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Not Treating – A Neglected Option

One of the criticisms of modern medicine is that doctors prescribe too many pills. That’s true. Patients and doctors sometimes get caught up in a mutual misunderstanding. The patient assumes that he needs a prescription, and the doctor assumes that the patient wants a prescription. But sometimes patients don’t either need or want a prescription.

I’ll use myself as an illustration. I get occasional episodes of funny, blurry spots in my visual field that gradually expand to a sparkling zigzag pattern and go away after 20 minutes. They are typical scintillating scotomas, the aura that precedes some migraines. I am lucky because I never get the headache. My doctor said we could try to prevent my symptoms with the same medications we use to prevent migraine, but there was no need to treat them from a medical standpoint. Nothing bad would happen if we didn’t treat. I told her I didn’t want them treated. They are a minor annoyance; I can carry on with my normal activities, even reading, throughout the episodes, and I have no desire to take pills with potential side effects and with the cost and the hassle of remembering when to take them.

If it had been a typical patient and a typical doctor, the sequence of events might have been very different. The patient might have been more frightened by the strange phenomenon than I was. (I thought the weird tricks my brain could play on me were fascinating and fun to watch, not scary.) The patient might have desperately wanted those threatening symptoms to go away without understanding how insignificant and non-threatening they really were. The doctor might have assumed the patient wanted them to go away. The pills might have been offered and accepted with little thought. (more…)

Posted in: General

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Why the latest Geier & Geier paper is not evidence that mercury in vaccines causes autism

Several people have been sending me either links to this paper or even the paper itself:

Young HA, Geier DA, Geier MR. (2008). Thimerosal exposure in infants and neurodevelopmental disorders: An assessment of computerized medical records in the Vaccine Safety Datalink. J Neurol Sci. 2008 May 14 [Epub ahead of print]. (Full text here.)

A few have asked me whether I was planning on deconstructing this study, given that antivaccinationists have apparently been promoting it as “evidence” that it really, truly, and honestly was the mercury in vaccines after all that caused autism. In actuality, I really didn’t feel the need to bother to do a full deconstruction because a new blogger called EpiWonk did a three part take-down that eviscerated this latest bit of “science” from Geier père et fils so thoroughly and with a much greater knowledge of epidemiology than I could ever muster, that I saw no need. Add to that a four-part takedown on the Pathophilia blog, and there was really no need for me to write a detailed deconstruction of my own. Unfortunately, since this study appears to be rearing its ugly head again and again in the blogosphere, I think it’s worth directing you to these discussions. I had been meaning to to this anyway, but had gotten side-tracked by numerous other topics. To make up for my lapse, here we go:

  1. New Study on Thimerosal and Neurodevelopmental Disorders: I. Scientific Fraud or Just Playing with Data?
  2. New Study on Thimerosal and Neurodevelopmental Disorders: II. What Happened to Control for Confounding?
  3. New Study on Thimerosal and Neurodevelopmental Disorders: III. Group-Level Units of Analysis and the Ecological Fallacy

Meanwhile, the Pathophilia blog also has a multi-part deconstruction of the latest Geier study from a different viewpoint:

  1. IRB Approval of Geier Autism Study: Yes or No?
  2. I’ve Been Sucked Into the Thimerosal-Autism-Geier Vortex
  3. Young-Geier Autism Study: What the—? (Part 1)
  4. Young-Geier Autism Study: What the—? (Part 2)
  5. Young-Geier Autism Study: What the—? (Part 3)
  6. Young-Geier Autism Study: What the—? (Part 4)

Ow! That’s gonna leave a mark!
Enjoy! And the next time an antivaccinationist points to this particular study, send ‘em over to see EpiWonk and Pathophilia.

Posted in: Public Health, Science and Medicine, Science and the Media, Vaccines

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The media versus the frontiers of medicine and surgery

A couple of months ago, one of my esteemed co-bloggers, Wally Sampson, wrote an excellent article about borderlines in research in conventional medicine. Such borderlines are particularly common in my area of expertise (cancer, which is also Dr. Sampson’s area of expertise) because there are so many cancers for which we do not as yet have reliably curative therapies. Patients faced with unresectable pancreatic cancer (as, for example, Patrick Swayze and the President of the American Medical Association have been diagnosed with) or metastatic solid cancers against which medicine generally has mostly palliative treatments, it is very tempting to take a “what have we got to lose?” attitude and pursue increasingly aggressive therapies that may actually shorten what little life a patient has left, all too often making that little bit of life more miserable than it had to be. As Dr. Sampson described in great detail, this sort of push to the borderlines and beyond led to the widespread acceptance during the 1990s of bone marrow transplantation as a treatment for advanced or inflammatory breast cancer based on uncontrolled studies that suggested a benefit. Later studies demonstrated no survival benefit (and possibly even a detriment), and that, or so it would seem, was that.

Except it wasn’t. Indeed, the other point that Dr. Sampson made was how the press covers these sorts of issues. He discussed a story that appeared in the San Francisco Chronicle about a young woman with advanced breast cancer who underwent stem cell transplantation for stage IV breast cancer at M.D. Anderson Cancer Center and was embroiled in a fight with Kaiser Permanente, her insurer, which refused to cover the treatment because it was deemed experimental and was at the time covering the cost of radiation therapy but refusing to cover the costs of extra followup scans required by the M.D. Anderson protocol. The article, not surprisingly, covered the story from the angle of the brave young cancer victim being further victimized by a greedy insurance company. And Evanthia Pappas is no doubt brave, and no one could read about her plight without rooting for her to beat the odds. The problem is that no consideration was given to just how unlikely this incredibly expensive treatment was to benefit her and whether it was even ethical to be doing such a study in which the patient bore over $200,000 of the cost for a treatment that was indeed experimental and being studied in an uncontrolled clinical trial. There are some very thorny medical, ethical, and financial issues there indeed.

Perhaps the reason Dr. Sampson’s post resonated with me was because it reminded me of a story that was extensively discussed last year, so much so that I saved the link to it. The story (Cancer Patients, Lost in a Maze of Uneven Care) appeared on the front page of the New York Times last summer. The article in question starts out by telling a truly sad story about a 35 year-old woman who, after giving birth, was diagnosed with Stage IV colon cancer as the human interest “hook” with which to represent what is described as a systemic problem with cancer care in this country:
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Posted in: Cancer, Medical Ethics, Science and Medicine, Science and the Media, Surgical Procedures

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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 1

Minnesota has recently become the 15th state in the U.S. to formally endorse the claims of a tiny group of naturopaths who portray themselves as physicians.* The bill , like the popular-media “CAM” reports that Steve Novella criticized on Wednesday, merely parrots what these naturopaths claim about themselves. It reveals no attempt to investigate or to judge the tenets of the field. The following excerpts present false assertions as though they were facts. I’ve underlined some of the more obvious examples:

“Naturopathic medicine” means a system of primary health care for the prevention, assessment, and treatment of human health conditions, injuries, and diseases

“Naturopathic physical medicine” includes, but is not limited to, the therapeutic use of the physical agents of air, water, heat, cold, sound, light, and electromagnetic nonionizing radiation and the physical modalities of electrotherapy, diathermy, ultraviolet light, hydrotherapy, massage, stretching, colon hydrotherapy, frequency specific microcurrent, electrical muscle stimulation, transcutaneous electrical nerve stimulation, and therapeutic exercise.

The practice of naturopathic medicine includes, but is not limited to, the following services: (1) ordering, administering, prescribing, or dispensing for preventive and therapeutic purposes: food, extracts of food, nutraceuticals, vitamins, minerals, amino acids, enzymes, botanicals and their extracts, botanical medicines, herbal remedies, homeopathic medicines, dietary supplements and nonprescription drugs as defined by the federal Food, Drug, and Cosmetic Act, glandulars, protomorphogens, lifestyle counseling, hypnotherapy, biofeedback, dietary therapy, electrotherapy, galvanic therapy, oxygen, therapeutic devices, barrier devices for contraception, and minor office procedures, including obtaining specimens to assess and treat disease

Unlike the Minnesota leglislators, I have substantial knowledge of the tenets and practices of “naturopathic physicians,” and I am capable of judging those tenets according to standards of reason, science, and modern, science-based medicine. Beginning with my stint on the Massachusetts Special Commission on Complementary and Alternative Medical Practitioners 6-8 years ago, I have spent years listening to “NDs,” reading their literature, and writing about them. I described a bit of my experience on that Commission in a post on Science-Based Medicine several weeks ago. I have continued to observe NDs’ cult-like behavior since then, and have seen no indication that they have begun to awaken from their collective, pseudoscientific stupor.

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Posted in: Health Fraud, Politics and Regulation, Vaccines

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Forks in the road

It’s been decades since the onslaught of organized quackery began against science and reason. Although most physicians are still capable of reasoning, the percentage of medical graduates whose brains have been cleansed of that ability seems to have increased. Either the brains have been cleansed or they have learned to coexist with unreason and to use both functions simultaneously. The latter is quite an accomplishment and is a testament to the flexibility and fluidity of the human mind (shorthand for brain function.) Psychologists have names for that function such as compartmentalization, rationalization, denial, heuristic maintenance, and cognitive dissonance.

Physician advocates of quackery are particularly unsettling because they seem to be so rational at times and appear so to the press and the public. Even more unsettling to me are the medical school department heads and deans and others who loosen the restrictions on the irrational so that peaceful coexistence and polite tolerance seem to be the preferred mode of mental existence in faculties. The NCCAM’s example needs no introduction.

Thus the matter-of-fact tone in which was reported an article in this week’s JAMA. As reported in our local papers, the headlines read: “St. John’s Wort fails to help kids with ADHD [Attention Deficit-Hyperactivity Disorder] in study.” That stopped me for more than one reason. First, any headline about a sectarian or implausible claim is a stopper. But second, StJW for ADHD? I’d never seen the claim. But the article explained that the author felt such a trial was worth doing because someone else had found that StJW increased the level of nor-epinephrine-like compounds in rat brains, so that perhaps St JW would work instead of stimulants for hyperactivity.

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Posted in: Clinical Trials, Medical Academia, Pharmaceuticals, Science and Medicine, Science and the Media

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The Media and “CAM”

Recently I have been generally critical of how mainstream media deals with scientific topics. Science is often complex and requires hard work and diligence on the part of a journalist to get the story right. In recent years mainstream news outlets have been downsizing or eliminating their science journalists and tasking general reporters and editors to handle science stories.

Meanwhile, as science progresses it grows more complex and challenging to distill for a lay audience. At the same time there are growing pseudoscientific institutions and social forces making it even more difficult to sort out the reliable from the nonsense. This is especially true, in my opinion, when it comes to medical reporting of controversial treatments and claims.

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Posted in: Science and Medicine, Science and the Media

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Mercury Must Be Bad – If Not in Vaccines, In Teeth

Those of us who are baby boomers or older can remember playing with mercury when we were young. The thermometer broke, and you pushed the little globules around. Or you fooled around with the stuff in science class. My husband says he used to get mercury to flow over the surface of a dime and make it look really shiny. Who knew our old playmate would turn out to be such a bugaboo?

The real dangers of mercury have been recognized. Guidelines have been published to limit exposure. Instructions for safe cleanup of mercury spills are available online. This is good. Other developments are not so good. Scaremongers have demonized mercury and blamed it for everything from autism to Alzheimer’s.

Just when you thought the mercury/autism scare was finally subsiding, another mercury scare has resurfaced. The alarm has been raised (again!) about the mercury in amalgam fillings. (more…)

Posted in: Dentistry, Health Fraud, Politics and Regulation, Science and the Media

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Jenny McCarthy, Jim Carrey, and “Green Our Vaccines”: Anti-vaccine, not “pro-safe vaccine”

Jenny McCarthy & Jim Carrey at Green Our Vaccines

Last week, there was a rally in Washington, D.C. How many people actually attended the rally is uncertain. The organizers themselves claim that 8,500 people attended, while more objective estimates from people not associated with the march put the number at probably less than 1,000. Of course, such wide variations in estimates for the attendance at such events are not uncommon. For my purposes it is irrelevant whether 500 or 8,000 attended because even if the lowest estimate is closer to the true number this march represented the largest march on Washington ever for this particular cause, the previous largest having occurred three years ago.

Fortunately for public health interests, the organizers’ timing was very bad (for them, at least) in that they marched last Wednesday, the very day after Barack Obama clinched the Democratic nomination. The media were rife with coverage of the history-making nomination of the first African-American as a nominee of a major party, as well as speculation about when and whether Hillary Clinton would concede and endorse Obama. Drowning out most other news, Obama’s nomination led to almost nonexistent news coverage of the rally, aside from a handful of television appearances by one of its celebrity organizers. Its relative lack of success notwithstanding, however, all who support science- and evidence-based medicine should nonetheless remain concerned about this rally, because it was a dagger aimed at the heart of the most effective public health innovation ever conceived by the human mind, an intervention that has arguably saved more lives over the course of human history than every other medical intervention combined. That this dagger turned out to be a toothpick is fortunate indeed but by no means a reason to dismiss the movement that spawned it as irrelevant.

I’m referring, of course, to the antivaccinationist movement, and the rally was known as the “Green Our Vaccines” rally, led by the celebrity couple Jenny McCarthy and Jim Carrey and organized and funded by Talk About Curing Autism (TACA), Generation Rescue (upon whose board McCarthy now sits), and a panoply of other groups that promulgate the myth that either vaccines containing mercury in the form of their thimerosal preservative or vaccines themselves cause autism.
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Posted in: Neuroscience/Mental Health, Politics and Regulation, Public Health, Science and the Media, Vaccines

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The Weekly Waluation of the Weasel Words of Woo #7

What Talent!

I, like Joe, am utterly humbled by the translations of the entry in the W^5/2 #6! Namidim (twice), Stu (m’man!), Michelle B (using the Now-Venerated, Awesome Power of Simple Substitution that had Suddenly Swept Stu to SuperStar Status lo! These many W^5/2s ago!), and Michael X (it’s Larry’s turn to cry!) each nailed that passage lacka split hawg through the Penetrating Power of Poignant Parody©.

Therefore:

I thought it wouldn’t happen for a while, if ever, and I tremble as I write this, but…I have no choice but to confer the legendary, coveted, Soaring Standard of Stu® upon each of the four prodigal W^5/2 scholars named above! My hat is also off to homeboy David Gorski, who followed that passage with a Perfectly Pertinent Post-post Posting©, demonstrating such uncanny, spontaneous timing and recall that he must be Duly Acknowledged as one of the Baddest Bosses of the Blogosphere®. (more…)

Posted in: General, Humor, Science and the Media

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Touched by a Touched Healing Toucher

Recent posts by Drs. Sampson and Hansen and some recent comments have got me to thinking for the umpteenth time about this issue: quackery is quackery, even if it seems harmless and even if some people seek it. This is the first of a series that will discuss it. I’m afraid I will ramble a bit; it may be that not every post will support that premise. Nevertheless, in the aggregate I’ll try to do exactly that.

The posts about Healing Touch sent me on a walk down memory lane, to one of my early forays into “CAM” skepticism. It was there that I discovered just how removed from reality some true believers, even those that project a superficial air of sobriety, can be. Here I’ll recount a brief exchange that I had with one such person, who was undoubtedly well-meaning. My attempts to influence her by the use of reason proved futile.

Shortly after the publication of the famous Emily Rosa article in 1998, I read a report about it in Newsday. It wasn’t all that bad, but my annoyance with mainstream publications giving the slightest credence to “alternative medicine” had been growing, and this moved me to act. I wrote a diatribe to Newsday that was not published (I can’t imagine why):

To the Editor:

“Therapeutic touch” is such obvious humbug that it never should have been taken seriously by anyone with the slightest aquaintance with how things work. Nevertheless, academic careers have been based on it, hundreds of useless papers have been written about it, courses in it have been given and even required of nursing students, grant money has been provided for it (but not used to test it!), and scores of ridiculous magazine and newspaper articles have praised it, apparently to a naive and credulous public. All of this constitutes a huge embarrassment to nurses, a fact that would appear to be lost on their largest professional organization (the ANA).

One of the statements in your article about the JAMA study was incorrect: the practitioners were not able to detect the energy field half of the time. They were able to guess the correct hand half the time, as would be predicted by chance alone. Thus there is no evidence that the “energy field” was detected at all. This is no surprise, because this kind of “energy field” exists only in the fantasies of true believers.

Dolores Krieger’s objection to the study, that the right practitioners were not tested, is disingenuous. She has been asked numerous times, by James Randi and others, to submit to testing of the same sort as described in Rosa’s study (Randi’s foundation has even offered a $1 million reward for anyone who can demonstrate the ability to detect the “energy field”!). Neither she nor any of her trainees or colleagues has come forward, nor has any of them published a single study supporting the efficacy of “therapeutic touch.”

Among the shamelessly fawning, uncritical articles on TT referred to above is one in Newsday by Tina Morales, 7/8/96. Really, now. There are very simple, basic skills useful for evaluating questionable claims. If the writer doesn’t have them the editor certainly should!

Before gentle readers admonish me for the scolding, schoolmarmish tone of that letter, let me assure them that I have long since learned to couch my objections to “woo” in more matter-of-fact, less provocative language. As frustrating as it may be, amiable, well-meaning, intelligent people who haven’t the slightest idea how to evaluate questionable claims vastly outnumber their more savvy counterparts, even in surprising fields: journalism and medicine, for example. Ten years ago I had no intention of becoming more than a temporary, annoying gadfly. I imagined that the “CAM” fad would soon blow over, and that I’d go back to spending my free time watching re-runs of Seinfeld and Law and Order. Alas, ’twas not to be. Patience.

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Posted in: Energy Medicine, Faith Healing & Spirituality, Health Fraud

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