve in practice. It is difficult for the general public to hear, but any intervention a physician makes, and indeed the decision to make no intervention, carries a risk of harm with it. Given enough time, every physician will make a decision which results in unintended harm to a patient, even death, and it haunts us every day of our careers. Faced with this horrible certainty, what is one to do? The only responsible, ethical position to take is to ensure that each patient receives the care most likely to generate a positive outcome, in other words, to stack the deck as steeply in favor of the patient as is possible. Diligent application of the scientific method to every therapy, novel and new, old and venerated, is the only way we as physicians can be certain we are doing the greatest good and the least harm to those who seek our help; it is the only way to assuage our conscience if things end badly.
Our professional organizations and academic institutions have been vital in formulating, propagating, and enforcing the practice of evidence based medicine (EBM). They have stood, to borrow the phrase from Carl Sagan, as “a candle in the dark,” promoting the best practices and protecting patients from those that are ineffective, fraudulent, harmful, or even simply sub-standard. It is a heartening environment in which to work.
USA Today has come out with a new survey – apparently, three out of every four people make up 75% of the population.
How popular is alternative medicine? One way is to survey people and ask them. Like all surveys, the nature of the question determines the answer. The first, and probably most referenced, and misquoted, article on ‘alternative’ medicine to address the question was “Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use” from the NEJM .
‘Alternative’ proponents quote this article, often as the opening sentence of the paper. “One in three respondents (34 percent) reported using at least one unconventional therapy in the past year.” No one, it appears, ever reads past the abstract. As is so often the case, the substance of the article may not reflect the spin found in the abstract.
There are many issues with this paper (see http://www.quackwatch.org/11Ind/eisenberg.html for a detailed critique) , not the least of which is the definition of unconventional therapy. To get to this huge percentage of users they had to include exercise (26%), prayer (25%) and relaxation techniques (13%) as unconventional therapies. Little did I know that I participate in unconventional therapies every day.